Lee A. Jennings

Missed opportunities for osteoporosis treatment in patients hospitalized for hip fracture

OBJECTIVES: Although osteoporosis treatment can dramatically reduce fracture risk, rates of treatment after hip fracture remain low. In‐hospital initiation of recommended medications has improved outcomes in heart disease; hospitalization for hip fracture may represent a similar opportunity for improvement. The objective of this study was to examine rates of in‐hospital treatment with a combination of calcium and vitamin D (Cal+D) and antiresorptive or bone‐forming medications in patients hospitalized for hip fractures

Unmet Needs of Caregivers of Individuals Referred to a Dementia Care Program

To characterize caregiver strain, depressive symptoms, and self‐efficacy for managing dementia‐related problems and the relationship between these and referring provider type.

Development of an algorithm to identify fall-related injuries and costs in Medicare data

BackgroundIdentifying fall-related injuries and costs using healthcare claims data is cost-effective and easier to implement than using medical records or patient self-report to track falls. We developed a comprehensive four-step algorithm for identifying episodes of care for fall-related injuries and associated costs, using fee-for-service Medicare and Medicare Advantage health plan claims data for 2,011 patients from 5 medical groups between 2005 and 2009.MethodsFirst, as a preparatory step, we identified care received in acute inpatient and skilled nursing facility settings, in addition to emergency department visits. Second, based on diagnosis and procedure codes, we identified all fall-related claim records. Third, with these records, we identified six types of encounters for fall-related injuries, with different levels of injury and care. In the final step, we used these encounters to identify episodes of care for fall-related injuries.ResultsTo illustrate the algorithm, we present a representative example of a fall episode and examine descriptive statistics of injuries and costs for such episodes. Altogether, we found that the results support the use of our algorithm for identifying episodes of care for fall-related injuries. When we decomposed an episode, we found that the details present a realistic and coherent story of fall-related injuries and healthcare services. Variation of episode characteristics across medical groups supported the use of a complex algorithm approach, and descriptive statistics on the proportion, duration, and cost of episodes by healthcare services and injuries verified that our results are consistent with other studies.ConclusionsThis algorithm can be used to identify and analyze various types of fall-related outcomes including episodes of care, injuries, and associated costs. Furthermore, the algorithm can be applied and adopted in other fall-related studies with relative ease.

Use of the Physician Orders for Life-Sustaining Treatment among California Nursing Home Residents

BackgroundPhysician Orders for Life-Sustaining Treatment (POLST) is a tool that facilitates the elicitation and continuity of life-sustaining care preferences. POLST was implemented in California in 2009, but how well it disseminated across a large, racially diverse population is not known and has implications for end-of-life care.ObjectiveTo evaluate the use of POLST among California nursing home residents, including variation by resident characteristics and by nursing home facility.DesignObservational study using California Minimum Data Set Section S.ParticipantsA total of 296,276 people with a stay in 1,220 California nursing homes in 2011.Main MeasuresThe proportion of residents with a completed POLST (containing a resuscitation status order and resident/proxy and physician signatures) and relationship to resident characteristics; change in POLST use during 2011; and POLST completion and unsigned forms within nursing homes.Key ResultsDuring 2011, POLST completion increased from 33 to 49 % of California nursing home residents. Adjusting for age and gender using a mixed-effects logistic model, long-stay residents were more likely than short-stay residents to have a completed POLST [OR = 2.36 (95 % CI 2.30, 2.42)]; severely cognitively impaired residents were less likely than unimpaired to have a completed POLST [OR = 0.89 (95 % CI 0.87, 0.92)]; and there was little difference by functional status. There was no difference in POLST completion among White non-Hispanic, Black, and Hispanic residents. Variation in POLST completion among nursing homes far exceeded that attributable to resident characteristics with 40 % of facilities having ≥80 % of long-stay residents with a completed POLST, while 20 % of facilities had ≤10 % of long-stay residents with a completed POLST. Thirteen percent of nursing home residents had a POLST containing a resuscitation preference but lacked a signature, rendering the POLST invalid.ConclusionsStatewide nursing home data show broad uptake of POLST in California without racial disparity. However, variation in POLST completion among nursing homes identifies potential areas for quality improvement.

Coordinated care management for dementia in a large academic health system.

Alzheimers disease and other dementias are chronic, incurable diseases that require coordinated care that addresses the medical, behavioral, and social aspects of the disease. With funding from the Center for Medicare and Medicaid Innovation, we launched a dementia care program in which a nurse practitioner acting as a dementia care manager worked with primary care physicians to develop and implement a dementia care plan that offers training and support to caregivers, manages care transitions, and facilitates access to community-based services. Postvisit surveys showed high levels of caregiver satisfaction. As program enrollment grows, outcomes will be tracked based on the Triple Aim developed by the Institute for Healthcare Improvement and adopted by the Centers for Medicare and Medicaid Services: better care, better health, and lower cost and utilization. The program, if successful at achieving the Triple Aim, may serve as a national model for how dementia and other chronic diseases can be managed in partnership with primary care practices. It may also inform policy and reimbursement decisions for the recently released transitional care management codes and the complex chronic care management codes to be released by Medicare in 2015.

Quality of Care Provided by a Comprehensive Dementia Care Comanagement Program.

Multiple studies have shown that quality of care for dementia in primary care is poor, with physician adherence to dementia quality indicators (QIs) ranging from 18% to 42%. In response, the University of California at Los Angeles (UCLA) Health System created the UCLA Alzheimers and Dementia Care (ADC) Program, a quality improvement program that uses a comanagement model with nurse practitioner dementia care managers (DCM) working with primary care physicians and community‐based organizations to provide comprehensive dementia care. The objective was to measure the quality of dementia care that nurse practitioner DCMs provide using the Assessing Care of Vulnerable Elders (ACOVE‐3) and Physician Consortium for Performance Improvement QIs. Participants included 797 community‐dwelling adults with dementia referred to the UCLA ADC program over a 2‐year period. UCLA is an urban academic medical center with primarily fee‐for‐service reimbursement. The percentage of recommended care received for 17 dementia QIs was measured. The primary outcome was aggregate quality of care for the UCLA ADC cohort, calculated as the total number of recommended care processes received divided by the total number of eligible quality indicators. Secondary outcomes included aggregate quality of care in three domains of dementia care: assessment and screening (7 QIs), treatment (6 QIs), and counseling (4 QIs). QIs were abstracted from DCM notes over a 3‐month period from date of initial assessment. Individuals were eligible for 9,895 QIs, of which 92% were passed. Overall pass rates of DCMs were similar (90–96%). All counseling and assessment QIs had pass rates greater than 80%, with most exceeding 90%. Wider variation in adherence was found among QIs addressing treatments for dementia, which patient‐specific criteria triggered, ranging from 27% for discontinuation of medications associated with mental status changes to 86% for discussion about acetylcholinesterase inhibitors. Comprehensive dementia care comanagement with a nurse practitioner can result in high quality of care for dementia, especially for assessment, screening, and counseling. The effect on treatment QIs is more variable but higher than previous reports of physician‐provided dementia care.

Effect of a Falls Quality Improvement Program on Serious Fall‐Related Injuries

To determine whether a program that improves the quality of care for falls reduces the number of episodes of care for serious fall‐related injuries.

Patient and caregiver goals for dementia care

AbstractPurposeMost health outcome measures for chronic diseases do not incorporate specific health goals of patients and caregivers. To elicit patient-centered goals for dementia care, we conducted a qualitative study using focus groups of people with early-stage dementia and dementia caregivers.MethodsWe conducted 5 focus groups with 43 participants (7 with early-stage dementia and 36 caregivers); 15 participants were Spanish-speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using both deductive and inductive approaches. Coded texts were grouped into domains and developed into a goal inventory for dementia care.ResultsParticipants identified 41 goals for dementia care within five domains (medical care, physical quality of life, social and emotional quality of life, access to services and supports, and caregiver support). Caregiver goals included ensuring the safety of the person with dementia and managing caregiving stress. Participants with early-stage dementia identified engaging in meaningful activity (e.g., work, family functions) and not being a burden on family near the end of life as important goals. Participants articulated the need to readdress goals as the disease progressed and reported challenges in goal-setting when goals differed between the person with dementia and the caregiver (e.g., patient safety vs. living independently at home). While goals were similar among English- and Spanish-speaking participants, Spanish-speaking participants emphasized the need to improve community education about dementia.ConclusionsPatient- and caregiver-identified goals for care are different than commonly measured health outcomes for dementia. Future work should incorporate patient-centered goals into clinical settings and assess their usefulness for dementia care.

An Automated Approach to Identifying Patients with Dementia Using Electronic Medical Records

Author(s): Reuben, David B; Hackbarth, Andrew S; Wenger, Neil S; Tan, Zaldy S; Jennings, Lee A

Team-Based Interprofessional Competency Training for Dementia Screening and Management

As many as 50% of people satisfying diagnostic criteria for dementia are undiagnosed. A team‐based training program for dementia screening and management was developed targeting four professions (medicine, nursing, pharmacy, social work) whose scope of practice involves dementia care. An interprofessional group of 10 faculty members was trained to facilitate four interactive competency stations on dementia screening, differential diagnoses, dementia management and team care planning, and screening for and managing caregiver stress. Registrants were organized into teams of five members, with at least one member of each profession per team. The teams rotated through all stations, completing assigned tasks through interprofessional collaboration. A total of 117 professionals (51 physicians, 11 nurses, 20 pharmacists, 24 social workers, 11 others) successfully completed the program. Change scores showed significant improvements in overall competence in dementia assessment and intervention (very low = 1; very high = 5; average change 1.12, P < .001), awareness of importance of dementia screening (average change 0.85, P < .001), and confidence in managing medication (average change 0.86, P < .001). Eighty‐seven participants (82.9%) reported feeling confident or very confident using the dementia toolkit at their home institution. In a survey administered 3 months after the session, 48 respondents reported that they had changed their approach to administering the Mini‐Cog test (78%), differential diagnosis (49%), assessment of caregiver stress (74%), and accessing community support and services (69%). In conclusion, team‐based interprofessional competency training is a team teaching model that can be used to enhance competency in dementia screening and management in medical, nursing, pharmacy, and social work practitioners.