Transitional Care Management in Persons With Dementia After Heart Failure Hospitalization and Skilled Nursing Facility Care

IF 4.5 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society Pub Date : 2025-06-06 DOI:10.1111/jgs.19563

Thomas A. Bayer, Hiren Varma, Peter A. Hollmann, Pedro L. Gozalo

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引用次数: 0

Abstract

Background

Dementia complicates care transitions, such as discharge from heart failure hospitalization to a skilled nursing facility (SNF) and then to home. Transitional care management (TCM), a bundled service that includes telephone communication within 2 business days and an office visit within 14 days, potentially addresses this problem.

Methods

We analyzed trends in TCM among Medicare beneficiaries with dementia hospitalized for heart failure in 2013–2017, comparing hospital–home discharges to hospital–SNF–home discharges. We then used a retrospective cohort study to estimate the risk-adjusted association of TCM with successful discharge home.

Results

TCM occurred in 45 (2.3%) of 1990 eligible hospital–SNF–home discharges in year 2013, increasing to 205 (9.8%) of 2095 eligible in year 2017. In a cohort of 11,376 hospital–SNF-home transitions, the relative risk (95% CI) of successful community discharge was 1.24 (1.11–1.40) with TCM compared with no office visit within 14 days of discharge or TCM.

Conclusions

Persons with dementia transitioning from heart failure hospitalization to SNF to home receive TCM less frequently than persons discharged directly home from the hospital. Nonetheless, TCM is associated with successful discharge in this vulnerable group of patients.

Abstract Image

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心力衰竭后痴呆患者住院和专业护理机构护理的过渡护理管理。

背景：痴呆症使护理转变复杂化，例如从心力衰竭住院到熟练护理机构（SNF），然后回家。过渡性护理管理（TCM）是一种捆绑服务，包括2个工作日内的电话沟通和14天内的办公室就诊，可能解决这一问题。方法：我们分析了2013-2017年因心力衰竭住院的老年痴呆症医疗保险受益人的中医趋势，比较了医院-家庭出院和医院- snf -家庭出院。然后，我们采用回顾性队列研究来评估中医与成功出院的关系。结果：2013年1990例符合条件的医院- snf -家庭出院患者中有45例（2.3%）出现中医，2017年2095例符合条件出院患者中有205例（9.8%）出现中医。在11,376个医院- snf -家庭转换队列中，与出院后14天内未就诊或中医相比，中医成功社区出院的相对风险（95% CI）为1.24（1.11-1.40）。结论：从心力衰竭住院过渡到SNF回家的痴呆患者接受中医治疗的频率低于直接出院回家的患者。尽管如此，中医与这一弱势群体的成功出院有关。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Journal of the American Geriatrics Society 医学-老年医学

CiteScore

10.00

自引率

6.30%

发文量

504

审稿时长

3-6 weeks

期刊介绍： Journal of the American Geriatrics Society (JAGS) is the go-to journal for clinical aging research. We provide a diverse, interprofessional community of healthcare professionals with the latest insights on geriatrics education, clinical practice, and public policy—all supporting the high-quality, person-centered care essential to our well-being as we age. Since the publication of our first edition in 1953, JAGS has remained one of the oldest and most impactful journals dedicated exclusively to gerontology and geriatrics.