Schreier, AnnCowin, Pamela B2019-02-142019-02-142018-122018-11-30December 2http://hdl.handle.net/10342/7057The purpose of this study was to examine the relationship of patient level factors including personal characteristics such as age, sex, and race, health indicators such as admission diagnosis, comorbidity, risk scores, and community factors such as caregiver identified, discharge disposition, and admitting hospital to the outcome indicator of readmission for patients transitioning to skilled nursing facilities. The study also compared the performance of an industry standard risk scoring index and a health system specific risk index in identifying patients at high risk for readmission. The study utilized a retrospective data set to examine research questions. Findings included that patient characteristics including sex, race, age, caregiver, diagnosis, and payor were not identified as factors in readmissions for patients transitioned to skilled nursing facilities. It was also noted that the industry standard risk scoring index appropriately identified patients who readmitted to acute care following a transition to a skilled nursing facility. Patients who were identified as high risk according to the index experienced higher rates of readmission than those who did not score as high risk. The health system specific readmission risk score was not as effective as the industry standard index in identifying patients at risk for hospital readmission across dispositions to home, home with home health services, and skilled nursing facilities as well as across academic and community hospitals. Attention to transitions of care will continue to grow as healthcare costs and outcomes are at the forefront of policymakers. It is imperative that nursing leaders and front-line staff understand the factors impacting patients during the transition process from acute care to skilled nursing facilities so that interventions may be implemented to facilitate positive transitions and mitigate risks from inhibiting factors. This study is unique in that the focus was on patient factors that impacted transitions of care from hospitals to skilled nursing facilities. This study allowed for these factors to be examined between patients that had a positive outcome of no readmission and those that had a negative outcome of readmission. By understanding these factors, nursing care delivery systems can be designed and implemented to support patient transitions and achieve positive outcomes.application/pdfenTransitionPatient ReadmissionSkilled Nursing FacilitiesRisk FactorsHospitalsMedicareDoctoral Dissertation2019-01-08