Policy Research Challenges in Comparing Care Models for Dual-Eligible Beneficiaries.

Providing affordable, high-quality care for the 10 million persons who are dual-eligible beneficiaries of Medicare and Medicaid is an ongoing health-care policy challenge in the United States. However, the workforce and the care provided to dual-eligible beneficiaries are understudied. The purpose of this article is to provide a narrative of the challenges and lessons learned from an exploratory study in the use of clinical and administrative data to compare the workforce of two care models that deliver home- and community-based services to dual-eligible beneficiaries. The research challenges that the study team encountered were as follows: (a) comparing different care models, (b) standardizing data across care models, and (c) comparing patterns of health-care utilization. The methods used to meet these challenges included expert opinion to classify data and summative content analysis to compare and count data. Using descriptive statistics, a summary comparison of the two care models suggested that the coordinated care model workforce provided significantly greater hours of care per recipient than the integrated care model workforce. This likely represented the coordinated care model's focus on providing in-home services for one recipient, whereas the integrated care model focused on providing services in a day center with group activities. The lesson learned from this exploratory study is the need for standardized quality measures across home- and community-based services agencies to determine the workforce that best meets the needs of dual-eligible beneficiaries.

Using Ethical Frameworks in Times of Transition and Uncertainty.

Health care policy is never easy and always fraught with concerns about quality, access, and cost. Currently, uncertainty abounds regarding new federal and state policies on the horizon for older adult care and quality. Empirics undergird most policy-making decisions regarding risk/benefit, cost, and knowing the best action to put in place for the best results. However, in times of great change in policy direction and political viewpoints, empirical knowledge must be combined with ethical knowledge for planning and implementation. Ethical and moral judgment has long been a mainstay of nursing practice and organizational leadership. Using ethical knowledge as a framework will be a crucial guide for nurses and health professionals and society to prioritize action and decisions in policy. [Journal of Gerontological Nursing, 43(3), 8-12.].

A Case Exemplar for National Policy Leadership: Expanding Program of All-Inclusive Care for the Elderly (PACE).

In November 2015, President Obama signed the Program of All-Inclusive Care for the Elderly (PACE) Innovation Act, which expands a proven model of care to serve high-cost and high-need populations. Specifically, the law provides the Centers for Medicare & Medicaid Services with the authority to waive Medicaid requirements that could not be waived without additional statutory authority. Those requirements include the age of the beneficiary to be served and nursing home eligibility as a condition for PACE enrollment. The law also allows providers and other entities who are not current PACE providers the opportunity to become PACE providers and serve a predominately dually eligible population that has high needs and high cost through a coordinated, integrated model. The current article describes the impact of nursing on the legislation and policy that has shaped the evolution of the PACE program for more than 40 years. [Journal of Gerontological Nursing, 42(3), 9-14.].

Looking Ahead After 50 Years of Medicare.

Fifty years of Medicare have led to enormous improvements in care of older adults in the United States. Policy changes in Medicare and Medicaid have undergirded the care of older adults and the workforce and professional development of nurses and advanced practice nurses. Reflecting on the decades of change in these 50 years and the context in which these changes occurred can prepare health care providers for future strategies to address needs of the rapidly growing older adult population.

Inflammation, functional status, and weight loss during recovery from cardiac surgery in older adults: a pilot study.

OBJECTIVE: To determine the nutritional, inflammatory, and functional aspects of unintentional weight loss after cardiac surgery that warrant further investigation. RESEARCH METHODS AND PROCEDURES: Twenty community-dwelling adults > 65 years old undergoing cardiac surgery (coronary artery bypass graft [CABG] or CABG + valve) were recruited for this prospective longitudinal (preoperative and 4-6 weeks postdischarge) pilot study. Anthropometrics (weight, standing height, and mid-arm and calf circumference), nutritional status (Mini-Nutritional Assessment™ [MNA]), appetite, physical performance (timed chair stand), muscle strength (hand grip) and functional status (basic and instrumental activities of daily living), and inflammatory markers (plasma leptin, ghrelin, interleukin [IL]-6, high-sensitivity[hs] C-reactive protein, and serum albumin and prealbumin) were measured. RESULTS: Participants who completed the study (n = 11 males, n = 3 females) had a mean age 70.21 ± 4.02 years. Of these, 12 lost 3.66 ± 1.44 kg over the study period. Weight, BMI, activities of daily living, and leptin decreased over time (p < .05). IL-6 increased over time (p < .05). Ghrelin, hs-CRP, and timed chair stand increased over time in those who underwent combined procedures (p < .05). Grip strength decreased in those who developed complications (p = .004). Complications, readmission status, and lowered grip strength were found in those with low preoperative MNA scores (p < .05). CONCLUSION: After cardiac surgery, postdischarge weight loss occurs during a continued inflammatory response accompanied by decreased physical functioning and may not be a positive outcome. The impacts of weight loss, functional impairment, and inflammation during recovery on disability and frailty warrant further study.

The bear and the canyon: toward an understanding of personal leadership.

Using Carper's fundamental patterns of knowing in nursing as a framework, the author reflects upon and intertwines experiences as a nurse leader and experiences in nature that called for resilience and courage.

Is it time for a public health nursing approach to aging?

Following the enactment of Medicare in 1965, access to health care for older adults in the United States improved. At the same time, nurse researchers and policy leaders developed individual and family-centered care interventions and programs that led to improvements in quality of health and life. In the next 20 to 30 years, U.S. and global projections of an expanding aging cohort with potential increases in health care needs, coupled with continued nursing shortage projections, present challenges and opportunities to enhance gerontological nursing's approach to aging care. Invigorating a public health nursing focus on the needs of a population of older adults could enhance nursing's ability to create policy and programs of care that promote quality of life for older adults and their families. Nurses using public health approaches can lead and support social policies regarding the physical environment and daily life circumstances that contribute to health equity. Heightened attention to competencies in community/public health nursing education and promotion of public health nursing careers will be important policy considerations as we face the looming increase in a population of older adults throughout the world.

Recruitment and retention strategies among older African American women enrolled in an exercise study at a PACE program.

PURPOSE: This study examined employment of specific recruitment and retention strategies in a study evaluating outcomes of a moderate activity exercise program for older African American women with functional impairments attending a Program for All-Inclusive Care of Elders (PACE). DESIGN AND METHODS: Recruitment and retention strategies focused on (1) partnership between researchers and participants, (2) partnership between researchers and clinicians, (3) overcoming administrative issues, and (4) reducing burden on clinicians and participants. The exercise protocol consisted of strength and endurance activity 2 to 3 times per week for 16 weeks. RESULTS: Fifty-two African American women (61.2% of target) were enrolled and 37 (71.2%) completed the 16-week exercise program. Fifteen did not complete due to non-descript reasons and/or preference for other program activities (n = 11), medical problems (n = 2), or need for physical therapy (n = 2). IMPLICATIONS: Success in recruitment and retention included use of a PACE program, hiring an advanced practice nurse to improve retention, and integration with site activities and sustaining the exercise program at the site. Challenges for recruitment and retention remain to engage older, frail adults in exercise as a life habit, and availability of time and place to do so.

Developing a financial framework for academic service partnerships: models of the United States and Europe.

PURPOSE: Academic service partnerships (ASPs) are structured linkages between academe and service which have demonstrated higher levels of innovation. In the absence of descriptions in the literature on financial frameworks to support ASPs, the purpose of this paper is to present the supporting financial frameworks of a Swiss and a U.S. ASP. METHODS: This paper used a case study approach. RESULTS: Two frameworks are presented. The U.S. model presented consists of a variety of ASPs, all linked to the School of Nursing of the University of Pennsylvania. The structural integration and governance system is elucidated. Each ASP has its own source of revenue or grant support with the goal to be fiscally in the black. Joint appointments are used as an instrument to realize these ASPs. The Swiss ASP entails a detailed description of the financial framework of one ASP between the Institute of Nursing Science at the University of Basel and the Inselspital Bern University Hospital. Balance in the partnership, in terms of both benefit and cost between both partners, was a main principle that guided the development of the financial framework and the translation of the ASP in budgetary terms. The model builds on a number of assumptions and provides the partnership management within a simple framework for monitoring and evaluation of the progress of the partnership. CONCLUSIONS: In operationalizing an ASP, careful budgetary planning should be an integral part of the preparation and evaluation of the collaboration. The proposed Swiss and U.S. financial frameworks allow doing so. CLINICAL RELEVANCE: Outcomes of care can be improved with strong nursing service and academic partnerships. Sustaining such partnerships requires attention to financial and contractual arrangements.

Innovative collaborations: a case study for academic owned nursing practice.

PURPOSE: Academic service partnerships are critical for schools of nursing to maintain credibility regarding their missions of education, research, service, and practice. METHODS: In this paper, we describe a case study of a ten year program, the Living Independently For Elders (LIFE) Program at the University of Pennsylvania School of Nursing that has provided community-based long-term care to high-risk older adults. FINDINGS: Quality of care and financial outcomes were met with nurse faculty engagement, administrative commitment, and integration of business practices. CONCLUSIONS: As a result, high risk older adults receive care in their communities rather than nursing homes, and the school- owned and -operated program is a nationally recognized innovative nursing model of care. CLINICAL RELEVANCE: Strategies are described that can be used globally as more schools of nursing embrace and strengthen service partnerships.

Detectable changes in physical performance measures in elderly African Americans.

BACKGROUND: African American older adults have higher rates of self-reported disability and lower physical performance scores compared with white older adults. Measures of physical performance are used to predict future morbidity and to determine the effect of exercise. Characteristics of performance measures are not known for African American older adults. OBJECTIVE: The purpose of this study was to estimate the standard error of measurement (SEM) and minimal detectable change (MDC) for the Short Physical Performance Battery (SPPB), Timed "Up & Go" Test (TUG) time, free gait speed, fast gait speed, and Six-Minute Walk Test (6MWT) distance in frail African American adults. DESIGN: This observational measurement study used a test-retest design. METHODS: Individuals were tested 2 times over a 1-week period. Demographic data collected included height, weight, number of medications, assistive device use, and Mini-Mental Status Examination (MMSE) scores. Participants then completed the 5 physical performance tests. RESULTS: Fifty-two participants (mean age=78 years) completed the study. The average MMSE score was 25 points, and the average body mass index was 29.4 kg/m(2). On average, participants took 7 medications, and the majority used assistive devices. Intraclass correlation coefficients (ICC [2,1]) were greater than .90, except for the SPPB score (ICC=.81). The SEMs were 1.2 points for the SPPB, 1.7 seconds for the TUG, 0.08 m/s for free gait speed, 0.09 m/s for fast gait speed, and 28 m for 6MWT distance. The MDC values were 2.9 points for the SPPB, 4 seconds for the TUG, 0.19 m/s for free gait speed, 0.21 m/s for fast gait speed, and 65 m for 6MWT distance. LIMITATIONS: The entire sample was from an urban area. CONCLUSIONS: The SEMs were similar to previously reported values and can be used when working with African American and white older adults. Estimates of MDC were calculated to assist in clinical interpretation.

Lessons learned from advanced practice nursing payment.

For more than 25 years, advanced practice nurses have been incrementally included as a part of the health care financing structure. Following physician payment revisions at the federal level, advanced practice nurses were overtly recognized as Medicare providers and have participated in the establishment of current procedural terminology codes and the subsequent relative work values associated with payment. Success in this regard has been the result of business, political, and policy savvy that has important lessons for moving forward in any health care restructuring for both nurses and advanced practice nurses. Principles of valuing nurse work, time, and intensity in the Resource-Based Relative Value Scale are discussed with implications for future opportunities of measuring nursing work and any potential relationship to quality outcomes of care.

Exercise among urban-dwelling older adults at risk for health disparities.

This study assessed factors that contribute to exercise in older adults at risk for health disparities living in a predominantly African American urban community. A local health database was used to gain an understanding of these factors, which then could be used to develop programs to improve health within a specific urban community. The sample included 112 participants (mean age = 81); the majority were women and African American. Participants were more likely to exercise if not insured by Medicaid, compared with those who did receive Medicaid. Adults with two or more limitations in instrumental activities of daily living (IADLs) were less likely to exercise. Among those who exercised, those with two or more limitations in IADLs were more likely to exercise less than adults with no such limitations, and adults with high blood pressure were more likely to exercise less than those without high blood pressure. The findings of this study will help generate discussion in both the community and outreach programs to invigorate exercise among older adults at risk for health disparities.

Delirium in older patients in surgical intensive care units.

PURPOSE: To examine the frequency and course of delirium in older adults admitted to a surgical intensive care unit (SICU). DESIGN AND METHODS: Prospective, observational cohort study of 114 English-speaking participants and their surrogates, aged 65 and older, admitted to an SICU, and managed by a surgical critical care service. Chart reviews and surrogate interviews were conducted within 24 hours of SICU admission to collect information regarding evidence of dementia using the short form of the Informant Questionnaire on Cognitive Decline in the Elderly. Participants were also screened for delirium daily throughout their hospitalization with either the Confusion Assessment Method-ICU (CAM-ICU) while in the SICU or the CAM while on medical/surgical units. RESULTS: In this population of older adults, 18.4% had evidence of dementia on admission to the SICU. Few older adults (2.6%) were admitted to the hospital with evidence of preexisting delirium, but 28.3% developed delirium in the SICU and 22.7% during the post-SICU period. A total of 52 of 114 (45.6%) participants were delirious sometime during their hospital stay or 24 hours before hospital admission. Episodes of deep sedation and nonarousal were uncommon, occurring in only 9.7% of the sample. CONCLUSIONS: Older adults admitted to SICUs were at high risk for developing delirium during hospitalization. Further research is needed to elucidate the risk factors for, and outcomes of, delirium in this uniquely vulnerable population.

Directions for the development of nursing knowledge.

Nurses and health care increasingly are embracing and guided by achievements and challenges of evidence-based practice and reflective practice. Nursing science advances have positioned nurses to move forward in the development of science. New directions for nursing knowledge need to emerge in several ways including the development of interdisciplinary knowledge, emphasis on the nursing care process, creation of new work-force patterns, and development of economic theories of nursing practice.

Art therapy: Using the creative process for healing and hope among African American older adults.

This article provides an introduction to the field of art therapy and the potential it can offer to address the emotional needs of the frail elderly. Two case studies are discussed, and examples of artwork are provided. The case studies and artwork were created under the guidance of an art therapist at a Program of All-Inclusive Care for the Elderly (PACE) site in an urban African American community. This article explores how art making addresses the specific developmental tasks of the elderly in a culturally competent manner. Included are practical considerations in the choice of art media and directives for working with elderly clients, as well as resources for further information on the use of art in therapy.

Functional outcomes for older adults with cognitive impairment in a comprehensive outpatient rehabilitation facility.

The purpose of the study was to examine functional outcomes of a nurse-managed, community-based Comprehensive Outpatient Rehabilitation Facility (CORF) for frail older adults and to compare the outcomes between two groups: older adults with cognitive impairment and those with intact cognition. A retrospective cohort design using healthcare record abstraction was used for the study. Two hundred and one older adults who were admitted to the CORF from the end of 1997 to early 1999 were included in the study. Data were abstracted from healthcare records, including clinician-generated Mini-Mental State Examination, Geriatric Depression Scale, and Functional Independence Measure scores from the healthcare records and investigator-constructed measures of functional gain, rehabilitation efficiency, days of service, and discharge location. Multivariate regression analyses were performed to compare rehabilitation outcomes between the two groups. Regardless of cognitive status, all subjects improved significantly in their levels of functional dependence through participating in this outpatient rehabilitation program (P<.001). Subjects with cognitive impairment exhibited more functional dependence at baseline and discharge than did their cognitively intact counterparts. Nevertheless, there was no difference between the two groups in functional gain (P=.63), rehabilitation efficiency (P=.66), days of service (P=.83), or discharge location (P=.69). Therefore, despite their greater degree of functional dependence on admission, older adults with cognitive impairment benefited from this CORF without requiring more days of service and should thus be referred for rehabilitation services.