Restarting the cycle: incidence and predictors of first acute care use after nursing home discharge

Life-Space of Older Adults after Discharge from Skilled Nursing Facilities

OBJECTIVES

Describe (1) patient or caregiver perceptions of physical function in 30 days after skilled nursing facility (SNF) discharge indicated by Life-Space Assessment (LSA) scores, and (2) patient and caregiver factors associated with LSA scores.

DESIGN

Secondary analysis of baseline and outcomes data from the cluster randomized trial of the Connect-Home transitional care intervention.

SETTING AND PARTICIPANTS

Six SNFs in North Carolina. Patient and caregiver dyads with LSA scores (N = 245).

METHODS

SNF patients or their caregivers serving as proxy reported the life-space of the SNF patient using the LSA tool, a measure of environmental and social factors that influence physical mobility. Simple scores for highest life-space attained depending on equipment and/or caregiver support range from 0 to 5, with higher scores indicating greater mobility. Multiple linear regression models for simple LSA scores and Composite Life-Space (0-120), adjusted for treatment, time via a COVID pandemic indicator, and treatment × COVID effect as fixed effects, were used to estimate the association of patient and caregiver variables and life-space.

RESULTS

Patients had a mean age of 76.3 years, 62.6% were female, and 74.7% were white. Caregivers were commonly female (73.9%) and adult children of the patient (46.5%). The mean Composite Life-Space score was 22.6 (16.09). The mean Assisted Life-Space score (range: 0-5) was 1.6 (1.47), and 76.3% of patients could not move beyond their bedroom, house, and yard without assistance of another person. Higher Composite Life-Space scores were associated with lower levels of cognitive impairment and shorter SNF length of stay.

CONCLUSIONS AND IMPLICATIONS

SNF patients and their caregivers reported very low LSA scores in 30 days after SNF care. Findings indicate the need for care redesign to promote recovery of physical function of older adults after SNF discharge, such as optimizing SNF rehabilitative therapy and adding postdischarge rehabilitative supports at home.

Postacute Care and Long-term Care for LGBTQ+ Older Adults

LGBTQ + older adults have a high likelihood of accessing nursing home care. This is due to several factors: limitations performing activities of daily living and instrumental activities of daily living, restricted support networks, social isolation, delay seeking assistance, limited economic resources, and dementia. Nursing home residents fear going in the closet, which can have adverse health effects. Cultivating an inclusive nursing home culture, including administration, staff, and residents, can help older LGBTQ + adults adjust and thrive in long-term care.

Health Trajectories of Skilled Nursing Facility Patients With Alzheimer's Disease and Related Dementias: Evidence for Practicing Nurses

PURPOSE

Older adults with Alzheimer's disease and related dementias (ADRD) are at high risk for acute medical problems and their health trajectories frequently include hospital admission and care in a skilled nursing facility (SNF). Their health trajectories after SNF discharge are poorly understood. Therefore, in the current study, we sought to describe health trajectories and factors associated with hospital read-missions for older adults with ADRD during the 30 days following SNF discharge.

METHOD

We conducted a secondary analysis of data from a clinical trial of transitional care of older adults with transitions from SNF to home and assisted living. A multiple case study design was used in the analysis of the health trajectories of 49 SNF patients with ADRD, 51% discharged from SNF to their own home, 34% discharged to a family member's home, and 15% transferred to assisted living.

RESULTS

Within 30 days of discharge, 20% of patients with ADRD experienced new or recurrent acute needs and hospital readmission.

CONCLUSION

Our findings suggest the need for nursing interventions to support patients with ADRD during care transitions, such as focusing care on the patient-caregiver dyad, providing transitional care, referring patients for palliative care consultation, and conducting nurse-led research to improve care transitions of these patients and their caregivers. [Journal of Gerontological Nursing, 50(4), 34-41.].

Coordinated-Transitional Care (C-TraC) for Veterans from Subacute Rehabilitation to Home

OBJECTIVES

To adapt a successful acute care transitional model to meet the needs of veterans transitioning from post-acute care to home.

DESIGN

Quality improvement intervention.

SETTING AND PARTICIPANTS

Veterans discharged from a subacute care unit in the VA Boston Healthcare System's skilled nursing facility.

METHODS

We used the Replicating Effective Programs framework and Plan-Do-Study-Act cycles to adapt the Coordinated-Transitional Care (C-TraC) program to the context of transitions from a VA subacute care unit to home. The major adaptation of this registered nurse-driven, telephone-based intervention was combining the roles of discharge coordinator and transitional care case manager. We report the details of the implementation, its feasibility, and results of process measures, and describe its preliminary impact.

RESULTS

Between October 2021 and April 2022, all 35 veterans who met eligibility criteria in the VA Boston Community Living Center (CLC) participated; none were lost to follow-up. The nurse case manager delivered core components of the calls with high fidelity-review of red flags, detailed medication reconciliation, follow-up with primary care physician, and discharge services were discussed and documented in 97.9%, 95.9%, 86.8%, and 95.9%, respectively. CLC C-TraC interventions included care coordination, patient and caregiver education, connecting patients to resources, and addressing medication discrepancies. Nine medication discrepancies were discovered in 8 patients (22.9%; average of 1.1 discrepancies per patient). Compared with a historical cohort of 84 veterans, more CLC C-TraC patients received a post-discharge call within 7 days (82.9% vs 61.9%; P = .03). There was no difference between rates of attendance to appointments and acute care admissions post-discharge.

CONCLUSIONS AND IMPLICATIONS

We successfully adapted the C-TraC transitional care protocol to the VA subacute care setting. CLC C-TraC resulted in increased post-discharge follow-up and intensive case management. Evaluation of a larger cohort to determine its impact on clinical outcomes such as readmissions is warranted.

Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial

BACKGROUND

Skilled nursing facility (SNF) patients and their caregivers who transition to home experience complications and frequently return to acute care. We tested the efficacy of the Connect-Home transitional care intervention on patient and caregiver preparedness for care at home, and other patient and caregiver-reported outcomes.

METHODS

We used a stepped wedge, cluster-randomized trial design to test the intervention against standard discharge planning (control). The setting was six SNFs and six home health offices in one agency. Participants were 327 dyads of patients discharged from SNF to home and their caregivers; 11.1% of dyads in the control condition and 81.2% in the intervention condition were enrolled after onset of COVID-19. Patients were 63.9% female and mean age was 76.5 years. Caregivers were 73.7% female and mean age was 59.5 years. The Connect-Home intervention includes tools, training, and technical assistance to deliver transitional care in SNFs and patients' homes. Primary outcomes measured at 7 days included patient and caregiver measures of preparedness for care at home, the Care Transitions Measure-15 (patient) and the Preparedness for Caregiving Scale (caregiver). Secondary outcomes measured at 30 and 60 days included the McGill Quality of Life Questionnaire, Life Space Assessment, Zarit Caregiver Burden Scale, Distress Thermometer, and self-reported number of patient days in the ED or hospital in 30 and 60 days following SNF discharge.

RESULTS

The intervention was not associated with improvement in patient or caregiver outcomes in the planned analyses. Post-hoc analyses that distinguished between pre- and post-pandemic effects suggest the intervention may be associated with increased patient preparedness for discharge and decreased number of acute care days.

CONCLUSIONS

Connect-Home transitional care did not improve outcomes in the planned statistical analysis. Post-hoc findings accounting for COVID-19 impact suggest SNF transitional care has potential to increase patient preparedness and decrease return to acute care.

Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients With a Primary Diagnosis of Heart Failure

OBJECTIVE

Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP).

DESIGN

This is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate.

SETTING AND PARTICIPANTS

Patients with a primary hospital discharge diagnosis of HF discharged to SNF.

METHODS

Composite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60 days post SNF admission. Linear mixed models accounted for patient clustering at the physician level.

RESULTS

Of 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10 years, 53% women, and mean ejection fraction 46% ± 15%. At 60 days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P = .02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% vs 31% in the usual care group (P = .11).

CONCLUSIONS AND IMPLICATIONS

Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60 days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF.

Skilled Nursing Facility-to-Home Trajectories for Older Adults With Mental Illness or Dementia

OBJECTIVES

To examine how mental illness (MI) and Alzheimer's disease and related dementias (ADRD) were associated with whether skilled nursing facility (SNF) residents returned to and remained in the community and if receipt of home health services was associated with post-SNF home time.

DESIGN

Retrospective cohort study based on secondary data analyses.

SETTING

New York State Medicare beneficiaries who were admitted to an SNF in 2014.

PARTICIPANTS

Total of 46,137 older adults admitted to SNFs and 25,357 discharged from SNFs to home.

MEASUREMENTS

We used Medicare claims and assessment databases to derive our outcomes (discharge to the community and home time [i.e., days alive in the community]), determine MI/ADRD status, and obtain socio-demographic and clinical characteristics.

RESULTS

Among SNF admissions, 22.9% had MI, 22.6% had ADRD, and 59.0% were discharged to the community. In analyses adjusting for socio-demographic and clinical characteristics, MI and ADRD were associated with decreased odds of community discharge and less home time during 90-days of follow-up. However, when we included depressive symptoms, aggressive behaviors, and daily functioning in the analyses, these associations were attenuated. Receipt of post-SNF home health services was associated with increased home time among those with MI or ADRD.

CONCLUSION

Newly admitted SNF residents with MI or ADRD were less likely to be discharged and, if discharged, spent less time in the community. Interventions targeting depressive symptoms, aggressive behaviors, and functioning and improving linkage with home health services may help decrease differences in post-acute care trajectories between those with and without MI and ADRD.

Improving Suicide Risk Detection and Clinical Follow-up after Discharge from Nursing Homes

Objectives: Suicide Awareness for Veterans Exiting Community Living Centers (SAVE-CLC) is a brief intervention to standardize suicide-risk screening and clinical follow-up after VA nursing home discharge. This paper examines the outcomes of SAVE-CLC compared to care as usual.Methods: A quasi-experimental evaluation was conducted (N = 124) with SAVE-CLC patients (n = 62) matched 1:1 to a pre-implementation comparison group. Data were obtained through VA Corporate Data Warehouse resources and chart reviews. Outcomes examined (within 30/90 days of discharge) included mortality rates, frequency of outpatient mental health visits, emergency department visits, rehospitalizations, depression screens (PHQ-2), and the latency period for outpatient mental health care.Results: A greater portion of SAVE-CLC patients received a depression screen after discharge, n = 42, 67.7% versus n = 8, 12.9%, OR = 14.2 (5.7, 35.3), p < .001. The number of days between discharge and first mental health visit was also substantially shorter for SAVE-CLC patients, M = 8.9, SD = 8.2 versus M = 17.6, SD = 9.1; t = 2.47 (122), p = .02. Significant differences were not observed in emergency department visits, hospitalizations, or mortality.Conclusions: SAVE-CLC is a time-limited intervention for detecting risk and speeding engagement in mental health care in the immediate high-risk post-discharge period.Clinical Implications: Care transitions present an important opportunity for addressing older adults' suicide risk; brief telephone-based interventions like SAVE-CLC may provide needed support to individuals returning home.

Transitional care following a skilled nursing facility stay: Utilization of nurse practitioners to reduce readmissions in high risk older adults

This quality improvement project's goal was to identify older adults who were at high risk for readmission following a skilled nursing facility (SNF) admission and evaluate the impact of a nurse practitioner (NP) visit within 72 hours of SNF discharge. The aims of this project were to reduce 30-day readmissions, identify gaps in care, and address care needs for patients recently discharged from a SNF. High readmission risk was estimated through use of readmission risk prediction and frailty tools. Results of the project revealed several gaps in care including medication discrepancies, delays in start of home health services, and lack of follow up with a primary care provider. Of the patients seen for a transitional care visit (TCV), none were readmitted. Project findings indicate there is value in seeing patients in their home soon after SNF discharge. Further work is indicated to improve care transitions in this area.

Where Skilled Nursing Facility Residents Get Acute Care: Is the Emergency Department the Medical Home?

OBJECTIVES

This study aimed to characterize the distribution of acute care visits among Medicare beneficiaries receiving skilled nursing facility (SNF) services.

METHODS

We conducted a cross-sectional analysis of a 20% sample of continuously enrolled Medicare beneficiaries in the 2012 Chronic Condition Warehouse data set. Beneficiaries were grouped by the number of days of SNF services, and acute care visits were categorized as "before SNF," "during SNF," or "after SNF."

RESULTS

Among the 10,717,786 Medicare beneficiaries analyzed, 384,312 (3.6%) had at least one SNF stay.

DISCUSSION

Beneficiaries who received SNF services had a higher proportion of acute care visits made to emergency departments (EDs) than beneficiaries who did not receive SNF services. Also, a higher proportion of acute care visits were made to EDs by beneficiaries after a SNF stay in comparison to residents actively residing in a SNF. The acute care capabilities of SNFs and post-SNF transitions of care to the community setting are discussed.

Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities

Therapy staffing declined in response to Medicare payment policy that removes incentives for intensive physical and occupational therapy in skilled nursing facilities, with therapy assistant staffing more impacted than therapist staffing. However, it is unknown whether therapy assistant staffing is associated with patient outcomes. Using 2017 national data, we examined associations between therapy assistant staffing and three outcomes: patient functional improvement, community discharge, and hospital readmissions, controlling for therapy intensity and facility characteristics. Assistant staffing was not associated with functional improvement. Compared with employing no assistants, staffing 25% to 75% occupational therapy assistants and 25% to 50% physical therapist assistants were associated with more community discharges. Higher occupational therapy assistant staffing was associated with higher readmissions. Higher intensity physical therapy was associated with better quality across outcomes. Skilled nursing facilities seeking to maximize profit while maintaining quality may be successful by choosing to employ more physical therapy assistants rather than sacrificing physical therapy intensity.

Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative

Proctor's Framework for Implementation Research describes the role of implementation strategies and outcomes in the pathway from evidence-based interventions to service and client outcomes. This report describes the evaluation of a learning collaborative to implement a transitional care intervention in skilled nursing facilities (SNF). The collaborative protocol included implementation strategies to promote uptake of a transitional care intervention in SNFs. Using RE-AIM to evaluate outcomes, the main findings were intervention reach to 550 SNF patients, adoption in three of four SNFs that expressed interest in participation, and high fidelity to the implementation strategies. Fidelity to the transitional care intervention was moderate to high; SNF staff provided the five key components of the transitional care intervention for 64-93% of eligible patients. The evaluation was completed during the COVID-19 pandemic, which suggests the protocol was valued by staff and feasible to use amid serious internal and external challenges.

Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives

BACKGROUND

Patients who undergo the complex series of transitions from the hospital to a skilled nursing facility (SNF) back to home represent a unique patient population with multiple comorbidities and impaired functional abilities. The needs and outcomes of patients who are discharged from the hospital to SNF before returning home are understudied in care transitions scholarship.

OBJECTIVE

To study the patient and caregiver challenges and perspectives on transitions from the hospital to the SNF and back to home.

DESIGN

Between 48 h and 1 week after discharge from the SNF, semi-structured interviews were performed with a convenience sample of patients and caregivers in their homes. Within 1 to 2 weeks after the baseline interview, follow-up interviews were performed over the phone.

PARTICIPANTS

A total of 39 interviewees comprised older adults undergoing the series of transitions from hospital to skilled nursing facility to home and their informal caregivers.

MAIN MEASURES

A constructionist, grounded-theory approach was used to code the interviews, identify major themes and subthemes, and develop a theoretical model explaining the outcomes of the SNF to home transition.

KEY RESULTS

The mean age of the patients was 76.6 years and 64.8 years for the caregivers. Four major themes were identified: comforts of home, information needs, post-SNF care, and independence. Patients noted an extended time away from home and were motivated to return to and remain in the home. Information needs were variably met and affected post-SNF care, including medication management, appointments, and therapy gains and setbacks. Interviewees identified independent function at home as the most important outcome of the transition home.

CONCLUSIONS

Post-SNF in home support is needed rapidly after discharge from the SNF to prevent adverse outcomes. In-home support needs to be highly individualized based on a patient's and caregiver's unique situation and needs.

A Pilot Study Exploring Treatment Burden in a Skilled Nursing Population

PURPOSE

This study aimed to measure treatment burden in adults diagnosed with multiple chronic conditions transitioning from a skilled nursing facility to home.

DESIGN

Prospective, two-time point, cohort design utilizing convenience sampling from one skilled nursing facility in Northeast, Ohio.

METHODS

Seventy-four men and women participated answering self-report questions measuring treatment burden at two time points: prior to discharge and 30 days after discharge.

RESULTS

t-test analysis determined treatment burden was not statistically different between time points (p > .05). Multivariate analysis explained 23% of treatment burden's variance, with the severity of multiple chronic conditions and the presence of a caregiver predicting treatment burden (p < .05).

CONCLUSION

Findings were contrary to our hypothesis of this population being at risk for high treatment burden.

CLINICAL RELEVANCE

Moderate, fluctuating levels of treatment burden suggest that it is possible to estimate demands of treatment prior to discharge from the skilled nursing facility to better inform discharge planning.

Transitional care from skilled nursing facilities to home: study protocol for a stepped wedge cluster randomized trial

Background

Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute care use is over 50% within 90 days of discharge, yet these patients and their caregivers often do not receive the quality of transitional care that prepares them to manage serious illnesses at home.

Methods

The study will test the efficacy of Connect-Home, a successfully piloted transitional care intervention targeting seriously ill SNF patients discharged to home and their caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and caregiver preparedness for caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute care use and (b) caregivers’ burden and distress.

Discussion

Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve transitional care for seriously ill SNF patients and their caregivers, (b) prevent avoidable days of acute care use in a population with persistent risks from chronic conditions, and (c) advance the science of transitional care within end-of-life and palliative care trajectories of SNF patients and their caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications.

Trial registration

ClinicalTrials.gov NCT03810534. Registered on January 18, 2019.

Receipt of Timely Primary Care Services Following Post-Acute Skilled Nursing Facility Care

OBJECTIVES

Our study examined the proportion of skilled nursing facility (SNF) post-acute care residents who did not receive timely primary care provider (PCP) services following discharge, factors associated with lack of timely PCP services, and factors associated with perfect 30-day home time among those who did not receive timely PCP services.

DESIGN

Longitudinal cohort study; data sources included Medicare claims and other administrative databases.

SETTING AND PARTICIPANTS

25,357 fee-for-service New York State Medicare beneficiaries aged 65 years and older admitted to SNFs for post-acute care in 2014 and then discharged to the community.

METHODS

Our outcomes were a timely PCP visit (within 7 days of SNF discharge) and perfect 30-day home time, and we examined their association with patient, SNF, and county factors.

RESULTS

Among SNF discharges, 60.6% had a timely PCP visit. In multivariate regression analyses, female sex, nonwhite race, Medicare only status, less functional impairment and medical comorbidity, a surgical hospitalization, fewer hospital days, more SNF days, absence of home health services, for-profit SNF status, higher SNF star rating, lower ratio of registered nurse/total nursing hours, and rural counties were associated with lower odds of a timely PCP visit following SNF discharge. Among those without a timely PCP visit, female sex, less cognitive and functional impairment, less medical comorbidity, a surgical hospitalization, fewer hospital days, receipt of home health services, and higher SNF star rating were associated with increased odds of perfect 30-day home time following SNF discharge.

CONCLUSIONS AND IMPLICATIONS

That 4 in 10 post-acute care SNF patients did not have a timely PCP visit post-SNF discharge, with racial minority and rural county status associated with decreased odds of a timely PCP visit, is concerning. Examination of whether the timing and type of outpatient visit may have varying effects on different post-acute care subpopulations would build on this work.

Risk of Readmission After Discharge From Skilled Nursing Facilities Following Heart Failure Hospitalization: A Retrospective Cohort Study

OBJECTIVE

Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home.

MEASURES

Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge.

RESULTS

Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78).

CONCLUSIONS/IMPLICATIONS

The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.

Patients discharged from higher-quality skilled nursing facilities spend more days at home

OBJECTIVE

To evaluate the association of skilled nursing facility (SNF) quality with days spent alive in nonmedical settings ("home time") after SNF discharge to the community.

DATA SOURCES

Secondary data are from Medicare claims for New York State (NYS) Medicare beneficiaries, the Area Health Resources File, and Nursing Home Compare.

STUDY DESIGN

We estimate home time in the 30- and 90-day periods following SNF discharge. Two-part zero-inflated negative binomial regression models characterize the association of SNF quality with home time.

DATA EXTRACTION METHODS

We use Medicare claims data to identify 25 357 NYS fee-for-service Medicare beneficiaries aged 65 years and older with an SNF admission for postacute care who were subsequently discharged to home in 2014.

PRINCIPAL FINDINGS

Following 30 and 90 days after SNF discharge, the average home time is 28.0 (SD = 6.1) and 81.6 (SD = 20.2) days, respectively. A number of patient- and SNF-level factors are associated with home time. In particular, within 30 and 90 days of discharge, respectively, patients discharged from 2- to 5-star SNFs spend 1.2-1.5 (P < .001) and 3.2-4.3 (P < .001) more days at home than those discharged from 1-star (lowest quality) SNFs.

CONCLUSIONS

Improved understanding of what is contributing to differences in home time could help guide efforts into optimizing post-SNF discharge outcomes.

Skilled Nursing Facility Patients Discharged to Home Health Agency Services Spend More Days at Home

OBJECTIVES

To investigate the association of the utilization of Medicare-certified home health agency (CHHA) services with post-acute skilled nursing facility (SNF) discharge outcomes that included home time, rehospitalization, SNF readmission, and mortality.

DESIGN

Retrospective cohort study.

SETTING

New York State fee-for-service Medicare beneficiaries aged 65 years and older admitted to SNFs for post-acute care and discharged to the community in 2014.

PARTICIPANTS

A total of 25,357 older adults.

MEASUREMENTS

The outcomes included days spent alive in the community ("home time"), rehospitalization, SNF readmission, and mortality within 30- and 90-day post-SNF discharge periods. The primary independent variables were SNF five-star overall quality rating and receipt of CHHA services within 7 days of SNF discharge. Zero-inflated negative binomial regression and logistic regression models characterized the association of CHHA linkage with home time and other outcomes, respectively.

RESULTS

Following SNF discharge, 17,657 (69.6%) patients received CHHA services. In analyses that adjusted for patient-, market-, and other SNF-level factors, older adults discharged from higher quality SNFs were more likely to receive CHHA services. In analyses that adjusted for patient- and market-level factors, receipt of post-SNF CHHA services was associated with 2.03 and 4.17 (P < .001) more days in the community over 30- and 90-day periods. Receiving CHHA services was also associated with decreased odds for rehospitalization (odds ratio [OR] = .68; P < .001; OR = .91; P = .008), SNF readmission (OR = .36; P < .001; OR = .62; P < .001), and death (OR = .34; P < .001; OR = .63; P < .001) over 30- and 90-day periods, respectively.

CONCLUSION

Among older adults discharged from a post-acute SNF stay, those who received CHHA services had better discharge outcomes. They were less likely to experience admissions to institutional care settings and had a lower mortality risk. Future efforts that examine how the type and intensity of CHHA services affect outcomes would build on this work. J Am Geriatr Soc 68:1573-1578, 2020.

Reducing Hospital Readmissions Through a Skilled Nursing Facility Discharge Intervention: A Pragmatic Trial

OBJECTIVE

To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents admitted to the SNF following an index hospitalization.

DESIGN

A pragmatic trial.

SETTING AND PARTICIPANTS

SNFs in southeastern Massachusetts, and residents discharged to the community.

METHODS

We compared SNFs that deployed an adapted RED intervention to a matched control group from the same region. The primary outcome was hospital readmission within 30 days after SNF discharge, among residents who had been admitted to the SNF following an index hospitalization and then discharged home. January 2016 through March 2017 was the baseline period; April 2017 through June 2018 was the follow-up period (after implementation of the intervention). We used a difference-in-differences analysis to compare the intervention SNFs to the control group, using generalized estimating equation regression and controlling for facility characteristics.

RESULTS

After implementation of RED, readmission rates were lower across all 4 measures in the intervention group; control facilities' readmission rates remained stable or increased. The relative decrease was 0.9% for the primary outcome of hospital readmission within 30 days after SNF discharge and 1.7% for readmission within 30 days of the index hospitalization discharge date (P ≤ .001 for both comparisons).

CONCLUSIONS AND IMPLICATIONS

We found that a systematic discharge process developed for the hospital can be adapted to the SNF environment and can reduce readmissions back to the hospital, perhaps through improved self-management skills and better engagement with community services. This work is particularly timely because of Medicare's new Value-Based Purchasing Program, in which nursing homes can receive incentive payments if their hospital readmission rates are low relative to their peers. To verify its scalability and broad potential, RED should be validated across a broader diversity of SNFs nationally.

What does it take to scale-up a complex intervention? Lessons learned from the Connect-Home transitional care intervention

AIMS

To discuss the multiple phases of research done to plan for wide-scale implementation (i.e. scale-up) of Connect-Home, a complex nurse-develop intervention. Barker et al.'s (Implementation Science, 2016, 11, 12) framework for intervention scale-up is applied to address the methods used to answer the following four questions: 'Who' needs to be involved in scale-up? 'What' intervention and implementation strategies need to be taken to scale? 'How' will scale-up be achieved? And what contextual factors influence 'when' scale-up is or is not successful?

DESIGN

Discussion paper.

DATA SOURCES

Data sources include the experience of our research team, supported by literature and theory. The Connect-Home team conducted multiple research studies to plan for Connect-Home scale-up. Early studies (2008-2015) focused on formative work to design the Connect-Home intervention. Recent studies have involved successive pilot tests of Connect-Home's effectiveness, implementation, and scale-up (2015-2019).

IMPLICATIONS FOR NURSING

This article describes a systematic approach that nurse researchers can apply to plan for taking their interventions to scale.

CONCLUSIONS

Planning for scale-up early in the process of intervention development is essential to speeding the translation of effective interventions into wide-scale practice.

IMPACT

This article details the methods that nursing researchers applied to develop and test the strategies needed to plan for taking a complex intervention to scale across multiple settings. The methods described are applicable to nursing and other health researchers' development and scale-up of any complex intervention.

Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization

BACKGROUND/OBJECTIVE

Heart failure (HF) readmission rates have plateaued despite scrutiny of hospital discharge practices. Many HF patients are discharged to skilled nursing facility (SNF) after hospitalization before returning home. Home healthcare (HHC) services received during the additional transition from SNF to home may affect readmission risk. Here, we examined whether receipt of HHC affects readmission risk during the transition from SNF to home following HF hospitalization.

DESIGN

Retrospective cohort study.

SETTING

Fee-for-service Medicare data, 2012 to 2015.

PARTICIPANTS

Beneficiaries, aged 65 years and older, hospitalized with HF who were subsequently discharged to SNF and then discharged home.

MEASUREMENTS

The primary outcome was unplanned readmission within 30 days of discharge to home from SNF. We compared time to readmission between those with and without HHC services using a Cox model.

RESULTS

Of 67 585 HF hospitalizations discharged to SNFs and subsequently discharged home, 13 257 (19.6%) were discharged with HHC, and 54 328 (80.4%) were discharged without HHC. Patients discharged home from SNFs with HHC had lower 30-day readmission rates than patients discharged without HHC (22.8% vs 24.5%; P < .0001) and a longer time to readmission. In an adjusted model, the hazard for readmission was 0.91 (0.86-0.95) with receipt of HHC.

CONCLUSIONS

Recipients of HHC were less likely to be readmitted within 30 days vs those discharged home without HHC. This is unexpected, as patients discharged with HHC likely have more functional impairments. Since patients requiring a SNF stay after hospital discharge may have additional needs, they may particularly benefit from restorative therapy through HHC; however, only approximately 20% received such services. J Am Geriatr Soc 68:96-102, 2019.

What Predicts Health Care Transitions for Older Adults Following Introduction of LTSS?

Objective: To determine predictors of health care transitions (i.e., acute care service use, transfers from lower to higher intensity services) among older adults new to long-term services and supports [LTSS]. Method: 470 new LTSS recipients followed for 24 months. Multivariable Poisson regression modeling within a generalized estimating equation framework. Results: Being male, having multiple chronic conditions, lower self-reported physical health ratings and lower quality of life ratings at baseline were associated with increased risk of health care transitions. Older adults in assisted living communities and nursing homes experienced decreases in health care transitions over time, while LTSS recipients at home had no change in risk. LTSS recipients who had orders to receive therapy, compared with those who did not, had a lower relative risk of transitions over time. Discussion: Predictors of future health care transitions support the need for LTSS providers to anticipate and monitor this risk for LTSS recipients.

Assessing the impact of Minnesota's return to community initiative for newly admitted nursing home residents

OBJECTIVE

To evaluate Minnesota's Return to Community Initiative's (RTCI) impact on community discharges from nursing homes.

DATA SOURCES

Secondary data were from the Minimum Data Set and RTCI staff (April 2014 - December 2016). The sample consisted of 18 444 non-Medicaid nursing home admissions in Minnesota remaining for at least 45 days, with high predicted probability of community discharge.

STUDY DESIGN

The RTCI facilitates community discharge for non-Medicaid nursing home residents by assisting with discharge planning, transitioning to the community, and postdischarge follow-up. A key evaluation question is how many of those transitions were directly attributable to the program. Return to Community Initiative was implemented statewide without a control group. Program impact was measured using regression discontinuity, a quasi-experimental design approach that leverages the programs targeting model.

PRINCIPAL FINDINGS

Return to Community Initiative increased community discharge rates by an estimated 11 percent (P < 0.05) for the targeted population. The program effect was robust to time and increased with level of facility participation in RTCI.

CONCLUSIONS

The RTCI had a modest yet significant impact on the community discharge rates for its targeted population. Findings have been applied in strengthening the RTCI's targeting approach and transitioning process.

Rehabilitation Providers' Prediction of the Likely Success of the SNF-to-Home Transition Differs by Discipline

OBJECTIVES

Our article's primary objective is to examine whether rehabilitation providers can predict which patients discharged from skilled nursing facility (SNF) rehabilitation will be successful in their transition to home, controlling for sociodemographic factors and physical, mental, and social health characteristics.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

One hundred-twelve English-speaking adults aged 65 years and older admitted to 2 SNF rehabilitation units.

MEASURES

Our outcome is time to "failed transition to home," which identified SNF rehabilitation patients who did not successfully transition from the SNF to home during the study. Our primary independent variable consisted of the prediction of medical providers, occupational therapists, physical therapists, and social workers about the likely success of their patients' SNF-to-home transition. We also examined the association of sociodemographic factors and physical, mental, and social health with a failed transition to home.

RESULTS

The predictions of occupational and physical therapists were associated with whether patients successfully transitioned from the SNF to their homes in bivariate [hazard ratio (HR) = 4.96, P = .014; HR = 10.91, P = .002, respectively] and multivariate (HR = 5.07, P = .036; HR = 53.33, P = .004) analyses. The predictions of medical providers and social workers, however, were not associated with our outcome in either bivariate (HR = 1.44, P = .512; HR = 0.84, P = .794, respectively) or multivariate (HR = 0.57, P = .487; HR = 0.54, P = .665) analyses. Living alone, more medical conditions, lower physical functioning scores, and greater depression scores were also associated with time to failed transition to home.

CONCLUSIONS/IMPLICATIONS

These findings suggest that occupational and physical therapists may be better able to predict post-SNF discharge outcomes than are other rehabilitation providers. Why occupational and physical therapists' predictions are associated with the SNF-to-home outcome whereas the predictions of medical providers and social workers are not is uncertain. A better understanding of the factors informing the postdischarge predictions of occupational and physical therapists may help identify ways to improve the SNF-to-home discharge planning process.

Adapting Project RED to Skilled Nursing Facilities

This article describes our recommendation for adapting hospital-based RED (Reengineered Discharge) processes to skilled nursing facilities (SNFs). Using focus groups, the SNFs' discharge processes were assessed twice additionally, research staff then recorded field notes documenting discussions about facility discharge processes as they related to RED processes. Data were systematically analyzed using thematic analysis to identify recommendations for adapting RED to the SNF setting including (a) rapidly identifying, involving, and preparing family/caregivers to implement a patient focused SNF discharge plan; (b) reconnecting patients quickly to primary care providers; and (c) educating patients at discharge about their target health condition, medications, and impact of changes on other chronic health needs. Limited SNF staff capacity and corporate-level policies limited adoption of some key RED components. Transitional care processes such as RED, developed to avoid discharge problems, can be adapted for SNFs to improve their discharges.

The Association Between Chronic Condition Symptoms and Treatment Burden in a Skilled Nursing Population

The purpose of the current study was to determine the relationship between chronic condition symptoms and treatment burden in older adults transitioning from skilled nursing facilities to home. Treatment burden is defined as the burden associated with adhering to a prescribed chronic condition self-management regimen. Analysis of correlations between chronic condition symptoms and treatment burden revealed that symptoms and treatment burden are positively correlated (p < 0.05). Multivariate analysis (adjusted R2 = 0.40, F[10, 63] = 5.96, p < 0.001), controlling for other known antecedents of treatment burden, demonstrated that fatigue (standardized beta coefficient = 0.47, p < 0.001) predicted higher levels of treatment burden. Post hoc analysis revealed caregiver presence partially mediated the effect of fatigue on treatment burden, decreasing treatment burden during transition. Findings support existing transitional care literature suggesting that clinical assessment, including symptom screening, treatment of symptoms, and/or intervention reducing the impact of symptoms on patients' health and well-being, may lower treatment burden, thus improving self-management adherence. [Journal of Gerontological Nursing, 44(12), 45-52.].

Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities

Prior studies have not described strategies for implementing transitional care in skilled nursing facilities (SNFs). As part of the Connect-Home study, we pilot tested the Transition Plan of Care (TPOC) template, an implementation tool that SNF staff used to deliver transitional care. A retrospective chart review was used to describe the impact of the TPOC template on three implementation outcomes: reach to patients, staff adoption of the template, and staff fidelity to the intervention protocol for transition care planning. The template reached 100% of eligible patients (N = 68). Adoption was high, with documentation by four disciplines in 90.6% of patient records (N = 61). Fidelity to the intervention protocol was moderately high, with 73% of documentation that was concordant with the protocol. Our findings suggest an electronic medical record (EMR)-based implementation tool may increase the ability of staff to prepare older adults and their caregivers for self-care at home. Further research is needed to test the efficacy of the protocol on patient outcomes after transitions from SNF to home.

Functional Status Is Associated With 30-Day Potentially Preventable Readmissions Following Skilled Nursing Facility Discharge Among Medicare Beneficiaries

OBJECTIVES

The objectives of this study were to determine the association between patients' functional status at discharge from skilled nursing facility (SNF) care and 30-day potentially preventable hospital readmissions, and to examine common reasons for potentially preventable readmissions.

DESIGN

Retrospective cohort study.

SETTING

SNFs and acute care hospitals submitting claims to Medicare.

PARTICIPANTS

National cohort of Medicare fee-for-service beneficiaries discharged from SNF care between July 15, 2013, and July 15, 2014 (n = 693,808). Average age was 81.4 (SD 8.1) years, 67.1% were women, and 86.3% were non-Hispanic white.

MEASUREMENTS

Functional items from the Minimum Data Set 3.0 were categorized into self-care, mobility, and cognition domains. We used specifications for the SNF potentially preventable 30-day postdischarge readmission quality metric to identify potentially preventable readmissions.

RESULTS

The overall observed rate of 30-day potentially preventable readmissions following SNF discharge was 5.7% (n = 39,318). All 3 functional domains were independently associated with potentially preventable readmissions in the multivariable models. Odds ratios for the most dependent category versus the least dependent category from multilevel models adjusted for patients' sociodemographic and clinical characteristics were as follows: mobility, 1.54 (95% confidence interval [CI] 1.49-1.59); self-care, 1.50 (95% CI 1.44-1.55); and cognition, 1.12 (95% CI 1.04-1.20). The 5 most common conditions were congestive heart failure (n = 7654, 19.5%), septicemia (n = 7412, 18.9%), urinary tract infection/kidney infection (n = 4297, 10.9%), bacterial pneumonia (n = 3663, 9.3%), and renal failure (n = 3587, 9.1%). Across all 3 functional domains, septicemia was the most common condition among the most dependent patients and congestive heart failure among the least dependent.

CONCLUSIONS

Patients with functional limitations at SNF discharge are at increased risk of hospital readmissions considered potentially preventable. Future research is needed to determine whether improving functional status reduces risk of potentially preventable readmissions among this vulnerable population.

Factors affecting residents transition from long term care facilities to the community: a scoping review

BACKGROUND

Long-term care facilities (LTCFs) are often places where persons with complex health needs that cannot be met in a community setting, reside and are cared for until death. However, not all persons experience continuous declines in health and functioning. For some residents who experience improvement in personal abilities and increased independence, transition from the LTCF to the community may be an option. This scoping review aimed to synthetize the existing evidence regarding the transition process from discharge planning to intervention and evaluation of outcomes for residents transitioning from LTCFs to the community.

METHODS

This review followed a five-stage scoping review framework to describe the current knowledge base related to transition from LTCFs to community based private dwellings as the location of the discharge (example: Person's own home or shared private home with a family member, friend, or neighbour). Of the 4221 articles retrieved in the search of 6 databases, 36 articles met the criteria for inclusion in this review.

RESULTS

The majority of studies focussed on an older adult population (aged 65 years or greater), were conducted in the USA, and were limited to small geographic regions. There was a lack of consistency in terminology used to describe both the facilities as well as the transition process. Literature consisted of a broad array of study designs; sample sizes ranged from less than 10 to more than 500,000. Persons who were younger, married, female, received intense therapy, and who expressed a desire to transition to a community setting were more likely to transition out of a LTCF while those who exhibited cognitive impairment were less likely to transition out of a LTCF to the community.

CONCLUSIONS

Findings highlight the heterogeneity and paucity of research examining transition of persons from LTCFs to the community. Overall, it remains unclear what best practices support the discharge planning and transition process and whether or not discharge from a LTCF to the community promotes the health, wellbeing, and quality of life of the persons. More research is needed in this area before we can start to confidently answer the research questions.

Factors affecting residents transition from long term care facilities to the community: a scoping review

Background

Long-term care facilities (LTCFs) are often places where persons with complex health needs that cannot be met in a community setting, reside and are cared for until death. However, not all persons experience continuous declines in health and functioning. For some residents who experience improvement in personal abilities and increased independence, transition from the LTCF to the community may be an option. This scoping review aimed to synthetize the existing evidence regarding the transition process from discharge planning to intervention and evaluation of outcomes for residents transitioning from LTCFs to the community.

Methods

This review followed a five-stage scoping review framework to describe the current knowledge base related to transition from LTCFs to community based private dwellings as the location of the discharge (example: Person’s own home or shared private home with a family member, friend, or neighbour). Of the 4221 articles retrieved in the search of 6 databases, 36 articles met the criteria for inclusion in this review.

Results

The majority of studies focussed on an older adult population (aged 65 years or greater), were conducted in the USA, and were limited to small geographic regions. There was a lack of consistency in terminology used to describe both the facilities as well as the transition process. Literature consisted of a broad array of study designs; sample sizes ranged from less than 10 to more than 500,000. Persons who were younger, married, female, received intense therapy, and who expressed a desire to transition to a community setting were more likely to transition out of a LTCF while those who exhibited cognitive impairment were less likely to transition out of a LTCF to the community.

Conclusions

Findings highlight the heterogeneity and paucity of research examining transition of persons from LTCFs to the community. Overall, it remains unclear what best practices support the discharge planning and transition process and whether or not discharge from a LTCF to the community promotes the health, wellbeing, and quality of life of the persons. More research is needed in this area before we can start to confidently answer the research questions.

Home Health Agency Characteristics and Quality Outcomes for Medicare Beneficiaries With Rehabilitation-Sensitive Conditions

OBJECTIVE

To examine associations between organizational characteristics of home health agencies (eg, profit status, rehabilitation therapy staffing model, size, and rurality) and quality outcomes in Medicare beneficiaries with rehabilitation-sensitive conditions, conditions for which occupational, physical, and/or speech therapy have the potential to improve functioning, prevent or slow substantial decline in functioning, or increase ability to remain at home safely.

DESIGN

Retrospective analysis.

SETTING

Home health agencies.

PARTICIPANTS

Fee-for-service beneficiaries (N=1,006,562) admitted to 9250 Medicare-certified home health agencies in 2009.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Institutional admission during home health care, community discharge, and institutional admission within 30 days of discharge.

RESULTS

Nonprofit (vs for-profit) home health agencies were more likely to discharge beneficiaries to the community (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13-1.33) and less likely to have beneficiaries incur institutional admissions within 30 days of discharge (OR, .93; 95% CI, .88-.97). Agencies in rural (vs urban) counties were less likely to discharge patients to the community (OR, .83; 95% CI, .77-.90) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.24; 95% CI, 1.18-1.30) and within 30 days of discharge (OR, 1.15; 95% CI, 1.10-1.22). Agencies with contract (vs in-house) therapy staff were less likely to discharge beneficiaries to the community (OR, .79, 95% CI, .70-.91) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.09; 95% CI, 1.03-1.15) and within 30 days of discharge (OR, 1.17; 95% CI, 1.07-1.28).

CONCLUSIONS

As payers continue to test and implement reimbursement mechanisms that seek to reward value over volume of services, greater attention should be paid to organizational factors that facilitate better coordinated, higher quality home health care for beneficiaries who may benefit from rehabilitation.

Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers

BACKGROUND

Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional care of SNF patients (i.e., time-limited services to ensure coordination and continuity of care) is poorly understood.

OBJECTIVE

To determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads.

DESIGN

A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family caregivers.

SETTING

Three SNFs in the Southeastern United States.

PARTICIPANTS

Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge.

INTERVENTION

The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver transitional care of patient and caregiver dyads.

MEASUREMENTS

Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15).

RESULTS

The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24).

CONCLUSION

Connect-Home is a promising transitional care intervention for older patients discharged from SNF care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.

Using the Eco-Map and Ecosystems Perspective to Guide Skilled Nursing Facility Discharge Planning

Growing numbers of seniors across the United States require skilled nursing facility care after an inpatient hospital stay. Previous studies indicate that roughly 20 percent of all hospitalized Medicare beneficiaries are admitted to a skilled nursing facility following a qualifying hospital stay. Social workers address psychosocial problems, social support, networks, and healthcare needs during transitions in care, particularly discharge planning. Ecosystems perspective and the eco-map as a discharge planning tool is presented. Social workers can use these tools to examine the patient with respect to their transactional relationships with systems. This will further will facilitate provision of wrap-around services upon discharge.

Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission

BACKGROUND

Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.

OBJECTIVE

To identify whether early post-SNF discharge care reduces likelihood of 30-day hospital readmissions.

DESIGN

Secondary data analysis using the Electronic Medical Record, Medicare, Medicaid and the Minimum Data Set.

PARTICIPANTS/SETTING

Older (age > 65 years), community-dwelling adults admitted to a safety net hospital in the Midwest for 3 or more nights and discharged home after an SNF stay (n = 1543).

MEASUREMENTS

The primary outcome was hospital readmission within 30 days of SNF discharge. The primary independent variables were either a home health visit or an outpatient provider visit within a week of SNF discharge.

RESULTS

Out of 8754 community-dwelling, hospitalized older adults, 3025 (34.6%) were discharged to an SNF, of whom 1543 (51.0%) returned home. Among the SNF to home group, a home health visit within a week of SNF discharge was associated with reduced hazard of 30-day hospital readmission [adjusted hazard ratio (aHR) 0.61, P < .001] but outpatient provider visits were not associated with reduced risk of hospital readmission (aHR = 0.67, P = .821).

CONCLUSION

For patients discharged from an SNF to home, the finding that a home health visit within a week of discharge is associated with reduced hazard of 30-day hospital readmissions suggests a potential avenue for intervention.

Skilled Nursing Facility Care for Patients With Heart Failure: Can We Make It "Heart Failure Ready?"

Skilled nursing facilities (SNFs) have emerged as an integral component of care for older adults with heart failure (HF). Despite their prominent role, poor clinical outcomes for the medically complex patients with HF managed in SNFs are common. Barriers to providing quality care include poor transitional care during hospital-to-SNF and SNF-to-community discharges, lack of HF training among SNF staff, and a lack of a standardized care process among SNF facilities. Although no evidence-based practice standards have been established, various measures and tools designed to improve HF management in SNFs are being investigated. In this review, we discuss the challenges of HF care in SNFs as well as potential targets and recommendations that can help improve care with respect to transitions, HF management within SNFs, and modifiable factors within facilities. Policy considerations that might help catalyze improvements in SNF-based HF management are also discussed.

The Residential Long-Term Care Role in Health Care Transitions

The objective of the current study is to describe the activities long-term care facilities are undertaking to reduce hospital admissions and readmissions by working to improve health care transitions. The data were collected via an online survey from 888 nursing facilities (NFs) and 527 residential care facilities (RCFs) that completed the care integration module of the Ohio Biennial Survey of Long-Term Care. Questions focused on partnerships, current work, type of care model, and perceived barriers to reducing hospital readmissions. More than nine in 10 (93.1%) of NFs and 63.6% of RCFs reported being engaged in a program to reduce hospital admissions/readmissions. Evidence-based care models were utilized by two thirds of NFs and one third of RCFs. Financial barriers were the most frequently cited challenges faced by facilities. Long-term care settings are increasingly becoming transitional care stops for short-term stay residents. Ensuring that facilities are well versed in current transition research and practice is critical to improve system outcomes.

Clinical pharmacist home visits and 30-day readmissions in Medicare Advantage beneficiaries

RATIONALE, AIMS & OBJECTIVES

A variety of transition of care interventions has been evaluated to date to reduce readmissions. No studies evaluated effectiveness of clinical pharmacist's home-visits to recently discharged Medicare Advantage patients with the goal of preventing subsequent readmissions and urgent care use. The objective of this study was to evaluate the effectiveness of in-home clinical pharmacist's transition of care program on 30-day all-cause readmissions, emergency department (ED) visits, outpatient visits, as well as to assess patient satisfaction with the program.

METHODS

The study used retrospective cohort design.

RESULTS

A total of 245 patients were included in the study (mean (SD) age 77.8 (8.7); mean Charlson's Comorbidity Index 5.0 (2.5); 53.5% male). Forty-seven patients (19.0%) experienced at least one ED visit and twenty-two patients (9.0%) were readmitted within 30 days. The two groups did not differ on available demographic and clinical characteristics (p > 0.05). There was no difference in 30-day readmission rates, percent of patients with ≥1 ED visit, ≥1 outpatient physician office visit between the groups (p > 0.05). A total of 78 program participants responded to a satisfaction survey with 95% agreeing the program helped to stay healthy at home.

CONCLUSION

Multiple medication-related problems were identified by in-home pharmacists and the program appeared to be well-accepted by participants. In this study we did not find that the program had an impact on reduction of inpatient or urgent healthcare use. Further research using a different study design and a larger sample to estimate the program effectiveness is warranted.

Transitional care in skilled nursing facilities: a multiple case study

BACKGROUND

Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement.

METHODS

In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services.

RESULTS

Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions.

CONCLUSIONS

Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.

Transitional care of older adults in skilled nursing facilities: A systematic review

Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients.

Health Care Use Before and After Entering Long-Term Services and Supports

Objective: We examined the health care utilization patterns of Medicare and Medicaid enrollees (MMEs) before and after initiating long-term care in the community or after admission to a nursing facility (NF). Method: We used administrative data to compare hospitalizations, emergency department (ED) visits, and post-acute care use of MMEs receiving long-term care in California in 2006-2007. Results: MMEs admitted to a NF for long-term care had much greater use of hospitalizations, ED visits, and post-acute care before initiating long-term care than those entering long-term care in the community. Post-entry, community service users had less than half the average monthly hospital and ED use compared with the NF cohort. Conclusion: Hospital and ED use prior to and following NF and personal care program entry suggest a need for reassessing the monitoring of these high-risk populations and the communication between health and community care providers.

Geriatric Syndromes in Hospitalized Older Adults Discharged to Skilled Nursing Facilities

OBJECTIVES

To determine the prevalence, recognition, co-occurrence, and recent onset of geriatric syndromes in individuals transferred from the hospital to a skilled nursing facility (SNF).

DESIGN

Quality improvement project.

SETTING

Acute care academic medical center and 23 regional partner SNFs.

PARTICIPANTS

Medicare beneficiaries hospitalized between January 2013 and April 2014 and referred to SNFs (N = 686).

MEASUREMENTS

Project staff measured nine geriatric syndromes: weight loss, lack of appetite, incontinence, and pain (standardized interview); depression (Geriatric Depression Scale); delirium (Brief Confusion Assessment Method); cognitive impairment (Brief Interview for Mental Status); and falls and pressure ulcers (hospital medical record using hospital-implemented screening tools). Estimated prevalence, new-onset prevalence, and common coexisting clusters were determined. The extent to which treating physicians commonly recognized syndromes and communicated them to SNFs in hospital discharge documentation was evaluated.

RESULTS

Geriatric syndromes were prevalent in more than 90% of hospitalized adults referred to SNFs; 55% met criteria for three or more coexisting syndromes. The most-prevalent syndromes were falls (39%), incontinence (39%), loss of appetite (37%), and weight loss (33%). In individuals who met criteria for three or more syndromes, the most common triad clusters were nutritional syndromes (weight loss, loss of appetite), incontinence, and depression. Treating hospital physicians commonly did not recognize and document geriatric syndromes in discharge summaries, missing 33% to 95% of syndromes present according to research personnel.

CONCLUSION

Geriatric syndromes in hospitalized older adults transferred to SNFs are prevalent and commonly coexist, with the most frequent clusters including nutritional syndromes, depression, and incontinence. Despite the high prevalence, this clinical information is rarely communicated to SNFs on discharge.

A Pilot Health Information Technology-Based Effort to Increase the Quality of Transitions From Skilled Nursing Facility to Home: Compelling Evidence of High Rate of Adverse Outcomes

OBJECTIVES

Older adults are often transferred from hospitals to skilled nursing facilities (SNFs) for post-acute care. Patients may be at risk for adverse outcomes after SNF discharges, but little research has focused on this period.

DESIGN

Assessment of the feasibility of a transitional care intervention based on a combination of manual information transmission and health information technology to provide automated alert messages to primary care physicians and staff; pre-post analysis to assess potential impact.

SETTING

A multispecialty group practice.

PARTICIPANTS

Adults aged 65 and older, discharged from SNFs to home; comparison group drawn from SNF discharges during the previous 1.5 years, matched on facility, patient age, and sex.

MEASUREMENTS

For the pre-post analysis, we tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days.

RESULTS

The intervention was developed and implemented with manual transmission of information between 8 SNFs and the group practice followed by entry into the electronic health record. The process required a 5-day delay during which a large portion of the adverse events occurred. Over a 1-year period, automated alert messages were delivered to physicians and staff for the 313 eligible patients discharged from the 8 SNFs to home. We compared outcomes to those of individually matched discharges from the previous 1.5 years and found similar percentages with 30-day rehospitalizations (31% vs 30%, adjusted HR 1.06, 95% CI 0.80-1.4). Within the adverse drug event (ADE) study, 30% of the discharges during the intervention period and 30% of matched discharges had ADEs within 45 days.

CONCLUSION

Older adults discharged from SNFs are at high risk of adverse outcomes immediately following discharge. Simply providing alerts to outpatient physicians, especially if delivered multiple days after discharge, is unlikely to have any impact on reducing these rates.

Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities

BACKGROUND AND OBJECTIVES

Older adults with ESRD often receive care in skilled nursing facilities (SNFs) after an acute hospitalization; however, little is known about acute care use after SNF discharge to home.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study used Medicare claims for North and South Carolina to identify patients with ESRD who were discharged home from a SNF between January 1, 2010 and August 31, 2011. Nursing Home Compare data were used to ascertain SNF characteristics. The primary outcome was time from SNF discharge to first acute care use (hospitalization or emergency department visit) within 30 days. Cox proportional hazards models were used to identify patient and facility characteristics associated with the outcome.

RESULTS

Among 1223 patients with ESRD discharged home from a SNF after an acute hospitalization, 531 (43%) had at least one rehospitalization or emergency department visit within 30 days. The median time to first acute care use was 37 days. Characteristics associated with a shorter time to acute care use were black race (hazard ratio [HR], 1.25; 95% confidence interval [95% CI], 1.04 to 1.51), dual Medicare-Medicaid coverage (HR, 1.24; 95% CI, 1.03 to 1.50), higher Charlson comorbidity score (HR, 1.07; 95% CI, 1.01 to 1.12), number of hospitalizations during the 90 days before SNF admission (HR, 1.12; 95% CI, 1.03 to 1.22), and index hospital discharge diagnoses of cellulitis, abscess, and/or skin ulcer (HR, 2.59; 95% CI, 1.36 to 4.45). Home health use after SNF discharge was associated with a lower rate of acute care use (HR, 0.72; 95% CI, 0.59 to 0.87). There were no statistically significant associations between SNF characteristics and time to first acute care use.

CONCLUSIONS

Almost one in every two older adults with ESRD discharged home after a post-acute SNF stay used acute care services within 30 days of discharge. Strategies to reduce acute care utilization in these patients are needed.