Direct Care Workers’ Recommendations for Training and Continuing Education Training of direct care workers (DCWs) varies depending upon the setting in which they work and the state in which they are trained. Evidence points to the importance of adequate training as critical to DCW job satisfaction and reduction in turnover. Several approaches have been taken to enhance the training of DCWs with the objective that as job satisfaction increases, the quality of care provided to consumers will also be enhanced. Based on a sample of 644 DCWs across the nursing home, assisted living, and home health settings, we share DCWs’ perceptions and recommendations for better training and continuing education. Read more
Training Direct Care Workers for Person-Centered Care The purpose of this article is threefold: to review challenges faced by paraprofessional workers in the long term care industry; to set forth principles of person-centered care as an approach to improve their working conditions and the quality of care they provide; and to focus on their recommendations for better education and training as a fruitful path to worker empowerment and advancement. The article is based on results obtained from over ten years of research by the authors on nursing assistants in nursing homes. It also draws on preliminary findings from a survey of 251 nurse assistants that is part of a larger study of 651 direct care workers in 49 nursing homes, assisted living facilities and home care agencies in northeast Ohio. The latter study is part of the national initiative to build a stronger direct care workforce, titled Better Jobs = Better Care and launched by the Institute for Future of Aging Services, with support from the Robert Wood Johnson Foundation and Atlantic Philanthropies (www.bjbc.org). Read more
Outcomes for Patients with Dementia from the Cleveland Alzheimer’s Managed Care Demonstration This investigation evaluates effects of care consultation delivered within a partnership between a managed health care system and Alzheimer’s Association chapter. Care consultation is a multi-component telephone intervention in which Association staff work with patients and caregivers to identify personal strengths and resources within the family, health plan, and community. The primary hypothesis is that care consultation will decrease utilization of managed care services and improve psychosocial outcomes. A secondary modifying-effects hypothesis posits benefits will be greater for patients with more severe memory impairment. The sample is composed of managed care patients whose medical records indicate a diagnosis of dementia or memory loss. Patients were randomly assigned to an intervention group, which was offered care consultation in addition to usual managed care services, or to a control group, which was offered only usual managed care services. Data come from two in-person interviews with patients, and medical and administrative records. Results supporting the primary hypothesis show intervention group patients feel less embarrassed and isolated because of their memory problems and report less difficulty coping. Findings consistent with the modifying-effects hypothesis show intervention group patients with more severe impairment have fewer physician visits, are less likely to have an emergency department visit or hospital admission, are more satisfied with managed care services, and have decreased depression and strain. Read more
The Cleveland Alzheimer’s Managed Care Demonstration Outcomes After 12 Months of Implementation Read more
Case Finding and Referral Model for Emergency Department Elders A Randomized Clinical Trial Study objective: Elderly emergency department patients have complex medical needs and limited social support. A transitional model of care adapted from hospitals was tested for its effectiveness in the ED in reducing subsequent service use. Methods: A randomized clinical trial was conducted at 2 urban, academically affiliated hospitals. Participants were 650 community-residing individuals 65 years or older who were discharged home after an ED visit. Main outcomes were service use rates, defined as repeat ED visits, hospitalizations, or nursing home admissions, and health care costs at 30 and 120 days. Intervention consisted of comprehensive geriatric assessment in the ED by an advanced practice nurse and subsequent referral to a community or social agency, primary care provider, and/or geriatric clinic for unmet health, social, and medical needs. Control group participants received usual and customary ED care. Results: The intervention had no effect on overall service use rates at 30 or 120 days. However, the intervention was effective in lowering nursing home admissions at 30 days (0.7% versus 3%; odds ratio 0.21; 95% confidence interval [CI] 0.05 to 0.99) and in increasing patient satisfaction with ED discharge care (3.41 versus 3.03; mean difference 0.37; 95% CI 0.13 to 0.62). The intervention was more effective for high-risk than low-risk elders. Conclusion: An ED-based transitional model of care reduced subsequent nursing home admissions but did not decrease overall service use for older ED patients. Further studies are needed to determine the best models of care for this setting and for at-risk patients. Read more
A Brief Risk-Stratification Tool to Predict Repeat Emergency Department Visits and Hospitalizations in Older Patients Discharged From the Emergency De Objectives: To evaluate the predictive ability of a simple six-item triage risk screening tool (TRST) to identify elder emergency department (ED) patients at risk for ED revisits, hospitalization, or nursing home (NH) placement within 30 and 120 days following ED discharge. Methods: Prospective cohort study of 650 community-dwelling elders (age 65 years or older) presenting to two urban academic EDs. Subjects were prospectively evaluated with a simple six- item ED nursing TRST. Participants were interviewed 30 and 120 days post-ED index visit and the utilization of EDs, hospitals, or NHs was recorded. Main outcome measurement was the ability of the TRST to predict the composite endpoint of subsequent ED use, hospital admission, or NH admission at 30 and 120 days. Individual outcomes of ED use, hospitalization, and NH admissions were also examined. Results: Increasing cumulative TRST scores were associated with significant trends for ED use, hospital admission, and composite outcome at both 30 and 120 days (p < 0.0001 for all, except 30-day ED use, p = 0.002). A simple, unweighted five-item TRST (‘‘lives alone’’ item removed after logistic regression modeling) with a cut-off score of 2 was the most parsimonious model for predicting composite outcome (AUC = 0.64) and hospitalization at 30 days (AUC = 0.72). Patients defined as high-risk by the TRST (score ≥ 2) were significantly more likely to require subsequent ED use (RR = 1.7; 95% CI = 1.2 to 2.3), hospital admission (RR = 3.3; 95% CI = 2.2 to 5.1), or the composite outcome (RR = 1.9; 95% CI = 1.7 to 2.9) at both 30 days and 120 days than the low-risk cohort. Conclusions: Older ED patients with two or more risk factors on a simple triage screening tool were found to be at significantly increased risk for subsequent ED use, hospitalization, and nursing home admission. Read more
Establishing a Case-Finding and Referral System for At-Risk Older Individuals in the Emergency Department Setting The SIGNET Model Older emergency department (ED) patients have complex medical, social, and physical problems. We established a program at four ED sites to improve case finding of at‐risk older adults and provide comprehensive assessment in the ED setting with formal linkage to community agencies. The objectives of the program are to (1) improve case finding of at‐risk older ED patients, (2) improve care planning and referral for those returning home, and (3) create a coordinated network of existing medical and community services. The four sites are a 1,000‐bed teaching center, a 700‐bed county teaching hospital, a 400‐bed community hospital, and a health maintenance organization (HMO) ED site. Ten community agencies also participated in the study: four agencies associated with the hospital/HMO sites, two nonprofit private agencies, and four public agencies. Case finding is done using a simple screening assessment completed by the primary or triage nurse. A geriatric clinical nurse specialist (GCNS) further assesses those considered at risk. Patients with unmet medical, social, or health needs are referred to their primary physicians or to outpatient geriatric evaluation and management centers and to community agencies. After 18 months, the program has been successfully implemented at all four sites. Primary nurses screened over 70% (n = 28,437) of all older ED patients, GCNSs conducted 3,757 comprehensive assessments, participating agency referrals increased sixfold, and few patients refused the GCNS assessment or subsequent referral services. Thus, case finding and community linkage programs for at‐risk older adults are feasible in the ED setting. Read more
