Date of Conferral
3-6-2025
Degree
Doctor of Healthcare Administration (D.H.A.)
School
Management
Advisor
Eboni Green
Abstract
When skilled nursing facilities fail to implement, enforce, and follow up with the discharge planning process before and after the resident transitions home, it can lead to a hospital admission. The purpose of this integrative review was to synthesize the literature to identify how the chronic care model (CCM) can support skilled nursing facilities with the pre- and postdischarge planning process and make recommendations for strategy or policy revisions. The review question was focused on determining how the CCM can be effectively implemented within SNFs to optimize pre- and postdischarge planning for residents with chronic conditions and what strategy revisions are necessary to facilitate this integration. A thorough integrative review was conducted using empirical and nonempirical literature published between 2016–2024, employing the John Hopkins evidence-based practice model to help determine what strategies can be incorporated into the pre and postdischarge planning process. Several themes emerged from the review, including coordinated care transitions and clear and consistent communication. The subthemes were early assessments, medication reconciliation, interdisciplinary team collaboration, resident and family engagement, follow-up visits, transition to home planning, addressing concerns, resident-centered communication, and clear instructions. Further studies are needed to examine the effectiveness of evidence-based interventions using the CCM on the overall health status of residents. Implementing these strategies can promote positive social change via collaborative efforts between skilled nursing facilities, hospitals, primary care and home health agencies to provide a seamless transition home.
Recommended Citation
McClendon, Tawauna Renea, "Strategies for Improving the Transition Process Home After Skilled Nursing for Chronically Ill Residents Who are 65 Years or Older" (2025). Walden Dissertations and Doctoral Studies. 17450.
https://scholarworks.waldenu.edu/dissertations/17450
