Information sharing to support care transitions for patients with complex mental health and social needs

Abstract

Background: Patients with complex behavioral and mental health conditions require significant transitional care coordination. It is unclear how skilled nursing facilities (SNFs) that serve these patients engage in care transfer with hospitals, specifically whether they experience discrepancies in the type of information shared by hospital partners and/or use different approaches to secure needed information.

Methods: Cross-sectional analysis of a national 2019-2020 SNF survey that collected information on transitional care practices with referring hospitals; respondents were directors of nursing services. We used chi-squared tests and descriptive statistics to characterize hospital information sharing practices experienced by facilities that accept complex patients (e.g., serious mental illness, substance use disorder, and/or medication assisted treatment), and to compare them to facilities that treat a less complex population.

Results: A total of 215 SNFs had sufficiently complete responses for inclusion in the analysis. Of these respondents, 57% accepted two or more types of patients with complex conditions of interest; these SNFs were more likely to be urban, for-profit, and serve more dual-eligible patients. SNFs accepting complex patients experience information sharing on par with other facilities, and are more likely to receive information on behavioral, social, mental, and functional status (25.41% vs. 12.90%; p = 0.023). These facilities are also more likely to consistently use electronic methods (e.g., an online portal, shared electronic health record [EHR] access) to retrieve information from partner hospitals.

Conclusions: SNFs accepting complex patients demonstrate some evidence of enhanced information retrieval via electronically mediated pathways. Overall, information sharing remains underdeveloped in this care context. Policymakers should continue to prioritize widespread digital infrastructure that supports post-acute care delivery.

Keywords: care transitions; information sharing; serious mental illness; skilled nursing facility.

FIGURE 1

Reported use of information retrieval methods among SNFs that do versus do not accept complex patients. This figure depicts the categorical (rarely/never, sometimes, always/often) use of various information retrieval methods reported by skilled nursing facilities (SNFs). The horizontal axis reports the frequency of use by (A) information retrieval methods (e.g., SNF staff onsite, secure text) and SNF acceptance of complex patients (0–1 vs. 2+). Survey respondents were asked if their facility accepts each of the following conditions: serious mental illness (SMI), substance use disorder (SUD), and/or medication assisted treatment/therapy (MAT). If the SNF reported accepting patients at least sometimes in two or more of the three focus conditions (i.e., 2+), we defined them as willing to accept more complex patients after hospital discharge.