Transitional Care Management in Persons With Dementia After Heart Failure Hospitalization and Skilled Nursing Facility Care

ABSTRACT Background Dementia complicates care transitions, such as discharge from heart failure hospitalization to a skilled nursing facility (SNF) and then to home. Transitional care management (TCM), a bundled service that includes telephone communication within 2 business days and an office visit...

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Veröffentlicht in:Journal of the American Geriatrics Society (JAGS) Jg. 73; H. 9; S. 2853 - 2858
Hauptverfasser: Bayer, Thomas A., Varma, Hiren, Hollmann, Peter A., Gozalo, Pedro L.
Format: Journal Article
Sprache:Englisch
Veröffentlicht: Hoboken, USA John Wiley & Sons, Inc 01.09.2025
Wiley Subscription Services, Inc
Schlagworte:
Aged
Aged, 80 and over
Beneficiaries
Cohort analysis
Congestive heart failure
Dementia
Dementia - complications
Dementia - therapy
Dementia disorders
Discharge
Female
Health care management
Heart failure
Heart Failure - therapy
Hospitalization
Hospitalization - statistics & numerical data
Humans
Male
Medicare
Medicare - statistics & numerical data
Nurses
Nursing
Patient Discharge - statistics & numerical data
Patients
post‐acute
rehabilitation
Retrospective Studies
Risk factors
Skilled Nursing Facilities - statistics & numerical data
successful discharge
Telephones
Transitional Care - statistics & numerical data
United States
United States
heart failure
dementia
successful discharge
rehabilitation
post‐acute
ISSN:0002-8614, 1532-5415, 1532-5415
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Zusammenfassung:ABSTRACT Background Dementia complicates care transitions, such as discharge from heart failure hospitalization to a skilled nursing facility (SNF) and then to home. Transitional care management (TCM), a bundled service that includes telephone communication within 2 business days and an office visit within 14 days, potentially addresses this problem. Methods We analyzed trends in TCM among Medicare beneficiaries with dementia hospitalized for heart failure in 2013–2017, comparing hospital–home discharges to hospital–SNF–home discharges. We then used a retrospective cohort study to estimate the risk‐adjusted association of TCM with successful discharge home. Results TCM occurred in 45 (2.3%) of 1990 eligible hospital–SNF–home discharges in year 2013, increasing to 205 (9.8%) of 2095 eligible in year 2017. In a cohort of 11,376 hospital–SNF‐home transitions, the relative risk (95% CI) of successful community discharge was 1.24 (1.11–1.40) with TCM compared with no office visit within 14 days of discharge or TCM. Conclusions Persons with dementia transitioning from heart failure hospitalization to SNF to home receive TCM less frequently than persons discharged directly home from the hospital. Nonetheless, TCM is associated with successful discharge in this vulnerable group of patients.
Bibliographie:This research was presented during a symposium at the 2024 American Geriatrics Society Annual Scientific Meeting. This research was also presented as a poster at the Gerontological Society of America, and an abstract describing the trend analysis was published in
Innovation in Aging
Funding
This work was supported by Alzheimer's Disease and Related Disorders Treatment and Outcomes in America: Changing Policies and Systems, NIA (5P01AG027296).
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ISSN:0002-8614
1532-5415
1532-5415
DOI:10.1111/jgs.19563