Strengthening Resident, Proxy, and Staff Engagement in Injury Prevention in Skilled Nursing Facilities

Background and Objectives Engaging residents, their proxies, and skilled nursing facility (SNF) staff through effective communication has potential for improving fall-related injury prevention. The purpose of this study was to understand how multiple stakeholders develop and communicate fall-related injury prevention plans to enhance sustained implementation. Research Design and Methods Descriptive qualitative study using framework analysis applied to open-ended semi-structured interviews (n=28) regarding experiences of communication regarding fall-related injury prevention, guided by the Patient and Family Engaged Care framework. Participants included residents at high risk of injury and their proxies, nursing assistants, nurses, and a nurse practitioner from three SNFs in the Eastern U.S. (Massachusetts and North Carolina). Results Interdisciplinary teams were viewed as essential for injury prevention. However, the roles of the interdisciplinary team members were sometimes unclear. Communication structures were often hierarchical, which reduced engagement of nursing assistants and frustrated proxies. Practices that enhanced engagement included knowing the residents, active listening skills, and use of strategies for respecting autonomy. Engagement was inhibited by time constraints, lack of proactive communication among staff, and by challenges eliciting the perspectives of residents with dementia. Resident barriers included desire for autonomy, strong preferences, and language differences. Discussion and Implications Strengthening team meeting processes and cultivating open communication and collaboration could facilitate staff, resident, and proxy engagement in injury prevention planning and implementation. Skill building and targeting resources to improve communication can address barriers related to staff practices, resident characteristics, and time constraints.

The Effect of Acute Inpatient Rehabilitation on Functional Outcomes and Discharge Disposition Following Liver Transplant

Background: Patients undergoing liver transplantation often face many challenges with functional independence, which acute rehabilitation can assist them in overcoming. Due to increased yearly liver transplantations, further investigation is required to evaluate the efficiency of acute rehabilitation. The objective of this study is to analyze the efficacy of acute rehabilitation in patients who underwent liver transplantation, primarily using Functional Independence Measure (FIMTM) scores and discharge disposition. Methods: A retrospective chart review was conducted on 143 encounters, consisting of 107 patients who underwent liver transplantation. Inclusion factors consisted of undergoing liver transplantation between January 2014–December 2018, admission into acute rehabilitation within 6 months post-transplant, and the availability of admission date, admission FIMTM, duration of stay, discharge FIMTM, and discharge disposition. These factors were evaluated in this study. Results: Patients who underwent acute rehabilitation following liver transplantation were found to have statistically significant positive FIMTM change (P < 0.00001) and FIMTM efficiency (P < 0.00001). The mean FIMTM change and efficiency were 25.4±18.5 and 2.0±1.6, respectively, for patients meeting inclusion criteria, and 35.7±11.8 and 2.4±1.0, respectively, when return to acute care (RTAC) encounters were excluded. A positive correlation was found between longer duration of stay in acute rehabilitation and positive FIMTM change for all patients meeting inclusion criteria (P < 0.00001, r = 0.465), and excluding RTAC encounters (P < 0.00001, r = 0.393). 34.3% (n = 49) of encounters had an RTAC, 3.5% (n = 5) were discharged to a skilled nursing facility (SNF), and 62.2% (n = 89) were discharged to the community. Overall, 83.2% (n = 89) of patients ultimately had a community discharge. Infection, respiratory/CV complications, and gastrointestinal complications were the most common causes for RTAC. Conclusion: Acute rehabilitation provides patients who have received a liver transplant with the opportunity to significantly improve their function and independence.

Preoperative Point-of-Care Ultrasound to Identify Frailty and Predict Postoperative Outcomes: A Diagnostic Accuracy Study

Background Frailty is increasingly being recognized as a public health issue, straining healthcare resources and increasing costs to care for these patients. Frailty is the decline in physical and cognitive reserves leading to increased vulnerability to stressors such as surgery or disease states. The goal of this pilot diagnostic accuracy study was to identify whether point-of-care ultrasound measurements of the quadriceps and rectus femoris muscles can be used to discriminate between frail and not-frail patients and predict postoperative outcomes. This study hypothesized that ultrasound could discriminate between frail and not-frail patients before surgery. Methods Preoperative ultrasound measurements of the quadriceps and rectus femoris were obtained in patients with previous computed tomography scans. Using the computed tomography scans, psoas muscle area was measured in all patients for comparative purposes. Frailty was identified using the Fried phenotype assessment. Postoperative outcomes included unplanned intensive care unit admission, delirium, intensive care unit length of stay, hospital length of stay, unplanned skilled nursing facility admission, rehospitalization, falls within 30 days, and all-cause 30-day and 1-yr mortality. Results A total of 32 patients and 20 healthy volunteers were included. Frailty was identified in 18 of the 32 patients. Receiver operating characteristic curve analysis showed that quadriceps depth and psoas muscle area are able to identify frailty (area under the curve–receiver operating characteristic, 0.80 [95% CI, 0.64 to 0.97] and 0.88 [95% CI, 0.76 to 1.00], respectively), whereas the cross-sectional area of the rectus femoris is less promising (area under the curve–receiver operating characteristic, 0.70 [95% CI, 0.49 to 0.91]). Quadriceps depth was also associated with unplanned postoperative skilled nursing facility discharge disposition (area under the curve 0.81 [95% CI, 0.61 to 1.00]) and delirium (area under the curve 0.89 [95% CI, 0.77 to 1.00]). Conclusions Similar to computed tomography measurements of psoas muscle area, preoperative ultrasound measurements of quadriceps depth shows promise in discriminating between frail and not-frail patients before surgery. It was also associated with skilled nursing facility admission and postoperative delirium. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Looking for a bright side: Tales from a recreational therapy virtual service-learning project during a pandemic

The everchanging policies and inability to utilize university students due to COVID-19 impacted both residents living in long-term care as well as the next generation of students pursuing careers in the field. University Wisconsin-La Crosse (UWL) faculty strategized solutions as restrictions threatened to impact hands-on opportunities for students. Was there a safe and effective solution to offer residents evidence-based programming while also providing students with vital field experience? Simply stated, the answer was yes. Thus, the UWL Happiness Project was born. This session will outline the UWL Happiness Project, a ten-week, telehealth program implemented between a skilled nursing facility in rural Wisconsin and the UWL Therapeutic Recreation Program, an AGHE Program of Merit for Health Professions designated program. The evidence-based curriculum was developed by an emerging UWL graduate student scholar with faculty mentorship. The innovative curriculum focuses on increasing feelings of happiness using PERMA, a theoretical model grounded in positive psychology. During virtual sessions, older adult residents (ages 65-85) and students built connection while working through weekly focus areas (e.g. vitality, mindfulness, friendship). An overview of AGHE competencies addressed within the project, online course demonstration, and assignment development will be discussed along with information about how these connections fostered an opportunity for students to see aging from a different perspective. This is the first time we are presenting results from the newly developed program. In this, we look forward to sharing student measurements and outcomes, as well as lessons learned during this meaningful, stimulating, and insightful educational session.

Poor Performance in SNF-VBP Program is Associated with Worse COVID-19 Outcomes in Nursing Homes

Skilled Nursing Facility Value-Based Purchasing (SNF-VBP) was a new Medicare payment program when COVID-19 began. SNF-VBP aims to improve care through payment bonuses and penalties. However, studies have shown that minority-serving nursing homes (NHs) tend to fare worse under SNF-VBP (more likely to receive penalties, less likely to receive bonuses). This study sought to examine whether SNF-VBP performance prior to the pandemic was associated with COVID-19 outcomes and whether associations varied in NHs where the majority of residents are Black/African American (majority-Black/AA). Using publicly available data on COVID-19 outcomes and vaccinations, SNF-VBP performance, and NH characteristics, we found that majority-Black/AA NHs were less likely to have zero infections; had higher case fatality rates; and had lower resident and staff vaccinations rates compared to NHs where the majority of residents are White. Across all NHs, worse SNF-VBP performance was associated with worse COVID-19 outcomes (the bottom quintile of SNF-VBP performers were more likely to experience COVID-19 infections and had lower vaccination rates; the highest performers had higher vaccination rates). However, in stratified analyses, SNF-VBP performance was not significantly associated with COVID-19 outcomes in majority-Black/AA NHs compared with majority-White NHs. The association between poor SNF-VBP performance and poor COVID-19 outcomes is concerning. Overall findings suggest that SNF-VBP performance prior to the pandemic is an important indicator of subsequent COVID-19 outcomes. However, it is unclear whether poor SNF-VBP performance is signaling overall poor quality or whether it is signaling a financial disadvantage caused by the program itself that in turn impacted COVID-19 outcomes.

Implications of Racial Differences in the Shifts in the Setting of Care for Alzheimer’s Disease and Related Dementias

The prevailing setting of care has strong associations with the progression of a disease at time of first diagnosis, subsequent treatment, resulting health outcomes as well as both long-term and short-term costs. The care of Alzheimer’s Disease (AD) and Related Dementias (ADRD) has been experiencing a shift from skilled nursing facility to home health care. However, changes in practice do not disseminate equally across the race/ethnicity spectrum of the U.S. and disadvantaged race/ethnicity-related groups often encounter differing conditions from those experienced by the majority. In this study, we calculated the race/ethnicity-related direct healthcare costs of individuals with AD and ADRD, stratified by care-provider structure (physician, inpatient, outpatient, skilled nursing facility, home health, hospice), and modeled the trends and the relative contributions of each setting over the 1991-2017 period using administrative claims from a 5% sample of Medicare beneficiaries. Inflation and the gradual switch of Medicare compensation to the HCC model between 2004 and 2007 were accounted for. We then applied an inverse probability weighting algorithm to propensity-score-match the AD/ADRD race/ethnicity-specific groups to Medicare beneficiaries to make them comparable in demographics and co-morbidity status but without AD/ADRD. Finally, we performed a comparison of the Medicare costs and associated survival within (AD/ADRD vs. No AD/ADRD) and between (Black vs. White vs. Hispanic) race/ethnicity-related groups. Comparisons were done for: i)1-year before; ii) 1-year after iii) years 2-11; iv)years 12-21 and v) years 22+ after an AD/ADRD diagnosis. We found significant race/ethnicity-related differences in costs and survival both before and after propensity score matching.

Deprescribing to Resolve Oversedation and Confusion in an Older Person Treated for Auditory Hallucinations and Poststroke Seizure Prophylaxis

This case study reviews the pharmacotherapy of a resident in a long-term care facility being treated for poststroke seizure, hallucinations, and dementia, a geriatric syndrome that is both common in regard to its prevalence and severe in regard to its impact on the individual, families, caregivers, and health care system. This case describes the past medical history of an older resident in a skilled nursing facility that was receiving pharmacological therapy for auditory hallucinations and for poststroke seizure prophylaxis, was noted to be having side effects from drug therapy, and how the nursing staff communicated with the consultant pharmacist to resolve these issues.

Challenges and Strategies to Maintain Fidelity to the MIRROR-TCM Intervention During the COVID-19 Pandemic

Randomized clinical trials (RCTs) have demonstrated that the multicomponent Transitional Care Model (TCM), an advanced practice registered nurse-led, team-based, care management strategy improves outcomes for older adults transitioning from hospital to home. However, healthcare systems’ adoption of the model has been limited. A multi-system, replication RCT (MIRROR-TCM) enrolling older adults hospitalized with heart failure, chronic obstructive pulmonary disease or pneumonia began in February 2020 just as the outbreak of COVID-19 in the U.S. dramatically changed the healthcare and research landscape. The goal of this qualitative descriptive study is to explore the impact of COVID-19 on fidelity to the TCM intervention during this clinical trial. Using directed content analysis, recorded monthly meetings with health system leaders and staff were coded to identify challenges and strategies to maintaining fidelity to the intervention in the context of the pandemic. Analyses showed that COVID-19 impacted all 10 TCM components. The components with the most challenges were delivering services from hospital-to-home due to quarantining, restrictive facility policies, lack of personal protective equipment and limited telehealth availability; coordinating care due reduced availability of services, and screening at risk individuals because of fewer eligible patients. Strategies for addressing challenges included: exploring alternatives (e.g., increasing reliance on telehealth, expanding study eligibility), building and engaging networks (e.g., direct outreach to skilled nursing facility staff) and anticipating needs (e.g., preparing for shorter hospital stays). Findings highlight the importance of monitoring the contextual challenges to implementing an evidence-based intervention and actively engaging partners in identifying strategies to achieve fidelity.

Utility of the Late Life Function and Disability Instrument (LLFDI) in rehabilitation services for older adults

Introduction The Late Life Function and Disability Instrument (LLFDI) is a valid self-report tool that quantifies disability based on activity limitations and participation restrictions in everyday life. Both the original longer tool (LLFDI) and the shorter computer adaptive version (LLFDI-CAT) offer practitioners a method for measuring function independent or in conjunction with performance-based assessment. Objectives: Examine scores of the LLFDI and LLFDI-CAT for measuring disability in older adults who are receiving rehabilitation services in community and institution settings. Method: A secondary data analysis was conducted comparing scores from occupational therapy evaluations with older adults from 3 groups: 1) older adults in primary care using the LLFDI; 2) older adults in primary care using the LLFDI-CAT; older adults in a skilled nursing facility (SNF) using the LLFDI-CAT. Results Mean scores for Activity Limitation and Participation Restriction were lowest for older adults in a SNF indicating greater disability. A one-way Analysis of variance on ranks showed a main effect for Activity Limitation, χ2 (2) = 22.267, p &lt; 0.001, and Participation Restriction, χ2 (2) = 60.372, p &lt; 0.001. Post-hoc analyses revealed significant differences between groups based on tool (i.e. LLFDI vs. LLFDI-CAT) for Activity Limitations and setting (i.e. primary care vs. SNF) for Participation Restriction. Conclusion The LLFDI-CAT may be the preferred instrument to measure disability in older adults across treatment settings. Additional research is warranted to understand how personal and environmental factors influence LLFDI-CAT outcomes.