title: Improving disposition outcomes for patients in a geriatric skilled nursing facility.
abstract: OBJECTIVE
  To evaluate an intervention to improve discharge disposition from a skilled nursing unit (SNU).
  
  
  METHODS
  Historical control comparison of discharge disposition before and after implementation.
  
  
  METHODS
  Fifty-bed SNU.
  
  
  METHODS
  All patients admitted from acute care hospitals to a SNU between June 2008 and May 2010.
  
  
  METHODS
  Physician admission procedures were standardized using a template, patients with three or more hospital admissions over the prior 6 months received palliative care consultations, and multidisciplinary root-cause analysis conferences for patients transferred back to the hospital acutely were conducted bimonthly to identify problems and improve processes of care.
  
  
  METHODS
  Patients' discharge disposition (i.e., acute care, long-term care, home, or death) before and after implementation were compared.
  
  
  RESULTS
  Discharge dispositions were determined for all 1,725 patients admitted during the study; 862 patients before (June-May 2008) and 863 during (June 2009-May 2010) the intervention. Discharge dispositions were significantly differently distributed across the two periods (P=.03). Readmission to acute care declined (from 16.5% to 13.3%, a nearly 20% decline). Multivariable logistic regression, controlling for age, sex, and case-mix index and adjusting for clustering due to repeated admissions of individual patients, suggests that, during the intervention period, patients were more likely than during the baseline period to die on the unit in accordance with their wishes than to be transferred out to the hospital (odds ratio=2.45, 95% confidence interval=1.09-5.5).
  
  
  CONCLUSIONS
  Interventions such as the ones implemented can lead to fewer hospital transfers for SNUs.
authors.affiliation: Hebrew SeniorLife, Boston, Massachusetts, USA. rberkowitz@hsl.harvard.edu
authors.forename: Randi E
authors.initials: RE
authors.lastname: Berkowitz
authors.forename: Richard N
authors.initials: RN
authors.lastname: Jones
authors.forename: Ron
authors.initials: R
authors.lastname: Rieder
authors.forename: Margaret
authors.initials: M
authors.lastname: Bryan
authors.forename: Robert
authors.initials: R
authors.lastname: Schreiber
authors.forename: Sharon
authors.initials: S
authors.lastname: Verney
authors.forename: Michael K
authors.initials: MK
authors.lastname: Paasche-Orlow
mesh_terms: D000203:Activities of Daily Living / Q000145:classification; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D003299:Cooperative Behavior; D019091:Critical Pathways; D003953:Diagnosis-Related Groups / Q000706:statistics & numerical data; D004185:Disability Evaluation; D005260:Female; D015577:Geriatric Assessment / Q000706:statistics & numerical data; D006302:Health Services Research / Q000706:statistics & numerical data; D006801:Humans; D033183:Interdisciplinary Communication; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008404:Massachusetts; D010166:Palliative Care / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data*; D010359:Patient Readmission / Q000706:statistics & numerical data*; D017064:Process Assessment, Health Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data*