Post-acute Care Facilities Research Articles

The Great Outdoors Are Good for Everyone, Especially in a Post-Acute and Long-Term Care Facility

The Great Outdoors Are Good for Everyone, Especially in a Post-Acute and Long-Term Care Facility

Passing the SNF Test: A Secondary Analysis of a Sepsis Transition Intervention Trial Among Patients Discharged to Post-Acute Care.

Sepsis survivors discharged to post-acute care facilities experience high rates of mortality and hospital readmission. This study compared the effects of a Sepsis Transition and Recovery (STAR) program vs usual care (UC) on 30-day mortality and hospital readmission among sepsis survivors discharged to post-acute care. Secondary analysis of a multisite pragmatic randomized clinical trial. Sepsis survivors discharged to post-acute care. We conducted a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) randomized clinical trial who were discharged to post-acute care. IMPACTS evaluated the effectiveness of STAR, a nurse-navigator-led program to deliver best practice post-sepsis care. Subjects were randomized to receive either STAR or UC. The primary outcome was 30-day readmission and mortality. We also evaluated hospital-free days alive as a secondary outcome. Of 691 patients enrolled in IMPACTS, 175 (25%) were discharged to post-acute care [143 (82%) to skilled nursing facilities, 12 (7%) to long-term acute care hospitals, and 20 (11%) to inpatient rehabilitation]. Of these, 87 received UC and 88 received the STAR intervention. The composite 30-day all-cause mortality and readmission endpoint occurred in 26 (29.9%) patients in the UC group vs 18 (20.5%) in the STAR group [risk difference-9.4% (95% CI-22.2 to 3.4); adjusted odds ratio 0.58 (95% CI 0.28 to 1.17)]. Separately, 30-day all-cause mortality was 8.1% in the UC group compared with 5.7% in the STAR group [risk difference-2.4% (95% CI-9.9 to 5.1)] and 30-day all-cause readmission was 26.4% in the UC group compared with 17.1% in the STAR program [risk difference-9.4% (95% CI-21.5 to 2.8)]. There are few proven interventions to reduce readmission among patients discharged to post-acute care facilities. These results suggest the STAR program may reduce 30-day mortality and readmission rates among sepsis survivors discharged to post-acute care facilities.

Traditional definition of healthcare-associated influenza underestimates cases associated with other healthcare exposures in a population-based surveillance system.

To provide comprehensive population-level estimates of the burden of healthcare-associated influenza. Retrospective cross-sectional study. US Influenza Hospitalization Surveillance Network (FluSurv-NET) during 2012-2013 through 2018-2019 influenza seasons. Laboratory-confirmed influenza-related hospitalizations in an 8-county catchment area in Tennessee. The incidence of healthcare-associated influenza was determined using the traditional definition (ie, positive influenza test after hospital day 3) in addition to often underrecognized cases associated with recent post-acute care facility admission or a recent acute care hospitalization for a noninfluenza illness in the preceding 7 days. Among the 5,904 laboratory-confirmed influenza-related hospitalizations, 147 (2.5%) had traditionally defined healthcare-associated influenza. When we included patients with a positive influenza test obtained in the first 3 days of hospitalization and who were either transferred to the hospital directly from a post-acute care facility or who were recently discharged from an acute care facility for a noninfluenza illness in the preceding 7 days, we identified an additional 1,031 cases (17.5% of all influenza-related hospitalizations). Including influenza cases associated with preadmission healthcare exposures with traditionally defined cases resulted in an 8-fold higher incidence of healthcare-associated influenza. These results emphasize the importance of capturing other healthcare exposures that may serve as the initial site of viral transmission to provide more comprehensive estimates of the burden of healthcare-associated influenza and to inform improved infection prevention strategies.

Annals for Hospitalists - April 2023

Annals for Hospitalists - April 2023

Is malnutrition as defined by the glim criteria a prognostic factor in the COVID-19 frail elderly hospitalized in a post-acute care facility?

Is malnutrition as defined by the glim criteria a prognostic factor in the COVID-19 frail elderly hospitalized in a post-acute care facility?

Number of Stairs at Home is Associated with Discharge to Post-Acute Care Facility Following Total Knee Arthroplasty

Background Discharge to post-acute care facility (PACF) carries significant cost and quality burdens to patients undergoing total knee arthroplasty (TKA). In a recent study of pre-bundled payment model patients, the number of stairs (NOS) at home did not influence discharge to PACF for total hip arthroplasty. However, no study has yet examined NOS as it relates to discharge destination after TKA. In a large metropolitan market, it is not uncommon to have several flights of stairs leading to a home. We hypothesize that the number of unavoidable stairs to enter a home is a significant risk factor for discharge to PACF. Methods We reviewed 557 patients who underwent elective TKA at a single urban academic medical center between November 2011 and October 2014. Demographic data as well as NOS, ASA score, RAPT score, LOS, operative time, and tranexamic acid use were collected. T-tests, ANOVA, and Kruskal-Wallis analysis were conducted followed by a logistic regression to compare associations of factors to discharge to PACF. Results Of the 540 patients included in analysis, 193 (35.7%) were discharged home and 347 (64.3%) were discharged to a PACF. NOS (OR=1.457, p<0.001) and increased age (OR=1.057, p<0.001) were found to be significant risk factors for discharge to PACF while female sex (OR=0.57, p=0.013) and higher RAPT scores (OR=0.83, p=0.004) were protective against discharge to PACF. Conclusion With the conclusion of recent bundled payment programs, financial carrots may disappear, though it is likely that sticks will remain. Therefore, all risk factors must be identified and addressed. We found, in a pre-bundled payments era, that stairs is a risk factor for non-home discharge in a metropolitan population, and we confirmed other known risk factors of older age, higher ASA score, and lower RAPT score.

Effect of the population health inpatient Medicare Advantage pharmacist intervention on hospital readmissions: A quasi-experimental controlled study

BACKGROUND: The population health inpatient Medicare Advantage pharmacist (PHIMAP) intervention is a pharmacist-led, transitions-of-care intervention that aims to reduce hospital readmissions among Medicare Advantage beneficiaries. PHIMAP includes inpatient pharmacist participation in interdisciplinary rounds, admission and discharge medication reconciliation, pharmacy staff delivery of discharge medications to the bedside, personalized discharge medication lists and counseling, and communication with outpatient pharmacists through an electronic health record. OBJECTIVE: To evaluate the effect of the PHIMAP intervention on unplanned 30-day same-hospital readmissions among Medicare Advantage patients. METHODS: Those included were patients admitted to a large urban academic medical center between May 2018 and March 2020 who had a Medicare Advantage plan and were aged at least 18 years. A 2-group, quasi-experimental design was utilized. Control patients received the usual care, which included a best possible medication history and a postdischarge phone call. A multivariable logistic regression model was estimated to predict unplanned 30-day same-hospital readmissions. This study was a Hypothesis Evaluating Treatment Effectiveness study. RESULTS: In total, 884 patients were included. The majority were White (59.0%), non-Hispanic (87.7%), English speaking (90.5%), and older adults (median age, 75 years; interquartile range, 70-83 years). We detected no statistically significant association between the PHIMAP intervention and unplanned 30-day same-hospital readmissions (odds ratio [OR] = 0.91, 95% CI = 0.56-1.52). After adjusting for patient demographics and clinical covariates, significant predictors of 30-day readmissions included the number of emergency department/inpatient visits within 180 days prior to index admission (OR = 1.40, 95% CI = 1.11-1.77); discharge to a post-acute care facility, such as an inpatient rehabilitation facility, long-term acute care facility, or skilled nursing facility (OR = 1.69, 95% CI = 1.06-2.66); hospital length of stay in days (OR = 1.04, 95% CI=1.01-1.07); and the Agency for Healthcare Research and Quality Elixhauser Comorbidity Index score (OR = 1.01, 95% CI = 1.01-1.02). CONCLUSIONS: Significant predictors of readmissions among Medicare Advantage beneficiaries were consistent with greater illness severity, including a recent history of prior hospital utilization, a discharge to post-acute care facility (vs home), a longer length of hospital stay, and a higher comorbidity burden. Although we detected no statistically significant association between PHIMAP and unplanned 30-day same-hospital readmissions, differences in study group assignment based on the day of hospital discharge (weekend vs weekday) was a noted limitation of this study. Future studies of inpatient pharmacist-led interventions should plan to minimize the risk of selection bias due to differences in the time of patient discharge. DISCLOSURES: This study was supported in part by the National Institute on Aging under award number R01AG058911 (to Pevnick) and the UCLA Clinical Translational Science Institute (UL1 TR001881). The sponsor had no role in the design and conduct of the study, nor the writing of this report.

Design, Development, and Evaluation of an Automated Solution for Electronic Information Exchange Between Acute and Long-term Postacute Care Facilities: Design Science Research.

Information exchange is essential for transitioning high-quality care between care settings. Inadequate or delayed information exchange can result in medication errors, missed test results, considerable delays in care, and even readmissions. Unfortunately, long-term and postacute care facilities often lag behind other health care facilities in adopting health information technologies, increasing difficulty in facilitating care transitions through electronic information exchange. The research gap is most evident when considering the implications of the inability to electronically transfer patients' health records between these facilities. This study aimed to design and evaluate an open standards-based interoperability solution that facilitates seamless bidirectional information exchange between acute care and long-term and postacute care facilities using 2 vendor electronic health record (EHR) systems. Using the design science research methodology, we designed an interoperability solution that improves the bidirectional information exchange between acute care and long-term care (LTC) facilities using different EHR systems. Different approaches were applied in the study with a focus on the relevance cycle, including eliciting detailed requirements from stakeholders in the health system who understand the complex data formats, constraints, and workflows associated with transferring patient records between 2 different EHR systems. We performed literature reviews and sought experts in the health care industry from different organizations with a focus on the rigor cycle to identify the components relevant to the interoperability solution. The design cycle focused on iterating between the core activities of implementing and evaluating the proposed artifact. The artifact was evaluated at a health care organization with a combined footprint of acute and postacute care operations using 2 different EHR systems. The resulting interoperability solution offered integrations with source systems and was proven to facilitate bidirectional information exchange for patients transferring between an acute care facility using an Epic EHR system and an LTC facility using a PointClickCare EHR system. This solution serves as a proof of concept for bidirectional data exchange between Epic and PointClickCare for medications, yet the solution is designed to expand to additional data elements such as allergies, problem lists, and diagnoses. Historically, the interoperability topic has centered on hospital-to-hospital data exchange, making it more challenging to evaluate the efficacy of data exchange between other care settings. In acute and LTC settings, there are differences in patients' needs and delivery of care workflows that are distinctly unique. In addition, the health care system's components that offer long-term and acute care in the United States have evolved independently and separately. This study demonstrates that the interoperability solution improves the information exchange between acute and LTC facilities by simplifying data transfer, eliminating manual processes, and reducing data discrepancies using a design science research methodology.

Too Many Walls and Not Enough Bridges: Care Transitions Models to Support Older Adults with Mental Illness and Cognitive Impairment

Challenges in transitions of care can lead to increased morbidity, mortality, and increased health care costs. In particular, older adults with mental illness (MI) or cognitive impairment (CI) are particularly vulnerable when transitioning from different health care settings and back to the community. For instance, almost half of older adults with cognitive impairment who are discharged home from the emergency department return within 30 days. Similarly, older adults with MI and CI admitted to a skilled nursing facility are less likely to be discharged and, if discharged, spend less time in the community. Importantly, these outcomes mediated by the presence of depression, agitation, and functional impairment, highlighting the need for interventions that provide symptom management and address frailty.Some interventions have been shown to improve transitions from acute care to post-acute care. The Institute for Health Improvement Age Friendly Health System Initiative incorporates the 4 M model of what matters most, mobility, medications, and mentation framework in order to bring to together evidenced based initiatives that improve safety and outcomes for older adults. These interventions embed comprehensive geriatric care throughout the care continuum: hospitals, transitions out of hospitals, and post-acute and long-term care facilities. Other interventions have utilized home visits upon discharge to minimize readmission and increase time at home. Less is known about initiatives which address the role of subspeciality care and community-based organizations (CBOs) in maintaining older adults with MI and CI in the community.Montefiore Einstein is a fully integrated academic health system including 11 hospitals including a rehabilitation hospital, 65 primary care sites, 18 mental health/ substance abuse treatments clinics, a care management organization, and a home health program. Montefiore's Center of Excellence for Alzheimer's Disease (CEAD) has successfully expanded the delivery of comprehensive, high-quality, cost-effective care for people with CI. The CEAD is staffed with board-certified neurologists, geriatricians, psychiatrists, neuropsychologists and social workers. Our focus on the early diagnosis of Alzheimer's disease and related dementias helps patients and their caregivers prepare for the future and better manage the cost of care, potentially avoiding costly, unnecessary emergency room visits and hospitalizations. It was also recently designated an IHI-designated Age Friendly system. Montefiore Home Care (MHC), established in 1947, is the nation's first hospital- based certified home health agency. 40% of homebound older adults have MI and CI but have limited access to appropriate evaluation and treatment. Accordingly in 2004, MHC developed a consultative geriatric program in collaboration with the Division of Geriatric Psychiatry to provide comprehensive social work and geriatric psychiatry assessments in the home after discharge from hospital. In addition to the collaboration with MHC, Montefiore Division of Geriatric Psychiatry has leveraged foundational funding to collaborate with CBOs to bring evidence-based mental health services to seniors over the past two decades.During this session, presenters will describe several ongoing and new Montefiore initiatives to address care transitions for older adults with MI and CI. Dr. Zwerling will describe how the CEAD is spearheading the transition for Montefiore Einstein to an Age Friendly system. Ms. Korenblatt will highlight how the MHC Geriatric Psychiatry Program social work team serves as a bridge between acute care and CBOs to minimize hospital readmissions. Finally, Dr. Ceïde will highlight a specific example of an evolving partnership with one specific CBO in order to maintain older adults with MI and CI in the community.

Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care

Deprescribing is a promising approach to addressing the burden of polypharmacy. Few studies have initiated comprehensive deprescribing in the hospital setting among older patients requiring ongoing care in a postacute care (PAC) facility. To evaluate the efficacy of a patient-centered deprescribing intervention among hospitalized older adults transitioning or being discharged to a PAC facility. This randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention was conducted between March 2016 and October 2020. Patients who were admitted to an academic medical center and discharged to 1 of 22 PAC facilities affiliated with the medical center were recruited. Patients who were 50 years or older and had 5 or more prehospital medications were enrolled and randomized 1:1 to the intervention group or control group. Patients who were non-English speaking, were unhoused, were long-stay residents of nursing homes, or had less than 6 months of life expectancy were excluded. An intention-to-treat approach was used. The intervention group received the Shed-MEDS intervention, which consisted of a pharmacist- or nurse practitioner-led comprehensive medication review, patient or surrogate-approved deprescribing recommendations, and deprescribing actions that were initiated in the hospital and continued throughout the PAC facility stay. The control group received usual care at the hospital and PAC facility. The primary outcome was the total medication count at hospital discharge and PAC facility discharge, with follow-up assessments during the 90-day period after PAC facility discharge. Secondary outcomes included the total number of potentially inappropriate medications at each time point, the Drug Burden Index, and adverse events. A total of 372 participants (mean [SD] age, 76.2 [10.7] years; 229 females [62%]) were randomized to the intervention or control groups. Of these participants, 284 were included in the intention-to-treat analysis (142 in the intervention group and 142 in the control group). Overall, there was a statistically significant treatment effect, with patients in the intervention group taking a mean of 14% fewer medications at PAC facility discharge (mean ratio, 0.86; 95% CI, 0.80-0.93; P < .001) and 15% fewer medications at the 90-day follow-up (mean ratio, 0.85; 95% CI, 0.78-0.92; P < .001) compared with the control group. The intervention additionally reduced patient exposure to potentially inappropriate medications and Drug Burden Index. Adverse drug event rates were similar between the intervention and control groups (hazard ratio, 0.83; 95% CI, 0.52-1.30). Results of this trial showed that the Shed-MEDS patient-centered deprescribing intervention was safe and effective in reducing the total medication burden at PAC facility discharge and 90 days after discharge. Future studies are needed to examine the effect of this intervention on patient-reported and long-term clinical outcomes. ClinicalTrials.gov Identifier: NCT02979353.

Integration of patient experience factors improves readmission prediction.

Many readmission prediction models have marginal accuracy and are based on clinical and demographic data that exclude patient response data. The objective of this study was to evaluate the accuracy of a 30-day hospital readmission prediction model that incorporates patient response data capturing the patient experience. This was a prospective cohort study of 30-day hospital readmissions. A logistic regression model to predict readmission risk was created using patient responses obtained during interviewer-administered questionnaires as well as demographic and clinical data. Participants (N = 846) were admitted to 2 inpatient adult medicine units at Massachusetts General Hospital from 2012 to 2016. The primary outcome was the accuracy (measured by receiver operating characteristic) of a 30-day readmission risk prediction model. Secondary analyses included a readmission-focused factor analysis of individual versus collective patient experience questions. Of 1754 eligible participants, 846 (48%) were enrolled and 201 (23.8%) had a 30-day readmission. Demographic factors had an accuracy of 0.56 (confidence interval [CI], 0.50-0.62), clinical disease factors had an accuracy of 0.59 (CI, 0.54-0.65), and the patient experience factors had an accuracy of 0.60 (CI, 0.56-0.64). Taken together, their combined accuracy of receiver operating characteristic = 0.78 (CI, 0.74-0.82) was significantly more accurate than these factors were individually. The individual accuracy of patient experience, demographic, and clinical data was relatively poor and consistent with other risk prediction models. The combination of the 3 types of data significantly improved the ability to predict 30-day readmissions. This study suggests that more accurate 30-day readmission risk prediction models can be generated by including information about the patient experience.

Analysis of length of stay and treatment emergent complications in hospitalized myasthenia gravis patients with exacerbation

IntroductionAIMSMyasthenia Gravis (MG) is an autoimmune neuromuscular disease in which patients suffer from recurrent exacerbation. There are insufficient data measuring the effects of the resources employed before and during acute exacerbation on subsequent disease outcomes. This study aims to identify factors which lead to lengthened hospital stay.MethodsThis is a retrospective chart review of acute MG exacerbations requiring hospitalization. Exacerbations were identified using ICD-9/ICD-10 codes and considered the following variables: age and Myasthenia Gravis Foundation of America (MGFA) class at initial MG diagnosis, age and MGFA class at exacerbation, sex, thymectomy, cause of exacerbation, treatment regimen at time of exacerbation, inpatient treatment regimen, length of hospital stay (LOS), intubation, use of noninvasive ventilation, complications, and disposition.ResultsSeventy patients with 141 hospitalizations were identified. Crisis management characterized by intubation and plasmapheresis positively correlated with LOS (both p < .001). Almost 1/5 hospitalizations required intubation. Previous thymectomy negatively correlated with LOS (p < .05). In contrast, male sex correlated with longer LOS (p < .05). One-third of hospital stays were followed by discharge to a post-acute care facility, 7% home with home health, and 1 hospitalization resulted in death.DiscussionPlasmapheresis, intubation, and male sex were associated with increased LOS in acute MG exacerbation. Intubation appears to be the strongest predictor of LOS. Those with previous thymectomy had shorter hospital stays. The role of thymectomy in the acute setting merits further analysis.

1794. Evaluation of Antimicrobial Susceptibility Patterns for Patients Admitted from Post-Acute Care Facilities in the Philadelphia Region

Abstract Background Antimicrobial resistance is a rapidly emerging threat and antibiograms are a key component in guiding empiric antimicrobial selection. Patients admitted from post-acute care facilities (PACF) are at a heightened risk for infections from multi-drug resistant organisms, posing a challenge for clinicians selecting empiric therapy. It is uncommon for antibiograms to differentiate between sources of admission. This study aimed to characterize culture proven infections and the appropriateness of empiric antimicrobial regimens for patients admitted from PACF in the Philadelphia region. Methods This was a retrospective quality improvement study that included patients admitted from Philadelphia PACF from August 2020 to June 2021. Patients were included if they had at least one positive culture within 72 hours of admission. Appropriate therapy was determined based on a comparison of empiric antimicrobial selection and susceptibilities that resulted from collected cultures. Descriptive statistics were employed for data analysis. Results A total of 106 patients and 154 cultures were evaluated during the study period. The majority of patients received initial empiric coverage for Pseudomonas aeruginosa (79%) and methicillin-resistant Staphylococcus aureus (59%). Over 50% of all cultures had been obtained from urinary sources. Enterococcus spp. were the most commonly isolated gram positive organism (61%) and Escherichia coli was the most common gram negative organism (33%). A portion of patients (32.7%) did not receive appropriate empiric therapy. Discrepancies in susceptibility patterns between our internal antibiogram and PACF patients were most notable for gram negative organisms including decreased levofloxacin susceptibilities to P. mirabilis isolates (89% vs 45%). Other notable discrepancies include decreased meropenem susceptibilities to P. aeruginosa isolates (88% vs 65%). Select susceptibility patterns are reported in Figure 1. Conclusion Antimicrobial susceptibility was discordant amongst patients admitted from PACF in the Philadelphia region compared to our general antibiogram. The increased resistance identified supports a need to re-evaluate empiric prescribing guidelines for this specific population. Disclosures All Authors: No reported disclosures.

1829. Dalbavancin versus standard of care as directed therapy for Staphylococcus aureus bacteremia in patients unable to receive OPAT

Abstract Background The purpose of this study was to compare dalbavancin to standard of care (SOC) for patients with S. aureus bacteremia (SAB) who were unable to receive outpatient parenteral antimicrobial therapy (OPAT) and would otherwise remain hospitalized or require placement into post-acute care facilities. Methods This retrospective cohort compared readmission rates related to the index infection between patients treated with dalbavancin or SOC for SAB between January 1, 2016, and August 31, 2021. Patients at least 18 years old seen by the ID consult service who received at least one dose of dalbavancin or at least one week of SOC parenteral antibacterials as directed therapy for SAB at the time of discharge were included. The SOC group consisted of patients transferred from the main hospital to one of the post-acute care facilities in a surrounding county to complete parenteral antibacterials. Patients were excluded if they were treated for polymicrobial infections with organisms other than S. aureus, had a creatinine clearance less than 30 mL/min, or required renal replacement therapy. The primary outcome was readmission rates within 30 days after completion of therapy. Secondary outcomes included readmission rates within 90 days after completion of therapy as well as antibacterial regimen adherence defined as achieving goal duration of therapy deemed appropriate by the ID consult service. Results During the study period, 27 patients received dalbavancin, and 27 patients received SOC. Baseline demographics were comparable between groups, though more patients in the SOC group had indwelling prostheses or hardware (4% vs 22%). The majority of SAB was caused by MSSA in both groups (56% vs 59%). The most common source was osteoarticular (15% vs 30%) and source control was attempted in a higher percentage of the SOC group who had an identified source (53% vs 86%). Readmission rates in the dalbavancin group were similar to those in the SOC group within 30 days (15% vs 22%, p=0.484) and 90 days (19% vs 22%, p=0.735) after completion of therapy. However, adherence was significantly higher among patients treated with dalbavancin (85% vs 44%, p &amp;lt; 0.05). Conclusion Dalbavancin offers similar clinical outcomes to SOC for patients with SAB who are unable to receive OPAT. Disclosures All Authors: No reported disclosures.

1174: A SEPSIS TRANSITION PROGRAM IMPROVES CARE DELIVERY TO SEPSIS SURVIVORS DISCHARGED TO POST-ACUTE CARE

Introduction: Sepsis survivors discharged to post-acute care facilities are at high risk for mortality and hospital readmission. In this study we compared receipt of transition care practices between patients enrolled in a Sepsis Transition and Recovery (STAR) program and patients receiving usual care. Methods: We conducted a secondary analysis of patients from the IMPACTS randomized trial who were discharged to a post-acute care facility. IMPACTS evaluated the effectiveness of STAR, a post-sepsis transition and recovery program using nurse navigators to deliver best practice post-sepsis care during and after hospitalization. The primary outcome for this secondary analysis was a set of transitional care elements including physical therapy, mental health assessment, speech therapy, follow-up visit within 10 days; documented medication reconciliation, and documentation of end-of-life care preferences. Analyses were conducted under an intention-to-treat approach. Outcome data were described using proportions and compared with chi-squared tests. Results: Of 691 patients enrolled in the IMPACTS trial, 175 (25%) were discharged to post-acute care facilities; 82% of this post-acute care cohort was discharged to skilled nursing, 11% to inpatient rehabilitation and 7% to long-term acute care. Medication reconciliation was documented in under half of patients overall but was nearly twice as frequent in the STAR group compared to the usual care group (62.5% vs 34.5%, p <.01). Few patients received depression screening after discharge although this was much higher among patients in the STAR group compared to usual care (34.1% vs 3.5%, p<.01). Completion of advance directives was also higher in the STAR group (50.0% vs 31.0%, p<.01) compared to the usual care group. Frequency of other care practices such as physical and occupational therapy and early physician followup were similar between STAR and usual care groups. Conclusions: Multiple barriers challenge delivery of transitional care for patients discharged to post-acute care facilities. Our secondary analysis of a clinical trial evaluating a sepsis-specific transition program found that structured transitional care increases the delivery of important care practices for sepsis survivors discharged to post-acute care facilities.

Is the Activity Measure for Postacute Care "6-Clicks" Tool Associated With Discharge Destination Postacute Stroke?

To investigate the association of poststroke physical function, measured within 24 hours prior to discharge from the acute care hospital using Activity Measure for Postacute Care (AM-PAC) Inpatient "6-Clicks" scores and discharge destination (home vs facility and inpatient rehabilitation facility [IRF] vs skilled nursing facility [SNF]). Retrospective cross-sectional cohort study. Acute care, University Hospital. Individuals post acute ischemic stroke, N=721, 51.3% male, mean age 63.6±16.4 years. Not applicable. AM-PAC "6-Clicks" 3 domains: basic mobility, daily activity, and applied cognition. AM-PAC basic mobility and daily activity were significant predictors of discharge. Those in the home discharge group had AM-PAC basic mobility mean t scale score of 48.5 compared with a score of 34.8 for individuals sent to a facility and daily activity score of 47.2 compared with 32.7 for individuals sent to a facility. The AM-PAC variables accounted for an additional 24% of the variance in the discharge destination, with basic mobility and daily activity accounting for most of the variance.The AM-PAC scores were not statistically different and were not able to discriminate between placement in an IRF vs SNF. The mean basic mobility t scale score for individuals going to an IRF was 34.9 compared with 34.6 for those going to an SNF. The daily activity score for IRF was 32.8 compared with 32.6 for SNF. The AM-PAC accounted for no additional variance in discharge destination to an IRF or SNF. The AM-PAC Inpatient "6-Clicks" 3 domains are able to distinguish individuals with stroke being discharged to home from postacute care (PAC) but not for differentiating between PAC facilities (IRF vs SNF) in this cohort of individuals post stroke.

Prolonged stay at an acute-care hospital in Israel among older adults awaiting transfer to post-acute care: retrospective study on risk factors and consequences.

Older adults frequently experience deconditioning following acute illnesses and require discharge from acute-care facilities to post-acute care facilities, which are limited. Our study aimed to explore predictors and outcomes associated with elongated length of stay (LOS) among older adults awaiting discharge to skilled nursing facility (SNF). Retrospective cohort study was conducted at Shamir Medical Center, Israel, among adults (> 65years) eligible for SNF. ROC curve analysis was used to determine prolonged LOS based on the risk to fall. Logistic and Cox regressions were used to analyze predictors and outcomes. Among 659 older adults awaiting transfer to SNF, 127 patients (24% among survivors of the index hospitalization) had prolonged LOS (> 12days). The median age of patients was 82years and 51% were females. The independent predictors for prolonged LOS were lower Norton index, higher MUST score, and admission from home. Prolonged LOS was independently associated with hospital-acquired infections, device related infections, and acquisitions of multidrug-resistant organisms. Prolonged LOS among older adults, awaiting transfer to SNF, should be suspected among non-institutionalized older adults with lower nutritional status and higher risk of pressure ulcers. The burden associated with establishing additional SNF beds, must be outweighed vs. the substantial infectious complications among awaiting older adults.

Number of Stairs at Home Does Not Influence Discharge Disposition following Elective Total Hip Arthroplasty

Background Pragmatic challenges of the patient’s home environment, specifically the number of stairs (NOS) required to enter or navigate a patient’s home may influence discharge destination (DD) and length of stay (LOS) following primary Total Hip Arthroplasty (THA). Questions/purposes This study investigates whether the NOS at home predicts discharge to a post-acute-care-facility (PACF) following THA. Methods 548 consecutive THA patients at a single urban arthroplasty center between 2011-2014 were reviewed. Patient factors including age, sex, BMI, length of stay, operative time, Anesthesia Score Assessment (ASA), the Risk-Assessment-and-Prediction-Tool (RAPT) and NOS stairs were analyzed. Logistic regression was performed to identify predictors for disposition to PACF. Groups were cohorted by number of stairs, and incidence of PACF discharge was determined. Results 238 (43.4%) patients were discharged to PACF. The NOS at home had no impact on discharge to PACF (OR 1.02, 95% CI .993-1.04, p=0.209). Older age (OR 1.09, 95% 1.07-1.10, p&lt;0.0001), LOS (OR 1.23, 95% 1.08-1.39, p=0.001), higher ASA (OR 1.74, 95% 1.19-2.53, p=0.004), and lower RAPT score (OR 0.0.865, 95% 0.781-0.958, p=0.005) were significant predictors for disposition to PACF (p&lt;0.005). Female sex was protective in discharge to PACF (OR 0.391, 95% 0.260-0.587, p&lt;0.0001). The incidence of PACF discharge was similar between groups of unavoidable stairs at home. Conclusion The NOS at home did not influence discharge destination following THA. This retrospective study helps discharge planning and in setting expectations for patients undergoing THA by supporting a home discharge in the setting of unavoidable stairs.

Trauma patients with limited English proficiency: Outcomes from two level one trauma centers

BackgroundOutcomes for surgical patients with limited English proficiency (LEP) may be worse compared to patients with English proficiency. We sought to evaluate the association of LEP with outcomes for trauma patients. MethodsAdmitted adult patients on trauma service at two Level One trauma centers from 2015 to 2019 were identified. Results12,562 patients were included in total; 7.3% had LEP. On multivariable analyses, patients with LEP had lower odds of discharge to post-acute care versus home compared to patients with English proficiency (OR 0.69; 95% CI 0.58–0.83; p < 0.001) but had similar length of stay (Beta coefficient 1.16; 95% CI 0.00–2.32; p = 0.05), and 30-day readmission (OR 1.08; 95% CI 0.87–1.35; p = 0.46). ConclusionsTrauma patients with LEP had comparable short-term outcomes to English proficient patients but were less likely to be discharged to post-acute care facilities. The role of structural barriers, family preferences, and other factors merit future investigation.

National survey of health services provided by pediatric post-acute care facilities in the US.

The need for pediatric post-acute facility care (PAC) is growing due to technological advances that extend the lives of many children, especially those with complex medical needs. The objectives were to describe [1] the types and settings of PAC; [2] the clinical characteristics of the pediatric patients requiring PAC; and [3] perceptions of PAC care delivery by clinical staff. An online survey was administered between 6/2018 to 12/2018 to administrative leaders in PAC facilities that have licensed beds for children and who were active members of the Pediatric Complex Care Association. Survey topics included types of health services provided; pediatric patient characteristics; clinical personnel characteristics; and perceptions of pediatric PAC health care delivery. Leaders from 26 (54%) PAC facilities in 16 U.S. states completed the survey. Fifty-four percent identified as skilled nursing facility/long-term care, 19% intermediate care facilities, 15% respite and medical group homes, and 12% post-acute rehabilitation facilities. Sixty-nine percent of facilities had a significant increase in the medical complexity of patients over the past 10 years. Most reported capability to care for children with tracheostomy/invasive ventilation (100%), gastrostomy tubes (96%), intrathecal baclofen pump (89%), non-invasive positive pressure ventilation (85%), and other medical technology. Most facilities (72%) turned away patients for admission due to bed unavailability occasionally or always. Most facilities (62%) reported that insurance reimbursement to cover the cost of providing PAC to children was not acceptable, and most reported that it was difficult to hire clinical staff (77%) and retain staff (58%). PAC in the U.S. is provided to an increasingly medically-complex population of children. There is a critical need to investigate financially-viable solutions for PAC facilities to meet the patient demands for their services and to sufficiently reimburse and retain staff for the challenging and important care that they provide.