To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents admitted to the SNF following an index hospitalization.
To derive and validate a model to predict a patient's probability of skilled nursing facility (SNF) discharge using data available from day 1 of hospitalization.
Improving care transitions is of critical importance for older patients, especially those with complex care needs. Our study examined the “Transitions of Care” (ToC) of complex, post-acute older adults at multiple time points. The objective of this article is to identify domains relevant to health care tra...
To evaluate the quality of communication between hospitals and home health care (HHC) clinicians and patient preparedness to receive HHC in a statewide sample of HHC nurses and staff.
To understand how a heart failure diagnosis and admission health instability predict health transitions and outcomes among newly admitted nursing home residents.
Our study examines factors associated with patient-reported outcomes in functioning among Medicare beneficiaries who reported receiving rehabilitation services in a nursing home or inpatient (ie, hospital or rehabilitation facility) setting in the prior year.
To examine whether neighborhood green space was related to frailty risk longitudinally and to examine the relative contributions of green space, physical activity, and individual health conditions to the frailty transitions.
The goals of the Missouri Quality Initiative (MOQI) for long-stay nursing home residents were to reduce the frequency of avoidable hospital admissions and readmissions, improve resident health outcomes, improve the process of transitioning between inpatient hospitals and nursing facilities, and reduce over...
Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.