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

 描述（由申请人提供）：1996年至2010年间，住院后出院到急性后护理（PAC）机构的老年人数量增加了50%，PAC支出现在是医疗保险成本增长最快的领域（2012年超过620亿美元）。PAC设施（如熟练的护理和康复设施）的存在，以康复老年人的目标是成功返回社区生活，但目前只有28%的医疗保险患者有PAC住院后返回社区100天内出院。该提案旨在更好地告知医院临床医生，患者和家属在出院时（决定进行PAC时），患者在PAC停留后返回家中的可能性，这对老年人的健康和功能状态具有深远的影响。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担心经济后果;明确的证据表明，益处可能会改变决策并改善结果。确定过渡到长期护理或在PAC期间或之后死亡的老年人对于提前护理规划非常重要。例如，三分之一的老年人在生命的最后六个月内有PAC停留，11人中有1人在停留期间死亡。这些成年人可能无法从PAC中获得预期的益处。也许最重要的是确定那些不回家的病人，但如果PAC的结构不同，并根据他们的需求量身定制，他们就可以回家。例如，老年人谁有一个从PAC经验再入院恶化的功能状态和死亡率增加。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前7天。虽然并非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改变的。识别与这些事件相关的因素可能会识别出需要加强护理过渡或在PAC出院前延长住院时间的患者。该提案首先使用了一个大型数据集的创新应用，以评估以下预测因素：1）PAC后返回社区（出院后100天内）; 2）PAC后长期护理住院或死亡;以及3）潜在的可修改因素（例如，预防恐惧再入院），这些因素的解决可以让更多的患者在PAC后返回家中。该数据集允许跨护理事件（医院，PAC）和支付方（Medicare，Medicaid）进行纵向评估。我们通过与医院和PAC临床医生以及患者及其护理人员的访谈来补充这些发现，以确定我们数据集中可能影响PAC结果的特征（例如护理人员支持或家庭环境）。目的1：确定与PAC结局相关的临床、人口统计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，国家老龄化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.