Skilled Nursing Facility Patients Research Articles

Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility.

This research aimed to understand the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs) by eliciting views from patients and hospital and skilled nursing facility staff. We conducted semi-structured interviews with hospital and skilled nursing facility staff and skilled nursing facility patients and their family members in an attempt to understand transitions between hospital and SNF. These interviews focused on all aspects of the discharge planning and nursing facility placement processes including who is involved, how decisions are made, patients' experiences, hospital-SNF communication, and the presence of programs to improve the transition process. Participants were 138 staff in 16 hospitals and 25 SNFs in 8 markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/or their family members in five of those markets. Interviews were qualitatively analyzed to identify overarching themes. Patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown. Results indicate problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members. Previous research suggests that problematic or hurried transitions from hospital to SNF are associated with medication errors and unnecessary rehospitalizations. Interventions to improve transitions from hospital to SNF that include a focus on patients and families are needed.

In-House Cardiology Consultation Reduces Readmission Rates and Costs for Patients in Skilled Nursing Facilities: 2 Years’ Experience in the Heart Failure Bundle Payment Care Improvement Initiative

Background Heart failure (HF) patients admitted to skilled nursing facilities (SNFs) are vulnerable to poor outcomes. CMS developed the Bundled Payments for Care Improvement Initiative (BPCI) which provides participating providers shared savings based on costs for 90-day episodes of care with the purpose of improving quality and cost-effectiveness. Greater availability of clinical staff has shown promise in improving outcomes for SNF patients. The effect of cardiology consultation for SNF patients with HF has not been evaluated. This study evaluates the impact of a SNF-based cardiologist-led HF program on 90-day readmission rate and resource utilization. Methods We performed a retrospective analysis using Medicare claims data of BPCI-enrolled HF patients admitted to St. Joseph's Center (SJC), a Genesis Healthcare SNF with a cardiologist-led HF program. Data were collected from October 2015 to September 2017. Readmission rates and cost savings versus CMS-determined cost targets were compared between SJC and 31 other enrolled SNFs, 24 of which had no HF program, 7 of which had standard programs composed of a multidisciplinary team of dietary, rehabilitation, social work and clinical staff. The SJC program additionally instructed staff to request cardiac consultation for patients with unstable vital signs, refractory volume overload or symptoms, or cardiac limitations to rehabilitative therapy. Cardiology rounds were conducted weekly and management was provided in the context of achieving subacute rehabilitation goals, clinical stability, and preparing for community discharge. The cardiologist identified and alerted staff to patients deemed high risk for readmission, and multidisciplinary monitoring and management for those patients was intensified. Results There were 602 total HF episodes in the 24-month evaluation period. Seventeen patients were admitted to SJC; 218 patients to a facility with a HF program; and 367 patients to a facility without a HF program. The case mix complexity at SJC included a higher percentage of patients with major complications and comorbid conditions (71% vs 60% for all other SNFs and 64% for SNFs with HF programs). More than 50% of patients at SJC prompted specialty consultation. Compared to other facilities, the percentage of SJC patients readmitted in the 90-day post HF hospitalization period was significantly lower (23.5% vs 43.4% (p = .052) for all other SNFs; and 48.2% (p = .025) for SNFs with a non-cardiologist based HF program). SJC achieved a higher margin of cost savings compared to facilities that did not have a consulting cardiologist (39% vs 15%). Conclusion Patient-centered cardiology consultation for high risk HF patients may effectively reduce re-hospitalizations and resource utilization within SNFs. These results identify a potential gap in care for this vulnerable cohort of HF patients and suggest that incorporating a cardiologist into the management team may impact outcomes.

Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data.

BackgroundMedicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees.Methods and findingsThis was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation.ConclusionsCompared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs.

Impact of Post-Discharge Disposition on Risk and Causes of Readmission Following Liver and Pancreas Surgery

BackgroundThe relationship between the post-discharge settings and the risk of readmission has not been well examined. We sought to identify the association between discharge destinations and readmission rates after liver and pancreas surgery. MethodsThe 2013–2015 Medicare-Provider Analysis and Review (MEDPAR) database was reviewed to identify liver and pancreas surgical patients. Patients were subdivided into three groups based on discharge destination: home/self-care (HSC), home with home health assistance (HHA), and skilled nursing facility (SNF). The association between post-acute settings, readmission rates, and readmission causes was assessed. ResultsAmong 15,141 liver or pancreas surgical patients, 60% (n=9046) were HSC, 26.9% (n=4071) were HHA, and 13.4% (n=2024) were SNF. Older, female patients and patients with ≥2 comorbidities, ≥2 previous admissions, an emergent index admission, an index complication, and ≥5-day length of stay were more likely to be discharged to HHA or SNF compared to HSC (all P<0.001). Compared to HSC, HHA and SNF patients had a 34 and a 67% higher likelihood of 30-day readmission, respectively. The HHA and SNF settings were also associated with a 33 and a 69% higher risk of 90-day readmission. There was no association between discharge destination and readmission causes. ConclusionAmong liver and pancreas surgical patients, HHA and SNF patients had a higher risk of readmission within 30 and 90 days. There was no difference in readmission causes and discharge settings. The association between discharge setting and the higher risk of readmission should be further evaluated as the healthcare system seeks to reduce readmission rates after surgery.

Interpreting the Impact of Physical Function in Skilled Nursing Facility Residents

Medicare mandates report of standardized measures of function in post-acute care to inform reimbursement policies and monitor the quality of care. As a result, skilled nursing facilities (SNFs) assess a patient’s level of assistance needed for mobility and basic daily activities using a portion of the Barthel Activities of Daily Living Index (BI). However, performance-based measures of physical function are not currently required, but often provide risk stratification for adverse events including rehospitalization, institutionalization, deaths, or falls. Yet, the functional profiles of patients in SNFs at evaluation and, more importantly, at discharge have not been well described. The purpose of this investigation was to describe and quantify functional status in a SNF population by examining the BI and performance-based measures such as the Short Physical Performance Battery (SPPB) and gait speed. The results have the potential to inform future clinical research initiatives designed to improve the quality and efficiency of rehabilitation care delivered, potentially through data-driven clinical decision-making resources.

Use of Robotic Cats to Reduce Falls in Skilled Nursing Facility

Falls are a major source of morbidity for patients in skilled nursing facilities. Each year, a typical nursing home with 100 beds reports 100 to 200 falls, and the average number of fall is 2.6 falls per person per year in SNF. 10-20% of nursing home falls cause serious injuries. As part of a targeted plan to reduce falls, our QAPI committee decided to trial the use of robotic cats - five of them - in our skilled nursing facility to see if using the cats with the residents would result in less overall falls. There has been one small study of 14 dementia patients observed interacting with these robotic cats that indicated less agitated behavior and better quality of life. The hypothesis was that perhaps by giving dementia patients with a history of frequent falls robotic cats to hold and pet, they may be less likely to get agitated and/or repeatedly stand unassisted.

Clinicians' Perspectives of Patient Engagement in Post-Acute Care: A Social Ecological Approach

ABSTRACTAims: To identify rehabilitation providers' perspectives on barriers and facilitators of patient engagement in hip fracture patients in skilled nursing facilities (SNFs) within the social ecological model. Methods: We conducted 13 focus groups in SNFs throughout Los Angeles County comprised of rehabilitation staff (n = 99). Focus groups were audio-recorded and transcribed. A secondary analysis of themes related to patient engagement were identified and organized within the social ecological model. Results: Clinicians identified barriers and facilitators of patient engagement across all levels of the social ecological model: public policy (e.g., insurance), organizational (e.g., facility culture), interpersonal (e.g., clinicians fostering self-reflection), and intrapersonal (e.g., patients' anxiety). Conclusions: Examining barriers and facilitators to patient engagement has highlighted areas which need to be sustained and improved. Thus, these findings will inform future efforts to enhance patient engagement in order can to optimize patient healthcare decisions.

Justifying Rehabilitation Intensity Through Functional Performance Measures in Postacute Care

The Centers for Medicare and Medicaid Services (CMS) has scrutinized the provision of rehabilitation services in skilled nursing facilities (SNFs) for some time. Little research guidance exists on appropriate dosage or rehabilitation intensity (RI) among SNF patients or patients in other postacute care (PAC) settings. CMS developed a PAC assessment, the Continuity Assessment Record and Evaluation (CARE) Tool, in response to questions about what issues drive placement in various PAC settings under Medicare. The ability to adequately assess functional outcomes and correlate them to the RI provided by using the CARE Tool is promising. However, further research, policy advocacy, and practice analysis must be undertaken to promote and protect adequate access to occupational therapy and physical therapy in SNFs and other PAC settings. Individual practitioners must participate in data gathering to ensure that the data for analysis are fully informed by the occupational therapy perspective.

The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities.

Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients. Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs. An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015. A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs. All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation. The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff. Thirty-day readmission rate for ECP patients compared to patients not enrolled in ECP. The average unadjusted, 30-day readmission rate for ECP patients over the 18-month study period was 17.2% compared to 23.0% among patients not enrolled in ECP (P < 0.001). After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P < 0.001). These effects were robust to stratified analyses, analyses adjusted for clustering, and balancing of covariates using propensity weighting. A coordinated, interdisciplinary team caring for SNF patients can reduce 30-day hospital readmissions.

Failure to Communicate: Transmission of Extensively Drug-Resistant bla OXA-237-Containing Acinetobacter baumannii-Multiple Facilities in Oregon, 2012-2014.

OBJECTIVE To determine the scope, source, and mode of transmission of a multifacility outbreak of extensively drug-resistant (XDR) Acinetobacter baumannii. DESIGN Outbreak investigation. SETTING AND PARTICIPANTS Residents and patients in skilled nursing facilities, long-term acute-care hospital, and acute-care hospitals. METHODS A case was defined as the incident isolate from clinical or surveillance cultures of XDR Acinetobacter baumannii resistant to imipenem or meropenem and nonsusceptible to all but 1 or 2 antibiotic classes in a patient in an Oregon healthcare facility during January 2012-December 2014. We queried clinical laboratories, reviewed medical records, oversaw patient and environmental surveillance surveys at 2 facilities, and recommended interventions. Pulsed-field gel electrophoresis (PFGE) and molecular analysis were performed. RESULTS We identified 21 cases, highly related by PFGE or healthcare facility exposure. Overall, 17 patients (81%) were admitted to either long-term acute-care hospital A (n=8), or skilled nursing facility A (n=8), or both (n=1) prior to XDR A. baumannii isolation. Interfacility communication of patient or resident XDR status was not performed during transfer between facilities. The rare plasmid-encoded carbapenemase gene bla OXA-237 was present in 16 outbreak isolates. Contact precautions, chlorhexidine baths, enhanced environmental cleaning, and interfacility communication were implemented for cases to halt transmission. CONCLUSIONS Interfacility transmission of XDR A. baumannii carrying the rare blaOXA-237 was facilitated by transfer of affected patients without communication to receiving facilities. Infect Control Hosp Epidemiol 2017;38:1335-1341.

Unexplained Variation for Hospitals' Use of Inpatient Rehabilitation and Skilled Nursing Facilities After an Acute Ischemic Stroke.

Rehabilitation is recommended after a stroke to enhance recovery and improve outcomes, but hospital's use of inpatient rehabilitation facilities (IRFs) or skilled nursing facility (SNF) and the factors associated with referral are unknown. We analyzed clinical registry and claims data for 31 775 Medicare beneficiaries presenting with acute ischemic stroke from 918 Get With The Guidelines-Stroke hospitals who were discharged to either IRF or SNF between 2006 and 2008. Using a multilevel logistic regression model, we evaluated patient and hospital characteristics, as well as geographic availability, in relation to discharge to either IRF or SNF. After accounting for observed factors, the median odds ratio was reported to quantify hospital-level variation in the use of IRF versus SNF. Of 31 775 patients, 17 662 (55.6%) were discharged to IRF and 14 113 (44.4%) were discharged to SNF. Compared with SNF patients, IRF patients were younger, more were men, had less health-service use 6 months prestroke, and had fewer comorbid conditions and in-hospital complications. Use of IRF or SNF varied significantly across hospitals (median IRF use, 55.8%; interquartile range, 34.8%-75.0%; unadjusted median odds ratio, 2.59; 95% confidence interval, 2.44-2.77). Hospital-level variation in discharge rates to IRF or SNF persisted after adjustment for patient, clinical, and geographic variables (adjusted median odds ratio, 2.87; 95% confidence interval, 2.68-3.11). There is marked unexplained variation among hospitals in their use of IRF versus SNF poststroke even after accounting for clinical characteristics and geographic availability. URL: https://clinicaltrials.gov. Unique identifier: NCT02284165.

Impact of a Connected Care Model on 30-Day Readmission Rates from Skilled Nursing Facilities.

About one-fifth of hospitalized Medicare beneficiaries are discharged to skilled nursing facilities (SNFs) for post-acute care. Readmissions are common but interventions to reduce readmissions are scarce. To assess the impact of a connected care model on 30-day hospital readmission rates among patients discharged to SNFs. Retrospective cohort. SNFs that receive referrals from an academic medical center in Cleveland, Ohio. All patients admitted to Cleveland Clinic main campus between January 1, 2011 and December 31, 2014 and subsequently discharged to 7 intervention SNFs or 103 control SNFs. Hospital-employed physicians and advanced practice professionals (nurse practitioners and physician assistants) visited SNF patients 4 to 5 times per week. During the study period, 13,544 patients were discharged to SNFs within a 25-miles radius of Cleveland Clinic main campus. Of these, 3334 were discharged to 7 intervention SNFs and 10,201 were discharged to 103 usualcare SNFs. During the intervention phase (2013-2014), adjusted 30-day readmission rates declined at the intervention SNFs (28.1% to 21.7%, P < 0.001), while there was a slight increase at control SNFs (27.1 % to 28.5%, P < 0.001). The absolute reductions ranged from 4.6% for patients at low risk for readmission to 9.1% for patients at high risk, and medical patients benefited more than surgical patients. A program of frequent visits by hospital employed physicians and advanced practice professionals at SNFs can reduce 30-day readmission rates. Journal of Hospital Medicine 2017;12:238-244.

A randomized trial of heart failure disease management in skilled nursing facilities (SNF Connect): Lessons learned.

Conducting clinical trials in skilled nursing facilities is particularly challenging. This manuscript describes facility and patient recruitment challenges and solutions for clinical research in skilled nursing facilities. Lessons learned from the SNF Connect Trial, a randomized trial of a heart failure disease management versus usual care for patients with heart failure receiving post-acute care in skilled nursing facilities, are discussed. Description of the trial design and barriers to facility and patient recruitment along with regulatory issues are presented. The recruitment of Denver-metro skilled nursing facilities was facilitated by key stakeholders of the skilled nursing facilities community. However, there were still a number of barriers to facility recruitment including leadership turnover, varying policies regarding research, fear of litigation and of an increased workload. Engagement of facilities was facilitated by their strong interest in reducing hospital readmissions, marketing potential to hospitals, and heart failure management education for their staff. Recruitment of patients proved difficult and there were few facilitators. Identified patient recruitment challenges included patients being unaware of their heart failure diagnosis, patients overwhelmed with their illness and care, and frequently there was no available proxy for cognitively impaired patients. Flexibility in changing the recruitment approach and targeting skilled nursing facilities with higher rates of admissions helped to overcome some barriers. Recruitment of skilled nursing facilities and patients in skilled nursing facilities for clinical trials is challenging. Strategies to attract both facilities and patients are warranted. These include aligning study goals with facility incentives and flexible recruitment protocols to work with patients in "transition crisis."

Surveillance Screening for Extended-Spectrum β-Lactamases in Skilled Nursing Facility Admissions

The spread of multidrug-resistant organisms (MDROs) continues to be major concern within the healthcare community. A subset of Gram-negative MDROs that has been on the rise is extended-spectrum β-lactamases (ESBL). These organisms account for approximately 26,000 infections per year. One of the areas affected the most by these organisms are skilled nursing facilities (SNFs). While many SNFs have programs in place to decrease the spread of ESBLs, they typically lack the resources for dedicated infection control personnel. The objective of this study was to determine whether surveillance screening would provide a healthcare system with information regarding SNFs at high risk for ESBL admissions. A retrospective review of patients who had a positive surveillance screening of an MDRO admitted to four separate hospital intensive care units (ICU) within a single healthcare system over the period of February 2016 to October 2016. A patient was considered positive for an MDRO if they had an organism that was susceptible to <2 classes of antibiotics and were classified as an ESBL based on each organism’s antibiotic resistance profile. The patients’ locations prior to admission were identified using the hospital electronic medical record. Over 6 months, there were 110 patients with unique organisms fitting the criteria for an MDRO. Of these 110, only 103 had a recorded species. Out of 103, 86(84%) were admitted from SNFs and 61(71%) of SNF admissions were classified as an ESBL. Of the 28 SNFs, 6 SNFs encompassed 51(59%) of all MDRO SNF admissions. Of these 51, 31(61%) were classified as an ESBL. The most prevalent ESBLs in SNFs were E. coli, K. pneumonia, and P. mirabilis with 44(72%), 11(18%), and 5(8%), respectively. Directed surveillance screening in the ICU could be a useful tool in determining which patients are at risk to carry ESBLs. Infection control personnel could use this information to create a database to help determine which SNF patients should be screened on admission to ensure proper isolation precautions. In the future, healthcare systems could use this data to work with local SNFs to improve and assist with the implementation of infectious control protocols further decreasing the spread of certain organisms. All authors: No reported disclosures.

SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients' Healthcare from Skilled Nursing Facilities to the Community.

We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.

Do hospital-owned skilled nursing facilities provide better post-acute care quality?

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.

Transitional care of older adults in skilled nursing facilities: A systematic review

Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients.

노인요양시설의 평면 특성에 관한 고찰

The purpose of this study is to clarify the actual conditions of the floor area of skilled nursing facilities in rural area. The thorough investigation and observation works were made from the viewpoints of floor area of the skilled nursing facilities. This article discusses about the basic condition and the floor area for daily living activities of the elderly in 3 skilled nursing facilities in west gyeongnam province. As the result, There is a wide gap between floor area ratio of skilled nursing facilities. The characteristics of the private establishment skilled nursing facilities in the west gyeongnam province were figured out through the analysis of spatial composition in skilled nursing facilities for the elderly. The skilled nursing facilities in west gyeongnam mainly focus on the living environment orientated toward the bedroom. The difficulty is to encourage the communication between the skilled nursing facility patients because the facilities are composed of small semi-public zone.

Abstract TMP36: Disability, Quality of Life and Institutionalization After Inpatient Rehabilitation and Skilled Nursing Facility Care for Ischemic Stroke Patients

Introduction: Stroke patients are the second highest post-acute rehabilitation users but there are few comparisons of inpatient rehabilitation (IRF) and skilled nursing facility (SNF) care on patient-reported outcomes. Methods: We compared 3 and 12 month dependence (modified Rankin Scale score=3-6), quality of life (QOL) (Euro-qol-5D continuous variable max=1; death=0), and institutionalization (residence recorded as nursing home, hospice or dead) for acute ischemic stroke (AIS) patients in GWTG-Stroke and the AVAIL (Adherence eValuation After Ischemic Stroke Longitudinal) study living at home pre-stroke and discharged to an IRF or SNF immediately after hospital discharge. Binary and continuous outcomes were modeled by logistic and linear regression, respectively. Inverse propensity weighting (IPW) was used to adjust for measured differences in demographic, clinical and hospital characteristics. Results: Of 473 AIS patients, 72% were discharged to IRFs vs 27% to SNFs. IRF compared with SNF patients were 73 vs. 77 years, with 23% vs. 18% ambulating independently at hospital discharge. After IPW adjustment patients who received IRF care reported better QOL and were less likely to be institutionalized at 3- and 12-months than those who received SNF care but the difference in dependence was not statistically significant (Table). In sensitivity analyses among patients with a NIHSS score, QOL at 3-months was significantly better for IRF compared with SNF patients with no other differences between groups. Conclusions: AIS patients referred to IRFs had higher QOL at 3-months and lower odds of institutionalization at 3 and 12 months post stroke compared with patients referred to SNFs. Further research is needed to discern the mechanisms for potential differences in patient reported outcomes between settings.

Feeding Intolerance and Edema in Children and Adults with Severe Neurological Impairment: Features in the Last Year of Life (TH306)

terminal delirium. There are clear and widely accepted guidelines in the hospice literature for the treatment of agitation. On the other hand, skilled nursing facilities (SNFs) are reporting increasing regulatory pressure to limit the use of psychoactive medications, specifically antipsychotics and benzodiazepines. These restrictions have increased in recent years due to the concern over their overuse as ‘‘chemical restraints’’ for nursing home residents with behavioral problems. In addition, concern over increased mortality with antipsychotic medication use and other side effects have led to crackdowns on use by the regulatory bodies that oversee nursing homes. This can lead to conflicts between the nursing homes and hospice agencies. Frequently, nursing home staff demand to have psychoactive medications removed from the hospice patient’s medication profile. They will ask the hospice staff to pursue invasive tests to work up delirium or ask the hospice to use alternative medications with a less beneficial safety profile. This talk will address the conflicting priorities between hospice and SNF staff in regard to the pharmacologic treatment of delirium/agitation. By way of case presentations and didactics, this session will provide the attendee with current data on pharmacologic treatment of delirium/agitation, with discussion of black box warnings on some antipsychotic medications, an update on Medicare/other governing bodies’ regulations of antipsychotic medication use with an emphasis on SNF strategies to successfully collaborate with SNF to manage agitated SNF patients on hospice.