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The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults


Aims — In Canada, a persistent barrier to achieving healthcare system efficiency has been patient-days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures and health risks associated with ALC. Our objective was to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult’s transition to independent living at home.

Methods — This case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between March 1, 2018, and June 30, 2019. TCU patients were propensity-score matched to hospitalized ALC patients (“usual care”). The primary outcome was days without requiring institutional care 6-months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated.

Results — TCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3-167.6d) within 6 months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3-148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $-6,129-$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care.

Limitations — The main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals who were not selected since the service was not available to them.

Conclusions — Through rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.



Murmann M, Sinden D, Hsu AT, Thavorn K, Bader Eddeen A, Sun AH, Robert B. J Med Econ. 2023; 26(1):61-9. Epub 2022 Dec 14.

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