Exploring Hospital Transfers for Long-Stay Nursing Home Residents With End-Stage Renal Disease.

BACKGROUND: Nursing home residents with end-stage renal disease (ESRD) are an understudied, yet growing population within nursing homes. PURPOSE: To describe hospital transfers for nursing home residents diagnosed with ESRD and receiving hemodialysis. METHODS: Data were analyzed for residents with ESRD transferred to the hospital between October 2016 and September 2020 (n = 219). Descriptive statistics, bivariate analyses, logistic regression, and content analysis were used for analysis. RESULTS: Clinical factors associated with transfers included abnormal vitals, altered mental state, and pain. Other factors included lack of care planning and advance directives, provider communication, resident/family preferences, missing/refusing dialysis, and facility resources. The odds of an observation/emergency department only visit was 2.02 times larger when transferred from the dialysis clinic. CONCLUSIONS: Advance care planning and coordinated care between nursing home and dialysis clinics are needed along with proactive planning when residents miss dialysis or experience a condition change at the dialysis clinic.

A Call to Address RN, Social Work, and Advanced Practice Registered Nurses in Nursing Homes: Solutions From the Missouri Quality Initiative.

BACKGROUND: US nursing homes (NHs) have struggled to overcome a historic pandemic that laid bare limitations in the number and clinical expertise of NH staff. PROBLEM: For nurse staffing, current regulations require only one registered nurse (RN) on duty 8 consecutive hours per day, 7 days per week, and one RN on call when a licensed practical/vocational nurse is on duty. There is no requirement for a degreed or licensed social worker, and advanced practice registered nurses (APRNs) in NHs cannot bill for services. APPROACH: It is time to establish regulation that mandates a 24-hour, 7-day-a-week, on-site RN presence at a minimum requirement of 1 hour per resident-day that is adjusted upward for greater resident acuity and complexity. Skilled social workers are needed to improve the quality of care, and barriers for APRN billing for services in NHs need to be removed. CONCLUSIONS: Coupling enhanced RN and social work requirements with access to APRNs can support staff and residents in NHs.

Testing Re-Engineered Discharge Program Implementation Strategies in SNFs.

The Re-Engineered Discharge (RED) program, designed for hospitals, is being trialed in skilled nursing facilities (SNFs) with promising results. This paper reports on the quantitative results of a multimethod study testing two different RED program implementation strategies in SNFs. A pretest-posttest design was used to compare utilization outcomes of two different RED implementation strategies (Enhanced and Standard) and overall group differences in four Midwestern SNFs. In the Standard group there were higher odds of being readmitted in the pre-intervention versus post-intervention period. After adjusting coefficients using Poisson regression, in the pre-intervention period the adjusted number of rehospitalizations for the Standard group was 45% higher at 30 days, 50% higher at 60 days (p = .01), and 39% higher at 180 days (p = .001). SNF RED may be a useful program to reduce rehospitalizations after discharge. Benefit of SNF RED is dependent on degree of adoption of the intervention.

Adapting Project RED to Skilled Nursing Facilities.

This article describes our recommendation for adapting hospital-based RED (Reengineered Discharge) processes to skilled nursing facilities (SNFs). Using focus groups, the SNFs' discharge processes were assessed twice additionally, research staff then recorded field notes documenting discussions about facility discharge processes as they related to RED processes. Data were systematically analyzed using thematic analysis to identify recommendations for adapting RED to the SNF setting including (a) rapidly identifying, involving, and preparing family/caregivers to implement a patient focused SNF discharge plan; (b) reconnecting patients quickly to primary care providers; and (c) educating patients at discharge about their target health condition, medications, and impact of changes on other chronic health needs. Limited SNF staff capacity and corporate-level policies limited adoption of some key RED components. Transitional care processes such as RED, developed to avoid discharge problems, can be adapted for SNFs to improve their discharges.

Reengineering Skilled Nursing Facility Discharge: Analysis of Reengineered Discharge Implementation.

BACKGROUND: There is a need to adopt evidence-based approaches to discharge planning in the skilled nursing facility (SNF) short stay population. PURPOSE: This article describes implementation of the Reengineered Discharge (RED) process in SNFs and makes recommendations for its future implementation. METHODS: The methods included a pre- and postanalysis of an 18-month RED implementation with a contemporaneous comparison of 4 Midwestern SNFs randomly assigned to 2 different RED implementation strategies. The Standard facilities received less implementation than Enhanced facilities. RESULTS: Standard SNFs made more improvements and were more satisfied with the improved process than Enhanced SNFs. Field notes revealed that corporate willingness to make process changes impacted the Standard group's capacity for change; both groups were heavily influenced by external forces, and turnover was an impediment to RED implementation. CONCLUSION: This research revealed that discharge processes are similar across settings and that evidence-based programs such as RED can be adapted to the SNF setting.

Analyzing Hospital Transfers Using INTERACT Acute Care Transfer Tools: Lessons from MOQI.

OBJECTIVES: We explored the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of Interventions to Reduce Acute Care Transfers (INTERACT) Acute Transfer Tools (ACTs) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement (QI) Initiative (MOQI). DESIGN: Cross-sectional descriptive study of 3996 ACTs for 32.5 calendar months from 2014 to 2016. Univariate analyses examined differences between potentially avoidable vs unavoidable transfers. Multivariate logistic regression analysis of candidate factors identified those contributing to avoidable transfers. SETTING: Sixteen nursing homes (NHs), ranging from 120 to 321 beds, in urban, metro, and rural communities within 80 miles of a large midwestern city. PARTICIPANTS: A total of 5168 residents with a median age of 82 years. MEASUREMENTS: Data from 3946 MOQI-adapted ACTs. RESULTS: A total of 54% of hospital transfers were identified as avoidable. QI opportunities related to avoidable transfers were earlier detection of new signs/symptoms (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.61-3.42; P < .001); discussions of resident/family preference (OR = 2.12; 95% CI = 1.38-3.25; P < .001); advance directive/hospice care (OR = 2.25; 95% CI = 1.33-3.82; P = .003); better communication about condition (OR = 4.93; 95% CI = 3.17-7.68; P < .001); and condition could have been managed in the NH (OR = 16.63; 95% CI = 10.9-25.37; P < .001). Three factors related to unavoidable transfers were bleeding (OR = .59; 95% CI = .46-.77; P < .001), nausea/vomiting (OR = .7; 95% CI = .54-.91; P = .007), and resident/family preference for hospitalization (OR = .79; 95% CI = .68-.93; P = .003). CONCLUSION: Reducing avoidable hospital transfers in NHs requires challenging assumptions about what is avoidable so QI efforts can be directed to improving NH capacity to manage ill residents. The APRNs served as the onsite coaches in the use and adoption of INTERACT. Changes in health policy would provide a revenue stream to support APRN presence in NH, a role that is critical to improving resident outcomes by increasing staff capacity to identify illness and guide system change. J Am Geriatr Soc 67:1953-1959, 2019.

Medication reconciliation in nursing homes: thematic differences between RN and LPN staff.

The purpose of this qualitative descriptive study was to describe medication reconciliation practices in nursing homes with a specific focus on nursing staff involvement in the process. The study was conducted in eight Midwestern nursing homes and included 46 onsite observations of resident transfers to the nursing home. Informal interviews of nursing staff performing medication reconciliation were conducted during each observation. Findings suggest nursing home nursing staff, including both RN and licensed practical nurse (LPN) staff, were primarily responsible for performing medication reconciliation; however, these staff often varied in how they processed resident transfer information to identify medication order discrepancies. Patterns of differences were found related to their perceptions about medication reconciliation, as well as their actions when performing the process. RN staff were more often focused on resident safety and putting the "big picture" together, whereas LPN staff were more often focused on the administrative assignment and "completing the task."

Evaluation of a leadership development academy for RNs in long-term care.

While evidence strongly suggests that nursing leadership impacts nursing home care, most nursing home (NH) RN leaders have not had the benefit of a structured educational program that emphasizes the skills necessary to effectively lead in today's complex NH environment. The University of Missouri Leadership Development Academy for RNs in Long-Term Care was developed as an innovative educational program to prepare NH RNs to become effective leaders. Early data evaluating the leadership academy suggest that participation in a structured leadership program over an extended period of time may enhance the leadership behaviors of NH RNs.

Technology implementation and workarounds in the nursing home.

OBJECTIVE: This study sought to explore the relationship of workarounds related to the implementation of an electronic medication administration record and medication safety practices in five Midwestern nursing homes. DESIGN: As a part of a larger study, this qualitative evaluation was conducted to identify workarounds associated with the implementation of an electronic medication administration record. Data were collected using multimethods including direct observation, process mapping, key informant interviews, and review of field notes from medication safety team meetings. MEASUREMENTS: Open and axial coding techniques were used to identify and categorize types of workarounds in relation to work flow blocks. RESULTS: Workarounds presented in two distinct patterns, those related to work flow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology. Workarounds such as safety alert overrides and shortcuts to documentation resulted from first-order problem solving of immediate blocks. Nursing home staff as individuals frequently used first-order problem solving instead of the more sophisticated second-order problem solving approach used by the medication safety team. CONCLUSION: This study provides important practical examples of how nursing home staff work around work flow blocks encountered during the implementation of technology. Understanding these workarounds as a means of first-order problem solving is an important consideration to understanding risk to medication safety.

Nursing home quality and pressure ulcer prevention and management practices.

OBJECTIVES: To measure pressure ulcer quality indicator (QI) scores and to describe the self-reported skin integrity assessment, pressure ulcer risk assessment, and pressure ulcer prevention and treatment practices in long-term care facilities (LTCFs). DESIGN: Retrospective analysis of a large data set and comparative survey. SETTING: LTCFs in Missouri. PARTICIPANTS: Three hundred sixty-two LTCFs participated in the survey. Three hundred twenty-one facilities had pressure ulcer QI scores between April 1 and September 30, 1999. MEASUREMENTS: Pressure ulcer QI scores, Pressure Ulcer Prevention & Treatment Practices Survey. RESULTS: The mean+/-standard deviation pressure ulcer QI score was 10.9+/-6.2%, with a risk-adjusted score of 15.7+/-8.9% for high-risk residents and 3.1+/-3.6% for low-risk residents. Minimizing head-of-bed elevation to less than 30 degrees was used by fewer than 20% of facilities. More than 40% of facilities used a risk assessment tool that was not evidence based. Fewer than 13% of facilities used the Agency for Health Care Policy and Research pressure ulcer prevention and treatment guidelines. No relationship was found between the number of prevention strategies (P=.892) or the number of treatment strategies (P=.921) and the pressure ulcer QI scores. CONCLUSION: Valid and reliable pressure ulcer risk assessment tools are seriously underused. Evidence-based pressure ulcer prevention and treatment guidelines appear to be rarely implemented. This study provides a basis for developing educational and quality improvement programs and future research related to pressure ulcer prevention and treatment in LTCFs.