Improving disposition outcomes for patients in a geriatric skilled nursing facility

OBJECTIVES: To evaluate an intervention to improve discharge disposition from a skilled nursing unit (SNU). DESIGN: Historical control comparison of discharge disposition before and after implementation. SETTING: Fifty‐bed SNU. PARTICIPANTS: All patients admitted from acute care hospitals to a SNU between June 2008 and May 2010. INTERVENTION: Physician admission procedures were standardized using a template, patients with three or more hospital admissions over the prior 6 months received palliative care consultations, and multidisciplinary root‐cause analysis conferences for patients transferred back to the hospital acutely were conducted bimonthly to identify problems and improve processes of care. MEASUREMENTS: Patients' discharge disposition (i.e., acute care, long‐term care, home, or death) before and after implementation were compared. RESULTS: Discharge dispositions were determined for all 1,725 patients admitted during the study; 862 patients before (June–May 2008) and 863 during (June 2009–May 2010) the intervention. Discharge dispositions were significantly differently distributed across the two periods (P=.03). Readmission to acute care declined (from 16.5% to 13.3%, a nearly 20% decline). Multivariable logistic regression, controlling for age, sex, and case‐mix index and adjusting for clustering due to repeated admissions of individual patients, suggests that, during the intervention period, patients were more likely than during the baseline period to die on the unit in accordance with their wishes than to be transferred out to the hospital (odds ratio=2.45, 95% confidence interval=1.09–5.5). CONCLUSION: Interventions such as the ones implemented can lead to fewer hospital transfers for SNUs.     

Indicators of the quality of nursing home residential care

OBJECTIVES: To identify quality indicators (QIs) that can be used to measure nursing home (NH) residential care processes. DESIGN: Modified-delphi panel process to rate potential QIs that were identified through reported interviews with residents and families and through a review of the scientific literature. SETTING: Meetings of panel of experts. PARTICIPANTS: A national panel of nine experts in NH care rated potential QIs. A content expert and a clinical oversight committee performed external reviews. MEASUREMENTS: Panelists' median validity and importance ratings for each QI choice. RESULTS: The panel considered 64 choices for QI content and rated 28 of these as valid and important for measuring residential care quality. These 28 choices translated into 18 QIs. The external review process resulted in the addition of one QI that was not considered by the NH panel. The 19 indicators address areas identified as important by residents and proxies. Ten of these QIs were rated feasible to implement with current resources in average community NHs, and nine were rated feasible only in better NHs. The panelists identified nine as being measured most reliably by direct observations of care. CONCLUSION: Experts identified 19 specific care processes as valid and important measures of the quality of NH residential care. Nine of these QIs may be measured best by direct observation of NH care, rather than by interviews or review of existing NH records. Almost half of the QIs were viewed as discriminating between better and average NHs. The panel deemed that only well-staffed nursing homes could consistently implement nine of the QIs.     

Site of death in the hospital versus nursing home of Medicare skilled nursing facility residents admitted under Medicare's Part A Benefit

OBJECTIVES: To determine factors that predict site of death (hospital vs nursing home (NH)), related costs, and geographic variation in site of death of NH residents admitted under the Medicare Part A Benefit. DESIGN: Retrospective cohort study. SETTING: NHs located in the United States (N=13,146). PARTICIPANTS: All persons admitted to skilled nursing facilities (SNFs) in 2001 who died in a SNF (n=101,307) or hospital (n=51,187). MEASUREMENTS: Patient, facility, and geographic characteristics associated with death in a hospital and receipt of Medicare payment. RESULTS: Absence of a do-not-resuscitate order, non-Caucasian ethnicity, greater functional independence, and higher cognitive status correlated with hospital as the site of death. Rural, hospital-based, and government-owned facilities had the lowest in-hospital death rates. Site of death varied widely from state to state. Of those who died in a hospital, 24.2% (12,410) died within 24 hours of transfer. The average daily combined stay Medicare payment for those who died in the hospital was $969, versus $300 for those who died in a NH. CONCLUSION: Patient and facility characteristics predict site of death of Medicare NH patients, but in-hospital death rather than NH death varies geographically and is associated with higher daily Medicare payment.     

Purchasing or providing nursing home care: can quality of care data provide guidance

OBJECTIVES: To examine whether quality of care differed for veterans in Department of Veterans Affairs (VA) nursing homes and those on contract in community nursing homes, and whether the VA was contracting with nursing homes providing better quality of care than other nursing homes. DESIGN: Observational study using administrative databases from 1997 to 1999. SETTING: Ten VA and 650 community nursing homes in New York state. PARTICIPANTS: Four thousand seven hundred sixty-three veteran and 195,438 nonveteran residents of these nursing homes. MEASUREMENTS: Risk-adjusted rates of pressure ulcer development, functional decline, behavioral decline, and mortality. RESULTS: Veterans in VA nursing homes were significantly (P< .05) less likely to develop a pressure ulcer (odds ratio (OR)=0.63) but more likely to experience functional decline (OR=1.6) than veterans in community nursing homes. Residents of community nursing homes with VA contracts were significantly (P< .05) less likely to develop a pressure ulcer (OR=0.91) but more likely to die than residents in noncontract homes. Few nursing homes were consistently among the best or worst performers on all measures; only seven of 650 nursing homes were in the top or bottom decile and 34 in the top or bottom quartile for each measure. CONCLUSION: Large purchasers and providers of nursing home care such as the VA are unlikely to find information on quality of care useful in making decisions on whether they should "make" or "buy" care. Nursing homes performing well on one quality measure may perform poorly on another, and it is difficult to identify nursing homes that are consistently among the best or worst. Other consumers may encounter similar difficulties when using data on nursing home quality.     

Measuring process of arthritis care: the Arthritis Foundation's quality indicator set for rheumatoid arthritis

OBJECTIVE: To describe the scientific evidence that supports each of the explicit process measures in the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis. METHODS: For each of the 27 measures in the Arthritis Foundation's Quality Indicator set, a comprehensive literature review was performed for evidence that linked the process of care defined in the indicator with relevant clinical outcomes and to summarize practice guidelines relevant to the indicators. RESULTS: Over 7500 titles were identified and reviewed. For each of the indicators the scientific evidence to support or refute the quality indicator was summarized. We found direct evidence that supported a process-outcome link for 15 of the indicators, an indirect link for 7 of the indicators, and no evidence to support or refute a link for 5. The processes of care described in the indicators for which no supporting/refuting data were found have been assumed to be so essential to care that clinical trails assessing their importance have not, and probably never will be, performed. The process of care described in all but 2 of the indicators is recommended in 1 or more practice guidelines. CONCLUSION: There are sufficient scientific evidence and expert consensus to support the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis, which defines a minimal standard of care that can be used to assess health care quality for patients with rheumatoid arthritis.     

To the hospital and back home again: a nurse practitioner-based transitional care program for hospitalized homebound people

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.     

Treatment of patients with acute myocardial infarction at a veterans affairs (VA) hospital and a non-VA hospital

Comparisons of care in Veterans Affairs (VA) hospitals with care in non-VA hospitals are needed to define the future role of the VA health care system. Therefore, the authors conducted a retrospective cohort study of 385 patients who had acute myocardial infarctions and were admitted to a private nonprofit teaching hospital and to a university-affiliated VA hospital, which were staffed by attending and resident physicians from a single medicine department. Data were obtained from hospital databases and from patient records. The authors found that the 206 VA patients, compared with the 179 non-VA patients, were younger and more likely to be men. The VA patients also had higher comorbidity but lower admission severity of illness, according to previously validated measures. Although the VA patients were less likely than the non-VA patients to receive thrombolytic therapy (6% vs 20%, respectively; p<0.05), they were more likely to undergo coronary angiography (67% vs 57%; p<0.05) and echocardiography or gated blood pool scanning (54% vs 44%; p<0.05) during hospitalization. Finally, the VA and the non-VA patients had similar rates of in-hospital mortality in univariate analysis (9% vs 11%, respectively; p=0.4) and in multivariate analysis, adjusting for covariates. These results suggest that the VA and the non-VA patients who had acute myocardial infarction had similar outcomes and generally received care of similar qualities. Future studies are needed to explore the generalizability of these findings and to provide the data needed to adequately define the VA’s future role in American health care. Received from the Section of Clinical Epidemiology, Division of General Internal Medicine, Department of Medicine, Cleveland Veterans Affairs Medical Center and University Hospitals of Cleveland; and Case Western Reserve University School of Medicine, Cleveland, Ohio. Presented in part at the Department of Veterans Affairs 11th Annual HSR&D Service Meeting, Washington, DC, April 27, 1993. Supported by a grant (LIP 41-063) from the Department of Veterans Affairs Great Lakes Regional HSR&D Field Program.     

Prevalence of movement disorders in an elderly nursing home population

We studied the prevalence of movement disorders in a large nursing home population (397 patients, mean age 86 years) in New York City. Patients were first evaluated by specially trained research coordinators and final clinical diagnoses were confirmed by a movement disorder specialist. A movement disorder was identified in 21% of patients (83/397). The most frequent movement disorders were essential tremor (ET) (8.8%) and parkinsonism (7.1%). Only half of those admitted with a diagnosis of parkinsonism were confirmed in their diagnosis by the movement disorder specialists. Three percent of patients exhibited drug-induced tremor, 1.3% had dystonia, 0.5% had myoclonus and 0.3% had generalized dyskinesias. Overall, our findings underline the high frequency of movement disorders in a nursing home population. The discrepancy between our findings and the prevalence rates for parkinsonism reported on the initial transfer diagnosis emphasizes the difficulty of accurate diagnosis of movement disorders and in particular parkinsonism.     

Quality of care of nursing home residents hospitalized with heart failure

OBJECTIVES: To determine whether the quality of heart failure (HF) care of hospitalized nursing home (NH) residents is different from that of patients admitted from other locations. DESIGN: Retrospective chart review. SETTING: Nursing home residents discharged from hospitals. PARTICIPANTS: Medicare beneficiaries aged 65 and older. MEASUREMENTS: Subjects were discharged with a primary discharge diagnosis of HF in Alabama in 1994. They were categorized as having been admitted from a NH or other locations. Bivariate logistic regression analysis was used to estimate crude odds ratios (ORs) and 95% confidence intervals (CIs) for left ventricular function (LVF) evaluation and angiotensin-converting enzyme (ACE) inhibitor use for NH residents relative to nonresidents. Multivariate generalized linear models were developed to determine independence of associations. RESULTS: Subjects (N = 1,067 years) had a mean age +/- standard deviation of 79 +/- 7.4, 60% were female, and 18% were African Americans. Fewer NH residents (n = 95) received LVF evaluation (39% vs 60%, P <.001) and ACE inhibitors (50% vs 72%, P =.111). NH residents had lower odds for LVF evaluation (OR = 0.42, 95% CI = 0.27-0.64). The odds for ACE inhibitor use, although of similar magnitude, did not reach statistical significance (OR = 0.40, 95% CI = 0.12-1.28). After adjustment of patient and care characteristics, admission from a NH was significantly associated with lower LVF evaluation (adjusted OR = 0.64, 95% CI = 0.49-0.82) but not with ACE inhibitor use (adjusted OR = 0.59, 95% CI = 0.16-2.14). CONCLUSIONS: Quality of HF care received by hospitalized NH residents was lower than that received by others. Further studies are needed to determine reasons for the lack of appropriate evaluation and treatment of NH patients with HF who are admitted to hospitals.     

优质护理服务在心血管内科临床护理中的应用

目的对优质护理服务在心血管内科临床护理中的应用进行研究探讨,总结相关的工作经验,为优质护理服务在心血管内科临床护理中的应用提供临床依据。方法选取2013年1月-11月期间收治的心血管内科的患者100例,将这100例患者按照随机分配的原则随机分为两组,一组是观察组,另外一组为对照组,每组各50例患者,对照组进行一般的常规护理,而观察组则是结合患者的实际情况,专门为患者制定一套综合的优质护理服务,然后将不同护理的两组病人状况和心理状态进行对比。结果对照组和观察组的护理结果也不一样,对照组经过一般护理之后,有效率为84%,观察组有效率为96%;对照组对护理工作的满意度90%,观察组的满意率为98.3%。结论 100例患者经过不同分组进行护理后,在心血管内科临床护理中对病患提供优质的护理服务有助于病患的治疗和恢复,对于病患的身体和心理方面的治疗都有极大的帮助。