Novel Definitions of Wellness and Distress among Family Caregivers of Patients with Acute Cardiorespiratory Failure: A Qualitative Study

Rationale: Family caregivers of patients with acute cardiorespiratory failure are at high risk for distress, which is typically defined as the presence of psychological symptoms such as anxiety, depression, or posttraumatic stress. Interventions to reduce caregiver distress and increase wellness have been largely ineffective to date. An incomplete understanding of caregiver wellness and distress may hinder efforts at developing effective support interventions. Objectives: To allow family caregivers to define their experiences of wellness and distress 6 months after patient intensive care unit (ICU) admission and to identify moderators that influence wellness and distress. Methods: Primary family caregivers of adult patients admitted to the medical ICU with acute cardiorespiratory failure were invited to participate in a semistructured interview 6 months after ICU admission as part of a larger prospective cohort study. Interview guides were used to assess caregiver perceptions of their own well-being, record caregiver descriptions of their experiences of family caregiving, and identify key stress events and moderators that influenced well-being during and after the ICU admission. This study was guided by the Chronic Traumatic Stress Framework conceptual model, and data were analyzed using the five-step framework approach. Results: Among 21 interviewees, the mean age was 58 years, 67% were female, and 76% were White. Nearly half of patients (47%) had died before the caregiver interview. At the time of the interview, 9 caregivers endorsed an overall sense of distress, 10 endorsed a sense of wellness, and 2 endorsed a mix of both. Caregivers defined their experiences of wellness and distress as multidimensional and composed of four main elements: 1) positive versus negative physical and psychological outcomes, 2) high versus low capacity for self-care, 3) thriving versus struggling in the caregiving role, and 4) a sense of normalcy versus ongoing life disruption. Postdischarge support from family, friends, and the community at large played a key role in moderating caregiver outcomes. Conclusions: Caregiver wellness and distress are multidimensional and extend beyond the absence or presence of psychological outcomes. Future intervention research should incorporate novel outcome measures that include elements of self-efficacy, preparedness, and adaptation and optimize postdischarge support for family caregivers.

Health Trajectories of Skilled Nursing Facility Patients With Alzheimer's Disease and Related Dementias: Evidence for Practicing Nurses

PURPOSE

Older adults with Alzheimer's disease and related dementias (ADRD) are at high risk for acute medical problems and their health trajectories frequently include hospital admission and care in a skilled nursing facility (SNF). Their health trajectories after SNF discharge are poorly understood. Therefore, in the current study, we sought to describe health trajectories and factors associated with hospital read-missions for older adults with ADRD during the 30 days following SNF discharge.

METHOD

We conducted a secondary analysis of data from a clinical trial of transitional care of older adults with transitions from SNF to home and assisted living. A multiple case study design was used in the analysis of the health trajectories of 49 SNF patients with ADRD, 51% discharged from SNF to their own home, 34% discharged to a family member's home, and 15% transferred to assisted living.

RESULTS

Within 30 days of discharge, 20% of patients with ADRD experienced new or recurrent acute needs and hospital readmission.

CONCLUSION

Our findings suggest the need for nursing interventions to support patients with ADRD during care transitions, such as focusing care on the patient-caregiver dyad, providing transitional care, referring patients for palliative care consultation, and conducting nurse-led research to improve care transitions of these patients and their caregivers. [Journal of Gerontological Nursing, 50(4), 34-41.].

Life-Space of Older Adults after Discharge from Skilled Nursing Facilities

OBJECTIVES

Describe (1) patient or caregiver perceptions of physical function in 30 days after skilled nursing facility (SNF) discharge indicated by Life-Space Assessment (LSA) scores, and (2) patient and caregiver factors associated with LSA scores.

DESIGN

Secondary analysis of baseline and outcomes data from the cluster randomized trial of the Connect-Home transitional care intervention.

SETTING AND PARTICIPANTS

Six SNFs in North Carolina. Patient and caregiver dyads with LSA scores (N = 245).

METHODS

SNF patients or their caregivers serving as proxy reported the life-space of the SNF patient using the LSA tool, a measure of environmental and social factors that influence physical mobility. Simple scores for highest life-space attained depending on equipment and/or caregiver support range from 0 to 5, with higher scores indicating greater mobility. Multiple linear regression models for simple LSA scores and Composite Life-Space (0-120), adjusted for treatment, time via a COVID pandemic indicator, and treatment × COVID effect as fixed effects, were used to estimate the association of patient and caregiver variables and life-space.

RESULTS

Patients had a mean age of 76.3 years, 62.6% were female, and 74.7% were white. Caregivers were commonly female (73.9%) and adult children of the patient (46.5%). The mean Composite Life-Space score was 22.6 (16.09). The mean Assisted Life-Space score (range: 0-5) was 1.6 (1.47), and 76.3% of patients could not move beyond their bedroom, house, and yard without assistance of another person. Higher Composite Life-Space scores were associated with lower levels of cognitive impairment and shorter SNF length of stay.

CONCLUSIONS AND IMPLICATIONS

SNF patients and their caregivers reported very low LSA scores in 30 days after SNF care. Findings indicate the need for care redesign to promote recovery of physical function of older adults after SNF discharge, such as optimizing SNF rehabilitative therapy and adding postdischarge rehabilitative supports at home.

Selecting outcomes for pragmatic clinical trials in dementia care: The IMPACT Collaboratory iLibrary

BACKGROUND

Many interventions improve care and outcomes for people with Alzheimer's Disease and related dementias (ADRD), yet are never disseminated. Pragmatic trials facilitate the adoption and dissemination of best practices, but gaps in pragmatic outcome measurement are a critical obstacle. Our objectives are (1) to describe the development and structure of the IMbedded Pragmatic ADRD Clinical Trials Collaboratory (IMPACT) iLibrary of potential outcome measures for ADRD pragmatic trials, and (2) to assess their pragmatic characteristics.

METHODS

We identified potential outcome measures from several sources: a database of administrative and clinical outcome measures from ADRD clinical trials registered in ClinicalTrials.gov, published reviews, and IMPACT pilot pragmatic trial outcome measures. The iLibrary reports (a) number of items, (b) completion time, (c) readability for diverse populations, (d) cost or copyright barriers to use, (e) method of administration, (f) assessor training burden, and (g) feasibility of data capture and interpretation in routine care; a summary of pragmatic characteristics of each outcome measure (high, moderate, low); items or descriptions of items; and links to primary citations regarding development or psychometric properties.

RESULTS

We included 140 outcome measures in the iLibrary: 66 administrative (100% were pragmatic) and 74 clinical (52% were pragmatic). The most commonly addressed outcome domains from administrative assessments included physical function, quality of care or communication concerns, and psychological symptoms or distress behaviors. The most commonly addressed outcome domains from clinical assessments were psychological symptoms or distress behaviors, physical function, cognitive function, and health-related quality of life.

CONCLUSIONS

Pragmatic outcome measures are brief, meaningful to diverse populations, easily scored and interpreted by clinicians, and available in electronic format for analysis. The iLibrary can facilitate the selection of measures for a wide range of outcomes relevant to people with ADRD and their care partners.

Perceptions of ACT Team Members on the Implementation of Physical Health Services: A Qualitative Study

BACKGROUND

Adults with severe mental illnesses have mortality rates 2.5 to 3 times higher than the general population, largely due to medical illnesses. Those with the most profound mental illnesses are served by assertive community treatment (ACT) teams that provide intensive mental health care; however, there are no clearly established models to integrate physical health treatment into ACT and this is a critical gap in the literature.

AIMS

To describe perceptions of ACT team members regarding services provided for their clients to treat physical health, how those services can be improved, and what implementation strategies would likely be needed to promote uptake and sustainability of those services on ACT teams.

METHOD

Qualitative interviews were conducted via Zoom using a semistructured interview guide with 19 employees from three ACT teams in a southeastern state. Interview transcripts were analyzed, using manifest content analysis, a form of qualitative analysis, to identify key themes in the interview transcripts.

RESULTS

ACT team members described limited physical health services for their clients. They reported (1) system-level barriers to improving physical health care, such as inadequate tools and training; and (2) patient-level barriers, such as limited awareness of physical care needs. ACT team members reported the need for additional medical staff and strengthened relationships with primary care providers. They also recommended changes in policy, education, and quality monitoring to implement new physical health care services.

CONCLUSIONS

Findings suggest intervention components and implementation strategies for improving physical health care of ACT consumers.

Palliative care for persons with late-stage Alzheimer's and related dementias and their caregivers: protocol for a randomized clinical trial

BACKGROUND

Limited access to specialized palliative care exposes persons with late-stage Alzheimer's disease and related dementias (ADRD) to burdensome treatment and unnecessary hospitalization and their caregivers to avoidable strain and financial burden. Addressing this unmet need, the purpose of this study was to conduct a randomized clinical trial (RCT) of the ADRD-Palliative Care (ADRD-PC) program.

METHODS

The study will use a multisite, RCT design and will be set in five geographically diverse US hospitals. Lead investigators and outcome assessors will be masked. The study will use 1:1 randomization of patient-caregiver dyads, and sites will enroll N = 424 dyads of hospitalized patients with late-stage ADRD with their family caregivers. Intervention dyads will receive the ADRD-PC program of (1) dementia-specific palliative care, (2) standardized caregiver education, and (3) transitional care. Control dyads will receive publicly available educational material on dementia caregiving. Outcomes will be measured at 30 days (interim) and 60 days post-discharge. The primary outcome will be 60-day hospital transfers, defined as visits to an emergency department or hospitalization ascertained from health record reviews and caregiver interviews (aim 1). Secondary patient-centered outcomes, ascertained from 30- and 60-day health record reviews and caregiver telephone interviews, will be symptom treatment, symptom control, use of community palliative care or hospice, and new nursing home transitions (aim 2). Secondary caregiver-centered outcomes will be communication about prognosis and goals of care, shared decision-making about hospitalization and other treatments, and caregiver distress (aim 3). Analyses will use intention-to-treat, and pre-specified exploratory analyses will examine the effects of sex as a biologic variable and the GDS stage.

DISCUSSION

The study results will determine the efficacy of an intervention that addresses the extraordinary public health impact of late-stage ADRD and suffering due to symptom distress, burdensome treatments, and caregiver strain. While many caregivers prioritize comfort in late-stage ADRD, shared decision-making is rare. Hospitalization creates an opportunity for dementia-specific palliative care, and the study findings will inform care redesign to advance comprehensive dementia-specific palliative care plus transitional care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04948866. Registered on July 2, 2021.

Characteristics of health care interventions in affordable senior housing: A scoping review

AIMS

Older adults in affordable senior housing often experience chronic illness and unmet health care needs. This review describes studies reporting the characteristics and primary outcomes of health care interventions for older adults living in affordable senior housing.

DESIGN

A scoping review METHODS: After a systematic search in three databases, a team of investigators screened 1,284 titles and abstracts and selected 31 records with reports on 28 studies for review. Narrative synthesis was used to describe studies of interventions in senior housing and primary outcomes.

RESULTS

Studies typically used observational designs and added clinical staff, such as nurses and social workers, to provide health care interventions in groups (n = 15) or with individuals (n = 13). Outcomes were classified in four groups: wellness, symptom management, health care use, and physical function. A subset of 23 studies (82.1%) reported effective interventions.

IMPACT

Findings identify innovative interventions to promote health in affordable senior housing.

Identifying unmet needs of older adults transitioning from home health care to independence at home: A qualitative study

Health care practices to prepare older adults and their family caregivers for transitions from home health care (HHC) to independence at home are rarely studied. The objective of this multiple case study was to describe HHC patient and clinician perceptions of unmet needs after HHC discharge and recommendations to address them in future research. In this qualitative study, data were collected using chart-reviews and semi-structured interviews with paired patients (or caregivers as proxy) and HHC clinicians (N=17 pairs). We identified three themes: (1) low patient and caregiver engagement in care planning increased risk for preventable health events after HHC discharge, (2) limited continuity of care restricted patient and caregiver access to community-based services, and (3) gaps in patient and caregiver education influenced independent care of chronic illnesses after discharge. Findings suggest opportunities to improve care practices to prepare older adults and their caregivers for transitions from HHC to independence at home.

Posttraumatic Stress Symptom Trajectories in Family Caregivers of Patients With Acute Cardiorespiratory Failure

Importance

Overall, 1 in 3 family caregivers of patients who require intensive care unit (ICU) admission will experience significant posttraumatic stress symptoms (PTSSs), but little is known about how PTSSs evolve over time. Measuring PTSS trajectories could facilitate the development of targeted interventions to improve mental health outcomes for family caregivers of critically ill patients.

Objective

To measure 6-month PTSS trajectories among caregivers of patients with acute cardiorespiratory failure.

Design, Setting, and Participants

This prospective cohort study was conducted in the medical ICU of a large academic medical center among adult patients requiring (1) vasopressors for shock, (2) high-flow nasal cannula, (3) noninvasive positive pressure ventilation, or (4) invasive mechanical ventilation. Each patient was enrolled along with their primary caregiver, ie, the unpaid individual who provided the most physical, emotional, or financial support prior to ICU admission.

Main Outcomes and Measures

Family caregiver PTSSs were assessed using the Impact of Events Scale-Revised within 48 hours of ICU admission, following ICU discharge, and 3 and 6 months after enrollment. Latent class growth analysis was used to measure PTSS trajectories. Preselected patient and caregiver characteristics measured at ICU admission were analyzed for association with trajectory membership. Six-month patient and caregiver outcomes were analyzed by caregiver trajectory.

Results

Overall, 95 family caregivers were enrolled and provided baseline data; mean (SD) age was 54.2 (13.6) years, 72 (76%) were women, 22 (23%) were Black individuals, and 70 (74%) were White individuals. Three trajectories were identified: persistently low (51 caregivers [54%]), resolving (29 [31%]), and chronic (15 [16%]). Low caregiver resilience, prior caregiver trauma, high patient severity of illness, and good patient premorbid functional status were associated with the chronic trajectory. Caregivers with the chronic PTSS trajectory had worse 6-month health-related quality of life (mean [SD] total 36-item Short Form Survey score, persistently low trajectory: 104.7 [11.3]; resolving trajectory: 101.7 [10.4]; chronic trajectory: 84.0 [14.4]; P < .001) and reduced effectiveness at work (mean [SD] perceived effectiveness at work score, persistently low trajectory: 86.0 [24.2]; resolving trajectory: 59.1 [32.7]; chronic trajectory: 72.3 [18.4]; P = .009).

Conclusions and Relevance

In this study, 3 distinct PTSS trajectories among ICU family caregivers were observed, with 16% of caregivers experiencing chronic PTSSs over the subsequent 6 months. Family caregivers with persistent PTSS had lower resilience, prior trauma, higher patient severity of illness, and higher baseline patient functional status compared with family caregivers with persistently low PTSS, with adverse effects on quality of life and work. Identifying these caregivers is an essential first step to develop interventions tailored to those with the greatest need for support.

Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial

BACKGROUND

Skilled nursing facility (SNF) patients and their caregivers who transition to home experience complications and frequently return to acute care. We tested the efficacy of the Connect-Home transitional care intervention on patient and caregiver preparedness for care at home, and other patient and caregiver-reported outcomes.

METHODS

We used a stepped wedge, cluster-randomized trial design to test the intervention against standard discharge planning (control). The setting was six SNFs and six home health offices in one agency. Participants were 327 dyads of patients discharged from SNF to home and their caregivers; 11.1% of dyads in the control condition and 81.2% in the intervention condition were enrolled after onset of COVID-19. Patients were 63.9% female and mean age was 76.5 years. Caregivers were 73.7% female and mean age was 59.5 years. The Connect-Home intervention includes tools, training, and technical assistance to deliver transitional care in SNFs and patients' homes. Primary outcomes measured at 7 days included patient and caregiver measures of preparedness for care at home, the Care Transitions Measure-15 (patient) and the Preparedness for Caregiving Scale (caregiver). Secondary outcomes measured at 30 and 60 days included the McGill Quality of Life Questionnaire, Life Space Assessment, Zarit Caregiver Burden Scale, Distress Thermometer, and self-reported number of patient days in the ED or hospital in 30 and 60 days following SNF discharge.

RESULTS

The intervention was not associated with improvement in patient or caregiver outcomes in the planned analyses. Post-hoc analyses that distinguished between pre- and post-pandemic effects suggest the intervention may be associated with increased patient preparedness for discharge and decreased number of acute care days.

CONCLUSIONS

Connect-Home transitional care did not improve outcomes in the planned statistical analysis. Post-hoc findings accounting for COVID-19 impact suggest SNF transitional care has potential to increase patient preparedness and decrease return to acute care.

Comfort First: Development and pilot testing of a web-based video training to disseminate Comfort Matters dementia care

BACKGROUND

Alzheimer's disease-related dementias (ADRD) are a leading cause of disability and death. In late-stage ADRD most people prioritize comfort, but care to achieve comfort is rare. Comfort Matters combines palliative and geriatric care practices for nursing home dementia care, but in-person training reaches few sites. To facilitate dissemination, we developed Comfort First, a web-based training toolkit with video demonstration of Comfort Matters practices.

METHODS

We developed and pilot-tested Comfort First (NIA Intervention Stage 1). Stakeholder advisors representing nursing home residents, caregiver, and clinical perspectives guided development. Professional videographers filmed Comfort Matters staff to illustrate comfort-focused dementia care skills. Video training modules, supported by an implementation manual, address Understanding the Person with Dementia, Promoting Quality of Life and Comfort, Working as a Team, Responding When People with Dementia are Distressed, Addressing Pain, and Making Comfort First a Reality. We then delivered Comfort First to 3 nursing homes. Implementation and outcome evaluation assessed the number and clinically diverse roles of trained staff and post-test knowledge.

RESULTS

Nursing home staff roles (n = 146) were diverse: certified nursing assistants (40%), nurses (19%), administrators (11%), activities staff (6%), therapy staff (5%) and other roles. Individual participants' knowledge scores ranged from 50-100%; however average post-test knowledge scores were high, ranging from 90% (Addressing Pain) to 99% (Promoting Quality of Life and Comfort, Making Comfort First a Reality).

CONCLUSIONS

The Comfort First web-based training toolkit combines best practices in palliative care and geriatric care for ADRD, using video demonstrations to support broader dissemination of these skills. Initial evaluation demonstrates acceptability and knowledge uptake for staff in diverse clinical roles; future research should include evaluation of practice change. Consistent with the intent of its public funding, Comfort First will be widely disseminated at a minimal cost.

GEEMAEE: A SAS macro for the analysis of correlated outcomes based on GEE and finite-sample adjustments with application to cluster randomized trials

BACKGROUND AND OBJECTIVES

Generalized estimating equations (GEE) are used to analyze correlated outcomes in marginal regression models with population-averaged interpretations of exposure effects. Limitations of popular software for GEE include: (i) user choice is restricted to a small set of within-cluster pairwise correlation (intra-class correlation; ICC) structures; and (ii) inference on ICC parameters is usually not possible because the precision of their estimates is not quantified. This is important because ICC values inform the design of cluster randomized trials. Beyond the standard GEE implementation, use of paired estimating equations (Prentice 1988) provides: (i) flexible specification of models for pairwise correlations and (ii) standard errors for ICC estimates. However, most GEEs give biased estimates of standard errors and correlations when the number of clusters is small (roughly, ≤40). Consequently, there is a need for software to provide GEE analysis with finite-sample bias-corrections.

METHODS

The SAS macro GEEMAEE implements paired estimating equations to simultaneously estimate parameters in marginal mean and ICC models. It provides bias-corrected standard errors and uses matrix-adjusted estimating equations (MAEE) for bias-corrected estimation of correlations. Several built-in correlation matrix options, rarely found in software, are offered for multi-period, cluster randomized trials and similarly structured longitudinal observational data structures. Additional options include user-specified correlation structures and deletion diagnostics, namely Cooks' Distance and DBETA statistics that estimate the influence of observations, cluster-periods (when applicable) and clusters.

RESULTS

GEEMAEE is illustrated for a binary and a count outcome in two stepped wedge cluster randomized trials and a binary outcome in a longitudinal study of disease surveillance. Use of MAEE resulted in larger values of correlation estimates compared to uncorrected estimating equations. Use of bias-corrected variance estimators resulted in (appropriately) larger values of standard errors compared to the usual sandwich estimators. Deletion diagnostics identified the clusters and cluster-periods having the most influence.

CONCLUSIONS

The SAS macro GEEMAEE provides regression analysis for clustered or longitudinal responses, and is particularly useful when the number of clusters is small. Flexible specification and bias-corrected estimation of pairwise correlation parameters and standard errors are key features of the software to provide valid inference in real-world settings.

A general method for calculating power for GEE analysis of complete and incomplete stepped wedge cluster randomized trials

Stepped wedge designs have uni-directional crossovers at randomly assigned time points (steps) where clusters switch from control to intervention condition. Incomplete stepped wedge designs are increasingly used in cluster randomized trials of health care interventions and have periods without data collection due to logistical, resource and patient-centered considerations. The development of sample size formulae for stepped wedge trials has primarily focused on complete designs and continuous responses. Addressing this gap, a general, fast, non-simulation based power procedure is proposed for generalized estimating equations analysis of complete and incomplete stepped wedge designs and its predicted power is compared to simulated power for binary and continuous responses. An extensive set of simulations for six and twelve clusters is based upon the Connect-Home trial with an incomplete stepped wedge design. Results show that empirical test size is well controlled using a t-test with bias-corrected sandwich variance estimator for as few as six clusters. Analytical power agrees well with a simulated power in scenarios with twelve clusters. For six clusters, analytical power is similar to simulated power with estimation using the correctly specified model-based variance estimator. To explore the impact of study design choice on power, the proposed fast GEE power method is applied to the Connect-Home trial design, four alternative incomplete stepped wedge designs and one complete design.

AGE-RELATED DIFFERENCES IN HEALTH-RELATED QUALITY OF LIFE AMONG WESTERN CANADIAN NURSING HOME RESIDENTS

Nursing homes (NHs) typically focus on health-related quality of life (HRQoL) among residents aged 65 and over despite approximately 7% of NH residents are younger (aged 18-64). Research suggests that the needs of younger NH residents are not being met and they may have low HRQoL. However, differences in HRQoL of younger and older NH residents may not be apparent in studies that use HRQoL measures designed for research with older NH residents. We hypothesized that the younger residents would have lower HRQoL mean scores than the older (aged ≥ 65) residents using a HRQoL measure based on the HRQoL score derived from Resident Assessment Instrument – Minimum Data Set 2.0 items. The measure uses items that emphasize physical aspects of quality of life rather than social aspects. In a sample of 21,129 residents from 94 NHs in Western Canada, we performed descriptive analyses, t-test, chi-square test, and an adjusted propensity score (PS) analysis through retrospective cohort study from years 2016 to 2017. The HRQoL index score ranged from -.351 to .996 (Mean= 0.693, SD=0.265). In the PS model, the adjusted mean score for younger was higher than for older adults with a mean difference at 0.061 (95% CI 0.031, 0.091) (p&lt;.001). Other domains such as mental health condition of quality of life must be examined in younger NH residents because it is a crucial factor influencing their daily lives, thereby we can explore a more complete set of HRQoL domains of them and redesign care for their unique needs.

UNMET TRANSITIONAL CARE NEEDS OF OLDER ADULTS DISCHARGED FROM HOME HEALTH CARE: A QUALITATIVE NEEDS ASSESSMENT

Transitional care is widely recognized as a set of time-limited services to support older adults during transfers between settings and providers of care; however, little is known about services that prepare older adults and their caregivers for transitions from Home Health Care (HHC) to independent self-care at home. The objective of this study was to describe HHC patients and clinician perceptions of unmet needs after HHC discharge and recommendations to address them in future research. A multiple case-study design was used in a single large HHC organization in North Carolina. Data were collected using chart reviews of HHC records and semi-structured interviews with paired patients (or caregivers as proxy) and HHC clinicians (Nf17 pairs). A transitional care intervention model was used as a conceptual framework to guide framework analysis of interview transcripts. Most patients were White (65%) and female (53%) with mean age of 83 years. Clinicians were Registered nurses and Physical therapists. Across cases, 17 patient and clinicians pairs described three unmet needs: (1)skills for symptom management; (2)community-based support for transportation, food, social engagement, and health services; (3)in-home support to assist with safety, and activities of daily living. HHC patients recommended new services while clinicians emphasized the need for resources to improve their capacity to prepare patients for discharge. These findings will inform an innovative adaptation of transitional care and other supports to prepare older adults and caregivers for transitions from HHC to independent self-care at home. Future research should explore adding transitional care services to address these needs.

LIGHT THERAPY FOR SLEEP DISTURBANCE OF NURSING FACILITY RESIDENTS WITH DEMENTIA: A SYSTEMATIC REVIEW

Background

Bright light therapy has shown promise in addressing sleep problems in nursing facility residents with dementia. However, recent studies yielded conflicting outcomes and few studies focused on nursing facilities. The purpose of this systematic review was to describe effectiveness of light interventions in nursing facility residents with dementia. Method: We searched PubMed, CINAHL, EMBASE, PsychINFO, and Scopus using key terms “sleep”, “dementia” and “residential facilities”, and synthesized data with thematic analysis and vote-counting.

Results

Of eight studies that met inclusion criteria, six were randomized controlled trials and 2 were quasi-experimental. Sample size ranged from 11 to 77 residents. Studies tested 3 light therapies: timed bright light (n=6), timed regular light (n=1), and variable 24hour light (n=1). Light delivery method, light exposure, and adherence to therapy protocols were not consistently reported. All studies indicated light therapy improved some resident outcomes, such as sleep efficacy and total sleep time; however, 88% of studies did not report sampling strategies or a statistical power analysis and 22% had small sample size (n < 15).

Conclusion

Insufficient evidence is available to recommend light therapies for nursing facility residents with dementia. Adequately statistically powered studies that are rigorously designed with representative samples are needed for robust estimation of the effects of light therapy on sleep. Future studies must account for the unique characteristics of nursing facility residents with dementia that impact their adherence to light therapy.

PATIENT AND CAREGIVER PERCEPTIONS OF MOBILITY AFTER DISCHARGE FROM SKILLED NURSING FACILITIES TO HOME

Functional outcomes of older adults in post-acute care is poorly understood. The purpose of this study was to describe skilled nursing facility (SNF) patient or caregiver perceptions of patient mobility and factors associated with patient mobility in 30 days after discharge from SNF to home. We conducted a secondary analysis of data from a stepped-wedge cluster randomized trial of the Connect-Home intervention set in 6 SNFs in North-Carolina. The sample included SNF patients (N=249) and their caregivers (N=249). In 30 days after discharge, SNF patients or their caregivers (as proxies) rated patient mobility using the Life-Space Assessment (LSA). LSA total-scores (range= 0-120), with higher scores indicating greater mobility. Linear mixed models, with random effects to adjust for clustering in SNFs, were used to describe associations between LSA total-score and patient, caregiver, and health-system factors. Participants were typically female (63%), White (74%), and average age of 76.3 years. In 30 days after discharge, LSA total-scores ranged from 0-90 with a mean score of 22 (SD=16.01). Most (85%) required caregiver and/or assistive devices to transfer inside and outside of their homes. In the mixed models, lower LSA scores were associated with older age [-0.232(0.108), p< 0.05], lower cognition score [1.182(0.384), p< 0.005], diagnosis of dementia [-6.863(3.057), p< 0.05], lower baseline mobility in the SNF [0.296(0.142), p< 0.05] and longer SNF stay [-0.200(0.068), p< 0.005]. Low LSA scores in this sample suggest the need for caregiver support to continue rehabilitation and promote functional ability at home. Studies are needed to augment transitional care and address these care needs.

Adapting the Connect-Home transitional care intervention for the unique needs of people with dementia and their caregivers: A feasibility study

AIMS

After leaving skilled nursing facilities (SNF), 20% of people with dementia (PWD) are re-hospitalized within 30 days. We assessed fidelity, acceptability, preliminary outcomes, and mechanisms of the Connect-Home ADRD transitional care intervention.

DESIGN

A feasibility study of Connect-Home ADRD.

METHODS

The Connect-Home intervention was adapted for dementia-specific needs. PWD and caregiver dyads in 2 SNFs received transitional care. Data sources included interviews with PWD and caregivers and a review of health records.

RESULTS

19 of 34 eligible dyads (56%) were enrolled. The intervention was feasible (components delivered for >84% of dyads) and acceptable (dyads rated it very helpful and not difficult to use). Connect-Home ADRD adaptations included in-home support to manage symptoms of dementia and unplanned events, such as transition to hospice.

IMPACT

Connect-Home ADRD is feasible, acceptable, and merits future research as an intervention to reduce rapid return to acute care following SNF stays.

A Cross-Sectional, Correlational Study Comparing Individual Characteristics of Younger and Older Nursing Home Residents Using Western Canadian Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0

OBJECTIVE

To compare characteristics of nursing home (NH) residents by age categories in Western Canada.

DESIGN

A cross-sectional, correlational analysis of secondary data.

SETTING AND PARTICIPANTS

89,231 residents living in Western Canada NHs in the provinces of Alberta, Manitoba, and British Columbia in 2016 and 2017.

METHODS

Resident characteristics (age, sex, marital status, body mass index, medical diagnoses, cognitive function, physical function, depressive symptoms) came from the Resident Assessment Instrument-Minimum Data Set 2.0 and were analyzed using chi-square, analysis of variance, and post hoc pairwise tests. Human developmental stage age categories were used to create 5 age groups: 18-34, 35-50, 51-64, 65-80, and 81 years and older.

RESULTS

The demographics, medical diagnoses, cognitive function, and physical function characteristics of NH residents among 5 age groups differed considerably (all P < .001). Residents aged 18-34 years were predominately male, never married, with a higher incidence of paralysis and traumatic brain injury. Residents aged 35-50 years had a higher incidence of stroke and multiple sclerosis, and residents aged 51-64 years mainly were morbidly obese and more prone to depression. Residents aged 65-80 years were predominately married and more prone to diabetes, and residents aged 81 years and older were predominately widowed, with a higher incidence of dementia compared with others.

CONCLUSIONS AND IMPLICATIONS

Findings describe the uniqueness of younger NH age groups and indicate that the youngest NH residents often have the severe disability and a modest support system (as defined by partnered status) compared to older residents in NHs. Future studies must analyze longitudinal data that track the growth of, and changes in, residents' health and functional status.

Unique Care Needs of People with Dementia and Their Caregivers during Transitions from Skilled Nursing Facilities to Home and Assisted Living: A Qualitative Study

OBJECTIVES

The purpose of the study was to describe unique care needs of people with dementia (PWD) and their caregivers during transitions from skilled nursing facilities (SNF) to home.

DESIGN

A qualitative study using focus groups, semistructured interviews, and descriptive qualitative analysis.

SETTING AND PARTICIPANTS

The study was set in one state, in 4 SNFs where staff had experience using a standardized transitional care protocol. The sample included 22 SNF staff, 4 home health nurses, 10 older adults with dementia, and their 10 family caregivers of whom 39 participated in focus groups and/or interviews.

METHODS

Data collection included 4 focus groups with SNF staff and semistructured interviews with home health nurses, SNF staff, PWD, and their family caregivers. Standardized focus group and interview guides were used to elicit participant perceptions of transitional care. We used the framework analytic approach to qualitative analysis. A steering committee participated in interpretation of findings.

RESULTS

Participants described 4 unique care needs: (1) PWD and caregivers may not be ready to fully engage in dementia care planning while in the SNF, (2) caregivers are not prepared to manage dementia symptoms at home, (3) SNF staff have difficulty connecting PWD and caregivers to community supports, and (4) caregivers receive little support to address their own needs.

CONCLUSIONS AND IMPLICATIONS

Based on findings, recommendations are offered for adapting transitional care to address the needs of PWD and their caregivers. Further research is needed (1) to confirm these findings in larger, more diverse samples and (2) to adapt and test interventions to support successful community discharge of PWD and their caregivers.

A Cross-Sectional Study Comparing Younger and Older Nursing Home Residents in Western Canada

Specialized care for younger nursing home (NH) residents may be necessary to meet their unique health and quality of life needs; however, key attributes of younger NH residents are poorly understood and limit the development of effective, tailored interventions. This study described differences in clinical and nonclinical characteristics of younger vs. older nursing NH residents. In a retrospective cohort study, we used SPSS and analyzed comprehensive Resident Assessment Instrument – Minimum Data Set (RAI-MDS 2.0) data from NHs in Western Canada, for the period from January 2016 to December 2017. We included all assessments (full and abbreviated) performed quarterly. These findings indicated that younger (age 18-64) vs. older (age >=65) NH residents differed considerably: younger residents were predominately male, single, more obese, more depressed, had higher prevalence of depression, cerebral vascular accident, and hemi- or quadriplegia, and required more assistance in activities of daily living than older residents. The findings will contribute a better comprehension of the characteristics of the younger NH population and how they differ from other residents. The study provides useful information to policymakers, providers, and researchers to guide them in developing tailored policies, programs, and interventions. Also, findings may guide consumers as they plan for long-term care needs of loved ones. Finally, the findings provide a baseline estimate as researchers continue to track the growth of and changes in, the populations served in nursing homes.

The Challenge of Providing Evidence-based Transitional Care

Transitions in care are events that occur as individuals transfer between settings and providers of healthcare. The movement from a hospital to home-based care is a common example of a care transition. Due to common breakdowns between health and social care systems, continuing risks for acute health events, and the lack of support to manage complex treatments at home, between 15-20% of hospitalized adults are rehospitalized within thirty days of returning home. This high rate of hospital readmissions points up the need for transitional care services to address challenges in continuing care at home

Quality improvement studies in nursing homes: a scoping review

BACKGROUND

Quality improvement (QI) is used in nursing homes (NH) to implement and sustain improvements in patient outcomes. Little is known about how QI strategies are used in NHs. This lack of information is a barrier to replicating successful strategies. Guided by the Framework for Implementation Research, the purpose of this study was to map-out the use, evaluation, and reporting of QI strategies in NHs.

METHODS

This scoping review was completed to identify reports published between July 2003 through February 2019. Two reviewers screened articles and included those with (1) the term "quality improvement" to describe their methods, or reported use of a QI model (e.g., Six Sigma) or strategy (e.g., process mapping) (2), findings related to impact on service and/or resident outcomes, and (3) two or more NHs included. Reviewers extracted data on study design, setting, population, problem, solution to address problem, QI strategies, and outcomes (implementation, service, and resident). Vote counting and narrative synthesis were used to describe the use of QI strategies, implementation outcomes, and service and/or resident outcomes.

RESULTS

Of 2302 articles identified, the full text of 77 articles reporting on 59 studies were included. Studies focused on 23 clinical problems, most commonly pressure ulcers, falls, and pain. Studies used an average of 6 to 7 QI strategies. The rate that strategies were used varied substantially, e.g., the rate of in-person training (55%) was more than twice the rate of plan-do-study-act cycles (20%). On average, studies assessed two implementation outcomes; the rate these outcomes were used varied widely, with 37% reporting on staff perceptions (e.g., feasibility) of solutions or QI strategies vs. 8% reporting on fidelity and sustainment. Most studies (n = 49) reported service outcomes and over half (n = 34) reported resident outcomes. In studies with statistical tests of improvement, service outcomes improved more often than resident outcomes.

CONCLUSIONS

This study maps-out the scope of published, peer-reviewed studies of QI in NHs. The findings suggest preliminary guidance for future studies designed to promote the replication and synthesis of promising solutions. The findings also suggest strategies to refine procedures for more effective improvement work in NHs.

Supporting the Dynamic Careers of Licensed Practical Nurses: A Strategy to Bolster the Long-Term Care Nurse Workforce

As the U.S. population ages and the demand for long-term care increases, an insufficient number of licensed practical nurses (LPNs) is expected in the nursing workforce. Understanding the characteristics of LPN participation in the workforce is essential to address this challenge. Drawing on the theory of boundaryless careers, the authors examined longitudinal employment data from LPNs in North Carolina and described patterns in LPN licensure and career transitions. Two career patterns were identified: (a) the continuous career, in which LPNs were licensed in 75% or more of the years they were eligible to be licensed and (b) the intermittent career, in which lapses in licensure occurred. Findings indicated that LPNs who made job transitions were more likely to demonstrate continuous careers, as were Black LPNs. These findings suggest the importance of organizational support for LPN career transitions and support for diversity in the LPN workforce.

St. Luke's International University and University of North Carolina at Chapel Hill collaboration project to develop the first DNP program in Japan

We report an international collaborative project to develop the first Doctor of Nursing Practice (DNP) program in Japan. We described the development and implementation of the first DNP program at the St. Luke's International University in Tokyo and the collaboration with the University of North Carolina at Chapel Hill in the United States. Faculty perceptions in both parties gradually evolved from the traditional perspective of international collaboration to the transitional and the beginning of the holistic partnership perspectives. The collaboration resulted in an innovative DNP program that directly addressed the gap between nursing education programs and Japan's clinical needs. The collaborative project cultivated a holistic international partnership. Rather than reporting a manual for international collaboration, we present our reflections and outcomes as narratives that others could use to achieve a holistic global partnership.

Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative

Proctor's Framework for Implementation Research describes the role of implementation strategies and outcomes in the pathway from evidence-based interventions to service and client outcomes. This report describes the evaluation of a learning collaborative to implement a transitional care intervention in skilled nursing facilities (SNF). The collaborative protocol included implementation strategies to promote uptake of a transitional care intervention in SNFs. Using RE-AIM to evaluate outcomes, the main findings were intervention reach to 550 SNF patients, adoption in three of four SNFs that expressed interest in participation, and high fidelity to the implementation strategies. Fidelity to the transitional care intervention was moderate to high; SNF staff provided the five key components of the transitional care intervention for 64-93% of eligible patients. The evaluation was completed during the COVID-19 pandemic, which suggests the protocol was valued by staff and feasible to use amid serious internal and external challenges.

Posttraumatic Stress Disorder Symptom Trajectories in ICU Family Caregivers

To use latent class growth analysis to identify posttraumatic stress disorder symptom trajectories in ICU family caregivers.

DESIGN

Prospective cohort study.

SETTING

The medical ICU at a tertiary-care center in the United States.

PARTICIPANTS

Adult patients experiencing acute cardiorespiratory failure (defined as requiring at least one of the following: 1) vasopressors, 2) noninvasive positive pressure ventilation, 3) high-flow nasal cannula, or 4) mechanical ventilation) were enrolled in a pair with their primary family caregivers.

MEASUREMENTS AND MAIN RESULTS

Participants were enrolled within the first 48 hours of ICU admission. Family caregiver posttraumatic stress disorder symptoms were measured using the Impact of Events Scale-Revised at four time points: at enrollment, shortly after ICU discharge, and at 3 and 6 months after ICU discharge. The data were examined using latent class growth analysis to identify posttraumatic stress disorder symptom trajectories. Two distinct symptom trajectories were identified: a persistently high trajectory, characterized by high posttraumatic stress disorder symptoms at initial assessment, which remained elevated over time, and a persistently low trajectory, characterized by low posttraumatic stress disorder symptoms at initial assessment, which remained low over time. Approximately two-thirds of caregivers belonged to the persistently high trajectory, and one-third of caregivers belonged to the persistently low trajectory.

CONCLUSIONS

Using latent class growth analysis to measure 6-month ICU family caregiver posttraumatic stress disorder symptom trajectories, we identified two distinct trajectories (persistently low and persistently high). A larger cohort study is warranted to further delineate posttraumatic stress disorder trajectories in this population, with the ultimate goal of targeting high-risk caregivers for interventions to reduce psychologic distress and improve long-term caregiver outcomes.

Transitional care from skilled nursing facilities to home: study protocol for a stepped wedge cluster randomized trial

Background

Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute care use is over 50% within 90 days of discharge, yet these patients and their caregivers often do not receive the quality of transitional care that prepares them to manage serious illnesses at home.

Methods

The study will test the efficacy of Connect-Home, a successfully piloted transitional care intervention targeting seriously ill SNF patients discharged to home and their caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and caregiver preparedness for caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute care use and (b) caregivers’ burden and distress.

Discussion

Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve transitional care for seriously ill SNF patients and their caregivers, (b) prevent avoidable days of acute care use in a population with persistent risks from chronic conditions, and (c) advance the science of transitional care within end-of-life and palliative care trajectories of SNF patients and their caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications.

Trial registration

ClinicalTrials.gov NCT03810534. Registered on January 18, 2019.

What does it take to scale-up a complex intervention? Lessons learned from the Connect-Home transitional care intervention

AIMS

To discuss the multiple phases of research done to plan for wide-scale implementation (i.e. scale-up) of Connect-Home, a complex nurse-develop intervention. Barker et al.'s (Implementation Science, 2016, 11, 12) framework for intervention scale-up is applied to address the methods used to answer the following four questions: 'Who' needs to be involved in scale-up? 'What' intervention and implementation strategies need to be taken to scale? 'How' will scale-up be achieved? And what contextual factors influence 'when' scale-up is or is not successful?

DESIGN

Discussion paper.

DATA SOURCES

Data sources include the experience of our research team, supported by literature and theory. The Connect-Home team conducted multiple research studies to plan for Connect-Home scale-up. Early studies (2008-2015) focused on formative work to design the Connect-Home intervention. Recent studies have involved successive pilot tests of Connect-Home's effectiveness, implementation, and scale-up (2015-2019).

IMPLICATIONS FOR NURSING

This article describes a systematic approach that nurse researchers can apply to plan for taking their interventions to scale.

CONCLUSIONS

Planning for scale-up early in the process of intervention development is essential to speeding the translation of effective interventions into wide-scale practice.

IMPACT

This article details the methods that nursing researchers applied to develop and test the strategies needed to plan for taking a complex intervention to scale across multiple settings. The methods described are applicable to nursing and other health researchers' development and scale-up of any complex intervention.

Advancing Long-Term Care Science Through Using Common Data Elements: Candidate Measures for Care Outcomes of Personhood, Well-Being, and Quality of Life

To support the development of internationally comparable common data elements (CDEs) that can be used to measure essential aspects of long-term care (LTC) across low-, middle-, and high-income countries, a group of researchers in medicine, nursing, behavioral, and social sciences from 21 different countries have joined forces and launched the Worldwide Elements to Harmonize Research in LTC Living Environments (WE-THRIVE) initiative. This initiative aims to develop a common data infrastructure for international use across the domains of organizational context, workforce and staffing, person-centered care, and care outcomes, as these are critical to LTC quality, experiences, and outcomes. This article reports measurement recommendations for the care outcomes domain, focusing on previously prioritized care outcomes concepts of well-being, quality of life (QoL), and personhood for residents in LTC. Through literature review and expert ranking, we recommend nine measures of well-being, QoL, and personhood, as a basis for developing CDEs for long-term care outcomes across countries. Data in LTC have often included deficit-oriented measures; while important, reductions do not necessarily mean that residents are concurrently experiencing well-being. Enhancing measurement efforts with the inclusion of these positive LTC outcomes across countries would facilitate international LTC research and align with global shifts toward healthy aging and person-centered LTC models.

Perceptions of Family Decision-makers of Nursing Home Residents With Advanced Dementia Regarding the Quality of Communication Around End-of-Life Care

OBJECTIVES

(1) Compare family decision-makers' perceptions of quality of communication with nursing home (NH) staff (nurses and social workers) and clinicians (physicians and other advanced practitioners) for persons with advanced dementia; (2) determine the extent to which characteristics of NH residents and family decision-makers are associated with those perceptions.

DESIGN

Secondary analysis of baseline data from a cluster randomized trial of the Goals of Care intervention.

SETTING

Twenty-two NHs in North Carolina.

PARTICIPANTS

Family decision-makers of NH residents with advanced dementia (n = 302).

MEASUREMENTS

During the baseline interviews, family decision-makers rated the quality of general communication and communication specific to end-of-life care using the Quality of Communication Questionnaire (QoC). QoC item scores ranged from 0 to 10, with higher scores indicating better quality of communication. Linear models were used to compare QoC by NH provider type, and to test for associations of QoC with resident and family characteristics.

RESULTS

Family decision-makers rated the QoC with NH staff higher than NH clinicians, including average overall QoC scores (5.5 [1.7] vs 3.7 [3.0], P < .001), general communication subscale scores (8.4 [1.7] vs 5.6 [4.3], P < .001), and end-of-life communication subscale scores (3.0 [2.3] vs 2.0 [2.5], P < .001). Low scores reflected failure to communicate about many aspects of care, particularly end-of-life care. QoC scores were higher with later-stage dementia, but were not associated with the age, gender, race, relationship to the resident, or educational attainment of family decision-makers.

CONCLUSION

Although family decision-makers for persons with advanced dementia rated quality communication with NH staff higher than that with clinicians, they reported poor quality end-of-life communication for both staff and clinicians. Clinicians simply did not perform many communication behaviors that contribute to high-quality end-of-life communication. These omissions suggest opportunities to clarify and improve interdisciplinary roles in end-of-life communication for residents with advanced dementia.

Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities

Prior studies have not described strategies for implementing transitional care in skilled nursing facilities (SNFs). As part of the Connect-Home study, we pilot tested the Transition Plan of Care (TPOC) template, an implementation tool that SNF staff used to deliver transitional care. A retrospective chart review was used to describe the impact of the TPOC template on three implementation outcomes: reach to patients, staff adoption of the template, and staff fidelity to the intervention protocol for transition care planning. The template reached 100% of eligible patients (N = 68). Adoption was high, with documentation by four disciplines in 90.6% of patient records (N = 61). Fidelity to the intervention protocol was moderately high, with 73% of documentation that was concordant with the protocol. Our findings suggest an electronic medical record (EMR)-based implementation tool may increase the ability of staff to prepare older adults and their caregivers for self-care at home. Further research is needed to test the efficacy of the protocol on patient outcomes after transitions from SNF to home.

Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes: A Cluster-Randomized Trial

IMPORTANCE

New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls.

OBJECTIVE

To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS).

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls.

INTERVENTIONS

CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality's Falls Management Program.

MAIN OUTCOMES AND MEASURES

Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate.

RESULTS

Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration.

CONCLUSIONS AND RELEVANCE

An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00636675.

Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers

BACKGROUND

Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional care of SNF patients (i.e., time-limited services to ensure coordination and continuity of care) is poorly understood.

OBJECTIVE

To determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads.

DESIGN

A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family caregivers.

SETTING

Three SNFs in the Southeastern United States.

PARTICIPANTS

Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge.

INTERVENTION

The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver transitional care of patient and caregiver dyads.

MEASUREMENTS

Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15).

RESULTS

The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24).

CONCLUSION

Connect-Home is a promising transitional care intervention for older patients discharged from SNF care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.

Rural-Urban Differences in the Effect of Follow-Up Care on Postdischarge Outcomes

OBJECTIVE

To assess rural-urban differences in quality of postdischarge care among Medicare beneficiaries, controlling for selection bias of postdischarge services.

DATA SOURCES

The Medicare Current Beneficiary Survey (MCBS), Cost and Use Files from 2000 to 2010, the Area Resource File, Provider of Services File, and the Dartmouth Atlas of Health Care.

STUDY DESIGN

Retrospective analysis of 30- and 60-day hospital readmission, emergency department (ED) use, and mortality using two-stage residual inclusion; receipt of 14-day follow-up care was the main independent variable.

DATA EXTRACTION METHOD

We defined index admission from the MCBS as any admission without a previous admission within 60 days.

PRINCIPAL FINDINGS

Noninstrumental variables estimation was the preferred estimation strategy. Fourteen-day follow-up care reduced the risk of readmission, ED use, and mortality. There were no rural- urban differences in the effect of 14-day follow-up care on readmission and mortality. Rural beneficiaries experienced a greater effect of 14-day follow-up care on reducing 30-day ED use compared to urban beneficiaries.

CONCLUSIONS

Follow-up care reduces 30- and 60-day readmission, ED use, and mortality. Rural and urban Medicare beneficiaries experience similar beneficial effects of follow-up care on the outcomes. Policies that improve follow-up care in rural settings may be beneficial.

An untapped resource in the nursing workforce: Licensed practical nurses who transition to become registered nurses

BACKGROUND

A more diverse registered nurse (RN) workforce is needed to provide health care in North Carolina (NC) and nationally. Studies describing licensed practical nurse (LPN) career transitions to RNs are lacking.

PURPOSE

To characterize the occurrence of LPN-to-RN professional transitions; compare key characteristics of LPNs who do and do not make such a transition; and compare key characteristics of LPNs who do transition in the years prior to and following their transition.

METHODS

A retrospective design was conducted using licensure data on LPNs from 2001 to 2013. Cohorts were constructed based on year of graduation.

FINDINGS

Of 39,398 LPNs in NC between 2001 and 2013, there were 3,161 LPNs (8.0%) who had a LPN-to-RN career transition between 2001 and 2013. LPNs were more likely to transition to RN if they were male; from Asian, American Indian, or other racial groups; held an associate or baccalaureate degree in their last year as an LPN (or their last year in the study if they did not transition); worked in a hospital inpatient setting; worked in the medical-surgical nursing specialty; and were from a rural area.

DISCUSSION

Our findings indicate that the odds of an LPN-to-RN transition were greater if LPNs were: male; from all other racial groups except white; of a younger age at their first LPN licensure; working in a hospital setting; working in the specialty of medical-surgical nursing; employed part-time; or working in a rural setting during the last year as an LPN.

CONCLUSION

This study fills an important gap in our knowledge of LPN-to-RN transitions. Policy efforts are needed to incentivize: LPNs to make a LPN-to-RN transition; educational entities to create and communicate curricular pathways; and employers to support LPNs in making the transition.

Study of Individualization and Bias in Nursing Home Fall Prevention Practices

OBJECTIVES

Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias.

DESIGN

Randomized factorial clinical vignette survey.

SETTING

Sixteen nursing homes in North Carolina.

PARTICIPANTS

Nursing, rehabilitation, and social services staff (n = 433).

MEASUREMENTS

Vignettes describing hypothetical residents were generated from a matrix of clinical and demographic characteristics. Resident age, race and gender were suggested by a photo. Participants completed up to four randomly assigned vignettes (n = 1615), rating the likelihood that 12 fall prevention activities would be used for the resident. Fixed and random effects mixed model analysis examined the impact of vignette resident characteristics and staff characteristics on four intervention categories.

RESULTS

Staff reported a higher likelihood of fall prevention activities in all four categories for residents with a prior fall (0.2-0.5 points higher, 10 point scale, P < 0.05), but other risk factors did not affect scores. There was little evidence of individualization; only dementia increased the reported likelihood of environmental modification (0.3, P < 0.001, 95% CI 0.2-0.5). Individualization did not vary with staff licensure category or clinical experience. Registered nurses consistently reported higher likelihoods of all fall prevention activities than did licensed practical nurses, unlicensed staff and other professional staff (1.0-2.7 points, P < 0.001 to 0.005). There was a small degree of implicit racial bias; staff indicated that environmental modification would be less likely to occur in otherwise identical vignettes including a photo of a black rather than a white resident (-0.2 points, 95% CI -0.3 to -0.1).

CONCLUSION

Nursing home staff report a standardized approach to fall prevention without individualization. We found a small impact from implicit racial bias that should be further explored.

Impact of Postdischarge Follow-Up Care on Medicare Expenditures: Does Rural Make a Difference?

Reducing postdischarge Medicare expenditures is a key focus for hospitals. Early follow-up care is an important piece of this focus, but it is unclear whether there are rural–urban differences in the impact of follow-up care on Medicare expenditures. To assess this difference, we use the Medicare Current Beneficiary Survey, Cost and Use Files, 2000-2010. We conduct a retrospective analysis of 30-day postdischarge Medicare expenditures using two-stage residual inclusion with a quantile regression, where the receipt of 7-day follow-up care was the main independent variable. Postdischarge follow-up care increased the 25th percentile of 30-day expenditures, decreased the 75th percentile, and there were no rural–urban differences. Partial effects show postdischarge follow-up care resulted in higher 30-day expenditures among low-cost rural beneficiaries. Ensuring early follow-up care for high-cost beneficiaries may be advantageous to both rural and urban providers in helping reduce postdischarge Medicare expenditures.

"In Our Corner": A Qualitative Descriptive Study of Patient Engagement in a Community-Based Care Coordination Program

The purpose of this study was to explore participants' experience in the Health Quality Partners (HQP) Care Coordination Program that contributed to their continued engagement. Older adults with multiple chronic conditions often have limited engagement in health care services and face fragmented health care delivery. This can lead to increased risk for disability, mortality, poor quality of life, and increased health care utilization. A qualitative descriptive design with two focus groups was conducted with a total of 20 older adults enrolled in HQP's Care Coordination Program. Conventional content analysis was the analytical technique. The overarching theme resulting from the analysis was "in our corner," with subthemes "opportunities to learn and socialize" and "dedicated nurses," suggesting that these are the primary contributing factors to engagement in HQP's Care Coordination Program. Study findings suggest that nurses play an integral role in patient engagement among older adults enrolled in a care coordination program.

Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers

Background

Little is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC.

Methods

In eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports.

Results

Staff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using “train the trainer” approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability.

Conclusions

When designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability.

Trial registration

ClinicalTrial.gov, NCT00636675

Transitional care in skilled nursing facilities: a multiple case study

BACKGROUND

Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement.

METHODS

In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services.

RESULTS

Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions.

CONCLUSIONS

Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.

Transitional care of older adults in skilled nursing facilities: A systematic review

Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients.

Managing Chronic Illness

Models of care coordination can significantly improve health outcomes for older adults with chronic illnesses if they can engage participants. The purpose of this study was to examine the impact of nursing contact on the rate of participants' voluntary disenrollment from a care coordination program. In this retrospective cohort study using administrative data for 1,524 participants in the Health Quality Partners Medicare Care Coordination Demonstration Program, the rate of voluntary disenrollment was approximately 11%. A lower risk of voluntary disenrollment was associated with a greater proportion of in-person (vs. telephonic) nursing contact (Hazard Ratio [HR] 0.137, confidence interval [CI] [0.050, 0.376]). A higher risk of voluntary disenrollment was associated with lower continuity of nurses who provided care (HR 1.964, CI [1.724, 2.238]). Findings suggest that in-person nursing contact and care continuity may enhance enrollment of chronically ill older adults and, ultimately, the overall health and well-being of this population.

Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities

BACKGROUND AND OBJECTIVES

Older adults with ESRD often receive care in skilled nursing facilities (SNFs) after an acute hospitalization; however, little is known about acute care use after SNF discharge to home.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study used Medicare claims for North and South Carolina to identify patients with ESRD who were discharged home from a SNF between January 1, 2010 and August 31, 2011. Nursing Home Compare data were used to ascertain SNF characteristics. The primary outcome was time from SNF discharge to first acute care use (hospitalization or emergency department visit) within 30 days. Cox proportional hazards models were used to identify patient and facility characteristics associated with the outcome.

RESULTS

Among 1223 patients with ESRD discharged home from a SNF after an acute hospitalization, 531 (43%) had at least one rehospitalization or emergency department visit within 30 days. The median time to first acute care use was 37 days. Characteristics associated with a shorter time to acute care use were black race (hazard ratio [HR], 1.25; 95% confidence interval [95% CI], 1.04 to 1.51), dual Medicare-Medicaid coverage (HR, 1.24; 95% CI, 1.03 to 1.50), higher Charlson comorbidity score (HR, 1.07; 95% CI, 1.01 to 1.12), number of hospitalizations during the 90 days before SNF admission (HR, 1.12; 95% CI, 1.03 to 1.22), and index hospital discharge diagnoses of cellulitis, abscess, and/or skin ulcer (HR, 2.59; 95% CI, 1.36 to 4.45). Home health use after SNF discharge was associated with a lower rate of acute care use (HR, 0.72; 95% CI, 0.59 to 0.87). There were no statistically significant associations between SNF characteristics and time to first acute care use.

CONCLUSIONS

Almost one in every two older adults with ESRD discharged home after a post-acute SNF stay used acute care services within 30 days of discharge. Strategies to reduce acute care utilization in these patients are needed.

Evaluation of Cueing Innovation for Pressure Ulcer Prevention Using Staff Focus Groups

The purpose of the manuscript is to describe long-term care (LTC) staff perceptions of a music cueing intervention designed to improve staff integration of pressure ulcer (PrU) prevention guidelines regarding consistent and regular movement of LTC residents a minimum of every two hours. The Diffusion of Innovation (DOI) model guided staff interviews about their perceptions of the intervention's characteristics, outcomes, and sustainability.

METHODS

This was a qualitative, observational study of staff perceptions of the PrU prevention intervention conducted in Midwestern U.S. LTC facilities (N = 45 staff members). One focus group was held in each of eight intervention facilities using a semi-structured interview protocol. Transcripts were analyzed using thematic content analysis, and summaries for each category were compared across groups.

RESULTS

The a priori codes (observability, trialability, compatibility, relative advantage and complexity) described the innovation characteristics, and the sixth code, sustainability, was identified in the data. Within each code, two themes emerged as a positive or negative response regarding characteristics of the innovation. Moreover, within the sustainability code, a third theme emerged that was labeled "brainstormed ideas", focusing on strategies for improving the innovation.

IMPLICATIONS

Cueing LTC staff using music offers a sustainable potential to improve PrU prevention practices, to increase resident movement, which can subsequently lead to a reduction in PrUs.