Effectiveness of the Sub-Acute Care for Frail Elderly (SAFE) Transitional Care Unit on Short-Term Functional Independence in Frail Older Patients Discharged from Hospital.

Background: Transitional care programs help improve continuity of care and post-discharge outcomes for frail older adults who are hospitalized. In this study, we examined the effectiveness of a transitional care model, based in a long-term care (LTC) home, on the functional independence of older hospitalized patients post-discharge.

Methods: We used a propensity-score matched cohort, whereby cases comprised patients who were admitted to a transitional care program-called the Sub-Acute Care for Frail Elderly (SAFE) Unit-following a hospitalization between March 1, 2018 and June 30, 2019. Controls were matched to Usual Care patients discharged from hospitals within the same health region and accrual period who did not receive transitional care in the SAFE Unit. Outcomes included acute care, LTC, and home care use within six-month post-discharge.

Results: Compared to Usual Care, SAFE Unit patients were less likely to be admitted into an LTC home (RR 0.44, 95% CI 0.23-0.86) within six months post-discharge. Additionally, on average, SAFE Unit patients spent 34 fewer days in LTC homes than controls. SAFE Unit patients also incurred significantly fewer home care service days (median: 52 days, IQR: 12-132 days) than Usual Care patients (median: 65.5 days, IQR: 19-158 days), particularly in terms of their reliance on general nursing and personal support. Both groups had similar risks of six-month hospital readmission and having an ED visit.

Conclusion: Rehabilitative and restorative-focused care provided through transitional programs, such as the SAFE Unit, have the potential to enable independent living for older hospitalized patients discharged to the community.