Table 2 Objectives and outcomes of the discharge from a LTCF to a community setting (N = 16)
Author | Outcomes Measured Following Discharge from a LTCF | Main Findings Related to Post-Discharge from a LTCF |
|---|---|---|
Aaland, Leffers & Hlaing, 2006 | ▪ Driving status ▪ Level of independence in feeding, expression, and locomotion | ▪ Majority of older adults were able to regain functional activities after discharge from LTCF to community ▪ 52.2% continued to drive a motor vehicle post-discharge |
Arling, Abrahamson, Cooke, Kane & Lewis, 2011 | ▪ Readmission during 1 year post-discharge | ▪ 12% had 1 nursing home readmission and 2% had 2 or more in year post-discharge |
Bardo, Applebaum, Kunkel, & Carpio, 2014 | ▪ Location status, State Medicaid waiver database and the nursing home MDS | ▪ Most diversion and transition consumers who were still alive at the 6-month follow-up were living in the community |
Callahan, Arling, Tu, Rosenman, Counsell, Stump, & Hendrie, 2012 | ▪ Transitions in care across all sites of care, outbound (transitioning out of the site), inbound (transitioning into the site), probability of a transfer between sites of care | ▪ For transitions out the nursing facility, the conditional probability was higher to return home without formal services and to go to the hospital ▪ 30-day rehospitalization rate in older adults with dementia was 23% |
Delate, Chester, Stubbings, & Barnes, 2008 | Impact of medication reconciliation program on: ▪ Post-discharge mortality ▪ Rehospitalization ▪ Ambulatory clinic, emergency department visits | 60 days after SNF discharge those in medication reconciliation group experienced: ▪ 78% reduction in risk of death ▪ Higher mean cumulative ambulatory care visits |
Gassoumis, Fike, Rahman, Enguidanos, & Wilber, 2013 | Discharge episodes and predictor variables: ▪ Sociodemographic ▪ Psychological ▪ Physical health ▪ Residential Facility ▪ Health care status | Those who transitioned to the community between 91 and 365 were more likely to have: ▪ Fallen within 180 days of admission ▪ Transitioned to and back from an acute care setting during the first 90 days of their episode. |
Graessel, Schmidt, & Schupp, 2014 | Living at home 2.5 years after discharge | 75% of stroke survivors were still living at home 30 months after discharge ▪ Those with higher functional independence and health related quality of life at time of discharge continued to live at home more frequently than those with lower scores |
Graham, Anderson, & Newcomer, 2005 | Impact of program on transitions: ▪ Transitions in/across care sites ▪ Outcomes of program post-discharge | After 180 days: ▪ 30/36 who were discharged to the community remained at home ▪ 5/36 readmitted to a skilled nursing facility ▪ 3/36 died |
Howell, Silberberg, Quinn, & Lucas, 2007 | ▪ Death ▪ Readmission to nursing home | ▪ 72.6% of the entire sample of persons (N = 1354) remained in the community during the first year after leaving the nursing home ▪ 18.8% persons who were discharged died sometime during first year at home ▪ More men than women had a LTCF readmission |
McCarthy, Szymanski, Karlin, & Katz, 2013 | ▪ Suicide rates 6 months post-discharge | ▪ Suicide risk was 2.4 times higher overall and 2.3 times higher for males following discharge from VA nursing home compared to age and gender matched persons receiving care from the entire VA system ▪ Suicide risk greatest in first 3 weeks post-discharge then rest of 6-month post-discharge period |
Mudrazija, Thomeer, & Angel, 2015 | ▪ Post-discharge living arrangements | ▪ Women were more likely to live alone or with kin after discharge ▪ Men were more likely to live with a spouse or transfer to another institution |
Robinson, Porter, Shugrue, Kleppinger, & Lambert, 2015 | ▪ Quality of Life ▪ Life Satisfaction ▪ Use of Health Services | ▪ For the majority of respondents who remained in the community, quality of life and life satisfaction improved significantly after transition, and stayed high ▪ 14% returned to an institution one year after transition |
Toles, Anderson, Massing, Naylor, Jackson, Peacock‐Hinton, & Colón‐Emeric, 2014 | ▪ Time to acute care utilization ▪ Emergency department visit ▪ Hospitalization | ▪ 22.1% of older adults had an episode of acute care use within 30 days; 7.2% had an ED visit and 14.8% had a rehospitalization ▪ 37.5% had first acute care use within 90 days ▪ Health outcomes following discharge from a skilled nursing facility are multifactorial and relate to individual and system characteristics |
Winkler, Farnworth, Sloan, & Brown, 2011 | • Aimed to understand transition experience and identify key outcomes perceived by the participants | • 9 key outcomes identified: Improved independence (improved continence, getting around & movement, speaking, swallowing & eating), improved well-being (happier & less distressed, less difficult behaviour), and increased social inclusion (having things to do, being known in the community, family & friends) |
Wysocki, Kane, Dowd, Golberstein, Lum, & Shippee, 2014 | ▪ First potentially preventable hospitalization experienced during observation period and first hospitalization of any type (preventable or non-preventable) ▪ Person’s group (stayer or nursing home transitioner) | ▪ Transitioners had increased hazard of experiencing potentially preventable hospitalization by 40% over nursing home stayers ▪ Transitioners had 58% greater risk of experiencing any types of hospitalization than nursing home stayers |
Young, 2006 | ▪ Adaptive and maladaptive behaviour ▪ Choice-making ▪ Objective life quality to reflect changes in skills and lifestyle after the institution. | ▪ Both groups increased adaptive behaviours, choice-making and life quality in new residential location compared to in institution ▪ No change in level of maladaptive behaviour |