The Coming Home After Rehabilitation and Transition from a Skilled nursing facility with Dementia Study (The CHARTS-D Study)

越来越多的阿尔茨海默病和相关痴呆（ADRD）患者正在接受治疗后， 专业护理机构（SNF）的住院护理。大多数人将从SNF转移到家中。虽然 人们对病人从医院到家的过渡给予了很大的关注， 很少有关于从SNF到家庭的过渡的研究。经历了从家到医院的多次过渡 对于ADRD患者及其护理人员来说，SNF和回家是困难的。从SNF出院后， 在家中，患者可能会重新进入过渡周期，遭受不利后果，如住院 再入院、用药错误、功能衰退和丧失独立性。 该项目将确定与30天再入院和其他不良结局相关的因素， 从SNF过渡到家庭的ADRD患者。我们将使用健康和退休研究（HRS）， 一个大型的全国性数据集，其中包括丰富的社会和经济信息，这些信息与 不良健康后果。我们的研究利用了HRS和医疗保险中心之间的联系 和医疗补助服务账单数据，特别是SNF停留期间收集的大量数据的链接， 最小数据集和家庭健康事件数据的结果和评估信息集。 对于目标1，我们将描述ADRD诊断与SNF中认知障碍严重程度的关系 对于从SNF过渡到家庭的患者，我们假设， 当控制Andersen模型因素时，ADRD的再入院风险更大。我们也 我建议，在患者留在SNF期间测量的更严重的认知障碍水平，将是 与更大的再入院风险相关。对于目标2，我们将确定早期门诊护理的效果， 无论是在诊所访问或通过家庭健康访问，减少再入院。我们假设早期门诊病人 护理可防止再入院。这是确定干预措施的第一步， 接受这种复杂医疗保健轨迹的ADRD患者的再入院率。 博士卡纳汉的职业发展计划将提供研究方法和卫生政策方面的全面培训 与老年ADRD患者的过渡有关。作为一名在SNF领域拥有专业知识的新兴衰老研究人员， Carnahan博士将利用这项研究的结果来设计一种干预措施， 经历这种复杂的医疗保健轨迹的认知受损患者的健康结果。她长长 长期目标是改善ADRD老年人的护理质量和健康结果。

Increasing numbers of patients with Alzheimer’s disease and related dementias (ADRD) are receiving post- hospitalization care in skilled nursing facilities (SNFs). Most will transition from the SNF to home. Although there has been a great deal of attention paid to patients’ transition from the hospital to home, there has been little research on transitions from the SNF to home. Experiencing multiple transitions from home to the hospital to a SNF and back to home is difficult for patients with ADRD and their caregivers. After discharge from SNF to home, patients may re-enter the cycle of transitions, suffering adverse outcomes such as hospital readmissions, medication errors, functional decline, and loss of independence. This project will identify factors associated with 30-day hospital readmission and other adverse outcomes for patients with ADRD who transition from the SNF to home. We will use the Health and Retirement Study (HRS), a large, national dataset that includes rich social and economic information that is pertinent to the risk of adverse health outcomes. Our study takes advantage of the link between the HRS and Centers for Medicare and Medicaid Services billing data, and especially the link to extensive data collected during SNF stay as part of the Minimum Data Set and home health event data from the Outcome and Assessment Information Set. For Aim 1, we will describe the relationship of ADRD diagnosis or severity of cognitive impairment in the SNF with hospital readmission for patients who transition from SNF to home. We hypothesize that individuals with ADRD are at greater risk of hospital readmission when controlling for Andersen model factors. We also propose that worse levels of cognitive impairment, as measured during a patient’s stay in the SNF, will be associated with greater risk readmission risk. For Aim 2, we will identify the effect of early outpatient care, either in clinic visit or via home health visit, on reducing readmissions. We hypothesize that early outpatient care is protective against readmission. This represents a first step in identifying interventions to reduce readmissions for people with ADRD who undergo this complex healthcare trajectory. Dr. Carnahan’s career development plan will provide thorough training in research methods and health policy related to transitions for older adults with ADRD. As an emerging aging researcher with expertise in the SNF to home care transition, Dr. Carnahan will use the results of this study to design an intervention that improves the health outcomes of cognitively impaired patients who experience this complex healthcare trajectory. Her long term goal is to improve the quality of care and health outcomes for older adults with ADRD.