The number of older adults discharged to post-acute care (PAC) facilities after hospitalization has increased by 50% between 1996 and 2010, and spending on PAC is now the most rapidly growing area of Medicare costs (>$62 billion in 2012). PAC facilities (such as skilled nursing and rehabilitation facilities) exist to rehabilitate older adults with the goal of a successful return to community living, but currently only 28% of Medicare patients who have a PAC stay following hospitalization return to the community within 100 days of hospital discharge. This proposal aims to better inform hospital clinicians, patients, and families at the time of hospital discharge (when the decision to pursue PAC is made) about the patients' likelihood of returning home after a PAC stay, which has far-reaching consequences for the health and functional status of older adults. Identifying older adults who return home from PAC is important because many older adults do not wish to go to a facility following hospital discharge or fear the financial consequences; clear evidence suggesting benefit may alter decision-making and improve outcomes. Identifying older adults who transition to long-term care or die during or following PAC is important for advance care planning. For example, one-third of older adults have a PAC stay in the last six months of their life, and 1 in 11 die during that stay. These adults may not be achieving their desired benefit from PAC. Perhaps most important is identifying patients who do not return home, but could if PAC were structured differently and tailored to their needs. For example, older adults who have a readmission from PAC experience worsened functional status and increased mortality. In our preliminary data, more than 2/3 of all readmissions from PAC occur in the first 7 days following hospital discharge. While not all of these readmissions may be preventable, they may be most predictable and modifiable at the time of hospital discharge. Identifying factors associated with these events may identify patients who need enhanced transitions of care or a longer hospital stay prior to PAC discharge. This proposal first uses an innovative application of a large dataset to evaluate predictors of 1) return to the community post-PAC (within 100 days of hospital discharge); 2) long-term care residence or death post-PAC; and3)potentiallymodifiablefactors(eg,preventionofearlyhospitalreadmission)thatifaddressedcouldallow more patients to return home after PAC. This dataset allows longitudinal evaluation across episodes of care (hospital, PAC) and payors (Medicare, Medicaid). We complement these findings through interviews with hospital and PAC clinicians, and patients and their caregivers, to identify features (e.g. caregiver support or home environment) poorly captured in our dataset that may influence outcomes of PAC.
The Aims are:
Aim 1 : Identify clinical, demographic, and functional patient factors associated with outcomes of PAC.
Aim 2 : Understand how hospital- and PAC-clinicians and patients evaluate potential outcomes of PAC. This work is of crucial importance to older adults, the National Institute of Aging, and the healthcare system.
This research seeks to improve the outcomes of older adults who are hospitalized and then are discharged to a skilled nursing or rehabilitation facility to recover and gain strength before returning home. While more and more older adults are going to these facilities after discharge at high cost, only 28% return home by 100 days after hospital discharge. Finding factors that help predict whether or not a particular older adult will return home after a facility stay, especially factors that could be changed so more older adults return home, has important implications for these older adults, their families, and the health care system.
