Dr. Sri Lekha Tummalapalli, assistant professor of population health sciences and medicine, and Dr. Mark A. Unruh, associate professor of population health sciences, have received an R01 from the National Institute of Diabetes & Digestive & Kidney Diseases to research transitions of care from hospitals to skilled nursing facilities (SNF) in patients with end-stage kidney disease (ESKD).
Over 550,000 people in the US have ESKD requiring dialysis. They are a medically complex population that often experience functional impairment and frailty, leading to high rates of hospitalization followed by SNF admission, also known as subacute rehabilitation facilities. Transitions of care for these patients can be very costly, accounting for billions in Medicare spending. Notably, transitions of care between these settings can prove suboptimal, leading to hospital readmission and other adverse outcomes.
“When I’m treating a patient on dialysis in the hospital, we lack evidence on how to best advise them,” explained Dr. Tummalapalli. “If, for example, they are choosing an SNF to go to after the hospital, we don’t know whether to recommend a SNF with on-site dialysis, versus recommending that they go back to their usual dialysis facility, which involves travel time. Understanding and evaluating those trade-offs could help us better advise patients on what is optimal for their care.”
As Dr. Tummalapalli described, the choice of SNF and the availability of on-site dialysis can shape both the continuity and quality of dialysis care. In the literature, little is known about the dialysis services SNFs provide, how and where patients receive dialysis after hospitalization, and whether patients will transition between types of dialysis treatments after discharge. Additionally, dialysis facilities, SNFs, and hospitals each use unique electronic health record systems. Therefore, a patient’s health records are not systematically shared among providers, potentially leading to crucial information being missed.
Using Medicare Fee-for-Service claims, Dr. Tummalapalli and Dr. Unruh aim to characterize patterns of hospital-to-SNF care transitions among patients with ESKD and identify patient, dialysis facility, SNF, and market characteristics associated with those patterns. They will then use novel machine learning methods to examine the association of hospital-to-SNF care transition patterns with quality of care among patients with ESKD. Finally, they will conduct qualitative interviews with dialysis patients recently admitted to an SNF, or their caregivers; physicians and advanced practice providers who care for patients on dialysis and in SNFs; and dialysis and SNF nurses to understand their care transition experiences and identify opportunities for improvement.
“We think that leveraging both the quantitative and qualitative angles will give us a better picture of what’s going on,” explained Dr. Tummalapalli. “In the future, this may inform individual clinicians and how they advise patients on where to go, or aid in designing interventions to improve the transitions of care. We can help identify better tools for information and health record sharing.”
This study will generate the first national data on hospital-to-SNF care transitions among patients with ESKD. Dr. Tummalapalli and Dr. Unruh will work with Dr. Arian Jung, associate professor of population health sciences, Dr. Ann O’Hare, professor of medicine at the University of Washington School of Medicine, and Dr. Alicia Arbaje, associate professor of medicine at the Johns Hopkins University School of Medicine.
“Over time, we have seen a shift of more people going to SNFs after hospitalization, and we do see an aging population in the US where patients have more medical comorbidities,” said Dr. Tummalapalli. “Ultimately, we want to ease the transition for all patients, not just those with ESKD, who are going from the hospital to SNFs.”
- Highlights