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Preferred Hospital-SNF Relationships and Variation in Information Sharing Practices: Impact on Care Transitions for Persons with AD/ADRD

Award Number: R03AG072215
ORGANIZATION: NATIONAL INSTITUTE ON AGING
OPDIV: NIH
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)
PERIOD OF PERFORMANCE START DATE: 06/15/2021
PERIOD OF PERFORMANCE END DATE: 02/29/2024

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Preferred Hospital-SNF Relationships and Variation in Information Sharing Practices: Impact on Care Transitions for Persons with AD/ADRD - Project Summary/Abstract Every year, over three million patients require post-acute care at a skilled nursing facility (SNF) following hospitalization. Many of these patients are diagnosed with, or exhibit symptoms consistent with, Alzheimer’s Disease or Alzheimer’s Disease related dementia (AD/ADRD). There is significant variation in where and how patients are placed for SNF care, and the processes in place to support patients’ transition to the SNF. Hospitals are increasingly aware of, and addressing, the quality deficits in these handoffs that put patients at increased risk for adverse events and rehospitalization. As hospitals invest more in transitional care improvements with SNFs, we explore two potential mechanisms through which variation in how these investments are made may fail to adequately support the transitional care needs for patients with AD/ADRD. First, dynamics that shape SNF placement decisions for AD/ADRD patients might restrict their access to facilities where transitional care improvements are being made. Hospitals often concentrate their transitional care investments in the SNFs to which they regularly send patients (i.e., their high volume or “preferred” SNFs). But, preliminary evidence suggests that these SNFs may be able to leverage their preferred status to limit admission of patients at increased risk of complications, rehospitalization, and/or long-term stay. These risks apply to AD/ADRD patients. We therefore must assess whether AD/ADRD patients experience limited access to hospitals’ preferred SNFs and the transitional care investments that are concentrated in those relationships. Second, there is significant variation in how hospitals implement transitional care improvements, especially with respect to how they share information to support transitions. Some hospitals routinely share information relevant to AD/ADRD care – including cognitive status, details that inform a social/behavioral care plan, and level of functional independence – while others do not. The variability in types of information shared, as well as the usability and timeliness of that information, suggests that hospitals do not know how SNFs define necessary information sharing for this population. As hospitals increasingly build new transitional care processes using electronic methods of information sharing, it is critical to inform those efforts with evidence on how timing and transmission of more complete patient information may better support better AD/ADRD transitions, measured by reduced likelihood of short-term readmission. Our study findings will inform policy makers about the potential risks of individuals with AD/ADRD not benefiting from targeted investments to improve post-acute transitional care processes, and will provide necessary insights in to the types of enhanced information sharing practices during patient transition that could particularly benefit this patient population.


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 = -$616 )
2024	2022	REGENTS OF THE UNIVERSITY OF MINNESOTA	200 OAK ST SE	MINNEAPOLIS	MN	55455	HENNEPIN	USA	Aging Research	000	2	6/24/2024	NON-COMPETING CONTINUATION	-$616
														Subtotal = -$616

Issue Date FY: 2022 ( Subtotal = $161,927 )
2022	2022	REGENTS OF THE UNIVERSITY OF MINNESOTA	200 OAK ST SE # 224	MINNEAPOLIS	MN	55455	HENNEPIN	USA	Aging Research	001	2	5/23/2022	NON-COMPETING CONTINUATION	$161,927
2022	2021	REGENTS OF THE UNIVERSITY OF MINNESOTA	200 OAK ST SE # 224	MINNEAPOLIS	MN	55455	HENNEPIN	USA	Aging Research	000	1	3/25/2022	NEW	$0
														Subtotal = $161,927

Issue Date FY: 2021 ( Subtotal = $127,941 )
2021	2021	REGENTS OF THE UNIVERSITY OF MINNESOTA	200 OAK ST SE # 224	MINNEAPOLIS	MN	55455	HENNEPIN	USA	Aging Research	000	1	6/11/2021	NEW	$165,121
2021	2021	REGENTS OF THE UNIVERSITY OF MINNESOTA	200 OAK ST SE # 224	MINNEAPOLIS	MN	55455	HENNEPIN	USA	Aging Research	001	1	8/6/2021	NEW	-$37,180
														Subtotal = $127,941

Grand Total All Awards = $289,252

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Preferred Hospital-SNF Relationships and Variation in Information Sharing Practices: Impact on Care Transitions for Persons with AD/ADRD

Award Number: R03AG072215

ORGANIZATION: NATIONAL INSTITUTE ON AGING

OPDIV: NIH

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)

PERIOD OF PERFORMANCE START DATE: 06/15/2021

PERIOD OF PERFORMANCE END DATE: 02/29/2024

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