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The Coming Home After Rehabilitation and Transition from a Skilled nursing facility with Dementia Study (The CHARTS-D Study)

Award Number: K23AG062797
ORGANIZATION: NATIONAL INSTITUTE ON AGING
OPDIV: NIH
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: TRAINING/TRAINEESHIP
PERIOD OF PERFORMANCE START DATE: 02/01/2020
PERIOD OF PERFORMANCE END DATE: 01/31/2026

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The Coming Home After Rehabilitation and Transition from a Skilled nursing facility with Dementia Study (The CHARTS-D Study) - Increasing numbers of patients with Alzheimer’s disease and related dementias (ADRD) are receiving post- hospitalization care in skilled nursing facilities (SNFs). Most will transition from the SNF to home. Although there has been a great deal of attention paid to patients’ transition from the hospital to home, there has been little research on transitions from the SNF to home. Experiencing multiple transitions from home to the hospital to a SNF and back to home is difficult for patients with ADRD and their caregivers. After discharge from SNF to home, patients may re-enter the cycle of transitions, suffering adverse outcomes such as hospital readmissions, medication errors, functional decline, and loss of independence. This project will identify factors associated with 30-day hospital readmission and other adverse outcomes for patients with ADRD who transition from the SNF to home. We will use the Health and Retirement Study (HRS), a large, national dataset that includes rich social and economic information that is pertinent to the risk of adverse health outcomes. Our study takes advantage of the link between the HRS and Centers for Medicare and Medicaid Services billing data, and especially the link to extensive data collected during SNF stay as part of the Minimum Data Set and home health event data from the Outcome and Assessment Information Set. For Aim 1, we will describe the relationship of ADRD diagnosis or severity of cognitive impairment in the SNF with hospital readmission for patients who transition from SNF to home. We hypothesize that individuals with ADRD are at greater risk of hospital readmission when controlling for Andersen model factors. We also propose that worse levels of cognitive impairment, as measured during a patient’s stay in the SNF, will be associated with greater risk readmission risk. For Aim 2, we will identify the effect of early outpatient care, either in clinic visit or via home health visit, on reducing readmissions. We hypothesize that early outpatient care is protective against readmission. This represents a first step in identifying interventions to reduce readmissions for people with ADRD who undergo this complex healthcare trajectory. Dr. Carnahan’s career development plan will provide thorough training in research methods and health policy related to transitions for older adults with ADRD. As an emerging aging researcher with expertise in the SNF to home care transition, Dr. Carnahan will use the results of this study to design an intervention that improves the health outcomes of cognitively impaired patients who experience this complex healthcare trajectory. Her long term goal is to improve the quality of care and health outcomes for older adults with ADRD.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2024 ( Subtotal = $178,039 )
2024	2024	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Aging Research	000	5	1/22/2024	NON-COMPETING CONTINUATION	$178,039
														Subtotal = $178,039

Issue Date FY: 2023 ( Subtotal = $179,271 )
2023	2023	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Aging Research	000	4	1/23/2023	NON-COMPETING CONTINUATION	$179,271
														Subtotal = $179,271

Issue Date FY: 2022 ( Subtotal = $180,190 )
2022	2022	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Aging Research	000	3	2/14/2022	NON-COMPETING CONTINUATION	$180,190
														Subtotal = $180,190

Issue Date FY: 2021 ( Subtotal = $181,533 )
2021	2021	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Aging Research	000	2	1/21/2021	NON-COMPETING CONTINUATION	$181,533
														Subtotal = $181,533

Issue Date FY: 2020 ( Subtotal = $183,417 )
2020	2020	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Aging Research	000	1	1/30/2020	NEW	$183,417
														Subtotal = $183,417

Grand Total All Awards = $902,450

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The Coming Home After Rehabilitation and Transition from a Skilled nursing facility with Dementia Study (The CHARTS-D Study)

Award Number: K23AG062797

ORGANIZATION: NATIONAL INSTITUTE ON AGING

OPDIV: NIH

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: TRAINING/TRAINEESHIP

PERIOD OF PERFORMANCE START DATE: 02/01/2020

PERIOD OF PERFORMANCE END DATE: 01/31/2026

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