Debra Parker-Oliver

The MDS Mortality Risk Index: The evolution of a method for predicting 6-month mortality in nursing home residents

BackgroundAccurate prognosis is vital to the initiation of advance care planning particularly in a vulnerable, at risk population such as care home residents. The aim of this paper is to report on the revision and simplification of the MDS Mortality Rating Index (MMRI) for use in clinical practice to predict the probability of death in six months for care home residents.MethodsThe design was a secondary analysis of a US Minimum Data Set (MDS) for long term care residents using regression analysis to identify predictors of mortality within six months.ResultsUsing twelve easy to collect items, the probability of mortality within six months was accurately predicted within the MDS database. The items are: admission to the care home within three months; lost weight unintentionally in past three months; renal failure; chronic heart failure; poor appetite; male; dehydrated; short of breath; active cancer diagnosis; age; deteriorated cognitive skills in past three months; activities of daily living score.ConclusionA lack of recognition of the proximity of death is often blamed for inappropriate admission to hospital at the end of an older persons life. An accurate prognosis for older adults living in a residential or nursing home can facilitate end of life decision making and planning for preferred place of care at the end of life. The original MMRI was derived and validated from a large database of long term care residents in the USA. However, this simplification of the revised index (MMRI-R) may provide a means for facilitating prognostication and end of life discussions for application outside the USA where the MDS is not in use. Prospective testing is needed to further test the accuracy of the MMRI-R and its application in the UK and other non-MDS settings.

Hospice and nonhospice nursing home residents.

OBJECTIVE To compare hospice residents in nursing homes with residents who are noted as end-stage, but not in hospice programs. DESIGN Descriptive comparison of the outcomes reported on Minimum Data Set (MDS) for all residents admitted to Missouri nursing homes in 1999. SETTING Nursing homes. PARTICIPANTS Residents of nursing homes designated as either hospice or end-stage on admission MDS. MEASUREMENTS Percentage of hospice residents having various conditions as compared with other end-stage residents. RESULTS/CONCLUSIONS Overall the clinical conditions of both hospice and nonhospice end-stage residents were similar. A greater percentage of hospice residents were found to have living wills, DNR orders, and cancer, and to be in moderate or severe pain. Hospice and nonhospice residents experienced similar time from admission to death or discharge (20 and 36 days, respectively). Based on the clinical condition of the two groups, it would appear that there are limited clinical reasons for the low utilization of the hospice benefit in nursing homes. The increased prevalence of advance care planning may lead toward use of hospice or may result from hospice enrollment. Hospice services seem to be thought of more frequently for residents with cancer and residents experiencing pain. Nursing homes must recognize their role as caregivers to the dying before palliative care is seen as a need for nursing home residents. Nursing homes need education in determining when a patient is appropriate for palliative care as only 4% are designated as end of life, and only 2% are shown to be receiving hospice care in hospice-contracted facilities.

Redefining hope for the terminally ill

This paper discusses how hospice social workers assist patients and families in finding new hope and meaning in their lives as care goals turn from cure to comfort. Assessment factors important to the redefinition process and intervention strategies are explored. Hope is defined as the positive expectation for meaning attached to life events with the emphasis on meaning instead of life events. The author seeks to demonstrate the importance of meaning to the feeling of hope and the possibility of socially constructing meaning to alleviate the traditional medical perspective that hope revolves around the outcome of disease.

Nursing Home Experience with Hospice

OBJECTIVE Much has been written regarding the problems of terminally ill people residing in nursing homes. Hospice care is one option these facilities have to assist in managing dying patients. The purpose of the study was to explore the knowledge base, experience, and attitudes of nursing home management with and toward hospice care. DESIGN A descriptive study that involved phone interviews of a systematic random sample of management personnel in nursing homes to explore their experiences with hospice care. SETTING Nursing homes. PARTICIPANTS 60 administrators and directors of nursing (DON) from 42 nursing homes in Missouri. MEASUREMENTS Measurements included overall experience with hospice, the benefit of hospice to residents, specific experiences with hospice service, knowledge of hospice regulation and reimbursement, and perception of pain assessment skills. RESULTS Results show that management personnel believe that hospice was positive and valuable for residents. Concerns included the frequency and availability of hospice services for nursing home residents, especially in rural areas. Nursing home management claimed that hospice was knowledgeable in pain management, yet when measured, pain management skills ranked 2.1 on a scale of 1 to 5 (1 being the best). Community and physician understanding of hospice was identified as a major barrier for residents. CONCLUSIONS While the results indicate a positive overall experience, a number of shortcomings are identified. The study points to opportunities for improvement in hospice/nursing home relationships. It also identifies opportunities for hospices and nursing homes to educate their medical directors in an effort to obtain active participation in the identification of patients for palliative care. In addition, the need for medical directors to assist in the education of nursing home staff regarding hospice services and benefits is indicated. Specifically, medical directors can educate nursing home staff on care plan responsibilities with hospice patients and other regulatory issues.

Hospice Experience and Perceptions in Nursing Homes

The purpose of this study was to describe the experiences and perceptions of hospice nurses caring for residents in long-term care facilities. The study used a fax-back survey to gather data from 69 hospice nursing and nurse managers in 24 hospices across one Midwestern state. Respondents reported negative experiences with pain management and care coordination in the nursing home setting. Although hospice is thought to be a benefit to residents, hospice staff report frustration in caring for nursing home patients, especially in trying to control pain. The study identifies opportunities for improvement in hospice and nursing home staff relationships.

Practice patterns of hospice medical directors in a Midwestern state

This study of hospice medical directors was conducted in a Midwestern state with the help of the state hospice organization in the summer of 1998. The hospice programs in this state were young and relatively small. While having practiced medicine for many years, the majority of hospice medical directors had been affiliated with a hospice program for less than five years. The programs reported little orientation or continuing education for their physician leaders. Pain management practices were analyzed and compared with practice standards in the hospice pain management literature. Attitudes on the scheduled dosing of opioids, use of adjuvant medications for bone pain, the assessment of pain by the patient, and physician comfort with high doses of morphine are consistent with suggested standards and attitudes in the literature. Practice patterns that differed with the literature included choice of drugs, routes of administration, and dosing issues. Opportunities exist to improve care and lower cost.

The Physician's Role in Patients' Nursing Home Care "She's a Very Courageous and Lovely Woman. I Enjoy Caring for Her"

More than 1.5 million adults live in US nursing homes, and approximately 30% of individuals in the United States will die with a nursing home as their last place of residence. Physicians play a pivotal role in the rehabilitation, complex medical care, and end-of-life care of this frail and vulnerable population. The reasons for admission are multifactorial and a comprehensive care plan based on the Minimum Data Set guides the multidisciplinary nursing home team in the care of the patient and provides assessments of the quality of care provided. Using the cases of 2 patients with different experiences, we describe the physicians role in planning for admission, participating as a team member in the ongoing assessment and care in the nursing home, and guiding care at the end of life. The increasing population of older adults has also promoted community-based and residential alternatives to traditional nursing homes. The future of long-term care will include additional challenges and rich innovations in services and options for older adults.

Defining Core Competencies for Generalist-Level Palliative Social Work

CONTEXT Care provided to seriously ill patients by frontline social workers is a component of generalist-level palliative care. The core competencies for high-quality generalist-level palliative social work are necessary to promote training curricula and best practices but have not yet been defined in the U.S. OBJECTIVE The objective of this study was to develop consensus-derived core competencies for generalist-level palliative social work. METHODS Fifty-five proposed social work competencies were categorized by the eight domains of palliative care identified by the National Consensus Project for Quality Palliative Care. The competencies were rated by 41 regionally dispersed, Masters level social workers selected through purposive and snowball sampling using a Delphi method. Each was rated as essential for generalist-level palliative social work, acceptable with modifications, or rejected based on the judgment that it was not essential for generalist-level palliative social work or was outside the scope of practice. Consensus was defined as >70% agreement to accept or reject a competency. Three review rounds were needed to achieve consensus on all competencies. RESULTS Two competencies were added to the original list. Of the 57 proposed competencies, 41 were accepted (19 after modification) and 16 were rejected. Competencies in the social, spiritual, cultural, and ethical/legal aspects of care domains were relatively more likely to be accepted compared with those in structure and processes of care, physical care, psychological care, and care of patient at the end of life. CONCLUSION The 41 consensus-derived competencies for generalist-level palliative social work may inform the development of training curricula and standards for high-quality care.