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

项目总结/摘要 许多老年患者在住院治疗后出院到专业护理机构（SNF），以改善其健康状况。 因此，他们可能会在30天内从SNF到家中进行第二次过渡， 出院天数。尽管出院到SNF的流行，但对从SNF到SNF的过渡知之甚少。 SNF回家我们以前证明，近四分之一的患者从SNF出院回家， 心力衰竭住院后，在SNF出院后30天内再次入院。这种高比例的 临时SNF患者的再入院表明，需要进一步的工作来检查从 SNF回家，并确定SNF出院后再住院的驱动因素。 Weerahandi博士的长期目标是创建有效的系统级干预措施，以改善过渡 照顾。由疾病状态如阿尔茨海默病和相关疾病引起的认知障碍和虚弱 痴呆（AD/ADRD）是医院到家庭过渡中不良事件的风险因素， 影响从SNF到家庭的过渡。理想情况下，这些因素应在从SNF出院时得到解决 以确保安全过渡回家然而，这些做法的程度和质量如何， 如果他们是根据AD/ADRD患者的需要进行的， 本行政补充的目的是（1）建立在博士的研究基础设施。 Weerahandi的职业发展奖，以研究从SNF到家庭的过渡， AD/ADRD患者和（2）扩大Weerahandi博士的研究计划，重点关注以下方面的结果： 在治疗过渡期间不良结局风险特别高的患者：AD/ADRD患者。 这笔补充资金将用于分析医疗保险数据，以确定重新入院的风险。 AD/ADRD患者的SNF回家，并评价SNF出院的质量和经验 这些患者的过程。

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.