Characteristics of Transitions from Skilled Nursing Facility to Home Following Heart Failure Hospitalization

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Project Summary/Abstract Many older patients are discharged to a skilled nursing facility (SNF) after hospitalization to improve function before returning home; consequently, they may incur a second transition, from SNF to home, within 30 days of hospital discharge. Despite the prevalence of discharge to SNF, little is known about the transition from SNF to home. We previously demonstrated that almost a quarter of patients discharged from SNF to home after heart failure hospitalization were readmitted within 30 days of SNF discharge. This high proportion of readmissions among temporary SNF patients suggests further work is needed to examine the transition from SNF to home and to identify drivers of rehospitalization after SNF discharge. Dr. Weerahandi’s long term goal is to create effective systems level interventions to improve transitions of care. Cognitive impairment and frailty resulting from disease states such as Alzheimer’s disease and related dementias (AD/ADRD) are a risk factors for adverse events in the hospital to home transition, and likely also affects the transition from SNF to home. Ideally, these factors should be addressed upon discharge from SNF to ensure a safe transition home. Yet it is uncertain to what degree and with what quality such practices are performed and if they are tailored to the needs of those with AD/ADRD. The objectives of this administrative supplement are to (1) build on the research infrastructure from Dr. Weerahandi’s career development award to study the transition from SNF to home after hospitalization in patients with AD/ADRD and (2) to expand Dr. Weerahandi’s research program to focus on outcomes for patients that are at particularly high risk of adverse outcomes during care transitions: patients with AD/ADRD. Funding from this supplement will be used to analyze Medicare data to determine the risk of readmission from SNF to home for patients with AD/ADRD and evaluate the quality and experience of the SNF discharge process for these patients.