Transitional Care Management in Persons With Dementia After Heart Failure Hospitalization and Skilled Nursing Facility Care
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View abstract on PubMed
Summary
This summary is machine-generated.Transitional care management (TCM) improves successful discharge for dementia patients transitioning from hospital to skilled nursing facility (SNF) and home. This care model shows a higher likelihood of community discharge for these vulnerable patients.
Area Of Science
- Gerontology
- Health Services Research
- Cardiology
Background
- Dementia significantly complicates care transitions for heart failure patients, particularly those moving from hospital to a skilled nursing facility (SNF) and then home.
- Transitional care management (TCM) offers a structured approach, including timely communication and follow-up visits, to mitigate these challenges.
Purpose Of The Study
- To analyze trends in TCM utilization for Medicare beneficiaries with dementia hospitalized for heart failure.
- To compare TCM's impact on successful discharge for patients discharged directly home versus those discharged via an SNF.
- To estimate the association between TCM and successful community discharge in the hospital-SNF-home transition pathway.
Main Methods
- Retrospective cohort study analyzing Medicare data from 2013-2017.
- Examined trends in TCM for heart failure patients with dementia.
- Assessed the risk-adjusted association of TCM with successful discharge home after SNF stay.
Main Results
- TCM use increased from 2.3% in 2013 to 9.8% in 2017 for hospital-SNF-home discharges.
- In a cohort of 11,376 transitions, TCM was associated with a 1.24 times higher relative risk of successful community discharge.
- Patients transitioning through SNF received TCM less frequently than direct hospital-to-home discharges.
Conclusions
- Transitional care management (TCM) is underutilized in dementia patients discharged from heart failure hospitalization to SNF and then home.
- Despite lower utilization, TCM is linked to improved successful discharge outcomes in this high-risk patient group.
- Further efforts may be needed to increase TCM adoption for complex care transitions involving dementia patients.
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