Predictors of Hospital Readmission for Patients Post-SNF discharged to Homes and Residential Care Facilities in a Post-Acute Care Setting
by Andrew Wang M.D., Alex Wang B.S., Austin Wang B.A., Parag Agnihotri M.D.
Sharp Extended Care, Sharp Health Care. Arbor Hills Skilled Nursing Rehabilitation Center, Generations Health Care

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Summary

Post-SNF 30-day hospital readmissions are more likely to occur in male, cognitively impaired, lower-functioning patients.  Allen Cognitive Level placemat test is a useful tool to stratify patients of higher risk for readmission. Caregiver guides for patients at different impairment levels can facilitate home health care in various aspects of activities of daily living.  Further testing is required to validate the effect. 

1. Introduction and Objectives

Hospital readmissions put patients at risk for complications, and are expensive. In a skilled nursing facility (SNF) 30-day potentially preventable readmission measure, the readmission may occur after the patient is discharged from the SNF.  A majority of patients in the post-acute care SNF setting are discharged to homes and residential care facilities which include assisted living, and board and care.

The objectives of this study are as follows: 1) Which patient characteristics are better indicators of hospital readmissions for patients post-SNF discharged? 2) Whether the disposition to residential care facilities increases risk of hospital readmissions? 3) What is the likelihood of hospital readmissions for patients who are discharged to homes vs residential care facilities? 

2. Methods

A cross-sectional study was conducted on 212 patients who were discharged home (n=159) or to residential care facilities (n=53) after post-acute care rehabilitation between January 1, 2016 and November 30, 2016. Patients admitted for IV antibiotic therapy or stayed at SNF 6 days or less were excluded from the study (Figure 1). Patient characteristics (Table 1) included age, gender, Allen Cognitive Levels placemat test (ACL), body mass index (BMI), functional independent measures score (FIM) prior to discharge (Table 2), length of stay (LOS), Saint Louis University Mental Status (SLUMS) score, and Initial Admitting Diagnosis (Graph 1).

3. Results

  1. Overall 30-day hospital readmission rate was 11.8% (25/212) in this study. Disposition to residential care facilities (RCFE) increased the risk of readmissions to 18.9% (10/53), vs home 9.4% (15/159) (p= 0.065). (Graph 2)
  2. Comparing readmitted patients (n= 25) to non-readmitted patients (n= 187), male gender increased readmissions from 31% (65/212) to 44% (11/25) (p= 0.124), ACL 3.69 (CI* 3.112-4.264) vs 4.03 (CI 3.866- 4.191) (p= 0.172), LOS 16.7 days (CI 14.8-18.64) vs 15.4 days (CI 14.57-16.16) (p= 0.246). * 95% CI
  3. ACL of RCF patients (n=53) vs ACL of home patients (n=159) was 3.73 (CI 3.397-4.052) vs 4.08 (CI 3.898- 4.258) (p=0.057). In RCF group, ACL of readmitted patients (n=10) vs ACL of non-readmitted patients (n=43) was 3.34 (CI 2.214-4.466) vs 3.81 (CI 3.504-4.124) (p=0.271). (Table 3)

4. Discussion and Conclusions

  1. Male patients are more prone to hospital readmission post-SNF discharge than female patients, probably because of more comorbidity and need of more care.
  2. Allen Cognitive Level (ACL) placemat test (Image 1) is a standardized measurement of visual cognitive functioning used by occupational therapy. It is a useful tool to stratify risks of hospital readmission as shown in this study. ACL caregiver guides facilitate the best ability of cognitively impaired patients at different levels in aspects of medication supervision, safety recommendations, eating, dressing and hygiene, toileting use, mobility and positioning, and daily activities. (Ref. 1)
  3. Patients placed at residential care facilities have more ADL disability and tend to be more likely to be readmitted to the hospital post-SNF rehabilitation than patients discharged to home.

Studies have shown that living situation, marriage status, social support, wealth and race are associated with hospital readmission. Providing patients with enhanced post-discharge instructions and/or support is the most commonly endorsed preventive strategies. Multifaceted broadly applied interventions may be more successful than those that rely on individual providers choosing specific services based on perceived risk factors. (Ref. 2, 3)

5. Summary

Post-SNF 30-days hospital readmissions are more likely to occur in male, cognitively impaired, lower functioning patients. Allen Cognitive Level placemat test is a useful tool to stratify patients of higher risk for readmission. Caregiver guides for patients at different impaired levels can facilitate home health care in various aspects of activities of daily living. Further testing is required to validate the effect.

6. References   

  1. Champagne, Tina. "Allen Cognitive Level Caregiver Guides." www.ot-innovations.com/clinical- practice/cognition-2/the-allen-cognitive-level-battery 
  2. Baier, Rosa R., and Amal N. Trivedi. "For Hospital Readmissions, Hindsight Is Not 20/20." Journal of General Internal Medicine 2016 Nov; 31(11): 1270-1271. 
  3. Herzig, Shoshana J., and Schnipper Jeffrey L. "Physician Perspectives on Factors Contributing to Readmissions and Potential Prevention Strategies: A Multicenter Survey." Journal of General Internal Medicine 2016 Nov; 31(11): 1287-1293.

Please see attached for graphs