Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: A targeted needs assessment using the Intervention Mapping framework

Abstract The CoreQ (not an acronym) consists of a limited number of satisfaction items (3-4 items, depending on setting) that are used to create an overall satisfaction score for long-term care facilities. This measure has been used in assisted living (AL) and skilled nursing facilities (SNFs) and has been endorsed by the National Quality Forum (NQF). Briefly, the development and psychometric testing of the CoreQ will be described, including the rationale for producing an overall satisfaction score and correlation with important quality indicators like Five-Star. Using data collected over the past 3 years, comprising more than 100,000 respondents, the use of the CoreQ measure will be described. For example, the CoreQ scores are used in MA to allow providers to benchmark their performance. The use of the scores in this way will be discussed including how providers have used the scores for quality improvement. Some states have elected to use CoreQ in pay for performance and other state initiatives. A case study of how New Jersey uses CoreQ with SNFs will be presented, including distribution of scores and addressing data collection challenges. CoreQ can be utilized as a short customer satisfaction measure to allow providers to benchmark their performance, residents and families in decision-making, and states and others to use for accountability.

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Outcomes of the Maryland Person-Centered Hospital Discharge Program: A Pilot Targeting Decreasing Long-Term Care Use and Hospital Readmissions

Care Management Journals ◽

10.1891/1521-0987.16.1.48 ◽

2015 ◽

Vol 16 (1) ◽

pp. 48-58 ◽

Cited By ~ 1

Author(s):

Allison Payne Carew ◽

Barbara Resnick

Keyword(s):

At Risk ◽

Nursing Home ◽

Hospital Discharge ◽

Long Term Care ◽

Care Coordinator ◽

Term Care ◽

Skilled Nursing ◽

Care Coordinators

The Person-Centered Hospital Discharge Program (PCHDP) was offered by the Centers for Medicare and Medicaid Services as a way to improve care to Medicare and Medicaid beneficiaries in Maryland. The PCHDP used a care nurse/coordinator to facilitate the successful transition of patients at risk for becoming eligible for Medicaid. The purpose of this study was to examine the outcomes of the PCHDP pilot, explore factors that influenced hospital and long-term care admissions following hospital discharge, and obtain operational data to develop new programs with related objectives. Area Agencies on Aging were provided with a care coordinator who obtained patient data, developed an individualized care plan, and determined visit frequency and length of services. Multivariate analysis of variance was conducted to examine differences between those hospitalized or admitted to a skilled nursing facility during the follow-up period. The sample consisted of 359 at-risk patients, and the mean length of follow-up was approximately two months. Most patients did not go to the emergency room (N = 319, 88%) during the period of follow-up and were not admitted to an acute care setting (N = 301, 84%) or skilled nursing home (N = 322, 86%). Those who were rehospitalized were slightly younger and had more visits from the care coordinator. We anticipate that the care coordinators identified individuals at greatest need for follow-up and support. Future research should explore ways in which these care coordinators can intervene to prevent hospital readmission and long-term nursing home care.

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COVID-19 Across the Landscape of Long-Term Care in Alameda County: Heterogeneity and Disparities

Gerontology and Geriatric Medicine ◽

10.1177/23337214211073419 ◽

2022 ◽

Vol 8 ◽

pp. 233372142110734

Author(s):

Terry E. Hill ◽

David J. Farrell

Keyword(s):

Public Health ◽

Long Term Care ◽

The Elderly ◽

Population Based ◽

Nursing Facilities ◽

Term Care ◽

Skilled Nursing ◽

Data Infrastructure ◽

Care Facilities

Throughout the pandemic, public health and long-term care professionals in our urban California county have linked local and state COVID-19 data and performed observational exploratory analyses of the impacts among our diverse long-term care facilities (LTCFs). Case counts from LTCFs through March 2021 included 4309 (65%) in skilled nursing facilities (SNFs), 1667 (25%) in residential care facilities for the elderly (RCFEs), and 273 (4%) in continuing care retirement communities (CCRCs). These cases led to 582 COVID-19 resident deaths and 12 staff deaths based on death certificates. Data on decedents’ age, race, education, and country of birth reflected a hierarchy of wealth and socioeconomic status from CCRCs to RCFEs to SNFs. Mortality rates within SNFs were higher for non-Whites than Whites. Staff accounted for 42% of LTCF-associated COVID-19 cases, and over 75% of these staff were unlicensed. For all COVID-19 deaths in our jurisdiction, both LTCF and community, 82% of decedents were age 65 or over. Taking a comprehensive, population-based approach across our heterogenous LTCF landscape, we found socioeconomic disparities within COVID-19 cases and deaths of residents and staff. An improved data infrastructure linking public health and delivery systems would advance our understanding and potentiate life-saving interventions within this vulnerable ecosystem.

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A Comparison of Emergency Preparedness Policies by Long-Term Care Setting Type in Ohio: Assisted Living Settings Lag Behind Nursing Homes in Key Areas

Journal of Applied Gerontology ◽

10.1177/0733464820902010 ◽

2020 ◽

pp. 073346482090201

Author(s):

Katherine A. Kennedy ◽

Cassandra L. Hua ◽

Ian Nelson

Keyword(s):

Assisted Living ◽

Emergency Preparedness ◽

Disaster Preparedness ◽

Long Term Care ◽

Nursing Facilities ◽

Community Based ◽

Term Care ◽

Skilled Nursing ◽

Care Facilities

Skilled nursing facilities (SNFs) have received regulatory attention in relation to their emergency preparedness. Yet, assisted living settings (ALs) have not experienced such interest due to their classification as a state-regulated, home- and community-based service. However, the growth in the number of ALs and increased resident acuity levels suggest that existing disaster preparedness policies, and therefore, plans, lag behind those of SNFs. We examined differences in emergency preparedness policies between Ohio’s SNFs and ALs. Data were drawn from the 2015 wave of the Ohio Biennial Survey of Long-Term Care Facilities. Across setting types, most aspects of preparedness were similar, such as written plans, specifications for evacuation, emergency drills, communication procedures, and preparations for expected hazards. Despite these similarities, we found SNFs were more prepared than large ALs in some key areas, most notably being more likely to have a backup generator and 7 days of pharmacy stocks and generator fuel.

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Predicting 3-year mortality and admission to acute-care hospitals, skilled nursing facilities, and long-term care facilities in Medicare beneficiaries

Archives of Gerontology and Geriatrics ◽

10.1016/j.archger.2017.08.005 ◽

2017 ◽

Vol 73 ◽

pp. 248-256 ◽

Cited By ~ 9

Author(s):

Jibby E. Kurichi ◽

Hillary R. Bogner ◽

Joel E. Streim ◽

Dawei Xie ◽

Pui L. Kwong ◽

...

Keyword(s):

Acute Care ◽

Long Term Care ◽

Acute Care Hospitals ◽

Skilled Nursing Facilities ◽

Nursing Facilities ◽

Medicare Beneficiaries ◽

Term Care ◽

Skilled Nursing ◽

Care Facilities

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The association of early postoperative desaturation in the operating theatre with hospital discharge to a skilled nursing or long-term care facility

Anaesthesia ◽

10.1111/anae.14517 ◽

2019 ◽

Vol 74 (4) ◽

pp. 457-467 ◽

Cited By ~ 15

Author(s):

P. Rostin ◽

B. J. Teja ◽

S. Friedrich ◽

S. Shaefi ◽

K. R. Murugappan ◽

...

Keyword(s):

Hospital Discharge ◽

Long Term Care ◽

Care Facility ◽

Operating Theatre ◽

Term Care ◽

Skilled Nursing ◽

Term Care Facility ◽

Long Term Care Facility

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Adapting Mindfulness-Based Interventions for Residents of Long-Term Care Facilities

Gerontology and Geriatric Medicine ◽

10.1177/23337214211057703 ◽

2021 ◽

Vol 7 ◽

pp. 233372142110577

Author(s):

Christian Terry ◽

Michael Penland ◽

Devon Garland ◽

Wendy Wang ◽

Taylor Burton ◽

...

Keyword(s):

Long Term Care ◽

Nursing Facilities ◽

Traditional Group ◽

Term Care ◽

Skilled Nursing ◽

Healthy Older Adults ◽

Care Facilities ◽

States Data ◽

Full Day

Mindfulness-based interventions (MBIs) have received increased clinical attention in recent years. While some MBI research has focused on healthy older adults, research with more emotionally and physically vulnerable populations, such as residents of long-term care facilities (LTCFs), is lacking. The current paper presents quantitative and qualitative results from a pilot study of an individual MBI designed for residents of LTCFs. Participants included 8 residents from two skilled nursing facilities in the southeastern United States. Data were collected between October 2016 through June 2017. A modified MBI is proposed with specific adaptations for LTCF residents. Recommended adaptations for LTCFs include a shift from a group to an individual format, individual weekly instructor–participant meetings, removal of the yoga and full-day silent retreat and shortening the duration of the formal practices. The current study found that these adaptations result in an individual MBI that is accessible to most LTCF residents while still providing the associated benefits of traditional group MBIs.

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