title: Post-acute referral decisions made by multidisciplinary experts compared to hospital clinicians and the patients' 12-week outcomes.
abstract: BACKGROUND
  Anticipating post-acute needs and making referrals for follow-up care are crucial for quality discharge planning. Several studies reveal serious gaps in quality for these common and important processes.
  
  
  OBJECTIVE
  Compare experts' and hospital clinicians' discharge referral decisions for the same elderly patients, and examine 12-week outcomes for patients whom experts identified for referral but were not referred by hospital clinicians to those who experts and clinicians agreed to refer or not.
  
  
  METHODS
  A comparative, descriptive analysis of referral decisions for 355 elderly patients and their 12-week outcomes.
  
  
  METHODS
  Older adults hospitalized with common medical surgical conditions from 6 hospitals in Northeast United States.
  
  
  RESULTS
  Experts identified 183 additional patients for post-acute referral. Experts were 18 times more likely to refer patients than hospital clinicians. Clinicians referred patients with obvious needs for post acute care, and experts with better information and time to consider the perspectives of other disciplines identified additional patients. These patients demonstrated a rehospitalization rate of 23%, not significantly different than those referred (20%), but nearly 5 times higher than patients not identified for referral. Similar to those who received referrals, they were significantly more likely to rate their health fair or poor and their functional status remained significantly worse at 12 weeks than the no referral group.
  
  
  CONCLUSIONS
  Experts identified additional patients in need of post-acute care. Negative outcomes reflect the costly results of this gap in quality and support the need to improve data presentation and referral decision making.
authors.affiliation: New Courtland Center for Health and Transitions, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA. bowles@nursing.upenn.edu
authors.forename: Kathryn H
authors.initials: KH
authors.lastname: Bowles
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Ratcliffe
authors.forename: John H
authors.initials: JH
authors.lastname: Holmes
authors.forename: Matthew
authors.initials: M
authors.lastname: Liberatore
authors.forename: Robert
authors.initials: R
authors.lastname: Nydick
authors.forename: Mary D
authors.initials: MD
authors.lastname: Naylor
mesh_terms: D000359:Aftercare / Q000706:statistics & numerical data*; D000368:Aged; D003266:Continuity of Patient Care; D003657:Decision Making; D020000:Decision Support Systems, Clinical; D005260:Female; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital; D008511:Medicine; D009511:New England; D017063:Outcome Assessment, Health Care; D010351:Patient Discharge / Q000592:standards*; D010359:Patient Readmission / Q000706:statistics & numerical data; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012044:Regression Analysis; D013038:Specialization; D013514:Surgical Procedures, Operative