title: Predicting Adverse Outcomes After Discharge From Complex Continuing Care Hospital Settings to the Community.
abstract: OBJECTIVE
  The purpose was to identify risk and protective factors assessed at complex continuing care (CCC) admission that were associated with three adverse outcomes (death, readmission, and incidence of or failure to improve possible depression) for persons discharged from CCC to the community with home care services.
  
  
  METHODS
  CCC, home care, community.
  
  
  METHODS
  The sample included all CCC patients in Ontario assessed with the Resident Assessment Instrument-Minimum Data Set 2.0 between January 2003 and December 2010 and who were subsequently assessed with the Resident Assessment Instrument-Home Care within 6 months of discharge to the community (n = 9,940). Separate multivariable logistic regression models were developed for each outcome.
  
  
  RESULTS
  Within 6 months, 4.9% of the sample had died, 6.5% were readmitted to any Ontario CCC facility, and 13.7% showed symptoms of new possible depression or failure to improve possible depression. Heart failure, chronic obstructive pulmonary disease (COPD), health instability, intravenous/tube feed, and pressure ulcer were associated with increased risk of death. Difficulty with comprehension, possible depression, COPD, unstable conditions, acute episode or flare-up, short-term prognosis, worsening self-sufficiency, and having either patient or caregiver optimistic about discharge were associated with increased risk of readmission. Existing depressive symptoms or depression, unsettled relationships, multimorbidity, and polypharmacy were associated with risk for incidence of or failure to improve possible depression. Optimism about rehabilitation potential and high social engagement were protective against readmission and depressive outcomes, respectively.
  
  
  CONCLUSIONS
  Person-level clinical data collected on admission to CCC can be used to identify high-risk patients and trigger early discharge planning processes and other in-home interventions. These results support the sharing of information between settings, and highlight key areas in which care teams in CCC and case managers in home care organizations can work together to support the transition to home and potentially reduce adverse postdischarge outcomes.
authors.affiliation: Chi-Ling Joanna Sinn, BSc, PhD(c), is a PhD student in the Aging, Health, and Well-being program under the supervision of Dr. John Hirdes. Her areas of research include care transitions, resource allocation, and quality improvement with a particular interest in exploring how systems thinking can be used to inform them. Jake Tran, BSc, MEd, is a registered respiratory therapist acting as the Patient Care Manger for the Complex Continuing Care unit and Professional Practice Leader for Allied Health Professionals at Toronto Grace Health Centre (TGHC). Jake is co-leading MDS 2.0 education and implementation at TGHC. Tim Pauley, MSc, is the manager of Research and Evaluation at Toronto Central CCAC and West Park Healthcare Centre. He has been recognized by two international research awards for his work in return-to-driving post-lower limb amputation. His areas of research are amputee rehabilitation and community health care. John Hirdes, PhD, FCAHS, is a professor in the School of Public Health and Health Systems at the University of Waterloo. He is a board member of interRAI, and chairs both the interRAI Network of Excellence in Mental Health (iNEMH) and the interRAI Network of Canada.
authors.forename: Chi-Ling Joanna
authors.initials: CL
authors.lastname: Sinn
authors.forename: Jake
authors.initials: J
authors.lastname: Tran
authors.forename: Tim
authors.initials: T
authors.lastname: Pauley
authors.forename: John
authors.initials: J
authors.lastname: Hirdes
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019090:Case Management; D003153:Community Health Services / Q000458:organization & administration*; D004496:Education, Continuing; D005260:Female; D005544:Forecasting; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data*; D010359:Patient Readmission / Q000706:statistics & numerical data* / Q000639:trends*