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Improving Care Transitions for Hospitalized Veterans Discharged to Skilled Nursing Facilities: A Focus on Polypharmacy and Geriatric Syndromes

1
Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, USA
2
Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN 37212, USA
3
Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN 37203, USA
4
Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN 37203, USA
5
Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
*
Author to whom correspondence should be addressed.
Geriatrics 2019, 4(1), 19; https://doi.org/10.3390/geriatrics4010019
Received: 30 December 2018 / Revised: 31 January 2019 / Accepted: 5 February 2019 / Published: 9 February 2019
(This article belongs to the Special Issue Geriatric Care Models)
Geriatric syndromes and polypharmacy are common in older patients discharged to skilled nursing facilities (SNFs) and increase 30-day readmission risk. In a U.S.A. Department of Veterans Affairs (VA)-funded Quality Improvement study to improve care transitions from the VA hospital to area SNFs, Veterans (N = 134) were assessed for geriatric syndromes using standardized instruments as well as polypharmacy, defined as five or more medications. Warm handoffs were used to facilitate the transfer of this information. This paper describes the prevalence of geriatric syndromes, polypharmacy, and readmission rates. Veterans were prescribed an average of 14.7 medications at hospital discharge. Moreover, 75% of Veterans had more than two geriatric syndromes, some of which began during hospitalization. While this effort did not reduce 30-day readmissions, the high prevalence of geriatric syndromes and polypharmacy suggests that future efforts targeting these issues may be necessary to reduce readmissions among Veterans discharged to SNF. View Full-Text
Keywords: polypharmacy; geriatric syndromes; care transitions; skilled nursing facilities; post-acute care; readmission polypharmacy; geriatric syndromes; care transitions; skilled nursing facilities; post-acute care; readmission
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Mixon, A.S.; Yeh, V.M.; Simmons, S.; Powers, J.; Ely, E.W.; Schnelle, J.; Vasilevskis, E.E. Improving Care Transitions for Hospitalized Veterans Discharged to Skilled Nursing Facilities: A Focus on Polypharmacy and Geriatric Syndromes. Geriatrics 2019, 4, 19.

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