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Item Comfort Measures Orders and Hospital Transfers: Insights From the OPTIMISTIC Demonstration Project(Elsevier, 2019) Unroe, Kathleen T.; O'Kelly Phillips, Erin; Effler, Shannon; Ersek, Mary; Hickman, Susan E.; Medicine, School of MedicineContext Nursing facility residents and their families may identify “comfort measures” as their overall goal of care, yet some hospital transfers still occur. Objectives Describe nursing facility residents with comfort measures and their hospital transfers. Methods Mixed methods, including root cause analyses of transfers by registered nurses and interviews with a subset of health care providers and family members involved in transfers. Participants were residents in 19 central Indiana facilities with comfort measures orders who experienced unplanned transfers to the hospital between January 1, 2015 and June 30, 2016. Project demographic and clinical characteristics of the residents were obtained from the Minimum Data Set 3.0. Interviews were conducted with stakeholders involved in transfer decisions. Participants were prompted to reflect on reasons for the transfer and outcomes. Interviews were transcribed and coded using qualitative descriptive methods. Results Residents with comfort measures orders (n = 177) experienced 204 transfers. Most events were assessed as unavoidable (77%). Communication among staff, or between staff and the resident/family, primary care provider, or hospital was the most frequently noted area needing improvement (59.5%). In interviews, participants (n = 11) highlighted multiple issues, including judgments about whether decisions were “good” or “bad,” and factors that were important to decision-making, including communication, nursing facility capabilities, clinical situation, and goals of care. Conclusion Most transfers of residents with comfort measures orders were considered unavoidable. Nonetheless, we identified several opportunities for improving care processes, including communication and addressing acute changes in status.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 Daily Situational Brief, May 18, 2011(MESH Coalition, 5/18/2011) MESH CoalitionItem Hospice use among nursing home and non-nursing home patients(Springer, 2015-02) Unroe, Kathleen T.; Sachs, Greg A.; Dennis, M.E.; Hickman, Susan E.; Stump, Timothy E.; Tu, Wanzhu; Callahan, Christopher; Department of Medicine, IU School of MedicineBACKGROUND: For nursing home patients, hospice use and associated costs have grown dramatically. A better understanding of hospice in all care settings, especially how patients move across settings, is needed to inform debates about appropriateness of use and potential policy reform. OBJECTIVE: Our aim was to describe characteristics and utilization of hospice among nursing home and non-nursing home patients. DESIGN AND PARTICIPANTS: Medicare, Medicaid and Minimum Data Set data, 1999-2008, were merged for 3,771 hospice patients aged 65 years and above from a safety net health system. Patients were classified into four groups who received hospice: 1) only in nursing homes; 2) outside of nursing homes; 3) crossover patients utilizing hospice in both settings; and 4) "near-transition" patients who received hospice within 30 days of a nursing home stay. MAIN MEASURES: Differences in demographics, hospice diagnoses and length of stay, utilization and costs are presented with descriptive statistics. KEY RESULTS: Nursing home hospice patients were older, and more likely to be women and to have dementia (p < 0.0001). Nearly one-third (32.3 %) of crossover patients had hospice stays > 6 months, compared with the other groups (16 % of nursing home hospice only, 10.7 % of non-nursing home hospice and 7.6 % of those with near transitions) (p < 0.0001). Overall, 27.7 % of patients had a hospice stay <1 week, but there were marked differences between groups-48 % of near-transition patients vs. 7.4 % of crossover patients had these short hospice stays (p < 0.0001). Crossover and near-transition hospice patients had higher costs to Medicare compared to other groups (p < 0.05). CONCLUSIONS: Dichotomizing hospice users only into nursing home vs. non-nursing home patients is difficult, due to transitions across settings. Hospice patients with transitions accrue higher costs. The impact of changes to the hospice benefit on patients who live or move through nursing homes near the end of life should be carefully considered.Item Hospital Transfers: Perspectives of Nursing Home Residents and Nurses(2022-05) Ahmetovic, Alma; Hickman, Susan E.; Draucker, Claire Burke; Huber, Lesa; Unroe, Kathleen T.Between 1 million and 2.2 million nursing home residents are transferred to a hospital emergency department each year. These transfers are costly, have negative health outcomes, and can increase the morbidity and mortality of residents. Few studies, however, have provided in-depth descriptions of transfer experiences. The purpose of this study was to examine the transfer process between the nursing home and the hospital from the perspectives of nursing home residents and nurses, focusing on how decisions were made to transfer residents. Using a qualitative descriptive method, 22 participants (10 residents and 12 nurses) were recruited from four nursing homes located in rural Indiana. Purposive sampling, semi-structured interviews, and conventional content analysis were used to collect and analyze narratives obtained from residents and nurses about their experiences with a recent transfer and to develop four in-depth case descriptions of these transfers. The participants described four aspects of the transfer process: transfer decisions, transport experiences, hospital stays, and returns to the nursing home. The most common reason for transfers was an acute exacerbation of a chronic condition, and the decision to transfer was often made by a nurse. Most participants found aspects of the transfer, including their hospital stay, to be aversive or upsetting. The return to the nursing home was typically welcomed but often challenging due to problems with mobility, medication adjustments, and cognitive changes. Participants also provided several recommendations for avoiding potentially preventable transfers including adding “in-house” diagnostic testing and treatment equipment, improving staff competencies in managing acute exacerbations, increasing staffing, improving communication among staff, and increasing staff familiarity with resident histories and preferences. The findings have several clinical and policy implications for preventing or decreasing the negative effects of hospital transfers.Item An Interim Analysis of an Advance Care Planning Intervention in the Nursing Home Setting(Wiley, 2016-11) Hickman, Susan E.; Unroe, Kathleen T.; Ersek, Mary T.; Buente, Bryce; Nazir, Arif; Sachs, Greg A.; IU School of NursingObjectives To describe processes and preliminary outcomes from the implementation of a systematic advance care planning (ACP) intervention in the nursing home setting. Design Specially trained project nurses were embedded in 19 nursing homes and engaged in ACP as part of larger demonstration project to reduce potentially avoidable hospitalizations. Setting Nursing homes. Participants Residents enrolled in the demonstration project for a minimum of 30 days between August 2013 and December 2014 (n = 2,709) and residents currently enrolled in March 2015 (n = 1,591). Measurements ACP conversations were conducted with residents, families, and the legal representatives of incapacitated residents using a structured ACP interview guide with the goal of offering ACP to all residents. Project nurses reviewed their roster of currently enrolled residents in March 2015 to capture barriers to engaging in ACP. Results During the initial implementation phase, 27% (731/2,709) of residents had participated in one or more ACP conversations with a project nurse, resulting in a change in documented treatment preferences for 69% (504/731). The most common change (87%) was the generation of a Physician Orders for Scope of Treatment form. The most frequently reported barrier to ACP was lack of time. Conclusion The time- and resource-intensive nature of robust ACP must be anticipated when systematically implementing ACP in the nursing home setting. The fact that these conversations resulted in changes over 2/3 of the time reinforces the importance of deliberate, systematic ACP to ensure that current treatment preferences are known and documented so that these preferences can be honored.Item Long-Stay Nursing Facility Resident Transfers: Who Gets Admitted to the Hospital?(AGS, 2020-09) Unroe, Kathleen T.; Caterino, Jeffrey M.; Stump, Timothy E.; Tu, Wanzhu; Carnahan, Jennifer L.; Vest, Joshua R.; Sachs, Greg A.; Hickman, Susan E.; Medicine, School of MedicineBACKGROUND/OBJECTIVES The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project is a successful, multicomponent demonstration project to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. To continue to reduce hospital transfers, a more detailed understanding of these transfer events is needed. The purpose of this study was to describe differences in transfer events that result in treatment in the hospital versus emergency department (ED) only. DESIGN OPTIMISTIC project nurses collected data on residents who transferred. Transfer events that resulted in treatment in ED versus hospitalization were compared using t-tests and chi-square tests. A generalized estimating equations regression model was used to assess the associations between hospital admission and transfer characteristics. PARTICIPANTS A total of 867 long-stay nursing facility residents enrolled in OPTIMISTIC, January 2015 to June 2016. MEASUREMENTS Resident and transfer characteristics from Minimum Data Set and project REDCap (Research Electronic Data Capture) database, including demographics, cognitive status, comorbidities, symptoms at time of transfer, and diagnoses. RESULTS The most common symptoms associated with treatment in the ED only were falls, trauma, or fracture (38% vs 10% admitted). Residents with cognitive impairment were more likely to be admitted to the hospital (odds ratio (OR) = 1.47; 95% confidence interval (CI) = 1.09–1.98; P = .011). Residents with respiratory complaints were more likely to be admitted (OR = 2.098; 95% CI = 1.198–3.675; P = .009); residents with hematological/bleeding (nongastrointestinal) (OR = 0.23; 95% CI = 0.107–0.494; P = .0002), pain (OR = 0.421; 95% CI = 0.254–0.698; P = .0008), or fall/trauma/fracture (OR = 0.181; 95% CI = 0.12–0.272; P < .001) were less likely to be admitted to the hospital. CONCLUSION Some presenting symptoms and other characteristics are more associated with ED only treatment versus hospitalization. A knowledge of who is likely to receive ED only care could prompt adoption of targeted resources and protocols to further reduce these types of transfer events. Opportunity may exist in the ED as well to reduce hospitalizations and increase discharges back to the facility.Item Music Therapy Clinical Practice in Hospice: Differences Between Home and Nursing Home Delivery(Oxford, 2015) Liu, Xiaodi; Burns, Debra S.; Stump, Timothy E.; Unroe, Kathleen T.; Department of Music and Arts Technology, School of Engineering and TechnologyBackground: Hospice music therapy is delivered in both homes and nursing homes (NH). No studies to date have explored differences in music therapy delivery between home and NH hospice patients. Objective: To compare music therapy referral reasons and delivery for hospice patients living in NH versus home. Methods: A retrospective, electronic medical record review was conducted from a large U.S. hospice of patients receiving music therapy between January 1, 2006, and December 31, 2010. Results: Among the 4,804 patients, 2,930 lived in an NH and 1,847 patients lived at home. Compared to home, NH hospice patients were more likely to be female, older, unmarried, and Caucasian. For home hospice patients, the top referral reasons were patient/family emotional and spiritual support, quality of life, and isolation. The most frequent referral reasons for NH hospice patients were isolation, quality of life, and patient/family emotional and spiritual support. Differences in music therapy delivery depended mainly on patients’ primary diagnosis and location of care. Conclusions: Results suggest differences in referral reasons and delivery based on an interaction between location of care and patient characteristics. Delivery differences are likely a result of individualized assessment and care plans developed by the music therapist and other interdisciplinary team members to address the unique needs of the patient. Thus, it is important to have professionally trained music therapists assess and provide tailored music-based interventions for patients with different referral reasons and personal characteristics. This study also supports staffing decisions based on patient need rather than average daily census.Item POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care(Elsevier, 2021-08) Hickman, Susan E.; Steinberg, Karl; Carney, John; Lum, Hillary D.; School of NursingPOLST (Physician Orders for Life-Sustaining Treatment) is a medical order form used to document preferences about cardiopulmonary resuscitation (CPR), medical interventions such as hospitalization, care in the intensive care unit, and/or ventilation, as well as artificial nutrition. Programs based on the POLST paradigm are used in virtually every state under names that include POST (Physician Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and MOST (Medical Orders for Scope of Treatment), and these forms are used in the care of hundreds of thousands of geriatric patients every year. Although POLST is intended for persons who are at risk of a life-threatening clinical event due to a serious life-limiting medical condition, some nursing homes and residential care settings use POLST to document CPR preferences for all residents, resulting in potentially inappropriate use with patients who are ineligible because they are too healthy. This article focuses on reasons that POLST is used as a default code status order form, the risks associated with this practice, and recommendations for nursing homes to implement appropriate use of POLST.