More of a Good Thing: A Framework to Grow and Strengthen the PALTC Careforce.

The current staffing shortage across all disciplines of post-acute and long-term care (PALTC) settings is affecting the health and safety of residents, as well as the well-being of the current staff. The need to retain and recruit new talent to this challenging but fulfilling setting demands that we look to existing evidence-based strategies and identify ways to implement them quickly, effectively, and in a sustainable way. Using the 4 Ms Framework of the Age-Friendly Health System developed by the Institute for Healthcare Improvement and the John A. Hartford Foundation (What Matters, Medication, Mentation, and Mobility), we can build on successful strategies to address what matters to staff, mental health, career mobility, and the overall safety and wellness of our nation's careforce. This paper summarizes "More of a Good Thing: A Framework to Grow and Strengthen the PALTC Careforce," a series of 6 roundtable discussions held in 2022 that brought together clinicians, industry leaders, and change-makers to share strategies that have been researched and successfully implemented and discuss ways to scale and disseminate them to a broader audience. The role of PALTC leadership is highlighted, with key points from the final roundtable discussion outlined, and challenging leadership to think about what they can begin doing immediately to build trust with existing staff and lay the foundation for a stronger nursing home careforce. Next steps for "More of a Good Thing" include a survey of participants about what they have tried, what has been successful, and what barriers they face; a series of focused interviews with leaders; and potential collaboration with quality improvement organizations to help facilities build on and implement the strategies presented.

Advancing clinical trials in nursing homes: A proposed roadmap to success.

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success.

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

Palliative Nursing Summit: Nurses Leading Change and Transforming Care: Our Journey to the Summit.

The Hospice and Palliative Nurses Association, in conjunction with the Hospice and Palliative Credentialing Center and the Hospice and Palliative Nurses Foundation, organized a Palliative Nursing Summit in Washington, DC, on May 12, 2017. The goal of the summit was to convene leaders from various nursing specialty organizations to develop a collaborative nursing agenda for primary palliative nursing. The work of the summit focused on 3 aspects of palliative nursing: communication/advance care planning, coordination/transitions of care, and pain and symptom management. The meeting objectives were to identify the current state of primary palliative nursing and to identify the greatest opportunities to advance primary palliative nursing within the 3 focus areas. Twenty-six nursing specialty organizations participated in the summit. This article describes the basis for the summit, the data and resources that informed the meeting's participants, the outcomes in each of the 3 categories, and next steps.

Education and referral criteria: impact on oncology referrals to palliative care.

OBJECTIVE: To describe a quality improvement project involving education and referral criteria to influence oncology provider referrals to a palliative care service. METHODS: A single group post-test only quasi-experimental design was used to evaluate palliative care service (PCS) referrals following an intervention consisting of a didactic presentation, education outreach visits (EOV) to key providers, and referral criteria. Data on patient demographics, cancer types, consult volume, reasons for referral, pre-consult length of stay, overall hospital stay, and discharge disposition were collected pre-intervention, then post-intervention for 7.5 months and compared. SETTING AND SAMPLE: Attending oncologists, nurse practitioner, and house staff from the solid tumor division at a 700-bed urban teaching hospital participated in the project. Two geriatricians, a palliative care nurse practitioner, and rotating geriatric fellows staffed the PCS. RESULTS: The percentage of oncology referrals to PCS increased significantly following the intervention (χ(2) = 6.108, p = .013). 24.9% (390) patients were referred in the 4.6 years pre-intervention and 31.5% (106) patients were referred during 7.5 months post-intervention. The proportion of consults for pain management was significantly greater post-intervention (χ(2) = 5.378, p = .02), compared to pre-intervention, when most referrals were related to end-of-life issues. Lung, pancreatic, and colon were the most common cancer types at both periods, and there were no significant differences in patient demographics, pre-referral length of hospitalization or overall hospital days. There was a trend toward more patients being discharged alive following the intervention. CONCLUSION: A quality improvement project supported the use of education and referral criteria to influence both the frequency and reasons for palliative care referral by oncology providers.

Current and future directions in frailty research.

The concept of frailty has been evolving dramatically for the past 30 years. Through its evolution, a variety of single and multidimensional models have been used to describe frailty. This article reviews the current literature related to the defining dimensions of frailty and identifies the gaps in the literature requiring additional research. A detailed literature review was performed to identify key dimensions and models currently being used to define frailty, classify interventions that have been developed to reverse frailty, and identify potential areas for future research within this field. Despite the large body of research defining the dimensions of frailty, no consensus exists on a comprehensive, operational definition. A standardized definition will be critical to design effective interventions at earlier stages along the continuum of frailty and interpret findings from evaluation studies. Identified gaps in the literature include studies supporting the utility of expanding the definition of frailty to incorporate social determinants, studies evaluating the role of obesity in the development of frailty, and the need for longitudinal studies for defining the pathways to developing frailty. This review highlights the need for an accurate definition of frailty and for longitudinal research to explore the development of frailty and evaluate the effectiveness of the frailty reversal interventions that may avert or delay adverse outcomes within this susceptible population. These future research needs are discussed within the context of the growing pressures to bring down health care costs, and the role of comparative effectiveness research and cost-effectiveness research in identifying interventions with the potential to help slow the growth of health care spending among the elderly.

Assessing pain in nonresponsive hospice patients: development and preliminary testing of the multidimensional objective pain assessment tool (MOPAT).

BACKGROUND: Accurate assessment in hospice patients who cannot communicate their pain is almost impossible, increasing their risk for unrecognized and inadequately managed pain. OBJECTIVE: The purpose of this article is to describe a series of small-scale projects aimed at developing and refining an instrument to assess acute pain in noncommunicative hospice patients. METHODS: Project 1 was a clinical project in which focus groups with hospice nurses yielded an adaptation of an existing pain assessment measure that was named the Multidimensional Objective Pain Assessment Tool (MOPAT) and had behavioral and physiological subscales. Projects 2 and 3 tested the MOPAT in 30 cognitively impaired/nonresponsive hospice inpatients and 28 alert and oriented hospice inpatients, with study nurses and hospice nurses rating pain with the MOPAT before and after a pain-relieving intervention and rating its clinical usefulness. Projects 3 and 4 analyzed the reliability, validity, and clinical utility of the MOPAT. RESULTS: Overall internal consistency reliability of the MOPAT was demonstrated with Cronbach's α coefficients of 0.79 before and 0.84 after the pain-relieving intervention. The behavioral and physiological subscale scores changed significantly (p < .035) after pain medication, demonstrating sensitivity to changes in pain. Principal components factor analysis revealed two factors matching the subscales and accounting for 66% of the variance. Nearly all the hospice nurses found the MOPAT helpful, easy to use and understand, and conducive to use in daily practice. CONCLUSION: The MOPAT has preliminary evidence of reliability, validity, and clinical utility. Full-scale psychometric testing in hospice and acute care hospital patients is currently underway.

End-of-life care for hospitalized patients with lung cancer: utilization of a palliative care service.

PURPOSE: High symptom burden and hospital mortality among patients with lung cancer argues for early palliative care intervention. Patient characteristics and discharge dispositions in hospitalized patients with lung cancer receiving usual care were compared to those referred to a new palliative care service. METHODS: A retrospective database review of all lung cancer discharges receiving usual care (UC) and palliative care service (PCS) consultation was conducted. Demographics, length of stay, discharge disposition, and mortality were described and compared. Palliative Performance Scale scores were described according to discharge disposition in the PCS group. Disposition of all patients receiving either chemotherapy or surgery was also noted. RESULTS: A total of 1476 hospital discharges with a diagnosis of lung cancer occurred between March 15, 2006 and June 30, 2009. Among all discharges, 9% received chemotherapy and 29% had surgery. The PCS was consulted for 8% of all lung cancer patients most commonly to address end-of-life-issues. PCS patients were more likely to be at the end-of-life than UC patients as evidenced by higher hospital mortality (31% versus 7%), higher intensive care (ICU) mortality (67% versus 16%) and more frequent discharge to hospice (41% versus 7%). PCS patients were hospitalized a median of 6 days before a referral was made. Hospitalization was significantly longer for PCS patients (M = 16.3 days, p < 0.001) than UC patients (M = 8.3 days). CONCLUSIONS: In the first 3 years of a new palliative care initiative consults for lung cancer patients occurred late in the hospital stay or when death was imminent.

Toward evidence-based prescribing at end of life: a comparative analysis of sustained-release morphine, oxycodone, and transdermal fentanyl, with pain, constipation, and caregiver interaction outcomes in hospice patients.

OBJECTIVE: The primary goal of this investigation was to examine selected outcomes in hospice patients who are prescribed one of three sustained-release opioid preparations. The outcomes examined include: pain score, constipation severity, and ability of the patient to communicate with caregivers. PATIENTS AND SETTINGS: This study included 12,000 terminally ill patients consecutively admitted to hospices and receiving pharmaceutical care services between the period of July 1 and December 31, 2002. DESIGN: We retrospectively examined prescribing patterns of sustained-release morphine, oxycodone, and transdermal fentanyl. We compared individual opioids on the aforementioned outcome markers, as well as patient gender, terminal diagnosis, and median length of stay. RESULTS: Patients prescribed a sustained-release opioid had similar average ratings of pain and constipation severity, regardless of the agent chosen. Patients prescribed transdermal fentanyl were reported to have more difficulty communicating with friends and family when compared with patients prescribed either morphine or oxycodone. On average, patients prescribed transdermal fentanyl had a shorter length of stay on hospice as compared with those receiving morphine or oxycodone. CONCLUSION: There was no difference in observed pain or constipation severity among patients prescribed sustained-release opioid preparations. Patients receiving fentanyl were likely to have been prescribed the medication due to advanced illness and associated dysphagia. Diminished ability to communicate with caregivers and a shorter hospice course would be consistent with this profile. Further investigation is warranted to examine the correlation between a patient's ability to interact with caregivers and pain control achieved.

Are newer, more expensive pharmacotherapy options associated with superior symptom control compared to less costly agents used in a collaborative practice setting?

Innovative approaches to care may be necessary to provide the most effective symptom management to hospice patients. One approach is prescribing newer pharmacotherapy options with the potential to improve symptom management in hospice. Such therapies are sometimes prescribed outside of Food and Drug Administration indications and are typically more costly than older agents used for the same symptoms. Another approach is the collaborative practice (CP) care model, whereby clinical pharmacists are given prescriptive authority according to evidence-based protocols and algorithms within boundaries approved by a physician. The agents typically included in CP protocols are those with wide therapeutic indices and with substantial evidence to support their use. The purpose of this study was to examine both approaches to management of pain, insomnia, and nausea, comparing symptom scores for those patients who received noncollaborative drug therapies (transdermal fentanyl, zolpidem, and ondansetron) to those who received agents under CP (oral sustained-release opioids, temazepam, and prochlorperazine). The object of the study was to investigate outcomes associated with newer drug therapy options as compared to older agents for the management of pain, insomnia, and nausea. A secondary goal is to compare symptom outcomes for patients receiving pharmaceutical care under CP and non-CP models. The study design was retrospective with a cohort. A total of 50 patients were randomly selected for each cohort of the pain and insomnia study arms. Only 45 patients prescribed oral ondansetron met inclusion criteria for the nausea group; 45 patients prescribed prochlorperazine were randomly selected as the comparator group. Patients were compared on their degree of response to the prescribed therapy. Response was classified as complete, partial, no improvement from baseline, worsened, or unknown. A complete response was defined as the symptom score improving to a 0 of 10, regardless of the previous value documented. A partial response was defined as any improvement in score that did not result in a 0 of 10. No improvement from baseline reflected a lack of overall change in score throughout the series of data points collected. A worsened response was any score found to be higher than the score documented at the time of dispense. The unknown category reflects any set of scores that had an "N/A " documented at the time of medication dispense or when documented for both attempts subsequent to dispensing the medication. A complete response was present in 14 of 50 (28 [corrected] percent) of the patients prescribed oral therapy [corrected] as compared with 12 of 50 (24 [corrected] percent) of those prescribed fentanyl [corrected] (p = .82). Responses defined as partial, no improvement over baseline, worsened, and unknown were also comparable between the two cohorts. A complete response was seen in 26 patients prescribed temazepam (52 percent), whereas only 11 (22 percent) of patients initially prescribed zolpidem achieved the same response (p = .0037). Both groups had a similar distribution of partial, no improvement over baseline, and worsened responses. For the nausea arm of the study, a difference was found in the number of complete responses, favoring prochlorperazine (22 of 45, 48.9 percent for prochlorperazine, 12 of 45, 26.7 percent for ondansetron, p = .0504), as well as an increased number of worse responses seen with ondansetron patients (p = .0513); however, neither difference was statistically significant. Newer pharmacotherapy options for the management of pain, insomnia, and nausea were not found to be superior when compared to older agents prescribed under CP.