Ameliorating Pain in Nursing Homes: A Collaborative Quality-Improvement Project

Pain and Associated Factors in Nursing Home Residents

BACKGROUND

Understanding factors associated with risk of pain allows residents and clinicians to plan care and set priorities, however, factors associated with pain in nursing home residents has not been conclusively studied.

AIM

To evaluate the association between pain and nursing home (NH) resident demographic and clinical characteristics.

DESIGN

Retrospective analysis of Minimum Data Set 3.0 records of nursing home residents residing in 44 Indiana NHs between September 27, 2011 and December 27, 2019 (N = 9,060).

RESULTS

Pain prevalence in this sample of NH residents was 23.7%. Of those with pain, 28.0% experienced moderate to severe/frequent pain and 54.6% experienced persistent pain. Risk factors for moderate to severe/frequent pain include female sex; living in a rural setting; intact, mildly, or moderately impaired cognition; arthritis; contracture; anxiety; and depression. In contrast, stroke and Alzheimer's disease and Alzheimer's-disease related dementias (AD/ADRD) were associated with decreased risk of reporting moderate to severe/frequent pain, likely representing both the under-assessment and under-reporting of pain among cognitively impaired NH residents. Risk factors for persistent pain included age <70, Black race, living in a rural location, intact cognition, contracture, and depression.

CONCLUSIONS

Pain remains a pressing problem for NH residents. In this study, we identified demographic and clinical factors associated with moderate to severe frequent pain and persistent pain. Residents with a diagnosis of AD/ADRD were less likely to report pain, likely representing the difficulty of evaluating pain in these residents. It is important to note that those with cognitive impairment may not experience any less pain, but assessment and reporting difficulties may make them appear to have less pain. Knowledge of factors associated with pain for NH residents has the potential for improving the ability to predict, prevent, and provide better pain care in NH residents.

Pain trajectories of nursing home residents

BACKGROUND

Understanding changes in nursing home (NH) resident pain over time would provide a more informed perspective, allowing opportunities to alter the course of illness, plan care, and set priorities. Therefore, the purpose of this analysis was to identify and characterize clinically meaningful, dynamic pain trajectories in NH residents.

METHODS

Retrospective longitudinal analysis of NH resident pain scores with a length of stay >100 days (N = 4864). Group-based trajectory modeling was applied to Minimum Data Set 3.0 assessments to identify pain trajectories. Trajectories were then characterized using unadjusted and adjusted cross-sectional associations between residents' demographic and clinical characteristics and their pain trajectory.

RESULTS

We identified four distinct trajectories: (1) consistent pain absence (48.9%), (2) decreasing-increasing pain presence (21.8%), (3) increasing-decreasing pain presence (15.3%), and (4) persistent pain presence (14.0%). Demographics of younger age and living in a rural area were associated with the persistent pain presence trajectory. Clinical variables of obesity and intact cognition were associated with being in the persistent pain presence trajectory. A smaller proportion of residents with moderately or severely impaired cognition were in any of the trajectory groups with pain.

CONCLUSIONS

We identified and characterized four pain trajectories among NH residents, including persistent pain presence which was associated with demographic characteristics (younger, female, rural) and clinical factors (obese, fracture, contracture). Moreover, residents with a diagnosis of Alzheimer's disease or dementia were less likely to be in any of the three trajectories with pain, likely representing the difficulty in evaluating pain in these residents. It is important that NH staff understand, recognize, and respond to the factors associated with the identified pain trajectories to improve mitigation of potentially persistent pain (e.g., hip fracture, contracture) or improve proxy pain assessment skills for residents at risk for under reporting of pain (e.g., Alzheimer's Disease).

A Systematic Review of Interventions to Improve Analgesic Use and Appropriateness in Long-Term Care Facilities

OBJECTIVES

To systematically review the effectiveness of interventions to improve analgesic use and appropriateness in long-term care facilities (LTCFs).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

MEDLINE, Embase, PsycINFO, and CINAHL Plus were searched from inception to June 2021. Randomized controlled trials (RCTs), controlled and uncontrolled prospective interventions that included analgesic optimization, and reported postintervention change in analgesic use or appropriateness in LTCFs were included.

METHODS

Screening, data extraction, and quality assessment were performed independently by 2 review authors.

RESULTS

Eight cluster RCTs, 2 controlled, and 6 uncontrolled studies comprising 9056 residents across 9 countries were included. The 16 interventions included education (n = 13), decision support (n = 7), system modifications (n = 6), and/or medication review (n = 3). Six interventions changed analgesic use or appropriateness, all of which included prescribers, 5 involved multidisciplinary collaboration, and 5 included a component of education. Education alone changed analgesic use and appropriateness in 1 study. Decision support was effective when combined with education in 3 interventions. Overall, 13 studies reported analgesic optimization as part of pain management interventions and 3 studies focused on medication optimization. Two pain management interventions reduced the percentage of residents reporting pain not receiving analgesics by 50% to 60% (P = .03 and P < .001, respectively), and 1 improved analgesic appropriateness (P = .03). One reduced nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .001) and another resulted in 3-fold higher odds of opioid prescription in advanced dementia [95% confidence interval (CI) 1.1-8.7]. One medication optimization intervention reduced NSAID prescription (P = .036), and another reduced as-needed opioid (95% CI 8.6-13.8) and NSAID prescription (95% CI 1.6-4.2).

CONCLUSIONS AND IMPLICATIONS

Interventions involving prescribers and enhanced roles for pharmacists and nurses, with a component of education, are most effective at changing analgesic use or appropriateness. Interventions combining education and decision support are also promising. Medication review interventions can change analgesic prescription, although there is currently minimal evidence in relation to possible corresponding improvements in resident-related outcomes.

Enablers and barriers to implementing care quality improvement program in nursing homes in China

Objective

To explore the perspectives of key stakeholders on necessary factors to implement care quality improvement program.

Methods

We conducted qualitative descriptive research in eight nursing homes in four major prefecture-level cities of Changsha, Xiangtan, Zhuzhou, and Yueyang. Data of 50 clinical nurses and 64 nurse assistants were included and analyzed. Ethical approval was given by the medical ethics committee of Chinese Clinical Trial Registry (No. ChiCTR-IOC-17013109, https://www.chictr.org.cn/index.aspx). One-to-one interviews were used with the nursing managers, and separate focus group discussions were used with the clinical nurses and nurse assistants. All of the interviews were audio recorded and later transcribed verbatim. In addition, the first author documented the responses of every participant in the field notes during the interviews and focus groups.

Results

The participants’ perspectives were characterized by two main themes: (1) enablers, with four subthemes of “organizational support”, “the evidence-based practice ability”, “proactivity”, “nursing supervision and feedback;” and (2) barriers, with five sub-themes of “low educational background”, “the limitations of self-role orientation”, “resistance to change”, “lack of job motivation”, and “organizational constraints”.

Conclusion

These findings recognize factors at the organizational level, staff level and societal level that are necessary to implement effective mentoring. The results of this study can provide reference for nursing home in improving nursing management quality, formulating, implementing and revising training policies.

Quality improvement studies in nursing homes: a scoping review

BACKGROUND

Quality improvement (QI) is used in nursing homes (NH) to implement and sustain improvements in patient outcomes. Little is known about how QI strategies are used in NHs. This lack of information is a barrier to replicating successful strategies. Guided by the Framework for Implementation Research, the purpose of this study was to map-out the use, evaluation, and reporting of QI strategies in NHs.

METHODS

This scoping review was completed to identify reports published between July 2003 through February 2019. Two reviewers screened articles and included those with (1) the term "quality improvement" to describe their methods, or reported use of a QI model (e.g., Six Sigma) or strategy (e.g., process mapping) (2), findings related to impact on service and/or resident outcomes, and (3) two or more NHs included. Reviewers extracted data on study design, setting, population, problem, solution to address problem, QI strategies, and outcomes (implementation, service, and resident). Vote counting and narrative synthesis were used to describe the use of QI strategies, implementation outcomes, and service and/or resident outcomes.

RESULTS

Of 2302 articles identified, the full text of 77 articles reporting on 59 studies were included. Studies focused on 23 clinical problems, most commonly pressure ulcers, falls, and pain. Studies used an average of 6 to 7 QI strategies. The rate that strategies were used varied substantially, e.g., the rate of in-person training (55%) was more than twice the rate of plan-do-study-act cycles (20%). On average, studies assessed two implementation outcomes; the rate these outcomes were used varied widely, with 37% reporting on staff perceptions (e.g., feasibility) of solutions or QI strategies vs. 8% reporting on fidelity and sustainment. Most studies (n = 49) reported service outcomes and over half (n = 34) reported resident outcomes. In studies with statistical tests of improvement, service outcomes improved more often than resident outcomes.

CONCLUSIONS

This study maps-out the scope of published, peer-reviewed studies of QI in NHs. The findings suggest preliminary guidance for future studies designed to promote the replication and synthesis of promising solutions. The findings also suggest strategies to refine procedures for more effective improvement work in NHs.

How quality improvement collaboratives work to improve healthcare in care homes: a realist evaluation

BACKGROUND

Quality improvement collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood.

METHODS

A realist evaluation to develop and test a programme theory of how QICs work to improve healthcare in care homes. A multiple case study design considered implementation across 4 sites and 29 care homes. Observations, interviews and focus groups captured contexts and mechanisms operating within QICs. Data analysis classified emerging themes using context-mechanism-outcome configurations to explain how NHS and care home staff work together to design and implement improvement.

RESULTS

QICs will be able to implement and iterate improvements in care homes where they have a broad and easily understandable remit; recruit staff with established partnership working between the NHS and care homes; use strategies to build relationships and minimise hierarchy; protect and pay for staff time; enable staff to implement improvements aligned with existing work; help members develop plans in manageable chunks through QI coaching; encourage QIC members to recruit multidisciplinary support through existing networks; facilitate meetings in care homes and use shared learning events to build multidisciplinary interventions stepwise. Teams did not use measurement for change, citing difficulties integrating this into pre-existing and QI-related workload.

CONCLUSIONS

These findings outline what needs to be in place for health and social care staff to work together to effect change. Further research needs to consider ways to work alongside staff to incorporate measurement for change into QI.

Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes

PURPOSE

We conducted a scoping review of quality improvement in care homes. We aimed to identify participating occupational groups and methods for evaluation. Secondly, we aimed to describe resident-level interventions and which outcomes were measured.

METHODS

Following extended PRISMA guideline for scoping reviews, we conducted systematic searches of Medline, CINAHL, Psychinfo, and ASSIA (2000-2019). Furthermore, we searched systematic reviews databases including Cochrane Library and JBI, and the grey literature database, Greylit. Four co-authors contributed to selection and data extraction.

RESULTS

Sixty five studies were included, 6 of which had multiple publications (75 articles overall). A range of quality improvement strategies were implemented, including audit feedback and quality improvement collaboratives. Methods consisted of controlled trials, quantitative time series and qualitative interview and observational studies. Process evaluations, involving staff of various occupational groups, described experiences and implementation measures. Many studies measured resident-level outputs and health outcomes. 14 studies reported improvements to a clinical measure; however, four of these articles were of low quality. Larger randomised controlled studies did not show statistically significant benefits to resident health outcomes.

CONCLUSION

In care homes, quality improvement has been applied with several different strategies, being evaluated by a variety of measures. In terms of measuring benefits to residents, process outputs and health outcomes have been reported. There was no pattern of which quality improvement strategy was used for which clinical problem. Further development of reporting of quality improvement projects and outcomes could facilitate implementation.

Effect of an Educational and Organizational Intervention on Pain in Nursing Home Residents: A Nonrandomized Controlled Trial

OBJECTIVES

To determine whether an intervention based on education and professional support to nursing home (NH) staff would decrease the number of residents with a pain complaint, and to determine whether the intervention would improve pain management.

DESIGN

Nonrandomized controlled trial. NHs were nonrandomly allocated either to a strong intervention group consisting in audit, feedback, and collaborative work on quality indicators with a hospital geriatrician, or to a light intervention group (LIG) consisting in audit and feedback only.

SETTING

One hundred fifty-nine NHs located in France.

PARTICIPANTS

A subgroup of 3722 residents.

MEASURES

Information on pain complaint and pain-related covariates at the resident-related and at the NH level were recorded by NH staff at baseline and 18 months later. These covariates were included in a mixed-effects logistic regression on resident's pain complaint. Pain management was compared between intervention groups by chi-square tests.

RESULTS

A greater reduction of residents with a pain complaint after the strong intervention (odds ratio 0.69, 95% confidence interval 0.53, 0.90) and a better pain management (47.6% gold standard, vs 30.6% in the LIG, P < .001) than controls.

CONCLUSION/IMPLICATIONS

Combining educational and organizational measures, evaluating pain as a patient-reported outcome and as a process endpoint, and implementing a broad-spectrum intervention were original approaches to improve quality of care in NHs. Our results support nonspecific, collaborative, educational, and organizational interventions in NHs to decrease residents' pain complaint and improve pain management.

Quality improvement collaborative aiming for Proactive HEAlthcare of Older People in Care Homes (PEACH): a realist evaluation protocol

INTRODUCTION

This protocol describes a study of a quality improvement collaborative (QIC) to support implementation and delivery of comprehensive geriatric assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching and assistance with project evaluation.

METHODS AND ANALYSIS

The QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in four local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as context-mechanism-outcome configurations describing what needs to be in place to use QICs to implement service improvements in care homes.

ETHICS AND DISSEMINATION

The study protocol was reviewed by the National Health Service Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham (reference: LT07092016) ethics committees. Both determined that the Proactive HEAlthcare of Older People in Care Homes study was a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphical illustration and a dissemination video.

Treating and reducing anxiety and pain in the paediatric emergency department-TIME FOR ACTION-the TRAPPED quality improvement collaborative

BACKGROUND/OBJECTIVES

In 2013, the TRAPPED-1 survey reported inconsistent availability of pain and distress management strategies across all 15 Canadian paediatric emergency department (PEDs). The objective of the TRAPPED-2 study was to utilize a procedural pain quality improvement collaborative (QIC) and evaluate the number of newly introduced pain and distress-reducing strategies in Canadian PEDs over a 2-year period.

METHODS

A QIC was created to increase implementation of new strategies, through collaborative information sharing among PEDs. In 2015, 11 of the 15 Canadian PEDs participated in the TRAPPED QIC. At the end of the year, the TRAPPED-2 survey was electronically sent to a representative member at each of the 15 PEDs. The successful introduction of the chosen strategies by the QIC was assessed as well as the addition of new strategies per site. The number of new strategies introduced in the participating and nonparticipating QIC sites were described.

RESULTS

All 15 PEDs (100%) completed the TRAPPED-2 survey. Overall, 10/11 of QIC-participating sites implemented the strategy they had initially identified. All 15 Canadian PEDs implemented some new strategies during the study period; participants in the QIC reported a mean of 5.2 (1-11) new strategies compared to 2.5 (1-4) in the nonactively participating sites.

CONCLUSION

While all PEDs introduced new strategies during the study, QIC-participating sites successfully introduced the majority of their previously identified new strategies in a short time period. Sharing deadlines and information between centres may have contributed to this success.

Evaluating a dementia learning community: exploratory study and research implications

Background

Access times for, the costs and overload of hospital services are an increasingly salient issue for healthcare managers in many countries. Rising demand for hospital care has been attributed partly to unplanned admissions for older people, and among these partly to the increasing prevalence of dementia. The paper makes a preliminary evaluation of the logic model of a Dementia Learning Community (DLC) intended to reduce unplanned hospital admissions from care homes of people with dementia. A dementia champion in each DLC care home trained other staff in dementia awareness and change management with the aims of changing work routines, improving quality of life, and reducing demands on external services.

Methods

Controlled mixed methods realistic evaluation comparing 13 intervention homes with 10 controls in England during 2013–15. Each link in the assumed logic model was tested to find whether that link appeared to exist in the DLC sites, and if so whether its effects appeared greater there than in control sites, in terms of selected indicators of quality of life (DCM Well/Ill-Being, QUALID, end-of-life planning); and impacts on ambulance call-outs and hospital admissions.

Results

The training was implemented as planned, and triggered cycles of Plan-Do-Study-Act activity in all the intervention care homes. Residents’ well-being scores, measured by dementia care mapping, improved markedly in half of the intervention homes but not in the other half, where indeed some scores deteriorated markedly. Most other care quality indicators studied did not significantly improve during the study period. Neither did ambulance call-out or emergency hospital admission rates.

Conclusions

PDSA cycles appeared to be the more ‘active ingredient’ in this intervention. The reasons why they impacted on well-being in half of the intervention sites, and not the others, require further research. A larger, longer study would be necessary to measure definitively any impacts on unplanned hospital admissions. Our evidence suggested revising the DLC logic model to include care planning and staff familiarisation with residents’ personal histories and needs as steps towards improving residents’ quality of life.

Are quality improvement collaboratives effective? A systematic review

Background

Quality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness.

Method

We searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards.

Results

Of the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study’s primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline.

Conclusions

QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.

Assessing the need for arthritis training among paid carers in UK residential care homes: A focus group and interview study

OBJECTIVE

The aim of the study was to perform an educational and training needs assessment for arthritis care in residential homes.

METHODS

Qualitative data were collected from three purposively selected residential homes: one independent, one in a regional chain and one in a national chain. Three researcher-led focus groups were conducted with paid carers (N = 22) using vignette exercises; interviews were undertaken with 12 residents with joint pain (N = 12), five managerial staff and two general practitioners (GPs). Data were compared and analysed thematically around care practices, communication and training.

RESULTS

There is a lack of arthritis awareness among paid carers, although they regularly identify and manage arthritic symptoms. Residents rely on paid carers to recognize when pain and mobility problems are treatable. Senior staff and GPs rely on carers to identify arthritic problems. However, paid carers themselves undervalued the health significance of their activities and lacked the confidence to communicate important information to healthcare professionals. Few of the paid carers had received training in arthritis and many expressed a strong desire to learn about it, to improve their ability to provide better care.

CONCLUSIONS

Education for paid carers regarding arthritis is lacking and lags behind education about conditions such as dementia and diabetes. To meet the expectations of their care roles fully, paid carers require an awareness of what arthritis is and how to recognize symptoms. We suggest that training should be aimed at improving confidence in communicating with colleagues, residents and health professionals, with senior care staff receiving more in-depth training.

The effectiveness of a nurse practitioner-led pain management team in long-term care: A mixed methods study

BACKGROUND

Considering the high rates of pain as well as its under-management in long-term care (LTC) settings, research is needed to explore innovations in pain management that take into account limited resource realities. It has been suggested that nurse practitioners, working within an inter-professional model, could potentially address the under-management of pain in LTC.

OBJECTIVES

This study evaluated the effectiveness of implementing a nurse practitioner-led, inter-professional pain management team in LTC in improving (a) pain-related resident outcomes; (b) clinical practice behaviours (e.g., documentation of pain assessments, use of non-pharmacological and pharmacological interventions); and, (c) quality of pain medication prescribing practices.

METHODS

A mixed method design was used to evaluate a nurse practitioner-led pain management team, including both a quantitative and qualitative component. Using a controlled before-after study, six LTC homes were allocated to one of three groups: 1) a nurse practitioner-led pain team (full intervention); 2) nurse practitioner but no pain management team (partial intervention); or, 3) no nurse practitioner, no pain management team (control group). In total, 345 LTC residents were recruited to participate in the study; 139 residents for the full intervention group, 108 for the partial intervention group, and 98 residents for the control group. Data was collected in Canada from 2010 to 2012.

RESULTS

Implementing a nurse practitioner-led pain team in LTC significantly reduced residents' pain and improved functional status compared to usual care without access to a nurse practitioner. Positive changes in clinical practice behaviours (e.g., assessing pain, developing care plans related to pain management, documenting effectiveness of pain interventions) occurred over the intervention period for both the nurse practitioner-led pain team and nurse practitioner-only groups; these changes did not occur to the same extent, if at all, in the control group. Qualitative analysis highlighted the perceived benefits of LTC staff about having access to a nurse practitioner and benefits of the pain team, along with barriers to managing pain in LTC.

CONCLUSIONS

The findings from this study showed that implementing a nurse practitioner-led pain team can significantly improve resident pain and functional status as well as clinical practice behaviours of LTC staff. LTC homes should employ a nurse practitioner, ideally located onsite as opposed to an offsite consultative role, to enhance inter-professional collaboration and facilitate more consistent and timely access to pain management.

Normalizing suffering: A meta-synthesis of experiences of and perspectives on pain and pain management in nursing homes

Older people who live in nursing homes commonly suffer from pain. Therefore, relieving suffering among older people that stems from pain demands knowledge improvement through an integration of international knowledge. This study aimed to integrate current international findings and strengthen the understanding of older people's experiences of and perspectives on pain and pain management in nursing homes. A meta-synthesis study using Noblit and Hare's interpretative meta-ethnography approach was conducted. Empirical research papers from journals were collected from various databases. The search process and appraisal determined six articles for inclusion. Two studies were conducted in the US and one each in Iceland, Norway, the UK, and Australia. The older people's experiences of pain as well as perspectives on pain management from all involved (older people, their family members, and healthcare staff) were integrated into a theoretical model using three themes of "identity of pain," "recognition of pain," and "response to pain." The metaphor of "normalizing suffering" was devised to illustrate the meaning of pain experiences and pain management in nursing homes. Society's common attitude that pain is unavoidable and therefore acceptable in old age in society-among older people themselves as well as those who are responsible for reporting, acknowledging, and relieving pain-must change. The article emphasizes that pain as a primary source of suffering can be relieved, provided that older people are encouraged to report their pain. In addition, healthcare staff require sufficient training to take a person-centered approach towards assessment and management of pain that considers all elements of pain.

An action-based approach to improving pain management in long-term care

PURPOSE

The study purposes were twofold: (1) to explore barriers to pain management and those associated with implementing a pain management program in long-term care (LTC); and (2) to develop an interprofessional approach to improve pain management in LTC.

METHODS

A case study approach included both qualitative and quantitative components. We collected data at two LTC sites using seven focus groups for the licensed nurses, unregulated care providers and physicians, and 10 interviews with other health care provider groups, administration, and residents. We reviewed documents and administered a short survey to study participants to assess perceptions of barriers to pain management.

RESULTS

The findings revealed barriers to effective LTC pain management at the resident/family, health care provider, and system levels. We then developed a six-tiered model with proposed interventions to address these barriers.

CONCLUSIONS

This model can guide the development of innovative approaches to improving pain management in LTC settings.

Positioning clinical nurse specialists and nurse practitioners as change champions to implement a pain protocol in long-term care

Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives.

Improving quality of life in nursing homes: the structured resident interview approach

The quality of life (QOL) of the approximately 1.5 million nursing facility (NF) residents in the US is undoubtedly lower than desired by residents, families, providers, and policy makers. Although there have been important advances in defining and measuring QOL for this population, there is a need for interventions that are tied to standardized measurement and quality improvement programs. This paper describes the development and testing of a structured, tailored assessment and care planning process for improving the QOL of nursing home residents. The Quality of Life Structured Resident Interview and Care Plan (QOL.SRI/CP) builds on a decade of research on measuring QOL and is designed to be easily implemented in any US nursing home. The approach was developed through extensive and iterative pilot testing and then tested in a randomized controlled trial in three nursing homes. Residents were randomly assigned to receive the assessment alone or both the assessment and an individualized QOL care plan task. The results show that residents assigned to the intervention group experienced improved QOL at 90- and 180-day follow-up, while QOL of residents in the control group was unchanged.

An evidence-based program to improve analgesic practice and pain outcomes in residential aged care facilities

Pain is common in individuals living in residential aged care facilities (RACFs), and a number of obstacles have been identified as recurring barriers to adequate pain management. To address this, the Australian Pain Society developed 27 recommendations for comprehensive good practice in the identification, assessment, and management of pain. This study reviewed preexisting pain management practice at five Australian RACFs and identified changes needed to implement the recommendations and then implemented an evidence-based program that aimed to facilitate better pain management. The program involved staff training and education and revised in-house pain-management procedures. Reviews occurred before and after the program and included the assessment of 282 residents for analgesic use and pain status. Analgesic use improved after the program (P<.001), with a decrease in residents receiving no analgesics (from 15% to 6%) and an increase in residents receiving around-the-clock plus as-needed analgesics (from 24% to 43%). There were improvements in pain relief for residents with scores indicative of pain, with Abbey pain scale (P=.005), Pain Assessment in Advanced Dementia Scale (P=.001), and Non-communicative Patient's Pain Assessment Instrument scale (P<.001) scores all improving. Although physical function declined as expected, Medical Outcomes Study 36-item Short-Form Survey bodily pain scores also showed improvement (P=.001). Better evidence-based practice and outcomes in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce using this program improved analgesic practice and pain relief in participating sites. Further attention to the continued targeted pain management training of aged care staff is likely to improve pain-focused care for residents.

Regulated provider perceptions of feedback reports

AIM

This paper reports on regulated (or licensed) care providers' understanding and perceptions of feedback reports in a sample of Canadian long-term care settings using a cross-sectional survey design.

BACKGROUND

Audit with feedback quality improvement studies have seldom targeted front-line providers in long-term care to receive feedback information.

METHODS

Feedback reports were delivered to front-line regulated care providers in four long-term care facilities for 13 months in 2009-10. Providers completed a postfeedback survey.

RESULTS

Most (78%) regulated care providers (n = 126) understood the reports and felt they provided useful information for making changes to resident care (64%). Perceptions of the report differed, depending on the role of the regulated care provider. In multivariable logistic regression, the regulated nurses' understanding of more than half the report was negatively associated with 'usefulness of information for changing resident care', and perceiving the report as generally useful had a positive association.

CONCLUSIONS

Front-line regulated providers are an appropriate target for feedback reports in long-term care.

IMPLICATIONS FOR NURSING MANAGEMENT

Long-term care administrators should share unit-level information on care quality with unit-level managers and other professional front-line direct care providers.

Geriatric palliative care in long-term care settings with a focus on nursing homes

Almost 1.7 million older Americans live in nursing homes, representing a large proportion of the frailest, most vulnerable elders needing long-term care. In the future, increasing numbers of older adults are expected to spend time and to die in nursing homes. Thus, understanding and addressing the palliative care needs of this population are critical. The goals of this paper are to describe briefly the current state of knowledge about palliative care needs, processes, and outcomes for nursing home residents; identify gaps in this knowledge; and propose priorities for future research in this area.

Understanding the components of quality improvement collaboratives: a systematic literature review

CONTEXT

In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence-based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level.

METHODS

A systematic search of five major health care databases generated 294 unique articles, twenty-four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi-experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative.

FINDINGS

We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in-person learning sessions, plan-do-study-act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient-level findings were less robust.

CONCLUSIONS

Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient- and provider-level outcomes.

Quality improvement under nursing home compare: the association between changes in process and outcome measures

BACKGROUND

Changes in resident outcomes may be driven by many factors, including changes in nursing home care processes. Understanding what processes, if any, lead to successful improvements in resident outcomes could create a stronger case for the continued use of these outcome measures in nursing home report cards.

OBJECTIVE

To test the extent to which improvements in outcomes of care are explained by changes in nursing home processes, a setting where, to our knowledge, this link has not been previously studied. RESEARCH DESIGN/MEASURES: We describe facility-level changes in resident processes and outcomes before and after outcomes were publicly reported. We then assess the extent to which the changes in outcomes are associated with changes in nursing home processes of care, using the public release of information on nursing home outcomes as a source of variation in nursing home outcomes to identify the process-outcome relationship.

SUBJECTS

All 16,623 US nursing homes included in public reporting from 2000 to 2009 in Online Survey, Certification and Reporting and the nursing home Minimum Data Set.

RESULTS

Of the 5 outcome measures examined, only improvements in the percentage of nursing home residents in moderate or severe pain were associated with changes in nursing home processes of care. Furthermore, these changes in the measured process of care explained only a small part of the overall improvement in pain prevalence.

CONCLUSIONS

A large portion of the improvements in nursing home outcomes were not associated with changes in measured processes of care suggesting that processes of care typically measured in nursing homes do little to improve nursing home performance on outcome measures. Developing quality measures that are related improved patient outcomes would likely benefit quality improvement. Understanding the mechanism behind improvements in nursing home outcomes is key to successfully achieving broad quality improvements across nursing homes.

Understanding the components of quality improvement collaboratives: a systematic literature review

CONTEXT

In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence-based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level.

METHODS

A systematic search of five major health care databases generated 294 unique articles, twenty-four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi-experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative.

FINDINGS

We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in-person learning sessions, plan-do-study-act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient-level findings were less robust.

CONCLUSIONS

Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient- and provider-level outcomes.

Psychoactive drugs in seven nursing homes

AIMS

We wanted to pinpoint any differences in treatment between participating nursing homes, investigate which drugs are currently prescribed most frequently for long-term patients in nursing homes, estimate prevalence of administration for the following drug groups: neuroleptics, antidepressants, antidementia agents, opioids and the neuroleptics/anti-Parkinson's drug combination, and study comorbidity correlations. We also wanted to study differences in the administration of medications to patients with reduced cognitive functions in relation to those with normal cognition.

METHODS

Information about 513 patients was collected from seven nursing homes in the city of Bergen, Norway, during the period March-April 2008. This consisted of copying personal medication records, weighing, recording the previous weight from records, electrocardiography, anamnestic particulars of any stroke suffered, recording if there is cognitive impairment or not and analyzing a standardized set of blood samples.

RESULTS

Considerable treatment differences existed between nursing homes, both percentage patients and Defined Daily Dosages. Patients with reduced cognitive functions were prescribed less drugs in general, except neuroleptics. Of all patients, 41.5% were given antidepressants, 24.4% neuroleptics, 22.0% benzodiazepines, 8.0% anticholinesterases and 5.0% memantine. The ratio of traditional to atypical neuroleptics was 122:23. In all, 30.0% of the patients taking neuroleptics were on more than one drug and 35.0% of the patients had opioids by way of regular or as-needed drugs, ratio 14.6%:28.7%. Of 146 patients on neuroleptics, five patients had anti-Parkinson's drugs too. The average use of regular drugs for patient with intact cognition was 7.1 drugs, and for patients with reduced cognitive functions 5.7 drugs.

CONCLUSIONS

There are differences in treatment with psychoactive drugs between nursing homes. Patients with reduced cognitive functions receive less cardiovascular drugs than patients with normal cognition. The reason for this still remains unclear. Improvement strategies are needed. The proportion of patients per institution on selected drugs can serve as a feedback parameter in quality systems.

An exploration of nursing home managers' knowledge of and attitudes towards the management of pain in residents with dementia

BACKGROUND

The aims of this study were to explore the knowledge, attitudes and beliefs that nursing home managers hold with regard to the assessment and management of pain in residents with dementia and to determine how these may be affected by the demographic characteristics of the respondents.

METHODS

A questionnaire comprising six sections was mailed, on two occasions during March and April 2010, to 244 nursing home managers in Northern Ireland (representing 96% of the nursing homes in Northern Ireland).

RESULTS

The response rate was 39%. Nearly all respondents (96%) provided care to residents with dementia, yet only 60% of managers claimed to use pain treatment guidelines within their nursing home. Respondents demonstrated good knowledge about pain in residents with dementia and acknowledged the difficulties surrounding accurate pain assessment. Nursing home managers were uncertain about how to manage pain in residents with dementia, demonstrating similar concerns about the use of opioid analgesics to those reported in previous studies about pain in older people. Managers who had received recent training (p = 0.044) were less likely to have concerns about the use of opioid analgesia than those who had not received training. Respondents' beliefs about painkillers were largely ambivalent and were influenced by the country in which they had received their nursing education.

CONCLUSIONS

The study has revealed that accurate pain assessment, training of nursing staff and a standardised approach to pain management (the use of pain management guidelines) within nursing homes all have a significant part to play in the successful management of pain in residents with dementia.

Translating research into practice in nursing homes: can we close the gap?

PURPOSE

A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model.

DESIGN AND METHODS

The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices.

RESULTS

A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature.

IMPLICATIONS

NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.

The effect of a translating research into practice (TRIP)--cancer intervention on cancer pain management in older adults in hospice

BACKGROUND

Pain is a major concern for individuals with cancer, particularly older adults who make up the largest segment of individuals with cancer and who have some of the most unique pain challenges. One of the priorities of hospice is to provide a pain-free death, and while outcomes are better in hospice, patients still die with poorly controlled pain.

OBJECTIVE

This article reports on the results of a Translating Research into Practice intervention designed to promote the adoption of evidence-based pain practices for older adults with cancer in community-based hospices.

SETTING

  This Institutional Human Subjects Review Board-approved study was a cluster randomized controlled trial implemented in 16 Midwestern hospices.

METHODS

Retrospective medical records from newly admitted patients were used to determine the intervention effect. Additionally, survey and focus group data gathered from hospice staff at the completion of the intervention phase were analyzed.

RESULTS

Improvement on the Cancer Pain Practice Index, an overall composite outcome measure of evidence-based practices for the experimental sites, was not significantly greater than control sites. Decrease in patient pain severity from baseline to post-intervention in the experimental group was greater; however, the result was not statistically significant (P = 0.1032).

CONCLUSIONS

Findings indicate a number of factors that may impact implementation of multicomponent interventions, including unique characteristics and culture of the setting, the level of involvement with the change processes, competing priorities and confounding factors, and complexity of the innovation (practice change). Our results suggest that future study is needed on specific factors to target when implementing a community-based hospice intervention, including determining and measuring intervention fidelity prospectively.

All teach, all learn, all improve?: the role of interorganizational learning in quality improvement collaboratives

BACKGROUND

Quality improvement collaboratives are an increasingly common strategy for implementing evidence-based practices in health care. However, research shows that many participating organizations do not achieve the level of performance improvement desired.

PURPOSE

This study examined the use of interorganizational learning activities (inter-OLAs) as an explanation for mixed performance improvement among collaborative participants. We tested the hypotheses that inter-OLA use is positively associated with participants' performance improvement and that this relationship is moderated by the use of intraorganizational learning activities (intra-OLAs) and quality-focused human resource (Q-HR) practices.

METHODOLOGY

We conducted a survey of organizational teams participating in 4 Institute for Healthcare Improvement Breakthrough Series collaboratives. Survey responses from 52 teams, regarding the use of inter-OLAs, intra-OLAs and Q-HR practices, were linked to performance improvement data obtained from the Institute for Healthcare Improvement and demographic data obtained from secondary sources.

FINDINGS

The more collaborative teams used inter-OLAs, the more their organizations' performance improved. Contrary to our hypothesis, the use of intra-OLAs did not moderate this relationship; teams' use of intra-OLAs added to, but did not multiply, the effect of inter-OLA use. In contrast, an organization's use of Q-HR practices multiplied the performance benefit of inter-OLA use.

PRACTICE IMPLICATIONS

Our findings suggest that organizations that participate in collaboratives are more likely to improve their performance if they use the inter-OLAs offered by the collaborative. Our results also suggest that complementing high use of inter-OLAs with intra-OLA use and Q-HR practices enhances performance improvement. For collaborative sponsors, our findings imply that including activities that facilitate interorganizational and intraorganizational learning are worthwhile.

The evaluation of an interdisciplinary pain protocol in long term care

OBJECTIVES

To evaluate the effectiveness of (1) dissemination strategies to improve clinical practice behaviors (eg, frequency and documentation of pain assessments, use of pain medication) among health care team members, and (2) the implementation of the pain protocol in reducing pain in long term care (LTC) residents.

DESIGN

A controlled before-after design was used to evaluate the effectiveness of the pain protocol, whereas qualitative interviews and focus groups were used to obtain additional context-driven data.

SETTING

Four LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group.

PARTICIPANTS

Data were collected from 200 LTC residents; 99 for the intervention and 101 for the control group.

INTERVENTION

Implementation of a pain protocol using a multifaceted approach, including a site working group or Pain Team, pain education and skills training, and other quality improvement activities.

MEASUREMENTS

Resident pain was measured using 3 assessment tools: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, the Pain Assessment in the Communicatively Impaired Elderly, and the Present Pain Intensity Scale. Clinical practice behaviors were measured using a number of process indicators; for example, use of pain assessment tools, documentation about pain management, and use of pain medications. A semistructured interview guide was used to collect qualitative data via focus groups and interviews.

RESULTS

Pain increased significantly more for the control group than the intervention group over the 1-year intervention period. There were significantly more positive changes over the intervention period in the intervention group compared with the control group for the following indicators: the use of a standardized pain assessment tool and completed admission/initial pain assessment. Qualitative findings highlight the importance of reminding staff to think about pain as a priority in caring for residents and to be mindful of it during daily activities. Using onsite champions, in this case advanced practice nurses and a Pain Team, were key to successfully implementing the pain protocol.

CONCLUSIONS

These study findings indicate that the implementation of a pain protocol intervention improved the way pain was managed and provided pain relief for LTC residents.

The coach is in: improving nutritional care in nursing homes

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.

Quality improvement in hospice: adding a big job to an already big job?

Hospice organizations are adopting quality measurement and quality improvement (QI) practices to comply with the Medicare Conditions of Participation effective January 31, 2009. However, little is known about organizational best practices or specific needs during implementation. This study identified and described the barriers and facilitators to QI implementation in hospice. Using semistructured interviews with a national sample of key informants (n = 52) concerning facilitators and barriers to QI in hospice, 4 major themes emerged from the data regarding participants' experiences and perceptions: (1) external factors constrain QI implementation; (2) internal factors limit capacity for QI; (3) research on best practices is limited; and (4) traditional QI may not be a good fit for hospice. Though challenging, participants provided recommendations that they believed would facilitate QI in hospice. Categorizing barriers and facilitators as within or outside an organization's control may help organizations assess their capabilities and locate resources to address areas for improvement.

The use of data for process and quality improvement in long term care and home care: a systematic review of the literature

BACKGROUND

Standardized resident or client assessments, including the Resident Assessment Instrument (RAI), have been available in long term care and home care settings (continuing care sector) in many jurisdictions for a number of years. Although using these data can make quality improvement activities more efficient and less costly, there has not been a review of the literature reporting quality improvement interventions using standardized data.

OBJECTIVES

To address 2 questions: (1) How have RAI and other standardized data been used in process or quality improvement activities in the continuing care sector? and (2) Has the use of RAI and similar data resulted in improvements to resident or other outcomes?

DATA SOURCES

Searches using a combination of keyword and controlled vocabulary term searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, the Cochrane Library, and PsychINFO. ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: English language publications from database inception to October 2008 were included. Eligibility criteria included the following: (1) set in continuing care (long-term care facility or home care), (2) involved some form of intervention designed to improve quality or process of care, and (3) used standardized data in the quality or process improvement intervention.

STUDY APPRAISAL AND SYNTHESIS METHODS

After reviewing the articles, we grouped the studies according to the type of intervention used to initiate process improvement. Four different intervention types were identified. We organized the results and discussion by these 4 intervention types.

RESULTS

Key word searches identified 713 articles, of which we excluded 639 on abstract review because they did not meet inclusion criteria. A further 50 articles were excluded on full-text review, leaving a total of 24 articles. Of the 24 studies, 10 used a defined process improvement model, 8 used a combination of interventions (multimodal), 5 implemented new guidelines or protocols, and 1 used an education intervention.

CONCLUSIONS/IMPLICATIONS

The most frequently cited issues contributing to unsuccessful quality improvement interventions were lack of staff, high staff turnover, and limited time available to train staff in ways that would improve client care. Innovative strategies and supporting research are required to determine how to intervene successfully to improve quality in these settings characterized by low staffing levels and predominantly nonprofessional staff. Research on how to effectively enable practitioners to use data to improve quality of care, and ultimately quality of life, needs to be a priority.

Collaborative quality improvement to manage pain in acute care hospitals

OBJECTIVE

Collaborative quality improvement programs have been successfully used to manage chronic diseases in adults and acute lung complications in premature infants. Their effectiveness to improve pain management in acute care hospitals is currently unknown. The purpose of this study was to determine whether a collaborative quality improvement program implemented at hospital level could improve pain management and overall pain relief.

DESIGN

To assess the effectiveness of the program, we performed a before-after trial comparing patient's self-reported pain management and experience before and after program implementation. We included all adult patients hospitalized for more than 24 hours and discharged either to their home or to a nursing facility, between March 1, 2001 and March 31, 2001 (before program implementation) and between September 15, 2005 and October 15, 2005 (after program implementation).

SETTING

A teaching hospital of 2,096 beds in Geneva, Switzerland.

PATIENTS

All adult patients hospitalized for more than 24 hours and discharged between 1 to 31 March 2001 (before program) and 15 September to 15 October 2005 (after program implementation).

INTERVENTIONS

Implementation of a collaborative quality improvement program using multifaceted interventions (staff education, opinion leaders, patient education, audit, and feedback) to improve pain management at hospital level.

OUTCOME MEASURES

Patient-reported pain experience, pain management, and overall hospital experience based on the Picker Patient Experience questionnaire, perceived health (SF-36 Health survey).

RESULTS

After implementation of the program only 2.3% of the patients reported having no pain relief during their hospital stay (vs 4.5% in 2001, P=0.05). Among nonsurgical patients, improvements were observed for pain assessment (42.3% vs 27.9% of the patients had pain intensity measured with a visual analog scale, P=0.012), pain management (staff did everything they could to help in 78.9% vs 67.9% of cases P=0.003), and pain relief (70.4% vs 57.3% of patients reported full pain relief P=0.008). In surgical patients, pain assessment also improved (53.7.3% vs 37.6%) as well as pain treatment. More patients received treatments to relieve pain regularly or intermittently after program implementation (95.1% vs 91.9% P=0.046).

CONCLUSION

Implementation of a collaborative quality improvement program at hospital level improved both pain management and pain relief in patients. Further studies are needed to determine the overall cost-effectiveness of such programs.

The growth of hospice care in U.S. nursing homes

OBJECTIVES

To inform efforts aimed at reducing Medicare hospice expenditures by describing the longitudinal use of hospice care in nursing homes (NHs) and examining how hospice provider growth is associated with use.

DESIGN

Longitudinal study using NH resident assessment (Minimum Data Set) and Medicare denominator and claims data for 1999 through 2006.

SETTING

NHs in the 50 U.S. states and the District of Columbia.

PARTICIPANTS

Persons dying in U.S. NHs.

MEASUREMENTS

Medicare beneficiaries dying in NHs, receipt of NH hospice, and lengths of hospice stay were identified. The number of hospices providing care in NHs was also identified, and a panel data fixed-effect (within) regression analysis was used to examine how growth in providers affected hospice use.

RESULTS

Between 1999 and 2006, the number of hospices providing care in NHs rose from 1,850 to 2,768, and rates of NH hospice use more than doubled (from 14% to 33%). With this growth came a doubling of mean lengths of stay (from 46 to 93 days) and a 14% increase in the proportion of NH hospice decedents with noncancer diagnoses (69% in 1999 to 83% in 2006). Controlling for time trends, for every 10 new hospice providers within a state, there was an average state increase of 0.58% (95% confidence interval=0.383-0.782) in NH hospice use. Much state variation in NH hospice use and growth was observed.

CONCLUSION

Policy efforts to curb Medicare hospice expenditures (driven in part by provider growth) must consider the potentially negative effect of changes on access for dying (mostly noncancer) NH residents.

Pain management in nursing homes: what do quality measure scores tell us?

Pain management for older adults residing in nursing homes continues to present multifaceted challenges to health care practitioners and researchers. This study, which focuses on improvement in pain assessment and management, is a secondary analysis of data from a larger study, which used an intervention simultaneously directed at all levels of staff with change in quality measure (QM)/quality indicator (QI) scores to determine improvement in resident outcomes. We anticipated that focused improvement efforts in resident care regarding pain management would be reflected by correspondingly lower QM/QI scores over time. Findings of increased QM/QI scores may be positive in that they may point to increased attention by staff regarding pain management for residents.

Hospices' preparation and practices for quality measurement

CONTEXT

Hospice and palliative care organizations need to measure and analyze quality of care, in response to national palliative care practice guidelines and new hospice regulatory requirements. Little is known about hospices' readiness to meet this new mandate.

OBJECTIVES

We analyzed data from a national survey of hospices to describe preparation and practices for quality measurement and research and to examine associated organizational characteristics.

METHODS

Web-based survey of hospice staff responsible for quality of care.

RESULTS

Survey respondents represented 652 National Hospice and Palliative Care Organization (NHPCO) member hospice organizations; 52% were participating in the NHPCO Quality Partners program. Most of these hospices involve clinical providers in decisions to change care practices (69%) and participate in quality improvement projects (64%), but research participation is uncommon (16%). Many hospices collect data about staff certification and training (76%) and use family surveys to measure care quality (70%). A minority of hospices have clinical data in electronic format (13%-29%). Large size, multiple sites, government ownership, and presence of a change leader in the organization were the characteristics associated with greater preparation for quality improvement and research.

CONCLUSION

Current organizational activities, data collection rates, and use of electronic data systems may limit hospices' preparation and practices related to quality improvement and research participation; larger size and designation of a change leader are associated with greater capacity. Hospices may need technical assistance and training to provide for meaningful measurement of quality of care.

Development of a brief survey to measure nursing home residents' perceptions of pain management

Persistent severe pain in nursing home residents remains an important public health problem. One major key to quality improvement efforts is the development of tools to assist in auditing and monitoring the quality of health care delivery to these patients. A qualitative synthesis of existing pain guidelines, and input from focus groups and an expert panel, were used to develop a 10-item instrument, the Resident Assessment of Pain Management (RAPM). The psychometric properties of the RAPM were examined in a sample of 107 (82% female, average age 85) cognitively intact nursing home residents living in six Rhode Island nursing homes. Reliability and internal consistency were evaluated with test-retest and Cronbach's alpha, respectively, and validity was examined against independent assessment of pain management by research nurses. After comparing the results of RAPM with the independent pain assessment and examining a frequency distribution and factor analysis, five of the 10 items were retained. Internal reliability of the final instrument was 0.55. The rate of reported concerns ranged from 8% stating that they were not receiving enough pain medication to 43% stating that pain interfered with their sleep. The median pain problem score (i.e., the count of the number of opportunities to improve) was 1, with 23% of residents reporting three or more concerns. Overall, RAPM was moderately correlated (Spearman correlation coefficient r=0.43) with an independent expert nurse assessment of the quality of pain management. Evidence of construct validity for RAPM is based on the correlation of the pain problem score with nursing home resident satisfaction with pain management (r=0.26), reported average pain intensity (r=0.41), research nurse completion of the Minimum Data Set pain items (r=0.52), and the quality of pain documentation in the medical record (r=0.28). In conclusion, RAPM is a brief survey tool easily administered to nursing home residents that identifies important concerns with pain management. Although there is concern with the low internal consistency, RAPM demonstrates both criterion and construct validity that suggests its potential use in quality improvement efforts.

End-of-life care in nursing home settings: do race or age matter?

OBJECTIVE

One-quarter of all U.S. chronic-disease deaths occur in nursing homes, yet few studies examine palliative care quality in these settings. This study tests whether racial and/or age-based differences in end-of-life care exist in these institutional settings.

METHODS

We abstracted residents' charts (N = 1133) in 12 nursing homes. Researchers collected data on indicators of palliative care in two domains of care--advance care planning and pain management--and on residents' demographic and health status variables. Analyses tested for differences by race and age.

RESULTS

White residents were more likely than minorities to have DNR orders (69.5% vs. 37.3%), living wills (39% vs. 5%), and health care proxies (36.2% vs. 11.8%; p < .001 for each). Advance directives were highly and positively correlated with age. In-depth advance care planning discussions between residents, families, and health care providers were rare for all residents, irrespective of demographic characteristics. Nursing staff considered older residents to have milder and less frequent pain than younger residents. We found no disparities in pain management based on race.

SIGNIFICANCE OF RESULTS

To the extent that advance care planning improves care at the end of life, racial minorities in nursing homes are disadvantaged compared to their white fellow residents. Focusing on in-depth discussions of values and goals of care can improve palliative care for all residents and may help to ameliorate racial disparities in end-of-life care. Staff should consider residents of all ages as appropriate recipients of advance care planning efforts and should be cognizant of the fact that individuals of all ages can experience pain. Nursing homes may do a better job than other health care institutions in eliminating racial disparities in pain management.