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

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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.