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
Understanding Consumer Satisfaction in Continuing Care Retirement Communities This study focused on examining consumer satisfaction with the care and services provided to elders residing in continuing care retirement communities (CCRCs). Telephone interviews were conducted with a total of 137 respondents residing in both Independent Living (IL) facilities and Assisted Living (AL) in eight different CCRCs. Of these, 116 were IL residents and 21 were AL residents. Nursing home residents were excluded because Ohio was implementing mandatory nursing home family and resident satisfaction surveys. Residents on average were, 83 years old, primarily Caucasian and the majority were widowed. Three-fourths of them were female and over half had some college or a college degree. In addition, 41 family members of the 137 residents were also interviewed. The family members were on average, 56 years old, Caucasian, and the majority were female children. Both residents and their family members said that the primary reason for choosing a particular CCRC was that it was close to family members. As to why residents had to move to a CCRC, both families and residents said that it was because of physical health problems of either the resident or his/her spouse. In fact, residents and families cited more similar than dissimilar answers regarding why they chose a particular CCRC, reasons for moving from the resident’s previous residence, and the importance of certain types of services, although the order of preferences differed slightly. Information from Administrators of all eight CCRCs was collected to examine the range of services that facilities offered and their price structure and these varied greatly between and within facilities. Monthly rent in the IL facilities ranged from $579.00 to $3,332. In the AL facilities, single occupancy monthly rent ranged from $2,040 to $5,710. Examining Satisfaction with Care and Services An instrument examining resident satisfaction care was tested for its reliability and validity. It proved to be a highly reliable and valid instrument that had six major domains/factors: Admission; Appearance of the Facility; Food and Dining Services; Maintenance of Facility; Management, and, Safety and Security. An underlying measure of Resident Overall Satisfaction was also identified comprising of 48 items that contained items from the above-mentioned six domains. A similar instrument was used to test family satisfaction with care and services. With respect to examining what predicted Resident Overall Satisfaction, a multiple regression was run and two areas proved to be significant predictors of Resident Overall Satisfaction: the positive nature of resident and staff interactions and the residents’ perception of what services are important to them. Similar analyses on Family Overall Satisfaction could not be conducted because of the small sample size of the family dataset (family n =41). An examination of the open-ended comments by the residents and families revealed that both had positive and negative comments to make. They complained of things like the physical design, the environment and its surroundings, management issues and meals and dining services. The topmost things that residents praised the CCRCs for were the freedom to live their own lifestyle, the pleasant and friendly atmosphere and feeling that they had a safety net. The topmost things that families praised were the surroundings and the environment (even though some criticized this), the positive interactions with staff and the services/conveniences. Implications for Practice The findings from the quantitative analyses and the comments suggest that understanding the consumer perspective is critical to providing appropriate services. We suggest that Administrators encourage positive interaction and communication between consumers and staff to provide care that is appropriate, considered important and enhances consumer satisfaction. Limitations of the Study The limitations of the study include the fact that it was conducted only in one State with a small sample of eight CCRCs. Further, more IL than AL residents were interviewed. The study needs to be replicated with a larger sample size, and in more states, with equal numbers of residents in IL, AL and nursing facilities to enhance the generalizability of the findings. Read more
Developing a Satisfaction Survey for Families of Ohio’s Nursing Home Residents Purpose: The purpose of this project was to develop a reliable and valid family satisfaction instrument for use in Ohio’s nursing homes. Design and Methods: Investigators worked with an advisory council to develop the survey. Purposive sampling techniques were largely used to select 12 small, medium, and large for-profit and proprietary facilities in one large county for the pretest. A total of 239 families who were ‘‘most involved’’ in their relative’s care completed an instrument with 97 satisfaction items. Results: Factor analyses identified nine factors that explained 59.44% of the variance in satisfaction. Investigator judgment modified some factors and developed scales. The scales had good internal reliability (a = .76 and above, except for one), test–retest reliability ranged from .49 to .88, and differences between families of short- and long-stay residents were in expected directions. A final instrument with 62 satisfaction and 17 background items was recommended for statewide implementation. Implications: Findings from the project can be used to further refine the instrument and protocols for use with larger populations in other states and by the federal government. Read more
Family Satisfation with Nursing Home Care for Relatives with Dementia Families of residents with dementia from five nursing homes were interviewed to assess if they believed improvements were needed in the care provided to their relatives. Quality of care was assessed in a variety of service and staff areas that factored into two domains of care: (a) environmental and administrative services and (b) direct care. Families who perceived significant improvements were needed in environmental and administrative services had more negative interactions with staff, perceived nurse assistants as being insensitive, and helped relatives with more activities of daily living (ADL). With respect to direct care, families perceived significant improvements were needed when they had more negative interactions with staff and helped their relatives with more ADL. These findings highlight the importance of promoting positive family-staff interactions, providing direct care in a sensitive manner, and exploring the reasons why families get involved in ADL to improve family satisfaction with care. 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
Evaluating the Ohio Elder Abuse and Domestic Violence in Late Life Screening Tool and Referral Protocol This article describes the evaluation processes employed in the Ohio project to develop and test screening tools and referral protocols on elder abuse and domestic violence. Three focus groups and a Roundtable of experts were utilized to develop the materials in the first year. In the second year, a formal quantitative evaluation that involved 160 practitioners in Ohio was implemented to review the materials and to use them with clients. Findings from the quantitative evaluation were incorporated to make changes that led to a final document that was much simpler, less lengthy, and more relevant to beginning practitioners. Read more
