"In Our Corner": A Qualitative Descriptive Study of Patient Engagement in a Community-Based Care Coordination Program

The purpose of this study was to explore participants' experience in the Health Quality Partners (HQP) Care Coordination Program that contributed to their continued engagement. Older adults with multiple chronic conditions often have limited engagement in health care services and face fragmented health care delivery. This can lead to increased risk for disability, mortality, poor quality of life, and increased health care utilization. A qualitative descriptive design with two focus groups was conducted with a total of 20 older adults enrolled in HQP's Care Coordination Program. Conventional content analysis was the analytical technique. The overarching theme resulting from the analysis was "in our corner," with subthemes "opportunities to learn and socialize" and "dedicated nurses," suggesting that these are the primary contributing factors to engagement in HQP's Care Coordination Program. Study findings suggest that nurses play an integral role in patient engagement among older adults enrolled in a care coordination program.

Using Electronic Case Summaries to Elicit Multi-Disciplinary Expert Knowledge about Referrals to Post-Acute Care

BACKGROUND

Eliciting knowledge from geographically dispersed experts given their time and scheduling constraints, while maintaining anonymity among them, presents multiple challenges.

OBJECTIVES

Describe an innovative, Internet based method to acquire knowledge from experts regarding patients who need post-acute referrals. Compare, 1) the percentage of patients referred by experts to percentage of patients actually referred by hospital clinicians, 2) experts' referral decisions by disciplines and geographic regions, and 3) most common factors deemed important by discipline.

METHODS

De-identified case studies, developed from electronic health records (EHR), contained a comprehensive description of 1,496 acute care inpatients. In teams of three, physicians, nurses, social workers, and physical therapists reviewed case studies and assessed the need for post-acute care referrals; Delphi rounds followed when team members did not agree. Generalized estimating equations (GEEs) compared experts' decisions by discipline, region of the country and to the decisions made by study hospital clinicians, adjusting for the repeated observations from each expert and case. Frequencies determined the most common case characteristics chosen as important by the experts.

RESULTS

The experts recommended referral for 80% of the cases; the actual discharge disposition of the patients showed referrals for 67%. Experts from the Northeast and Midwest referred 5% more cases than experts from the West. Physicians and nurses referred patients at similar rates while both referred more often than social workers. Differences by discipline were seen in the factors identified as important to the decision.

CONCLUSION

The method for eliciting expert knowledge enabled national dispersed expert clinicians to anonymously review case summaries and make decisions about post-acute care referrals. Having time and a comprehensive case summary may have assisted experts to identify more patients in need of post-acute care than the hospital clinicians. The methodology produced the data needed to develop an expert decision support system for discharge planning.

Transitional care in skilled nursing facilities: a multiple case study

BACKGROUND

Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement.

METHODS

In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services.

RESULTS

Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions.

CONCLUSIONS

Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.

Effects of alternative interventions among hospitalized, cognitively impaired older adults

AIM

Compare within site effects of three interventions designed to enhance outcomes of hospitalized cognitively impaired elders.

METHODS

Prospective, nonrandomized, confirmatory phased study. In Phase I, 183 patients received one of three interventions: augmented standard care (ASC), resource nurse care (RNC) or Transitional Care Model (TCM). In Phase II, 205 patients received the TCM.

RESULTS

Time to first rehospitalization or death was longer for the TCM versus ASC group (p = 0.017). Rates for total all-cause rehospitalizations and days were significantly reduced in the TCM versus ASC group (p < 0.001, both). No differences were observed between RNC versus TCM.

CONCLUSION

Findings suggest the TCM is more effective than ASC. However, potential effects of the RNC relative to the TCM warrant further study.

Achieving a High-Quality Cancer Care Delivery System for Older Adults: Innovative Models of Care

OBJECTIVES

To examine innovative models and other research-based interventions that hold potential to assure high-quality care for the growing older adult population living with cancer as one of multiple chronic conditions. Evidence from these care delivery approaches provides a roadmap for the development of future care models.

DATA SOURCES

Published peer-reviewed literature, policy analyses, and web-based resources.

CONCLUSION

Available evidence suggests the need for models that engage patients and their family caregivers, focus on patient's functional capacities, emphasize palliative care, and maximize the contributions of all team members.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are uniquely positioned to lead or play a major role in the evolution and implementation of care models targeting older adults with cancer, but must increase their knowledge and skills related to both oncology and geriatrics to maximize their contributions.

Continuity of Care: The Transitional Care Model

Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness. Identifying effective strategies to improve care transitions and outcomes for this population is essential. One rigorously tested model that has consistently demonstrated effectiveness in addressing the needs of this complex population while reducing healthcare costs is the Transitional Care Model (TCM). The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. This article provides a detailed summary of the evidence base for the TCM and the model's nine core components. We also discuss measuring the TCM's core components and the overall impact of this evidence-based care management approach.

Factors Associated With Changes in Perceived Quality of Life Among Elderly Recipients of Long-Term Services and Supports

OBJECTIVES

Advance knowledge about changes in multiple dimensions of health related quality of life (HRQoL) among older adults receiving long-term services and supports (LTSS) over time and across settings.

DESIGN

A prospective, observational, longitudinal cohort design.

SETTING

Nursing homes (NHs), assisted living facilities (ALFs), community.

PARTICIPANTS

A total of 470 older adults who were first-time recipients of LTSS.

MEASUREMENT

Single-item quality-of-life measure assessed every 3 months over 2 years. HRQoL domains of emotional status, functional status, and social support were measured using standardized instruments.

RESULTS

Multivariable mixed effects model with time varying covariates revealed that quality-of-life ratings decreased over time (P < .001). Quality-of-life ratings were higher among enrollees with fewer depressive symptoms (P < .001), higher general physical function (P < .001), enhanced emotional well-being (P < .001), and greater social support (P = .004). Ratings also were higher among those with increased deficits in activities of daily living (P = .02). Ratings were highest among enrollees who received LTSS from ALFs, followed by NHs, then home and community-based services (H&CBS), but only findings between ALFs and H&CBS were statistically significant (P < .001). Finally, ratings tended to decrease over time among enrollees with greater cognitive impairment and increase over time among enrollees with less cognitive impairment (P < .001).

CONCLUSIONS

Findings advance knowledge regarding what is arguably the most important outcome of elderly LTSS recipients: quality of life. Understanding associations between multiple HRQoL domains and quality of life over time and directly from LTSS recipients represents a critical step in enhancing care processes and outcomes of this vulnerable population.

Managing Chronic Illness

Models of care coordination can significantly improve health outcomes for older adults with chronic illnesses if they can engage participants. The purpose of this study was to examine the impact of nursing contact on the rate of participants' voluntary disenrollment from a care coordination program. In this retrospective cohort study using administrative data for 1,524 participants in the Health Quality Partners Medicare Care Coordination Demonstration Program, the rate of voluntary disenrollment was approximately 11%. A lower risk of voluntary disenrollment was associated with a greater proportion of in-person (vs. telephonic) nursing contact (Hazard Ratio [HR] 0.137, confidence interval [CI] [0.050, 0.376]). A higher risk of voluntary disenrollment was associated with lower continuity of nurses who provided care (HR 1.964, CI [1.724, 2.238]). Findings suggest that in-person nursing contact and care continuity may enhance enrollment of chronically ill older adults and, ultimately, the overall health and well-being of this population.

An Assessment of State-Led Reform of Long-Term Services and Supports

Health care in the United States is fragmented, inefficient, and rife with quality concerns. These shortcomings have particularly serious implications for adults with disabilities and functionally impaired older adults in need of long-term services and supports (LTSS). Three strategies have been commonly pursued by state governments to improve LTSS: expanding noninstitutional care, integrating payment and care delivery, and realigning incentives through market-based reforms. These strategies were analyzed using an evaluation framework consisting of the following dimensions: ease of access; choice of setting/provider; quality of care/life; support for family caregivers; effective transitions among multiple providers and across settings; reductions in racial/ethnic disparities; cost-effectiveness; political feasibility; and implementability. Although the analysis highlights potential benefits and drawbacks associated with each strategy, the limited breadth of the evidentiary base precludes an assessment of impact across all nine dimensions. More importantly, the analysis exposes the interdependent, complex system of care within which LTSS is situated, suggesting that policy makers will require a holistic and long-term perspective to achieve needed changes. Addressing the nation's LTSS needs will require a multipronged strategy incorporating a range of health and social services to meet the complex care needs of a diverse population in a variety of settings.

Engaging older adults in their transitional care: what more needs to be done?

Multiple studies reveal that the healthcare needs of chronically ill older adults are poorly managed and often have devastating consequences. This paper examines available evidence related to improving care management and outcomes in this vulnerable patient group. Findings reinforce the need for enhanced patient engagement and suggest comparative effectiveness research as an important and immediate path to optimize patient-clinician partnerships. An ongoing study in care management is described as an example of such comparative effectiveness research. An overview of the barriers to implementation of evidence-based strategies related to health literacy, shared decision-making and accountability for self-management is provided, followed by a set of recommendations designed to facilitate comparative effectiveness research that advances engagement of high-risk older adults and their family caregivers.

Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults

AIM

This article reports the effects of three evidence-based interventions of varying intensity, each designed to improve outcomes of hospitalized cognitively impaired older adults.

MATERIALS & METHODS

In this comparative effectiveness study, 202 older adults with cognitive impairment (assessed within 24 h of index hospitalization) were enrolled at one of three hospitals within an academic health system. Each hospital was randomly assigned one of the following interventions: Augmented Standard Care (ASC; lower dose: n = 65), Resource Nurse Care (RNC; medium dose: n = 71) or the Transitional Care Model (TCM; higher dose: n = 66). Since randomization at the patient level was not feasible due to potential contamination, generalized boosted modeling that estimated multigroup propensity score weights was used to balance baseline patient characteristics between groups. Analyses compared the three groups on time with first rehospitalization or death, the number and days of all-cause rehospitalizations per patient and functional status through 6-month postindex hospitalization.

RESULTS

In total, 25% of the ASC group were rehospitalized or died by day 33 compared with day 58 for the RNC group versus day 83 for the TCM group. The largest differences between the three groups on time to rehospitalization or death were observed early in the Kaplan-Meier curve (at 30 days: ASC = 22% vs RNC = 19% vs TCM = 9%). The TCM group also demonstrated lower mean rehospitalization rates per patient compared with the RNC (p < 0.001) and ASC groups (p = 0.06) at 30 days. At 90-day postindex hospitalization, the TCM group continued to demonstrate lower mean rehospitalization rates per patient only when compared with the ASC group (p = 0.02). No significant group differences in functional status were observed.

CONCLUSION

Findings suggest that the TCM intervention, compared with interventions of lower intensity, has the potential to decrease costly resource use outcomes in the immediate postindex hospitalization period among cognitively impaired older adults.

Burden in caregivers of cognitively impaired elderly adults at time of hospitalization: a cross-sectional analysis

OBJECTIVES

To describe the factors associated with burden that caregivers of cognitively impaired older adults (dementia, delirium, or both) at the time of hospitalization experienced.

DESIGN

Cross-sectional data analyses.

SETTING

Three hospitals-one academic tertiary hospital and two associated community hospitals.

PARTICIPANTS

Caregivers (N = 495) of cognitively impaired older adults at the time of hospital admission.

MEASUREMENTS

Multivariable linear regression was performed to analyze the effect of the independent variables (caregiver: demographic characteristics, depressive symptoms, self-efficacy; older adult: neuropsychiatric symptoms, delirium, functional deficits) on caregiver burden.

RESULTS

Higher burden was associated with younger caregiver age (P = .02), being a spouse (P = .03), depressive symptoms (P < .001), caregivers' lower perceived self-efficacy in managing care recipient symptoms (P = .002), and limited finances at the end of the month (P = .01). Caregiver burden was also strongly associated with the care recipient factors distressing neuropsychiatric symptoms (P = .001), delirium (P = .001), and greater functional deficits in basic activities of daily living (P = .001).

CONCLUSION

These findings suggest that caregivers of older adults who were cognitively impaired at hospital admission experience burden. Understanding the factors that contribute to burden at the time of hospitalization for caregivers of persons with cognitive impairment can inform the development of interventions targeted throughout the hospitalization that have the potential to decrease burden.

Restarting the cycle: incidence and predictors of first acute care use after nursing home discharge

OBJECTIVES

To describe the time to first acute care use (e.g., emergency department (ED) use without hospitalization or rehospitalization) for older adults discharged to home after receiving postacute care in skilled nursing facilities (SNFs); to identify predictors of first acute care use.

DESIGN

Retrospective cohort study using administrative claims data.

SETTING

SNFs providing postacute care for patients in North and South Carolina (N = 1,474).

PARTICIPANTS

A cohort of Medicare beneficiaries aged 65 and older (N = 55,980) who were hospitalized and then transferred to a SNF for postacute care and subsequently discharged home (January 1, 2010, to August 31, 2011).

MEASUREMENTS

Medicare institutional claims data (Parts A and B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute care use was explored. Cox proportional hazards regression models were used to describe individual-, home care-, and nursing facility-level predictors.

RESULTS

After discharge from SNF to home, 22.1% of older adults had an episode of acute care use within 30 days, including 7.2% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5% of older adults had their first acute care use within 90 days. Male sex, dual eligibility status, higher Charlson comorbidity score, certain primary diagnoses at index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient-day were associated with greater likelihood of acute care use.

CONCLUSION

Medicare beneficiaries have a high use of acute care services after discharge from SNFs, and several factors associated with acute care use are potentially modifiable. Findings suggest the need for interventions to support beneficiaries as they transition from SNFs to home.

High-value transitional care: translation of research into practice

OBJECTIVE

To evaluate the impact of translating into a large US health plan, the Transitional Care Model (TCM), an evidence-based approach to address the needs of chronically ill older adults throughout acute episodes of illness.

METHODS

A prospective, quasi-experimental study of 172 at-risk Aetna Medicare Advantage members in the mid-Atlantic region who received the TCM. A baseline and post-intervention (average of 2 months) comparison of enrolees' health status and quality of life was conducted. Member and physician satisfaction were assessed within 1 month post intervention. Health resource utilization and cost outcomes were compared to a matched control group of Aetna members at multiple intervals through 1 year.

RESULTS

Improvements in all health status and quality of life measures were observed post- intervention compared to pre-intervention. Among 155 stringently matched pairs, a significant decrease in number of re-hospitalizations (45 vs. 60, P < 0.041) and total hospital days (252 vs. 351, P < 0.032) were observed at 3 months. Reductions in other utilization outcomes or time points were not statistically significant. The TCM was associated with a short-term decrease of $439 per member per month in total health care costs at 3 months and cumulative per member savings of $2170 at 1 year (P < 0.037).

CONCLUSIONS

Findings demonstrate that a rigorously tested model of transitional care for chronically ill older adults can be successfully translated into a real-world organization and achieve higher value.

Case study: Transitional care for a patient with benign prostatic hyperplasia and recurrent urinary tract infections

Chronic urologic conditions, including benign prostatic hyperplasia, recurrent urinary tract infections, and urinary incontinence, are common in older adults. This article highlights the urologic and transitional care needs of an elderly, cognitively impaired male during and after an acute hospitalization. Collaboration between the patient, his family, the advanced practice nurse, primary care providers, and outpatient urology office are described. The importance of mutual goal setting and a focused plan for transitional care are discussed.

Advancing Alzheimer's disease diagnosis, treatment, and care: recommendations from the Ware Invitational Summit

To address the pending public health crisis due to Alzheimer's disease (AD) and related neurodegenerative disorders, the Marian S. Ware Alzheimer Program at the University of Pennsylvania held a meeting entitled "State of the Science Conference on the Advancement of Alzheimer's Diagnosis, Treatment and Care," on June 21-22, 2012. The meeting comprised four workgroups focusing on Biomarkers; Clinical Care and Health Services Research; Drug Development; and Health Economics, Policy, and Ethics. The workgroups shared, discussed, and compiled an integrated set of priorities, recommendations, and action plans, which are presented in this article.

Transitions in care among older adults receiving long-term services and supports

Recipients of long-term services and supports (LTSS) frequently transition between LTSS settings (e.g., assisted living facilities, nursing homes) and hospitals for acute changes in health. In this qualitative study, we analyzed findings from interviews with 57 recently hospitalized LTSS recipients and their family caregivers and described barriers and facilitators to high-quality care to support older adults through these care transitions. The themes that emerged strongly suggest that LTSS recipients and family caregivers do not receive needed information about the reasons for their transfers to hospitals, medical diagnoses, and planned treatments to address acute changes in health. Our findings indicate an urgent need for nurses and other health care team members to talk with LTSS recipients (and family caregivers) and ensure they are engaged and informed participants in care. We also found the need for research to test evidence-based transitional care for high-risk LTSS recipients and their family caregivers.

Health-related quality of life: expanding a conceptual framework to include older adults who receive long-term services and supports

For older adults receiving long-term services and supports (LTSS), health-related quality of life (HRQoL) has emerged as a critical construct to examine because of its focus on components of well-being, which are affected by progressive changes in health status, health care, and social support. HRQoL is a health-focused quality of life (QOL) concept that encompasses aspects of QOL that affect health such as function, physical, and emotional health. Examining existing theoretical constructs and indicators of HRQoL among LTSS recipients led us to posit a revised conceptual framework for studying HRQoL among LTSS recipients. We adapted the Wilson and Cleary HRQoL model by expanding function to specifically include cognition, adding behavior and LTSS environmental characteristics in order to create a more robust HRQoL conceptual framework for older adults receiving LTSS. This refined conceptual model allows for the measurement of a mix of structural, process, and outcome measures. Continued development of a multidimensional conceptual framework with specific HRQoL measures that account for the unique characteristics of older adults receiving LTSS will contribute significantly to LTSS research, policy, and planning efforts.

Unintended consequences of steps to cut readmissions and reform payment may threaten care of vulnerable older adults

The US health care system is characterized by fragmentation and misaligned incentives, which creates challenges for both providers and recipients. These challenges are magnified for older adults who receive long-term services and supports. The Affordable Care Act attempts to address some of these challenges. We analyzed three provisions of the act: the Hospital Readmissions Reduction Program; the National Pilot Program on Payment Bundling; and the Community-Based Care Transitions Program. These three provisions were designed to enhance care transitions for the broader population of adults coping with chronic illness. We found that these provisions inadequately address the unique needs of vulnerable subgroup members who require long-term services and supports and, in some instances, could produce unintended consequences that would contribute to avoidable poor outcomes. We recommend that policy makers anticipate such unintended consequences and advance payment policies that integrate care. They should also prepare the delivery system to keep up with new requirements under the Affordable Care Act, by supporting providers in implementing evidence-based transitional care practices, recrafting strategic and operational plans, developing educational and other resources for frail older adults and their family caregivers, and integrating measurement and reporting requirements into performance systems.

A qualitative analysis of an advanced practice nurse-directed transitional care model intervention

PURPOSE

The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs).

DESIGN AND METHODS

APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences.

RESULTS

Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond.

IMPLICATIONS

APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.

The care span: The importance of transitional care in achieving health reform

Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

What factors are associated with having an advance directive among older adults who are new to long term care services?

OBJECTIVES

To explore differences in having an advance directive among older adults newly transitioned to long term services and support (LTSS) settings (ie, nursing homes [NHs]; assisted living facilities [ALFs]; home and community-based services).

DESIGN

Cross sectional survey.

SETTING

LTSS in New York and Pennsylvania.

PARTICIPANTS

Participants were 470 older adults who recently started receiving LTSS. Included in this analyses, N = 442 (ALF: n = 153; NH: n = 145; home and community-based services: n = 144).

MEASUREMENTS

Interviews consisted of questions about advance directives (living will and health care power of attorney), significant health changes in the 6 months before the start of long term care support services, Mini-Mental State Examination, and basic demographics.

RESULTS

Sixty-one percent (270/442) of older adults receiving LTSS reported having either a living will and/or an health care power of attorney. ALF residents reported having an advance directive more frequently than NH residents and older adults receiving LTSS in their own home (living will: χ(2)[2]= 120.9; P < .001; health care power of attorney: χ(2)[2]= 69.1; P < .001). In multivariate logistic regression models, receiving LTSS at an ALF (OR = 5.01; P < .001), being white (OR = 2.87; P < .001), having more than 12 years of education (OR = 2.50; P < .001), and experiencing a significant health change in past 6 months (OR = 1.97; P = .007) were predictive of having a living will. Receiving LTSS at an ALF (OR = 4.16; P < .001), having more than 12 years of education (OR = 1.74, P = .022), and having had a significant change in health in the last 6 months (OR = 1.61; P = .037) were predictive in having an health care power of attorney in this population of LTSS recipients.

CONCLUSIONS

These data provide insight into advance directives and older adults new to LTSS. Future research is needed to better understand the barriers to completing advance directives before and during enrollment in LTSS as well as to assess advance directive completion changes over time for this population of older adults.

Cognitive Impairment among Older Adults in the Emergency Department

BACKGROUND

Within the next 30 years, the number of visits older adults will make to emergency departments (EDs) is expected to double from 16 million, or 14% of all visits, to 34 million and comprise nearly a quarter of all visits.

OBJECTIVE

The objectives of this study were to determine prevalence rates of cognitive impairment among older adults in the ED and to identify associations, if any, between environmental factors unique to the ED and rates of cognitive impairment.

METHODS

A cross-sectional observational study of adults 65 and older admitted to the ED of a large, urban, tertiary academic health center was conducted between September 2007 and May 2008. Patients were screened for cognitive impairment in orientation, recall and executive function using the Six-Item Screen (SIS) and the CLOX1, clock drawing task. Cognitive impairment among this ED population was assessed and both patient demographics and ED characteristics (crowding, triage time, location of assessment, triage class) were compared through adjusted generalized linear models.

RESULTS

Forty-two percent (350/829) of elderly patients presented with deficits in orientation and recall as assessed by the SIS. An additional 36% of elderly patients with no impairment in orientation or recall had deficits in executive function as assessed by the CLOX1. In full model adjusted analyses patients were more likely to screen deficits in orientation and recall (SIS) if they were 85 years or older (Relative Risk [RR]=1.63, 95% Confidence Interval [95% CI]=1.3-2.07), black (RR=1.85, 95% CI=1.5-2.4) and male (RR=1.42, 95% CI=1.2-1.7). Only age was significantly associated with executive functioning deficits in the ED screened using the clock drawing task (CLOX1) (75-84 years: RR=1.35, 95% CI= 1.2-1.6; 85+ years: RR=1.69, 95% CI= 1.5-2.0).

CONCLUSION

These findings have several implications for patients seen in the ED. The SIS coupled with a clock drawing task (CLOX1) provide a rapid and simple method for assessing and documenting cognition when lengthier assessment tools are not feasible and add to the literature on the use of these tools in the ED. Further research on provider use of these tools and potential implication for quality improvement is needed.

The effect of telehomecare on heart failure self care

Heart failure (HF) afflicts nearly 6 million Americans and the prevalence continues to rise as the population ages. Hospital use for HF is high and about half of readmissions are believed to be preventable. Promoting self care through telehomecare is an emerging strategy for managing chronic illness. Hospitalized heart failure patients were randomly assigned at discharge to receive usual home care or telehomecare, nurse visits and daily use of monitoring devices such as blood pressure cuffs, scales, glucometers, and pulse oximetry to monitor their symptoms. Nurses at the home care agency monitored the results and interacted with patients as needed to teach self care and treat symptoms. Self care was measured at baseline, 60, 120, and 180 days using the Self Care Heart Failure Index. Despite improving the overall readmission rate, findings suggest telehomecare had no significant effect on self care over usual home care.

Scaling up: bringing the transitional care model into the mainstream

Elderly, chronically ill people experience frequent changes in health status that require transitions among health care providers and settings. This issue brief describes two projects that identified the essential elements of effective care management interventions for this population and the facilitators of translating one such intervention, the Transitional Care Model (TCM), into mainstream practice. Together these projects demonstrate that successful translation of the TCM, which incorporates both in-person contact and a nurse-led, interdisciplinary team approach, can effectively interrupt patterns of frequent rehospitalizations, reduce costs, and improve patient health status. Findings from these projects inform challenges that must be overcome to facilitate the translation of effective care management innovations into mainstream practice.

Translating research into practice: transitional care for older adults

RATIONALE

Over the last decade, in order to close the safety and health care quality chasm, there has been a growing imperative to translate evidence-based research into practice.

AIMS AND OBJECTIVES

This study examines the major facilitators and barriers of implementing in a large US insurance organization - Aetna Corporation - an evidence-based model of care, the Transitional Care Model, which has been rigorously tested over the past twenty years by a multidisciplinary team at the University of Pennsylvania.

METHODS

Semi-structured interviews of 19 project leaders, case managers, and transitional care nurses were conducted during two phases of translation - start-up and roll out. Qualitative analysis was used to identify more than a dozen key barriers to and facilitators of translation in these two critical phases. Results Six facilitators and seven barriers that are consistent with the literature were identified during and categorized as either start-up or roll-out.

CONCLUSION

The combined results have important practical implications for other, subsequent translational efforts and for assisting providers, policy makers, payers, and other change agents in integrating evidence-based practice with "real world" management.

Transitions of elders between long-term care and hospitals

Elderly long-term care recipients who require acute hospitalizations must navigate a fragmented system with poor "handoffs," often resulting in negative outcomes. This article makes the case that reducing preventable hospitalizations and improving transitions to and from hospitals will enhance health care quality and outcomes among these elders. Immediate action targeting diffusion of evidence-based care is recommended to decrease avoidable rehospitalizations and achieve cost savings. Policy changes are needed to address barriers to high-quality transitional care, including deficits in health professionals' and caregivers' knowledge and resources, regulatory obstacles, and inadequate financial incentives and clinical information systems.

What works in chronic care management: the case of heart failure

The evidence base of what works in chronic care management programs is underdeveloped. To fill the gap, we pooled and reanalyzed data from ten randomized clinical trials of heart failure care management programs to discern how program delivery methods contribute to patient outcomes. We found that patients enrolled in programs using multi-disciplinary teams and in programs using in-person communication had significantly fewer hospital readmissions and readmission days than routine care patients had. Our study offers policymakers and health plan administrators important guideposts for developing an evidence base on which to build effective policy and programmatic initiatives for chronic care management.

The terrible choice: re-evaluating hospice eligibility criteria for cancer

PURPOSE

To be eligible for the Medicare Hospice Benefit, cancer patients with a life expectancy of 6 months or less must give up curative treatment. Our goal was to determine whether willingness to make this choice identifies patients with greater need for hospice services.

PATIENTS AND METHODS

Three hundred patients with cancer and 171 family members were recruited from six oncology practices. Respondents completed conjoint interviews in which their perceived need for five hospice services was calculated from the choices they made among combinations of services. Patients' preferences for treatment were measured, and patients were followed for 6 months or until death.

RESULTS

Thirty-eight patients (13%) said they would not want cancer treatment even if it offered an almost 100% chance of 6-month survival. These patients, who would have been eligible for hospice, did not have greater perceived need for hospice services compared with other patients (n = 262; mean, 1.75 v 1.98; Wilcoxon rank sum test, P = .46), nor did their family members (mean, 1.95 v 2.04; Wilcoxon rank sum test, P = .80). Instead, independent predictors of patients' perceived need for hospice services included African American ethnicity, less social support, worse functional status, and a greater burden of psychological symptoms. For families, predictors included caregiver burden, worse self-reported health, working outside the home, and caring for a patient with worse functional status.

CONCLUSION

The requirement that patients forgo life-sustaining treatment does not identify patients with greater perceived need for hospice services. Other characteristics offer a better way to identify the patients who are most likely to benefit from hospice.

Advancing the science in the measurement of health care quality influenced by nurses

A robust set of quality measures is essential to provide consumers with a vehicleto evaluate nurses' contributions to the care of hospitalized patients, providers, and systems with a set of nursing processes and outcomes to guide quality improvement, and insurers with indicators to reward hospitals for high quality nursing services. The processes employed by the Nursing Care Performance Measures Steering Committee convened by the National Quality Forum (NQF) in 2004 resulted in the endorsement of 15 indicators of health care quality influenced by nurses and contributed to the identification of significant gaps in measurement and priority areas for future research. This critical review of the state of the science related to health care processes and outcomes that reflect nurses' contributions to the quality of care for hospitalized patients is intended to push the boundaries in the measurement of nursing performance. Specific recommendations for future research and measure development are presented.

Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology

BACKGROUND

Age is an important determinant of outcomes for patients with acute coronary syndromes (ACS); however, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients with ACS who would stand to benefit. Reasons include limited trial data to guide the care of older adults and uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age or complex health status.

METHODS AND RESULTS

This 2-part American Heart Association scientific statement summarizes evidence on patient heterogeneity, clinical presentation, and treatment of non-ST-elevation ACS in relation to age (< 65, 65 to 74, 75 to 84, and > or = 85 years). In addition, we review methodological issues that influence the acquisition and application of evidence to the elderly patients treated in community practice. A writing group combining international cardiovascular and geriatric perspectives convened to summarize available data from trials (5 combined Virtual Coordinating Center for Global Collaborative Cardiovascular Research [VIGOUR] trials) and 3 registries (Global Registry of Acute Coronary Events, National Registry of Myocardial Infarction, and the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines national quality improvement initiative [CRUSADE]) to provide a conceptual framework for future work in the care of the elderly with acute cardiac disease. Treatment for non-ST-segment-elevation ACS (Part I) and ST-segment-elevation myocardial infarction (Part II) are reviewed. In addition, ethical considerations pertaining to acute care and secondary prevention are considered (Part II). The primary goal is to identify the areas in which sufficient evidence is available to guide practice, as well as to determine areas that warrant further study. Although treatment-related benefits should rise in an elderly population with high disease risk, data to assess these benefits are limited, outcomes of importance vary, and heterogeneity among the elderly increases treatment-related risks. Although a uniform approach to care in the oldest of the old is unlikely, understanding the major contributors to benefits and risks from treatment will advance the ability to apply guideline-based care in this subset of patients.

CONCLUSIONS

Although a few recent trials have described treatment effects in older patients, others continue to exclude patients on the basis of age. Going forward, prospective trials should enroll elderly subjects proportionate to their prevalence among the treated population to define risk and benefit. Findings from age subgroup analyses should be reported in a consistent manner across trials, including absolute and relative risks for efficacy and safety. Outcomes of particular relevance to the elderly, such as quality of life, physical function, and independence, should also be considered. Creatinine clearance should be calculated for every elderly patient to enable appropriate dosing. In addition, physicians need an understanding of conditions unique to older patients (eg, frailty, cognitive impairment) that influence treatment goals and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed in the health context of the elderly patient with ACS.

Community-Based Care Model for High-Risk Adults with Severe Disabilities

Objective: Evaluate the effectiveness of a home-based intervention for adults with serious physical disabilities at high risk for poor health outcomes.

Design: A pretest/post-test design; content analysis of case studies.

Setting: Five-county Philadelphia metropolitan area.

Patients and Other Participants: Forty-nine community-dwelling adults aged 20—55.

Intervention: Six-month comprehensive care management intervention implemented by Advanced Practice Nurses (APNs) focused on improvement of functional status or prevention of functional decline; management of health problems; and enhancement of self-direction of care by subjects and caregivers.

Main Outcome Measures: Functional status; total hospitalizations, emergency department (ED) and acute care physician visits; symptom management; depression; quality of life; and satisfaction with care.

Results: Between baseline assessment and nine months post-APN intervention, functional status improved (mean = 33.42 → 24.97, p = 0.014). There was a trend toward reductions in average hospitalization rate from 1.10 at baseline to 0.68 nine months post-APN intervention and ED rates from 0.90 to 0.50. Acute care visits to physicians increased from 0.52 to 0.95 from baseline to nine months post-APN intervention. The use of home health aides (mean = 2.72 → 1.37, p = 0.008) and physical therapists (mean = 1.16 → 0.42, p = 0.001) also decreased from baseline to nine months post-APN intervention. Facilitators and barriers to care are identified.

Conclusions: Findings suggest potential benefit of a comprehensive, individualized intervention coordinated by APNs in improving health and functional outcomes and decreasing the use of

Acute Coronary Care in the Elderly, Part II

Background— Age is an important determinant of outcomes for patients with acute coronary syndromes. However, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients who would stand to benefit. Limited trial data are available to guide care of older adults, which results in uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age and complex health status.

Methods and Results— Part II of this American Heart Association scientific statement summarizes evidence on presentation and treatment of ST-segment–elevation myocardial infarction in relation to age (<65, 65 to 74, 75 to 84, and ≥85 years). The purpose of this statement is to identify areas in which the evidence is sufficient to guide practice in the elderly and to highlight areas that warrant further study. Treatment-related benefits should rise in an elderly population, yet data to confirm these benefits are limited, and the heterogeneity of older populations increases treatment-associated risks. Elderly patients with ST-segment–elevation myocardial infarction more often have relative and absolute contraindications to reperfusion, so eligibility for reperfusion declines with age, and yet elderly patients are less likely to receive reperfusion even if eligible. Data support a benefit from reperfusion in elderly subgroups up to age 85 years. The selection of reperfusion strategy is determined more by availability, time from presentation, shock, and comorbidity than by age. Additional data are needed on selection and dosing of adjunctive therapies and on complications in the elderly. A “one-size-fits-all” approach to care in the oldest old is not feasible, and ethical issues will remain even in the presence of adequate evidence. Nevertheless, if the contributors to treatment benefits and risks are understood, guideline-recommended care may be applied in a patient-centered manner in the oldest subset of patients.

Conclusions— Few trials have adequately described treatment effects in older patients with ST-segment–elevation myocardial infarction. In the future, absolute and relative risks for efficacy and safety in age subgroups should be reported, and trials should make efforts to enroll the elderly in proportion to their prevalence among the treated population. Outcomes of particular relevance to the older adult, such as quality of life, physical function, and independence, should also be evaluated, and geriatric conditions unique to this age group, such as frailty and cognitive impairment, should be considered for their influence on care and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed within the health context of the elderly patient.

Advanced Practice Nurse Strategies to Improve Outcomes and Reduce Cost in Elders with Heart Failure

The aim of this study was to investigate whether, in a randomized controlled trial (RCT) of vulnerable elders with heart failure (HF), advanced practice nurses (APNs) who were coordinating care in the transition from hospital to home could improve outcomes, prevent rehospitalizations, and reduce costs when compared with usual care. The APN strategies focused on improving patient and family or caregiver effectiveness in managing their illnesses, strengthening the patient-provider relationship, and managing comorbid conditions while improving overall health. The results were positive. By capitalizing on the patient's desire to achieve their identified goals, APNs successfully educated patients about the meaning of their symptoms and appropriate self-management strategies; improved patient-provider communication patterns; and marshaled caregiver and community resources to maximize patient adherence to the treatment plan and overall quality of life. While HF was the primary reason for enrollment in the study, optimal health outcomes demanded a strong focus on integrating management of comorbid conditions and other long-standing health problems. Specific strategies used by the APN to achieve these positive outcomes are addressed in this report. These strategies are compared with nursing interventions used in other RCTs of HF home management. Directions for future research are explored.

Transitional care: a critical dimension of the home healthcare quality agenda

Focusing on the critical transitions of patients and their caregivers across healthcare settings and among providers is a promising approach to enhancing care coordination and improving quality. This article describes the research base for the transitional care of older adults and offers recommendations to advance the science, translate best practices into home healthcare settings, and improve the transitions of high-risk older adults to and from home healthcare. Home healthcare is a component of the healthcare industry uniquely positioned to improve transitional care and outcomes for the growing population of older adults with continuous complex needs.

Opportunities for Improving Post-Hospital Home Medication Management Among Older Adults

Effective post-hospital home medication management among older adults is a convoluted, error-prone process. Older adults, whose complex medication regimens are often changed at hospital discharge, are susceptible to medication-related problems (e.g. Adverse Drug Events or ADEs) as they resume responsibility for managing their medications at home. Human error theory frames the discussion of multi-faceted, interacting factors including care system functions, like discharge medication teaching that contribute to post-hospital ADEs. The taxonomy and causes of post-hospital ADEs and related risk factors are reviewed, as we describe in high-risk older adults a population that may benefit from targeted interventions. Potential solutions and future research possibilities highlight the importance of interdisciplinary teams, involvement of clinical pharmacists, use of transitional care models, and improved use of informational technologies.

Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial

OBJECTIVES

To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure.

DESIGN

Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge.

SETTING

Six Philadelphia academic and community hospitals.

PARTICIPANTS

Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure.

INTERVENTION

A 3-month APN-directed discharge planning and home follow-up protocol.

MEASUREMENTS

Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care.

RESULTS

Mean age of patients (control n=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001).

CONCLUSION

A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.

Transitional care for older adults: a cost-effective model

Although the quality of care in hospitals and ambulatory settings is undergoing more scrutiny, far less attention has focused on the care patients receive as they move from one setting to another. Older patients who transition from hospital to home are particularly vulnerable: many of these patients have multiple health problems that continue beyond discharge. In response, investigators at the University of Pennsylvania developed a model of care delivered by nurse experts who follow vulnerable elders though their hospitalization and monitor their progress at home. This Issue Brief summarizes more than a decade of research on this model of transitional care and its effects on the costs and quality of care for hospitalized elderly patients.

Nursing Intervention Research and Quality of Care

BACKGROUND

Improvement of healthcare in the United States is a national priority. Nursing intervention science can contribute substantially to addressing this priority.

OBJECTIVES

The aim of this study was to describe strategies needed to maximize the base of nursing intervention science.

METHODS

The study involved a review of reports on the state of quality in healthcare and an examination of nurse-led intervention studies funded by the National Institute of Nursing Research aimed at improving healthcare processes and outcomes.

RESULTS

Nursing has contributed valuable data regarding the meaning of quality from the perspectives of individuals, families, and communities. Increased efforts are needed to ensure that this science informs ongoing initiatives to define, assess, and improve the quality of healthcare.

CONCLUSIONS

Nurse-led intervention research is making significant contributions to the advancement of the science underpinning quality healthcare. However, the message regarding the substantive and unique contributions of this body of work needs to be disseminated more broadly. Future nursing intervention research aimed at improving healthcare quality should consider individual behavior in a broader context, extend the traditional foci of interventions, and be grounded in the sciences of multiple disciplines.

Hospital discharge referral decision making: a multidisciplinary perspective

Patients discharged without home care referral were presented as case studies to nurses, social workers, physicians, and discharge planners experienced in discharge planning. Observations and tape-recorded interviews were used to identify patterns clinicians used when gathering information, determine information essential to discharge referral decisions, and explore why patients in need may not be referred for service. Clinicians collected information randomly, and content analysis of their interviews identified mental and functional status, treatment adherence, medical and co-existing conditions, medication management, social support, and prior hospitalization as essential information. Three themes describe why patients may not receive needed referrals: patient characteristics, workload and staffing, and educational issues. Suggestions for improved practice and further research are based on these themes.

Expert consensus for discharge referral decisions using online delphi

This paper describes the results of using a modified Delphi approach designed to achieve consensus from eight discharge planning experts regarding the decision to refer hospitalized older adults for post-discharge follow-up. Experts reviewed 150 cases using an online website designed to facilitate their interaction and efforts to reach agreement on the need for a referral for post-discharge care and the appropriate site for such care. In contrast to an average of eight weeks to complete just 50 cases using the traditional mail method, the first online Delphi round for 150 cases were completed in six weeks. Data provided by experts suggest that online Delphi is a time efficient and acceptable methodology for reaching group consensus. Other benefits include instant access to Delphi decision results, live knowledge of the time requirements and progress of each expert, and cost savings in postage, paper, copying, and storage of paper documents. This online Delphi methodology is highly recommended.

Transitional care of older adults

This chapter reviews 94 published research reports on transitional care of older adults by nurse researchers and researchers from other disciplines. Reports were identified through searches of MEDLINE, CINAHL, HealthSTAR, Sociological Abstracts and PsycINFO using combinations of the following search terms: transitional care, discharge planning, care coordination, case management, continuity of care, referrals, postdischarge follow-up, patient assessment, patient needs, interventions, and evaluation. Reports were included if published between 1985 and 2001, if conducted on samples age 55 and older, if relevant to nursing research, and if published in English. Intervention studies had to have a control or comparison group and a test for statistical significance. Four key findings from this review were identified. A high proportion of elders and their caregivers report substantial unmet transitional care needs, with the need for information and increased access to services consistently among the top priorities. Differences in expectations between and among patients, families, and health care providers, and the need for increased patient and family involvement in decision making, are common themes in discharge planning studies. Gaps in communication have been identified through the discharge planning process. Evidence about the effects of innovations in transitional care on quality and cost outcomes is sparse. Four main recommendations are made. Differences in older adults' transitional care needs based on race, ethnicity, and educational level, with attention to potential disparities, require further study. Studies of strategies to promote effective involvement of patients and families in decision making throughout discharge planning are needed. The development and testing of referral and other information systems designed to promote the transfer of accurate and complete information across sites of care should be a research focus. A priority for future research should be continued study of strategies to improve transitional care outcomes of older adults and their caregivers.

Patient characteristics at hospital discharge and a comparison of home care referral decisions

OBJECTIVES

Describe the characteristics of hospitalized older adults who were not referred for home care, compare the referral decisions of hospital clinicians with those of nurses with expertise in discharge planning and transitional care, and compare the characteristics of hospitalized older adults who did not receive a home care referral with patients who did receive a home care referral.

DESIGN

Secondary analysis, descriptive, case series.

SETTING

Subjects were discharged to home from one of two urban hospitals in Philadelphia, Pennsylvania.

PARTICIPANTS

Ninety-nine patients for this study were drawn from the control group (n = 186) of a prior randomized clinical trial of advanced practice nurse hospital discharge planning and home follow-up. These 99 patients, or 56 of the control group, did not receive a home care referral even though they were screened into the original study as meeting at least one of the risk criteria associated with poor postdischarge outcomes.

MEASUREMENTS

Case studies were generated from research records of the control group patients who did not receive a home care referral. They included patient sociodemographic and health characteristics. Nurses with expertise in discharge planning and transitional care, blinded to the actual decision, reviewed each case study and made a referral decision.

RESULTS

Case studies revealed that control group patients, discharged without home follow-up, had many characteristics associated with the need for a home care referral, with the likelihood of receiving a referral, or with developing poor postdischarge outcomes. Overall, compared with control group patients who did not receive home care, those who did were older, had a longer hospital stay, more often rated their health as fair or poor, and had worse functional status. However, transitional care nurses judged that 96 of 99 of the control group patients discharged without home care had unmet discharge needs that may have benefited from a postdischarge referral. In addition, the transitional care nurses identified 49 of these 99 patients as having a high-priority need for home care. These patients had at least three of the characteristics associated with the need for a home care referral, the likelihood of receiving a referral, or of developing poor postdischarge outcomes. High-priority patients were significantly different in many sociodemographic and health characteristics and were rehospitalized significantly more often than other control group patients who were discharged without home care (P = .032).

CONCLUSION

Study findings have demonstrated that the majority of older adults in this sample were discharged without postdischarge referrals despite the presence of several characteristics associated with the need for home care and risk of poor discharge outcomes. Findings suggest the need for improved methods to identify and synthesize patient characteristics associated with the need for postdischarge referral and to support clinical decision-making. Insurance or homebound status should also be explored as barriers to patients receiving the postdischarge care that they need.