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

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PROJECT SUMMARY/ABSTRACT The primary objective of this application is to support Dr. Weerahandi's career development from a mentored researcher to an independent clinician-investigator focused on improving patient outcomes by targeting poor transitions and failures of care coordination. This K23 award will provide her with the support needed to accomplish the following goals: (1) to develop skills in mixed methods research, (2) to conduct investigations using large databases to identify systems level areas for intervention to improve transitions, (3) to implement advanced biostatistical models in health services research, (4) to become an expert in health services research on the post-acute management of heart failure (HF) patients. To achieve these goals, she has assembled a multidisciplinary mentoring team. Dr. Horwitz, her primary mentor, is an accomplished clinician- investigator focused on improving healthcare systems. Dr. Jones, her co-mentor, is a statistician who will supervise Dr. Weerahandi's training in advanced survival analyses methods. Her scientific advisors include Dr. Boxer, an experienced health services researcher in the area of HF management in skilled nursing facilities (SNF) and Dr. Dodson, a geriatric cardiologist who will oversee Dr. Weerahandi's training in geriatric HF management. Discharge to SNF is common in HF patients, occurring in 1 in 5 Medicare beneficiaries after HF admission. Despite the prevalence of discharge to SNF, little is known about the transition from SNF to home. While studies have examined the transition from hospital to home, the quality of the specific transition from SNF to home for patients with HF is unknown. Ideally, transitional care should occur when patients are discharged from SNF to home. Yet it is uncertain to what degree and with what quality such practices are performed. The research objective of this application is to better characterize discharge process quality during the transition from SNF to home after a HF hospitalization. Dr. Weerahandi will conduct a convergent mixed-methods study to assess discharge process quality from SNF to home by interviewing staff, patients, and caregivers; and examining discharge instructions elements (Aim 1). While Dr. Weerahandi's long term goal is to create effective systems level interventions to improve this transition, patient level factors that may drive readmission and mortality in Medicare populations must also be accounted for, particularly degree of frailty and cognitive impairment. Informed by her preliminary data, she will conduct a retrospective cohort study using Medicare data linked with the Minimum Dataset to determine if frailty score or degree of cognitive impairment are associated with adverse events following the transition from SNF to home after HF hospitalization (Aim 2). This research plan takes advantage of existing resources including Dr. Horwitz's AHRQ- funded research group, Dr. Boxer's NHLBI-funded research group and the NYU CTSA.