-
Long-Term Care and the Electronic Medical Record
The article by Dr Marilyn Rantz and colleagues on the impact of the Electronic Medical Record (EMR) in nursing homes is timely as health information technology (HIT) diffuses into the long-term care setting. The authors point out that implementation of bedside EMR in the nursing facility setting is not cost neutral and that increased costs are attributable to ongoing hardware and software expenses, continual technical support for the EMR, and constant staff orientation rather than to increased direct care staffing or increased staff turnover. They suggest that EMR use is associated with improved performance on selected quality indicators and that care can be enhanced even more with on-site consultation by nurses with graduate education in nursing and expertise in gerontology.
-
Directions & Connections
-
Contents
-
Author Guidelines
-
End-of-Life Care in a PACE Program: Respecting the Patient's Wishes While Supporting the Caregiver
Family caregivers play a key role at the end of life. They provide high levels of assistance and are often called on to make complex medical decisions. This is a period where there is potential for conflict, particularly when the patient lacks decision-making capacity. This case report describes how an interdisciplinary team helped an end-of-life caregiver to find closure while advocating for the patient's wishes to be carried out. The intervention of appropriate advanced care planning and frequent communication resulted in a positive outcome.
-
Flu in 15: A Novel 15-Minute Education Program to Promote Acceptance of the Influenza Vaccine Among Health Care Workers
Introduction and Rationale: A performance improvement project was undertaken to increase health care worker (HCW) influenza vaccination acceptance rates in the long-term care setting by using a novel 15-minute education intervention called the “Flu in 15.” As a core principle, we taught that more Americans die from complications of influenza than hepatitis B, yet there remains individual reluctance and barriers to achieve high acceptance rates of influenza vaccination among HCWs.Methods: During chance encounters we offered the Flu in 15 in-service to all HCWs at the Johns Hopkins Bayview Care Center including certified nursing assistants (also called geriatric nursing assistants), registered nurses, registered dieticians, environment staff, physical therapists, occupational therapists, speech therapists, respiratory therapists, social workers, and administrators. Of the 106 of 347 HCWs who participated in the Flu in 15 in-service, 58 were by chance encounters selected to be surveyed based on convenience. We surveyed 68 of 241 HCWs who did not attend the Flu in 15 in-service as a comparison.Results: Of the 58 participants who were asked if the in-service helped them understand why a flu vaccine is needed yearly, we found that 15% responded “tremendously,” 48% “a lot,” 26% “some,” 7% “a little,” and 2% “no.” We had 24% report that the program was effective in changing their behavior to accept the flu vaccination for the first time. We found that 49% responded that the in-service was effective in either changing their behavior to accept the flu vaccination for the first time or reaccept it if recently declined in previous years. With respect to motivation, 42% of the certified nursing assistants stated that the in-service made them think more about returning to school to get a license in some area of health care. Although not cause and effect, we observed an increase in the HCW acceptance rate of the influenza vaccine from 65% in 2006–2007 to 73% in 2007–2008. We noticed a decreased trend in patient deaths attributed to complications of influenza with 4 deaths in 2006–2007 and no deaths in 2007–2008.Conclusions: The Flu in 15 in-service promoted a better understanding of the importance of the influenza vaccine and demonstrated an associated increase in HCW acceptance of the flu vaccine. Although we cannot claim cause and effect, we noted a decrease in resident mortality in the intervention year compared with the prior year. Now that some medical centers require yearly influenza vaccines among HCWs, the education component remains relevant to provide reason behind the mandate.
-
General Information
-
Prevention of Venous Thromboembolism in Long-Term Care: Time for Action?
To the Editor: It was invigorating to read 2 articles in the March 2010 issue of the Journal pertinent to venous thromboembolism (VTE) in long-term care (LTC); one attempted to develop a risk stratification tool for VTE and immobility to assist clinicians in the care of residents in LTC, the second, an editorial, stated that although available research does not support specific pharmacological agents for patients at risk for VTE, this does not mean that risk reduction of any nature should not be used. The editorial comments are appropriate, and perhaps it is time that more attention is paid to the entity of VTE prevention in LTC.
-
Editorial Board
-
An Analysis of the Interactions Between Individual Comorbidities and Their Treatments—Implications for Guidelines and Polypharmacy
Background: With aging there is an increase in frailty and chronic disease leading to a potential increase in medication use. Most clinical trials have excluded old, frail individuals and have failed to take into account the effects of outcome interaction.Methods and Results: In this article we provide a mathematical model demonstrating that comorbidities, including old age, interact with therapies, reducing their effectiveness.Conclusion: These findings question the validity of single disease guidelines in old persons or in persons with multiple chronic diseases.
-
End-of-Life Care in the Nursing Home
“Death is still a fearful, frightening happening, and the fear of death is a universal fear even if we think we have mastered it on many levels”Elisabeth Kübler-Ross, MD. On Death and Dying
-
The Tongue, Oral Hygiene, and Prevention of Pneumonia in the Institutionalized Elderly
The dorsum of the tongue may support extensive biofilm formation. Biofilm adheres/colonizes mucosal surfaces, teeth, and foreign bodies including dentures. Biofilm is composed of layers of slow-growing often polymicrobial bacterial colonies embedded in carbohydrate-rich glycocalyx. Glycocalyx interferes with antibiotic penetration, and slow growth within the biofilm makes bacteria relatively resistant to growth-dependent antibiotic killing and the bacteria may be difficult to culture using standard techniques. Killing bacteria in biofilm requires antibiotic/disinfectant concentrations 10 to 1000 times those needed to kill free-living (planktonic) bacteria. Antibiotic dosing based on conventional culture-based sensitivity data derived from free-living bacteria should not be expected to be effective against bacteria embedded in a biofilm. A biofilm site may function like a fortress, launching attacks of free-floating bacteria that can seed contiguous areas and produce infection. In general, the most effective way to treat biofilm is by mechanical debridement.
-
End-of-Life Care in Nursing Homes: The Importance of CNA Staff Communication
Objective: Staff communication has been shown to influence overall nursing home (NH) performance. However, no empirical studies have focused specifically on the impact of CNA communication on end-of-life (EOL) care processes. This study examines the relationship between CNA communication and nursing home performance in EOL care processes.Design: Secondary data analysis of 2 NH surveys conducted in 2006–2007.Setting: One hundred seven nursing homes in New York State.Participants: Participants were 2636 CNAs and 107 directors of nursing (DON).Measurements: The measures of EOL care processes—EOL assessment and care delivery (5-point Likert scale scores)—were obtained from survey responses provided by 107 DONs. The measure of CNA communication was derived from survey responses obtained from 2636 CNAs. Other independent variables included staff education, hospice use intensity, staffing ratio, staff-resident ethnic overlap index, facility religious affiliation, and ownership.Methods: The reliability and validity of the measures of EOL care processes and CNA communication were tested in the current study sample. Multivariate linear regression models with probability weights were used. The analysis was conducted at the facility level.Results: We found better CNA communication to be significantly associated with better EOL assessment (P = .043) and care delivery (P = .098). Two potentially modifiable factors—staff education and hospice use intensity—were associated with NHs' performance in EOL care processes. Facilities with greater ethnic overlap between staff and residents demonstrated better EOL assessment (P = .051) and care delivery scores (P = .029).Conclusion: Better CNA communication was associated with better performance in EOL care processes. Our findings provide specific insights for NH leaders striving to improve EOL care processes and ultimately the quality of care for dying residents.
-
The Paradigm of Life Extension
The certainty of aging and death is a major concern of humans with a consequent endless search for methods to contract aging's effects and delay death as long as possible. Charlatans may take advantage of the wish of people to live longer, proposing miraculous, unproven, and profitable antiaging products. Conversely, key advances in the understanding of the mechanism(s) behind the biology of aging and the increase in human life expectancy during the 20th century worldwide, make it possible that postponing natural death may indeed be plausible. Prolongation of life expectancy with disability is an empty prize. Interventions that prolong not only life span but also health span involve lifestyle strategies, as well as diagnosis of diseases at an early stage and appropriate use of advanced medical care.
-
Psychoactive Drugs as Risk Factors for Functional Decline Among Noninstitutionalized Dependent Elderly People
Objective: To analyze the association between use of psychoactive drugs and functional decline among noninstitutionalized dependent elderly people.Design: Cross-sectional study.Participants: A total of 161 community-dwelling elderly people with functional dependence.Measurements: The data were analyzed using logistic regression with adjustment for age models. The independent variables were the following: use of psychoactive drugs (antidepressants, anticonvulsants, anxiolytics, antipsychotics, or sedatives), cognitive decline (Mini-Mental State Examination score<20), and daytime sleepiness. The dependent variables were the following: dependence relating to activities of daily living (ADLs) and dependence relating to instrumental activities of daily living (IADLs).Results: Data on 131 individuals of mean age 77.5 years were analyzed. Psychoactive drugs were used by 33.6%. Age-adjusted univariate analysis showed associations between psychoactive drug use and both ADLs and IADLs. However, in multivariate analysis, only ADLs showed a significant association with psychoactive drug use, independent of cognitive decline and daytime sleepiness (OR=2.67; 95% CI: 1.04–6.85; P=.04).Conclusions: There is a greater risk of impairment of ADLs among noninstitutionalized elderly people using psychoactive drugs. These results indicate the need for rational use of medication groups among this population with greater risk of functional impairment.
-
Cost, Staffing and Quality Impact of Bedside Electronic Medical Record (EMR) in Nursing Homes
Objective: There is growing political pressure for nursing homes to implement the electronic medical record (EMR) but there is little evidence of its impact on resident care. The purpose of this study was to test the unique and combined contributions of EMR at the bedside and on-site clinical consultation by gerontological expert nurses on cost, staffing, and quality of care in nursing homes.Methods: Eighteen nursing facilities in 3 states participated in a 4-group 24-month comparison: Group 1 implemented bedside EMR, used nurse consultation; Group 2 implemented bedside EMR only; Group 3 used nurse consultation only; Group 4 neither. Intervention sites (Groups 1 and 2) received substantial, partial financial support from CMS to implement EMR. Costs and staffing were measured from Medicaid cost reports, and staff retention from primary data collection; resident outcomes were measured by MDS-based quality indicators and quality measures.Results: Total costs increased in both intervention groups that implemented technology; staffing and staff retention remained constant. Improvement trends were detected in resident outcomes of ADLs, range of motion, and high-risk pressure sores for both intervention groups but not in comparison groups.Discussion: Implementation of bedside EMR is not cost neutral. There were increased total costs for all intervention facilities. These costs were not a result of increased direct care staffing or increased staff turnover.Conclusions: Nursing home leaders and policy makers need to be aware of on-going hardware and software costs as well as costs of continual technical support for the EMR and constant staff orientation to use the system. EMR can contribute to the quality of nursing home care and can be enhanced by on-site consultation by nurses with graduate education in nursing and expertise in gerontology.
-
The Complexity of Implementing Culture Change Practices in Nursing Homes
Purpose: The culture change (CC) movement aims to transform the traditional nursing home (NH) that is institutional in design with hierarchical management structure into a homelike environment that empowers residents and frontline staff. This study examines differences in adoption of CC practices according to a NH's self-reported extent of CC implementation and its duration of CC adoption. Furthermore, it examines differences in adoption by whether a CC practice is considered less versus more complex, using complexity theory as the theoretical framework for this classification.Design and Methods: Using data from a 2007 Commonwealth-funded study, we analyzed a national sample of 291 US nursing homes that identified as being “for the most part” or “completely” CC facilities for “1 to 3 years” or “3+ years.” Also, using a complexity theory framework, we ranked 16 practices commonly associated with CC as low, moderately, or highly complex based on level of agreement needed to actuate the process (number of parties involved) and the certainty of intended outcomes. We then examined the prevalence of CC-associated practices in relation to their complexity and the extent and duration of a NH's CC adoption.Results: We found practices ranked as less complex were implemented more frequently in NHs with both shorter and longer durations of CC adoption. However, more complex CC practices were more prevalent among NHs reporting “complete” adoption for 3+ years versus 1 to 3 years. This was not observed in NHs reporting having CC “for the most part.”Conclusions/Implications: Less complex practices may be more economical and easier to implement. These early successes may result in sufficient momentum so that more complex change can follow. A nursing home that more completely embraces the culture change movement may be more likely to attempt these complex changes.
-
A Synopsis of Phosphate Disorders in the Nursing Home
Elderly patients are at an increased risk of developing both hypophosphatemia and hyperphosphatemia. Renal insufficiency predisposes elderly patients to elevated serum concentrations of phosphate. On the other hand, poor dietary intake and loss of phosphorus in the urine can lead to deficiency states. It is well documented that hyperphosphatemia is correlated with an increase in morbidity and mortality as a result of vascular calcification. This article reviews the etiology, pathophysiology, symptoms, and treatment of hypophosphatemia and hyperphosphatemia.
-
Reflections of Medical Students Regarding the Care of Geriatric Patients in the Continuing Care Retirement Community
Objective: There is growing recognition that students training to provide care for older adults need to be trained in all settings where older adults receive care, including retirement communities. The purpose of this study was to allow medical students to see older patients living and participating in activities in the long-term care setting and examine the effects that this experience had on the students.Methods: Medical students were assigned to write an open-ended reflection paper about a community health experience. Forty-eight students wrote their reflection papers on their experience in a continuing care retirement facility. Three independent reviewers examined these reflective narratives for common themes.Results: After analyzing the students' narratives, 6 themes emerged: (1) The initial exposure to dementia, (2) confronting death and dying, (3) the diversity of care and services for the elderly, (4) the cost of care for the elderly, (5) seniors can lead active lives if given the opportunity, and (6) the rewards of the health care team-patient relationship.Conclusion: The students' reflective narratives provide valuable insights into how medical students view retirement communities, the physician's role in the care of geriatric patients, the importance of interdisciplinary health care, the cost of care for elderly patients, and their views on dementia and dying. Through this experience, students received valuable lessons about taking care of older adults in the community that their interactions with patients in the hospital and ambulatory medical offices had not provided.
-
Beyond CMS Quality Measure Adjustments: Identifying Key Resident and Nursing Home Facility Factors Associated With Quality Measures
Objective: This quality improvement (QI) project was initiated to understand what differentiates nursing homes (NHs) that perform well on publicly reported Centers for Medicare and Medicaid Services (CMS) Quality Measures (QMs). The intent was to assist NH staff to direct QI efforts to positively impact QM rates. A key step was to determine if any resident or facility characteristics might account for some of the variability in QMs of high-risk pressure ulcers (HRPrUs), low-risk incontinence (LRI), and Activities of Daily Living (ADL) decline, beyond those already adjusted for by CMS.Design: Observational Study.Setting and Participants: The setting was 147 NHs across 12 northeast states owned by 1 for-profit, multifacility organization in 2006 and 2007.Intervention: NoneMeasurements: Minimum Data Set (MDS), patient admission information, facility staffing metrics, and CMS QM data.Results: Relationships of facility and resident characteristics to QMs were evaluated using regression analyses performed separately for 2006 and 2007. Among factors found consistently to be significant (P ≤ .05) for HRPrUs were percent admissions with pressure ulcers and percent residents with end-stage disease. For LRI, there was significant association with percent residents readmitted and percent incontinent of bladder on admission. ADL decline showed significant associations with licensed nurse turnover and facilities in specific states.Conclusion: Several resident and facility factors were associated with QMs beyond those previously adjusted for by CMS. With introduction of MDS 3.0, we suggest further exploration of resident and facility factors identified in this study.
|
