Abstract
Objectives
Most transitional care initiatives to reduce rehospitalization have focused on the
transition that occurs between a patient's hospital discharge and return home. However,
many patients are discharged from a skilled nursing facility (SNF) to their homes.
The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT)
program (hereafter called program) among patients discharged from SNFs to their homes.
Design
Propensity-matched control-intervention trial.
Intervention
Patients in the intervention group received care management following nursing stay
(a home visit and nursing phone calls).
Setting and Participants
Patients enrolled after discharge from an SNF to home were matched to patients who
did not receive intervention because of refusal, program capacity, or distance. Patients
were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF.
Methods
Program enrollees were matched through propensity score to nonenrollees on the basis
of age, sex, comorbid health burden, and mortality risk score. Conditional logistic
regression analysis examined 30-day hospitalization and emergency department (ED)
use; Cox proportional hazards analyses examined 180-day hospital stay and ED use.
Results
Each group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years].
Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and
3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for
program patients compared with 11.3% and 25.0% in the comparison group (P < .001).
Conclusions and Implications
We found no evidence of reduced hospitalization or ED visits by program patients vs
the comparison group. Such findings are crucial because they illustrate how aggressive
stabilization care within the SNF may mitigate the program role. Furthermore, we found
higher ED and hospitalization rates at 180 days in program patients than the comparison
group.
Keywords
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Article info
Publication history
Published online: May 10, 2021
Footnotes
This study was funded by the National Institute on Aging grant K23AG051679 (B.T.) and National Institute of Diabetes and Digestive and Kidney Diseases grant K23 K23DK114497 (R.G.M.). Additional support was provided by the National Center for Advancing Translational Sciences grant UL1 TR000135. The interpretation and reporting of the data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government.
The authors declare no conflicts of interest.
Identification
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© 2021 Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.
