Using the community health assessment to screen for continued driving.

This project used the interRAI based, community health assessment (CHA) to develop a model for identifying current elder drivers whose driving behavior should be reviewed. The assessments were completed by independent housing sites in COLLAGE, a non-profit, national senior housing consortium. Secondary analysis of data drawn from older adults in COLLAGE sites in the United States was conducted using a baseline assessment with 8042 subjects and an annual follow-up assessment with 3840 subjects. Logistic regression was used to develop a Driving Review Index (DRI) based on the most useful items from among the many measures available in the CHA assessment. Thirteen items were identified by the logistic regression to predict drivers whose driving behavior was questioned by others. In particular, three variables reference compromised decision-making abilities: general daily decisions, a recent decline in ability to make daily decisions, and ability to manage medications. Two additional measures assess cognitive status: short-term memory problem and a diagnosis of non-Alzheimers dementia. Functional measures reflect restrictions and general frailty, including receiving help in transportation, use of a locomotion appliance, having an unsteady gait, fatigue, and not going out on most days. The final three clinical measures reflect compromised vision, little interest or pleasure in things normally enjoyed, and diarrhea. The DRI focuses the review process on drivers with multiple cognitive and functional problems, including a significant segment of potentially troubled drivers who had not yet been publicly identified by others. There is a need for simple and quickly identified screening tools to identify those older adults whose driving should be reviewed. The DRI, based on the interRAI CHA, fills this void. Assessment at the individual level needs to be part of the backdrop of science as society seeks to target policy to identify high risk drivers instead of simply age-based testing.

Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility.

CONTEXT: Patients admitted to skilled nursing facilities (SNFs) have a high risk for rehospitalization. OBJECTIVE: The goal of this project was to implement Project RED in an SNF to increase patient preparedness for care transitions and lower rehospitalization rates in the 30 days after discharge from the SNF facility. DESIGN: Intervention study with historical control; phone survey 30 days after discharge from the SNF for data collection. SETTING: The study was conducted in an SNF admitting patients from acute care hospitals in Boston, MA. PATIENTS OR OTHER PARTICIPANTS: A consecutive sample of patients in the SNF before (n = 524) and after initiation (n = 100) of the intervention. Participants had an average age of 80 (SD = 10), 67% were female, and 84% were non-Hispanic white. Phone surveys were completed with 88% of participants in each group. INTERVENTION(S): We adapted Project RED for use in an SNF. This includes a comprehensive approach to transitions of care that includes creating and teaching a personalized care plan to patients and their families. Software facilitating these activities was integrated into the electronic medical record of the SNF; intervention activities were delivered by existing staff. MAIN OUTCOME MEASURE(S): The main outcome was hospital readmission within 30 days of discharge from the SNF. Secondary outcomes included attendance to a medical appointment within 30 days of discharge from the SNF and preparedness for care transitions as measured by a 6-item survey. RESULTS: The rate of hospitalization 30 days after discharge from the SNF for participants prior to the intervention was 18.9% and for participants during the intervention was 10.2%, P < .05. This remained significant adjusting for multiple potential confounders (P = .045). More patients in the intervention group had attended an outpatient appointment within 30 days of discharge (70.5% versus 52.0%, P < .003). In addition, intervention participants reported a higher level of preparedness for care transitions. CONCLUSIONS: Patients in the intervention had a lower rate of returning to the hospital within 30 days of discharge from the SNF, were more likely to attend medical appointments, and were better prepared for their care transition.

Team improvement and patient safety conferences: culture change and slowing the revolving door between skilled nursing facility and the hospital.

To improve the safety culture of a skilled nursing facility, we conducted multidisciplinary "Team Improvement for Patient and Safety" (TIPS) case conferences biweekly to identify causes of transfers to acute care hospitals and improvement opportunities. Staff perceptions of organizational patient safety culture were assessed with the Nursing Home Survey on Patient Safety Culture. Over the course of the year, we held 22 TIPS conferences. Mean item scores increased during the study, indicating improved staff perceptions of patient safety culture (P < .005).

Improving disposition outcomes for patients in a geriatric skilled nursing facility.

OBJECTIVES: To evaluate an intervention to improve discharge disposition from a skilled nursing unit (SNU). DESIGN: Historical control comparison of discharge disposition before and after implementation. SETTING: Fifty-bed SNU. PARTICIPANTS: All patients admitted from acute care hospitals to a SNU between June 2008 and May 2010. INTERVENTION: Physician admission procedures were standardized using a template, patients with three or more hospital admissions over the prior 6 months received palliative care consultations, and multidisciplinary root-cause analysis conferences for patients transferred back to the hospital acutely were conducted bimonthly to identify problems and improve processes of care. MEASUREMENTS: Patients' discharge disposition (i.e., acute care, long-term care, home, or death) before and after implementation were compared. RESULTS: Discharge dispositions were determined for all 1,725 patients admitted during the study; 862 patients before (June-May 2008) and 863 during (June 2009-May 2010) the intervention. Discharge dispositions were significantly differently distributed across the two periods (P=.03). Readmission to acute care declined (from 16.5% to 13.3%, a nearly 20% decline). Multivariable logistic regression, controlling for age, sex, and case-mix index and adjusting for clustering due to repeated admissions of individual patients, suggests that, during the intervention period, patients were more likely than during the baseline period to die on the unit in accordance with their wishes than to be transferred out to the hospital (odds ratio=2.45, 95% confidence interval=1.09-5.5). CONCLUSION: Interventions such as the ones implemented can lead to fewer hospital transfers for SNUs.