Older adults are at high risk of rehospitalization after an acute event and at even higher risk of permanently losing an activity of daily living with each hospitalization. This is especially true in those with encephalopathy, delirium, dementia, falls, and failure to thrive. Although it is widely known that rehospitalization rates are higher in patients who discharge to skilled nursing and long-term care facilities, geriatrics consultations have not been shown to consistently decrease this risk. In this study, we added a novel component specific to transitions of care alongside a traditional geriatrics consultation for patients discharging to a skilled nursing or long-term care facility. Results show evidence of significant rehospitalization reduction for patients with markers of cognitive impairment and frailty.
Keywords: Long-term care; readmission; rehospitalization; skilled nursing facility; transitions of care.
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