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

项目摘要/摘要 每年有300多万名患者需要在熟练的护理机构(SNF)接受急性后护理 在住院后。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)。有很大的不同 患者被安置在哪里以及如何接受SNF护理，以及支持患者过渡的适当流程 给特种部队。医院越来越多地意识到并解决这些移交中的质量缺陷 使患者面临更高的不良事件和再次住院风险。随着医院更多地投资于 通过SNF改善过渡期护理，我们探索了两种潜在的机制，通过这些机制 这些投资的方式可能无法充分支持患者的过渡性护理需求 使用AD/ADRD。 首先，影响AD/ADRD患者SNF放置决定的动态因素可能会限制他们的 进入正在改善过渡期护理的设施。医院经常集中他们的 对他们定期将患者送往的SNF的过渡性护理投资(即，他们的高容量或 “首选”SNF)。但是，初步证据表明，这些SNF可能能够利用他们的 优先地位，以限制并发症、再次住院和/或风险增加的患者入院 长期居留。这些风险适用于AD/ADRD患者。因此，我们必须评估AD/ADRD是否 患者体验到获得医院首选SNF和过渡性医疗投资的机会有限 都集中在这些关系上。 第二，医院实施过渡性护理改进的方式存在显著差异， 尤其是关于它们如何共享信息以支持过渡。一些医院通常会分享 与AD/ADRD护理相关的信息-包括认知状态、告知社会/行为的详细信息 护理计划和功能独立程度-而其他人则不是。信息类型的可变性 共享，以及这些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建造新的 使用信息共享的电子方法的过渡护理过程，至关重要的是告知那些 有证据表明，如何更好地安排和传输更完整的患者信息 支持更好的AD/ADRD过渡，通过降低短期重新入院的可能性来衡量。 我们的研究结果将使政策制定者了解AD/ADRD患者的潜在风险 没有受益于改善急性后过渡护理进程的有针对性的投资，并将提供 对患者过渡期间增强信息共享实践的类型的必要见解 可能会让这些患者特别受益。

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.