- Email: [email protected]
Direct Admission to Intermediate Care for Older Adults With Reactivated Chronic Diseases: Avoiding Both Conventional Hospitalization and Emergency Department Use?
444
Letters to the Editor / JAMDA 14 (2013) 443e449
Table 1 Attitude of Caregivers (Mean Standard Deviation) Variables Workers capacity
Education participation
Job satisfaction
Before (n ¼ 94)
After (n ¼ 94)
Interesting
3.7 0.9
Importance Prospects Adaptation Workload Knowledge Problem solving ability Total Internet usage
3.2 3.5 3.5 3.1 3.2 3.4
Voluntary participation Positive anticipation Activation Profession Active participation Computer usage Total Satisfaction Pride Growth Professional Total
Total
3.0 3.3 3.3 3.4 3.4 3.2 22.6 3.5 3.5 3.5 3.6 14.0 60.3
3.9 0.8
1.0 0.9 0.8 0.9 0.7 0.7
23.6 4.4 3.0 1.0 1.0 0.9 1.0 0.9 0.9 0.9 5.1 0.9 0.9 0.9 1.0 3.3 11.1
P
3.5 3.6 3.7 3.4 3.5 3.5
.046
0.9 0.9 0.8 1.0 0.7 0.8
.010 .048 .033 .002 <.001 .099
25.2 4.6 3.2 1.0
.001 .036
3.2 3.5 3.5 3.5 3.5 3.5 23.9 3.7 3.8 3.7 3.7 14.8 63.8
1.1 0.9 0.9 0.9 0.9 1.0 5.4 0.9 0.8 0.9 0.9 3.3 11.7
.072 .124 .159 .359 .181 .009 .024 .039 .019 .036 .197 .028 .004
Results Attitude changes of the caregivers are described in Table 1. Attitudes such as workers capacity, education participation, and job satisfaction significantly improved (P < .05). Among the attitude changes, worker capacity was the most improved attitude through the long term care education (P ¼ .001). Awareness of safety management in caregivers through the education program is described in Table 2. Before applying long term care education program, total safety management score was 57.6; after applying the program, total score was 61.9. Its statistical significance was P < .001. Of the safety management variables, awareness of disappearance management and therapeutic diet were not improved through the education program (P > .05).
conflict, socioemotional support, duration of care, physical health, and personal and social resources.3e6 According to our research, home healthcare for older adults might require consideration of attitude and job awareness of the caregivers related to the care recipients. Therefore, this study might help to increase safety consciousness of caregivers and increase safety for care recipients. Conclusion A newly developed long term care education program could improve the attitude of caregivers who engage in home healthcare service for older adults. Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2010-0003393). References 1. Howell S, Silberberg M, Quinn WV, Lucas JA. Determinants of remaining in the community after discharge: Results from New Jersey’s Nursing Home Transition Program. Gerontologist 2007;47:535e547. 2. Boczko F, McKeon S, Sturkie D. Long term care and oral health knowledge. J Am Med Dir Assoc 2009;10:204e206. 3. Gaugler JE, Pearlin LI, Leitsch SA, Davey A. Relinquishing in-home dementia care: Difficulties and perceived helpfulness during the nursing home transition. Am J Alzheimers Dis Other Demen 2001;16:32e42. 4. Beck LA, Scroggins LM. Optimizing health of individuals with tetraplegia. SCI Nurs 2001;18:181e186. 5. Gitlin LN, Reever K, Dennis MP, et al. Enhancing quality of life of families who use adult day services: Short- and long-term effects of the adult day services plus program. Gerontologist 2006;46:630e639. 6. Papadatou D. Training health professionals in caring for dying children and grieving families. Death Stud 1997;21:575e600.
TaeBum Lee, PhD Korea Electrotechnology Research Institute Advanced Medical Device Research Center Ansan, South Korea HyunSook Chang, PhD Department of Elderly Welfare, Namseoul University Cheonan, South Korea
Discussion http://dx.doi.org/10.1016/j.jamda.2013.02.015 There are some important factors for caregivers who work in long term care service such as education, career, mastery, family Table 2 Awareness of Safety Management (Mean Standard Deviation) Variables
Before
Fall prevention Infection control Skin management Medication Emergency condition Dementia Physical restriction Disappearance management Burn management Fire prevention Therapeutic diet Intubation feeding Food poisoning Elderly abuse Suicide prevention Residential environment Total
3.7 3.7 3.9 3.7 3.8 3.8 3.5 3.6 3.5 3.5 3.5 3.5 3.5 3.4 3.5 3.5 57.6
After 0.9 1.0 0.9 1.0 1.0 0.9 1.0 1.0 0.9 0.9 0.9 1.0 0.9 1.0 1.0 1.0 12.1
4.0 4.1 4.1 4.1 4.0 4.0 3.8 3.7 3.7 3.7 3.7 3.8 3.9 3.8 3.8 3.8 61.9
P 0.8 0.8 0.8 0.8 0.8 0.8 0.9 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.9 0.9 10.6
.005 <.001 .006 .001 .032 .009 .009 .332 .071 .010 .069 .004 <.001 <.001 .003 .025 <.001
Direct Admission to Intermediate Care for Older Adults With Reactivated Chronic Diseases: Avoiding Both Conventional Hospitalization and Emergency Department Use? To the Editor: In an article published in the Journal of the American Medical Directors Association, Colprim et al1 reported preliminary results of direct admission of older adults with reactivated chronic diseases to postacute intermediate-care geriatric units (ICGUs) as a potential alternative to conventional hospitalization for selected patients in need of acute treatment and low intensity rehabilitation. We would
Letters to the Editor / JAMDA 14 (2013) 443e449
like to support this article based on our experience in admission to Intermediate Care (referrals from emergency department [ED] or directly from the community by a coordinated multidisciplinary team managed by a geriatrician) in a comparable facility situated in the same geographic area. Because of the high use of ED by vulnerable older patients and associated risks of adverse events2e4 of ED admission in this population, in our country several groups have been developing intermediate care hospital research for subacute older patients, as an alternative to acute hospitalization, suggested by Catalan Health Department programs.5,6 Our unit has focused on avoiding conventional hospitalization and reducing ED use, managing acute phase of reactivated chronic diseases in old patients in need of specific low-intensity geriatric management, not focused on rehabilitation. From 2009 December to 2012 July, 201 patients were admitted to our ICGU. Main characteristics of the sample were comparable to the work of Colprim et al1: age 84.2 (10.2) years; Barthel Index 40 (35.9); cognitive impairment in 56%; referrals from ED in 87%; and directly from the community in 13%. Main admission acute conditions were respiratory infection (57%), heart failure (18%), urinary infection (10%), and other (15%). Length of stay in our unit was 10.4 (5.6) days. Readmission rate for the same reason within 30 days following discharge was 5.5%. The rate of health care resources use within 30 days of discharge was 7.8%. Main data were consistent with the standards established by expert consensus of local health department for such units.7 In our experience, we agree with the authors that ICGUs seem an opportunity as an alternative to conventional hospitalization of selected older patients with reactivated chronic disease. This resource could potentially avoid a negative effect of conventional hospitalization and provide care focused on needs of vulnerable patients. References 1. Colprim D, Martin R, Parer M, et al. Direct admission to intermediate care for older adults with reactivated chronic diseases as an alternative to conventional hospitalization. J Am Med Dir Assoc 2013;14:300e302. 2. Ministerio de Sanidad y Política Social. Informes, estudios e investigación 2010. Unidad de urgencias hospitalaria. Estándares y recomendaciones. Available at: www.msc.es/organizacion/sns/planCalidadSNS/docs/UUH.pdf. Accessed February 19, 2013. 3. Platts-Mills TF, Leacock B, Cabañas JG, et al. Emergency medical services use by the elderly: Analysis of a statewide database. Prehosp Emerg Care 2010;14:329e333. 4. Tomás S, Chanovas M, Roqueta F, et al. EVADUR: eventos adversos ligados a la asistencia en los servicios de urgencias de hospitales españoles. Emergencias 2010;22:415e428. 5. Generalitat de Catalunya, Departament de Salut. Programa de Prevenció i Atenció a la Cronicitat. Alternatives assistencials per a pacients crònics complexos en el marc de sistemes integrats. Reordenació de la xarxa sociosanitaria. Available at: http://www20.gencat.cat/docs/salut/Home/Ambits%20tematics/ Linies%20dactuacio/Model_assistencial/Atencio_al_malalt_cronic/documents/ front2_ss.pdf. Accessed February 19, 2013. 6. Inzitari M, Espinosa SL, Perez Bocanegra MC, et al. Intermediate hospital care for subacute elderly patients as an alternative to prolonged acute hospitalization. Gac Sanit 2012;26:166e169. 7. Generalitat de Catalunya, Departament de Salut, Planificació i Avaluació. Pla Director Sociosanitari 2004. Available at: www.gencat.cat/salut/depsalut/pdf/ pdsocisanitari271006.pdf. Accessed February 19, 2013.
Sebastià J. Santaeugènia, MD Santiago Tomás, MD, PhD Margarita Álvaro, MD Gemma Porta, MD Miquel Àngel Mas, MD Department of Geriatric Medicine and Palliative Care Badalona Serveis Assistencials Badalona, Catalonia, Spain http://dx.doi.org/10.1016/j.jamda.2013.02.013
445
Operationalizing the MDS 3.0 in the Nursing Home To the Editor: Many thanks to Dr. Debra Saliba and others for their excellent work overviewing and testing the Minimum Data Set (MDS) 3.0 revisions (article series in the Journal, Issue 13, 2012). Revisions and further testing were long overdue. As noted in her articles, the validated interviews embedded into MDS 3.0 have improved the reliability, validity, and clinical utility of the MDS. With better mental status and depression symptom evaluation interviews, the Resident Assessment Instrument (RAI) process can better support processes for individualized care. The “elephant in the room” now is, if the information gleaned from the MDS is actually being used by long term care providers to support processes for individualized care. Since the implementation of MDS 3.0 in October 2010, there have been several changes in coding to enable different uses of the MDS for the Centers for Medicare and Medicaid (CMS). For example, some responses on the MDS dictate reimbursement that a facility will receive for their Medicare residents; other responses are the data source for the publicly reported Quality Measures (available on-line since July 2012). The manual for coding the MDS consists of hundreds of pages of directions. Yet, the chapter on the Care Assessment Areas and individualized care planning is only 40 pages long. Since implementing MDS 3.0, most efforts have focused on the financial implications and the impact on publically reported quality measures. Now, we need to examine the “elephant” and focus on the original intent of MDS 3.0 and Dr. Saliba’s original workdto improve individualized care for older people living in nursing homes. In the spring of 2012, CMS hosted a National Training Session in St. Louis, Missouri, for long term care providers. During that training, CMS reminded providers that the new resident interviews were very important to do. Anecdotal data they had collected to that point indicated that facilities were by-passing the interview and completing those sections by staff observation. Providers were warned that if interviews were not being done when appropriate, survey citations could be given. As Dr. Saliba and colleagues report, 90% of the national sample (n ¼ 3258) of nursing home residents were able to complete the Brief Interview for Mental Status (BIMS).1 Additionally, 86% of these residents also completed the Patient Health Questionnaire-9 interview.2 Providers need to strive for completion rates that are similar or exceed these from the national sample. With participation from residents, individualized care can be enhanced. National organizations are working with long term care communities to demonstrate how new information about residents from MDS 3.0 can improve care. For example, the Pioneer Network is currently working with state learning networks and homes to “incubate” ways to encourage the use of the MDS data to provide individualized care. The homes in the project are learning ways to use the information more effectively to facilitate quality individualized care. We cannot assume all homes are using MDS data they collect as it was intended. Early adopters are likely leading the charge; now, we need to reach out and help the others. Research has found that most nursing homes have difficulty making sustained change.3,4 For change to be embraced and sustained, individualized care needs to be a major focus for staff, from the front-line staff to the Medical Directors and Administrators. Knowing each resident and his/her goals and wishes is foundational to helping the nursing home team provide individualized care. The MDS 3.0 data collected and the RAI process brings important
Letters to the Editor / JAMDA 14 (2013) 443e449
Table 1 Attitude of Caregivers (Mean Standard Deviation) Variables Workers capacity
Education participation
Job satisfaction
Before (n ¼ 94)
After (n ¼ 94)
Interesting
3.7 0.9
Importance Prospects Adaptation Workload Knowledge Problem solving ability Total Internet usage
3.2 3.5 3.5 3.1 3.2 3.4
Voluntary participation Positive anticipation Activation Profession Active participation Computer usage Total Satisfaction Pride Growth Professional Total
Total
3.0 3.3 3.3 3.4 3.4 3.2 22.6 3.5 3.5 3.5 3.6 14.0 60.3
3.9 0.8
1.0 0.9 0.8 0.9 0.7 0.7
23.6 4.4 3.0 1.0 1.0 0.9 1.0 0.9 0.9 0.9 5.1 0.9 0.9 0.9 1.0 3.3 11.1
P
3.5 3.6 3.7 3.4 3.5 3.5
.046
0.9 0.9 0.8 1.0 0.7 0.8
.010 .048 .033 .002 <.001 .099
25.2 4.6 3.2 1.0
.001 .036
3.2 3.5 3.5 3.5 3.5 3.5 23.9 3.7 3.8 3.7 3.7 14.8 63.8
1.1 0.9 0.9 0.9 0.9 1.0 5.4 0.9 0.8 0.9 0.9 3.3 11.7
.072 .124 .159 .359 .181 .009 .024 .039 .019 .036 .197 .028 .004
Results Attitude changes of the caregivers are described in Table 1. Attitudes such as workers capacity, education participation, and job satisfaction significantly improved (P < .05). Among the attitude changes, worker capacity was the most improved attitude through the long term care education (P ¼ .001). Awareness of safety management in caregivers through the education program is described in Table 2. Before applying long term care education program, total safety management score was 57.6; after applying the program, total score was 61.9. Its statistical significance was P < .001. Of the safety management variables, awareness of disappearance management and therapeutic diet were not improved through the education program (P > .05).
conflict, socioemotional support, duration of care, physical health, and personal and social resources.3e6 According to our research, home healthcare for older adults might require consideration of attitude and job awareness of the caregivers related to the care recipients. Therefore, this study might help to increase safety consciousness of caregivers and increase safety for care recipients. Conclusion A newly developed long term care education program could improve the attitude of caregivers who engage in home healthcare service for older adults. Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2010-0003393). References 1. Howell S, Silberberg M, Quinn WV, Lucas JA. Determinants of remaining in the community after discharge: Results from New Jersey’s Nursing Home Transition Program. Gerontologist 2007;47:535e547. 2. Boczko F, McKeon S, Sturkie D. Long term care and oral health knowledge. J Am Med Dir Assoc 2009;10:204e206. 3. Gaugler JE, Pearlin LI, Leitsch SA, Davey A. Relinquishing in-home dementia care: Difficulties and perceived helpfulness during the nursing home transition. Am J Alzheimers Dis Other Demen 2001;16:32e42. 4. Beck LA, Scroggins LM. Optimizing health of individuals with tetraplegia. SCI Nurs 2001;18:181e186. 5. Gitlin LN, Reever K, Dennis MP, et al. Enhancing quality of life of families who use adult day services: Short- and long-term effects of the adult day services plus program. Gerontologist 2006;46:630e639. 6. Papadatou D. Training health professionals in caring for dying children and grieving families. Death Stud 1997;21:575e600.
TaeBum Lee, PhD Korea Electrotechnology Research Institute Advanced Medical Device Research Center Ansan, South Korea HyunSook Chang, PhD Department of Elderly Welfare, Namseoul University Cheonan, South Korea
Discussion http://dx.doi.org/10.1016/j.jamda.2013.02.015 There are some important factors for caregivers who work in long term care service such as education, career, mastery, family Table 2 Awareness of Safety Management (Mean Standard Deviation) Variables
Before
Fall prevention Infection control Skin management Medication Emergency condition Dementia Physical restriction Disappearance management Burn management Fire prevention Therapeutic diet Intubation feeding Food poisoning Elderly abuse Suicide prevention Residential environment Total
3.7 3.7 3.9 3.7 3.8 3.8 3.5 3.6 3.5 3.5 3.5 3.5 3.5 3.4 3.5 3.5 57.6
After 0.9 1.0 0.9 1.0 1.0 0.9 1.0 1.0 0.9 0.9 0.9 1.0 0.9 1.0 1.0 1.0 12.1
4.0 4.1 4.1 4.1 4.0 4.0 3.8 3.7 3.7 3.7 3.7 3.8 3.9 3.8 3.8 3.8 61.9
P 0.8 0.8 0.8 0.8 0.8 0.8 0.9 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.9 0.9 10.6
.005 <.001 .006 .001 .032 .009 .009 .332 .071 .010 .069 .004 <.001 <.001 .003 .025 <.001
Direct Admission to Intermediate Care for Older Adults With Reactivated Chronic Diseases: Avoiding Both Conventional Hospitalization and Emergency Department Use? To the Editor: In an article published in the Journal of the American Medical Directors Association, Colprim et al1 reported preliminary results of direct admission of older adults with reactivated chronic diseases to postacute intermediate-care geriatric units (ICGUs) as a potential alternative to conventional hospitalization for selected patients in need of acute treatment and low intensity rehabilitation. We would
Letters to the Editor / JAMDA 14 (2013) 443e449
like to support this article based on our experience in admission to Intermediate Care (referrals from emergency department [ED] or directly from the community by a coordinated multidisciplinary team managed by a geriatrician) in a comparable facility situated in the same geographic area. Because of the high use of ED by vulnerable older patients and associated risks of adverse events2e4 of ED admission in this population, in our country several groups have been developing intermediate care hospital research for subacute older patients, as an alternative to acute hospitalization, suggested by Catalan Health Department programs.5,6 Our unit has focused on avoiding conventional hospitalization and reducing ED use, managing acute phase of reactivated chronic diseases in old patients in need of specific low-intensity geriatric management, not focused on rehabilitation. From 2009 December to 2012 July, 201 patients were admitted to our ICGU. Main characteristics of the sample were comparable to the work of Colprim et al1: age 84.2 (10.2) years; Barthel Index 40 (35.9); cognitive impairment in 56%; referrals from ED in 87%; and directly from the community in 13%. Main admission acute conditions were respiratory infection (57%), heart failure (18%), urinary infection (10%), and other (15%). Length of stay in our unit was 10.4 (5.6) days. Readmission rate for the same reason within 30 days following discharge was 5.5%. The rate of health care resources use within 30 days of discharge was 7.8%. Main data were consistent with the standards established by expert consensus of local health department for such units.7 In our experience, we agree with the authors that ICGUs seem an opportunity as an alternative to conventional hospitalization of selected older patients with reactivated chronic disease. This resource could potentially avoid a negative effect of conventional hospitalization and provide care focused on needs of vulnerable patients. References 1. Colprim D, Martin R, Parer M, et al. Direct admission to intermediate care for older adults with reactivated chronic diseases as an alternative to conventional hospitalization. J Am Med Dir Assoc 2013;14:300e302. 2. Ministerio de Sanidad y Política Social. Informes, estudios e investigación 2010. Unidad de urgencias hospitalaria. Estándares y recomendaciones. Available at: www.msc.es/organizacion/sns/planCalidadSNS/docs/UUH.pdf. Accessed February 19, 2013. 3. Platts-Mills TF, Leacock B, Cabañas JG, et al. Emergency medical services use by the elderly: Analysis of a statewide database. Prehosp Emerg Care 2010;14:329e333. 4. Tomás S, Chanovas M, Roqueta F, et al. EVADUR: eventos adversos ligados a la asistencia en los servicios de urgencias de hospitales españoles. Emergencias 2010;22:415e428. 5. Generalitat de Catalunya, Departament de Salut. Programa de Prevenció i Atenció a la Cronicitat. Alternatives assistencials per a pacients crònics complexos en el marc de sistemes integrats. Reordenació de la xarxa sociosanitaria. Available at: http://www20.gencat.cat/docs/salut/Home/Ambits%20tematics/ Linies%20dactuacio/Model_assistencial/Atencio_al_malalt_cronic/documents/ front2_ss.pdf. Accessed February 19, 2013. 6. Inzitari M, Espinosa SL, Perez Bocanegra MC, et al. Intermediate hospital care for subacute elderly patients as an alternative to prolonged acute hospitalization. Gac Sanit 2012;26:166e169. 7. Generalitat de Catalunya, Departament de Salut, Planificació i Avaluació. Pla Director Sociosanitari 2004. Available at: www.gencat.cat/salut/depsalut/pdf/ pdsocisanitari271006.pdf. Accessed February 19, 2013.
Sebastià J. Santaeugènia, MD Santiago Tomás, MD, PhD Margarita Álvaro, MD Gemma Porta, MD Miquel Àngel Mas, MD Department of Geriatric Medicine and Palliative Care Badalona Serveis Assistencials Badalona, Catalonia, Spain http://dx.doi.org/10.1016/j.jamda.2013.02.013
445
Operationalizing the MDS 3.0 in the Nursing Home To the Editor: Many thanks to Dr. Debra Saliba and others for their excellent work overviewing and testing the Minimum Data Set (MDS) 3.0 revisions (article series in the Journal, Issue 13, 2012). Revisions and further testing were long overdue. As noted in her articles, the validated interviews embedded into MDS 3.0 have improved the reliability, validity, and clinical utility of the MDS. With better mental status and depression symptom evaluation interviews, the Resident Assessment Instrument (RAI) process can better support processes for individualized care. The “elephant in the room” now is, if the information gleaned from the MDS is actually being used by long term care providers to support processes for individualized care. Since the implementation of MDS 3.0 in October 2010, there have been several changes in coding to enable different uses of the MDS for the Centers for Medicare and Medicaid (CMS). For example, some responses on the MDS dictate reimbursement that a facility will receive for their Medicare residents; other responses are the data source for the publicly reported Quality Measures (available on-line since July 2012). The manual for coding the MDS consists of hundreds of pages of directions. Yet, the chapter on the Care Assessment Areas and individualized care planning is only 40 pages long. Since implementing MDS 3.0, most efforts have focused on the financial implications and the impact on publically reported quality measures. Now, we need to examine the “elephant” and focus on the original intent of MDS 3.0 and Dr. Saliba’s original workdto improve individualized care for older people living in nursing homes. In the spring of 2012, CMS hosted a National Training Session in St. Louis, Missouri, for long term care providers. During that training, CMS reminded providers that the new resident interviews were very important to do. Anecdotal data they had collected to that point indicated that facilities were by-passing the interview and completing those sections by staff observation. Providers were warned that if interviews were not being done when appropriate, survey citations could be given. As Dr. Saliba and colleagues report, 90% of the national sample (n ¼ 3258) of nursing home residents were able to complete the Brief Interview for Mental Status (BIMS).1 Additionally, 86% of these residents also completed the Patient Health Questionnaire-9 interview.2 Providers need to strive for completion rates that are similar or exceed these from the national sample. With participation from residents, individualized care can be enhanced. National organizations are working with long term care communities to demonstrate how new information about residents from MDS 3.0 can improve care. For example, the Pioneer Network is currently working with state learning networks and homes to “incubate” ways to encourage the use of the MDS data to provide individualized care. The homes in the project are learning ways to use the information more effectively to facilitate quality individualized care. We cannot assume all homes are using MDS data they collect as it was intended. Early adopters are likely leading the charge; now, we need to reach out and help the others. Research has found that most nursing homes have difficulty making sustained change.3,4 For change to be embraced and sustained, individualized care needs to be a major focus for staff, from the front-line staff to the Medical Directors and Administrators. Knowing each resident and his/her goals and wishes is foundational to helping the nursing home team provide individualized care. The MDS 3.0 data collected and the RAI process brings important