Building a community-academic partnership to improve screening for intimate partner violence: Integrating advocates in healthcare clinic settings

AIMS

To develop an innovative community-academic partnership to advance, test and promote intimate partner violence screening and referral protocols by comparing the effect of integrating intimate partner violence advocates versus enhancing medical training in medical clinic settings serving women from vulnerable populations. Detecting intimate partner violence in healthcare settings allows for survivors to connect to safety and referral resources prior to violence escalating. Screening for intimate partner violence and connecting patients to referral resources requires creating a safe and trusting relationship between healthcare providers and patients. Developing screening and referral protocols responsive to survivors' needs requires involvement of clinic staff, survivors and community agencies that support survivors.

DESIGN

Three phases of the project include Discovery, Implementation and Dissemination. Mixed-methodology will help in understanding current practices and effects of interventions.

METHODS

Actions included in each phase: Discovery: 1) nurse-led focus groups of clinic staff, providers and survivors to understand current clinic practices; 2) retrospective chart review of the number of screens performed, positive screens detected and interventions performed.

IMPLEMENTATION

1) randomization of patients to be interviewed by a trained advocate or by healthcare provider with enhanced training; and 2) assess the number of screenings and referrals performed in each arm and 3) evaluate outcomes of intervention. Dissemination through: presentations, manuscripts and policy recommendations at the institutional and regional level. This IRB-approved proposal was funded in July 2021 by an Advancing a Healthier Wisconsin grant.

DISCUSSION

The partnership has improved channels of communication and understanding between diverse clinical care providers, survivors and community agency staff as they navigate the complex challenges to the development and integration of screening and referral protocols.

IMPACT

This project will provide evidence of the most effective intimate partner violence screening and referral methodology that can be utilized in a wide variety of medical settings.

Testing Re-Engineered Discharge Program Implementation Strategies in SNFs

The Re-Engineered Discharge (RED) program, designed for hospitals, is being trialed in skilled nursing facilities (SNFs) with promising results. This paper reports on the quantitative results of a multimethod study testing two different RED program implementation strategies in SNFs. A pretest-posttest design was used to compare utilization outcomes of two different RED implementation strategies (Enhanced and Standard) and overall group differences in four Midwestern SNFs. In the Standard group there were higher odds of being readmitted in the pre-intervention versus post-intervention period. After adjusting coefficients using Poisson regression, in the pre-intervention period the adjusted number of rehospitalizations for the Standard group was 45% higher at 30 days, 50% higher at 60 days (p = .01), and 39% higher at 180 days (p = .001). SNF RED may be a useful program to reduce rehospitalizations after discharge. Benefit of SNF RED is dependent on degree of adoption of the intervention.

THE RELATIONSHIP BETWEEN ADVANCE DIRECTIVE COMPLETION AND POTENTIALLY AVOIDABLE HOSPITALIZATIONS

Advance directive (AD) completion can improve transitions between hospitals and skilled nursing facilities (SNF’s). One CMS Innovations Demonstration Project, The Missouri Quality Initiative (MOQI), focused on improving advance directive documentation and use in sixteen SNF’s. An analysis was conducted of data collected from annual chart inventories occurring over four years. Using a logistic mixed model, results indicated statistical significance (p<0.001) for increased AD documentation. Greatest gains occurred at project mid-point. The relationship between having an advance directive and occurrence of transfer to a hospital was tested on a sample of 1563 residents with length of stays more than 30 days. Residents who did not have an advance directive were more likely to be transferred. A logistic regression was conducted and the results were statistically significant (p<0.02). The MOQI model and initiatives will be explained followed by a discussion of research methodology, data collection, and analyses. Practice implications will be discussed.

SNF TO HOME: OUTCOMES OF THE SNF RE-ENGINEERED (RED) DISCHARGE PROCESS

Re-engineered (RED) Discharge Process has been effective in hospitals but little tested in SNFs. This study tested the effect of an 18-month adapted RED implementation in four Midwestern SNFs on 30, 60, 180 day hospital, SNF, and emergency department (ED) readmissions. The sample included 1026 SNF residents discharged to the community during 2013 (n = 526) and 2015 (n = 500). We used Medicare claims Data and Minimum Data Set (3.0) File to identify SNF admissions and readmissions to SNF, acute care, or ED. Data were linked across all four facilities by year and compared using appropriate statistics for descriptive, comparison, and regression tests. Residents discharged in 2013 had statistically significantly higher Charlson Comorbidity Scores 4.65 vs 3.97 in 2015 (p &lt; 0.01), while those discharged in 2015 had significantly worse cognitive status, mood, and ADL self-performance. Overall, rates and number of 30, 60-day, 180 rehospitalization, SNF readmission, ED visits with rehospitalization were lower for all 2015 compared to 2013, but not statistically significantly different, except for the number of 180-day rehospitalizations in 2015. Likewise, the only statistically significantly different result was in the regression model was 180 day rehospitalizations. However, in the two facilities that had the best uptake of the intervention, numbers of readmissions were lower at 60 and 180 days (p=.0106 and .0013, respectively for regression results). SNF RED may be a useful tool for SNFs to use to reduce rehospitalizations after discharge; however, benefit depends on the degree of adoption of the intervention.

Analyzing Hospital Transfers Using INTERACT Acute Care Transfer Tools: Lessons from MOQI

OBJECTIVES

We explored the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of Interventions to Reduce Acute Care Transfers (INTERACT) Acute Transfer Tools (ACTs) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement (QI) Initiative (MOQI).

DESIGN

Cross-sectional descriptive study of 3996 ACTs for 32.5 calendar months from 2014 to 2016. Univariate analyses examined differences between potentially avoidable vs unavoidable transfers. Multivariate logistic regression analysis of candidate factors identified those contributing to avoidable transfers.

SETTING

Sixteen nursing homes (NHs), ranging from 120 to 321 beds, in urban, metro, and rural communities within 80 miles of a large midwestern city.

PARTICIPANTS

A total of 5168 residents with a median age of 82 years.

MEASUREMENTS

Data from 3946 MOQI-adapted ACTs.

RESULTS

A total of 54% of hospital transfers were identified as avoidable. QI opportunities related to avoidable transfers were earlier detection of new signs/symptoms (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.61-3.42; P < .001); discussions of resident/family preference (OR = 2.12; 95% CI = 1.38-3.25; P < .001); advance directive/hospice care (OR = 2.25; 95% CI = 1.33-3.82; P = .003); better communication about condition (OR = 4.93; 95% CI = 3.17-7.68; P < .001); and condition could have been managed in the NH (OR = 16.63; 95% CI = 10.9-25.37; P < .001). Three factors related to unavoidable transfers were bleeding (OR = .59; 95% CI = .46-.77; P < .001), nausea/vomiting (OR = .7; 95% CI = .54-.91; P = .007), and resident/family preference for hospitalization (OR = .79; 95% CI = .68-.93; P = .003).

CONCLUSION

Reducing avoidable hospital transfers in NHs requires challenging assumptions about what is avoidable so QI efforts can be directed to improving NH capacity to manage ill residents. The APRNs served as the onsite coaches in the use and adoption of INTERACT. Changes in health policy would provide a revenue stream to support APRN presence in NH, a role that is critical to improving resident outcomes by increasing staff capacity to identify illness and guide system change. J Am Geriatr Soc 67:1953-1959, 2019.

Adapting Project RED to Skilled Nursing Facilities

This article describes our recommendation for adapting hospital-based RED (Reengineered Discharge) processes to skilled nursing facilities (SNFs). Using focus groups, the SNFs' discharge processes were assessed twice additionally, research staff then recorded field notes documenting discussions about facility discharge processes as they related to RED processes. Data were systematically analyzed using thematic analysis to identify recommendations for adapting RED to the SNF setting including (a) rapidly identifying, involving, and preparing family/caregivers to implement a patient focused SNF discharge plan; (b) reconnecting patients quickly to primary care providers; and (c) educating patients at discharge about their target health condition, medications, and impact of changes on other chronic health needs. Limited SNF staff capacity and corporate-level policies limited adoption of some key RED components. Transitional care processes such as RED, developed to avoid discharge problems, can be adapted for SNFs to improve their discharges.

The Poverty and Housing Scale: report on a pilot study

The measurement of beliefs and attitudes on poverty and housing is important to researchers and social workers interested in examining the role that belief structures have on the development of policy and programs in these areas. This article reports pilot study findings of a new scale, The Poverty and Housing Scale (PHS), that measures this concept and evaluates its psychometric properties. Preliminary reliability was in the very good range. Examinations of content and face validity provided support of the instrument as a valid measure of beliefs and attitudes on poverty and housing. The factor analysis emerged a one factor, 13-item scale. Unlike other related scales, the PHS attempts to link the social factor of poverty and housing together. Theoretical and methodological strengths and weaknesses are considered and the implications for social work practice are discussed. The authors provide recommendations for additional testing of the instrument.

Preserving end-of-life autonomy: the Patient Self-Determination Act and the Uniform Health Care Decisions Act

As medical technology continues to advance and health care choices become more complicated, the preservation of end-of-life autonomy is an increasingly important issue faced by various client populations. This article examines two legislative efforts aimed at preserving end-of-life autonomy: The Patient Self-Determination Act and the Uniform Health Care Decisions Act. The enactment of both acts will provide a more comprehensive approach to advance directive planning. The article advocates for passage of the Uniform Health Care Decisions Act in all 50 states. Implications for social work practice are discussed from a research, community action, and clinical perspective.