Reducing Hospital Readmissions of Older Adults Pursuing Postacute Care at Skilled Nursing Facilities: A Scoping Review

Abstract

Importance: Unplanned hospital readmissions can profoundly affect older adults’ quality of life and the financial status of skilled nursing facilities (SNFs). Although many clinical practices focus on reforming these issues, occupational therapy’s involvement remains unclear.

Objective: To explore clinical practices aimed at reducing hospital readmissions of older adults pursuing postacute care (PAC) at SNFs and describe how they align with occupational therapy’s scope of practice.

Data Sources: We searched CINAHL, Scopus, PubMed, and OTseeker for articles published from January 2011 to February 2020.

Study Selection and Data Collection: We conducted a scoping review of peer-reviewed articles with functional outcomes of clinical practices reducing unplanned hospital readmissions of patients older than age 65 yr pursuing PAC services in SNFs. Trained reviewers completed the title and abstract screens, full-text reviews, and data extraction.

Findings: Thirteen articles were included and focused on five areas: risk and medical disease management and follow-up, hospital-to-SNF transition, enhanced communication and care, function, and nutrition. Early coordination of care and early identification of patients’ needs and risk of readmission were common features. All clinical practices aligned with occupational therapy domains and processes, but only 1 study specified occupational therapy as part of the research team.

Conclusions and Relevance: Comprehensive, multipronged clinical practices encompassing care coordination and early identification and management of acute conditions are critical in reducing preventable readmissions among older adults pursuing PAC services in SNFs. Further research is needed to support occupational therapy’s value in preventing hospital readmissions of older adults in this setting.

What This Article Adds: This scoping review maps the presence of occupational therapy’s domains and processes in the clinical practices that reduce hospital readmissions of older adults pursuing PAC services in SNFs. Findings provide occupational therapy practitioners with opportunities to assume roles beyond direct patient care, research, advocate, and publish more, thereby increasing their presence and adding value to occupational therapy interventions that reduce hospital readmissions.

This scoping review maps the presence of occupational therapy’s domains and processes in the clinical practices that reduce hospital readmissions of older adults pursuing PAC services in SNFs.

The U.S. health care system has been rapidly changing because of its growing aging population and increased concern for health care value (Dieter et al., 2019), especially for those pursuing postacute care (PAC) in skilled nursing facilities (SNFs). The establishment of a prospective payment system by the Centers for Medicare & Medicaid Services in the 1980s, along with a rise in managed care in the 1990s, caused a reduction in length of stay in hospitals across the United States (Burke et al., 2016). Between 1996 and 2010, this change led to an almost 50% increase in patients discharged to PAC from the hospital (Burke et al., 2016; Sacks et al., 2015).

In 2010, the Triple Aim, a framework developed by the U.S. Institute of Healthcare Improvement, became part of the U.S. national strategy for tackling health care issues to simultaneously improve patients’ care experiences and population health and to reduce per capita cost (Berwick et al., 2008). The Triple Aim led to changes in PAC-related policy, such as the Hospital Readmissions Reduction Program, the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 (Pub. L. 113-185), and the Patient-Driven Payment Model (adopted in 2019). These programs emphasize a demand for SNF-driven, patient-centered PAC services and the pursuit of clinical practices for optimizing PAC recipients’ health (White, 2019; Ziakas & Mylonakis, 2020).

Compared with younger adults, hospitalized older adults typically require a longer time to recover from an acute illness or injury (Ribbink et al., 2019; Wang et al., 2019). They are more likely to present with geriatric syndromes, defined as multifactorial health conditions that do not fit into discrete categories of disease, such as impairments in activities of daily living (ADLs), cognitive decline, frailty, polypharmacy, and multimorbidity, among others (Bell et al., 2016; Sanford et al., 2020; van Seben et al., 2019). Prevalent among hospitalized older adults discharged to SNFs, geriatric syndromes sometimes remain at posthospital discharge, placing the older adult at high risk for readmission to the hospital (Bell et al., 2016; van Seben et al., 2019).

The shift to early hospital discharges often necessitates that older adults transfer to PAC settings to complete the recovery process. Kortebein (2019) reported that approximately 40% of older Medicare patients require some form of PAC. Werner and Konetzka (2018) noted that 20% of the discharges to PAC facilities are to SNFs. However, nearly 23% of these patients readmit to the hospital within 30 days (Chandra et al., 2019). Still, most hospital readmissions have been shown to be potentially preventable (Calsolaro et al., 2019 ; Center for Healthcare Quality and Payment Reform, 2013). However, the leading factors for rehospitalization from SNFs must be identified and addressed while considering older adults’ unique needs.

Preliminary literature reviews have shown that occupational therapy practitioners have the skills and abilities to help patients achieve optimal health and well-being, thereby reducing their risk of rehospitalization (Leland et al., 2015; Rafeedie et al., 2018; Roberts & Robinson, 2014). Rogers et al. (2017) examined the association between hospital costs for services and 30-day readmission rates for older adults with heart failure, acute myocardial infarction, and pneumonia. Results showed occupational therapy as the only profession with statistically significant numbers in lowering hospital readmission rates for all three diagnoses. Rogers et al. attributed this finding to occupational therapy practitioners’ ability to address patients’ functional and social needs, which are vital in reducing hospital readmissions.

In another study, Beach et al. (2020) explored the correlation of adults older than age 65 yr having unmet needs in ADLs and instrumental activities of daily living (IADLs). Beach et al. concluded that adverse consequences and high financial costs occurred when ADL and IADL needs were left unmet. In a retrospective cohort study of the population-based Health and Retirement Study, Schiltz et al. (2020) ranked ADL and IADL limitations as the two most important predictors of 30-day readmission. Similar studies have supported occupational therapy practitioners’ skills and abilities to provide clinical intervention and to achieve outcomes that affect the health and well-being of older people (Clark et al., 2012; Jutkowitz et al., 2012 ; Szanton et al., 2016), potentially reducing their risk of hospital readmission. However, research on occupational therapy’s effects on readmission is needed (Schiltz et al., 2020).

Overall, evidence of clinical practices is growing, in the form of interventions, programs, and initiatives aimed at reducing hospital readmissions of older adults receiving PAC in SNFs (Boxer et al., 2013; Leutgeb et al., 2019; Pedersen et al., 2018). However, the extent to which occupational therapy plays a role in these practices is not clear. Therefore, a scoping review was conducted to explore the literature, to identify the clinical practices aimed at reducing unplanned hospital readmissions among older adults pursuing PAC in SNFs, and to describe how these practices align with the scope of occupational therapy.

Method

The scoping review methodology was guided by Arksey and O’Malley’s (2005) framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA–ScR), as recommended by the Joanna Briggs Institute (Peters et al., 2015). Unlike systematic reviews, which evaluate the quality of the literature, scoping reviews summarize the range of evidence on topics and identify gaps in the literature for future research (Peters et al., 2015). Institutional review board approval is not required for this approach. However, we designed a protocol a priori to ensure rigor and transparency using a five-step process: (1) develop and identify the research question; (2) identify relevant studies; (3) carefully select the studies; (4) chart the data; and (5) collate the results to determine the study’s implications for policy, practice, and future research (Arksey & O’Malley, 2005).

Research Questions

The specific aims of the scoping review were to (1) identify and describe clinical practices used to reduce unplanned hospital readmissions of older adults admitted to SNFs for PAC services, (2) identify the professional disciplines that provide these clinical practices, and (3) describe how these clinical practices align with the scope of occupational therapy on the basis of the domains and processes of the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; OTPF–3; American Occupational Therapy Association [AOTA], 2014).

Research Teams

The scoping review used three research teams. The title and abstract screening team consisted of an occupational therapy graduate assistant completing her first year of the Master of Science in Occupational Therapy program (Gabrielle Khalifa), a speech-language pathologist with research experience and familiarity with occupational therapy’s scope of practice (Arpana Lingaraj); and the primary investigator (Antoinette Shaw). The full-text review team was composed of the graduate assistant, an occupational therapist with >30 yr of clinical experience (Carol Ruddock), and the primary investigator. The data extraction team consisted of three occupational therapists (Diane Hunter, Ivy Bishop, and Carol Ruddock), each with >30 yr of clinical experience. The primary investigator provided synchronous and asynchronous training to each team member, including communication on the research question, the scoping review protocol, timelines, due dates, and updates on the project.

Search Strategy

We carried out the search for relevant studies in February 2020 using the CINAHL, Scopus, PubMed, and OTseeker databases. The keywords included the following Medical Subject Headings terms: (aged OR elderly) AND (skilled nursing facility OR nursing home) AND (transitional care OR subacute care OR postacute care) AND (clinical program OR clinical programs OR clinical interventions OR clinical initiatives) AND (unplanned hospital readmission OR hospital readmission OR unplanned rehospitalization). A professional librarian with experience in health care–related topics provided consultation, support, and coaching to the primary investigator.

Inclusion and Exclusion Criteria

The search comprised peer-reviewed articles published in English after January 2011, consistent with the adoption of the Triple Aim affecting PAC services in SNFs. Included articles studied clinical practices directed toward adults older than age 65 yr receiving PAC in SNFs and reported outcomes related to reducing unplanned hospital readmissions. We excluded gray literature, articles not printed in English, and those focused on palliative or hospice care.

Review Process

For the review process, we used Covidence systematic review software (Version 1.0; Veritas Health Innovation, Melbourne, Victoria, Australia). The primary investigator loaded all the titles and abstracts from CINAHL, Scopus, and PubMed into Covidence. We formatted the titles and abstracts from OTseeker using EndNote X9 software, and then we loaded them into Covidence. Each title and abstract was screened independently by the primary investigator or another team member randomly assigned by Covidence. The full-text review articles were loaded into Covidence by the primary investigator and then reviewed by the team. The second author (Pamela Talero Cabrejo) resolved discrepancies throughout the review process. Figure 1 shows the flow diagram of the process.

Figure 1.

Flow diagram for inclusion and exclusion of peer-reviewed studies in the scoping review.

Data Extraction and Management

A data extraction form (see Supplement 1, available online with this article at https://research.aota.org/ajot) was loaded, stored, and shared via Google Drive. The review team charted the main characteristics of each article (see Table A.1 in the Supplemental Appendix, available online with this article) and the presence of occupational therapy practice domains and processes outlined in the OTPF–3 (AOTA, 2014; Supplemental Appendix Table A.2). Team members extracted data independently and discussed the results with the primary investigator to achieve 100% consensus.

Data Analysis

The primary investigator examined each study’s design, population, type of clinical practice, focus areas, the disciplines involved, the discipline’s role, outcome measures, and conclusion. Clinical practices were grouped by focus of the articles. Results were discussed with the second author, mapped, and presented in a diagrammatic format, showing how the clinical practices align with the occupational therapy scope of practice (see Supplemental Table A.2). The scoping review questions and research objectives provided a base for interpreting the results and guiding the discussion and conclusions.

Results

As shown in Figure 1, the literature search led to 861 articles. After removing duplicates, 706 titles and abstracts were screened, and 576 were deemed irrelevant. Of the remaining articles, 130 moved into full-text review, of which 13 met the criteria for data extraction. For this scoping review, 100% agreement was achieved on identifying the occupational therapy domains and processes represented in the clinical practices according to the OTPF–3, the disciplines involved in each clinical practice, and their respective roles in implementing the intervention and identifying gaps and opportunities.

As shown in Supplemental Appendix Table A.1, 10 studies (77%) were conducted in the United States, and only 3 studies (23%; Folven et al., 2018; Leutgeb et al., 2019; Pedersen et al., 2018) were conducted elsewhere. The most common study design was retrospective cohort (n = 4, 31%; Carnahan et al., 2017; Keswani et al., 2015; Middleton et al., 2016; Rosen et al., 2017), followed by prospective cohort (n = 3, 23%; Farris et al., 2017; Folven et al., 2018; Moore et al., 2017). The remaining 6 studies (46%) used a distinct design, as noted in Supplemental Appendix Table A.1 (Berkowitz et al., 2013; Boxer et al., 2013; Huckfeldt et al., 2018; Krol et al., 2018; Leutgeb et al., 2019; Pedersen et al., 2018).

Clinical Practices Used to Reduce Unplanned Hospital Readmissions Among Older Adults Admitted to Skilled Nursing Facilities for Postacute Care Services

Clinical practices were grouped into five categories on the basis of the studies’ primary areas of focus: risk and medical disease management and follow-up (n = 5; Boxer et al., 2013; Carnahan et al., 2017; Keswani et al., 2015; Leutgeb et al., 2019; Pedersen et al., 2018), enhanced communication and care delivery (n = 3; Farris et al., 2017; Huckfeldt et al., 2018; Rosen et al., 2017), hospital-to-SNF transition (n = 3; Berkowitz et al., 2013; Krol et al., 2018; Moore et al., 2017), function (n = 1; Middleton et al., 2016), and nutrition (n = 1; Folven et al., 2018). The most recurrent features reducing hospital readmissions among older adults receiving PAC in SNFs were early coordination of care (n = 9; Berkowitz et al., 2013; Boxer et al., 2013; Carnahan et al., 2017; Farris et al., 2017; Leutgeb et al., 2019; Middleton et al., 2016; Moore et al., 2017; Pedersen et al., 2018; Rosen et al., 2017) and early identification of patients’ needs and risk of readmission (n = 9; Berkowitz et al., 2013; Carnahan et al., 2017; Farris et al., 2017; Folven et al., 2018; Huckfeldt et al., 2018; Keswani et al., 2015; Krol et al., 2018; Middleton et al., 2016; Moore et al., 2017). Adequate staffing in numbers, distribution, and level of preparedness was the most common challenge (n = 4; Berkowitz et al., 2013; Boxer et al., 2013; Leutgeb et al., 2019; Moore et al., 2017). Farris et al. (2017) and Berkowitz et al. (2013) also identified care fragmentation in SNFs as a pressing need.

On average, study participants were female (66.13% of all participants in the 12 studies that reported gender) and White (78.66% of all participants in the 7 studies that reported race). Most studies used mixed diagnosis (n = 9; Carnahan et al., 2017; Farris et al., 2017; Folven et al., 2018; Krol et al., 2018; Leutgeb et al., 2019; Middleton et al., 2016; Moore et al., 2017; Pedersen et al., 2018; Rosen et al., 2017), whereas 1 study focused on heart failure (Boxer et al., 2013) and 1 study focused on hip and knee fractures (Keswani et al., 2015). Two studies did not specify the diagnoses (Berkowitz et al., 2013; Huckfeldt et al., 2018). All 13 studies reported successful outcomes that supported their claim or research question, indicating reduced unplanned rehospitalization or effectively supporting the care of older adults, preventing hospital readmission.

Professional Disciplines Involved in Clinical Practices

Most clinical practices used an interdisciplinary team that included a medical doctor (MD), nurse practitioner (NP), pharmacist, pharmacy technician, nurse educator, program administrator, and medical director (n = 4; Berkowitz et al., 2013; Farris et al., 2017; Moore et al., 2017; Rosen et al., 2017). Two clinical practices used a multidisciplinary team of NPs, geriatricians, hospitalists, geriatrics fellows, nursing leadership, case management, hospital leadership representatives, and administrative leaders (Folven et al., 2018; Krol et al., 2018). Moore et al. (2017) and Farris et al. (2017) included physical therapists as members of the interdisciplinary care team. Four studies used either a MD or a nurse serving individually (Boxer et al., 2013; Carnahan et al., 2017; Huckfeldt et al., 2018; Leutgeb et al., 2019). The remaining 3 studies had either one MD and one nurse serving together (Pedersen et al., 2018), a team of researchers including an occupational therapist (Middleton et al., 2016), or a team of trained claim reviewers (Keswani et al., 2015).

Clinical Practices Alignment With Occupational Therapy Domains and Processes

As shown in Supplemental Appendix Table A.2, all clinical practices (n = 13) aligned with occupational therapy domains and processes; however, only Middleton et al. (2016) specified occupational therapy as part of the research team. The distribution of the construct “contexts and environments” was present in most clinical practices (n = 11), followed by “occupations” (n = 8) and “performance skills” (n = 8). Analysis of the processes used to implement each clinical practice showed “education and training” as the highest intervention type (n = 11). For the intervention approach, “maintain” was present in most clinical practices (n = 8). Several process outcomes were noted, with the most salient being “prevention” (n = 13), followed by “occupational performance” (n = 8) and “health and wellness” (n = 8). The least addressed occupational therapy domain was “performance patterns” (n = 2), and the least addressed process outcomes were “participation” (n = 3) and “well-being” (n = 2). None of the interventions aligned with “occupational justice” or “role competence.”

Discussion

On the basis of the findings, comprehensive, multipronged clinical practices comprising care coordination and early identification and management of acute conditions are critical in reducing preventable readmissions among older adults pursuing PAC services in SNFs. Increasing clinical touchpoints during SNF stay creates opportunities to address minor issues before they turn into clinical emergencies requiring hospital readmission (Berkowitz et al., 2013; Rosen et al., 2017). The following practices are also noteworthy: improving interdisciplinary teamwork between discharging and receiving facilities (Moore et al., 2017); advanced care planning (Huckfeldt et al., 2018; Rosen et al., 2017); and early coordination of home health visits within 1 wk of SNF discharge, including therapy (Carnahan et al., 2017).

Another necessity is the consistent use of the standardized measures of self-care, mobility, and cognitive function across PAC settings as required by the IMPACT Act (Middleton et al., 2016). Without appropriate and consistent grading schemes and validation, the implementation may not be widely adopted and used to provide better clinical outcomes (Meuten et al., 2018). In this scoping review, “occupations” and “performance skills” were largely represented as ADLs and IADLs, self-care, mobility, and cognitive skills that play a crucial role in reducing preventable rehospitalizations. This finding is consistent with other research indicating that cognitive decline, impairments in ADLs, frailty, and geriatric syndromes are high-risk factors for rehospitalization (Ribbink et al., 2019; Schiltz et al., 2020; van Seben et al., 2019).

In the context of changing service delivery and value-based reimbursement models in PAC, the articles alert readers to care fragmentation and support a culture shift in SNFs by educating patients and their families about care transitions and better allocating professional roles within the SNF. This model includes an urgent need for stabilizing staffing patterns in the delivery of nursing and therapy services in SNFs (Jewell et al., 2019 ; Livingstone et al., 2020; Roberts et al., 2020); training SNF staff in anticipating patient and family needs (Rosen et al., 2017); and focusing on care coordination and care goals (Moore et al., 2017) through interdisciplinary, multifaceted, individualized interventions to prevent further morbidity and disability of older adults (Berkowitz et al., 2013; Boxer et al., 2013; van Seben et al., 2019).

The sampling used in most of the articles targeted older White women. Therefore, findings should be read cautiously. The clinical practices’ inability to examine a higher percentage of men and other minority groups could have missed valuable information that affects hospital readmission. A report by the United Nations (2019) indicated that non-White populations show the fastest growth of people older than age 65 yr. The report also suggested that the gender gap in survival rates between men and women is narrowing (United Nations, 2019). Therefore, future clinical practices and research need broader samples, including minority patients entering SNFs for PAC. Social determinants of health—such as older adults’ economic stability, neighborhood and built environment, health behavior, education, and social and community contexts—also require further study. The dynamics among these determinants and health inequalities, including the designation of short- versus long-term care in SNFs, could represent differences in staffing and care of patients (Moore et al., 2017). These determinants introduce hidden differences among facilities, limit SNF choice for older adults, and contribute to nursing home segregation and disparities in quality of care (Cimarolli et al., 2020; Rivera-Hernandez et al., 2019).

Limitations

This scoping review has several limitations. The review included only peer-reviewed literature focused on reducing unplanned hospital readmissions among older adults pursuing PAC in SNFs and was limited to literature in four databases screened in February 2020; therefore, perhaps we missed studies indexed in other databases or indexed later. Our dismissal of the terms “occupational therapy” and “rehabilitation” in favor of a broader “postacute care” in our search to capture that level of care in SNFs may have overlooked studies in which occupational therapy was specified. In addition, when we conducted the study, the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4; AOTA, 2020) was still in press, so we chose to use the OTPF–3, which did not capture the added processes of “health management” and “transitions.” However, the included literature presents valuable considerations to PAC services in the SNF setting. It also offers myriad opportunities for occupational therapy practitioners to advocate for active roles in care transitions in this setting and to engage in publishing their work.

Implications for Occupational Therapy Practice

The results of this scoping review have the following implications for occupational therapy practice:

Although this scoping review explored the literature and identified considerable gaps where occupational therapy practitioners were not explicitly acknowledged as care providers in the clinical practices, the profession’s scope of practice is well represented.

Further advocacy efforts are needed from occupational therapy practitioners to accurately portray their scope of practice, acknowledge their contributions to achieving successful PAC outcomes, and effectively communicate needs and progress in multidisciplinary meetings; these efforts are essential as Medicare continues to focus on patient outcomes and provider performance.

Another opportunity highlighted by this scoping review is the need to address care fragmentation through self-management by actively engaging patients in their care, which has shown promise in effectively reducing hospital readmissions (Schiltz et al., 2020).

Occupational therapy practitioners have the skills to engage older adults and to address their multiple needs and problems through occupation-centered interventions (Jewell et al., 2019 ; Roberts et al., 2020); as members of interdisciplinary teams, they offer great insight into care planning related to their daily occupations.

The presence of occupational therapy practitioners in multiple care settings and their staffing ratio consistency, despite SNF policy changes (Livingstone et al., 2020), make them ideal agents for delivering positive patient outcomes and engaging in comprehensive research across the continuum of care.

Conclusion

Hospital readmissions are multifactorial and require an integrative multisectoral and multidisciplinary response. The 13 articles used in this scoping review highlighted clinical practices that are reducing unplanned hospital readmissions of older adults admitted to SNFs for PAC services. Although the articles described interventions aligned with the occupational therapy scope of practice, occupational therapy practitioners were not explicitly represented in the articles. Yet, occupational therapy practitioners are able to provide quality patient-centered care in response to older adults’ diverse and multiple needs. Therefore, further research is needed to emphasize occupational therapy effects on PAC interventions that are contributing to reducing hospital readmissions from SNFs.

Supplemental Material

Supplemental Information

Supplementary material for Reducing Hospital Readmissions of Older Adults Pursuing Postacute Care at Skilled Nursing Facilities: A Scoping Review

Supplementary material, sj-docx-1-aot-10.5014_ajot.2022.049082.docx for Reducing Hospital Readmissions of Older Adults Pursuing Postacute Care at Skilled Nursing Facilities: A Scoping Review by Antoinette Shaw, Pamela Talero Cabrejo, Abby Adamczyk and MJ Mulcahey in The American Journal of Occupational Therapy

Footnotes

*

Indicates studies included in the scoping review.

Acknowledgments

We acknowledge the role and contribution of our review team members—Carol Ruddock, Ivy Bishop, Diane Hunter, Arpana Lingaraj, and Gabrielle Khalifa—for their assistance with the screening of articles and data extraction. This study was conducted in partial fulfillment of Antoinette Shaw’s doctorate in occupational therapy at Thomas Jefferson University. No extramural funding was received for this study. This scoping review is registered on the Open Science Framework ().

References

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy , 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.2014.682006

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy , 74(Suppl. 2), 7412410010. https://doi.org.10.5014/ajot.2020.74S2001

Arksey

, & O’Malley

(2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology , 8 , 19–32. https://doi.org/10.1080/1364557032000119616

Beach

S. R.

Schulz

Friedman

E. M.

Rodakowski

Martsolf

R. G.

, & James

A. E.

(2020). Adverse consequences of unmet needs for care in high-need/high-cost older adults. Journals of Gerontology: Series B , 75 , 459–470. https://doi.org/10.1093/geronb/gby021

Bell

S. P.

Vasilevskis

E. E.

Saraf

A. A.

Jacobsen

J. M.

Kripalani

Mixon

A. S.

, . . . Simmons

S. F.

(2016). Geriatric syndromes in hospitalized older adults discharged to skilled nursing facilities. Journal of the American Geriatrics Society , 64 , 715–722. https://doi.org/10.1111/jgs.14035

* Berkowitz

R. E.

Fang

Helfand

B. K. I.

Jones

R. N.

Schreiber

, & Paasche-Orlow

M. K.

(2013). Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility. Journal of the American Medical Directors Association , 14 , 736–740. https://doi.org/10.1016/j.jamda.2013.03.004

Berwick

D. M.

Nolan

T. W.

, & Whittington

(2008). The Triple Aim: Care, health, and cost. Health Affairs , 27 , 759–769. https://doi.org/10.1377/hlthaff.27.3.759

*Boxer

R. S.

Dolansky

M. A.

Bodnar

C. A.

Singer

M. E.

Albert

J. M.

, & Gravenstein

(2013). A randomized trial of heart failure disease management in skilled nursing facilities: Design and rationale. Journal of the American Medical Directors Association , 14 , 710.e5–710.e11. https://doi.org/10.1016/j.jamda.2013.05.023

Burke

R. E.

Whitfield

E. A.

Hittle

Min

S.-J.

Levy

Prochazka

A. V.

, . . . Ginde

A. A.

(2016). Hospital readmission from post-acute care facilities: Risk factors, timing, and outcomes. Journal of the American Medical Directors Association , 17 , 249–255. https://doi.org/10.1016/j.jamda.2015.11.005

10.

Calsolaro

Antognoli

Pasqualetti

Okoye

Aquilini

Cristofano

, . . . Monzani

(2019). 30-day potentially preventable hospital readmissions in older patients: Clinical phenotype and health care related risk factors. Clinical Interventions in Aging , 14 , 1851–1858. https://doi.org/10.2147/CIA.S208572

11.

* Carnahan

J. L.

Slaven

J. E.

Callahan

C. M.

, & Torke

A. M.

(2017). Transitions from skilled nursing facility to home: The relationship of early outpatient care to hospital readmission. Journal of the American Medical Directors Association , 18 , 853–859. https://doi.org/10.1016/j.jamda.2017.05.007

12.

Center for Healthcare Quality and Payment Reform. (2013). Reducing hospital readmissions: A major opportunity for rapid savings. https://www.chqpr.org/readmissions.html

13.

Chandra

Rahman

P. A.

Sneve

McCoy

R. G.

Thorsteinsdottir

Chaudhry

, . . . Takahashi

P. Y.

(2019). Risk of 30-day hospital readmission among patients discharged to skilled nursing facilities: Development and validation of a risk-prediction model. Journal of the American Medical Directors Association , 20 , 444–450.e2. https://doi.org/10.1016/j.jamda.2019.01.137

14.

Cimarolli

V. R.

Falzarano

, & Hicks

(2020). Predictors of rehospitalization in post-acute rehabilitation among different ethnic groups. Journal of the American Medical Directors Association , 21 , 513–518. https://doi.org/10.1016/j.jamda.2019.10.008

15.

Clark

Jackson

Carlson

Chou

C.-P.

Cherry

B. J.

Jordan-Marsh

, . . . Azen

S. P.

(2012). Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: Results of the Well Elderly 2 Randomised Controlled Trial. Journal of Epidemiology and Community Health , 66 , 782–790. https://doi.org/10.1136/jech.2009.099754

16.

Dieter

W. B.

Collins

J. P.

, & Guccione

A. A.

(2019). Predicting outcomes within an innovative post-acute rehabilitation model for older adults. BMC Geriatrics , 19 , 146. https://doi.org/10.1186/s12877-019-1147-6

17.

*Farris

Sircar

Bortinger

Moore

Krupp

J. E.

Marshall

, . . . Mattison

(2017). Extension for community healthcare outcomes—C transitions: Enhancing geriatric care transitions through a multidisciplinary videoconference. Journal of the American Geriatrics Society , 65 , 598–602. https://doi.org/10.1111/jgs.14690

18.

*Folven

K. I.

Biringer

, & Abrahamsen

J. F.

(2018). Mini Nutritional Assessment Short-Form (MNA-SF) predicts institutionalisation in an intermediate post-acute care setting. Journal of Nutrition, Health and Aging , 22 , 199–204. https://doi.org/10.1007/s12603-017-0879-2

19.

*Huckfeldt

P. J.

Kane

R. L.

Yang

Engstrom

Tappen

Rojido

, . . . Ouslander

J. G.

(2018). Degree of implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program associated with number of hospitalizations. Journal of the American Geriatrics Society , 66 , 1830–1837. https://doi.org/10.1111/jgs.15476

20.

Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, Pub. L. 113–185.

21.

Jewell

Pickens

N. D.

, & Burns

(2019). Occupational therapy interventions in skilled nursing facilities: A scoping review. Annals of International Occupational Therapy , 2 , 79–90. https://doi.org/10.3928/24761222-20190218-03

22.

Jutkowitz

Gitlin

L. N.

Pizzi

L. T.

Lee

, & Dennis

M. P.

(2012). Cost effectiveness of a home-based intervention that helps functionally vulnerable older adults age in place at home. Journal of Aging Research , 2012 , 680265. https://doi.org/10.1155/2012/680265

23.

* Keswani

Tasi

M. C.

Fields

Lovy

A. J.

Moucha

C. S.

, & Bozic

K. J.

(2015). Discharge destination after total joint arthroplasty: An analysis of postdischarge outcomes, placement risk factors, and recent trends. Journal of Arthroplasty , 31 , 1155–1162. https://doi.org/10.1016/j.arth.2015.11.044

24.

Kortebein

(2019). Post-acute care determination for hospitalized older adults. Current Physical Medicine and Rehabilitation Reports , 7 , 126–133. https://doi.org/10.1007/s40141-019-00219-6

25.

* Krol

M. L.

Allen

Matters

Jolly Graham

English

, & White

H. K.

(2018). Health Optimization Program for elders. Journal of Nursing Care Quality , 34 , 217–222. https://doi.org/10.1097/ncq.0000000000000375

26.

Leland

N. E.

Crum

Phipps

Roberts

, & Gage

(2015). Advancing the value and quality of occupational therapy in health service delivery. American Journal of Occupational Therapy , 69 , 6901090010. https://doi.org/10.5014/ajot.2015.691001

27.

* Leutgeb

Berger

S. J.

Szecsenyi

, & Laux

(2019). Potentially avoidable hospitalisations of German nursing home patients? A cross-sectional study on utilisation patterns and potential consequences for healthcare. BMJ Open , 9 , e025269. https://doi.org/10.1136/bmjopen-2018-025269

28.

Livingstone

Hefele

, & Leland

(2020). Physical and occupational therapy staffing patterns in nursing homes and their association with long-stay resident outcomes and quality of care. Journal of Aging and Social Policy. Advance online publication. https://doi.org/10.1080/08959420.2020.1824544

29.

Meuten

Munday

J. S.

, & Hauck

(2018). Time to standardize? Time to validate? Veterinary Pathology , 55 , 195–199. https://doi.org/10.1177/0300985817753869

30.

* Middleton

Graham

J. E.

Lin

Y.-L.

Goodwin

J. S.

Bettger

J. P.

Deutsch

, & Ottenbacher

K. J.

(2016). Motor and cognitive functional status are associated with 30-day unplanned rehospitalization following post-acute care in Medicare fee-for-service beneficiaries. Journal of General Internal Medicine , 31 , 1427–1434. https://doi.org/10.1007/s11606-016-3704-4

31.

Moher

Liberati

Tetzlaff

, & Altman

D. G.

; PRISMA Group. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA statement. PLoS Medicine , 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097

32.

* Moore

A. B.

Krupp

J. E.

Dufour

A. B.

Sircar

Travison

T. G.

Abrams

, . . . Lipsitz

L. A.

(2017). Improving transitions to postacute care for elderly patients using a novel video-conferencing program: Echo-care transitions. American Journal of Medicine , 130 , 1199–1204. https://doi.org/10.1016/j.amjmed.2017.04.041

33.

*Pedersen

L. H.

Gregersen

Barat

, & Damsgaard

E. M.

(2018). Early geriatric follow-up visits to nursing home residents reduce the number of readmissions: A quasi-randomised controlled trial. European Geriatric Medicine , 9 , 329–337. https://doi.org/10.1007/s41999-018-0045-3

34.

Peters

M. D.

Godfrey

C. M.

McInerney

Soares

C. B.

Kahlil

, & Parker

(2015). The Joanna Briggs Institute reviewers’ manual 2015: Methodology for JBI scoping reviews. https://nursing.lsuhsc.edu/JBI/docs/ReviewersManuals/Scoping-.pdf

35.

Rafeedie

Metzler

, & Lamb

A. J.

(2018). Opportunities for occupational therapy to serve as a catalyst for culture change in nursing facilities. American Journal of Occupational Therapy , 72 , 7204090010. https://doi.org/10.5014/ajot.2018.724003

36.

Ribbink

M. E.

van Seben

Reichardt

L. A.

Aarden

J. J.

van der Schaaf

van der Esch

, . . . Buurman

B. M.

; Hospital-ADL Study Group. (2019). Determinants of post-acute care costs in acutely hospitalized older adults: The Hospital-ADL Study. Journal of the American Medical Directors Association , 20 , 1300–1306.e1. https://doi.org/10.1016/j.jamda.2019.03.013

37.

Rivera-Hernandez

Rahman

Mukamel

D. B.

Mor

, & Trivedi

A. N.

(2019). Quality of post-acute care in skilled nursing facilities that disproportionately serve Black and Hispanic patients. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences , 74 , 689–697. https://doi.org/10.1093/gerona/gly089

38.

Roberts

, & Robinson

(2014). Occupational therapy’s role in preventing acute readmissions. American Journal of Occupational Therapy , 68 , 254–259. https://doi.org/10.5014/ajot.2014.683001

39.

Roberts

Robinson

Furniss

, & Metzler

(2020). Occupational therapy’s value in provision of quality care to prevent readmissions. American Journal of Occupational Therapy , 74 , 7403090010. https://doi.org/10.5014/ajot.2020.743002

40.

Rogers

A. T.

Bai

Lavin

R. A.

, & Anderson

G. F.

(2017). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review: MCRR , 74 , 668–686. https://doi.org/10.1177/1077558716666981

41.

*Rosen

B. T.

Halbert

R. J.

Hart

Diniz

M. A.

Isonaka

, & Black

J. T.

(2017). The enhanced care program: Impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. Journal of Hospital Medicine , 13 , 229–235. https://doi.org/10.12788/jhm.2852

42.

Sacks

G. D.

Lawson

E. H.

Dawes

A. J.

Gibbons

M. M.

Zingmond

D. S.

, & Ko

C. Y.

(2015). Which patients require more care after hospital discharge? An analysis of post-acute care use among elderly patients undergoing elective surgery. Journal of the American College of Surgeons , 220 , 1113–1121.e2. https://doi.org/10.1016/j.jamcollsurg.2015.02.029

43.

Sanford

A. M.

Morley

J. E.

Berg-Weger

Lundy

Little

M. O.

Leonard

, & Malmstrom

T. K.

(2020). High prevalence of geriatric syndromes in older adults. PLoS One , 15 , e0233857. https://doi.org/10.1371/journal.pone.0233857

44.

Schiltz

N. K.

Dolansky

M. A.

Warner

D. F.

Stange

K. C.

Gravenstein

, & Koroukian

S. M.

(2020). Impact of instrumental activities of daily living limitations on hospital readmission: An observational study using machine learning. Journal of General Internal Medicine , 35 , 2865–2872. https://doi.org/10.1007/s11606-020-05982-0

45.

Szanton

S. L.

Leff

Wolff

J. L.

Roberts

, & Gitlin

L. N.

(2016). Home-based care program reduces disability and promotes aging in place. Health Affairs , 35 , 1558–1563. https://doi.org/10.1377/hlthaff.2016.0140

46.

United Nations. (2019). World population ageing 2019: Highlights. https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf

47.

van Seben

Reichardt

L. A.

Aarden

J. J.

van der Schaaf

van der Esch

Engelbert

R. H. H.

, . . . Buurman

B. M.

; Hospital-ADL Study Group. (2019). The course of geriatric syndromes in acutely hospitalized older adults: The Hospital-ADL Study. Journal of the American Medical Directors Association , 20 , 152–158.e2. https://doi.org/10.1016/j.jamda.2018.08.003

48.

Wang

Y.-C.

Chou

M.-Y.

Liang

C.-K.

Peng

L.-N.

Chen

L.-K.

, & Loh

C.-H.

(2019). Post-acute care as a key component in a healthcare system for older adults. Annals of Geriatric Medicine and Research , 23 , 54–62. https://doi.org/10.4235/agmr.19.0009

49.

Werner

R. M.

, & Konetzka

R. T.

(2018). Trends in post-acute care use among Medicare beneficiaries: 2000 to 2015. JAMA , 319 , 1616–1617. https://doi.org/10.1001/jama.2018.2408

50.

White

H. K.

(2019). Post-acute care: Current state and future directions. Journal of the American Medical Directors Association , 20 , 392–395. https://doi.org/10.1016/j.jamda.2019.02.027

51.

Ziakas

P. D.

, & Mylonakis

(2020). Spatial association patterns between post-acute care services and acute care facilities in the United States. PLoS One , 15 , e0240624. https://doi.org/10.1371/journal.pone.0240624

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