In-hospital low mobility, suboptimal continence care, and poor nutrition account for immediate and 1-month posthospitalization functional decline. These are potentially modifiable hospitalization risk factors for which practice and policy should be targeted in efforts to curb the posthospitalization functional decline trajectory.

BACKGROUND Recent efforts to prevent readmissions are increasingly focusing on early identification of high‐risk patients. OBJECTIVE To test whether information on functioning during hospitalization contributes to the ability to accurately identify older adults at high risk of readmission beyond their baseline risk. DESIGN Prospective cohort study. SETTING Internal medicine wards at 2 medical centers. PATIENTS Five hundred fifty‐nine community‐dwelling older adults (aged ≥70 years) discharged to their homes. MEASUREMENTS Data on unplanned 30‐day readmissions were retrieved from electronic health records. Data on at‐admission activities of daily living (ADL) and in‐hospital ADL decline were collected using validated questionnaires. Multivariate logistic regression was used to model the association between functioning and readmission controlling for known risk factors. RESULTS Higher in‐hospital ADL decline was significantly associated with readmission (odds ratio for each 10‐point decrease in ADL = 1.32, 95% confidence interval = 1.02‐1.72) but did not contribute to the overall discrimination of the model, as compared with the at‐admission data (C statistic = 0.81 for each model). Identifying high‐risk (10th highest percentile) patients by the at‐admission model did not detect 7/55 (12.7%) of patients who would have been categorized as high risk if risk identification was postponed to the discharge date and included data on in‐hospital ADL decline. CONCLUSIONS The study highlights the ability to identify patients at high risk for readmission already early in the index hospitalization using data on functioning, nutrition, chronic morbidity, and prior hospitalizations. Nonetheless, at‐discharge functional assessment can detect additional patients whose readmission risk changes during the index hospitalization. Journal of Hospital Medicine 2016;11:636–641. © 2016 Society of Hospital Medicine

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decline in SPMSQ score during acute hospitalisation has a detrimental effect on functional decline after acute hospitalisation, defined by incidence IADL dependency. This finding emphasises the need to identify cognitive decline during hospitalisation to allow timely intervention to prevent post-discharge functional decline in this population.

Anxiety at time of hospitalization is associated with falls 30-days post-discharge, controlling for several well-known confounders. This relationship is partially mediated by functional decline. Identifying patients with anxiety for inclusion in targeted rehabilitation interventions may be an important component of fall prevention strategies.

Background With the aging population, family caregivers provide increasingly complex and intense care for older adults and persons with disabilities. There is growing interest in developing community-based services to support family caregivers. Caregiving occurs around the clock, and caregivers face challenges in accessing community-based services at convenient times owing to the demands of care. Web-based resources hold promise for accessible real-time support. CareNav (TM), a caregiver resource information system, is a web-based platform designed to support real-time universal caregiver assessment, a record of client encounters, development of a care plan, tailored information and resource content, access to web-based caregiver resources, the capacity to track service authorization and contracts, and secure communications. The assessment includes needs and health conditions of both the care recipient and caregiver; current resources; and priorities for support, information, and referral. In 2019, the California Department of Health Care Services funded the 11 nonprofit California Caregiver Resource Centers (CRCs) to expand and improve family caregiver services and enhance CRC information technology services. Deployment of a statewide information system offered a unique opportunity to examine structures and processes facilitating implementation, providing feedback to the sites as well as lessons learned for similar projects in the future. Objective The aim of this paper was to describe the statewide implementation of the comprehensive CareNav system using the Consolidated Framework for Implementation Research as an organizing structure for synthesizing the evaluation. Methods This mixed methods study used two major approaches to evaluate the implementation process: a survey of all staff who completed training (n=82) and in-depth qualitative interviews with 11 CRC teams and 3 key informants (n=35). We initially analyzed interview transcripts using qualitative descriptive methods and then identified subthemes and relationships among ideas, mapping the findings to the Consolidated Framework for Implementation Research. Results We present findings on the outer setting, inner setting, characteristics of the intervention, characteristics of the staff, and the implementation process. The critical elements for success were leadership, communication, harmonization of processes across sites, and motivation to serve clients in more accessible and convenient ways. Conclusions These findings have implications for technology deployment in diverse community-based agencies that aspire to enhance web-based services.

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