Predicting and Identifying Risk Factors for Short Time at Home in Older Adults after Hospitalization

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ABSTRACT The time after hospitalization is a critical window for older adults recovering from acute medical problems. Roughly 1 in 5 Medicare beneficiaries are discharged from hospital to skilled nursing facilities (SNFs) for post- acute care and rehabilitation, accounting for over 2 million stays annually. Although SNF stays are intended to restore independence and function, many patients cycle between re-hospitalizations and SNF in a downward spiral. Time at home quantifies this phenomenon of being ‘rehabbed to death’ by counting the number of days spent alive in the community, out of the hospital or SNF. However, tools that assess risk for short time at home have not been developed in the SNF setting, and identifying these can inform the design of interventions. Frailty is a common state of vulnerability known to increase risks of hospitalizations and mortality among older adults. Although rehabilitation interventions improve function and outcomes among non-frail adults in outpatient settings, frail compared to more robust older adults do not benefit from the same rehabilitation approaches. Moreover, whether modifiable risk factors such as delirium, depression, and potentially inappropriate medications (PIMs), independently impact short time at home in the setting of frailty is unclear. Thus, frailty measures have the potential to risk-stratify rehabilitation patients for short time at home while informing targeting of meaningful and efficacious interventions. This proposal aims to elucidate predictors of short time at home after SNF discharge among well- established frailty measures and modifiable risk factors. This research will leverage an existing dataset of a nationally representative cohort of Medicare beneficiaries, the National Health and Aging Trends Study (NHATS) linked to Medicare claims. The specific aims are to: 1) Assess and compare the ability of two measures of pre-hospitalization frailty to predict short time at home after post-acute SNF rehabilitation, in a nationally representative cohort of Medicare beneficiaries, and 2) Identify modifiable risk factors (delirium, depression, PIMs, rehabilitation characteristics) that are independently associated with short time at home after post-acute SNF rehabilitation. IMPACT: This award will support the principal investigator’s (PI’s) early career development and pathway to becoming a national leader in geriatric post-acute SNF rehabilitation. As a geriatrician with experience in aging research, Dr. Shi will acquire new insight and perspective from rehabilitation medicine and develop the skills to design and lead multidisciplinary SNF rehabilitation interventions. This proposal is supported by a collaborative team of highly experienced mentors and a rich research environment. The research and training will provide the PI with foundational knowledge in longitudinal data analysis, risk stratification, and modifiable risk factors for short time at home after SNF rehabilitation. In doing so, it will lead to the next logical step: designing and evaluating a tailored intervention guided by the frailty status of older patients, maximizing their time at home.