Transitions in care for older adults with and without dementia

Abstract

Objectives: To describe transitions in care of persons with dementia with attention to nursing facility transitions.

Design: Prospective cohort.

Setting: Public health system.

Participants: Four thousand one hundred ninety-seven community-dwelling older adults.

Measurements: Participants' electronic medical records were merged with Medicare claims, Medicaid claims, the Minimum Data Set (MDS), and the Outcome and Assessment Information Set (OASIS) from 2001 to 2008 with a mean follow-up of 5.2 years from the time of enrollment.

Results: Older adults with prevalent (n = 524) or incident (n = 999) dementia had greater Medicare (44.7% vs 44.8% vs 11.4%, P < .001) and Medicaid (21.0% vs 16.8% vs 1.4%, P < .001) nursing facility use, greater hospital (76.2% vs 86.0% vs 51.2%, P < .001) and home health (55.7% vs 65.2% vs 27.3%, P < .001) use, more transitions in care per person-year of follow-up (2.6 vs 2.7 vs 1.4, P < .001), and more mean total transitions (11.2 vs 9.2 vs 3.8, P < .001) than those who were never diagnosed (n = 2,674). For the 1,523 participants with dementia, 74.5% of transitions to nursing facilities were transfers from hospitals. For transitions from nursing facilities, the conditional probability was 41.0% for a return home without home health care, 10.7% for home health care, and 39.8% for a hospital transfer. Of participants with dementia with a rehospitalization within 30 days, 45% had been discharged to nursing facilities from the index hospitalization. At time of death, 46% of participants with dementia were at home, 35% were in the hospital, and 19% were in a nursing facility.

Conclusion: Individuals with dementia live and frequently die in community settings. Nursing facilities are part of a dynamic network of care characterized by frequent transitions.

Figure 1

Time to First Nursing Facility Use Following Diagnosis of Dementia

Figure 2. Transitions between Sites of Care for Subjects Following a Diagnosis of Dementia

The denominator (n) is the number of transitions for each origin state. Transition probabilities sum to 1 for each origin state. Where sum is less than 1 for outbound transitions, remainder is the probability of transition to death (see text for transition to death rates)