Commonwealth Care Alliance, Boston, MA.
J Am Med Dir Assoc. 2013 Oct;14(10):736-40. doi: 10.1016/j.jamda.2013.03.004. Epub 2013 Apr 20.
Patients admitted to skilled nursing facilities (SNFs) have a high risk for rehospitalization.
The goal of this project was to implement Project RED in an SNF to increase patient preparedness for care transitions and lower rehospitalization rates in the 30 days after discharge from the SNF facility.
Intervention study with historical control; phone survey 30 days after discharge from the SNF for data collection.
The study was conducted in an SNF admitting patients from acute care hospitals in Boston, MA.
A consecutive sample of patients in the SNF before (n = 524) and after initiation (n = 100) of the intervention. Participants had an average age of 80 (SD = 10), 67% were female, and 84% were non-Hispanic white. Phone surveys were completed with 88% of participants in each group.
INTERVENTION(S): We adapted Project RED for use in an SNF. This includes a comprehensive approach to transitions of care that includes creating and teaching a personalized care plan to patients and their families. Software facilitating these activities was integrated into the electronic medical record of the SNF; intervention activities were delivered by existing staff.
MAIN OUTCOME MEASURE(S): The main outcome was hospital readmission within 30 days of discharge from the SNF. Secondary outcomes included attendance to a medical appointment within 30 days of discharge from the SNF and preparedness for care transitions as measured by a 6-item survey.
The rate of hospitalization 30 days after discharge from the SNF for participants prior to the intervention was 18.9% and for participants during the intervention was 10.2%, P < .05. This remained significant adjusting for multiple potential confounders (P = .045). More patients in the intervention group had attended an outpatient appointment within 30 days of discharge (70.5% versus 52.0%, P < .003). In addition, intervention participants reported a higher level of preparedness for care transitions.
Patients in the intervention had a lower rate of returning to the hospital within 30 days of discharge from the SNF, were more likely to attend medical appointments, and were better prepared for their care transition.
入住熟练护理设施（SNF）的患者有再次住院的高风险。
本项目的目标是在 SNF 实施项目 RED，以提高患者对护理过渡的准备程度，并降低 SNF 设施出院后 30 天内的再住院率。
干预研究，具有历史对照；出院后 30 天对 SNF 进行电话调查以收集数据。
该研究在波士顿 MA 的一家 SNF 进行，该 SNF 收治来自急性护理医院的患者。
干预前（n = 524）和干预后（n = 100）SNF 中连续样本的患者。参与者的平均年龄为 80（SD = 10），67%为女性，84%为非西班牙裔白人。每组有 88%的参与者完成了电话调查。
我们为 SNF 改编了项目 RED。这包括一种全面的护理过渡方法，包括为患者及其家属创建和教授个性化护理计划。便于这些活动的软件已集成到 SNF 的电子病历中；干预活动由现有员工提供。
主要结果是出院后 30 天内再次住院。次要结果包括出院后 30 天内参加医疗预约以及通过 6 项调查衡量的护理过渡准备情况。
干预前参与者出院后 30 天内住院率为 18.9%，干预期间参与者为 10.2%，P <.05。调整多个潜在混杂因素后仍然显著（P =.045）。干预组中有更多的患者在出院后 30 天内参加了门诊预约（70.5%对 52.0%，P <.003）。此外，干预组参与者报告称他们对护理过渡的准备程度更高。
干预组患者出院后 30 天内再次住院的比例较低，更有可能参加医疗预约，并且对他们的护理过渡准备得更好。
