Post-acute Care Transitions Research Articles

Post-acute care transitions during COVID-19: Racial, ethnic, and socioeconomic differences in older adults with Alzheimer's disease and related dementia.

Differences in the post-acute care (PAC) destinations among racial, ethnic, and socioeconomic groups have been documented before the COVID-19 pandemic. Yet, the pandemic's impact on these differences remains unknown. We examined the impact of the COVID-19 pandemic on PAC destinations and its variation by individual race, ethnicity, and socioeconomic status among community-dwelling older adults with Alzheimer's disease and related dementia (ADRD). We linked 2019-2021 national data (Medicare claims, Minimum Data Set, Master Beneficiary Summary File) and several publicly available datasets, including Provider of Services File, Area Deprivation Index, Area Health Resource File, and COVID-19 infection data. PAC discharge destinations included skilled nursing facilities (SNFs), home health agencies (HHA), and homes without services. Key variables of interest included individual race, ethnicity, and Medicare-Medicaid dual status. The analytic cohort included 830,656 community-dwelling Medicare fee-for-service beneficiaries with ADRD who were hospitalized between 2019 and 2021. Regression models with hospital random effects and state-fixed effects were estimated, stratified by the time periods, and adjusted for the individual, hospital, and county-level covariates. SNF discharges decreased while home and HHA discharges increased during the pandemic. The trend was more prominent among racial and ethnic minoritized groups and even more so among dual-eligible beneficiaries. For instance, the reduction in the probabilities of SNF admissions between the pre-pandemic period and the 2nd year of COVID was 4.6 (White non-duals), 18.5 (White duals), 8.7 (Black non-duals), and 20.1 (Black duals) percentage-point, respectively. We also found that non-duals were more likely to replace SNF with HHA services, while duals were more likely to be discharged home without HHA. The COVID-19 pandemic significantly impacted PAC destinations for individuals with ADRD, especially among socioeconomically disadvantaged and racial and ethnic minoritized populations. Future research is needed to understand if and how these transitions may have affected health outcomes.

ENGAGEMENT DURING POST–ACUTE CARE TRANSITION: PERCEPTIONS AND EXPERIENCES OF DEMENTIA FAMILY CAREGIVERS

Abstract Hospitalized persons with dementia (PwD) are three times more likely to discharge to skilled nursing facilities (SNF) than those without dementia, and family caregivers are essential during post-acute care transitions (PACT). Descriptions of caregiver engagement are largely provider-centric, derived from either acute or residential settings. Little is known about PACT experiences of family caregivers. This study explored meaning, barriers, and facilitators of engagement for family caregivers navigating PACT, and elucidated caregiver support needs. An interpretive descriptive approach, using Meleis’s Middle Range Transition Theory was used to interview family caregivers during a PACT. Data were inductively coded and thematically analyzed. A conceptual framework illustrating caregivers’ meaning of engagement was developed, and facilitators, barriers, and needs were described. Participants (n=15), mostly white (n=12, 80%), female (n=13, 87%), married (n=7, 47%), adult children (n=11, 73%), average age of 63 (range: 38-81, SD=12.9). The core concept was advocacy. Key related themes were caregivers’ sense of being present, communication with providers, and meaningful connections with the PwD. Barriers to engagement centered on poor communication from professional caregivers and being isolated from the PwD. A facilitator to engagement was effective communication with professional caregivers. Similarly, caregivers’ support needs included receiving information related to the transition, and the health status of the PwD. Communication was central to both caregiver engagement and advocacy of PACT. Future policy/practice recommendations should include communication training for both providers and caregivers. Interventions that facilitate caregivers’ shared access and input into health information during PACT will promote integral roles on the care team.

RE-IMAGINING DEMENTIA FAMILY CAREGIVER ENGAGEMENT FOR POST–ACUTE CARE TRANSITIONS: LESSONS LEARNED FROM COVID-19

Abstract Family caregivers of persons with dementia (PwD) experience three-times more post-acute care transitions (PACT) to skilled nursing facilities than other caregivers. During Covid-19, visitation policies drastically changed, limiting family caregiver engagement in the skilled nursing facility. This was a widespread experience; yet, few studies have examined dementia family caregivers’ perceptions of PACT engagement during Covid-19 restrictions. This qualitative study focused on the findings and lessons learned about the meaning of engagement, barriers, facilitators, and support needs during Covid-19 using an interpretive descriptive approach. Participants (n=15) were mostly female (n=13), adult children (n=8), and the majority (n=9) had a PACT experience during the Covid-19 pandemic. Family caregivers reported improved engagement with the PwD and healthcare team in the acute care setting, because hospital policies on Covid-19 allowed one visitor which gave family caregivers the option to be physically present and advocate for the PwD. However, after the PACT, only essential workers were allowed at the skilled nursing facility making it impossible for family caregivers to visit the PwD and communicate with professional caregivers. Lack of perceived support negatively affected family caregivers’ ability to communicate, share knowledge, advocate, and participate in critical decision making. These Covid-19 challenges highlight the importance of being physically present as a necessary component to engagement which was a form of communication compensation that improves outcomes for the PwD. Future practice policies should view family caregivers as essential to the healthcare team and develop innovative solutions to connect family caregivers to the PwD during Covid-19 or future pandemics.

Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home

ObjectivesMedications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders’ perspectives on challenges in deprescribing these medications for post-acute HHC patients. DesignQualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. Setting and ParticipantOlder HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MeasuresInterview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. ResultsWe interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. Conclusions and ImplicationsPost-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.

Training to Transition: Using Simulation-Based Training to Improve Resident Physician Confidence in Hospital Discharges.

Hospital discharge is a highly critical and complex process that is prone to medical errors, poor communication, and ineffective synchronization of transitional teams. Improving safety during postacute care transitions has become a national focus. Simulation-based training is an underutilized method of instruction for medical resident transitions of care education. As an integral part of a transitions curriculum, 36 PGY 1 residents from internal medicine and transitional year residency programs underwent a discharge simulation utilizing a trained simulated participant (SP) and a lay caregiver. The objective of the training was to implement a simulation-based education intervention to improve transition practices and discharge communication in graduate medical education. A faculty observer used a case-specific discharge rubric to standardize feedback to the resident and observed the resident navigate the electronic medical record (EMR) for discharge orders. Pretest and posttest surveys assessing resident attitudes and confidence regarding specific areas of the discharge process were distributed to all participating residents for completion. Thirty-six internal medicine and transitional year residents (100%) completed an observed discharge simulation with an SP and a separate encounter with the EMR discharge navigator. All 36 residents (100%) completed the pretest survey, and 23 (63%) completed the postsurvey evaluation. Postsurvey results showed residents agreed (92%, p < .05) that the simulation increased their confidence in safely discharging a patient. Simulation encounters are an effective adjunct to postacute care transition education.

Lost in Transition: Missed Opportunities for the 4Ms to Support Post-Acute Care Transitions.

Thousands of health systems have adopted the 4Ms framework, a set of evidence-based practices specific to older adults, as part of the Age-Friendly Health Systems (AFHS) initiative. However, implementation efforts have largely been setting-specific and approaches to achieve continuity of the 4Ms during care transitions are nascent. Transitions from hospitals to skilled nursing facilities (SNFs) are one type of care transition that would greatly benefit from continuity of 4Ms practices. Drawing from the authors' insights and 5 exploratory interviews at 3 health systems that implemented the 4Ms in the inpatient setting, we describe a set of current-state challenges when trying to extend specific inpatient 4Ms practices (eg, deprescribing of high-risk medications) as well as the nuanced understanding of the individual's clinical trajectory developed during an inpatient stay. We also offer concrete opportunities, such as developing 4 Ms-centric discharge summary templates, to address the challenges. With the large investment in AFHS transformation and associated efforts to implement the 4Ms framework in all care settings used by older adults, it is critical to raise awareness of the specific obstacles to promoting continuity of successful 4Ms practices during care transitions and work to overcome them. Our insights from hospital-to-SNF transitions offer a starting point.

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.

Higher levels of multimorbidity are associated with increased risk of readmission for older people during post-acute transitional care

Key summary pointsAimTo investigate the association between multimorbidity and readmission amongst patients on Transitional Aged Care Program (TACP).FindingsHospital readmission rates increased with multimorbidity and the Charlson Comorbidity Index (CCI) is independently associated with a 30-day hospital readmission in TACP cohort.MessageIdentifying vulnerability to readmission, such as multimorbidity may allow future exploration of targeted interventions to optimise transitional care and individualise patient care to improve functional independence and prevent premature Residential Aged Care Facilities (RACF) admissions in older people.

Perceptions of information continuity key to understanding quality of post-acute care transitions.

Skilled nursing facilities' (SNFs) ability to provide optimal post-acute care depends on effective receipt of information from hospitals ("information continuity"). Little is known about how SNFs perceive information continuity and how it may relate to upstream information sharing processes, organizational context, and downstream outcomes. First, this study aims to identify how SNF perceptions of information continuity may be shaped by hospital information sharing practices, including measures of completeness, timeliness, and usability, as well as characteristics of the transitional care environment (i.e., integrated care relationships and/or consistency of information sharing practices across different hospital partners). Second, we analyze which of these characteristics are associated with quality of transitional care (measured by 30-day readmissions). A cross-sectional analysis of nationally representative SNF survey ( N = 212) linked to Medicare claims was performed. SNF perceptions of information continuity are strongly and positively associated with hospital information sharing practices. Adjusting for actual information sharing practices, SNFs that experienced discordance across hospitals reported lower perceptions of continuity (β = -0.73, p = .022); evidence of stronger relationships with a given hospital partner appears to help facilitate resources and communication that helps to close this gap. Perceptions of information continuity, more so than the upstream information sharing processes reported, exhibited a more reliable and significant association with rates of readmissions as an indicator of transitional care quality. SNF perceptions of information continuity are strongly associated with patient outcomes and are reflective of both hospital information sharing practices as well as characteristics of the transitional care environment that can mitigate or amplify the cognitive and administration challenge of their work. Improving transitional care quality requires that hospitals improve information sharing behaviors but also invest in capacity for learning and process improvement in the SNF environment.

“Second set of eyes:” Family caregivers and post-acute home health care during the COVID-19 pandemic

ObjectivesThis study aimed to explore how the COVID-19 pandemic shaped the experiences of family caregivers of older adults who were hospitalized with COVID-19 and discharged to post-acute, skilled home health care (HHC) services. MethodsThirty semi-structured interviews with family caregivers of older adults who received services from a large, not-for-profit HHC agency following hospitalization with COVID-19 infection were conducted between March-July 2021 and analyzed using thematic analysis. ResultsDuring the pandemic, family caregivers encountered societal and institutional barriers to assisting older adults across post-acute care transitions. These barriers included hospital visitation restrictions as well as difficulties accessing community-based resources and medical equipment. Despite limitations and delays in HHC services, many family caregivers identified post-acute HHC, delivered in-person or via telehealth, as important to addressing care gaps for older adults, as well as their own needs for training and support during the pandemic. ConclusionsPolicies intended to reduce the spread of COVID-19 introduced new challenges for caregivers during HHC. However, HHC agencies and their staff adapted within this context to provide a needed bridge of support.

Organizational Factors Associated with Perceptions of Continuity during Post-Acute Transitional Care

Skilled nursing facilities’ (SNFs) perception of information continuity with hospitals is a critical indicator of the staff’s ability to provide safe and effective post-acute patient care. This perception depends on the quality of information sent by hospitals, and the transitional care environment in which information is received. Using a nationally representative survey of SNF Nursing Directors who reported transitional care relationships with two different hospital referral partners, we assessed this transitional care environment by first analyzing the extent of hospital-SNF integration behaviors (i.e. preferred network status) that could strengthen perception through relational familiarity. Second, we analyzed the presence of discordant or disruptive transitional care practices. SNFs with disparate information sharing behaviors across hospitals lack consistent routines and staff may experience additional cognitive or administration burden to their work that dampens perception of continuity. We found that perception of continuity mediates the relationship between hospital information sharing practices and transitional care outcomes (e.g. readmissions). Holding information sharing practices constant, some care integration practices increase perceptions of continuity while SNFs that experienced discordance across hospitals have lower perceptions of continuity. Improving transitional care quality requires that hospitals improve information sharing behaviors and help build capacity for process improvement in the SNF environment.

Time trends in cancer and dementia related hospital admissions among Medicare fee-for-service population, 2013–2018

Cancer and dementia are two complicated morbidities that are commonly found in older adults and require substantial healthcare resources.[ [1] Caba Y. et al. The impact of dementia on cancer treatment decision-making, cancer treatment, and mortality: a mixed studies review. JNCI Cancer Spectr. 2021; 5: 1-18 Crossref Google Scholar , [2] McWilliams L. et al. A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care. Aging Ment Health. 2017; : 1-18 Google Scholar ] Caring for patients with the co-presence of cancer and dementia, who suffer from impaired cognitive function with complex medical needs, is challenging for clinicians, caregivers, and healthcare systems. With the aging US population, the increasing number of older adults with these two comorbid conditions is likely to place a high demand on hospitals. Meanwhile, the shift of care delivery from inpatient to settings such as outpatient and homes, increasing reliance on family caregivers, and improved community care support may help reduce unnecessary hospitalizations.[ 3 2021 Alzheimer's disease facts and figures Alzheimers Dement. 2021; 17: 327-406 Crossref PubMed Scopus (739) Google Scholar , 4 Federman A.D. et al. Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences. JAMA Intern Med. 2018; 178: 1033-1040 Crossref PubMed Scopus (88) Google Scholar , 5 Handley N.R. Bekelman J.E. The oncology hospital at home. J Clin Oncol. 2019; 37: 448-452 Crossref PubMed Scopus (23) Google Scholar ] It is important to understand the pattern of hospitalization, which is one of the major drivers of healthcare costs and high financial and caregiving burden for patients and their families, among the growing population with cancer and dementia. While there has been extensive research on the incidence, prevalence, and healthcare utilization among older adults with either cancer or dementia, existing literature examining older adults with both conditions is scarce and limited in scope. [ [1] Caba Y. et al. The impact of dementia on cancer treatment decision-making, cancer treatment, and mortality: a mixed studies review. JNCI Cancer Spectr. 2021; 5: 1-18 Crossref Google Scholar , [2] McWilliams L. et al. A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care. Aging Ment Health. 2017; : 1-18 Google Scholar , [6] Kedia S.K. et al. Health care utilization among elderly medicare beneficiaries with coexisting dementia and cancer. Gerontol Geriatr Med. 2017; 3 (p. 2333721416689042) Crossref PubMed Google Scholar , [7] Liu B. et al. Trends of hospitalizations among patients with both cancer and dementia diagnoses in New York 2007-2017. Healthc (Amst). 2021; 9100565 Google Scholar ] In particular, no national estimates exist regarding the hospitalization rates among older adults with comorbid cancer and dementia. To fill this gap, we examined the national and state-level trends in hospitalization rates among Medicare fee-for-service (FFS) beneficiaries with the co-presence of a major cancer (breast, prostate, lung, and colorectal) and dementia diagnoses. We hypothesized a growing trend of inpatient use among this population during the years 2013–2018. Due to the heterogeneity in cancer-specific prognosis and treatment, we also examined the trend of hospitalizations among this population by cancer types.

Cost of home hospitalization versus inpatient hospitalization inclusive of a 30-day post-acute period.

Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.-focused, or did not include post-acute costs in their analyses. Our objective was to determine if combined acute and 30-day post-acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH. A single-center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital-level care and 30-days of post-acute transitional care. Main outcomes were costs of care of the acute and post-acute 30-day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics. Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD=12.3] years vs. 74.6 [SD=14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI -$10,262 to $30, p=0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI -$10,758 to -$1196, p=0.01) lower. HaH combined with 30-day post-acute transition care was less costly than inpatient care.

Post-acute care transitions and outcomes among medicare beneficiaries in assisted living communities.

Despite the rapid growth of assisted living (AL) and frequent hospitalizations among AL residents, little is known about their patterns of post-acute care transitions and outcomes. This study examined the post-acute care transitions among AL residents and their association with outcomes in the first 30 and 60 days after hospital discharge. This study used data from 2018 national Medicare enrollment and claims datasets, the Minimum Data Set (MDS), and Medicare Provider Analysis and Review (MedPAR) of 104,497 unique Medicare beneficiaries residing in ALs in the U.S. Post-acute care referrals, based on hospital discharge status, to skilled nursing facilities (SNF), home with home health care (HHC), home without HHC, and other settings. Outcomes included 30-day and 60-day hospital readmissions, emergency department (ED) visits, long-stay care nursing home placement, and mortality. Multinomial logistic regression analysis and logistic regression analysis were conducted. The most common post-acute care referral was to SNF (40%), followed by home without HHC (28%), home with HHC (17%), and others (15%). Compared to discharge home without HHC, discharge to SNF was associated with a lower likelihood of ED visits (Odds Ratio=0.597, p < 0.01) and hospital readmissions (OR=0.856, p < 0.001), and higher likelihood of long-stay nursing home placement (OR=11.224, p < 0.01) and mortality (OR=2.025, p < 0.01). Discharge home with HHC was associated with a higher likelihood of hospital readmissions (OR=1.148, p < 0.01) and a lower likelihood of long-stay nursing home placement (OR=0.737, p < 0.05) than discharge home without HHC. The results were similar within the first 30 days as well as 60 days after hospital discharge. AL residents who are discharged to different post-acute care settings tend to differ in 30-day and 60-day outcomes. At hospital discharge, clinicians and discharge planners should be provided information about the exact type and availability of services at AL to make the most appropriate discharge referrals for AL residents.

Provider and Staff Responses to Non-Facility Specific Patient Experience Feedback with Post-Acute Care Transitions

While a large portion of efforts related to improving patient experience, reducing medical errors, and improving clinical outcomes have focused on acute care settings, improvements in the quality of post-acute care and patient experience with transitions from general acute care settings to post-acute levels of care are key to accomplishing population health goals. While patient experience surveys are utilized nationwide, there is evidence of a need for deliberate efforts to create and implement recommendations derived from analyzing patient experience data with healthcare staff and providers. In 2019, 14 focus group sessions were conducted with providers and staff, including nursing, pharmacy, therapy, and case management from skilled nursing facilities, long-term acute care hospitals, and inpatient rehabilitation facilities. To minimize bias while studying reactions to patient comments regarding care transitions, participants from different facilities were placed into groups together and provided de-identified patient comments to review and discuss key themes and potential solutions. Attribution, discourse, and summative content analyses were performed to identify the key themes. A framework was developed to understand provider and staff reactions to non-facility-specific patient experience feedback as well as recommendations for improving post-acute care transitions

Effect of a Multicomponent Sepsis Transition and Recovery Program on Mortality and Readmissions After Sepsis: The Improving Morbidity During Post-Acute Care Transitions for Sepsis Randomized Clinical Trial.

To evaluate whether a nurse navigator-led, multicomponent Sepsis Transition And Recovery program improves 30-day mortality and readmission outcomes after sepsis hospitalization. n: Multisite pragmatic randomized clinical trial. Three hospitals in North Carolina from January 2019 to March 2020. Eligible patients hospitalized for suspected sepsis and deemed high-risk for mortality or readmission by validated internal risk models. Patients were randomized to receive usual care alone (i.e., routine transition support, outpatient care; n = 342) or additional Sepsis Transition And Recovery support (n = 349). The 30-day intervention involved a multicomponent transition service led by a nurse navigator through telephone and electronic health record communication to facilitate best practice postsepsis care strategies during and after hospitalization including: postdischarge medication review, evaluation for new impairments or symptoms, monitoring comorbidities, and palliative care approach when appropriate. Clinical oversight was provided by a Hospital Medicine Transition Services team. The primary outcome was a composite of mortality or hospital readmission at 30 days. Logistic regression models were constructed to evaluate marginal and conditional odds ratios (adjusted for prognostic covariates: age, comorbidity, and organ dysfunction at enrollment). Among 691 randomized patients (mean age = 63.7 ± 15.1 yr; 52% female), a lower percentage of patients in the Sepsis Transition And Recovery group experienced the primary outcome compared with the usual care group (28.7% vs 33.3%; risk difference, 4.7%; odds ratio, 0.80; 95% CI, 0.58-1.11; adjusted odds ratio, 0.80; 95% CI, 0.64-0.98). There were 74 deaths (Sepsis Transition And Recovery: 33 [9.5%] vs usual care: 41 [12.0%]) and 155 rehospitalizations (Sepsis Transition And Recovery: 71 [20.3%] vs usual care: 84 [24.6%]). In a multisite randomized clinical trial of patients hospitalized with sepsis, patients provided with a 30-day program using a nurse navigator to provide best practices for postsepsis care experienced a lower proportion of either mortality or rehospitalization within 30 days after discharge. Further research is needed to understand the contextual factors associated with successful implementation.

The Trauma Dyad: The Role of Informal Caregivers for Older Adults After Traumatic Injury.

To investigate the association between higher injury severity and increased informal caregiving received by injured older adults. Injured older adults experience high rates of functional decline and disability after hospitalization. Little is known about the scope of caregiving received post-discharge, particularly from informal caregivers such as family. We used the National Health and Aging Trends Study 2011 to 2018 linked to Medicare claims to identify adults ≥65 with hospital admission for traumatic injury and a National Health and Aging Trends Study interview within 12 months pre- and post-trauma. Injury severity was assessed using the injury severity score (ISS, low 0-9; moderate 10-15; severe 16-75). Patients reported the types and hours of formal and informal help received and any unmet care needs. Multi variable logistic regression models examined the association between ISS and increase in informal caregiving hours after discharge. We identified 430 trauma patients. Most were female (67.7%), non-Hispanic White (83.4%) and half were frail. The most common mechanism of injury was fall (80.8%) and median injury severity was low (ISS = 9). Those reporting receiving help with any activity increased post-trauma (49.0% to 72.4%, P < 0.01), and unmet needs nearly doubled (22.8% to 43.0%, P < 0.01). Patients had a median of 2 caregivers and most (75.6%) were informal, often family members. Median weekly hours of care received pre- versus post-injury increased from 8 to 14 (P < 0.01). ISS did not independently predict increase in caregiving hours; pre-trauma frailty predicted an increase in hours ≥8 per week. Injured older adults reported high baseline care needs which increased significantly after hospital discharge and were mostly met by informal caregivers. Injury was associated with increased need for assistance and unmet needs regardless of injury severity. These results can help set expectations for caregivers and facilitate post-acute care transitions.

Behavioral Health Services with Short-Stay Residents in Skilled Nursing Facilities: A Qualitative Study of Clinicians and Administrators

ABSTRACT Objectives The perspectives of professionals involved in behavioral health (BH) services with short-stay residents in skilled nursing facilities (SNFs) are rarely captured in the literature. This study examines the real-world experiences of BH clinicians and administrators in post-acute/subacute care units in SNFs. Methods This qualitative study used semi-structured interviews with 18 clinicians (e.g., psychologists and social workers) and five administrators (e.g., directors of social services or BH company executives) involved in BH services with short-stay SNF residents. Interviews were recorded, transcribed, and analyzed by two independent coders using conventional thematic content analysis. Results Three themes emerged from the data: (1) BH needs are high among short-stay residents and families during post-acute care transitions; (2) BH services offer multiple unique opportunities to enhance post-acute/subacute care in SNFs; and (3) barriers to providing optimal BH care exist at multiple levels and require action from BH clinicians and stakeholders. Conclusions Variability in clinician roles and barriers to optimized care suggest the need for future research targeting best practices and implementation strategies for BH services with short-stay SNF residents. Clinical Implications Results identified multiple ways in which BH services may enhance resident, family, and staff outcomes, as well as the milieu in SNFs.

Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care.

Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services. Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File. AL facilities and Medicare HH agencies in the United States. 741,926 Medicare HH admissions of AL residents in 2017. Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission. Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)). For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.

SAVE-CLC: An Intervention to Reduce Suicide Risk in Veterans Who Discharge From VA Nursing Homes

Prior research has established transitions into and out of nursing homes as periods of suicide risk for older adults. Deaths by suicide were found to be 2.4 times as likely among Veterans within six months of discharge from US Veterans Health Administration (VA) nursing homes when compared with gender and age-matched Veterans from the general VA patient population (McCarthy, Szymanski, Karlin, & Katz, 2013). Despite these trends, suicide prevention interventions implemented during nursing home and post-acute care transitions, including those taking place from Centers for Medicare and Medicaid Services regulated nursing homes, are lacking. Suicide Awareness for Veterans Exiting the Community Living Center (SAVE-CLC) was piloted as a quality improvement intervention to reduce suicide risk for older Veterans discharging from VA nursing homes. VA clinicians from three sites provided a friendly contact by phone after discharge (n = 66) to screen for depression, facilitate a strengths-based discussion about service needs, and provide service referrals. Compared to a group of patients discharged prior to the start of the intervention (matched on location, age range, and Care Assessment Need scores), SAVE-CLC patients received more depression screening within 30 days after discharge (chi square = 38.7, p < .001) and were seen more quickly for mental health care (t = 3.1, p = .005) when indicated. Implications for suicide prevention with older Veterans and for the general population of older adults receiving short stay services in US nursing homes will be addressed.