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Tytuł:
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Outcomes of a Nursing Home-to-Community Care Transition Program.
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Autorzy:
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Takahashi PY; Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA. Electronic address: .
Chandra A; Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA.
McCoy RG; Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
Borkenhagen LS; Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA.
Larson ME; Employee and Community Health, Mayo Clinic, Rochester, MN, USA.
Thorsteinsdottir B; Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA.
Hickman JA; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
Swanson KM; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
Hanson GJ; Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA; Division of Community Palliative Medicine, Mayo Clinic, Rochester, MN, USA.
Naessens JM; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Źródło:
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Journal of the American Medical Directors Association [J Am Med Dir Assoc] 2021 Dec; Vol. 22 (12), pp. 2440-2446.e2. Date of Electronic Publication: 2021 May 11.
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Typ publikacji:
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Controlled Clinical Trial; Journal Article; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't
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Język:
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English
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Imprint Name(s):
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Publication: 2005- : [New York?] : Elsevier
Original Publication: Hagerstown, MD : Lippincott Williams & Wilkins, c2000-
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MeSH Terms:
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Patient Transfer*
Transitional Care*
Aged ; Aged, 80 and over ; Hospitalization ; Humans ; Patient Discharge ; Patient Readmission ; Retrospective Studies ; Skilled Nursing Facilities
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References:
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Grant Information:
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K23 AG051679 United States AG NIA NIH HHS; K23 DK114497 United States DK NIDDK NIH HHS; UL1 TR000135 United States TR NCATS NIH HHS
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Contributed Indexing:
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Keywords: Care transition; emergency department; hospitalization; nursing home
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Entry Date(s):
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Date Created: 20210513 Date Completed: 20220107 Latest Revision: 20220531
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Update Code:
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20240105
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PubMed Central ID:
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PMC8581072
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DOI:
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10.1016/j.jamda.2021.04.010
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PMID:
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33984293
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Objectives: Most transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes.
Design: Propensity-matched control-intervention trial.
Intervention: Patients in the intervention group received care management following nursing stay (a home visit and nursing phone calls).
Setting and Participants: Patients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention because of refusal, program capacity, or distance. Patients were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF.
Methods: Program enrollees were matched through propensity score to nonenrollees on the basis of age, sex, comorbid health burden, and mortality risk score. Conditional logistic regression analysis examined 30-day hospitalization and emergency department (ED) use; Cox proportional hazards analyses examined 180-day hospital stay and ED use.
Results: Each group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years]. Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and 3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for program patients compared with 11.3% and 25.0% in the comparison group (P < .001).
Conclusions and Implications: We found no evidence of reduced hospitalization or ED visits by program patients vs the comparison group. Such findings are crucial because they illustrate how aggressive stabilization care within the SNF may mitigate the program role. Furthermore, we found higher ED and hospitalization rates at 180 days in program patients than the comparison group.
(Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)
