Characterizing and Optimizing the Skilled Nursing Facility to Home Transition

表征和优化熟练护理设施到家庭的过渡

• 批准号: 10213604
• 负责人: Adam C Simning
• 金额: $ 18.61万
• 依托单位: UNIVERSITY OF ROCHESTER
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-07-01 至 2023-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10213604
• 关键词: Acute; Address; Admission activity; Affect; Aging; Back; Caregivers; Caring; Catheters; Communities; Complement 2; Continuous Positive Airway Pressure; Data; Data Analyses; Data Set; Databases; Development; Dialysis procedure; Elderly; Ensure; Failure; Fee-for-Service Plans; Geriatrics; Gerontology; Goals; Health; Health Personnel; Health Services; Home; Impaired cognition; Impairment; Individual; Injectable; Inpatients; Intervention; Length of Stay; Link; Literature; Long-Term Care; Longitudinal Studies; Measures; Medical; Medicare; Mental Depression; Mentors; Modeling; New York; Ostomy; Outcome; Outcome Assessment; Outcomes Research; Outpatient Health Services; Outpatients; Oxygen; Patients; Pattern; Pharmaceutical Preparations; Physical Function; Physicians; Process; Provider; Regression Analysis; Rehabilitation therapy; Research; Research Project Grants; Risk; Risk Factors; Services; Skilled Nursing Facilities; Social isolation; Social support; Testing; Theoretical model; Time; Tracheostomy procedure; Training; United States National Institutes of Health; Universities; Variant; Vulnerable Populations; Workload; acute care; administrative database; base; beneficiary; cancer therapy; career development; cost; design; efficacy study; feasibility testing; health care delivery; health care quality; health care service utilization; health care settings; health service use; hospital readmission; interest; intervention effect; patient home care; programs; psychologic; recruit; secondary analysis; service providers; service utilization; social; social vulnerability; success; therapy design; therapy development; wound care

In 2014, 1.7 million fee-for-service Medicare beneficiaries were admitted to skilled nursing facilities (SNFs) for post-acute care. These Medicare beneficiaries comprise a medically, psychologically, and socially vulnerable group and, following SNF discharge, many of them fare poorly and are rehospitalized. Little is known, however, about the factors that influence how older adults transition into the community after receiving post-acute care in SNFs. The candidate's career development goal is to become a leading expert on optimizing the transition of older adults from the SNF to home. The Training Objectives are: Objective 1, Obtain expertise on patient-level factors affecting an older adult's ability to transition across health settings and maintain independence; Objective 2, Obtain expertise on how in-home and outpatient health services utilization is associated with the ability of older adults to remain in the community following the SNF-to-home transition; and Objective 3, Obtain expertise in designing and conducting an intervention to help older adults transition from the SNF to home. The candidate's long-term research goal is to develop an intervention that optimizes the SNF-to-home transition and helps maintain the independence of older adults. To realize this goal, the candidate will conduct three separate, but related studies. Study 1 will link administrative databases (e.g., Minimum Data Set, Physician Part B File, Outcome and Assessment Information Set) for New York State Medicare beneficiaries (n=1,850,000). Study 2 will examine data from a longitudinal study of SNF rehabilitation residents (n=120). Studies 1 and 2 consist of secondary data analyses for which multivariable regression analyses will examine patient factors (encompassing physical, psychological, and social health domains) and healthcare utilization patterns that affect an older adult's ability to transition to and remain in the community. Study 3 consists of developing a care transitions intervention to pilot test in 40 residents being discharged from an SNF. The Research Aims are thereby: Study 1 Aim, Use Medicare data to examine the relationships between patients' capacity and health needs, their use of outpatient and in-home health services, and the number of days at home following SNF discharge; Study 2 Aim, Use data from a longitudinal study of SNF short-stay residents to characterize the association of physical functioning, depression, cognitive impairment, and social isolation with the patients' transition to and ability to remain in the community; and Study 3 Aim, With guidance from an Advisory Panel of consumers, caregivers, and SNF and community providers, develop and pilot test a care transitions intervention (intervention development Stages Ia and Ib, respectively). The candidate is based at University of Rochester, which has the experts in geriatrics, gerontology, health services, and community-based interventions necessary to ensure the success of these K23 activities. Findings from these activities will inform a community-based efficacy study (Stage III) that will be powered to examine the care transition intervention's effect on helping older adults remain in the community following SNF discharge.

2014年，有170万名按服务收费的医疗保险受益人进入了熟练护理机构（SNF）， 急性期后护理这些医疗保险受益人包括医疗、心理和社会弱势群体， 在SNF出院后，他们中的许多人情况不佳，再次住院。然而，鲜为人知的是， 关于影响老年人在接受急性期后护理后如何过渡到社区的因素， SNFs。候选人的职业发展目标是成为一个领先的专家，优化过渡， 老人从SNF回家。培训目标是：目标1，获得患者层面的专业知识 影响老年人跨健康环境过渡和保持独立能力的因素;目的 2.获得关于家庭和门诊卫生服务利用率如何与以下能力相关的专业知识： 老年人在从SNF到家庭的过渡后留在社区;和目标3，获得专业知识 设计和实施干预措施，帮助老年人从SNF过渡到家庭。 候选人的长期研究目标是开发一种干预措施，优化SNF到家庭的过渡 帮助老年人保持独立性。为了实现这一目标，候选人将进行三个 独立但相关的研究。研究1将链接管理数据库（例如，最小数据集，医生部分 B文件，结果和评估信息集）的纽约州医疗保险受益人（n=1,850,000）。 研究2将检查SNF康复居民（n=120）的纵向研究数据。研究1和2 包括二次数据分析，多变量回归分析将检查患者因素 （包括身体，心理和社会健康领域）和医疗保健利用模式，影响 老年人过渡到社区并留在社区的能力。研究3包括制定一项护理计划， 在40名从SNF出院的居民中将干预过渡到试点测试。研究目的是 因此：研究1的目的是，使用医疗保险数据来检查患者的能力和健康之间的关系 需要，他们使用门诊和家庭卫生服务，以及SNF后在家的天数 研究2目的，使用SNF短期居留居民纵向研究的数据来描述 身体功能、抑郁、认知障碍和社会孤立与患者的 过渡到社区和留在社区的能力;以及研究3目标，在咨询小组的指导下， 消费者、护理者、SNF和社区提供者，制定并试点测试护理过渡干预措施 （干预发展阶段Ia和Ib）。 候选人来自罗切斯特大学，该大学拥有老年医学、老年学、健康 服务和社区干预措施，以确保这些K23活动的成功。结果 这些活动将为一项以社区为基础的疗效研究（第三阶段）提供信息，该研究将有能力检查 护理过渡干预对帮助老年人在SNF出院后留在社区的影响。