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Lifetyles: Using Q-Methodology to Assess Quality of Life and Care Priorities in Frail Elders
and evaluation and monitoring processes. A variety of Quality Management and Change Acceleration Process tools were used during the project, including identification of stakeholders, creating a Charter with ground rules, training on how to create a change environment and leading change, and identifying challenges and opportunities. This led to consensus building, strengthening of the team approach and aligning systems as a interdisciplinary process. Educational opportunities were also identified, implemented and outcomes monitored. Results: As a result of this initiative and data collection from December 2002 to March 2007, unplanned significant weight loss was reduced from 17.2% to 4%. Other areas of improvement were noted, with customer satisfaction increasing, supplement usage decreasing, improved documentation and enhanced interdisciplinary communicaton pathways. These results were reported to the Quality Committee and captured in all four quadrants of the facilities Balanced Scorecard. Conclusion/Discussion: Successful process change was possible through education, identifying the problem, stakeholders involved, issues affecting the subject, and following through with an interdisciplinary focus. By leading change, this project resulted in a proactive vs reactive workforce and set the standard for aligning systems and structures with projects that have followed. Disclosures: Suzanne C. Cryst, RD, CSG, LD has no disclosures to be made that are pertinent to this abstract.
ITP in the elderly, rare but serious Presenting Author(s): Renante Ignacio, MD, Mercy of Northern New York, Elder Medical Services, Oswego, NY Author(s): Renante Ignacio, MD Introduction/Objective: Introduction: Idiopathic (Autoimmune) Thrombocytopenic purpura (ITP) is an autoimmune disorder in which an IgG autoantibody is formed that binds to platelets. The antiplatelet antibody may then bind complements. Platelet destruction occurs in the spleen. It occurs commonly in childhood, usually due to a viral prodrome and is self limited. It also occurs among adults, with peak incidence between ages 20-50 and rarely follows a viral infection. It tends to be a chronic disease among adults. Bone marrow biopsy reveals its pathognomic finding of normal cytology with normal or increased megakaryocytes. Patients are usually asymptomatic and afebrile. It usually presents as mucosal or skin bleeding. There is no abnormal physical finding except those related to bleeding. Rarely such an entity occurs in the elderly, but they are more prone to serious life threatening complications. Below is a clear example of how early diagnosis and empiric treatment of such a rare disease can save the life of an afflicted elderly. Design/Methodology: Case Report: An 86 year old, long term care resident, Caucasian female with dementia and hypertension presented with gradually worsening thrombocytopenia. It was initially noted to be at 109 x 10 3/ul then later plummeted to 30 x 10 3/ul in 6 months. Physical examination findings did not reveal any remarkable findings except for isolated ecchymoses on her bilateral forearms. No petechia or active bleeding. No splenomegaly noted. Comprehensive laboratory work was done to rule out its possible different etiologies. Serum protein electrophoresis, Hepatitis panel, ANA, Rheumatoid factor was essentially unremarkable. Vitamin B12 and Folic Acid levels were within normal limits. Medications were reviewed and none of them has thrombocytopenic effect. A bone marrow biopsy for definitive diagnosis was contemplated but her family later opted not to pursue such procedure. She was empirically started on Prednisone 1mg/kg for possible ITP. Her platelet count gradually returned to its normal level after a month of tapering steroid dose. She has remained clinically stable during her treatment course. Results: n/a Conclusion/Discussion: This exceptional case illustrates an atypical case of ITP in the elderly. It has been shown that it can still have a favorable response to steroid therapy, even among octogenarians. As geriatricians, we should always be aware that such rare entity can still occur and if treated promptly, can treat the disease and ultimately offer a better quality of life among our frail patients. B16
Disclosures: Renante Ignacio, MD received a speaker honorarium from Pfizer Inc.
Keeping INRs therapeutic: The Kings Harbor protocol Presenting Author(s): Roy J. Goldberg, MD, Kings Harbor Multicare Center, Albert Einstein College of Medicine Author(s): Roy J. Goldberg, MD; Louis A. Kaplan, PA-C; Toni Ann Mooney, RN, APN; Liezel T. Vince Cruz, RN, ANP Introduction/Objective: Few medications undergo as detailed a risk/benefit analysis as warfarin. Fewer still are scrutinized as carefully when a negative outcome occurs. There are many different possibilities as to why an INR becomes elevated leading to a potential iatrogenic problem. Often, only in retrospect is it determined where the process failed. We developed a protocol, identifying numerous decision points where a patient could ”fall through the cracks” to minimize the possibility of future negative outcomes. Our objective was to sensitize all disciplines to the risks of warfarin therapy and to improve the percentage of INRs in the therapeutic range for those patients prescribed warfarin. Design/Methodology: A simple to use, interdisciplinary form was developed and implemented in our 720 bed subacute and LTC facility in the Bronx, NY. Involved disciplines include the medical staff, nursing, consulting pharmacy, laboratory, and dispensing pharmacy. Results: Physicians and nurses have enthusiastically accepted our new protocol with excellent compliance. Our pharmacy consultant, pharmacy provider, and laboratory have active roles cross checking prescribing and laboratory ordering. A monthly Performance Improvement review tool has noted no areas of concern, and has noted 100% correlation between information obtained from our laboratory and pharmacy for those patients prescribed warfarin. Uniformity throughout the facility has made follow-up standardized. As time progresses we expect to liberalize physician choice in the process. Conclusion/Discussion: Our new INR protocol addresses the following issues identified as potential failure-points leading to iatrogenic complications of warfarin therapy. 1. 2. 3. 4. 5. 6. 7. 8.
Adding a new medication that affects INR. Discontinuing/Holding warfarin without remembering to restart it. Forgetting to order follow-up INRs. Follow-up INRs not being obtained due to technical problems, patient refusal, nursing error. Lack of physician notification of INRs by lab or nursing. Patient refusal to take Rx without medical staff knowledge. Nursing error (ie: transcription mistakes to MAR). Medical Staff error (ie: changing dosage incorrectly).
In the three months since our protocol has been implemented, there have been no negative outcomes and a much higher percentage of INRs in the therapeutic range. This tool can be utilized in all facilities regardless of size or frequency of physician visits. Disclosures: Roy J. Goldberg, MD, Toni Ann Mooney, RN, APN, and Liezel T. Vince Cruz, RN, ANP have no disclosures to be made that are pertinent to this abstract. Louis A. Kaplan, PA-C received a speaker honorarium from Health Point.
Lifetyles: Using Q-methodology to assess quality of life and care priorities in frail elders Presenting Author(s): Richard O. Schamp, MD, St. Louis University, Program of All Inclusive Care of the Elderly Author(s): Richard O. Schamp, MD; John Chibnall, PhD; Diane Peterson, MSW; Andria Van Landuyt, MSW Introduction/Objective: Standard measures of quality of life, especially tools with incremental choices (e.g., Likert scales) perform less well as cognition, mood, function and health status decrease, such as in nursing home levels of care. Likewise, assessing effects of interventions is challenging for the interdisciplinary team, especially in chronic conditions and syndromes that affect well-being, such as persistent pain and heart failure. After assessing multiple JAMDA – March 2008
existing tools, our interdisciplinary team set out to design a tool to assess patient satisfaction in six biopsychosocial domains and to identify care priorities. Lifetyles is a card-sorting activity, based on Q-methodology, that presents 58 common activities representing spiritual, social, medical, functional, recreational and mobility domains. Patients sort the cards into three stacks: satisfied, not satisfied, and not applicable. The not satisfied stack is further sorted to identify the patient’s top three priorities for improvement. Our objective is to determine reliability and validity of this new tool. Design/Methodology: Cross-sectional study of a convenience sample of 52 patients enrolled in the Program of All-inclusive Care in St. Louis, MO. We performed test-retest with the Lifetyles tool and a comparator, the Quality of Life Enjoyment and Satisfaction Questionnaire (by J. Endicott). We recorded demographic and certain disease states. Results: 44 of the 52 test-retest pairs were suitable for analysis. The tested sample was similar to the overall PACE population in race and gender, but younger and more cognitively intact. The card sorting among the subjects between the test and retest showed high (⬎.99) correlation. Reliability was good overall (r⫽.67). Sub-sample analyses also showed reliabilities over 0.65 with better performance among younger subjects with intact cognition, more education and treated depression. Factor analysis showed strongest correlations in the Social and Recreational domains, with statistical significance. Conclusion/Discussion: This pilot study of card-sorting to assess satisfaction in multiple domains of life is reliable for frail elders with fair cognition. Face validity of patients’ claims about satisfaction is a reasonable proxy for quality of life and underscores the validity of an instrument that is more concrete, requires non-incremental judgments and involves multiple senses when considering items. Limitations include small numbers of subjects, who were younger and more functional than PACE enrollees overall, and the lack of a gold standard for assessing quality of life in frail elders. The utility of this instrument may be found in the priorities selected from the pile of unsatisfied activities; to incorporate as goals (when applicable) into care-planning. Secondly, the global measure of satisfaction may be regarded as a measure of well-being that can be monitored over time. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Medical director perceptions of mental health care in nursing facilities Presenting Author(s): Brenda K. Keller, MD, University of Nebraska Medical Center Author(s): Brenda K. Keller, MD; Emily C. Olson; Thomas M. Magnuson, MD Introduction/Objective: Approximately 80% of the residents of long-term care facilities suffer from diagnosable psychiatric disorders, such as dementia, psychosis, depression, and anxiety. In a survey of six states in 1998, a majority of responding nursing homes were dissatisfied with the amount of mental health services provided to their facilities. Nearly ten years later, after increased federal monitoring of psychiatric conditions and medications through the MDS, we sought to determine the availability of psychiatric services and the satisfaction of medical directors with these services. Design/Methodology: A 16 item survey was mailed to medical directors of 680 facilities in Nebraska and Iowa. Medical directors were asked about the availability, access and satisfaction with mental health care in their facilities. Results: Medical directors from 195 (31%) facilities returned the survey. Approximately 90% of respondents were from homes with less than 100 residents and ⬎80% lived in communities with a population less than 25,000. Mental health services were available at 90% of facilities. Psychiatrists provided services to residents of 76% of facilities, however, onsite services were available only at 37% of facilities. Travel of up to 50 miles was needed to see a psychiatrist in 22% of NH and 7% of facilities needed to transport their residents ⬎ 50 miles for psychiatric care. 58% of medical directors were satisfied with the mental health services provided. Presence of any mental health services (chi sq 6.4, p⫽0.01) or psychiatrist services (chi sq 8.8 p⫽0.003.) were positively related to satisfaction with mental health care. Community size, census, or prevalence of psychiatric medication use did not predict satisfaction. Conclusion/Discussion: Medical directors of nursing homes in smaller communities of Nebraska and Iowa seem to be more satisfied than the states ABSTRACTS
surveyed in 1998. This may be due to impact of OBRA on mental health recognition or simply a regional variation in expectations of Medical Directors toward mental health services in rural areas. Additional study is needed on the factors related to outcomes and satisfaction with psychiatric services in long term care residents. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Medical director’s perceptions and activities: A nursing home survey of medical directors in the state of Rhode Island Presenting Author(s): Michael P. Gerardo, DO, MPH, Brown University, Ohio University Author(s): Michael P. Gerardo, DO, MPH; Tom Wachtel, MD Introduction/Objective: As a response to public concern for quality of care in nursing homes, federal and state regulatory agencies have increased their focus on the role of Medical Directors in U.S. nursing homes. However, little data describes Medical Director performance in nursing homes. The purpose of this study is to examine the perceptions and activities of Medical Directors in their role within nursing homes. Design/Methodology: We surveyed all sixty-five Medical Directors in the state of Rhode Island. Three domains were addressed with Likerd scale questions- support of medical directorship by nursing home administration, responsibility for resident care policies, and coordination of medical care. In addition, we obtained demographic information. We report mean percentages of the responses with 95% confidence intervals. Results: At twelve-week post initial survey mailing, 23 medical directors responded to our survey (response rate ⫽ 35.4%). Follow-up procedures of the non-responders are currently underway. Responders were overwhelmingly male (83%) with a mean age of 56 years. Twenty percent of responders reported being a Certified Medical Director (CMD). Ninety-one percent of responders either agreed or strongly agreed that the nursing home management supports their performance as Medical Director. Ninety-two percent of responders were informed of a state survey while it occurred in a nursing home; and fifty percent of responders were present in the home at some time during the survey. Sixty-three percent of responders agreed or strongly agreed that they proactively initiate policy development concerning medical issues. Eighty-three percent of the responders agreed or strongly agreed that a Medical Director should evaluate health care providers in the nursing home; but only forty – two percent of responders agreed or strongly agreed that they should have authority over nurses and nurses’ aides. Eighty-eight percent of the responders participated in some type of quality assurance activity; and sixty-two percent of responders informed physicians of nursing home expectations and policies. Conclusion/Discussion: While Medical Directors overwhelming felt that the nursing home administration supports their role as director, we observed variations in the function performed by medical directors. Future research should examine facilitators and barriers to medical directorship and whether an increased role in nursing home care translates into better quality care. Disclosures: Michael P. Gerardo, DO, MPH has no disclosures to be made that are pertinent to this abstract. As of submission, Tom Wachtel, MD has not provided disclosures.
Minimizing nutritional products in skilled nursing facilities: Costeffective nutritional supplementation for nursing home residents Presenting Author(s): Scott M. Bolhack, MD, CMD, TLC HealthCare QIO Author(s): Scott M. Bolhack, MD, CMD; G. M. Anderson, BSNS; Barbara Viggiano, RN; Shirley Grant, LPN; Rebecca Torres Introduction/Objective: Most skilled nursing facilities (SNFs) stock a multitude of nutritional supplements without any understanding of patient needs or costs to the facility. One facility evaluated their current nutritional supplements to determine: costs/serving, nutritional characteristics of the products, and if certain products offered a cost-effective approach to supplementation. Comparisons were made to determine if we could minimize the formulary, maximize patient benefit, decrease nursing administration time, better utilize storage space and create a better understanding of prescribed B17
ITP in the elderly, rare but serious Presenting Author(s): Renante Ignacio, MD, Mercy of Northern New York, Elder Medical Services, Oswego, NY Author(s): Renante Ignacio, MD Introduction/Objective: Introduction: Idiopathic (Autoimmune) Thrombocytopenic purpura (ITP) is an autoimmune disorder in which an IgG autoantibody is formed that binds to platelets. The antiplatelet antibody may then bind complements. Platelet destruction occurs in the spleen. It occurs commonly in childhood, usually due to a viral prodrome and is self limited. It also occurs among adults, with peak incidence between ages 20-50 and rarely follows a viral infection. It tends to be a chronic disease among adults. Bone marrow biopsy reveals its pathognomic finding of normal cytology with normal or increased megakaryocytes. Patients are usually asymptomatic and afebrile. It usually presents as mucosal or skin bleeding. There is no abnormal physical finding except those related to bleeding. Rarely such an entity occurs in the elderly, but they are more prone to serious life threatening complications. Below is a clear example of how early diagnosis and empiric treatment of such a rare disease can save the life of an afflicted elderly. Design/Methodology: Case Report: An 86 year old, long term care resident, Caucasian female with dementia and hypertension presented with gradually worsening thrombocytopenia. It was initially noted to be at 109 x 10 3/ul then later plummeted to 30 x 10 3/ul in 6 months. Physical examination findings did not reveal any remarkable findings except for isolated ecchymoses on her bilateral forearms. No petechia or active bleeding. No splenomegaly noted. Comprehensive laboratory work was done to rule out its possible different etiologies. Serum protein electrophoresis, Hepatitis panel, ANA, Rheumatoid factor was essentially unremarkable. Vitamin B12 and Folic Acid levels were within normal limits. Medications were reviewed and none of them has thrombocytopenic effect. A bone marrow biopsy for definitive diagnosis was contemplated but her family later opted not to pursue such procedure. She was empirically started on Prednisone 1mg/kg for possible ITP. Her platelet count gradually returned to its normal level after a month of tapering steroid dose. She has remained clinically stable during her treatment course. Results: n/a Conclusion/Discussion: This exceptional case illustrates an atypical case of ITP in the elderly. It has been shown that it can still have a favorable response to steroid therapy, even among octogenarians. As geriatricians, we should always be aware that such rare entity can still occur and if treated promptly, can treat the disease and ultimately offer a better quality of life among our frail patients. B16
Disclosures: Renante Ignacio, MD received a speaker honorarium from Pfizer Inc.
Keeping INRs therapeutic: The Kings Harbor protocol Presenting Author(s): Roy J. Goldberg, MD, Kings Harbor Multicare Center, Albert Einstein College of Medicine Author(s): Roy J. Goldberg, MD; Louis A. Kaplan, PA-C; Toni Ann Mooney, RN, APN; Liezel T. Vince Cruz, RN, ANP Introduction/Objective: Few medications undergo as detailed a risk/benefit analysis as warfarin. Fewer still are scrutinized as carefully when a negative outcome occurs. There are many different possibilities as to why an INR becomes elevated leading to a potential iatrogenic problem. Often, only in retrospect is it determined where the process failed. We developed a protocol, identifying numerous decision points where a patient could ”fall through the cracks” to minimize the possibility of future negative outcomes. Our objective was to sensitize all disciplines to the risks of warfarin therapy and to improve the percentage of INRs in the therapeutic range for those patients prescribed warfarin. Design/Methodology: A simple to use, interdisciplinary form was developed and implemented in our 720 bed subacute and LTC facility in the Bronx, NY. Involved disciplines include the medical staff, nursing, consulting pharmacy, laboratory, and dispensing pharmacy. Results: Physicians and nurses have enthusiastically accepted our new protocol with excellent compliance. Our pharmacy consultant, pharmacy provider, and laboratory have active roles cross checking prescribing and laboratory ordering. A monthly Performance Improvement review tool has noted no areas of concern, and has noted 100% correlation between information obtained from our laboratory and pharmacy for those patients prescribed warfarin. Uniformity throughout the facility has made follow-up standardized. As time progresses we expect to liberalize physician choice in the process. Conclusion/Discussion: Our new INR protocol addresses the following issues identified as potential failure-points leading to iatrogenic complications of warfarin therapy. 1. 2. 3. 4. 5. 6. 7. 8.
Adding a new medication that affects INR. Discontinuing/Holding warfarin without remembering to restart it. Forgetting to order follow-up INRs. Follow-up INRs not being obtained due to technical problems, patient refusal, nursing error. Lack of physician notification of INRs by lab or nursing. Patient refusal to take Rx without medical staff knowledge. Nursing error (ie: transcription mistakes to MAR). Medical Staff error (ie: changing dosage incorrectly).
In the three months since our protocol has been implemented, there have been no negative outcomes and a much higher percentage of INRs in the therapeutic range. This tool can be utilized in all facilities regardless of size or frequency of physician visits. Disclosures: Roy J. Goldberg, MD, Toni Ann Mooney, RN, APN, and Liezel T. Vince Cruz, RN, ANP have no disclosures to be made that are pertinent to this abstract. Louis A. Kaplan, PA-C received a speaker honorarium from Health Point.
Lifetyles: Using Q-methodology to assess quality of life and care priorities in frail elders Presenting Author(s): Richard O. Schamp, MD, St. Louis University, Program of All Inclusive Care of the Elderly Author(s): Richard O. Schamp, MD; John Chibnall, PhD; Diane Peterson, MSW; Andria Van Landuyt, MSW Introduction/Objective: Standard measures of quality of life, especially tools with incremental choices (e.g., Likert scales) perform less well as cognition, mood, function and health status decrease, such as in nursing home levels of care. Likewise, assessing effects of interventions is challenging for the interdisciplinary team, especially in chronic conditions and syndromes that affect well-being, such as persistent pain and heart failure. After assessing multiple JAMDA – March 2008
existing tools, our interdisciplinary team set out to design a tool to assess patient satisfaction in six biopsychosocial domains and to identify care priorities. Lifetyles is a card-sorting activity, based on Q-methodology, that presents 58 common activities representing spiritual, social, medical, functional, recreational and mobility domains. Patients sort the cards into three stacks: satisfied, not satisfied, and not applicable. The not satisfied stack is further sorted to identify the patient’s top three priorities for improvement. Our objective is to determine reliability and validity of this new tool. Design/Methodology: Cross-sectional study of a convenience sample of 52 patients enrolled in the Program of All-inclusive Care in St. Louis, MO. We performed test-retest with the Lifetyles tool and a comparator, the Quality of Life Enjoyment and Satisfaction Questionnaire (by J. Endicott). We recorded demographic and certain disease states. Results: 44 of the 52 test-retest pairs were suitable for analysis. The tested sample was similar to the overall PACE population in race and gender, but younger and more cognitively intact. The card sorting among the subjects between the test and retest showed high (⬎.99) correlation. Reliability was good overall (r⫽.67). Sub-sample analyses also showed reliabilities over 0.65 with better performance among younger subjects with intact cognition, more education and treated depression. Factor analysis showed strongest correlations in the Social and Recreational domains, with statistical significance. Conclusion/Discussion: This pilot study of card-sorting to assess satisfaction in multiple domains of life is reliable for frail elders with fair cognition. Face validity of patients’ claims about satisfaction is a reasonable proxy for quality of life and underscores the validity of an instrument that is more concrete, requires non-incremental judgments and involves multiple senses when considering items. Limitations include small numbers of subjects, who were younger and more functional than PACE enrollees overall, and the lack of a gold standard for assessing quality of life in frail elders. The utility of this instrument may be found in the priorities selected from the pile of unsatisfied activities; to incorporate as goals (when applicable) into care-planning. Secondly, the global measure of satisfaction may be regarded as a measure of well-being that can be monitored over time. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Medical director perceptions of mental health care in nursing facilities Presenting Author(s): Brenda K. Keller, MD, University of Nebraska Medical Center Author(s): Brenda K. Keller, MD; Emily C. Olson; Thomas M. Magnuson, MD Introduction/Objective: Approximately 80% of the residents of long-term care facilities suffer from diagnosable psychiatric disorders, such as dementia, psychosis, depression, and anxiety. In a survey of six states in 1998, a majority of responding nursing homes were dissatisfied with the amount of mental health services provided to their facilities. Nearly ten years later, after increased federal monitoring of psychiatric conditions and medications through the MDS, we sought to determine the availability of psychiatric services and the satisfaction of medical directors with these services. Design/Methodology: A 16 item survey was mailed to medical directors of 680 facilities in Nebraska and Iowa. Medical directors were asked about the availability, access and satisfaction with mental health care in their facilities. Results: Medical directors from 195 (31%) facilities returned the survey. Approximately 90% of respondents were from homes with less than 100 residents and ⬎80% lived in communities with a population less than 25,000. Mental health services were available at 90% of facilities. Psychiatrists provided services to residents of 76% of facilities, however, onsite services were available only at 37% of facilities. Travel of up to 50 miles was needed to see a psychiatrist in 22% of NH and 7% of facilities needed to transport their residents ⬎ 50 miles for psychiatric care. 58% of medical directors were satisfied with the mental health services provided. Presence of any mental health services (chi sq 6.4, p⫽0.01) or psychiatrist services (chi sq 8.8 p⫽0.003.) were positively related to satisfaction with mental health care. Community size, census, or prevalence of psychiatric medication use did not predict satisfaction. Conclusion/Discussion: Medical directors of nursing homes in smaller communities of Nebraska and Iowa seem to be more satisfied than the states ABSTRACTS
surveyed in 1998. This may be due to impact of OBRA on mental health recognition or simply a regional variation in expectations of Medical Directors toward mental health services in rural areas. Additional study is needed on the factors related to outcomes and satisfaction with psychiatric services in long term care residents. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Medical director’s perceptions and activities: A nursing home survey of medical directors in the state of Rhode Island Presenting Author(s): Michael P. Gerardo, DO, MPH, Brown University, Ohio University Author(s): Michael P. Gerardo, DO, MPH; Tom Wachtel, MD Introduction/Objective: As a response to public concern for quality of care in nursing homes, federal and state regulatory agencies have increased their focus on the role of Medical Directors in U.S. nursing homes. However, little data describes Medical Director performance in nursing homes. The purpose of this study is to examine the perceptions and activities of Medical Directors in their role within nursing homes. Design/Methodology: We surveyed all sixty-five Medical Directors in the state of Rhode Island. Three domains were addressed with Likerd scale questions- support of medical directorship by nursing home administration, responsibility for resident care policies, and coordination of medical care. In addition, we obtained demographic information. We report mean percentages of the responses with 95% confidence intervals. Results: At twelve-week post initial survey mailing, 23 medical directors responded to our survey (response rate ⫽ 35.4%). Follow-up procedures of the non-responders are currently underway. Responders were overwhelmingly male (83%) with a mean age of 56 years. Twenty percent of responders reported being a Certified Medical Director (CMD). Ninety-one percent of responders either agreed or strongly agreed that the nursing home management supports their performance as Medical Director. Ninety-two percent of responders were informed of a state survey while it occurred in a nursing home; and fifty percent of responders were present in the home at some time during the survey. Sixty-three percent of responders agreed or strongly agreed that they proactively initiate policy development concerning medical issues. Eighty-three percent of the responders agreed or strongly agreed that a Medical Director should evaluate health care providers in the nursing home; but only forty – two percent of responders agreed or strongly agreed that they should have authority over nurses and nurses’ aides. Eighty-eight percent of the responders participated in some type of quality assurance activity; and sixty-two percent of responders informed physicians of nursing home expectations and policies. Conclusion/Discussion: While Medical Directors overwhelming felt that the nursing home administration supports their role as director, we observed variations in the function performed by medical directors. Future research should examine facilitators and barriers to medical directorship and whether an increased role in nursing home care translates into better quality care. Disclosures: Michael P. Gerardo, DO, MPH has no disclosures to be made that are pertinent to this abstract. As of submission, Tom Wachtel, MD has not provided disclosures.
Minimizing nutritional products in skilled nursing facilities: Costeffective nutritional supplementation for nursing home residents Presenting Author(s): Scott M. Bolhack, MD, CMD, TLC HealthCare QIO Author(s): Scott M. Bolhack, MD, CMD; G. M. Anderson, BSNS; Barbara Viggiano, RN; Shirley Grant, LPN; Rebecca Torres Introduction/Objective: Most skilled nursing facilities (SNFs) stock a multitude of nutritional supplements without any understanding of patient needs or costs to the facility. One facility evaluated their current nutritional supplements to determine: costs/serving, nutritional characteristics of the products, and if certain products offered a cost-effective approach to supplementation. Comparisons were made to determine if we could minimize the formulary, maximize patient benefit, decrease nursing administration time, better utilize storage space and create a better understanding of prescribed B17