Browsing by Subject "Long-term care"
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Item Continuity Strategies for Long-Stay PICU Patients: Consensus Statements From the Lucile Packard Foundation PICU Continuity Panel(Wolters Kluwer, 2023) Edwards, Jeffrey D.; Wocial, Lucia D.; Madrigal, Vanessa N.; Moon, Michelle M.; Ramey-Hunt, Cheryl; Walter, Jennifer K.; Baird, Jennifer D.; Leland, Brian D.; Pediatrics, School of MedicineObjectives: To develop consensus statements on continuity strategies using primary intensivists, primary nurses, and recurring multidisciplinary team meetings for long-stay patients (LSPs) in PICUs. Participants: The multidisciplinary Lucile Packard Foundation PICU Continuity Panel comprising parents of children who had prolonged PICU stays and experts in several specialties/professions that care for children with medical complexity in and out of PICUs. Design/methods: We used modified RAND Delphi methodology, with a comprehensive literature review, Delphi surveys, and a conference, to reach consensus. The literature review resulted in a synthesized bibliography, which was provided to panelists. We used an iterative process to generate draft statements following panelists' completion of four online surveys with open-ended questions on implementing and sustaining continuity strategies. Panelists were anonymous when they voted on revised draft statements. Agreement of 80% constituted consensus. At a 3-day virtual conference, we discussed, revised, and re-voted on statements not reaching or barely reaching consensus. We used Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of the evidence and rate the statements' strength. The Panel also generated outcome, process, and balancing metrics to evaluate continuity strategies. Results: The Panel endorsed 17 consensus statements in five focus areas of continuity strategies (Eligibility Criteria, Initiation, Standard Responsibilities, Resources Needed to Implement, Resources Needed to Sustain). The quality of evidence of the statements was low to very low, highlighting the limited evidence and the importance of panelists' experiences/expertise. The strength of the statements was conditional. An extensive list of potential evaluation metrics was generated. Conclusions: These expert/parent-developed consensus statements provide PICUs with novel summaries on how to operationalize, implement, and sustain continuity strategies for LSP, a rapidly growing, vulnerable, resource-intensive population in PICUs.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 Determinants of inter-organizational implementation success: A mixed-methods evaluation of Veteran Directed Care(Elsevier, 2022) Sperber, Nina R.; Miech, Edward J.; Clary, Alecia Slade; Perry, Kathleen; Edwards-Orr, Merle; Rudolph, James L.; Van Houtven, Courtney Harold; Thomas, Kali S.; Emergency Medicine, School of MedicineBackground: Veteran Directed Care (VDC) aims to keep Veterans at risk for nursing home placement in their communities. VA medical centers (VAMCs) purchase VDC from third-party organizational providers who then partner with them during implementation. Experiences with VDC implementation have varied. Objectives: We sought to identify conditions differentiating partnerships with higher enrollment (implementation success). Methods: We conducted a case-based study with: qualitative data on implementation determinants two and eight months after program start, directed content analysis to assign numerical scores (-2 strong barrier to +2 strong facilitator), and mathematical modeling using Coincidence Analysis (CNA) to identify key determinants of implementation success. Cases consisted of VAMCs and partnering non-VAMC organizations who started VDC during 2017 or 2018. The Consolidated Framework for Implementation Research (CFIR) guided analysis. Results: Eleven individual organizations within five partnerships constituted our sample. Two CFIR determinants- Networks & Communication and External Change Agent-uniquely and consistently identified implementation success. At an inter-organizational partnership level, Networks & Communications and External Change Agent +2 (i.e., present as strong facilitators) were both necessary and sufficient. At a within-organization level, Networks & Communication +2 was necessary but not sufficient for the non-VAMC providers, whereas External Change Agent +2 was necessary and sufficient for VAMCs. Conclusion: Networks & Communication and External Change Agent played difference-making roles in inter-organizational implementation success, which differ by type of organization and level of analysis. Implications: This multi-level approach identified crucial difference-making conditions for inter-organizational implementation success when putting a program into practice requires partnerships across multiple organizations.Item Examining the Effects of Aging in Place on Quality of Life Compared to a Long-Term Care Facility: A Rapid Systematic Review(2023-05-04) Clayton, Ella; Doss, Breanna; Harrison, Stephanie; Mukhtar, Anam; Notter, Hope; Reyher, Whitney; Sego, Daniel; Chase, Anthony; Department of Occupational Therapy, School of Health and Human SciencesAs individuals age, they face impacted occupational performance which present as challenges performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) independently. This rapid systematic review seeks to investigate the effectiveness of existing occupational therapy (OT) interventions for older adults who are both aging in place and residing in long term care facilities through examining the evidence of 29 studies. Occupational therapy interventions investigated through this study were found to have common themes related to quality of life, occupational performance, self-efficacy, and psychological well-being. Common limitations found among studies include lack of randomization, small sample sizes, and lack of generalizability to different populations. Findings reveal that OT interventions with a focus on client-centered care contribute to improved occupational performance, participation, and quality of life for older adults. This systematic review supports implementing OT interventions for older adults aging in place and in long term care facilities. However, further research is needed to increase generalizability of conclusions and further examine the differences in outcomes between settings.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 Identification, Quantification, and Characterization of Nursing Home Resident Pain Trajectories(2022-05) Cole, Connie Sue; Hickman, Susan; Blackburn, Justin; Carpenter, Janet S.; Chen, Chen X.Pain prevalence in nursing home (NH) residents is high. Studies report up to 85.0% of NH residents experience pain and up to 58.0% experience persistent pain. Pain in NH residents can lead to decreased happiness, quality of life, and life satisfaction. Traditionally, pain has been studied in relation to specific comorbid conditions or pain subtypes (nociceptive, neuropathic) with little consideration for the dynamic (temporal) nature of pain. Current pain subtypes are clinically linked to recommended pain treatments and provide insight into underlying mechanisms. However, current pain subtypes are limited by their focus on pain origin, do not include severity or duration of the pain experience, and do not illustrate how the course or trajectory of pain changes over time. Understanding the trajectory of pain experience can provide opportunities to alter the course of pain experience, improve residents’ quality of life and prevent adverse outcomes. This dissertation provides the first evidence of four distinct pain trajectories among NH residents including persistent pain which was associated with several resident characteristics and clinically relevant diagnosis. Using residents’ characteristics associated with persistent pain, such as a history of fracture or contracture, may improve care planning based on early identification or risk stratification and can improve mitigation of persistent pain. To identify and characterize pain trajectories in NH residents, the following activities were completed (1) systematic review of the literature related to prevalence of pain and associated factors in NH residents, (2) cross-sectional analysis of secondary data to examine prevalence of pain, persistent pain, and factors associated with pain in NH residents, and (3) a longitudinal retrospective analysis of secondary data using group-based trajectory modeling to identify, quantify, and characterize NH pain trajectories. The findings from this study highlight the prevalence and complexity of pain in NH residents.Item “It is all About Giving Priority to Older Adults’ Needs:” Challenges of Formal Caregivers in Two Old Age Homes in Ethiopia(Springer, 2022-12) Dawud, Meriem; Kotecho, Messay Gebremariam; Adamek, Margaret E.; School of Social WorkWith a growing older population needing long-term care in Ethiopia, this study examined the challenges and needs of formal caregivers at two older adult homes. A qualitative, exploratory design was employed. Purposive sampling was used to identify 14 formal caregivers and 6 key informants who engaged in in-depth interviews. Formal caregivers assisted older adults with personal care, medication administration, and emotional support. As a result of high workloads, long work hours, an absence of training, and minimal compensation, caregivers faced many challenges including managing older adults’ difficult behavior, exposure to health hazards, and task burden. The all-encompassing demands of caring for older adults in resource-poor environments contributed to negative consequences that spilled over into caregivers’ personal lives. The capacity of formal caregivers to meet the needs of long term care residents in developing nations can be enhanced through training in geriatric care, adequate compensation, and best practice guidelines for long term care.Item Perceptions of Nurses Delivering Nursing Home Virtual Care Support: A Qualitative Pilot Study(Sage, 2023-03-22) Mills, Carol A.; Tran, Yvette; Yeager, Valerie A.; Unroe, Kathleen T.; Holmes, Ann; Blackburn, Justin; Health Policy and Management, School of Public HealthAvoidable hospitalizations among nursing home residents result in poorer health outcomes and excess costs. Consequently, efforts to reduce avoidable hospitalizations have been a priority over the recent decade. However, many potential interventions are time-intensive and require dedicated clinical staff, although nursing homes are chronically understaffed. The OPTIMISTIC project was one of seven programs selected by CMS as “enhanced care & coordination providers” and was implemented from 2012 to 2020. This qualitative study explores the perceptions of the nurses that piloted a virtual care support project developed to expand the program’s reach through telehealth, and specifically considered how nurses perceived the effectiveness of this program. Relationships, communication, and access to information were identified as common themes facilitating or impeding the perceived effectiveness of the implementation of virtual care support programs within nursing homes.Item Perceptions of Nurses Delivering Nursing Home Virtual Care Support: A Qualitative Pilot Study(Sage, 2023-03-22) Mills, Carol A.; Tran, Yvette; Yeager, Valerie A.; Unroe, Kathleen T.; Holmes, Ann; Blackburn, Justin; Health Policy and Management, School of Public HealthAvoidable hospitalizations among nursing home residents result in poorer health outcomes and excess costs. Consequently, efforts to reduce avoidable hospitalizations have been a priority over the recent decade. However, many potential interventions are time-intensive and require dedicated clinical staff, although nursing homes are chronically understaffed. The OPTIMISTIC project was one of seven programs selected by CMS as “enhanced care & coordination providers” and was implemented from 2012 to 2020. This qualitative study explores the perceptions of the nurses that piloted a virtual care support project developed to expand the program’s reach through telehealth, and specifically considered how nurses perceived the effectiveness of this program. Relationships, communication, and access to information were identified as common themes facilitating or impeding the perceived effectiveness of the implementation of virtual care support programs within nursing homes.Item Pragmatic Trials in Long-Term Care: Research Challenges and Potential Solutions in Relation to Key Areas of Care(Elsevier, 2022-08) Resnick, Barbara; Zimmerman, Sheryl; Gaugler, Joseph; Ouslander, Joseph; Abrahamson, Kathleen; Brandt, Nicole; Colón-Emeric, Cathleen; Galik, Elizabeth; Gravenstein, Stefan; Mody, Lona; Sloane, Philip D.; Unroe, Kathleen; Verbeek, Hilde; Medicine, School of MedicineAs a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.