Post-acute Long-term Care Research Articles

Utilization of Telemedicine to Supervise Medical Students in the Post-Acute/Long-Term Care Setting

ObjectivesTelemedicine has become a widely accepted alternative to face-to-face patient encounters. Although there have been several peer-reviewed journal articles on incorporating telemedicine into the medical school curriculum, particularly during the COVID-19 pandemic, assessments of the effectiveness of remote supervision of medical students have not been reported. This prospective cohort study of student subjects using observational survey data evaluated the efficacy of telemedicine as an educational resource by comparing learning outcomes between osteopathic medical students receiving direct (physically present) supervision with a group who received remote (telemedicine) supervision by clinical faculty within a post-acute/long-term care (PA/LTC) setting. Learning outcomes in the domains of patient rapport, attitudes, knowledge, and behavior were measured using standardized survey instruments. DesignProspective cohort study of student subjects using observational survey data. Setting and ParticipantsA total of 167 fourth-year osteopathic medical students at a teaching nursing home (TNH). MethodsA total of 167 fourth-year osteopathic medical students (OMS-4s) were randomly assigned face-to-face PA/LTC patient encounters at the TNH. The encounters were follow-up visits to residents of the TNH that were supervised by faculty geriatricians. Half were accompanied by the physician and the other half were supervised by the physician through telemedicine. Evaluation using validated survey instruments measured patient rapport, verbal communication, and physical examination skills as well as attitudes, knowledge, and behaviors of the student/subjects. ResultsA nonparametric statistical analysis of 4 dependent variables measuring patient rapport, attitudes, knowledge and behavior showed no significant difference between the 2 teaching modalities. Conclusions and ImplicationsThe results of this prospective cohort study indicate that telemedicine supervision is comparable (noninferior) to direct supervision of medical student trainees in a PA/LTC setting.

Recommendations for Next Steps in Our Understanding of Use of Antipsychotics Among Older People in the Post-Acute Long-Term Care Environments: Article 3 of 3.

This article is the third installment of a multi-part series on the history and usage of antipsychotics in older people living in nursing and assisted living facilities. This article presents next steps and recommendations for appropriate usage of antipsychotics in the older population based on the lead author's early drafts, submitted to the editors prior to his untimely death, of this series and on his consultations with the coauthors. Dr Levenson emphasized in his focus on next steps related to antipsychotic use: that all providers should review the history of antipsychotic use and recognize clinically legitimate alternative explanations for the findings. His conclusions were that "off label" usage should not be a reason to exclude the appropriate use of antipsychotics. His overall recommendations to clinicians are to assess and diagnose the underlying cause of the problem, understand the treatment options and select the best one to address the clinical problem and/or the symptom if the problem cannot be fully resolved, and to focus on all medications, not just antipsychotics, in a patient's regimen to aid in a comprehensive understanding of the assessment and inform therapeutic recommendations.

A Nurse Practitioner-Driven Palliative and Supportive Care Service in Nursing Homes: Evaluation of a Quality Improvement Project.

This article describes a quality improvement project implemented by a national postacute long-term care organization aimed at enhancing the provision of palliative care to nursing home residents. The project focused on improving advance care planning, end-of-life care, symptom management, and care of people living with serious illness. Both generalist and specialist palliative care training were provided to nurse practitioners in addition to implementing a system to identify residents most likely to benefit from a palliative approach to care. To evaluate the nurse practitioner experiences of the program, survey data were collected from nurse practitioners (N = 7) involved in the project at 5 months after implementation. Nurse practitioners reported the program was well received by nursing home staff, families, and residents. Most nurse practitioners felt more confident managing residents' symptoms and complex care needs; however, some reported needing additional resources for palliative care delivery. Most common symptoms that were managed included pain, delirium, and dyspnea; most common diagnoses cared for were dementia and chronic organ failure (eg, cardiac, lung, renal, and neurological diseases). In the next steps, the project will be expanded throughout the organization, and person- and family-centered outcomes will be evaluated.

The 21st Century Cures Act Information Blocking Rule in Post-Acute Long-Term Care

Included as part of the 21st Century Cures Act, the information blocking rule entered the first compliance phase in April 2021. Under this rule, post-acute long-term care (PALTC) facilities must not engage in any activity that interferes with accessing, using, or exchanging electronic health information. In addition, facilities must respond to information requests in a timely fashion and allow records to be readily available to patients and their delegates. Although hospitals have been slow to adapt to these changes, skilled nursing and other PALTC centers have been even slower. With a Final Rule enacted in recent years, awareness of the information-blocking rules became more crucial. We believe this commentary will help our colleagues interpret the rule for the PALTC setting. In addition, we provide points of emphasis to help guide those providers and administrative staff workers toward compliance and avoid potential penalties.

Optimizing Osteoporosis Intervention After Fragility Fracture in Post-Acute Long-Term Care

Optimizing Osteoporosis Intervention After Fragility Fracture in Post-Acute Long-Term Care

Design, Development, and Evaluation of an Automated Solution for Electronic Information Exchange Between Acute and Long-term Postacute Care Facilities: Design Science Research.

Information exchange is essential for transitioning high-quality care between care settings. Inadequate or delayed information exchange can result in medication errors, missed test results, considerable delays in care, and even readmissions. Unfortunately, long-term and postacute care facilities often lag behind other health care facilities in adopting health information technologies, increasing difficulty in facilitating care transitions through electronic information exchange. The research gap is most evident when considering the implications of the inability to electronically transfer patients' health records between these facilities. This study aimed to design and evaluate an open standards-based interoperability solution that facilitates seamless bidirectional information exchange between acute care and long-term and postacute care facilities using 2 vendor electronic health record (EHR) systems. Using the design science research methodology, we designed an interoperability solution that improves the bidirectional information exchange between acute care and long-term care (LTC) facilities using different EHR systems. Different approaches were applied in the study with a focus on the relevance cycle, including eliciting detailed requirements from stakeholders in the health system who understand the complex data formats, constraints, and workflows associated with transferring patient records between 2 different EHR systems. We performed literature reviews and sought experts in the health care industry from different organizations with a focus on the rigor cycle to identify the components relevant to the interoperability solution. The design cycle focused on iterating between the core activities of implementing and evaluating the proposed artifact. The artifact was evaluated at a health care organization with a combined footprint of acute and postacute care operations using 2 different EHR systems. The resulting interoperability solution offered integrations with source systems and was proven to facilitate bidirectional information exchange for patients transferring between an acute care facility using an Epic EHR system and an LTC facility using a PointClickCare EHR system. This solution serves as a proof of concept for bidirectional data exchange between Epic and PointClickCare for medications, yet the solution is designed to expand to additional data elements such as allergies, problem lists, and diagnoses. Historically, the interoperability topic has centered on hospital-to-hospital data exchange, making it more challenging to evaluate the efficacy of data exchange between other care settings. In acute and LTC settings, there are differences in patients' needs and delivery of care workflows that are distinctly unique. In addition, the health care system's components that offer long-term and acute care in the United States have evolved independently and separately. This study demonstrates that the interoperability solution improves the information exchange between acute and LTC facilities by simplifying data transfer, eliminating manual processes, and reducing data discrepancies using a design science research methodology.

Innovations in Fatality Management During the COVID-19 Pandemic.

Innovations in Fatality Management During the COVID-19 Pandemic.

Comparison of Preparation Times and Cost for Compounded, Outsourced and Premixed Vancomycin Products in a Long-Term Care Pharmacy

Multiple drug resistant organism (MDRO) infections are increasingly being treated in post-acute long-term care (PA-LTC) settings, due to high costs associated with treating MDRO in the hospital. While MDRO therapies are increasingly given in PA-LTC settings, studies suggest PA-LTCs may also be a reservoir of MDROs, perhaps more so than hospital settings. Intravenous antimicrobial agents effective against MDRO, such as vancomycin, must increasingly be provisioned to PA-LTC settings, but preparation time and cost of provisioning vancomycin is not well characterized in the literature.

Post-acute long-term care COVID-19 medication optimization survey: Informing medication management initiatives

The Medication Management Guide (MMG) provides guidance on strategies to optimize medication management in PA-LTC and simplify administration to reduce the transmission risk of COVID-19. The objectives of this study were to evaluate the utility of the MMG, determine the barriers and facilitators of the MMG implementation in PALTC sites to help inform future research and initiatives. Individuals who accessed MMG during the pandemic (April 2020-March 2021) were contacted to elicit feedback on this tool via an online survey. The survey response rate was 7.7% (156/2,018) after three rounds of emails. Respondents consisted of 31% (n=49) pharmacists, 27% (n=42) physicians, 11% (n=18) nurses, and 12% (n=19) nurse practitioners. The “Other” respondents (11%, n=17) included dieticians (n=4), physician assistants (n=3), pharmacy technicians (n=3), students (n=1), consultants (n=1), and educators (n=2). From these respondents, 77% (n=122) took tactics to optimize medications at their facilities during COVID-19.

Tribute to Larry Robbins MD (1950–2021)

Tribute to Larry Robbins MD (1950–2021)

The Importance of Electronic Health Record Access For Accurately Completing Drug Regimen Reviews

OBJECTIVE: To challenge the standard of practice by evaluating the identification of medication discrepancies found depending on type of access to an electronic health record (EHR). In other words, is there a difference in the number of discrepancies between a pharmacist with only access to the postacute long-term care (PALTC) EHR (ie, single-access pharmacist [SAP]) compared with a pharmacist with access to both the PALTC and hospital EHRs (ie, dual-access pharmacist DAP) In October 2018, the Improving Medicare PostAcute Care Transformation (IMPACT) Act mandated admission drug review (DRR) upon admission to a postacute, long-term care (PALTC) facility.<br/> SUMMARY:This was a prospective study investigating the occurrence of medication therapy problems (MTP) identified by two different DRR processes; SAP versus DAP. Data were collected in a community hospital and a stand-alone PALTC facility. It was found that the DAP identified more safety-related medication needs and medication omissions than an SAP. There was a significant association between the type of access and whether a MTP (ie, yes or no) was discovered, the type of medication-related need, and MTP category.<br/> CONCLUSION: These results strongly suggest that current standard of practice should change to require access to both hospital and PALTC EHR systems for a pharmacist completing the medication reconciliation. Until the gap in EHR interoperability is closed, the potential breakdown in communication associated with SAP places patients transitioning from hospital to PALTC facilities at increased risk for medication problems and accompanying adverse medication events.

The Importance of Electronic Health Record Access For Accurately Completing Drug Regimen Reviews.

OBJECTIVE: To challenge the standard of practice by evaluating the identification of medication discrepancies found depending on type of access to an electronic health record (EHR). In other words, is there a difference in the number of discrepancies between a pharmacist with only access to the postacute long-term care (PALTC) EHR (ie, single-access pharmacist [SAP]) compared with a pharmacist with access to both the PALTC and hospital EHRs (ie, dual-access pharmacist DAP) In October 2018, the Improving Medicare PostAcute Care Transformation (IMPACT) Act mandated admission drug review (DRR) upon admission to a postacute, long-term care (PALTC) facility.<br/> SUMMARY:This was a prospective study investigating the occurrence of medication therapy problems (MTP) identified by two different DRR processes; SAP versus DAP. Data were collected in a community hospital and a stand-alone PALTC facility. It was found that the DAP identified more safety-related medication needs and medication omissions than an SAP. There was a significant association between the type of access and whether a MTP (ie, yes or no) was discovered, the type of medication-related need, and MTP category.<br/> CONCLUSION: These results strongly suggest that current standard of practice should change to require access to both hospital and PALTC EHR systems for a pharmacist completing the medication reconciliation. Until the gap in EHR interoperability is closed, the potential breakdown in communication associated with SAP places patients transitioning from hospital to PALTC facilities at increased risk for medication problems and accompanying adverse medication events.

Understanding patient and clinician perspectives of antibiotic use for the treatment of UTIs

Background. Multidrug resistant organisms are highly prevalent in post-acute long-term care [LTC] and skilled nursing facilities [SNF], driven by overdiagnosis of urinary tract infections [UTI] and overuse of antibiotics, despite clinical guidelines for UTI management. Using the Systems Engineering Initiative for Patient Safety [SEIPS] framework to understand sociotechnical work systems within LTC/SNFs, we are conducting mixed methodological research to examine work systems gaps that may require structural modification to ensure appropriate prescribing behaviors. Methods. To begin this research, we conducted semi-structured interviews with residents, caregivers, and clinical staff at three LTC/SNF locations. Resident and caregiver interviews queried knowledge, attitudes, and beliefs about UTIs and antibiotics, previous use, and communication with clinical staff. Clinical staff interviews queried procedures for diagnosing UTIs, prescribing decisions, communication with residents/caregivers, and resident/caregiver demand. Findings. Resident/caregiver interviews highlighted three common themes: (1) doctors have the right to deny antibiotics, but communication about decisions is critical; (2) trust doctors’ knowledge and use of objective testing for decision-making; (3) want detailed explanations and education about antibiotics, including potential side effects. Clinical staff described: (1) caregiver as the primary barrier, even with education about antibiotics; (2) using a general protocol for diagnosis, but also prior knowledge and experience with the resident; (3) importance of educating and communicating with residents/caregivers about antibiotic treatment, prescribing recommendations, or side effects. Conclusions. Our study highlights a gap in communication and workflow between residents, caregivers, and clinical staff that may be amendable to improved interventions that decrease inappropriate prescribing of antibiotics for this population.

Medical Staffing Organization and Quality of Care Outcomes in Post-acute Care Settings.

Medical providers are significant drivers of care in post-acute long-term care (PALTC) settings, yet little research has examined the medical provider workforce and its role in ensuring quality of care. This study examined the impact of nursing home medical staffing organization (NHMSO) dimensions on the quality of care in U.S. nursing homes. The principal data source was a survey specifically designed to study medical staff organization for post-acute care. Respondents were medical directors and attending physicians providing PALTC. We linked a number of medical provider and nursing home characteristics to the Centers for Medicaid and Medicare Services Nursing Home Compare quality measures hypothesized to be sensitive to input by medical providers. From the sample of nursing home medical providers surveyed (n = 1,511), 560 responses were received, yielding a 37% response rate; 425 medical provider responses contained sufficient data for analysis. The results of the impact of NHMSO dimensions were mixed, with many domains not having any significance or having negative relationships between provider characteristics and quality measures. Respondents who reported having a formal process for granting privileges and nursing homes with direct employment of physicians reported significantly fewer emergency visits. Further research is needed regarding what quality measures are sensitive to both medical provider characteristics and NHMSO characteristics.

Fierce Advocates for Building All-Hazards Resurgence and Resilience: NYC Health + Hospitals' COVID-19 Experiences Applied.

Fierce Advocates for Building All-Hazards Resurgence and Resilience: NYC Health + Hospitals' COVID-19 Experiences Applied.

The predictive efficacy of multidimensional prognostic index in the elderly with heart failure and reduced ejection fraction in a real world sample: the Post-Acute Long-Term Care setting

The multidimensional prognostic index (MPI) is an accurate predictor of mortality validated in hospitalized older patients. Aim of this study was to evaluate the reliability of the MPI in predicting shortand long-term mortality in patients with heart failure (HF), particularly in those with reduced left ventricular ejection fraction (HFrEF). The study population included all patients older than 65 years admitted in a Post-Acute Long-Care Unit from 2013 to 2018. Patients were divided into two groups: patients with HF (N=143) and patients without HF as controls (N=1254). Furthermore, patients affected by HF were subdivided according to echocardiographic left ventricular ejection fraction (LVEF), i.e. reduced, mid-range and preserved LVEF (respectively HFrEF, HFmrEF, HFpEF). All patients underwent a comprehensive geriatric assessment (CGA) to calculate the MPI based on information on functional, cognitive, nutritional and mobility status, comorbidity, poli-pharmacy and co-habitation. Mortality rates in the HF group was 46% in patients MPI-1 or MPI-2 groups versus 59% in patients included in the MPI- 3 group. In particular, of 32 HF patients with HFrEF 67.7% were in the MPI-3 class compared to 43% of 14 patients with HFmrEF group and to 41% of 63 patients with HFpEF. These findings suggest that MPI is a reliable predictor of mortality in HF patients and that it was particularly useful in the subgroup of patients with HFrEF.

Wounds Related to Malignancy in Postacute and Long-term Care: A Case Series.

To study the epidemiology and characteristics of wounds related to malignancy in a large, academically affiliated postacute/long-term care (PALTC) facility. Retrospective case series of 1 year of wound care consultations. Inclusion criteria included a cancer diagnosis with wounds related to malignancy or complications from cancer-related debility and/or treatment. Academically affiliated 514-bed PALTC facility. Of 190 consults, 27 residents (14.2%) met the inclusion criteria. Of these, 20 (74.1%) were female, and 7 (25.9%) were male. The average age of residents with a cancer diagnosis and wounds was 69.5 years (range, 48.1-86.7 years), and 25 (92.6%) were on the postacute service. The most common reasons for consultation included pressure injuries (44.4%), surgical wounds (21.4%), and malignant wounds (14.8%). Seventy-six percent of pressure injuries were present on admission. Breast (29.6%), gastrointestinal (25.9%), and gynecologic (11.1%) malignancies were most common. Of the studied residents, 14 (51.9%) had metastases, and 13 (92.9%) had pressure injuries. These findings begin to fill a gap in understanding the spectrum of wounds in PALTC residents with cancer and reinforce the importance of the wound care skill set, including pressure injury prevention. Quality cancer care for older adults must anticipate severe skin complications not only from the tumor and its treatment, but also from the sequelae of immobility, immune compromise, malnutrition, and skin failure. The close association of metastatic disease with pressure injury raises issues of unavoidability and casts new doubt upon the use of pressure injuries for quality measurement.

539. Canaries in a Coal Mine?: Early Identification of Regional Spread of Novel Multidrug-resistant Organisms (MDROs) Using Sentinel Surveillance in Skilled Nursing Facilities Caring For Ventilated Patients (vSNFs)

BackgroundRegional containment of novel or targeted MDROs depends on detecting their presence as soon as possible following their introduction. Prior modeling studies suggest that after importation to a region, novel MDROs appear relatively quickly in certain high-risk post-acute long-term care facilities via patient movement. Sentinel surveillance in such facilities might facilitate early detection of emergent MDROs, thereby enhancing the effectiveness of containment efforts.MethodsWe simulated the introduction and spread of carbapenem-resistant Enterobacteriaceae (CRE) in a region using an adaptation of a previously described susceptible-infectious-susceptible model (Clin Infect Dis. 2019 March 28 doi: 10.1093/cid/ciz248). The model includes the patient sharing network among healthcare facilities in an exemplar US state, using claims data and the Minimum Data Set from the Centers for Medicare & Medicaid Services for 2015. Disease progression, transmission and testing rates were estimated for CRE using data from the literature. Each simulated outbreak was initiated with a single importation to a Dartmouth Atlas of Health Care hospital referral region. The predicted timing of first CRE detection using two different data sources was compared: (1) real-time monitoring of clinical microbiology test results, or (2) results from quarterly point prevalence colonization surveys (PPSs). For each data source, the timing of earliest detection was compared according to availability of data from: (a) all healthcare facilities statewide, (b) only long-term acute care hospitals, (c) only vSNFs, or (d) only the largest acute care hospitals in the state (n = 23).ResultsCompared with real-time monitoring of clinical microbiology testing results from all facilities statewide, quarterly PPSs at all facilities detected CRE 446 days (median; range 312–608 days) earlier, while PPSs at only vSNFs (representing 4.4% of inpatient beds statewide) detected CRE 385 days (range 194–553 days) earlier (figures).ConclusionRegular point prevalence surveys in vSNFs may detect new MDROs in a region approximately one year sooner than real-time monitoring of clinical microbiology results, and may be an efficient strategy for early regional detection and subsequent containment. Disclosures All authors: No reported disclosures.

Identifying Potential Medication Discrepancies During Medication Reconciliation in the Post-Acute Long-Term Care Setting.

Medication reconciliation has been an area with increased focus among transitions of care due to associations with error rates and risk of patient harm. Chart reviews were performed to evaluate the discrepancies between the initial physician order sheet (POS), hospital discharge summary, electronic health record (EHR), health information exchange (HIE), and the patient interview/home medication list. The objectives were to determine which medication information source provided the least number of discrepancies and describe the different types of discrepancies among sources. Of all orders, 30% contained a discrepancy. The average number of discrepancies per medication source per patient included: 5.6 for the hospital discharge summary, 7.6 for the EHR, and 9.6 for the home medication list/interview. The most frequent types of discrepancies included: omission of medication orders between lists (42.7%), additional medications not included on the initial POS (24.6%), and discrepancies in frequency (11.8%). The hospital discharge summary proved to be the medication source that provided the least number of discrepancies, compared to the initial POS. [Journal of Gerontological Nursing, 45(7), 5-10.].

Expanding Opportunities in the Postacute Long-Term Care Setting: Bringing Medication Safety to the Next Level.

Skilled nursing facilities and nursing homes are care settings that offer increasing opportunities for pharmacists to take the lead when addressing the new updated Centers for Medicare and Medicaid Services (CMS) requirements coupled with enhanced quality measures reporting. In addition, the complexity of the medication-related needs and comorbidities of the patients served in long-term care facilities promotes pharmacists practicing to the top of their license. Medication stewardship needs to be an interdisciplinary team activity led by the pharmacist. This article highlights areas of opportunity and innovation focusing on the four areas that reflect new regulations and enhanced scrutiny by CMS: psychotropic medications, transitions in care, antibiotic stewardship, and pain management.