Rosa R. Baier

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.

Ameliorating pain in nursing homes: A collaborative quality-improvement project

Objectives: To evaluate a multifaceted intervention to improve pain‐management processes of care and outcomes in nursing homes.

Quality Improvement for Pressure Ulcer Care in the Nursing Home Setting: The Northeast Pressure Ulcer Project

OBJECTIVES The objectives of this study were to evaluate the impact of a collaborative model of quality improvement in nursing homes on processes of care for the prevention and treatment of pressure ulcers. STUDY DESIGN The study design was experimental. SETTING We studied 29 nursing homes in New Jersey, Pennsylvania, and Rhode Island. PARTICIPANTS Participants consisted of pressure ulcer quality improvement teams in 29 nursing homes. INTERVENTION Quality improvement teams attended a series of workshops to review clinical guidelines and quality improvement principles and to share best practices, and worked one-on-one with mentors to implement quality improvement techniques and to collect data independently. MEASUREMENTS We calculated process measures based on the Agency for Healthcare Research and Quality (AHRQ) guidelines. Process measures addressed each facilitys processes of care for the prevention and treatment of pressure ulcers at baseline and after 12 months of intervention. Prevention measures focused on recent admissions and high-risk residents; treatment measures focused on patients newly diagnosed with pressure ulcers and all patients with pressure ulcers. RESULTS Overall, 6 of 8 prevention process measures improved significantly, with percent difference between baseline and follow up ranging from 11.6% to 24.5%. Three of 4 treatment process measures improved significantly, with 5.0%, 8.9%, and 25.9% difference between baseline and follow up. For each process measure, between 5 and 12 facilities demonstrated significant improvement between baseline and follow up, and only 2 or fewer declined for each process measure. CONCLUSION Improvement in processes of care after the use of a structured collaborative quality improvement approach is possible in the nursing home setting.

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.

Individualized Music Program is Associated with Improved Outcomes for U.S. Nursing Home Residents with Dementia

OBJECTIVES The objective of this study was to compare resident outcomes before and after implementation of an individualized music program, MUSIC & MEMORY (M&M), designed to address the behavioral and psychological symptoms associated with dementia (BPSD). SETTING 98 nursing homes trained in the M&M program during 2013 and 98 matched-pair comparisons. PARTICIPANTS Long-stay residents with Alzheimers disease and related dementias (ADRD) residing in M&M participating facilities (N = 12,905) and comparison facilities (N = 12,811) during 2012-2013. INTERVENTION M&M is a facility-level quality improvement program that provides residents with music specific to their personal histories and preferences. MEASUREMENTS Discontinuation of anxiolytic and antipsychotic medications, and reductions in behavioral problems and depressed mood in 2012 (pre-intervention) and 2013 (intervention), calculated using Minimum Data Set (MDS) assessments. RESULTS The proportion of residents who discontinued antipsychotic medication use over a 6-month period increased from 17.6% to 20.1% among M&M facilities, while remaining stable among comparison facilities (15.9% to 15.2%). The same trend was observed for anxiolytic medications: Discontinuation of anxiolytics increased in M&M facilities (23.5% to 24.4%), while decreasing among comparison facilities (24.8% to 20.0%). M&M facilities also demonstrated increased rates of reduction in behavioral problems (50.9% to 56.5%) versus comparison facilities (55.8% to 55.9%). No differences were observed for depressed mood. CONCLUSIONS These results offer the first evidence that the M&M individualized music program is associated with reductions in antipsychotic medication use, anxiolytic medication use, and BPSD symptoms among long-stay nursing home residents with ADRD.

Burden of hospital-onset Clostridium difficile infection in patients discharged from Rhode Island hospitals, 2010-2011: application of present on admission indicators.

OBJECTIVE The year 2010 is the first time that the Rhode Island hospital discharge database included present on admission (POA) indicators, which give us the opportunity to distinguish cases of hospital-onset Clostridium difficile infection (CDI) from cases of community-onset CDI and to assess the burden of hospital-onset CDI in patients discharged from Rhode Island hospitals during 2010 and 2011. DESIGN Observational study. PATIENTS Patients 18 years of age or older discharged from one of Rhode Islands 11 acute-care hospitals between January 1, 2010, and December 31, 2011. METHODS Using the newly available POA indicators in the Rhode Island 2010 and 2011 hospital discharge database, we identified patients with hospital-onset CDI and without CDI. Adjusting for patient demographic and clinical characteristics using propensity score matching, we measured between-group differences in mortality, length of stay, and cost for patients with hospital-onset CDI and without CDI. RESULTS In 2010 and 2011, the 11 acute-care hospitals in Rhode Island had 225,999 discharges. Of 4,531 discharged patients with CDI (2.0% of all discharges), 1,211 (26.7%) had hospital-onset CDI. After adjusting for patient demographic and clinical characteristics, discharged patients with hospital-onset CDI were found to have higher mortality rates, longer lengths of stay, and higher costs than those without CDI. CONCLUSIONS Our results highlight the burden of hospital-onset CDI in Rhode Island. These findings emphasize the need to track longitudinal trends to tailor and target population-health and quality-improvement initiatives.

A Qualitative Study of Choosing Home Health Care After Hospitalization: The Unintended Consequences of ‘Patient Choice’ Requirements

ABSTRACTBACKGROUNDAlthough hospitals are increasingly held accountable for patients’ post-discharge outcomes, giving them incentive to help patients choose high-performing home health agencies, little is known about how quality reports inform decision making.OBJECTIVEWe aimed to learn how quality reports are used when choosing home care in one northeast state (Rhode Island) .DESIGNThe study consisted of focus groups with home health consumers and structured interviews with hospital case managers.PARTICIPANTSThirteen consumers and 28 case managers from five hospitals participated in the study.APPROACHWe identified key themes and illustrative quotes by audiotaping each session, and then three independent reviewers conducted repeated examination and content analysis.KEY RESULTSNo participants were aware of existing state or Medicare home health agency public reports. Case managers provided agency lists to consumers, who routinely asked case managers to tell them which agencies to choose or which were best; but case managers felt unable to directly respond to consumers’ requests for help in making the choice, because they did not have additional information to provide and because they feared violating federal laws requiring freedom of patient choice. Case managers also felt that there was little difference in agency quality, although they acknowledged they might not be aware of problems related to post-hospital care.CONCLUSIONSHome health consumers and hospital case managers were unaware of public reports about home health quality, which limited consumers’ ability to make informed decisions and case mangers’ ability to assist them in that decision-making process. Case managers were otherwise prohibited from recommending specific providers to patients and viewed the ‘patient choice’ laws as restricting their ability to respond to patients’ requests for help in choosing home health agencies. Public reports can be marketed as tools that case managers can use to help patients differentiate among providers, while supporting patient autonomy.

Creating a Survey to Assess Physicians’ Adoption of Health Information Technology

Information on state-level health information technology (HIT) adoption will become increasingly important with the implementation of incentive payments to accelerate uptake. Recognizing this, the Rhode Island Department of Health selected physician HIT adoption as a subject for its legislatively mandated quality reporting program. This article discusses the state’s process for developing HIT adoption measures, including the importance of stakeholder involvement in the development of a survey and the difficulty of accurately defining electronic medical record (EMR) adoption. This article describes the challenges in defining “true” EMRs, which may be addressed, in part, by ensuring local consensus about EMR measures and by piloting the survey and measures, prior to public reporting or the calculation of a statewide baseline. It also presents results from the 2009 administration of this survey to all 3,883 Rhode Island–licensed physicians providing direct patient care.

“It’s like texting at the dinner table”: A qualitative analysis of the impact of electronic health records on patient-physician interaction in hospitals

Background Electronic health records (EHRs) may reduce medical errors and improve care, but can complicate clinical encounters. Objective To describe hospital-based physicians’ perceptions of the impact of EHRs on patient–physician interactions and contrast these findings against office-based physicians’ perceptions. Methods We performed a qualitative analysis of comments submitted in response to the 2014 Rhode Island Health Information Technology Survey to gain a more in-depth understanding of individual physicians’ experiences using their EHRs. Office- and hospital-based physicians licensed in Rhode Island, in active practice, and located in Rhode Island or neighboring states completed the survey about their Electronic Health Record use. Results The survey’s response rate was 68.3% and 2,236 (87.1%) respondents had EHRs. Among survey respondents, 27.3% of hospital-based and 37.8% of office-based physicians with EHRs responded to the question about patient interaction. Five main themes emerged for hospital-based physicians, with respondents generally perceiving EHRs as negatively altering patient interactions. We noted the same five themes among office-based physicians, but the rank order of the top two responses differed by setting: hospital-based physicians commented most frequently that they spend less time with patients because they have to spend more time on computers; office-based physicians commented most frequently on EHRs worsening the quality of their interactions and relationships with patients. Conclusion In our analysis of a large sample of physicians, hospital-based physicians generally perceived EHRs as negatively altering patient interactions, although they emphasized different reasons than their office-based counterparts. These findings add to the prior literature that focuses on outpatient physicians, and can shape interventions to improve how EHRs are used in inpatient settings.

Antimicrobial Stewardship in Rhode Island Long-Term Care Facilities: Current Standings and Future Opportunities.

Our survey of antimicrobial stewardship practices among Rhode Island long-term care facilities demonstrated opportunities to develop formal programs. Results suggest infection preventionists are largely responsible for ensuring appropriate antibiotic use in long-term care facilities and there is a need for increased interdisciplinary access to individuals with antimicrobial stewardship expertise. Infect Control Hosp Epidemiol 2016;37:979-982.