Michael A. LaMantia

Interventions to Improve Transitional Care Between Nursing Homes and Hospitals: A Systematic Review

Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve transitional care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for elderly patients who transition between nursing homes and hospitals. MEDLINE, ISI Web, and EBSCO Host (from inception to June 2008) were searched for original, English‐language research articles reporting interventions to improve communication of medication lists and advance directives. Five studies ultimately met all inclusion criteria. Two described interventions that enhanced transmission of advance directives, two described interventions that improved communication of medication lists, and one intervention addressed both goals. One study was a randomized controlled trial, whereas the remaining studies used historical or no controls. Study results indicate that a standardized patient transfer form may assist with the communication of advance directives and medication lists and that pharmacist‐led review of medication lists may help identify omitted or indicated medications on transfer. Although preliminary evidence supports adoption of these methods to improve transitions between nursing home and hospital, further research is needed to define target populations and outcomes measures for high‐quality transitional care.

Accuracy of the Emergency Severity Index triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention.

OBJECTIVES The study objective was to determine the sensitivity and specificity of the Emergency Severity Index (ESI) triage instrument for the identification of elder patients receiving an immediate life-saving intervention in the emergency department (ED). METHODS The authors reviewed medical records for consecutive patients 65 years or older who presented to a single academic ED serving a large community of elders during a 1-month period. ESI triage scores were compared to actual ED course with attention to the occurrence of an immediate life-saving intervention. The sensitivity and specificity of an ESI triage level of 1 for the identification of patients receiving an immediate intervention was calculated. For 50 cases, the triage nurse ESI designation was compared to the triage level determined by an expert triage nurse based on retrospective record review. RESULTS Of 782 consecutive patients 65 years or older who presented to the ED, 18 (2%) had an ESI level of 1, 176 (23%) had an ESI level of 2, 461 (60%) had an ESI level of 3, 100 (13%) had an ESI level of 4, and 18 (2%) had an ESI level of 5. Twenty-six patients received an immediate life-saving intervention. ESI triage scores for these 26 individuals were as follows: ESI 1, 11 patients; ESI 2, nine patients; and ESI 3, six patients. The sensitivity of ESI to identify patients receiving an immediate intervention was 42.3% (95% confidence interval [CI]=23.3% to 61.3%); the specificity was 99.2% (95% CI=98.0% to 99.7%). For 17 of 50 cases in which actual triage nurse and expert nurse ESI levels disagreed, undertriage by the triage nurses was more common than overtriage (13 vs. 4 patients). CONCLUSIONS The ESI triage instrument identified fewer than half of elder patients receiving an immediate life-saving intervention. Failure to follow established ESI guidelines in the triage of elder patients may contribute to apparent undertriage.

Predicting hospital admission and returns to the emergency department for elderly patients.

OBJECTIVES Methods to accurately identify elderly patients with a high likelihood of hospital admission or subsequent return to the emergency department (ED) might facilitate the development of interventions to expedite the admission process, improve patient care, and reduce overcrowding. This study sought to identify variables found among elderly ED patients that could predict either hospital admission or return to the ED. METHODS All visits by patients 75 years of age or older during 2007 at an academic ED serving a large community of elderly were reviewed. Clinical and demographic data were used to construct regression models to predict admission or ED return. These models were then validated in a second group of patients 75 and older who presented during two 1-month periods in 2008. RESULTS Of 4,873 visits, 3,188 resulted in admission (65.4%). Regression modeling identified five variables statistically related to the probability of admission: age, triage score, heart rate, diastolic blood pressure, and chief complaint. Upon validation, the c-statistic of the receiver operating characteristic (ROC) curve was 0.73, moderately predictive of admission. We were unable to produce models that predicted ED return for these elderly patients. CONCLUSIONS A derived and validated triage-based model is presented that provides a moderately accurate probability of hospital admission of elderly patients. If validated experimentally, this model might expedite the admission process for elderly ED patients. Our models failed, as have others, to accurately predict ED return among elderly patients, underscoring the challenge of identifying those individuals at risk for early ED returns.

Systematic Review of Non-Pharmacologic Interventions to Delay Functional Decline in Community-Dwelling Patients with Dementia

Objectives: Older adults with dementia experience progressive functional decline, which contributes to caregiver burden and nursing home placement. The goal of this systematic review was to determine if any non-pharmacologic interventions have delayed functional decline among community-dwelling dementia patients. Method: We completed a systematic literature review to identify controlled clinical trials reporting the impact of non-pharmacologic interventions on any measure of functional impairment or disability among community-dwelling dementia patients. We included studies that reported any proxy-respondent, self-reported, or performance-based standardized assessments. Results: We identified 18 published clinical trials that met inclusion criteria and found that study interventions fell into three different groups: occupational therapy, exercise, and multi-faceted (“other”) interventions. The three groups of studies tended to vary systematically regarding the conceptual framework for the disabling process, target of intervention, and type of outcome measure. Approximately half the studies were conducted in the United States with mean sample size of 99 (from 27 to 1131) and follow-up periods between three months and two years. Instruments used to measure functional impairment or disability varied widely with 55 instruments across 18 studies. Nine studies reported a statistically significant improvement in functional decline in the intervention group. Conclusion: The current literature provides clinical trial evidence that non-pharmacologic interventions can delay progression of functional impairment or disability among community-dwelling dementia patients. The clinical significance of this early evidence is uncertain. These early studies provide rationale for larger and longer-term studies to determine if these interventions are sufficiently potent to delay institutionalization.

Healthy Aging Brain Center Improved Care Coordination And Produced Net Savings

Over the past two decades the collaborative care model within primary care has proved to be effective in improving care quality, efficiency, and outcomes for older adults suffering from dementia and depression. In collaboration with community partners, scientists from Indiana University have implemented this model at the Healthy Aging Brain Center (HABC), a memory care clinic that is part of Eskenazi Health, an integrated safety-net health care system in Indianapolis, Indiana. The HABC generates an annual net cost savings of up to

Predictive Value of Initial Triage Vital Signs for Critically Ill Older Adults

2,856 per patient, which adds up to millions of dollars for Eskenazi Healths patients. This article demonstrates the financial sustainability of the care processes implemented in the HABC, as well as the possibility that payers and providers could share savings from the use of the HABC model. If it were implemented nationwide, annual cost savings could be in the billions of dollars.

Risk factors for the progression of mild cognitive impairment to dementia.

Introduction: Triage of patients is critical to patient safety, yet no clear information exists as to the utility of initial vital signs in identifying critically ill older emergency department (ED) patients. The objective of this study is to evaluate a set of initial vital sign thresholds as predictors of severe illness and injury among older adults presenting to the ED. Methods: We reviewed all visits by patients aged 75 and older seen during 2007 at an academic ED serving a large community of older adults. Patients’ charts were abstracted for demographic and clinical information including vital signs, via automated electronic methods. We used bivariate analysis to investigate the relationship between vital sign abnormalities and severe illness or injury, defined as intensive care unit (ICU) admission or ED death. In addition, we calculated likelihood ratios for normal and abnormal vital signs in predicting severe illness or injury. Results: 4,873 visits by patients aged 75 and above were made to the ED during 2007, and of these 3,848 had a complete set of triage vital signs. For these elderly patients, the sensitivity and specificity of an abnormal vital sign taken at triage for predicting death or admission to an ICU were 73% (66,81) and 50% (48,52) respectively (positive likelihood ratio 1.47 (1.30,1.60); negative likelihood ratio 0.54 (0.30,0.60). Conclusion: Emergency provider assessment and triage scores that rely primarily on initial vital signs are likely to miss a substantial portion of critically ill older adults.

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

The increasing prevalence of cognitive impairment among the older adult population warrants attention to the identification of practices that may minimize the progression of early forms of cognitive impairment, including the transitional stage of mild cognitive impairment (MCI), to permanent stages of dementia. This article identifies both markers of disease progress and risk factors linked to the progression of MCI to dementia. Potentially modifiable risk factors may offer researchers a point of intervention to modify the effect of the risk factor and to minimize the future burden of dementia.

Emergency Department Use Among Older Adults 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.

The Aging Brain Care Medical Home: Preliminary Data

Although persons with dementia are frequently hospitalized, relatively little is known about the health profile, patterns of health care use, and mortality rates for patients with dementia who access care in the emergency department (ED). We linked data from our hospital system with Medicare and Medicaid claims, Minimum Data Set, and Outcome and Assessment Information Set data to evaluate 175,652 ED visits made by 10,354 individuals with dementia and 15,020 individuals without dementia over 11 years. Survival rates after ED visits and associated charges were examined. Patients with dementia visited the ED more frequently, were hospitalized more often than patients without dementia, and had an increased odds of returning to the ED within 30 days of an index ED visit compared with persons who never had a dementia diagnosis (odds ratio, 2.29; P<0.001). Survival rates differed significantly between patients by dementia status (P<0.001). Mean Medicare payments for ED services were significantly higher among patients with dementia. These results show that older adults with dementia are frequent ED visitors who have greater comorbidity, incur higher charges, are admitted to hospitals at higher rates, return to EDs at higher rates, and have higher mortality after an ED visit than patients without dementia.