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Schnelle JF, Buchowski MS, Ikizler TA, Durkin DW, Beuscher L, Simmons SF. Evaluation of two fatigability severity measures in elderly adults. J Am Geriatr Soc 2012; 60:1527-33. [PMID: 22860899 DOI: 10.1111/j.1532-5415.2012.04062.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To document the stability, concurrent validity, and clinical correlates of two fatigability severity measures as recommended by the American Geriatrics Society. DESIGN Descriptive, cross-sectional. SETTING Two independent living and one community senior centers. PARTICIPANTS Forty-three participants, with an average age 85 ± 6. MEASUREMENTS Perceived fatigability severity was quantified by directly asking participants to report change in energy after a standardized 10-minute walk at a self-selected pace. Performance fatigability severity was defined as a ratio of change in walking speed to total distance walked. The walk test was repeated within 2 weeks to assess stability. Total daily physical activity (PA) was measured over 7 consecutive days using a waist-worn accelerometer. Frailty was measured using the Vulnerable Elders Survey interview scale, and gait speed was measured using a standardized 25-feet walk test. RESULTS The perceived and performance fatigability severity measures were significantly correlated (correlation coefficient (r) = 0.94, P < .001) and stable over two assessments (r = 0.82 and 0.85, P < .001). Both fatigability severity measures were significantly correlated with PA level (r = -0.42 and r = -0.44, respectively, P = .02), frailty (r = 0.47 and 0.53, respectively, P = .001) and gait speed (r = -0.45, P = .003 and r = -0.54, P = .001, respectively). CONCLUSION The methodology described in this study permits the calculation of two highly correlated fatigability severity scores, which summarize the relationship between a person's change in self-reported tiredness or change in physical performance and concurrently measured PA. The fatigability severity scores are reproducible and correlated with clinical measures predictive of decline. The methods used to quantify fatigability severity can be implemented during a brief assessment (<15 minutes) and should be useful in the design and evaluation of interventions to increase PA in older adults at risk of functional decline.
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Simmons SF, Durkin DW, Rahman AN, Schnelle JF, Beuscher LM. The value of resident choice during daily care: do staff and families differ? J Appl Gerontol 2012; 33:655-71. [PMID: 25143465 DOI: 10.1177/0733464812454010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Allowing long-term care (LTC) residents to make choices about their daily life activities is a central tenet of resident-centered care. This study examined whether staff and family rated care episodes involving choice differently from care episodes not involving choice. Seventeen nurse aide and 15 family participants were shown paired video vignettes of care interactions. Participants were asked to rate their preferred care vignette using a standardized forced-choice questionnaire. Focus groups were held separately for staff and family members following this rating task to determine reasons for their preferences. Both staff and family rated the vignettes depicting choice as "strongly" preferred to the vignettes without choice. Reasons provided for the preference ratings during the focus group discussions related to resident well-being, sense of control, and respondents' own personal values. These findings have implications for LTC staff training related to resident-centered care to promote choice.
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Simmons SF, Durkin DW, Rahman AN, Choi L, Beuscher L, Schnelle JF. Resident characteristics related to the lack of morning care provision in long-term care. THE GERONTOLOGIST 2012; 53:151-61. [PMID: 22565494 DOI: 10.1093/geront/gns065] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The purpose of this study was to examine usual long-term care (LTC) practices related to 3 aspects of morning care and determine if there were resident characteristics related to the lack of care. DESIGN AND METHODS Participants were 169 long-stay residents in 4 community LTC facilities who required staff assistance with either transfer out of bed, dressing, and/or incontinence care and were able to respond to structured interview questions about their morning care preferences. Trained research staff conducted standardized observations during 4 consecutive morning hours once per week per participant for 3 consecutive months during usual LTC conditions and interviewed participants about their morning care preferences using a structured interview protocol once per month during this same time period. RESULTS Overall, 40% of the observations showed a lack of morning care provision, including any staff-resident communication about care, during the 4-hr observation period. Participants rated by staff as more physically dependent and requiring 2 staff for transfer were more likely to not receive morning care. Even when care in a particular area was absent, the majority of participants expressed a stable preference for care to remain the "same" (range of proportions was .75 to .87 for the 3 targeted care areas) and infrequently made requests for care. IMPLICATIONS Efforts to promote resident-directed care should consider staffing issues related to missed care occurrences and resident issues related to level of dependency on staff as well as reduced expectations for care, which can lead to resident acceptance of low care frequencies.
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Simmons SF, Sims N, Durkin DW, Shotwell MS, Erwin S, Schnelle JF. The Quality of Feeding Assistance Care Practices for Long-Term Care Veterans. J Appl Gerontol 2012; 32:669-86. [DOI: 10.1177/0733464811433487] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The primary purpose of this study was to determine the quality of feeding assistance care and identify areas in need of improvement for a sample of long-term care veterans. A secondary purpose was to compare these findings with the results of previous studies in community facilities to determine ways in which the VA sample might differ. A repeated measures observational study was conducted in two VA facilities with 200 long-stay residents. Research staff conducted standardized observations during and between meals for 3 months. There was a trend for better feeding assistance care quality during meals in the VA sample, but there were still multiple aspects of care in need of improvement both during and between meals. Higher licensed nurse staffing levels in the VA should enable effective supervision and management, but observation-based measures of care quality are necessary for accurate information about daily feeding assistance care provision.
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Rahman AN, Simmons SF, Applebaum R, Lindabury K, Schnelle JF. The coach is in: improving nutritional care in nursing homes. THE GERONTOLOGIST 2011; 52:571-80. [PMID: 22048808 DOI: 10.1093/geront/gnr111] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE This article describes and evaluates a long distance coaching course aimed at improving nutritional care in nursing homes (NHs). The course was structured to provide more support than traditional training programs offer. METHODS In a series of 6 monthly teleconferences led by an expert in NH nutritional care, participating NH staff received step-by-step instructions for implementing an evidence-based nutritional management program. After each session, participants were asked to implement the care step they had just learned. Coaching calls helped facilitate implementation. Staff in 18 NHs in 12 states completed the course. Evaluation data were collected using a resident data form, pre- and post-training quizzes, a participant course evaluation survey, and a supervisor's report. RESULTS NH staff attended an average of 4.8 teleconferences, with 5 staff members typically attending each teleconference. Average quiz scores increased 30% (p < .0001) from pre- to post-training. A majority of course participants (N = 35) said they would participate in a similar course (82.9%) and would recommend the course (80%). Just under half preferred the coaching course to a more traditional 1- to 2-day conference. Nine of 12 reporting supervisors said their facility planned to continue the new nutritional care program. The 10 NHs that submitted resident data assessed an average of 5 residents using the recommended protocols. IMPLICATIONS We recommend the coaching course format. Dissemination outcomes may improve if resources currently used for short-duration training activities are used instead on coaching activities that support NHs over extended periods.
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Simmons SF, Rahman A, Beuscher L, Jani V, Durkin DW, Schnelle JF. Resident-directed long-term care: staff provision of choice during morning care. THE GERONTOLOGIST 2011; 51:867-75. [PMID: 21719629 DOI: 10.1093/geront/gnr066] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To develop an observational protocol to assess the quality of staff-resident communication relevant to choice and describe staff-resident interactions as preliminary evidence of the usefulness of the tool to assess current nursing home practices related to offering choice during morning care provision. DESIGN AND METHODS This study included 73 long-stay residents in 2 facilities. Research staff conducted observations for 4 consecutive morning hours during targeted care activities (transfer out of bed, incontinence, dressing, and dining location). Observations were conducted weekly for 12 consecutive weeks. Staff-resident interactions were measured related to staff offers of choice and residents' responses. RESULTS Interrater agreement was achieved for measures of staff offers of choice (kappa = .83, p < .001), type of choice provided (kappa = .75, p < .001), and resident requests related to choice (kappa = .72, p < .001). Observations over 2,766 care episodes during 4 aspects of morning care showed that staff offered residents choice during 18% of the episodes. Most observations (70%) were coded as staff offering "no choice." IMPLICATIONS Nursing home staff can use a simplified version of this standardized observational tool to reliably measure staff-resident interactions related to choice during morning care provision as a first step toward improving resident-directed care practice.
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Bertrand RM, Porchak TL, Moore TJ, Hurd DT, Shier V, Sweetland R, Simmons SF. The Nursing Home Dining Assistant Program. J Gerontol Nurs 2011; 37:34-43. [DOI: 10.3928/00989134-20100730-04] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 04/29/2010] [Indexed: 11/20/2022]
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Simmons SF, Zhuo X, Keeler E. Cost-effectiveness of nutrition interventions in nursing home residents: a pilot intervention. J Nutr Health Aging 2010; 14:367-72. [PMID: 20424804 PMCID: PMC3686278 DOI: 10.1007/s12603-010-0082-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Unintentional weight loss is a prevalent and costly clinical problem among nursing home (NH) residents. One of the most common nutrition interventions for residents at risk for weight loss is oral liquid nutrition supplementation. The purpose of this study was to determine the cost effectiveness of supplements relative to offering residents' snack foods and fluids between meals to increase caloric intake. DESIGN Randomized, controlled trial. SETTING Three long-term care facilities. PARTICIPANTS Sixty-three long-stay residents who had an order for nutrition supplementation. INTERVENTION Participants were randomized into one of three groups: (1) usual NH care control; (2) supplement, or (3) between-meal snacks. For groups two and three, trained research staff provided supplements or snacks twice daily between meals, five days per week, for six weeks with assistance and encouragement to promote consumption. MEASUREMENTS Research staff observed residents during and between meals for two days at baseline, weekly, and post six weeks to estimate total daily caloric intake. For both intervention groups, research staff documented residents' caloric intake between meals from supplements or snack items, refusal rates and the amount of staff time required to provide each intervention. RESULTS Both interventions increased between meal caloric intake significantly relative to the control group and required more staff time than usual NH care. The snack intervention was slightly less expensive and more effective than the supplement intervention. CONCLUSIONS Offering residents a choice among a variety of foods and fluids twice per day may be a more effective nutrition intervention than oral liquid nutrition supplementation.
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Schnelle JF, Bertrand R, Hurd D, White A, Squires D, Feuerberg M, Hickey K, Simmons SF. The Importance of Standardized Observations to Evaluate Nutritional Care Quality in the Survey Process. J Am Med Dir Assoc 2009; 10:568-74. [DOI: 10.1016/j.jamda.2009.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 05/13/2009] [Accepted: 05/15/2009] [Indexed: 10/20/2022]
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Schnelle JF, Simmons SF, Beuscher L, Peterson EN, Habermann R, Leung F. Prevalence of constipation symptoms in fecally incontinent nursing home residents. J Am Geriatr Soc 2009; 57:647-52. [PMID: 19392956 DOI: 10.1111/j.1532-5415.2009.02215.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the prevalence of constipation symptoms and the effects of a brief toileting assistance trial on constipation in a sample of fecally incontinent nursing home (NH) residents. DESIGN Observational study. SETTING Five NHs. PARTICIPANTS One hundred eleven fecally incontinent NH residents. MEASURES Research staff measured bowel movement frequency every 2 hours for 10 days. The following week, residents were offered toileting assistance every 2 hours for 2 days to determine resident straining, time required for a bowel movement, and resident perceptions of feeling empty after a bowel movement. Constipation data were abstracted from the medical record. RESULTS The frequency of bowel movements during usual NH care was low (mean=0.32 per person per day), and most episodes were incontinent. The frequency of bowel movements increased significantly, to 0.82 per person per day, and most episodes were continent during the 2 days that research staff provided toileting assistance. Eleven percent of residents showed evidence of straining, and 21% of the time after a continent bowel movement, residents reported not feeling empty. Five percent of participants had medical record or Minimum Data Set documentation indicative of constipation symptoms. CONCLUSION Low rates of bowel movements during the day that are potentially indicative of constipation were immediately improved during a 2-day trial of toileting assistance in approximately 68% of the residents, although other symptoms of constipation remained in a subset of residents who increased toileting frequency.
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Simmons SF, Peterson EN, You C. The accuracy of monthly weight assessments in nursing homes: implications for the identification of weight loss. J Nutr Health Aging 2009; 13:284-8. [PMID: 19262969 PMCID: PMC3913049 DOI: 10.1007/s12603-009-0074-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The prevalence of weight loss is a quality indicator for nursing homes (NH), and monthly weight assessments are conducted by NH staff to determine weight loss. METHODS A longitudinal study was conducted with 90 long-stay residents in four NHs for 12 study months. Monthly weight values documented in the medical record by NH staff were compared to independent weight values collected by research staff using a standardized protocol. Weight loss was defined according to the Minimum Data Set (MDS) criterion: >or= 5% in 30 days or >or= 10% in 180 days. RESULTS The total frequency of weight loss episodes per person was comparable between NH and research staff weight assessments across the 12 study months. However, monthly weight values recorded by NH staff were consistently higher than values recorded by research staff, which resulted in a higher prevalence of weight loss and earlier identification of weight loss according to research staff weight values using a standardized weighing protocol. CONCLUSIONS A standardized weighing protocol improved the detection of weight loss among NH residents and should allow for earlier nutrition intervention.
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Simmons SF, Cleeton P, Porchak T. Resident complaints about the nursing home food service: relationship to cognitive status. J Gerontol B Psychol Sci Soc Sci 2009; 64:324-7. [PMID: 19251880 DOI: 10.1093/geronb/gbp007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Most nursing home (NH) residents are not interviewed about their satisfaction with the food service due to cognitive impairment. The purpose of this study was to determine the proportion of NH residents able to complete a structured interview to assess food complaints when no cognitive status criteria were used to exclude residents from interview. Eighty-nine percent of 163 residents were able and willing to complete the interview, and 65% expressed complaints about the NH food service. Residents who expressed complaints ate less of their meals, had less cognitive impairment, and had more depressive symptoms than those who did not. This study shows that the majority of NH residents are able to reliably answer questions about their satisfaction with the food service, regardless of cognitive status, and the presence of complaints is related to poor meal intake and depressive symptoms.
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Gill CE, Bryant J, Charles PD, Schnelle JF, Simmons SF. Poster 100: Prevalence and Impact of Spasticity in a Single Nursing Home. Arch Phys Med Rehabil 2008. [DOI: 10.1016/j.apmr.2008.09.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Whiteman E, Ward K, Simmons SF, Sarkisian CA, Moore AA. Testing the effect of specific orders to provide oral liquid nutritional supplements to nursing home residents: a quality improvement project. J Nutr Health Aging 2008; 12:622-5. [PMID: 18953459 DOI: 10.1007/bf03008272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To improve nursing home (NH) staff delivery of oral liquid nutritional supplements between meals to residents with a history of weight loss. DESIGN Pre-Post intervention study. SETTING Two skilled nursing homes. PARTICIPANTS Eighteen long term care residents. INTERVENTION At baseline all participants had a non-specific physician's order to receive a nutritional supplement. The intervention consisted of specifying the physician's order as follows: "Give 4 oz high protein supplement at 10 am, 2 pm, and 7 pm". MEASUREMENTS Research staff conducted direct observations for two days during and between meals for a total of 4 days, or 12 possible observation periods per participant before and one week following the intervention. Research staff documented NH staff delivery of snacks (including high protein supplements) and amount consumed (fluid ounces) for the high protein supplements using a standardized protocol during each observation period. RESULTS Before the specific order was written participants were offered any type of snack an average of 1.82 times per day and a high protein supplement 0.59 times per day. After the specific order was written participants were offered any type of snack an average of 1.59 times per day and a high protein supplement 0.91 times per day. There were no statistically significant differences in the average number of times snacks or supplements were offered before and after the specific order was written. The proportion of snacks offered that were high protein supplements did increase after the specific order was written (p<0.001). When a high protein supplement was provided, most residents consumed 100% of it. CONCLUSIONS Oral liquid nutritional supplements were not provided consistent with orders in NH practice. The specificity of the order related to type of supplement and time of delivery did not influence when and how often supplements are provided to residents but it did influence the type of nutritional supplement offered.
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Simmons SF, Keeler E, Zhuo X, Hickey KA, Sato HW, Schnelle JF. Prevention of unintentional weight loss in nursing home residents: a controlled trial of feeding assistance. J Am Geriatr Soc 2008; 56:1466-73. [PMID: 18637983 DOI: 10.1111/j.1532-5415.2008.01801.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the effects of a feeding assistance intervention on food and fluid intake and body weight. DESIGN Crossover controlled trial. SETTING Four skilled nursing homes (NHs). PARTICIPANTS Seventy-six long-stay NH residents at risk for unintentional weight loss. INTERVENTION Research staff provided feeding assistance twice per day during or between meals, 5 days per week for 24 weeks. MEASUREMENTS Research staff independently weighed residents at baseline and monthly during a 24-week intervention and 24-week control period. Residents' food and fluid intake and the amount of staff time spent providing assistance to eat was assessed for 2 days at baseline and 3 and 6 months during each 24-week period. RESULTS The intervention group showed a significant increase in estimated total daily caloric intake and maintained or gained weight, whereas the control group showed no change in estimated total daily caloric intake and lost weight over 24 weeks. The average amount of staff time required to provide the interventions was 42 minutes per person per meal and 13 minutes per person per between-meal snack, versus usual care, during which residents received, on average, 5 minutes of assistance per person per meal and less than 1 minute per person per snack. CONCLUSION Two feeding assistance interventions are efficacious in promoting food and fluid intake and weight gain in residents at risk for weight loss. Both interventions require more staff time than usual NH care. The delivery of snacks between meals requires less time than mealtime assistance and thus may be more practical to implement in daily NH care practice.
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Simmons SF, Bertrand R, Shier V, Sweetland R, Moore TJ, Hurd DT, Schnelle JF. A Preliminary Evaluation of the Paid Feeding Assistant Regulation: Impact on Feeding Assistance Care Process Quality in Nursing Homes. THE GERONTOLOGIST 2007; 47:184-92. [PMID: 17440123 DOI: 10.1093/geront/47.2.184] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality sponsored a nationwide study to evaluate the federal paid feeding assistant (PFA) regulation that allows nursing homes to hire single-task workers to provide feeding assistance to nursing home residents. Organizers designed the PFA regulation to increase the number of staff available to provide assistance with eating and improve nutritional care process quality. DESIGN AND METHODS Trained research staff used standardized protocols to conduct direct observations during meals and face-to-face staff interviews in a convenience sample of seven facilities with PFA programs to evaluate care process quality. RESULTS Most (84%) of the trained PFAs in the seven site visit facilities were non-nursing staff within the facility; the quality of feeding assistance care provided by these workers was comparable to that provided by indigenous nurse aides. There were no reported changes in existing staffing levels (nurse aide or licensed nurses) following PFA program implementation, and the majority (> 90%) of indigenous staff at all levels reported positive benefits of the PFA program for both staff and residents. IMPLICATIONS Findings from this preliminary study indicate that the PFA regulation may serve to increase the utilization of existing non-nursing staff to improve feeding assistance care during meals without having a negative impact on existing nurse aide and licensed nurse staffing levels.
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Simmons SF. Quality Improvement for Feeding Assistance Care in Nursing Homes. J Am Med Dir Assoc 2007; 8:S12-7. [PMID: 17336870 DOI: 10.1016/j.jamda.2006.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Revised: 11/30/2006] [Accepted: 12/05/2006] [Indexed: 11/19/2022]
Abstract
Unintentional weight loss is a common problem among nursing home residents and one that can lead to adverse and costly clinical outcomes. Observational studies have shown that residents often receive inadequate and poor-quality feeding assistance during meals, and residents consume few calories between meals from oral liquid nutritional supplements or other food and fluid items. Improvements in the adequacy and quality of feeding assistance either during or between meals have been shown to improve residents' daily oral food and fluid consumption and promote weight gain. However, these feeding assistance interventions require significantly more time than nursing home staff currently spend on feeding assistance care activities. Alternative staffing models are explored through the recent federal "paid feeding assistant" regulation and an observational tool is described for use in practice to improve feeding assistance care.
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Levy-Storms L, Schnelle JF, Simmons SF. What Do Family Members Notice Following an Intervention to Improve Mobility and Incontinence Care for Nursing Home Residents? An Analysis of Open-Ended Comments. THE GERONTOLOGIST 2007; 47:14-20. [PMID: 17327536 DOI: 10.1093/geront/47.1.14] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the sensitivity of family members' responses to open-ended interview questions about an intervention to improve incontinence and mobility care for their relative in a nursing home. DESIGN AND METHODS The study was a randomized, controlled intervention trial with incontinent nursing home residents (N = 145), wherein research staff provided toileting and walking assistance of sufficient intensity to significantly improve continence and mobility outcomes in the treatment group. Interviewers posed open-ended interview questions to family members after 8 weeks of intervention to assess if they noticed a difference in care. RESULTS Family responses to open-ended questions showed that, compared to the control group, the intervention group noticed significant overall improvement in incontinence and mobility care and in residents' outcomes in mobility. IMPLICATIONS Families' responses to open-ended questions were sensitive to improvements in incontinence and mobility care and may provide evidence for important care quality differences that would be missed if only direct satisfaction and discrepancy-based closed-ended questions were asked.
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Simmons SF, Patel AV. Nursing Home Staff Delivery of Oral Liquid Nutritional Supplements to Residents at Risk for Unintentional Weight Loss. J Am Geriatr Soc 2006; 54:1372-6. [PMID: 16970644 DOI: 10.1111/j.1532-5415.2006.00688.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe nursing home (NH) staff delivery of oral liquid nutritional supplements to residents with an order to receive supplementation. DESIGN Descriptive. SETTING Six skilled NHs. PARTICIPANTS One hundred thirty-two long-stay residents. MEASUREMENTS Research staff conducted direct observations for 2 days during and between meals and documented NH staff delivery of supplements, amount consumed (fluid ounces), and amount of assistance (minutes) provided by staff to encourage consumption. RESULTS Eighty-eight percent had an order to receive a supplement one to three times daily (mode = 3); 12% had an order to receive a supplement four to six times daily. Fewer than 10% received the supplement consistent with their orders during the 2 observation days. On average, NH staff provided a supplement less than once per participant per day during or between meals. When a supplement was provided, residents consumed an average+/-standard deviation of 4.91+/-2.19 fluid ounces during meals with 6.16+/-7.46 minutes of staff assistance and 3.98+/-2.60 fluid ounces between meals with less than 1 minute of staff assistance. Participants with orders that specified time of delivery received the supplement at a significantly higher frequency between meals. CONCLUSION Oral liquid nutritional supplements are not provided consistent with orders in NH practice. Staff spends little time promoting supplement consumption during or between meals. The specificity of the order related to time of delivery may influence when and how often supplements are provided to residents.
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Schnelle JF, Osterweil D, Simmons SF. Improving the quality of nursing home care and medical-record accuracy with direct observational technologies. THE GERONTOLOGIST 2006; 45:576-82. [PMID: 16199391 DOI: 10.1093/geront/45.5.576] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Nursing home medical-record documentation of daily-care occurrence may be inaccurate, and information is not documented about important quality-of-life domains. The inadequacy of medical record data creates a barrier to improving care quality, because it supports an illusion of care consistent with regulations, which reduces the motivation and ability of providers to identify areas for improvement. Observational protocols designed for use by survey and quality-assurance staff can provide the independent information necessary for improving both medical record accuracy and residents' quality of life. Unfortunately, observational protocols currently used in survey and quality-assurance activities are not designed in a manner that is consistent with the scientific principles that guide observational measurement. The purpose of this article is to describe the steps to develop a standardized and scientifically defensible observational system to assess nursing home care quality.
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Simmons SF, Schnelle JF. Feeding assistance needs of long-stay nursing home residents and staff time to provide care. J Am Geriatr Soc 2006; 54:919-24. [PMID: 16776786 DOI: 10.1111/j.1532-5415.2006.00812.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe the staff time requirements to provide feeding assistance to nursing home residents who require three different types of assistance to improve oral food and fluid intake (social stimulation, verbal cuing, or both; physical guidance; or full physical assistance) and to determine whether physically dependent residents require more staff time, as defined in the national Resource Utilization Group System (RUGS) used for reimbursement. DESIGN Descriptive. SETTING Six skilled nursing homes. PARTICIPANTS Ninety-one long-stay residents with low oral intake who responded to improved feeding assistance. MEASURMENTS Research staff conducted direct observations of usual nursing home care for 2 consecutive days (total of six meals) to measure oral food and fluid consumption (total percentage eaten) and staff time spent providing assistance (minutes and seconds). Research staff then implemented a standardized graduated-assistance protocol on 2 separate days (total of six meals) that enhanced residents' oral food and fluid intake. RESULTS Staff time to provide feeding assistance that improved food and fluid consumption was comparable across different levels of eating dependency. Across all levels, residents required an average of 35 to 40 minutes of staff time per meal; thus, residents who needed only supervision and verbal cuing required just as much time as those who were physically dependent on staff for eating. CONCLUSION The current RUGS system used for reimbursement likely underestimates the staff time required to provide feeding assistance care that improves oral intake.
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Cadogan MP, Schnelle JF, Al-Sammarrai NR, Yamamoto-Mitani N, Cabrera G, Osterweil D, Simmons SF. A standardized quality assessment system to evaluate pain detection and management in the nursing home. J Am Med Dir Assoc 2006; 7:S11-9, S10. [PMID: 16500269 DOI: 10.1016/j.jamda.2005.12.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
CONTEXT Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain. OBJECTIVE Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain. DESIGN Descriptive. SETTING Thirty nursing homes (NHs). PARTICIPANTS Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator. MEASUREMENTS Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware. RESULTS Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview. CONCLUSIONS Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.
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Schnelle JF, Ouslander JG, Simmons SF. Direct observations of nursing home care quality: Does care change when observed? J Am Med Dir Assoc 2006; 7:541-4. [PMID: 17095417 DOI: 10.1016/j.jamda.2006.03.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Recent research demonstrates that care recorded by nursing home (NH) staff is often inaccurate. Direct observations of care may therefore be of critical importance in assessing and improving care in this setting. Unfortunately, despite their apparent use in several types of quality assurance activities, there is little written information about the reliability or accuracy of observational procedures in NHs. This paper provides information about one important measurement issue (reactivity) that is often cited as a limitation of observational procedures in measuring usual care practices accurately. DESIGN Descriptive. SETTING Seven nursing homes. PARTICIPANTS Staff and residents. MEASUREMENTS Direct observational time in bed; repositioning and feeding assistance. RESULTS Observational measures of care quality were stable over multiple observation periods and consistently detected quality problems even on the first and last days of observation. CONCLUSION Direct observations of care provided to residents do not appear to change provider behavior.
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Simmons SF, Levy-Storms L. The effect of staff care practices on nursing home residents' preferences: implications for individualizing care. J Nutr Health Aging 2006; 10:216-21. [PMID: 16622583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
PURPOSE To examine the effect of staff care practices on nursing home residents' preferences for dining location. METHODS A cross-sectional study was conducted with 304 long-stay residents in six skilled nursing homes. Research staff conducted direct observations during meals for two days and interviewed residents on the same two days about their preferences for dining location for each scheduled meal (breakfast, lunch and dinner). RESULTS Staff care practices were significantly related to residents' preferences to eat in the dining room for all meals after adjusting for resident characteristics and nurse aide staffing level. For each unit increase in the proportion of residents taken to the dining room for meals by staff, residents' preferences to eat in the dining room also significantly increased by approximately three to four percent for each mealtime period. DISCUSSION Staff care practices may influence residents' reported preferences for dining location. Daily care practices may be inappropriately justified by residents' preferences, which are shaped by their nursing home care experience and reduced expectations. In efforts to individualize resident care, nursing home staff should consider the influence of established care practices on residents' reported preferences for daily care.
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Simmons SF. Continuous Quality Improvement for Nutritional Care Services in Nursing Homes: The Importance of Direct Observation. J Am Med Dir Assoc 2006; 7:61-2. [PMID: 16413437 DOI: 10.1016/j.jamda.2005.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2005] [Indexed: 11/16/2022]
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