Date of Award

Spring 5-2021

Degree Type


Degree Name

PhD Health Sciences


Health and Medical Sciences


Genevieve Pinto-Zipp, Ed.D.

Committee Member

Annette L. Kirchgessner, Ph.D.

Committee Member

Gerard H. McCarren, S.T.D.


quality of care, long-term care, skilled nursing facility, aging, communication


Background and Purpose of the Study: The need for skilled care and long-term care services often becomes necessary as the older adult transitions into the golden years. In the United States, more than 1.5 million adults live in long-term care facilities, with this number expected to double by 2050 (Johnson, Pope joy & Radina, 2010). Effective communication between the healthcare professionals who refer individuals from an acute care setting to a skilled nursing facility can be challenging and ultimately impact their transfer status and Plan of Care (POC) or plan of action implementation for meeting healthcare goals of the patient (Benzar et al, 2011, CDC, 2020). The purpose of this qualitative research study is to explore the communication initiatives (processes) employed as part of the transition process from the acute care to long term care setting, in order to promote patient POC and quality of care.

Methods: The focus of this general qualitative study was to employ a descriptive research design using qualitative interviews. An inductive approach was used to collect data relevant to the topic of interest and patterns in the data were used to develop a theory that could explain those data. The aim of the study was to explore communication barriers between acute care and skilled care settings professionals in the transition process. A sample of 7 healthcare professionals across acute-care and skilled care settings participated in this study.

Results: Qualitative thematic analysis resulted in 6 overarching themes: 1) The transition teams’ perceived communication initiatives include written and verbal communication employed among the teams to exchange vital information can be challenging and impact the transfer status. Insufficiency, and clarity issues are important to identify early within the transfer process.

Daily meetings help eliminate obstacles and establish key issues within patient medical history. 2) The transition teams’ perceived barriers center around skilled care facility requirements. Additionally, there are time delays, diverse issues with patient needs, and problems with information retrieval. Management routine communication practices helps improve transfer process. 3) The transition teams’ perceived pressures are the facility’s time sensitivity issues, limited facility policy and communication between acute care setting and the skilled care facility leading to errors such as improper discharge. 4)The Transition teams’ perceived benefits centers around an effective team based plan of care, person centered care and creating patient initial assessment which fosters teamwork for the patient overall health and quality of life.5) The transition team’s perceived key acuity measures include measuring discharge planning by employing HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) which is designed to enhances scores on internal set criteria as well as enhance scores on external criteria which allows the team to concentrate on facility policies for smoother transitions and reduces the length of stay by positively impacting the effectiveness of patient satisfaction in the transition process. 6) The transition teams’ experiences are often stressful but communication practices, education and knowledge, trial, and error support better decision-making outcomes.

Conclusion: Written and verbal communication, policies and procedures, facility time sensitivity issues, effective communication, setting realistic goals for the patient and the team collaboration are important components in the transitioning process. The journey from hospital to sub-acute or long-term care facility can become an involved task for everyone responsible for both direct and indirect patient care. As acute care hospitals discharge patients back to the community and/or refer patients to skilled facilities for sub-acute care and/or long-term care, a team of experts must be present for this transition of care and aid in the communication necessary to uphold quality. Effective communication is the foundation for successful outcomes and quality of life when the patient transitions from acute care to skilled nursing facility. Future research should focus on a potential case study over time and/or survey research utilizing the Delphi technique to gauge a larger transition team member population and/or inclusion of more facilities for comparison purposes from additional states within the U.S and/or international populations.

Keywords: quality of care, long-term, skilled nursing facility (SNF), transitioning, communication, aging