Outcomes of a Nursing Home-to-Community Care Transition Program.

ABSTRACT:

Objectives

Most transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes.

Design

Propensity-matched control-intervention trial.

Intervention

Patients in the intervention group received care management following nursing stay (a home visit and nursing phone calls).

Setting and participants

Patients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention becaus

SUBMITTER: Takahashi PY 

PROVIDER: S-EPMC8581072 | biostudies-literature | 2021 Dec

REPOSITORIES: biostudies-literature