R01AG077706

Project Hope: Achieving Home Discharge for Institutionally-Bound Patients with PROMs, AI, and the EHR

Unnecessary discharges from a hospital to a skilled nursing facility (SNF) are costly and may accelerate patients' functional losses and requirement for long-term institutionalization. Patients with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) and other types of cognitive impairment are uniquely disadvantaged by this status quo in that they are twice as likely to be hospitalized, four times more likely to be discharged to SNFs with less than 50% returning to their homes.

This situation can be addressed as it is the product of a typically rushed discharge planning process with inadequate time to discover, much less address, a patient's barriers to home discharge. Recent reports suggest that as many as a third of patients dismissed to SNFs, including those with AD/ADRD, could return directly home if their post-acute care (PAC) needs and barriers were anticipated and addressed.

Several key deficits prevent broad realization of a patient's potential to discharge directly home, or their home PAC potential (Hope). These include a limited ability to: 1) quantify factors that determine PAC needs, 2) identify and address remediable barriers to home discharge, and 3) mobilize stakeholders for advancement of individualized discharge plans. Collectively, these deficits prevent the timely initiation of acute care services that can realize a patient's potential for home discharge, with PAC as necessary.

Rehabilitation-focused, hospital-home healthcare agency (HHA) partnerships have established that interdisciplinary care plans enacted early in a hospital stay with patient and caregiver involvement increase the likelihood of a patient's return home. Our team developed an Epic Electronic Health Record (EHR)-based discharge planning system that triangulates EHR, patient reported outcomes (PROs), and social determinants of health data to identify Hope barriers and direct needs-matched rehabilitation service delivery.

A pilot of the system among 358 patients increased the home discharge rate by over 25% and revealed high user acceptability. However, the pilot also identified the need to improve addressing of cognitive impairments, targeting of high-yield Hope barriers, and engagement of non-clinical stakeholders.

We propose to address these limitations by pursuing three specific aims: 1) develop a low-burden computerized adaptive test PRO to assess the domains of functional cognition relevant to a safe home discharge; 2) develop a machine learning algorithm to prioritize actionable Hope barriers and estimate the degree of change needed for home discharge; and 3) apply user-centered design principles to refine the EHR discharge planning system for optimal usability and enhanced EHR portal patient, caregiver, and HHA staff access.

Our goal is to both integrate and pilot these deliverables in a mature and optimally usable EHR discharge planning system, and to evaluate the feasibility and acceptability of its implementation. We anticipate that the system will be scalable and amenable to inter-institution transfer for testing in a multi-site pragmatic trial.

Mayo Clinic

TO ENCOURAGE BIOMEDICAL, SOCIAL, AND BEHAVIORAL RESEARCH AND RESEARCH TRAINING DIRECTED TOWARD GREATER UNDERSTANDING OF THE AGING PROCESS AND THE DISEASES, SPECIAL PROBLEMS, AND NEEDS OF PEOPLE AS THEY AGE. THE NATIONAL INSTITUTE ON AGING HAS ESTABLISHED PROGRAMS TO PURSUE THESE GOALS. THE DIVISION OF AGING BIOLOGY EMPHASIZES UNDERSTANDING THE BASIC BIOLOGICAL PROCESSES OF AGING. THE DIVISION OF GERIATRICS AND CLINICAL GERONTOLOGY SUPPORTS RESEARCH TO IMPROVE THE ABILITIES OF HEALTH CARE PRACTITIONERS TO RESPOND TO THE DISEASES AND OTHER CLINICAL PROBLEMS OF OLDER PEOPLE. THE DIVISION OF BEHAVIORAL AND SOCIAL RESEARCH SUPPORTS RESEARCH THAT WILL LEAD TO GREATER UNDERSTANDING OF THE SOCIAL, CULTURAL, ECONOMIC AND PSYCHOLOGICAL FACTORS THAT AFFECT BOTH THE PROCESS OF GROWING OLD AND THE PLACE OF OLDER PEOPLE IN SOCIETY. THE DIVISION OF NEUROSCIENCE FOSTERS RESEARCH CONCERNED WITH THE AGE-RELATED CHANGES IN THE NERVOUS SYSTEM AS WELL AS THE RELATED SENSORY, PERCEPTUAL, AND COGNITIVE PROCESSES ASSOCIATED WITH AGING AND HAS A SPECIAL EMPHASIS ON ALZHEIMER'S DISEASE. SMALL BUSINESS INNOVATION RESEARCH (SBIR) PROGRAM: TO EXPAND AND IMPROVE THE SBIR PROGRAM, TO INCREASE PRIVATE SECTOR COMMERCIALIZATION OF INNOVATIONS DERIVED FROM FEDERAL RESEARCH AND DEVELOPMENT, TO INCREASE SMALL BUSINESS PARTICIPATION IN FEDERAL RESEARCH AND DEVELOPMENT, AND TO FOSTER AND ENCOURAGE PARTICIPATION OF SOCIALLY AND ECONOMICALLY DISADVANTAGED SMALL BUSINESS CONCERNS AND WOMEN-OWNED SMALL BUSINESS CONCERNS IN TECHNOLOGICAL INNOVATION. SMALL BUSINESS TECHNOLOGY TRANSFER (STTR) PROGRAM: TO STIMULATE AND FOSTER SCIENTIFIC AND TECHNOLOGICAL INNOVATION THROUGH COOPERATIVE RESEARCH DEVELOPMENT CARRIED OUT BETWEEN SMALL BUSINESS CONCERNS AND RESEARCH INSTITUTIONS, TO FOSTER TECHNOLOGY TRANSFER BETWEEN SMALL BUSINESS CONCERNS AND RESEARCH INSTITUTIONS, TO INCREASE PRIVATE SECTOR COMMERCIALIZATION OF INNOVATIONS DERIVED FROM FEDERAL RESEARCH AND DEVELOPMENT, AND TO FOSTER AND ENCOURAGE PARTICIPATION OF SOCIALLY AND ECONOMICALLY DISADVANTAGED SMALL BUSINESS CONCERNS AND WOMEN-OWNED SMALL BUSINESS CONCERNS IN TECHNOLOGICAL INNOVATION.

93.866 - Aging Research

National Institute on Aging (NIA) [HHS - NIH]

Rochester, Minnesota 559050001 United States

Single Zip Code

Research on Current Topics in Alzheimer's Disease and Its Related Dementias (R01 Clinical Trial Optional) (PAR-19-070)

Amendment Since initial award the total obligations have increased 320% from $1,047,570 to $4,403,711.