The Post-Acute Delayed Discharge Risk Scale: Derivation and Validation With Ontario Alternate Level of Care Patients in Ontario Complex Continuing Care Hospitals

What Factors Increase Odds of Long-Stay Delayed Discharge in Alternate Level of Care Patients?

OBJECTIVE

The objective of this study was to determine the factors that increase the odds of long-stay delayed discharge in alternate level of care (ALC) patients using data collected from the Ontario Wait Time Information System (WTIS) database.

DESIGN

Retrospective cohort study utilizing data from Niagara Health's WTIS database. WTIS includes individuals admitted to any of the Niagara Health sites that have been designated as ALC.

SETTING AND PARTICIPANTS

Sample consisted of 16,429 ALC patients who received care in Niagara Health hospitals from September 2014 to September 2019 and were recorded in the WTIS database.

METHODS

ALC designation of 30 or more days was used as the threshold for a long-stay delayed discharge. This study used binary logistic regression modeling to analyze sex, age, admission source, and discharge destination as well needs/barriers requirements to assess the likelihood of a long-stay delayed discharge among acute care (AC) and post-acute care (PAC) patients given the presence of each variable. Sample sizes calculations and receiver operating characteristic curves were used to verify the validity of the regression model.

RESULTS

Overall, 10.2% of the sample were considered long-stay ALC patients. Both AC and PAC long-stay ALC patients were more likely to be male [OR = 1.23, (1.06-1.43); OR = 1.28, (1.03-1.60)] and have a discharge destination of a long-term care bed [OR = 28.68, (22.83-36.04); OR = 6.22, (4.75-8.15)]. AC patients had bariatric [OR = 7.16, (3.45-14.83)], behavioral [OR = 1.89, (1.22-2.91)], infection (isolation) [OR = 2.31, (1.63-3.28)], and feeding [OR = 6.38, (1.82-22.30)] barriers hindering discharge. PAC patients had no significant barriers hindering patient discharge.

CONCLUSIONS AND IMPLICATIONS

Shifting the focus from ALC patient designation to short- vs long-stay ALC patients allowed this study to focus on the subset of patients that are disproportionately affecting delayed discharges. Understanding the importance of specialized patient requirements in addition to clinical factors can help hospitals become more prepared in preventing delayed discharges.

Multistate Competing Risk Analysis of Transition Back to the Community Among Long-Term Care Home (LTC) Destined Patients: A Brief Report

OBJECTIVE

The demand for long-term care in community and facilitybased settings in Canada is expected to increase with population growth. The Toronto Grace Health Center piloted an intervention program that aims to support return to the community of acute hospital patients designated for LTC placement. We investigated whether this program was effective in transitioning the program patients back to their homes in the community and the factors associated with transitioning patients to different destinations.

METHOD

We performed a competing risk multi-state analysis of 111 patients enrolled into the Harbour Light (HL) transitional unit program between January 2020 and June 2023.

RESULTS

At the time of the study, 92 enrolled patients had been discharged and of those these, 48.9% (45) were successfully transitioned back to their private home in the community. The remaining 51.1% (46) were discharged to other destinations. Being a female was the only positive predictor of transitioning back home. Higher CPS scores (HR 0.53, 95% CI 0.31-0.88), PADDRS scale of 1+, and higher ADL Hierarchy scale, strongly predicted lower odds of transitioning back to the community.

CONCLUSION

Within the context of rising LTC bed demand and lengthy waiting time in Canada, with appropriate measures, this program successfully transitioned LTC home bound persons back to their homes. If replicable on a large scale, this could provide short and long-term solution to LTC bed demand in Canada.

Predictors of improvement in urinary incontinence in the postacute setting: A Canadian cohort study

PURPOSE

To determine factors associated with improvement in urinary incontinence (UI) for long-stay postacute, complex continuing care (CCC) patients.

DESIGN

A retrospective cohort investigation of patients in a CCC setting using data obtained from the Canadian Institute for Health Information's Continuing Care Reporting System collected with interRAI Minimum Data Set 2.0.

SETTING AND PARTICIPANTS

Individuals aged 18 years and older, were admitted to CCC hospitals in Ontario, Canada, between 2010 and 2018.

METHODS

Multivariable logistic regression was used to determine the independent effects of predictors on UI improvement, for patients who were somewhat or completely incontinent on admission and therefore had the potential for improvement.

RESULTS

The study cohort consisted of 18 584 patients, 74% (13 779) of which were somewhat or completely incontinent upon admission. Among those patients with potential for improvement, receiving bladder training, starting a new medication 90 days prior (odds ratio, OR: 1.54 [95% confidence interval, CI: 1.36-1.75]), and triggering the interRAI Urinary Incontinence Clinical Assessment Protocol to facilitate improvement (OR: 1.36 [95% CI: 1.08-1.71]) or to prevent decline (OR: 1.32 [95% CI: 1.13-1.53]) were the strongest predictors of improvement. Conversely, being totally dependent on others for transfer (OR: 0.62 [95% CI: 0.42-0.92]), is rarely or never understood (OR: 0.65 [95% CI: 0.50-0.85]), having a major comorbidity count of ≥3 (OR: 0.72 [95% CI: 0.59-0.88]), Parkinson's disease, OR: 0.77 (95% CI: 0.62-0.95), Alzheimer/other dementia, OR: 0.83 (95% CI: 0.74-0.93), and respiratory infections, OR: 0.57 (95% CI: 0.39-0.85) independently predicted less likelihood of improvement in UI.

CONCLUSIONS AND IMPLICATIONS

Findings of this study suggest that improving physical function, including bed mobility, and providing bladder retraining have strong positive impacts on improvement in UI for postacute care patients. Evidence generated from this study provides useful care planning information for care providers in identifying patients and targeting the care that may lead to better success with the management of UI.

Association of Psychiatric Diagnoses and Medicaid Coverage with Length of Stay Among Inpatients Discharged to Skilled Nursing Facilities

BACKGROUND

Inpatients with psychiatric diagnoses often require higher levels of care in skilled nursing facilities (SNFs) and are more likely to be covered by Medicaid, which reimburses SNFs at significantly lower rates than Medicare and commercial payors.

OBJECTIVE

To characterize factors affecting length of stay in inpatients discharged to SNFs.

DESIGN

A retrospective cross-sectional study design using 2016-2018 data from National Inpatient Sample.

PARTICIPANTS

Inpatients aged ≥ 40 who were discharged to SNFs.

EXPOSURES

Primary discharge diagnosis (medical, psychiatric, or substance use) and primary payor.

MAIN OUTCOMES AND MEASURES

Length of stay, categorized non-exclusively as >3 days, >7 days, or > 14 days.

RESULTS

Among 9,821,155 inpatient discharges to SNFs between 2016 and 2018, 95.7% had medical primary discharge diagnoses, 3.3% psychiatric diagnoses, and 1.0% substance use diagnoses; Medicare was the most common primary payor (83.3%), followed by private insurance (7.9%), Medicaid (6.6%), and others (2.2%). Median length of stay for all patients was 5.0 days (interquartile range [IQR], 3.0-8.0), 5.0 (IQR, 3.0-8.0) for those with medical diagnoses, 8.0 (IQR, 4.0-15.0) for psychiatric diagnoses, and 5.0 (IQR, 3.0-8.0) for substance use diagnoses. After multivariable adjustment, compared to patients with medical diagnoses, patients with psychiatric diagnoses were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to Medicare patients, Medicaid patients were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to patients with medical diagnoses, those with psychiatric diagnoses were also more likely to have lengths of stay 1 times, 1.5 times, and 2 times greater than the national geometric mean length of stay for that diagnosis-related group (p < 0.001).

CONCLUSIONS

Patients discharged to SNFs after inpatient hospitalization for psychiatric diagnoses and with Medicaid coverage were more likely to have longer lengths of stay than patients with medical diagnoses and those with Medicare coverage, respectively.

Changes in Urinary Continence After Admission to a Complex Care Setting: A Multistate Transition Model

OBJECTIVES

To examine changes in urinary continence for post-acute, Complex Continuing Care hospital patients from time of admission to short-term follow-up, either in hospital or after discharge to long-term care or home with services.

DESIGN

Retrospective cohort study of patients in Complex Continuing Care hospitals using clinical data collected with interRAI Minimum Data Set 2.0 and interRAI Resident Assessment Instrument Home Care.

SETTING AND PARTICIPANTS

Adults aged 18 years and older, admitted to Complex Continuing Care hospitals in Ontario, Canada, between 2009 and 2015 (n = 78,913).

METHODS

A multistate transition model was used to characterize the association between patient characteristics measured at admission and changes in urinary continence state transitions (continent, sometimes continent, and incontinent) between admission and follow-up.

RESULTS

The cohort included 27,896 patients. At admission, 9583 (34.3%) patients belonged to the continent state, 6441 (23.09%) patients belonged to the sometimes incontinent state, and the remaining 11,872 (42.6%) patients belonged to the incontinent state. For patients who were continent at admission, the majority (62.7%) remained continent at follow-up. However, nearly a quarter (23.9%) transitioned to the sometimes continent state, and an additional 13.4% became incontinent at follow-up. Several factors were associated with continence state transitions, including cognitive impairment, rehabilitation potential, stroke, Parkinson's disease, Alzheimer's disease and related dementias, and hip fracture.

CONCLUSIONS AND IMPLICATIONS

This study suggests that urinary incontinence is a prevalent problem for Complex Continuing Care hospital patients and multiple factors are associated with continence state transitions. Standardized assessment of urinary incontinence is helpful in this setting to identify patients in need of further assessment and patient-centered intervention and as a quality improvement metric to examine changes in continence from admission to discharge.

Dementia and Poor Continuity of Primary Care Delay Hospital Discharge in Older Adults: A Population-Based Study From 2001 to 2016

OBJECTIVES

Delayed discharge, remaining in acute care longer than medically necessary, reflects less than optimal use of hospital care resources and can have negative implications for patients. We studied (1) the change over time in delayed discharge in people with and without dementia, and (2) the association of delayed discharge with discharge destination and with the continuity of primary care prior to urgent admission.

DESIGN

A retrospective population-based study.

SETTING AND PARTICIPANTS

Delayed discharge after urgent admission and length of delayed discharge were studied in all hospital users aged ≥70 years with at least 1 urgent admission in British Columbia, Canada, in years 2001/02, 2005/06, 2010/11, and 2015/16 (N = 276,299).

METHODS

Linked administrative data provided by Population Data BC were analyzed using generalized estimating equations (GEE), logistic regression analysis, and negative binomial regression analyses.

RESULTS

Delayed discharge increased among people with dementia and decreased among people without dementia, whereas the length of delay decreased among both. Dementia was the strongest predictor of delayed discharge [odds ratio 4.76; 95% confidence interval (CI) 4.59-4.93], whereas waiting for long-term care placement [incidence rate ratio (IRR) 1.56; 95% CI 1.50-1.62] and dementia (IRR 1.50; 95% CI 1.45-1.54) predicted a higher number of days of delay. Continuity and quantity of care with the same physician before urgent admission was associated with a decreased risk of delayed discharge, especially in people with dementia.

CONCLUSIONS AND IMPLICATIONS

This study demonstrates the need for better system integration and patient-centered care especially for people with dementia. Population aging will likely increase the number of patients at risk of delayed discharge. Delayed discharge is associated with both the patient's complex needs and the inability of the system to meet these needs during and after urgent care. Sufficient investments are needed in both primary care and long-term care resources to reduce delayed discharges.