Complex Continuing Care Facility Research Articles

The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults

Objective In Canada, a persistent barrier to achieving healthcare system efficiency has been patient days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures associated with ALC. We sought to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult’s transition to independent living at home. Methods This case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between 1 March 2018 and 30 June 2019. TCU patients were propensity score matched to hospitalized ALC patients (“usual care”). The primary outcome was days without requiring institutional care six months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities, complex continuing care facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated. Results TCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3–167.6d) within six months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3–148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $–6,129–$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care. Limitations The main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals. Conclusions Through rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.

Clinical Complexity and Use ofAntipsychotics and Restraints inLong-Term Care Residents withParkinson's Disease.

Patients with Parkinson's disease (PD) and/or Parkinsonism are affected by acomplex burden of comorbidity. Many ultimately require institutional care, where they may be subject to the application of physical restraints or the prescription of antipsychotic medications, making them more vulnerable to adverse outcomes. The objectives of this paper are to: 1) describe the clinical complexity of older institutionalized persons with PD; and 2) examine patterns and predictors of restraint use and prescription of antipsychotics in this population. Population-based cross-sectional cohort study. Residents with PD and/or Parkinsonism living in long-term care (LTC) facilities in 6 Canadian provinces and 1 Northern Territory and Complex Continuing Care (CCC) facilities in Manitoba and Ontario, Canada. The RAI MDS 2.0 instrument was used to assess all LTC residents and CCC residents. Clinical characteristics and the prevalence of major comorbidities were examined. Multivariate modeling was used to identify the characteristics of PD residents most associated with the prescription of antipsychotics and the use of restraints in LTC and CCC facilities. Residents with PD in LTC and CCC exhibit ahigh prevalence of dementia, major psychiatric disorders, stroke, heart failure, chronic obstructive pulmonary disease and diabetes mellitus. More than 90% of LTC and CCC residents with PD had cognitive impairment; with more than half having moderate to severe impairment. Residents with PD were more likely to receive antipsychotics than those without PD. Antipsychotic use was associated with psychosis and aggressive behaviours, but also with unsteady gait and higher comorbidity and medication count. Similarly, although more common in CCC than LTC facilities, both psychosis and aggressive behaviours were associated with restraint use, as was greater cognitive and functional impairment, and urinary incontinence. Younger age, male gender, and lower physician access were all associated with greater antipsychotic and restraint use. LTC and CCC residents with PD are very complex medically. Use of antipsychotics and restraints is common, and their use is often associated with factors other than psychosis or aggression.

Predicting Adverse Outcomes After Discharge From Complex Continuing Care Hospital Settings to the Community.

The purpose was to identify risk and protective factors assessed at complex continuing care (CCC) admission that were associated with three adverse outcomes (death, readmission, and incidence of or failure to improve possible depression) for persons discharged from CCC to the community with home care services. CCC, home care, community. The sample included all CCC patients in Ontario assessed with the Resident Assessment Instrument-Minimum Data Set 2.0 between January 2003 and December 2010 and who were subsequently assessed with the Resident Assessment Instrument-Home Care within 6 months of discharge to the community (n = 9,940). Separate multivariable logistic regression models were developed for each outcome. Within 6 months, 4.9% of the sample had died, 6.5% were readmitted to any Ontario CCC facility, and 13.7% showed symptoms of new possible depression or failure to improve possible depression. Heart failure, chronic obstructive pulmonary disease (COPD), health instability, intravenous/tube feed, and pressure ulcer were associated with increased risk of death. Difficulty with comprehension, possible depression, COPD, unstable conditions, acute episode or flare-up, short-term prognosis, worsening self-sufficiency, and having either patient or caregiver optimistic about discharge were associated with increased risk of readmission. Existing depressive symptoms or depression, unsettled relationships, multimorbidity, and polypharmacy were associated with risk for incidence of or failure to improve possible depression. Optimism about rehabilitation potential and high social engagement were protective against readmission and depressive outcomes, respectively. Person-level clinical data collected on admission to CCC can be used to identify high-risk patients and trigger early discharge planning processes and other in-home interventions. These results support the sharing of information between settings, and highlight key areas in which care teams in CCC and case managers in home care organizations can work together to support the transition to home and potentially reduce adverse postdischarge outcomes.

Enacting change through action learning: mobilizing and managing power and emotion

This paper reports on a study of how action learning facilitates the movement of knowledge between social contexts. The study involved a community organization that provides educational services related to aphasia and members of a complex continuing care (CCC) practice that received training from the agency. People with aphasia (PWA) (a disability often caused by stroke) retain inherent cognitive competence but have difficulty communicating (speaking, writing, and understanding). The agency has developed a communication technique that improves the ability of PWA to communicate. This project used action learning to introduce a reflective learning cycle into two groups: the agency project team responsible for providing the training and the CCC practice members who received the training. Research participants at both the agency and the CCC facility focused on issues of skill and capacity, and both groups credit the action learning process with introducing a helpful problem-solving cycle into the workplace. CCC participants found that the action learning set provided an emotional container for the anxieties experienced in their workplace. Agency participants found that they were able to use power differences as a way of bringing about beneficial changes.

The development and evaluation of a training programme for nurses working with persons with communication disorders in a complex continuing care facility

Background: Positive interactions between caregivers and residents in long-term care institutions have been documented to improve residents' quality of life, their psychological and social well-being as well as their life expectancy. Residents with language disorders pose a unique challenge due to their difficulties understanding conversation, speaking, reading, and writing. The success and efficiency of such residents' communication can be improved by enhancing partners' abilities to communicate with them. Individualised communication plans, education and training, and staff support have been documented to be important components in this type of intervention. Aims: This paper reports on the development and evaluation of a communication training programme for nurses working with persons with language impairments in a complex continuing care facility. The specific aims of this study were (a) to explore changes in staff knowledge about language impairment, (b) to determine their perception of the training workshop, and (c) to explore staff's perceptions of the Communication Plans' usefulness in practice. Methods & Procedures: Eighteen nursing staff and nine residents with communication impairments participated in this study with a descriptive design. The intervention consisted of three components: developing Communication Plans, holding a 1-day workshop, and offering support while implementing the plans into practice. Outcomes & Results: There was a statistically significant increase in staff's knowledge of language disorders after training. Staff perceived the Communication Plans to be very useful in their interactions with residents. Conclusions: Individualised Communication Plans, a 1-day workshop, and the follow-up and support of a speech-language pathologist can have a beneficial effect on staff outcomes. Nursing staff demonstrated an enhancement in their knowledge and perceived skills in caring for residents with communication impairments. Results have implications for the speech-language pathologist's role with residents with communication impairments in complex continuing care.

The Aggressive Behavior Scale: A New Scale to Measure Aggression Based on the Minimum Data Set

To examine the reliability and validity of the Aggressive Behavior Scale (ABS), derived from the Minimum Data Set (MDS 2.0). Retrospective analysis of MDS 2.0 and Cohen Mansfield Agitation Inventory (CMAI) data. Ontario nursing homes (NHs) and complex continuing care (CCC) hospitals and units. Two hundred fourteen patients of a CCC hospital, 652 residents of four NH facilities who adopted the MDS 2.0 before its mandatory implementation, 124,259 CCC patients assessed with the MDS 2.0 between July 1996 and October 2006. In all samples, trained facility clinical staff completed the MDS 2.0 as part of normal clinical practice. The ABS is a 4-item summary scale measuring verbal and physical abuse, socially inappropriate behavior, and resisting care. In the single CCC facility, clinical facility staff completed the CMAI during the same assessment period as the MDS 2.0. Alphas for the ABS were between 0.79 and 0.93 for the three samples. A strong relationship was found between the ABS and the aggressive subscale of the CMAI (correlation coefficient=0.72, P<.001). Impairment in cognition was found to be related to higher ABS scores in all three samples. In CCC, individuals who had higher ABS scores also had a higher prevalence of psychiatric diagnoses and greater frequency of daily restraint use (P<.001 for each dependent variable). The ABS provides a useful measure of the severity of aggressive behavior that can be used for care planning, quality measurement, and research.

Safe Medication Swallowing in Dysphagia: A Collaborative Improvement Project

Episodes of choking during medication administration to patients with dysphagia prompted a chart audit and caregiver interview to identify system problems that allowed inappropriate drug administration to occur. Sixty elderly patients residing on two patient care areas in a 500-bed complex continuing care facility were studied. The audit explored the actual nursing medication administration methods and compared this to the information obtained from various communication tools including instructions that appeared on the medication administration record (MAR), the current diet order, the recommendations of the speech-language pathologist (SLP) and comments on the nursing care plan. The audit yielded a number of discrepancies between nursing actions and the instructions obtain from these sources. We proposed that changes to the process of communicating medication swallowing recommendations among team members would lead to greater patient safety. Major practice changes included the use of standardized language by the SLP when making recommendations, the writing of SLP recommendations in the doctor's orders, the inclusion of SLP recommendations on the MAR and the creation of a "dysphagia alert" on the pharmacy computer system. An educational intervention was conducted to implement process changes. Its effectiveness was evaluated using a pre- and post-test and a participant satisfaction survey. A post-implementation audit showed compliance with the practice change. In summary, process changes were implemented to improve compliance with SLP medication-related swallowing recommendations and to prevent the inadvertent prescribing, dispensing or crushing of sustained-release medications in patients with dysphagia.

Health Care Aides' Struggle to Build and Maintain Relationships with Families in Complex Continuing Care Settings

Research on the relationships between health care aides (HCAs) and families of clients has been situated mainly in long-term care settings and includes scant findings about the perceptions of HCAs. Based on the findings of a larger qualitative study using a grounded theory approach, this paper addresses the topic of HCA-family relationships in complex continuing care (CCC). In-depth individual interviews with eight HCAs and a follow-up focus group with HCAs from three CCC facilities were analysed. Building relationships with families entailed "being there for them and their relatives", while maintaining relationships involved "dealing with disappointments". Factors influencing building and maintaining HCA-family relationships included "having supportive team members", "having resources available", and "functioning within care-team hierarchies". The findings highlight the importance of minimizing the unit and organizational factors that disrupt HCA-family relationships.

Communication enhancement: nurse and patient satisfaction outcomes in a complex continuing care facility

This paper presents an evaluation of a communication enhancement intervention on staff and patients in a complex continuing care facility. The importance of effective communication as a fundamental element of nursing has been emphasized and is regarded as integral to the provision of quality patient care. For people residing in complex continuing care (similar to long-term care facilities), opportunities for socialization occur primarily during interactions or communication with staff, and these interactions have been found to be limited. One way to improve nursing staff communication is through a communication enhancement intervention. Twenty-one nursing staff members (Registered Nurses, Registered Practical Nurses and healthcare aides) working in a complex continuing care environment and 16 patients participated in this study, conducted in the summer of 2003. A repeated measures design was used to evaluate the effects of the communication enhancement intervention on outcomes. Data were collected from patients and nurses at baseline, 5 weeks into the intervention and at 10 weeks after the intervention. Nurse outcome variables included nurses' job satisfaction and their relationships with patients; patient outcome variables included two measures of patient satisfaction with care. Nursing staff felt closer to their patients (F(2,40) = 3.0, P = 0.045) following the intervention and reported higher levels of job satisfaction (F(2,40) = 4.1, P = 0.02). No changes were found in the level of patient satisfaction with care. Our results suggest that nursing staff can feel better about their job and about their patients as they enhance their communication skills. Understanding the barriers to finding time to talk with patients for a few minutes a day, outside of direct hands-on caregiving, requires further exploration.

Unit Manager's Role with Family Members of Clients in Complex Continuing Care Settings: An Untold Story

Most literature on staff-family relationships has come from studies of long-term care settings, has focused mainly on the families' perspectives on factors affecting their relationships with staff, and has included scant findings from the staff's perspective. No studies that examined staff-family relationships in complex continuing care (CCC) environments from the perspective of staff were found in the literature. A qualitative study that draws on a grounded theory approach was conducted to explore staff-family relationships in CCC, and the findings presented in this article illuminate the unit manager's role. Data were collected through in-depth interviews with nine unit managers and a follow-up focus group with five unit managers who work in three CCC facilities. Three categories reflecting the unit manager's role with family members of clients in CCC settings were derived: establishing supportive entry; building and preserving relationships; and closing the loop. Implications of the findings for practice and future research are presented.

Payer incentives and physical rehabilitation therapy for nonelderly institutional long-term care residents: evidence from Michigan and Ontario

Wodchis WP, Fries BE, Pollack H. Payer incentives and physical rehabilitation therapy for nonelderly institutional long-term care residents: evidence from Michigan and Ontario. Arch Phys Med Rehabil 2004;85:210–7. Objective To examine the effect of payment incentives on the provision of rehabilitation therapy to nonelderly nursing home residents. Design Retrospective cross-sectional study. Setting Nursing homes in Michigan or complex continuing care facilities in Ontario, Canada, in 1998 or 1999. Participants Nonelderly nursing home residents (N=5189) admitted to nursing homes. Interventions Not applicable. Main outcome measures The effect of payment on access to physical therapy (PT) and occupational therapy (OT) and total weekly time for each therapy type. Results A Medicare policy change from cost-based to a patient-specific case-mix payment method was associated with greater likelihood of receiving OT but reduced weekly minutes of PT and OT provided to residents. Medicare cost-based and private insurance were associated with greater likelihood of receiving OT and PT and more therapy time for both types of therapy compared with private-pay residents. Global budget payment was associated with greater access to PT but fewer weekly minutes of OT and PT. Conclusions Little information exists to describe the characteristics and treatment of nonelderly nursing home residents. This study found that many of these residents received rehabilitation and that residents whose care was paid for by more generous payers, such as Medicare, received more therapy than those paid for by less generous payers.

Facilitating the Process of Medication Re-evaluation and Withdrawal in the Long-Term Institutionalized Population: The Example of Cisapride

INTRODUCTION It is well documented that many patients in long-term or complex continuing care* facilities receive medications that are considered inappropriate, are not indicated, or are not utilized optimally, and that these problems occur at a higher rate than among their counterparts living at home.1-3 The prevalence of inappropriate prescribing is reportedly as high as 40% in nursing homes.4-6 For many medications prescribed to patients living in nursing homes, the indications are often not documented, which makes it difficult to evaluate the effectiveness of drug therapy.7 The occurrence of avoidable adverse drug reactions is the most serious consequence of suboptimal medication use. Drugs identified as particularly hazardous in this population include antipsychotics, antidepressants, sedatives, digoxin, diuretics, and nonsteroidal anti-inflammatory drugs.8-11 It is challenging to recognize treatment-emergent symptoms as adverse effects because they may not present in the standard way in frail elderly or chronically ill patients and may be misinterpreted as part of the normal aging process. The economic burden of the cost of medications, the cost of medication administration time, and the cost (although difficult to measure) of the negative pharmacotherapeutic outcomes associated with suboptimal medication use are also of concern.12 Such concerns regarding cost often create the impetus for facilities to take on the challenge of reducing inappropriate or suboptimal medication use. Attempts to decrease inappropriate medication use and corresponding costs have been successful to varying degrees. Mechanisms include consultant pharmacists providing medication reviews, interdisciplinary medication review, face-to-face educational interventions for physicians and nurses, academic detailing, pharmacy and therapeutics committee policies on formulary management, application of criteria to identify inappropriate prescribing, and drug utilization review of specific drugs or categories of drugs.13-26 Studies examining the outcome of medication withdrawal in elderly patients have shown that a high percentage of medications can be discontinued without adverse consequences.27 The nursing home or long-term care setting is believed to be a good environment in which to attempt drug withdrawal because patients can be monitored closely for adverse drug withdrawal events.28 The SCO Health Service provides long-term care, complex continuing care, palliative care, and rehabilitation services through 3 main sites in Ottawa: Elisabeth Bruyere Health Centre, St. Vincent Hospital, and Residence St. Louis (the abbreviation SCO refers to the founding Soeurs de la charite d’Ottawa or Sisters of Charity of Ottawa). In addition to an ongoing patient-specific interdisciplinary medication review conducted every 4 months at this institution, it was decided, in 1999, to explore the possibility of a targeted medication withdrawal program. In this program a drug or group of drugs would be identified for withdrawal, and the withdrawal process would be applied to all 437 patients in the institution’s complex continuing care program at the same time, rather than waiting for individual medication reviews (during which numerous issues may have to be addressed). The first drug identified for withdrawal was cisapride. A number of patients were receiving it, it accounted for a substantial portion of the institution’s drug budget, and its potential side effects are significant. A random chart audit revealed that cisapride had usually been initiated upon insertion of a feeding tube to prevent symptoms of gastroesophageal reflux disease (GERD) or aspiration pneumonia. This article describes how a carefully planned and monitored medication withdrawal program for one drug was successful in decreasing medication use and costs in a complex continuing care facility and in identifying patients who required alternative or continued medication for their condition. This example illustrates the need for continuous re-evaluation of medication treatment in long-term institutionalized patients. The process described here is one method of ensuring that medication therapy does get re-evaluated in patients for whom pharmacists and physicians may have difficulty making medication therapy changes.