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Wallace LG, Hirschman KB, Huang L, Cacchione PZ, Naylor MD. Hospitalizations, Emergency Department Visits, and Home Health Use Among Older Adults With Sensory Loss. J Aging Health 2024; 36:133-142. [PMID: 37207352 PMCID: PMC11062497 DOI: 10.1177/08982643231176669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Objectives: This study examines healthcare resource use (hospitalizations, emergency department [ED] visits, and home health episodes) among adults 65 and older diagnosed with hearing, vision, or dual sensory loss (SL) seen in the primary care setting of an academic health system. Methods: Multivariable logistic regression models were used to examine the relationship between SL (identified using ICD-10 codes) and healthcare resource use for 45,000 primary care patients. Results: The sample included 5.5% (N = 2479) with hearing loss, 10.4% (N = 4697) with vision loss, and 1.0% with dual SL (N = 469). Hearing loss increased the likelihood of having an ED visit (OR = 1.22, CI: 1.07-1.39), and home health services (OR = 1.27, CI: 1.07-1.51) compared to older adults without any SL. Vision loss reduced the likelihood of having a hospitalization (OR = .81, CI: .73-.91). Discussion: Findings support research into the drivers of healthcare use among older adults with sensory loss.
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Affiliation(s)
- Laura G. Wallace
- University of Pennsylvania School of Nursing
- NewCourtland Center for Transitions and Health at the University of Pennsylvania
- Jonas Foundation Vision Scholars
- Leonard Davis Institute of Health Economics at the University of Pennsylvania
| | - Karen B. Hirschman
- University of Pennsylvania School of Nursing
- NewCourtland Center for Transitions and Health at the University of Pennsylvania
- Leonard Davis Institute of Health Economics at the University of Pennsylvania
| | - Liming Huang
- University of Pennsylvania School of Nursing
- NewCourtland Center for Transitions and Health at the University of Pennsylvania
| | - Pamela Z. Cacchione
- University of Pennsylvania School of Nursing
- NewCourtland Center for Transitions and Health at the University of Pennsylvania
- Jonas Foundation Vision Scholars
- Leonard Davis Institute of Health Economics at the University of Pennsylvania
| | - Mary D. Naylor
- University of Pennsylvania School of Nursing
- NewCourtland Center for Transitions and Health at the University of Pennsylvania
- Leonard Davis Institute of Health Economics at the University of Pennsylvania
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Naylor MD, Hirschman KB, Morgan B, McHugh M, Hanlon AL, Ahrens M, McCauley K, Shaid EC, Pauly MV. The study protocol to evaluate implementation of the transitional care model in four U.S. healthcare systems during the Covid-19 pandemic. Arch Gerontol Geriatr 2023; 108:104944. [PMID: 36709563 PMCID: PMC9873366 DOI: 10.1016/j.archger.2023.104944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/10/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
This study protocol describes the conceptual framework, design, and methods being employed to evaluate the implementation of the Transitional Care Model (TCM) as part of a randomized controlled trial. The trial, designed to examine the health and cost outcomes of at-risk hospitalized older adults, is being conducted in the context of the COVID-19 pandemic. This parallel study is guided by the Practical, Robust, Implementation and Sustainability Model (PRISM) and uses a fixed, mixed methods convergent parallel design to identify challenges encountered by participating hospitals and post-acute and community-based providers that impact the implementation of the TCM with fidelity, strategies implemented to address those challenges and the relationships between challenges, strategies, and rates of fidelity to TCM's core components over time. Prior to the study's launch and throughout its implementation, qualitative and quantitative data related to COVID and non-COVID challenges are being collected via surveys and meetings with healthcare system staff. Strategies implemented to address challenges and fidelity to TCM's core components are also being assessed. Analyses of quantitative (established metrics to evaluate TCM's core components) and qualitative data (barriers and facilitators to implementation) are being conducted independently. These datasets are then merged and interpreted together. General linear and mixed effects modeling using all merged data and patients' socio-demographic and social determinants of health characteristics, will be used to examine relationships between key variables and fidelity rates. Implications of study findings in the context of COVID-19 and future research opportunities are suggested. Trial registration: ClinicalTrials.gov Identifier: NCT04212962.
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Affiliation(s)
- Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104.
| | - Karen B Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Brianna Morgan
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Molly McHugh
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Alexandra L Hanlon
- Center for Biostatistics and Health Data Science, College of Science, Department of Statistics, Virginia Tech, Four Riverside Circle, Roanoke, VA 24016
| | - Monica Ahrens
- Center for Biostatistics and Health Data Science, College of Science, Department of Statistics, Virginia Tech, Four Riverside Circle, Roanoke, VA 24016
| | - Kathleen McCauley
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Elizabeth C Shaid
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104
| | - Mark V Pauly
- Wharton School, University of Pennsylvania, Philadelphia, PA 19104
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Britt KC, Cacchione PZ, Naylor MD. Faith-based organizations can support dementia caregivers in a post-pandemic world. Res Nurs Health 2023; 46:282-284. [PMID: 37042730 PMCID: PMC10187066 DOI: 10.1002/nur.22309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 04/13/2023]
Affiliation(s)
- Katherine Carroll Britt
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Luci Baines Johnson and Ian J. Turpin Center for Gerontological Nursing, University of Texas at Austin School of Nursing, Austin, Texas, USA
| | - Pamela Z Cacchione
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Penn Presbyterian Medical Center, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Toles M, Preisser JS, Colón-Emeric C, Naylor MD, Weinberger M, Zhang Y, Hanson LC. Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial. J Am Geriatr Soc 2023; 71:1068-1080. [PMID: 36625769 PMCID: PMC10089938 DOI: 10.1111/jgs.18218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Skilled nursing facility (SNF) patients and their caregivers who transition to home experience complications and frequently return to acute care. We tested the efficacy of the Connect-Home transitional care intervention on patient and caregiver preparedness for care at home, and other patient and caregiver-reported outcomes. METHODS We used a stepped wedge, cluster-randomized trial design to test the intervention against standard discharge planning (control). The setting was six SNFs and six home health offices in one agency. Participants were 327 dyads of patients discharged from SNF to home and their caregivers; 11.1% of dyads in the control condition and 81.2% in the intervention condition were enrolled after onset of COVID-19. Patients were 63.9% female and mean age was 76.5 years. Caregivers were 73.7% female and mean age was 59.5 years. The Connect-Home intervention includes tools, training, and technical assistance to deliver transitional care in SNFs and patients' homes. Primary outcomes measured at 7 days included patient and caregiver measures of preparedness for care at home, the Care Transitions Measure-15 (patient) and the Preparedness for Caregiving Scale (caregiver). Secondary outcomes measured at 30 and 60 days included the McGill Quality of Life Questionnaire, Life Space Assessment, Zarit Caregiver Burden Scale, Distress Thermometer, and self-reported number of patient days in the ED or hospital in 30 and 60 days following SNF discharge. RESULTS The intervention was not associated with improvement in patient or caregiver outcomes in the planned analyses. Post-hoc analyses that distinguished between pre- and post-pandemic effects suggest the intervention may be associated with increased patient preparedness for discharge and decreased number of acute care days. CONCLUSIONS Connect-Home transitional care did not improve outcomes in the planned statistical analysis. Post-hoc findings accounting for COVID-19 impact suggest SNF transitional care has potential to increase patient preparedness and decrease return to acute care.
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Affiliation(s)
- Mark Toles
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John S. Preisser
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Cathleen Colón-Emeric
- School of Medicine, Duke University and Geriatric Research Education and Clinical Center at the Durham VA Medical Center, Durham, North Carolina
| | - Mary D. Naylor
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Morris Weinberger
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ying Zhang
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Laura C. Hanson
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Goldman AS, Abbott KM, Huang L, Naylor MD, Hirschman KB. Changes in Tangible Social Support Over Time Among Older Adults Receiving Long-Term Services and Supports. J Appl Gerontol 2023; 42:981-991. [PMID: 36650926 PMCID: PMC10081952 DOI: 10.1177/07334648221150966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The purpose of this study was to examine changes in and predictors of perceived tangible social support over a 2-year period among older adults new to LTSS. Linear mixed effects models were used to model repeated measures of tangible social support as a function of LTSS type [NH, AL, HCBS], personal, clinical, and health-related quality of life variables. AL residents reported greater initial tangible social support, but NH and HCBS residents improved more over time. Predictors of increased tangible social support over time included greater positive affect, sense of aesthetics, education, satisfaction with family relationships, and total number of close friends and family. Decreased tangible support over time was associated with greater depressive symptoms. Findings indicate the positive influence of NH and HCBS services on perception of tangible social support, and the importance of addressing depressive symptoms and assisting with the maintenance of important relationships.
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Affiliation(s)
| | - Katherine M Abbott
- Scripps Gerontology Center, Department of Sociology and Gerontology, Miami University, Oxford, OH, USA
| | - Liming Huang
- School of Nursing, 16142University of Pennsylvania, Philadelphia, PA, USA
| | - Mary D Naylor
- School of Nursing, 16142University of Pennsylvania, Philadelphia, PA, USA
| | - Karen B Hirschman
- School of Nursing, 16142University of Pennsylvania, Philadelphia, PA, USA
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Travers JL, D’Arpino S, Bradway C, Kim SJ, Naylor MD. Minority Older Adults' Access to and Use of Programs of All-Inclusive Care for the Elderly. J Aging Soc Policy 2022; 34:976-1002. [PMID: 35125064 PMCID: PMC9357232 DOI: 10.1080/08959420.2021.2024411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 04/26/2021] [Indexed: 10/19/2022]
Abstract
Programs of All-Inclusive Care for the Elderly (PACE) are an effective approach to improve care quality and delay institutional admissions especially for Black and Hispanic older adults who have seen a disproportionate rise in nursing home use. Guided by Andersen's Behavioral Model of Health Services Use and employing focus groups and one-on-one interviews, we qualitatively examined factors influencing access to and use of PACE by Black and Hispanic older adults. The study sample consisted of thirty-two PACE enrollees, six marketing-team members, and four family-caregivers from three PACE sites in a northeast urban city. Informed knowledge, cultural beliefs, and attitudes toward PACE were found to affect access. Community resources, available services, and care quality facilitated enrollment/participation. Barriers identified included poor dissemination of information and inadequate emphasis on staff's sensitivity to enrollees' cultural and disability differences. Findings will help healthcare leaders capitalize on facilitators and address barriers to enhance access and use of PACE by racial and ethnic minority older adults.
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Affiliation(s)
- Jasmine L. Travers
- New York University Rory Meyers College of Nursing, 433 1 Avenue, New York, NY 10010
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Ulrich CM, Ratcliffe SJ, Zhou Q, Huang L, Hochheimer C, Gordon T, Knafl K, Miller V, Naylor MD, Schapira MM, Richmond TS, Grady C, Mao JJ. Association of Perceived Benefit or Burden of Research Participation With Participants' Withdrawal From Cancer Clinical Trials. JAMA Netw Open 2022; 5:e2244412. [PMID: 36449287 PMCID: PMC9713607 DOI: 10.1001/jamanetworkopen.2022.44412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Attrition in cancer clinical trials (CCTs) can lead to systematic bias, underpowered analyses, and a loss of scientific knowledge to improve treatments. Little attention has focused on retention, especially the role of perceived benefits and burdens, after participants have experienced the trial. OBJECTIVES To examine the association between patients' perceived benefits and burdens of research participation and CCT retention. DESIGN, SETTING, AND PARTICIPANTS This survey study was conducted at a National Cancer Institute-designated comprehensive cancer center in the Northeast region of the US. The sample included adult patients with a cancer diagnosis participating in cancer therapeutic trials. Data were collected from September 2015 to June 2019. Analysis of study data was ongoing since November 2019 through October 2022. EXPOSURES Self-reported validated survey instrument with a list of 22 benefits and 23 burdens of research participation that can be rated by patients with a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). MAIN OUTCOMES AND MEASURES A primary outcome was actual withdrawal from the CCT, and a composite outcome was composite withdrawal that included both actual withdrawal and thoughts of withdrawing. Bivariate and multivariable logistic regressions were used. RESULTS Among the 334 participants in the sample, the mean (SD) age was 61.9 (11.5) years and 174 women (52.1%) were included. Top-cited benefits included both aspirational and action-oriented goals, including helping others (94.2%), contributing to society (90.3%), being treated respectfully (86.2%), and hoping for a cure (86.0%). Worry over receiving a placebo (61.3%), rearranging one's life (41.9%), and experiencing bothersome adverse effects (41.6%) were notable burdens. An increased burden score was associated with a higher probability of actual withdrawal (adjusted odds ratio [OR], 1.86; 95% CI, 1.1-3.17; P = .02) or composite withdrawal (adjusted OR, 3.44; 95% CI, 2.09-5.67; P < .001). An increased benefit score was associated with lower composite withdrawal (adjusted OR, 0.40; 95% CI, 0.24-0.66; P < .001). For participants who reported the benefits as being equal to or greater than the burdens, 13.4% withdrew. For those who perceived the benefits as being less than the burdens, 33.3% withdrew (adjusted OR, 3.38; 95% CI, 1.13-10.14; P = .03). The risk of withdrawal was even higher for the composite outcome (adjusted OR, 7.70; 95% CI, 2.76-21.48; P < .001). CONCLUSIONS AND RELEVANCE This survey study found that patients perceived important benefits from CCT participation, and this perception was associated with trial retention, even among those who also perceived substantial burdens. A broader dialogue among stakeholders can inform an ethical and patient-centric focus on benefits throughout the course of a CCT to increase retention.
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Affiliation(s)
- Connie M. Ulrich
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia
| | | | - Qiuping Zhou
- Department of Policy, Population and Systems Community, The George Washington University, Washington, DC
| | - Liming Huang
- Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia
| | - Camille Hochheimer
- Center for Innovative Design and Analysis, Colorado School of Public Health, Aurora
| | - Thomas Gordon
- Department of Psychology, University of Massachusetts Lowell, Lowell
| | - Kathleen Knafl
- University of North Carolina at Chapel Hill, Chapel Hill
| | - Victoria Miller
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mary D. Naylor
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia
| | - Marilyn M. Schapira
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
| | - Therese S. Richmond
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia
| | - Christine Grady
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland
| | - Jun J. Mao
- Integrative Medicine, Bendheim Integrative Medicine Center, Memorial Sloan Kettering, New York, New York
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Hirschman KB, Rivera E, Sefcik JS, McCauley K, Hanlon AL, Pauly MV, Press MJ, Naylor MD. Older Adult and Family Caregiver Perspectives on Engagement in Primary Care. J Gerontol Nurs 2022; 48:7-13. [PMID: 36286501 PMCID: PMC10337119 DOI: 10.3928/00989134-20221003-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
The purpose of the current in-depth qualitative study was to explore the experiences of older adults and family caregivers in primary care. Twenty patients and caregivers from six Comprehensive Primary Care Plus (CPC+) practices' Patient and Family Advisory Councils within a large academic health system participated in telephone interviews from December 2018 to May 2019. Participants were mostly women (60%), with an average age of 71 years and nine chronic conditions. Transcripts were coded using conventional content analysis. Two key themes emerged related to person-centered care (PCC): Engagement in Health Care and Patient-Provider Relationship. Engagement in health care was defined by participants as: being proactive, centering on patient goals in treatment discussions, adherence, and self-triaging. Approximately all participants discussed the importance of the relationship and interactions with their provider as influencing their engagement. The identified themes offer recommendations for further improvement of primary PCC. [Journal of Gerontological Nursing, 48(11), 7-13.].
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Affiliation(s)
- Karen B. Hirschman
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health, Philadelphia, PA
| | - Eleanor Rivera
- University of Illinois – Chicago, College of Nursing, Chicago, IL
| | - Justine S. Sefcik
- Drexel University College of Nursing and Health Professions, Philadelphia, PA
| | - Kathleen McCauley
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health, Philadelphia, PA
| | - Alexandra L. Hanlon
- Virginia Polytechnic Institute and State University, Center for Biostatistics and Health Data Science, Roanoke, VA
| | - Mark V. Pauly
- Wharton School at the University of Pennsylvania, Philadelphia, PA
| | - Matthew J. Press
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mary D. Naylor
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health, Philadelphia, PA
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Sefcik JS, Petrovsky DV, Huang L, Behrens LL, Naylor MD, Hodgson NA, Hirschman KB. Predictors of change over time in satisfaction with outdoor activities ratings among long-term care services and supports recipients. Geriatr Nurs 2022; 45:153-159. [PMID: 35472750 PMCID: PMC9353871 DOI: 10.1016/j.gerinurse.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To identify predictors of change in older adults' satisfaction with outdoor activities ratings over the first two years of enrollment in long-term services and supports (LTSS). METHODS Self-rated satisfaction with outdoor activities (not at all satisfied to extremely satisfied) was the primary outcome of this secondary data analysis. Mixed-effects linear regression modeling with a backward elimination process was used for analyses. RESULTS In the final model (N = 453) older LTSS recipients at baseline had lower ratings of satisfaction with outdoor activities over time, whereas younger recipients had higher ratings over time. Those who moved into a residential facility at baseline had an increase in outdoor activity satisfaction ratings over time compared to older adults who received home and community-based services that had a decrease. DISCUSSION LTSS clinicians can use these findings to support older adults with decision-making around enrollment into LTSS, address preferences, and develop person-centered care interventions for outdoor activity.
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Affiliation(s)
- Justine S Sefcik
- Drexel University College of Nursing and Health Professions, 1601 Cherry St., Room 377, Philadelphia, PA 19102, United States.
| | - Darina V Petrovsky
- Rutgers University School of Nursing and Institute for Health, Health Care Policy, and Aging Research, 112 Paterson St, New Brunswick, NJ, 08901, United States
| | - Liming Huang
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
| | - Liza L Behrens
- Ross and Carol Nese College of Nursing, The Pennsylvania State University, 201 Nursing Sciences Building, University Park, PA 16803, United States
| | - Mary D Naylor
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
| | - Nancy A Hodgson
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
| | - Karen B Hirschman
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
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Rubin DJ, Gogineni P, Deak A, Vaz C, Watts S, Recco D, Dillard F, Wu J, Karunakaran A, Kondamuri N, Zhao H, Naylor MD, Golden SH, Allen S. The Diabetes Transition of Hospital Care (DiaTOHC) Pilot Study: A Randomized Controlled Trial of an Intervention Designed to Reduce Readmission Risk of Adults with Diabetes. J Clin Med 2022; 11:1471. [PMID: 35329797 PMCID: PMC8949063 DOI: 10.3390/jcm11061471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 12/10/2022] Open
Abstract
Hospital readmission within 30 days of discharge (30-day readmission) is a high-priority quality measure and cost target. The purpose of this study was to explore the feasibility and efficacy of the Diabetes Transition of Hospital Care (DiaTOHC) Program on readmission risk in high-risk adults with diabetes. This was a non-blinded pilot randomized controlled trial (RCT) that compared usual care (UC) to DiaTOHC at a safety-net hospital. The primary outcome was all-cause 30-day readmission. Between 16 October 2017 and 30 May 2019, 93 patients were randomized. In the intention-to-treat (ITT) population, 14 (31.1%) of 45 DiaTOHC subjects and 15 (32.6%) of 46 UC subjects had a 30-day readmission, while 35.6% DiaTOHC and 39.1% UC subjects had a 30-day readmission or ED visit. The Intervention−UC cost ratio was 0.33 (0.13−0.79) 95%CI. At least 93% of subjects were satisfied with key intervention components. Among the 69 subjects with baseline HbA1c >7.0% (53 mmol/mol), 30-day readmission rates were 23.5% (DiaTOHC) and 31.4% (UC) and composite 30-day readmission/ED visit rates were 26.5% (DiaTOHC) and 40.0% (UC). In this subgroup, the Intervention−UC cost ratio was 0.21 (0.08−0.58) 95%CI. The DiaTOHC Program may be feasible and may decrease combined 30-day readmission/ED visit risk as well as healthcare costs among patients with HbA1c levels >7.0% (53 mmol/mol).
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Affiliation(s)
- Daniel J. Rubin
- Section of Endocrinology, Diabetes, and Metabolism, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (P.G.); (C.V.); (A.K.); (N.K.); (S.A.)
| | - Preethi Gogineni
- Section of Endocrinology, Diabetes, and Metabolism, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (P.G.); (C.V.); (A.K.); (N.K.); (S.A.)
| | - Andrew Deak
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (A.D.); (S.W.); (D.R.); (F.D.)
| | - Cherie Vaz
- Section of Endocrinology, Diabetes, and Metabolism, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (P.G.); (C.V.); (A.K.); (N.K.); (S.A.)
| | - Samantha Watts
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (A.D.); (S.W.); (D.R.); (F.D.)
| | - Dominic Recco
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (A.D.); (S.W.); (D.R.); (F.D.)
| | - Felicia Dillard
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (A.D.); (S.W.); (D.R.); (F.D.)
| | - Jingwei Wu
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, PA 19140, USA;
| | - Abhijana Karunakaran
- Section of Endocrinology, Diabetes, and Metabolism, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (P.G.); (C.V.); (A.K.); (N.K.); (S.A.)
| | - Neil Kondamuri
- Section of Endocrinology, Diabetes, and Metabolism, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (P.G.); (C.V.); (A.K.); (N.K.); (S.A.)
| | - Huaqing Zhao
- Department of Biomedical Education and Data Science, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA;
| | - Mary D. Naylor
- School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Sherita H. Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Shaneisha Allen
- Section of Endocrinology, Diabetes, and Metabolism, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA; (P.G.); (C.V.); (A.K.); (N.K.); (S.A.)
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Demiris G, Oliver DP, Washington KT, Chadwick C, Voigt JD, Brotherton S, Naylor MD. Examining spoken words and acoustic features of therapy sessions to understand family caregivers’ anxiety and quality of life. Int J Med Inform 2022; 160:104716. [PMID: 35183870 PMCID: PMC8902633 DOI: 10.1016/j.ijmedinf.2022.104716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Speech and language cues are considered significant data sources that can reveal insights into one's behavior and well-being. The goal of this study is to evaluate how different machine learning (ML) classifiers trained both on the spoken word and acoustic features during live conversations between family caregivers and a therapist, correlate to anxiety and quality of life (QoL) as assessed by validated instruments. METHODS The dataset comprised of 124 audio-recorded and professionally transcribed discussions between family caregivers of hospice patients and a therapist, of challenges they faced in their caregiving role, and standardized assessments of self-reported QoL and anxiety. We custom-built and trained an Automated Speech Recognition (ASR) system on older adult voices and created a logistic regression-based classifier that incorporated audio-based features. The classification process automated the QoL scoring and display of the score in real time, replacing hand-coding for self-reported assessments with a machine learning identified classifier. FINDINGS Of the 124 audio files and their transcripts, 87 of these transcripts (70%) were selected to serve as the training set, holding the remaining 30% of the data for evaluation. For anxiety, the results of adding the dimension of sound and an automated speech-to-text transcription outperformed the prior classifier trained only on human-rendered transcriptions. Specifically, precision improved from 86% to 92%, accuracy from 81% to 89%, and recall from 78% to 88%. INTERPRETATION Classifiers can be developed through ML techniques which can indicate improvements in QoL measures with a reasonable degree of accuracy. Examining the content, sound of the voice and context of the conversation provides insights into additional factors affecting anxiety and QoL that could be addressed in tailored therapy and the design of conversational agents serving as therapy chatbots.
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Affiliation(s)
- George Demiris
- School of Nursing, University of Pennsylvania, Philadelphia, PA, United States.
| | | | | | | | | | | | - Mary D Naylor
- School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
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Maxwell TL, Hanlon AL, Naylor MD. A Systematized Approach to Advancing the Quality of Community-Based Palliative Care. Am J Hosp Palliat Care 2021; 39:951-955. [PMID: 34961345 DOI: 10.1177/10499091211065173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite growing recognition of the importance of community-based palliative care, optimizing the use of services continues to be a challenge. Until recently, key barriers were reimbursement and limited access. As services have become increasingly available, engagement of patients and their caregivers has emerged as a major obstacle. The Palliative Activation SystemTM (PAS) is a comprehensive, quality improvement methodology designed to promote enhanced engagement of seriously ill adults and their caregivers in optimizing the use of community-based palliative care services and accelerate clinicians' progress in meeting patients' and caregivers' care goals. This paper describes the design of the PAS. Experts in patient engagement and the development and evaluation of palliative care programs advised organizational leaders in the development of this methodology. The "Patient and Family Engagement" framework proposed by Carman and colleagues (2013) guided this work. The framework informed the selection of three core concepts-care alignment, illness trajectory, and social determinants of health-as foundational to the goals of the PAS. Additionally, this framework guided the selection of measures that will be used to assess progress in achieving enhanced engagement. This background work, coupled with findings from interviews with patients and caregivers who are current recipients of palliative care services, resulted in the implementation and ongoing testing of strategies targeting clinicians and organizational leaders and designed to enhance engagement. Lessons learned from the design phase of the PAS will advance the efforts of other organizations committed to increasing patient and caregiver engagement and enhancing attainment of their goals.
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Affiliation(s)
| | - Alexandra L Hanlon
- Department of Statistics, Center for Biostatistics and Health Data Science, 1757Virginia Tech, Roanoke, VA, USA
| | - Mary D Naylor
- NewCourtland Center for Transitions and Health, 6572University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Isasi F, Naylor MD, Skorton D, Grabowski DC, Hernández S, Rice VM. Patients, Families, and Communities COVID-19 Impact Assessment: Lessons Learned and Compelling Needs. NAM Perspect 2021; 2021:202111c. [PMID: 35118349 PMCID: PMC8803391 DOI: 10.31478/202111c] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Mary D Naylor
- NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing
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Naylor MD, Toles M. The Challenge of Providing Evidence-based Transitional Care. Investg Enferm Imagen Desarollo 2021. [DOI: 10.11144/javeriana.ie23.dpct] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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15
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Naylor MD, Toles M. The Challenge of Providing Evidence-based Transitional Care. Investg Enferm Imagen Desarollo 2021. [DOI: 10.11144/javeriana.ie23.cpet] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Transitions in care are events that occur as individuals transfer between settings and providers of healthcare. The movement from a hospital to home-based care is a common example of a care transition. Due to common breakdowns between health and social care systems, continuing risks for acute health events, and the lack of support to manage complex treatments at home, between 15-20% of hospitalized adults are rehospitalized within thirty days of returning home. This high rate of hospital readmissions points up the need for transitional care services to address challenges in continuing care at home
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Ritter AZ, Kelly J, Kent RM, Howard P, Theil R, Cavanaugh P, Hollingsworth J, Duffey JS, Schuler M, Naylor MD. Implementation of a Coronavirus Disease 2019 Vaccination Condition of Employment in a Community Nursing Home. J Am Med Dir Assoc 2021; 22:1998-2002. [PMID: 34418376 PMCID: PMC8346362 DOI: 10.1016/j.jamda.2021.07.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022]
Abstract
The rate of coronavirus disease 2019 (COVID-19) vaccination uptake by US nursing home staff remains low despite the increased risks of viral transmission and related morbidity and mortality in this setting. This study describes vaccine uptake activities including a COVID-19 vaccination condition of employment (COE) policy in one community nursing home. This case study summarizes the timeline of vaccination uptake activities, staff vaccination rates over time, and stakeholder perspectives around the implementation of a COVID-19 vaccination COE. Organizational data were used to calculate vaccination rates from January 1, 2021 until May 1, 2021 among all nursing home staff. Interviews were held with the executive leadership team, human resources leadership, and nursing home staff to understand the process of implementation. During a 4-month period, nursing home leaders provided 8 written handouts about COVID-19 to all staff, hosted 5 on-site vaccination clinics in partnership with area pharmacies, conducted 2 virtual presentations for staff in addition to individual outreach and internal communications. Fewer than one-half of the staff were vaccinated prior to the decision to pursue a vaccine COE on February 9, 2021. The decision to pursue a COVID-19 vaccination COE was supported by executive leadership and nursing home staff to protect the health and safety of each other and their residents. By May 1, 2021 a total of 221 of the 246 (89.8%) nursing home staff members received a COVID-19 vaccination. The facility reached 100% compliance with the vaccination COE policy with 18 people who chose to resign and 7 people who were exempt or on a leave of absence. In combination with frequent, personalized outreach, a COVID-19 vaccination COE resulted in high staff vaccination rates and minimal staff turnover. This case study provides a detailed summary of vaccination uptake activities within an organizational context to inform efforts at other healthcare facilities.
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Affiliation(s)
- Ashley Z Ritter
- NewCourtland, Philadelphia, PA, USA; NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | | | | | | | | | | | | | | | | | - Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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17
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Travers JL, Hirschman KB, Naylor MD. Older Adults' Goals and Expectations When Using Long-Term Services and Supports. J Appl Gerontol 2021; 41:709-717. [PMID: 34315240 DOI: 10.1177/07334648211033671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Despite recent research focused on aging well, little is known regarding the goals and expectations from long-term services and supports (LTSS) use among older adults. METHODS To address this knowledge gap, interviewer-guided surveys with older adults newly receiving LTSS in home and community-based, assisted living, and nursing home settings in Philadelphia, New Jersey, and New York were conducted. RESULTS Twelve subthemes regarding the goals and expectations of 464 older adults receiving LTSS and in the context of Aging Well emerged from our analysis: maintaining function, optimizing health and circumstances, maintaining the status quo, transitioning back to the previous state, achieving independence, preserving cognitive function and capacity for psychosocial and emotional health, achieving purpose, increasing quality of life, receiving social support, increasing engagement, relieving burden, and feeling a sense of security/safety. DISCUSSION This in-depth analysis of qualitative data provides context for LTSS use among older adults.
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Affiliation(s)
| | | | - Mary D Naylor
- University of Pennsylvania School of Nursing, Philadelphia, USA
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18
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Travers JL, Naylor MD, Coe NB, Meng C, Li F, Cohen AB. Demographic Characteristics Driving Disparities in Receipt of Long-term Services and Supports in the Community Setting. Med Care 2021; 59:537-542. [PMID: 33827107 PMCID: PMC8119333 DOI: 10.1097/mlr.0000000000001544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS). OBJECTIVE We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity. METHODS We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences. RESULTS There were 186 minority older adults (community=75%, NH=25%) and 357 White older adults (community=50%, NH=50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community. CONCLUSION Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.
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Affiliation(s)
| | - Mary D. Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing
| | - Norma B. Coe
- University of Pennsylvania Perelman School of Medicine
| | - Can Meng
- Yale Center for Analytical Sciences, Department of Biostatistics, Yale School of Public Health
| | - Fangyong Li
- Yale Center for Analytical Sciences, Department of Biostatistics, Yale School of Public Health
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Sefcik JS, Hirschman KB, Petrovsky DV, Hodgson NA, Naylor MD. Satisfaction With Outdoor Activities Among Northeastern U.S. Newly Enrolled Long-Term Services and Supports Recipients. J Appl Gerontol 2021; 40:590-597. [PMID: 32608313 PMCID: PMC7775289 DOI: 10.1177/0733464820933774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Older adults receiving long-term services and supports (LTSS) experience barriers to outdoor activities and satisfaction ratings with such experiences are not well understood. Our study used cross-sectional data (n = 329) to (a) examine whether those new to LTSS were satisfied with their outdoor activities and (b) describe the characteristics and factors associated with satisfaction levels. Self-report of satisfaction with outdoor activities was the outcome variable. Multivariable linear regression modeling of the outcome was conducted. Fifty-nine percent were satisfied with their outdoor activities. More depressive symptoms (p < .001) and higher cognitive functioning (p = .011) were associated with lower ratings. Higher self-rated physical health (p = .009) and more independence with activities of daily living (p = .022) were associated with greater satisfaction. Findings suggest an unmet need among four in 10 new recipients of LTSS (41%) related to their outdoor activities. LTSS interdisciplinary teams can use these findings to inform their assessments, develop person-centered care plans, and address barriers.
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Affiliation(s)
- Justine S Sefcik
- Drexel University College of Nursing and Health Professions, Philadelphia, PA, USA
| | | | | | - Nancy A Hodgson
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Mary D Naylor
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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20
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Giordano NA, Compton P, Joseph PV, Romano CA, Piano MR, Naylor MD. Opportunities and challenges presented by recent pedagogical innovations in doctoral nursing education. J Prof Nurs 2021; 37:228-234. [PMID: 33674100 DOI: 10.1016/j.profnurs.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
The demand to expand the nurse scientist pipeline over the past decade has generated numerous pedagogical innovations in nursing doctoral education. A PhD nursing education summit was held at the University of Pennsylvania in October 2019 to discuss pedagogical innovations. The main pedagogical innovations discussed by Summit attendees included: 1) the expansion of both 3-year PhD programs and BSN to PhD programs; 2) changes in learning opportunities and curricula content; and 3) the role of postdoctoral fellowships. This overview examines the numerous opportunities and challenges generated by these innovations. Opportunities include producing scholars with research careers that are potentially longer than historically seen in the nursing profession, as well as the emergence of unique educational and mentoring opportunities both during and after doctoral studies. Challenges involve the impact condensed program timelines have had on both the content and delivery of curricula, as well as the research expertise and skillsets of nursing PhD program graduates. There is a need to conduct a national coordinated evaluation of PhD program using shared metrics in order to better evaluate the effect of these pedagogical innovations on the development of nurse scientists, and ultimately, the discipline.
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Affiliation(s)
- Nicholas A Giordano
- Emory University Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, United States of America.
| | - Peggy Compton
- Department of Family and Community Health, University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104, United States of America
| | - Paule V Joseph
- Biobehavioral Branch, Division of Intramural Research, National Institute of Nursing Research (NINR), National Institute on Alcohol Abuse and Alcoholism (NIAAA), 10 Center Drive, Bethesda, MD 20892, United States of America
| | - Carol Ann Romano
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States of America
| | - Mariann R Piano
- Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, United States of America
| | - Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104, United States of America
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21
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Khan TS, Hirschman KB, McHugh MD, Naylor MD. Self-efficacy of family caregivers of older adults with cognitive impairment: A concept analysis. Nurs Forum 2021; 56:112-126. [PMID: 32888197 PMCID: PMC8549654 DOI: 10.1111/nuf.12499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 07/01/2020] [Accepted: 08/13/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Research demonstrates that increased self-efficacy can help family caregivers of older adults with Alzheimer's and other types of cognitive impairment experience lower burden and depressive symptom severity. AIMS The purpose of this concept analysis is to address fundamental gaps in the understanding of self-efficacy in family caregivers of older adults with cognitive impairment, including updating the 26-year-old concept analysis with a contemporary definition. METHODS This study utilizes Walker and Avant's (2019) concept analysis method, an eight-step iterative process that helps to clarify ambiguous concepts. A literature review was conducted from July 1993 through March 2019 using PubMed/MEDLINE, Scopus, CINAHL, and Embase. Inclusion criteria encompassed peer-reviewed research articles and review articles that included family caregivers of older adults with cognitive impairment. RESULTS Eight defining attributes of this concept are identified. The revised definition of self-efficacy in this population is a family caregiver's confidence in their ability to: manage behaviors and other caregiving stresses, control upsetting thoughts, acquire medical information, manage medical issues, obtain self-care, access community supports, assist with activities of daily living and other care, and maintain a good relationship with a relative, friend, or neighbor of an older adult with cognitive impairment. CONCLUSION This paper utilizes over a quarter-century of research to build on the original analysis by Mowat and Spence Laschinger (1994) and update the concept's definition. This analysis should provide researchers with a clearer understanding of this concept and a renewed emphasis on the importance of targeting interventions to improve self-efficacy in this vulnerable caregiving population.
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Affiliation(s)
- Tarik S. Khan
- School of Nursing, New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen B. Hirschman
- School of Nursing, New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew D. McHugh
- School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary D. Naylor
- School of Nursing, New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania
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22
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Keim SK, Ratcliffe SJ, Naylor MD, Bowles KH. Patient Factors Linked with Return Acute Healthcare Use in Older Adults by Discharge Disposition. J Am Geriatr Soc 2020; 68:2279-2287. [PMID: 33267559 DOI: 10.1111/jgs.16645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 04/24/2020] [Accepted: 05/12/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Compare patient characteristics by hospital discharge disposition (home without services, home with home healthcare (HHC) services, or post-acute care (PAC) facilities). Examine timing and rates of 30-day healthcare utilization (rehospitalization, emergency department (ED) visit, or observation (OBS) visit) and patient characteristics associated with rehospitalization by discharge location. DESIGN Retrospective analysis of hospital administrative and clinical data. SETTING AND PARTICIPANTS A total of 3,294 older adult inpatients discharged home with or without HHC services or to a PAC facility. MEASUREMENTS Patient-level sociodemographic and clinical characteristics. Number of and time to occurrences of rehospitalization or ED/OBS visit within 30 days of hospital discharge. RESULTS Most rehospitalizations and ED/OBS visits occurred within 14 days from hospital discharge. Patients who returned within 24 hours came mostly from inpatient rehabilitation facilities (IRFs). More intense levels of PAC services were linked with higher rehospitalization risk. However, specific predictors differed by discharge location. Being unemployed, being single, and having more comorbidities were most associated with rehospitalization in those who went home with or without services, whereas patients rehospitalized from IRFs were younger, with less chronic illness burden, but greater and recent functional decline. Those discharged with HHC services had more return ED/OBS visits. CONCLUSIONS Although sicker patients were referred for more intense levels of PAC services, patients with greater chronic illness burden were still most often rehospitalized. In addition to unique patient differences, rehospitalizations from IRF within 24 hours suggest systems factors are contributory. Most return acute healthcare utilization occurred within 14 days; therefore, interventions should focus on smoothing transitions to all discharge locations. Because predictors of rehospitalization risk differed by discharge disposition, future research is necessary to study approaches aimed at matching patients' care needs with the most suitable PAC services at the right time. J Am Geriatr Soc 68:2279-2287, 2020.
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Affiliation(s)
- Susan K Keim
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah J Ratcliffe
- Division of Biostatistics, University of Virginia, Charlottesville, Virginia, USA
| | - Mary D Naylor
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathryn H Bowles
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Visiting Nurse Service of New York, New York, New York, USA
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Rivera E, Hirschman KB, Naylor MD. Reported Needs and Depressive Symptoms Among Older Adults Entering Long-Term Services and Supports. Innov Aging 2020; 4:igaa021. [PMID: 32685704 PMCID: PMC7334621 DOI: 10.1093/geroni/igaa021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Long-term services and supports (LTSS) are vital for older adults with physical and cognitive disabilities. LTSS can be provided in settings such as nursing homes, assisted living, or via community-based services. During the transition to LTSS, older adults are at risk of increased depressive symptoms. In addition, older adults may identify unmet needs despite having access to new LTSS resources. The goal of this study was to examine the factors associated with increased depressive symptoms among a pool of older adults, with a focus on change in reported needs after starting LTSS. RESEARCH DESIGN AND METHODS This cross-sectional analysis of a cohort study included 352 older adults new to LTSS (R01AG025524). The outcome of depressive symptoms was measured using the Geriatric Depression Scale-Short Form. Reported needs included supportive equipment, devices, transportation, and social activities. Bivariate and linear regression modeling using change in needs 3 months later were performed. RESULTS Depressive symptoms were present among 40% of the LTSS recipients at enrollment and 3 months. At baseline, 29% of LTSS recipients reported a need for supportive equipment, 30% for transportation, and 23% for social activities. After 3 months, an average of 12% of LTSS recipients' needs were met, 13% of LTSS recipients' needs persisted, and 11% of LTSS recipients reported new needs. Depressive symptoms 3 months later were higher for those who reported persistent unmet needs compared with those who reported no needs at all, controlling for functional status and LTSS type. DISCUSSION AND IMPLICATIONS The transition to LTSS is a vulnerable time for older adults. Assessing the need for equipment, transportation, and social activities during this period may identify opportunities to improve the lives and emotional status of this population.
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Affiliation(s)
- Eleanor Rivera
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia
| | - Karen B Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia
| | - Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia
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Abstract
As of May 2020, nursing home residents account for a staggering one-third of the more than 80,000 deaths due to COVID-19 in the U.S. This pandemic has resulted in unprecedented threats to achieving and sustaining care quality even in the best nursing homes, requiring active engagement of nursing home leaders in developing solutions responsive to the unprecedented threats to quality standards of care delivery during the pandemic. This perspective offers a framework, designed with the input of nursing home leaders, to facilitate internal and external decision-making and collective action to address these threats. Policy options focus on assuring a shared understanding among nursing home leaders and government agencies of changes in the operational status of nursing homes throughout the crisis, improving access to additional essential resources needed to mitigate the crisis' impact, and promoting shared accountability for consistently achieving accepted standards in core quality domains.
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Affiliation(s)
- Liza L Behrens
- Postdoctoral Research Fellow, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing , Philadelphia, Pennsylvania, USA
| | - Mary D Naylor
- Marian S. Ware Professor in Gerontology, Director of the NewCourtland Center for Transitions and Health, University of Pennsylvania , Philadelphia, Pennsylvania, USA
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Demiris G, Corey Magan KL, Parker Oliver D, Washington KT, Chadwick C, Voigt JD, Brotherton S, Naylor MD. Spoken words as biomarkers: using machine learning to gain insight into communication as a predictor of anxiety. J Am Med Inform Assoc 2020; 27:929-933. [PMID: 32374378 DOI: 10.1093/jamia/ocaa049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/03/2020] [Accepted: 04/03/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The goal of this study was to explore whether features of recorded and transcribed audio communication data extracted by machine learning algorithms can be used to train a classifier for anxiety. MATERIALS AND METHODS We used a secondary data set generated by a clinical trial examining problem-solving therapy for hospice caregivers consisting of 140 transcripts of multiple, sequential conversations between an interviewer and a family caregiver along with standardized assessments of anxiety prior to each session; 98 of these transcripts (70%) served as the training set, holding the remaining 30% of the data for evaluation. RESULTS A classifier for anxiety was developed relying on language-based features. An 86% precision, 78% recall, 81% accuracy, and 84% specificity were achieved with the use of the trained classifiers. High anxiety inflections were found among recently bereaved caregivers and were usually connected to issues related to transitioning out of the caregiving role. This analysis highlighted the impact of lowering anxiety by increasing reciprocity between interviewers and caregivers. CONCLUSION Verbal communication can provide a platform for machine learning tools to highlight and predict behavioral health indicators and trends.
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Affiliation(s)
- George Demiris
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Debra Parker Oliver
- Family Medicine, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Karla T Washington
- Family Medicine, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | | | | | | | - Mary D Naylor
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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26
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Affiliation(s)
- Mary D. Naylor
- Marian S. Ware Professor in Gerontology, Director of the NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Karen B. Hirschman
- Research Associate Professor, NewCourtland Term Chair in Health Transitions Research, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Kathleen McCauley
- Professor of Cardiovascular Nursing, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Naylor MD, Morgan B, Ritter AZ. Stemming the Rising Toll of People Living with Complex Care Needs. JAMA Health Forum 2020; 1:e200282. [PMID: 36218608 PMCID: PMC9999413 DOI: 10.1001/jamahealthforum.2020.0282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia
| | - Brianna Morgan
- NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia
| | - Ashley Z Ritter
- NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia.,National Clinician Scholars Program, University of Pennsylvania, Philadelphia
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Thompson HJ, Santacroce SJ, Pickler RH, Allen JK, Armer JM, Bakken S, Bowles KH, Conley YP, Dunbar SA, Ellington L, Grey M, Heitkemper MM, Herr KA, Lake E, McCarthy AM, Melnyk B, Miaskowski CA, Moore SM, Naylor MD, Stone PW, Titler MG, Weiss SJ. Use of individual development plans for nurse scientist training. Nurs Outlook 2020; 68:284-292. [PMID: 32197775 DOI: 10.1016/j.outlook.2020.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/14/2019] [Accepted: 01/01/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Hilaire J Thompson
- Biobehavioral Nursing and Health Informatics, The University of Washington, Seattle, WA.
| | | | - Rita H Pickler
- Martha S. Pitzer Center for Women, Children and Youth, The Ohio State University College of Nursing, Columbus, OH
| | - Jerilyn K Allen
- The Johns Hopkins University School of Nursing, Baltimore, MD
| | - Jane M Armer
- Sinclair School of Nursing, University of Missouri, Columbia, MO
| | - Suzanne Bakken
- School of Nursing and Department of Biomedical Informatics, Columbia University, New York, NY
| | - Kathryn H Bowles
- Biobehavioral Health Science Department, New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Yvette P Conley
- Department of Health Promotion and Development, University of Pittsburgh, Pittsburgh, PA
| | - Sandra A Dunbar
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, UT
| | | | - Margaret M Heitkemper
- Biobehavioral Nursing and Health Informatics, The University of Washington, Seattle, WA
| | - Keela A Herr
- College of Nursing, University of Iowa, Iowa City, IA
| | - Eileen Lake
- Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA
| | | | | | | | - Shirley M Moore
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH
| | - Mary D Naylor
- Biobehavioral Health Science Department, New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Patricia W Stone
- Center for Health Policy, Columbia University School of Nursing, New York, NY
| | - Marita G Titler
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI
| | - Sandra J Weiss
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, San Francisco, CA
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Travers JL, Hirschman KB, Naylor MD. Adapting Andersen's expanded behavioral model of health services use to include older adults receiving long-term services and supports. BMC Geriatr 2020; 20:58. [PMID: 32059643 PMCID: PMC7023712 DOI: 10.1186/s12877-019-1405-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 12/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Andersen's Expanded Behavioral Model of Health Services Use describes factors associated with the use of long-term services and supports (LTSS). This model, however, has only been tested on the intent to use such services among African-American and White older adults and not the actual use. Given the increasing diversity of older adults in the U.S., the ability to conceptualize factors associated with actual use of LTSS across racial/ethnic groups is critical. METHODS We applied Andersen's Expanded model in the analysis of 2006-2010 qualitative data using multiple methods to understand both the relevancy of factors for older adults who currently use LTSS vs. those who intend to use LTSS (as described in Andersen's original exploration). We additionally explored differences in these factors across racial/ethnic groups and included Hispanic older adults in our analyses. RESULTS Four additional constructs linked with actual LTSS use emerged: losses and changes, tangible support, capability to provide informal support, and accessibility of informal support. Racial differences were seen in level of participation in decisions to use nursing home services (Not involved: 45% African-Americans vs. 24% Whites). Reports of LTSS use to avoid burdening one's family were greater among White older adults compared to African-American older adults. CONCLUSIONS Findings around decision-making and burden along with other constructs enhance our understanding of determinants that influence actual LTSS use and require targeted interventions.
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Affiliation(s)
- Jasmine L. Travers
- Yale University School of Medicine, 333 Cedar Street, SHM I-456, PO Box 208088, New Haven, CT 06510-8088 USA
- Yale University School of Nursing, 333 Cedar Street, SHM I-456, PO Box 208088, New Haven, CT 06510-8088 USA
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104 USA
| | - Karen B. Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104 USA
| | - Mary D. Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104 USA
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Travers JL, Hirschman KB, Hanlon AL, Huang L, Naylor MD. Factors Associated With Perceived Worsened Physical Health Among Older Adults Who Are Newly Enrolled Long-term Services and Supports Recipients. Inquiry 2020; 57:46958019900835. [PMID: 31994424 PMCID: PMC6990604 DOI: 10.1177/0046958019900835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 12/07/2019] [Accepted: 12/17/2019] [Indexed: 11/18/2022]
Abstract
Limited information exists on the perceived health of older adults new to receiving long-term services and supports (LTSS) compared with the year prior, posing challenges to the anticipation of health care need and optimization of wellness efforts for this growing population. In response, we sought to identify differences in perceived worsened physical health across three LTSS types (nursing home, assisted living, and home and community-based services) along with health-related quality of life (HRQoL) characteristics associated with older adults' ratings of perceived worsened physical health at the start of receiving LTSS. Enrolled LTSS recipients completed a single interview assessing their HRQoL. Bivariate and multivariable logistic regression analyses were performed to determine associations in LTSS types and HRQoL characteristics with perceived worsened physical health among older adults (≥60 years old) since 1 year prior to study enrollment. Among the 467 LTSS recipients, perceived physical health was rated as worse than the previous year by 36%. Bivariate analyses revealed no differences in perceived worsened physical health across LTSS types. In adjusted analyses, religiousness/spirituality and better mental and general health perception had a decreased odds of being associated with perceived worsened physical health (P < .05). Participants with major changes in their health in the past 6 months were more likely to report perceived worsened physical health (P < .001). Findings provide information that may be used to target efforts to enhance perceived physical health and improve quality of life among LTSS enrollees.
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Affiliation(s)
- Jasmine L. Travers
- Yale University, New Haven, CT, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | | | | | - Liming Huang
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Mary D. Naylor
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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31
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Petrovsky DV, Hirschman KB, Brewster G, Hanlon AL, Huang L, McPhillips MV, Hodgson NA, Naylor MD. CHANGES OVER TIME IN DAYTIME SLEEPINESS AMONG OLDER ADULTS RECEIVING LONG-TERM SERVICES AND SUPPORTS. Innov Aging 2019. [PMCID: PMC6840148 DOI: 10.1093/geroni/igz038.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
The purpose of this study was to examine the predictors of excessive daytime sleepiness (EDS) over the first two years of long-term services and supports (LTSS) for 470 older adults in assisted living communities (ALCs), nursing homes (NHs), or their homes. Mixed effects linear regression modeling using a backward elimination process was used to build a final multivariable model. In the final model, being female (p<0.001) and fewer functional deficits (p<0.001) at baseline were associated with decreases in EDS, while higher baseline measures of BMI (p=0.004) and number of symptoms (p<0.001) were associated with higher EDS. Compared to older adults living in the community and receiving LTSS, those in NHs and ALCs had higher EDS (p<0.001). Greater feelings of belonging and depressive symptoms at baseline were associated with slower rates of increase in EDS over time (both p<0.001). Modifiable predictors of EDS and clinical implications will be discussed.
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Affiliation(s)
| | - Karen B Hirschman
- University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Glenna Brewster
- Nell Hodgson Woodruff School of Nursing Emory University, Atlanta, Georgia, United States
| | - Alexandra L Hanlon
- Virginia Polytechnic Institute and State University, Roanoke, Virginia, United States
| | - Liming Huang
- University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | | | - Nancy A Hodgson
- University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Mary D Naylor
- University of Pennsylvania, Philadelphia, Pennsylvania, United States
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32
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Hirschman KB, Toles MP, Hanlon AL, Huang L, Naylor MD. What Predicts Health Care Transitions for Older Adults Following Introduction of LTSS? J Appl Gerontol 2019; 39:702-711. [PMID: 30819004 DOI: 10.1177/0733464819833565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To determine predictors of health care transitions (i.e., acute care service use, transfers from lower to higher intensity services) among older adults new to long-term services and supports [LTSS]. Method: 470 new LTSS recipients followed for 24 months. Multivariable Poisson regression modeling within a generalized estimating equation framework. Results: Being male, having multiple chronic conditions, lower self-reported physical health ratings and lower quality of life ratings at baseline were associated with increased risk of health care transitions. Older adults in assisted living communities and nursing homes experienced decreases in health care transitions over time, while LTSS recipients at home had no change in risk. LTSS recipients who had orders to receive therapy, compared with those who did not, had a lower relative risk of transitions over time. Discussion: Predictors of future health care transitions support the need for LTSS providers to anticipate and monitor this risk for LTSS recipients.
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Affiliation(s)
| | - Mark P Toles
- The University of North Carolina at Chapel Hill, USA
| | | | - Liming Huang
- University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Mary D Naylor
- University of Pennsylvania School of Nursing, Philadelphia, USA
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33
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Bowles KH, Ratcliffe SJ, Holmes JH, Keim S, Potashnik S, Flores E, Humbrecht D, Whitehouse CR, Naylor MD. Using a Decision Support Algorithm for Referrals to Post-Acute Care. J Am Med Dir Assoc 2018; 20:408-413. [PMID: 30414821 DOI: 10.1016/j.jamda.2018.08.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Although hospital clinicians strive to effectively refer patients who require post-acute care (PAC), their discharge planning processes often vary greatly, and typically are not evidence-based. DESIGN Quasi-experimental study employing pre-/postdesign. Aimed at improving patient-centered discharge processes, we examined the effects of the Discharge Referral Expert System for Care Transitions (DIRECT) algorithm that provides clinical decision support (CDS) regarding which patients to refer to PAC and to what level of care (home care or facility). SETTING AND PARTICIPANTS Conducted in 2 hospitals, DIRECT data elements were collected in the pre-period (control) but discharging clinicians were blinded to the advice and provided usual discharge care. During the postperiod (intervention), referral advice was provided within 24 hours of admission to clinicians, and updated twice daily. Propensity modeling was used to account for differences between the pre-/post patient cohorts. MEASURES Outcomes compared between the control and the intervention periods included PAC referral rates, patient characteristics, and same-, 7-, 14-, and 30-day readmissions or emergency department visits. RESULTS Although 24%-25% more patients were recommended for PAC referral by DIRECT algorithm advice, the proportion of patients receiving referrals for PAC did not significantly differ between the control (3302) and intervention (5006) periods. However, the characteristics of patients referred for PAC services differed significantly and inpatient readmission rates decreased significantly across all time intervals when clinicians had DIRECT CDS compared with without. There were no differences observed in return emergency department visits. Largest effects were observed when clinicians agreed with the algorithm to refer (yes/yes). CONCLUSIONS/IMPLICATIONS Our findings suggest the value of timely, automated, discharge CDS for clinicians to optimize PAC referral for those most likely to benefit. Although overall referral rates did not change with CDS, the algorithm may have identified those patients most in need, resulting in significantly lower inpatient readmission rates.
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Affiliation(s)
- Kathryn H Bowles
- University of Pennsylvania School of Nursing, New Courtland Center for Transitions and Health, Philadelphia, PA.
| | - Sarah J Ratcliffe
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - John H Holmes
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sue Keim
- University of Pennsylvania School of Nursing, New Courtland Center for Transitions and Health, Philadelphia, PA
| | - Sheryl Potashnik
- University of Pennsylvania School of Nursing, New Courtland Center for Transitions and Health, Philadelphia, PA
| | - Emilia Flores
- University of Pennsylvania School of Nursing, New Courtland Center for Transitions and Health, Philadelphia, PA
| | | | - Christina R Whitehouse
- University of Pennsylvania School of Nursing, New Courtland Center for Transitions and Health, Philadelphia, PA
| | - Mary D Naylor
- University of Pennsylvania School of Nursing, New Courtland Center for Transitions and Health, Philadelphia, PA
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34
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Chase JAD, Hirschman KB, Hanlon AL, Huang L, Bowles KH, Naylor MD. Physical Functioning Among Older Adults New to Long-Term Services and Supports. Gerontologist 2018; 58:1147-1155. [PMID: 28549107 DOI: 10.1093/geront/gnx082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 05/04/2017] [Indexed: 11/12/2022] Open
Abstract
Background and Objectives To identify determinants of self-reported physical functioning (PF) among older adults new to long-term services and supports (LTSS). Research Design and Method Using the International Classification of Function, Disability, and Health (ICF) framework, we conducted a secondary analysis of self-reported data on symptoms, basic/instrumental activities of daily living, quality of life, assistive devices, physical therapy needs, prior healthcare utilization, health status, and demographics from 470 older adults new to LTSS (Home/Community-Based n = 156; Assisted Living n = 156; Nursing Home n = 158). Multiple linear regression was used to identify associations between ICF constructs and self-reported PF (SF-12 Physical Composite Summary score [SF12PCS], lower scores indicate worse PF). Results LTSS recipients were mostly female (71%) and over age 80 (Mean: 80.9 years, SD: 8.7). LTSS recipients' mean SF12PCS score was 37.3 (SD 11.0), indicating overall low self-reported PF. LTSS recipients living in their homes (b = -3.35, p = .003) or assisted living facilities (b = -2.93, p = .012) had significantly lower mean scores compared to recipients in nursing homes. Higher SF12PCS scores were associated with fewer activities of daily living deficits (p < .001), and better quality of life (p < .001). Lower scores were associated with more symptoms (p < .001), poorer nutrition (p = .013), ambulation aid use (p < .001), and physical therapy (p < .026). Discussion and Implications Diverse health, activity, and environmental factors may facilitate early identification of new LTSS recipients most in need of interventions to optimize self-reported PF. Several health conditions may be targets for such interventions. Additional research is needed to evaluate and compare PF trajectories among older adults receiving LTSS in diverse settings.
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Affiliation(s)
- Jo-Ana D Chase
- School of Nursing, University of Pennsylvania, Philadelphia.,University of Missouri, Columbia
| | - Karen B Hirschman
- NewCourtland Term Chair in Health Transitions Research, School of Nursing, University of Pennsylvania, Philadelphia
| | | | - Liming Huang
- School of Nursing, University of Pennsylvania, Philadelphia
| | - Kathryn H Bowles
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, Nursing Excellence, University of Pennsylvania, Philadelphia
| | - Mary D Naylor
- NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia
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35
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Hirschman KB, Yu Z, Pennock MJ, Pepe K, Rouse W, Pauly MV, Naylor MD. WHAT FACTORS ARE IMPORTANT WHEN DECIDING TO ADOPT THE EVIDENCE-BASED TRANSITIONAL CARE MODEL (TCM)? Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- K B Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania, United States
| | - Z Yu
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
| | - M J Pennock
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
| | - K Pepe
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
| | - W Rouse
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
| | - M V Pauly
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - M D Naylor
- NewCourland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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36
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Naylor MD, Shaid EC, McCauley K, Carpenter D, Gass B, Levine C, Li J, Williams MV. COMPONENTS OF COMPREHENSIVE AND EFFECTIVE TRANSITIONAL CARE. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
| | - E C Shaid
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - K McCauley
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - D Carpenter
- Center for Healthcare Delivery Research and Evaluation, Westat, Rockville, MD, USA
| | - B Gass
- Telligen, Division of Health Management, Greenwood Village, CO, USA
| | - C Levine
- Families and Health Care Project, United Hospital Fund, New York, NY, USA
| | - J Li
- Center for Health Services Research, University of Kentucky, Lexington, KY, USA
| | - M V Williams
- Univeristy of Kentucky, Lexinton, KY, USA; Center for Health Services Research, University of Kentucky, Lexington, LY, USA
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Naylor MD, Hirschman KB. UNDERSTANDING FACILITATORS AND BARRIERS TO CARE TRANSITIONS: PROJECT ACHIEVE. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - K B Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
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38
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Hirschman KB, Naylor MD. THE USE OF POLICY SIMULATION IN MAKING DECISIONS TO IMPLEMENT THE TRANSITIONAL CARE MODEL. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- K B Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
| | - M D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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39
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Yu Z, Rouse W, Naylor MD, Pennock MJ, Hirschman KB, Pauly MV, Pepe K. POLICY FLIGHT SIMULATORS: ACCELERATING DECISIONS TO ADOPT EVIDENCE-BASED HEALTH INTERVENTIONS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Z Yu
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, New Jersey, United States
| | - W Rouse
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
| | - M D Naylor
- NewCourland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - M J Pennock
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
| | - K B Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - M V Pauly
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - K Pepe
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
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40
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Pennock MJ, Yu Z, Pepe K, Hirschman KB, Pauly MV, Naylor MD, Rouse W. BUILDING A TRANSITIONAL CARE MODEL (TCM) POLICY FLIGHT SIMULATOR. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M J Pennock
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, New Jersey, United States
| | - Z Yu
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
| | - K Pepe
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
| | - K B Hirschman
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - M V Pauly
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - M D Naylor
- NewCourland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - W Rouse
- Stevens Institute of Technology, School of Systems and Enterprises, Hoboken, NJ, USA
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41
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Naylor MD, Hodgson NA, Demiris G. Changing the Care System Long Before the "End Game". J Am Geriatr Soc 2018; 66:2050-2051. [PMID: 30302751 DOI: 10.1111/jgs.15618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 08/31/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Mary D Naylor
- School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Nancy A Hodgson
- School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - George Demiris
- School of Nursing, University of Pennsylvania, Philadelphia, PA
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Pauly MV, Hirschman KB, Hanlon AL, Huang L, Bowles KH, Bradway C, McCauley K, Naylor MD. Cost impact of the transitional care model for hospitalized cognitively impaired older adults. J Comp Eff Res 2018; 7:913-922. [PMID: 30203668 DOI: 10.2217/cer-2018-0040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM The goal of this study was to compare postacute care costs of three care management interventions. MATERIALS & METHODS A total of 202 hospitalized older adults with cognitive impairment received either Augmented Standard Care, Resource Nurse Care or the Transitional Care Model. The Lin method was used to estimate costs at 30 and 180 days postindex hospital discharge. RESULTS The Transitional Care Model had significantly lower costs than the Augmented Standard Care group at both 30 (p < 0.001) and 180 days (p = 0.03) and significantly lower costs than Resource Nurse Care at 30 days (p = 0.02). CONCLUSION These findings suggest that the Transitional Care Model can reduce both the amount of other postacute care and the total cost of care compared with alternative services for cognitively impaired older adults. Clinicaltrials.gov : NCT00294307.
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Affiliation(s)
- Mark V Pauly
- The Wharton School at the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Karen B Hirschman
- NewCourtland Center for Transitions & Health at the University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Alexandra L Hanlon
- NewCourtland Center for Transitions & Health at the University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Liming Huang
- NewCourtland Center for Transitions & Health at the University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Kathryn H Bowles
- NewCourtland Center for Transitions & Health at the University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Christine Bradway
- NewCourtland Center for Transitions & Health at the University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Kathleen McCauley
- NewCourtland Center for Transitions & Health at the University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
| | - Mary D Naylor
- NewCourtland Center for Transitions & Health at the University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
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43
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Naylor MD, Hirschman KB, Toles MP, Jarrín OF, Shaid E, Pauly MV. Adaptations of the evidence-based Transitional Care Model in the U.S. Soc Sci Med 2018; 213:28-36. [PMID: 30055423 DOI: 10.1016/j.socscimed.2018.07.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 05/29/2018] [Accepted: 07/14/2018] [Indexed: 11/29/2022]
Abstract
Despite a growing body of evidence that adaptations of evidence-based interventions (EBI) are ubiquitous, few studies have examined the nature and rationale for modifications to the components of these interventions. The primary aim of this study was to describe and classify common local adaptations of the Transitional Care Model (TCM), an EBI comprised of 10 components that has been proven in multiple clinical trials to improve the care and outcomes of chronically ill older adults transitioning from hospitals to home. Guided by Stirman's System of Classifying Adaptations, 582 transitional care clinicians in health systems and community-based organizations throughout the U.S. completed a survey between September 2014 and January 2015; interviews were then conducted with a subset of survey respondents (N = 24) between April and December 2015. A total of 342 survey respondents (59%) reported implementation of the TCM in distinct organizations. Of this group, 96% reported a mean of 4.4 adaptations to the 10 TCM components (40%, one to three; 43%, four to six; and 17%, seven to nine). Nine of ten respondents (94%) reported contextual adaptations while content adaptations were less frequently reported (58%). The top three reported adaptations all related to context (i.e., delivering services from hospital to home, relying on advance practice nurses, and fostering care continuity); interviews clarified a diverse set of reasons for such modifications. Findings reinforce the need for investment in adaptation science and suggest hypotheses to guide rigorous examination of the association between adaptations of TCM components and desired outcomes.
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Affiliation(s)
- Mary D Naylor
- University of Pennsylvania School of Nursing, Philadelphia, PA, United States.
| | - Karen B Hirschman
- University of Pennsylvania School of Nursing, Philadelphia, PA, United States
| | - Mark P Toles
- University of North Carolina Chapel Hill, Chapel Hill, NC, United States
| | - Olga F Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Elizabeth Shaid
- University of Pennsylvania School of Nursing, Philadelphia, PA, United States
| | - Mark V Pauly
- Wharton School at the University of Pennsylvania, Philadelphia, PA, United States
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Bowles KH, Ratcliffe SJ, Naylor MD, Holmes JH, Keim SK, Flores EJ. Nurse Generated EHR Data Supports Post-Acute Care Referral Decision Making: Development and Validation of a Two-step Algorithm. AMIA Annu Symp Proc 2018; 2017:465-474. [PMID: 29854111 PMCID: PMC5977719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Objective: Build and validate a clinical decision support (CDS) algorithm for discharge decisions regarding referral for post-acute care (PAC) and to what site of care. Materials and Methods: Case studies derived from EHR data were judged by 171 interdisciplinary experts and prediction models were generated. Results: A two-step algorithm emerged with area under the curve (AUC) in validation of 91.5% (yes/no refer) and AUC 89.7% (where to refer). Discussion: CDS for discharge planning (DP) decisions may remove subjectivity, and variation in decision-making. CDS could automate the assessment process and alert clinicians of high need patients earlier in the hospital stay. Conclusion: Our team successfully built and validated a two-step algorithm to support discharge referral decision-making from EHR data. Getting patients the care and support they need may decrease readmissions and other adverse events. Further work is underway to test the effects of the CDS on patient outcomes in two hospitals.
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Affiliation(s)
- Kathryn H Bowles
- University of Pennsylvania, Philadelphia, PA
- Visiting Nurse Service of New York
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Toles M, Colón-Emeric C, Naylor MD, Asafu-Adjei J, Hanson LC. Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers. J Am Geriatr Soc 2017; 65:2322-2328. [PMID: 28815552 DOI: 10.1111/jgs.15015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional care of SNF patients (i.e., time-limited services to ensure coordination and continuity of care) is poorly understood. OBJECTIVE To determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads. DESIGN A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family caregivers. SETTING Three SNFs in the Southeastern United States. PARTICIPANTS Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge. INTERVENTION The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver transitional care of patient and caregiver dyads. MEASUREMENTS Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15). RESULTS The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24). CONCLUSION Connect-Home is a promising transitional care intervention for older patients discharged from SNF care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.
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Affiliation(s)
- Mark Toles
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Mary D Naylor
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Laura C Hanson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Tisminetzky M, Bayliss EA, Magaziner JS, Allore HG, Anzuoni K, Boyd CM, Gill TM, Go AS, Greenspan SL, Hanson LR, Hornbrook MC, Kitzman DW, Larson EB, Naylor MD, Shirley BE, Tai-Seale M, Teri L, Tinetti ME, Whitson HE, Gurwitz JH. Research Priorities to Advance the Health and Health Care of Older Adults with Multiple Chronic Conditions. J Am Geriatr Soc 2017; 65:1549-1553. [PMID: 28555750 DOI: 10.1111/jgs.14943] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To prioritize research topics relevant to the care of the growing population of older adults with multiple chronic conditions (MCCs). DESIGN Survey of experts in MCC practice, research, and policy. Topics were derived from white papers, funding announcements, or funded research projects relating to older adults with MCCs. SETTING Survey conducted through the Health Care Systems Research Network (HCSRN) and Claude D. Pepper Older Americans Independence Centers (OAICs) Advancing Geriatrics Infrastructure and Network Growth Initiative, a joint endeavor of the HCSRN and OAICs. PARTICIPANTS Individuals affiliated with the HCSRN or OAICs and national MCC experts, including individuals affiliated with funding agencies having MCC-related grant portfolios. MEASUREMENTS A "top box" methodology was used, counting the number of respondents selecting the top response on a 5-point Likert scale and dividing by the total number of responses to calculate a top box percentage for each of 37 topics. RESULTS The highest-ranked research topics relevant to the health and healthcare of older adults with MCCs were health-related quality of life in older adults with MCCs; development of assessment tools (to assess, e.g., symptom burden, quality of life, function); interactions between medications, disease processes, and health outcomes; disability; implementation of novel (and scalable) models of care; association between clusters of chronic conditions and clinical, financial, and social outcomes; role of caregivers; symptom burden; shared decision-making to enhance care planning; and tools to improve clinical decision-making. CONCLUSION Study findings serve to inform the development of a comprehensive research agenda to address the challenges relating to the care of this "high-need, high-cost" population and the healthcare delivery systems responsible for serving it.
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Affiliation(s)
- Mayra Tisminetzky
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts.,Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado.,Department of Family Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jay S Magaziner
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Maryland
| | | | - Kathryn Anzuoni
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
| | - Cynthia M Boyd
- Division of Geriatric Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Thomas M Gill
- School of Medicine, Yale University, New Haven, Connecticut
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Susan L Greenspan
- New Courtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mark C Hornbrook
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Dalane W Kitzman
- Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Eric B Larson
- Kaiser Washington Health Research Institute, Seattle, Washington
| | - Mary D Naylor
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin E Shirley
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
| | - Linda Teri
- School of Nursing, University of Washington, Seattle, Washington
| | - Mary E Tinetti
- School of Medicine, Yale University, New Haven, Connecticut
| | - Heather E Whitson
- Duke University Aging Center, Duke University, Durham, North Carolina.,Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts.,Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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Van Cleave JH, Egleston BL, Abbott KM, Hirschman KB, Rao A, Naylor MD. Multiple Chronic Conditions and Hospitalizations Among Recipients of Long-Term Services and Supports. Nurs Res 2017; 65:425-434. [PMID: 27801713 DOI: 10.1097/nnr.0000000000000185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Among older adults receiving long-term services and supports (LTSS), debilitating hospitalizations is a pervasive clinical and research problem. Multiple chronic conditions (MCCs) are prevalent in LTSS recipients. However, the combination of MCCs and diseases associated with hospitalizations of LTSS recipients is unclear. OBJECTIVE The purpose of this analysis was to determine the association between classes of MCCs in newly enrolled LTSS recipients and the number of hospitalizations over a 1-year period following enrollment. METHODS This report is based on secondary analysis of extant data from a longitudinal cohort study of 470 new recipients of LTSS, 60 years and older, receiving services in assisted living facilities, nursing homes, or through home- and community-based services. Using baseline chronic conditions reported in medical records, latent class analysis was used to identify classes of MCCs and posterior probabilities of membership in each class. Poisson regressions were used to estimate the relative ratio between posterior probabilities of class membership and number of hospitalizations during the 3-month period prior to the start of LTSS (baseline) and then every 3 months forward through 12 months. RESULTS Three latent MCC-based classes named Cardiopulmonary, Cerebrovascular/Paralysis, and All Other Conditions were identified. The Cardiopulmonary class was associated with elevated numbers of hospitalizations compared to the All Other Conditions class (relative ratio [RR] = 1.88, 95% CI [1.33, 2.65], p < .001). CONCLUSION Older LTSS recipients with a combination of MCCs that includes cardiopulmonary conditions have increased risk for hospitalization.
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Affiliation(s)
- Janet H Van Cleave
- Janet H. Van Cleave, PhD, RN, is Assistant Professor, New York University Rory Meyers College of Nursing. Brian L. Egleston, PhD, is Associate Research Professor, Biostatistics Facility, Fox Chase Cancer Center, Philadelphia, Pennsylvania. Katherine M. Abbott, PhD, MGS, is Assistant Professor of Gerontology, Miami University, Oxford, Ohio. Karen B. Hirschman, PhD, MSW, is NewCourtland Term Chair in Health Transitions Research and Research Associate Professor of Nursing, University of Pennsylvania School of Nursing, Philadelphia. Aditi Rao, PhD, RN, is Director of Nursing Practice, Hospital of the University of Pennsylvania, Philadelphia. Mary D. Naylor, PhD, RN, FAAN, is Marian S. Ware Professor in Gerontology, Director, NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia
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Van Cleave JH, Egleston BL, Brosch S, Wirth E, Lawson M, Sullivan-Marx EM, Naylor MD. Policy Research Challenges in Comparing Care Models for Dual-Eligible Beneficiaries. Policy Polit Nurs Pract 2017; 18:72-83. [PMID: 28735567 PMCID: PMC7133145 DOI: 10.1177/1527154417721909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Providing affordable, high-quality care for the 10 million persons who are dual-eligible beneficiaries of Medicare and Medicaid is an ongoing health-care policy challenge in the United States. However, the workforce and the care provided to dual-eligible beneficiaries are understudied. The purpose of this article is to provide a narrative of the challenges and lessons learned from an exploratory study in the use of clinical and administrative data to compare the workforce of two care models that deliver home- and community-based services to dual-eligible beneficiaries. The research challenges that the study team encountered were as follows: (a) comparing different care models, (b) standardizing data across care models, and (c) comparing patterns of health-care utilization. The methods used to meet these challenges included expert opinion to classify data and summative content analysis to compare and count data. Using descriptive statistics, a summary comparison of the two care models suggested that the coordinated care model workforce provided significantly greater hours of care per recipient than the integrated care model workforce. This likely represented the coordinated care model's focus on providing in-home services for one recipient, whereas the integrated care model focused on providing services in a day center with group activities. The lesson learned from this exploratory study is the need for standardized quality measures across home- and community-based services agencies to determine the workforce that best meets the needs of dual-eligible beneficiaries.
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Affiliation(s)
| | - Brian L Egleston
- 2 Biostatistics Facility, Fox Chase Cancer, Philadelphia, PA, USA
| | | | | | | | | | - Mary D Naylor
- 4 NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Naylor MD, Shaid EC, Carpenter D, Gass B, Levine C, Li J, Malley A, McCauley K, Nguyen HQ, Watson H, Brock J, Mittman B, Jack B, Mitchell S, Callicoatte B, Schall J, Williams MV. Components of Comprehensive and Effective Transitional Care. J Am Geriatr Soc 2017; 65:1119-1125. [PMID: 28369722 DOI: 10.1111/jgs.14782] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve health outcomes and reduce preventable hospital readmissions, yet little is known about the critical elements of effective TC and how they relate to patients' and caregivers' needs and experiences. To address this gap, the Patient-Centered Outcomes Research Institute (PCORI) funded a national study, Achieving patient-centered Care and optimized Health In care transitions by Evaluating the Value of Evidence (Project ACHIEVE). A primary aim of the study is the identification of TC components that yield desired patient and caregiver outcomes. Project ACHIEVE established a multistakeholder workgroup to recommend essential TC components for vulnerable Medicare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components and then analyzed how well the set aligned with real-world patients' and caregivers' experiences. Through this process, the workgroup identified eight TC components: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients' and caregivers' well-being, care continuity, and accountability. Although the degree of attention given to each component will vary based on the specific needs of patients and caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all Medicare beneficiaries.
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Affiliation(s)
- Mary D Naylor
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth C Shaid
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deborah Carpenter
- Center for Healthcare Delivery Research and Evaluation, Westat, Rockville, Maryland
| | - Brianna Gass
- Division of Health Management, Telligen, Greenwood Village, Colorado
| | - Carol Levine
- Families and Health Care Project, United Hospital Fund, New York, New York
| | - Jing Li
- Center for Health Services Research, University of Kentucky, Lexington, Kentucky
| | - Ann Malley
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen McCauley
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Heather Watson
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Jane Brock
- Division of Health Management, Telligen, Greenwood Village, Colorado
| | - Brian Mittman
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Brian Jack
- School of Medicine, Boston University, Boston Medical Center, Boston, Massachusetts
| | - Suzanne Mitchell
- School of Medicine, Boston University, Boston Medical Center, Boston, Massachusetts
| | - Becky Callicoatte
- School of Medicine, Louisiana State University, Baton Rouge, Louisiana
| | - John Schall
- Caregiver Action Network, Washington, District of Columbia
| | - Mark V Williams
- Center for Health Services Research, University of Kentucky, Lexington, Kentucky
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Shaid EC, Hirschman KB, Byrnes MB, Naylor MD. Meeting the Needs of the Complex Older Adult Patient with Urinary Retention: A Case Study. Urol Nurs 2017; 37:75-80. [PMID: 29240371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This article presents a case study of how a homebound older adult patient with urinary retention is managed by a patient-centered medical home/transitional care model. A description of how a root cause analysis can effectively improve outcomes is also provided.
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Affiliation(s)
- Elizabeth C Shaid
- Advanced Practice Nurse and a member of the New Courtland Center for Transitions and Health, the University of Pennsylvania, School of Nursing, Philadelphia, PA
| | - Karen B Hirschman
- Research Associate Professor and New Courtland Term Chair in Health Transitions Research, the University of Pennsylvania, School of Nursing, Philadelphia, PA
| | - Mary Beth Byrnes
- Clinical Nurse Specialist, Richard Byrnes, D.O. Family Medicine, an NCQA-Certified Level 3 Patient-Centered Medical Home, Souderton, PA
| | - Mary D Naylor
- The Marian S. Ware Professor of Gerontology and Director of the New Courtland Center for Transitions and Health, the University of Pennsylvania, School of Nursing, Philadelphia, PA
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