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Table 3 Purpose and main findings of all articles included in this scoping review (N = 36)

From: Factors affecting residents transition from long term care facilities to the community: a scoping review

Study (Year)

Author institutional affiliations

Study Purpose

Main Study Findings/Study Conclusions

Aaland, Leffers, & Hlaing, 2006

Parkview Hospital, Indiana University-Purdue University

“The objective of this study was to evaluate if elderly patients discharged to a NH improved in their physical impairment related to trauma enough to be discharged from the NH or if the NH became a permanent address change” (p. 815).

▪ Hospital discharge to a NH following a motor vehicle accident trauma should be perceived as a transitional step back to a community setting

▪ At time of discharge from a NH, older adults were able to recover partial or full functional independence

Arling, Abrahamson, Cooke, Kane & Lewis, 2011

Indiana University, Western Kentucky University

“The aim of our study was to identify facility and market factors that influence the transition from nursing home to community to develop system-level interventions that complement our individuality focused return to community initiative” (p. 791)

▪ Multiple factors influence discharge from NH to the community including resident, facility, and market factors

▪ Residents entering Medicare oriented facility more likely to be discharged to the community and less likely to become long-stay NH clients

Arling, Kane, Cooke & Lewis, 2010

Indiana University, University of Minnesota, Minnesota Department of Human Services

“To analyze nursing home utilization patterns in order to identify potential targeting criteria for transitioning residents back to the community.” (p. 691)

▪ Majority of discharges (85%) occurred within first 30 days of admission

▪ Interventions for community transition should ideally occur between 90 and 120 days following first admissions

▪ Interventions should focus on residents who prefer discharge to a community setting

Arling, Williams, & Kopp, 2000

University of Missouri, Medicalodges

“Our objectives are to describe factors related to receipt of therapies at admission to the facility, and to examine three outcomes within 90 days after nursing home admission: community discharge, death, or remaining in the nursing facility”. (p. 588)

▪ Therapy use, when controlling for other covariates, was positively associated with community discharge and negatively with mortality

▪ Medicare was associated with access to therapy

▪ Therapy provision was influenced by both resident and staff view of potential for improvement in functional abilities

Bardo, Applebaum, Kunkel, & Carpio, 2014

Miami University, Arizona Health Care Cost Containment System, Scripps Gerontology Center

“to evaluate the effectiveness of Ohio’s Diversion and Transition Program, which was specifically designated for individuals who were 60 years old or older.” (p. 210)

▪ Barriers and promising practices were identified.

▪ Revealed innovative intervention strategies

▪ Most diversion and transition consumers still alive at 6 month follow up were living in the community

Brown, Raue, Mlodzianowski, Meyers, Greenberg, & Bruce, 2006

Stein Gerontological Institute, Miami Jewish Home and Hospital; Well Medical College of Cornell University

“To assess the completeness and accuracy of clinical information provided by referral sources to visiting nurses for patients admitted to receive home health care.” (p. 339)

▪ Essential clinical information often missing during transfer of older adult to home care sector

▪ 88.4% had medication discrepancies between in-home nurse review and admission information (n = 215)

▪ 34.9% lacked clinical information on medication allergies

Callahan, Arling, Tu, Rosenman, Counsell, Stump, & Hendrie, 2012

Multiple departments at Indiana University; Regenstrief Institute, Inc.

“To gain a more-complete understanding of the frequency and type of transitions in care of older adults with and without dementia, giving particular attention to transitions to and from nursing facility care over time.” (p. 814)

▪ Persons with dementia had greater Medicare and Medicaid nursing facility use, greater hospital and home health use, more transitions to care per person-year of follow-up, and more transitions.

Chen & Berkowitz, 2012

National Taiwan University; Columbia University

“The purpose of this study was to better understand the interplay between older adults’ home- and community based services and their residential transitions.” (p. 2)

▪ Use of different home and community based services and combinations thereof were associated with different directions in residential transitions

Delate, Chester, Stubbings, & Barnes, 2008

Departments of Pharmacy and Continuing Care, Kaiser Permanente Colorado; School of Pharmacy, University of Colorado at Denver and Health Sciences Center

“The purpose of this investigation was to assess the effectiveness of the KPCO medication reconciliation program after discharge from an SNF with regard to its impact on mortality, rehospitalizations, ambulatory clinic visits, and emergency department visits compared with usual care.” (p.445)

▪ Pharmacist-managed program resulted in 78% reduction in risk of death after SNF discharge

▪ Higher mean cumulative ambulatory care visits

Fries & James, 2012

University of Michigan

“Our intent was to enable states to improve Nursing Facility Transition (NFT) targeting strategies and thereby improve the use of scarce fiscal resources earmarked for transition activities.” (p.2)

• To examine characteristics of long-stay residents discharged from nursing facilities

• Identify target population of nursing home residents who may benefit from nursing facility discharge program

• To create a discharge algorithm from the MDS 2.0

▪ Substantial differences observed by client length of stay for all characteristics tested

▪ Lower-acuity persons more prevalent among transitionees than among those remaining in the nursing facility

Gassoumis, Fike, Rahman, Enguidanos, & Wilber, 2013

Davis School of Gerontology, University of Southern California; Innovate50, San Francisco

“The purpose of this study is to: (a) examine natural patterns of discharge among NF residents in California, and (b) compare characteristics that predict community discharge among short-stay residents and long-stay residents.” (p. 77)

▪ Half of all admissions resulted in community discharge within 365 days (n = 1879; 49.9%)

▪ Over 90% of discharges to the community occurred within the first 90 days

▪ Transition to and back from acute care had greatest negative affect on potential to discharge while having a support person who is positive towards discharge had the strongest positive affect associated with discharge within the first 90 days

▪ Few characteristics predicted discharge to community for longer stay (>90 days) residents

▪ Cancer reduced odds of discharge 62%

▪ Severe cognitive impairment reduced odds of discharge 56%

▪ Resident preference to discharge had no effect after 90 days

Gozalo, Leland, Christian, Mor, & Teno, 2015

Department of Health Services, Brown University; Division of Occupational Science and Occupational Therapy, University of Southern California; Abt Associates Inc.; Providence Veteran’s Administration Medical Center

“To examine the effect of the relationship between volume (number of hip fracture admissions during the 12 months before participant’s fracture) and other facility characteristics on outcomes.” (p.2043)

▪ Overall rate of successful discharge to the community was 31% within 30 days of discharge from the hospital

▪ Participants discharged to high-volume SNFs (all else equal) were approximately twice as likely to achieve successful discharge to the community

Graessel, Schmidt, & Schupp, 2014

Department of Psychiatry and Psychotherapy, Center for Health Services Research in Medicine, Friedrich-Alexander-Universitaet Erlangen-Nuernberg; Erlangen-Nuernberg Department of Neurology and Neuropsychology, Clinic for Specialized In- and Outpatient Rehabilitation Medicine, Herzogenaurach, Germany

“To determine whether stroke patients’ functional status or health-related quality of life would predict whether they lived at home 2.5 years after discharge from neurological inpatient rehabilitation.” (p.212)

▪ 30 months after discharge, 75% of the stroke survivors were still living at home.

▪ Patients continued to live at home significantly more frequently when they had fewer mortality-relevant comorbidities, higher BMI and higher increase in functional independence

Graham, Anderson, & Newcomer, 2005

University of California, Berkeley; Contra Costa County Aging and Adult Services; University of California

“This article describes [Providing Assistance to Caregivers in Transition] PACT’s features and the issues affecting its success during its initial 24 months of operations. Among these are recruitment, enrollment, and participant and staff perceptions about the value of the program.” (p.93)

▪ During first 2 years, 38/42 opened cases were assisted to discharge to the community

▪ Feedback of the program by caregivers indicated satisfaction with instrumental and emotional support provided through the PACT program

▪ Most PACT participants (n = 38) remained in the community after 180 days

Holup, Gassoumis, Wilber, & Hyer, 2015

Florida Policy Exchange Center on Aging, School of Aging Studies, University of South Florida; Davis School of Gerontology, University of Southern California,

“Examines the influence of facility characteristics on the transition of nursing home residents to the community after a short stay (within 90 days of admission) or long stay (365 days of admission) across states with different long-term services and supports systems.” (p.1)

▪ Facility characteristics, including size, occupancy, ownership, average length of stay, proportion of Medicare and Medicaid residents, and the proportion of residents admitted from acute care facilities are associated with discharge

▪ Facility characteristics were more strongly related to community discharge than the characteristics of the markets in which they were located

Howell, Silberberg, Quinn, & Lucas, 2007

Rutgers Center for State Health Policy; Duke University Medical Center; New Jersey Department of the Public Advocate, Division of Elder Advocacy, Trenton, NJ; Institute for Health, Health Care Policy, and Aging Research, Rutgers University

“To inform states with nursing home transition programs, we determine what risk factors are associated with participants’ long-term readmission to nursing homes within 1 year after discharge.” (p. 535)

▪ At time of one year post-discharge: 72% continued to live in community, 18.8% had died, and 8.6% readmitted to a nursing home for >90 days

▪ Multiple factors significantly associated one year post-discharge outcomes included: sex, health beliefs, living situation, informal/formal assistance with ADLs, transportation, medication managements, ADL/IADL abilities, and post-discharge acute health events (e.g., falls, ED visits or hospitalizations)

Marcum & Hardy, 2015

Division of Geriatric Medicine, School of Medicine, University of Pittsburgh; Summit ElderCare, Worcester, Massachusetts

“Objective of this pilot study was to describe potential medication management deficiencies of older SNF residents transitioning home.” (p.1267)

▪ Medication management deficiencies were found to be common in a high-risk group of elderly adults making this important transition

Martikainen, Moustgaard, Murphy, Elinio, Koskinen, Martelin, & Noro, 2009

Department of Sociology, University of Helsinki, Finland; London School of Economics, UK; National Institute for Health and Welfare, Helsinki, Finland

“The focus of this article is on the effects of three important sociodemographic factors – living arrangements, housing tenure, and household income – on entry to and exit from long-term institutional care … Our specific aims were to (a) assess how gender, age, living arrangements, housing tenure, and household income are associated with the risk for entry into and exit from long-term institutional care, through either death or return to the community; (b) assess whether these associations are independent of each other and mediated by health status; (c) evaluate, in particular, why gender is associated with institutionalization and how it modifies the impact of other variables; and (d) estimate the mean number of days spent in institutional care.” (p. 36)

▪ At time of 5 year follow-up, 28.4% of men and 28.1% of women had been discharged to the community

▪ Factors that increase risk to enter long-term care are same risk factors for exit from long-term care but associations were weaker and in the opposite direction (with exception of age).

McCarthy, Szymanski, Karlin, & Katz, 2013

Department of Veterans Affairs; Yale School of Public Health

“Evaluated suicide rates following discharge from Veterans Affairs nursing homes … Evaluated measures of serious mental illness, depression, dementia, behavior problems, and pain as predictors of suicide after discharge.” (p. 2261)

▪ Suicide risk was elevated following 6 months post-nursing home discharge

▪ Suicide risk was 2.4 times as high overall and 2.3 times as high for men (p. 2264)

Meador, Chen, Schultz, Norton, Henderson, & Pillemer, 2011

Cornell University; Community Health Foundation of Central and Western New York;

“This article describes barriers to nursing home discharge encountered in an intervention designed to transition nursing home residents to the community.” (p.2)

▪ No differences found between social, demographic, and health characteristics of the person

▪ Barriers to discharge from nursing home to the community included a)level of medical complexity; b)family and social support, and c)availability of appropriate housing in the community((page 10)

▪ Staff knowledge of transition process and network of contacts helped simplify and streamline discharge process for residents

Mudrazija, Thomeer, & Angel, 2015

Edward R. Roybal Institute on Aging, School of Social Work, University of Southern California; Department of Sociology, University of Alabama at Birmingham; Lyndon B. Johnson School of Public Affairs, The University of Texas at Austin

“To identify the ways in which gender influences likelihood of discharge from LTC facilities, duration of stay in LTC facilities, and post-discharge living arrangements.” (p.442)

▪ Women are more likely than men to be discharged from LTC facilities during the first year of stay.

▪ Women are more likely to live alone or with kin after discharge, whereas men are more likely to live with a spouse or transfer to another institution.

▪ Gender differences in the availability and use of family support may partly account for the gender disparity of LTC discharge and post-discharge living arrangements.

Naomi, Shiroiwa, Fukuda, & Murashima, 2012

The Japan Baptist Hospital; Ritsumeikan University; University of Tokyo

“To examine the effectiveness of deinstitutionalizing the disabled elderly with the aim of cost reduction.” (P. 1)

“This study examines the effectiveness of the deinstitutionalization of disabled elderly individuals for the purpose of cost reduction, and clarifies the policy issues surrounding an aging society.” (p.3)

▪ 87/139 patients considered candidates for deinstitutionalization at discretion of care managers and home visiting nurses

▪ Estimated home care costs were higher than institutional care costs

▪ Deinstitutionalization of the elderly did not reduce healthcare costs. (p. 9)

Newcomer, Kang, & Graham, 2006

University of California, San Francisco; University of California, Berkley

Evaluate the effectiveness of the Providing Assistance to Caregivers in Transition (PACT) program.

“We compare nursing home discharge rates and length of stay between those individuals in the intervention group and those in the usual care or control group” (p. 385–386)

▪ No statistical differences observed in the discharge rate (84% treatment vs 76% controls) or in the median length of stay (42 days vs 55 days) between the intervention and control groups

Nishita, Wilber, Matsumoto, & Schnelle, 2008

University of Southern California; Vanderbilt Center for Quality Aging, Nashville, Tennessee.

“To examine nursing facility residents’ or their legal proxies’ perspectives on transitioning out of nursing facilities by assessing residents’ perceptions of their ability to live more independently, their preferences regarding leaving the facility, and the feasibility of transitioning with community support.” (p.1)

▪ 23% believed resident had ability to transition

▪ 46% indicated preference to transition

▪ After discussions of potential living arrangements and supports, 33% thought transition was feasible

▪ More residents who preferred transition were identified through screen than through MDS 2.0

Penrod, Kane, & Kane, 2000

University of Nebraska; University of Minnesota

“This study examines the effect of family caregiving on the probability that nursing home residents would be discharged to the community within 6 weeks following nursing home admission” (p.66)

▪ 34% of residents went home by 6 weeks post-hospital discharge

▪ Informal care provision (not solely presence of a caregiver visiting daily) may increase the quality and amount of care residents receive thus influencing rehabilitation outcomes and return to home

▪ Caregiver advocacy may signal a well-functioning support system

Poole, Duvall, & Wofford, 2006

College of Social Work, University of South Carolina,

“Our study is the first application to planning and evaluation of a state nursing home-to-community transition project. We used three research questions to guide this component of the evaluation during implementation of the CARS project: 1) What key elements or conceptual domains must be addressed to help a person with physical disabilities move out of a nursing facility successfully? 2) How important is each element or domain? 3) To what extent does the Texas CARS project address these elements or domains?” (p.12)

▪ Resulted in a visual statistical model of 14 key conceptual elements that they deemed essential in a nursing home-to-community transition project

▪ Community participants reported that strategic components of the state project generally fit well with their perception of the ideal transition model

▪ Original study did not advance knowledge very far beyond observations and findings reported in the literature

Robinson, Porter, Shugrue, Kleppinger, & Lambert, 2015

Center on Aging at University of Connecticut Health Center; Division of Health Services, Connecticut Department of Social Services

“Investigated long-term outcomes of transitioning from institutions to community living over six years of the Money Follows the Person program, 2008–14, in Connecticut.” (p. 1634)

▪ For majority of participants, quality of life and life satisfaction improved significantly after transition

▪ About half of the participants visited hospitals or emergency departments after transition

▪ Only 14% returned to an institution one year after transition

▪ Predictors of re-institutionalization included some not previously observed: mental health disability, difficulties with family members before transition, and not exercising choice and control in daily life.

Seekins, Ravesloot, Katz, Liston, Oxford, Altom White, Petty, & Kafka, 2011

University of Montana Rural Institute; Topeka Independent Living Resource Center; Association of Programs for Rural Independent Living; University of Kansas; ILRU at TIRR Memorial Hermann

“The objectives of this research were to: (1) assess the levels of nursing home emancipation services and barriers to nursing home transitions, including the role of secondary health conditions, and (2) to assess nursing home transition policies and procedures.” (p.245)

▪ Transitioned 2389 residents from nursing homes back to community living arrangements

▪ Only 4% returned to a nursing home for any reason

Spirgiene, Routasalo, & Macijauskiene, 2013

Lithuanian University of Health Sciences; University of Helsinki

“To examine residents’ resources for potential transition to the community after entry to LTCFs.” (p.523)

▪ 1/3 of residents preferred transition back to the community

▪ Many residents had resources (e.g. 10% had no cognitive impairment; 40% were ADL independent; 2/3 would feel safe in the community), yet none were involved in a discharge process due to lack of established nursing/social care services and transitional care plans

▪ A population of residents with no cognitive or functional impairments resided in long-term care facilities who were suitable candidates for transition back to the community

Thomas, Gassoumis, & Wilber, 2010

University of Southern California

“To determine the effect of a Social Health Maintenance Organization (S/HMO) on diverting older adults admitted into a nursing facility from converting to long-stay placement” (p.333)

▪ After controlling for selected sociodemographics, comorbidities, behavioral issues, mental health conditions, and other risk factors, being enrolled in the S/HMO increased the likelihood of successful discharge by 26%

Thorn, Pittman, Myers, & Slaughter, 2009

Pinecrest Supports and Services Center, United States; University of South Florida,

“Our aim was to design a functional system in a large residential facility that would increase community integrated learning opportunities. This was conducted with particular focus on increasing successful transitions to community-based living settings.” (p.893)

▪ “Highlights the advantages of creating a therapeutic milieu fostering learning and practicing functional skills in real-life activities and how this translates to increased community integration success for individuals with significant ID.” (p.899)

▪ Significant increases in the areas of community presence, community participation, community integration and community inclusion through community integrated learning opportunities.

Toles, Anderson, Massing, Naylor, Jackson, Peacock‐Hinton, & Colón‐Emeric, 2014

University of Northern Carolina; Duke University; University of Pennsylvania; Veterans Affairs Medical Centre

“To describe the time to first acute care use (e.g. emergency department (ED) use without hospitalization or rehospitalization) for older adults discharged to home after receiving post acute care in skilled nursing facilities (SNFs);to identify predictors of first acute care use.” (p.79)

▪ Post SNF discharge to the community, 22.1% of older adults used acute care within 30 days; 37.5% within 90 days

▪ Medicare beneficiaries had high use of acute care services post-SNF discharge

▪ Factors associated with acute care use are potentially modifiable

Winkler, Farnworth, Sloan, & Brown, 2011

Summer Foundation (Australia); Monash University, Australia; OT/Neuropsychologists from Osborn, Sloan, & Associates (Australia)

“To explore the transition experiences of young people with acquired brain injury who have lived in age care facilities and moved to the community-as well as the perspectives of their significant carer/carers. The study aimed to understand the outcomes of transition from residential aged care to the community; to identify key outcomes from their perspectives.” (p.155)

▪ A range of positive outcomes were identified resulting from transition from aged care settings to the community including increased independence, improved wellbeing and greater degree of social inclusion

▪ Environmental factors were critical to facilitating a positive outcome

Wodchis, Teare, Naglie, Bronskill, Gill, Hillmer, Anderson, Rochon, & Fries, 2005

Toronto Rehabilitation Institute; Institute for Clinical Evaluative Sciences; University of Toronto; University Health Network; Baycrest Centre for Geriatric Care; University of Michigan; Veterans Affairs, Ann Arbor, MI

“To determine the relation between rehabilitation therapy (RT) intensity and time to discharge home for stroke patients in skilled nursing facilities (SNFs).” (p.442)

▪ Rehabilitation therapy increased the likelihood of discharge to the community for all groups except those expected to be discharged within 30 days.

Wysocki, Kane, Dowd, Golberstein, Lum, & Shippee, 2014

Center for Gerontology and Healthcare Research, Brown University; School of Public Health, University of Minnesota; Department of Social Work and Social Administration and Sau Po Center on Ageing, The University of Hong Kong,

“To compare hospitalizations of dually eligible older adults who had an extended Medicaid nursing home (NH) stay and transitioned out to receive Medicaid home- and community-based services (HCBS) with hospitalizations of those who remained in the NH.” (p.71)

▪ Persons who transitioned from the nursing home to Medicaid home- and community-based services had a greater risk of hospitalization.

Young, 2006

School of Medicine, The University of Queensland, Mayne Medical School (Australia)

“To monitor changes in skills and life circumstances as residents of an institution that was to be permanently closed were progressively relocated into either dispersed homes in the community or cluster centres and to record any changes in adaptive and maladaptive behaviour, choice-making and objective life quality.” (p.421)

▪ Community group had a greater number of significant improvements and achieved more domestic skills in cleaning, laundry, table setting, food preparation and other routine household chores.

▪ Community group had significantly improved levels of trustworthiness and decreased sexual behavior

▪ Community group had significantly increased opportunities for everyday choice-making

▪ Both groups experienced improved objective quality of life in all areas measured over 2 years of living in the new location.