What Predicts Health Care Transitions for Older Adults Following Introduction of LTSS?

Objective: To determine predictors of health care transitions (i.e., acute care service use, transfers from lower to higher intensity services) among older adults new to long-term services and supports [LTSS]. Method: 470 new LTSS recipients followed for 24 months. Multivariable Poisson regression modeling within a generalized estimating equation framework. Results: Being male, having multiple chronic conditions, lower self-reported physical health ratings and lower quality of life ratings at baseline were associated with increased risk of health care transitions. Older adults in assisted living communities and nursing homes experienced decreases in health care transitions over time, while LTSS recipients at home had no change in risk. LTSS recipients who had orders to receive therapy, compared with those who did not, had a lower relative risk of transitions over time. Discussion: Predictors of future health care transitions support the need for LTSS providers to anticipate and monitor this risk for LTSS recipients.

Adaptations of the evidence-based Transitional Care Model in the U.S.

Despite a growing body of evidence that adaptations of evidence-based interventions (EBI) are ubiquitous, few studies have examined the nature and rationale for modifications to the components of these interventions. The primary aim of this study was to describe and classify common local adaptations of the Transitional Care Model (TCM), an EBI comprised of 10 components that has been proven in multiple clinical trials to improve the care and outcomes of chronically ill older adults transitioning from hospitals to home. Guided by Stirman's System of Classifying Adaptations, 582 transitional care clinicians in health systems and community-based organizations throughout the U.S. completed a survey between September 2014 and January 2015; interviews were then conducted with a subset of survey respondents (N = 24) between April and December 2015. A total of 342 survey respondents (59%) reported implementation of the TCM in distinct organizations. Of this group, 96% reported a mean of 4.4 adaptations to the 10 TCM components (40%, one to three; 43%, four to six; and 17%, seven to nine). Nine of ten respondents (94%) reported contextual adaptations while content adaptations were less frequently reported (58%). The top three reported adaptations all related to context (i.e., delivering services from hospital to home, relying on advance practice nurses, and fostering care continuity); interviews clarified a diverse set of reasons for such modifications. Findings reinforce the need for investment in adaptation science and suggest hypotheses to guide rigorous examination of the association between adaptations of TCM components and desired outcomes.

Resident Vignettes for Assessing Care Quality in Nursing Homes.

OBJECTIVES: Validated process measures that correlate with patient outcomes are needed for research and quality improvement. DESIGN: Cross-sectional analysis within a cluster-randomized fall prevention study. SETTING: Nursing homes in North Carolina (n = 16). PARTICIPANTS: Nursing home staff (n = 541) and residents with 1 or more falls in 6 months (n = 597). MEASUREMENTS: Fall-prevention process measures in 4 categories derived from Assessing Care of Vulnerable Elders quality indicators were measured in 2 ways: (1) chart abstraction; and (2) staff responses to clinical vignettes of hypothetical residents at risk for falls. Recurrent fall rates (falls/resident/year) were measured. The proportion of the total variation in falls rates explained by the scores for each method (chart abstraction or vignette) was calculated using multilevel adjusted models. RESULTS: Chart and vignette measures of comorbidity management were moderately correlated (Pearson correlation coefficient 0.43), whereas other process measure categories had low or negative correlation between the 2 methods (psychoactive medication reduction 0.13, environmental modification -0.42, and exercise/rehabilitation -0.08). Measures of environmental modification and comorbidity management explained a moderate amount of the total variation in recurrent fall fates, vignettes (7%-10% variation explained) were superior to chart abstraction (2%-6% variation explained). Vignette responses from unlicensed staff (nurse aides and rehabilitation aides) explained more variance than registered nurses, licensed practical nurses, or other licensed staff in these categories. Process measures for psychoactive medication reduction and exercise/rehabilitation did not explain any of the variation in fall outcomes. Overall, vignette process measures explained 3.9% and chart abstraction measures explained 0% of the variation in fall outcomes. CONCLUSIONS: Clinical vignettes completed by nursing home staff had greater association with resident recurrent fall rates than traditional chart abstraction process measures.

Patient Participation in Communication about Treatment Decision-Making for Localized Prostate Cancer during Consultation Visits.

OBJECTIVES: To describe the communication behaviors of patients and physicians and patient participation in communication about treatment decision-making during consultation visits for localized prostate cancer (LPCa). METHODS: This is a secondary analysis of data from 52 men enrolled in the usual care control group of a randomized trial that focused on decision-making for newly diagnosed men with LPCa. We analyzed the patient-physician communication using the transcribed audio-recordings of real-time treatment consultations and a researcher-developed coding tool, including codes for communication behaviors (information giving, seeking, and clarifying/ verifying) and contents of clinical consultations (health histories, survival/mortality, treatment options, treatment impact, and treatment preferences). After qualitative content analysis, we categorized patient participation in communication about treatment-related clinical content, including "none" (content not discussed); "low" (patient listening only); "moderate" (patient providing information or asking questions); and "high" (patient providing information and asking questions). RESULTS: Physicians mainly provided information during treatment decision consultations and patients frequently were not active participants in communication. The participation of patients with low and moderate cancer risk typically was: 1) "moderate and high" in discussing health histories; 2) "low" in discussing survival/mortality; 3) "low and moderate" in discussing treatment options; 4) "none and low" in discussing treatment impacts; and 5) "low" in discussing treatment preferences. CONCLUSIONS: Findings suggest opportunities for increasing patient participation in communication about treatment decision-making for LPCa during clinical consultations.

Local interaction strategies and capacity for better care in nursing homes: a multiple case study.

BACKGROUND: To describe relationship patterns and management practices in nursing homes (NHs) that facilitate or pose barriers to better outcomes for residents and staff. METHODS: We conducted comparative, multiple-case studies in selected NHs (N = 4). Data were collected over six months from managers and staff (N = 406), using direct observations, interviews, and document reviews. Manifest content analysis was used to identify and explore patterns within and between cases. RESULTS: Participants described interaction strategies that they explained could either degrade or enhance their capacity to achieve better outcomes for residents; people in all job categories used these 'local interaction strategies'. We categorized these two sets of local interaction strategies as the 'common pattern' and the 'positive pattern' and summarize the results in two models of local interaction. CONCLUSIONS: The findings suggest the hypothesis that when staff members in NHs use the set of positive local interaction strategies, they promote inter-connections, information exchange, and diversity of cognitive schema in problem solving that, in turn, create the capacity for delivering better resident care. We propose that these positive local interaction strategies are a critical driver of care quality in NHs. Our hypothesis implies that, while staffing levels and skill mix are important factors for care quality, improvement would be difficult to achieve if staff members are not engaged with each other in these ways.

Transitions in care among older adults receiving long-term services and supports.

Recipients of long-term services and supports (LTSS) frequently transition between LTSS settings (e.g., assisted living facilities, nursing homes) and hospitals for acute changes in health. In this qualitative study, we analyzed findings from interviews with 57 recently hospitalized LTSS recipients and their family caregivers and described barriers and facilitators to high-quality care to support older adults through these care transitions. The themes that emerged strongly suggest that LTSS recipients and family caregivers do not receive needed information about the reasons for their transfers to hospitals, medical diagnoses, and planned treatments to address acute changes in health. Our findings indicate an urgent need for nurses and other health care team members to talk with LTSS recipients (and family caregivers) and ensure they are engaged and informed participants in care. We also found the need for research to test evidence-based transitional care for high-risk LTSS recipients and their family caregivers.