More Research Needed on Care Transition Impact

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Karen Utterback By Karen Utterback 
Former Vice President, Product Marketing and Strategy, McKesson (Retired)
Care Transitions Can Affect Patient Care

A recent study illuminates the need for coordinating patient care transitions from skilled nursing facilities (SNFs) to their homes in order to reduce the incidence of acute care. The intensity or duration of home health use and its link to outcomes following a SNF discharge is one of the areas where authors suggest more research is needed.

“Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge” was published in the Journal of the American Geriatrics Society. The study focuses on Medicare claims data for North and South Carolina beneficiaries for a 20-month period beginning January 1, 2010. Its objective was to identify predictors of first acute care use following a SNF discharge.

The study showed that one in four patients either visited an ED or were readmitted to a hospital within 30 days of a SNF discharge. A higher risk of ED use or rehospitalizations was noted among dual-eligibles, males, African-Americans, a higher Charlson comorbidity score, more hospitalizations in the 90 days preceding the SNF stay, diagnosis of neoplasms and respiratory diseases, or care in a for-profit nursing facility.

ED visits and rehospitalizations impacted 37.5% of former residents at the 90-day mark. It’s interesting to note that the study linked more LPN or RN hours per resident with a lower rate of subsequent hospital visits. Data also showed that home care use was associated with higher acute care use within 90 days.

The authors are quick to point out that more research is needed on the effectiveness of care transitions from SNFs to home, including the need to “examine elements of community health care that follows SNF discharge (e.g., follow-up with primary care physicians and the intensity or duration of home care) and to describe the relationship between community healthcare and first use of acute care services.”

As more research focuses on the importance of quality care transitions from one patient setting to the next, I believe the importance of home health will win out.

Learn more about how home care software can help improve care during care transitions and subscribe to our blog to stay up to date on news for the home care industry.

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