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Introduction: For end‐stage renal disease (ESRD) patients residing in skilled nursing facilities (SNFs), the logistics and physical exhaustion of life‐saving hemodialysis therapy often conflict with rehabilitation goals. Integration of dialysis care with rehabilitation programs in a scalable and cost‐efficient manner has been a significant challenge. SNF‐resident ESRD patients receiving onsite, more frequent hemodialysis (MFD) have reported rapid post‐dialysis recovery. We examined whether such patients have improved Physical Therapy (PT) participation. Methods: We conducted a retrospective electronic medical records review of SNF‐resident PT participation rates within a multistate provider of SNF rehabilitation care from January 1, 2022 to June 1, 2022. We compared three groups: ESRD patients receiving onsite MFD (Onsite‐MFD), ESRD patients receiving offsite, conventional 3×/week dialysis (Offsite‐Conventional‐HD), and the general non‐ESRD SNF rehabilitation population (Non‐ESRD). We evaluated physical therapy participation rates based on a predefined metric of missed or shortened (<15 min) therapy days. Baseline demographics and functional status were assessed. Findings: Ninety‐two Onsite‐MFD had 2084 PT sessions scheduled, 12,916 Non‐ESRD had 225,496 PT sessions scheduled, and 562 Offsite‐Conventional‐HD had 9082 PT sessions scheduled. In mixed model logistic regression, Onsite‐MFD achieved higher PT participation rates than Offsite‐Conventional‐HD (odds ratio: 1.8, CI: 1.1–3.0; p < 0.03), and Onsite‐MFD achieved equivalent PT participation rates to Non‐ESRD (odds ratio: 1.2, CI: 0.3–1.9; p < 0.46). Baseline mean ± SD Charlson Comorbidity score was significantly higher in Onsite‐MFD (4.9 ± 2.0) and Offsite‐Conventional‐HD (4.9 ± 1.8) versus Non‐ESRD (2.6 ± 2.0; p < 0.001). Baseline mean self‐care and mobility scores were significantly lower in Onsite‐MFD versus Non‐ESRD or Offsite‐Conventional‐HD. Discussion: SNF‐resident ESRD patients receiving MFD colocated with rehabilitation had higher PT participation rates than those conventionally dialyzed offsite and equivalent PT participation rates to the non‐ESRD SNF‐rehabilitation general population, despite being sicker, less independent, and less mobile. We report a scalable program integrating dialysis and rehabilitation care as a potential solution for ESRD patients recovering from acute hospitalization. [ABSTRACT FROM AUTHOR]

Urinary tract infections (UTIs) are commonly suspected in nursing home (NH) residents, commonly resulting in antimicrobial prescriptions, even when symptoms are non-specific. To improve the diagnosis and management of suspected UTIs in NH residents, we conducted a pilot test of a paper-based clinical algorithm across NHs in the southern U.S. with ten advanced practice providers (APPs). The paper-based algorithm was modified based on the clinical care needs of our APPs and included antimicrobial treatment recommendations. The APPs found the UTI antimicrobial stewardship and clinical decision support acceptable. The educational sessions and algorithm improved baseline confidence toward UTI diagnosing and treatment. The APPs thought the algorithm was useful and did not negatively impact workload. Feedback from the pilot study will be used to improve the next iteration of the algorithm as we assess its impact on prescribing outcomes. [ABSTRACT FROM AUTHOR]

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real‐world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce findings that are more reproducible. Although pragmatic methodology in long‐term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long‐term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants identified 4 cross‐cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) stakeholder engagement, (2) diversity and inclusion, (3) organizational strain and readiness, and (4) learn from adaptations. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long‐term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long‐term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence‐based care interventions. See related editorial by Zimmerman et al. and Special Articles by Gurwitz et al. and Resnick et al. in this issue. [ABSTRACT FROM AUTHOR]

Objectives To describe processes and preliminary outcomes from the implementation of a systematic advance care planning ( ACP) intervention in the nursing home setting. Design Specially trained project nurses were embedded in 19 nursing homes and engaged in ACP as part of larger demonstration project to reduce potentially avoidable hospitalizations. Setting Nursing homes. Participants Residents enrolled in the demonstration project for a minimum of 30 days between August 2013 and December 2014 (n = 2,709) and residents currently enrolled in March 2015 (n = 1,591). Measurements ACP conversations were conducted with residents, families, and the legal representatives of incapacitated residents using a structured ACP interview guide with the goal of offering ACP to all residents. Project nurses reviewed their roster of currently enrolled residents in March 2015 to capture barriers to engaging in ACP. Results During the initial implementation phase, 27% (731/2,709) of residents had participated in one or more ACP conversations with a project nurse, resulting in a change in documented treatment preferences for 69% (504/731). The most common change (87%) was the generation of a Physician Orders for Scope of Treatment form. The most frequently reported barrier to ACP was lack of time. Conclusion The time- and resource-intensive nature of robust ACP must be anticipated when systematically implementing ACP in the nursing home setting. The fact that these conversations resulted in changes over 2/3 of the time reinforces the importance of deliberate, systematic ACP to ensure that current treatment preferences are known and documented so that these preferences can be honored. [ABSTRACT FROM AUTHOR]

Physician burnout is a critical factor influencing the quality of care delivered in various healthcare settings. Although the prevalence and consequences of burnout have been well documented for physicians in various jurisdictions, no studies to date have reported on burnout in the postacute and long-term care setting. In this exploratory study, we sought to quantify the prevalence of burnout among 3 cohorts of physicians, each practicing in nursing homes in the United States (US), Canada, or The Netherlands. International comparisons were solicited to highlight cultural and health system factors potentially impacting burnout levels. Using standard survey techniques, a total of 721 physicians were solicited to participate (Canada 393; US 110; The Netherlands 218). Physicians agreeing to participate were asked to complete the “Maslach Burnout Inventory” using the Survey Monkey platform. A total of 118 surveys were completed from The Netherlands, 59 from Canada, and 65 from the US for response rates of 54%, 15%, and 59%, respectively. While US physicians demonstrated more negative scores in the emotional exhaustion subscale compared with their counterparts in Canada and The Netherlands, there were no meaningful differences on the depersonalization and personal accomplishments subscales. Factors explaining these differences are explored as well as approaches to future research on physician burnout in postacute and long-term care. [ABSTRACT FROM AUTHOR]

Heart failure (HF) is highly prevalent among older patients in skilled nursing facilities (SNFs). HF outcomes for SNF patients suffer because of many factors, including staff training, lack of physician availability, and failure to implement evidence-based care. AMDA – The Society for Post-Acute and Long-Term Care Medicine has recently updated the Clinical Practice Guidelines for Heart Failure Management in SNFs. This review supplements the Guidelines with a robust focus on best practices for transitional care, symptom management, treatment and monitoring, and palliative care in patients with HF. [ABSTRACT FROM AUTHOR]

Skilled nursing facilities (SNFs) are organizations that represent complex adaptive systems, offering barriers to the implementation of quality improvement (QI) initiatives. The current article describes the authors' efforts to use the approach of reflective adaptive process to implement a new model of care (i.e., the Skilled Heart Unit Program) for effective heart failure (HF) care in one SNF. A team of stakeholders from the local hospital system and a local SNF was convened to design and implement this new model. Evaluation of the implementation processes confirmed the value of the implementation approach, which centered on team-based approaches, staff engagement, and flexibility of processes to respect the SNF's needs and culture. Interviews with facility staff and the administrator revealed their perceptions that the strategy resulted in better HF care, enhanced teamwork between staff and clinicians, and improved staff job satisfaction. This work provides a unique blueprint of strategic QI implementation for patients with HF in the SNF setting. [Journal of Gerontological Nursing, 47(5), 26-33.] [ABSTRACT FROM AUTHOR]

Abstract: Background: The role of interdisciplinary interventions in the nursing home (NH) setting remains unclear. We conducted a systematic evidence review to study the benefits of interdisciplinary interventions on outcomes of NH residents. We also examined the interdisciplinary features of successful trials, including those that used formal teams. Data Sources: Medline was searched from January 1990 to August 2011. Search terms included residential facilities, long term care, clinical trial, epidemiologic studies, epidemiologic research design, comparative study, evaluation studies, meta-analysis and guideline. Study Selection: We included randomized controlled trials (RCTs) evaluating the efficacy of interdisciplinary interventions conducted in the NH setting. Measurements: We used the Cochrane Collaboration tools to appraise each RCT, and an RCT was considered positive if its selected intervention had a significant positive effect on the primary outcome regardless of its effect on any secondary outcome. We also extracted data from each trial regarding the participating disciplines; for trials that used teams, we studied the reporting of various team elements, including leadership, communication, coordination, and conflict resolution. Results: We identified 27 RCTs: 7 had no statistically significant effect on the targeted primary outcome, 2 had a statistically negative effect, and 18 demonstrated a statistically positive effect. Participation of residents’ own primary physicians (all 6 trials were positive) and/or a pharmacist (all 4 trials were positive) in the intervention were common elements of successful trials. For interventions that used formal team meetings, presence of communication and coordination among team members were the most commonly observed elements. Conclusion: Overall interdisciplinary interventions had a positive impact on resident outcomes in the NH setting. Participation of the residents’ primary physician and/or a pharmacist in the intervention, as well as team communication and coordination, were consistent features of successful interventions. [Copyright &y& Elsevier]

Background: Behavioral and psychological symptoms associated with dementia are common in nursing home residents. Quality indicators (QI) assessing quality of care for these residents are minimally risk adjusted and can provide inaccurate information regarding the quality of care provided by the facility. Objective: Evaluate the performance of a new QI for the incidence of worsening behaviors in nursing home residents with behavioral and psychological symptoms association with dementia. Design: Retrospective cohort study. Setting: A total of 381 Minnesota nursing homes with 26,165 residents. Data Sources: Minimum Data Set records for the first 2 calendar quarters of 2008. Measurements: We calculated incidence of worsening behaviors QI by comparing items from the “behavior” section of the Minimum Data Set records from 2 consecutive quarters and reported the incidence rates by both the residents’ level of cognitive impairment and the presence or absence of special care unit for dementia (SCU). Results: The incidence rates of the worsening behavior QI in SCU ranged from 14% in residents with very severe cognitive impairment (a cognitive performance score = 6) to 30% in those with moderate cognitive impairment (a cognitive performance score = 3). The incidence QI rates among residents residing in conventional unit ranged from 15% among those with very severe cognitive impairment to 20% among those with moderate cognitive impairment. These differences in QI rates between the 2 units were statistically significant with a P value = .001. After risk adjustment for level of cognitive impairment, number of facilities with SCUs that flagged for problem behaviors dropped from 18.4% to 12.4% and the number of conventional units in the low-risk category from 16.8% to 4.7%. Conclusion: Resident cognitive function and the facility utility of SCU are associated with worsening behavior QI and should be adjusted for in any nursing home quality reporting measure. [Copyright &y& Elsevier]

Our nation's nursing home industry has been in need of overhaul for decades—a situation made all the more evident by COVID-19. AMDA–The Society for Post-Acute and Long-Term Care Medicine is dedicated to quality in post-acute and long-term care process and outcomes. This special article presents 5 keys to solving the COVID-19 crisis in post-acute and long-term care, related to policy, collaboration, individualization, leadership, and reorganization. Taking action during this crisis may prevent sinking back into the complacency and habits of our pre-COVID-19 lives. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Prevention and public reporting of falls have suffered due to inadequate attention given to the association of falls and cognitive impairment (CI) among nursing home (NH) residents. This study examines the relationship between CI, residence on dementia special care units (SCUs) and other resident characteristics and likelihood of residents experiencing new falls in NHs. Design: Retrospective cohort study. Setting and Participants: A total of 21,587 residents from 381 Minnesota NHs. Measurements: The NH Minimum Data Set (MDS) for 21,587 residents from 381 Minnesota NHs in the first calendar quarter of 2008 were analyzed. New falls, (fall noted on a current MDS assessment but not on a prior assessment); cognitive status, (as defined by Cognitive Performance Scale); residence on an SCU, and health and functional status covariates were recorded. A random effects logistic regression model was used to examine relationships between new falls and the resident''s cognitive status, type of unit, and covariates. Results: The likelihood of a new fall had a nonlinear association with CI. Compared with residents with normal or mild CI, the likelihood of a new fall was significantly higher among residents with moderate CI (OR = 1.43). The risk decreased slightly (OR = 1.34) for residents with more advanced CI, whereas the presence of severe CI was not significantly associated with new falls. Overall the likelihood of new falls was significantly higher for residents on SCUs compared with those on conventional units (OR = 1.27). Conclusions: Severity of CI and residence on SCU impact fall incidence and should be accounted for in future fall- prevention interventions and quality-reporting indicators and measures. [Copyright &y& Elsevier]

Objectives The objective of this study was to evaluate the feasibility and impact of implementing a person-centered medical care model for post-acute care residents within a skilled nursing facility (SNF). Design A mixed-method (qualitative and quantitative) pilot evaluation. Setting An 89-bed SNF located within a large midwestern city. Participants Forty SNF post-acute patients admitted to the facility during a 6-month period were enrolled in the pilot evaluation. The patients were 75% women, 57% African American, and had an average age of 73. To meet inclusion criteria, patients must have been admitted to the facility for rehabilitation with a plan for community discharge, and be cognitively able to consent as indicated by a cognitive screening tool or assent to participation with family member consent. Intervention The person-centered medical care model included (1) biweekly interdisciplinary care plan meetings, scheduled at a time of patients' preference and held in the patient's room; (2) patient selection of health-related goals that guide team discussions; (3) use of lay-language that facilitated patient understanding; (4) team accountability to the patient for patient care preferences; and (5) monthly care-team meetings to exchange feedback regarding the team's performance and the model. Measurement Evaluation data included admission and discharge Patient Activation Measure surveys; admission and discharge Care of Chronic Conditions surveys; admission and biweekly modified Castle Satisfaction Surveys; admission and discharge Patient and Caregiver Engagement surveys; and semistructured interviews with a sample of staff, family members, and patients. Results A significant ( P < .01) improvement was noted between admission and discharge on both the Care for Chronic Conditions and the Patient Activation Measure surveys. Patient satisfaction surveys trended toward higher ratings over time on most questions, with significant improvement in 2 questions addressing satisfaction with their medical provider. Interviews revealed a perception that the model encouraged an environment of respect and honesty in patient communications, and an overall positive experience. The challenges of scheduling and time were noted by respondents. Conclusions Implementation of person-centered medical care within an SNF was feasible, yet required changing care processes to better address individual goals and facilitate communication among patients, providers, and SNF staff. Overall pilot results indicated that patients and staff members viewed the person-centered care experience positively. Further research is needed to examine long-term effects of the model on resident outcomes. [ABSTRACT FROM AUTHOR]