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Partnering with Patients and Caregivers to Optimize Expectations and Outcomes for Post-Acute Rehabilitation
B20
Quality Improvement / JAMDA 16 (2015) B16eB25
patient measures of functioning and other factors which may improve the quality of life of individuals with dementia in LTC. Through this project we hope to improve the care of frail older adults with dementia in LTC and identify strategies that could be adopted by other LTC homes in the future. Conclusion: The OPAL project is a stepped-wedge controlled trial evaluating the impact of a multi-component intervention to reduce inappropriate antipsychotic use in 30 LTC homes in Canada. Through this project we aim to improve the care and outcomes of the growing number of older adults with dementia in LTC and identify strategies to help LTC facilities provide the best care for the growing number of older adults with dementia in LTC. Author Disclosures: Funding for this study is provided to Dr. Seitz through the Canadian Institutes of Health Research research program the Canadian Consortium on Neurodegeneration in Aging.
Partnering with Patients and Caregivers to Optimize Expectations and Outcomes for Post-Acute Rehabilitation Presenting Author: Bobaker Elalem, MB BCH, Duke University Author(s): Bobaker Elalem, MB BCH, Adedayo Fashoyin, MD, Rachel Suter, MD, Sarah Wingfield, MD, Mamata Yanamadala, MBBS, MS; and Heidi White, MD, MEd
Background: Using a nominal group technique to elicit priorities from our SNF colleagues, we found that they prioritized detailed information regarding patient goals of care as something that was too often missing at hospital discharge and desperately needed to facilitate patient-centered care. When not effectively addressed and communicated, unrealistic expectations may hinder rehabilitation progress. For example inattention to this aspect of personalized care may result in patient/family dissatisfaction, frustration amongst the SNF staff, and higher readmission rates. Objective/Aim: To address, document and communicate discussions during hospitalization of a patient’s expectations regarding goals of care to the SNF in at least 50% of patients seen over 6 months. Quality Improvement Methods: The HOPE (Health Optimization Program for Elders) program at Duke University Hospital ensures the transitional care needs of vulnerable seniors are met via integrated geriatric care services. The following questions were added to the HOPE consultation template in order to assess patient goals: What is your understanding of your diagnosis/prognosis? What are your concerns about transfer to the SNF? What do you hope to accomplish at the SNF? Are you open to discussing contingency plans if your goals are not met? Do you have personal habits or preferences you would like the SNF to know about? Primary measures will be the number of times we are able to collect and document patient’s response to these questions, and gauge the impact of this documentation on the post-acute stay and patient goal achievement. Results: Results will be available for the poster presentation. Conclusion: Advance care planning for older adults who will receive post-acute rehabilitation should include documentation of patient understanding of diagnosis, prognosis and expectations for rehabilitation. Communication of such discussions will personalize their care and is likely to improve patient satisfaction and set up the SNF professional staff for meeting the needs and expectations. Author Disclosures: The presenting author has no financial disclosures to be made that are pertinent to this abstract.
Persistence of Delirium Upon Transition from Acute to Post-Acute Care Presenting Author: Ravindra Amin, MD, New York University School of Medicine Author(s): Ravindra Amin, MD; and Gangaiah Kanakamedala, MD
Background: Prevalence of delirium, a syndrome associated with high morbidity and mortality, is reported to be 14% to 23% at the time of admission to a post-acute care setting in the studies that used validated screening or assessment tools to identify delirium cases. Impact of research findings on clinical practice is unknown.
Objective/Aim: To estimate prevalence and management variables of delirium in routine clinical practice upon transition from acute to the postacute care setting. Quality Improvement Methods: In a 240 bed post-acute care facility, a retrospective chart review was conducted to review the admitting assessments and psychiatric consultations for all consecutive admissions over a six months period. Data were collected to measure the prevalence of delirium, and it’s etiological and management correlates. Results: Delirium was diagnosed in 47 of the 195 psychiatric consultations performed among 613 consecutive admissions from January 1st to June 30th 2014. There was no delirium diagnosis among the patients not seen by the psychiatrist. Hand-off from acute to post-acute care: 15/47 delirium cases were treated with antipsychotic medications upon the transition, but none of the 613 admissions were given a diagnosis of delirium. Major causes of delirium were hip fracture (14/47, 29.8%), non-hip fracture (5/47, 10.4%), infection - including sepsis, UTI, pneumonia, cellulitis - (11/47, 23.4%) among others. Dementia was co-morbid in 24/47 patients with delirium. Antipsychotic use pattern: A) 15/47 patients with delirium were on an antipsychotic upon admission to post-acute setting; the antipsychotic was discontinued in 9/15, and continued in 6/15. B) Of the 32 patients who were not on antipsychotic medication upon admission, 9 were started on antipsychotic medication. C) 24/47 cases received an antipsychotic medication at any time; 23/47 delirium cases did not receive any antipsychotic medication. Safety considerations: There was no use of restraints of 1:1 staff observation in any patient with delirium, but 10 delirium patients were placed or moved very close to the nurses’ station for close observation. Family distress: 15 families of delirium cases eudured intense distress and received support and education from the psychiatrist. Conclusion: Delirium persists in a significant number of patients upon transition from acute to post-acute care and it tends to remain underidentified. Studies to measure the magnitude and causes of the gap between prevalence of delirium in research setting and clinical practice are indicated. Focused staff education to improve the efficacious use of delirium screening tool (Confusion Assessment Method) that is an integral part of the Minimum Data Set is warranted. A consulting psychiatrist has a unique opportunity to provide in vivo staff and family education to improve identification and management of delirium. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
POISe-Care: A Team-based Bedside Model for Care in SNF Setting Presenting Author: Arif Nazir, MD, CMD, Indiana University Author(s): Arif Nazir, MD, CMD; and Kathleen Abrahamson, RN, PhD
Background: Patients admitted to skilled nursing facilities (SNFs) have complex medical, functional and psychosocial needs. Several barriers (e.g. low staffing, inadequate training and time constraints) impede provision of a truly interdisciplinary and patient-centered experience in the SNF setting. Physician and patient-engagement in care is critical and improves quality of care. Unfortunately, current SNFs lack formal interdisciplinary processes that include physicians or facilitate patient and caregiver engagement. Objective/Aim: A team that included the SNF medical director, director of nursing, administrator, front-line staff and two patient representatives was assembled to: 1) Design a model that: a) included providers as active team members and b) engaged patients/ caregivers to direct care based on their own goals and preferences. 2) Create tools to: a) assure consistent and timely care and b) provide prompt and continuous feedback to the team on its performance (team accountability). 3) Devise the implementation and evaluation strategy for the model. Quality Improvement Methods: The quality improvement initiative was conducted at Westpark, the Center for Patient-Oriented and Team-based Rehabilitation – an 82-bed, urban SNF in Indianapolis. The team met regularly to design the model, discuss logistics, and devise tools and strategies for implementation and evaluation. Results: A new model, “Patient-Oriented Interdisciplinary Sub-acute Care” (POISe-Care) was designed with the unique philosophy of “Patients
Quality Improvement / JAMDA 16 (2015) B16eB25
patient measures of functioning and other factors which may improve the quality of life of individuals with dementia in LTC. Through this project we hope to improve the care of frail older adults with dementia in LTC and identify strategies that could be adopted by other LTC homes in the future. Conclusion: The OPAL project is a stepped-wedge controlled trial evaluating the impact of a multi-component intervention to reduce inappropriate antipsychotic use in 30 LTC homes in Canada. Through this project we aim to improve the care and outcomes of the growing number of older adults with dementia in LTC and identify strategies to help LTC facilities provide the best care for the growing number of older adults with dementia in LTC. Author Disclosures: Funding for this study is provided to Dr. Seitz through the Canadian Institutes of Health Research research program the Canadian Consortium on Neurodegeneration in Aging.
Partnering with Patients and Caregivers to Optimize Expectations and Outcomes for Post-Acute Rehabilitation Presenting Author: Bobaker Elalem, MB BCH, Duke University Author(s): Bobaker Elalem, MB BCH, Adedayo Fashoyin, MD, Rachel Suter, MD, Sarah Wingfield, MD, Mamata Yanamadala, MBBS, MS; and Heidi White, MD, MEd
Background: Using a nominal group technique to elicit priorities from our SNF colleagues, we found that they prioritized detailed information regarding patient goals of care as something that was too often missing at hospital discharge and desperately needed to facilitate patient-centered care. When not effectively addressed and communicated, unrealistic expectations may hinder rehabilitation progress. For example inattention to this aspect of personalized care may result in patient/family dissatisfaction, frustration amongst the SNF staff, and higher readmission rates. Objective/Aim: To address, document and communicate discussions during hospitalization of a patient’s expectations regarding goals of care to the SNF in at least 50% of patients seen over 6 months. Quality Improvement Methods: The HOPE (Health Optimization Program for Elders) program at Duke University Hospital ensures the transitional care needs of vulnerable seniors are met via integrated geriatric care services. The following questions were added to the HOPE consultation template in order to assess patient goals: What is your understanding of your diagnosis/prognosis? What are your concerns about transfer to the SNF? What do you hope to accomplish at the SNF? Are you open to discussing contingency plans if your goals are not met? Do you have personal habits or preferences you would like the SNF to know about? Primary measures will be the number of times we are able to collect and document patient’s response to these questions, and gauge the impact of this documentation on the post-acute stay and patient goal achievement. Results: Results will be available for the poster presentation. Conclusion: Advance care planning for older adults who will receive post-acute rehabilitation should include documentation of patient understanding of diagnosis, prognosis and expectations for rehabilitation. Communication of such discussions will personalize their care and is likely to improve patient satisfaction and set up the SNF professional staff for meeting the needs and expectations. Author Disclosures: The presenting author has no financial disclosures to be made that are pertinent to this abstract.
Persistence of Delirium Upon Transition from Acute to Post-Acute Care Presenting Author: Ravindra Amin, MD, New York University School of Medicine Author(s): Ravindra Amin, MD; and Gangaiah Kanakamedala, MD
Background: Prevalence of delirium, a syndrome associated with high morbidity and mortality, is reported to be 14% to 23% at the time of admission to a post-acute care setting in the studies that used validated screening or assessment tools to identify delirium cases. Impact of research findings on clinical practice is unknown.
Objective/Aim: To estimate prevalence and management variables of delirium in routine clinical practice upon transition from acute to the postacute care setting. Quality Improvement Methods: In a 240 bed post-acute care facility, a retrospective chart review was conducted to review the admitting assessments and psychiatric consultations for all consecutive admissions over a six months period. Data were collected to measure the prevalence of delirium, and it’s etiological and management correlates. Results: Delirium was diagnosed in 47 of the 195 psychiatric consultations performed among 613 consecutive admissions from January 1st to June 30th 2014. There was no delirium diagnosis among the patients not seen by the psychiatrist. Hand-off from acute to post-acute care: 15/47 delirium cases were treated with antipsychotic medications upon the transition, but none of the 613 admissions were given a diagnosis of delirium. Major causes of delirium were hip fracture (14/47, 29.8%), non-hip fracture (5/47, 10.4%), infection - including sepsis, UTI, pneumonia, cellulitis - (11/47, 23.4%) among others. Dementia was co-morbid in 24/47 patients with delirium. Antipsychotic use pattern: A) 15/47 patients with delirium were on an antipsychotic upon admission to post-acute setting; the antipsychotic was discontinued in 9/15, and continued in 6/15. B) Of the 32 patients who were not on antipsychotic medication upon admission, 9 were started on antipsychotic medication. C) 24/47 cases received an antipsychotic medication at any time; 23/47 delirium cases did not receive any antipsychotic medication. Safety considerations: There was no use of restraints of 1:1 staff observation in any patient with delirium, but 10 delirium patients were placed or moved very close to the nurses’ station for close observation. Family distress: 15 families of delirium cases eudured intense distress and received support and education from the psychiatrist. Conclusion: Delirium persists in a significant number of patients upon transition from acute to post-acute care and it tends to remain underidentified. Studies to measure the magnitude and causes of the gap between prevalence of delirium in research setting and clinical practice are indicated. Focused staff education to improve the efficacious use of delirium screening tool (Confusion Assessment Method) that is an integral part of the Minimum Data Set is warranted. A consulting psychiatrist has a unique opportunity to provide in vivo staff and family education to improve identification and management of delirium. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
POISe-Care: A Team-based Bedside Model for Care in SNF Setting Presenting Author: Arif Nazir, MD, CMD, Indiana University Author(s): Arif Nazir, MD, CMD; and Kathleen Abrahamson, RN, PhD
Background: Patients admitted to skilled nursing facilities (SNFs) have complex medical, functional and psychosocial needs. Several barriers (e.g. low staffing, inadequate training and time constraints) impede provision of a truly interdisciplinary and patient-centered experience in the SNF setting. Physician and patient-engagement in care is critical and improves quality of care. Unfortunately, current SNFs lack formal interdisciplinary processes that include physicians or facilitate patient and caregiver engagement. Objective/Aim: A team that included the SNF medical director, director of nursing, administrator, front-line staff and two patient representatives was assembled to: 1) Design a model that: a) included providers as active team members and b) engaged patients/ caregivers to direct care based on their own goals and preferences. 2) Create tools to: a) assure consistent and timely care and b) provide prompt and continuous feedback to the team on its performance (team accountability). 3) Devise the implementation and evaluation strategy for the model. Quality Improvement Methods: The quality improvement initiative was conducted at Westpark, the Center for Patient-Oriented and Team-based Rehabilitation – an 82-bed, urban SNF in Indianapolis. The team met regularly to design the model, discuss logistics, and devise tools and strategies for implementation and evaluation. Results: A new model, “Patient-Oriented Interdisciplinary Sub-acute Care” (POISe-Care) was designed with the unique philosophy of “Patients