Michael L. Malone

Aggressive behaviors among the institutionalized elderly.

Objective: To describe the incidence and characteristics of aggressive behaviors in a group of institutionalized elderly.

Beta blocker use in the treatment of community hospital patients discharged after myocardial infarction

Objective: To explore the reasons for underutilization of beta blocker treatment after acute myocardial infarction.Design: A retrospective chart review.Setting: Two large community hospitals in Milwaukee, Wisconsin.Patients/participants: All subjects (n=694) discharged alive from July 1, 1990, to June 30, 1991, who had a diagnosis of acute myocardial infarction were eligible. Of these, 250 had missing data, resulting in a final sample of 444.Results: Twenty-nine percent of the 444 patients were prescribed beta blocker therapy on discharge. Characteristics of the patients and their treatment associated with receipt of beta blocker therapy were identified with a logistic regression model. The adjusted odds ratios were 0.52 for female gender, 0.34 for no health insurance, 0.21 for chronic obstructive pulmonary disease, 0.46 for congestive heart failure, 0.28 for atrioventricular block, 1.86 for hypertension, 1.93 for chest pain during acute myocardial infarction, and 4.65 for prehospital beta blocker use. Prescription of beta blocker therapy was also influenced by receipt of other treatment modalities. The adjusted odds ratios were 0.23 for receipt of beta blocker therapy associated with myocardial revascularization, 0.18 for prescription on discharge of calcium channel blockers, and 0.22 for receipt of angiotensin-converting enzyme inhibitors.Conclusion: A minority of patients discharged after acute myocardial infarction receive beta blocker therapy, and women are only half as likely as men to receive it, after controlling for other factors. Though there are no data relating to whether calcium channel blockers or angiotensin-converting enzyme inhibitors lessen the protective effect of beta blocker therapy post—acute myocardial infarction, it would appear that these agents are frequently being used in lieu of beta blocker therapy for post—acute myocardial infarction patients.

Educational characteristics of ambulatory morning report

The educational characteristics of ambulatory morning report were compared with those of the inpatient morning report sessions over a five-month period. Ambulatory morning report had fewer total participants and was more likely to cover general internal medicine topics (p<0.05), the medical interview (6.8% vs 1.2%, p=0.02), and social issues (9.6% vs 1.2%, p=0.02). Morning report conference can be replicated in the ambulatory setting, thus providing an opportunity to discuss general medicine topics not usually addressed in the inpatient setting.

Age-Related Differences in the Utilization of Therapies Post Acute Myocardial Infarction

OBJECTIVE: To describe the effect of age on the care of patients hospitalized with acute myocardial infarction (MI).

What do senior internal medicine residents do in their continuity clinics

Objective: To describe the activities of second- and third-year internal medicine residents during their outpatient continuity clinics.Design: Descriptive observational study.Setting: Medical school-affiliated community hospital primary care clinic.Patients/participants: All second-year (n=15) and third-year (n=14) residents enrolled in the internal medicine training program were observed at one-minute intervals during their routine half-day continuity clinics.Measurements and main results: An average of 203 observations were recorded for each resident. The distribution of resident activities was as follows: 1) direct interaction with patients (29.5%); 2) charting or writing prescriptions (24.0%); 3) social interactions with staff (13.7%); 4) attending conferences or reviewing medical literature (9.4%); 5) waiting or transiting (8.2%); 6) ward responsibilities (4.9%); 7) reviewing cases with attending physician (4.4%); and 8) miscellaneous activities (4.9%). Analysis of variance procedures revealed that the following variables significantly (p<0.05) affected the residents’ activities: 1) the actual number of patients seen produced predictable increases in direct and indirect patient care activities; and 2) the year of training had an impact on the mean number of observations of interactions with the supervising attending physician (PGY-2=11.4, PGY-3=3.8).Conclusions: These results suggest that this senior resident continuity experience is clinically intensive, yet provides surprisingly infrequent direct resident supervision. Further analysis of the educational activities occurring on these half-days is necessary to judge whether they are quantitatively and qualitatively adequate.

Geriatrics Models of Care

Geriatrics models of care : , Geriatrics models of care : , کتابخانه دیجیتال جندی شاپور اهواز

Complications of acute myocardial infarction in patients ≥90 years of age

Forty consecutive 90-year-old persons with an acute myocardial infarction were studied to describe the noncardiac complications of their care. Common negative consequences of hospitalization of these patients included delirium, pressure ulcers, and poor ambulatory status at discharge.

Medicare Access and CHIP Reauthorization Act: What do Geriatrics Healthcare Professionals Need to Know About the Quality Payment Program?

Commencing in 2017, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will change how Medicare pays health professionals. By enacting MACRA, Congress brought an end to the (un)sustainable growth rate formula while also setting forth a vision for how to transform the U.S. healthcare system so that clinicians deliver higher‐quality care with smarter spending by the Centers for Medicare and Medicaid Services (CMS). In October 2016, CMS released the first of what stakeholders anticipate will be a number of (annual) rules related to implementation of MACRA. CMS received extensive input from stakeholders including the American Geriatrics Society. Under the Quality Payment Program, CMS streamlined multiple Medicare value‐based payment programs into a new Merit‐based Incentive Payment System (MIPS). CMS also outlined how it will provide incentives for participation in Advanced Alternative Payment Models (called APMs). Although Medicare payments to geriatrics health professionals will not be based on the new MIPS formula until 2019, those payments will be based upon performance during a 90‐day period in 2017. This article defines geriatrics health professionals as clinicians who care for a predominantly older adult population and who are eligible to bill under the Medicare Physician Fee Schedule. Given the current paucity of eligible APMs, this article will focus on MIPS while providing a brief overview of APMs.

American Geriatrics Society Policy Priorities for New Administration and 115th Congress

This paper is a statement of the American Geriatrics Societys (AGS) core policy priorities and the Societys positions on federal programs and policies that support older Americans as articulated to the new administration. Among the AGS priorities discussed in this paper are health reform, Medicare, and Medicaid. The AGS is committed to leveraging its expertise to inform regulatory and legislative policy proposals.

Do More with Less

The marching orders are clear: “Do more with less.” This communication from a community hospital chief medical officer to the geriatrics leadership team is the context in which new geriatrics models are considered. This editorial describes the environment in which we are implementing geriatrics models of care. We will provide some reflections on the article by Boyd and colleagues in this month’s Journal of the American Geriatrics Society, and we will note how this study compares with prior descriptions of the use of advanced practice nurses in longterm care settings. We will conclude with some ideas about strategies to do more with less. Traditionally, fee-for-service reimbursement has supported emergency department evaluation and hospitalization of nursing facility residents instead of on-site assessment or clinical guidelines and coaching strategies to enhance licensed nurse interventions. As the U.S. healthcare system shifts its focus from a fee-for-service system to a value-based model, the delivery of care will undoubtedly transition as well. This is no truer than in the case of older adults in long-term care facilities, where increasingly complex care needs are stretching already thin budgets and staff. Given this context and future expectations of an increasingly older U.S. demographic, it is critical that geriatric models of care consider care and cost-effectiveness outcomes equally as we address “doing more with less.” Contributing to our knowledge at this critical junction are the results presented by Boyd and colleagues in this month’s Journal of the American Geriatrics Society. This group specifically examined whether the use of advanced practice nurses (APNs) influenced rates of hospitalization in 29 New Zealand residential aged care (RAC) facilities. This setting is similar to chronic supportive care that skilled nursing facilities provide in the United States. Individuals in New Zealand who require subacute care or short-stay rehabilitation services receive that care in the hospital. The design was not blinded, and the randomization occurred at the level of the facilities. The intervention was primarily a nursing staff development program with a focus on supporting staff with clinical coaching, education, and care coordination, rather than direct care. The overall time spent at each facility (the dosage or intensity of exposure) was remarkably low. Accordingly, the results were modest. The intervention and control groups had an increase in hospitalization. The intervention group had an increase in hospitalization of 16%, and the hospitalization rate for the control group increased 59%. Boyd and colleagues’ findings mirror those of other studies of APNs in long-term care, such as those of the Evercare model. The Evercare outcomes show that increasing nursing capacity and collaborating with physicians improves resident care and decreases systemic costs. There is good evidence that this care reduces emergency department and hospital use. Likewise, this type of collaboration in an academic nursing home practice improved functional status and resident satisfaction with care and morale. Because reimbursement mechanisms did not provide incentives to physicians to provide sufficient on-site care to nursing home residents, it makes sense that the addition of APNs in a primary care role with regular contact with residents would improve outcomes. Although professional organizations such as the American Medical Directors Association have supported the growth of physicians specializing in nursing home practice, the numbers remain low. Thus, other primary care providers such as APNs as part of a group practice (within a Medicare managed care model or as nursing home employees or consultants) is another growing trend. In addition to direct clinical work, some APNs work as staff educators, managers, or clinical coaches to facilitate nursing practice. There are no educational or certification requirements for licensed nurses to work in nursing homes, which means that APNs may be the only master’s-prepared nurses with advanced clinical skills and geriatric care knowledge in this setting. Boyd and colleagues capitalized on APNs in this role to heighten nursing staff proficiency in assessment and communication with primary care providers. Quality improvement interventions that enhance nursing staff skills (e.g., Interventions to Reduce Acute Care Transfers (INTERACT II)) have shown benefit for large cohorts of skilled nursing facility residents in the United States. Each of these strategies has used a systems-based methodology of improving a care process: identification and assessment of a vulnerable older adult (Stop and Watch), communication with other professionals about a change in resident status (Situation Background Assessment Recommendation), or assessment tools for residents with common conditions (Care Paths). Doing more with less will require us to review how we use the limited resource of our APNs. On the one hand, they provide follow up and urgent care visits and order tests and medications and thus enhance the physician workforce. In this case the APNs provide direct care in collaboration with the physician, thus extending the reach of the physician. On the other hand, Boyd and colleagues demonstrate that APNs can also implement and support health programs of indirect care at the facilDOI: 10.1111/jgs.13025