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.
