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Meehan A, Brazier JF, Grabowski DC, Rahman M, Shield RR, Gadbois EA. Administrator Perspectives on the Impact of COVID-19 on the Administration of the Patient Driven Payment Model in U.S. Skilled Nursing Facilities. Med Care Res Rev 2024; 81:223-232. [PMID: 38419595 DOI: 10.1177/10775587241233018] [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] [Indexed: 03/02/2024]
Abstract
The Patient Driven Payment Model (PDPM) was implemented in U.S. skilled nursing facilities (SNFs) in October 2019, shortly before COVID-19. This new payment model aimed to reimburse SNFs for patients' nursing needs rather than the previous model which reimbursed based on the volume of therapy received. Through 156 semi-structured interviews with 40 SNF administrators from July 2020 to December 2021, this qualitative study clarifies the impact of COVID-19 on the administration of PDPM at SNFs. Interview data were analyzed using modified grounded theory and thematic analysis. Our findings show that SNF administrators shifted focus from management of the PDPM to COVID-19-related delivery of care adaptations, staff shortfalls, and decreased admissions. As the pandemic abated, administrators re-focused their attention to PDPM. Policy makers should consider the continued impacts of the pandemic at SNFs, particularly on delivery of care, admissions, and staffing, on the ability of SNF administrators to administer a new payment model.
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Gadbois EA, Brazier JF, White EM, Hawes C, Meehan A, Rafat A, Geng F, Rahman M, Grabowski DC, Shield RR. Caring for nursing home residents with dementia during the COVID-19 pandemic: Perspectives from administrators. J Am Geriatr Soc 2024; 72:935-941. [PMID: 37823457 DOI: 10.1111/jgs.18634] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/08/2023] [Accepted: 09/17/2023] [Indexed: 10/13/2023]
Abstract
See related Editorial by Unroe and Towsley in this issue.
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Affiliation(s)
- Emily A Gadbois
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Joan F Brazier
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Elizabeth M White
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Courtney Hawes
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Amy Meehan
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Aseel Rafat
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Fangli Geng
- Harvard Medical School, Boston, Massachusetts, USA
| | - Momotazur Rahman
- Brown University School of Public Health, Providence, Rhode Island, USA
| | | | - Renee R Shield
- Brown University School of Public Health, Providence, Rhode Island, USA
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Gadbois EA, Brazier JF, Meehan A, Madrigal C, White EM, Rafat A, Grabowski D, Shield RR. COVID-19 Vaccination Among Skilled Nursing Facility Staff: Challenges and Strategies Identified by Administrators. Med Care Res Rev 2023; 80:608-618. [PMID: 37170944 PMCID: PMC10185450 DOI: 10.1177/10775587231168435] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/16/2023] [Indexed: 05/13/2023]
Abstract
COVID-19 vaccinations are critical for mitigating outbreaks and reducing mortality for skilled nursing facility (SNF) residents and staff, yet uptake among SNF staff varies widely and remains suboptimal. Understanding which strategies are successful for promoting staff vaccination, and examining the relationship between vaccination policies and staff retention/turnover is key for identifying best practices. We conducted repeated interviews with SNF administrators at 3-month intervals between July 2020 and December 2021 (n = 156 interviews). We found that COVID-19 vaccines were initially met with both enthusiasm and skepticism by SNF staff. Administrators reported strategies to increase staff vaccine acceptance, including incentives, one-on-one education, and less stringent personal protective equipment requirements. Federal and state vaccination mandates further promoted vaccine uptake. This combination of mandates with prioritization of the vaccine by SNFs and their leadership was successful at increasing staff vaccination acceptance, which may be critical to increase staff booster uptake from its current suboptimal levels.
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Meehan A, Gadbois EA, Brazier JF, Madrigal C, Grabowski DC, Shield RR. "It's Not a Sprint, It's a Marathon": Stages of Managing a Nursing Home Throughout the Pandemic. J Am Med Dir Assoc 2023; 24:1579-1585.e2. [PMID: 37268013 PMCID: PMC10226846 DOI: 10.1016/j.jamda.2023.04.024] [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: 09/28/2022] [Revised: 02/03/2023] [Accepted: 04/17/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To qualitatively examine the impact of COVID-19 on nursing homes over the course of the pandemic from the perspective of nursing home administrators. DESIGN In-depth, semi-structured interviews with nursing home administrators, repeated 3 months apart for a total of 4 each from July 2020 through December 2021. SETTINGS AND PARTICIPANTS Administrators from a total of 40 nursing homes from 8 health care markets across the United States. METHODS Interviews were conducted virtually or via phone. The research team identified overarching themes using applied thematic analysis, and iteratively coded transcribed interviews. RESULTS Nursing home administrators across the United States reported challenges of managing nursing homes during a pandemic. We found their experiences could generally be categorized into 4 stages, not necessarily coinciding with surge levels of the virus. The initial stage was characterized by fear and confusion. The second stage, by a "new normal," a term administrators used to report feeling better prepared for an outbreak and how residents, staff, and families began to adjust to life with COVID. Administrators started using the phrase "a light at the end of the tunnel" to describe the third stage, characterized by the hope associated with the availability of vaccinations. The fourth stage was marked by "caregiver fatigue" as nursing homes experienced numerous breakthrough cases. Some challenges, like staffing issues and uncertainty about the future, were reported throughout the pandemic, as was a continued mission to keep residents safe. CONCLUSIONS AND IMPLICATIONS As the ability of nursing homes to provide safe, effective care faces unprecedented and continued challenges, the insights reported here from longitudinal perspectives of nursing home administrators may help policy makers develop solutions to encourage high-quality care. Knowing how the needs for resources and support vary across the progression of these stages has the potential to be helpful in addressing these challenges.
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Affiliation(s)
- Amy Meehan
- Center of Gerontology and Healthcare Research at Brown University's School of Public Health, Providence, RI, USA.
| | - Emily A Gadbois
- Center of Gerontology and Healthcare Research at Brown University's School of Public Health, Providence, RI, USA
| | - Joan F Brazier
- Center of Gerontology and Healthcare Research at Brown University's School of Public Health, Providence, RI, USA
| | - Caroline Madrigal
- Center of Innovation for Long-term Services and Supports at the Providence VA Medical Center, Providence, RI, USA
| | - David C Grabowski
- Department of Health Care Policy at Harvard Medical School, Boston, MA, USA
| | - Renee R Shield
- Center of Gerontology and Healthcare Research at Brown University's School of Public Health, Providence, RI, USA
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Brazier JF, Geng F, Meehan A, White EM, McGarry BE, Shield RR, Grabowski DC, Rahman M, Santostefano C, Gadbois EA. Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e2325993. [PMID: 37498600 PMCID: PMC10375301 DOI: 10.1001/jamanetworkopen.2023.25993] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 07/28/2023] Open
Abstract
Importance Staffing shortages have been widely reported in US nursing homes during the COVID-19 pandemic, but traditional quantitative research analyses have found mixed evidence of staffing shortfalls. Objective To examine whether nursing home administrator perspectives can provide context for conflicting aggregate staffing reports in US nursing homes during the COVID-19 pandemic. Design, Setting, and Participants In a qualitative study, convergent mixed-methods analysis integrating qualitative and quantitative data sets was used. Semistructured qualitative interviews were conducted between July 14, 2020, and December 16, 2021. Publicly available national Payroll Based Journal data were retrieved from January 1, 2020, to September 30, 2022, on 40 US nursing homes in 8 health care markets that varied by region and nursing home use patterns. Staffing and resident measures were derived from Payroll Based Journal data and compared with national trends for 15 436 US nursing homes. Nursing home administrators were recruited for interviews. Of the 40 administrators who consented to participate, 4 were lost to follow-up. Exposure Four repeated, semistructured qualitative interviews with participants were conducted. Interview questions focused on the changes noted during the COVID-19 pandemic in nursing homes. Main Outcomes and Measures Thematic description of nursing home administrator compensatory strategies to provide context for quantitative analyses on nursing home staffing levels during the COVID-19 pandemic. Results A total of 156 interviews were completed with 40 nursing home administrators. Administrators reported experiencing staff shortages during the COVID-19 pandemic and using compensatory strategies, such as overtime, cross-training, staff-to-resident ratio adjustments, use of agency staff, and curtailing admissions, to maintain operations and comply with minimum staffing regulations. Payroll Based Journal data measures graphed from January 1, 2020, to September 30, 2022, supported administrator reports showing that study facilities had reductions in staff hours, increased use of agency staff, and decreased resident census. Findings were similar to national trends. Conclusions and Relevance In this qualitative, convergent mixed-methods study, nursing home administrators reported the major staffing strain they experienced at their facilities and the strategies they used to offset staffing shortages. Their experiences provide context to quantitative analyses on aggregate nursing home census data. The short-term compensatory measures administrators used to comply with regulations and maintain operations may be detrimental to the long-term stability of this workforce.
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Affiliation(s)
- Joan F Brazier
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Fangli Geng
- Student, PhD Program in Health Policy, Harvard University, Cambridge Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Amy Meehan
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Elizabeth M White
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Brian E McGarry
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Renee R Shield
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Momotazur Rahman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Christopher Santostefano
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Emily A Gadbois
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
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Margraf AM, Davoodi NM, Chen K, Shield RR, McAuliffe LM, Collins CM, Zullo AR. Provider beliefs about the ideal design of an opioid deprescribing and substitution intervention for older adults. Am J Health Syst Pharm 2023; 80:53-60. [PMID: 36205419 DOI: 10.1093/ajhp/zxac282] [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: 10/01/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Opportunities exist to meaningfully reduce suboptimal prescription opioid use among older adults. Deprescribing is one possible approach to reducing suboptimal use. Appropriate interventions should outline how to carefully taper opioids, closely monitor adverse events, substitute viable alternative and affordable nonopioid pain treatments, and initiate medications for opioid use disorder to properly manage use disorders, as needed. We sought to document and understand provider perceptions to begin developing effective and safe opioid deprescribing interventions. METHODS We conducted 3 semistructured focus groups that covered topics such as participant perspectives on opioid deprescribing in older adults, how to design an ideal intervention, and how to identify potential barriers or facilitators in implementing an intervention. Focus group transcripts were double coded and qualitatively analyzed to identify overarching themes. RESULTS Healthcare providers (n = 17), including physicians, pharmacists, nurses, social workers, and administrative staff, participated in 3 focus groups. We identified 4 key themes: (1) involve pharmacists in deprescribing and empower them as leaders of an opioid deprescribing service; (2) ensure tight integration and close collaboration throughout the deprescribing process from the inpatient to outpatient settings; (3) more expansive inclusion criteria than age alone; and (4) provision of access to alternative pharmacological and nonpharmacological pain management modalities to patients. CONCLUSION Our findings, which highlight various healthcare provider beliefs about opioid deprescribing interventions, are expected to serve as a framework for other organizations to develop and implement interventions. Future studies should incorporate patients' and family caregivers' perspectives.
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Affiliation(s)
- Alissa M Margraf
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | | | - Kevin Chen
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Renee R Shield
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Laura M McAuliffe
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | - Christine M Collins
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | - Andrew R Zullo
- Department of Pharmacy, Rhode Island Hospital, Providence, RI.,Departments of Epidemiology, Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
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Thomas KS, Dosa DM, Fisher A, Gadbois E, Harrison J, Hilgeman M, Largent EA, Lima J, McAuliff K, McCreedy E, Mills W, Ornstein KA, Shield RR, Barron M, Callaghan S, Clark K, Culak C, Faris V, Frankhauser AE, Huerta S, Krause K, Martinez I, Mayer A, Rodriguez J, Theilheimer L, Truelove W, Wilson I, Gutman R. Home-delivered meals for people with dementia: Which model delays nursing home placement? - Protocol for a feasibility pilot. Contemp Clin Trials 2022; 121:106897. [PMID: 36055581 PMCID: PMC9817376 DOI: 10.1016/j.cct.2022.106897] [Citation(s) in RCA: 2] [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: 01/21/2022] [Revised: 07/29/2022] [Accepted: 08/22/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Home-delivered meals promote food security, socialization, and independence among homebound older adults. However, it is unclear which of the two predominant modes of meal delivery, daily-delivered vs. drop-shipped, frozen meals, promotes community living for homebound older adults with dementia. Our objective is to present the protocol for a pilot multisite, two-arm, pragmatic feasibility trial comparing the effect of two modes of meal delivery on nursing home placement among people with dementia. We include justifications for individual randomization with different consent processes and waivers for specific elements of the trial. METHODS 236 individuals with dementia on waiting lists at three Meals on Wheels programs' in Florida and Texas will be randomized to receive either: 1) meals delivered multiple times per week by a Meals on Wheels volunteer or paid driver who may socialize with and provide an informal wellness check or 2) frozen meals that are mailed to participants' homes every two weeks. We will evaluate and refine processes for recruitment and randomization; assess adherence to the intervention; identify common themes in participant experience; and test processes for linking participant data with Medicare records and nursing home assessment data. We will conduct exploratory analyses examining time to nursing home placement, the primary outcome for the larger trial. CONCLUSION This pilot will inform the follow-on large-scale, definitive pragmatic trial. In addition, the justifications for individual randomization with differing consent procedures for elements of a pragmatic trial provide a model for future trialists looking to develop ethical and feasible pragmatic studies enrolling people with dementia.
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Affiliation(s)
- Kali S. Thomas
- Brown University School of Public Health, Providence, RI, USA,Providence VA Medical Center, Providence, RI, USA,Corresponding author at: Brown University School of Public Health, 21 S. Main Street, Providence, RI, 02912, USA. (K.S. Thomas)
| | - David M. Dosa
- Providence VA Medical Center, Providence, RI, USA,Brown University, Providence, RI, USA
| | - Alison Fisher
- Brown University School of Public Health, Providence, RI, USA
| | - Emily Gadbois
- Brown University School of Public Health, Providence, RI, USA
| | - Jill Harrison
- Brown University School of Public Health, Providence, RI, USA
| | - Michelle Hilgeman
- Research & Development Service, Tuscaloosa VA Medical Center, Tuscaloosa, AL, USA,Psychology Department, & Alabama Research Institute on Aging, The University of Alabama, Tuscaloosa, AL, USA,Department of Medicine, Division of Gerontology, Geriatrics, & Palliative Care, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emily A. Largent
- Perelman School of Medicine, University of Pennsylvania, Phildelphia, PA, USA
| | - Julie Lima
- Brown University School of Public Health, Providence, RI, USA
| | - Katie McAuliff
- Brown University School of Public Health, Providence, RI, USA
| | - Ellen McCreedy
- Brown University School of Public Health, Providence, RI, USA
| | - Whitney Mills
- Brown University School of Public Health, Providence, RI, USA,Providence VA Medical Center, Providence, RI, USA
| | | | - Renee R. Shield
- Brown University School of Public Health, Providence, RI, USA
| | | | | | - Kayla Clark
- Visiting Nurse Association of Texas, Dallas, TX, USA
| | - Chris Culak
- Visiting Nurse Association of Texas, Dallas, TX, USA
| | | | | | | | | | | | | | | | | | | | - Inga Wilson
- Visiting Nurse Association of Texas, Dallas, TX, USA
| | - Roee Gutman
- Brown University School of Public Health, Providence, RI, USA
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Gadbois EA, Bélanger E, Shield RR, Plassman BL, Van Houtven CH, Wetle TF. "Now at least we have something to call it": Patient and care partner experiences receiving an amyloid PET scan. J Am Geriatr Soc 2022; 70:2938-2947. [PMID: 35833618 PMCID: PMC10028617 DOI: 10.1111/jgs.17937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/15/2021] [Revised: 04/29/2022] [Accepted: 05/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The primary objective of this paper was to examine perspectives and experiences of individuals with cognitive impairment who received an amyloid PET scan and their care partners, with regard to the process, logistics, and decision-making associated with receiving an amyloid PET scan and its results. METHODS Structured telephone interviews were conducted with 200 randomly sampled scan recipient/care partner dyads from the CARE IDEAS study. The audio-recorded, transcribed responses were analyzed using an inductive qualitative content analytic approach. RESULTS Participating individuals and care partners described their experiences in seeking a diagnosis for memory issues, including decision-making and logistics involved with receiving an amyloid PET scan. Participants discussed the factors contributing to their decision to seek a diagnosis for their memory issues and their hopes and expectations in completing the scan. Participants also described the trajectory of this process, and although some described relatively straightforward trajectories, others described problems associated with identifying appropriate providers and coordinating care across numerous providers to obtain a diagnosis for their memory issues. Participants described an additional challenge of physicians attributing cognitive decline to normal aging, rather than signs of a neurodegenerative disorder. CONCLUSIONS Findings shed light on the barriers and delays that individuals and care partners experience in connecting with physicians and obtaining a comprehensive evaluation for cognitive problems. Results from this study have implications for physicians who provide care to older adults, and specifically highlight the need for greater care coordination and clearer communication with and systems of referral for patients.
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Affiliation(s)
- Emily A. Gadbois
- Brown University School of Public Health, Department of Health Services, Policy, and Practice and Center for Gerontology and Healthcare Research
| | - Emmanuelle Bélanger
- Brown University School of Public Health, Department of Health Services, Policy, and Practice and Center for Gerontology and Healthcare Research
| | - Renee R. Shield
- Brown University School of Public Health, Department of Health Services, Policy, and Practice and Center for Gerontology and Healthcare Research
| | - Brenda L. Plassman
- Duke University School of Medicine, Departments of Psychiatry and Neurology
| | - Courtney H. Van Houtven
- Durham VA Health Care System
- Duke University, Department of Population Health Sciences
- Duke-Margolis Center for Health Policy
| | - Terrie Fox Wetle
- Brown University School of Public Health, Department of Health Services, Policy, and Practice and Center for Gerontology and Healthcare Research
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Haubrick KK, Gadbois EA, Campbell SE, Young J, Zhang T, Rizvi S, Shireman TI, Shield RR. The Lived Experiences of Adults with Multiple Sclerosis. R I Med J (2013) 2021; 104:38-42. [PMID: 34323878] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Multiple sclerosis (MS), a chronic, often disabling, nervous system disease, affects over 2.3 million people worldwide. This research examined the lived experiences of 46 community-dwelling adults with MS. We conducted five focus groups that covered topics such as diagnosis, decision-making regarding MS treatment, learning about and paying for assistance, and unmet needs. Focus group transcripts were qualitatively analyzed to identify overarching themes. Participants described how MS affects both current and future physical and financial security, how they often feel unheard or misunderstood by loved ones and healthcare providers, and how MS support organizations provide a vital collaborative and compassionate environment. Our findings reflect the importance of MS support organizations, and the incorporation of social workers in MS care teams, as they can foster communication and empathy between parties, provide psycho- social treatment, and link patients to needed services.
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Affiliation(s)
- Kayla K Haubrick
- Brown University, Center for Gerontology and Healthcare Research
| | - Emily A Gadbois
- Brown University, Center for Gerontology and Healthcare Research
| | - Susan E Campbell
- Brown University, Center for Gerontology and Healthcare Research
| | | | - Tingting Zhang
- Brown University, Center for Gerontology and Healthcare Research
| | - Syed Rizvi
- Rhode Island Hospital, Multiple Sclerosis Center & Brown University Warren Alpert Medical School, Neurology
| | | | - Renee R Shield
- Brown University, Center for Gerontology and Healthcare Research
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Gadbois EA, Brazier JF, Meehan A, Grabowski DC, Shield RR. "I don't know how many nursing homes will survive 2021": Financial sustainability during COVID-19. J Am Geriatr Soc 2021; 69:2785-2788. [PMID: 34287843 PMCID: PMC8447370 DOI: 10.1111/jgs.17380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Emily A Gadbois
- Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Joan F Brazier
- Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Amy Meehan
- Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Renee R Shield
- Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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McHugh JP, Shield RR, Gadbois EA, Winblad U, Mor V, Tyler DA. Readmission Reduction Strategies for Patients Discharged to Skilled Nursing Facilities: A Case Study From 2 Hospital Systems in 1 City. J Nurs Care Qual 2021; 36:91-98. [PMID: 31834200 PMCID: PMC7266704 DOI: 10.1097/ncq.0000000000000459] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Some hospitals seek integration with skilled nursing facilities (SNFs) to reduce readmissions while others focus more on patients discharged home. PURPOSE Our objective was to understand different approaches for readmission reduction for patients discharged to SNFs based on contrasting strategies from 2 competing hospital systems. METHODS Employing a case study methodology, we compared 1 hospital system that integrated with SNFs to a competing system that did not. We compared interview data from clinical and administrative staff and publicly reported rehospitalization rate changes from the 2 systems. RESULTS Analysis of integrating hospital system interviews noted providing patients detailed discharge information and educating SNF staff regarding care protocols. Integrated hospital system all-cause readmission rates declined by nearly 1 percentage point more than the nonintegrated hospital system (coefficient, -0.008; 95% confidence interval, -0.003 to -0.012) between 2014 and 2017. CONCLUSION As hospitals explore care transition improvements to SNFs, developing more embedded relationships highlights one approach to improve value.
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Affiliation(s)
- John P McHugh
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York (Dr McHugh); Department of Health Services Policy and Practice (Drs Shield and Mor) and Center for Gerontology and Healthcare Research (Dr Gadbois), School of Public Health, Brown University, Providence, Rhode Island; Department of Public Health and Caring Sciences, Uppsala University, Sweden (Dr Winblad); and Aging, Disability and Long Term Care Program, RTI International, Raleigh, North Carolina (Dr Tyler)
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Gettel CJ, Hayes K, Shield RR, Guthrie KM, Goldberg EM. Care Transition Decisions After a Fall-related Emergency Department Visit: A Qualitative Study of Patients' and Caregivers' Experiences. Acad Emerg Med 2020; 27:876-886. [PMID: 32053283 DOI: 10.1111/acem.13938] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/04/2020] [Accepted: 02/07/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Falls are a leading cause of injury-related emergency department (ED) visits and may serve as a sentinel event for older adults, leading to physical and psychological injury. Our primary objective was to characterize patient- and caregiver-specific perspectives about care transitions after a fall. METHODS Using a semistructured interview guide, we conducted in-depth, qualitative interviews using grounded theory methodology. We included patients enrolled in the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare) trial aged 65 years and older who had an ED visit for a fall and their caregivers. Patients with cognitive impairment (CI) were interviewed in patient-caregiver dyads. Domains assessed included the postfall recovery period, the skilled nursing facility (SNF) placement decision-making process, and the ease of obtaining outpatient follow-up. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed for a priori and emergent themes. RESULTS A total of 22 interviews were completed with 10 patients, eight caregivers, and four patient-caregiver dyads within the 6-month period after initial ED visits. Patients were on average 83 years old, nine of 14 were female, and two of 14 had CI. Six of 12 caregivers were interviewed in reference to a patient with CI. We identified four overarching themes: 1) the fall as a trigger for psychological and physiological change, 2) SNF placement decision-making process, 3) direct effect of fall on caregivers, and 4) barriers to receipt of recommended follow-up. CONCLUSIONS Older adults presenting to the ED after a fall report physical limitations and a prominent fear of falling after their injury. Caregivers play a vital role in securing the home environment; the SNF placement decision-making process; and navigating the transition of care between the ED, SNF, and outpatient visits after a fall. Clinicians should anticipate and address feelings of isolation, changes in mobility, and fear of falling in older adults seeking ED care after a fall.
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Affiliation(s)
- Cameron J. Gettel
- From the Department of Emergency Medicine Yale University School of Medicine New Haven CT United States
- the Department of Internal Medicine National Clinician Scholars ProgramYale University School of Medicine New Haven CT
| | | | - Renee R. Shield
- the Department of Health Services, Policy and Practice Brown University School of Public Health Providence RI United States
| | - Kate M. Guthrie
- the Department of Psychiatry and Human Behavior Centers for Behavioral and Preventive Medicine Miriam HospitalThe Warren Alpert Medical School of Brown University Providence RI
| | - Elizabeth M. Goldberg
- the Department of Health Services, Policy and Practice Brown University School of Public Health Providence RI United States
- and the Department of Emergency Medicine The Warren Alpert Medical School of Brown University Providence RI
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Morris AM, Engelberg JK, Schmitthenner B, Dosa D, Gadbois E, Shield RR, Akobundu U, Thomas KS. Leveraging Home-Delivered Meal Programs to Address Unmet Needs for At-Risk Older Adults: Preliminary Data. J Am Geriatr Soc 2019; 67:1946-1952. [PMID: 31188480 DOI: 10.1111/jgs.16013] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/17/2019] [Accepted: 04/20/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Home-delivered meal programs serve a predominantly homebound older adult population, characterized by multiple chronic conditions, functional limitations, and a variety of complex care needs, both medical and social. DESIGN A pilot study was designed to test the feasibility of leveraging routine meal-delivery service in two home-delivered meal programs to proactively identify changes in older adult meal recipients' (clients') health, safety, and well-being and address unmet needs. INTERVENTION Meal delivery personnel (drivers) were trained to use a mobile application to submit electronic alerts when they had a concern or observed a change in a client's condition. Alerts were received by care coordinators, who followed up with clients to offer support and help connect them to health and community services. RESULTS Over a 12-month period, drivers submitted a total of 429 alerts for 189 clients across two pilot sites. The most frequent alerts were submitted for changes in health (56%), followed by self-care or personal safety (12%) and mobility (11%). On follow-up, a total of 132 referrals were issued, with most referrals for self-care (33%), health (17%), and care management services (17%). Focus groups conducted with drivers indicated that most found the mobile application easy to use and valued change of condition monitoring as an important contribution. CONCLUSION Findings suggest that this is a feasible approach to address unmet needs for vulnerable older adults and may serve as an early-warning system to prevent further decline and improve quality of life. Efforts are underway to test the protocol across additional home-delivered meal programs. J Am Geriatr Soc 67:1946-1952, 2019.
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Affiliation(s)
| | | | | | - David Dosa
- Department of Veterans Affairs Medical Center, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Emily Gadbois
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Renee R Shield
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | | | - Kali S Thomas
- Department of Veterans Affairs Medical Center, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
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14
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Gadbois EA, Gordon SH, Shield RR, Vivier PM, Trivedi AN. Quality Management Strategies in Medicaid Managed Care: Perspectives From Medicaid, Plans, and Providers. Med Care Res Rev 2019; 78:36-47. [PMID: 30947600 DOI: 10.1177/1077558719841157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medicaid managed care allows Medicaid beneficiaries to receive services through contractual relationships between managed care organizations and state Medicaid offices. Medicaid offices monitor quality of care, and many states encourage or require plans to adopt quality management practices. This research examines quality management in Medicaid managed care from the perspectives of Medicaid officials, managed care plan representatives, and providers through 25 qualitative interviews in one Northeastern state. Plan representatives described quality management efforts as robust and discussed strategies targeting providers and beneficiaries. Medicaid officials indicated motivations for plans to be responsible for quality management. Providers were unaware of plan efforts or reported them to be counterproductive since performance data were thought to be inaccurate or limited, and modest incentive programs presented excessive administrative burden. Providers' general skepticism about managed care plans' quality improvement efforts may hinder their effectiveness, cause frustration, and lead to administrative burden that may harm care quality.
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Affiliation(s)
| | | | | | | | - Amal N Trivedi
- Brown University, Providence, RI, USA.,Providence Veterans Affairs Medical Center, Providence, RI, USA
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15
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Goldberg EM, Gettel CJ, Hayes K, Shield RR, Guthrie KM. GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention for Emergency Department Patients - A Qualitative Evaluation. ACTA ACUST UNITED AC 2019; 3. [PMID: 32352082 PMCID: PMC7189708 DOI: 10.21926/obm.geriatr.1904078] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Three million US emergency department (ED) visits occur for falls each year. The mortality of falls is increasing and only one fourth of older adults report their fall to their primary care provider, suggesting that valuable preventative opportunities are missed. A fall prevention intervention initiated in the ED immediately after a fall has the potential to reduce subsequent falls, but ED providers lack the time and resources to complete fall risk assessments on their patients. GAPcare, the Geriatric Acute and Post-Acute Fall Prevention Intervention, was developed to address this need. Methods: GAPcare combines a pharmacist-led medication therapy management intervention with a physical therapist (PT)-administered fall risk assessment and disposition planning. A key objective of this pilot randomized controlled trial (RCT) was to create a patient and caregiver-centric intervention. This manuscript reports on the results of the qualitative companion study in which we conducted in-depth interviews with patients and caregivers to determine their lived experience with the intervention, barriers and perceived impact of the intervention, and to obtain their recommendations for the improvement of GAPcare. We recruited patients and their caregivers from the RCT into 30 minutes interviews in the participants’ home singularly or in dyads (patient and caregiver together). Interviews were audio-recorded, transcribed, and double-coded. We used applied thematic analysis to guide the data analysis. Results: We conducted 20 interviews; patients (n=12), caregivers (n=11). Patients were on average 83 years old, 7/12 were female, and 2/14 had cognitive impairment. 6/11 caregiver interviews were in reference to a patient with dementia. Patients and caregivers reported they embraced the experience of motivational interviewing elements, citing its collaborative and inclusive nature. Caregivers in particular said they felt that PT helped their loved one recognize and overcome functional limitations. Barriers included lack of time, the burden of coordinating multiple service providers once home, and concerns that PT would be ineffective or increase pain. Areas for improvement included better screening for those who would benefit from the individual components (pharmacy vs. PT consultation), improving identification of GAPcare pharmacists and PTs vs. other hospital staff in the ED, and expanding the role of GAPcare personnel to provide culturally competent, comprehensive care to improve adherence and medication education. Conclusions: We found that GAPcare, a new team-based intervention for fall prevention in the ED, was welcomed by patients and their caregivers. Several suggestions to improve the intervention were made that will inform the screening, content, and communication with patients in GAPcare.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Cameron J Gettel
- Department of Emergency Medicine, National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA
| | - Kelsey Hayes
- College of Our Lady of the Elms, Chicopee, MA, USA
| | - Renee R Shield
- Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Kate M Guthrie
- Centers for Behavioral and Preventive Medicine, Miriam Hospital, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Thomas KS, Gadbois EA, Shield RR, Akobundu U, Morris AM, Dosa DM. "It's Not Just a Simple Meal. It's So Much More": Interactions Between Meals on Wheels Clients and Drivers. J Appl Gerontol 2018; 39:151-158. [PMID: 30569811 DOI: 10.1177/0733464818820226] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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
Background and Objectives: Meals on Wheels (MOW) programs provide home-delivered meals to over 1.5 million older adults; yet, very little is known about the drivers who make meal deliveries possible. Specifically, we do not have clear insight into their interaction with clients or the benefits that they may receive through their service. The objective of this article is to describe the characteristics of MOW drivers, the interactions among drivers and clients, and the benefits of the program to both. Research Design and Method: This qualitative research study reports on interviews with 84 MOW staff (leadership, case managers/client assessors, volunteer coordinators) and drivers at six geographically and operationally distinct programs across the United States. Results: Qualitative analysis of the interviews with MOW staff and drivers revealed the following key themes: (a) clients have multiple vulnerabilities; (b) clients appear to derive social, as well as nutritional benefit from receiving meals; (c) drivers report they provide additional support to their clients beyond delivering the meal; (d) social bonds between drivers and clients were reported to strengthen over time; (e) drivers claim that they, too, derive validation and personal benefit through their meal delivery. Discussion and Implications: This research highlights the significant contributions that meal delivery drivers made in the lives of MOW clients beyond the actual meal itself. This research also spotlights the perceived benefits experienced by the drivers and points to the importance of conducting further research to determine the effects of meal delivery on client and drivers' outcomes, more broadly.
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Affiliation(s)
- Kali S Thomas
- U.S. Department of Veterans Affairs Medical Center, Providence, RI, USA.,Brown University School of Public Health, Providence RI, USA
| | - Emily A Gadbois
- Brown University School of Public Health, Providence RI, USA
| | - Renee R Shield
- Brown University School of Public Health, Providence RI, USA
| | | | | | - David M Dosa
- U.S. Department of Veterans Affairs Medical Center, Providence, RI, USA.,Brown University School of Public Health, Providence RI, USA
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Gadbois EA, Tyler DA, Shield RR, McHugh JP, Winblad U, Trivedi A, Mor V. Medicare Advantage control of postacute costs: perspectives from stakeholders. Am J Manag Care 2018; 24:e386-e392. [PMID: 30586487 PMCID: PMC6344939] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Medicare Advantage (MA) plans have strong incentives to control costs, including postacute spending; however, to our knowledge, no research has examined the methods that MA plans use to control or reduce postacute costs. This study aimed to understand such MA plan efforts and the possible unintended consequences. STUDY DESIGN A multiple case study method was used. METHODS We conducted 154 interviews with administrative and clinical staff working in 10 MA plans, 16 hospitals, and 25 skilled nursing facilities (SNFs) in 8 geographically diverse markets across the United States. RESULTS Participants discussed how MA plans attempted to reduce postacute care spending by controlling the SNF to which patients are discharged and SNF length of stay (LOS). Plans typically influenced SNF selection by providing patients with a list of facilities in which their care would be covered. To influence LOS, MA plans most commonly authorized patient stays in SNFs for a certain number of days and required that SNFs adhere to this limitation, but they did not provide guidance or assistance in ensuring that the LOS goals were met. Hospital and SNF responses to the largely authorization-based system were frequently negative, and participants expressed concerns about potential unintended consequences. CONCLUSIONS In their interactions with hospitals and SNFs, MA plans attempted to influence the choice of SNF and LOS to control postacute spending. However, exerting too much influence over hospitals and SNFs, as these results seem to indicate, may have the negative consequences of delayed hospital discharge and SNFs' avoidance of burdensome plans.
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Affiliation(s)
- Emily A Gadbois
- Brown University School of Public Health, 121 S Main St, Providence, RI 02903.
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18
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Mor V, McHugh JP, Shield RR, Winblad U, Gadbois EA, Tyler DA. THE UNINTENDED CONSEQUENCES OF REDUCED SKILLED NURSING FACILITY LENGTH OF STAY. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- V Mor
- Brown University School of Public Health, Providence, Rhode Island, United States
| | - J P McHugh
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - R R Shield
- Brown University School of Public Health, Providence, RI
| | | | - E A Gadbois
- Brown University School of Public Health, Providence, RI, USA
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Gadbois EA, Tyler DA, Shield RR, McHugh JP, Winblad U, Trivedi A, Mor V. MEDICARE ADVANTAGE CONTROL OF POST-ACUTE COSTS: PERSPECTIVES FROM PLANS, HOSPITALS, AND SKILLED NURSING FACILITIES. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- E A Gadbois
- Brown University, Providence, Rhode Island, United States
| | | | - R R Shield
- Brown University School of Public Health, Providence, RI
| | - J P McHugh
- Columbia University Mailman School of Public Health, New York, NY, USA
| | | | - A Trivedi
- Brown University School of Public Health, Providence, RI
| | - V Mor
- Brown University School of Public Health, Providence, RI, USA
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20
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Miller SC, Schwartz ML, Lima JC, Shield RR, Tyler DA, Berridge CW, Lepore MJ, Clark MA. THE 2016/17 PREVALENCE OF CULTURE CHANGE PRACTICE IN U.S. NURSING HOMES. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- S C Miller
- Brown University, Warwick, Rhode Island, United States
| | - M L Schwartz
- Brown University School of Public Health, Providence, RI, USA
| | - J C Lima
- Brown University School of Public Health, Providence, RI, USA
| | - R R Shield
- Brown University School of Public Health, Providence, RI, USA
| | - D A Tyler
- Research Triangle Institute, Boston, MA, USA:
| | - C W Berridge
- School of Social Work, University of Washington, Seattle, WA, USA:
| | - M J Lepore
- Research Triangle Institute, Washington, DC, USA; Brown University School of Public Health, Providence, RI, USA
| | - M A Clark
- University of Massachusetts Medical School, Worcester, MA, USA
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21
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McHugh J, Shield RR, Tyler DA, Gadbois EA, Winblad U, Mor V. DIVERGENT APPROACHES TO POST-ACUTE CARE MANAGEMENT – A CASE FOR RELATIONAL COORDINATION. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J McHugh
- Mailman School of Public Health, Columbia University, New York, New York, United States
| | - R R Shield
- Brown University School of Public Health, Providence, RI
| | | | - E A Gadbois
- Brown University School of Public Health, Providence, RI, USA
| | | | - V Mor
- Brown University School of Public Health, Providence, RI, USA
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22
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Tyler D, Gadbois EA, McHugh JP, Shield RR, Winblad U, Mor V. HOW “PATIENT CHOICE” AFFECTS HOSPITAL RECOMMENDATIONS OF SKILLED NURSING FACILITIES. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- D Tyler
- RTI International, Hancock, Maine, United States
| | - E A Gadbois
- Brown University School of Public Health, Providence, RI, USA
| | - J P McHugh
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - R R Shield
- Brown University School of Public Health, Providence, RI
| | | | - V Mor
- Brown University School of Public Health, Providence, RI, USA
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23
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Gordon SH, Gadbois EA, Shield RR, Vivier PM, Ndumele CD, Trivedi AN. Qualitative perspectives of primary care providers who treat Medicaid managed care patients. BMC Health Serv Res 2018; 18:728. [PMID: 30241523 PMCID: PMC6150984 DOI: 10.1186/s12913-018-3516-9] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background Declining job satisfaction and concurrent reductions in Medicaid participation among primary care providers have been documented, but there is limited qualitative work detailing their first-hand experiences treating Medicaid patients. The objective of this study is to describe the experiences of some primary care providers who treat Medicaid patients using in-depth qualitative analysis. Methods We conducted qualitative interviews with 15 primary care providers treating Medicaid patients in a Northeastern state. Participant recruitment efforts focused on including different types of primary care providers practicing in diverse settings. Qualitative interviews were conducted using a semi-structured interview protocol. We developed a coding scheme to analyze interview transcripts and identify themes. Results Providers expressed challenges effectively meeting their patients’ needs under current policy. They described low Medicaid reimbursement and underinvestment in care coordination programs to adequately address the social determinants of health. Providers shared other concerns including poor access to behavioral health services, discontinuous Medicaid coverage due to enrollment and renewal policies, and limited reimbursement for alternative pain treatment. Providers offered their own suggestions for the allocation of financial investments, Medicaid policy, and primary care practice. Conclusions Underinvestment in primary care in Medicaid may detract from providers’ professional satisfaction and hinder care coordination for Medicaid patients with complex healthcare needs. Policy solutions that improve the experience of primary care providers serving Medicaid patients are urgently needed to ensure sustainability of the workforce and improve care delivery.
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Affiliation(s)
- Sarah H Gordon
- Department of Health Services, Policy, and Practice, Brown University, 121 South Main Street, Providence, RI, 02912, USA.
| | - Emily A Gadbois
- Department of Health Services, Policy, and Practice, Brown University, 121 South Main Street, Providence, RI, 02912, USA
| | - Renee R Shield
- Department of Health Services, Policy, and Practice, Brown University, 121 South Main Street, Providence, RI, 02912, USA
| | - Patrick M Vivier
- Department of Health Services, Policy, and Practice, Brown University, 121 South Main Street, Providence, RI, 02912, USA.,Hassenfeld Child Health Innovation Institute, Brown University, Providence, RI, USA
| | - Chima D Ndumele
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA
| | - Amal N Trivedi
- Department of Health Services, Policy, and Practice, Brown University, 121 South Main Street, Providence, RI, 02912, USA.,Providence VA Medical Center, Providence, RI, USA
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Gordon SH, Lee Y, Ndumele CD, Vivier PM, Gutman R, Swaminathan S, Gadbois EA, Shield RR, Kind AJH, Trivedi AN. The Impact of Medicaid Managed Care Plan Type on Continuous Medicaid Enrollment: A Natural Experiment. Health Serv Res 2018; 53:3770-3789. [PMID: 29952062 DOI: 10.1111/1475-6773.13000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 11/30/2022] Open
Abstract
OBJECTIVE To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage. DATA SOURCES 2011-2016 Medicaid claims from a Northeastern state. STUDY DESIGN Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis. DATA COLLECTION We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011. PRINCIPAL FINDINGS Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid. CONCLUSIONS Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features.
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Affiliation(s)
- Sarah H Gordon
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Yoojin Lee
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | | | - Patrick M Vivier
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI.,Hassenfeld Child Health Innovation Institute at Brown University, Providence, RI
| | - Roee Gutman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Shailender Swaminathan
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI.,Public Health Foundation of India, New Delhi, India
| | - Emily A Gadbois
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Renee R Shield
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Amy Jo Haavisto Kind
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, William S. Middleton VA Hospital-GRECC, Madison, WI
| | - Amal N Trivedi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI.,Providence VA Medical Center, Providence, RI
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Dang CTM, Shield RR, Giddon DB. Willingness of Rhode Island Dentists to Provide Limited Preventive Primary Care. R I Med J (2013) 2016; 99:12-14. [PMID: 27379351] [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] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In response to the shortage of primary care physicians and the need for greater intercollaboration among health professionals, dentists with sufficient medical and surgical training are an untapped resource to provide limited preventive primary care (LPPC), such as chairside screening for chronic diseases. The objective of this study was to determine attitudes of Rhode Island dentists toward becoming more involved in the overall health of their patients. Using a 5-point scale (1 being highest), a pretested survey was administered to 92 respondent RI dentists who were asked to indicate their willingness to become more involved in patients' overall health, and undergo additional training to provide LPPC. Their moderate level of willingness was offset by great concern for liability, with older dentists being significantly more willing to assume these additional responsibilities than younger dentists (p< .05). Rank order of designation of oral health providers among dentist, dental physician, oral physician, odontologist, stomatologist, and stomiatrist was still dentist first, but with no significant difference between the mean ranks of dentist and oral physician.[Full article available at http://rimed.org/rimedicaljournal-2016-07.asp, free with no login].
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Affiliation(s)
| | - Renee R Shield
- Clinical Professor of Health Services, Policy and Practice, Brown University
| | - Donald B Giddon
- Professor of Developmental Biology Emeritus, Harvard School of Dental Medicine; Clinical Professor Emeritus of Behavioral and Social Sciences, Brown University
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26
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Tyler DA, Lepore M, Shield RR, Looze J, Miller SC. Overcoming resistance to culture change: nursing home administrators' use of education, training, and communication. Gerontol Geriatr Educ 2013; 35:321-36. [PMID: 24266678 PMCID: PMC4160411 DOI: 10.1080/02701960.2013.837049] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Nursing home culture change is becoming more prevalent, and research has demonstrated its benefits for nursing home residents and staff-but little is known about the role of nursing home administrators in culture change implementation. The purpose of this study was to determine what barriers nursing home administrators face in implementing culture change practices, and to identify the strategies used to overcome them. The authors conducted in-depth individual interviews with 64 administrators identified through a nationally representative survey. Results showed that a key barrier to culture change implementation reported by administrators was staff, resident, and family member resistance to change. Most nursing home administrators stressed the importance of using communication, education and training to overcome this resistance. Themes emerging around the concepts of communication and education indicate that these efforts should be ongoing, communication should be reciprocal, and that all stakeholders should be included.
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Affiliation(s)
- Denise A. Tyler
- Assistant Professor of Health Services, Policy & Practice (Research), Brown University Center for Gerontology & Health Care Research, 121 South Main St, G-S121-6, Providence, RI 02912, 401-863-3894 (p), 401-863-3489 (f),
| | - Michael Lepore
- Director of Quality, Research, and Evaluation, Planetree
| | - Renee R. Shield
- Professor of Health Services, Policy & Practice (Clinical), Brown University Center for Gerontology & Health Care Research
| | - Jessica Looze
- Brown University Center for Gerontology & Health Care Research
| | - Susan C. Miller
- Professor of Health Services, Policy & Practice (Research), Brown University Center for Gerontology & Health Care Research
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27
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Doyle RJ, Wang N, Anthony D, Borkan J, Shield RR, Goldman RE. Computers in the examination room and the electronic health record: physicians' perceived impact on clinical encounters before and after full installation and implementation. Fam Pract 2012; 29:601-8. [PMID: 22379185 DOI: 10.1093/fampra/cms015] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [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: 11/14/2022] Open
Abstract
PURPOSE We compared physicians' self-reported attitudes and behaviours regarding electronic health record (EHR) use before and after installation of computers in patient examination rooms and transition to full implementation of an EHR in a family medicine training practice to identify anticipated and observed effects these changes would have on physicians' practices and clinical encounters. METHODS We conducted two individual qualitative interviews with family physicians. The first interview was before and second interview was 8 months later after full implementation of an EHR and computer installation in the examination rooms. Data were analysed through project team discussions and subsequent coding with qualitative analysis software. RESULTS At the first interviews, physicians frequently expressed concerns about the potential negative effect of the EHR on quality of care and physician-patient interaction, adequacy of their skills in EHR use and privacy and confidentiality concerns. Nevertheless, most physicians also anticipated multiple benefits, including improved accessibility of patient data and online health information. In the second interviews, physicians reported that their concerns did not persist. Many anticipated benefits were realized, appearing to facilitate collaborative physician-patient relationships. Physicians reported a greater teaching role with patients and sharing online medical information and treatment plan decisions. CONCLUSIONS Before computer installation and full EHR implementation, physicians expressed concerns about the impact of computer use on patient care. After installation and implementation, however, many concerns were mitigated. Using computers in the examination rooms to document and access patients' records along with online medical information and decision-making tools appears to contribute to improved physician-patient communication and collaboration.
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Affiliation(s)
- Richard J Doyle
- Department of Family Medicine, Warren Alpert School of Medicine of Brown University, Providence, RI 02908, USA.
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Abstract
BACKGROUND Increasing numbers of Americans die in nursing homes. Little is known about the roles and experiences of family members of persons who die in nursing homes. METHODS The authors conducted 54 qualitative telephone interviews of close family or friends of individuals who had spent at least 48 hours in the last month of life in a nursing home. Respondents had earlier participated in a national survey that found 587 of 1578 decedents (37.2%) received end-of-life nursing home care. In qualitative interviews respondents described the last year of life, focusing on the nursing home experience. Interviews were analyzed by a multidisciplinary team to identify key themes of areas of concern. RESULTS An important interview theme revealed families often felt the need to advocate for their dying relative because of low expectations or experiences with poor quality nursing home care. They noted staff members who did not fully inform them about what to expect in the dying process. Respondents reported burden and gratification in care they themselves provided, which sometimes entailed collaboration with staff. Interviews also identified ways hospice care impacted families, including helping to relieve family burden. CONCLUSIONS End-of-life advocacy takes on increased urgency when those close to the dying resident have concerns about basic care and do not understand the dying course. Enhancing communication, preparing families at the end of life, and better understanding of hospice are likely to increase family trust in nursing home care, improve the care of dying residents, and help reduce family burden.
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Affiliation(s)
- Renee R Shield
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island 02912, USA.
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Shield RR. Pathways and porches: a focus on corridors in nursing homes. R I Med J (1976) 1990; 73:155-60. [PMID: 2336521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- R R Shield
- Department of Community Health, Brown University, Providence, Rhode Island
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Shield RR, Aronson SM. The shrinking sensory world of the elderly. R I Med J (1976) 1989; 72:159. [PMID: 2762725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Aronson SM, Shield RR. The domain of the elderly. R I Med J (1976) 1982; 65:359-63. [PMID: 6957962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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