Transitions across various continuing care settings

Hospitalization of German and Dutch Nursing Home Residents Depend on Different Long-Term Care Structures: A Systematic Review on Periods of Increased Vulnerability

OBJECTIVE

To investigate proportions of hospitalized nursing home residents during periods of increased vulnerability, ie, the first 6 months after institutionalization and the last 6 months before death, and comparing the figures between Germany and the Netherlands.

DESIGN

Systematic review, registered in PROSPERO (CRD42022312506).

SETTING AND PARTICIPANTS

Newly admitted or deceased residents.

METHODS

We searched MEDLINE via PubMed, EMBASE, and CINAHL from inception through May 3, 2022. We included all observational studies that reported the proportions of all-cause hospitalizations among German or Dutch nursing home residents during these defined vulnerable periods. Study quality was assessed using the Joanna Briggs Institute's tool. We assessed study and resident characteristics and outcome information and descriptively reported them separately for both countries.

RESULTS

We screened 1856 records for eligibility and included 9 studies published in 14 articles (Germany: 8; Netherlands: 6). One study for each country investigated the first 6 months after institutionalization. A total of 10.2% of the Dutch and 42.0% of the German nursing home residents were hospitalized during this time. Overall, 7 studies reported on in-hospital deaths, with proportions ranging from 28.9% to 29.5% for Germany and from 1.0% to 16.3% for the Netherlands. Proportions for hospitalization in the last 30 days of life ranged from 8.0% to 15.7% (Netherlands: n = 2) and from 48.6% to 58.0% (Germany: n = 3). Only German studies assessed the differences by age and sex. Although hospitalizations were less common at older ages, they were more frequent in male residents.

CONCLUSIONS AND IMPLICATIONS

During the observed periods, the proportion of nursing homes residents being hospitalized differed greatly between Germany and the Netherlands. The higher figures for Germany can probably be explained by differences in the long-term care systems. There is a lack of research, especially for the first months after institutionalization, and future studies should examine the care processes of nursing home residents following acute events in more detail.

Comprehensive Care Plan Development Using Resident Assessment Instrument Framework: Past, Present, and Future Practices

Development of the comprehensive care plan (CCP) is a requirement for nursing homes participating in the federal Medicare and Medicaid programs, referred to as skilled nursing facilities. The plan must be developed within the context of the comprehensive interdisciplinary assessment framework-the Resident Assessment Instrument (RAI). Consistent compliance with this requirement has been difficult to achieve. To improve the quality of CCP development within this framework, an increased understanding of complex factors contributing to inconsistent compliance is required. In this commentary, we examine the history of the comprehensive care plan; its development within the RAI framework; linkages between the RAI and registered nurse staffing; empirical evidence of the CCP's efficacy; and the limitations of extant standards of practices in CCP development. Because of the registered nurse's educational preparation, professional practice standards, and licensure obligations, the essential contributions of professional nurses in CCP development are emphasized. Recommendations for evidence-based micro and macro level practice changes with the potential to improve the quality of CCP development and regulatory compliance are presented. Suggestions for future research are given.

Does quality influence consumer choice of nursing homes? Evidence from nursing home to nursing home transfers

We estimated Cox proportional hazards models using assessment data from the Minimum Data Set to test whether nursing home residents and their proxies respond to quality of care by changing providers. Various indicators of poor quality increased the likelihood of transfer. Residents of for-profit homes or homes with excess capacity also were more likely to transfer. Inability to participate in care decisions and factors indicating frailty limited residents' ability to transfer. The apparent responsiveness to quality is encouraging. Nonetheless, because the absolute transfer rate is low, significant barriers to movement among nursing homes still may exist.

From nursing home to hospital and back again: an educational program to improve care for hospitalized nursing home patients

Hospital nurses have little knowledge of the geriatric syndromes and the processes of caregiving in nursing homes. This lack of knowledge is a barrier to continuity of care for patients admitted to hospitals from nursing homes. An educational program, including both classroom and clinical components, was designed to help bridge this gap. A plan for dissemination to other hospital staff was developed by the 15 nurses who participated.

Lower respiratory infections in nursing home residents with dementia: a tale of two countries

PURPOSE

A focus on palliative care for residents with dementia is much more common in Dutch nursing homes than in the United States. We compared treatment and mortality in U.S. and Dutch nursing home residents with lower respiratory infections (LRI), which are often the immediate cause of death in dementia.

DESIGN AND METHODS

We studied two prospective cohorts--a study of pneumonia (n = 706) conducted in 61 psychogeriatric nursing homes throughout the Netherlands and 701 subjects with likely dementia from a study of LRIs in 36 nursing homes in Missouri.

RESULTS

Nursing home residents with dementia were more often treated without antibiotics in the Netherlands (23%) than in Missouri (15%). Indicators of severe illness operate in opposite directions: more severe illness is associated with antibiotic treatment in the United States, but with palliative treatment without antibiotics in the Netherlands.

IMPLICATIONS

Our findings are consistent with others in indicating problems with transition to palliative care for U.S. nursing home residents with dementia.

The role of the specialist physician in nursing homes: the Netherlands' experience

BACKGROUND

Dutch nursing homes employ physicians who have completed a two year specialist training programme to become a qualified nursing home physician. This paper describes the origin of the profession of nursing home medicine in the context of Dutch nursing homes.

METHOD

Review of the history and development of the need for specialist physicians in care of residents in nursing homes. Examination of the competencies required and training available for physicians and the benefits of this arrangement in improving quality of care.

RESULTS

Relevant skills and competencies of the specialist physician in nursing homes are discussed. The role and tasks, and the nursing home physician's method of working and providing care are explained, as well as the benefits and disadvantages of organizing medical care in this way.

CONCLUSIONS

The benefits of a specialist physician are considered greater than the disadvantages. Specialist training for this role is considered to be highly desirable.

Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: evaluation of a guideline

We evaluated a new guideline, in the form of a "checklist of considerations," to support end-of-life decision making in the treatment of demented patients with pneumonia. Questionnaires were sent to nursing home physicians (NHPs) in The Netherlands at three times: before implementation of the checklist (concerning 91 individual patients), during use of the checklist (concerning another 107 individual patients), and after data collection (concerning the targeted patient category of demented nursing home patients with pneumonia as a whole). In the last questionnaire, one NHP from each nursing home (n = 55 NHPs) gave his or her general opinion about the checklist. We measured the usefulness of the checklist in supporting decision making and its frequency of actual use. The NHPs accepted the contents of the checklist for use in the targeted patient category. It was used in 46% of the incident cases of pneumonia. The checklist was considered more useful in supporting decision making for the targeted patient category (85% of the NHPs) than for the individual patient (47%). Possible explanations for this discrepancy in "usefulness" include the difference in the nature of the outcome measures and the fact that the checklist was used more frequently for the "easier cases." Information on individual patient level, patient category level, and nursing home and NHP characteristics is used to suggest checklist improvements.