Long-term Care Placement Research Articles

Decreasing Disruptive Behavior While Decreaseing Psychoactive Medications in Our Nurisng Facility

Many older adults would like to remain at home as they age. Many of these older adults have dementia and behavioral health challenges. Psychoactive medications such as antipsychotics and anxiolytics are prescribed to manage these behaviors and facilitate the provision of care by the family members. These medications often place the individual at risk for sedation, falls, elevated blood sugar, elevated lipids, and even sudden death. Additionally, some carry a “black box” warning if prescribed for management of behavior in patients with dementia. Eventually, these patients present to nursing facilities for long-term care placement. The challenge then is that CMS lists only schizophrenia, Huntington's Disease, and Tourette's Syndrome as acceptable diagnoses in a nursing facility for which antipsychotics are appropriate treatment.

Mental Health Integration in Geriatric Patient-Aligned Care Teams in the Department of Veterans Affairs

To inform geriatric mental health policy by describing the role of behavioral healthcare providers within a geriatric patient-aligned care team (GeriPACT), a patient-centered medical home model of care within the Veterans Health Administration (VHA), serving older veterans with chronic disease, functional dependency, cognitive decline, and psychosocial challenges, and/or those who have elder abuse, risk of long-term care placement, or impending disability. The authors used mixed methods, consisting of a national survey and site visits between July 2016 and February 2017, at VHA outpatient clinics. The participants, 101 GeriPACTs at 44 sites, completed surveys, and 24 medical providers were interviewed. A standardized survey and semi-structured interview guide were developed based on the program handbook, with input from experts in the VHA Office of Geriatrics and Extended Care Services, guided by the Consolidated Framework for Implementation Science Research. Of surveyed GeriPACTs, 42.6% had a mental health provider on the team-a psychiatrist (28.7%) and/or psychologist (23.8%). Of these, the mean was 0.27 full-time equivalent psychiatrists and 0.44 full-time equivalent psychologists per team (suggested panel = 800 patients). In surveys, teams with behavioral health providers were more likely to manage psychosocial χ2 = 8.87, cognitive χ2 = 8.68, and depressive χ2 = 11.85 conditions in their panel than those without behavioral health providers. GeriPACT mental health integration is less than 50%. Population differences between general primary care and geriatric primary care may require different care approaches and provider competencies and need further study.

Botulism Outbreak in a Regional Community Hospital: Lessons Learned in Transfer and Transport Considerations

Botulism is a potentially lethal disease caused by a toxin released by Clostridium botulinum. Outbreaks of botulism from food sources can lead to a Mass Casualty Incident (MCI) involving sometimes hundreds of individuals. We report on a recent outbreak of botulism treated at a regional community hospital with a focus on emergency medical services (EMS) response and transport considerations. Case Presentation: There were 53 patient evaluated for botulism at the sending facility. In total, 11 botulism exposures required intubation at the sending facility. Twenty-four patients were ultimately transported by critical care capable ALS crews with the majority (16) of these transports occurred in the first 24 hours. There was one fatality in the first days of the outbreak and a second death that occurred in a patient who died after long-term acute care (LTAC) placement several months after hospital discharge. Conclusion: Local EMS providers and public safety officers have a critical role in identifying and following up on potentially exposed botulism cases. The organization of transporting agencies and the logistics of transfer turned out to be 2 opportunities for improvement in response to this mass casualty incident.

MIND at Home-Streamlined: Study protocol for a randomized trial of home-based care coordination for persons with dementia and their caregivers

BackgroundDementia is associated with high health care costs, premature long-term care (LTC) placement, medical complications, reduced quality of life, and caregiver burden. Most health care providers and systems are not yet organized or equipped to provide comprehensive long-term care management for dementia, although a range of effective symptoms and supportive care approaches exist. The Maximizing Independence at Home-Streamlined (MIND-S) is a promising model of home-based dementia care coordination designed to efficiently improve person-centered outcomes, while reducing care costs. This report describes the rationale and design of an NIA-funded randomized controlled trial to test the impact of MIND-S on time to LTC placement, person with dementia outcomes (unmet needs, behavior, quality of life), family caregiver outcomes (unmet needs, burden), and cost offset at 18 (primary end point) and 24 months, compared to an augmented usual care group. MethodsThis is a 24-month, parallel group, randomized trial evaluating MIND-S in a cohort of 304 community-living persons with dementia and their family caregivers in Maryland. MIND-S dyads receive 18 months of care coordination by an interdisciplinary team comprised of trained non-clinical community workers (e.g. Memory Care Coordinators), a registered nurse, and a geriatric psychiatrist. Intervention components include in-home dementia-related needs assessments; individualized care planning; implementation of standardized evidence-based care strategy protocols; and ongoing monitoring and reassessment. Outcomes are assessed by blinded evaluators at baseline, 4.5, 9, 13.5, 18, and 24 months. DiscussionTrial results will provide rigorous data to inform innovations in effective system-level approaches to dementia care.

Differences Between Skilled Nursing Facilities in Risk of Subsequent Long-Term Care Placement.

ObjectivesTo determine how the risk of subsequent long‐term care (LTC) placement varies between skilled nursing facilities (SNFs) and the SNF characteristics associated with this risk.DesignPopulation‐based national cohort study with participants nested in SNFs and hospitals in a cross‐classified multilevel model.SettingSNFs (N=6,680).ParticipantsFee‐for‐service Medicare beneficiaries (N=552,414) discharged from a hospital to a SNF in 2013.MeasurementsParticipant characteristics from Medicare data and the Minimum Data Set. SNF characteristics from Medicare and Nursing Home Compare. Outcome was a stay of 90 days or longer in a LTC nursing home within 6 months of SNF admission.ResultsWithin 6 months of SNF admission, 10.4% of participants resided in LTC. After adjustments for participant characteristics, the SNF where a participant received care explained 7.9% of the variance in risk of LTC, whereas the prior hospital explained 1.0%. Individuals in SNFs with excellent quality ratings had 22% lower odds of transitioning to LTC than those in SNFs with poor ratings (odds ratio=0.78, 95% confidence interval=0.74–0.84). Variation between SNFs and associations with quality markers were greater in sensitivity analyses limited to individuals least likely to require LTC. Results were essentially the same in a number of other sensitivity analyses designed to reduce potential confounding.ConclusionRisk of subsequent LTC placement, an important and negatively viewed outcome for older adults, varies substantially between SNFs. Individuals in higher‐quality SNFs are at lower risk.

A population-based cohort study defines prognoses in severe chronic kidney disease

In older people with chronic kidney disease (CKD) and comorbidities, the risk of death or disability may overshadow the risk of kidney failure. To help refine this we did a retrospective population-based cohort study to evaluate the relative likelihood of adverse outcomes as functions of age and comorbidity burden among 47,228 adults with severe non-dialysis dependent CKD. We identified comorbidities using 29 validated algorithms applied to administrative data and assessed death, end-stage renal disease (ESRD), cardiovascular disease (CVD) events, and long-term care. Over five years of follow-up, 53.4% of participants died, 24.1% had a CVD event, 14.3% were placed into long-term care and 5.3% developed ESRD. Death was 145 times more likely and 11 times more likely than ESRD for participants aged 80 years or more and 60-79 years, respectively; long-term care was 30 times more likely and 1.7 times as likely as ESRD for participants aged 80 years or more and 60-79 years, respectively. Increasing comorbidity burden was similarly associated with increased risk of death and long-term care placement but reduced the likelihood of ESRD, and the risks of increasing age were similarly incremental. Thus, among patients with severe CKD, older age and/or higher comorbidity burden, death and long-term care placement are markedly more likely than ESRD. Hence, clinicians, patients and families should all consider the relative magnitude of these risks when making decisions about renal replacement.

Using Critical Creativity to Reveal Nursing Student Learning in Long-Term Care.

The use of teaching-learning strategies that emphasize critical reflection aids students in making sense of complex clinical placement settings, such as those in long-term care (LTC) settings. A qualitative descriptive research design was used to explore the assumptions, anticipations, and realizations of six undergraduate nursing students regarding aging, gerontological nursing, and LTC as they engaged in facilitated critical reflection activities during a 12-week LTC placement. The content analysis process revealed four main categories describing the student learning experience: Exploring the Therapeutic Nurse-Resident Relationship, Navigating Preceptor Relationships, Expanding Awareness of Context, and Embracing Many Feelings. Students placed in LTC were challenged by the realization of LTC as a complex setting, especially with minimal support from preceptors. Educators should present LTC as a challenging environment, rich with complex issues. There is potential in easing the strain on preceptors by leveraging the faculty educator role in facilitating student learning through critically creative approaches. [J Nurs Educ. 2018;57(3):150-153.].

Delirium Superimposed on Dementia

Abstract Delirium and dementia are 2 different pathophysiologic processes, each manifesting signs that so overlap that they are often indistinguishable to the practicing clinician. Delirium superimposed on dementia is an underdiagnosed disease process associated with increased mortality and morbidity, longer recovery rates, higher cost, increased risk for falls, and long-term care placement. This article presents an overview of this disease with a focus on early recognition and prevention. Recommendations for treatment strategies, derived from evidence, are presented for consideration by family and adult and geriatric acute care nurse practitioners.

Adverse Events in Home Care: Identifying and Responding with interRAI Scales and Clinical Assessment Protocols.

Outcomes of adverse events in home care are varied and multifactorial. This study tested a framework combining two health measures to identify home care recipients at higher risk of long-term care placement or death within one year. Both measures come from the Resident Assessment Instrument-Home Care (RAI-HC), a standardized comprehensive clinical assessment. Persons scoring high in the Method for Assigning Priority Levels (MAPLe) algorithm and Changes in Health, End-stage disease, Signs and Symptoms (CHESS) scale were at the greatest risk of placement or death and more than twice as likely to experience either outcome earlier than others. The target group was more likely to trigger mood, social relationship, and caregiver distress issues, suggesting mental health and psychosocial interventions might help in addition to medical care and/or personal support services. Home care agencies can use this framework to identify home care patients who may require a more intensive care coordinator approach.

Physical Frailty Is Associated with Longitudinal Decline in Global Cognitive Function in Non-Demented Older Adults: A Prospective Study.

To assess the relationship between physical frailty and subsequent decline in global cognitive function in the non-demented elderly. A prospective population-based study in a west Japanese suburban town, with two-year follow-up. Community-dwellers aged 65 and older without placement in long-term care, and not having a history of dementia, Parkinson's disease and depression at baseline, who participated in the cohort of the Sasaguri Genkimon Study and underwent follow-up assessments two years later (N = 1,045). Global cognitive function was assessed using the Montreal Cognitive Assessment (MoCA). Physical frailty was identified according to the following five components: weight loss, low grip strength, exhaustion, slow gait speed and low physical activities. Linear regression models were used to examine associations between baseline frailty status and the MoCA scores at follow-up. Logistic regression models were used to estimate the risk of cognitive decline (defined as at least two points decrease of MoCA score) according to baseline frailty status. Seven hundred and eight non-demented older adults were included in the final analyses (mean age: 72.6 ± 5.5 years, male 40.3%); 5.8% were frail, and 40.8% were prefrail at baseline. One hundred and fifty nine (22.5%) participants experienced cognitive decline over two years. After adjustment for baseline MoCA scores and all confounders, being frail at baseline was significantly associated with a decline of 1.48 points (95% confidence interval [CI], -2.37 to -0.59) in MoCA scores, as compared with non-frailty. Frail persons were over two times more likely to experience cognitive decline (adjusted odds ratio 2.28; 95% CI, 1.02 to 5.08), compared to non-frail persons. Physical frailty is associated with longitudinal decline in global cognitive function in the non-demented older adults over a period of two years. Physically frail older community-dwellers should be closely monitored for cognitive decline that can be sensitively captured by using the MoCA.

Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus-Study protocol.

Despite availability of effective care strategies for dementia, most health care systems are not yet organized or equipped to provide comprehensive family-centered dementia care management. Maximizing Independence at Home-Plus is a promising new model of dementia care coordination being tested in the U.S. through a Health Care Innovation Award funded by the Centers for Medicare and Medicaid Services that may serve as a model to address these delivery gaps, improve outcomes, and lower costs. This report provides an overview of the Health Care Innovation Award aims, study design, and methodology. This is a prospective, quasi-experimental intervention study of 342 community-living Medicare-Medicaid dual eligibles and Medicare-only beneficiaries with dementia in Maryland. Primary analyses will assess the impact of Maximizing Independence at Home-Plus on risk of nursing home long-term care placement, hospitalization, and health care expenditures (Medicare, Medicaid) at 12, 18 (primary end point), and 24 months, compared to a propensity-matched comparison group. The goals of the Maximizing Independence at Home-Plus model are to improve care coordination, ability to remain at home, and life quality for participants and caregivers, while reducing total costs of care for this vulnerable population. This Health Care Innovation Award project will provide timely information on the impact of Maximizing Independence at Home-Plus care coordination model on a variety of outcomes including effects on Medicaid and Medicare expenditures and service utilization. Participant characteristic data, cost savings, and program delivery costs will be analyzed to develop a risk-adjusted payment model to encourage sustainability and facilitate spread.

Sleep and Long-Term Care.

Long-term care (LTC) involves a range of support and services for people with chronic illness and disabilities who can not perform activities of daily living independently. Poor sleep increases the risk of LTC placement, and sleep disturbance is extremely common among LTC residents. The identification and management of sleep disturbance in LTC residents is a vital, but perhaps underappreciated, aspect of offering high-quality care for this already compromised population. This review describes the nature and consequences of sleep disturbances in LTC, clinical assessment and management of sleep disturbances in LTC, and implications for future research and clinical practice.

Mortality among referrals to a community-based intermediate care team

ObjectivesIntermediate care services have been introduced to help mitigate unnecessary hospital demand and premature placement in long-term residential care. Many patients are elderly and/or with complex comorbidities, but little consideration...

Undergraduate Placements in Geriatric Care Facilities: Students Gaining Experience With Challenging/Responsive Behaviors.

Undergraduate nursing students may experience challenging behaviors in residents during their clinical placement in geriatric long-term care (GLTC) facilities. Bachelor of Nursing students participated in an anonymous online questionnaire (n = 116). The students witnessed a wide range of challenging behaviors, also referred to as responsive behaviors, in GLTC residents. The most frequent behaviors included agitation/restlessness, repetitive talk, and wandering. Although behaviors such as physical aggression and disinhibited sexual behavior were experienced less frequently, students found these behaviors the most distressing. Students felt ill-prepared to manage these behaviors, which was associated with higher levels of distress. The students demonstrated good theoretical knowledge about responsive behaviors, but the lack of personal experience in managing such behaviors left the students feeling ill-prepared and distressed. Incorporating the opportunity to experience behaviors in a supported environment, such as in simulation, could reduce student distress and increase their sense of competency. [J Nurs Educ. 2017;56(10):623-627.].

GP.03 Outcomes after gastrostomy tube placement in patients with acute stroke: A 10-year population-based study using the Ontario Stroke Registry

Background: Dysphagia is a common and devastating complication after acute stroke. Percutaneous endoscopic gastrostomy (PEG) tubes are often placed for persistent dysphagia. However, little is known regarding outcomes after PEG tube placement. Methods: We used a 10-year Ontario Stroke Registry to shed light on the clinical outcomes of patients with PEG tube insertion after ischemic stroke or intracranial hemorrhage compared to patients with only NG tubes, including rate of pneumonia, disability, and mortality. Results: Using propensity score matching, 1,793 patients were successfully matched and had similar baseline characteristics. Compared with NG, patients with PEG had a higher rate of pneumonia (32.6% vs. 20.6%; RR 1.59), higher disability at discharge (modified Rankin Scale Score 3-5; 74.0% vs. 65.4%; RR 1.13), and higher rate of long-term care placement (27.1% vs. 9.3%; RR 2.9). >From stroke onset, there was a lower rate of death in patients with PEG compared to NG at 30 days (15.3% vs. 34.3%; RR 0.45) but no difference at 2 years (52.8% vs. 53.5%; RR 0.99, p=0.71). *All significant p <0.0001. Conclusions: In conclusion, PEG tube placement after stroke may prolong survival in patients with poor outcomes. Our study provides a framework for discussions between physicians, patients, and families with regards to expected prognosis after PEG tube placement.

Transplant Professionals' Perceptions of Long-Term Care Residents' Candidacy for Kidney Transplantation.

Given the aging end-stage renal disease (ESRD) population, kidney transplant (KTx) centers may experience an increase in referrals of patients living in long-term care (LTC) settings (eg, skilled nursing facilities, assisted living facilities, group homes, and boarding homes). To identify best practices among KTx professionals when considering individuals in LTC settings for transplantation. A cross-sectional survey administered online to US transplant professionals via e-mail LISTSERVs and other professional networks. One hundred twenty-six KTx professionals working in the United States. The survey was composed of demographic questions and 6 hypothetical scenarios. These scenarios asked participants to assess transplant candidacy of patients with ESRD living in LTC settings based on the information provided in the scenario. Each scenario presented a different variable that necessitated LTC placement, including lack of social support, moderate intellectual disability, stable neurological condition, mild dementia, a psychiatric condition controlled on medications, and limited mobility. The only scenario that elicited an overwhelmingly negative response was mild dementia with 73.9% of participants unwilling to consider such patients for KTx. By contrast, the proportion of KTx professionals reluctant to proceed with KTx in the remaining scenarios ranged between 40.0% and 50.6%. This survey of a large number of KTx professionals suggests that there is presently no best practice consensus regarding offering KTx to patients living in LTC settings. Further research should include a broader range of KTx professionals and should also include a study of outcomes with KTx in this particular patient population.

Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort.

BackgroundFor community-dwelling older persons with dementia, the presence of multimorbidity can create complex clinical challenges for both individuals and their physicians, and can contribute to poor outcomes. We quantified the associations between level of multimorbidity (chronic disease burden) and risk of hospitalization and risk of emergency department (ED) visit in a home care cohort with dementia and explored the role of continuity of physician care (COC) in modifying these relationships.Methods and findingsA retrospective cohort study using linked administrative and clinical data from Ontario, Canada, was conducted among 30,112 long-stay home care clients (mean age 83.0 ± 7.7 y) with dementia in 2012. Multivariable Fine–Gray regression models were used to determine associations between level of multimorbidity and 1-y risk of hospitalization and 1-y risk of ED visit, accounting for multiple competing risks (death and long-term care placement). Interaction terms were used to assess potential effect modification by COC.Multimorbidity was highly prevalent, with 35% (n = 10,568) of the cohort having five or more chronic conditions. In multivariable analyses, risk of hospitalization and risk of ED visit increased monotonically with level of multimorbidity: sub-hazards were 88% greater (sub-hazard ratio [sHR] = 1.88, 95% CI: 1.72–2.05, p < 0.001) and 63% greater (sHR = 1.63; 95% CI: 1.51–1.77, p < 0.001), respectively, among those with five or more conditions, relative to those with dementia alone or with dementia and one other condition. Low (versus high) COC was associated with an increased risk of both hospitalization and ED visit in age- and sex-adjusted analyses only (sHR = 1.11, 95% CI: 1.07–1.16, p < 0.001, for hospitalization; sHR = 1.07, 95% CI: 1.03–1.11, p = 0.001, for ED visit) but did not modify associations between multimorbidity and outcomes (Wald test for interaction, p = 0.566 for hospitalization and p = 0.637 for ED visit). The main limitations of this study include use of fixed (versus time-varying) covariates and focus on all-cause rather than cause-specific hospitalizations and ED visits, which could potentially inform interventions.ConclusionsOlder adults with dementia and multimorbidity pose a particular challenge for health systems. Findings from this study highlight the need to reshape models of care for this complex population, and to further investigate health system and other factors that may modify patients’ risk of health outcomes.

World Health Organization Disability Health Assessment 2.0 for Health Monitoring: Examining the potential use of the WHODAS 2.0 as a health screening tool among older adults in rural North Carolina

Unless measures are taken, escalating healthcare costs and an aging population will increasingly contribute to financial burdens on federal and state healthcare budgets. With the help of appropriate supports, many older adults can remain in their homes and communities and delay expensive long-term care placements. An important aspect of aging in place is health monitoring so that health issues can be addressed before they escalate. The WHODAS 2.0 is a standardized assessment tool that may be valuable for recreational therapists and others to use to monitor health and functional status of community-dwelling older adults.

Predictors of long-term care placement in persons with dementia: a systematic review and meta-analysis.

The main objective of this study was to summarize the effects of various individual, caregiver, and system-related factors on the risk of long-term care (LTC) placement for persons with dementia. We searched electronic databases for longitudinal studies reporting on predictors of LTC placement for persons with dementia residing in the community or supportive care settings. We performed meta-analyses with hazard ratios (HRs) of various predictors using random effects models and stratified the HRs with several study variables. Data on predictors not included in the meta-analyses were summarized descriptively. Full-text reviews of 360 papers were performed with data from 37 papers used to calculate pooled HRs for LTC placement of select person with dementia (age, sex, race, marital status, type of dementia, living arrangement, and relationship to caregiver) and caregiver (age, sex, and depressive symptoms) characteristics. White race [HR = 1.67, 95% confidence intervals (CI): 1.41-1.99], greater dementia severity (HR = 1.05, 95% CI: 1.03-1.06), and older age (HR = 1.02, 95% CI: 1.01-1.03) increased the risk of LTC placement. Married persons with dementia (HR = 0.38, 95% CI: 0.16-0.86) and living with their caregiver (HR = 0.72, 95% CI: 0.56-0.92) had a lower risk. Behavioral and psychological symptoms of dementia, the degree of functional impairment, and caregiver burden had a consistent effect on the risk of LTC placement in our descriptive review. We quantified the predictive effect of several risk factors for LTC placement. These estimates could be used to more precisely categorize the risk of institutionalization and potentially link those at higher risk to appropriate services. Copyright © 2016 John Wiley & Sons, Ltd.

Circles of Support and personalization: Exploring the economic case.

Circles of Support aim to enable people with learning disabilities (and others) to live full lives as part of their communities. As part of a wider study of the economic case for community capacity building conducted from 2012 to 2014, we conducted a mixed methods study of five Circles in North West England. Members of these Circles were supporting adults with moderate to profound learning disabilities and provided accounts of success in enabling the core member to live more independent lives with improved social care outcomes within cost envelopes that appeared to be less than more traditional types of support. The Circles also reported success in harnessing community resources to promote social inclusion and improve well-being. This very small-scale study can only offer tentative evidence but does appear to justify more rigorous research into the potential of Circles to secure cost-effective means of providing support to people with learning disabilities than the alternative, which in most cases would have been a long-term residential care placement.