Post Hospital Transition Care Among Patients

Michigan State University, East Lansing MI

Investigators

Abstract

Dually eligible (Medicare Medicaid) patients have high rates of multiple chronic conditions, poor performance, and heavy use of medical care services. The dually eligible include all persons who are 65 years of age and older and who meet state criteria for being medically indigent as well as patients with severe developmental disabilities, serious mental illness, or complex comorbid conditions This application will conduct secondary analyses of Medicare (Parts A, B, and D) linked with Medicaid claim and encounter data and the Minimum Data Set information for both home and nursing home care services for the period of 01/01/2008 through 12/31/2011. As defined, 198,644 patients are eligible and available for analyses. The goal of this application is to conduct secondary analyses of this large complex data set in order to determine the role of demographics, sub population beneficiary categories, multiple chronic conditions, and discharge diagnoses are associated with configurations of post hospital transition care and, in turn, the impact of transition care configurations on: a) subsequent hospitalizations, b) the time between hospitalizations described as time at home or in the least intensive care setting and c) the costs of services between each hospital discharge and the subsequent hospitalization. Post hospital discharge configurations to be examined include; discharge to home with or without skilled home care, to nursing home for skilled care followed by custodial care, or directly to custodial nursing home care, or to hospice. .All analyses will adjust for age, sex, sub population beneficiary categories, number and type of chronic conditions, and discharge diagnoses. Each configuration of transition care will be treated as a multi-nomial dependent variable and analyzed over time. This application is significant because these analyses can, based on demographics and numbers of chronic conditions, suggest which discharge strategies are associated with longer time at home, fewer re-hospitalizations, and lower costs.