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

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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.