How Are Nurses Making the Connection?

When assisting a patient through a care transition, does an inpatient nurse really understand what a skilled nursing facility offers, how a health coach could help or why the Community Care-based Transitions Program (CCTP) could play a critical role?

Those are the questions that leaders of Aligning Forces for Quality – South Central PA’s (AF4Q-SCPA) Nurses Council needed to answer.  While the Council began with leaders from the hospital setting, they soon realized that in order to fill in the gaps of health care, they needed the voices of nurses throughout the continuum of care. Today, the Council is composed of representatives from Area Agencies on Aging, skilled nursing facilities, rehabilitation organizations and home health nurses.

“As nurses, we are very fragmented… you only see the patient in your own light,” said Samantha Obeck, quality improvement coordinator for AF4Q-SCPA. “We need to identify the gaps in care…and have meaningful conversations to make sure patients have safe transitions.”

To address these concerns from a regional perspective, on October 30, the Nurses Council convened the first-ever Nursing Summit titled, “Making the Connection.” More than 125 nursing professionals from across central Pennsylvania attended the event in New Cumberland to learn strategies to improve transitions of care and reduce re-hospitalizations.

Summit presentations were led by Dr. Beth Ann Swan, PhD, CRNP, professor and dean of Jefferson School of Nursing at Thomas Jefferson University, as well as representatives from York County Area Agency on Aging; Wilmac Corporation; Visiting Nurses Association of Hanover and Spring Grove; Hospital Association of Pennsylvania; WellSpan Health and AF4Q-SCPA.

Even as a health care professional, Dr. Swan expressed her family’s personal struggles with caring for her husband after he suddenly suffered a brain stem stroke. As she explains it, “I had 55 pages of discharge instructions, yet it still wasn’t enough.”

Samantha echoed her thoughts, saying, “In the hospital, the nurse manages a patient’s medications, verifying the order is correct; administers the medication in the proper fashion at the correct time; and evaluates for effectiveness or adverse reactions.  But at home, the patient is now expected to navigate the many steps involved with the medication regimen. The patient must process everything: reading it, getting it filled, bringing it home and taking it at the right time. It is the same intensity of care that a patient receives while in the hospital without clinical support.”

Elaborating further, she said, “We are really setting patients up to fail unless we identify and address barriers to a safe transition… How are they going to be able to care for themselves after they leave our care? That’s why programs like CCTP are so important. While they aren’t delivering health care services, like bathing, they are asking what patients need to be successful and connecting them to additional resources to manage their own health and be safe.”

In fact, social influences or barriers cause many of the biggest gaps for patients. For example, if a patient receives a hip replacement, the nurse knows that he or she will need a raised toilet seat. Until recently, however, nurses weren’t instructed to take a closer look at social needs such as transportation to follow-up appointments or food security – potential obstacles outside of medicine.

Attendees also discussed how to make the Teach-Back Method even more powerful by not only asking patients to repeat what they are supposed to do and why it is important, but also explaining step-by-step how they will follow the instructions.

To illustrate this point, Samantha recalls a story she heard at a health literacy conference of an elderly patient who was instructed to take her medication using the Teach-Back method, but no one asked her how she was physically going to take her medications.

“She had severe arthritis in her hands, and she couldn’t open the caps to the medication,” said Samantha.

Without in-depth conversations, the team wouldn’t have learned that the patient previously worked in a deli and was now using a meat slicer to open her medications. We have to think, how many more patients are struggling with similar barriers?

Among other key learnings and insights, attendees also shared:

• “Listening to Dr. Swan talk about her trials navigating the health care system reinforces that we as an industry do not do as good of a job as we think we do with discharge planning.  Also, I hope to implement some of the suggestions Cindy Hipszer spoke about in her Teach-Back workshop.” – Joni Griffin, chief clinical officer at Visiting Nurses Association of Hanover & Spring Grove.

• “The importance for attending the conference was to increase the understanding of the tiers of care and how to work better with each other to make patient flow between each tier easier for the patient,” said Tammy Clabaugh, RN, NHA, CNDLTC, corporate director of Nursing at Wilmac Corporation.

• “I had never attended a workshop on “teach-back” and plan to implement some of the concepts presented,” June Main, RN, at York County Area Agency on Aging and clinical supervisor for the York/Adams Care Transition Coalition.

• “The role of the nurse is changing rapidly and we are rapidly moving from being the bedside caregiver to the coordinator of care to ensure not only a safe hospitalization but a safe transition to home, skilled facility, etc. It is important that we understand the team that can help make this all happen for the patient!” said Ann Proctor, MSN, RN, OCN, oncology outpatient clinical educator, staff nurse on oncology and current Practice/Quality Council Chair at WellSpan Health.

In the months to come, the Nurses Council will incorporate feedback and learnings from the Summit into future outreach.  If you’re interested in learning more about the Council, please contact Samantha Obeck at

Join the I Can! Challenge

Have diabetes or heart disease? Join the 12-week, step-by-step program to help you learn how to set goals, partner with your doctor, and incorporate healthy eating and exercise into your life. Like I Can! on Facebook!