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Summary: Following a hospital stay for a broken arm and dislocated shoulder, an older man was discharged to a skilled nursing facility (SNF) for rehabilitation. Providers were concerned about his ability to live independently given results of cognitive and living skills assessments performed during the hospital stay. Although the hospital social worker had begun the process of applying for home care and meals for the patient, the SNF discharged him home with no access to care, food, or his medications. Mark Toles, PhD, RN, of the University of North Carolina at Chapel Hill, explores weaknesses in skilled nursing facility discharge planning and suggests that transitional care should focus on family caregivers, who assume the largest share of patient care after discharge, to improve safety.
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