A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients

OBJECTIVE: to prove the effectiveness of geriatric evaluation and management for elderly, hospitalized patients, combined with post-discharge home intervention by an interdisciplinary team. DESIGN: randomized controlled trial with outcome and costs assessed for 12 months after the date of admission. SETTING: university-affiliated geriatric hospital and the homes of elderly patients. SUBJECTS: 545 patients with acute illnesses admitted from home to the geriatric hospital. INTERVENTIONS: patients were randomly assigned to receive either comprehensive geriatric assessment and post-discharge home intervention (intervention), comprehensive geriatric assessment alone (assessment) or usual care. MAIN OUTCOME MEASURES: survival, functional status, rehospitalization, nursing home placement and direct costs over 12 months. RESULTS: the intervention group showed a significant reduction in length of hospital stay (33.49 days vs 40.7 days in the assessment group and 42.7 days in the control group; P < 0.05) and rate of immediate nursing home placement (4.4% vs 7.3% and 8.1%; P < 0.05). There was no difference in survival, acute care hospital readmissions or new admissions to nursing homes but the intervention group had significantly shorter hospital readmissions (22.2 days vs 34.2 days and 35.7 days; P < 0.05) and nursing home placements (114.7 days vs 161.6 days and 170.0 days; P < 0.05). Direct costs were lower in the intervention group [about DM 7000 (US $4000) per person per year]. Functional capacities were significantly better in the intervention group. CONCLUSIONS: comprehensive geriatric assessment in combination with post-discharge home intervention does not improve survival, but does improve functional status and can reduce the length of the initial hospital stay and of subsequent readmissions. It can reduce the rate of immediate nursing home admissions and delay permanent nursing home placement. It may also substantially reduce direct costs of hospitalized patients.     

Outcomes in a nursing home transition case-management program targeting new admissions

PURPOSE: The Providing Assistance to Caregivers in Transition (PACT) program offers nursing home discharge planning and case management for individuals in the transitional period following a return to the community. The PACT program targeted individuals newly admitted to nursing homes and worked with a family caregiver to develop and implement a nursing home discharge plan. DESIGN AND METHOD: Reported are the results of a randomized control design evaluating the program's effectiveness. Those individuals randomly assigned to the intervention group (n = 33) received PACT case management in addition to their usual medical and nursing home care. The individuals in the control group (n = 29) continued their usual care. RESULT: There were no statistical differences in the discharge rate (84% treatment vs 76% controls) or in the median length of stay (42 days vs 55 days) between the two groups of individuals. IMPLICATIONS: Replications or extensions of a PACT-type intervention might consider a broader mix of nursing homes, working directly with the nursing home's admission Minimum Data Set coordinator in patient selection, or working with Medicare or Medicaid HMO plans.     

Evaluation of a hospital diabetes specialist nursing service: a randomized controlled trial.

AIMS: To evaluate the effectiveness and cost implications of a hospital diabetes specialist nursing service. METHODS: We conducted a prospective, open, randomized, controlled trial of standard in-patient care for adults with diabetes, with and without the intervention of a diabetes specialist nursing (DSN) service. The setting was a single UK university hospital. SUBJECTS: were unselected patients referred to the hospital DSN service. Primary outcome measures were length of hospital stay and patterns of readmission (frequency and time to first readmission). Secondary outcome measures were subjects' diabetes-related quality of life, diabetes knowledge score, satisfaction with treatment, and GP and community care contacts following discharge. Costs were estimated from the hospital and published sources. RESULTS: Median length of stay was lower in the intervention group (11.0 vs. 8.0 days, P < 0.01). Readmission rates were the same in the two groups (25%), and mean time to readmission was similar in the two groups, although slightly less in the control group (278 vs. 283 days, P = 0.80). The cost per patient for nursing input was 38.94 pounds sterling. However, when the reduced length of stay was accounted for, the intervention produced a mean cost per admission of 436 ponds sterling lower than that of the control group (P = 0.19). Patients in the intervention group were more knowledgeable regarding their diabetes and more satisfied with their care. CONCLUSIONS: Diabetes specialist nurses are potentially cost saving by reducing hospital length of stay (LOS). There was no evidence of an adverse effect of reduced LOS on re-admissions, use of community resources, or patient perception of quality of care.     

Activities of daily living function and disability in older adults in a randomized trial of the health enhancement program

BACKGROUND: Disability in basic activities of daily living (ADLs) implies a loss of independence and increases the risk for hospitalization, nursing home admission, and death. Little is known about ways by which ADL disability can be prevented or reversed. The authors evaluated the efficacy of the Health Enhancement Program in preventing and reducing ADL disability in community-dwelling older adults. METHODS: The authors analyzed data from a 12-month, randomized, single-blinded, controlled trial of a disability prevention, chronic disease self-management program involving 201 adults aged 70 years and older that was conducted from February 1995 to June 1996 at a senior center in western Washington state. Activities of daily living disability incidence, improvement, and worsening were assessed using intention-to-treat methods. RESULTS: The cumulative incidence of ADL disability among those who were not ADL disabled at baseline (n = 56 in the intervention group, n = 57 in the control group) was modestly lower in the intervention group than in the control group at 12 months (14.3% vs 21.3%, p = .466). Cumulative improvement in ADL function among those who reported any ADL disability at baseline (n = 41 in the intervention group, n = 43 in the control group) was greater in the intervention group at 12 months (80.5% vs 46.5%, p = .026). The likelihood for ADL improvement was greater in the intervention group compared with controls at 12 months (adjusted hazard ratio, 1.84; 95% confidence interval, 1.05 to 3.22; p = .020). Cumulative worsening of ADL function was slightly lower in the intervention group at 12 months (18.6% vs 26.5%, p = .237). Intervention participants tended to be at lower risk for ADL worsening (adjusted hazard ratio, 0.71; 95% confidence interval, 0.38 to 1.30; p = .266) compared with control participants. CONCLUSION: The Health Enhancement Program intervention led to improved ADL functioning in those who were disabled initially and thereby offers a promising strategy for limiting or reversing functional decline in disabled elderly persons.     

Effects of functional status changes before and during hospitalization on nursing home admission of older adults

BACKGROUND: Functional status changes before and during hospitalization may have important effects on outcomes in older adults, but these effects are not well understood. We determined the influence of functional status changes on the risk of nursing home (NH) admission after hospitalization. METHODS: Subjects were 551 general medical patients > or = 70 years old (66% female; mean age = 80 years) admitted from home to a large Midwestern teaching hospital. Functional status change measures were based on patients' need for assistance in five personal activities of daily living (ADL) 2 weeks prior to hospital admission, the day of admission, and the day of discharge. Sociodemographic and clinical characteristics were included in multivariate models predicting NH admission. RESULTS: Functional status change categories were: stable in function before and during hospitalization (45% of study patients); decline in function before and improvement during hospitalization (26%); stable before and decline during hospitalization (15%); decline before and no improvement during hospitalization (13%). In multivariate analyses, patients in the decline-no improvement group (odds ratio [OR] = 3.19; 95% confidence interval [CI] = 1.46-6.96) and patients in the stable-decline group (OR = 2.77; 95% CI = 1.29-5.96) were at greater risk for NH admission than patients in the stable-stable group. In a multivariate model that controlled for ADL function at hospital discharge, functional status change was no longer statistically significantly associated with NH admission. CONCLUSIONS: Discharge function is a key risk factor for NH admission among hospitalized older adults. Because functional status changes before and during hospitalization are key determinants of discharge function, they provide important clues about the potential to modify that risk. Functional recovery during a hospital stay after prior functional decline, and prevention of in-hospital functional decline after prior functional stability, are important targets for clinical intervention to minimize the risk of NH admission.     

Effects of a care protocol on care outcomes in older nursing home patients with chronic obstructive pulmonary disease

OBJECTIVES: To evaluate the effects of a care protocol used by community nurses to support nursing home staff in the care of patients with chronic obstructive pulmonary disease (COPD). DESIGN: Matched, randomized case-control trial. SETTING: Forty-five nursing homes of the New Territories South (NTS) cluster of Hong Kong. PARTICIPANTS: Eighty-nine older people (> or =65, present resident of a nursing home in the NTS region, main diagnosis of COPD, at least one hospital admission in previous 6 months) discharged to the nursing homes from the geriatric units of two hospitals. INTERVENTION: Using a care protocol, community nurses followed up older patients in the experimental group for 6 months after their discharge from the hospitals to the nursing homes. MEASUREMENTS: Data on functional, respiratory, and psychological parameters were collected at entry to study and 6 months later with standard measures. Data on hospital service utilization, nursing home staff, and patient satisfaction were also collected at 6 months. RESULTS: Experimental group participants had significant (P =.008) improvements in psychological well-being. Nursing home staff and experimental group patients were highly satisfied with the use of the protocol. There was no significant difference between the two groups in functional and respiratory outcomes or hospital service utilization. CONCLUSION: Psychological well-being as an important factor in rehabilitation in chronic illness has been much neglected in the literature. Supporting nursing home staff in the care of COPD patients through community nursing visits can enhance older residents' psychological well-being. Psychological aspects of care should be emphasized and incorporated into the delivery of regular nursing home care.     

The Functional Autonomy Measurement System (SMAF): a measure of functional change with rehabilitation

The Functional Autonomy Measurement System (SMAF) is an instrument developed for the measurement of needs of the elderly and the handicapped. As this study shows, it can be used to demonstrate progress during rehabilitation. Of the 94 patients admitted and discharged from a 22 bed acute/rehabilitation ward for the elderly, 78 were discharged home or to their original accommodation, 7 died in hospital and 9 were transferred to a continuing care ward or a nursing home. The mean total score (admission vs. discharge: 18.06 vs. 9.18, P < 0.0001) as well as the score for subsections of Activities of Daily Living (ADL) (admission vs. discharge: 15.69 vs. 8.15, P < 0.0001), Communication (admission vs. discharge: 1.01 vs. 0.5, P < 0.0001) and Mental Function (admission vs. discharge: 1.29 vs. 0.64, P < 0.0001) showed significant improvement in the 78 patients who were discharged back to their original accommodation. Patients who died or required placement into a continuing care bed or nursing home showed no change in mean scores with treatment. The inter-observer agreement between two nurses and a doctor showed that the minor modifications to SMAF did not significantly affect the instrument.     

The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients

OBJECTIVES: To determine the association between indwelling urinary catheterization without a specific medical indication and adverse outcomes. DESIGN: Prospective cohort. SETTING: General medical inpatient services at a teaching hospital. PARTICIPANTS: Five hundred thirty-five patients aged 70 and older admitted without a specific medical indication for urinary catheterization. INTERVENTION: Indwelling urinary catheterization within 48 hours of admission. MEASUREMENTS: Death, length of hospital stay, decline in ability to perform activities of daily living (ADLs), and new admission to a nursing home. RESULTS: Indwelling urinary catheters were placed in 76 of the 535 (14%) patients without a specific medical indication. Catheterized patients were more likely to die in the hospital (6.6% vs 1.5% of those not catheterized, P=.006) and within 90 days of hospital discharge (25% vs 10.5%, P<.001); the greater risk of death with catheterization persisted in a propensity-matched analysis (hazard ratio (HR)=2.42, 95% confidence interval (CI)=1.04-5.65). Catheterized patients also had longer lengths of hospital stay (median, 6 days vs 4 days; P=.001); this association persisted in a propensity-matched analysis (HR=1.46, 95% CI=1.03-2.08). Catheterization was not associated (P>.05) with decline in ADL function or with admission to a nursing home. CONCLUSION: In this cohort of older patients, urinary catheterization without a specific medical indication was associated with greater risk of death and longer hospital stay.     

Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial

OBJECTIVES: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure. DESIGN: Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge. SETTING: Six Philadelphia academic and community hospitals. PARTICIPANTS: Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure. INTERVENTION: A 3-month APN-directed discharge planning and home follow-up protocol. MEASUREMENTS: Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care. RESULTS: Mean age of patients (control n=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001). CONCLUSION: A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.     

Daily oral care and cough reflex sensitivity in elderly nursing home patients

BACKGROUND: Intensive oral care can reduce the incidence of pneumonia in elderly nursing home patients, but the mechanism is unknown. OBJECTIVE: To explore the effects of intensive oral care on impaired cough reflex sensitivity, which is a known risk factor of aspiration pneumonia. METHODS: Cough reflex sensitivity to citric acid was measured in elderly nursing home patients, who were randomly assigned to the intervention group (n = 30) and the control group (n = 29). The patients in the intervention group had their teeth and gingiva cleaned by caregivers after every meal for 1 month. The patients in the control group performed their own oral care during the same period. Serum substance P (SP) concentration, cognitive function, and activities of daily living (ADL) were also assessed. RESULTS: In the intervention group, cough reflex sensitivity at 30 days showed significantly higher sensitivity than baseline (p < 0.01). At 30 days, the cough reflex sensitivities in the intervention group were significantly higher than that of the control group (p < 0.05). Compared with the control group, the odds ratio of improvement of cough reflex sensitivity was 5.3 (95% confidence interval, 1.7 to 16.0; p < 0.005) for the intervention group. One month of intensive oral care did not have a significant effect on serum SP concentration, cognitive function, and ADL. CONCLUSION: Intensive oral care may reduce the incidence of pneumonia by improving cough reflex sensitivity in elderly nursing home patients.     

Urinary incontinence and its association with death, nursing home admission, and functional decline

OBJECTIVES: To determine whether urinary incontinence (UI) is an independent predictor of death, nursing home admission, decline in activities of daily living (ADLs), or decline in instrumental activities of daily living (IADLs). DESIGN: A population-based prospective cohort study from 1993 to 1995. SETTING: Community-dwelling within the United States. PARTICIPANTS: Six thousand five hundred six of the 7,447 subjects aged 70 and older in the Asset and Health Dynamics Among the Oldest Old study who had complete information on continence status and did not require a proxy interview at baseline. MEASUREMENTS: The predictor was UI, and the outcomes were death, nursing home admission, ADL decline, and IADL decline. Potential confounders considered were comorbid conditions, baseline function, sensory impairment, cognition, depressive symptoms, body mass index, smoking and alcohol, demographics, and socioeconomic status. RESULTS: The prevalence of UI was 14.8% (18.5% in women; 8.5% in men). At 2-year follow-up, subjects incontinent at baseline were more likely to have died (10.9% vs 8.7%; unadjusted odds ratio (OR)=1.29, 95% confidence interval (CI)=1.02-1.64), be admitted to a nursing home (4.4% vs 2.6%, OR=1.77; 95% CI=1.18-2.63), and to have declined in ADL function (13.6% vs 8.1%; OR=1.78, 95% CI=1.36-2.33) and IADL function (21.2% vs 13.8%; OR 1.69, 95% CI 1.39-2.05). However, after adjusting for confounders, UI was not an independent predictor of death (adjusted OR (AOR)= 0.90, 95% CI=0.67-1.21), nursing home admission (AOR=1.33, 95% CI=0.86-2.04), or ADL decline (AOR=1.24, 95% CI=0.92-1.68). Incontinence remained a predictor of IADL decline (AOR=1.31; 95% CI=1.05-1.63), although adjustment markedly reduced the strength of this association. CONCLUSION: Higher levels of baseline illness severity and functional impairment appear to mediate the relationship between UI and adverse outcomes. The results suggest that, although UI appears to be a marker of frailty in community-dwelling elderly, it is not a strong independent risk factor for death, nursing home admission, or functional decline.     

Organizational characteristics and restraint use for hospitalized nursing home residents

OBJECTIVES: To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents.
DESIGN: Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents.
SETTING: Eleven medical and surgical units in one 600-bed teaching hospital.
PARTICIPANTS: One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days.
MEASUREMENTS: Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient–registered nurse (RN) ratio, patient–total nursing staff ratio, and skill mix.
RESULTS: Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient–RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38–2.68, P < .001; weekend day and patient–total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37–2.66, P < .001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37–2.67, P < .001).
CONCLUSION: Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.     

Risk factors for early hospital readmission in a select population of geriatric rehabilitation patients: the significance of nutritional status.

OBJECTIVE: To test the strength of the evidence in favor of the hypothesis that protein-energy undernutrition is an independent risk factor for non-elective hospital readmission within 3 months of discharge in a population of elderly hospitalized patients. DESIGN: Retrospective analysis of data from prospective observational study. METHODS: All 110 elderly patients admitted to a geriatric recuperative care and rehabilitation unit during a 6-month period completed a comprehensive in-patient evaluation. Ninety-eight of these patients were subsequently discharged alive and followed prospectively for 3 months. All hospital readmissions during the observation period were identified by patient interview and, within the VA hospital system, computer tracking of admissions. Based on the discharge assessment, the strongest predictors of non-elective readmission were identified using univariate and multivariate statistical procedures. RESULTS: Twenty-eight of the 98 patients discharged alive and completing the 3-month follow-up (29%) had at least one non-elective readmission. The patients discharged home were non-electively readmitted more frequently than were the patients discharged to a nursing home (32% vs 11%, P = 0.05). Of the 109 discharge assessment variables analyzed, the best predictor of which patients would have at least one non-elective hospital readmission was the discharge serum albumin, followed by a diagnosis of dementia, discharge gamma globulin, the subscapular skinfold thickness, home ownership, and the discharge Katz Index of ADL score. Discharge serum albumin concentration, subscapular skinfold thickness, and discharge serum gamma globulin concentration were all negatively correlated with risk of non-elective readmission. The presence of functional debilitation or dementia was associated with a lower likelihood of non-elective readmission compared with the absence of these conditions. CONCLUSIONS: Protein-energy undernutrition appears to be a strong independent risk factor for non-elective hospital readmission especially among the highest risk patients, those who are functionally independent and cognitively intact.     

Role of pharmacist counseling in preventing adverse drug events after hospitalization

BACKGROUND: Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs. METHODS: We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs. RESULTS: Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization. CONCLUSIONS: Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.     

Effect of preventive home visits for ambulatory housebound elders in Japan: a pilot study

BACKGROUND AND AIMS: Programs of preventive home visits for ambulatory housebound elders have not yet become established in Japan. The aim of this randomized pilot study was to investigate effects of such visits by public health nurses in Japan. METHODS: A randomized controlled study with 18-month follow-up was conducted in a small Japanese agricultural town. Participants (n=119) were ambulatory housebound elders aged 65 and over, who were able to walk but who went outdoors less than three times a week at baseline survey. They were randomly assigned to intervention (n=59) or control group (n=60). Intervention group subjects received preventive home visits by public health nurses over 18 months (mean home visits=4.3). Control group subjects received usual primary and community care. Activities of daily living (ADLs), functional capacity, self-efficacy for daily activities, self-efficacy for health promotion, depression, and social support were collected via questionnaire at baseline and at the 18-month follow-up point. RESULTS: At follow-up, 81.4% of intervention group subjects were still living at home vs 73.3% of control group subjects (NS). Simple group comparisons following repeated measures (ANCOVA) showed that the intervention group had higher ADL scores than the control group at follow-up (p=0.044). CONCLUSIONS: These pilot results suggest that home visits by public health nurses may be effective in helping to reduce ADL decline among ambulatory housebound elders.     

The effect of a social work intervention to enhance advance care planning documentation in the nursing home

OBJECTIVES: To assess the effect of a multicomponent advance care planning intervention directed at nursing home social workers on identification and documentation of preferences for medical treatments and on patient outcomes. DESIGN: Controlled clinical trial. SETTING: New York City nursing home. PARTICIPANTS: One hundred thirty-nine newly admitted long-term care residents. INTERVENTION: Nursing home social workers were randomized to the intervention or control groups. The intervention consisted of baseline education in advance care planning that incorporated small-group workshops and role play/practice sessions for intervention social workers; structured advance care planning discussions with residents and their proxies at admission, after any change in clinical status, and at yearly intervals; formal structured review of residents' goals of care at preexisting regular team meetings; "flagging" of advance directives on nursing home charts; and feedback to individual healthcare providers of the congruence of care they provided and the preferences specified in the advance care planning process. Control social workers received an educational training session on New York State law regarding advance directives but no additional training or interventions. Subjects were enrolled from January 9, 2001 through May 25, 2003 and followed for 6 months after enrollment. MEASUREMENTS: Nursing home chart documentation of advance directives (healthcare proxies, living wills) and do-not-resuscitate orders; preferences for artificial nutrition and hydration, intravenous antibiotics, and hospitalization; and concordance of treatments received with documented preferences were compared for residents assigned to intervention and control social workers. RESULTS: Intervention residents were significantly more likely than residents in the control group to have their preferences regarding cardiopulmonary resuscitation (40% vs 20%, P=.005), artificial nutrition and hydration (47% vs 9%, P<.01), intravenous antibiotics (44% vs 9%, P<.01), and hospitalization (49% vs 16%, P<.01) documented in the nursing home chart. Control residents were significantly more likely than intervention residents to receive treatments discordant with their prior stated wishes. Two of 49 (5%) intervention residents received a treatment in conflict with their prior stated wishes (one hospitalization, one episode of intravenous antibiotics), compared with 17 of 96 (18%) control patients (P=.04). CONCLUSION: This generalizable intervention directed at nursing home social workers significantly improved the documentation and identification of patients' wishes regarding common life-sustaining treatments and resulted in a higher concordance between patients' prior stated wishes and treatments received.     

Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age

OBJECTIVES: To describe the changes in activities of daily living (ADL) function occurring before and after hospital admission in older people hospitalized with medical illness and to assess the effect of age on loss of ADL function. DESIGN: Prospective observational study. SETTING: The general medical service of two hospitals. PARTICIPANTS: Two thousand two hundred ninety-three patients aged 70 and older (mean age 80, 64% women, 24% nonwhite). MEASUREMENTS: At the time of hospital admission, patients or their surrogates were interviewed about their independence in five ADLs (bathing, dressing, eating, transferring, and toileting) 2 weeks before admission (baseline) and at admission. Subjects were interviewed about ADL function at discharge. Outcome measures included functional decline between baseline and discharge and functional changes between baseline and admission and between admission and discharge. RESULTS: Thirty-five percent of patients declined in ADL function between baseline and discharge. This included the 23% of patients who declined between baseline and admission and failed to recover to baseline function between admission and discharge and the 12% of patients who did not decline between baseline and admission but declined between hospital admission and discharge. Twenty percent of patients declined between baseline and admission but recovered to baseline function between admission and discharge. The frequency of ADL decline between baseline and discharge varied markedly with age (23%, 28%, 38%, 50%, and 63% in patients aged 70-74, 75-79, 80-84, 85-89, and > or =90, respectively, P <.001). After adjustment for potential confounders, age was not associated with ADL decline before hospitalization (odds ratio (OR) for patients aged > or =90 compared with patients aged 70-74 = 1.26, 95% confidence interval (CI) = 0.88-1.82). In contrast, age was associated with the failure to recover ADL function during hospitalization in patients who declined before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 2.09, 95% CI = 1.20-3.65) and with new losses of ADL function during hospitalization in patients who did not decline before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 3.43, 95% CI = 1.92-6.12). CONCLUSION: Many hospitalized older people are discharged with ADL function that is worse than their baseline function. The oldest patients are at particularly high risk of poor functional outcomes because they are less likely to recover ADL function lost before admission and more likely to develop new functional deficits during hospitalization     

The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients.

BACKGROUND: Malnutrition is common in hospitalized older people and may predict adverse outcomes. Previous studies of the relationship between nutritional status and hospital outcomes are limited by inadequate accounting for other potential predictors of adverse outcomes, the failure to consider functional outcomes, and the omission of clinical assessments of nutritional status. OBJECTIVE: To measure the relationship between a clinical assessment of nutritional status on hospital admission and subsequent mortality, functional dependence, and nursing home use. DESIGN: Prospective cohort study SETTING: A tertiary care hospital PATIENTS: A total of 369 patients at least 70 years old (mean age 80.3, 62% women) admitted to a general medical service MEASUREMENTS: Nutritional status was measured with the Subjective Global Assessment, a validated measure of nutritional status based on historical and physical exam findings. Patients were classified as severely malnourished (generally at least a 10% weight loss over the previous 6 months and marked physical signs of malnutrition), moderately malnourished (generally a 5 to 10% weight loss and moderate physical signs), or well nourished. Vital status, independence in activities of daily living, and nursing home use were determined through patient or surrogate interview at admission and 90 days and 1 year after discharge. Indices of comorbidity and illness severity were determined from chart review. RESULTS: 219 patients (59.3%) were well nourished, 90 (24.4%) were moderately malnourished, and 60 (16.3%) were severely malnourished. Severely malnourished patients were more likely than moderately malnourished or well nourished patients to die by 90 days (31.7%, 23.3%, and 12.3%, respectively, P < .001) and 1 year (55.0%, 35.6%, and 27.9%, P < .001) after discharge. In logistic regression models controlling for acute illness severity, comorbidity, and functional status on admission, severely malnourished patients were more likely than well nourished patients to die within 1 year of discharge (OR = 2.83, 95% CI, 1.47-5.45), to be dependent in activities of daily living 3 months after discharge (OR = 2.81, 1.06-7.46), and to spend time in a nursing home during the year after discharge (OR = 3.22, 1.05-9.87). CONCLUSION: Malnutrition was common in hospitalized patients with medical illness and was associated with greater mortality, delayed functional recovery, and higher rates of nursing home use. These adverse outcomes were not explained by greater acute illness severity, comorbidity, or functional dependence in malnourished patients on hospital admission.     

Organizational relationships between nursing homes and hospitals and quality of care during hospital-nursing home patient transfers

OBJECTIVES: To identify organizational factors and hospital and nursing home organizational relationships associated with more-effective processes of care during hospital-nursing home patient transfer. DESIGN: Mailed survey. SETTING: Medicare- or Medicaid-certified nursing homes in New York State. PARTICIPANTS: Nursing home administrators, with input from other nursing home staff. MEASUREMENTS: Key predictor variables were travel time between the hospital and the nursing home, affiliation with the same health system, same corporate owner, trainees from the same institution, pharmacy or laboratory agreements, continuous physician care, number of beds in the hospital, teaching status, and frequency of geriatrics specialty care in the hospital. Key dependent variables were hospital-to-nursing home communication, continuous adherence to healthcare goals, and patient and family satisfaction with hospital care. RESULTS: Of 647 questionnaires sent, 229 were returned (35.4%). There was no relationship between hospital-nursing home interorganizational relationships and communication, healthcare goal adherence, and satisfaction measures. Geriatrics specialty care in the hospital (r=0.157; P=.04) and fewer hospital beds (r=-0.194; P=.01) were each associated with nursing homes more often receiving all information needed to care for patients transferred from the hospital. Teaching status (r=0.230; P=.001) and geriatrics specialty care (r=0.185; P=.01) were associated with hospital care more often consistent with healthcare goals established in the nursing home. CONCLUSION: No management-level organizational relationship between nursing home and hospital was associated with better hospital-to-nursing home transfer process of care. Geriatrics specialty care and characteristics of the hospital were associated with better hospital-to-nursing home transfer processes.     

Academic affiliation with a nursing home. Impact on patient outcome

In a prospective study, 46 patients discharged from a teaching hospital to a "teaching unit" nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P less than .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P less than .01). Long-term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.