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Keywords:

  • transitional care;
  • adverse event;
  • elderly;
  • healthcare utilization;
  • skilled nursing facility

Objectives

To evaluate an intervention to improve care transitions at the time of skilled nursing facility (SNF) discharge.

Design

Natural experiment using a pre–post design.

Setting

Veterans Affairs hospital, community SNF, and outpatient clinic.

Participants

The pre-intervention group comprised 134 individuals discharged to the community from posthospitalization SNF care, and the intervention group was 217 individuals who received a postdischarge clinic (PDC) intervention at SNF discharge after receiving posthospitalization care at the SNF.

Intervention

This study is a natural experiment using a pre–post design. The intervention was a one-time visit to a PDC before SNF discharge, where an advanced nurse practitioner conducted medication reconciliation, ordered medical supplies and equipment and home health services if needed, provided individual and caregiver education, and communicated the information to the individual's primary outpatient care provider through electronic medical records.

Measurements

The pre-PDC and PDC intervention groups were compared on various measures of hospital utilization within 30 days of the SNF discharge (number of rehospitalizations, acute care inpatient days, and emergency department (ED) visits).

Results

Although there was a 23% rehospitalization rate in the pre-PDC group, participants in the PDC intervention group had a 14% rehospitalization rate within 30 days of SNF discharge (P = .02). Those who received the PDC intervention had significantly fewer acute care inpatient days during the 30-day follow-up (P < .001). Although the difference in the number of ED visits between the two groups was not statistically significant, the number of ED visits per 1,000 patient follow-up days during the 30-day interval was significantly lower in the PDC intervention group (P = .03).

Conclusion

Comprehensive care coordination at the time of SNF discharge can reduce postdischarge hospital use in settings with shared electronic records.