Kathleen T. Unroe

The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Approach: Preliminary Data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project

The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project aims to reduce avoidable hospitalizations of long‐stay residents enrolled in 19 central Indiana nursing facilities. This clinical demonstration project, funded by the Centers for Medicare and Medicaid Services Innovations Center, places a registered nurse in each nursing facility to implement an evidence‐based quality improvement program with clinical support from nurse practitioners. A description of the model is presented, and early implementation experiences during the first year of the project are reported. Important elements include better medical care through implementation of Interventions to Reduce Acute Care Transfers tools and chronic care management, enhanced transitional care, and better palliative care with a focus on systematic advance care planning. There were 4,035 long‐stay residents in 19 facilities enrolled in OPTIMISTIC between February 2013 and January 2014. Root‐cause analyses were performed for all 910 acute transfers of these long stay residents. Of these transfers, the project RN evaluated 29% as avoidable (57% were not avoidable and 15% were missing), and opportunities for quality improvement were identified in 54% of transfers. Lessons learned in early implementation included defining new clinical roles, integrating into nursing facility culture, managing competing facility priorities, communicating with multiple stakeholders, and developing a system for collecting and managing data. The success of the overall initiative will be measured primarily according to reduction in avoidable hospitalizations of long‐stay nursing facility residents.

Hospital Readmission Penalties: Coming Soon to a Nursing Home Near You!

The Protecting Access to Medicare Act of 2014 includes provisions for hospital readmission penalties for skilled nursing facilities (SNFs) starting in 2018. This presents an opportunity for care improvement but also raises several concerns regarding quality of care. The readmission measure for SNFs is similar to the current readmission measure for hospitals mandated under the Affordable Care Act, with the exception of adjustments made for sex. Because these measures for hospitals are similar, lessons can be learned from implementation of the existing hospital readmission penalties. In addition, there are three specific concerns that the authors relate to implementing the proposed measure in SNFs. There is poor communication and care coordination between care settings, including posthospitalization and post‐SNF care in the current healthcare system. Adding readmission penalties to SNF regulations may create perverse incentives for prolonged SNF stays. The evidence base for the best means of caring for individuals after a brief stay in a SNF needs enrichment. These challenges need to be addressed as part of implementation of these new hospital readmission penalties for SNFs to improve care and prevent new unintended consequences.

Hospice Use Among Nursing Home Patients

OBJECTIVES Among hospice patients who lived in nursing homes, we sought to: (1) report trends in hospice use over time, (2) describe factors associated with very long hospice stays (>6 months), and (3) describe hospice utilization patterns. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective study from an urban, Midwest cohort of hospice patients, aged ≥ 65 years, who lived in nursing homes between 1999 and 2008. MEASUREMENTS Demographic data, clinical characteristics, and health care utilization were collected from Medicare claims, Medicaid claims, and Minimum Data Set assessments. Patients with overlapping nursing home and hospice stays were identified. χ(2) and t tests were used to compare patients with less than or longer than a 6-month hospice stay. Logistic regression was used to model the likelihood of being on hospice longer than 6 months. RESULTS A total of 1452 patients received hospice services while living in nursing homes. The proportion of patients with noncancer primary hospice diagnoses increased over time; the mean length of hospice stay (114 days) remained high throughout the 10-year period. More than 90% of all patients had 3 or more comorbid diagnoses. Nearly 20% of patients had hospice stays longer than 6 months. The hospice patients with stays longer than 6 months were observed to have a smaller percentage of cancer (25% vs 30%) as a primary hospice diagnosis. The two groups did not differ by mean cognitive status scores, number of comorbidities, or activities of daily living impairments. The greater than 6 months group was much more likely to disenroll before death: 33.9% compared with 13.8% (P < .0001). A variety of patterns of utilization of hospice across settings were observed; 21% of patients spent some of their hospice stay in the community. CONCLUSIONS Any policy proposals that impact the hospice benefit in nursing homes should take into account the difficulty in predicting the clinical course of these patients, varying utilization patterns and transitions across settings, and the importance of supporting multiple approaches for delivery of palliative care in this setting.

Research priorities in geriatric palliative care: Policy initiatives

Coordinated palliative care matched to patient needs improves quality of care for vulnerable patients with serious illness and reduces costly use of hospitals and emergency departments. Unfortunately, there is a disconnect in translating geriatric palliative care models and principles into policy and widespread practice. Gaps in policy-relevant research are addressed, including implementation strategies to scale up existing care models, the role of palliative care and geriatrics in health care payment reform efforts, development of quality measures for complex patients, strategies to address workforce shortages, and an approach to hospice reform.

Transitions in Care in a Nationally Representative Sample of Older Americans with Dementia.

To describe transitions in care for older adults with dementia identified from a nationally representative cohort and to describe transition rates in those with more‐severe levels of cognitive and functional impairment.

Concordance of Advance Care Plans With Inpatient Directives in the Electronic Medical Record for Older Patients Admitted From the Emergency Department

CONTEXT Measuring What Matters identified quality indicators to examine the percentage of patients with documentation of a surrogate decision maker and preferences for life-sustaining treatments. OBJECTIVES To determine the rate of advance care planning in older adults presenting to the emergency department (ED) and translation into medical directives in the electronic medical record (EMR). METHODS A convenience sample of adults 65 years or older was recruited from a large urban ED beginning in January 2012. We administered a baseline interview and survey in English or Spanish, including questions about whether patients had a documented health care proxy or living will. For patients admitted to the hospital who had a health care proxy or living will, chart abstraction was performed to determine whether their advance care preferences were documented in the EMR. RESULTS From February 2012 to May 2013, 53.8% (367 of 682) of older adults who completed the survey in the ED reported having a health care proxy, and 40.2% (274 of 682) had a living will. Of those admitted to the hospital, only 4% (4 of 94) of patients who said they had a living will had medical directives documented in the EMR. Similarly, only 4% (5 of 115) of patients who had a health care proxy had the persons name or contact information documented in their medical record. CONCLUSION About half of the patients 65 years or older arriving in the ED have done significant advance care planning, but most plans are not recorded in the EMR.

The IOM Report on Dying in America: A Call to Action for Nursing Homes

a Indiana University School of Medicine, Geriatrics, Indianapolis, IN b Indiana University Center for Aging Research, Indianapolis, IN Regenstrief Institute, Indianapolis, IN National PROMISE (Performance Reporting and Outcomes Measurement to Improve the Standard of care at End-of-life) Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA University of Pennsylvania School of Nursing, Philadelphia, PA University of Maryland, School of Social Work, Baltimore, MD

Adherence to Measuring What Matters Measures Using Point-of-Care Data Collection Across Diverse Clinical Settings

CONTEXT Measuring What Matters (MWM) for palliative care has prioritized data collection efforts for evaluating quality in clinical practice. How these measures can be implemented across diverse clinical settings using point-of-care data collection on quality is unknown. OBJECTIVES To evaluate the implementation of MWM measures by exploring documentation of quality measure adherence across six diverse clinical settings inherent to palliative care practice. METHODS We deployed a point-of-care quality data collection system, the Quality Data Collection Tool, across five organizations within the Palliative Care Research Cooperative Group. Quality measures were recorded by clinicians or assistants near care delivery. RESULTS During the study period, 1989 first visits were included for analysis. Our population was mostly white, female, and with moderate performance status. About half of consultations were seen on hospital general floors. We observed a wide range of adherence. The lowest adherence involved comprehensive assessments during the first visit in hospitalized patients in the intensive care unit (2.71%); the highest adherence across all settings, with an implementation of >95%, involved documentation of management of moderate/severe pain. We observed differences in adherence across clinical settings especially with MWM Measure #2 (Screening for Physical Symptoms, range 45.7%-81.8%); MWM Measure #5 (Discussion of Emotional Needs, range 46.1%-96.1%); and MWM Measure #6 (Documentation of Spiritual/Religious Concerns, range 0-69.6%). CONCLUSION Variations in clinician documentation of adherence to MWM quality measures are seen across clinical settings. Additional studies are needed to better understand benchmarks and acceptable ranges for adherence tailored to various clinical settings.

Quality of hospice care for individuals with dementia

Dementia affected an estimated 5 million older Americans in 2012; by 2050, prevalence is predicted to approach 14 million, and half of these individuals will be aged 85 and older. The late stages of dementia are characterized by major challenges to quality of life, including inability to communicate, initiate movement, or walk; difficulty eating and swallowing; agitation; incontinence; and a high risk of infection and pressure ulcers. The sources of suffering for individuals with dementia go beyond fear, depression, and confusion and include significant physical symptoms, including pain, coughing, choking, dyspnea, agitation, and weakness. The need for palliative care focused on maximizing quality of life and keeping people with dementia in familiar, safe, and reassuring environments is clear. Most nursing home residents have cognitive impairment, and nursing homes are the site of death for half of people with dementia. Nearly all family members of nursing home residents with advanced dementia report that comfort is the primary goal for their care. Nonetheless, a minority of Medicare decedents with dementia are referred to hospice before death, and repeated burdensome transitions between hospitals and nursing homes and feeding tube placement commonly occur, despite lack of evidence of quality of life or survival benefit. Dementia is increasingly recognized as a terminal disease, meaning that it is the proximate cause of death for persons with the diagnosis. Although it leads inexorably to death, the decline is often slow and gradual, and—like other progressive conditions such as heart failure, chronic obstructive pulmonary disease, frailty, and end-stage renal disease—prognostic uncertainty is the norm rather than the exception. In 2011, more than half of individuals in hospice across all settings had a noncancer primary diagnosis. The eligibility criteria under the Medicare hospice benefit were originally designed to serve persons with terminal cancer and require that two physicians certify the individual is within 6 months of death. Despite the difficulty of accurately identifying a 6-month prognosis in persons with advanced dementia, roughly 30% of all individuals with dementia enter hospice, and the primary diagnosis is dementia in 13% of all individuals in hospice. The article by Albrecht and colleagues in this month’s issue compares quality of hospice care for individuals with and without dementia in a national sample. Quality was measured in this study by identifying relevant metrics collected in the 2007 National Home and Hospice Care Survey. The authors, following the National Consensus Project for Quality Palliative Care guidelines (www.nation alconsensusproject.org), chose report of depression, report of pain at the last assessment in hospice care, presence of standing orders for pain medication if pain was reported, greater than Stage 2 pressure ulcers, use of antibiotics, tube feeding, lack of continuity of residence, emergency care, hospice for 3 days or less, presence of a do-not-resuscitate order, and presence of any advanced directive as measures. More than half of these individuals with dementia in hospice lived in nursing homes, compared with only 20% of individuals in hospice with other terminal conditions. The individuals in hospice with dementia were also more likely to receive care from a for-profit hospice and to have a significantly longer duration of hospice care than individuals in hospice with other terminal diagnoses, consistent with previous work that has found that for-profit hospices enroll higher numbers of individuals with dementia than not-for-profit hospices. Nearly one-quarter of these beneficiaries with dementia survived beyond the 6-month limit. Others have found that individuals with noncancer diagnoses and nursing home residents tend to have longer lengths of stay in hospice. In addition, rates of disenrollment from hospice were higher for individuals with dementia in this study. Disenrollment from hospice represents a disruption in care and has been associated with high rates of subsequent hospitalization. The rigid Medicare hospice benefit prognostication requirement for diseases with highly uncertain prognoses creates a lack of fit of the current hospice model for individuals with dementia and is one explanation for these findings. Although individuals with dementia in hospice were twice as likely to undergo placement of a feeding tube, few other differences in quality of care were observed between individuals in hospice with and without dementia in this sample. Individuals with dementia were less likely than individuals in hospice with other terminal diagnoses to undergo burdensome transitions or to have pain identified. How can access to high quality of palliative care be improved for this growing and uniquely vulnerable population? Inclusion of metrics relevant to the needs of persons with advanced dementia, many of whom live in a nursing home or other residential facility, are required in valuebased purchasing and other regulatory frameworks to incentivize delivery of this care. Important measures of quality for this population include placement of a feeding tube, rate of burdensome transitions to acute care, receipt of care concordant with preferences, and symptom, including pain, identification and management. A growing body of evidence fails to demonstrate any benefit in terms of quality or quantity of life associated DOI: 10.1111/jgs.12318

An Interim Analysis of an Advance Care Planning Intervention in the Nursing Home Setting

To describe processes and preliminary outcomes from the implementation of a systematic advance care planning (ACP) intervention in the nursing home setting.