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CDA 14-411 – HSR&D Study

Pre-Funded | New | Current | Completed | DRA | DRE | Portfolios/Projects | Centers | Career Development Projects
CDA 14-411
Improving Transitional Care for Veterans Discharged to Post-acute Care Facilities
Robert E. Burke MD MS
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
Philadelphia, PA
Funding Period: October 2015 - September 2020

The number of Veterans being discharged from hospitals to post-acute care facilities for continued care (such as skilled nursing facilities or rehabilitation facilities) is increasing. Unfortunately, many of these Veterans return to the hospital shortly after they were discharged, and this can lead to a downward spiral leading to long-term nursing home placement or even premature death for Veterans. These outcomes vary significantly site-by-site, suggesting different processes of care are employed. The processes and outcomes of post-acute care in the VA system are unknown.

Our work will evaluate transitions of care from hospitals to post-acute care facilities. We will identify important factors that lead to poor outcomes and best practices that lead to better outcomes, and then pilot interventions to improve transitions of care that may be of use for all Veterans being discharged from the hospital to a post-acute care facility.

Using a novel database that ties together VA, Medicare, and Medicaid data called the Residential History File, we will assess transitional care outcomes and evaluate structures and processes identified as important contributors in the ITC framework (Aim 1). Our primary composite outcome is hospital readmissions, ED visits, and mortality within 7 days of discharge. Secondary outcomes include 30-day utilization, mortality, and functional status. We will augment this analysis with interviews with key hospital and PAC providers as well as Veterans transitioning to PAC at high- and low-performing sites. These interviews will allow us to delve deeper into key processes within ITC domains that impact outcomes (Aim 2). Finally, we will pilot test a nurse-led intervention to improve transitions of care from hospital to PAC based on the ITC framework and informed by quantitative and qualitative data (Aim 3).

Not yet available.

This work will improve the outcomes of the large number of older Veterans who receive post-acute care in a skilled nursing facility after hospitalization.


Journal Articles

  1. Burke RE, Xu Y, Ritter AZ. Outcomes of post-acute care in skilled nursing facilities in Medicare beneficiaries with and without a diagnosis of dementia. Journal of the American Geriatrics Society. 2021 Oct 1; 69(10):2899-2907.
  2. Manges KA, Wallace AS, Groves PS, Schapira MM, Burke RE. Ready to Go Home? Assessment of Shared Mental Models of the Patient and Discharging Team Regarding Readiness for Hospital Discharge. Journal of hospital medicine. 2021 Jun 1; 16(6):326-332.
  3. Burke RE, Phelan J, Cross D, Werner RM, Adler-Milstein J. Integration Activities Between Hospitals and Skilled Nursing Facilities: A National Survey. Journal of The American Medical Directors Association. 2021 Dec 1; 22(12):2565-2570.e4.
  4. Limes J, Callister C, Young E, Burke RE, Albert T, Cornia PB, Sehgal R, Jones CD. A Cross-Sectional Survey of Internal Medicine Residents' Knowledge, Attitudes, and Current Practices Regarding Patient Transitions to Post-Acute Care. Journal of The American Medical Directors Association. 2021 Nov 1; 22(11):2344-2349.
  5. Leonard C, Gilmartin H, McCreight M, Kelley L, Mayberry A, Burke RE. Training registered nurses to conduct pre-implementation assessment to inform program scale-up: an example from the rural Transitions Nurse Program. Implementation science communications. 2021 Mar 8; 2(1):28.
  6. Park S, Jung J, Burke RE, Larson EB. Trends in Use of Low-Value Care in Traditional Fee-for-Service Medicare and Medicare Advantage. JAMA Network Open. 2021 Mar 1; 4(3):e211762.
  7. Valverde PA, Ayele R, Leonard C, Cumbler E, Allyn R, Burke RE. Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives. Journal of general internal medicine. 2021 Aug 1; 36(8):2251-2258.
  8. Park S, Langellier BA, Burke RE. Telehealth Benefits Offered by Medicare Advantage Plans in 2020. Medical care. 2021 Jan 1; 59(1):53-57.
  9. Burke RE, Canamucio A, Medvedeva E, Hume EL, Navathe AS. Association of Discharge to Home vs Institutional Postacute Care With Outcomes After Lower Extremity Joint Replacement. JAMA Network Open. 2020 Oct 1; 3(10):e2022382.
  10. Lawrence E, Casler JJ, Jones J, Leonard C, Ladebue A, Ayele R, Cumbler E, Allyn R, Burke RE. Variability in skilled nursing facility screening and admission processes: Implications for value-based purchasing. Health care management review. 2020 Oct 1; 45(4):353-363.
  11. Manges KA, Ayele R, Leonard C, Lee M, Galenbeck E, Burke RE. Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach. BMJ quality & safety. 2021 Aug 1; 30(8):648-657.
  12. Stutzbach J, Jones J, Taber A, Recicar J, Burke RE, Stevens-Lapsley J. Systems Approach Is Needed for In-Hospital Mobility: A Qualitative Metasynthesis of Patient and Clinician Perspectives. Archives of physical medicine and rehabilitation. 2021 May 1; 102(5):984-998.
  13. Ayele R, Manges KA, Leonard C, Lee M, Galenbeck E, Molla M, Levy C, Burke RE. How Context Influences Hospital Readmissions from Skilled Nursing Facilities: A Rapid Ethnographic Study. Journal of The American Medical Directors Association. 2021 Jun 1; 22(6):1248-1254.e3.
  14. Park S, Langellier BA, Burke RE, Figueroa JF, Coe NB. Association of Medicare Advantage Penetration With Per Capita Spending, Emergency Department Visits, and Readmission Rates Among Fee-for-Service Medicare Beneficiaries With High Comorbidity Burden. Medical care research and review : MCRR. 2021 Dec 1; 78(6):703-712.
  15. Burke RE, Canamucio A, Medvedeva E, Manges KA, Ersek M. External Validation of the Skilled Nursing Facility Prognosis Score for Predicting Mortality, Hospital Readmission, and Community Discharge in Veterans. Journal of the American Geriatrics Society. 2020 Sep 1; 68(9):2090-2094.
  16. Burke RE, Canamucio A, Glorioso TJ, Barón AE, Ryskina KL. Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities. Medical care. 2020 Apr 1; 58(4):301-306.
  17. Ayele RA, Lawrence E, McCreight M, Fehling K, Glasgow RE, Rabin BA, Burke RE, Battaglia C. Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System. Journal of hospital medicine. 2020 Mar 1; 15(3):133-139.
  18. McCreight MS, Rabin BA, Glasgow RE, Ayele RA, Leonard CA, Gilmartin HM, Frank JW, Hess PL, Burke RE, Battaglia CT. Using the Practical, Robust Implementation and Sustainability Model (PRISM) to qualitatively assess multilevel contextual factors to help plan, implement, evaluate, and disseminate health services programs. Translational behavioral medicine. 2019 Nov 25; 9(6):1002-1011.
  19. Denson JL, Knoeckel J, Kjerengtroen S, Johnson R, McNair B, Thornton O, Douglas IS, Wechsler ME, Burke RE. Improving end-of-rotation transitions of care among ICU patients. BMJ quality & safety. 2020 Mar 1; 29(3):250-259.
  20. Kumar A, Rivera-Hernandez M, Karmarkar AM, Chou LN, Kuo YF, Baldwin JA, Panagiotou OA, Burke RE, Ottenbacher KJ. Social and Health-Related Factors Associated with Enrollment in Medicare Advantage Plans in Older Adults. Journal of the American Geriatrics Society. 2020 Feb 1; 68(2):313-320.
  21. Burke RE, Leonard C, Lee M, Ayele R, Cumbler E, Allyn R, Greysen SR. Cognitive Biases Influence Decision-Making Regarding Postacute Care in a Skilled Nursing Facility. Journal of hospital medicine. 2020 Jan 1; 15(1):22-27.
  22. Daddato AE, Dollar B, Lum HD, Burke RE, Boxer RS. Identifying Patient Readmissions: Are Our Data Sources Misleading?. Journal of The American Medical Directors Association. 2019 Aug 1; 20(8):1042-1044.
  23. Burke RE, Canamucio A, Glorioso TJ, Barón AE, Ryskina KL. Transitional Care Outcomes in Veterans Receiving Post-Acute Care in a Skilled Nursing Facility. Journal of the American Geriatrics Society. 2019 Sep 1; 67(9):1820-1826.
  24. Cordasco KM, Frayne SM, Kansagara D, Zulman DM, Asch SM, Burke RE, Post EP, Fihn SD, Klobucar T, Meyer LJ, Kirsh SR, Atkins D. Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference. Journal of general internal medicine. 2019 May 1; 34(Suppl 1):11-17.
  25. Leonard C, Gilmartin H, McCreight M, Kelley L, Lippmann B, Mayberry A, Coy A, Lawrence E, Burke RE. Operationalizing an Implementation Framework to Disseminate a Care Coordination Program for Rural Veterans. Journal of general internal medicine. 2019 May 1; 34(Suppl 1):58-66.
  26. McCreight MS, Gilmartin HM, Leonard CA, Mayberry AL, Kelley LR, Lippmann BK, Coy AS, Radcliff TA, Côté MJ, Burke RE. Practical Use of Process Mapping to Guide Implementation of a Care Coordination Program for Rural Veterans. Journal of general internal medicine. 2019 May 1; 34(Suppl 1):67-74.
  27. Gilmartin H, Lawrence E, Leonard C, McCreight M, Kelley L, Lippmann B, Coy A, Burke RE. Brainwriting Premortem: A Novel Focus Group Method to Engage Stakeholders and Identify Preimplementation Barriers. Journal of nursing care quality. 2019 Apr 1; 34(2):94-100.
  28. Libbon JV, Austin CM, Gill-Scott LC, Burke RE. Improving the Transition of Care Process for Veterans Hospitalized at Non-VHA Facilities. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2019 Mar 1; 41(2):68-74.
  29. Ayele R, Jones J, Ladebue A, Lawrence E, Valverde P, Leonard C, Cumbler E, Allyn R, Burke RE. Perceived Costs of Care Influence Post-Acute Care Choices by Clinicians, Patients, and Caregivers. Journal of the American Geriatrics Society. 2019 Apr 1; 67(4):703-710.
  30. Falvey JR, Burke RE, Levy CR, Gustavson AM, Price L, Forster JE, Stevens-Lapsley JE. Impaired Physical Performance Predicts Hospitalization Risk for Participants in the Program of All-Inclusive Care for the Elderly. Physical Therapy. 2019 Jan 1; 99(1):28-36.
  31. Falvey JR, Bade MJ, Forster JE, Burke RE, Jennings JM, Nuccio E, Stevens-Lapsley JE. Home-Health-Care Physical Therapy Improves Early Functional Recovery of Medicare Beneficiaries After Total Knee Arthroplasty. The Journal of Bone and Joint Surgery. American volume. 2018 Oct 17; 100(20):1728-1734.
  32. Jones CD, Burke RE. Web Exclusive. Annals for Hospitalists Inpatient Notes - Getting Past the "Black Box"-Opportunities for Hospitalists to Improve Postacute Care Transitions. Annals of internal medicine. 2018 May 15; 168(10):HO2-HO3.
  33. Burke RE, Glorioso T, Barón AK, Kaboli PJ, Ho PM. Within-Hospital Variation in 30-Day Adverse Events: Implications for Measuring Quality. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2018 May 1; 40(3):147-154.
  34. Rabin BA, McCreight M, Battaglia C, Ayele R, Burke RE, Hess PL, Frank JW, Glasgow RE. Systematic, Multimethod Assessment of Adaptations Across Four Diverse Health Systems Interventions. Frontiers in public health. 2018 Apr 9; 6(102):102.
  35. Burke RE, Hess E, Barón AE, Levy C, Donzé JD. Predicting Potential Adverse Events During a Skilled Nursing Facility Stay: A Skilled Nursing Facility Prognosis Score. Journal of the American Geriatrics Society. 2018 May 1; 66(5):930-936.
  36. Burke RE, Jones J, Lawrence E, Ladebue A, Ayele R, Leonard C, Lippmann B, Matlock DD, Allyn R, Cumbler E. Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care. Journal of general internal medicine. 2018 May 1; 33(5):678-684.
  37. Burke RE, Jones CD, Hosokawa P, Glorioso TJ, Coleman EA, Ginde AA. Influence of Nonindex Hospital Readmission on Length of Stay and Mortality. Medical care. 2018 Jan 1; 56(1):85-90.
  38. Misky GJ, Burke RE, Johnson T, Del Pino Jones A, Hanson JL, Reid MB. Hospital Readmission From the Perspective of Medicaid and Uninsured Patients. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2018 Jan 1; 40(1):44-50.
  39. Jones J, Lawrence E, Ladebue A, Leonard C, Ayele R, Burke RE. Nurses' Role in Managing "The Fit" of Older Adults in Skilled Nursing Facilities. Journal of gerontological nursing. 2017 Dec 1; 43(12):11-20.
  40. Leonard C, Lawrence E, McCreight M, Lippmann B, Kelley L, Mayberry A, Ladebue A, Gilmartin H, Côté MJ, Jones J, Rabin BA, Ho PM, Burke R. Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study. Implementation science : IS. 2017 Oct 23; 12(1):123.
  41. Burke RE, Kelley L, Gunzburger E, Grunwald G, Gokhale M, Plomondon ME, Ho PM. Improving Transitions of Care for Veterans Transferred to Tertiary VA Medical Centers. American journal of medical quality : the official journal of the American College of Medical Quality. 2018 Mar 1; 33(2):147-153.
  42. Burke RE, Lawrence E, Ladebue A, Ayele R, Lippmann B, Cumbler E, Allyn R, Jones J. How Hospital Clinicians Select Patients for Skilled Nursing Facilities. Journal of the American Geriatrics Society. 2017 Nov 1; 65(11):2466-2472.
  43. Burke RE, Jones CD, Coleman EA, Falvey JR, Stevens-Lapsley JE, Ginde AA. Use of post-acute care after hospital discharge in urban and rural hospitals. American journal of accountable care. 2017 Mar 10; 5(1):16-22.
  44. Horney C, Capp R, Boxer R, Burke RE. Factors Associated With Early Readmission Among Patients Discharged to Post-Acute Care Facilities. Journal of the American Geriatrics Society. 2017 Jun 1; 65(6):1199-1205.
  45. Burke RE, Schnipper JL, Williams MV, Robinson EJ, Vasilevskis EE, Kripalani S, Metlay JP, Fletcher GS, Auerbach AD, Donzé JD. The HOSPITAL Score Predicts Potentially Preventable 30-Day Readmissions in Conditions Targeted by the Hospital Readmissions Reduction Program. Medical care. 2017 Mar 1; 55(3):285-290.
  46. Burke RE, Cumbler E, Coleman EA, Levy C. Post-acute care reform: Implications and opportunities for hospitalists. Journal of hospital medicine. 2017 Jan 1; 12(1):46-51.
  47. Jones CD, Cumbler E, Honigman B, Burke RE, Boxer RS, Levy C, Coleman EA, Wald HL. Hospital to Post-Acute Care Facility Transfers: Identifying Targets for Information Exchange Quality Improvement. Journal of The American Medical Directors Association. 2017 Jan 1; 18(1):70-73.
  48. Hegeman TW, Glorioso TJ, Hess E, Barón AE, Ho PM, Maddox TM, Bradley SM, Burke RE. Facility-Level Percutaneous Coronary Intervention Readmission Rates Are Not Associated With Facility-Level Mortality: Insights From the VA Clinical Assessment, Reporting, and Tracking (CART) Program. Journal of the American Heart Association. 2016 Sep 14; 5(9).
  49. Jones CD, Wald HL, Boxer RS, Masoudi FA, Burke RE, Capp R, Coleman EA, Ginde AA. Characteristics Associated with Home Health Care Referrals at Hospital Discharge: Results from the 2012 National Inpatient Sample. Health services research. 2017 Apr 1; 52(2):879-894.
  50. Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Physical Therapy. 2016 Aug 1; 96(8):1125-34.
  51. Burke RE, Johnson-Koenke R, Nowels C, Silveira MJ, Jones J, Bekelman DB. Can we engage caregiver spouses of patients with heart failure with a low-intensity, symptom-guided intervention? Heart & lung : the journal of critical care. 2016 Mar 1; 45(2):114-20.
  52. Burke RE, Whitfield EA, Hittle D, Min SJ, Levy C, Prochazka AV, Coleman EA, Schwartz R, Ginde AA. Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes. Journal of The American Medical Directors Association. 2016 Mar 1; 17(3):249-55.
  53. Burke RE, Rooks SP, Levy C, Schwartz R, Ginde AA. Identifying Potentially Preventable Emergency Department Visits by Nursing Home Residents in the United States. Journal of The American Medical Directors Association. 2015 May 1; 16(5):395-9.
  54. Burke RE, Juarez-Colunga E, Levy C, Prochazka AV, Coleman EA, Ginde AA. Rise of post-acute care facilities as a discharge destination of US hospitalizations. JAMA internal medicine. 2015 Feb 1; 175(2):295-6.
  55. Burke RE, Jones CD, Levy C, Ginde AA. Electronic communication capabilities of residential care facilities at times of transition. Journal of the American Geriatrics Society. 2014 Jul 1; 62(7):1381-3.
  56. Burke RE, Halpern MS, Baron EJ, Gutierrez K. Pediatric and neonatal Staphylococcus aureus bacteremia: epidemiology, risk factors, and outcome. Infection control and hospital epidemiology. 2009 Jul 1; 30(7):636-44.
  57. Benes FM, Matzilevich D, Burke RE, Walsh J. The expression of proapoptosis genes is increased in bipolar disorder, but not in schizophrenia. Molecular Psychiatry. 2006 Mar 1; 11(3):241-51.
  58. Burke RE, Walsh J, Matzilevich D, Benes FM. Mapping of hippocampal gene clusters regulated by the amygdala to nonlinkage sites for schizophrenia. Molecular Psychiatry. 2006 Feb 1; 11(2):158-71.
  59. Benes FM, Burke RE, Walsh J, Berretta S, Matzilevich D, Minns M, Konradi C. Acute amygdalar activation induces an upregulation of multiple monoamine G protein coupled pathways in rat hippocampus. Molecular Psychiatry. 2004 Oct 1; 9(10):932-45, 895.
Journal Other

  1. Jones CD, Nearing KA, Burke RE, Lum HD, Boxer RS, Stevens-Lapsley JE, Ozkaynak M, Levy CR. "What Would It Take to Transform Post-Acute Care?" 2019 Conference Proceedings on Re-envisioning Post-Acute Care. Journal of The American Medical Directors Association. 2020 Aug 1; 21(8):1012-1014.
  2. Gilmartin HM, Liu VX, Burke RE. Web Exclusive. Annals for Hospitalists Inpatient Notes - The Role of Hospitalists in the Creation of Learning Healthcare Systems. Annals of internal medicine. 2020 Jan 21; 172(2):HO2-HO3.
  3. Burke RE, Myers JS. Waiting for Godot: The Quest to Promote Scholarship in Hospital Medicine. [Editorial]. Journal of hospital medicine. 2019 Aug 1; 14(8):508-509.
  4. Burke RE, Werner RM. Quality measurement and nursing homes: measuring what matters. [Editorial]. BMJ quality & safety. 2019 Jul 1; 28(7):520-523.
  5. Burke RE, Ibrahim SA. Discharge Destination and Disparities in Postoperative Care. JAMA. 2018 Apr 24; 319(16):1653-1654.
  6. Burke RE, Greysen SR. Reducing SNF Readmissions: At What Cost?. [Editorial]. Journal of hospital medicine. 2018 Apr 1; 13(4):285-286.
  7. Burke RE, Shojania KG. Rigorous evaluations of evolving interventions: can we have our cake and eat it too?. [Editorial]. BMJ quality & safety. 2018 Apr 1; 27(4):254-257.

DRA: Health Systems
DRE: Technology Development and Assessment
Keywords: Outcomes - Patient
MeSH Terms: none

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