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Objectives: To explore patterns of change in nursing home (NH) residents� activities of daily living (ADLs), particularly surrounding acute hospital stays. Design: Longitudinal study using Medicare and Minimum Data Set (MDS) assessments. Setting: National sample of long-stay NH residents. Participants: NH residents who were hospitalized for the seven most-common inpatient diagnoses (N = 40,128). Each hospital admission was at least 90 days after any prior hospitalization and had at least two preceding MDS assessments. Measurements: The MDS ADL long-form score, a simple sum of seven self-care variables coded from 0 (independent) to 4 (totally dependent) was used to indicate resident ADL function. Scores ranged from 0 to 28, with higher scores indicating greater impairment. A linear mixed model describing ADL trajectories was jointly estimated with time-to-event models for mortality and hospital readmission. Results: Before hospitalization, the most common trajectory was stable (53.7%), with 27.5% of residents worsening and 18.8% improving. ADL function after hospital discharge was most often characterized as stable (43.1%) or worsening (39.2%). Mortality (20.3%) was higher for those with worsening prehospital ADL function (28.9%) than for those with stable (19.1%) or improving (11.3%) trajectories. Hospital diagnosis was associated with amount of ADL worsening and rate of subsequent ADL change. Most residents with the best initial function continued to worsen after hospital discharge. Cognitive impairment was associated with poorer ADL function and accelerated worsening of ADLs. Conclusion: For many long-stay NH residents, substantial and sustained ADL worsening accompanies acute hospitalization, so acute hospitalization presents an opportunity to revisit care goals; the results of the current study can help inform decision-making.

Objectives The objective of this paper was to assess the relative impact of different types of stimuli on agitated behaviors of nursing home residents with dementia.

OBJECTIVES: To describe nursing home (NH) staff delivery of oral liquid nutritional supplements to residents with an order to receive supplementation. DESIGN: Descriptive. SETTING: Six skilled NHs. PARTICIPANTS: One hundred thirty-two long-stay residents. MEASUREMENTS: Research staff conducted direct observations for 2 days during and between meals and documented NH staff delivery of supplements, amount consumed (fluid ounces), and amount of assistance (minutes) provided by staff to encourage consumption. RESULTS: Eighty-eight percent had an order to receive a supplement one to three times daily (mode=3); 12% had an order to receive a supplement four to six times daily. Fewer than 10% received the supplement consistent with their orders during the 2 observation days. On average, NH staff provided a supplement less than once per participant per day during or between meals. When a supplement was provided, residents consumed an average±standard deviation of 4.91±2.19 fluid ounces during meals with 6.16±7.46 minutes of staff assistance and 3.98±2.60 fluid ounces between meals with less than 1 minute of staff assistance. Participants with orders that specified time of delivery received the supplement at a significantly higher frequency between meals. CONCLUSION: Oral liquid nutritional supplements are not provided consistent with orders in NH practice. Staff spends little time promoting supplement consumption during or between meals. The specificity of the order related to time of delivery may influence when and how often supplements are provided to residents.

OBJECTIVES: To describe the staff time requirements to provide feeding assistance to nursing home residents who require three different types of assistance to improve oral food and fluid intake (social stimulation, verbal cuing, or both; physical guidance; or full physical assistance) and to determine whether physically dependent residents require more staff time, as defined in the national Resource Utilization Group System (RUGS) used for reimbursement. DESIGN: Descriptive. SETTING: Six skilled nursing homes. PARTICIPANTS: Ninety-one long-stay residents with low oral intake who responded to improved feeding assistance. MEASURMENTS: Research staff conducted direct observations of usual nursing home care for 2 consecutive days (total of six meals) to measure oral food and fluid consumption (total percentage eaten) and staff time spent providing assistance (minutes and seconds). Research staff then implemented a standardized graduated-assistance protocol on 2 separate days (total of six meals) that enhanced residents' oral food and fluid intake. RESULTS: Staff time to provide feeding assistance that improved food and fluid consumption was comparable across different levels of eating dependency. Across all levels, residents required an average of 35 to 40 minutes of staff time per meal; thus, residents who needed only supervision and verbal cuing required just as much time as those who were physically dependent on staff for eating. CONCLUSION: The current RUGS system used for reimbursement likely underestimates the staff time required to provide feeding assistance care that improves oral intake.

Objectives: To pilot and assess the role of videoconferencing in clinicians' medical decision-making and their interactions with nursing home residents (NHRs). Design: Paired virtual and bedside examinations. Face-to-face (FTF) examination of NHRs by off-site clinicians immediately followed videoconferencing between the same clinician–NHR pair. Setting: A 240-bed, county-managed, urban nursing home. Participants: NHRs (n=35) and clinicians (n=3) receiving or providing routine care between 2002 and 2003. Measurements: Orders generated by clinicians, clinicians' ratings of videoconferencing, and coded review of video encounters. After both examinations, clinicians rated the encounters and generated orders necessary for NHRs. Orders were categorized and counted according to timing (before or after the FTF visit). Clinician–NHR interactions were assessed using coding videos with a 31-item instrument. Results: For 71% of the encounters, clinicians stated that videoconferencing facilitated their assessment. Difficulties included sound quality (19%) and participants' familiarity with videoconferencing (7%). Although NHRs were alert in 50% of encounters, 62% of alert NHRs did not indicate understanding of the recommended treatment. Conclusion: FTF examination was superior for most assessments, but videoconferencing was judged to be valuable, especially for wound care. Even when NHRs were alert, informed medical decision-making by NHRs with their clinicians was limited. Enhancing videoconferencing quality and providing more training about informed decision-making using videoconferencing might improve the effectiveness of the technology.

RESUME: Contexte : l'objectif de cette etude de cohorte prospective etait de determiner la relation entre la survenue d'infections et la dependance fonctionnelle chez des residents d'etablissements de long sejour durant une periode de 6 mois. Population et methode : les patients inclus (1324 residents) etaient âges de 65 ans et plus (âge moyen 85.7 ans, 76.6% de femmes), etaient des residents de 39 EMS du canton de Vaud. Au baseline, des donnees demographiques, medicales, concernant les facteurs de risque et protecteurs des infections ont ete recoltees. Au cours du suivi de 6 mois, les infirmieres des EMS ont documente la survenue de symptomes et signes d'infection en utilisant les criteres developpes specifiquement par l'APIC pour les etablissements de long sejour. Les mesures du status fonctionnel ont ete evaluees au baseline, a 3 mois et a 6 mois. Deux outcomes differents ont ete utilises : a) le declin fonctionnel defini comme le deces ou une diminution des capacites fonctionnelles au suivi, b) le status fonctionnel mesure par une echelle standardisee. Resultats : a la fin du suivi, la mortalite etait de 14.6%, similaire pour les residents avec et sans infection (16.2% versus 13.1%, P .11). Durant les 2 periodes de suivi de 3 mois, les sujets ayant presente une ou plusieurs infections avaient des odds de declin fonctionnel plus eleves, y compris apres ajustement pour les caracteristiques demographiques, medicales et fonctionnelles du baseline, ainsi que la survenue de nouvelles maladies (odds ratio ajustes (OR) = 1.6, intervalle de confiance a 95% (IC) = 1.2-2.2, P = .002 et OR = 1.5, 95% IC= 1.1-2.0, P= .008, respectivement). Compares aux residents non infectes, les odds de declin fonctionnel augmentaient significativement et graduellement chez ceux ayant eu une, respectivement 2 infections ou plus. L'analyse predisant le score fonctionnel (restreinte aux sujets ayant survecu) a donne des resultats similaires. Finalement, une analyse de survie predisant le temps jusqu'a la premiere infection a confirme une augmentation progressive de la probabilite d'infection chez les sujets avec dependance fonctionnelle moderee, respectivement severe, compares aux sujets independants a la ligne de base. Conclusion : chez les residents de long sejour, les infections sont a la fois cause et consequence de la dependance fonctionnelle. Des etudes futures devraient etre entreprises pour investiguer si des programmes de prevention des infections peuvent egalement contribuer a prevenir le declin fonctionnel, un facteur important pour la qualite de vie de ces residents. ABSTRACT: Objectives: To determine the relationship between infections and functional impairment in nursing home residents. Design: Prospective cohort study (follow-up period, 6 months). Setting: Thirty-nine nursing homes in western Switzerland. Participants: A total of 1,324 residents aged 65 and older (mean age 85.7; 76.6% female) who agreed to participate, or their proxies, by oral informed consent. Measurements: Functional status measured every 3 months. Two different outcomes were used: (a) functional decline defined as death or decreased function at follow-up and (b) functional status score using a standardized measure. Results: At the end of follow-up, mortality was 14.6%, not different for those with and without infection (16.2% vs 13.1%, P= .11) During both 3-month periods, subjects with infection had higher odds of functional decline, even after adjustment for baseline characteristics and occurrence of a new illness (adjusted odds ratio (AOR) = 1.6, 95% confidence interval (CI) = 1.2-2.2, P = .002, and AOR 1.5, 95% CI 1.1-2.0, P .008, respectively). The odds of decline increased in a stepwise fashion in patients with zero, one, and two or more infections. The analyses predicting functional status score (restricted to subjects who survived) gave similar results. A survival analysis predicting time to first infection confirmed a stepwise greater likelihood of infection in subjects -with moderate and severe impairment at baseline than in subjects with no or mild functional impairment at baseline. Conclusion: Infections appear to be both a cause and a consequence of functional impairment in nursing home residents. Further studies should be undertaken to investigate whether effective infection control programs can also contribute to preventing functional decline, an important component of these residents' quality of life.

OBJECTIVE: To characterize the use of formal primary care programs by health maintenance organizations (HMOs) for their members who are long-stay residents of nursing homes. DESIGN: Using mail survey techniques, 34 Medicare risk-contracting HMOs with the largest Medicare beneficiary enrollments were asked to complete a written questionnaire. HMOs were asked how they evaluate care in nursing home settings and whether they operate a formal primary care program for members who are long-stay nursing home residents. Those reporting they had programs were asked about the program features, participation in the program, roles performed by clinical practitioners, and clinical caseloads. Surveys were completed by 21 (61.8%) of the HMOs. PARTICIPANTS: HMO management personnel who know the primary care programs the HMOs operate in affiliated nursing homes. MEASUREMENTS: Descriptive summaries of the HMOs' responses to the survey questions were generated. For HMOs with primary care programs, caseloads of physicians and nurse practitioners were estimated using survey data reported by the HMOs. RESULTS: Eight (38.1%) of the responding HMOs operate formal primary care programs in affiliated nursing homes. HMOs with programs consider more factors than non-program HMOs in evaluating care for nursing home residents. Reasons cited most frequently for not having a program are costs and too few nursing home residents. The most common primary care program features are designated physicians and use of physician extenders. CONCLUSIONS: Survey findings point to the potential importance of formal HMO primary care programs for long-term nursing home residents, which may expand with growth in the older population and Medicare-managed care. Program adoption, however, may depend on sufficient resident participation to be financially feasible. J Am Geriatr Soc 47:139–144, 1999.

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs. DESIGN: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year. SETTING: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West). PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems. J Am Geriatr Soc 47:131–138, 1999.

In a prospective study, 46 patients discharged from a teaching hospital to a "teaching unit" nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P less than .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P less than .01). Long-term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.