Characterizing and Optimizing the Skilled Nursing Facility to Home Transition

2014年，170万按服务收费的医疗保险受益人进入熟练护理设施(SNF)接受治疗 急诊后护理。这些医疗保险受益人包括医疗、心理和社会上的弱势群体 他们中的许多人情况不佳，重新入院治疗。然而，人们对此知之甚少， 关于影响老年人在接受急性后护理后如何过渡到社区的因素 SNF。候选人的职业发展目标是成为优化转型方面的领先专家 老年人从三军到家。培训目标为：目标1，获取患者层面的专业知识 影响老年人跨越健康环境并保持独立性的能力的因素；目标 2、获取有关家庭和门诊卫生服务利用率如何与以下能力相关联的专业知识 老年人在从国家安全部队过渡到家庭后继续留在社区；和目标3，获得专门知识 设计和实施一项干预措施，帮助老年人从SNF过渡到家。 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 并有助于保持老年人的独立性。为了实现这一目标，候选人将进行三次 独立的，但相关的研究。研究1将链接管理数据库(例如，最低数据集、医生部分 B文件、结果和评估信息集)，适用于纽约州医疗保险受益人(n=1,850,000人)。 研究2将检验来自SNF康复居民(n=120)的纵向研究的数据。研究1和研究2 由二手数据分析组成，多变量回归分析将检查患者因素 (包括生理、心理和社会健康领域)和医疗保健利用模式 老年人过渡到社区并留在社区的能力。研究3包括发展一种护理 将干预措施转变为试点试验，对40名从SNF出院的居民进行干预。研究的目的是 因此：研究1目的，使用医疗保险数据来检查患者能力与健康之间的关系 需求、他们对门诊和居家卫生服务的使用，以及在SNF之后在家中的天数 出院；研究2目的，使用来自SNF短期逗留居民的纵向研究数据来表征 躯体功能、抑郁、认知障碍和社会隔离与患者的 过渡到社区并有能力继续留在社区；以及研究3的目标，由 消费者、护理人员、SNF和社区提供者开发并试行护理过渡干预措施 (干预发展阶段分别为Ia和Ib)。 候选人在罗切斯特大学工作，该大学拥有老年学、老年学、卫生学等方面的专家 服务，以及确保这些K23活动取得成功所必需的社区干预措施。发现 这些活动将为以社区为基础的功效研究(第三阶段)提供信息，该研究将有权审查 护理过渡干预在帮助老年人在SNF出院后留在社区的效果。

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.