Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA.
Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA.
J Am Med Dir Assoc. 2021 Dec;22(12):2440-2446.e2. doi: 10.1016/j.jamda.2021.04.010. Epub 2021 May 11.
Most transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes.
Propensity-matched control-intervention trial.
Patients in the intervention group received care management following nursing stay (a home visit and nursing phone calls).
Patients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention because of refusal, program capacity, or distance. Patients were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF.
Program enrollees were matched through propensity score to nonenrollees on the basis of age, sex, comorbid health burden, and mortality risk score. Conditional logistic regression analysis examined 30-day hospitalization and emergency department (ED) use; Cox proportional hazards analyses examined 180-day hospital stay and ED use.
Each group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years]. Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and 3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for program patients compared with 11.3% and 25.0% in the comparison group (P < .001).
We found no evidence of reduced hospitalization or ED visits by program patients vs the comparison group. Such findings are crucial because they illustrate how aggressive stabilization care within the SNF may mitigate the program role. Furthermore, we found higher ED and hospitalization rates at 180 days in program patients than the comparison group.
大多数旨在减少再住院率的过渡护理计划都集中在患者出院和返回家中的过渡阶段。然而，许多患者是从疗养院出院回家的。本研究旨在评估 Mayo 诊所过渡护理（MCCT）计划（以下简称计划）在从疗养院出院回家的患者中的有效性。
倾向匹配对照干预试验。
干预组患者在护理期间接受护理管理（家访和护理电话）。
出院后从疗养院返回家中的患者与因拒绝、计划能力或距离而未接受干预的患者相匹配。患者年龄≥60 岁，有住院高风险，且从疗养院出院。
根据年龄、性别、合并健康负担和死亡率风险评分，通过倾向评分将计划参与者与非参与者进行匹配。条件逻辑回归分析评估 30 天内的住院和急诊（ED）就诊情况；Cox 比例风险分析评估 180 天内的住院和 ED 就诊情况。
每组各有 160 名患者[平均（标准差）年龄，85.4（7.4）岁]。在计划组中，30 天内的住院和 ED 就诊率分别为 4.4%和 10.0%，在常规护理组中分别为 3.8%和 10.0%（住院治疗 P =.76；ED 就诊 P>.99）。在 180 天，计划组患者的住院和 ED 就诊率分别为 30.6%和 46.3%，而对照组患者分别为 11.3%和 25.0%（P<.001）。
我们没有发现计划组患者与对照组相比住院或 ED 就诊减少的证据。这些发现至关重要，因为它们说明了疗养院中积极的稳定护理如何减轻该计划的作用。此外，我们发现计划组患者在 180 天的 ED 和住院率高于对照组。
