Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission
Open accessAbstract
Background Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.Objective To identify whether early post-SNF discharge care reduces likelihood of 30-day hospital readmissions.Design Secondary data analysis using the Electronic Medical Record, Medicare, Medicaid and the Minimum Data Set.Participants/setting Older (age > 65 years), community-dwelling adults admitted to a safety net hospital in the Midwest for 3 or more nights and discharged home after an SNF stay (n = 1543).Measurements The primary outcome was hospital readmission within 30 days of SNF discharge. The primary independent variables were either a home health visit or an outpatient provider visit within a week of SNF discharge.Results Out of 8754 community-dwelling, hospitalized older adults, 3025 (34.6%) were discharged to an SNF, of whom 1543 (51.0%) returned home. Among the SNF to home group, a home health visit within a week of SNF discharge was associated with reduced hazard of 30-day hospital readmission [adjusted hazard ratio (aHR) 0.61, P < .001] but outpatient provider visits were not associated with reduced risk of hospital readmission (aHR = 0.67, P = .821).Conclusion For patients discharged from an SNF to home, the finding that a home health visit within a week of discharge is associated with reduced hazard of 30-day hospital readmissions suggests a potential avenue for intervention.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Direct care workers provide care to individuals returning from a hospital stay and help reduce their risk of readmission.
“They also provide care to individuals returning from a hospital stay and help reduce their risk of readmission.[661][662][663]”
From 2023 Alzheimer's disease facts and figures (2023) · cites this paper as [661]
The Results report that a home health visit within a week of discharge from a skilled nursing facility to home was associated with a lower hazard of 30-day hospital readmission. The paper does not identify those visits as care by direct care workers, establish that the visits caused the reduction, or extend the finding to everyone returning directly home from a hospital stay. Page numbers were not available in our copy. (LLM, conf=0.87)
Experimental — accuracy not yet measuredAcross settings, direct care workers provide care to individuals returning from a hospital stay and can help reduce the risk of readmission, as well as assist with end-of-life care transitions.
“Across settings, they also provide care to individuals returning from a hospital stay and can help reduce the risk of readmission, as well as assist with end‐of‐life care transitions.”
From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [769]
The Discussion reports that home health visits within a week of discharge from a skilled nursing facility were associated with fewer 30-day hospital readmissions. It does not establish that direct care workers specifically reduced readmissions across settings, and it does not address end-of-life care transitions. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Controlling the False Discovery Rate: A Practical and Powerful Approach to Multiple Testing
Benjamini, Y., & Hochberg, Y. (1995) · Journal of the Royal Statistical Society Series B: Statistical Methodology · doi:10.1111/j.2517-6161.1995.tb02031.x · Cited by 109,482 · see citing works
Rehospitalizations among Patients in the Medicare Fee-for-Service Program
Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009) · New England Journal of Medicine · doi:10.1056/nejmsa0803563 · Cited by 5,164 · see citing works
The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital
Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003) · Annals of Internal Medicine · doi:10.7326/0003-4819-138-3-200302040-00007 · Cited by 1,888 · see citing works
Morris, J. N., Fries, B. E., & Morris, S. A. (1999) · The Journals of Gerontology Series A: Biological Sciences and Medical Sciences · doi:10.1093/gerona/54.11.m546 · Cited by 1,408 · see citing works
Neighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization
Kind, A., Jencks, S., Brock, J., Yu, M., Bartels, C. M., Ehlenbach, W. J., Greenberg, C., & Smith, M. (2014) · Annals of Internal Medicine · doi:10.7326/m13-2946 · Cited by 1,383 · see citing works
van Walraven, C., Dhalla, I. A., Bell, C. M., Etchells, E. E., Stiell, I. G., Zarnke, K. B., Austin, P. C., & Forster, A. J. (2010) · Canadian Medical Association Journal · doi:10.1503/cmaj.091117 · Cited by 966 · see citing works
Geriatric Conditions and Disability: The Health and Retirement Study
Cigolle, C. T., Langa, K. M., Kabeto, M. U., Tian, Z., & Blaum, C. S. (2007) · Annals of Internal Medicine · doi:10.7326/0003-4819-147-3-200708070-00004 · Cited by 403 · see citing works
Arbaje, A. I., Wolff, J. L., Yu, Q., Powe, N. R., Anderson, G. F., & Boult, C. (2008) · The Gerontologist · doi:10.1093/geront/48.4.495 · Cited by 305 · see citing works
Transitions in Care for Older Adults with and without Dementia
Callahan, C. M., Arling, G., Tu, W., Rosenman, M. B., Counsell, S. R., Stump, T. E., & Hendrie, H. C. (2012) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2012.03905.x · Cited by 253 · see citing works
Self-citationEmergency Department Use Among Older Adults With Dementia
LaMantia, M. A., Stump, T. E., Messina, F. C., Miller, D. K., & Callahan, C. M. (2016) · Alzheimer Disease & Associated Disorders · doi:10.1097/wad.0000000000000118 · Cited by 235 · see citing works
Self-citationMeddings, J. A., Reichert, H., Smith, S. N., Iwashyna, T. J., Langa, K. M., Hofer, T. P., & McMahon, L. F. (2016) · Journal of General Internal Medicine · doi:10.1007/s11606-016-3869-x · Cited by 136 · see citing works
Berkowitz, R. E., Fang, Z., Helfand, B. K. I., Jones, R. N., Schreiber, R., & Paasche-Orlow, M. K. (2013) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2013.03.004 · Cited by 128 · see citing works
Ingber, M. J., Feng, Z., Khatutsky, G., Wang, J. M., Bercaw, L. E., Zheng, N. T., Vadnais, A., Coomer, N. M., & Segelman, M. (2017) · Health Affairs · doi:10.1377/hlthaff.2016.1310 · Cited by 120 · see citing works
Greysen, S. R., Cheung, D. H., Garcia, V., Kessell, E. R., Sarkar, U., Goldman, L., Schneidermann, M., Critchfield, J., Pierluissi, E., & Kushel, M. (2014) · Journal of the American Geriatrics Society · doi:10.1111/jgs.12928 · Cited by 108 · see citing works
Geriatric Syndromes in Hospitalized Older Adults Discharged to Skilled Nursing Facilities
Bell, S. P., Vasilevskis, E. E., Saraf, A. A., Jacobsen, J. M. L., Kripalani, S. B., Mixon, A. S., Schnelle, J. F., & Simmons, S. F. (2016) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14035 · Cited by 107 · see citing works
Murtaugh, C. M., Deb, P., Zhu, C., Peng, T. R., Barrón, Y., Shah, S., Moore, S. M., Bowles, K. H., Kalman, J., Feldman, P. H., et al. (2017) · Health Services Research · doi:10.1111/1475-6773.12537 · Cited by 104 · see citing works
Emergency Department Use by Nursing Home Residents
Ackermann, R. J., Kemle, K. A., Vogel, R. L., & Griffin, R. (1998) · Annals of Emergency Medicine · doi:10.1016/s0196-0644(98)70235-5 · Cited by 87 · see citing works
Unroe, K. T., Nazir, A., Holtz, L. R., Maurer, H., Miller, E. W., Hickman, S. E., LaMantia, M. A., Bennett, M., Arling, G. W., & Sachs, G. A. (2014) · Journal of the American Geriatrics Society · doi:10.1111/jgs.13141 · Cited by 85 · see citing works
Burke, R. E., Juarez‐Colunga, E., Levy, C. R., Prochazka, A. V., Coleman, E. A., & Ginde, A. A. (2015) · Medical Care · doi:10.1097/mlr.0000000000000359 · Cited by 85 · see citing works
Ouslander, J. G., Diaz, S., Hain, D., & Tappen, R. M. (2010) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2010.02.015 · Cited by 77 · see citing works
Wong, F. K. Y., Chow, S. K. Y., Chan, T. M. F., & Tam, S. K. (2013) · Age and Ageing · doi:10.1093/ageing/aft123 · Cited by 76 · see citing works
Delate, T., Chester, E. A., Stubbings, T., & Barnes, C. A. (2008) · Pharmacotherapy The Journal of Human Pharmacology and Drug Therapy · doi:10.1592/phco.28.4.444 · Cited by 75 · see citing works
Hazards of Hospitalization: Residence Prior to Admission Predicts Outcomes
Friedman, S. M., Mendelson, D. A., Bingham, K. W., & McCann, R. M. (2008) · The Gerontologist · doi:10.1093/geront/48.4.537 · Cited by 69 · see citing works
Pending Laboratory Tests and the Hospital Discharge Summary in Patients Discharged To Sub-Acute Care
Walz, S. E., Smith, M. A., COX, E. D., Sattin, J. A., & Kind, A. (2010) · Journal of General Internal Medicine · doi:10.1007/s11606-010-1583-7 · Cited by 61 · see citing works
Home Health Nursing Care and Hospital Use for Medically Complex Children
Gay, J. C., Thurm, C. W., Hall, M., Fassino, M. J., Fowler, L., Palusci, J. V., & Berry, J. G. (2016) · PEDIATRICS · doi:10.1542/peds.2016-0530 · Cited by 61 · see citing works
Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge
Toles, M., Anderson, R. A., Massing, M. W., Naylor, M. D., Jackson, E., Peacock‐Hinton, S., & Colon-Emeric, C. S. (2014) · Journal of the American Geriatrics Society · doi:10.1111/jgs.12602 · Cited by 60 · see citing works
Field, T. S., Ogarek, J., Garber, L., Reed, G., & Gurwitz, J. H. (2015) · Journal of General Internal Medicine · doi:10.1007/s11606-014-3106-4 · Cited by 60 · see citing works
Nyweide, D. J., & Bynum, J. (2016) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2016.06.027 · Cited by 59 · see citing works
Hospital Readmission Penalties: Coming Soon to a Nursing Home Near You!
Carnahan, J. L., Unroe, K. T., & Torke, A. M. (2016) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14021 · Cited by 52 · see citing works
Self-citationLaMantia, M. A., Lane, K. A., Tu, W., Carnahan, J. L., Messina, F. C., & Unroe, K. T. (2016) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2016.02.011 · Cited by 47 · see citing works
Self-citationImproving Disposition Outcomes for Patients in a Geriatric Skilled Nursing Facility
Berkowitz, R. E., Jones, R. N., Rieder, R., Bryan, M., Schreiber, R., Verney, S., & Paasche‐Orlow, M. K. (2011) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2011.03417.x · Cited by 43 · see citing works
Seematter‐Bagnoud, L., Wietlisbach, V., Yersin, B., & Büla, C. (2006) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2006.00743.x · Cited by 41 · see citing works
Middleton, A., Graham, J. E., Lin, Y., Goodwin, J. S., Bettger, J. P., Deutsch, A. F., & Ottenbacher, K. J. (2016) · Journal of General Internal Medicine · doi:10.1007/s11606-016-3704-4 · Cited by 36 · see citing works
Association of Discharge Home with Home Health Care and 30-Day Readmission after Pancreatectomy
Sanford, D. E., Olsen, M. A. A., Bommarito, K. M., Shah, M. N., Fields, R. C., Hawkins, W. G., Jaques, D. P., & Linehan, D. C. (2014) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2014.07.008 · Cited by 32 · see citing works
Frontloading and Intensity of Skilled Home Health Visits: A State of the Science
O’Connor, M. L., Bowles, K. H., Feldman, P. H., Pierre, M. S., Jarrin, O. F., Shah, S., & Murtaugh, C. M. (2014) · Home Health Care Services Quarterly · doi:10.1080/01621424.2014.931768 · Cited by 32 · see citing works
Lindquist, L. A., Miller, R. K., Saltsman, W. S., Carnahan, J. L., Rowe, T. A., Arbaje, A. I., Werner, N. E., Boockvar, K. S., Steinberg, K. E., & Baharlou, S. (2016) · Journal of General Internal Medicine · doi:10.1007/s11606-016-3850-8 · Cited by 26 · see citing works
Self-citationExploring the Value of Clinical Data Standards to Predict Hospitalization of Home Care Patients
Swanberg, H., Oancea, S. C., Westra, B. L., & Monsen, K. A. (2012) · Applied Clinical Informatics · doi:10.4338/aci-2012-05-ra-0016 · Cited by 19 · see citing works
Fried, T. R., Niehoff, K. M., Tjia, J., Redeker, N. S., & Goldstein, M. K. (2016) · BMC Geriatrics · doi:10.1186/s12877-016-0240-3 · Cited by 18 · see citing works
David, S., Sheikh, F., Mahajan, D., Greenough, W. B., & Bellantoni, M. F. (2016) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2016.05.004 · Cited by 11 · see citing works
Care Transitions: It’s the How, Not Just the What
Li, J., & Williams, M. V. (2015) · Journal of General Internal Medicine · doi:10.1007/s11606-015-3225-6 · Cited by 9 · see citing works
Flagged first, then by citations
Research works printed but not linked: 1
- [36]Hines AL Barrett ML Jiang HJ Steiner CA Conditions With the Largest Number of Adult Hospital Readmissions by Payer, 2011: Statistical Brief #172 Healthcare Cost and Utilization Project (HCUP) Statistical Briefs Rockville (MD) Agency for Healthcare Research and Quality (US) 2014 24901179
Cited by
Sorted by citations
2023 Alzheimer's disease facts and figures
(2023) · Alzheimer's & Dementia · doi:10.1002/alz.13016 · Cited by 3,212 · see citing works
2024 Alzheimer's disease facts and figures
(2024) · Alzheimer's & Dementia · doi:10.1002/alz.13809 · Cited by 2,536 · see citing works
2022 Alzheimer's disease facts and figures
Anonymous (2022) · Alzheimer s & Dementia · doi:10.1002/alz.12638 · Cited by 2,384 · see citing works
2025 Alzheimer's disease facts and figures
(2025) · Alzheimer s & Dementia · doi:10.1002/alz.70235 · Cited by 569 · see citing works
Sezgin, D., Ó’Caoimh, R., Liew, A., O’Donovan, M. R., Illario, M., Salem, M. A., Kennelly, S., Carriazo, A. M., López-Samaniego, L., Arnal, C., et al. (2020) · European Geriatric Medicine · doi:10.1007/s41999-020-00365-4 · Cited by 85 · see citing works
2026 Alzheimer's disease facts and figures
(2026) · Alzheimer s & Dementia · doi:10.1002/alz.71345 · Cited by 61 · see citing works
Shi, S., Olivieri‐Mui, B. L., Oh, G., McCarthy, E. P., & Kim, D. H. (2022) · JAMA Network Open · doi:10.1001/jamanetworkopen.2022.25452 · Cited by 38 · see citing works
Home Health Care After Skilled Nursing Facility Discharge Following Heart Failure Hospitalization
Weerahandi, H. M., Bao, H., Herrin, J. S., Dharmarajan, K., Ross, J. S., Jones, S., & Horwitz, L. I. (2019) · Journal of the American Geriatrics Society · doi:10.1111/jgs.16179 · Cited by 37 · see citing works
Bowles, K. H., Murtaugh, C. M., Jordan, L., Barrón, Y., Mikkelsen, M. E., Whitehouse, C. R., Chase, J. D., Ryvicker, M. B., & Feldman, P. H. (2019) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2019.11.001 · Cited by 32 · see citing works
Toles, M., Colon-Emeric, C. S., Hanson, L. C., Naylor, M. D., Weinberger, M., Covington, J., & Preisser, J. S. (2021) · Trials · doi:10.1186/s13063-021-05068-0 · Cited by 19 · see citing works
Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives
Carnahan, J. L., Inger, L., Rawl, S. M., Iloabuchi, T. C., Clark, D. O., Callahan, C. M., & Torke, A. M. (2020) · Journal of General Internal Medicine · doi:10.1007/s11606-020-06332-w · Cited by 18 · see citing works
Self-citationWeerahandi, H. M., Li, L., Bao, H., Herrin, J. S., Dharmarajan, K., Ross, J. S., Kim, K. L., Jones, S., & Horwitz, L. I. (2019) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2019.01.135 · Cited by 16 · see citing works
Skilled Nursing Facility Patients Discharged to Home Health Agency Services Spend More Days at Home
Simning, A., Orth, J., Wang, J., Caprio, T. V., Li, Y., & Temkin‐Greener, H. (2020) · Journal of the American Geriatrics Society · doi:10.1111/jgs.16457 · Cited by 16 · see citing works
Toles, M., Leeman, J., McKay, M. H., Covington, J., & Hanson, L. C. (2022) · Geriatric Nursing · doi:10.1016/j.gerinurse.2022.09.016 · Cited by 14 · see citing works
Wang, J., Dietrich, M. S., Bell, S. P., Maxwell, C. A., Simmons, S. F., & Kripalani, S. B. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-024766 · Cited by 11 · see citing works
Discharge processes in a skilled nursing facility affected by COVID ‐19
Weerahandi, H. M., Mak, W., Burack, O. R., Canter, B. E., Reinhardt, J. P., & Boockvar, K. S. (2021) · Journal of the American Geriatrics Society · doi:10.1111/jgs.17228 · Cited by 10 · see citing works
Burke, R. E., Canamucio, A., Medvedeva, E. L., Manges, K. A., & Ersek, M. T. (2020) · Journal of the American Geriatrics Society · doi:10.1111/jgs.16650 · Cited by 9 · see citing works
Adapting Project RED to Skilled Nursing Facilities
Popejoy, L., Vogelsmeier, A., Wakefield, B. J., Galambos, C. M., Lewis, A. M., Huneke, D., & Mehr, D. R. (2018) · Clinical Nursing Research · doi:10.1177/1054773818819261 · Cited by 9 · see citing works
Progress Toward Digital Transformation in an Evolving Post-Acute Landscape
Cross, D. A., & Adler‐Milstein, J. (2022) · Innovation in Aging · doi:10.1093/geroni/igac021 · Cited by 8 · see citing works
Nijhawan, A. E., Higashi, R. T., Marks, E. G., Tiruneh, Y. M., & Lee, S. J. C. (2019) · Journal of the International Association of Providers of AIDS Care (JIAPAC) · doi:10.1177/2325958219827615 · Cited by 8 · see citing works
Schreiner, N., Schreiner, S., & Daly, B. J. (2018) · Journal of Gerontological Nursing · doi:10.3928/00989134-20181019-01 · Cited by 8 · see citing works
Outcomes of a Nursing Home-to-Community Care Transition Program
Takahashi, P. Y., Chandra, A., McCoy, R. G., Borkenhagen, L. S., Larson, M. E., Thorsteinsdottir, B., Hickman, J. A., Swanson, K. M., Hanson, G. J., & Naessens, J. M. (2021) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2021.04.010 · Cited by 7 · see citing works
Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities
Prusynski, R. A., Frogner, B. K., Skillman, S. M., Dahal, A., & Mroz, T. M. (2021) · Journal of Applied Gerontology · doi:10.1177/07334648211033417 · Cited by 6 · see citing works
The Macro Impact of Microtransitions in Post-acute and Long-Term Care
Green, A.-N. S., Pagali, S. R., & Palat, S. T. (2023) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2023.06.032 · Cited by 5 · see citing works
Hurtaud, A., Lallier, F., Heidet, M., Arnoult, C., Dramé, M., & Canouï‐Poitrine, F. (2019) · Age and Ageing · doi:10.1093/ageing/afz143 · Cited by 5 · see citing works
Shaw, A., Cabrejo, P. T., Adamczyk, A. L., & Mulcahey, M. J. (2022) · American Journal of Occupational Therapy · doi:10.5014/ajot.2022.049082 · Cited by 5 · see citing works
Venkatesh, A. K., Gettel, C. J., Mei, H., Chou, S., Rothenberg, C., Liu, S., D’Onofrio, G., Lin, Z., & Krumholz, H. M. (2020) · Journal of Applied Gerontology · doi:10.1177/0733464820950125 · Cited by 4 · see citing works
Preparedness for care transitions to home and acute care use of skilled nursing facility patients
Toles, M., Zhang, Y., Hanson, L. C., Cary, M. P., & Preisser, J. S. (2025) · BMC Geriatrics · doi:10.1186/s12877-025-05803-1 · Cited by 3 · see citing works
Deardorff, W. J., Gan, S., Jing, B., Boscardin, W. J., Smith, A. K., & Lee, S. J. (2025) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2025.105775 · Cited by 3 · see citing works
A Novel Risk Score to Predict Thirty-Day Readmissions after Acute Type A Aortic Dissections
Ahmad, D., Aranda-Michel, E. C., Serna-Gallegos, D. R., Arnaoutakis, G. J., Brown, J. A., Yousef, S., Rao, R., Wang, Y., Phillippi, J. A., & Sultan, I. S. (2023) · The Heart Surgery Forum · doi:10.59958/hsf.6819 · Cited by 3 · see citing works
Wang, S., Temkin‐Greener, H., Simning, A., Konetzka, R. T., & Cai, S. (2024) · Journal of Applied Gerontology · doi:10.1177/07334648241242942 · Cited by 2 · see citing works
Carnahan, J. L., Kaehr, E. W., & Wagle, K. C. (2019) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2019.07.021 · Cited by 2 · see citing works
Self-citationTesting Re-Engineered Discharge Program Implementation Strategies in SNFs
Popejoy, L., Vogelsmeier, A., Wang, Y., Wakefield, B. J., Galambos, C. M., & Mehr, D. R. (2020) · Clinical Nursing Research · doi:10.1177/1054773820982612 · Cited by 2 · see citing works
Coordinated-Transitional Care (C-TraC) for Veterans from Subacute Rehabilitation to Home
Sison, S. D. M., John, J., Mac, C., Ruopp, M. D., & Driver, J. A. (2023) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2023.05.007 · Cited by 2 · see citing works
A Healthcare Pathway to Nirvana? The SNF Transition to Home
Saltsman, W. S. (2018) · Geriatrics · doi:10.3390/geriatrics3030054 · Cited by 2 · see citing works
Life-Space of Older Adults after Discharge from Skilled Nursing Facilities
Bankole, A. O., Zhang, Y., Hu, D., Preisser, J. S., Colon-Emeric, C. S., & Toles, M. (2024) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2024.01.006 · Cited by 1 · see citing works
Connect-Home: Transitional Care in Skilled Nursing Facilities
Toles, M., & Hanson, L. C. (2024) · Springer eBooks · doi:10.1007/978-3-031-56204-4_11 · Cited by 1 · see citing works
Receipt of Timely Primary Care Services Following Post-Acute Skilled Nursing Facility Care
Simning, A., Orth, J., Caprio, T. V., Li, Y., Wang, J., & Temkin‐Greener, H. (2020) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2020.09.016 · Cited by 1 · see citing works
LGBTQ+ inclusivity of the U.S. Department of Veterans Affairs’ Home Based Primary Care services
Lee, J. L.-Y., Hilgeman, M. M., Menen, T., Stigar, L. V., Sweeney, N. R., Mulcahy, A., & Carnahan, J. L. (2026) · Innovation in Aging · doi:10.1093/geroni/igag012
Self-citationReadmission Risk Coming Home After Rehabilitation in a Skilled Nursing Home With Dementia
Carnahan, J. L., Roy, I., Slaven, J. E., Ludden, E. F., Tu, W., Clark, D. O., Callahan, C. M., Unroe, K. T., & Torke, A. M. (2026) · Journal of the American Geriatrics Society · doi:10.1111/jgs.70752
Self-citation
- Authors
- Carnahan, J. L., Slaven, J. E., Callahan, C. M., Tu, W., & Torke, A. M.
- Affiliations
- Regenstrief Institute (US)
- Indiana University Indianapolis (US)
- Indiana University Health (US)
- Corresponding author
- Carnahan, Jennifer L.
- Venue
- Journal of the American Medical Directors Association
- Publisher
- Elsevier BV
- Published
- 2017-10
- Volume
- 18
- Issue
- 10
- Pages
- 853-859
- ISSN
- 1525-8610 (ISSN-L)
- PMC
- PMC5612845
- OpenAlex
- W2647277178
- Cited by
- 41
- References
- 40
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 4 · 2023: 4 · 2022: 5 · 2021: 4 · 2020: 8 · 2019: 7 · 2018: 3
- FWCI
- 7.98
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Journal of the American Medical Directors Association (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- IUScholarWorks (Indiana University) (submittedVersion)
- PMC
- Funders
- National Institute on Aging (R01AG031222, K24AG053794)
- Topics
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Medical Practices and Rehabilitation
- Keywords
- skilled nursing facility discharge, hospital readmission, 30-day readmission, home health visits, outpatient care, older adults, community-dwelling adults, post-discharge care, safety-net hospitals
- MeSH terms
- Adult, Aged, Aged, 80 and over, Ambulatory Care, Female, Humans, Male, Middle Aged, Patient Readmission, Patient Transfer, Primary Health Care, Skilled Nursing Facilities, Databases, Factual
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
