Interdisciplinary videoconference model for identifying potential adverse transition of care events following hospital discharge to postacute care

Discharge from hospitals to postacute care settings is a vulnerable time for many older adults, when they may be at increased risk for errors occurring in their care. We developed the Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) programme in an effort to mitigate these risks through a mulitdisciplinary, educational, case-based teleconference between hospital and skilled nursing facility providers. The programme was implemented in both academic and community hospitals. Through weekly sessions, patients discharged from the hospital were discussed, clinical concerns addressed, errors in care identified and plans were made for remediation. A total of 1432 discussions occurred for 1326 patients. The aim of this study was to identify errors occurring in the postdischarge period and factors that predict an increased risk of experiencing an error. In 435 discussions, an issue was identified that required further discussion (known as a transition of care event), and the majority of these were related to medications. In 14.7% of all discussions, a medical error, defined as 'any preventable event that may cause or lead to inappropriate medical care or patient harm', was identified. We found that errors were more likely to occur for patients discharged from surgical services or the emergency department (as compared with medical services) and were less likely to occur for patients who were discharged in the morning. This study shows that a number of errors may be detected in the postdischarge period, and the ECHO-CT programme provides a mechanism for identifying and mitigating these events. Furthermore, it suggests that discharging service and time of day may be associated with risk of error in the discharge period, thereby suggesting potential areas of focus for future interventions.

Linking AM-PAC Cognition to PROMIS Cognitive Function

OBJECTIVE

To link the Activity Measure for Post-Acute Care (AM-PAC) Applied Cognition to the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function, allowing for a common metric across scales.

DESIGN

Cross-sectional survey study.

SETTING

Outpatient rehabilitation clinics.

PARTICIPANTS

Consecutive sample of 500 participants (N=500) aged ≥18 years presenting for outpatient therapy (physical, occupation, speech).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

AM-PAC Medicare and Generic Cognition short forms and PROMIS Cognitive Function items representing the PROMIS Cognitive Function item bank.

RESULTS

The calibration of 25 AM-PAC cognition items with 11 fixed PROMIS cognitive function item parameters using item-response theory indicated that items were measuring the same underlying construct (cognition). Both scales measured a wide range of functioning. The AM-PAC Generic Cognitive assessment showed more reliability with lower levels of cognition, whereas the PROMIS Cognitive Function full-item bank was more reliable across a larger distribution of scores. Data were appropriate for a fixed-anchor item response theory-based crosswalk and AM-PAC Cognition raw scores were mapped onto the PROMIS metric.

CONCLUSIONS

The crosswalk developed in this study allows for converting scores from the AM-PAC Applied Cognition to the PROMIS Cognitive Function scale.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients

IMPORTANCE

The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown.

OBJECTIVE

To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs.

MAIN OUTCOME MEASURES

Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident.

RESULTS

The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities.

CONCLUSIONS

The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

The Cost of Implementing and Sustaining the COMprehensive Post-Acute Stroke Services Model

BACKGROUND

The COMprehensive Post-Acute Stroke Services (COMPASS) model, a transitional care intervention for stroke patients discharged home, was tested against status quo postacute stroke care in a cluster-randomized trial in 40 hospitals in North Carolina. This study examined the hospital-level costs associated with implementing and sustaining COMPASS.

METHODS

Using an activity-based costing survey, we estimated hospital-level resource costs spent on COMPASS-related activities during approximately 1 year. We identified hospitals that were actively engaged in COMPASS during the year before the survey and collected resource cost estimates from 22 hospitals. We used median wage data from the Bureau of Labor Statistics and COMPASS enrollment data to estimate the hospital-level costs per COMPASS enrollee.

RESULTS

Between November 2017 and March 2019, 1582 patients received the COMPASS intervention across the 22 hospitals included in this analysis. Average annual hospital-level COMPASS costs were $2861 per patient (25th percentile: $735; 75th percentile: $3,475). Having 10% higher stroke patient volume was associated with 5.1% lower COMPASS costs per patient (P=0.016). About half (N=10) of hospitals reported postacute clinic visits as their highest-cost activity, while a third (N=7) reported case ascertainment (ie, identifying eligible patients) as their highest-cost activity.

CONCLUSIONS

We found that the costs of implementing COMPASS varied across hospitals. On average, hospitals with higher stroke volume and higher enrollment reported lower costs per patient. Based on average costs of COMPASS and readmissions for stroke patients, COMPASS could lower net costs if the model is able to prevent about 6 readmissions per year.

Identifying and Bridging the Gaps in Antimicrobial Stewardship in Post-Acute and Long-Term Care

National organizations have developed guidelines and tools for antimicrobial stewardship (AMS) in post-acute and long-term care (PALTC), but there is a need to effectively translate these into actionable, measurable, and impactful programs. An electronic needs assessment survey was developed and distributed to health care providers and administrators involved with AMS activities in PALTC facilities in Maryland. The results of this survey were used to develop a statewide initiative to improve AMS in nursing facilities. The survey revealed that barriers to implementing AMS include limited access or poor utilization of experts in AMS and infectious disease, adverse event data collection tools, and locally developed protocols and guidelines. Strategies to improve AMS included the provision of free continuing education to a multidisciplinary audience and improved access to individuals with expertise in infectious disease and the development of an adverse drug event tool. Continuing to provide meaningful tools and resources that address the specific needs of nursing facilities should lead to improved compliance with regulations and ultimately improved resident outcomes. [Journal of Gerontological Nursing, 46(1), 8-13.].

Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission

BACKGROUND

Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments.

METHODS

We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests.

RESULTS

Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use.

CONCLUSION

Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.

Combining Items From 3 Federally Mandated Assessments Using Rasch Measurement to Reliably Measure Cognition Across Postacute Care Settings

OBJECTIVE

To combine items from the Functional Independence Measure, Minimum Data Set (MDS) 2.0, and the Outcome and Assessment Information Set (OASIS)-B to reliably measure cognition across postacute care settings and facilitate future studies of patient cognitive recovery.

DESIGN

Rasch analysis of data from a prospective, observational cohort study.

SETTING

Postacute care inclusive of inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies.

PARTICIPANTS

Patients (N=147) receiving rehabilitation services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional Independence Measure, MDS 2.0, and the OASIS-B.

RESULTS

Six cognition items demonstrated good construct validity with no misfitting items, unidimensionality, good precision (person separation reliability, 0.95), and an item hierarchy that reflected a clinically meaningful continuum of cognitive challenge.

CONCLUSIONS

This is the first attempt to combine the cognition items from the 3 historically, federally mandated assessments to create a common metric for cognition. These 6 items could be adopted as standardized patient assessment data elements to improve cognitive assessment across postacute care settings.

Post-Intensive Care Unit Follow-up of Pulmonary Embolism

The post-intensive care unit follow-up of patients hospitalized with pulmonary embolism is crucial to the comprehensive care of these patients. This article discusses the recommended duration of intensive care unit stay after high-intermediate risk or high-risk pulmonary embolism, duration of anticoagulation after venous thromboembolism event, retrieval of inferior vena cava filters, post-hospitalization follow-up and assessment of right ventricular function, and assessment for chronic thromboembolic pulmonary hypertension, chronic thromboembolic disease, and post-pulmonary embolism syndrome.

Variation in Facility-Level Rates of All-Cause and Potentially Preventable 30-Day Hospital Readmissions Among Medicare Fee-for-Service Beneficiaries After Discharge From Postacute Inpatient Rehabilitation

IMPORTANCE

The Improving Medicare Post-Acute Care Transformation Act of 2014 mandated a quality measure of potentially preventable 30-day hospital readmission for inpatient rehabilitation facilities (IRFs). Examining IRF performance nationally may help inform health care quality initiatives for Medicare beneficiaries.

OBJECTIVE

To examine variation in Centers for Medicare & Medicaid Services Quality Reporting Program measures for US facility-level risk-adjusted all-cause and potentially preventable hospital readmission rates after inpatient rehabilitation.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of Medicare claims data included 454 378 Medicare beneficiaries discharged from 1162 IRFs between June 1, 2013, and July 1, 2015. Data were analyzed March 23, 2018, through June 24, 2019.

MAIN OUTCOMES AND MEASURES

All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities and the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation. Specifications from the Centers for Medicare & Medicaid Services were followed to identify the cohort, define outcomes, and calculate risk-standardized facility-level rates.

RESULTS

Among a cohort of 454 378 patients, the mean (SD) age was 76.2 (10.6) years and 263 546 (58.0%) were women. The all-cause readmission rate was 12.3% (95% CI, 12.2%-12.4%), and the potentially preventable readmission rate was 5.3% (95% CI, 5.3%-5.4%). Across 1162 included IRFs, risk-standardized all-cause readmission rates ranged from 10.1% (95% CI, 8.9%-11.6%) to 15.9% (95% CI, 13.6-18.6%) and potentially preventable readmission rates ranged from 4.3% (95% CI, 3.7%-5.4%) to 7.3% (95% CI, 5.7%-8.3%). Using the All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities, 16 IRFs (1.4%) had 95% CIs above the national mean rate, 1137 IRFs (97.9%) had 95% CIs containing the national mean rate, and 9 IRFs (0.8%) had 95% CIs below the national mean rate. Using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation, 8 IRFs (0.7%) had 95% CIs above the national mean rate, 1153 IRFs (99.2%) had 95% CIs containing the national mean rate, and 1 IRF (0.1%) had a 95% CI below the national mean rate.

CONCLUSIONS AND RELEVANCE

This cohort study found that readmission rates were lower when using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation and further reduced discrimination between facilities compared with the recently discontinued All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities. This finding may indicate there is a lack of room for improvement in readmission rates. Given the rationale of the Centers for Medicare & Medicaid Services for removing measures that fail to discriminate quality performance, this suggests that the current readmission measure should not be implemented as part of the Inpatient Rehabilitation Quality Reporting Program.

Partnering in postacute darkness? CMS has data that will help

Health systems will improve postacute outcomes when CMS begins sharing its performance data on nursing facility chains.

Key mechanisms by which post-ICU activities can improve in-ICU care: results of the international THRIVE collaboratives

Objective

To identify the key mechanisms that clinicians perceive improve care in the intensive care unit (ICU), as a result of their involvement in post-ICU programs.

Methods

Qualitative inquiry via focus groups and interviews with members of the Society of Critical Care Medicine’s THRIVE collaborative sites (follow-up clinics and peer support). Framework analysis was used to synthesize and interpret the data.

Results

Five key mechanisms were identified as drivers of improvement back into the ICU: (1) identifying otherwise unseen targets for ICU quality improvement or education programs—new ideas for quality improvement were generated and greater attention paid to detail in clinical care. (2) Creating a new role for survivors in the ICU—former patients and family members adopted an advocacy or peer volunteer role. (3) Inviting critical care providers to the post-ICU program to educate, sensitize, and motivate them—clinician peers and trainees were invited to attend as a helpful learning strategy to gain insights into post-ICU care requirements. (4) Changing clinician’s own understanding of patient experience—there appeared to be a direct individual benefit from working in post-ICU programs. (5) Improving morale and meaningfulness of ICU work—this was achieved by closing the feedback loop to ICU clinicians regarding patient and family outcomes.

Conclusions

The follow-up of patients and families in post-ICU care settings is perceived to improve care within the ICU via five key mechanisms. Further research is required in this novel area.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05647-5) contains supplementary material, which is available to authorized users.

Variant Post-acute Care Needs Measuring To Be Managed

Areas of the country with high concentrations of long-term acute care hospitals or inpatient rehabilitation facilities often have much higher utilization rates, even if a skilled nursing facility or home health provider could provide care comparable in quality and at a much lower price.

Do hospital-owned skilled nursing facilities provide better post-acute care quality?

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.

Doing better to do good: the impact of strategic adaptation on nursing home performance

OBJECTIVE

To test the hypothesis that a greater commitment to strategic adaptation, as exhibited by more extensive implementation of a subacute/rehabilitation care strategy in nursing homes, will be associated with superior performance.

DATA SOURCES

Online Survey, Certification, and Reporting (OSCAR) data from 1997 to 2004, and the area resource file (ARF).

STUDY DESIGN

The extent of strategic adaptation was measured by an aggregate weighted implementation score. Nursing home performance was measured by occupancy rate and two measures of payer mix. We conducted multivariate regression analyses using a cross-sectional time series generalized estimating equation (GEE) model to examine the effect of nursing home strategic implementation on each of the three performance measures, controlling for market and organizational characteristics that could influence nursing home performance. DATA COLLECTION/ABSTRACTION METHODS: OSCAR data was merged with relevant ARF data.

PRINCIPAL FINDINGS

The results of our analysis provide strong support for the hypothesis.

CONCLUSIONS

From a theoretical perspective, our findings confirm that organizations that adjust strategies and structures to better fit environmental demands achieve superior performance. From a managerial perspective, these results support the importance of proactive strategic leadership in the nursing home industry.

Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: I. Activity outcomes

OBJECTIVE

To examine score agreement, precision, validity, efficiency, and responsiveness of a computerized adaptive testing (CAT) version of the Activity Measure for Post-Acute Care (AM-PAC-CAT) in a prospective, 3-month follow-up sample of inpatient rehabilitation patients recently discharged home.

DESIGN

Longitudinal, prospective 1-group cohort study of patients followed approximately 2 weeks after hospital discharge and then 3 months after the initial home visit.

SETTING

Follow-up visits conducted in patients' home setting.

PARTICIPANTS

Ninety-four adults who were recently discharged from inpatient rehabilitation, with diagnoses of neurologic, orthopedic, and medically complex conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Summary scores from AM-PAC-CAT, including 3 activity domains of movement and physical, personal care and instrumental, and applied cognition were compared with scores from a traditional fixed-length version of the AM-PAC with 66 items (AM-PAC-66).

RESULTS

AM-PAC-CAT scores were in good agreement (intraclass correlation coefficient model 3,1 range, .77-.86) with scores from the AM-PAC-66. On average, the CAT programs required 43% of the time and 33% of the items compared with the AM-PAC-66. Both formats discriminated across functional severity groups. The standardized response mean (SRM) was greater for the movement and physical fixed form than the CAT; the effect size and SRM of the 2 other AM-PAC domains showed similar sensitivity between CAT and fixed formats. Using patients' own report as an anchor-based measure of change, the CAT and fixed length formats were comparable in responsiveness to patient-reported change over a 3-month interval.

CONCLUSIONS

Accurate estimates for functional activity group-level changes can be obtained from CAT administrations, with a considerable reduction in administration time.

An evaluation of the timing between key insulin administration-related processes: the reasons why these processes happen when they do, and how to improve their timing

We investigated the incidence of timing problems with insulin-related processes in a subacute inpatient unit in Melbourne and found that nursing staff often conduct blood glucose level (BGL) testing longer than 30 minutes before insulin administration (between 22% and 41%). Nurses are better at administering rapid-acting insulin doses within the recommended time before food intake (94%) than conventional insulin analogue doses (43%). BGL testing is carried out too early due to established ward practices and busy mornings, as well as poor guidance from an outdated policy. The timing of conventional insulin analogue administration is by nature more complex than that of rapidacting analogues. Current timing places inpatients at risk of harm from hypoglycaemia. The high level of care demand in our subacute unit contributed to timing problems, and this is likely to be a problem in other units. Process redesign, policy revision and staff education could be used to reduce the risk of hypoglycaemia in this subacute inpatient unit.

Measuring healthcare outcomes to improve quality of care across post--acute care provider settings

Post-acute care (PAC) occurs in a variety of settings-skilled nursing facilities (nursing homes), rehabilitation facilities, and home health agencies. To evaluate the impact of care processes on clinical outcomes and implement changes designed to improve outcomes, one must begin by measuring outcomes in a valid, reliable manner that allows for comparisons to reference or benchmarking data. Currently, several data sets exist in PAC settings for the purpose of outcome measurement. However, there is a need for comparable information across settings to ensure the quality and continuity of care. This article reviews various existing data sets used in PAC settings, examines ongoing projects to create a single set of measures, and suggests some directions for future research.

Score comparability of short forms and computerized adaptive testing: Simulation study with the activity measure for post-acute care

OBJECTIVE

To compare simulated short-form and computerized adaptive testing (CAT) scores to scores obtained from complete item sets for each of the 3 domains of the Activity Measure for Post-Acute Care (AM-PAC).

DESIGN

Prospective study.

SETTING

Six postacute health care networks in the greater Boston metropolitan area, including inpatient acute rehabilitation, transitional care units, home care, and outpatient services.

PARTICIPANTS

A convenience sample of 485 adult volunteers who were receiving skilled rehabilitation services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Inpatient and community-based short forms and CAT applications were developed for each of 3 activity domains (physical & mobility, personal care & instrumental, applied cognition) using item pools constructed from new items and items from existing postacute care instruments.

RESULTS

Simulated CAT scores correlated highly with score estimates from the total item pool in each domain (4- and 6-item CAT r range,.90-.95; 10-item CAT r range,.96-.98). Scores on the 10-item short forms constructed for inpatient and community settings also provided good estimates of the AM-PAC item pool scores for the physical & movement and personal care & instrumental domains, but were less consistent in the applied cognition domain. Confidence intervals around individual scores were greater in the short forms than for the CATs.

CONCLUSIONS

Accurate scoring estimates for AM-PAC domains can be obtained with either the setting-specific short forms or the CATs. The strong relationship between CAT and item pool scores can be attributed to the CAT's ability to select specific items to match individual responses. The CAT may have additional advantages over short forms in practicality, efficiency, and the potential for providing more precise scoring estimates for individuals.

Short-form activity measure for post-acute care

OBJECTIVE

To develop a comprehensive set of short forms using item response theory (IRT) and item pooling procedures for the purpose of monitoring postacute care functional recovery.

DESIGN

Prospective study.

SETTING

Six postacute health care networks in the greater Boston area, including inpatient acute rehabilitation, transitional care units, home care, and outpatient services.

PARTICIPANTS

A convenience sample of 485 adult volunteers who were currently receiving skilled rehabilitation services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We developed a set of 6 short forms across 3 activity domains from new items and items from existing postacute care instruments.

RESULTS

Inpatient- and community-based short forms were developed for each of 3 activity domains: physical & movement, applied cognition, and personal care & instrumental. Items were selected for inclusion on the short forms to maximize content coverage and information value of items across the range of content and to minimize ceiling and floor effects. We were able to match the distribution of sample scores with very good item precision for 1 of the constructs (physical & movement); the other 2 domains (personal care & instrumental, applied cognition) were more challenging because of the variability in patient recovery and ceiling effects.

CONCLUSIONS

ITR methods and item pooling procedures were valuable in developing paired sets of short-form instruments for inpatient and community rehabilitation that provided estimates of functioning along a common metric for use across postacute care settings.

Admission and discharge guidelines for the pediatric patient requiring intermediate care

During the past three decades, the specialty of pediatric critical care medicine has grown rapidly, leading to a number of pediatric intensive care units being opened across the country. Many patients who are admitted to the hospital require a higher level of care than the routine inpatient general pediatric care, yet not to the degree of intensity as pediatric critical care; therefore, an intermediate care level has been developed in institutions providing multiple disciplinary subspecialty pediatric care. These patients may require frequent monitoring of vital signs and nursing interventions but usually do not require invasive monitoring. The admission of the pediatric intermediate care patient is guided by physiologic parameters depending on the respective organ system involved relative to the institution's resources and capacity in caring for a patient in a general care environment. This report provides admission and discharge guidelines for intermediate pediatric care. Intermediate care promotes greater flexibility in patient triage and provides a cost-effective alternative to admission to a pediatric intensive care unit. This level of care may enhance the efficiency of care and improve the healthcare affordability for patients receiving intermediate care.

Deep Vein Thrombosis in Elderly Patients Hospitalized in Subacute Care Facilities

BACKGROUND

The efficacy of venous thromboembolism prophylaxis has not been established, to our knowledge, in elderly patients hospitalized in subacute care facilities.

OBJECTIVES

To describe risk factors and physician practices in the prevention of venous thromboembolism and to estimate the prevalence of deep vein thrombosis.

METHODS

A multicenter cross-sectional study was conducted in the subacute care departments of 36 French hospitals. The study population included 852 inpatients older than 64 years. Systematic ultrasound examination was performed by angiologists.

RESULTS

Of the 852 inpatients, 178 (20.9%; 95% confidence interval [CI], 18.2%-23.8%) had 3 or more risk factors other than age, while 144 patients (16.9%; 95% CI, 14.4%-19.6%) had none. The rate of prophylactic anticoagulant treatment was 56.1%, ranging from 20.0% to 86.9%, depending on the department. In multivariate analysis, prophylaxis use was associated with acute immobilization (odds ratio [OR], 4.17; 95% CI, 2.48-7.01), chronic immobilization (OR, 3.19; 95% CI, 2.22-4.60), major surgical procedure (OR, 6.81; 95% CI, 4.26-10.88), and congestive heart failure (OR, 1.65; 95% CI, 1.02-2.67). Prophylaxis use was low in patients who had cancer (OR, 0.49; 95% CI, 0.29-0.84) or myocardial infarction (OR, 0.39; 95% CI, 0.14-1.00). It was not significantly associated with paralytic stroke or history of venous thromboembolism. Deep vein thrombosis was detected in 135 patients (15.8%; 95% CI, 13.4%-18.5%): 50 (5.9%; 95% CI, 4.4%-7.7%) had proximal vein thrombosis and 85 (10.0%; 95% CI, 8.0%-12.2%) had calf vein thrombosis.

CONCLUSIONS

The prevalence of deep venous thrombosis is high in these patients, despite wide use of prophylaxis. Further prospective studies assessing the clinical benefit of extended duration prophylaxis are needed in elderly patients hospitalized in subacute care settings.

Development and evaluation of intermediate care

Intermediate care is being developed as part of the national strategy for older people in England and Wales to prevent their admission to hospital and facilitate early discharge. Evaluation of intermediate care is implicit within current policy directives. This project evaluated the client information across a number of intermediate care schemes within one National Health Service community trust for 3 months and disseminated the results to staff as part of a reflective workshop which also provided an opportunity for additional data collection. Rates of referral and acceptance on intermediate care were high for all the schemes except one, indicating reliable referral and inclusion criteria. Older people were the recipients of intermediate care with nearly half of them having experienced falls. A number of developments were identified by staff covering both current services and long-term strategy for intermediate care and indicating the importance of involving providers in the evaluation and development of services. Fall prevention initiatives and involvement of users and carers in the evaluation and development of intermediate care were also identified.

Risk adjusting outcome measures for post-acute care

This article examines whether different risk adjusters are needed for home care outcome measures for post-acute care clients. Multiple risk adjusters that met clinical and policy criteria were tested using multiple logistic regression on a sample of 4403 post-acute home care clients from Michigan. Two of the 6 outcome measures had substantially different risk adjusters for the post-acute care population versus the general population. Care should be taken to select outcome measures and risk adjusters for special home care populations.

Comparison of functional status tools used in post-acute care

There is a growing health policy mandate for comprehensive monitoring of functional outcomes across post-acute care (PAC) settings. This article presents an empirical comparison of four functional outcome instruments used in PAC with respect to their content, breadth of coverage, and measurement precision. Results illustrate limitations in the range of content, breadth of coverage, and measurement precision in each outcome instrument. None appears well-equipped to meet the challenge of monitoring quality and functional outcomes across settings where PAC is provided. Limitations in existing assessment methodology has stimulated the development of more comprehensive outcome assessment systems specifically for monitoring the quality of services provided to PAC patients.

Redesigning geriatric healthcare: how cross-functional teams and process improvement provide a competitive advantage

This study examines the consequences of adding a geriatric subacute unit to the traditional health care mix offered by a nonprofit hospital. Historically, geriatric health care offerings have been limited to either acute care units or long-term care facilities. The study's findings demonstrate that the addition of a subacute unit that is operated by an interdisciplinary team is a competitively rational move for two reasons. First, it provides a continuum of care that integrates services and departments, thereby reducing costs. Second, it provides a supportive environment for patients and their families. As a consequence patients have a higher probability of returning home than patients who are assigned to more traditional modes of care.

Effects of using consumer and expert ratings of an activities of daily living scale on predicting functional outcomes of postacute care

To test the effects of using preference weights for activities of daily living (ADL) outcome measures derived from different sources, data from a large study of the outcomes of postacute care (PAC study) were analyzed using two different weightings for the ADL measures. Both were developed using the same magnitude estimation technique; one from a panel of long-term care experts (the expert rating system); the other from a group of elderly Medicare beneficiaries (the consumer rating system). Neither group was directly involved in the PAC study. Although ADL scores generated by both rating systems were highly correlated prior to hospitalization and at hospital discharge, the consumer and expert rating systems generated significantly different functional outcomes measured by the change of ADL scores with a few exceptions. Compared to the consumer rating system, the expert rating system generated a greater change in functional outcomes at each of three follow-up time points after hospital discharge. This study suggests that the choice of weights for ADL items is important.

Colonization of skilled-care facility residents with antimicrobial-resistant pathogens

OBJECTIVES

To determine the frequency of and risk factors for colonization of skilled-care unit residents by several antimicrobial-resistant bacterial species, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), or extended-spectrum-beta-lactamase-producing (ESBL-producing) (ceftazidime resistant) Klebsiella pneumoniae or Escherichia coli.

DESIGN

Point-prevalence survey and medical record review.

SETTING

The skilled-care units in one healthcare facility.

PARTICIPANTS

120 skilled-care unit residents.

MEASUREMENTS

Colonization by each of the four antimicrobial-resistant pathogens during a point-prevalence survey, using rectal, nasal, gastrostomy-tube site, wound, and axillary cultures, June 1-3, 1998; 117 (98%) had at least one swab collected and 114 (95%) had a rectal swab collected. Demographic and clinical characteristics were evaluated as risk factors for colonization. All isolates were strain typed by pulsed-field gel electrophoresis of total genomic deoxyribonucleic acid.

RESULTS

Of 117 participants, 50 (43%) were culture positive for > or =1 antimicrobial-resistant pathogen: MRSA (24%), ESBL-producing K. pneumoniae (18%) or E. coli (15%), and VRE (3.5%). Of 50 residents culture positive for any of these four antimicrobial-resistant species, 13 (26%) were colonized by more than one resistant species; only three (6%) were on contact-isolation precautions at the time of the prevalence survey. Risk factors for colonization varied by pathogen: total dependence on healthcare workers (HCWs) for activities of daily living (ADLs) and antimicrobial receipt for MRSA, total dependence on HCWs for ADLs for ESBL-producing K. pneumoniae, and antimicrobial receipt for VRE. No significant risk factors were identified for colonization by ESBL-producing E. coli. Among colonized patients, there was a limited number of strain types for MRSA (24 patients, 4 strain types) and ESBL-producing K. pneumoniae (21 patients, 3 strain types), and a high proportion of unique strain types for VRE (4 patients, 4 strain types) and FSBL-producing E. coli (17 patients, 10 strain types).

CONCLUSION

A large unrecognized reservoir of skilled-care-unit residents was colonized by antimicrobial-resistant pathogens, and co-colonization by more than one target species was common. To prevent transmission of antimicrobial-resistant pathogens in long-term care facilities in which residents have high rates of colonization, infection-control strategies may need to be modified. Potential modifications include enhanced infection-control strategies, such as universal gloving for all or high-risk residents, or screening of high-risk residents, such as those with total dependence on HCWs for ADLs or recent antimicrobial receipt, and initiation of contact-isolation precautions for colonized residents.

The future of subacute care

Subacute care is a program of care for individuals with recent or current illness or injury. Currently, the services received by patients in subacute care vary considerably among sites, partly because these sites may specialize in certain treatments and partly because providers often define subacute care according to their own areas of expertise. Certain approaches to patient care, however, are universal regardless of diagnosis, and care that is given should be based on essential geriatric principles. In setting a standard for care in the subacute care setting, certain parameters must be clarified, including (1) defining subacute care, including what it is and what it is not; (2) selecting the right patient to receive subacute care; (3) making sure that care is centered on patients rather than sites or providers; and (4) ensuring that care is reimbursed adequately and appropriately. These issues are addressed, and guidelines on how to accomplish the goal of standardizing subacute care are provided.

The advanced practice nurse & home care

Home care providers are experiencing higher acuity of patients in a climate of restricted reimbursement for care. This results in an increased need to develop more efficient systems and to employ staff with expert skills. One way to fill this need is to use nurses with advanced preparation at a graduate-degree level. However, Medicare regulations must change before patients and providers can take advantage of these professionals in the home care setting.

Intermediate care. Bed spread

A health authority which has been using beds in independent nursing homes as alternatives to hospital for older people since 1997 has found this a satisfactory model of care. Initially the beds were used for terminal care only. Last winter the scheme was extended to provide intermediate care. The scheme uses a maximum of five beds for terminal care in one nursing home at any one time. The scheme is thought to have saved some 2,000 bed days each year. The length of stay has been reduced and now stands at 33 days.

Best place of care for older people after acute and during subacute illness: a systematic review

OBJECTIVES

To assess the evaluative research literature on the costs, quality and effectiveness of different locations of care for older patients.

METHODS

A systematic review of evaluative research from 1988 using CRD4 guidelines. Twenty-five databases were searched, using processes developed specially for this review. Library OPACS, the Internet and research registers were also searched for relevant material. The final stage of the review was confined to randomised and pseudorandomised trials. Studies were selected for review by pairs of researchers working independently who then met to reach a decision. Analysis was predominantly descriptive; simple pooled odds ratios were used to explore some outcomes.

RESULTS

Eighty-four papers from 45 trials were included. Firm conclusions were difficult to draw, except in relation to some outcomes for stroke units, early discharge schemes and geriatric assessment units. Few trials in this area have adequately addressed issues of patients' quality of life and costs to health services, social care providers, patients and their families.

CONCLUSIONS

Despite considerable recent development of different forms of care for older patients, evidence about effectiveness and costs is weak. However, evidence is also weak for longer-standing care models. A substantial service evaluation agenda emerges from this review. This study also raises questions about the usefulness of systematic review techniques in the area of service delivery and organisation.

Evaluation of fiscal and treatment outcomes in major joint replacement

The market demand for major arthroplasty procedures is increasing. This descriptive comparative study was conducted to examine clinical and fiscal outcomes in total joint arthroplasty patients discharged either to home or to a subacute unit. The post-acute care setting was self-selected by patients after information was provided on both options. The Self-Administered Joint Rating Questionnaire served as the primary data collection tool. Age, health status, and living alone were significant factors in post-acute care site selection. Although there were no significant differences in clinical outcomes between the two groups, overall costs were substantially different. Opportunities to maintain outcome status, while reducing total costs, in the subacute group are discussed.

Commentary: methodological issues for quality management in long-term care

The interest in quality management in long-term care has been rapidly escalating. This movement to assess and improve quality parallels the effort carried out by hospital management in the past 10 years. The methodological concerns of the 2 areas are similar. This essay identifies 10 issues to which quality management leaders should pay attention as they begin to expand the capability of addressing quality in long-term care: client-centered performance versus whole-organization performance; standardization of methods and instruments; reliability; and validity, multimethod thinking, the meaning of data, comparability of data across organizations, cost barriers, feedback mechanisms, management use of quality data, and public control of data.