Outcomes of a Nursing Home-to-Community Care Transition Program

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. (C) 2021 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Automated summary

The study evaluated the effectiveness of the Mayo Clinic Care Transitions program for patients discharged from skilled nursing facilities to their homes. Results showed no significant difference in 30-day hospitalization and ED rates between program patients and the comparison group, but at 180 days, program patients had significantly higher rates of hospitalization and ED visits.