Duke HOPE Smooths Transition to Skilled Nursing Facilities

By Liz Switzer

The Duke Health Optimization Program for Elders (HOPE)— a Duke Geriatrics-led inpatient transitional care service for older adults transferring from acute care settings to skilled nursing facilities (SNF)—is working to decrease hospital readmissions while building bridges of transitional care across the health system that improve patient care.

Since HOPE started in 2015 as a pilot consultative service (1), it has grown and evolved into a program, which consists of HOPE Transitions in Care and the HOPE Skilled Nursing Facility Collaborative, and Duke TeleHOPE, the newest service offering under the HOPE umbrella.

A patient comparison in the TeleHOPE intervention cohort, with historic controls in the same Skilled Nursing Facilities, found that hospital readmission rates dropped significantly.  From July 2019 to January 2020, the 30-day readmission rate in the intervention cohort was 12.23%, down from 18.83% in the historic control (2). 

Duke TeleHOPE was piloted in 2019 with the support of a Duke Innovation for Healthcare Improvement (DIHI) Grant with the goal of addressing high hospital readmission rates among nursing home patientsa complex patient cohort with a historically high risk for readmission and mortality—strengthening the clinical partnership between Duke and area skilled nursing facilities (SNFs), and a desire to expand the HOPE clinical program. The TeleHOPE service quickly demonstrated benefits in both harm and cost reduction and is now sustained by the Duke Population Health Management Office as part of its strategy to enhance quality of care across the care continuum and reduce readmissions.

“Our geriatric nurse practitioner pays close attention to how we can reduce risk for geriatric patients and address common barriers to rehab,” say Aubrey Jolly Graham, MD, assistant professor in the division of General Internal Medicine and Medical Director of the Duke TeleHOPE Program. “We also focus on clarifying patients' goals of care.”

The TeleHOPE program tracked transition-related errors and found a total of 327. Of the 327 errors uncovered, 54% (177) were related to communication, 43% (139) to medications, and 3% (11) to durable medical equipment (DME).  These errors have resulted in a cascade of Plan-Do-Study-Act cycles executed through Duke’s existing safety reporting and quality improvement infrastructure and have resulted in widescale improvements in Duke’s processes for discharge from hospital to SNF. 

“With humans taking care of humans, two things that can be really challenging are expectation management and communication,” says HOPE Medical Director, Neema Sharda, MD, assistant professor in the division of Geriatrics. “When you’re sick, you're vulnerable and scared and when things aren't going well, it’s often because everybody is not on the same page. HOPE helps put everyone on the same page.”

Colette Allen, NP, works with HOPE patients every day at Duke University Hospital. “I'm here to help bridge the transition,” she says. A lot of anxiety comes up with that term ‘nursing home’ so I can communicate about what to expect. If they're going to a SNF for the first time or they've been before and had a bad experience, we can help mitigate that. And if there are things that might impede their chances of success like their pain regimen, sleep issues or delirium, we try to minimize that.”  Allen follows up after the discharge either through an in person visit or telephone discussion with the SNF team members.

One of the most important functions of HOPE is pharmacological review to catch medication errors,  a major driver of hospital admissions, says Heidi White, MD, clinical vice chief of the division of Geriatrics and chair of the Steering Committee of the Geriatrics Operational Plan for the Duke University Health System. “What is more, the HOPE Collaborative is fostering an understanding of nursing home operations in the acute-care-to-SNF transition,” she adds.

Thanks to this program, more people in the Duke Health system understand how nursing homes operate and how they can work with them to improve success. “It has been rewarding to  see how expertise and collaborative practice have evolved,” says White.

1. Krol ML, Allen C, Matters L, Jolly Graham A, English W, White HK. Health Optimization Program for Elders: Improving the Transition from Hospital to Skilled Nursing Facility. J Nurs Care Qual. 2019 Jul/Sep;34(3):217-222. PubMed PMID:305504922.

2. Julia Bellantoni MD, Elspeth Clark DO, Jonathan Wilson MS, Jane Pendergast PhD, Juliessa M. Pavon MD MHS, Heidi K. White MD, MHS, Med, Deanna Malone PharmD, BCPS, William Knechtle MBA MPH, Aubrey Jolly Graham MD. Implementation of a telehealth videoconference to improve hospital-to-skilled nursing care transitions: Preliminary data. J Am Geriatr Soc. 2022 Jun;70(6):1828-1837. doi: 10.1111/jgs.17751. Epub 2022 Mar 25.PMID: 35332931