According to the
HCIA Complex/High-Risk Patient Targeting: Third Annual
- The program reached 1,691 patients between January
2013 and June 2015.
- Emergency department visits decreased by 70 per 1,000
discharges per quarter.
- 30-day practitioner follow-up visits increased to 58
per 1,000 discharges per quarter.
- There was a 5% reduction in 30-day hospital
readmissions, although not statistically significant.
Findings from the CMS award led to two randomized
controlled trials (listed in Vanderbilt Center for
Quality Aging projects) to implement a
patient-centered deprescribing intervention during the
hospital stay for older patients discharged to area SNFs.
The Shed-MEDS clinical trial is funded by the National
Institute of Aging, and the Drug Reduction in Older
Patients trial is funded by the VA Health Services
Research & Development.
For more information on program results:
Petersen, A.W., Shah, A.S., Simmons, S.F., Shotwell,
M.S., Jacobsen, J.M.L., … & Vasilevskis, E.E. (2018).
Pilot of a Patient-Centered Deprescribing Framework
Reduces Medications in Hospitalized Older Adults Being
Transferred to Inpatient Postacute Care.
Therapeutic Advances in Drug Safety, 9(9),
Vasilevskis, E.E., Ouslander, J.G., Mixon, A.S., Bell,
S.P., Jacobsen, J.M.L., Saraf, A.A., … & Schnelle, J.F.
Avoidable Readmissions of Patients Discharged to
Post-Acute Care: Perspectives of Hospital and Skilled
Nursing Facility Staff. Journal of American
Geriatric Society, 65(2), 269-276.
Jacobsen, J.M.L., Schnelle, J.F., Saraf, A.A., Long,
E.A., Vasilevskis, E.E., Kripalani, S., & Simmons, S.F.
of Hospital Readmissions from Skilled Nursing Facilities:
A Consumer Perspective. The Gerontologist,
Simmons, S.F., Schnelle, J.F., Saraf, A.A., Coelho, C.S.,
Jacobsen, J.M.L., Kripalani, S., … & Vasilevskis, E.E.
and Satisfaction with Pain Management among Older
Patients during the Transition from Acute to Skilled
Nursing Care. The Gerontologist, 56(6),
Bell, S.P., Vasilevskis, E.E., Saraf, A.A., Jacobsen,
J.M.L., Kripalani, S., Mixon, A.S., … & Simmons, S.F.
Syndromes in Hospitalized Older Adults Discharged to
Skilled Nursing Facilities. Journal of the
American Geriatrics Society, 64(4), 715-722.
Simmons, S.F., Bell, S., Saraf, A.A., Coelho, C.S., Long,
E.A., Jacobsen, J.M.L., … & Vasilevskis, E.E. (2016).
of Geriatric Syndromes in Hospitalized Medicare Patients
Discharged to Skilled Nursing Facilities. Journal
of the American Geriatrics Society, 64(10),
Saraf, A.A., Peterson, A.W., Simmons, S.F., Schnelle,
J.F., Bell, S.P., Kripalani, S., … & Vasilevskis, E.E.
Associated with Geriatric Syndromes (MAGS) and their
Prevalence in Older Hospitalized Adults Discharged to
Skilled Nursing Facilities. Journal of Hospital
Medicine, 11(10), 694-700.