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Principal Investigator: Jennifer Lynn Carnahan
Organization: INDIANA UNIVERSITY INDIANAPOLIS
Fiscal Year: 2024
Award: $178,039
Funding agency: National Institute on Aging
Increasing numbers of patients with Alzheimer’s disease and related dementias (ADRD) are receiving post-
hospitalization care in skilled nursing facilities (SNFs). Most will transition from the SNF to home. Although
there has been a great deal of attention paid to patients’ transition from the hospital to home, there has been
little research on transitions from the SNF to home. Experiencing multiple transitions from home to the hospital
to a SNF and back to home is difficult for patients with ADRD and their caregivers. After discharge from SNF to
home, patients may re-enter the cycle of transitions, suffering adverse outcomes such as hospital
readmissions, medication errors, functional decline, and loss of independence.
This project will identify factors associated with 30-day hospital readmission and other adverse outcomes for
patients with ADRD who transition from the SNF to home. We will use the Health and Retirement Study (HRS),
a large, national dataset that includes rich social and economic information that is pertinent to the risk of
adverse health outcomes. Our study takes advantage of the link between the HRS and Centers for Medicare
and Medicaid Services billing data, and especially the link to extensive data collected during SNF stay as part
of the Minimum Data Set and home health event data from the Outcome and Assessment Information Set.
For Aim 1, we will describe the relationship of ADRD diagnosis or severity of cognitive impairment in the SNF
with hospital readmission for patients who transition from SNF to home. We hypothesize that individuals with
ADRD are at greater risk of hospital readmission when controlling for Andersen model factors. We also
propose that worse levels of cognitive impairment, as measured during a patient’s stay in the SNF, will be
associated with greater risk readmission risk. For Aim 2, we will identify the effect of early outpatient care,
either in clinic visit or via home health visit, on reducing readmissions. We hypothesize that early outpatient
care is protective against readmission. This represents a first step in identifying interventions to reduce
readmissions for people with ADRD who undergo this complex healthcare trajectory.
Dr. Carnahan’s career development plan will provide thorough training in research methods and health policy
related to transitions for older adults with ADRD. As an emerging aging researcher with expertise in the SNF to
home care transition, Dr. Carnahan will use the results of this study to design an intervention that improves the
health outcomes of cognitively impaired patients who experience this complex healthcare trajectory. Her long
term goal is to improve the quality of care and health outcomes for older adults with ADRD.
Terms: <AD related dementia><ADRD><Accident and Emergency department><Active Follow-up><Admission><Admission activity><Age><Aging><Alzheimer's and related dementias><Alzheimer's disease and related dementia><Alzheimer's disease and related disorders><Alzheimer's disease or a related dementia><Alzheimer's disease or a related disorder><Alzheimer's disease or related dementia><Alzheimer's disease patient><Alzheimer's disease related dementia><Alzheimer's patient><Ambulatory Care><Amentia><Attention><Back><Care Givers><Caregivers><Caring><Centers for Medicare and Medicaid Services><Characteristics><Clinic Visits><Cognitive Disturbance><Cognitive Impairment><Cognitive decline><Cognitive function abnormal><Complex><Computerized Medical Record><Data><Data Set><Dementia><Development Plans><Diagnosis><Discharge from Health Care Facility><Discharge from Healthcare Facility><Disturbance in cognition><Domiciliary Care><Dorsum><Economic Income><Economical Income><Economics><Electronic Medical Record><Emergency Department><Emergency room><Event><Extended Care Facilities><Funding><Future><Gender><Goals><Health><Health Care Financing Administration><Health Care Utilization><Health Policy><Health and Retirement Study><Healthcare><Home><Home Care><Home Care Services><Hospital Admission><Hospitalization><Hospitals><Impaired cognition><Income><Indiana><Individual><Injury><Intervention><Intervention Strategies><Intervention Trial><Interventional trial><Interview><Investigators><Length of Stay><Link><Measures><Medical><Medical Rehabilitation><Medicare/Medicaid><Medication Errors><Modeling><Number of Days in Hospital><Out-patients><Outcome><Outpatient Care><Outpatients><Patient Discharge><Patient Readmission><Patient outcome><Patient-Centered Outcomes><Patient-Focused Outcomes><Patients><Persons><Physical Function><Population Heterogeneity><QOC><Quality of Care><Rehabilitation><Rehabilitation therapy><Research><Research Methodology><Research Methods><Research Personnel><Researchers><Risk><Scholarship><Severities><Skilled Nursing Facilities><Social isolation><Time><Training><United States Centers for Medicare and Medicaid Services><United States Health Care Financing Administration><Visit><Work><active followup><acute care><adverse consequence><adverse outcome><ages><billing data><career development><cognitive dysfunction><cognitive loss><decline in function><decline in functional status><diverse populations><economic><experience><follow up><follow-up><followed up><followup><functional decline><functional status decline><health care><health care policy><health care service use><health care service utilization><health care settings><healthcare policy><healthcare service use><healthcare service utilization><healthcare settings><healthcare utilization><heterogeneous population><high risk><home based service><home health care><home healthcare><homes><hospital days><hospital length of stay><hospital re-admission><hospital readmission><hospital stay><improved><incomes><injuries><insight><intervention design><interventional strategy><medication administration errors><older adult><older adulthood><outpatient treatment><patient home care><patient homecare><patient living with Alzheimer's disease><patient oriented outcomes><patient re-admission><patient suffering from Alzheimer's disease><patient with Alzheimer's><patient with Alzheimer's disease><population diversity><posthospitalization care><prevent><preventing><primary outcome><re-admission><re-admission risk><re-hospitalization><readmission><readmission risk><rehab therapy><rehabilitative><rehabilitative therapy><rehospitalization><research and methods><secondary outcome><social><support network><therapy design><treatment design>