Preparedness for care transitions to home and acute care use of skilled nursing facility patients.

Background: The purpose of this study was two-fold: (1) describe the relationship between patient or caregiver reported preparedness for care transitions, and acute care use in 30 days after discharge from a skilled nursing facility (SNF); and (2) explore how this relationship is influenced by patient, Charlson index, race and social determinants.

Method: The design was a secondary analysis of data collected as part of a cluster randomized trial of the Connect-Home transitional care intervention. The setting was 6 skilled nursing facilities located in the US state of North Carolina. The sample was 249 patient and caregiver dyads with acute care use data (i.e., emergency department or hospital readmission) in 30 days after transfers from SNFs to home. Preparedness for care transitions was measured with the Care Transitions Measure-15 (CTM-15), a 15 item Likert scaled measure with scores potentially ranging from 0 to 100, with higher scores indicating better preparedness. The association of preparedness and acute care use, in the overall study sample and within subgroups defined by five selected dyad background characteristics, was quantified as an incident rate ratio corresponding to the multiplicative change in the mean number of acute care use days for a 10 unit increase in CTM-15 score, using marginalized zero-inflated negative binomial regression.

Results: Patients had a mean age of 76.4 years, 63.8% were female, and 73.6% were White. Caregivers were female (73.6%) and adult children (42.3%). The mean CTM-15 score was 72.9 and the mean days of acute care use in 30 days after SNF discharge was 0.62. For a 10 unit increase in preparedness score, among male patients the mean number of acute care use days decreased by 33% (IRR = 0.67; 95%CI: 0.44, 0.99); White patients had a 25% reduction (IRR = 0.75; 95%CI: 0.55, 1.02), patients with low area deprivation score (lower quartile, ADI = 54) had a 31% reduction in acute care use (IRR = 0.69; 95%CI: 0.47, 1.01), and patients with a high Charlson total score (upper quartile of 9) have a 22% reduction in acute care use (IRR = 0.78; 95%CI: 0.61, 1.02).

Conclusion: Preparedness of care transitions is an important outcome of high-quality SNF care and is associated with reduced use of further acute care. More research is necessary to evaluate the CTM-15 as an outcome measure among sociodemographic subgroups.