Skilled Nursing Facility Setting Research Articles

Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents

Clinician specialization in the care of nursing home (NH) residents or patients in skilled nursing facilities (SNFs) has become increasingly common. It is not known whether clinicians focused on NH care, often referred to as SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF setting), are associated with a reduced likelihood of burdensome transitions in the last 90 days of life for residents, which are a marker of poor-quality end-of-life (EOL) care. To quantify the association between receipt of care from an SNFist and quality of EOL care for NH residents. This cohort study analyzed Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries to examine burdensome transitions among NH decedents at the EOL from January 1, 2013, through December 31, 2019. Statistical analyses were conducted from December 2022 to June 2023. Receipt of care from an SNFist, defined as physicians and advanced practitioners who provided 80% or more of their evaluation and management visits in NHs annually. This study used augmented inverse probability weighting in analyses of Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries. Main outcomes included 4 measures of burdensome transitions: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization in the last 90 days of life; (3) multiple hospitalizations in the last 90 days of life for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis; and (4) any hospitalization in the last 90 days of life for an ambulatory care-sensitive condition. Of the 2 091 954 NH decedents studied (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]), 953 722 (45.6%) received care from SNFists and 1 138 232 (54.4%) received care from non-SNFists; 422 575 of all decedents (20.2%) experienced a burdensome transition at the EOL. Receipt of care by an SNFist was associated with a reduced risk of (1) hospital transfer in the last 3 days of life (-1.6% [95% CI, -2.5% to -0.8%]), (2) lack of continuity in NHs after hospitalization (-4.8% [95% CI, -6.7% to -3.0%]), and (3) decedents experiencing multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (-5.8% [95% CI, -10.1% to -1.7%]). There was not a statistically significant association with the risk of hospitalization for an ambulatory care-sensitive condition in the last 90 days of life (0.0% [95% CI, -14.7% to 131.7%]). This study suggests that SNFists may be an important resource to improve the quality of EOL care for NH residents.

Efficacy of Utilizing the Group Mode of Treatment Delivery in OT for Skilled Nursing Facility Settings

Abstract Date Presented 04/20/2023 This quasi-experimental study completed at six skilled nursing facilities (SNFs) found statistically significant improvements in self-care utilizing an evidence-based group protocol that included fine motor, cognition, strength, flexibility, balance, and occupational components. Primary Author and Speaker: Melissa K Luchynsky Contributing Authors: Katie Ashbaugh, Amber Bowser, Emily Campisi, Morgan Gleixner, Byron Heinbach, Allison Snak

VIRTUAL TELEHEALTH CLINICAL EXPERIENCE TO PREPARE STUDENT PHYSICAL THERAPISTS FOR PRACTICE IN A SNF

Abstract Student training was suspended in most post-acute settings in the United States due to the COVID-19 pandemic. Through a collaborative partnership between a university and a healthcare organization we offered a virtual telehealth clinical experience to prepare student physical therapists for practice in a skilled nursing facility (SNF) setting. 35 students engaged virtually for 80 hours with two clinical instructors. The curriculum included eight virtual learning modules along with four telehealth patient encounters that exposed students to interdisciplinary teams in the SNF context. Students completed a retrospective pre/post Self-Perception of Learning Survey. Results demonstrated students’ self-perception of learning was significantly increased implying an improved ability to practice in the SNF setting. This approach advanced student learning in patient care management, interprofessional practice, and telehealth practice in the SNF setting. Future work is planned to expand the program to include 20 physical therapy, occupational therapy, and speech and language pathology students.

ENSURING A KNOWLEDGEABLE GERIATRIC WORKFORCE: INTERDISCIPLINARY EDUCATION IN LONG-TERM SERVICES AND SUPPORTS

Abstract In this symposium, we describe five interdisciplinary educational programs to enhance the geriatric workforce in long-term services and supports (LTSS): Skilled nursing facilities (SNFs), assisted living, and home health and hospice. The interdisciplinary teams that came together to offer the programs leveraged technology to maximize access to experts in both the curriculum development process and the delivery of the educational programs for a wide range of target learners. The first program, an interdisciplinary telementoring series on dementia care for therapists in SNFs, was developed by a team of experts from occupational, physical and speech therapy. The program included asynchronous online didactic content and case-based learning relevant to therapists. The second program engaged faculty from seven graduate programs: Pharmacy, Physical Therapy, Occupational Therapy, Dentistry, Social Work, Nursing and Physician Assistant to co-create an interprofessional LTSS graduate certificate in Gerontology. The certificate encompasses asynchronous online courses to enable flexibility across programs and cover content specific to LTSS. In the third program, LTSS nurses completed an online educational course to better prepare them to care for complex older adults, improve leadership skills, become more resilient, and complete QAPI projects. The fourth program focused on utilizing interdisciplinary perspectives to educate LTSS direct care staff on the unique needs of LGBTQ older adults. The fifth program offered a virtual telehealth clinical experience to prepare physical therapy students for practice in a SNF setting. The curriculum included eight virtual modules and four telehealth patient encounters that exposed students to interdisciplinary teams in the SNF context.

Let's Integrate! The Case for Bringing Behavioral Health to Nursing Home-Based Post-Acute and Subacute Care.

Behavioral health (BH) concerns are prevalent among residents (eg, depression, anxiety, and insomnia), family care partners (eg, depression and burden), and staff (eg, burnout and depression) in nursing home-based post-acute and subacute care, referred to as skilled nursing facility (SNF) care. When untreated, BH concerns can lead to negative care outcomes, including limited functional improvements, longer lengths of stay, and elevated risk of rehospitalization and mortality. Despite the high clinical need, the field lacks evidence and consensus regarding an optimal model of BH services and roles for BH clinicians in SNFs. Developing such a model can inform the testing of BH interventions that best align with clinical operations, moving the field toward answering questions regarding the effectiveness and implementation of BH services in SNFs. Evidence-based BH models from the primary care literature include coordinated, colocated, and integrated care, each of which present potential benefits and challenges for the SNF setting. In this special article, we argue that an integrated model of BH services in SNFs may (1) increase access to and engagement with BH; (2) strengthen positive biopsychosocial resident outcomes and quality of care; and (3) prevent or improve BH concerns among stakeholders involved in resident care, including family care partners and staff. From our evidence-based discussion, we propose a Stepped-Care Model of Integrated BH for SNFs that can help clarify the scope of practice and clinical roles for licensed BH clinicians in this setting (eg, psychologists, clinical social workers, master's-level counselors). We conclude with a discussion of policy and research implications with a focus on potential policy changes that may be necessary for BH integration in SNFs. Future research to establish feasibility, clinical benefit (eg, efficacy, effectiveness), and financial justification for our proposed model is needed. This article can serve as a guide for such future research endeavors.

Applying an Urgent Care Model to the Skilled Nursing Facility Setting

Reducing readmissions to hospitals and ED visits has been a priority among health systems and skilled nursing facilities. Approximately 20% of Medicare-funded hospitalizations result in discharge to a skilled nursing facility (SNF). Transitions to and from the hospital setting frequently occurs. In an analysis of SNF hospital readmissions 23% were found to be preventable. To reduce hospital readmissions from SNFs, we have deployed the Urgent Care model (UCM) within the SNF setting. Urgent care is typically defined as healthcare that is needed for a condition that requires prompt attention (within 24 h) but is not a life-threatening emergency. UCM are designed to manage unscheduled conditions, which often arise outside core office hours. The UCM has rapidly emerged over the last several decades out of demand to alleviate ED wait times and visits for patients. Several studies found that UCM have reduced visits to nearby EDs.

Nursing Administrative Support Role Proves Reduction in Nursing Overtime and Staff Turnover

Nursing Administrative Support Role Proves Reduction in Nursing Overtime and Staff Turnover

Improving Medication Reconciliation with Comprehensive Evaluation at a Veterans Affairs Skilled Nursing Facility.

Unintentional medication discrepancies due to inadequate medication reconciliation pose a threat to patient safety. Skilled nursing facilities (SNFs) are an important care setting where patients are vulnerable to unintentional medication discrepancies due to increased medical complexity and care transitions. This study describes a quality improvement (QI) approach to improve medication reconciliation in an SNF setting as part of the Multi-Center Medication Reconciliation Quality Improvement Study 2 (MARQUIS2). This study was conducted at a 112-bed US Department of Veterans Affairs SNF. The researchers used several QI methods, including data benchmarking, stakeholder surveys, process mapping, and a Healthcare Failure Mode and Effect Analysis (HFMEA) to complete comprehensive baseline assessments. Baseline assessments revealed that medication reconciliation processes were error-prone, with high rates of medication discrepancies. Provider surveys and process mapping revealed extremely labor-intensive and highly complex processes lacking standardization. Factors contributing were polypharmacy, limited resources, electronic health record limitations, and patient exposure to multiple care transitions. HFMEA enabled a methodical approach to identify and address challenges. The team validated the best possible medication history (BPMH) process for hospital settings as outlined by MARQUIS2 for the SNF setting and found it necessary to use additional medication lists to account for multiple care transitions. SNFs represent a critical setting for medication reconciliation efforts due to challenges completing the reconciliation process and the concomitant high risk of adverse drug events in this population. Initial baseline assessments effectively identified existing problems and can be used to guide targeted interventions.

The patient-driven payment model: A missed opportunity for patient-centered cancer care.

Hospitalized older patients with advanced cancer who were discharged to a skilled nursing facility (SNF) for rehabilitation are unlikely to receive future cancer treatment, have high 30-day readmission rates, and high mortality yet minimal hospice use. The Medicare SNF benefit was designed to be a bridge and provide short-term nursing and rehabilitation care for patients after a hospitalization. However, advanced cancer patients churn through the health system cycling between the hospital, post-acute care facilities, and home in the last months of life. This article explores the potential impact of the patient-driven payment model, a new SNF reimbursement model introduced by the Center for Medicare and Medicaid Services in 2019, on the experience of older cancer patients. Previously, SNF reimbursement was based on the hours of rehabilitative therapy provided to patients, unintentionally incentivizing SNFs to provide more therapy resulting in long lengths of stay and increased Medicare expenditure. The new patient-driven payment model bases reimbursement on patient clinical characteristics and resources utilized during their SNF stay. We discuss the impact this payment model might have on cancer patients in the SNF setting and highlight the importance of access to palliative care for this population. We discuss challenges policymakers face in creating palliative care guidelines and developing palliative care delivery models in SNFs. We highlight the policy gaps that remain in creating a system that achieves high-quality SNF care and conclude by offering suggestions that might better incorporate a patient's illness trajectory, prognosis, and goals of care.

Recovery of Functional Mobility with a Long-Term Nursing Facility Patient Utilizing the Fascial Distortion Model: A Case Study

Abstract Functional immobility has demonstrated a higher risk of all-cause mortality in geriatric population. It is noted that musculoskeletal pain is one major factor involved with geriatric functional immobility. The fascial distortion model (FDM) utilizes pathognomonic physical gestures to diagnose and treat musculoskeletal pain. In this case study, a long-term nursing facility patient with significantly prolonged wheelchair-to-bed transfer presented with several upper and lower extremity fascial distortions. After FDM treatment, the patient demonstrated a moderate return of functional mobility. This case presents the utility of FDM treatment in cases of decreased functional mobility due to musculoskeletal pain as well as treatment for patients in skilled nursing facility settings.

Older adults in skilled nursing facilities demonstrate low physical activity during and after discharge

Purpose This study sought to quantify physical activity and sedentary time among older adults during a skilled nursing facility (SNF) stay and after the transition home, a critical period when patients are at high risk for adverse events. Materials and methods We performed an observational cohort study of physical activity and sedentary behavior during the last 3–5 days before discharge from SNF and the initial 3–5 days at home using accelerometers. Participants answered questions about perceived physical activity in the SNF and at home. Results A convenience sample of thirty-one residents from two SNFs were included. Participants spent a median 12.2% (interquartile range [IQR], 17.3%) of time upright in the SNF and 16.8% (IQR, 15.2%) of their time upright at home (p = 0.002) and took a median of 849 steps (IQR, 1772) in the SNF and 922 steps (IQR, 1906) at home (p = 0.57), per day. Participants averaged fewer sitting bouts at home (p = 0.03), but there was no difference in sit-to-stand transitions (p = 0.32) or activity scores (p = 0.67). Subjective perceptions of physical activity appeared to be higher than objective measurements. Conclusion In an exploratory study, SNF residents demonstrated profoundly low levels of physical activity both during and after their SNF stay. Future studies using larger sample sizes should examine physical activity during the SNF to home transition as well as barriers and facilitators to physical activity in post-acute care environments. IMPLICATIONS FOR REHABILITATION SNF residents in this study demonstrated low levels of physical activity and high rates of sedentary behavior that persisted after discharge home. Interventions to improve physical activity levels in the SNF are sorely needed, and those interventions should include a plan for progressing physical activity after the transition home. Objective measurement of physical activity using activity monitors may prove clinically useful for older adults following hospitalization in the SNF and home settings.

Compassion Fatigue Among RNs Working in Skilled Nursing Facilities.

Nurses employed in skilled nursing facilities (SNFs) are at risk for developing compassion fatigue. Compassion fatigue negatively impacts patient outcomes and is associated with decreased quality of care. Some nurses leave the profession due to compassion fatigue. There are no published studies in the United States focused on compassion fatigue among SNF nurses. The purpose of this interpretive phenomenological study was to identify the shared meanings of compassion fatigue among RNs caring for residents in SNFs. Shared meanings among participants were identified as: (1) I feel conflicted, which causes my compassion fatigue; (2) I feel physical and emotional manifestations of compassion fatigue; (3) Compassion fatigue is infused in every aspect of my life; and (4) We are trying to cope with compassion fatigue. Of paramount importance was the desire to make a difference in the lives of residents. Three participants sought employment outside the SNF setting due to compassion fatigue. Further research and education are needed to improve knowledge, policy, and practice. [Research in Gerontological Nursing, 13(6), 320-328.].

Reengineering Skilled Nursing Facility Discharge: Analysis of Reengineered Discharge Implementation.

There is a need to adopt evidence-based approaches to discharge planning in the skilled nursing facility (SNF) short stay population. This article describes implementation of the Reengineered Discharge (RED) process in SNFs and makes recommendations for its future implementation. The methods included a pre- and postanalysis of an 18-month RED implementation with a contemporaneous comparison of 4 Midwestern SNFs randomly assigned to 2 different RED implementation strategies. The Standard facilities received less implementation than Enhanced facilities. Standard SNFs made more improvements and were more satisfied with the improved process than Enhanced SNFs. Field notes revealed that corporate willingness to make process changes impacted the Standard group's capacity for change; both groups were heavily influenced by external forces, and turnover was an impediment to RED implementation. This research revealed that discharge processes are similar across settings and that evidence-based programs such as RED can be adapted to the SNF setting.

Derivation of a Model to Guide Empiric Therapy for Carbapenem-Resistant Klebsiella pneumoniae Bloodstream Infection in an Endemic Area.

BackgroundAppropriate therapy for carbapenem-resistant Klebsiella pneumoniae (CRKP) bloodstream infection (BSI) is often given late in the course of infection, and strategies for identifying CRKP BSI earlier are needed.MethodsA retrospective case–control study was performed at a tertiary care hospital, university hospital, and community hospital in Bronx, New York. All participants had a blood culture sent and received an antibiotic within 48 hours of the culture. The case group (n = 163) had a blood culture with CRKP. The control group (n = 178) had a blood culture with carbapenem-susceptible Klebsiella. Data were obtained by electronic or conventional medical record abstraction. A multiple logistic regression model was built to identify associated factors and develop a clinical model for CRKP BSI. Model performance characteristics were estimated using a 10-fold cross-validation analysis.ResultsA prior nonblood culture with carbapenem-resistant Enterobacteriaceae, skilled nursing facility (SNF) residence, mechanical ventilation, and admission >3 days were strongly associated risk factors. A significant interaction led to development of separate clinical models for subjects admitted <3 days at the time of positive blood culture from those admitted at least 3 days. The derived models had a good ability to discriminate between subjects with and without CRKP BSI. A clinical classification rule to guide therapy can prioritize sensitivity or specificity.ConclusionsPrior nonblood cultures showing resistance and exposure to SNF and health care settings are factors associated with carbapenem resistance. The clinical classification rules derived in this work should be validated for ability to guide therapy.

Healthcare resource utilization and costs among nonvalvular atrial fibrillation patients initiating rivaroxaban or warfarin in skilled nursing facilities: a retrospective cohort study

Objective Atrial fibrillation (AF) is present in up to 17% of patients in skilled nursing facilities (SNFs). This study compared healthcare resource utilization (HRU) and costs between AF patients initiating rivaroxaban or warfarin in SNFs. Methods Using de-identified claims from Optum Clinformatics Extended Data Mart (1 January 2013 to 31 December 2017), this retrospective cohort study indexed AF patients with first SNF admission during which rivaroxaban or warfarin was initiated within 3 days of admission. To adjust for selection bias, inverse probability of treatment weighting (IPTW) was applied for baseline characteristics. Logistic regression and generalized linear models were used to compare HRU and costs. Results 519 rivaroxaban and 1129 warfarin patients met inclusion criteria. After IPTW, the cohorts were well balanced for baseline characteristics. The average length of index SNF stay was 32.07 and 37.44 days for rivaroxaban and warfarin patients, respectively. During SNF stay, rivaroxaban patients had 27% lower odds of hospitalization (p < .0001), 2.7 fewer international normalized ratio (INR) tests per-patient-per-month (PPPM; p < .001), and 2.3 fewer pathology/laboratory encounters PPPM (p < .0001) than warfarin patients. All-cause healthcare costs were $2638 lower with rivaroxaban versus warfarin (p < .0001) during the index SNF stay, with lower medical costs (p < .0001) but higher pharmacy costs (p < .0001). Total all-cause healthcare costs 100 days post-index SNF were $8746 lower with rivaroxaban versus warfarin (p < .0001). Conclusions In the SNF setting, AF patients treated with rivaroxaban had 5-day shorter length of stay, lower HRU, and lower all-cause total and medical costs compared to warfarin, despite higher treatment costs. These findings may help inform clinical decision-making to reduce economic burden.

Return home after dysvascular major amputation of the lower limb: A multicentre observational study in the Netherlands.

To report the rates of persons returning home within one year following dysvascular major amputation of the lower limb in the Netherlands, and to identify factors associated with returning home directly after hospital admission and after discharge to care facilities. Retrospective cohort study. Dysvascular major amputation of the lower limb, n = 382, mean age 71.9 years (standard deviation (SD) 12.5 years), 65% male. Medical records of all persons undergoing major amputation of the lower limb in 2012-2013 in 12 hospitals in Northern Netherlands were reviewed. Odds ratios (OR) were calculated using multivariate logistic regression. Among persons admitted from home and surviving the hospital admission, 21% returned home, with higher odds of returning home being associated with living with a partner (OR = 2.8, p = 0.006) and younger age (< 65 years). Among those discharged to care and surviving the first year, 77% returned home within one year after amputation, with higher odds being associated with younger age (<75 years) and admission to inpatient rehabilitation (OR = 10.6, p = 0.004) or geriatric rehabilitation in skilled nursing facilities (OR = 3.5, p = 0.030). Four out of 5 persons surviving dysvascular major amputation of the lower limb return home within one year, although a majority requires care in either inpatient rehabilitation or a skilled nursing facilities setting.

PDB22 ANTIHYPERGLYCEMIC TREATMENT REGIMENS BEFORE AND AFTER A SKILLED NURSING FACILITY STAY AMONG PATIENTS WITH TYPE 2 DIABETES

This proof-of-concept study used real-world claims data to explore antihyperglycemic treatment regimens in patients with Type 2 diabetes (T2DM) prior to and after a short stay in a skilled nursing facility (SNF). Commercial and Medicare Advantage with Part D (MAPD) enrollees from the Optum Research Database with a SNF stay between November 2014 and June 2017 (index=first SNF admission date), pre-index diagnosis of T2DM, aged ≥18 years, with continuous enrollment for ≥6 months pre-index and ≥6 months post SNF discharge were selected. Patients with SNF stays >100 days, Type 1 diabetes, pregnancy, or cancer during the study period were excluded. Antihyperglycemic treatment at class level (oral, insulin, or GLP-1 RA) during 3 months pre-index and through ≤30 days post SNF discharge were captured. Discontinuation of treatment was defined as a gap >30 days between two fills. The sample included 62,316 patients with mean age 75 years; 60% female; mean Quan-Charlson score 2.8; and 58% with SNF stays ≤20 days. During 3 months pre SNF admission, 46% had no antihyperglycemic prescriptions, 34% had oral-only regimen, 12% had insulin-only regimen, 0.3% had GLP-1 RA-only regimen, and 7% had a combination regimen. Upon SNF discharge, three SNF treatment pattern cohorts emerged: continuing without any antihyperglycemic prescription (41%); no changes to pre-index regimen (39%); and ≥1 regimen change (20%). Among those with regimen changes, 89% experienced only one therapy change. The most common non-mutually exclusive changes were: discontinuation of oral(s) (32%), discontinuation of injectable(s) (31%), augmentation with injectable(s) (25%), augmentation with oral(s) (21%), and switching between injectables (3%). Among commercial and MAPD patients with T2DM discharged from a SNF, 20% experienced changes in antihyperglycemic regimens, including both augmentation and discontinuation of injectables and/or orals. Future research should explore the clinical impact of changes in antihyperglycemic regimens in SNF setting.

Cardiac Limited Ultrasound Exam (CLUE) Protocol for CHF Management in a Skilled Nursing Facility Setting

Cardiac Limited Ultrasound Exam (CLUE) protocol using portable ultrasound has been being more widely adopted by clinicians to augment the bedside cardiac physical examination, especially for patients with CHF. We present a case to illustrate the role of portable ultrasound in CHF management to reduce the risk of hospital readmission for patients in SNF settings.

Are Productivity Goals in Rehabilitation Practice Associated With Unethical Behaviors?

ObjectivesTo evaluate the presence of productivity goals among licensed rehabilitation clinicians and their relationship with observed unethical behavior. DesignExploratory, cross-sectional survey. SettingOnline. ParticipantsLicensed physical therapy clinicians (N=3446). InterventionNot applicable. Main Outcome MeasureParticipants completed an electronic survey regarding use of clinical productivity goals. They rated the frequency in which they observed 6 unethical behaviors on a 7-point Likert scale in their practice setting from 1=never to 7=always. An overall observed unethical behavior score was calculated by summing these scales. ResultsThe response rate was 12.8% (N=3446), with analyses showing low risk of nonresponse bias. Many respondents (73.9%) had a formal productivity goal. Most (89.4%) reported observing some form of unethical behavior, but many (68.6%) reported it occurred “rarely” or “never.” Those in skilled nursing facility (SNF) settings reported higher frequencies of observance and were 4.1 times more likely to report more unethical behavior than the median compared with all other settings. A positive correlation existed between expected productivity rate and rate of unethical behaviors observed (ρ=0.225; P<.0001). Amounts of organizational emphases on ethical practice (ρ=−0.509; P<.0001) and evidence-based practice (ρ=−0.492; P<.0001) were negatively correlated with total observed unethical behavior. ConclusionsUse of productivity goals in rehabilitation practice is significantly related with rate of unethical behavior observed. Frequency of observed unethical behavior in rehabilitation practice was very low overall. Organizational culture appears to be a greater predictor of observed unethical behavior than any individual clinician-related characteristics. The SNF setting displays the greatest areas of ethical concern.

Adapting Project RED to Skilled Nursing Facilities.

This article describes our recommendation for adapting hospital-based RED (Reengineered Discharge) processes to skilled nursing facilities (SNFs). Using focus groups, the SNFs' discharge processes were assessed twice additionally, research staff then recorded field notes documenting discussions about facility discharge processes as they related to RED processes. Data were systematically analyzed using thematic analysis to identify recommendations for adapting RED to the SNF setting including (a) rapidly identifying, involving, and preparing family/caregivers to implement a patient focused SNF discharge plan; (b) reconnecting patients quickly to primary care providers; and (c) educating patients at discharge about their target health condition, medications, and impact of changes on other chronic health needs. Limited SNF staff capacity and corporate-level policies limited adoption of some key RED components. Transitional care processes such as RED, developed to avoid discharge problems, can be adapted for SNFs to improve their discharges.