Post-Acute Care Transitions for Older Adult Medicare Beneficiaries with Serious Mental Illness

项目摘要/摘要 大约150万联邦医疗保险患者在急性呼吸道感染后在熟练的护理设施(SNF)接受护理 每年住院治疗一次。患有严重精神疾病(SMI)的老年人(65岁以上)是一个庞大且不断增长的群体 SNF人群中的一部分，具有特殊需求，使这些人容易受到 关心。了解患有SMI的老年人如何与急性SNF护理相关，以及他们如何过渡 对于确保获得适当水平的服务和高质量的服务，紧急情况下的SNF护理至关重要 整个连续体的护理。到目前为止，很少有关于急性后护理(PAC)的研究 患有SMI的老年人的轨迹。本研究提出了两个目标。首先，我将(1)评估 SNF放置方式因SMI患者不同而不同。这样做的动机是担心医院是众所周知的 与SNF合作伙伴有选择地投资于改善过渡护理实践；如果这些投资不是 与SMI患者被送往哪里接受治疗相一致，随着时间的推移，护理差异可能会持续或恶化。至 评估SNF安置模式，我将描述老年患者从医院到SNF出院的模式 没有(A)狭窄的SMI分组(精神分裂症、双相情感障碍)，以及(B)广泛的SMI分组(狭窄 SMI+严重抑郁、焦虑、强迫症)与医院所针对的情况进行比较 再入院减少计划(HRRP)。患有HRRP疾病的患者是一个有用的对照组，因为他们 代表医院最有可能投资于高质量护理过渡以减少 再次入院的处罚风险。我将使用离散选择模型来评估医院的模式 出院给首选的SNF合作伙伴，以确定患有SMI的老年人是否有平等的机会 医院更首选的SNF合作伙伴，如果这一点因HRRP条件的存在而有所缓和。在我的 第二个目标，我将(2)确定与出院相关的患者、设施和县级特征 患有SMI的老年人在急性发作后100天内进入社区。表征相关因素 考虑到服务的重要性，回归社区而不是转换为长期停留(100天以上)是很重要的 在家庭或社区提供的服务具有更高的价值，并与患者的偏好保持一致。我将使用 三水平混合效应模型用于确定与患有SMI的老年人是否出院相关的因素 在特种部队逗留后的社区。这项研究量化了(1)患有SMI的老年患者如何分类 SNF；以及(2)与社区出院相关的患者、设施和县级地理因素 在SNF逗留之后，这是高质量护理的重要组成部分。通过确定患有SMI的老年人 接受SNF护理以及这如何影响他们的护理轨迹，这项工作将产生关键的见解，旨在 指导决策者和组织领导人评估和改进薪酬/激励措施 影响向这一人群提供护理服务的结构和监管要求。

PROJECT SUMMARY/ABSTRACT Roughly 1.5 million Medicare patients receive care in a skilled nursing facility (SNF) following acute hospitalization each year. Older adults (65+ years) with serious mental illness (SMI) are a large and growing segment of the SNF population, with specific needs that leave these individuals vulnerable to gaps or errors in care. Understanding how older adults with SMI are connected to post-acute SNF care and how they transition out of post-acute SNF care is essential to ensuring access to an appropriate level of services and high-quality care across the continuum. To date, there has been little work characterizing the post-acute care (PAC) trajectory of older adults with SMI. This study proposes two aims. First, I will (1) assess the extent to which SNF placement patterns differ for patients with SMI. This is motivated by the concern that hospitals are known to invest selectively with SNF partners in improved transitional care practices; if these investments are not aligned with where patients with SMI are sent for care, care disparities may persist or worsen over time. To assess SNF placement patterns, I will describe patterns of hospital to SNF discharge for older adults with and without (a) narrow groupings of SMI (schizophrenia, bipolar disorder), and (b) broad groupings of SMI (narrow SMI + major depression, anxiety, compulsive disorders) as compared to conditions targeted by the hospital readmission reduction program (HRRP). Patients with HRRP conditions are a useful comparison group as they represent populations where hospitals are most likely to have invested in high-quality care transitions to reduce the risk of penalties for hospital readmission. I will use a discrete choice model to evaluate patterns of hospital discharge to preferred-SNF partners to determine whether older adults with SMI have equitable access to hospitals’ more preferred SNF partners, and if this is moderated by the presence of HRRP conditions. In my second aim, I will (2) identify patient-, facility-, and county-level characteristics associated with discharge of older adults with SMI to the community within the 100-day post-acute period. Characterizing factors associated with return to community rather than conversion to long-stay (100+ days) is important given that services provided in the home or community are of higher value and in alignment with patient preferences. I will use a three-level mixed effects model to identify factors related to whether an older adult with SMI is discharged to the community following a SNF stay. This research quantifies (1) how older adult patients with SMI sort into SNFs; and (2) patient, facility, and county-level geographic factors associated with community discharge following a SNF stay, an important component of high-quality care. By identifying where older adults with SMI receive SNF care and how this influences their care trajectory, this work will generate key insights meant to guide policymakers and organizational leaders in the evaluation and improvement of payment/incentive structures and regulatory requirements that affect care delivery for this population.