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Kosar CM, Thapa BB, Muench U, Santostefano C, Gadbois EA, Oh H, Gozalo PL, Rahman M, White EM. Nurse Practitioner Care, Scope of Practice, and End-of-Life Outcomes for Nursing Home Residents With Dementia. JAMA Health Forum 2024; 5:e240825. [PMID: 38728021 PMCID: PMC11087831 DOI: 10.1001/jamahealthforum.2024.0825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/07/2024] [Indexed: 05/13/2024] Open
Abstract
Importance Nursing home residents with Alzheimer disease and related dementias (ADRD) often receive burdensome care at the end of life. Nurse practitioners (NPs) provide an increasing share of primary care in nursing homes, but how NP care is associated with end-of-life outcomes for this population is unknown. Objectives To examine the association of NP care with end-of-life outcomes for nursing home residents with ADRD and assess whether these associations differ according to state-level NP scope of practice regulations. Design, Setting, and Participants This cohort study using fee-for-service Medicare claims included 334 618 US nursing home residents with ADRD who died between January 1, 2016, and December 31, 2018. Data were analyzed from April 6, 2015, to December 31, 2018. Exposures Share of nursing home primary care visits by NPs, classified as minimal (<10% of visits), moderate (10%-50% of visits), and extensive (>50% of visits). State NP scope of practice regulations were classified as full vs restrictive in 2 domains: practice authority (authorization to practice and prescribe independently) and do-not-resuscitate (DNR) authority (authorization to sign DNR orders). Main Outcomes and Measures Hospitalization within the last 30 days of life and death with hospice. Linear probability models with hospital referral region fixed effects controlling for resident characteristics, visit volume, and geographic factors were used to estimate whether the associations between NP care and outcomes varied across states with different scope of practice regulations. Results Among 334 618 nursing home decedents (mean [SD] age at death, 86.6 [8.2] years; 69.3% female), 40.5% received minimal NP care, 21.4% received moderate NP care, and 38.0% received extensive NP care. Adjusted hospitalization rates were lower for residents with extensive NP care (31.6% [95% CI, 31.4%-31.9%]) vs minimal NP care (32.3% [95% CI, 32.1%-32.6%]), whereas adjusted hospice rates were higher for residents with extensive (55.6% [95% CI, 55.3%-55.9%]) vs minimal (53.6% [95% CI, 53.3%-53.8%]) NP care. However, there was significant variation by state scope of practice. For example, in full practice authority states, adjusted hospice rates were 2.88 percentage points higher (95% CI, 1.99-3.77; P < .001) for residents with extensive vs minimal NP care, but the difference between these same groups was 1.77 percentage points (95% CI, 1.32-2.23; P < .001) in restricted practice states. Hospitalization rates were 1.76 percentage points lower (95% CI, -2.52 to -1.00; P < .001) for decedents with extensive vs minimal NP care in full practice authority states, but the difference between these same groups in restricted practice states was only 0.43 percentage points (95% CI, -0.84 to -0.01; P < .04). Similar patterns were observed in analyses focused on DNR authority. Conclusions and Relevance The findings of this cohort study suggest that NPs appear to be important care providers during the end-of-life period for many nursing home residents with ADRD and that regulations governing NP scope of practice may have implications for end-of-life hospitalizations and hospice use in this population.
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Affiliation(s)
- Cyrus M. Kosar
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Bishnu B. Thapa
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ulrike Muench
- Department of Social Behavioral Sciences, University of California at San Francisco School of Nursing, San Francisco
| | - Christopher Santostefano
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Emily A. Gadbois
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Hyesung Oh
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L. Gozalo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Elizabeth M. White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
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Javier Afonso-Argilés F, Comas Serrano M, Castells Oliveres X, Cirera Lorenzo I, García Pérez D, Pujadas Lafarga T, Ichart Tomás X, Puig-Campmany M, Vena Martínez AB, Renom-Guiteras A. Emergency department admissions and economic costs burden related to ambulatory care sensitive conditions in older adults living in care homes. Rev Clin Esp 2023; 223:585-595. [PMID: 37838224 DOI: 10.1016/j.rceng.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/10/2023] [Accepted: 09/27/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVES To assess the frequency of emergency department admissions (EDA) for ambulatory care sensitive conditions (ACSC) and non-ACSC among older adults living in care homes (CH), to describe and compare their demographic and clinical characteristics, the outcomes of the hospitalisation process and the associated costs. METHOD This multicenter, retrospective and observational study evaluated 2444 EDAs of older adults ≥ 65 years old living in care homes in 5 emergency departments in Catalonia (Spain) by ACSC and non-ACSC, in 2017. Sociodemographic variables, prior functional and cognitive status, and information on diagnosis and hospitalisation were collected. Additionally, the costs related with the EDAs were calculated, as well as a sensitivity analysis using different assumptions of decreased admissions due to ACSC. RESULTS A total of 2444 ED admissions were analysed. The patients' mean (SD) age was 85.9 (7.2) years. The frequency of ACSC-EDA and non-ACSC-EDA was 56.6% and 43.4%, respectively. Severe dependency and cognitive impairment were present in 56.6% and 78%, respectively, with no differences between the two groups. The three most frequent ACSC were falls/trauma (13.8%), chronic obstructive pulmonary disease/asthma (11.4%) and urinary tract infection (7.4%). The average cost per ACSC-EDA was є1,408.24. Assuming a 60% reduction of ACSC-EDA, the estimated cost savings would be є1.2 million. CONCLUSIONS Emergency admissions for ACSC from care homes have a significant impact on both frequency and costs. Reducing these conditions through targeted interventions could redirect the avoided costs towards improving care support in residential settings.
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Affiliation(s)
- F Javier Afonso-Argilés
- Servicio de Geriatría, Fundació Sanitària Mollet, Barcelona, Spain; Estudiante de doctorado de la Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - M Comas Serrano
- Servicio de Epidemiología y Evaluación, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Hospital del Mar, Barcelona, Spain; Miembro de la Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Madrid, Spain
| | - X Castells Oliveres
- Servicio de Epidemiología y Evaluación, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Hospital del Mar, Barcelona, Spain; Miembro de la Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Madrid, Spain
| | | | - D García Pérez
- Servicio de Urgencias, Fundació Althaia, Xarxa Assistencial Universitaria de Manresa, Barcelona, Spain
| | - T Pujadas Lafarga
- Servicio de Geriatría y Cuidados Paliativos, Badalona Serveis Assistencials, Barcelona, Spain
| | - X Ichart Tomás
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - M Puig-Campmany
- Servicio de Urgencias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A B Vena Martínez
- Servicio de Geriatría, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - A Renom-Guiteras
- Miembro de la Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Madrid, Spain; Servicio de Geriatría, Hospital del Mar, Barcelona, Spain
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Hamasaki Y, Sakata N, Jin X, Sugiyama T, Morita K, Uda K, Matsuda S, Tamiya N. Facility staffing associated with potentially avoidable hospitalizations in nursing home residents in Japan: a retrospective cohort study. BMC Geriatr 2023; 23:566. [PMID: 37715180 PMCID: PMC10504825 DOI: 10.1186/s12877-023-04278-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Wide variations in facility staffing may lead to differences in care, and consequently, adverse outcomes such as hospitalizations. However, few studies focused on types of occupations. Therefore, we aimed to examine the association between a wide variety of facility staffing and potentially avoidable hospitalizations of nursing home residents in Japan. METHODS In this retrospective cohort study using long-term care and medical insurance claims data in Ibaraki Prefecture from April 2018 to March 2019, we identified individuals aged 65 years and above who were newly admitted to nursing homes. In addition, facility characteristic data were obtained from the long-term care insurance service disclosure system. Subsequently, we conducted a multivariable Cox regression analysis and evaluated the association between facility staffing and potentially avoidable hospitalizations. RESULTS A total of 2909 residents from 235 nursing homes were included. The cumulative incidence of potentially avoidable hospitalizations at 180 days was 14.2% (95% confidence interval [CI] 12.7-15.8). Facilities with full-time physicians (adjusted hazard ratio [HR]: 0.59, 95% CI: 0.37-0.94) and a higher number of dietitians (HR: 0.72, 95% CI: 0.54-0.97) were significantly associated with a lower likelihood of potentially avoidable hospitalizations. In contrast, having nurses or trained caregivers during the night shift (HR: 1.72, 95% CI: 1.25-2.36) and a higher number of care managers (HR: 1.37, 95% CI: 1.03-1.83) were significantly associated with a high probability of potentially avoidable hospitalizations. CONCLUSIONS We revealed that variations in facility staffing were associated with potentially avoidable hospitalizations. The results suggest that optimal allocation of human resources, such as dietitians and physicians, may be essential to reduce potentially avoidable hospitalizations. To provide appropriate care to nursing home residents, it is necessary to establish a system to effectively allocate limited resources. Further research is warranted on the causal relationship between staff allocation and unnecessary hospitalizations, considering the confounding factors.
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Affiliation(s)
- Yoko Hamasaki
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Nobuo Sakata
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan.
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-Dai, Tsukuba, Ibaraki, 305-8575, Japan.
- Heisei Medical Welfare Research Institute, Shibuya-ku, Tokyo, Japan.
| | - Xueying Jin
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Social Science, Research Institute, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-Dai, Tsukuba, Ibaraki, 305-8575, Japan
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kojiro Morita
- Global Nursing Research Center, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kazuaki Uda
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-Dai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-Dai, Tsukuba, Ibaraki, 305-8575, Japan
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Guo W, Cai S, Caprio T, Schwartz L, Temkin-Greener H. End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations. J Am Med Dir Assoc 2023:S1525-8610(23)00110-X. [PMID: 36913979 DOI: 10.1016/j.jamda.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 12/19/2022] [Accepted: 02/03/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations. DESIGN Cohort study. SETTING AND PARTICIPANTS Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N = 113,662). METHODS We used Medicare claims and assessment data for a cohort of assisted living decedents. Generalized linear models were used to examine the associations between state staffing and training requirements and end-of-life care transitions. The frequency of end-of-life care transitions was the outcome of interest. State staffing and training regulations were the key covariates. We controlled for individual, assisted living, and area-level characteristics. RESULTS End-of-life care transitions were observed among 34.89% of our study sample in the last 30 days before death, and among 17.25% in the last 7 days. Higher frequency of care transitions in the last 7 days of life was associated with higher regulatory specificity of licensed [incidence risk ratio (IRR) = 1.08; P = .002] and direct care worker staffing (IRR = 1.22; P < .0001). Greater regulatory specificity of direct care worker training (IRR = 0.75; P < .0001) was associated with fewer transitions. Similar associations were found for direct care worker staffing (IRR = 1.15; P < .0001) and training (IRR = 0.79; P < .001) and transitions within 30 days of death. CONCLUSIONS AND IMPLICATIONS There were significant variations in the number of care transitions across states. The frequency of end-of-life care transitions among assisted living decedents during the last 7 or 30 days of life was associated with state regulatory specificity for staffing and staff training. State governments and assisted living administrators may wish to set more explicit guidelines for assisted living staffing and training to help improve end-of-life quality of care.
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Affiliation(s)
- Wenhan Guo
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Thomas Caprio
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Searle B, Barker RO, Stow D, Spiers GF, Pearson F, Hanratty B. Which interventions are effective at decreasing or increasing emergency department attendances or hospital admissions from long-term care facilities? A systematic review. BMJ Open 2023; 13:e064914. [PMID: 36731926 PMCID: PMC9896242 DOI: 10.1136/bmjopen-2022-064914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE UK long-term care facility residents account for 185 000 emergency hospital admissions each year. Avoidance of unnecessary hospital transfers benefits residents, reduces demand on the healthcare systems but is difficult to implement. We synthesised evidence on interventions that influence unplanned hospital admissions or attendances by long-term care facility residents. METHODS This is a systematic review of randomised controlled trials. PubMed, MEDLINE, EMBASE, ISI Web of Science, CINAHL and the Cochrane Library were searched from 2012 to 2022, building on a review published in 2013. We included randomised controlled trials that evaluated interventions that influence (decrease or increase) acute hospital admissions or attendances of long-term care facility residents. Risk of bias and evidence quality were assessed using Cochrane Risk Of Bias-2 and Grading of Recommendations Assessment, Development and Evaluation. RESULTS Forty-three randomised studies were included in this review. A narrative synthesis was conducted and the weight of evidence described with vote counting. Advance care planning and goals of care setting appear to be effective at reducing hospitalisations from long-term care facilities. Other effective interventions, in order of increasing risk of bias, were: nurse practitioner/specialist input, palliative care intervention, influenza vaccination and enhancing access to intravenous therapies in long-term care facilities. CONCLUSIONS Factors that affect hospitalisation and emergency department attendances of long-term care facility residents are complex. This review supports the already established use of advance care planning and influenza vaccination to reduce unscheduled hospital attendances. It is likely that more than one intervention will be needed to impact on healthcare usage across the long-term care facility population. The findings of this review are useful to identify effective interventions that can be combined, as well as highlighting interventions that either need evaluation or are not effective at decreasing healthcare usage. PROSPERO REGISTRATION NUMBER CRD42020169604.
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Affiliation(s)
- Ben Searle
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Robert O Barker
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel Stow
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Gemma F Spiers
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Pearson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Abstract
Residents who are terminally ill often experience transfers to the emergency department resulting in hospitalizations, which may be potentially avoidable with treatment in the nursing home. This qualitative study explored the perspectives of 15 residents, 10 family members, and 20 nursing home staff regarding end-of-life care and the circumstances prompting resident transfers. Data analysis of participant interviews conducted January to May 2019 in a South Florida nursing home identified four themes related to transfer to the hospital: time left to live, when aggressive treatments would be unavailing, not knowing what the nursing home can do, and transfer decisions are situation-dependent. Study findings underscore the importance of increasing resident and family awareness of treatments available in the nursing home and person-centered advance care planning discussions. Further research should explore the reasons for residents' and family members' choice of aggressive therapies and their goals for care at the end of life.
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Affiliation(s)
- Janet Sopcheck
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, United States
| | - Ruth M Tappen
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, United States
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Dosa D, Jester D, Peterson L, Dobbs D, Black K, Brown L. Applying the age-friendly-health system 4M paradigm to reframe climate-related disaster preparedness for nursing home populations. Health Serv Res 2023; 58 Suppl 1:36-43. [PMID: 35908191 PMCID: PMC9843084 DOI: 10.1111/1475-6773.14043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- David Dosa
- Providence VA Medical CenterProvidenceRhode IslandUSA
- Warren Alpert School of MedicineBrown UniversityProvidenceRhode IslandUSA
- School of Public HealthBrown UniversityProvidenceRhode IslandUSA
| | - Dylan Jester
- Department of PsychiatryUniversity of California San DiegoLa JollaCaliforniaUSA
- Sam and Rose Stein Institute for Research on AgingUniversity of California San DiegoLa JollaCaliforniaUSA
| | - Lindsay Peterson
- Florida Policy Exchange Center of AgingSchool of Aging Studies, University of South FloridaTampaFloridaUSA
| | - Debra Dobbs
- Florida Policy Exchange Center of AgingSchool of Aging Studies, University of South FloridaTampaFloridaUSA
| | - Kathy Black
- School of Aging StudiesUniversity of South Florida Sarasota‐Manatee CampusSarasotaFloridaUSA
| | - Lisa Brown
- Risk and Resilience LabPalo Alto UniversityPalo AltoCaliforniaUSA
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Katz PR, Smalbrugge M, Karuza J, Costa A, Nazir A, Wasserman MR, Nelson D, Levenson SA, Resnick B. Raising the Bar for Physicians Practicing in Nursing Homes: The Path to Sustainable Improvement. J Am Med Dir Assoc 2023; 24:131-133. [PMID: 36725202 DOI: 10.1016/j.jamda.2022.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Paul R Katz
- Department of Geriatrics, FSU College of Medicine, Tallahassee, FL, USA.
| | - Martin Smalbrugge
- Department of Medicine for Older People Vrije University and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Jurgis Karuza
- Division of Geriatrics, University of Rochester, Rochester, NY, USA
| | - Andrew Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Arif Nazir
- Chief Medical Officer, Primary Care at BrightSpring Health Services, Louisville, KY, USA
| | | | - Dallas Nelson
- Division of Geriatrics, University of Rochester, Rochester, NY, USA
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O'Neill BJ, Dwyer T, Parkinson L, Reid-Searl K, Jeffrey D. Identifying the core components of a nursing home hospital avoidance programme. Int J Older People Nurs 2023; 18:e12493. [PMID: 35943901 PMCID: PMC10078518 DOI: 10.1111/opn.12493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 05/23/2022] [Accepted: 06/27/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Nursing home hospital avoidance programmes have contributed to a reduction in unnecessary emergency transfers but a description of the core components of the programmes has not been forthcoming. A well-operationalised health-care programme requires clarity around core components to evaluate and replicate the programme. Core components are the essential functions and principles that must be implemented to produce expected outcomes. OBJECTIVES To identify the core components of a nursing home hospital avoidance programme by assessing how the core components identified at one nursing home (Site One) translated to a second nursing home (Site Two). METHODS Data collected during the programme's implementation at Site Two were reviewed for evidence of how the core components named at Site One were implemented at Site Two and to determine if any additional core components were evident. The preliminary updated core components were then shared with seven evaluators familiar with the hospital avoidance programme for consensus. RESULTS The updated core components were agreed to include the following: Decision Support Tools, Advanced Clinical Skills Training, Specialist Clinical Support and Collaboration, Facility Policy and Procedures, Family and Care Recipient Education and Engagement, Culture of Staff Readiness, Supportive Executive and Facility Management. CONCLUSION This study launches a discussion on the need to identify hospital avoidance programme core components, while providing valuable insight into how Site One core programme components, such as resources, education and training, clinical and facility support, translated to Site Two, and why modifications and additions, such as incorporating the programme into facility policy, family education and executive support were necessary, and the ramifications of those changes. The next step is to take the eight core component categories and undertake a rigorous fidelity assessment as part of formal process evaluation where the components can be critiqued and measured across multiple nursing home sites. The core components can then be used as evidence-based building blocks for developing, implementing and evaluating nursing home hospital avoidance programmes.
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Affiliation(s)
- Barbara J O'Neill
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, Queensland, Australia.,School of Nursing, University of Connecticut, Storrs, Connecticut, USA
| | - Trudy Dwyer
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | - Lynne Parkinson
- School of Medicine and Public Health, University of New Castle, Callaghan, New South Wales, Australia
| | - Kerry Reid-Searl
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Rockhampton, Queensland, Australia
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TYLER DENISEA, FENG ZHANLIAN, GRABOWSKI DAVIDC, BERCAW LAWREN, SEGELMAN MICAH, KHATUTSKY GALINA, WANG JOYCE, GASDASKA ANGELA, INGBER MELVINJ. CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned. Milbank Q 2022; 100:1243-1278. [PMID: 36573335 PMCID: PMC9836234 DOI: 10.1111/1468-0009.12594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 12/28/2022] Open
Abstract
Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone. CONTEXT In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only). METHODS Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. FINDINGS Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations. CONCLUSIONS Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.
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Chang S. Registered Nurses’ Experiences of End-of-Life Care in Nursing Homes of South Korea: A Qualitative Study. Healthcare (Basel) 2022; 10:2213. [PMID: 36360554 PMCID: PMC9690043 DOI: 10.3390/healthcare10112213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022] Open
Abstract
This study aimed to qualitatively describe how registered nurses (RNs) experienced and perceived end-of-life (EOL) care for older residents in South Korean nursing homes. The participants included 11 nurses with experience of providing EOL care for older residents in six nursing homes. Data were collected through one-on-one in-depth interviews using semi-structured questions from 27 December 2019 to 22 October 2020. Around 1–2 interviews were conducted for each participant, and each interview lasted between 40 min and two hours. The interview data were analyzed using qualitative content analysis. Eight sub-themes were identified and abstracted under three themes: (a) “feeling fulfilled for doing my best until the last day,” (b) “defensive coping due to legal and institutional limitations,” and (c) “requirements for effective EOL care.” This study suggests that there are many challenges and issues regarding EOL care at nursing homes. In order to provide effective EOL care to older residents, the foundation of the EOL care system, as well as skills training, should be strengthened. Furthermore, securing qualified nursing manpower and achieving institutional improvement by reducing obstacles are warranted.
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Kim H, Cho J, Lee J. End-of-life care practices in Korean nursing homes: a national survey. Int J Nurs Stud 2022. [DOI: 10.1016/j.ijnurstu.2022.104173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/10/2021] [Accepted: 01/04/2022] [Indexed: 11/24/2022]
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Bhagianadh D, Arora K. Legalization of Medical Cannabis and Site of Death: Evidence From National Vital Statistics Mortality Data. J Appl Gerontol 2021; 41:806-816. [PMID: 34930063 DOI: 10.1177/07334648211058720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We examined whether Medical Marijuana Legislation (MML) was associated with site of death. Using state-level data (1992-2018) from the National Vital Statistics System (NVSS), we employed difference-in-differences method to compare changes in death rate among older adults at four sites-nursing home (NH), hospital, home, hospice/other-over time in states with and without MML. Heterogeneity analyses were conducted by timing of MML adoption, and by decedent characteristics. Results show a negative association between MML implementation and NH deaths. Among early adopters (states with weakly regulated programs) and decedents with musculoskeletal disorders, there was a positive association between MML implementation and hospital deaths, whereas among late adopters (states with "medicalized" programs), there was a positive association between MML implementation and hospice deaths. Decline in NH deaths may reflect increased likelihood of transfers due to threat of Federal enforcement, penalties for poor outcomes, and liability concerns. Future studies should examine these associations further.
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Affiliation(s)
- Divya Bhagianadh
- Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| | - Kanika Arora
- Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
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Schippel N, Dust G, von Reeken C, Voltz R, Strupp J, Rietz C. Can we determine burdensome transitions in the last year of life based on time of occurrence and frequency? An explanatory mixed-methods study. Palliat Support Care. [DOI: 10.1017/s1478951521001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Objective
Burdensome transitions are typically defined as having a transition in the last three days or multiple hospitalizations in the last three months of life, which is seldom verified with qualitative accounts from persons concerned. This study analyses types and frequencies of transitions in the last year of life and indicators of burdensome transitions from the perspective of bereaved relatives.
Method
Cross-sectional explanatory mixed-methods study with 351 surveyed and 41 interviewed bereaved relatives in a German urban area. Frequencies, t-tests, and Spearman correlations were computed for quantitative data. Qualitative data were analyzed using content analysis with provisional and descriptive coding/subcoding.
Results
Transitions rise sharply during the last year of life. 8.2% of patients experience a transition in the last three days and 7.8% three or more hospitalizations in the last three months of life. An empathetic way of telling patients about the prospect of death is associated with fewer transitions in the last month of life (r = 0.185, p = 0.046). Professionals being aware of the preferred place of death corresponds to fewer hospitalizations in the last three months of life (1.28 vs. 0.97, p = 0.021). Qualitative data do not confirm that burden in transitions is linked to having transitions in the last three days or multiple hospitalizations in the last three months of life. Burden is associated with (1) late and non-empathetic communication about the prospect of death, (2) not coordinating care across settings, and (3) not considering patients’ preferences.
Significance of results
Time of occurrence and frequency appear to be imperfect proxies for burdensome transitions. The subjective burden seems to be associated rather with insufficient information, preparation, and management of transitions.
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Orth J, Li Y, Simning A, Zimmerman S, Temkin-Greener H. Nursing Home Residents With Dementia: Association Between Place of Death and Patient Safety Culture. Gerontologist 2021; 61:1296-1306. [PMID: 33206175 PMCID: PMC8809190 DOI: 10.1093/geront/gnaa188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Nursing homes (NHs) care for 70% of Americans dying with dementia. Many consider deaths in NHs rather than hospitals as preferable for most of these residents. NH characteristics such as staff teamwork, communication, and other components of patient safety culture (PSC), together with state minimum NH nurse staffing requirements, may influence location of death. We examined associations between these variables and place of death (NH/hospital) among residents with dementia. RESEARCH DESIGN AND METHODS Cross-sectional study of 11,957 long-stay NH residents with dementia, age 65+, who died in NHs or hospitals shortly following discharge from one of 800 U.S. NHs in 2017. Multivariable logistic regression systematically estimated effects of PSC on odds of in-hospital death among residents with dementia, controlling for resident, NH, county, and state characteristics. Logistic regressions also determined moderating effects of state minimum NH nurse staffing requirements on relationships between key PSC domains and location of death. RESULTS Residents with dementia in NHs with higher PSC scores in communication openness had lower odds of in-hospital death. This effect was stronger in NHs located in states with higher minimum NH nurse staffing requirements. DISCUSSION AND IMPLICATIONS Promoting communication openness in NHs across nursing disciplines may help avoid unnecessary hospitalization at the end of life, and merits particular attention as NHs address nursing staff mix while adhering to state staffing requirements. Future research to better understand unintended consequences of staffing requirements is needed to improve end-of-life care in NHs.
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Affiliation(s)
- Jessica Orth
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Adam Simning
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York, USA
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, New York, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research and The Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York, USA
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Jester DJ, Peterson LJ, Thomas KS, Dosa DM, Andel R. Nursing Home Compare Star Rating and Daily Direct-Care Nurse Staffing During Hurricane Irma. J Am Med Dir Assoc 2021; 23:1409-1412.e1. [PMID: 34740564 DOI: 10.1016/j.jamda.2021.09.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Nursing homes (NHs) are affected by major hurricanes and other natural disasters. To mitigate adverse effects of a major hurricane, NHs often increase their direct-care nurse staffing levels to meet the needs of their residents. However, the quality rating of the NH may affect the resources available to obtain and retain staff. This data brief provides estimates of direct-care nurse staffing levels by quality star rating during Hurricane Irma. DESIGN Retrospective cohort study from September 3, 2017, to September 10, 2017. SETTING AND PARTICIPANTS 570 Florida NHs that sheltered in place during Hurricane Irma. METHODS We stratified NHs by their NH Compare overall quality star rating and then measured change in direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants. RESULTS We found that the NH Compare overall star rating was positively associated with a greater staffing level response during Hurricane Irma among registered nurses, licensed practical nurses, and certified nursing assistants. This change was largest for 5-star facilities and smallest for 1-star facilities. CONCLUSIONS AND IMPLICATIONS Higher-quality NHs may be more responsive and have the resources to be more responsive, to increased needs during a natural disaster. Our findings may serve as a platform for ongoing discussion on the role of the federal, state, and local governments in ensuring minimum staffing standards during natural disasters.
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Affiliation(s)
- Dylan J Jester
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA, USA; Florida Policy Exchange Center of Aging, School of Aging Studies, University of South Florida, Tampa, FL, USA.
| | - Lindsay J Peterson
- Florida Policy Exchange Center of Aging, School of Aging Studies, University of South Florida, Tampa, FL, USA
| | - Kali S Thomas
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; School of Public Health, Brown University, Providence, RI, USA
| | - David M Dosa
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; School of Public Health, Brown University, Providence, RI, USA; Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Ross Andel
- Florida Policy Exchange Center of Aging, School of Aging Studies, University of South Florida, Tampa, FL, USA
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Blackburn J, Balio CP, Carnahan JL, Fowler NR, Hickman SE, Sachs GA, Tu W, Unroe KT. Facility and resident characteristics associated with variation in nursing home transfers: evidence from the OPTIMISTIC demonstration project. BMC Health Serv Res 2021; 21:492. [PMID: 34030672 DOI: 10.1186/s12913-021-06419-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/19/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Centers for Medicare and Medicaid Services (CMS) funded demonstration project to evaluate financial incentives for nursing facilities providing care for 6 clinical conditions to reduce potentially avoidable hospitalizations (PAHs). The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) site tested payment incentives alone and in combination with the successful nurse-led OPTIMISTIC clinical model. Our objective was to identify facility and resident characteristics associated with transfers, including financial incentives with or without the clinical model. METHODS This was a longitudinal analysis from April 2017 to June 2018 of transfers among nursing home residents in 40 nursing facilities, 17 had the full clinical + payment model (1726 residents) and 23 had payment only model (2142 residents). Using CMS claims data, the Minimum Data Set, and Nursing Home Compare, multilevel logit models estimated the likelihood of all-cause transfers and PAHs (based on CMS claims data and ICD-codes) associated with facility and resident characteristics. RESULTS The clinical + payment model was associated with 4.1 percentage points (pps) lower risk of all-cause transfers (95% confidence interval [CI] - 6.2 to - 2.1). Characteristics associated with lower PAH risk included residents aged 95+ years (- 2.4 pps; 95% CI - 3.8 to - 1.1), Medicare-Medicaid dual-eligibility (- 2.5 pps; 95% CI - 3.3 to - 1.7), advanced and moderate cognitive impairment (- 3.3 pps; 95% CI - 4.4 to - 2.1; - 1.2 pps; 95% CI - 2.2 to - 0.2). Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score above most stable (CHESS score 4) increased the risk of PAH by 7.3 pps (95% CI 1.5 to 13.1). CONCLUSIONS Multiple resident and facility characteristics are associated with transfers. Facilities with the clinical + payment model demonstrated lower risk of all-cause transfers compared to those with payment only, but not for PAHs.
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Temkin-Greener H, Yan D, Wang S, Cai S. Racial disparity in end-of-life hospitalizations among nursing home residents with dementia. J Am Geriatr Soc 2021; 69:1877-1886. [PMID: 33749844 DOI: 10.1111/jgs.17117] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/20/2021] [Accepted: 02/02/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Explore within and across nursing home (NH) racial disparities in end-of-life (EOL) hospitalizations for residents with Alzheimer's disease or related dementia (ADRD), and examine whether severe cognitive impairment influences these relationships. DESIGN Observational study merging, at the individual level, C2014-2017 national-level Minimum Data Set (MDS), Medicare Beneficiary Summary Files (MBSF), and Medicare Provider Analysis and Review (MedPAR). Nursing Home Compare (NHC) was also used. SETTING Long-stay residents who died in a NH or a hospital within 8 days of discharge. PARTICIPANTS Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities. MAIN OUTCOMES AND MEASURES The outcome was hospitalization within 30 days of death. Key independent variables were race, severe cognitive impairment, and NH-level proportion of black residents. Other covariates included socio-demographics, dual eligibility, hospice enrollment, and chronic conditions. Facility-level characteristics were also included (e.g. profit status, staffing hours, etc.). We fit linear probability models with robust standard errors, fixed and random effects. RESULTS Compared to whites, black decedents had a significantly (p < 0.01) higher risk of EOL hospitalizations (7.88%). Among those with severe cognitive impairment, whites showed a lower risk of hospitalizations (6.04%). But EOL hospitalization risk among blacks with severe cognitive impairment was still significantly elevated (β = 0.0494; p < 0.01). A comparison of the base model with the fixed and random-effects models showed statistically significant hospitalization risk by decedent's race both within and across facilities. CONCLUSIONS AND RELEVANCE We found disparities between black and white residents with ADRD both within and across facilities. The within-facility disparities may be due to residents' preferences and/or NH practices that contribute to differential treatment. The across facility differences point to the overall quality of care disparities in homes with a higher prevalence of black residents. Persistence of such systemic disparities among the most vulnerable individuals is extremely troubling.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Di Yan
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sijiu Wang
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Macgregor A, Rutherford A, McCormack B, Hockley J, Ogden M, Soulsby I, McKenzie M, Spilsbury K, Hanratty B, Forbat L. Palliative and end-of-life care in care homes: protocol for codesigning and implementing an appropriate scalable model of Needs Rounds in the UK. BMJ Open 2021; 11:e049486. [PMID: 33619205 PMCID: PMC7903098 DOI: 10.1136/bmjopen-2021-049486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Palliative and end-of-life care in care homes is often inadequate, despite high morbidity and mortality. Residents can experience uncontrolled symptoms, poor quality deaths and avoidable hospitalisations. Care home staff can feel unsupported to look after residents at the end of life. Approaches for improving end-of-life care are often education-focused, do not triage residents and rarely integrate clinical care. This study will adapt an evidence-based approach from Australia for the UK context called 'Palliative Care Needs Rounds' (Needs Rounds). Needs Rounds combine triaging, anticipatory person-centred planning, case-based education and case-conferencing; the Australian studies found that Needs Rounds reduce length of stay in hospital, and improve dying in preferred place of care, and symptoms at the end of life. METHODS AND ANALYSIS This implementation science study will codesign and implement a scalable UK model of Needs Rounds. The Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to identify contextual barriers and use facilitation to enable successful implementation. Six palliative care teams, working with 4-6 care homes each, will engage in two phases. In phase 1 (February 2021), stakeholder interviews (n=40) will be used to develop a programme theory to meet the primary outcome of identifying what works, for whom in what circumstances for UK Needs Rounds. Subsequently a workshop to codesign UK Needs Rounds will be run. Phase 2 (July 2021) will implement the UK model for a year. Prospective data collection will focus on secondary outcomes regarding hospitalisations, residents' quality of death and care home staff capability of adopting a palliative approach. ETHICS AND DISSEMINATION Frenchay Research Ethics Committee (287447) approved the study. Findings will be disseminated to policy-makers, care home/palliative care practitioners, residents/relatives and academic audiences. An implementation package will be developed for practitioners to provide the tools and resources required to adopt UK Needs Rounds. REGISTRATION DETAILS Registration details: ISRCTN15863801.
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Affiliation(s)
- Aisha Macgregor
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | - Brendan McCormack
- Divisions of Nursing, Occupational Therapy & Arts Therapies, Queen Margaret University, Edinburgh, UK
| | - Jo Hockley
- Usher Institute, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Margaret Ogden
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Irene Soulsby
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Maisie McKenzie
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK
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Harrison JM, Agarwal M, Stone PW, Gracner T, Sorbero M, Dick AW. Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents? J Palliat Med 2021; 24:1334-1341. [PMID: 33605787 DOI: 10.1089/jpm.2020.0577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: An estimated 50% of nursing home (NH) residents experience hospital transfers in their last year of life, often due to infections. Hospital transfers due to infection are often of little clinical benefit to residents with advanced illness, for whom aggressive treatments are often ineffective and inconsistent with goals of care. Integration of palliative care and infection management (i.e., merging the goals of palliative care and infection management at end of life) may reduce hospital transfers for residents with advanced illness. Objectives: Evaluate the association between integration and (1) all-cause hospital transfers and (2) hospital transfers due to infection. Design: Cross-sectional observational study. Setting/Subjects: 143,223 U.S. NH residents, including 42,761 residents in the advanced stages of dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Measurement: Cross-sectional, nationally representative NH survey data (2017-2018) were combined with resident data from the Minimum Data Set 3.0 and Medicare inpatient data (2016-2017). NH surveys measured integration of palliative care and infection management using an index of 0-100. Logistic regression models were used to estimate the relationships between integration intensity (i.e., the degree to which NHs follow best practices for integration) and all-cause hospital transfer and transfer due to infection. Results: Among residents with advanced dementia, integration intensity was inversely associated with all-cause hospital transfer and transfer due to infection (p < 0.001). Among residents with advanced COPD, integration intensity was inversely associated with all-cause hospital transfer (p < 0.05) but not transfers due to infection. Among residents with advanced CHF, integration intensity was not associated with either outcome. Conclusions: NH policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia. For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at end of life.
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Affiliation(s)
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, New York, USA
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Orth J, Li Y, Simning A, Zimmerman S, Temkin-Greener H. End-of-Life Care among Nursing Home Residents with Dementia Varies by Nursing Home and Market Characteristics. J Am Med Dir Assoc 2021; 22:320-328.e4. [PMID: 32736989 PMCID: PMC7855379 DOI: 10.1016/j.jamda.2020.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/30/2020] [Accepted: 06/05/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Nursing homes (NHs) are critical end-of-life (EOL) care settings for 70% of Americans dying with Alzheimer's disease/related dementias (ADRD). Whether EOL care/outcomes vary by NH/market characteristics for this population is unknown but essential information for improving NH EOL care/outcomes. Our objectives were to examine variations in EOL care/outcomes among decedents with ADRD and identify associations with NH/market characteristics. DESIGN Cross-sectional. OUTCOMES Place-of-death (hospital/NH), presence of pressure ulcers, potentially avoidable hospitalizations (PAHs), and hospice use at EOL. Key covariates were ownership, staffing, presence of Alzheimer's units, and market competition. SETTING AND PARTICIPANTS Long-stay NH residents with ADRD, age 65 + years of age, who died in 2017 (N = 191,435; 14,618 NHs) in NHs or hospitals shortly after NH discharge. METHODS National Medicare claims, Minimum Data Set, public datasets. Descriptive analyses and multivariable logistic regressions. RESULTS As ADRD severity increased, adjusted rates of in-hospital deaths and PAHs decreased (17.0% to 6.3%; 11.2% to 7.0%); adjusted rates of dying with pressure ulcers and hospice use increased (8.2% to 13.5%; 24.5% to 40.7%). Decedents with moderate and severe ADRD had 16% and 13% higher likelihoods of in-hospital deaths in for-profit NHs. In NHs with Alzheimer's units, likelihoods of in-hospital deaths, dying with pressure ulcers, and PAHs were significantly lower. As ADRD severity increased, higher licensed nurse staffing was associated with 14%‒27% lower likelihoods of PAHs. Increased NH market competition was associated with higher likelihood of hospice use, and lower likelihood of in-hospital deaths among decedents with moderate ADRD. CONCLUSIONS AND IMPLICATIONS Decedents with ADRD in NHs that were nonprofit, had Alzheimer's units, higher licensed nurse staffing, and in more competitive markets, had better EOL care/outcomes. Modifications to state Medicaid NH payments may promote better EOL care/outcomes for this population. Future research to understand NH care practices associated with presence of Alzheimer's units is warranted to identify mechanisms possibly promoting higher-quality EOL care.
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Affiliation(s)
- Jessica Orth
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Adam Simning
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research and The Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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22
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Armijo-Olivo S, Craig R, Corabian P, Guo B, Souri S, Tjosvold L. Nursing Staff Time and Care Quality in Long-Term Care Facilities: A Systematic Review. Gerontologist 2020; 60:e200-e217. [PMID: 31115444 DOI: 10.1093/geront/gnz053] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In long-term care (LTC) facilities, nursing staff are important contributors to resident care and well-being. Despite this, the relationships between nursing staff coverage, care hours, and quality of resident care in LTC facilities are not well understood and have implications for policy-makers. This systematic review summarizes current evidence on the relationship between nursing staff coverage, care hours, and quality of resident care in LTC facilities. RESEARCH DESIGN AND METHODS A structured literature search was conducted using four bibliographic databases and gray literature sources. Abstracts were screened by two independent reviewers using Covidence software. Data from the included studies were summarized using a pretested extraction form. The studies were critically appraised, and their results were synthesized narratively. RESULTS The systematic searched yielded 15,842 citations, of which 54 studies (all observational) were included for synthesis. Most studies (n = 53, 98%) investigated the effect of nursing staff time on resident care. Eleven studies addressed minimum care hours and quality of care. One study examined the association between different nursing staff coverage models and resident outcomes. Overall, the quality of the included studies was poor. DISCUSSION AND IMPLICATIONS Because the evidence was inconsistent and of low quality, there is uncertainty about the direction and magnitude of the association between nursing staff time and type of coverage on quality of care. More rigorously designed studies are needed to test the effects of different cutoffs of care hours and different nursing coverage models on the quality of resident care in LTC facilities.
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Affiliation(s)
- Susan Armijo-Olivo
- Institute of Health Economics (IHE), Edmonton, Alberta, Canada.,Faculty of Rehabilitation Medicine, Department of Physical Therapy/Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Rodger Craig
- Institute of Health Economics (IHE), Edmonton, Alberta, Canada
| | - Paula Corabian
- Institute of Health Economics (IHE), Edmonton, Alberta, Canada
| | - Bing Guo
- Institute of Health Economics (IHE), Edmonton, Alberta, Canada
| | - Sepideh Souri
- Institute of Health Economics (IHE), Edmonton, Alberta, Canada
| | - Lisa Tjosvold
- Institute of Health Economics (IHE), Edmonton, Alberta, Canada.,John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
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Houchens N, Gupta A. Quality and safety in the literature: September 2020. BMJ Qual Saf 2020; 29:780-784. [DOI: 10.1136/bmjqs-2020-011887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 06/27/2020] [Indexed: 11/04/2022]
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Wang S, Temkin-Greener H, Conwell Y, Cai S. Policy to Reduce Antipsychotic Use and Hospitalization of Nursing Home Residents With Dementia. J Am Med Dir Assoc 2020; 21:1617-1622.e3. [PMID: 32527648 DOI: 10.1016/j.jamda.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Following the 2012 launch of the National Partnership to Improve Dementia Care in Nursing Homes (the National Partnership), the use of antipsychotics has declined. However, little is known about the impact of this effort on quality of care and outcomes for nursing home (NH) residents with Alzheimer's disease and related dementia (ADRD). The objective of this study is to examine changes in hospitalizations for NH long-stay residents with ADRD after the launch of the National Partnership. DESIGN Observational cross-sectional study. SETTING/PARTICIPANTS NH residents who were newly admitted into NHs and became long-stay residents between January 2011 and March 2015 (n = 565,885). METHODS We estimated linear probability models to explore the relationship between the National Partnership and the likelihood of NH-originated hospitalizations for NH long-stay residents with ADRD, accounting for facility fixed effect, individual covariates, and concurrent changes in hospitalizations among residents without ADRD. We further stratified the analysis by NHs according to their prevalence of antipsychotic use at baseline (ie, prior to the National Partnership). RESULTS We detected a 0.7-percentage point relative increase (P value <.01) in risk-adjusted probabilities of hospitalizations among residents with ADRD compared with non-ADRD residents in the post-Partnership period. In the stratified analysis, we detected a 1.2-percentage point increase (P = .037) in the probability of hospitalizations among ADRD residents in NHs with high antipsychotic use at baseline but no significant change among those in NHs with low antipsychotic use. CONCLUSIONS AND IMPLICATIONS Although the National Partnership may have reduced exposure to antipsychotics, our findings suggest this was related to an increase in hospitalization risk for residents with ADRD. Further research is needed to elucidate the reasons behind the observed relationship and to examine the impact of the National Partnership on other health outcomes.
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Affiliation(s)
- Sijiu Wang
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Forbat L, Liu WM, Koerner J, Lam L, Samara J, Chapman M, Johnston N. Reducing time in acute hospitals: A stepped-wedge randomised control trial of a specialist palliative care intervention in residential care homes. Palliat Med 2020; 34:571-579. [PMID: 31894731 DOI: 10.1177/0269216319891077] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Care home residents are frequently transferred to hospital, rather than provided with appropriate and timely specialist care in the care home. AIM To determine whether a model of care providing specialist palliative care in care homes, called Specialist Palliative Care Needs Rounds, could reduce length of stay in hospital. DESIGN Stepped-wedge randomised control trial. The primary outcome was length of stay in acute care (over 24-h duration), with secondary outcomes being the number and cost of hospitalisations. Care homes were randomly assigned to cross over from control to intervention using a random number generator; masking was not possible due to the nature of the intervention. Analyses were by intention to treat. The trial was registered with ANZCTR: ACTRN12617000080325. Data were collected between 1 February 2017 and 30 June 2018. SETTING/PARTICIPANTS 1700 residents in 12 Australian care homes for older people. RESULTS Specialist Palliative Care Needs Rounds led to reduced length of stay in hospital (unadjusted difference: 0.5 days; adjusted difference: 0.22 days with 95% confidence interval: -0.44, -0.01 and p = 0.038). The intervention also provided a clinically significant reduction in the number of hospitalisations by 23%, from 5.6 to 4.3 per facility-month. A conservative estimate of annual net cost-saving from reduced admissions was A$1,759,011 (US$1.3 m; UK£0.98 m). CONCLUSION The model of care significantly reduces hospitalisations through provision of outreach by specialist palliative care clinicians. The data offer substantial evidence for Specialist Palliative Care Needs Rounds to reduce hospitalisations in older people approaching end of life, living in care homes.
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Affiliation(s)
- Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK.,Australian Catholic University, Canberra, ACT, Australia
| | - Wai-Man Liu
- Australian National University, Canberra, ACT, Australia
| | - Jane Koerner
- Australian Catholic University, Canberra, ACT, Australia
| | - Lawrence Lam
- University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Michael Chapman
- Australian National University, Canberra, ACT, Australia.,ACT Health, Canberra Hospital, Canberra, ACT, Australia
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26
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Blackburn J, Stump TE, Carnahan JL, Hickman SE, Tu W, Fowler NR, Unroe KT. Reducing the Risk of Hospitalization for Nursing Home Residents: Effects and Facility Variation From OPTIMISTIC. J Am Med Dir Assoc 2020; 21:545-549.e1. [DOI: 10.1016/j.jamda.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 11/26/2022]
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McCarthy EP, Ogarek JA, Loomer L, Gozalo PL, Mor V, Hamel MB, Mitchell SL. Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations. JAMA Intern Med 2020; 180:385-394. [PMID: 31886827 PMCID: PMC6990757 DOI: 10.1001/jamainternmed.2019.6130] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population. OBJECTIVE To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019. MAIN OUTCOMES AND MEASURES The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained. RESULTS The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%). CONCLUSIONS AND RELEVANCE The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.
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Affiliation(s)
- Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Mary Beth Hamel
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Fassmer AM, Pulst A, Spreckelsen O, Hoffmann F. Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies. BMC Fam Pract 2020; 21:29. [PMID: 32046652 PMCID: PMC7014634 DOI: 10.1186/s12875-020-01108-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023]
Abstract
Background Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement. Methods Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests. Results We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492). Conclusions A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.
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Affiliation(s)
- Alexander Maximilian Fassmer
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
| | - Alexandra Pulst
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany.,Health Sciences, University of Bremen, Bremen, Germany
| | - Ove Spreckelsen
- Division of General Practice, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Division of Outpatient Care and Pharmacoepidemiology, Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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Strautmann A, Allers K, Fassmer AM, Hoffmann F. Nursing home staff's perspective on end-of-life care of German nursing home residents: a cross-sectional survey. BMC Palliat Care 2020; 19:2. [PMID: 31900141 PMCID: PMC6942381 DOI: 10.1186/s12904-019-0512-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/26/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany. METHODS A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested. RESULTS 486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement. CONCLUSIONS Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.
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Affiliation(s)
- Anke Strautmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
- Department of Health Services Research, School VI - Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstr. 114-118, D-26129, Oldenburg, Germany.
| | - Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | | | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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30
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Muench U, Simon M, Guerbaai RA, De Pietro C, Zeller A, Kressig RW, Zúñiga F. Preventable hospitalizations from ambulatory care sensitive conditions in nursing homes: evidence from Switzerland. Int J Public Health 2019; 64:1273-1281. [PMID: 31482196 PMCID: PMC6867979 DOI: 10.1007/s00038-019-01294-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES Reducing nursing home hospitalizations for ambulatory care sensitive conditions (ACSC) has been identified as an opportunity to improve patient well-being and reduce costs. The aim of this study was to identify number of hospitalizations for ACSCs for nursing home residents in a Swiss national sample, examine demographic characteristics of nursing home hospitalizations due to ACSCs, and calculate hospital expenses from these hospitalizations. METHODS Using merged hospital administrative data with payment data based on diagnosis-related groups (DRGs) for the year 2013, we descriptively examined nursing home residents who were 65 years of age or older and were admitted to an acute care hospital. RESULTS Approximately 42% of all nursing home admissions were due to ACSCs. Payments to Swiss hospitals for ACSCs can be estimated at between 89 and 105 million Swiss francs in 2013. CONCLUSIONS A sizable share of hospitalizations for nursing home residents is for ACSCs, and the associated costs are substantial. Programs and policies designed to reduce these potentially avoidable hospitalizations from the nursing home setting could lead to an increased patient well-being and lower costs.
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Affiliation(s)
- Ulrike Muench
- Department of Social and Behavioural Sciences, University of California San Francisco, School of Nursing, San Francisco, USA
| | - Michael Simon
- Department of Public Health, Institute of Nursing Science, Faculty of Medicine, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland.,Nursing and Midwifery Research Unit, Inselspital Bern University Hospital, Bern, Switzerland
| | - Raphaëlle-Ashley Guerbaai
- Department of Public Health, Institute of Nursing Science, Faculty of Medicine, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland
| | - Carlo De Pietro
- Department of Business Economics, Health and Social Care at the University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
| | - Andreas Zeller
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Center for Primary Health Care, University of Basel, Basel, Switzerland
| | - Reto W Kressig
- Faculty of Medicine, University of Basel, Basel, Switzerland.,FELIX PLATTER, University Medicine of Aging, Basel, Switzerland
| | - Franziska Zúñiga
- Department of Public Health, Institute of Nursing Science, Faculty of Medicine, University of Basel, Bernoullistr. 28, 4056, Basel, Switzerland.
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31
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Hanratty B, Craig D, Brittain K, Spilsbury K, Vines J, Wilson P. Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis. Health Serv Deliv Res 2019. [DOI: 10.3310/hsdr07270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BackgroundFlexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.AimTo conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.Objectives(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?Data sourcesSearches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.DesignMapping review and rapid, systematic evidence syntheses.SettingCare homes with and without nursing in high-income countries.Review methodsPublished literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.ResultsSeven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.LimitationsThis review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.ConclusionsThis review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.Future workFuture work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.Study registrationThis study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Barbara Hanratty
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Katie Brittain
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | | | - John Vines
- Northumbria School of Design, Northumbria University, Newcastle upon Tyne, UK
| | - Paul Wilson
- Alliance Manchester Business School, University of Manchester, Manchester, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, University of Manchester, Manchester, UK
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van der Roest HG, van Eenoo L, van Lier LI, Onder G, Garms-Homolová V, Smit JH, Finne-Soveri H, Jónsson PV, Draisma S, Declercq A, Bosmans JE, van Hout HPJ. Development of a novel benchmark method to identify and characterize best practices in home care across six European countries: design, baseline, and rationale of the IBenC project. BMC Health Serv Res 2019; 19:310. [PMID: 31092244 PMCID: PMC6521361 DOI: 10.1186/s12913-019-4109-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 04/17/2019] [Indexed: 11/15/2022] Open
Abstract
Background Europe’s ageing society leads to an increased demand for long-term care, thereby putting a strain on the sustainability of health care systems. The ‘Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of Community Care’ (IBenC) project aims to develop a new benchmark methodology based on quality of care and cost of care utilization to identify best practices in home care. The study’s baseline data, methodology, and rationale are reported. Methods Home care organizations in Belgium, Finland, Germany, Iceland, Italy, and the Netherlands, home care clients of 65 years and over receiving home care, and professionals working in these organizations were included. Client data were collected according to a prospective longitudinal design with the interRAI Home Care instrument. Assessments were performed at baseline, after six and 12 months by trained (research) nurses. Characteristics of home care organizations and professionals were collected cross-sectionally with online surveys. Results Thirty-eight home care organizations, 2884 home care clients, and 1067 professionals were enrolled. Home care clients were mainly female (66.9%), on average 82.9 years (± 7.3). Extensive support in activities of daily living was needed for 41.6% of the sample, and 17.6% suffered cognitive decline. Care professionals were mainly female (93.4%), and over 45 years (52.8%). Considerable country differences were found. Conclusion A unique, international, comprehensive database is established, containing in-depth information on home care organizations, their clients and staff members. The variety of data enables the development of a novel cost-quality benchmark method, based on interRAI-HC data. This benchmark can be used to explore relevant links between organizational efficiency and organizational and staff characteristics. Electronic supplementary material The online version of this article (10.1186/s12913-019-4109-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henriëtte G van der Roest
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health research institute, Amsterdam UMC, VU University medical center, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands.
| | - Liza van Eenoo
- LUCAS Centre for Care Research and Consultancy, KU Leuven, Leuven, Belgium
| | - Lisanne I van Lier
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health research institute, Amsterdam UMC, VU University medical center, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands
| | - Graziano Onder
- Department of Geriatrics, Neuroscience and Orthopedics, Agostino Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vjenka Garms-Homolová
- Department of Economics and Law, HTW Berlin, University of Applied Sciences, Berlin, Germany
| | - Johannes H Smit
- Department of Psychiatry, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands & GGZ inGeest Specialized Mental Health Care, Research and Innovation, Amsterdam, The Netherlands
| | - Harriet Finne-Soveri
- Department of Wellbeing, National Institute for Health and Welfare, Helsinki, Finland
| | - Pálmi V Jónsson
- Department of Geriatrics, Landspitali University Hospital, and Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Stasja Draisma
- Department of Wellbeing, National Institute for Health and Welfare, Helsinki, Finland
| | - Anja Declercq
- LUCAS Centre for Care Research and Consultancy, KU Leuven, Leuven, Belgium
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Science, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Hein P J van Hout
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health research institute, Amsterdam UMC, VU University medical center, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands
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Stadler DS, Oliver BJ, Raymond JG, Routzhan GF, Flaherty EA, Stahl JE, Batsis JA, Bartels SJ. Reducing Avoidable Facility Transfers (RAFT): Outcomes of a Team Model to Minimize Unwarranted Emergency Care at Skilled Nursing Facilities. J Am Med Dir Assoc 2019; 20:929-34. [PMID: 31072695 DOI: 10.1016/j.jamda.2019.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/27/2019] [Accepted: 03/15/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute health care interventions for residents of skilled nursing facilities (SNFs) are often unwarranted, unwanted, and/or harmful. We describe a provider-focused care model to reduce unwarranted or unwanted acute health care utilization. OBJECTIVE Assess the capability of the Reducing Avoidable Facility Transfers (RAFT) model to reduce unwanted and unwarranted acute health care utilization among residents in 3 rural SNFs between January 1, 2016 and June 30, 2017. DESIGN Prospective cohort, pre/post study. SETTING Three rural SNFs in collaboration with a geriatric practice in a tertiary academic medical center. PARTICIPANTS Post-acute care (PAC) and long-term care (LTC) residents of 3 rural SNFs. INTERVENTION RAFT includes the following components: (1) a small team of providers who manage longitudinal care and after hours call; (2) elicitation of advance care plans and preferences regarding acute care; (3) standardized communication process engaging the provider at the identification of an acute care event; (4) a biweekly case review of all emergency department (ED) transfers. MEASURES ED and hospital utilization. RESULTS RAFT demonstrated a 35% reduction in monthly ED transfers and a 30.5% reduction in monthly hospitalizations. These reductions were greatest for LTC residents. CONCLUSIONS/IMPLICATIONS The RAFT approach substantially reduced unwarranted ED and hospital utilization in this study. Results support replication and evaluation in a larger, more diverse setting and population.
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Kouyoumdjian V, Perceau-Chambard E, Sisoix C, Filbet M, Tricou C. Physician's perception leading to the transfer of a dying nursing home resident to an emergency department: A French qualitative study. Geriatr Gerontol Int 2019; 19:249-253. [PMID: 30623550 DOI: 10.1111/ggi.13600] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 09/19/2018] [Accepted: 12/04/2018] [Indexed: 11/27/2022]
Abstract
AIM The aim of the present study was to find out physicians' perceptions about the transfer of dying nursing home residents to emergency departments. METHOD This qualitative study used semi-structured interviews, and data were analyzed using qualitative methods. Participants were medical directors of nursing homes who were informed by e-mail and included when they agreed to take part in our study. RESULTS We interviewed 12 medical directors until data saturation. The following themes emerged: (i) related to the resident - difficulties in identifying the end of life, refractory symptoms and lack of knowledge of the resident's wishes; (ii) related to the family - denial of the end of life/fear of death, lack of confidence in the nursing home and conflict among family members; (iii) related to the nursing staff - fear of death, lack of communication, lack of training, lack of staff (especially of nurses during the nightshift) and use of temporary employees; and (iv) related to the physicians - lack of anticipation of the end of life situation, difficulty in accessing some drugs, inadequate working hours in the nursing home, conflicting medical opinions of the GP and medical director, and lack of training on palliative care issues. CONCLUSIONS These results suggest many ways of reducing the transfer of dying residents to emergency departments through palliative care training, and communication about advance care planning. Geriatr Gerontol Int 2019; 19: 249-253.
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Affiliation(s)
- Valentin Kouyoumdjian
- Department of Palliative Care, Hospital Center Lyon-Sud, Lyon's Civil Hospitals, Pierre-Bénite, France
| | - Elise Perceau-Chambard
- Department of Palliative Care, Hospital Center Lyon-Sud, Lyon's Civil Hospitals, Pierre-Bénite, France
| | - Corinne Sisoix
- Department of Palliative Care, Hospital Center Lyon-Sud, Lyon's Civil Hospitals, Pierre-Bénite, France
| | - Marilène Filbet
- Department of Palliative Care, Hospital Center Lyon-Sud, Lyon's Civil Hospitals, Pierre-Bénite, France
| | - Colombe Tricou
- Department of Palliative Care, Hospital Center Lyon-Sud, Lyon's Civil Hospitals, Pierre-Bénite, France
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Jeon B, Tamiya N, Yoshie S, Iijima K, Ishizaki T. Potentially avoidable hospitalizations, non-potentially avoidable hospitalizations and in-hospital deaths among residents of long-term care facilities. Geriatr Gerontol Int 2019; 18:1272-1279. [PMID: 30136395 DOI: 10.1111/ggi.13458] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 04/20/2018] [Accepted: 05/27/2018] [Indexed: 11/29/2022]
Abstract
AIM The present study aimed to examine the percentage of and risk factors for potentially avoidable hospitalizations (PAH), non-PAH and in-hospital deaths among residents of special nursing homes for the elderly (SNH) and geriatric health service facilities (GHSF). METHODS Long-term care and national health insurance claims data (April 2012 to September 2013) were obtained from a suburban city in Chiba prefecture, Japan. Study participants were aged ≥75 years and resided in either SNH (n = 1138) or GHSF (n = 885). The PAH were defined using 17 medical condition groups, and the percentage of PAH, non-PAH and in-hospital deaths was identified, and associated factors were compared using multilevel logistic regression models for SNH and GHSF, respectively. RESULTS A total of 34.5% SNH residents experienced any hospitalization, and this was composed of PAH (16.3%), non-PAH (12.2%) or in-hospital deaths (6.1%). Of the GHSF residents, 23.8% experienced any hospitalization, and this was comprised of PAH (9.5%), non-PAH (10.6%) and in-hospital death (3.7%). More than 70% of the PAH were related to respiratory infections, urinary tract infections or congestive heart failure. In both SNH and GHSF, artificial nutrition was positively associated with PAH and non-PAHs, and male sex was positively associated with non-PAHs and in-hospital deaths. However, there were also discrepancies between SNH and GHSF in terms of risk factors for PAH. CONCLUSIONS The percentage of PAH was higher in SNH than in GHSF, which might be related to their different personnel and managerial regulations. The linkage of health and long-term care claims data might facilitate data-based evidence on policy-making. Geriatr Gerontol Int 2018; 18: 1272-1279.
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Affiliation(s)
- Boyoung Jeon
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.,Division of Health Service for the Disabled, National Rehabilitation Center, Seoul, Republic of Korea
| | - Nanako Tamiya
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.,Health Services Research & Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Satoru Yoshie
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.,Institute of Gerontology, The University of Tokyo, Tokyo, Japan.,Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Katsuya Iijima
- Institute of Gerontology, The University of Tokyo, Tokyo, Japan
| | - Tatsuro Ishizaki
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.,Research Team for Human Care, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
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Weech-Maldonado R, Lord J, Pradhan R, Davlyatov G, Dayama N, Gupta S, Hearld L. High Medicaid Nursing Homes: Organizational and Market Factors Associated With Financial Performance. Inquiry 2019; 56:46958018825061. [PMID: 30739512 PMCID: PMC6376504 DOI: 10.1177/0046958018825061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 11/29/2018] [Accepted: 12/14/2018] [Indexed: 11/17/2022]
Abstract
High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower quality and poorer financial performance. However, there is significant variation in performance among high Medicaid nursing homes. The purpose of this study is to examine the organizational and market factors that may be associated with better financial performance among high Medicaid nursing homes. Data sources included Long-Term Care Focus (LTCFocus), Centers for Medicare and Medicaid Services' (CMS) Medicare Cost Reports, CMS Nursing Home Compare, and the Area Health Resource File (AHRF) for 2009-2015. There were approximately 1108 facilities with high Medicaid per year. The dependent variables are nursing homes operating and total margin. The independent variables included size, chain affiliation, occupancy rate, percent Medicare, market competition, and county socioeconomic status. Control variables included staffing variables, resident quality, for-profit status, acuity index, percent minorities in the facility, percent Medicaid residents, metropolitan area, and Medicare Advantage penetration. Data were analyzed using generalized estimating equations with state and year fixed effects. Results suggest that organizational and market slack resources are associated with performance differentials among high Medicaid nursing homes. Higher financial performing facilities are characterized as having nurse practitioners/physician assistants, more beds, higher occupancy rate, higher Medicare and Medicaid census, and being for-profit and located in less competitive markets. Higher levels of Registered Nurse (RN) skill mix result in lower financial performance in high Medicaid nursing homes. Policy and managerial implications of the study are discussed.
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Affiliation(s)
| | | | - Rohit Pradhan
- University of Arkansas for Medical Sciences, Little Rock, USA
| | | | - Neeraj Dayama
- University of Arkansas for Medical Sciences, Little Rock, USA
| | - Shivani Gupta
- The University of Southern Mississippi, Hattiesburg, USA
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Chan DKY, Liu FX, Irwanto D, Prasetyo D, Ozorio G, Li F, Smith M, Sharma A, Chen J. Experience of establishing an acute geriatric outreach service versus subacute service to nursing homes. Intern Med J 2018; 48:1396-1399. [DOI: 10.1111/imj.14104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/05/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Daniel K. Y. Chan
- Department of Aged Care and RehabilitationBankstown‐Lidcombe Hospital Sydney New South Wales Australia
- Faculty of MedicineUniversity of NSW Sydney New South Wales Australia
- Neurocognitive and Molecular Biology Laboratory, Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Frank X. Liu
- Department of Aged Care and RehabilitationBankstown‐Lidcombe Hospital Sydney New South Wales Australia
| | - Deni Irwanto
- Department of Aged Care and RehabilitationBankstown‐Lidcombe Hospital Sydney New South Wales Australia
| | - Davin Prasetyo
- Department of Aged Care and RehabilitationBankstown‐Lidcombe Hospital Sydney New South Wales Australia
| | - Gerard Ozorio
- Department of Aged Care and RehabilitationBankstown‐Lidcombe Hospital Sydney New South Wales Australia
| | - Feika Li
- Geriatric DepartmentRuijin Hospital Shanghai China
| | - Matthew Smith
- Faculty of MedicineUniversity of NSW Sydney New South Wales Australia
- Emergency DepartmentBankstown‐Lidcombe Hospital Sydney New South Wales Australia
| | - Anurag Sharma
- Faculty of MedicineUniversity of NSW Sydney New South Wales Australia
| | - Jack Chen
- Faculty of MedicineUniversity of NSW Sydney New South Wales Australia
- Simpson Centre for Health Services ResearchSouth Western Clinical School, University of New South Wales Sydney New South Wales Australia
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Temkin-Greener H, Lee T, Caprio T, Cai S. Rehabilitation Therapy for Nursing Home Residents at the End-of-Life. J Am Med Dir Assoc 2018; 20:476-480.e1. [PMID: 30287262 DOI: 10.1016/j.jamda.2018.07.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/31/2018] [Accepted: 07/31/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Ultrahigh therapy use has increased in SNFs without concomitant increases in residents' characteristics. It has been suggested that this trend may also have influenced the provision of high-intensity rehabilitation therapies to residents who are at the end of life (EOL). Motivated by lack of evidence, we examined therapy use and intensity among long-stay EOL residents. DESIGN An observational study covering a time period 2012-2016. SETTING AND PARTICIPANTS New York State nursing homes (N = 647) and their long-stay decedent residents (N = 55,691). METHODS Data sources included Minimum Data Set assessments, vital statistics, Nursing Home Compare website, LTCfocus, and Area Health Resource File. Therapy intensity in the last month of life was the outcome measure. Individual-level covariates were used to adjust for health conditions. Facility-level covariates were the key independent variables of interest. Multinomial logistic regression models with facility random effects were estimated. RESULTS Overall, 13.6% (n = 7600) of long-stay decedent residents had some therapy in the last month of life, 0% to 45% across facilities. Of those, almost 16% had very high/ultrahigh therapy intensity (>500 minutes) prior to death. Adjusting for individual-level covariates, decedents in the for-profit facilities had 18% higher risk of low/medium therapy [relative risk ratio (RRR) = 1.182, P < .001], and more than double the risk of high/ultrahigh therapy (RRR = 2.126, P < .001), compared to those with no therapy use in the last month of life. In facilities with higher physical therapy staffing, decedents had higher risk (RRR = 16.180, P = .002) of high/ultrahigh therapy, but not of low/medium therapy intensity. The use of high/ultrahigh therapy in this population has increased over time. CONCLUSIONS AND RELEVANCE This is a first study to empirically demonstrate that facility characteristics are associated with the provision of therapy intensity to EOL residents. Findings suggest that facilities with a for-profit mission, and with higher staffing of therapists, may be more incentivized to maximize therapy use, even among the sickest of the residents.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Tiffany Lee
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Thomas Caprio
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Abstract
Aims: Most people approaching the end of life develop care needs, which typically change over time. Moves between care settings may be required as health deteriorates. However, in some cases, care setting transitions may have little to do with end-of-life care needs and instead reflect the needs, demands, availability, or funding provisions of the country or funding body and organizations providing care. This paper is a scoping review of the international peer-reviewed research literature to gain evidence on the frequency and types of end-of-life care setting transitions, and the reasons for these moves. Methods: All relevant print and open access research articles published in 2000+ were sought using the Directory of Open Access Journals and EBSCO Discovery Host. Results: A total of 39 research articles were identified and reviewed. However, minimal useful evidence was revealed. Most articles focused solely on hospital admissions near death, and some focused on nursing home admissions, with other moves infrequently studied. Conclusions: This review demonstrates the need to quantify and justify end-of-life care setting transitions as it appears dying people are frequently moved, often as death nears. This research is needed to distinguish transitions related to end-of-life care needs and those arising from pressures on or from care providers and others unrelated to the person's care needs.
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Affiliation(s)
- Donna M Wilson
- Faculty of Nursing, University of Alberta, Canada
- Faculty of Education and Health Sciences, University of Limerick, Ireland
| | - Stephen Birch
- Centre for Health Economics and Policy Analysis, McMaster University, Canada
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Banerjee A, James R, Mcgregor M, Lexchin J. Nursing Home Physicians Discuss Caring for Elderly Residents: An Exploratory Study. Can J Aging 2018; 37:133-44. [PMID: 29618397 DOI: 10.1017/s0714980818000089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
RÉSUMÉMalgré la complexité croissante des soins en foyers de soins de longue durée, le rôle des médecins dans la prestation des soins aux résidents a été peu étudié. Cette étude exploratoire internationale visait à mieux comprendre les rôles des médecins, leurs responsabilités et leurs tâches, ainsi qu’à explorer les caractéristiques uniques de la pratique médicale dans les foyers de soins de longue durée. Des entrevues ont été menées avec 18 médecins. Ces médecins ont mentionné qu’ils contribuaient fortement à la qualité des soins pour les résidents, en clarifiant les objectifs des soins, en prenant des mesures pour réduire les hospitalisations et les prescriptions de médicaments non nécessaires, et en contribuant à la formation du personnel. Les pratiques en foyers de soins de longue durée impliquaient les médecins au centre de réseaux de relations qui assuraient non seulement une meilleure qualité des soins médicaux, mais aussi une satisfaction professionnelle chez les médecins. L’importance de ces relations est telle qu’elle permettait d’aller au-delà des démarcations traditionnelles entre le domaine médical et le domaine social, et mettait en évidence qu’une bonne pratique médicale implique de bonnes pratiques sociales. Considérant la nature exploratoire de l’étude, les auteurs recommandent que de futures recherches soient menées pour mieux comprendre les dimensions relationnelles associées à la pratique de la médecine en foyers de soins de longue durée.
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Wilson DM, Birch S. Moving from place to place in the last year of life: A qualitative study identifying care setting transition issues and solutions in Ontario. Health Soc Care Community 2018; 26:232-239. [PMID: 29108131 DOI: 10.1111/hsc.12513] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
Moving from one care setting to another is common as death nears. Many concerns exist over these end-of-life (EOL) care setting transitions, including low-quality moves as mistakes and other mishaps can occur. Delayed or denied moves are also problematic, such as a move out of hospital for dying inpatients who want to spend their last hours or days at home. The aim of the study was to identify current issues or problems with care setting transitions during the last year of life as well as potential or actual solutions for these problems. A grounded theory analysis approach was used based on interviews with 38 key informants who represent a wide range of healthcare providers, healthcare managers, government representatives, lawyers, healthcare recipients and their family/friends across Ontario in 2016. Three interrelated themes were revealed: (a) communication complexities, (b) care planning and coordination gaps and (c) health system reform needs. Six solutions were highlighted, with these designed to prevent care setting transition issues and monitor care setting transitions for continued improvements.
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Affiliation(s)
- Donna M Wilson
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Stephen Birch
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
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Cordato NJ, Kearns M, Smerdely P, Seeher KM, Gardiner MD, Brodaty H. Management of Nursing Home Residents Following Acute Hospitalization: Efficacy of the "Regular Early Assessment Post-Discharge (REAP)" Intervention. J Am Med Dir Assoc 2018; 19:276.e11-276.e19. [PMID: 29396192 DOI: 10.1016/j.jamda.2017.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/08/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Rehospitalization of nursing home (NH) residents is frequent, costly, potentially avoidable and associated with diminished quality of life and poor survival. This study aims to evaluate the impact and cost-effectiveness of the Regular Early Assessment Post-Discharge (REAP) protocol of coordinated specialist geriatrician and nurse practitioner visits on rates of rehospitalization, hospital length of stay, and emergency department presentations for NH residents recently discharged from hospital. DESIGN Prospective randomized controlled study of recently hospitalized NH residents. SETTING Twenty-one of 24 eligible NHs within the geographical catchment area of St George Hospital, a 650-bed university hospital in Sydney, Australia. PARTICIPANTS NH residents from eligible facilities admitted to St George Hospital's geriatric service were enrolled prior to hospital discharge. INTERVENTION REAP intervention of monthly coordinated specialist geriatrician and nurse practitioner assessments within participants' NHs for 6 months following hospital discharge. MEASUREMENTS Impact of the REAP intervention on hospital readmissions, hospital inpatient days, emergency department utilization, general practitioner visits, investigations and associated costs during the study intervention period. RESULTS Forty-three NH residents were randomly allocated to REAP intervention (n = 22) or control (n = 21) groups. The REAP intervention group had almost two-thirds fewer hospital readmissions (P = .03; Cohen's d = 0.73) and half as many emergency department visits than controls. Total costs were 50% lower in the REAP intervention group, with lower total hospital inpatient (P = .04; Cohen's d = 0.63) and total emergency department (P = .04; Cohen's d = 0.65) costs. CONCLUSION Cost-effective reductions in the utilization of hospital-related services were demonstrated following implementation of the REAP intervention for NH residents recently discharged from hospital.
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Affiliation(s)
- Nicholas J Cordato
- Department of Aged Care, St George Hospital, Kogarah, Australia; Calvary Health Care Sydney, Kogarah, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | - Mary Kearns
- Department of Aged Care, St George Hospital, Kogarah, Australia
| | - Peter Smerdely
- Department of Aged Care, St George Hospital, Kogarah, Australia; Calvary Health Care Sydney, Kogarah, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Katrin M Seeher
- Faculty of Medicine, University of New South Wales, Sydney, Australia; Dementia Centre for Research Collaboration, University of New South Wales, Sydney, Australia; Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia
| | - Matthew D Gardiner
- Calvary Health Care Sydney, Kogarah, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Henry Brodaty
- Faculty of Medicine, University of New South Wales, Sydney, Australia; Dementia Centre for Research Collaboration, University of New South Wales, Sydney, Australia; Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia; Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Randwick, Australia.
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Jain S, Gonski PN, Jarick J, Frese S, Gerrard S. Southcare Geriatric Flying Squad: an innovative Australian model providing acute care in residential aged care facilities. Intern Med J 2018; 48:88-91. [DOI: 10.1111/imj.13672] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 07/21/2017] [Accepted: 07/21/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Shikha Jain
- Southcare, Aged and Extended Care; The Sutherland Hospital; Sydney New South Wales Australia
| | - Peter N. Gonski
- Southcare, Aged and Extended Care; The Sutherland Hospital; Sydney New South Wales Australia
| | - Jeannette Jarick
- Southcare, Aged and Extended Care; The Sutherland Hospital; Sydney New South Wales Australia
| | - Sandra Frese
- Southcare, Aged and Extended Care; The Sutherland Hospital; Sydney New South Wales Australia
| | - Sheena Gerrard
- Southcare, Aged and Extended Care; The Sutherland Hospital; Sydney New South Wales Australia
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Temkin-Greener H, Mukamel DB, Ladd H, Ladwig S, Caprio TV, Norton SA, Quill TE, Olsan TH, Cai X. Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial. Med Care 2018; 56:11-8. [PMID: 29068904 DOI: 10.1097/MLR.0000000000000835] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. OBJECTIVE Test the impact of PCTeams on end-of-life outcomes. RESEARCH DESIGN Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect. SUBJECTS In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). MEASURES Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. RESULTS Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations. CONCLUSIONS The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.
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Seeger I, Luque Ramos A, Hoffmann F. Ambulante Notfallversorgung von Pflegeheimbewohnern: Auswertung von GKV-Routinedaten. Z Gerontol Geriatr 2018; 51:650-5. [DOI: 10.1007/s00391-017-1293-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 06/21/2017] [Accepted: 06/29/2017] [Indexed: 12/16/2022]
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Abstract
BACKGROUND The Nursing Home Compare (NHC) report card does not include end-of-life (EOL) quality measures (QMs). OBJECTIVES To develop and examine the properties of EOL QMs. SUBJECTS A total of 39,590 nursing home decedents in 626 facilities in New York State in fiscal year 2012. DESIGN Statistical analyses of Minimum Data Set 3 data, including multivariable regression analyses and descriptive statistics. MEASURES Death in the hospital, number of hospitalizations, pain, and depression during the last 90 days before death. RESULTS Overall, 32% of residents died in the hospital. They averaged 0.49 hospitalizations in the last 90 days before death, 10% reported moderate to severe pain, and 17% had depressive symptoms. The EOL QMs exhibited variation across facilities similar to that observed for other QMs. They showed low or moderate correlations. The pain and depression QMs were significantly better among nursing homes ranked by NHC as 4 and 5 stars compared with those ranked as 1 and 2 stars for most dimensions. The hospitalizations QMs were significantly better among nursing homes ranked by NHC as 4 and 5 stars compared with those ranked as 1 and 2 stars only when compared on the staffing dimension. CONCLUSIONS The Minimum Data Set 3 includes much information that can be used to assess quality of EOL care in nursing homes. The prototype measures we developed could be improved if information about advance directives and the nonclinical aspects of care, such as comfort and emotional support for both the resident and the family and respect for resident and family preferences, were collected.
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Nakashima T, Young Y, Hsu W. Are Hospital/ED Transfers Less Likely Among Nursing Home Residents With Do-Not-Hospitalize Orders? J Am Med Dir Assoc 2017; 18:438-41. [DOI: 10.1016/j.jamda.2016.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/02/2016] [Accepted: 12/02/2016] [Indexed: 11/21/2022]
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Abstract
OBJECTIVES To determine how do-not-hospitalize (DNH) orders are interpreted and used in nursing homes (NHs) once they are in place. DESIGN Qualitative study using in-depth semi-structured interviews performed from December 2013 to April 2014. SETTING Eight skilled nursing facilities in Connecticut that ranked in the top 10% or bottom 10% in hospitalization rates from 2008 to 2010. PARTICIPANTS Nursing facility staff members (N = 31). MEASUREMENTS A multidisciplinary team performed qualitative content analysis. The constant comparative method was used to develop a coding structure and identify themes. RESULTS DNH orders were uncommon at low- and high-hospitalizing facilities. Participants reported that they did not interpret these orders literally. A DNH order was not a prohibition against hospitalization but was understood to have a variety of exceptions. These orders functioned primarily as a signal that hospitalization should be questioned and discussed with the family when an acute event occurred. CONCLUSION In-the-moment discussions about hospitalization are still necessary even when a DNH order is in place. Work to reduce potentially burdensome NH-hospital transfers needs to focus not just on eliciting preferences in advance, but also on preparing residents and their families to make the best decisions about hospitalization when the time comes.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - M Tish Knobf
- Division of Acute Care/Health Systems, Yale School of Nursing, Yale University, New Haven, Connecticut
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut.,Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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Temkin-Greener H, Ladwig S, Ye Z, Norton SA, Mukamel DB. Improving palliative care through teamwork (IMPACTT) in nursing homes: Study design and baseline findings. Contemp Clin Trials 2017; 56:1-8. [PMID: 28315478 DOI: 10.1016/j.cct.2017.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life. METHODS/DESIGN This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention. DISCUSSION Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more "skilled" care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services.
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