Care Plan Interventions Research Articles

Adaptive Care for Perioperative Patients With Developmental Disabilities: An Exploration of Interventions and Family Experience

Patients with developmental disabilities commonly experience psychological distress during health care visits. There is limited research describing which individualized interventions are being implemented to promote optimal care in the perioperative area. In this prospective observational study of 60 patients with developmental diagnoses, aged 3-21 years, we recorded adaptive care plan (ACP) interventions and assessed family experience. Patients receiving ACPs had diverse diagnoses, including autism spectrum and 10 other unique syndromes. Most patients received previsit planning (90%), adaptations to standard protocols (60%), child life specialist preparation (67%), procedural support (90%), and were given fast-acting anxiolytics before anesthesia induction (68%). Families reported that ACPs were important for managing a child's stress (94%) and promoting safety (92%). ACPs promote safe, productive health care encounters for patients with various diagnoses, ages, and coping abilities. Families find ACPs important for stress management and promoting safety.

Abstract PO-024: Survivorship care plan for cancer prevention and screening for people living with HIV (PLWH)

Abstract BACKGROUND. Over 1.2 million people living with HIV (PLWH) in the US are aging, many with the chance for normal or near-nomal life expectancy. Yet PLWH are at significantly increased risk for non-AIDS associated cancers due to immunocompromise, antiretroviral medications, lifestyle factors, and social determinants of health issues. HIV disproportionately affects Blacks, those from lower socioeconomic status, the uninsured, and the Southern US. Outcomes from PLWH diagnosed wtih cancer are consistently worse compared to those who are HIV negative, even when diagnosed at the same stage. However, PLWH are often unaware of their higher risk status and are infrequently referred for cancer prevention or screening by providers, despite these disparities in screening and outcomes. METHODS: To explore reasons why PLWH did not engage in cancer prevention or screening activities, we partnered with urban and rural community clinics with a mixed methods study design, including a quantitative survey and focus groups. RESULTS: In our sample (N=178), 90.4% Black, 57% female, significant differences were found between rural and urban settings related to guideline-concordant uptake of cancer screening and prevention. Only 37% subjects overall reported participating in regular cancer screening. Among women over 50 years who met criteria for breast cancer screening, 100% of women in the rural setting were screened while 55% of eligible women in the urban community received breast cancer screening (p=0.009). Participants from both settings demonstrated gaps in knowledge of their own cancer risk or need to pursue screening. Urban participants were more likely than rural to strongly disagree wtih the statement that HIV+ individuals are at higher risk for cancer (p<0.001). Qualitative data indicated the main reason why PLWH did not participate in prevention or screening activities was because participants were seldom referred for screening by their HIV clinic provider or informed of their risk status. Other qualitative data themes were shock and surprise at learning of their increased risk, or how certain behaviors might reduce cancer risk. DISCUSSION: Upon reviewing results with community partners, the suggestion was made that an HIV Survivorship Care Plan, similar to a Cancer Survivor Care Plan, be developed that could be part of the medical record. The HIV Survivorship Care Plan would incorporate cancer and other chronic disease screening, prevention interventions, and surveillance that would be important for aging PLWH to ensure both patients and providers adhered to evidence-based practices. CONCLUSIONS: PLWH are at increased risk for cancer incidence and mortality as they age, yet are often overlooked as a high-risk population that could greatly benefit from prevention and screening.The application of an HIV Survivorship Care Plan intervention is a novel approach to reduce disparities and improve quality of care and outcomes for PLWH. The tool will be tested and evaluated through additional community-engaged partnerships targeting PLWH. Citation Format: Theresa W. Gillespie, Loree Mincey, Yuan Liu, Denise Ballard, Kimberly W. Scott, Robert Knott, Minh Ly T. Nguyen, Saurabh Chawla, Joseph Lipscomb, Jessica H. Wells. Survivorship care plan for cancer prevention and screening for people living with HIV (PLWH) [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-024.

The effect of quality improvement interventions on inpatient cancer malnutrition documentation and coding in an academic medical center.

38 Background: Malnutrition (MN) is common yet underdiagnosed in hospitalized cancer patients. Effective assessments can identify those who need nutritional care and help plan intervention. We examined the effect of quality improvement (QI) interventions on the dietitian documented MN (DDMN) and physician coded malnutrition (PCMN). We also determined if the registered dietitian (RD) and physician assessments of MN agreed. Methods: Electronic medical records (EMR) were reviewed for a consecutive cohort of inpatients with a solid tumor diagnosis staged I-IV and admitted to Atrium Health’s Carolinas Medical Center at least once between 1/1/2016 to 5/31/2019. Data were collected from the first admission EMR encounter closest to the cancer diagnosis date. RD assessments were reviewed for DDMN. PCMN diagnosis was based on MN ICD-10 codes in the discharge summary. MN was graded as mild, moderate, and severe. Two QI interventions were implemented during the study period: 1) 8/2016: RD message via EMR to query MD approval for MN diagnosis; 2) 4/2018: Clinical Documentation Integrity Team query MD by sending ASPEN criteria via an alert integrated into MD workflow. Agreement in MN identification was defined as the absence or presence of both DDMN and PCMN; agreement in severity was defined as the absence of DDMN and PCMN or the agreement in presence and severity of DDMN and PCMN. Cochran-Armitage tests for trend assessed prevalence and agreement across the three periods (N1=652; N2=2858; N3=1622) defined by the two sequential QI interventions. Results: N=5143; 52% males. Median age 63 (range 18-102) years. 70% White; 24% Black, 3% Latino. Commonest cancer diagnostic groups: Upper Gastrointestinal 22%, Thoracic (19%), Genitourinary 18%. 28% had stage IV disease. 11% (N=557) met criteria for DDMN and/or PCMN. Of the 557, 40% (N=223) met criteria for both DDMN and PCMN. DDMN (N=420) was mild 2%, moderate 19%, and severe 79%. On discharge, PCMN (N=360) was mild in 10%, moderate in 21%, and severe in 69%. The RD and MD agreed on the presence or absence (94%) and severity (93%) of MN. Significant trends were observed as DDMN prevalence increased from 3.1%, 8.1%, to 10.3% (p<.001), and PCMN prevalence from 0.5%, 7.8%, to 8.2% (p<.001). While rates of mild, moderate, and severe MN varied across the periods, statistically significant change in these distributions was not identified in DDMN (p=0.62) or PCMN (p=0.20) after the second QI intervention. Conclusions: MN was under-diagnosed compared to nutrition intervention studies. When MN was identified, it was moderate or severe in the majority. Evaluations by RD and MD were highly congruent for MN prevalence and severity. Implementation of nutrition-focused QI interventions improved documentation and coding of MN. Improved communication between the RD and the MD could improve the recognition and diagnosis of MN.

Implementation of a Frailty Assessment and Targeted Care Interventions and Its Association with Reduced Postoperative Complications in Elderly Surgical Patients

Older patients with frailty syndrome have a greater risk of poor postoperative outcomes. In this study, we used a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to implement an assessment tool to identify frail patients and targeted interventions to improve their outcomes. We implemented a 5-question frailty assessment tool for patients 65 years and older admitted to the general and vascular surgery services from January 1, 2018 to December 31, 2019. Identified frail patients received evidence-based clinical orders and nursing care plan interventions tailored to optimize recovery. A RE-AIM framework was used to assess implementation effectiveness through provider and nurse surveys, floor audits, and chart review. Of 1,158 patients included in this study, 696 (60.1%) were assessed for frailty. Among these, 611 patients (87.8%) scored as frail or intermediately frail. After implementation, there were significant increases in the completion rates of frailty-specific care orders for frail patients, including delirium precautions (52.1% vs 30.7%; p < 0.001), aspiration precautions (50.0% vs 26.9%; p < 0.001), and avoidance of overnight vitals (32.5% vs 0%). Floor audits, however, showed high variability in completion of care plan components by nursing staff. Multivariate analysis showed significant decreases in 30-day complication rates (odds ratio 0.532; p < 0.001) after implementation. A frailty assessment was able to identify elderly patients for provision of targeted, evidence-based frailty care. Despite limited uptake of the assessment by providers and completion of care plan components by nursing staff, implementation of the assessment and care interventions was associated with substantial decreases in complications among elderly surgical patients.

"A catalyst for action": Factors for implementing clinical risk prediction models of infection in home care settings.

The study sought to outline how a clinical risk prediction model for identifying patients at risk of infection is perceived by home care nurses, and to inform how the output of the model could be integrated into a clinical workflow. This was a qualitative study using semi-structured interviews with 50 home care nurses. Interviews explored nurses' perceptions of clinical risk prediction models, their experiences using them in practice, and what elements are important for the implementation of a clinical risk prediction model focusing on infection. Interviews were audio-taped and transcribed, with data evaluated using thematic analysis. Two themes were derived from the data: (1) informing nursing practice, which outlined how a clinical risk prediction model could inform nurse clinical judgment and be used to modify their care plan interventions, and (2) operationalizing the score, which summarized how the clinical risk prediction model could be incorporated in home care settings. The findings indicate that home care nurses would find a clinical risk prediction model for infection useful, as long as it provided both context around the reasons why a patient was deemed to be at high risk and provided some guidance for action. It is important to evaluate the potential feasibility and acceptability of a clinical risk prediction model, to inform the intervention design and implementation strategy. The results of this study can provide guidance for the development of the clinical risk prediction tool as an intervention for integration in home care settings.

Theory-guided interventions for Chinese patients to adapt to heart failure: A quasi-experimental study

ObjectivesTo examine the effects of the Roy Adaptation Model-based interventions on adaptation in persons with heart failure. MethodsA quasi-experimental study was conducted in Hangzhou, China, from March 2018 to November 2019. A convenience sample of 112 participants with heart failure from a multi-campus hospital was enrolled. Participants were allocated into an intervention group (n = 55) and a control group (n = 57) according to their hospitalized campus. A culturally-tailored care plan intervention based on the Roy Adaptation Model was performed in the intervention group. The control group received bedside patient education and a regular booklet for HF home care before discharge. Heart ultrasound, Minnesota Living with Heart Failure Questionnaire (MLHFQ), a knowledge survey, Self-care Heart failure Index (SCHFI), and Coping and Adaptation Processing Scale-Short Form (CAPS-SF) were used to measure patients’ levels of adaptation of physical function, self-concept, role function, and interdependence at baseline and six months after discharge. ResultsNinety-one participants with complete data, 43 in the intervention group and 48 in the control group, were included in the analysis for the primary endpoints and showed adaptive improvement trends. Most patients in the intervention group completed 60% or more of the given interventions. At the sixth month after discharge, compared with the control group, the intervention group had improved adaptive behaviors showing higher scores of the MLHFQ (70.90 ± 22.45 vs. 54.78 ± 18.04), heart failure-related knowledge (13.79 ± 2.45 vs. 10.73 ± 4.28), SCHFI maintenance (57.67 ± 13.22 vs. 50.35 ± 10.88), and CAPS-SF (40.23 ± 4.36 vs. 38.27 ± 2.60) at the six-month follow-up (P ＜ 0.05). There were no significant differences between the two groups in the scores of left ventricular ejection fraction, scores of SCHFI management and SCHFI confidence subscales (P > 0.05). ConclusionsThe findings reported evidence of positive adaptation in patients with heart failure, indicating that the Roy Adaptation Model is an effective guide for developing an implemented framework for the nursing practice of the patients. The culturally-tailored care plan intervention is helpful to improve adaptation of patients with heart failure.

Communicating health information and improving coordination with primary care (CHIIP): Rationale and design of a randomized cardiovascular health promotion trial for adult survivors of childhood cancer

BackgroundLong-term survival for children diagnosed with cancer exceeds 80%. Notably, premature cardiovascular disease has become the leading non-cancer cause of late mortality among these survivors. Methods/designThis randomized controlled trial (RCT; NCT03104543) focuses on adult participants in the Childhood Cancer Survivor Study identified as high risk for ischemic heart disease or heart failure due to their cancer treatment. Participants undergo a home-based evaluation of blood pressure and laboratory tests to determine the prevalence of undiagnosed and/or undertreated hypertension, dyslipidemia, and diabetes. Those with abnormal values are then enrolled in an RCT to test the efficacy of a 12-month personalized, remotely delivered survivorship care plan (SCP) intervention designed to reduce undertreatment of these three target conditions. The intervention approximates a clinical encounter and is based on chronic disease self-management strategies. ResultsWith a goal of 750, currently 342 out of 742 eligible participants approached have enrolled (46.1%). Initially, we randomized participants to different recruitment strategies, including shorter approach packets and a tiered consent, but did not find significant differences in participation rates (40.7% to 42.9%; p = .95). Subsequently, slightly greater participation was seen with larger upfront unconditional incentive checks ($50 vs. $25: 50.7% vs. 44.1%; p = .10). Overall, the financial impact of the $50 upfront incentive was cost neutral, and possibly cost-saving, vs. a $25 upfront incentive. ConclusionThe overall study will determine if a National Academy of Medicine-recommended SCP intervention can improve cardiovascular outcomes among long-term survivors of childhood cancer. Modifications to the recruitment strategy may improve participation rates over time.

Challenges and needs of informal caregivers in elderly care: Qualitative research in four European countries, the TRACE project

BackgroundProviding informal care may affects caregivers' life in different ways. Determining the needs of caregivers and supporting them can improve both the quality of life of the caregivers, as well as the elderly they take care of. ObjectiveTo explore the experiences and needs of the informal caregivers in four countries. DesignQualitative research method was used in the study. MethodsThe qualitative data was collected through focus groups and individual interviews between December 2016–May 2017. In all countries interviews were conducted in the mother language of the informants.Informants of the qualitative research were adult people who take primary care of an individual with chronic diseases, aged 65 years or older. Data were collected from 72 informal caregivers from four European countries. Inductive content analysis was performed. ResultsInformal caregivers identified 2 themes, 5 subthemes, 19 categories and 7 subtcategories. The themes highlighted two major issues: informal caregiver's challenges and needs related to the management of care of elderly and caregivers' personal needs. ConclusionThe important and charming results of the present study are, difficulties of managing caregiver's own life, and coping with emotions are common in four countries. Identifying challenges and needs of informal caregivers enable healthcare professionals to develop care strategies and plan interventions focused to support and help to reduce the burden of care for elderly with chronic diseases.

Hip Fracture With Resistance to Care

Hip Fracture With Resistance to Care

Regulatory and Litigation Risks of Elopement

Regulatory and Litigation Risks of Elopement

Codesigned Shared Decision-Making Diabetes Management Plan Tool for Adolescents With Type 1 Diabetes Mellitus and Their Parents: Prototype Development and Pilot Test.

BackgroundAdolescents with type 1 diabetes mellitus have difficulty achieving optimal glycemic control, partly due to competing priorities that interfere with diabetes self-care. Often, significant diabetes-related family conflict occurs, and adolescents’ thoughts and feelings about diabetes management may be disregarded. Patient-centered diabetes outcomes may be better when adolescents feel engaged in the decision-making process.ObjectiveThe objective of our study was to codesign a clinic intervention using shared decision making for addressing diabetes self-care with an adolescent patient and parent advisory board.MethodsThe patient and parent advisory board consisted of 6 adolescents (teens) between the ages 12 and 18 years with type 1 diabetes mellitus and their parents recruited through our institution’s Pediatric Diabetes Program. Teens and parents provided informed consent and participated in 1 or both of 2 patient and parent advisory board sessions, lasting 3 to 4 hours each. Session 1 topics were (1) patient-centered outcomes related to quality of life, parent-teen shared diabetes management, and shared family experiences; and (2) implementation and acceptability of a patient-centered diabetes care plan intervention where shared decision making was used. We analyzed audio recordings, notes, and other materials to identify and extract ideas relevant to the development of a patient-centered diabetes management plan. These data were visually coded into similar themes. We used the information to develop a prototype for a diabetes management plan tool that we pilot tested during session 2.ResultsSession 1 identified 6 principal patient-centered quality-of-life measurement domains: stress, fear and worry, mealtime struggles, assumptions and judgments, feeling abnormal, and conflict. We determined 2 objectives to be principally important for a diabetes management plan intervention: (1) focusing the intervention on diabetes distress and conflict resolution strategies, and (2) working toward a verbalized common goal. In session 2, we created the diabetes management plan tool according to these findings and will use it in a clinical trial with the aim of assisting with patient-centered goal setting.ConclusionsPatients with type 1 diabetes mellitus can be effectively engaged and involved in patient-centered research design. Teens with type 1 diabetes mellitus prioritize reducing family conflict and fitting into their social milieu over health outcomes at this time in their lives. It is important to acknowledge this when designing interventions to improve health outcomes in teens with type 1 diabetes mellitus.

The Oncological Patient in the Palliative Situation.

Palliative care approaches patients and their suffering with a bio-psycho-social-spiritual model. Thus, it is the strength of palliative care to complement the diagnosis driven approach of medical cancer care by a problem and resources-based assessment, participatory care plan and person-directed interventions. Interventions need to reflect timely prognosis, target population (the patient, the family carer, the professional) and level of trust and remaining energy. In palliative care the relevance of psycho-oncological aspects in the care of the terminally ill is considerable in the understanding of the overall suffering of patients approaching death and their loved ones and in their care and support. There is little evidence to date in terms of clinical benefit of specific psycho-oncological interventions in the last months or weeks of life, but there is evidence on effects of stress reduction and reduced anxiety if locus of control can stay within the patient as long as possible. One major challenge in psychosocial and palliative care research, however, is defining patient relevant outcomes.

Patient-centered support in the survivorship care transition: Outcomes from the Patient-Owned Survivorship Care Plan Intervention.

To the authors' knowledge, few studies to date have evaluated the effects of survivorship care planning on the care transition process from specialty cancer care to self-management and primary care, patient experience, or health outcomes. The Patient-owned Survivorship Transition Care for Activated, Empowered survivors (POSTCARE) is a single coaching encounter based on the Chronic Care Model that uses motivational interviewing techniques to engage survivors of breast cancer. The current study examined the effects of the POSTCARE intervention on patient outcomes and care coordination. A total of 79 survivors of American Joint Commision on Cancer TNM System stage 0 to IIIB breast cancer were randomized to POSTCARE (40 patients) or usual care (39 patients). Patient outcomes were assessed using the 36-Item Short Form Health Survey (SF-36), Social/Role Activities Limitations, Self-Efficacy for Managing Chronic Disease 6-Item Scale, the Patient Activation Measure-Short Form, and Patient Health Questionnaire depression scale at baseline and at 3-month follow-up. Care coordination was assessed using confirmed primary care physician visits and reported discussion of the survivorship care plan at the 3-month follow-up. Logistic and linear regression analyses were conducted to examine the effect of POSTCARE on selected outcomes. Participants in the intervention group versus those receiving usual care demonstrated significantly higher self-reported health (F-statistic (3,71), 3.63; P =.017) and lower social role limitations (F (3,70), 3.82; P =.014) and a trend toward greater self-efficacy (F (3,69), 2.51; P = .07). Three quality-of-life domains reached clinically meaningful improvement at the 3-month follow-up, including physical role (P =.0009), bodily pain (P =.03), and emotional role (P =.04). The POSTCARE intervention appeared to have a positive impact on patient outcomes and demonstrated promise as a strategy with which to improve survivors' experience, care coordination, and health outcomes. Cancer 2016;122:3232-42. © 2016 American Cancer Society.

Evaluation of Evidence-based Nursing Pain Management Practice

It is important to ensure that cancer pain management is based on the best evidence. Nursing evidence-based pain management can be examined through an evaluation of pain documentation. The aim of this study was to modify and test an evaluation tool for nursing cancer pain documentation, and describe the frequency and quality of nursing pain documentation in one oncology unit via the electronic medical system. A descriptive cross-sectional design was used for this study at an oncology unit of an academic medical center in the Pacific Northwest. Medical records were examined for 37 adults hospitalized during April and May 2013. Nursing pain documentations (N = 230) were reviewed using an evaluation tool modified from the Cancer Pain Practice Index to consist of 13 evidence-based pain management indicators, including pain assessment, care plan, pharmacologic and nonpharmacologic interventions, monitoring and treatment of analgesic side effects, communication with physicians, and patient education. Individual nursing documentation was assigned a score ranging from 0 (worst possible) to 13 (best possible), to reflect the delivery of evidence-based pain management. The participating nurses documented 90% of the recommended evidence-based pain management indicators. Documentation was suboptimal for pain reassessment, pharmacologic interventions, and bowel regimen. The study results provide implications for enhancing electronic medical record design and highlight a need for future research to understand the reasons for suboptimal nursing documentation of cancer pain management. For the future use of the data evaluation tool, we recommend additional modifications according to study settings.

Abstract P1-09-07: Patient centered support in the survivorship care transition: Outcomes from the patient-owned survivorship care plan intervention

Abstract Background: Survivorship care plans will be mandated for use by 2015. Few studies have focused on the care transition process, and few show an impact on the patient experience or health outcomes. This study examines the effect of a patient-owned survivorship care plan (POSCP) intervention on patient outcomes and care coordination. Based on a conceptual model that incorporates IOM survivorship priorities and the chronic care model, the POSCP intervention is a single coaching encounter utilizing motivational interviewing to engage patients in the development of a POSCP that incorporates health goals and strategies related to surveillance, symptom management, and health behavior. Methods: 79 recent breast cancer survivors Stage I-IIIB were randomized to receive POSCP intervention (n=40) or usual care (n=39). Patient outcomes were assessed using SF-36 Health Survey (SF-36), Social/Role Activities Limitations, Self-Efficacy for Managing Chronic Disease Scale, and Personal Health Questionnaire Depression Scale (PHQ-9) at baseline and 3 month follow up. Care coordination was assessed using confirmed primary care physician (PCP) visits and reported discussion of survivorship plan at follow up. Logistic and linear regressions were conducted to examine the effect of intervention on care coordination, patient experience, and health outcomes. Results: In this sample age M= 58.35, SD = 10.62, 81% (N=64) non-hispanic white, 16.5% (N=13) African American. A greater proportion of participants in the intervention group reported a confirmed appointment (59.5% vs. 51.4%) and discussed survivorship issues (47.4% vs. 35.1%) with their PCPs compared to those in the usual care group, however these differences did not achieve statistical significance (p= .70 and .65). After controlling for education and perceived financial adequacy, participants in the intervention group demonstrated significantly higher self-reported health (F (3, 70) = 3.57, p&amp;lt; .05), lower social role limitation (F (3, 70) = 3.82, p &amp;lt; .05), as well as a trend toward greater self-efficacy (F (3, 69) = 2.51, p = .07) compared to those in the usual care group. Results of paired-samples t-tests revealed a significant decrease in depression scores from baseline to 3 months follow up in the intervention group, t (36)= 3.21, p &amp;lt; .01, η^2 =.23. No between group differences were identified in symptom burden or patient activation. Conclusion: This pilot study of a POSCP process utilizing motivational interviewing techniques to enhance patient engagement has a positive impact on patient outcomes and demonstrates promise as a strategy to improve survivor patient experience, care coordination, and health outcomes. Citation Format: Elizabeth A Kvale, Wendy Demark-Wahnefried, Karen Meneses, Sejong Bae, Chao-Hui S Huang, Casey B Azuero, Christine S Ritchie. Patient centered support in the survivorship care transition: Outcomes from the patient-owned survivorship care plan intervention [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-07.

Palliative assessment and advance care planning in severe dementia: An exploratory randomized controlled trial of a complex intervention

Patients with advanced dementia often receive poor end-of-life care. We aimed to design and pilot a palliative care and advance care plan (ACP) intervention. Patients had undergone emergency hospital admission and had severe dementia. The intervention consisted of a palliative care patient assessment which informed an ACP discussion with the carer, who was offered the opportunity to write an ACP for the person with dementia. Carer–patient dyads were randomized to ‘usual care’ or the intervention. Carer-related outcome measures included the Kessler Distress Scale, Decision Satisfaction Inventory, Client Satisfaction Questionnaire and the Euroqol-5D, measured at baseline, six weeks, six months and three months after bereavement. The Satisfaction with End of Life Care in Dementia Scale was completed if the patient died. The 32 patient participants were physically frail and in the advanced stages of dementia: 62% had pressure damage to the skin, all needed feeding assistance and 95% were in pain. Nearly 50% died during the six-month follow-up period. Carers were difficult to recruit during acute admission; 33 patients and carers entered the study (22 intervention arm; 11 control arm). Only seven carers made ACPs. The care planning discussion was well received, but few carers wrote an ACP, despite intensive support from an experienced nurse specialist. Advance care planning is, in theory, a necessary intervention for people with severe dementia; the reluctance of carers to write plans needs to be explored further.

Fall Risk Care Processes in Nursing Home Facilities

To explore the relationships between fall risk factors and care plan intervention and implementation. Observational cohort study. Nursing homes in Central Ontario, Canada. Residents (n = 635) of 8 nursing homes across Ontario, Canada. Chart reviews and observational rounds on nursing units were carried out to examine how well nursing staff (1) identified fall risk, (2) documented nursing care plan interventions, and (3) implemented nursing care plan interventions in residents who had fallen in the preceding year. Of the 635 fallers, two thirds (65.9%) had a history of falls. A total of 94 fallers across the 8 facilities had no fall risk care plan included in their medical record, despite having fallen previously. Only 63.46% of nursing care plan interventions were successfully implemented. Shorter length of stay (P < .001; odds ratio [OR] 0.09; 95% confidence interval [CI] 0.04-0.23), fall history (P = .002; OR 2.14; 95% CI 1.32-3.46), and those who are widowed (P = .001; OR 2.53; 95% CI 1.43-4.48) and divorced (P = .03; OR 2.16; 95% CI 1.06-4.40) predicted a higher likelihood of falls. This study revealed significant breakdowns in care related to the lack of documented care plan interventions for residents with a history of falls, and lack of implementation in cases where care plan interventions were made. Policies and procedures to improve the selection and implementation of care plan interventions may result in substantial improvements in nursing home safety.

Impact of Geriatric Assessment and Self-Management Support on Community-Dwelling Older Adults with Chronic Illnesses

Purpose: The purpose of this study was to assess the effectiveness of interdisciplinary geriatric home-based assessment and self-management support services to community-dwelling older adults. Design: A quasi-experimental, pre-post test design tested two types of service delivery models. The first protocol included geriatric assessment services, with a brief self-management care plan intervention. The second protocol added a telephone support intervention. Results: All participants showed significant progress in improved self–efficacy, self-rated health, functional status and physical mobility (specifically lower extremity muscle strength), mental health (specifically reduced depression) and in reduced fall hazards in their physical home environment. The telephone support intervention protocol did not provide additional value to the first protocol. Implications: This study demonstrates the value of non-medical intervention strategies for community dwelling older adults with chronic illnesses.

Quality improvement initiative to integrate teaching diabetes standards into home care visits.

This quality improvement project was initiated to determine the quality of diabetes care for clients of a home health agency and to integrate the teaching of diabetes standards of care into home care nursing visits. A descriptive study design was used to evaluate the effectiveness of teaching materials and the Standards of Care Teaching Program. Performance indicators and outcome measures from the American Diabetes Association Provider Recognition Program (ADA PRP) were used to determine the baseline status of diabetes care and for comparing performance measures from 50 home care clients. The educational materials and care plan interventions helped nurses learn the standards and facilitated tracking interventions and performance measures. These results showed statistical significance in performance measures for eye, foot, lipid tests, and diabetes self-management education, but not for hemoglobin A1C, urine protein, and medical nutrition therapy. The Standards of Care Teaching Program was a useful way to integrate the standards into a diabetes program and home care visits. Comparing clients' diabetes performance measures with national standards helped identify specific areas for quality improvement.

Bedrails: choosing the best alternative.

This article discusses the importance of resident assessment in the decision to use bedrails, highlights the importance of an interdisciplinary approach to decision-making, and offers a compendium of care plan interventions and devices that serve as alternatives to bedrails.