Nursing Care Facilities Research Articles

Should we provide outreach rehabilitation to very old people living in Nursing Care Facilities after a hip fracture? A randomised controlled trial.

Objectiveto determine whether a 4-week postoperative rehabilitation program delivered in Nursing Care Facilities (NCFs) would improve quality of life and mobility compared with receiving usual care.Designparallel randomised controlled trial with integrated health economic study.SettingNCFs, in Adelaide South Australia.Subjectspeople aged 70 years and older who were recovering from hip fracture surgery and were walking prior to hip fracture.Measurementsprimary outcomes: mobility (Nursing Home Life-Space Diameter (NHLSD)) and quality of life (DEMQOL) at 4 weeks and 12 months.Resultsparticipants were randomised to treatment (n = 121) or control (n = 119) groups. At 4 weeks, the treatment group had better mobility (NHLSD mean difference −1.9; 95% CI: −3.3, −0.57; P = 0.0055) and were more likely to be alive (log rank test P = 0.048) but there were no differences in quality of life. At 12 months, the treatment group had better quality of life (DEMQOL sum score mean difference = −7.4; 95% CI: −12.5 to −2.3; P = 0.0051), but there were no other differences between treatment and control groups. Quality adjusted life years (QALYs) gained over 12 months were 0.0063 higher per participant (95% CI: −0.0547 to 0.0686). The resulting incremental cost effectiveness ratios (ICERs) were $5,545 Australian dollars per unit increase in the NHLSD (95% CI: $244 to $15,159) and $328,685 per QALY gained (95% CI: $82,654 to $75,007,056).Conclusionsthe benefits did not persist once the rehabilitation program ended but quality of life at 12 months in survivors was slightly higher. The case for funding outreach home rehabilitation in NCFs is weak from a traditional health economic perspective.Trial registrationACTRN12612000112864 registered on the Australian and New Zealand Clinical Trials Registry. Trial protocol available at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 361980

Perceived Costs of Care Influence Post-Acute Care Choices by Clinicians, Patients, and Caregivers.

Older adults frequently receive post-acute care (PAC) after hospital discharge, but little is known about how perceived costs influence PAC choices. This research study sought to understand how clinicians, patients, and their caregivers evaluate the cost of skilled nursing facility (SNF) care in their decisions about whether to utilize SNFs after hospital discharge. Guided by principles of social constructivist theory, we conducted a qualitative interpretative study using semistructured interviews with clinicians, patients, and caregivers. The study took place in three SNFs and three hospitals located in an urban area. Purposive sampling was used to maximize variability in SNFs, hospitals, units within hospitals, and staff. A total of 104 participants made up the study: 25 hospital clinicians, 20 SNF clinicians, 20 hospital patients, 15 SNF patients, 14 hospital caregivers, and 10 SNF caregivers who were directly involved in patients' transition from acute hospitalization to SNFs. Central themes related to how perceived costs of care influence PAC choices. Clinicians, patients, and caregivers did not understand the nuances of SNF insurance coverage or out-of-pocket costs. They felt constrained by insurance coverage in their discharge disposition choices and faced delays in hospital discharge due to insurance authorization processes. Some clinicians reacted to these constraints by "documenting failure," sending patients home to "fail" so they could justify SNF to insurers. Others changed their recommendations to provide patients "some" postdischarge care, even if inadequate, because of cost constraints. Clinicians discussed conserving resources to take maximal advantage of insurance-covered SNF days. Overall, cost constraint resulted in patient safety concerns, clinician professional dilemma, and moral distress. Improving patient and caregiver understanding about costs and constraints of PAC would improve decision making. There is a need for improved comprehension of cost and insurance coverage of SNF care for informed patient and provider decision making at the time of hospital discharge. J Am Geriatr Soc 67:703-710, 2019.

The association of early postoperative desaturation in the operating theatre with hospital discharge to a skilled nursing or long-term care facility.

It is unclear which criteria should be used to define readiness for tracheal extubation in the operating theatre. We studied the effects of desaturation in the operating theatre immediately after tracheal extubation on long-term outcomes. Performing a pre-specified, retrospective analysis of 71,025 cases involving previously independent adults undergoing non-cardiac surgery, we evaluated the association between desaturation events (oxygen saturation <90%) within 10min of tracheal extubation and adverse discharge (to a skilled nursing facility or long-term care facility). A total of 404 (12.3%) cases with, and 5035 (7.4%) cases without, early postoperative desaturation had an adverse discharge. Early postoperative desaturation was associated with higher odds of being discharged to a nursing facility (adjusted odds ratio 1.36 (95%CI 1.20-1.54); p<0.001). Increased duration of desaturation augmented the effect (p for trend <0.001). Desaturation was associated with a higher risk of respiratory, renal and cardiovascular complications as well as increased duration of hospital stay, postoperative intensive care unit admission frequency and cost. Several modifiable factors were associated with desaturation including: high intra-operative long-acting opioid administration; high neostigmine dose; high intra-operative inspired oxygen concentration; and low oxygen delivery immediately before tracheal extubation. There was substantial provider variability between anaesthetists in the incidence of postoperative desaturation unexplained by patient- and procedure-related factors. Early postoperative desaturation is a potentially preventable complication associated with a higher risk of adverse discharge disposition. Anaesthetists may consider developing guidelines to define tracheal extubation readiness that contain postoperative desaturation as an adverse outcome after tracheal extubation.

Mobile Outreach: An Innovative Program for Older Orthopedic Patients in Care Facilities.

Introduction:The worldwide incidence of fragility fractures is increasing and the greatest burden is borne by the oldest population. Mobile Outreach, an innovative orthopedic-based program providing on-site musculoskeletal care for individuals in nursing care facilities, was implemented as part of our Geriatric Orthopaedic Trauma Program. The objectives of this report are to describe characteristics of patients cared for through Mobile Outreach and to report specific services provided.Program Description:Based from a nonprofit, private hospital that serves as the community’s level 1 trauma center and teaching hospital, the Mobile Outreach Program is directed by an orthopedic surgeon with geriatric subspecialization and staffed by a full-time geriatric nurse practitioner. Patients receive care for musculoskeletal concerns and fracture assessments at their nursing care facilities by a Mobile Outreach care provider. Referral for care is from nursing care facilities or as scheduled postoperative follow-up.Results:In 2016, the program treated 458 patients (76% female) in the patients’ care settings for a total of 689 visits. The mean age was 81 years (standard deviation = 14; range 25-107). Care of patients included nonoperative fracture care in 100 (22%), postoperative fracture follow-up in 149 (33%), injections for pain management in 184 (40%), and other orthopedic care in 25 (5%). Visits occurred at 88 facilities, mean 7 visits per site (range 1-57).Conclusions:Mobile Outreach was implemented to improve postoperative fracture care in the elderly patients. The program also provides on-site nonoperative fracture care and care of frail elderly individuals with chronic musculoskeletal conditions. This report aims to establish the feasibility of a program focused on the provision of appropriate, coordinated care for older fracture patients in their care facility. Level of Evidence: Level V.

Activity of daily living improvement after cataract surgery for patients in nursing care facilities

Activity of daily living improvement after cataract surgery for patients in nursing care facilities

Dysphagia Hinders Hospitalized Patients with Heart Failure from Being Discharged to Home.

Dysphagia, defined as a dysfunction in any stage or process of eating, is common among heart failure (HF) patients. In some diseases state, dysphagia hinders patients from being discharged to home. However, it remains unclear whether dysphagia affects discharge disposition of HF patients. This study aimed to identify the impact of dysphagia on discharge disposition of HF patients. A total of 323 patients, hospitalized with acute exacerbation of HF, were eligible for the study (excluding patients who lived at nursing care facilities before admission). Following the withdrawal of 37 patients, a total of 286 patients were analyzed. Dysphagia was determined using the functional oral intake scale (FOIS), which evaluates a patient's ability to swallow. The FOIS is a 7-point scale, with a level of ≤ 5 indicating dysphagia. Of the 286 patients analyzed, 231 (80.8%) were discharged to home, and 55 were discharged to nursing care facilities or rehabilitation hospitals (non-home). FOIS level was significantly lower, and dysphagia incidence was significantly higher among patients discharged to non-home than among those discharged to home. Multivariate analysis showed that FOIS level was an independent predictor of discharge disposition. Additionally, after propensity score matching, which was performed to adjust for baseline characteristics, FOIS level remained significantly lower in patients discharged to non-home than in those discharged to home. In conclusion, dysphagia hinders patients hospitalized with HF from being discharged to home. We conclude that evaluating dysphagia and its severity on admission is useful for predicting discharge disposition in patients hospitalized with HF.

Thoreau in Pittsburgh: Reflections on Domestic Terrorism

Thoreau in Pittsburgh:Reflections on Domestic Terrorism Joshua David Bellin (bio) I grew up in Squirrel Hill, a five-minute walk from the Tree of Life synagogue. Though I wasn't raised in the Jewish faith—a detail that escaped the spectators who screamed anti-Semitic obscenities at me when I played Pony League baseball games in their neighborhoods—I did have many Jewish friends, and I attended their bar mitzvahs at Tree of Life. Likewise, though I didn't know any of the eleven men and women who were murdered there on Saturday, 27 October 2018, I was in Squirrel Hill when it happened, visiting my father, a nonobservant Jew, at the nursing care facility that used to be called the Jewish Home for the Aged. The building was on lockdown while the standoff with police played out a couple of miles away. The Monday following the shooting, my American literature class met at La Roche University, a small Catholic institution in Pittsburgh's northern suburbs. As it happened, we were scheduled to discuss Thoreau's "Resistance to Civil Government" (1849). But the students were visibly shaken by the mass murder in their community, and we ended up talking about that instead: about their fears, their disbelief, their connections to Squirrel Hill. One woman had attended a wedding at Tree of Life the previous week. She knew congregants who were killed, and she couldn't shake the feeling that, if not for a quirk of fate, she could have been among them. Like most Pittsburgh residents, I've had trouble forgetting that day. As a teacher, there have been moments when my activities pale beside the enormity of what happened at Tree of Life; I've wondered what difference American literature makes in a world where innocent people are slain in houses [End Page 553] of worship. Perhaps because I've been wrestling with such dissonance, I've given considerable thought to the question of Thoreau's relationship to what we now term domestic terrorism. We can easily draw such connections: at the end of a decade that saw Thoreau's increasing antislavery radicalism, he delivered "A Plea for Captain John Brown" (1859), which celebrates the life and martyrdom of the antebellum era's most notorious domestic terrorist.1 Could it be, I've wondered, that the almost unthinkable incongruity of these two events—a terrible act of hatred in my old neighborhood, the study of Thoreau's celebrated statement of political nonviolence in the college classroom's ostensibly safe confines—harbors a deeper affinity? To put it more plainly: was Thoreau a sponsor, an apologist, and a disciple of the homegrown terrorism of his day? To answer such a question, I had to (re)turn to Brown, whom I've long found both fascinating and repellent. I inherited my interest in this controversial figure from my father, a Brown enthusiast whose long life ended roughly a month after the shooting. More than forty years earlier, my dad piled the family into our Buick Skylark convertible and embarked on a meandering voyage through southwestern Pennsylvania in search of a tannery Brown operated. That trip ended in disappointment when, on the barely drivable dirt track that led to the site, we ran over a nail and popped a tire. I've gone on many Brown odysseys of my own since then. In a climate-controlled storage vault in the Massachusetts Historical Society, I stood face to blade with one of the pikes Brown commissioned to arm freed slaves at Harpers Ferry; in a cluttered museum in Charles Town, West Virginia, I surveyed the wagon in which the convicted killer was carried to the site of his execution. With my teenage son, I poked around in the restored Maryland farmhouse where Brown gathered his arms and men before marching on the federal arsenal. Our next trip will be to Chambersburg, Pennsylvania, where Brown met with Frederick Douglass in an abandoned [End Page 554] quarry and, unable to convince the seasoned orator to join his team, recruited Douglass' much younger companion, fellow escaped slave Shields Green. Green, like Brown, would later be captured at Harpers Ferry and executed.2 In my research...

PREDICTING 30-DAY MORTALITY AND 30-DAY RE-HOSPITALIZATION RISKS IN MEDICARE PATIENTS WITH HEART FAILURE DISCHARGED TO SKILLED NURSING FACILITIES: DEVELOPMENT AND VALIDATION OF MODELS USING ADMINISTRATIVE DATA

Despite the growing importance of skilled nursing facility care for Medicare patients hospitalized with heart failure, no risk prediction models for these patients exist. To develop and validate separate predictive models for 30-day all-cause mortality and 30-day all-cause re-hospitalization. Retrospective cohort study using a nationwide Medicare claims data cross-linked with Minimum Data Set 3.0. 11,529 skilled nursing facilities in the United States (2011-2013). 77,670 hospitalized heart failure patients discharged to skilled nursing facilities (randomly split into development (2/3) and validation (1/3) cohorts). Using data on patient sociodemographic and clinical characteristics, health service use, functional status, and facility-level factors, we developed separate prediction models for 30-day mortality and 30-day re-hospitalization using logistic regression models in the development cohort. Within 30 days, 6.8% died and 24.2% were re-hospitalized. Thirteen patient-level factors remained in the final model for 30-day mortality and 10 patient-level factors for re-hospitalization with good calibration. The area under receiver operating characteristic curves were 0.71 for 30-day mortality and 0.63 for re-hospitalization in the validation cohort. Among Medicare patients with heart failure discharged to skilled nursing facilities, predicting 30-day mortality and re-hospitalization using administrative data is challenging. Further work identifying factors for re-hospitalization remains needed.

Relationship between Functional Improvement and Cognition in Short-Stay Nursing Home Residents.

Improving function is an important outcome of postacute care in skilled nursing facilities (SNFs), but cognitive impairment can limit a resident's ability to improve during a postacute care stay. Our objective was to examine the association between residents' cognitive status on admission and change in self-care and mobility during a Medicare-covered SNF stay. Retrospective analysis of Medicare beneficiaries who had a new SNF stay between January and June 2017. SNFs in the United States. Newly admitted residents with Medicare-covered SNF stays between January and June 2017 (n = 246 395). Residents' self-care and mobility at SNF admission and discharge were determined using items from Section GG (eating, oral hygiene, toileting hygiene, sit to lying, lying to sitting, sit to stand, chair/bed transfer, and toilet transfer) of the Minimum Data Set. Residents were classified as cognitively intact, mildly impaired, moderately impaired, or severely impaired, according to the Cognitive Function Scale. Multivariable regression models controlling for residents' demographic and clinical characteristics and SNF fixed effects were used to identify residents whose discharge scores for self-care and mobility were better or the same as expected according to their cognitive status on admission. Residents who were cognitively impaired on admission had lower functional status on admission and were less likely to improve in self-care and mobility compared with residents who were cognitively intact. Approximately 63% of residents who were cognitively intact had discharge scores for self-care and mobility that were better or the same as expected compared with 45% of residents with severe cognitive impairment. Cognitive impairment is associated with poorer self-care and mobility function among SNF residents. These findings have important implications for clinicians, who may need additional support when caring for residents with cognitive impairment to make the same improvements in functional status as residents who are cognitively intact. J Am Geriatr Soc 67:553-557, 2019.

Meaning in life of older adults living in residential and nursing homes

ABSTRACTBackground: The purpose of this study was to contribute to the analysis of older people’s Meaning in Life and the implications of dwelling in residential and nursing homes. The transition from one’s private home to a residential or nursing care facility is a challenge for many older people. An individualized (not standardized) approach to meaning in life programming can help professionals in developing tailored interventions to support residents and their families.Participants: The participants (n = 106, 76% women, mean age 84.4 ± 6 years, 93% Christians) were living in residential (52%) and nursing homes (48%).Methods: An anonymous cross-sectional survey was conducted in nine care homes in Southern Germany using validated instruments such as the Schedule for Meaning in Life Evaluation (SMiLE) and Religious Trust (SpREUK-15 subscale).Results: Leisure time, nature experience, and family were the most important meaning-giving areas. Spirituality was also perceived as a major resource.Conclusions: Residents living in retirement homes were more spiritually satisfied than those living in nursing homes. It will be necessary to specifically support individuals living in institutional-care in their spiritual and psychosocial dimension to improve their feelings of security and to meet their core needs.

Stroke Survivor and Caregiver Perspectives on Post-Stroke Visual Concerns and Long-Term Consequences.

Approximately 800,000 people in the United States have a stroke annually. Up to two thirds of stroke survivors have some visual problems, which result in disability and can affect survivors' overall rehabilitation outcomes. Although some post-stroke visual impairments can be corrected and respond well to intervention, ocular signs can be subtle and may not be recognized or reported by the stroke survivor but rather by a vigilant caregiver. The purpose of this study was to explore the post-stroke visual concerns and consequences expressed by stroke survivors and caregivers. This study employed a qualitative design using semistructured interviews conducted with a convenience sample of stroke survivors and caregivers recruited from either a community support group or skilled nursing and long-term care facilities. Interviews were recorded and transcribed verbatim. Comparative content analysis was used to identify vision-related themes by two independent coders. All research team members completed quality checking of coding. Twenty participants (11 stroke survivors and 9 caregivers) expressed visual concerns or consequences following stroke: (1) eye movement problems, (2) perceptual issues, and (3) consequences of vision problems or issues, which affected their daily life/quality of life. Stroke survivors and caregivers reported receiving vision care from (1) eye doctors, (2) occupational therapists, and (3) other healthcare professionals. All vision care providers need to be observant of potential post-stroke visual concerns. Stroke survivors should have a thorough vision evaluation to optimize their independence in everyday activities and quality of life.

Comprehensive cost of illness of dementia in Japan: a time trend analysis based on Japanese official statistics.

To analyze the chronological change in social burden of dementia in Japan for policy implications of appropriate resource allocation and quality improvement. National, population-based, observational study from 2002 to 2014. Seven nationwide data sets from Japanese official statistics. Comprehensive Cost of Illness method. The outcome variables included healthcare services, nursing care services, informal care (unpaid care offered by family and relatives), mortality cost and morbidity cost. The number of patients with dementia increased 2.50 times from 0.42 million in 2002 to 1.05 million in 2014. While the number of patients living in homes and communities increased by 3.22 times that of patients living in nursing care facilities increased by 1.42 times. The total social burden increased 2.06-2.27 times from JPY 1.84-2.42 to 3.79-5.51 trillion (JPY 1 trillion = US$ 100 billion). Regarding the total burden, the proportion of informal care provided increased from 36.6-51.9% to 37.7-57.2%. Furthermore, the proportion of primary caretakers aged ≥70 years increased from 27.6% to 37.6%. Owing to the promotion of 'Deinstitutionalization' (shift of nursing care site from in-facilities to in-home and in-community), 'Elderly care by the elderly,' and 'Earlier diagnosis of dementia,' the average cost per patient reduced by 0.82-0.91 times from JPY 4.37-5.77 to 3.60-5.24 million. Therefore, the management of informal care in a manner that does not exceed the acceptable limit of the patients' caretakers, while maintaining patient safety and quality of care, is imperative.

Quality Clinical Care in Nursing Facilities

Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, and care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.

Interventions for preventing falls in older people in care facilities and hospitals.

Cochrane review, hvor hensikten var a vurdere effekten av intervensjoner designet for reduksjon av fall blant eldre mennesker i sykehjem og sykehus.

Conflict Behaviours of Administrators in Long Term Care Facilities Influence Facility Ratings: SOS-Semantics of Self in Conflict™

Long term care (LTC) facilities, also called nursing homes, are often ripe for conflicts which cause stress for residents, their families and staff. This article presents the results of a survey showing how nursing facility administrators in Harris County, Texas, managed conflict within their facilities and how a more positive approach was consistently reflected in how their facilities were rated in US government quality consumer ratings. The concept at the centre of this study, SOS-Semantics of Self in Conflict™, recognises that the degradation of standards due to conflict is not just an event in a nursing care facility. It is a process that is heavily influenced, and in some cases exacerbated, by the way in which facility administrators react to conflict. These reactions have important broader implications for the facility’s best practice retrospectively.

Chronic obstructive pulmonary disease is an independent predictor for 30-day readmissions following 1- to 2-level posterior lumbar fusions.

Chronic obstructive pulmonary disease (COPD) is a common cause of morbidity and mortality worldwide. Past literature has demonstrated that patients with COPD are at an increased risk of post-operative complications. We assessed the impact of COPD on 30-day outcomes following a 1- to 2-level posterior lumbar fusion (PLF). The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using current procedural terminology (CPT) codes 22612, 22630 and 22633 to identify patients undergoing PLFs. Only patients undergoing a 1- to 2-level PLF for degenerative spine pathologies were included. In total, 1,123 (4.8%) of 23,481 patients undergoing an elective PLF had a diagnosis of COPD at the time of the surgery. Following adjusted logistic regression analysis, COPD was significantly associated with a longer length of stay of >3 days [odds ratio (OR), 1.40; 95% confidence interval (CI): 1.32-1.48; P=0.008], shorter total operative time (OR, 0.83; 95% CI: 0.73-0.94; P=0.003), discharge to skilled nursing care or rehabilitation facility (OR, 1.28; 95% CI: 1.09-1.51; P=0.002), pneumonia (OR, 2.53; 95% CI: 1.62-3.97; P<0.001) and 30-day readmissions (OR, 1.31; 95% CI: 1.03-1.65; P=0.025). Patients with COPD are more likely to have a longer length of stay, discharge to nursing care/rehabilitation facility, and higher risk of pneumonia and readmissions within 30-days following 1- and 2-level PLF. Our analysis of a large national cohort of patients highlights the importance of pre-operative and post-operative medical optimization in these high-risk patients.

Occurrence of oral health problems and planned measures in dependent older people in nursing care.

To describe oral health problems and planned measures in older people receiving nursing care. Poor oral health conditions have a negative impact on the quality of life of older people. Therefore, oral care is an important task in daily nursing activities. Data were obtained from the web-based Swedish national quality register Senior Alert. Data regarding oral health status and planned measures in individuals ≥65years from one county in Sweden between July 2014-June 2015 were included. The Revised Oral Assessment Guide-the Jönköping (ROAG-J) was used routinely by nursing staff in nursing care facilities to measure oral health status. Oral assessments were made on 2,567 individuals (65.7% women). The most common oral health problem was related to "Teeth" (43.0%), which indicates deficient oral hygiene and/or broken teeth. At least one measure was planned in all the participants. The most common planned measures were "Moistening of the mouth" (16.6%), followed by "Brushing - assistance or complete help" (13.5%). Oral health problems were common, and planned measures did not seem to be sufficient to address the identified problems. The results indicate that greater priority should be given to the oral health care of older people in nursing care. The study highlights the importance of not only identifying oral health problems but also having knowledge and strategies for oral health care. Collaboration is needed to support nurses in caring for the oral health care of older people in nursing homes.

Multifaceted Interventions at Skilled Nursing and Long Term Care Facilities Reduce 30 day Heart failure Readmissions

Introduction: Preventing 30 day Heart Failure (HF) readmissions can improve morbidity and mortality, and the financial wellbeing of health care systems. One of the factors affecting readmissions is inconsistent quality of care and adverse outcomes at Skilled Nursing (SNF)/Long term Care (LTAC) facilities/ Home care (after discharge from hospitals). Hypothesis Identifying SNF/LTAC/Home care that are specifically appropriate for HF care and then ensure collaborating facilities undergo HF based training/education, and adhere to HF established protocol will reduce 30 day HF readmissions. Methods Allegheny Health Network (AHN), PA piloted a comprehensive multifaceted centralized CRNP led program (with RN and Pharm D support and HF physician consultation) to ensure continuum of quality care after the transition from inpatient to SNF/LTAC/Home care. The network partnered exclusively with nine SNF's, one LTAC and a Home Care Agency after scrutinized review of following criteria: physician extender coverage, staffing ratios, clinical competency including dietary/clinical testing/treatment and availability of PT/OT. Education of Nurse practitioners from each facility included 32 hours of evidenced based curriculum training with the Advanced HF team. In addition to Nurse Practitioner training, Nursing Aides (3 hours) and Nurses (6 hours) were also required to undergo HF specific training at the AHN Simulation Teaching Center. Protocol establishment with central CRNP in charge of orchestrating the following: • Baseline Admission assessment and medication reconciliation, and completion of medical order for specific medical treatments during emergency. • Participating in daily fifteen minute phone huddle along with daily telehealth from the partnered facilities with daily reporting/monitoring of progress as follows: ○ CRNP/PA/RN daily clinical assessment of vitals, weights, symptoms, edema, lung sounds, pulse ox. ○ Review of low sodium diet. ○ Review of base line BNP/BMP and BMP 2x/week ○ Review progress of ambulation/activity ○ Discharge planning under the supervision of central CRNP ○ Physician follow-up ○ Medication reconciliation/call Pharmacy ○ Referral to Cardiac Rehab Results: The data reveals that the 2017 HF related 30 day readmission rate were significantly decreased from 10.7 % to 3.7% (see Table 1) after the program was instituted. Conclusion: Multifaceted multidisciplinary centralized interventions including education and monitoring may provide optimal quality/continuity of care during the continuum of care from the hospital to the SNF/LTAC setting and in turn reduces 30 day HF readmissions.

Improving Nursing Facility Care Through an Innovative Payment Demonstration Project: Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Phase 2

Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) is a 2-phase Center for Medicare and Medicaid Innovations demonstration project now testing a novel Medicare Part B payment model for nursing facilities and practitioners in 40 Indiana nursing facilities. The new payment codes are intended to promote high-quality care in place for acutely ill long-stay residents. The focus of the initiative is to reduce hospitalizations through the diagnosis and on-site management of 6 common acute clinical conditions (linked to a majority of potentially avoidable hospitalizations of nursing facility residents): pneumonia, urinary tract infection, skin infection, heart failure, chronic obstructive pulmonary disease or asthma, and dehydration. This article describes the OPTIMISTIC Phase 2 model design, nursing facility and practitioner recruitment and training, and early experiences implementing new Medicare payment codes for nursing facilities and practitioners. Lessons learned from the OPTIMISTIC experience may be useful to others engaged in multicomponent quality improvement initiatives.

Hip fracture rehabilitation for people living in nursing homes: Randomised trial

It is unclear whether team based rehabilitation will improve survival or recovery in people from nursing care facilities (NCFs) who frequently have dementia and substantial disability. The objective was to determine whether post-operative rehabilitation delivered in NCFs would improve quality of life and mobility compared to receiving usual care and to perform an economic evaluation of this intervention. Randomised controlled trial in NCFs, in Adelaide South Australia. Participants were people aged 70 years and older who were recovering from hip fracture surgery and were walking (independently, with aids or with one person assistance) prior to hip fracture. They received either a 4-week rehabilitation program delivered by hospital outreach team, or usual care. Those assessing the outcomes were blinded to group assignment. The primary outcomes were mobility [Nursing Home Life-Space Diameter (NHLSD)] and quality of life (DEMQOL) at one month (30 days) and 12 months. The incremental costs per unit improvement in mobility (NHLSD) and the incremental costs per quality adjusted life year (QALY) gained were calculated. At one month, the treatment group had better mobility (NHLSD) (mean difference −2.4; 95% CI: −3.8, −0.9; P = 0.0014), better quality of life (DEMQOL: mean difference −0.14; 95% CI: −0.26, −0.01; P = 0.0363 and DEMQOL-Proxy: −0.09; 95% CI: − 0.17, −0.02; P = 0.017) and were more likely to be alive (log rank test P = 0.048). At 12 months there were no differences between treatment and control groups. The survival and functional benefits did not persist once the rehabilitation program ended. The case for funding home rehabilitation in NCFs is weak from a traditional health economic perspective.