Implementation of a telehealth videoconference to improve hospital-to-skilled nursing care transitions: Preliminary data

Facilitators and barriers to implementation of telemedicine in nursing homes: A qualitative systematic review and meta-aggregation

BACKGROUND

Telemedicine is an effective way to provide nursing home residents ease of access to consultations with healthcare professionals. It is safe, effective, and time- and cost-efficient, and can be used when there are movement restrictions, such as during the COVID-19 pandemic. This literature focuses only on healthcare professionals' experiences and perspectives on the use of telemedicine in long-term care facilities.

OBJECTIVES

This review concentrated on telemedicine programs that did not involve remote monitoring. It aimed to comprehensively appraise existing literature examining the facilitators and barriers in implementing telemedicine services in nursing homes.

METHODS

A systematic qualitative review was conducted with content analysis. Database searching was conducted in PubMed, Embase, Cochrane, Scopus, and CINAHL. Hand searching for gray literature and reference lists of included papers was also performed. Qualitative studies or mixed-method studies with a qualitative analysis addressing implementation of telemedicine in any long-term care facilities were included. The Critical Appraisal Skills Programme qualitative checklist was used to assess the quality of the included studies. The data were extracted and cross-checked between two reviewers. A third reviewer was consulted for any disagreements. Meta-aggregation was used to synthesize the results.

RESULTS

Eighty-one findings were extracted, which informed 16 categories and 13 synthesized findings. The synthesized findings were related to the innovation domain, infrastructure, work processes, individuals, and implementation processes.

LINKING EVIDENCE TO ACTION

This review highlighted factors that affect the successful implementation of a telemedicine service in nursing homes. These findings provide evidence to support the future utilization of this service in the nursing home setting. Further research should explore the best approach to address these barriers and facilitators.

Information technology-supported integrated health service for older adults in long-term care settings

BACKGROUND

To examine the effectiveness and safety of a data sharing and comprehensive management platform for institutionalized older patients.

METHODS

We applied information technology-supported integrated health service platform to patients who live at long-term care hospitals (LTCHs) and nursing homes (NHs) with cluster randomized controlled study. We enrolled 555 patients aged 65 or older (461 from 7 LTCHs, 94 from 5 NHs). For the intervention group, a tablet-based platform comprising comprehensive geriatric assessment, disease management, potentially inappropriate medication (PIM) management, rehabilitation program, and screening for adverse events and warning alarms were provided for physicians or nurses. The control group was managed with usual care. Co-primary outcomes were (1) control rate of hypertension and diabetes, (2) medication adjustment (PIM prescription rate, proportion of polypharmacy), and (3) combination of potential quality-of-care problems (composite quality indicator) from the interRAI assessment system which assessed after 3-month of intervention.

RESULTS

We screened 1119 patients and included 555 patients (control; 289, intervention; 266) for analysis. Patients allocated to the intervention group had better cognitive function and took less medications and PIMs at baseline. The diabetes control rate (OR = 2.61, 95% CI 1.37-4.99, p = 0.0035), discontinuation of PIM (OR = 4.65, 95% CI 2.41-8.97, p < 0.0001), reduction of medication in patients with polypharmacy (OR = 1.98, 95% CI 1.24-3.16, p = 0.0042), and number of PIMs use (ꞵ =  - 0.27, p < 0.0001) improved significantly in the intervention group. There was no significant difference in hypertension control rate (OR = 0.54, 95% CI 0.20-1.43, p = 0.2129), proportion of polypharmacy (OR = 1.40, 95% CI 0.75-2.60, p = 0.2863), and improvement of composite quality indicators (ꞵ = 0.03, p = 0.2094). For secondary outcomes, cognitive and motor function, quality of life, and unplanned hospitalization were not different significantly between groups.

CONCLUSIONS

The information technology-supported integrated health service effectively reduced PIM use and controlled diabetes among older patients in LTCH or NH without functional decline or increase of healthcare utilization.

TRIAL REGISTRATION

Clinical Research Information Service, KCT0004360. Registered on 21 October 2019.

Pharmacists' Impact on Older Adults Transitioning To and From Patient Care Centers: A Scoping Review

Objective: Expand upon previous reviews conducted on transitions of care (TOC) services with a focus on pharmacist interventions for older adults specifically transitioning to and from long-term care, acute rehabilitation, residential care facilities, care homes, skilled nursing, or assisted living facilities, collectively termed patient care centers (PCC). Data Sources: A PubMed and Ovid MEDLINE search was conducted including citations between 1974 and July 14, 2022. Bibliographies were also reviewed for additional citations. Methods: Articles included described pharmacist interventions during TOC for patients transitioning to and from PCC, were written in English, and reported outcomes pertaining to TOC services. Of 873 citations reviewed, 22 articles met the inclusion criteria. Results: Most studies were prospective in design with small sample sizes, of limited duration, and with varying interventions and reported outcomes. Most explored the transition from hospital to PCC and included a pharmacist intervention involving the identification of medication errors and discrepancies during the TOC. Few studies reported cost savings or 30- and 60-day reductions in readmission rates or mortality. Conclusions: This scoping review revealed a lack of robust clinical trials to assess the effectiveness of specific interventions performed by pharmacists for patients transitioning to and from PCC. Of the available data, pharmacist involvement within an interprofessional team can be an effective intervention to resolve medication discrepancies, reduce readmissions, and medication-related adverse events. An opportunity exists for future studies to explore ways to improve outcomes during TOC within PCC.

Preventing Avoidable Rehospitalizations through Standardizing Management of Chronic Conditions in Skilled Nursing Facilities

OBJECTIVES

This study evaluated the impact of standardized care protocols, as a part of a quality improvement initiative (J10ohns Hopkins Community Health Partnership, J-CHiP), on hospital readmission rates for patients with a diagnosis of congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) after being discharged to skilled nursing facilities (SNFs).

DESIGN

A retrospective study comparing 30-day hospital readmission rates the year before and 2 years following the implementation of the care protocol interventions.

SETTINGS AND PARTICIPANTS

Patients discharged from Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center to the participating SNFs diagnosed with CHF and/or COPD.

METHODS

The standardized protocols included medical provider or nurse assessments on SNF admission, multidisciplinary care planning, and medication management to avoid unplanned readmissions to the hospital. Descriptive analyses were conducted to illustrate the 30-day readmission rates before and after protocol implementation.

RESULTS

There were 1128 patients in the pre-J-CHiP cohort and 2297 patients in the J-CHiP cohort. About half of the patients with a recorded diagnosis of CHF without COPD had the standardized protocol initiated, whereas 47% of the patients with a recorded diagnosis of COPD without CHF had the standardized protocol initiated. Of patients with recorded diagnoses of COPD and CHF, 49% had both protocols initiated. A reduction in the readmission rate was observed for patients with COPD protocols, from 23.5% in 2011 to 12.1% in 2015. However, fluctuations in the readmission rates were observed for patients who initiated the CHF protocols.

CONCLUSIONS AND IMPLICATIONS

There were improvements in the readmission rates in this study, especially for patients who had initiated standardized care protocols in the SNFs. Our findings demonstrate great value in standardizing care management and strengthening collaboration with chronic care settings to facilitate a smooth transition of medically complex patients discharged from large health care systems. Future interventions could consider assessing nonclinical factors that may impact preventable hospital readmissions.

Hospitalists Improving Transitions of Care Through Virtual Collaborative Rounding with Skilled Nursing Facilities-the HiToC SNF Study

BACKGROUND

Over one in five Medicare patients discharged to skilled nursing facilities (SNFs) are re-hospitalized within 30 days of discharge. Poor communication between the hospital and SNF upon hospital discharge is frequently cited as the most common cause of readmission.

AIM

The goal of this program was to assess the ability of a weekly post-discharge hospitalist led virtual rounding program to augment the written discharge summary sent to SNFs.

SETTING

Two academic hospitals and six SNFs in Baltimore, MD.

PARTICIPANTS

Hospitalists and medical directors or directors of nursing from the partner SNF.

PROGRAM DESCRIPTION

During weekly encounters, the hospitalist and SNF providers discussed the clinical status, discharge medications, treatment plan, and follow-up care of all discharged patients. The intervention took place from July 2021 to December 2021.

PROGRAM EVALUATION

During the study, 544 patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists identified clinically significant errors in 124 discharge summaries. A survey of participating hospitalists and SNF medical and nursing leadership indicated the intervention was thought to improve care transitions.

DISCUSSION

Our innovation was successful in identifying errors in discharge summaries and was thought to improve the transition of care by participating SNF and hospitalist providers.