Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning.

Improvements in health care are slow, in part because doctors and nurses lack skills in quality improvement, patient safety, and interprofessional teamwork. This article reports on the Retooling for Quality and Safety initiative of the Josiah Macy Jr. Foundation and the Institute for Healthcare Improvement, which sought to integrate improvement and patient safety into medical and nursing school curricula. In one academic year, 2009-10, the initiative supported new learning activities (87 percent of which were interprofessional, involving both medical and nursing students) in classrooms, simulation centers, and clinical care settings that involved 1,374 student encounters at six universities. The work generated insights-described in this article-into which learning goals require interprofessional education; how to create clinically based improvement learning for all students; and how to demonstrate the effects on students' behavior, organizational practice, and benefits to patients. A commonly encountered limiting factor for the programs was the lack of a critical mass of clinically based faculty members who were ready to teach about the improvement of care. What's more, the paucity of robust evaluation strategies for such programs suggests a future research agenda that deserves to be funded.

Automated technology to speed recognition of signs of illness in older adults.

Our team has developed a technological innovation that detects changes in health status that indicate impending acute illness or exacerbation of chronic illness before usual assessment methods or self-reports of illness. We successfully used this information in a 1-year prospective study to alert health care providers so they could readily assess the situation and initiate early treatment to improve functional independence. Intervention participants showed significant improvements (as compared with the control group) for the Short Physical Performance Battery gait speed score at Quarter 3 (p = 0.03), hand grip-left at Quarter 2 (p = 0.02), hand grip-right at Quarter 4 (p = 0.05), and the GAITRite functional ambulation profile score at Quarter 2 (p = 0.05). Technological methods such as these could be widely adopted in older adult housing, long-term care settings, and in private homes where older adults wish to remain independent for as long as possible.

Passive sensor technology interface to assess elder activity in independent living.

BACKGROUND: The effectiveness of clinical information systems to improve nursing and patient outcomes depends on human factors, including system usability, organizational workflow, and user satisfaction. OBJECTIVE: The aim of this study was to examine to what extent residents, family members, and clinicians find a sensor data interface used to monitor elder activity levels usable and useful in an independent living setting. METHODS: Three independent expert reviewers conducted an initial heuristic evaluation. Subsequently, 20 end users (5 residents, 5 family members, 5 registered nurses, and 5 physicians) participated in the evaluation. During the evaluation, each participant was asked to complete three scenarios taken from three residents. Morae recorder software was used to capture data during the user interactions. RESULTS: The heuristic evaluation resulted in 26 recommendations for interface improvement; these were classified under the headings content, aesthetic appeal, navigation, and architecture, which were derived from heuristic results. Total time for elderly residents to complete scenarios was much greater than for other users. Family members spent more time than clinicians but less time than residents did to complete scenarios. Elder residents and family members had difficulty interpreting clinical data and graphs, experienced information overload, and did not understand terminology. All users found the sensor data interface useful for identifying changing resident activities. DISCUSSION: Older adult users have special needs that should be addressed when designing clinical interfaces for them, especially information as important as health information. Evaluating human factors during user interactions with clinical information systems should be a requirement before implementation.

Evaluation of aging in place model with home care services and registered nurse care coordination in senior housing.

A state-sponsored evaluation of aging in place (AIP) as an alternative to assisted living and nursing home has been underway in Missouri. Cost, physical, and mental health assessment data reveal the cost-effectiveness and positive health measures of AIP. Findings of the first four years of the AIP evaluation of two long-term care settings in Missouri with registered nurse care coordination are compared with national data for traditional long-term care. The combined care and housing cost for any resident who received care services beyond base services of AIP and who qualified for nursing home care has never approached or exceeded the cost of nursing home care at either location. Both mental health and physical health measures indicate the health restoration and independence effectiveness of the AIP model for long-term care.

Improving nurse care coordination with technology.

Technology offers potential solutions to the pending crisis of healthcare for older adults, while healthcare workers are in short supply. Technology can enable remote monitoring of individuals and early detection of potential problems, so that early interventions can help older adults remain as healthy and independent as possible. Research is under way with passive monitoring technology in senior housing that is finding patterns in the data that can enhance nurse care coordination through early illness detection. With early detection, interventions can be more effective and reduce hospitalization and other healthcare expenses. Case studies are presented, and implications are discussed.

Smart Carpet: Developing a sensor system to detect falls and summon assistance.

Cognitive deficits experienced by older adults with dementia limit use of wearable devices (necklaces or bracelets) that summon assistance after the older adult falls. To use these wearable devices, older adults must choose to wear them, remember how to use them, and be conscious after falling. Devices such as the Smart Carpet substitute pre-programmed or automatic functions for functions requiring deliberation and decision. After development of a Smart Carpet prototype, 11 volunteers participated in tests to measure sensitivity of sensors embedded in the Smart Carpet. The embedded sensors were not perceptible to the volunteers as they walked across the Smart Carpet and successfully detected gait characteristics. Findings confirmed the feasibility of fall detection. Measurements obtained of gait characteristics will be used in development of more advanced versions of the Smart Carpet.

Developing a comprehensive electronic health record to enhance nursing care coordination, use of technology, and research.

As in acute care, use of health information technology in long-term care holds promise for increased efficiency, better accuracy, reduced costs, and improved outcomes. A comprehensive electronic health record (EHR), which encompasses all health care measures that clinicians want to use-both standard health care assessments and those acquired through emerging technology-is the key to improved, efficient clinical decision making. New technologies using sensors to passively monitor older adults at home are being developed and are commercially available. However, integrating the clinical information systems with passive monitoring data so that clinical decision making is enhanced and patient records are complete is challenging. Researchers at the University of Missouri (MU) are developing a comprehensive EHR to: (a) enhance nursing care coordination at TigerPlace, independent senior housing that helps residents age in place; (b) integrate clinical data and data from new technology; and (c) advance technology and clinical research.

Helping nursing homes "at risk" for quality problems: a statewide evaluation.

The Quality Improvement Program for Missouri (QIPMO), a state school of nursing project to improve quality of care and resident outcomes in nursing homes, has a special focus to help nursing homes identified as "at risk" for quality concerns. In fiscal year 2006, 92 of 492 Medicaid-certified facilities were identified as "at risk" using quality indicators (QIs) derived from Minimum Data Set (MDS) data. Sixty of the 92 facilities accepted offered on-site clinical consultations by gerontological expert nurses with graduate nursing education. Content of consultations include quality improvement, MDS, care planning, evidence-based practice, and effective teamwork. The 60 "at-risk" facilities improved scores 4%-41% for 5 QIs: pressure ulcers (overall and high risk), weight loss, bedfast residents, and falls; other facilities in the state did not. Estimated cost savings (based on prior cost research) for 444 residents who avoided developing these clinical problems in participating "at-risk" facilities was more than $1.5 million for fiscal year 2006. These are similar to estimated savings of $1.6 million for fiscal year 2005 when 439 residents in "at-risk" facilities avoided clinical problems. Estimated savings exceed the total program cost by more than $1 million annually. QI improvements demonstrate the clinical effectiveness of on-site clinical consultation by gerontological expert nurses with graduate nursing education.

Uncovering differences among health professions trainees exposed to an interprofessional patient safety curriculum.

In response to the Institute of Medicine challenge to improve patient safety and quality of care, an office directing patient safety/quality of care at an academic medical center and faculty from health professions schools collaborated on design, delivery, and evaluation of an interprofessional student curriculum on patient safety, quality, and teamwork. Annually for 6 years, second-year medical students, senior baccalaureate nursing students, second-year masters in health administration students, and junior baccalaureate respiratory therapy students participated. A pre-/postsurvey assessing students' attitudes about quality, safety, and teamwork was developed and modified to reflect course revisions. Survey items were grouped into 1 of the 6 subscales: human fallibility, disclosure, teamwork/communication, error reporting, systems of care, and curricular time spent with other professionals. At pretest, there were significant professional group differences in all the 6 subscales. At completion, differences in 4 subscales were resolved with the exception of human fallibility (P < .001) and curricular time spent together (P < .001). Interprofessional exercises within our curriculum mediated most differences among student groups. As more interprofessional curricular experiences are designed, examining baseline group differences is essential to optimize learning outcomes.

Linguistic Summarization of Video for Fall Detection Using Voxel Person and Fuzzy Logic.

In this paper, we present a method for recognizing human activity from linguistic summarizations of temporal fuzzy inference curves representing the states of a three-dimensional object called voxel person. A hierarchy of fuzzy logic is used, where the output from each level is summarized and fed into the next level. We present a two level model for fall detection. The first level infers the states of the person at each image. The second level operates on linguistic summarizations of voxel person's states and inference regarding activity is performed. The rules used for fall detection were designed under the supervision of nurses to ensure that they reflect the manner in which elders perform these activities. The proposed framework is extremely flexible. Rules can be modified, added, or removed, allowing for per-resident customization based on knowledge about their cognitive and physical ability.

Field testing, refinement, and psychometric evaluation of a new measure of quality of care for assisted living.

Field test results are reported for the Observable Indicators of Nursing Home Care Quality Instrument-Assisted Living Version, an instrument designed to measure the quality of care in assisted living facilities after a brief 30-minute walk-through. The OIQ-AL was tested in 207 assisted-living facilities in two states using classical test theory, generalizability theory, and exploratory factor analysis. The 34-item scale has a coherent six-factor structure that conceptually describes the multidimensional concept of care quality in assisted living. The six factors can be logically clustered into process (Homelike and Caring, 21 items) and structure (Access and Choice; Lighting; Plants and Pets; Outdoor Spaces) subscales and for a total quality score. Classical test theory results indicate most subscales and the total quality score from the OIQ-AL have acceptable interrater, test-retest, and strong internal consistency reliabilities. Generalizability theory analyses reveal that dependability of scores from the instrument are strong, particularly by including a second observer who conducts a site visit and independently completes an instrument, or by a single observer conducting two site visits and completing instruments during each visit. Scoring guidelines based on the total sample of observations (N = 358) help guide those who want to use the measure to interpret both subscale and total scores. Content validity was supported by two expert panels of people experienced in the assisted-living field, and a content validity index calculated for the first version of the scale is high (3.43 on a four-point scale). The OIQ-AL gives reliable and valid scores for researchers, and may be useful for consumers, providers, and others interested in measuring quality of care in assisted-living facilities.

TigerPlace, A State-Academic-Private Project to Revolutionize Traditional Long-Term Care.

The Aging in Place Project at the University of Missouri (MU) required legislation in 1999 and 2001 to be fully realized. An innovative home health agency was initiated by the Sinclair School of Nursing specifically to help older adults age in place in the environment of their choice. In 2004, an innovative independent living environment was built and is operated by a private long term care company, as a special facility where residents can truly age in place and never fear being moved to a traditional nursing home unless they choose to do so. With care provided by the home care agency with registered nurse care coordination services, residents receive preventative and early illness recognition assistance that have markedly improved their lives. Evaluation of aging in place reveal registered nurse care coordination improves outcomes of cognition, depression, activities of daily living, incontinence, pain, and shortness of breath as well as delaying or preventing nursing home placement. Links with MU students, faculty, and nearly every school or college on campus enrich the lives of the students and residents of the housing environment. Research projects are encouraged and residents who choose to participate are enjoying helping with developing cutting technology to help other seniors age in place.

Sensor systems for monitoring functional status in assisted living facility residents.

This article provides results of an expert review of data displays for a sensor system used to monitor functional abilities in older adults. The research took place at TigerPlace, an assisted living facility where the sensor system is currently being evaluated. A checklist of 16 heuristic criteria was used to evaluate the sensor data displays, with consideration to the users of the system: residents, their families, and health care providers. Results of this expert review indicate that flexibility and efficiency of use, help and documentation, navigation, and skills were not well developed in the sensor data displays. Conversely, sensor data displays were rated highly for their aesthetic value and the ample visual contrast on the main display components. Through the use of a sensor system, new ways of detecting functional decline in elderly residents of assisted living facilities can be accomplished.

Early detection of health changes in older adults.

We have placed a network of sensors in a residential home for the elderly who are aging in place. Restlessness data is displayed as graph of event counts detected by sensors over some time interval, typically a day. This data is related to the actual activities as recorded by the resident. We show two cases of elderly individuals. In both cases the individuals underwent surgery. The restlessness indicators showed changes in patterns that were related to those events. Analyzing the data even at this level we gain increased confidence that technology will be a welcome addition as the population ages and require increasing care.

Facilitating interdisciplinary design specification of "smart" homes for aging in place.

"Smart homes" are defined as residences equipped with sensors and other advanced technology applications that enhance residents' independence and can be used for aging in place. The objective of this study is to determine design specifications for smart residences as defined by professional groups involved both in care delivery to senior citizens and development of devices and technologies to support aging. We assessed the importance of specific devices and sensors and their advantages and disadvantages as perceived by the interdisciplinary expert team. This work lays the ground for the implementation of smart home residencies and confirms that only an interdisciplinary design approach can address all the technical, clinical and human factors related challenges associated with home-based technologies that support aging. Our findings indicate that the use of adaptive technology that can be installed in the home environment has the potential to not only support but also empower individual senior users.