Ruth M. Tappen

Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project

A substantial proportion of hospitalizations of nursing home (NH) residents may be avoidable. Medicare payment reforms, such as bundled payments for episodes of care and value‐based purchasing, will change incentives that favor hospitalization but could result in care quality problems if NHs lack the resources and training to identify and manage acute conditions proactively. Interventions to Reduce Acute Care Transfers (INTERACT) II is a quality improvement intervention that includes a set of tools and strategies designed to assist NH staff in early identification, assessment, communication, and documentation about changes in resident status. INTERACT II was evaluated in 25 NHs in three states in a 6‐month quality improvement initiative that provided tools, on‐site education, and teleconferences every 2 weeks facilitated by an experienced nurse practitioner. There was a 17% reduction in self‐reported hospital admissions in these 25 NHs from the same 6‐month period in the previous year. The group of 17 NHs rated as engaged in the initiative had a 24% reduction, compared with 6% in the group of eight NHs rated as not engaged and 3% in a comparison group of 11 NHs. The average cost of the 6‐month implementation was

Exercise training for depressed older adults with Alzheimer’s disease

7,700 per NH. The projected savings to Medicare in a 100‐bed NH were approximately

Effect of Exercise on Mood in Nursing Home Residents With Alzheimer’s Disease

125,000 per year. Despite challenges in implementation and caveats about the accuracy of self‐reported hospitalization rates and the characteristics of the participating NHs, the trends in these results suggest that INTERACT II should be further evaluated in randomized controlled trials to determine its effect on avoidable hospitalizations and their related morbidity and cost.

The Effect of Planned Walking on Communication in Alzheimer's Disease

The purpose of this study was to compare the effects of 16 weeks of a comprehensive exercise routine to supervised walking and social conversation on depression in nursing home residents with Alzheimers disease (AD). Method: This study was a three-group, repeated-measures design with random assignment to treatment group. Forty-five nursing home residents with moderate to severe AD were randomly assigned to a 16-week programme of comprehensive exercise, supervised walking or social conversation. Raters were blinded to treatment group assignment. Major outcome variables were depression measured by the Cornell Scale for Depression in Dementia, mood measured by the Dementia Mood Assessment Scale and the Alzheimers Mood Scale, and affect measured by the Observed Affect Scale. Depression was reduced in all three groups with some evidence of superior benefit from exercise. Depression is a common problem with serious and costly consequences for nursing home residents with AD. Exercise as a behavioural approach to treatment of depression in nursing home residents with severe AD evidenced a clear benefit to participants in this study. More research is needed to clarify the relative benefits of different types of exercise in conjunction with or without pharmacological intervention.

Communicating with individuals with Alzheimer's disease: Examination of recommended strategies

The purpose oF this study was to examine the eFFects oF 3 behavioral interventions on aFFect and mood in nursing home residents with Alzheimers disease. In a pre—post design, 90 residents with Alzheimers disease were randomized to 3 groups: supervised walking, comprehensive exercise (walking plus strength training, balance, and Flexibility exercises), and social conversation (casual rather than therapeutic themes). Interventions were provided 5 days a week and progressed up to 30 minutes per session over 16 weeks. Interventions were conducted primarily indoors. Outcome measures included the Lawton Observed AFFect Scale, Alzheimer Mood Scale, and Dementia Mood Assessment. At posttest, participants receiving comprehensive exercise exhibited higher positive and lower negative aFFect and mood. The social conversation group exhibited the least positive and most negative mood and aFFect. Results suggest that exercise programs be emphasized in long-term care, particularly whole-body involvement rather than walking alone.

Avoidability of hospital transfers of nursing home residents: Perspectives of frontline staff

One of the effects of Alzheimers disease is a diminution in the ability to communicate. A randomized, non‐blinded two‐group experimental study was undertaken to determine if planned walking has the capacity to improve the communication performance of patients with moderate to severe Alzheimers disease. Thirty subjects meeting NINCDS‐ADRDA diagnostic criteria for probable Alzheimers disease, selected from two nursing homes, participated in the study. Intervention and comparison groups were each made up of subjects from both nursing homes. Subjects in one group were walked individually for 30 minutes three times a week for 10 weeks. Subjects in the comparison group were engaged in conversation for the same amount of time for 10 weeks.

Frequency and Diagnoses Associated With 7- and 30-Day Readmission of Skilled Nursing Facility Patients to a Nonteaching Community Hospital

Meaningful conversation with individuals in the later stages of Alzheimers disease (AD) has been considered difficult if not impossible. Limiting communication to simple concrete subjects and closed-ended questions is frequently recommended. Thirty-five 30 minute conversations with individuals with advanced AD (mean Mini-Mental State Examination [MMSE] = 10) were transcribed and the interactions examined. No significant differences in length or relevance of response by type of question was found indicating that subjects were able to respond to open-ended questions. Use of broad opening statements or questions, establishing commonalities, speaking as equals, and sharing of self-facilitated expression of feeling; recognizing themes with salience for the individual helped to maintain the discussion.

Relationships of religion and spirituality to glycemic control in Black women with type 2 diabetes.

OBJECTIVES: To describe nursing home (NH) staff perceptions of avoidability of hospital transfers of NH residents.

A randomized controlled trial of an activity specific exercise program for individuals with alzheimer disease in long-term care settings

OBJECTIVES To determine the frequency and diagnoses associated with 7- and 30-day acute hospital readmissions of patients discharged to a skilled nursing facility (SNF) from an acute hospital. DESIGN A quality improvement project focusing on 30-day hospital readmissions, using retrospective data derived from the hospitals electronic data repository. SETTING A 350-bed nonteaching community hospital in southeast Florida. MEASUREMENTS Data were collected on all discharges of Medicare fee-for-service patients age 75 and older for a 17-month period in 2007 and 2008. The primary source of data was the hospitals electronic data repository. Seven and 30-day hospital readmission rates were calculated for all discharges to SNFs. Index hospital and readmission diagnoses were determined by hospital coders and categorized by the physician coauthors. RESULTS Among 10,777 discharges of patients age 75 and older, 3254 (30%) were discharged to an SNF, and of these, 584 (18%) were readmitted to the hospital within 30 days; 191 (33%) of these readmissions occurred within 7 days. The index diagnostic categories with the highest readmission rates were genitourinary disorders (30%) and cardiovascular disorders (25%). Specific diagnoses associated with the highest readmission rates included congestive heart failure (CHF) (31%), urinary tract infection (28%), renal failure (27%), and pneumonia and chronic obstructive pulmonary disease (23% each). Infections and cardiovascular disorders were the primary diagnoses for 63% of the hospital readmissions (36% and 27% respectively). The most frequent readmission primary diagnosis was the same as the index admission primary diagnosis in less than half the cases. CONCLUSION In this community hospital population, close to 1 in 5 discharges to an SNF resulted in a hospital readmission within 30 days. CHF, renal failure, UTI, pneumonia, and COPD were common index hospital and readmission diagnoses. Care paths and guidelines are available for these conditions that should be helpful to SNFs in initiatives designed to improve transitional care and reduce potentially avoidable hospital readmissions, as well as their associated morbidity and cost.

Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations.

Background: Although religion and spirituality are prominent in the lives of Black women with type 2 diabetes (T2DM), there is little research on the relationships of religion and spirituality to glycemic control (GC) in this population. Objective: To examine the relations of religion and spirituality to GC. Methods: Using a cross-sectional, descriptive, correlational design, a convenience sample of 109 Black women with T2DM was recruited. Measures of demographic (age, income, and education), clinical (body mass index and use of diabetes medications), psychosocial (emotional distress and social support), religion and spirituality (religious and existential well-being), and GC (hemoglobin A1c) factors were collected. A theoretical model, based on the work of Koenig, McCullough, and Larson (2001), informed linear regression analyses to examine the relations of religion and spirituality to GC, with psychosocial factors as putative mediators. Results: With age (&bgr; = −.133, SE = .020, p = .145), income (&bgr; = .020, SE = .139, p = .853), education (&bgr; = −.221, SE = .204, p = .040), body mass index (&bgr; = −.237, SE = .031, p = .011), and diabetes medications (&bgr; = .338, SE = .216, p < .001) held constant, religion and spirituality demonstrated significant relations with GC (&bgr; = .289, SE = .032, p = .028 and &bgr; = − .358, SE = .030, p = .006, respectively). Evidence of emotional distress and social support as mediators in the relationships of religion and spirituality to GC was lacking. Discussion: Religion and spirituality were related to GC, with evidence of psychosocial mediation lacking, thereby forcing revision of the model for the study population. Research is warranted to validate the findings, with further examination of theoretical mediators linking religion and spirituality to GC. Findings suggest that religion and spirituality be addressed in diabetes care to improve GC in Black women with T2DM.