By Verena Cimarolli
Providers could use the results of a recent study to reduce the likelihood of rehospitalization after post-acute rehabilitation.
Each year in the U.S., over 3 million older adults are discharged from acute-care hospitals to post-acute care settings within skilled nursing facilities (SNFs) so they can receive needed rehabilitation to recover from an injury or illness.
The optimal outcome for these older adults would be to return to independent living at home after discharge from post-acute rehabilitation. The least optimal outcome would be a return to the acute-care setting.
Unfortunately, about 12% of older adults who are admitted to SNFs for post-acute rehabilitation are readmitted to acute care within 30 days. This pattern takes a toll on older adults and on health care expenditures.
FACTORS INFLUENCING REHOSPITALIZATION
Researchers have investigated factors that either increase the risk for rehospitalization or protect older adults from being rehospitalized.
The major culprits in rehospitalization are frailty and certain types of admitting conditions. But personal characteristics—including gender and age—are also a factor. Patients who are men or who have reached an advanced age are less likely to return home after rehab than women and younger patients.
Ethnicity can also be a factor in rehospitalization, although the findings are somewhat contradictory.
Some research shows that 30-day rehospitalization rates are significantly higher for African American and Hispanic post-acute rehabilitation patients, compared to whites. That finding also holds up in other care settings, including acute care, where black and Hispanic patients have consistently higher hospital readmission rates, compared to whites.
But other research shows that Latinos and African Americans are more likely than white older adults to be discharged home from post-acute care, even though physical functioning at discharge is less optimal in minority groups.
MAKING SENSE OF BAFFLING FINDINGS
What is happening here?
That’s the question 2 of my colleagues—Francesca Falzarano from Weill Cornell Medicine and Stephanie Hicks from Columbia University—joined me in asking as we considered how best to develop evidence-based rehabilitation programs that optimize rehabilitation outcomes for older patients.
To answer the question, we designed and implemented a study at The New Jewish Home, a LeadingAge member in New York City. We wanted to investigate risk and protective factors associated with rehospitalizations among members of 3 different ethnic groups: Latinos, African Americans, and whites. We had 2 research goals:
- To identify what each ethnic group needed from the rehabilitation experience in order to go home rather than back to the hospital.
- To look at the role that the quality of the patient’s neighborhood would play in rehabilitation outcomes. We used 5 indicators to form our community quality index: crime rate, unemployment rate, median educational attainment, median household income, and proportion of vacant housing units.
Basically, we set out to investigate the relationship between individual characteristics among members of different ethnic groups—like gender, neighborhood characteristics, and health behaviors—with the chance of being rehospitalized after post-acute rehabilitation.
We focused our study on older adult patients who were discharged from a SNF after receiving post-acute rehabilitation for cardiovascular disease. We chose patients with cardiovascular diseases because these diseases are prevalent among minorities, are a frequent precipitant for post-acute rehabilitation stays, and are a leading cause of death in the United States.
WHAT DID WE FIND?
Francesca, Stephanie, and I found that several variables raised the risk of rehospitalization among different ethnic groups:
- Hispanic patients: Lower community quality was associated with a greater likelihood of being rehospitalized.
- African American patients: Lack of social support, including not having a family member or friend present during the post-acute stay, was associated with a higher likelihood of being rehospitalized. So was having more difficulty carrying out tasks at the time of admission to post-acute care, and a shorter post-acute length of stay.
- White patients: Being male, and having no social support was associated with rehospitalization, as was lower cognitive ability and higher depression at admission; and shorter length of stay in rehab.
WHAT DOES THIS MEAN FOR PROVIDERS?
Based on our findings, we believe clinicians in post-acute care settings of SNFs should be aware of characteristics that have the potential to result in less optimal patient outcomes.
Most importantly, SNF providers could use the knowledge gained from our study to address risk factors before they result in less optimal rehabilitation outcomes.
Our finding that lack of social support is a risk factor for rehospitalization among African American and white patients represents an intervention opportunity for practitioners. These providers might be able to improve rehabilitation outcomes by encouraging patients to have family members and friends present during post-acute stay, and particularly during care plan meetings.
Providers could ensure the most optimal patient outcomes by being aware of and addressing risk factors as part of initial care planning, family and patient education, and discharge planning.
Verena Cimarolli, Ph.D., is senior health services research associate in the Washington, DC, office of the LeadingAge LTSS Center @UMass Boston. Her research focuses on the psychosocial challenges faced by older adults with chronic illness, and strategies for supporting those adults and their families.