Factors influencing long-term home care utilization by the older population: implications for targeting

This research was designed to explore factors that affect the choice of long-term care modalities in the older population and to discuss the appropriate target population of home health care services within the entire long-term care system. The study subjects' activities of daily living limitations, cognitive status, and sociodemograhic data at the time of admission were obtained from retrospective chart reviews. The sample included 134 older subjects who were receiving long-term care from a Long-Term Home Health Care Program or a nursing home in New York City. The results indicated that Long-Term Home Health Care Program use by older persons was characterized by a higher rate of being admitted from private homes, less cognitive impairments, less limitations in activities of daily living, and younger age than older patients who were nursing home residents. Consequently, in the choice of different care modalities, health-related factors of the older population were found to be more important predictors than sociodemographic characteristics or support system. The implication to both nurses and researchers is the development of eligibility criteria that captures the unique characteristics of disabled older persons in each of the different long-term care programs to serve them better in a cost-effective manner.

Transferring dying nursing home residents to the hospital: DON perspectives on the nurse's role in transfer decisions

This qualitative study elicits factors that influence decision-making by nurses about transferring a dying resident from the nursing home to the hospital. Focus groups with directors of nursing (DONs) from long-term care facilities revealed those decisions are influenced by knowledge (or lack thereof) of resident or family preferences, nurse interactions with physicians, nursing home technological and personnel resources, and nurse concerns about institutional liability. DONs can improve transfer decisions by communicating with all parties, clarifying nursing home processes for end-of-life care, and scheduling early and thorough conversations with residents and families about end-of-life care. DONs can implement improvements through staff education on communication issues, rigorous evaluation and performance outcome measures related to patient transfer, and conveyance to staff of the institution's mission and the nursing service's values.

Advance directives: older adults with dementia

The benefits and risks for older adults with dementia executing advance directives are discussed. Salient issues related to decision-specific capacity and models for advance planning and end-of-life decisions by cognitively impaired older adults are presented.

Profiling care and benchmarking best practice in care of hospitalized elderly: the Geriatric Institutional Assessment Profile

This article reports on a new instrument, the Geriatric Institutional Assessment Profile (GIAP), developed to assess (1) hospital workers' knowledge, attitudes, and perceptions regarding care of geriatric patients, and (2) the perceived adequacy of an institutional environment to serve geriatric patients' needs. Findings are reported from 303 questionnaires completed by health care employees from a 658-bed academic medical center. Internal consistency estimates were consistently high for the various components of the GIAP. Factor analysis was performed to examine underlying dimensions of knowledge and institutional environment. The GIAP has the potential to narrow the gap between actual and best practice in geriatric care by identifying staff information needs and concerns, as well as institutional barriers and facilitators to providing quality geriatric hospital care.

Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial

CONTEXT

Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied.

OBJECTIVE

To examine the effectiveness of an advanced practice nurse-centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions.

DESIGN

Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge.

SETTING

Two urban, academically affiliated hospitals in Philadelphia, Pa.

PARTICIPANTS

Eligible patients were 65 years or older, hospitalized between August 1992 and March 1996, and had 1 of several medical and surgical reasons for admission.

INTERVENTION

Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses.

MAIN OUTCOME MEASURES

Readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction.

RESULTS

A total of 363 patients (186 in the control group and 177 in the intervention group) were enrolled in the study; 70% of intervention and 74% of control subjects completed the trial. Mean age of sample was 75 years; 50% were men and 45% were black. By week 24 after the index hospital discharge, control group patients were more likely than intervention group patients to be readmitted at least once (37.1 % vs 20.3 %; P<.001). Fewer intervention group patients had multiple readmissions (6.2% vs 14.5%; P = .01) and the intervention group had fewer hospital days per patient (1.53 vs 4.09 days; P<.001). Time to first readmission was increased in the intervention group (P<.001). At 24 weeks after discharge, total Medicare reimbursements for health services were about $1.2 million in the control group vs about $0.6 million in the intervention group (P<.001). There were no significant group differences in post-discharge acute care visits, functional status, depression, or patient satisfaction.

CONCLUSIONS

An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. Thus, the intervention demonstrated great potential in promoting positive outcomes for hospitalized elders at high risk for rehospitalization while reducing costs.

The teaching nursing home program. Outcomes of care

Increased patient acuity, relative absence of professional providers, and isolation of nursing homes from the mainstream of health care precipitated the initiation of Teaching Nursing Home Programs (TNHP). The Robert Wood Johnson Foundation TNHP provided funding for 11 schools of nursing in collaboration with 12 nursing homes for the purpose of upgrading clinical care in nursing homes, creating an environment supportive of education, and promoting clinical research. A complete evaluation of a TNHP requires consideration of outcome, process, and structure. Quality of care and professional decision making are discussed as two of four areas by which TNHPs were evaluated.

Mental impairment of elderly hospitalized hip fracture patients

Mental impairment recorded at admission, following surgery and at discharge was assessed by studying the hospital records of 98 community residing persons, 60 years and older (mean age 76.2), hospitalized for a hip fracture and discharged alive. Of the total sample, the proportion mentally impaired following surgery was 33%. In a subsample of 74 patients for whom data were known at admission and after surgery, 15% were identified as persistently mentally impaired at admission and post-surgery, 26% were impaired only post-surgically and 59% had no recorded impairment either at admission or after surgery. Length of hospitalization (LOS) differed significantly among these three impairment groups, with persistently impaired having significantly longer stays (mean number of days = 53) than the never impaired (mean number of days = 24) and the newly impaired (mean number of days = 38) falling in between (p less than 0.005). Mental impairment continued to exhibit a significant and independent relationship with length of stay even when age and total diagnoses were held constant. The substantial prevalence of mental impairment during hospitalization, coupled with the increased length of stay in patients exhibiting impairment persisting from time of admission or newly evident after surgery, underscore the importance of mental status for recovery. Findings suggest that assessing the progression of mental impairment over the course of a hospital stay yields more accurate information about the relationship of mental status to recovery indicators and that accurate assessment of impairment at admission identifies a patient group at high risk for increased lengths of stay.(ABSTRACT TRUNCATED AT 250 WORDS)

Differences in outcome between black and white elderly hip fracture patients

Because blacks make up a small proportion of the hip fracture population, little is known about how blacks' experience following hip fracture compares to that of whites. This study, a retrospective review of the medical records of 119 community residing subjects, 60 years of age and older, 37% of whom were black, admitted with a diagnosis of hip fracture to a large urban teaching hospital, investigated differences between black and white patients in factors associated with outcome following hip fracture and outcomes at time of hospital discharge. Blacks were significantly more likely than whites to exhibit a high total number of diagnoses, urinary incontinence following surgery, low admission hemoglobins and mental impairment. Blacks experienced significantly longer hospitalizations than whites, were significantly more likely to be nonambulatory at discharge and showed different patterns of discharge destination. Multiple regression and logistic regression indicated that the greater amount of illness of blacks is a consistent significant predictor of these differences in outcomes, but that race, delays to surgery and non-surgical treatment also make independent significant contributions. These findings indicate the importance of planning for the in-hospital care of black hip fracture patients, and the examination of the financial consequences of DRG's for hospitals serving black or poor populations.