The Coming Home After Rehabilitation and Transition from a Skilled nursing facility with Dementia Study (The CHARTS-D Study)

越来越多的阿尔茨海默病和相关痴呆症(ADRD)患者正在接受后治疗 在熟练护理机构(SNF)进行住院护理。大多数人将从国家安全部队过渡到国内。虽然 病人从医院到家的过渡已经引起了人们的极大关注， 很少有关于从SNF到Home的过渡的研究。经历从家里到医院的多次过渡 对于ADRD患者和他们的照顾者来说，到SNF并回到家是困难的。从SNF排放到 在家中，患者可能会重新进入过渡周期，遭受住院等不良后果 再次入院、用药错误、功能衰退和丧失独立性。 该项目将确定与30天再次住院相关的因素和其他不良后果 从SNF过渡到家的ADRD患者。我们将使用健康和退休研究(HRS)， 包含丰富的社会和经济信息的大型国家数据集，这些信息与艾滋病的风险有关 不利的健康后果。我们的研究利用了HRS和医疗保险中心之间的联系 和Medicaid Services帐单数据，特别是指向在SNF逗留期间收集的大量数据的链接 来自结果和评估信息集的最低数据集和家庭健康事件数据。 对于目标1，我们将描述ADRD诊断与SNF中认知损害严重程度的关系 为从SNF过渡到家的患者重新入院。我们假设，有 在控制Andersen模型因素时，ADRD再次住院的风险更大。我们也 提出，在SNF期间测量的认知损害更严重的水平将是 与更大的风险重新入院风险相关。对于目标2，我们将确定早期门诊护理的效果， 无论是在诊所就诊还是通过家庭健康就诊，都可以减少再入院。我们假设早期的门诊病人 护理是防止再次入院的保护性措施。这是确定干预措施以减少 经历这种复杂的医疗保健轨迹的ADRD患者的重新入院。 卡纳汉博士的职业发展计划将提供研究方法和卫生政策方面的全面培训 与患有ADRD的老年人的过渡有关。作为一名新兴的老年研究人员，在SNF方面拥有专业知识 家庭护理过渡，卡纳汉博士将利用这项研究的结果来设计一种干预措施，以改善 经历了这一复杂的医疗保健轨迹的认知受损患者的健康结果。她的长发 长期目标是改善患有ADRD的老年人的护理质量和健康结果。

Increasing numbers of patients with Alzheimer’s disease and related dementias (ADRD) are receiving post- hospitalization care in skilled nursing facilities (SNFs). Most will transition from the SNF to home. Although there has been a great deal of attention paid to patients’ transition from the hospital to home, there has been little research on transitions from the SNF to home. Experiencing multiple transitions from home to the hospital to a SNF and back to home is difficult for patients with ADRD and their caregivers. After discharge from SNF to home, patients may re-enter the cycle of transitions, suffering adverse outcomes such as hospital readmissions, medication errors, functional decline, and loss of independence. This project will identify factors associated with 30-day hospital readmission and other adverse outcomes for patients with ADRD who transition from the SNF to home. We will use the Health and Retirement Study (HRS), a large, national dataset that includes rich social and economic information that is pertinent to the risk of adverse health outcomes. Our study takes advantage of the link between the HRS and Centers for Medicare and Medicaid Services billing data, and especially the link to extensive data collected during SNF stay as part of the Minimum Data Set and home health event data from the Outcome and Assessment Information Set. For Aim 1, we will describe the relationship of ADRD diagnosis or severity of cognitive impairment in the SNF with hospital readmission for patients who transition from SNF to home. We hypothesize that individuals with ADRD are at greater risk of hospital readmission when controlling for Andersen model factors. We also propose that worse levels of cognitive impairment, as measured during a patient’s stay in the SNF, will be associated with greater risk readmission risk. For Aim 2, we will identify the effect of early outpatient care, either in clinic visit or via home health visit, on reducing readmissions. We hypothesize that early outpatient care is protective against readmission. This represents a first step in identifying interventions to reduce readmissions for people with ADRD who undergo this complex healthcare trajectory. Dr. Carnahan’s career development plan will provide thorough training in research methods and health policy related to transitions for older adults with ADRD. As an emerging aging researcher with expertise in the SNF to home care transition, Dr. Carnahan will use the results of this study to design an intervention that improves the health outcomes of cognitively impaired patients who experience this complex healthcare trajectory. Her long term goal is to improve the quality of care and health outcomes for older adults with ADRD.