Advance Directives in the Nursing Home Setting: An Initiative to Increase Completion and Reduce Potentially Avoidable Hospitalizations

Advance Directives for Adolescents and Young Adults Living With Neuromuscular Disease: A Nurse Practitioner-Driven Intervention

The literature shows that adolescents and young adults (AYAs) living with neuromuscular disease want to have discussions about goals of care and want them sooner. Conversations about goals of care and advance directives are not common practice in the neuromuscular clinic setting. This nurse practitioner-led project used a conversation tool as a 1-time intervention to guide conversations about participants' goals and wishes, comparing the number of participants with advance directives before and after the use of the intervention, and their satisfaction with having had a conversation about goals of care using this tool was measured. A total of 14 AYAs with genetically confirmed neuromuscular disease were enrolled in this project. There was a 92.9% increase in the number of AYAs with an advance directive demonstrating clinical meaningfulness. Most project participants were either quite a bit satisfied (21.4%) or very much satisfied (57.1%) with having used the intervention to discuss goals of care. This quality improvement project demonstrated that, if asked, AYAs with neuromuscular disease willingly agreed to discuss their goals of care and found satisfaction in using the intervention to complete an advance directive. Advanced Practice Registered Nurses should consider systematic processes to include these discussions as a part of routine practice.

Untangling the complex web of avoidable nursing home-to-hospital transfers of residents with dementia

INTRODUCTION

Nursing home (NH) residents with Alzheimer's disease or related dementias (ADRD) are at high risk for hospital transfer. We aimed to (1) describe characteristics and predictors of avoidable transfer of residents with ADRD and (2) explore how "what matters" influences the decision to transfer.

METHODS

We applied an exploratory, mixed methods design using data collected as part of a Centers for Medicare and Medicaid Services demonstration project. Advanced practice registered nurses documented retrospective details about nursing home (NH)-to-hospital transfers (n = 3687) from 16 NHs.

RESULTS

NH residents with ADRD had 1.22 times higher odds of having an avoidable NH-to-hospital transfer (odds ratio = 1.22; 95% confidence interval = 1.03, 1.45). Factors contributing to avoidable transfers were age, stage of ADRD, what matters to the resident and their family, changes in condition, and resources available in the NH.

DISCUSSION

These findings highlight the need for enhanced specificity in the discussion and documentation of resident and family preferences and continued investments in the NH workforce.

HIGHLIGHTS

This article reports on factors contributing to avoidable nursing home (NH)-to-hospital transfer of residents with Alzheimer's disease and related dementias (ADRD). The mixed methods design used in this study offers insight beyond what is possible using a single-method design. Using data collected from a Centers for Medicare and Medicaid Services demonstration project, advanced practice registered nurses documented retrospective details about NH-to-hospital transfers (n = 3687) of residents. NH residents with ADRD were more likely to have an avoidable NH-to-hospital transfer. Factors contributing to avoidable transfers were age, stage of ADRD, what matters to the resident and their family, changes in condition, and resources available in the NH. These findings highlight the need for enhanced specificity in discussion and documentation of resident and family preferences and continued investments in the NH workforce.

Reducing unplanned hospital admissions from care homes: a systematic review

Background

Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost.

Objectives

Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings.

Data sources

We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked.

Methods

We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect.

Results

We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence.

Conclusions

Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation.

Limitations

Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible.

Future work

We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes.

Study registration

This study is registered as PROSPERO database CRD42021289418.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.

Social Workers Critical to Honoring Commitments to Residents and Families in Long-Term Care

Social workers have been at the forefront of research and advocacy to improve nursing home care for several decades. However, United States (U.S.) regulations have not kept pace with professional standards, as nursing home social services workers are still not required to have a degree in social work and many are assigned caseloads that are untenable for providing quality psychosocial and behavioral health care. The National Academies of Sciences, Engineering, and Medicine (NASEM)'s recently published interdisciplinary consensus report, The National Imperative to Improve Nursing Home Quality: Honoring our Commitment to Residents, Families, and Staff (NASEM, 2022) makes recommendations for changing these regulations, reflecting years of social work scholarship and policy advocacy. In this commentary, we highlight the NASEM report recommendations for social work and chart a course for continuing scholarship and policy advocacy to improve resident outcomes.

A qualitative study exploring nursing home care environments where nurse practitioners work

Research is needed to support the growing nurse practitioner workforce to assure higher quality care for older adults in nursing homes. Nursing homes with optimal care environments that support nurse practitioner roles, increased visibility, independence, and relationships are better positioned to support care of older adults. This study reports findings of thirteen qualitative interviews with nurse practitioners to explore facets of nursing home care environments and adapt a tool to measure care environments. Our team incorporated deductive and inductive coding to identify three major emerging themes impacting care environments: 1) nurse practitioner practice in nursing homes, 2) overall goals of practice, 3) workplace challenges. Themes were derived from seven overarching categories and 33 codes describing aspects of NH care environment important to nurse practitioners. Some of the most highly important survey items measured nurse practitioner and physician relationships. Less important items measured relationships between nurse practitioners and administration.

Evaluating the implementation fidelity to a successful nurse-led model (INTERCARE) which reduced nursing home unplanned hospitalisations

BACKGROUND

Implementation fidelity assesses the degree to which an intervention is delivered as it should be. Fidelity helps to determine if the outcome(s) of an intervention are attributed to the intervention itself or to a failure of its implementation. Little is known about how fidelity impacts the intended outcome(s) and what elements or moderators can affect the fidelity trajectory over time. We exemplify the meaning of implementation fidelity with INTERCARE, a nurse-led care model that was implemented in eleven Swiss nursing homes (NHs) and showed effectiveness in reducing unplanned hospital transfers. INTERCARE comprises six core elements, including advance care planning and tools to support inter- and interprofessional communication, which were introduced with carefully developed implementation strategies.

METHODS

A mixed-methods convergent/triangulation design was used to investigate the influence of implementation fidelity on unplanned transfers. A fidelity questionnaire measuring the degree of fidelity to INTERCARE's core components was fielded at four time points in the participating NHs. Two-monthly meetings were conducted with NHs (September 2018-January 2020) and structured notes were used to determine moderators affecting fidelity (e.g., participant responsiveness). We used the fidelity scores and generalized linear mixed models to analyze the quantitative data. The Framework method was used for the qualitative analysis. The quantitative and qualitative findings were integrated using triangulation.

RESULTS

A higher overall fidelity score showed a decreasing rate of unplanned hospital transfers post-intervention (OR: 0.65 (CI = 0.43-0.99), p = 0.047). A higher fidelity score to advance care planning was associated with lower unplanned transfers (OR = 0.24 (CI 0.13-0.44), p = < 0.001) and a lower fidelity score for communication tools (e.g., ISBAR) to higher rates in unplanned transfers (OR = 1.69 (CI 1.30-2.19), p = < 0.003). In-house physicians with a collaborative approach and staff's perceived need for nurses working in extended roles, were important moderators to achieve and sustain high fidelity.

CONCLUSION

Implementation fidelity is challenging to measure and report, especially in complex interventions, yet is crucial to better understand how such interventions may be tailored for scale-up. This study provides both a detailed description of how fidelity can be measured and which ingredients highly contributed to reducing unplanned NH transfers.

TRIAL REGISTRATION

The INTERCARE study was registered at clinicaltrials.gov Protocol Record NCT03590470.

Reducing Hospitalizations Among Nursing Facility Residents: Policy Environment and Suggestions for the Future in Seven States

The current study examined the policy and market context existing in the seven states where the Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents took place. Stakeholder organizations with knowledge of the skilled nursing facility environment but who were not directly involved with the CMS Initiative were interviewed to assess the impact of policies and programs affecting transfers to the hospital from long-term care facilities. Focused interviews were used to identify areas of quality improvement as well as market forces that contributed to hospitalization rates. Interviews were qualitatively coded and emerging patterns and themes were identified. Market pressures were similar across states. Few policies were found that may have affected the Initiative, but most states had regional coalitions focused on improving some aspect of care. When asked what else could be done to reduce hospitalizations among nursing facility residents, participants across the stakeholder organizations suggested greater presence of physicians and nurse practitioners in nursing facilities, better training around behavioral health issues for frontline staff, and more advance care planning and education for families regarding end of life. [Journal of Gerontological Nursing, 48(8), 10-16.].

Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity

Background

Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers.

Methods

This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described.

Results

Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable.

Conclusions

Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

Value Propositions for Health Information Exchange Toward Improving Nursing Home Hospital Readmission Rates

The importance of health information technology use in nursing home (NH) care delivery is a major topic in research exploring methods to improve resident care. Topics of interest include how technology investments, infrastructure, and work-force development lead to better methods of nursing care delivery and outcomes. Value propositions, including perceived benefits, incentives, and system changes recognized by end-users, are important resources to inform NH leaders, policymakers, and stakeholders about technology. The purpose of the current research was to identify and disseminate value propositions from a community of stakeholders using a health information exchange (HIE). Researchers used a nominal group process, including 49 individual stakeholders participating in a national demonstration project to reduce avoidable hospitalizations in NHs. Stakeholders identified 41 total anticipated changes from using HIE. Ten stakeholder types were perceived to have experienced the highest impact from HIE in areas related to resident admissions, communication, and efficiency of care delivery. [Journal of Gerontological Nursing, 48(1), 15-20.].

A Call to Address RN, Social Work, and Advanced Practice Registered Nurses in Nursing Homes: Solutions From the Missouri Quality Initiative

BACKGROUND

US nursing homes (NHs) have struggled to overcome a historic pandemic that laid bare limitations in the number and clinical expertise of NH staff.

PROBLEM

For nurse staffing, current regulations require only one registered nurse (RN) on duty 8 consecutive hours per day, 7 days per week, and one RN on call when a licensed practical/vocational nurse is on duty. There is no requirement for a degreed or licensed social worker, and advanced practice registered nurses (APRNs) in NHs cannot bill for services.

APPROACH

It is time to establish regulation that mandates a 24-hour, 7-day-a-week, on-site RN presence at a minimum requirement of 1 hour per resident-day that is adjusted upward for greater resident acuity and complexity. Skilled social workers are needed to improve the quality of care, and barriers for APRN billing for services in NHs need to be removed.

CONCLUSIONS

Coupling enhanced RN and social work requirements with access to APRNs can support staff and residents in NHs.

Financial and Work-flow Benefits of Reducing Avoidable Hospitalizations of Nursing Home Residents

OBJECTIVES

1) Explain the financial benefit of potential revenue recapture (PRR) for non-billable days due to hospitalizations of nursing home (NH) residents using a six-year longitudinal analysis of 11 of 16 NHs participating in the Missouri Quality Initiative (MOQI); and 2) Discuss the work-flow benefits of early detection of changes in health status using qualitative data from all MOQI homes.

DESIGN

A CMS funded demonstration project with full-time advanced practice registered nurses (APRN) and operations support team focused on reducing avoidable hospitalizations for long stay NH residents (2012-2020).

SETTING AND PARTICIPANTS

Setting was a sample of 11 of 16 US NHs participating in the CMS project. The NHs ranged in size between 121 and 321 beds located in urban and rural areas in one midwestern geographic region.

METHODS

Financial and occupancy data were analyzed using descriptive methods. Data are readily available from most NH financial systems and include information about short and long stay residents to calculate non-billable days due to hospitalizations. Average hospital transfer rates per 1000 resident days were used. Qualitative data collected in MOQI informed the work-flow benefits analysis.

RESULTS

There was over $2.6 million in actual revenue recapture due to hospitalization of long stay residents in the 11 participating NHs during five years, 2015-2019, with 2014 as baseline; savings to payers was more than $31 million during those same years. The PRR for both short and long stay residents combined totaled $32.5 million for six years (2014-2019); for each NH this ranged from $590,000 to over $5 million. On average, an additional $500,000 of revenue each year per 200 beds could have been recaptured by further reducing hospitalizations. Workflow improved for nurses and nursing assistants using INTERACT and focusing on early detection of health changes.

CONCLUSIONS

Reducing avoidable hospitalizations reduces costs to payers and increases revenue by substantially recapturing revenue lost each day of hospitalization.

IMPLICATIONS

Focusing nursing staff on early illness recognition and management of condition changes within NHs has benefits for residents as the stress of hospital transfer and resulting functional decline is avoided. Nurses and nursing assistants benefit from workflow improvements by focusing on early illness detection, managing most condition changes within NHs. NHs benefit financially from increased revenue by reducing empty bed days.

Longitudinal Impact of APRNs on Nursing Home Quality Measures in the Missouri Quality Initiative

OBJECTIVES

To measure the impact of advanced practice nurses (APRNs) on quality measures (QM) scores of nursing homes (NHs) in the CMS funded Missouri Quality Initiative (MOQI) that was designed to reduce avoidable hospitalizations of NH residents, improve quality of care, and reduce overall healthcare spending.

DESIGN

A four group comparative analysis of longitudinal data from September 2013 thru December 2019.

SETTING

NHs in the interventions of both Phases 1 (2012-2016) and 2 (2016-2020) of MOQI (n=16) in the St. Louis area; matched comparations in the same counties as MOQI NHs (n=27); selected Phase 2 payment intervention NHs in Missouri (n=24); NHs in the remainder of the state (n=406).

PARTICIPANTS

NHs in Missouri Intervention: Phase 1 of The Missouri Quality Initiative (MOQI), a Centers for Medicare and Medicaid (CMS) Innovations Center funded research initiative, was a multifaceted intervention in NHs in the Midwest, which embedded full-time APRNs in participating NHs to reduce hospitalizations and improve care of NH residents. Phase 2 extended the MOQI intervention in the original intervention NHs and added a CMS designed Payment Intervention; Phase 2 added a second group of NHs to receive the Payment. Intervention Only.

MEASUREMENTS

Eight QMs selected by CMS for the Initiative were falls, pressure ulcers, urinary tract infections, indwelling catheters, restraint use, activities of daily living, weight loss, and antipsychotic medication use. For each of the monthly QMs (2013 thru 2019) an unobserved components model (UCM) was fitted for comparison of groups.

RESULTS

The analysis of QMs reveals that that the MOQI Intervention + Payment group (group with the embedded APRNs) out-performed all comparison groups: matched comparison with neither intervention, Payment Intervention only, and remainder of the state.

CONCLUSION

These results confirm the QM analyses of Phase 1, that MOQI NHs with full-time APRNs are effective to improve quality of care.