Table 3 Concepts measured, measures, data source, and timing (days)

Preparedness for discharge

Care Transitions Measure-15 (CTM-15). High reliability (alpha range = 0.93–0.95), 15 items on a 4-point scale, measuring self-reported knowledge and skills for continuing care at home. Standardized summary score range 0–100; higher scores associated with less acute care use after discharge [45, 46].

Pt

x

Preparedness for caregiving

Preparedness for Caregiving Scale (PCS). Moderate to high reliability (alpha = 0.86–0.92, 8 items on a 5-point Likert scale (0–4), measuring self-reported readiness for caregiving. Range = 0–32; higher scores associated with less anxiety [47,48,49].

CG

x

Quality of life

McGill Quality of Life Questionnaire (MQoL). Moderate reliability (alpha = .80), 16 items on a 7-point Likert scale; the scale is recommended for studies of palliative care and measures quality of life across disease trajectories [50, 51].

Pt

x

x

Function

Life Space Assessment. High reliability, (alpha = 0.96), 5 Likert scales corresponding to a hierarchy of levels of mobility (each scored from 0 to 4) where weights are the product of the “Life-space level” (range 1–5) and the “independence” score (range 1–2); range = 1–120. Lower scores are associated with falls and hospitalization [52,53,54,55].

x

x

Caregiver burden

Zarit Caregiver Burden Scale. High reliability, (alpha = 0.89), with 12 items on a 5-point scale, measuring caregiver perceptions that “caregiving has an adverse effect on their emotional, social, financial, physical and spiritual functioning.” Scores range 0–48; higher scores associated with depression and social isolation [56, 57].

CG

x

x

Caregiver distress

Distress Thermometer includes 1 item on an 11-point scale, measuring negative affect (e.g., sadness and fear) related to caregiving for a severely ill person. Score ranges 0–10, with scores > 4 associated with poor coping and depression [58].

x

x

Days of acute care use

Self-reported number of combined number of days the patient spends in the ED or hospital in 30 and 60 days after SNF discharge [59].

Pt

x

x

Falls

Self-reported number of patient falls with injury (those requiring medical attention) and without injury; falls are defined as an “unintentional change in position resulting in a resident coming to rest on the ground or lower level” [60].

Pt

x

x

Hospice enrollment

Self-reported enrollment in hospice (yes/no) in 30 and 60 days after SNF discharge.

x

x

Home health care use

Number of days of home health care provided by nurses and rehabilitation therapists in 30 and 60 days after SNF discharge

x

x

Hospital use

Self-reported count of hospital readmissions, either acute or observational stays after SNF discharge in 30 and 60 days after SNF discharge.

x

x

ED use

Self-reported count of emergency department visits without hospital stay, in 30 and 60 days after SNF discharge.

x

x

Death

Caregiver-reported death of the patient in 30 and 60 days after SNF discharge.

CG

x

x