Background: Nursing home residents with end-stage renal disease (ESRD) are an understudied, yet growing population within nursing homes.

Purpose: To describe hospital transfers for nursing home residents diagnosed with ESRD and receiving hemodialysis.

Methods: Data were analyzed for residents with ESRD transferred to the hospital between October 2016 and September 2020 (n = 219). Descriptive statistics, bivariate  analyses, logistic regression, and content analysis were used for analysis. (more…)

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Objectives: Research shows advanced practice registered nurses (APRNs) embedded in nursing homes (NHs) reduce resident hospitalizations. However, the specific APRN activities that reduce hospitalizations have not been adequately investigated. This study aims to identify the causal links between APRN activities and NHs resident  hospitalization. The study also examined relationships among other variables, including advanced directives, clinical diagnosis, and length of hospitalization.

Design: Secondary data analysis.

Setting and Participants: Residents of NHs participating in the Missouri Quality Initiative for Nursing Homes, 2016e2019.

Methods: We performed a secondary analysis of data from the Missouri Quality Initiative for Nursing Homes Intervention using causal discovery analysis, a machine learning, data-driven technique to determine causal relationships across data. The resident roster and INTERACT resident hospitalization datasets were combined to create the final dataset. Variables in the analysis model were divided into before and after hospitalization. Expert consensus was used to validate and interpret the outcomes.

Results: The research team analyzed 1161 hospitalization events and their associated NH activities. APRNs evaluated NH residents before a transfer, expedited follow-up nursing assessments, and authorized hospitalization when necessary. No significant causal relationships were found between APRN activities and the clinical diagnosis of a resident. The analysis also showed multifaceted relationships related to having advanced directives and duration of hospitalization.

Conclusions and Implications: This study demonstrated the importance of APRNs embedded in NHs to improve resident outcomes. APRNs in NHs can facilitate communication and collaboration among the nursing team, leading to early identification and treatment for resident status changes. APRNs can also initiate more timely transfers by reducing the need for physician authorization. These findings emphasize the crucial role of APRNs in NHs and suggest that budgeting for APRN services may be an effective strategy to reduce hospitalizations. Additional findings regarding advance directives are discussed.

Knoo, L., Kummerfeld, E., Robinson, E., Anderson, L., & Rantz, M. (2023). Data-driven analytics to discover APRNs impact on nursing home hospitalization: causal discovery analysis. Journal of the American Medical Directors Association, 24(11), 1746-1754.

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Injuries, infections, behavioral incidents and family insistence often drive hospital admissions among nursing home residents, and a new study finds many of those transfers may be unavoidable.

Researchers: More hospital admissions are ‘unavoidable’ than previously thought – McKnight’s Long-Term Care News

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Context: In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only).

Methods: Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality.

Findings: Three key components were necessary for successful implementation of the Initiative—staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations.

Conclusions: Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations.Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve

Tyler, D.A., Feng, Z., Grabowski, D.C., Bercaw, L., Segelman, M., Khatutsky, G., Wang, J., Gasdaska, A., & Ingber, M.J. (2022). CMS initiative to reduce potentially avoidable hospitalizations among long‐stay nursing facility residents: lessons learnedThe Milbank Quarterly, 100(4), 1243-1278.

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Study also found those with ‘full-code’ status regarding end-of-life care more likely to have repeat transfers than those with ‘do-not-resuscitate’ status.

Nursing homes transfer roughly 25% of their residents to the hospital at least once, at a cost of $14.3 billion to Medicare, according to a federal report by the Office of Inspector General.

But a new study by the University of Missouri discovered the number of repeat transfers are much higher for Black nursing home residents and those under age 65.

In one of the few studies to analyze the demographics of nursing home residents who get repeatedly transferred to the hospital, Amy Vogelsmeier, an associate professor in the MU Sinclair School of Nursing, found that Black nursing home residents, those under age 65 and those with “full-code” status were significantly more likely to be transferred to the hospital, at least four times or more in a given year.

“Black Nursing Home Residents, Those under Age 65 More Likely to Have Repeat Transfers to Hospital, MU Study Finds.” ShowMeMizzou, 1 July 2022, https://showme.missouri.edu/2022/black-nursing-home-residents-those-under-age-65-more-likely-to-have-repeat-transfers-to-hospital-mu-study-finds/. Accessed 5 July 2022.

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Background: Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers.

Methods: This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described.

Results: Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable.

Conclusions: Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

Vogelsmeier, A., Popejoy, L., Fritz, E., Canada, K., Ge, B., Brandt, L., & Rantz, M. (2022). Repeat hospital transfers among long stay nursing home residents: A mixed methods analysis of age, race, code status, and clinical complexity. BMC Health Services Research, 22(1), 626-638.

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The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff

The Committee on the Quality of Care in Nursing Homes began their work in the fall of 2020 at a pivotal time when a bright light had been cast on care delivered in nursing homes because of the COVID-19 pandemic. While much of society previously had little awareness of the care delivered in nursing homes, the evening news channels and social media projected daily images of the pandemic’s impact and of the inadequate care that put the safety of both residents and staff at risk while distraught family members watched from afar as their frail older loved ones were kept in isolation. The committee worked to describe the care being delivered in nursing homes before the pandemic, now made manifest by the crisis.

Read the full report HERE! Or check out the highlights (summary document) HERE!

Press regarding the report release: Associated Press | McKnights Long-Term Care News | STAT | Modern Healthcare | ABC 17 (KMIZ) News

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Marilyn Rantz, a Curators’ professor emerita at the MU Sinclair School of Nursing, is a member of the Committee on the Quality of Care in Nursing Homes. The panel was organized by the National Academies of Sciences, Engineering and Medicine and first met in the fall of 2020, according to a news release.

Read the full article about the committee’s report HERE!

KOMU News, April 18, 2022. Written by Hannah Norton.

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The importance of health information technology use in nursing home (NH) care delivery is a major topic in research exploring methods to improve resident care. Topics of interest include how technology investments, infrastructure, and workforce development lead to better methods of nursing care delivery and outcomes. Value propositions, including perceived benefits, incentives, and system changes recognized by end-users, are important resources to inform NH leaders, policymakers, and stakeholders about technology. The purpose of the current research was to identify and disseminate value propositions from a community of stakeholders using a health information exchange (HIE). Researchers used a nominal group process, including 49 individual stakeholders participating in a national demonstration project to reduce avoidable hospitalizations in NHs. Stakeholders identified 41 total anticipated changes from using HIE. Ten stakeholder types were perceived to have experienced the highest impact from HIE in areas related to resident admissions, communication, and efficiency of care delivery.

Alexander, G.L., Galambos, C., Rantz, M., Shumate, S., Vogelsmeier, A., Popejoy, L., & Crecelius, C. (2022). Value propositions for health information exchange toward improving nursing home hospital readmission rates. Journal of Gerontological Nursing, 48(1), 15-20.

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Background: US nursing homes (NHs) have struggled to overcome a historic pandemic that laid bare limitations in the number and clinical expertise of NH staff.

Problem: For nurse staffing, current regulations require only one registered nurse (RN) on duty 8 consecutive hours per day, 7 days per week, and one RN on call when a licensed practical/vocational nurse is on duty. There is no requirement for a degreed or licensed social worker, and advanced practice registered nurses (APRNs) in NHs cannot bill for services.

Approach: It is time to establish regulation that mandates a 24-hour, 7-day-a-week, on-site RN presence at a minimum requirement of 1 hour per resident-day that is adjusted upward for greater resident acuity and complexity. Skilled social workers are needed to improve the quality of care, and barriers for APRN billing for services in NHs need to be removed.

Conclusions: Coupling enhanced RN and social work requirements with access to APRNs can support staff and residents in NHs.

Popejoy, L.L., Vogelsmeier, A.A., Canada, K.E., Kist, S., Miller, S.J., Galambos, C., Alexander, G.L., Crecelius, C., & Rantz, M. (2021). A call to address RN, social work, and advanced practice registered nurses in nursing homes. Journal of Nursing Care Quality, 37(1), 21-27.

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