DESCRIPTION (provided by applicant): There is perhaps no more crucial time period for the health and functional outcomes of Veterans than an acute hospitalization followed by a stay in a post-acute care (PAC) facility (rehabilitatio or skilled nursing facility). The population of Veterans who undergo this transition are generally elderly, frail, ill, and disabled. As a result, many are sent back to the Emergency Department or readmitted to the hospital. This is often the start of a downward spiral of recurrent admissions, worsening functional status resulting in long-term care placement, and early mortality. For example, our preliminary data indicates Veterans discharged to PAC were readmitted or sent to the Emergency Department 5 times on average in the 12 months following their index admission. Transitions from the hospital to PAC are becoming more and more common, but poor outcomes may be preventable. In our preliminary data, we found nearly half of all readmissions from PAC facilities occurred in the first seven days after hospital discharge. Substantial research supports the idea that poorly-executed transitions of care from the hospital to the post-acute care facility underlie many poor outcomes of Veterans who undergo this transition. However, little is known about the outcomes of Veterans discharged to post-acute care, nor what factors contribute to these outcomes. To identify which factors might affect outcomes in these transitions of care, the proposal uses the Ideal Transitions of Care framework, developed by the nominee, to identify key domains that may affect transitional care outcomes. In this proposal, our Aims include: Aim 1: Assess the impact of five key domains of the ITC framework on 7-day hospital utilization and mortality. Domains and examples include: discharge planning (hospital plan for delivery of high-intensity interventions in PAC), information transfer (PAC access to hospital EMR), medication safety (medication reconciliation and monitoring of high-risk medications), advance care planning (addressing and communicating code status), and patient monitoring (time to initial PAC physician evaluation). Aim 2: Determine modifiable transitional care processes that help explain positive deviance in high-performing hospital-PAC sites. Aim 3: Pilot test a nurse-directed transitional care intervention in a hospital PAC site based on key domains of the ITC framework identified in Aims 1 and 2. This work is of crucial importance to Veterans and the VA healthcare system nationally and has the support of the Office of Geriatrics and Extended Care. Three accomplished investigators will guide the nominee's project work and development as an independent investigator. Dr. Michael Ho is the primary mentor with expertise in mixed methods, multicomponent interventions, and implementation science. He is the Co-Director of the Ischemic Heart Disease QUERI, Co-Director of the Denver-Seattle COIN, and a widely-published and well- f...