Preferred Hospital-SNF Relationships and Variation in Information Sharing Practices: Impact on Care Transitions for Persons with AD/ADRD

项目总结/摘要 每年，超过300万患者需要在专业护理机构（SNF）接受急性期后护理 住院后。这些患者中的许多人被诊断为或表现出与以下症状一致的症状， 阿尔茨海默病或阿尔茨海默病相关痴呆（AD/ADRD）。差异很大 患者在何处以及如何接受SNF护理，以及支持患者过渡的流程 在SNF。医院越来越意识到，并解决，在这些医疗服务的质量缺陷， 使患者发生不良事件和再次住院的风险增加。随着医院投资的增加， 通过SNF的过渡性护理改善，我们探索了两种潜在的机制， 如何进行这些投资可能无法充分支持患者的过渡性护理需求， AD/ADRD。 首先，塑造AD/ADRD患者SNF放置决策的动态可能会限制他们的治疗。 获得正在改善过渡性护理的设施。医院经常集中他们的 在他们定期将患者送往的SNF中的过渡性护理投资（即，其高容量或 “优选的”SNF）。但是，初步证据表明，这些SNF可能能够利用其 限制并发症、再住院风险增加的患者入院的首选状态，和/或 长期停留。这些风险适用于AD/ADRD患者。因此，我们必须评估AD/ADRD是否 患者对医院首选SNF和过渡性护理投资的使用有限， 集中在这些关系中。 其次，医院如何实施过渡性护理改进存在显著差异， 特别是关于它们如何共享信息以支持过渡。一些医院通常会 与AD/ADRD护理相关的信息-包括认知状态，告知社会/行为 护理计划和功能独立性水平-而其他人则没有。信息类型的可变性 共享，以及该信息的可用性和及时性，表明医院不知道如何 SNF为这一群体定义了必要的信息共享。随着医院越来越多地新建 过渡性护理过程中使用电子方法的信息共享，这是至关重要的通知那些 努力提供证据，说明更完整的患者信息的定时和传输如何能够更好地 支持更好的AD/ADRD过渡，通过降低短期再入院的可能性来衡量。 我们的研究结果将告知政策制定者AD/ADRD个体的潜在风险 没有从改善急性后过渡性护理流程的有针对性的投资中受益，并将提供 对患者过渡期间增强信息共享实践类型的必要见解， 对这部分患者群体尤其有益。

Project Summary/Abstract Every year, over three million patients require post-acute care at a skilled nursing facility (SNF) following hospitalization. Many of these patients are diagnosed with, or exhibit symptoms consistent with, Alzheimer’s Disease or Alzheimer’s Disease related dementia (AD/ADRD). There is significant variation in where and how patients are placed for SNF care, and the processes in place to support patients’ transition to the SNF. Hospitals are increasingly aware of, and addressing, the quality deficits in these handoffs that put patients at increased risk for adverse events and rehospitalization. As hospitals invest more in transitional care improvements with SNFs, we explore two potential mechanisms through which variation in how these investments are made may fail to adequately support the transitional care needs for patients with AD/ADRD. First, dynamics that shape SNF placement decisions for AD/ADRD patients might restrict their access to facilities where transitional care improvements are being made. Hospitals often concentrate their transitional care investments in the SNFs to which they regularly send patients (i.e., their high volume or “preferred” SNFs). But, preliminary evidence suggests that these SNFs may be able to leverage their preferred status to limit admission of patients at increased risk of complications, rehospitalization, and/or long-term stay. These risks apply to AD/ADRD patients. We therefore must assess whether AD/ADRD patients experience limited access to hospitals’ preferred SNFs and the transitional care investments that are concentrated in those relationships. Second, there is significant variation in how hospitals implement transitional care improvements, especially with respect to how they share information to support transitions. Some hospitals routinely share information relevant to AD/ADRD care – including cognitive status, details that inform a social/behavioral care plan, and level of functional independence – while others do not. The variability in types of information shared, as well as the usability and timeliness of that information, suggests that hospitals do not know how SNFs define necessary information sharing for this population. As hospitals increasingly build new transitional care processes using electronic methods of information sharing, it is critical to inform those efforts with evidence on how timing and transmission of more complete patient information may better support better AD/ADRD transitions, measured by reduced likelihood of short-term readmission. Our study findings will inform policy makers about the potential risks of individuals with AD/ADRD not benefiting from targeted investments to improve post-acute transitional care processes, and will provide necessary insights in to the types of enhanced information sharing practices during patient transition that could particularly benefit this patient population.