Outcomes after Hospital Discharge to Home Versus Discharge to a Facility for Older Patients with Alzheimer’s Disease and Alzheimer’s Disease Related Dementias

University Of California Los Angeles, Los Angeles CA

Investigators

Abstract

Project Summary As adults age, they are much more likely to be hospitalized. Of those hospitalized, 2 in 5 receive rehabilitative post-acute care, often at home or at a facility. Patients and caregivers predominantly prefer home-based care, but half of hospitalized older patients receiving post-acute care received such care at a facility. Patients with Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD), who are even more likely to be hospitalized as patients without AD/ADRD, also prefer home-based care, but they are half as likely as patients without AD/ADRD to be discharged home. Therefore, the decision of whether to discharge a patient to home versus to a facility is an important one for older patients—including older patients with AD/ADRD—and their caregivers. Our long-term goal is to provide rigorous evidence on outcomes of home-based versus facility- based care. Research comparing outcomes by discharge destination, however, has been largely stymied by the issue of confounding by indication. Since patients who are discharged home tend to be healthier than those discharged to facilities, comparisons between the two groups are challenging. To address this issue, our proposed work will employ a novel research strategy: we will use differences in the influence of physical therapists (PTs) on the discharge destination as a “randomizing device” for a patient’s discharge destination. This research strategy requires the inpatient PT’s identity, which is not contained in commonly-used large claims datasets. By using Veterans Affairs (VA) electronic health record data, we can bring this novel research strategy to bear across almost 100 VA hospitals. This allows us to answer the fundamental question of who benefits or may be harmed by a discharge to home versus to a facility in a rigorous manner on a nationwide scale. Under this research strategy, we can measure outcomes after discharging to home versus to a facility for patients we call “on the cusp” between home and facility, for whom different PTs might come to a different discharge destination recommendation (i.e., patients whose discharge destination might change based on which inpatient PT they are assigned to). These patients, for whom discharge recommendations are uncertain, would particularly benefit from better evidence on the benefits or harms of discharging to home. We propose 3 Aims: (1) examine outcomes, such as re-hospitalization and costs, after being discharged to home versus to a facility, both for older patients with AD/ADRD and for older patients overall; (2) examine characteristics that distinguish patients for whom different PTs may come to different discharge recommendations and identify characteristics of patients with particularly better or worse health outcomes when going home versus to a facility after hospitalization; and (3) perform qualitative interviews of inpatient PTs to better understand the factors they take into account when seeing patients for whom the recommendation may not be clear-cut, and how these factors may differ for patients with AD/ADRD. Our project will produce evidence for hospitals, health care organizations, and policymakers on discharge decision-making and discharge planning for older adults.