Early clinical and quality impacts of the Age-Friendly Health System in a Veterans Affairs skilled nursing facility.

BACKGROUND: Skilled nursing facilities (SNFs) are an ideal setting to implement the Age-Friendly Health System (AFHS) approach, an initiative by the Institute for Healthcare Improvement (IHI) centered on the 4Ms: what matters, mobility, mentation, and medication. AFHS implementation has not been well studied in SNFs. METHODS: A 112-bed VA SNF implemented a facility-wide AFHS initiative including the following: (1) participating in a national IHI Age-Friendly Action Community; (2) establishing an AFHS workgroup centered on the 4Ms; (3) identifying meaningful clinical tools and frameworks for capturing each M; and (4) developing sustainment methods. Clinical (life-sustaining treatment, falls, disruptive behaviors, and medication deprescribing) and quality outcomes (rehospitalization, emergency department utilization, and discharge to the community) in addition to patient satisfaction were compared pre- and post-AFHS implementation (bed days of care [BDOC] 17413) to post-implementation (BDOC 20880). RESULTS: Clinical outcomes demonstrated improvements in the 4Ms, including: (1) what matters: 14% increase in life-sustaining treatment documentation (82%-96%; p < 0.01); (2) mobility: reduction in fall rate by 34% (8.15 falls/1000 BDOC to 5.41; p < 0.01); (3) mentation: decrease in disruptive behavior reporting system (DBRS) by 62% (5.11 DBRS/1000 BDOC to 1.96; p = 0.04); (4) medications: 53% increase in average potentially inappropriate medications (PIMs) deprescribing (0.38-0.80 interventions/patient; p < 0.01). Quality outcomes improved including rehospitalization (25.6%-17.9%) and emergency department utilization (5.3%-2.8%) within 30 days of admission. Patient satisfaction scores improved from a mean of 77.2 (n = 31, scale 1-100) to 81.3 (n = 42). CONCLUSIONS: Implementation of the AFHS initiative in a SNF was associated with improved clinical and quality outcomes and patient satisfaction. We describe here a sustainable, interprofessional approach to implementing the AFHS in a SNF.

Coordinated-Transitional Care (C-TraC) for Veterans from Subacute Rehabilitation to Home.

OBJECTIVES: To adapt a successful acute care transitional model to meet the needs of veterans transitioning from post-acute care to home. DESIGN: Quality improvement intervention. SETTING AND PARTICIPANTS: Veterans discharged from a subacute care unit in the VA Boston Healthcare System's skilled nursing facility. METHODS: We used the Replicating Effective Programs framework and Plan-Do-Study-Act cycles to adapt the Coordinated-Transitional Care (C-TraC) program to the context of transitions from a VA subacute care unit to home. The major adaptation of this registered nurse-driven, telephone-based intervention was combining the roles of discharge coordinator and transitional care case manager. We report the details of the implementation, its feasibility, and results of process measures, and describe its preliminary impact. RESULTS: Between October 2021 and April 2022, all 35 veterans who met eligibility criteria in the VA Boston Community Living Center (CLC) participated; none were lost to follow-up. The nurse case manager delivered core components of the calls with high fidelity-review of red flags, detailed medication reconciliation, follow-up with primary care physician, and discharge services were discussed and documented in 97.9%, 95.9%, 86.8%, and 95.9%, respectively. CLC C-TraC interventions included care coordination, patient and caregiver education, connecting patients to resources, and addressing medication discrepancies. Nine medication discrepancies were discovered in 8 patients (22.9%; average of 1.1 discrepancies per patient). Compared with a historical cohort of 84 veterans, more CLC C-TraC patients received a post-discharge call within 7 days (82.9% vs 61.9%; P = .03). There was no difference between rates of attendance to appointments and acute care admissions post-discharge. CONCLUSIONS AND IMPLICATIONS: We successfully adapted the C-TraC transitional care protocol to the VA subacute care setting. CLC C-TraC resulted in increased post-discharge follow-up and intensive case management. Evaluation of a larger cohort to determine its impact on clinical outcomes such as readmissions is warranted.

Student-Valued Measurable Teaching Behaviors of Award-Winning Pharmacy Preceptors.

OBJECTIVE: To identify specific preceptor teaching-coaching, role modeling, and facilitating behaviors valued by pharmacy students and to develop measures of those behaviors that can be used for an experiential education quality assurance program. METHODS: Using a qualitative research approach, we conducted a thematic analysis of student comments about excellent preceptors to identify behaviors exhibited by those preceptors. Identified behaviors were sorted according to the preceptor's role as role model, teacher/coach, or learning facilitator; measurable descriptors for each behavior were then developed. RESULTS: Data analysis resulted in identification of 15 measurable behavior themes, the most frequent being: having an interest in student learning and success, making time for students, and displaying a positive preceptor attitude. Measureable descriptors were developed for 5 role-modeling behaviors, 6 teaching-coaching behaviors, and 4 facilitating behaviors. CONCLUSION: Preceptors may need to be evaluated in their separate roles as teacher-coach, role model, and learning facilitator. The developed measures in this report could be used in site quality evaluation.