Hospital-to-SNF Transitions of Care in Patients with End-Stage Kidney Disease

Weill Medical Coll Of Cornell Univ, New York NY

Investigators

Abstract

PROJECT SUMMARY/ABSTRACT Over 550,000 Americans have end-stage kidney disease (ESKD) requiring dialysis and patients with ESKD have very high rates of hospitalization and skilled nursing facility (SNF) admission. Transitions of care between acute and post-acute settings can be suboptimal because patients with ESKD have a high degree of medical complexity. Suboptimal hospital-to-SNF care transitions likely contribute to the very high hospital readmission rates (33%) among patients with ESKD. Hospitalizations, readmissions, and SNF stays for patients with ESKD account for >$10 billion in Medicare spending. Although SNF admissions are common and costly among patients with ESKD, very little is known about hospital-to-SNF care transitions in this population. The choice of SNF and whether dialysis is available on-site can shape both the continuity and quality of dialysis care. For example, it is unknown how commonly patients with ESKD receive hemodialysis treatments on-site at the SNF, off-site at the same dialysis facility they used prior to hospitalization, or off-site at a different dialysis facility during the SNF stay. It is also unknown how often patients receiving peritoneal dialysis (the dominant form of home dialysis in the US) are able to continue peritoneal dialysis while admitted to a SNF vs. having to transition to hemodialysis and whether such transitions are temporary or sustained. Optimizing hospital-to-SNF care transitions among patients with ESKD is crucial to improve quality of care for this medically complex population. In Aim 1, we will characterize patterns of hospital-to-SNF care transitions among patients with ESKD using Medicare claims and identify patient, dialysis facility, SNF, and market characteristics associated with those patterns. Aim 2 will examine the association of hospital-to-SNF care transitions patterns for patients with ESKD with established measures of quality of care (e.g., discharge home, 30-day readmissions, 30-day ED visits, functional improvement, pain, mortality). Our central hypothesis is that there will be significant variation in continuity and quality of care by patient, dialysis facility, SNF, and market characteristics, and that on-site hemodialysis and off-site hemodialysis with continuity will be associated with better outcomes, compared to not having continuity in outpatient dialysis facilities. Aim 3 will elicit the qualitative experiences and perspectives regarding hospital-to-SNF care transitions of patients with ESKD and their clinicians. In semi-structured interviews informed by care transitions conceptual frameworks, we will seek to understand ESKD care transition experiences and identify opportunities for improvement. Findings from this research will generate the first national data on hospital-to-SNF care transitions among patients with ESKD while building foundational insights that will inform future interventions to improve care transitions in this population.