Suzanne M. Gillespie

Health Care Providers' Opinions on Communication Between Nursing Homes and Emergency Departments

OBJECTIVES To characterize the beliefs and opinions of nursing home (NH) and emergency medicine providers about communication between NH and emergency departments (ED) during transitions of care of NH residents. DESIGN A cross-sectional study using a mailed and Internet survey. PARTICIPANTS AND SETTING Physicians, nurse practitioners, physicians assistants, and nurses who practice in ED settings and NH settings, affiliated with hospitals of an academic medical center in Rochester, New York. MEASUREMENTS Opinions on communication; beliefs about frequency of information transmission; opinions on how often verbal communication should occur. RESULTS A total of 155 nurses and medical providers participated in the survey for a response rate of 32.2% (155/481). Of the survey participants, 63.0% and 56.8% had been more than 5 years in their position and facility, respectively. Most respondents felt that important information was lost during patient transfers between NH and ED settings. Providers from ED and NH settings had different opinions on the likelihood that key information would be readily identifiable at patient transfer and that care would include requested tests and follow-up. Providers from both sites of care supported verbal communication at their position when NH residents are transferred to the other setting. CONCLUSION Nurses and medical providers from both emergency and NH settings agree that transitional communication is poor between NHs and EDs and support a role for verbal communication during the ED transitions of care of NH residents.

A Qualitative Evaluation of a Telemedicine-Enhanced Emergency Care Program for Older Adults

To document the experiences of patients, their caregivers, healthcare personnel, and staff members with a program that provides telemedicine‐enhanced emergency care to older adults residing in senior living communities (SLCs) and to delineate perceived barriers and facilitators.

High-Intensity Telemedicine-Enhanced Acute Care for Older Adults: An Innovative Healthcare Delivery Model

Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high‐intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the programs operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety‐four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high‐intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident‐level outcomes and the development of sustainable business models.

Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center.

Abstract Objective. We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. Methods. We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. Results. We identified 15 scales for evaluation. The panels criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales –level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) –may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. Conclusions. Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.

Transitional care of the long-term care patient.

This article reviews the literature on transitional care to and from the LTC environment, highlighting strategies to improve the quality of care transitions. Several factors are vital in the improvement of systems of care dealing with transitions. Key factors include communication with and among health care providers, effective medication reconciliation, advanced discharge planning, and timely use of palliative care.

Potential of telemedicine to provide acute medical care for adults in senior living communities.

OBJECTIVES Older adults dwelling in senior living communities (SLCs) often experience barriers to medical care when they experience acute illness. The potential of telemedicine as a substitute for standard routes of evaluating and caring for individuals with acute illness (e.g., in-person or telephone-based interactions with primary care providers and emergency department [ED] visits) was explored in this study. METHODS In this cross-sectional, observational study, the authors conducted a 6-month retrospective review of the medical records of adults enrolled in a university-affiliated geriatrics practice that offers on-site primary medical care in SLCs. For each episode of acute care, patient demographics, medical history, and chief complaint were collected and presented to an expert panel of physicians, who determined whether telemedicine could have been used to provide acute evaluation and care. The care actually provided, including outcomes, was also noted. Descriptive statistics were used to characterize the population and potential for telemedicine care. RESULTS The medical records of 646 patients were reviewed, accounting for 1,535 unique episodes of acute care. The expert panel identified 576 visits (38%) as potentially appropriate for telemedicine-based acute care, with 38, 47, and 27% of phone, in-home, and ED visits being eligible, respectively. Chief complaints most likely to be deemed potentially appropriate were falls and dermatologic, respiratory, and gastrointestinal illnesses, representing 58% of visits identified for telemedicine-based acute care. CONCLUSIONS Telemedicine has a potentially significant role in the provision of acute care for older adults residing in SLCs. Studies are needed to evaluate the feasibility, acceptability, effectiveness, and efficiency of acute care telemedicine for this population.

“Geriatricizing” Hospitalists: Identifying Educational Opportunities

The objective of this study was to identify differences between geriatricians and hospitalists in caring for hospitalized older adults, so as to inform faculty development programs that have the goal of improving older patient care. Eleven hospitalists and 13 geriatricians were surveyed regarding knowledge, confidence, and practice patterns in caring for hospitalized older adults, targeting areas previously defined as central to taking care of older hospitalized patients. Overall, geriatricians had more confidence and more knowledge in caring for older hospitalized adults. The areas in which hospitalists expressed the least confidence were in caring for patients with dementia, self-care issues, and care planning. Geriatricians reported more routine medication reviews, functional and cognitive assessments, and fall evaluations. Geriatricians and hospitalists differ in their approach to older adults. Where these differences reflect lack of knowledge or experience, they set the stage for developing curricula to help narrow these gaps.

Reducing Emergency Department Utilization Through Engagement in Telemedicine by Senior Living Communities

BACKGROUND High-intensity telemedicine has been shown to reduce the need for emergency department (ED) care for older adult senior living community (SLC) residents with acute illnesses. We evaluated the effect of SLC engagement in the telemedicine program on ED use rates. MATERIALS AND METHODS We performed a secondary analysis of data from a prospective cohort study evaluating the effectiveness of high-intensity telemedicine for SLC residents. We compared the annual rate of change in ED use among subjects who resided in SLC units that were more engaged in telemedicine services with that among subjects who resided in SLC units that were less engaged in telemedicine and control subjects who lived at facilities without access to telemedicine services. RESULTS During the study, subjects had 503 telemedicine visits, with 362 (72.0%) in the more engaged SLCs and 141 (28.0%) in the less engaged SLCs. For subjects residing in more engaged SLCs, ED use decreased at an annualized rate of 28% (rate ratio [RR] = 0.72; 95% confidence interval [CI], 0.58-0.89), whereas in the less engaged (RR = 0.962; 95% CI, 0.776-1.19) and control (RR = 0.909, 95% CI, 0.822-1.07) groups there was no significant change in ED use (p = 0.036 for group × time interaction). CONCLUSIONS Individuals residing in more engaged SLCs experienced a greater decrease in ED use compared with subjects residing in less engaged SLCs or those without access to high-intensity telemedicine for acute illnesses. We identified potential factors associated with more engaged SLCs, but further research is needed to understand resident and staff engagement and how to increase it.

National Structural Survey of Veterans Affairs Home‐Based Primary Care Programs

To describe the current structural and practice characteristics of the Department of Veterans Affairs (VA) Home‐Based Primary Care (HBPC) program.