Outcomes of a Nursing Home-to-Community Care Transition Program.
Paul Y Takahashi, Anupam Chandra, Rozalina G McCoy and 7 others
PMID 33984293WHAT IT FOUND
The program did not reduce 30-day rehospitalizations or emergency visits after nursing home discharge.
At 180 days, enrolled patients had more hospitalizations and emergency visits than usual care, but this was not the primary outcome.
Key findings
01At 30 days after SNF discharge, rehospitalization was 4.4% in the program group and 3.8% in usual care, with no significant difference.
02At 30 days, emergency department visits occurred in 10% of both groups, with no significant difference.
03At 180 days, hospitalization was 30.6% in the program group and 11.3% in usual care, and emergency visits were 46% and 25%.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
Patients chose whether to enroll, so the groups were not randomised and differences may be due to confounding. After matching, illness count and dementia still differed between groups. The study could not adjust for activities of daily living after skilled nursing facility discharge, caregiver support, home health use, or all socioeconomic factors. Outcomes were taken from one health system, so hospitalizations or emergency visits outside it may have been missed. The comparison group's 30-day hospitalization rate was under 4%, lower than about 25% in other published data, so usual care here may not be typical. The sample was mostly from southeastern Minnesota and may not apply to other populations. The program was designed for hospital-to-home transitions and lasted up to 60 days, not SNF-specific long-term follow-up.
Declared interests
The authors declared no conflicts of interest. The supplied publication metadata indicates NIH and non-U.S. government research support, but the article text does not give a funding statement.
The easy way to misread this
Do not read the higher 180-day hospitalizations and emergency visits as proof that the program harmed patients. Patients chose enrollment, and the study was not randomised, so unmeasured differences could explain the secondary findings.