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Abstract
There are more than one million fee-for-service Medicare beneficiaries admitted to skilled nursing facilities (SNFs) annually for post-acute care, and relatively little is known about the SNF-to-home transition and outcomes of older adults post-SNF discharge. Limited data suggest that older adults admitted to SNFs for post-acute care struggle with the transition back to the community. From March 2016 to November 2017 we used state-of-the-art, NIH-sponsored Patient Reported Outcome Measurement Information System (“PROMIS”) computerized adaptable testing methods to characterize physical, mental, and social health among a longitudinal cohort study of 112 SNF rehabilitation patients. How these physical, mental, and social domains affect the ability of an older adult to transition to and remain in the community will be discussed. Implications for optimizing the SNF-to-home care transition also will be examined.
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1 University of Rochester Medical Center, Pittsford, New York, United States
2 Division of Geriatrics, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
3 Office for Aging Research and Health Services, University of Rochester Medical Center, Rochester, NY, USA; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
4 Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
5 Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA; Office for Aging Research and Health Services, University of Rochester Medical Center, Rochester, NY, USA