Browsing by Subject "nursing facility"

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    Improving Nursing Facility Care Through an Innovative Payment Demonstration Project: Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Phase 2
    (Wiley, 2018-08) Unroe, Kathleen T.; Fowler, Nicole R.; Carnahan, Jennifer L.; Holtz, Laura R.; Hickman, Susan E.; Effler, Shannon; Evans, Russell; Frank, Kathryn I.; Ott, Monica L.; Sachs, Greg; Medicine, School of Medicine
    Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) is a 2‐phase Center for Medicare and Medicaid Innovations demonstration project now testing a novel Medicare Part B payment model for nursing facilities and practitioners in 40 Indiana nursing facilities. The new payment codes are intended to promote high‐quality care in place for acutely ill long‐stay residents. The focus of the initiative is to reduce hospitalizations through the diagnosis and on‐site management of 6 common acute clinical conditions (linked to a majority of potentially avoidable hospitalizations of nursing facility residents1): pneumonia, urinary tract infection, skin infection, heart failure, chronic obstructive pulmonary disease or asthma, and dehydration. This article describes the OPTIMISTIC Phase 2 model design, nursing facility and practitioner recruitment and training, and early experiences implementing new Medicare payment codes for nursing facilities and practitioners. Lessons learned from the OPTIMISTIC experience may be useful to others engaged in multicomponent quality improvement initiatives.
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    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 Medicine
    BACKGROUND/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.
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    Nursing Facility Residents’ Cardiopulmonary Resuscitation Decisions
    (Wiley, 2020-12) Myers, Anne L.; Matthias, Marianne S.; School of Nursing
    Context As many as one-quarter of all residents in nursing facilities have cardiopulmonary resuscitation (CPR) as a documented choice in the medical record, despite the likelihood of limited medical benefit in this setting. Objectives The aim of this study was to understand the perspectives of healthcare providers and nursing facility residents regarding CPR decisions. Methods We used qualitative interviews to examine the perspectives of residents with a documented decision for CPR in the medical record. We then compared residents’ views with those of healthcare providers who routinely conduct advance care planning (ACP) conversations in the nursing facility setting. Results Five themes emerged from the interviews: (a) Resident versus Provider Concerns, (b) Offering Information versus Avoidance, (c) Lack of Understanding of CPR, (d) Lack of Awareness, and (e) ‘Don't Keep Me on Machines'. Residents held misconceptions about CPR and/or exhibited an overall poor understanding of the relationship between their own health status and the likelihood of a successful CPR attempt. Although healthcare providers offer information and health education in an attempt to address knowledge gaps, these efforts are not always successful or even accepted by residents. Resident viewpoints and priorities differed from healthcare providers in ways that affected communication about CPR. Conclusions Unrecognised differences in perceptions between providers and residents affect key aspects of ACP communication that can impact CPR decision-making. The concerns and priorities of institutionalized older adults may differ from those of healthcare providers, creating challenges for engaging some residents in ACP. Implications for Practice ACP communication models and training should be designed not only to explore nursing facility residents' goals, values, and preferences, but also to elicit any underlying differences in perceptions that may affect communication. Healthcare providers can identifying the primary concerns of residents and assist them with integrating or reframing these issues as a part of ACP discussions.
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    Reducing the Risk of Hospitalization for Nursing Home Residents: Effects and Facility Variation From OPTIMISTIC
    (Elsevier, 2020-04) Blackburn, Justin; Stump, Timothy E.; Carnahan, Jennifer L.; Hickman, Susan E.; Tu, Wanzhu; Fowler, Nicole R.; Unroe, Kathleen T.; Health Policy and Management, School of Public Health
    Objectives The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project led to significant decreases in potentially avoidable hospitalizations of long-stay nursing facility residents in external evaluation. The purpose of this study was to quantify hospitalization risk from the start of the project and describe the heterogeneity of the enrolled facilities in order to better understand the context for successful implementation. Design Pre-post analysis design of a prospective intervention within a single group. Setting and Participants A total of 4320 residents in the 19 facilities were included from admission until time to the first hospitalization. Measures Data were extracted from Minimum Data Set assessments and linked with facility-level covariates from the LTCFocus.org data set. Kaplan-Meier and Cox proportional hazards regression were used to assess risk of hospitalization during the preintervention period (2011-2012), a “ramp-up” period (2013-2014), and an intervention period (2015-2016). Results The cohort consisted of 4230 long-stay nursing facility residents. Compared with the preintervention period, residents during the intervention period had an increased probability of having no hospitalizations within 1 year, increasing from 0.51 to 0.57, which was statistically significant ( P < .001). In adjusted Cox models, the risk of hospitalization was lower in the ramp-up period compared to the pre-period [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.75-0.95] and decreased further during the intervention period (HR 0.74, 95% CI 0.65-0.84). Conclusions and Implications As part of a large multisite demonstration project, OPTIMISTIC has successfully reduced hospitalizations. However, this study highlights the magnitude and extent to which results differ across facilities. Implementing the OPTIMISTIC program was associated with a 16% risk reduction after the first 18 months and continued to a final risk reduction of 26% after 5½ years. Although this model of care reduces hospitalizations overall, facility variation should be expected.
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    The Role of the Palliative Care Registered Nurse in the Nursing Facility Setting
    (Wolters Kluwer, 2020-04) Hickman, Susan E.; Parks, Melanie; Unroe, Kathleen T.; Ott, Monica; Ersek, Mary; School of Nursing
    There is a growing recognition of significant, unmet palliative care needs in nursing facilities, yet limitations in the workforce limit access to palliative care services. Attention to palliation is particularly important when there are efforts to reduce hospitalizations to help ensure there are no unintended harms associated with treating residents in place. A specialized palliative care registered nurse (PCRN) role was developed as part of the OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care) program, a federally funded project to reduce potentially avoidable hospitalizations. Working in collaboration with existing clinical staff and medical providers, the PCRN focuses on managing symptoms, advance care planning, achieving goal concordant care, and promoting quality of life. The PCRN serves as a resource for families through education and support. The PCRN also provides education and mentorship to staff to increase their comfort, knowledge, and skills with end-of-life care. The goals of this article are to provide an overview of the PCRN role and its implementation in nursing facilities and describe core functions that are transferrable to other contexts.
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    Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents
    (Wiley, 2019-08) Hickman, Susan E.; Unroe, Kathleen T.; Ersek, Mary; Stump, Timothy E.; Tu, Wanzhu; Ott, Monica; Sachs, Greg A.; School of Nursing
    BACKGROUND/OBJECTIVES The Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project is a successful, multicomponent demonstration project to reduce potentially avoidable hospitalizations of long‐stay nursing facility residents. Systematic advance care planning (ACP) is a core component of the intervention, based on research suggesting ACP is associated with decreased hospitalizations of nursing facility residents. The purpose of this study was to describe associations between ACP documentation resulting from the OPTIMISTIC intervention and hospitalizations. DESIGN Specially trained project nurses were embedded in 19 nursing facilities and systematically engaged in ACP as part of a larger demonstration project. PARTICIPANTS Residents (n = 1482) enrolled in the demonstration project for a minimum of 30 days between January 1, 2015, and June 30, 2016. MEASUREMENTS ACP status: (1) Physician Orders for Scope of Treatment (POST) comfort measures or do not hospitalize (DNH) orders; (2) ACP orders with no hospitalization limit (eg, code status only); and (3) no ACP (potentially avoidable and all‐cause hospitalizations per 1000 resident days). RESULTS Residents with POST comfort measures/DNH orders (33.2% or n = 493) were less likely than residents with no ACP (14.7% or n = 218) to experience a potentially avoidable hospitalization (P = .001) or all‐cause hospitalization (P = .001). These differences became statistically nonsignificant after adjusting for age, functional status, and cognitive functioning. CONCLUSION In this successful multicomponent demonstration project to reduce potentially avoidable hospitalizations, ACP outcomes were not associated with hospitalization rates of nursing facility residents after adjusting for resident characteristics. These findings highlight the challenge of measuring the contributions of individual components of complex, multicomponent interventions. Associations between lower hospitalization rates and ACP completion may be influenced by contextual factors, such as clinical expertise and resources to manage acute conditions leading to hospitalization, in addition to interventions to increase ACP.