Staff interaction strategies that optimize delivery of transitional care in a skilled nursing facility: A multiple case study

Mark Toles, Julie Barroso, Cathleen Colón-Emeric, Kirsten Corazzini, Eleanor McConnell, Ruth A. Anderson

Research output: Contribution to journalArticle

9 Scopus citations


After hospitalization, more than 1.5 million older adults each year receive postacute care in skilled nursing facilities (SNFs). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from an SNF to home, have rarely been studied. Thus, we conducted a longitudinal, multiple case study of transitional care provided in an SNF to explore the care processes and staff interaction strategies that SNF staff members used to optimize delivery of transitional care. Using qualitative data from 89 interviews, 118 field observations, and 70 chart, or document reviews, we observed that transitional care services were not solely formalized processes, but rather were embedded in the interactions among older adult patients, their family caregivers, and members of interdisciplinary care teams. We found, moreover, that staff member interactions with patients and family caregivers increased the capacity of patient care teams for optimizing patient-centered care, information exchange, and coordination of transitional care.

Original languageEnglish (US)
Pages (from-to)334-344
Number of pages11
JournalFamily and Community Health
Issue number4
StatePublished - Oct 1 2012



  • family caregivers
  • interactions
  • older adults
  • skilled nursing facilities
  • transitional care

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health

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