title: Trajectories of Disability Among Older Persons Before and After a Hospitalization Leading to a Skilled Nursing Facility Admission.
abstract: OBJECTIVE
  To identify distinct sets of disability trajectories in the year before and after a Medicare qualifying skilled nursing facility (Q-SNF) admission, evaluate the associations between the pre-and post-Q-SNF disability trajectories, and determine short-term outcomes (readmission, mortality).
  
  
  METHODS
  Prospective cohort study including 754 community-dwelling older persons, 70+ years, and initially nondisabled in their basic activities of daily living. The analytic sample included 394 persons, with a first hospitalization followed by a Q-SNF admission between 1998 and 2012.
  
  
  METHODS
  Disability in the year before and after a Q-SNF admission using 13 basic, instrumental, and mobility activities. Secondary outcomes included 30-day readmission and 12-month mortality.
  
  
  RESULTS
  The mean (SD) age of the sample was 84.9 (5.5) years. We identified 3 disability trajectories in the year before a Q-SNF admission: minimal disability (37.3% of participants), mild disability (44.6%), and moderate disability (18.2%). In the year after a Q-SNF admission, all participants started with moderate to severe disability scores. Three disability trajectories were identified: substantial improvement (26.0% of participants), minimal improvement (36.5%), and no improvement (37.5%). Among participants with minimal disability pre-Q-SNF, 52% demonstrated substantial improvement; the other 48% demonstrated minimal improvement (32%) or no improvement (16%) and remained moderately to severely disabled in the year post-Q-SNF. Among participants with mild disability pre-Q-SNF, 5% showed substantial improvement, whereas 95% showed little to no improvement. Of participants with moderate disability pre-Q-SNF, 15% remained moderately disabled showing little improvement, whereas 85% showed no improvement. Participants who transitioned from minimal disability pre-Q-SNF to no improvement post-Q-SNF had the highest rates of 30-day readmission and 12-month mortality (rate/100 person-days 1.3 [95% CI 0.6-2.8] and 0.3 [95% CI 0.15-0.45], respectively).
  
  
  CONCLUSIONS
  Among older persons, distinct disability trajectories were observed in the year before and after a Q-SNF admission. The likelihood of improvement in disability was greatly constrained by the pre-Q-SNF disability trajectory. Most older persons remained moderately to severely disabled in the year following a Q-SNF admission.
authors.affiliation: Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, The Netherlands. Electronic address: b.m.vanes@amc.nl.
authors.forename: Bianca M
authors.initials: BM
authors.lastname: Buurman
authors.affiliation: Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
authors.forename: Ling
authors.initials: L
authors.lastname: Han
authors.affiliation: Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
authors.forename: Terrence E
authors.initials: TE
authors.lastname: Murphy
authors.affiliation: Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
authors.forename: Evelyne A
authors.initials: EA
authors.lastname: Gahbauer
authors.affiliation: Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
authors.forename: Linda
authors.initials: L
authors.lastname: Leo-Summers
authors.affiliation: Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
authors.forename: Heather G
authors.initials: HG
authors.lastname: Allore
authors.affiliation: Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Gill
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006233:Persons with Disabilities / Q000706:statistics & numerical data; D005260:Female; D006760:Hospitalization; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D010359:Patient Readmission / Q000639:trends; D010360:Patient Transfer; D011446:Prospective Studies; D012866:Skilled Nursing Facilities
keywords: Skilled nursing facility; disability; elderly; functional decline; hospitalization; mortality; post-acute care; readmission