Kaye, Suzie E.

Transitions in care have been a national priority for decades to promote the safe and timely passage of patients between levels of healthcare and across care settings. Improving hospital discharge processes is an important quality improvement initiative to reduce adverse outcomes, and thirty-day readmission rates and increase patients’ satisfaction after discharge. This qualitative design study explored the perceptions, experiences, and gaps in understanding the needs of the resident and family in the transition from a hospital to a skilled nursing facility (SNF). It is essential to understand the perspective of the residents, families, and healthcare professionals who experience this transitional process to inform future research, and practice initiatives and to effectively prepare the residents and families for this transition. The purposive sample included 15 residents, 13 family members, and 12 SNF staff. The setting was a SNF within a continuing care residential community with an 89-licensed-bed capacity in Palm Beach County, FL. This doctoral research applied a descriptive qualitative methodology to capture the essence of the perceptions of residents, families, and staff participants transitioning from acute care to a skilled nursing facility. Interviews were qualitatively analyzed with an interactive model utilizing open, pattern, and thematic coding, and data (network) display to help organize, inform, and justify conclusions and explanations. Overall, 53% of residents, and 62% of families expressed confusion, frustration, concern, uncertainty, disappointment, and stress.