Conceptualization of a toolkit to evaluate everyday competence in planning transitions from nursing homes to the community

Living independently in the community is a primary goal for older adults, particularly for the estimated 10% to 20% of long-stay nursing home residents who have low care requirements. According to the model of person-environment fit, individuals with high levels of everyday competence have the ability to solve problems associated with everyday life. Nursing home residents with high levels of everyday competence and low care needs have poor person-environment fit, placing them at risk for declines in function, maladaptive behavior, and affective disorders. The goal of this article is to present a framework for the integration of everyday competence with standardized goal-setting and care-planning processes to enable the transition of appropriate nursing home residents back to the community. Barriers to community transitions exist across several Key Domains: rehabilitation, personal assistance and services, caregiver support, finances, housing, and transportation. We propose a research agenda to develop and implement a toolkit based on this framework that nursing home staff can use to overcome barriers to transition by (1) assessing residents' everyday competence, (2) developing personally meaningful goals that facilitate transition, and (3) conducting structured care planning to support resident goals around returning to the community. If successful, this toolkit has the potential to reduce costs associated with nursing home care and to improve functional health, psychological well-being, and quality of life for older adults. The proposed framework and toolkit complement national efforts focused on transitioning nursing home residents back into the community.