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David Gomez JC, Cochran A, Smith M, Zayas-Cabán G. Prediction of rehospitalization and mortality risks for skilled nursing facilities using a dimension reduction approach. BMC Geriatr 2023; 23:394. [PMID: 37380969 PMCID: PMC10304328 DOI: 10.1186/s12877-023-03995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/24/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Hospitals are incentivized to reduce rehospitalization rates, creating an emphasis on skilled nursing facilities (SNFs) for post-hospital discharge. How rehospitalization rates vary depending on patient and SNF characteristics is not well understood, in part because these characteristics are high-dimensional. We sought to estimate rehospitalization and mortality risks by patient and skilled nursing facility (SNF) leveraging high-dimensional characteristics. METHODS Using 1,060,337 discharges from 13,708 SNFs of Medicare patients residing or visiting a provider in Wisconsin, Iowa, and Illinois, factor analysis was performed to reduce the number of patient and SNF characteristics. K-means clustering was applied to SNF factors to categorize SNFs into groups. Rehospitalization and mortality risks within 60 days of discharge was estimated by SNF group for various values of patient factors. RESULTS Patient and SNF characteristics (616 in total) were reduced to 12 patient factors and 4 SNF groups. Patient factors reflected broad conditions. SNF groups differed in beds and staff capacity, off-site services, and physical and occupational therapy capacity; and in mortality and rehospitalization rates for some patients. Patients with cardiac, orthopedic, and neuropsychiatric conditions are associated with better outcomes when assigned to SNFs with greater on-site capacity (i.e. beds, staff, physical and occupational therapy), whereas patients with conditions related to cancer or chronic renal failure are associated with better outcomes when assigned to SNFs with less on-site capacity. CONCLUSIONS Risks of rehospitalization and mortality appear to vary significantly by patient and SNF, with certain SNFs being better suited for some patient conditions over others.
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Affiliation(s)
- Juan Camilo David Gomez
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, USA
| | - Amy Cochran
- Department of Population Health Sciences, Department of Mathematics, University of Wisconsin-Madison, Madison, USA
| | - Maureen Smith
- Department of Population Health Sciences, Department of Mathematics, University of Wisconsin-Madison, Madison, USA
| | - Gabriel Zayas-Cabán
- Department of Industrial and Systems Engineering and BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 3107 Mechanical Engineering Building, 1513 University Avenue, Madison, WI 53726 USA
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Piazza KM, Ashcraft LE, Rose L, Hall DE, Brown RT, Bowen MEL, Mavandadi S, Brecher AC, Keddem S, Kiosian B, Long JA, Werner RM, Burke RE. Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults. Implement Sci Commun 2023; 4:57. [PMID: 37231459 PMCID: PMC10209584 DOI: 10.1186/s43058-023-00431-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/23/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults. METHODS We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions. DISCUSSION To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities. TRIAL REGISTRATION Registered 05 May 2021, at ISRCTN #60,657,985. REPORTING GUIDELINES Standards for Reporting Implementation Studies (see attached).
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Affiliation(s)
- Kirstin Manges Piazza
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA.
| | - Laura Ellen Ashcraft
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Liam Rose
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, CA, USA
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rebecca T Brown
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Geriatrics and Extended Care Program, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Mary Elizabeth Libbey Bowen
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Education, and Clinical Center, VISN4 Mental Illness Research, Corporal Michael JCrescenz VA Medical Center, Philadelphia, PA, USA
| | - Shahrzad Mavandadi
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- School of Nursing, University of Delaware, Newark, DE, USA
| | | | - Shimrit Keddem
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine & Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bruce Kiosian
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Geriatrics and Extended Care Program, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Judith A Long
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel M Werner
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Walton L, Courtright K, Demiris G, Gorman EF, Jackson A, Carpenter JG. Telehealth Palliative Care in Nursing Homes: A Scoping Review. J Am Med Dir Assoc 2023; 24:356-367.e2. [PMID: 36758619 PMCID: PMC9985816 DOI: 10.1016/j.jamda.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Many adults older than 65 spend time in a nursing home (NH) at the end of life where specialist palliative care is limited. However, telehealth may improve access to palliative care services. A review of the literature was conducted to synthesize the evidence for telehealth palliative care in NHs to provide recommendations for practice, research, and policy. DESIGN Joanna Briggs Institute guidance for scoping reviews, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews frameworks were used to guide this literature review. SETTINGS AND PARTICIPANTS Reviewed articles focused on residents in NHs with telehealth palliative care interventionists operating remotely. Participants included NH residents, care partner(s), and NH staff/clinicians. METHODS We searched Medline (Ovid), Embase (Elsevier), Cochrane Library (WileyOnline), Scopus (Elsevier), CINHAL (EBSCOhost), Trip PRO, and Dissertations & Theses Global (ProQuest) in June 2021, with an update in January 2022. We included observational and qualitative studies, clinical trials, quality improvement projects, and case and clinical reports that self-identified as telehealth palliative care for NH residents. RESULTS The review yielded 11 eligible articles published in the United States and internationally from 2008 to 2020. Articles described live video as the preferred telehealth delivery modality with goals of care and physical aspects of care being most commonly addressed. Findings in the articles focused on 5 patient and family-centered outcomes: symptom management, quality of life, advance care planning, health care use, and evaluation of care. Consistent benefits of telehealth palliative care included increased documentation of goals of care and decrease in acute care use. Disadvantages included technological difficulties and increased NH financial burden. CONCLUSIONS AND IMPLICATIONS Although limited in scope and quality, the current evidence for telehealth palliative care interventions shows promise for improving quality and outcomes of serious illness care in NHs. Future empirical studies should focus on intervention effectiveness, implementation outcomes (eg, managing technology), stakeholders' experience, and costs.
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Affiliation(s)
- Lyle Walton
- The University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Katherine Courtright
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George Demiris
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily F Gorman
- Health Sciences and Human Services Library, University of Maryland, Baltimore, MD, USA
| | - Amy Jackson
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Joan G Carpenter
- University of Maryland School of Nursing, Baltimore, MD, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
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Manges KA, Medvedeva E, Ersek M, Burke RE. VA nursing home compare metrics as an indicator of skilled nursing facility quality for veterans. J Am Geriatr Soc 2022; 70:2269-2279. [PMID: 35678768 DOI: 10.1111/jgs.17906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 03/18/2022] [Accepted: 04/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Veterans Administration (VA) provides several post-acute care (PAC) options for Veterans, including VA-owned nursing homes (called Community Living Centers, CLCs). In 2016, the VA released CLC Compare star ratings to support decision-making. However, the relationship between CLC Compare star ratings and Veterans CLC post-acute outcomes is unknown. METHODS Retrospective observational study using national VA and Medicare data for Veterans discharged to a CLC for PAC. We used a multivariate regression model with hospital random effects to examine the association between CLC Compare overall star ratings and PAC outcomes while controlling for patient, facility, and hospital factors. Our sample included Veteran enrollees age 65+ who were community-dwelling, experienced a hospitalization, and were discharged to a CLC in 2016-2017. PAC outcomes included 30-day unplanned hospital readmission, 30-day mortality, 100-day successful community discharge, and a secondary composite outcome of unplanned readmission or death within 30-days of the hospital discharge. RESULTS Of the 25,107 CLC admissions, 4088 (16.3%) experienced an unplanned readmission, 4069 (16.2%) died within 30-days of hospital discharge, and 12,093 (48.2%) had a successful 100-day community discharge. Admission to a lower-quality (1-star) facility was associated with lower odds of successful community discharge (OR 0.78; 95% CI 0.66, 0.91) and higher odds of a combined endpoint of 30-day mortality and readmission (OR 1.27; 95% CI 1.09, 1.49), compared to 5-star facilities. However, outcomes were not consistently different between 5-star and 2, 3, or 4-star facilities. Star ratings were not associated with individual readmission or mortality outcomes when considered separately. CONCLUSION These findings suggest comparisons of 1-star and 5-star CLCs may provide meaningful information for Veterans making decisions about post-acute care. Identifying ways to alter the star ratings so they are differentially associated with outcomes meaningful to Veterans at each level is essential. We found that 1-star facilities had higher rates of 30-day unplanned hospital readmission/death, and lower rates of 100-day successful community discharges compared to 5-star facilities. Yet, like past work on CMS Nursing Home Compare ratings, these relationships were found to be inconsistent or not meaningful across all star levels. CLC Compare may provide useful information for discharge and organizational planning, with some limitations.
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Affiliation(s)
- Kirstin A Manges
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elina Medvedeva
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Mary Ersek
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Ayele R, Manges KA, Leonard C, Lee M, Galenbeck E, Molla M, Levy C, Burke RE. How Context Influences Hospital Readmissions from Skilled Nursing Facilities: A Rapid Ethnographic Study. J Am Med Dir Assoc 2021; 22:1248-1254.e3. [PMID: 32943342 PMCID: PMC7956149 DOI: 10.1016/j.jamda.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Improving hospital discharge processes and reducing adverse outcomes after hospital discharge to skilled nursing facilities (SNFs) are gaining national recognition. However, little is known about how the social-contextual factors of hospitals and their affiliated SNFs may influence the discharge process and drive variations in patient outcomes. We sought to categorize contextual drivers that vary between high- and low-performing hospitals in older adult transition from hospitals to SNFs. DESIGN To identify contextual drivers, we used a rapid ethnographic approach with interviews and direct observations of hospital and SNF clinicians involved in discharging patients. We conducted thematic analysis to categorize contextual factors and compare differences in high- and low-performing sites. SETTING AND PARTICIPANTS We stratified hospitals on 30-day hospital readmission rates from SNFs and used convenience sampling to identify high- and low-performing sites and associated SNFs. The final sample included 4 hospitals (n = 2 high performing, n = 2 low performing) and affiliated SNFs (n = 5) with 148 hours of observations. MEASURES Central themes related to how contextual factors influence variations in high- and low-performing hospitals. RESULTS We identified 3 main contextual factors that differed across high- and low-performing hospitals and SNFs: team dynamics, patient characteristics, and organizational context. First, we observed high-quality communication, situational awareness, and shared mental models among team members in high-performing sites. Second, the types of patients cared for at high-performing hospitals had better insurance coverage that made it feasible for clinicians to place patients based on their needs instead of financial abilities. Third, at high-performing hospitals a more engaged staff in the transition process and building rapport with SNFs characterized smooth transitions from hospitals to SNFs. CONCLUSIONS AND IMPLICATIONS Contextual factors distinguish high- and low-performing hospitals in transitions to SNF and can be used to develop interventions to reduce adverse outcomes in transitions.
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Affiliation(s)
- Roman Ayele
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA; University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
| | - Kirstin A Manges
- National Clinician Scholar, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Chelsea Leonard
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA
| | - Marcie Lee
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA
| | - Emily Galenbeck
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA
| | - Mithu Molla
- Hospital Medicine Section, UC Davis Health System, Sacramento, CA, USA
| | - Cari Levy
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA; University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Robert E Burke
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, USA
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Abstract
OBJECTIVE We aimed to identify socioeconomic and clinical risk factors for post-intensive care unit (ICU)-related long-term cognitive impairment (LTCI). SUMMARY BACKGROUND DATA After delirium during ICU stay, LTCI has been increasingly recognized, but without attention to socioeconomic factors. METHODS We enrolled a prospective, multicenter cohort of ICU survivors with shock or respiratory failure from surgical and medical ICUs across 5 civilian and Veteran Affairs (VA) hospitals from 2010 to 2016. Our primary outcome was LTCI at 3- and 12 months post-hospital discharge defined by the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS) global score. Covariates adjusted using multivariable linear regression included age, sex, race, AHRQ socioeconomic index, Charlson comorbidity, Framingham stroke risk, Sequential Organ Failure Assessment, duration of coma, delirium, hypoxemia, sepsis, education level, hospital type, insurance status, discharge disposition, and ICU drug exposures. RESULTS Of 1040 patients, 71% experienced delirium, and 47% and 41% of survivors had RBANS scores >1 standard deviation below normal at 3- and 12 months, respectively. Adjusted analysis indicated that delirium, non-White race, lower education, and civilian hospitals (as opposed to VA), were associated with at least a half standard deviation lower RBANS scores at 3- and 12 months (P ≤ 0.03). Sex, AHRQ socioeconomic index, insurance status, and discharge disposition were not associated with RBANS scores. CONCLUSIONS Socioeconomic and clinical risk factors, such as race, education, hospital type, and delirium duration, were linked to worse PICS ICU-related, LTCI. Further efforts may focus on improved identification of higher-risk groups to promote survivorship through emerging improvements in cognitive rehabilitation.
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Manges KA, Ayele R, Leonard C, Lee M, Galenbeck E, Burke RE. Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach. BMJ Qual Saf 2020; 30:648-657. [PMID: 32958550 DOI: 10.1136/bmjqs-2020-011204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/07/2020] [Accepted: 08/02/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite the increased focus on improving patient's postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe processes used to prepare patients for postacute care in SNFs, and to explore differences between hospital-SNF pairs with high or low 30-day readmission rates. DESIGN We used a rapid ethnographic approach with intensive multiday observations and key informant interviews at high-performing and low-performing hospitals, and their most commonly used SNF. We used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals. SETTING AND PARTICIPANTS Hospitals were classified as high or low performers based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals (n=2 high performing, n=2 low performing) and corresponding SNFs (n=5). FINDINGS We identified variation in five major processes prior to SNF discharge that could affect care transitions: recognising need for postacute care, deciding level of care, selecting an SNF, negotiating patient fit and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: (1) earlier, ongoing, systematic identification of high-risk patients; (2) discussing the decision to go to an SNF as an iterative team-based process and (3) anticipating barriers with knowledge of transitional and SNF care processes. CONCLUSION Identifying variations in processes used to prepare patients for SNF provides critical insight into the best practices for transitioning patients to SNFs and areas to target for improving care of high-risk patients.
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Affiliation(s)
- Kirstin A Manges
- National Clinician Scholar, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA .,Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Roman Ayele
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Chelsea Leonard
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Marcie Lee
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Emily Galenbeck
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Section of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Burke RE, Canamucio A, Medvedeva E, Manges KA, Ersek M. External Validation of the Skilled Nursing Facility Prognosis Score for Predicting Mortality, Hospital Readmission, and Community Discharge in Veterans. J Am Geriatr Soc 2020; 68:2090-2094. [DOI: 10.1111/jgs.16650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Robert E. Burke
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Anne Canamucio
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Elina Medvedeva
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Kirstin A. Manges
- Division of General Internal Medicine, Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
- National Clinician Scholars Program University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Mary Ersek
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
- University of Pennsylvania School of Nursing Philadelphia Pennsylvania USA
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Burke RE, Canamucio A, Glorioso TJ, Barón AE, Ryskina KL. Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities. Med Care 2020; 58:301-306. [PMID: 31895308 PMCID: PMC11078064 DOI: 10.1097/mlr.0000000000001282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The period after transition from hospital to skilled nursing facility (SNF) is high-risk, but variability in outcomes related to transitions across hospitals is not well-known. OBJECTIVES Evaluate variability in transitional care outcomes across Veterans Health Administration (VHA) and non-VHA hospitals for Veterans, and identify characteristics of high-performing and low-performing hospitals. RESEARCH DESIGN Retrospective observational study using the 2012-2014 Residential History File, which concatenates VHA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans. SUBJECTS Veterans aged 65 or older who were acutely hospitalized in a VHA or non-VHA hospital and discharged to SNF; 1 transition was randomly selected per patient. MEASURES Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS Among the 365,942 Veteran transitions from hospital to SNF across 1310 hospitals, the composite outcome rate ranged from 3.3% to 23.2%. In multivariable analysis adjusting for patient characteristics, hospital discharge diagnosis and SNF category, no single hospital characteristic was significantly associated with the 7-day adverse outcomes in either VHA or non-VHA hospitals. Very few high or low-performing hospitals remained in this category across all 3 years. The increased odds of having a 7-day event due to being treated in a low versus high-performing hospital was similar to the odds carried by having an intensive care unit stay during the index admission. CONCLUSIONS While variability in hospital outcomes is significant, unmeasured care processes may play a larger role than currently measured hospital characteristics in explaining outcomes.
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Affiliation(s)
- Robert E. Burke
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VHA Medical Center
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Anne Canamucio
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VHA Medical Center
| | - Thomas J. Glorioso
- Center of Innovation for Veteran-Centered and Value-Driven Care, Denver VHA Medical Center, Denver
| | - Anna E. Barón
- Center of Innovation for Veteran-Centered and Value-Driven Care, Denver VHA Medical Center, Denver
- Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Kira L. Ryskina
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Gardner RL, Pelland K, Youssef R, Morphis B, Calandra K, Hollands L, Gravenstein S. Reducing Hospital Readmissions Through a Skilled Nursing Facility Discharge Intervention: A Pragmatic Trial. J Am Med Dir Assoc 2019; 21:508-512. [PMID: 31812334 DOI: 10.1016/j.jamda.2019.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/05/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Rebekah L Gardner
- Healthcentric Advisors, Providence, RI; Department of Medicine, Alpert Medical School of Brown University, Providence, RI.
| | | | | | | | | | | | - Stefan Gravenstein
- Healthcentric Advisors, Providence, RI; Department of Medicine, Alpert Medical School of Brown University, Providence, RI; Department of Health Services Policy and Practice and the Gerontology Center for Healthcare Research, Brown University School of Public Health, Providence, RI; Providence Veterans Administration Medical Center, Providence, RI
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