Kudos to Michael Cary, Elizabeth C. Clipp Term Chair in Nursing, and the entire team for the submission of their R03 application to NIH entitled: "Facilitators and Barriers to Successful Community Discharge Following Inpatient Rehabilitation." This proposal request funding for a two-year period with a start date of April 1, 2022. 

Nearly 1 in 8 of the 339,000 Medicare beneficiaries who receive post-acute care (PAC) in Inpatient Rehabilitation Facilities (IRFs) is readmitted within 30 days. Reductions in 30-day readmission rates have been achieved in acute care settings with effective transitional care –processes designed to ensure the coordination and continuity of patient care between different settings or levels of care. However, little is known about the transitional care delivered in post-acute IRF settings. Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence) is a promising example of a comprehensive transitional care framework with eight core components. Interventions based on the ACHIEVE framework are recommended for older adults transitioning from hospitals to home by way of skilled nursing facilities, but ACHIEVE has not been applied to transitions from IRFs. Further, the qualitative studies on which ACHIEVE is based on lacked representation of racial/ethnic minorities. Without recommendations for how to operationalize the ACHIEVE framework for the IRF setting including the perspectives of stakeholders and racial/ethnic patient groups, it will not be possible to improve transitional care outcomes or disparities observed among underrepresented racial/ethnic groups. 

To further develop the ACHIEVE framework, we propose a multi-method study focused on older adults (age >65 and older) admitted and later discharged from IRFs. In aim 1of this study, we will identify transitional care processes in operationalizing each of ACHIEVE’s framework components, and identify barriers and facilitators to successful community discharge as perceived by key stakeholders (IRF patient, caregivers, providers, administrators). We will 1) conduct qualitative, semi-structured interviews with stakeholders from two IRFs (one hospital-based unit and one free-standing facility), and 2) oversample IRF patients belonging to racial/ethnic minority groups to support subgroup comparisons. In aim 2 of this study, we will prioritize care processes and supports needed for an effective and pragmatic transitional care intervention in IRFs. We will convene an expert panel to participate in a modified Delphi technique to 1) develop consensus on how IRF care processes can be effectively operationalized within each of ACHIEVE’s framework components, and 2) identify tools and best practices needed to inform the development of a comprehensive and effective transitional care intervention in IRFs. Following completion of the proposed study, we will use the findings to develop and pilot a culturally congruent transitional care program targeting IRF patients at high risk for readmission.