Description
The purpose of this project is to compare the quality of care during, and re-hospitalization rates following, admission to a local skilled nursing facility (SNF) for post acute care between:
1) patients admitted prior to institution of an evidence-based SNF nurse monitoring protocol and patient/caregiver home monitoring and diet education program on December 1, 2011 and
2) patients admitted after the institution of the monitoring protocol and education program.
PI is Sandra Wilson, PhD. PAMF Co-Investigator is Sangeeta Kopardeker, MD.
1) patients admitted prior to institution of an evidence-based SNF nurse monitoring protocol and patient/caregiver home monitoring and diet education program on December 1, 2011 and
2) patients admitted after the institution of the monitoring protocol and education program.
PI is Sandra Wilson, PhD. PAMF Co-Investigator is Sangeeta Kopardeker, MD.
Funder
Palo Alto Medical Foundation
Related Studies
Advance Care Planning in Older Adults With Multiple Medical Conditions Undergoing High-Risk Surgery
Goal is to determine the prevalence of preop documentation of ACP among older, high-risk surgical pts with multiple conditions.
Investigator: External PI, Principal Investigator
Does the Medicare Preventive Visit Coverage Benefit Seniors With Multiple Chronic Conditions?
We will assess the impact of covered preventive visits among Medicare beneficiaries using electronic health records data from PAMF, between 2006 and 2015.
Advance Care Planning Practices in Caring for Vulnerable Elders with Multiple Chronic Conditions
To examine the impact of the palliative care program on the patterns of ACP documentation in EHR of patients with multiple chronic conditions.
Creating a Patient-Centered Tool to Help Medicare Beneficiaries Choose Prescription Drug Plans
Goals are to develop and test a tool for PAMF pts providing out-of-pocket costs in different Medicare Part D plans.
Investigators: Cheryl Stults, Ph.D., Albert S. Chan, M.D., M.S., FAAFP
Advancing Geriatrics Infrastructure and Network Growth
To improve individual and population health and health care through research leveraging the resources and capabilities of learning health care systems.
Aspirin in Reducing Events in the Elderly (ASPREE)
The purpose of this study is to determine whether the potential benefits of aspirin outweigh the risks for people over age 65.
Estimating the Prevalence of Harmful and Hazardous Alcohol Consumption in Older U.S. Adults
This study incorporates data from NHANES to estimate the national prevalence of at-risk drinking among older U.S. adults.
Sutter Health’s Advanced Illness Management program
Expand pilot of SH's Advanced Illness Management program across entire Sutter Health system to study quality of care, total care cost, and implementation.
Investigators: Sylvia Sudat, PhD, External PI, Principal Investigator
Lost in the Shuffle? Documentation of End-of-Life Care Decisions
The study's objective is to identify the locations of ACP documentation in EpicCare EHR and to determine which patient and primary care provider (PCP) characteristics are associated with having a scanned ACP document.
Transitional Care for Older Adults
This study evaluates a program to reduce hospital readmissions by engaging community-based resources to assist high-risk seniors.