Kristen Butterfield

The Care Transitions Intervention: Translating From Efficacy to Effectiveness

BACKGROUND Well-executed communication among hospital providers, patients, and receiving providers at the time of hospital discharge contributes to better health outcomes and lower overall health care costs. The Care Transitions Intervention has reduced 30-day hospital readmissions by 30% in a randomized controlled trial in an integrated health system but requires real-world testing to establish effectiveness in other settings. We hypothesized that coaching would reduce 30-day readmission rates for fee-for-service Medicare beneficiaries, even in open, urban health care delivery systems. METHODS This was a quasi-experimental prospective cohort study. From January 1, 2009, through June 30, 2010, coaches recruited a convenience sample of fee-for-service Medicare patients in 6 Rhode Island hospitals to receive the Care Transitions Intervention. We paired coaching data with Medicare claims and enrollment data and used logistic regression to compare the odds of 30-day readmission for the intervention group vs internal and external control groups. RESULTS Compared with individuals who did not receive any part of the intervention (20.0% readmission rate), 30-day readmissions were fewer for participants who received coaching (12.8%; odds ratio, 0.61; 95% confidence interval, 0.42-0.88). Individuals in the internal control group (declined to participate or were lost to follow-up before completing a home visit) had readmission rates similar to those of the external control group (18.6%; odds ratio, 0.94, 95% confidence interval, 0.77-1.14). CONCLUSIONS The Care Transitions Intervention appears to be effective in this real-world implementation. This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings.

Association of dementia with early rehospitalization among Medicare beneficiaries

Preventable hospital readmissions have been recognized as indicators of hospital quality, a source of increased healthcare expenditures, and a burden for patients, families, and caregivers. Despite growth of initiatives targeting risk factors associated with potentially avoidable hospital readmissions, the impact of dementia on the likelihood of rehospitalization is poorly characterized. Therefore, the primary objective of this retrospective cohort study was to investigate whether dementia was an independent predictor of 30-day readmissions. Administrative claims data for all admissions to Rhode Island hospitals in 2009 was utilized to identify hospitalizations of Medicare fee-for-service beneficiaries with a diagnosis of Alzheimers Disease or other dementias. Demographics, measures of comorbid disease burden, and other potential confounders were extracted from the data and the odds of 30-day readmission to any United States hospital was calculated from conditional logistic regression models. From a sample of 25,839 hospitalizations, there were 3908 index admissions of Medicare beneficiaries who fulfilled the study criteria for a dementia diagnosis. Nearly 20% of admissions (n=5133) were followed by a readmission within thirty days. Hospitalizations of beneficiaries with a dementia diagnosis were more likely to be followed by a readmission within thirty days (adjusted odds ratio (AOR) 1.18; 95% CI, 1.08, 1.29), compared to hospitalizations of those of without dementia. Controlling for discharge site of care did not attenuate the association (AOR 1.21; 95% CI, 1.10, 1.33).

Identifying Star Performers: The Relationship Between Ambitious Targets and Nursing Home Quality Improvement

Setting Targets—Achieving Results (STAR) is a Web‐based tool that helps nursing home leadership select annual performance goals, or targets, for a subset of publicly reported quality measures. Previous results demonstrate that nursing homes whose staff implement STAR targets demonstrate greater improvement on the related outcomes. In this analysis, the authors hypothesized that nursing homes whose staff select the most ambitious targets (reflecting large improvement over their current performance) may be more successful in their related quality improvement efforts than homes with less‐ambitious targets (reflecting lesser improvement). The authors analyzed data from 7,091 Medicare‐ or Medicaid‐certified nursing homes that set STAR targets in 2005 or 2006 for two quality measures: the proportion of residents who were physically restrained daily and the proportion of high‐risk residents with pressure ulcers. Targets were classified as ambitious or less ambitious based on the 75th and 50th rank‐ordered percentiles, respectively. Improvement was calculated using four‐quarter averages for baseline (the year ending when the target was set) and remeasurement (the subsequent year). The results indicate that nursing homes with ambitious targets demonstrate greater improvement than their peers selecting less‐ambitious targets. With limited federal and local resources to assist providers with quality improvement, target values may be a used as a “flag” to help agencies allocate scarce resources to nursing homes committed to quality improvement efforts and with the organizational capacity to improve.

We can Do it: Nursing Educational Intervention to Increase DeliriumDocumentation

Background/Objectives: Delirium is a widely recognized complication during hospitalization, but poorly documented. We examined the effectiveness of a geriatrician-guided delirium training intervention to increase nurses’ delirium documentation, knowledge, and self- confidence. Design: Prospective cohort study Setting: Orthopedic surgical inpatient unit Participants: Twenty-six nursing staff Intervention: Nurses participated in a geriatrician-guided delirium training intervention. Each nurse received two 45-minute didactic sessions on delirium causes, screening, and prevention using the Confusion Assessment Method (CAM). Measurements: Nursing delirium documentation pre- and post-educational intervention was determined during the months of March and June 2013. Nurses also completed a pre- and 3-month post-interventional survey to assess confidence and knowledge of delirium detection. Results: Nursing mean age was 46 years, with 17 years of experience. Patients with CAM documentation increased significantly post-intervention from 13 to 91% (p<0.001). On average, rate of nursing CAM documentation per shift increased from 5.5 to 70.8%, (p<0.001). Post-interventional nursing knowledge scores significantly improved from 44 to 73% correct (p<0.001). As compared to pre-intervention, nurses scored significantly higher on number of delirium risk factors from 32 to 71% (p<0.001), medications to avoid in the elderly from 20 to 70% (p<0.001), and correct management strategies for patients with delirium from 52 to 84% (p<0.001). Nurses’ confidence in detecting delirium increased significantly post-intervention from 7.8 to 8.6 points out of a 10-point scale (p=0.021). Conclusion: Nursing knowledge and documentation of delirium using the CAM, as well as nursing confidence in identifying delirium all significantly increased after formal geriatrician-guided educational intervention.

Dementia is associated with increased risk of hospital readmission within 30 days of discharge

RISK OF HOSPITAL READMISSION WITHIN 30 DAYS OF DISCHARGE Lori Daiello, Rebekah Gardner, Gary Epstein-Lubow, Kristen Butterfield, Stefan Gravenstein, Alzheimer’s Disease and Memory Disorders Center at Rhode Island Hospital, Providence, Rhode Island, United States; 2 HealthCentric Advisors, Providence, Rhode Island, United States; Warren Alpert Medical School at Brown University, Providence, Rhode Island, United States.