Long-Term Impact of Discharge Destinations and Transitional Care Uses on Health and Medical Utilization for High-Risk Discharged Older Adults (2/3)

The need of transitional care is common after discharge among older adults, and adverse health events such as readmission or death are more frequent among high-risk patients. Effective high-risk screening procedure before discharge could identify the key problems patients may confront and it could assist patients to get sufficient information during hospitalization to plan for follow-up care need, including post-acute care, supportive care at home, or short-term institutional care. Appropriate discharge destinations and continuous care for high-risk patients will improve patients’ health and well-being, reduce medical costs, meet patients’ care needs and improve life quality of caregivers. Therefore, the purposes of this project are as below: (1) Confirming the predictability and effectiveness of discharge high-risk screening tools by comparing the screening results between different tools with the judgment of the multi-disciplinary team in this study. Then the team will simulates the health care and social needs and trigger to the appropriate care services to construct a case-mix model for predicting follow-up transitional care of high-risk discharged patients. (2) After screening the high-risk discharged patients with the best discriminative evaluation tool in the previous part, this study will start the first telephone interview on the 7th day after discharge from the high-risk patients to confirm the patient's discharge destinations and track the health conditions, medical services use, and transitional care services use by telephone interviews on the 15th, 30th, 90th, 180th, and 365th day after discharge. (3) High-risk patients’ baseline data will be collected during the hospitalization period. During the follow-up period from the discharge date to the 1-year period, a total of 6 visit evaluations will be conducted. Later in the study, we will analyze the data by cross-sectional study using logistic regression and by longitudinal research design using generalized estimating equation to explore the causal relationship between discharge destination, transitional care use, and health condition and medical services use.