There is perhaps no more crucial time period for the health and functional outcomes of Veterans than an acute hospitalization followed by a stay in a post-acute care (PAC) facility (rehabilitatio or skilled nursing facility). The population of Veterans who undergo this transition are generally elderly, frail, ill, and disabled. As a result, many are sent back to the Emergency Department or readmitted to the hospital. This is often the start of a downward spiral of recurrent admissions, worsening functional status resulting in long-term care placement, and early mortality. For example, our preliminary data indicates Veterans discharged to PAC were readmitted or sent to the Emergency Department 5 times on average in the 12 months following their index admission. Transitions from the hospital to PAC are becoming more and more common, but poor outcomes may be preventable. In our preliminary data, we found nearly half of all readmissions from PAC facilities occurred in the first seven days after hospital discharge. Substantial research supports the idea that poorly-executed transitions of care from the hospital to the post-acute care facility underlie many poor outcomes of Veterans who undergo this transition. However, little is known about the outcomes of Veterans discharged to post-acute care, nor what factors contribute to these outcomes. To identify which factors might affect outcomes in these transitions of care, the proposal uses the Ideal Transitions of Care framework, developed by the nominee, to identify key domains that may affect transitional care outcomes. In this proposal, our Aims include:
Aim 1 : Assess the impact of five key domains of the ITC framework on 7-day hospital utilization and mortality. Domains and examples include: discharge planning (hospital plan for delivery of high-intensity interventions in PAC), information transfer (PAC access to hospital EMR), medication safety (medication reconciliation and monitoring of high-risk medications), advance care planning (addressing and communicating code status), and patient monitoring (time to initial PAC physician evaluation).
Aim 2 : Determine modifiable transitional care processes that help explain positive deviance in high-performing hospital-PAC sites.
Aim 3 : Pilot test a nurse-directed transitional care intervention in a hospital PAC site based on key domains of the ITC framework identified in Aims 1 and 2. This work is of crucial importance to Veterans and the VA healthcare system nationally and has the support of the Office of Geriatrics and Extended Care. Three accomplished investigators will guide the nominee's project work and development as an independent investigator. Dr. Michael Ho is the primary mentor with expertise in mixed methods, multicomponent interventions, and implementation science. He is the Co-Director of the Ischemic Heart Disease QUERI, Co-Director of the Denver-Seattle COIN, and a widely-published and well- funded expert in health outcomes research. Dr. Cari Levy is a co-mentor with significant content expertise relevant to the proposal, including experience with the main dataset used in the proposal, as a geriatrician and prior nursing home medical director, and as an accomplished researcher in the PAC setting. Dr. Allan Prochazka is a senior investigator with substantial Career Development Award mentorship experience as Director of Mentorship and Career Development at the Denver-Seattle COIN. Career development activities include gaining expertise in longitudinal and clustered data analysis, qualitative data methods, and implementation science. This will be facilitated by mentorship with two content experts (Dr. Jacqueline Jones, a qualitative expert, and Dr. Anna Baron, a statistical expert), coursework, and seminars taking advantage of the rich resources of the Denver-Seattle COIN and University of Colorado. The mentorship, training, and protected time afforded by this award will ensure the nominee's development as an independent investigator dedicated to improving transitions of care after hospital discharge throughout the VA system.

Public Health Relevance

The number of Veterans being discharged from hospitals to post-acute care facilities for continued care (such as skilled nursing facilities or rehabilitation facilities) is increasing. Unfortunately, many of these Veterans return to the hospital shortly after they were discharged, and this can lead to a downward spiral. Research shows a cycle of hospital discharges and readmissions can lead to long-term nursing home placement or even premature death for Veterans. Our work will evaluate transitions of care from hospitals to post-acute care facilities. We will identify important factors that lead to poor outcomes and best practices that lead to better outcomes, and then pilot an intervention to improve transitions of care that may be of use for all Veterans being discharged from the hospital to a post-acute care facility. This is directlyin line with the VA Office of Geriatrics and Extended Care's mission to optimize the well-being of Veterans with chronic conditions and disability as these are the Veterans most likely to be transitioning to post-acute care facilities.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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HSR&D Career Development Award (CDA0)
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VA Eastern Colorado Health Care System
United States
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