ArticleJournal of general internal medicine2021
Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives.
Article in Journal of general internal medicine, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 10 papers, 1 of them a synthesis that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
10 citing papers in PubMed, 1 synthesis or guideline pooled it.
- The impact of facility-based transitional care programs on function and discharge destination for older adults with cognitive impairment: a systematic review.BMC geriatrics · 2022Pooled it
- Preparedness for care transitions to home and acute care use of skilled nursing facility patients.BMC geriatrics · 2025Trial
- Health Trajectories of Skilled Nursing Facility Patients With Alzheimer's Disease and Related Dementias: Evidence for Practicing Nurses.Journal of gerontological nursing · 2024Trial
- Hospital-to-Home Neurological Transition Care: A Scoping Review Across Selected Chronic Neurological Disorders.Medical sciences (Basel, Switzerland) · 2026Article
- Can I Stay, or Must I Go Now? A Cohort Study of Discharge Appeals in a Post-Acute Skilled Nursing Facility.Journal of the American Medical Directors Association · 2026Article
- Realist review of informal carer involvement in the transition of medicines-related care for patients moving from hospital to home.BMJ open · 2025Review
- Gaps in Primary Care Follow-Up After Hospital Discharge Among Medicare Beneficiaries.Journal of the American Geriatrics Society · 2025Article
- Pre-procedural nursing home length of stay and outcomes of transcatheter aortic valve replacement.Journal of the American Geriatrics Society · 2024Article
- Postacute Care and Long-term Care for LGBTQ+ Older Adults.Clinics in geriatric medicine · 2024Review
- Developing a User-Centered Mobile Application Prototype: Bridging Lower-Limb Fracture Care from Skilled Nursing Facility and Back to the Community.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2024Article
Corrections and comments
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Authors and funding
7 authors.
Funding
Abstract
backgroundPatients who undergo the complex series of transitions from the hospital to a skilled nursing facility (SNF) back to home represent a unique patient population with multiple comorbidities and impaired functional abilities. The needs and outcomes of patients who are discharged from the hospital to SNF before returning home are understudied in care transitions scholarship.
objectiveTo study the patient and caregiver challenges and perspectives on transitions from the hospital to the SNF and back to home.
designBetween 48 h and 1 week after discharge from the SNF, semi-structured interviews were performed with a convenience sample of patients and caregivers in their homes. Within 1 to 2 weeks after the baseline interview, follow-up interviews were performed over the phone.
participantsA total of 39 interviewees comprised older adults undergoing the series of transitions from hospital to skilled nursing facility to home and their informal caregivers. MAIN MEASURES: A constructionist, grounded-theory approach was used to code the interviews, identify major themes and subthemes, and develop a theoretical model explaining the outcomes of the SNF to home transition. KEY
resultsThe mean age of the patients was 76.6 years and 64.8 years for the caregivers. Four major themes were identified: comforts of home, information needs, post-SNF care, and independence. Patients noted an extended time away from home and were motivated to return to and remain in the home. Information needs were variably met and affected post-SNF care, including medication management, appointments, and therapy gains and setbacks. Interviewees identified independent function at home as the most important outcome of the transition home.
conclusionsPost-SNF in home support is needed rapidly after discharge from the SNF to prevent adverse outcomes. In-home support needs to be highly individualized based on a patient's and caregiver's unique situation and needs.
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