title: Determinants of remaining in the community after discharge: results from New Jersey's Nursing Home Transition Program.
abstract: OBJECTIVE
  To inform states with nursing home transition programs, we determine what risk factors are associated with participants' long-term readmission to nursing homes within 1 year after discharge.
  
  
  METHODS
  We obtained administrative data for all 1,354 nursing home residents who were discharged, and we interviewed 628 transitioning through New Jersey's nursing home transition program in 2000. We used the Andersen behavioral model to select predictors of long-term nursing home readmission, and we used Cox proportional hazards regressions to examine the relative risk of experiencing such readmissions.
  
  
  RESULTS
  Overall, 72.6% of the 1,354 individuals remained in the community, with 8.6% readmitted to a nursing home for long stays (>90 days) and 18.8% dying during the study year. Cox proportional hazards regression analysis showed that being male, single, and dissatisfied with one's living situation; living with others; and falling within 8 to 10 weeks after discharge were significant predictors of long-term nursing home readmission during the first year after discharge.
  
  
  CONCLUSIONS
  Most of the factors predicting long-term readmission were predisposing, not need, factors. This fact points to the limits of formulaic approaches to assessing candidates for discharge and the importance of working with clients to understand and address their particular vulnerabilities. Consumers, state policy makers, nursing home transition staff, discharge planners, and caregivers can use these findings to understand and help clients understand their particular risks and options, and to identify those individuals needing the greatest attention during the transition period as well as risk-specific services such as fall-prevention programs that should be made available to them.
authors.affiliation: Rutgers Center for State Health Policy, 55 Commercial Avenue, Third Floor, New Brunswick, NJ 08901, USA. showell@ifh.rutgers.edu
authors.forename: Sandra
authors.initials: S
authors.lastname: Howell
authors.forename: Mina
authors.initials: M
authors.lastname: Silberberg
authors.forename: Winifred V
authors.initials: WV
authors.lastname: Quinn
authors.forename: Judith A
authors.initials: JA
authors.lastname: Lucas
mesh_terms: D000359:Aftercare; D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D020380:Needs Assessment; D009515:New Jersey; D009735:Nursing Homes / Q000458:organization & administration / Q000706:statistics & numerical data*; D010351:Patient Discharge / Q000706:statistics & numerical data*; D010359:Patient Readmission / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors