Published Date2018-05-01
JournalProfessional case management, 2018-05-01, Volume 23 Find other publications in this journal
Author Info
  • Nina M. Flanagan, PhD, GNP, is Assistant Professor, Decker School of Nursing, Binghamton University. Her research focus is on the role of nursing in the management of older adults with cognitive impairment and medical comorbidities. Victoria M. Rizzo, PhD, LCSW-R, is Department Chair and Associate Professor, Department of Social Work, Binghamton University. Her research examines the impact of interprofessional interventions including social workers on older adults coping with chronic illnesses and the implications of health care policy and financing on the provision of these services to older adults. Gary D. James, is Director of the Biomedical Anthropology Program, Director of the Institute for Primary and Preventative Health Care, and Professor of Anthropology, Nursing, and Biomedical Engineering at Binghamton University. He is a fellow of the Society of Behavioral Medicine and AAAS and a member of the Harvey Society. Adele Spegman, PhD, RN, is Director of Nursing Research for the Geisinger Health System in Pennsylvania. Her current studies focus on pain management and nurses' work environment. Dr. Spegman holds degrees from Oregon Health and Science University, University of Minnesota, and Niagara University. Najla A. Barnawi, MS, RN, is PhD candidate at Decker School of Nursing, Binghamton University. She started her career as a clinical instructor in a private diploma nursing institution for one full year. In 2003, she worked as Teaching Assistant at King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS) mainly in maternity and community nursing care.


The specific aims of this descriptive study were to (1) examine the relationships between individual-level determinants of health using standard care admission assessments of residents admitted to a skilled nursing facility (SNF) and those residents readmitted to the hospital within 30 days from discharge from the same SNF; (2) identify and describe the risk factors of the residents readmitted to the hospital within 30 days; and (3) use the findings to inform and refine current practice to target the mutable risk factors correlated with 30-day hospital readmission.A 180-bed skilled nursing center in Northeastern Pennsylvania.A retrospective paper medical record review of patients discharged from an SNF to community living was conducted to examine the relationship between individual determinants of health behaviors and 30-day hospital readmissions. The study sample (N = 221) included adults 65 years and older who were admitted to the SNF from January to December 2014 for subacute physical rehabilitation following an acute care hospital stay with a discharge plan to community living.The 30-day readmission rate was 11%. The results of the logistic regression including diagnosis at readmission showed that the odds of readmission before 30 days were nearly three times greater in patients who had congestive heart failure (p < .02). Patients who were at "very high risk" on the Braden Scale were 20 times more likely to be readmitted before 30 days compared with those at low risk. Age and gender were not predictors. None of the other standard screening assessments for delirium, depression, functional status, and fall risk were predictive of 30-day readmission.(1) Care coordination and communication with residents, caregivers, and home health can have an impact on 30-day readmissions post-SNF discharge. (2) Chronic respiratory diseases continue to be a challenge in prevention of hospital readmissions.