Improving the outcomes of older adults discharged to post-acute care facilities after hospitalization

 描述(由申请人提供)：1996至2010年间，住院后出院的老年人人数增加了50%，用于PAC的支出现在是医疗保险成本中增长最快的领域(2012年为620亿美元)。PAC设施(如熟练护理和康复设施)旨在为老年人康复，目标是成功地恢复社区生活，但目前只有28%的住院后PAC住院的医疗保险患者在出院后100天内返回社区。这项建议旨在更有效地告知出院时的医院临床医生、病人和家属(在作出推行PAC的决定时)病人在PAC住院后回家的可能性，这对老年人的健康和功能状况具有深远的影响。确定从PAC回家的老年人很重要，因为许多老年人不希望在出院后去医院，或者害怕经济后果；明确的证据表明，受益可能会改变决策和改善结果。确定过渡到长期护理的老年人或在PAC期间或之后死亡的老年人对于提前护理计划非常重要。例如，三分之一的老年人在生命的最后六个月里有过政治行动委员会，11%的人在这段时间内死亡。这些成年人可能没有从PAC中获得他们想要的好处。也许最重要的是确定哪些患者不会回家，但如果PAC的结构不同，并根据他们的需求量身定做，他们可以回家。例如，从PAC重新入院的老年人功能状态恶化，死亡率增加。在我们的初步数据中，超过2/3的PAC再入院发生在出院后的头7天。虽然不是所有这些再入院都是可以预防的，但在出院时它们可能是最可预测和最可修改的。确定与这些事件相关的因素可以确定需要加强护理过渡或在PAC出院前住院更长时间的患者。这项建议首先使用大型数据集的创新应用来评估1)PAC后重返社区(出院100天内)的预测因素；2)长期护理居住地或PAC后死亡；以及3)潜在的可修改因素(例如，preventionofearlyhospitalreadmission)thatifaddressedcouldallow更多的患者在PAC后返回家)。此数据集允许对护理事件(医院、PAC)和付款人(联邦医疗保险、医疗补助)进行纵向评估。我们通过采访医院和PAC临床医生以及患者和他们的照顾者来补充这些发现，以确定在我们的数据集中捕捉不佳的可能影响PAC结果的特征(例如，照顾者支持或家庭环境)。目的是：目的1：确定与PAC预后相关的临床、人口学和功能性患者因素。目的2：了解医院和PAC临床医生和患者如何评估PAC的潜在结果。这项工作对老年人、国家老龄研究所和医疗保健系统至关重要。

 DESCRIPTION (provided by applicant): The number of older adults discharged to post-acute care (PAC) facilities after hospitalization has increased by 50% between 1996 and 2010, and spending on PAC is now the most rapidly growing area of Medicare costs (>$62 billion in 2012). PAC facilities (such as skilled nursing and rehabilitation facilities) exist to rehabilitate older adults with the goal of a successful return to community living, but currently only 28% of Medicare patients who have a PAC stay following hospitalization return to the community within 100 days of hospital discharge. This proposal aims to better inform hospital clinicians, patients, and families at the time of hospital discharge (when the decision to pursue PAC is made) about the patients' likelihood of returning home after a PAC stay, which has far-reaching consequences for the health and functional status of older adults. Identifying older adults who return home from PAC is important because many older adults do not wish to go to a facility following hospital discharge or fear the financial consequences; clear evidence suggesting benefit may alter decision-making and improve outcomes. Identifying older adults who transition to long-term care or die during or following PAC is important for advance care planning. For example, one-third of older adults have a PAC stay in the last six months of their life, and 1 in 11 die during that stay. These adults may not be achieving their desired benefit from PAC. Perhaps most important is identifying patients who do not return home, but could if PAC were structured differently and tailored to their needs. For example, older adults who have a readmission from PAC experience worsened functional status and increased mortality. In our preliminary data, more than 2/3 of all readmissions from PAC occur in the first 7 days following hospital discharge. While not all of these readmissions may be preventable, they may be most predictable and modifiable at the time of hospital discharge. Identifying factors associated with these events may identify patients who need enhanced transitions of care or a longer hospital stay prior to PAC discharge. This proposal first uses an innovative application of a large dataset to evaluate predictors of 1) return to the community post-PAC (within 100 days of hospital discharge); 2) long-term care residence or death post-PAC; and3)potentiallymodifiablefactors(eg,preventionofearlyhospitalreadmission)thatifaddressedcouldallow more patients to return home after PAC. This dataset allows longitudinal evaluation across episodes of care (hospital, PAC) and payors (Medicare, Medicaid). We complement these findings through interviews with hospital and PAC clinicians, and patients and their caregivers, to identify features (e.g. caregiver support or home environment) poorly captured in our dataset that may influence outcomes of PAC. The Aims are: Aim 1: Identify clinical, demographic, and functional patient factors associated with outcomes of PAC. Aim 2: Understand how hospital- and PAC-clinicians and patients evaluate potential outcomes of PAC. This work is of crucial importance to older adults, the National Institute of Aging, and the healthcare system.