Andrea Gilmore-Bykovskyi

The Consequences of Poor Communication During Transitions from Hospital to Skilled Nursing Facility: A Qualitative Study

To examine how skilled nursing facility (SNF) nurses transition the care of individuals admitted from hospitals, the barriers they experience, and the outcomes associated with variation in the quality of transitions.

Understanding nurses' decisions to treat pain in nursing home residents with dementia.

Nursing home (NH) residents with dementia continue to receive inadequate pain treatment. The purpose of this qualitative study was to examine how nurses make decisions to pharmacologically treat pain in NH residents with dementia. Using Grounded Dimensional Analysis, 15 in-depth interviews were conducted with 13 nurses from four skilled nursing facilities in Wisconsin. Nurses experienced varying levels of certainty regarding suspected pain in response to particular resident characteristics and whether pain was perceived as visible/obvious or nonvisible/not obvious. Nurses felt highly uncertain about pain in residents with dementia. Suspected pain in residents with dementia was nearly always conceptualized as a change in behavior to which nurses responded by trialing multiple interventions in attempts to return the resident to baseline, which despite current recommendations, did not include pain relief trials. Residents with dementia were described as being at greatest risk for experiencing underassessment, undertreatment, and delayed treatment for pain

Determinants of behavioral and psychological symptoms of dementia: A scoping review of the evidence

BACKGROUND Behavioral and psychological symptoms of dementia (BPSD) are prevalent in people with neurodegenerative diseases. PURPOSE In this scoping review the Kales, Gitlin and Lykestos framework is used to answer the question: What high quality evidence exists for the patient, caregiver and environmental determinants of five specific BPSD: aggression, agitation, apathy, depression and psychosis? METHOD An a priori review protocol was developed; 692 of 6013 articles retrieved in the search were deemed eligible for review. Goughs Weight of Evidence Framework and the Cochrane Collaborations tool for assessing risk of bias were used. The findings from 56 high quality/low bias articles are summarized. DISCUSSION Each symptom had its own set of determinants, but many were common across several symptoms: neurodegeneration, type of dementia, severity of cognitive impairments, and declining functional abilities, and to a lesser extent, caregiver burden and communication. CONCLUSION Research and policy implications are relevant to the National Plan to Address Alzheimers Disease.

Caregiver Person-Centeredness and Behavioral Symptoms in Nursing Home Residents With Dementia: A Timed-Event Sequential Analysis

PURPOSE Evidence suggests that person-centered caregiving approaches may reduce dementia-related behavioral symptoms; however, little is known about the sequential and temporal associations between specific caregiver actions and behavioral symptoms. The aim of this study was to identify sequential associations between caregiver person-centered actions, task-centered actions, and resident behavioral symptoms and the temporal variation within these associations. DESIGN AND METHODS Videorecorded observations of naturally occurring interactions (N = 33; 724min) between 12 nursing home (NH) residents with dementia and eight certified nursing assistants were coded for caregiver person-centered actions, task-centered actions, and resident behavioral symptoms and analyzed using timed-event sequential analysis. RESULTS Although caregiver actions were predominantly person-centered, we found that resident behavioral symptoms were significantly more likely to occur following task-centered caregiver actions than person-centered actions. IMPLICATIONS Findings suggest that the person-centeredness of caregivers is sequentially and temporally related to behavioral symptoms in individuals with dementia. Additional research examining the temporal structure of these relationships may offer valuable insights into the utility of caregiver person-centeredness as a low-cost strategy for improving behavioral symptom management in the NH setting.

Overcoming the Challenges of Unstructured Data in Multisite, Electronic Medical Record-based Abstraction

Background:Unstructured data encountered during retrospective electronic medical record (EMR) abstraction has routinely been identified as challenging to reliably abstract, as these data are often recorded as free text, without limitations to format or structure. There is increased interest in reliably abstracting this type of data given its prominent role in care coordination and communication, yet limited methodological guidance exists. Objectives:As standard abstraction approaches resulted in substandard data reliability for unstructured data elements collected as part of a multisite, retrospective EMR study of hospital discharge communication quality, our goal was to develop, apply and examine the utility of a phase-based approach to reliably abstract unstructured data. This approach is examined using the specific example of discharge communication for warfarin management. Research Design:We adopted a “fit-for-use” framework to guide the development and evaluation of abstraction methods using a 4-step, phase-based approach including (1) team building; (2) identification of challenges; (3) adaptation of abstraction methods; and (4) systematic data quality monitoring. Measures:Unstructured data elements were the focus of this study, including elements communicating steps in warfarin management (eg, warfarin initiation) and medical follow-up (eg, timeframe for follow-up). Results:After implementation of the phase-based approach, interrater reliability for all unstructured data elements demonstrated &kgr;’s of ≥0.89—an average increase of +0.25 for each unstructured data element. Conclusions:As compared with standard abstraction methodologies, this phase-based approach was more time intensive, but did markedly increase abstraction reliability for unstructured data elements within multisite EMR documentation.

Preparing Tomorrow’s Nursing Home Nurses: The Wisconsin Long Term Care Clinical Scholars Program

Preparing future nurses to care for the growing population of older adults has become a national priority. The demand for long term care services is expected to double between 2000 and 2040, yet the field remains stigmatized as an undesirable place for highly skilled nurses to work. Recent efforts to increase student preparation in geriatrics have been shown to improve student attitudes toward working with older adults and increase knowledge, but long term care settings remain unattractive to students. This article reports on the development, implementation, and evaluation of The Wisconsin Long Term Care Clinical Scholars Program, a nursing home internship for baccalaureate nursing students. The program couples a paid nursing home work experience with an evidence-based long term care nursing curriculum. The program increased student preparation and interest in working both with older adults and in nursing homes, while increasing the capacity of nursing homes to provide a positive student experience.

Caregiver person-centeredness and behavioral symptoms during mealtime interactions: Development and feasibility of a coding scheme

Mealtime behavioral symptoms are distressing and frequently interrupt eating for the individual experiencing them and others in the environment. A computer-assisted coding scheme was developed to measure caregiver person-centeredness and behavioral symptoms for nursing home residents with dementia during mealtime interactions. The purpose of this pilot study was to determine the feasibility, ease of use, and inter-observer reliability of the coding scheme, and to explore the clinical utility of the coding scheme. Trained observers coded 22 observations. Data collection procedures were acceptable to participants. Overall, the coding scheme proved to be feasible, easy to execute and yielded good to very good inter-observer agreement following observer re-training. The coding scheme captured clinically relevant, modifiable antecedents to mealtime behavioral symptoms, but would be enhanced by the inclusion of measures for resident engagement and consolidation of items for measuring caregiver person-centeredness that co-occurred and were difficult for observers to distinguish.

Omission of Physical Therapy Recommendations for High-Risk Patients Transitioning From the Hospital to Subacute Care Facilities

OBJECTIVES To assess the quality and explore the potential impact of the communication of physical therapy (PT) recommendations in hospital discharge summaries/orders for high-risk subacute care populations, specifically targeting recommendations for (1) maintenance of patient safety, (2) assistance required for mobility, and (3) use of assistive devices. DESIGN Medical record abstraction of retrospective cohort comparing discharge recommendations made by inpatient PT to orders included in written hospital discharge summaries/orders, the primary form of hospital-to-subacute care communication. Data were linked to Medicare outcomes from corresponding years for all Medicare beneficiaries in the cohort. SETTING Academic hospital. PARTICIPANTS All hospitalized patients (N=613 overall) 18 years and older with primary diagnoses of stroke or hip fracture, with an inpatient PT consultation and discharged to subacute care during the years 2006 to 2008; 366 of these were Medicare beneficiaries. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Combined rehospitalization, emergency department visit, and/or death within 30 days of discharge. RESULTS Omission of recommendations for maintaining patient safety occurred in 54% (316/584) of patients; for assistance required for mobility, in approximately 100% (535/537); and for use of assistive devices, in 77% (409/532). As compared with those without patient safety restriction/precaution omissions, Medicare beneficiaries with such omissions demonstrated a trend toward more negative 30-day outcomes (26% vs 18%, P=.10). Similar, albeit nonsignificant, outcome trends were observed in the other omission categories. CONCLUSIONS PT recommendations made during a hospital stay in high-risk patients are routinely omitted from hospital discharge communications to subacute care facilities. Interventions to reliably improve this communication are needed.

The Model of Care Partner Engagement: Use in delirium management

Care partner engagement is a central tenant of person-centered care. Despite widespread interest in transforming current health care delivery to a more person-centered system, little is known about effective strategies for engaging care partners. The Model of Care Partner Engagement is introduced and described as an evidence-informed framework that nurses can use to guide the development of care partnerships. The case of hospitalized older adults with cognitive impairment and delirium is used to illustrate implementation of the model. Care partner engagement is integral to national efforts that promote affordable, equitable, high quality care and is a growing expectation of older adults and their families.

Sepsis Survivors Admitted to Skilled Nursing Facilities: Cognitive Impairment, Activities of Daily Living Dependence, and Survival*

Objective: Severe sepsis survivors frequently experience cognitive and physical functional impairment. The degree of impairment and its association with mortality is understudied, particularly among those discharged to a skilled nursing facility. Our objective was to quantify the cognitive and physical impairment among severe sepsis survivors discharged to a skilled nursing facility and to investigate the relationship between impairment and long-term mortality. Design: Retrospective cohort study. Setting: United States. Subjects: Random 5% sample of Medicare patients discharged following severe sepsis hospitalization, 2005–2009 (n = 135,370). Measurement and Main Results: Medicare data were linked with the Minimum Data Set; Minimum Data Set-Cognition Scale was used to assess cognitive function, and the Minimum Data Set activities of daily living hierarchical scale was used to assess functional dependence. Associations were evaluated using multivariable logistic regression, Kaplan-Meier curves, and Cox proportional hazards regression. Of 66,540 beneficiaries admitted to a skilled nursing facility following severe sepsis, 34% had severe or very severe cognitive impairment, and 72.5% had maximal, dependence, or total dependence in activities of daily living. Median survival was 19.4 months for those discharged to a skilled nursing facility without having been in a skilled nursing facility in the preceding 1 year and 10.4 months for those discharged to a skilled nursing facility who had spent time in a skilled nursing facility in the prior year. The adjusted hazard ratio for death was 3.1 for those with very severe cognitive impairment relative to those who were cognitively intact (95% CI, 2.9–3.2; p < 0.001) and 4.3 for those with “total dependence” in activities of daily livings relative to those who were independent (95% CI, 3.8–5.0; p < 0.001). Conclusions: Discharge to a skilled nursing facility following severe sepsis hospitalization among Medicare beneficiaries was associated with shorter survival, and cognitive impairment and activities of daily living dependence were each strongly associated with shortened survival. These findings can inform decision-making by patients and physicians and underscores high palliative care needs among sepsis survivors discharged to skilled nursing facility.