Multimorbidity is the most significant condition affecting older adults, and it impacts every component of health care management and delivery. Multimorbidity significantly increases with age. For ...individuals with a diagnosis of cardiovascular disease, multimorbidity has a significant effect on the presentation of the disease and the diagnosis, management, and patient-centered preferences in care. Evidence-based therapeutics have focused on cardiovascular focused morbidity. Over the next 25 years, the proportion of adults aged 65 and older is estimated to increase three-fold. The needs of these patients require a fundamental shift in care from single disease practices to a more patient-centered framework.
Objectives
To determine the prevalence, recognition, co‐occurrence, and recent onset of geriatric syndromes in individuals transferred from the hospital to a skilled nursing facility (SNF).
Design
...Quality improvement project.
Setting
Acute care academic medical center and 23 regional partner SNFs.
Participants
Medicare beneficiaries hospitalized between January 2013 and April 2014 and referred to SNFs (N = 686).
Measurements
Project staff measured nine geriatric syndromes: weight loss, lack of appetite, incontinence, and pain (standardized interview); depression (Geriatric Depression Scale); delirium (Brief Confusion Assessment Method); cognitive impairment (Brief Interview for Mental Status); and falls and pressure ulcers (hospital medical record using hospital‐implemented screening tools). Estimated prevalence, new‐onset prevalence, and common coexisting clusters were determined. The extent to which treating physicians commonly recognized syndromes and communicated them to SNFs in hospital discharge documentation was evaluated.
Results
Geriatric syndromes were prevalent in more than 90% of hospitalized adults referred to SNFs; 55% met criteria for three or more coexisting syndromes. The most‐prevalent syndromes were falls (39%), incontinence (39%), loss of appetite (37%), and weight loss (33%). In individuals who met criteria for three or more syndromes, the most common triad clusters were nutritional syndromes (weight loss, loss of appetite), incontinence, and depression. Treating hospital physicians commonly did not recognize and document geriatric syndromes in discharge summaries, missing 33% to 95% of syndromes present according to research personnel.
Conclusion
Geriatric syndromes in hospitalized older adults transferred to SNFs are prevalent and commonly coexist, with the most frequent clusters including nutritional syndromes, depression, and incontinence. Despite the high prevalence, this clinical information is rarely communicated to SNFs on discharge.
Background
Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF ...perspectives.
Objectives
To determine the percentage of readmissions from post‐acute care that are considered potentially avoidable from hospital and SNF perspectives.
Design
Prospective cohort study.
Setting
One academic medical center and 23 SNFs.
Participants
We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days.
Measurements
Hospital‐based physicians and SNF‐based staff performed structured root‐cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions.
Results
The 30‐day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively.
Conclusion
A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.
Nursing aides provide most of the labor-intensive activities of daily living (ADL) care to nursing home (NH) residents. Currently, most NHs do not determine nurse aide staffing requirements based on ...the time to provide ADL care for their unique resident population. The lack of an objective method to determine nurse aide staffing requirements suggests that many NHs could be understaffed in their capacity to provide consistent ADL care to all residents in need. Discrete event simulation (DES) mathematically models key work parameters (eg, time to provide an episode of care and available staff) to predict the ability of the work setting to provide care over time and offers an objective method to determine nurse aide staffing needs in NHs.
This study had 2 primary objectives: (1) to describe the relationship between ADL workload and the level of nurse aide staffing reported by NHs; and, (2) to use a DES model to determine the relationship between ADL workload and nurse aide staffing necessary for consistent, timely ADL care.
Minimum Data Set data related to the level of dependency on staff for ADL care for residents in over 13,500 NHs nationwide were converted into 7 workload categories that captured 98% of all residents. In addition, data related to the time to provide care for the ADLs within each workload category was used to calculate a workload score for each facility. The correlation between workload and reported nurse aide staffing levels was calculated to determine the association between staffing reported by NHs and workload. Simulations to project staffing requirements necessary to provide ADL care were then conducted for 65 different workload scenarios, which included 13 different nurse aide staffing levels (ranging from 1.6 to 4.0 total hours per resident day) and 5 different workload percentiles (ranging from the 5th to the 95th percentile). The purpose of the simulation model was to determine the staffing necessary to provide care within each workload percentile based on resident ADL care needs and compare the simulated staffing projections to the NH reported staffing levels.
The percentage of scheduled care time that was omitted was estimated by the simulation model for each of the 65 workload scenarios using optimistic assumptions about staff productivity and efficiency.
There was a low correlation between ADL workload and reported nurse aide staffing (Pearson = .11; P < .01), which suggests that most of the 13,500 NHs were not using ADL acuity to determine nurse aide staffing levels. Based on the DES model, the nurse aide staffing required for ADL care that would result in a rate of care omissions below 10% ranged from 2.8 hours/resident/day for NHs with a low workload (5th percentile) to 3.6 hours/resident/day for NHs with a high workload (95th percentile). In contrast, NHs reported staffing levels that ranged from an average of 2.3 to 2.5 hours/resident/day across all 5 workload percentiles. Higher workload NHs had the largest discrepancies between reported and predicted nurse aide staffing levels.
The average nurse aide staffing levels reported by NHs falls below the level of staffing predicted as necessary to provide consistent ADL care to all residents in need. DES methodology can be used to determine nurse aide staffing requirements to provide ADL care and simulate management interventions to improve care efficiency and quality.
A structured interview was conducted with Medicare patients readmitted to a private, tertiary teaching hospital from skilled nursing facilities (SNFs) to assess their perspectives of readmission ...preventability and their role in the readmission.
Data were collected at Vanderbilt University Medical Center using a 6-item interview administered at the bedside to Medicare beneficiaries with unplanned hospital readmissions from 23 SNFs within 60 days of a previous hospital discharge. Mixed analytical methods were applied, including a content analysis that evaluated factors contributing to hospital readmission as perceived by consumers.
Among 208 attempted interviews, 156 were completed, of which 53 (34%) respondents rated their readmission as preventable. 28.3% of the 53 consumers attributed the readmission to hospital factors, 52.8% attributed it to the SNF, and 18.9% believed both sites could have prevented the readmission. The primary driver of the readmission was a family member/caregiver in 31 cases and the patient in 24 of the 156 cases, amounting to 55 (35.3%) consumer-driven readmissions. Contributing factors included: premature hospital discharge (16.3%); poor discharge planning (16.3%); a clinical issue not resolved in the hospital (14.3%); inadequate treatment at the SNF (69.4%); improper medication management at the SNF (20.4%); and poor decision-making regarding the transfer (14.3%).
Interviewing readmitted patients provides information relevant to reducing readmissions that may otherwise be omitted from hospital and SNF records. Consumers identified quality issues at both the hospital and SNF and perceived themselves as initiating a significant number of readmissions.
Objectives
To assess multiple geriatric syndromes in a sample of older hospitalized adults discharged to skilled nursing facilities (SNFs) and subsequently to home to determine the prevalence and ...stability of each geriatric syndrome at the point of these care transitions.
Design
Descriptive, prospective study.
Setting
One large university‐affiliated hospital and four area SNFs.
Participants
Fifty‐eight hospitalized Medicare beneficiaries discharged to SNFs (N = 58).
Measurements
Research personnel conducted standardized assessments of the following geriatric syndromes at hospital discharge and 2 weeks after SNF discharge to home: cognitive impairment, depression, incontinence, unintentional weight loss, loss of appetite, pain, pressure ulcers, history of falls, mobility impairment, and polypharmacy.
Results
The average number of geriatric syndromes per participant was 4.4 ± 1.2 at hospital discharge and 3.8 ± 1.5 after SNF discharge. There was low to moderate stability for most syndromes. On average, participants had 2.9 syndromes that persisted across both care settings, 1.4 syndromes that resolved, and 0.7 new syndromes that developed between hospital and SNF discharge.
Conclusion
Geriatric syndromes were prevalent at the point of each care transition but also reflected significant within‐individual variability. These findings suggest that multiple geriatric syndromes present during a hospital stay are not transient and that most syndromes are not resolved before SNF discharge. These results underscore the importance of conducting standardized screening assessments at the point of each care transition and effectively communicating this information to the next provider to support the management of geriatric conditions.
Abstract
Purpose:
Approximately 20% of hospitalized Medicare beneficiaries are discharged from the hospital to skilled nursing facilities (SNFs); and up to 23% of SNF patients return to the hospital ...within 30 days of hospital discharge, with pain as one of the most common symptoms precipitating hospital readmission. We sought to examine the prevalence of moderate to severe pain at hospital discharge to SNF, the incidence of new moderate to severe pain (relative to prehospitalization), and satisfaction with pain management among older acute care patients discharged to SNF.
Design and Methods:
Structured patient interviews were conducted with 188 Medicare beneficiaries discharged to 23 area SNFs from an academic medical center. Pain level (0–10) and satisfaction with pain management were assessed upon hospital admission, discharge, and within 1 week after transition to SNF.
Results:
There was a high prevalence of moderate to severe pain at each time point including prehospital (51%), hospital discharge (38%), and following SNF admission (53%). Twenty-eight percent of participants reported new moderate to severe pain at hospital discharge, whereas 44% reported new moderate to severe pain following SNF admission. Most participants reported being “satisfied” with their pain treatment, even in the context of moderate to severe pain.
Implications:
Moderate to severe pain is a common problem among hospitalized older adults discharged to SNF and continues during their SNF stay. Pain assessment and management should involve a specific, planned process between hospital and SNF clinicians at the point of care transition, even if patients express “satisfaction” with current pain management.
Older adults presenting with an acute myocardial infarction (MI) have an increased morbidity and mortality as compared to younger adults. The management of MI in older adults is dependent on accurate ...risk stratification incorporating the vast patient heterogeneity characteristic of this population. Traditional risk stratification methods differ in their predictive validity as age increases and important geriatric risk factors such as multimorbidity and geriatric syndromes (e.g., frailty) are often not taken into consideration when developing patient-centered care plans. The dearth of specific clinical practice guidelines for this population, due in part to the exclusion of representative older adults in clinical trials, has resulted in elderly patients with an MI receiving evidence based reperfusion and secondary prevention therapies at much lower rates compared to their younger counterparts. Recent developments in geriatric cardiology have begun to identify and address these gaps, but much evidence still needs to be established in this area.
Objectives
To examine the effect of late-life body mass index (BMI) and rapid weight loss on incident mild cognitive impairment (MCI) and Alzheimer’s disease (AD).
Design
Prospective longitudinal ...cohort study.
Setting
National Alzheimer’s Coordinating Center (NACC) Uniform Data Set, including 34 past and current National Institute on Aging-funded AD Centers across the United States.
Participants
6940 older adults (n=5061 normal cognition NC; n=1879 MCI).
Measurements
BMI (kg/m
2
) and modified Framingham Stroke Risk Profile (FSRP) score (sex, age, systolic blood pressure, anti-hypertension medication, diabetes mellitus, cigarette smoking, prevalent cardiovascular disease, atrial fibrillation) were assessed at baseline. Cognition and weight were assessed annually.
Results
Multivariable binary logistic regression, adjusting for age, sex, race, education, length of follow-up, and modified FSRP related late-life BMI to risk of diagnostic conversion from NC to MCI or AD and from MCI to AD. Secondary analyses related late-life BMI to diagnostic conversion in the presence of rapid weight loss (>5% decrease in 12 months) and apolipoprotein E (APOE) ε4. During a mean 3.8-year follow-up period, 12% of NC participants converted to MCI or AD and 49% of MCI participants converted to AD. Higher baseline BMI was associated with a reduced probability of diagnostic conversion, such that for each one-unit increase in baseline BMI there was a reduction in diagnostic conversion for both NC (OR=0.977, 95%CI 0.958-0.996, p=0.015) and MCI participants (OR=0.962, 95%CI 0.942-0.983, p<0.001). The protective effect of higher baseline BMI did not persist in the setting of rapid weight loss but did persist when adjusting for APOE ε4.
Conclusions
Higher late-life BMI is associated with a lower risk of incident MCI and AD but is not protective in the presence of rapid weight loss.
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