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Browsing by Author "Carnahan, Jennifer L."
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Item Age-specific rates of hospital transfers in long-stay nursing home residents(Oxford Academic, 2022-01) Tu, Wanzhu; Li, Ruohong; Stump, Timothy E.; Fowler, Nicole R.; Carnahan, Jennifer L.; Blackburn, Justin; Sachs, Greg A.; Hickman, Susan E.; Unroe, Kathleen T.; Biostatistics, School of Public HealthIntroduction hospital transfers and admissions are critical events in the care of nursing home residents. We sought to determine hospital transfer rates at different ages. Methods a cohort of 1,187 long-stay nursing home residents who had participated in a Centers for Medicare and Medicaid demonstration project. We analysed the number of hospital transfers of the study participants recorded by the Minimum Data Set. Using a modern regression technique, we depicted the annual rate of hospital transfers as a smooth function of age. Results transfer rates declined with age in a nonlinear fashion. Rates were the highest among residents younger than 60 years of age (1.30-2.15 transfers per year), relatively stable between 60 and 80 (1.17-1.30 transfers per year) and lower in those older than 80 (0.77-1.17 transfers per year). Factors associated with increased risk of transfers included prior diagnoses of hip fracture (annual incidence rate ratio or IRR: 2.057, 95% confidence interval (CI): [1.240, 3.412]), dialysis (IRR: 1.717, 95% CI: [1.313, 2.246]), urinary tract infection (IRR: 1.755, 95% CI: [1.361, 2.264]), pneumonia (IRR: 1.501, 95% CI: [1.072, 2.104]), daily pain (IRR: 1.297, 95% CI: [1.055,1.594]), anaemia (IRR: 1.229, 95% CI [1.068, 1.414]) and chronic obstructive pulmonary disease (IRR: 1.168, 95% CI: [1.010,1.352]). Transfer rates were lower in residents who had orders reflecting preferences for comfort care (IRR: 0.79, 95% CI: [0.665, 0.936]). Discussion younger nursing home residents may require specialised interventions to reduce hospital transfers; declining transfer rates with the oldest age groups may reflect preferences for comfort-focused care.Item The Avoidable Transfer Scale: A New Tool for Identifying Potentially Avoidable Hospital Transfers of Nursing Home Residents(Oxford University Press, 2022-05-11) Carnahan, Jennifer L.; Unroe, Kathleen T.; Evans, Russell; Klepfer, Sarah; Stump, Timothy E.; Monahan, Patrick O.; Torke, Alexia M.; Medicine, School of MedicineBackground and objectives: Prior approaches to identifying potentially avoidable hospital transfers (PAHs) of nursing home residents have involved detailed root cause analyses that are difficult to implement and sustain due to time and resource constraints. They relied on the presence of certain conditions but did not identify the specific issues that contributed to avoidability. We developed and tested an instrument that can be implemented using review of the electronic medical record. Research design and methods: The OPTIMISTIC project was a Centers for Medicare and Medicaid Services demonstration to reduce avoidable hospital transfers of nursing home residents. The OPTIMISTIC team conducted a series of root cause analyses of transfer events, leading to development of a 27-item instrument to identify common characteristics of PAHs (Stage 1). To refine the instrument, project nurses used the electronic medical record (EMR) to score the avoidability of transfers to the hospital for 154 nursing home residents from 7 nursing homes from May 2019 through January 2020, including their overall impression of whether the transfer was avoidable (Stage 2). Each transfer was rated independently by 2 nurses and assessed for interrater reliability with a kappa statistic. Results: Kappa scores ranged from -0.045 to 0.556. After removing items based on our criteria, 12 final items constituted the Avoidable Transfer Scale. To assess validity, we compared the 12-item scale to nurses' overall judgment of avoidability of the transfer. The 12-item scale scores were significantly higher for submissions rated as avoidable than those rated unavoidable by the nurses (mean 5.3 vs 2.6, p < .001). Discussion and implications: The 12-item Avoidable Transfer Scale provides an efficient approach to identify and characterize PAHs using available data from the EMR. Increased ability to quantitatively assess the avoidability of resident transfers can aid nursing homes in quality improvement initiatives to treat more acute changes in a resident's condition in place.Item Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives(Springer, 2021) Carnahan, Jennifer L.; Inger, Lev; Rawl, Susan M.; Iloabuchi, Tochukwu C.; Clark, Daniel O.; Callahan, Christopher M.; Torke, Alexia M.; Medicine, School of MedicineBackground: Patients who undergo the complex series of transitions from the hospital to a skilled nursing facility (SNF) back to home represent a unique patient population with multiple comorbidities and impaired functional abilities. The needs and outcomes of patients who are discharged from the hospital to SNF before returning home are understudied in care transitions scholarship. Objective: To study the patient and caregiver challenges and perspectives on transitions from the hospital to the SNF and back to home. Design: Between 48 h and 1 week after discharge from the SNF, semi-structured interviews were performed with a convenience sample of patients and caregivers in their homes. Within 1 to 2 weeks after the baseline interview, follow-up interviews were performed over the phone. Participants: A total of 39 interviewees comprised older adults undergoing the series of transitions from hospital to skilled nursing facility to home and their informal caregivers. Main measures: A constructionist, grounded-theory approach was used to code the interviews, identify major themes and subthemes, and develop a theoretical model explaining the outcomes of the SNF to home transition. Key results: The mean age of the patients was 76.6 years and 64.8 years for the caregivers. Four major themes were identified: comforts of home, information needs, post-SNF care, and independence. Patients noted an extended time away from home and were motivated to return to and remain in the home. Information needs were variably met and affected post-SNF care, including medication management, appointments, and therapy gains and setbacks. Interviewees identified independent function at home as the most important outcome of the transition home. Conclusions: Post-SNF in home support is needed rapidly after discharge from the SNF to prevent adverse outcomes. In-home support needs to be highly individualized based on a patient's and caregiver's unique situation and needs.Item The Complexity of Determining Whether a Nursing Home Transfer Is Avoidable at Time of Transfer(Wiley, 2018-05) Unroe, Kathleen T.; Carnahan, Jennifer L.; Hickman, Susan E.; Sachs, Greg A.; Hass, Zachary; Arling, Greg; Medicine, School of MedicineObjectives To describe the relationship between nursing facility resident risk conditions and signs and symptoms at time of acute transfer and diagnosis of conditions associated with potentially avoidable acute transfers (pneumonia, urinary tract infection, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or asthma, dehydration, pressure sores). Design As part of a demonstration project to reduce potentially avoidable hospital transfers, Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project clinical staff collected data on residents who transferred to the emergency department (ED) or hospital. Cross‐tabulations were used to identify associations between risk conditions or symptoms and hospital diagnoses or death. Mixed‐effects logistic regression models were used to describe the significance of risk conditions, signs, or symptoms as predictors of potentially avoidable hospital diagnoses or death. Setting Indiana nursing facilities (N=19). Participants Long‐stay nursing facility residents (N=1,174), who experienced 1,931 acute transfers from November 2014 to July 2016. Measurements Participant symptoms, transfers, risk factors, and hospital diagnoses. Results We found that 44% of acute transfers were associated with 1 of 6 potentially avoidable diagnoses. Symptoms before transfer did not discriminate well among hospital diagnoses. Symptoms mapped into multiple diagnoses and most hospital diagnoses had multiple associated symptoms. For example, more than two‐thirds of acute transfers of residents with a history of CHF and COPD were for reasons other than exacerbations of those two conditions. Conclusion Although it is widely recognized that many transfers of nursing facility residents are potentially avoidable, determining “avoidability” at time of transfer is complex. Symptoms and risk conditions were only weakly predictive of hospital diagnoses.Item COVID‐19 disease trajectories among nursing home residents(Wiley, 2021-09) Carnahan, Jennifer L.; Lieb, Kristi M.; Albert, Lauren; Wagle, Kamal; Kaehr, Ellen; Unroe, Kathleen T.; Medicine, School of MedicineIntroduction Older adults are at greater risk of both infection with and mortality from COVID‐19. Many U.S. nursing homes have been devastated by the COVID‐19 pandemic, yet little has been described regarding the typical disease course in this population. The objective of this study is to describe and identify patterns in the disease course of nursing home residents infected with COVID‐19. Setting and Methods This is a case series of 74 residents with COVID‐19 infection in a nursing home in central Indiana between March 28 and June 17, 2020. Data were extracted from the electronic medical record and from nursing home medical director tracking notes from the time of the index infection through August 31, 2020. The clinical authorship team reviewed the data to identify patterns in the disease course of the residents. Results The most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. The duration of symptoms was extended, with an average of over 3 weeks. Of those infected 25 died; 23 of the deaths were considered related to COVID‐19 infection. A subset of residents with COVID‐19 infection experienced a rapidly progressive, fatal course. Discussion/Conclusions Nursing home residents infected with COVID‐19 from the facility we studied experienced a prolonged disease course regardless of the severity of their symptoms, with implications for the resources needed to care for and support of these residents during active infection and post‐disease. Future studies should combine data from nursing home residents across the country to identify the risk factors for disease trajectories identified in this case series.Item Describing Transfers Originating Out-of-Facility for Nursing Home Residents(Elsevier, 2022) Webb, Hanna T.; Lieb, Kristi M.; Stump, Timothy E.; Unroe, Kathleen T.; Carnahan, Jennifer L.; Medicine, School of MedicineObjectives: Potentially avoidable hospitalizations are harmful to nursing home residents. Despite extensive care transitions research, no studies have described transfers originating outside the nursing home (eg, visiting family members or at a dialysis center). This article describes 82 out-of-facility (community) transfers and compares them to transfers originating within the nursing home (direct transfers). Design: Secondary data analysis with multivariable model for community transfer risk factors. Setting and participants: Eighty-two community transfers and 1362 transfers originating in the nursing home, involving 870 residents enrolled in the OPTIMISTIC demonstration project between January 1, 2015, and June 30, 2016. Methods: Transfers were compared using data from the Minimum Data Set and root cause analyses performed at time of transfer. Multivariable associations were assessed at the transfer level to define risk factors for community transfers. Project nurses collected data on community transfers to inform a root cause analysis. Results: Residents with community transfers were younger (74.4 years vs 78.2 years), with lower prevalence of cognitive impairment (44.8% vs 70.3%) and higher rates of heart failure (38.7% vs 23.3%) than residents with direct transfers. Community transfers were more likely due to cardiovascular illness (31.2% vs 8.7%), whereas less likely to be for cognitive, behavioral, and psychiatric concerns (11.7% vs 22.7%). Nearly half (46%) of community transfers originated at dialysis centers. Residents transferred outside the nursing home were less likely to have documented limitations to care such as a do not resuscitate code status. Communication during community transfers was identified on root cause analyses as a potential area for improvement. Conclusions and implications: Community transfers were more likely to occur in younger residents with higher rates of cardiovascular disease and lower rates of cognitive impairment. Improved communication between nursing home staff and outside providers as well as more extensive advance care planning for residents with cardiovascular disease may reduce community transfers.Item Discharge Education for Residents: A Study of Trainee Preparedness for Hospital Discharge(2015-10) Carnahan, Jennifer L.; Fletcher, Kathlyn E.; Department of Medicine, IU School of MedicineBACKGROUND: Safe hospital discharges have become a major focus in the national discussion on transitions of care and care coordination. Education on the hospital discharge process is evolving as the needs of trainees are better understood. PURPOSE: This study is a cross-sectional survey of residents in a Midwestern residency program about their confidence in safely discharging patients from the hospital, including how they have or have not learned to do so. METHODS: An anonymous paper questionnaire was distributed to a convenience sample of interns and residents at a weekly meeting of the residency program. RESULTS: Most residents reported a general confidence in their abilities to safely discharge patients from the hospital; however, further probing revealed that their confidence breaks down when required to competently perform specific tasks of the discharge process such as activity restrictions or facilitation of home care. More than 50% of house staff surveyed responded that their education in many specific aspects of the discharge process are lacking. CONCLUSION: Interdisciplinary care education, and the discharge summary in particular, warrant further scrutiny as a care transition tool and means of teaching safe hospital discharge to trainees. We present a questionnaire that may serve useful as an anonymous tool to gauge residents' educational needs.Item Effects of Mindfulness-Based Interventions on Fatigue in Cancer Survivors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials(Elsevier, 2021-04) Johns, Shelley A.; Tarver, Will L.; Secinti, Ekin; Mosher, Catherine E.; Stutz, Patrick V.; Carnahan, Jennifer L.; Talib, Tasneem L.; Shanahan, Mackenzie L.; Faidley, Micah T.; Kidwell, Kelley M.; Rand, Kevin L.; Psychology, School of ScienceThis systematic review and meta-analysis was designed to determine the efficacy of mindfulness-based interventions (MBIs) in improving fatigue-related outcomes in adult cancer survivors. Randomized controlled trials (RCTs) were identified from PubMed, MEDLINE, PsycINFO, CINAHL, Web of Science, and EMBASE databases and reference lists of included studies. Separate random-effects meta-analyses were conducted for fatigue and vitality/vigor. Twenty-three studies reporting on 21 RCTs (N=2,239) met inclusion criteria. MBIs significantly reduced fatigue compared to controls at post-intervention (g=0.60, 95% CI [0.36, 0.83]) and first follow-up (g=0.42, 95% CI [0.20, 0.64]). Likewise, MBIs significantly improved vitality/vigor at post-intervention (g=0.39, 95% CI [0.25, 0.52]) and first follow-up (g=0.35, 95% CI [0.03, 0.67]). The evidence grade was low due to risk of bias, substantial heterogeneity, and publication bias among studies. MBIs show promise in improving fatigue and vitality/vigor in cancer survivors. More rigorous trials are needed to address current gaps in the evidence base.Item Facility and resident characteristics associated with variation in nursing home transfers: evidence from the OPTIMISTIC demonstration project(BMC, 2021-05-24) Blackburn, Justin; Balio, Casey P.; Carnahan, Jennifer L.; Fowler, Nicole R.; Hickman, Susan E.; Sachs, Greg A.; Tu, Wanzhu; Unroe, Kathleen T.; Health Policy and Management, School of Public HealthBackground: Centers for Medicare and Medicaid Services (CMS) funded demonstration project to evaluate financial incentives for nursing facilities providing care for 6 clinical conditions to reduce potentially avoidable hospitalizations (PAHs). The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) site tested payment incentives alone and in combination with the successful nurse-led OPTIMISTIC clinical model. Our objective was to identify facility and resident characteristics associated with transfers, including financial incentives with or without the clinical model. Methods: This was a longitudinal analysis from April 2017 to June 2018 of transfers among nursing home residents in 40 nursing facilities, 17 had the full clinical + payment model (1726 residents) and 23 had payment only model (2142 residents). Using CMS claims data, the Minimum Data Set, and Nursing Home Compare, multilevel logit models estimated the likelihood of all-cause transfers and PAHs (based on CMS claims data and ICD-codes) associated with facility and resident characteristics. Results: The clinical + payment model was associated with 4.1 percentage points (pps) lower risk of all-cause transfers (95% confidence interval [CI] - 6.2 to - 2.1). Characteristics associated with lower PAH risk included residents aged 95+ years (- 2.4 pps; 95% CI - 3.8 to - 1.1), Medicare-Medicaid dual-eligibility (- 2.5 pps; 95% CI - 3.3 to - 1.7), advanced and moderate cognitive impairment (- 3.3 pps; 95% CI - 4.4 to - 2.1; - 1.2 pps; 95% CI - 2.2 to - 0.2). Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score above most stable (CHESS score 4) increased the risk of PAH by 7.3 pps (95% CI 1.5 to 13.1). Conclusions: Multiple resident and facility characteristics are associated with transfers. Facilities with the clinical + payment model demonstrated lower risk of all-cause transfers compared to those with payment only, but not for PAHs.Item Factors Associated With Posthospital Nursing Facility Discharge for Patients With Impaired Decision Making(Elsevier, 2018-10) Carnahan, Jennifer L.; Inger, Lev; Young, Robert S.; Slaven, James E.; Torke, Alexia M.; Medicine, School of Medicine
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