Physical activity is a potential measure of physical resilience in older adults receiving hemodialysis

BackgroundPhysical resilience, or the ability to recover after a physical stressor, declines with aging. Efforts to preserve physical resilience in the older dialysis population are critically needed; however, validated, patient-centered measures that are sensitive to change are also needed. Our objective was to assess accelerometer-derived step count variability, or a measure of intra-individual variation in physical activity, as a potential measure of physical resilience among older adults receiving hemodialysis.MethodsCommunity-dwelling ambulatory older adults receiving in-center hemodialysis were prospectively enrolled. Participants wore wrist accelerometers during daytime hours on both dialysis and non-dialysis days up to 14 days, and the feasibility of accelerometer use was assessed from wear time. We used accelerometer data to compute step counts in 4-hour blocks and step count variability. Physical function was assessed with the Short Physical Performance Battery (SPPB which includes gait speed test), grip strength, activities of daily living (ADLs) instruments, and life space mobility. We assessed interval fatigue (subjective rating from 0 to 10) on dialysis and non-dialysis days and self-reported recovery time. We assessed the correlations of step count variability with measures of physical function and step count and interval fatigue.ResultsOf 37 enrolled participants, 29 had sufficient accelerometer data for analyses. Among the 29 participants, mean (SD) age was 70.6(4.8) years, and 55% (n=16) were male and 72% (n=21) were Black race. Participants were largely sedentary with median (Q1-Q3) self-reported total kilocalories per week of 200 (36–552). Step count variability was positively correlated with measures of physical function: SPPB (r=0.50, p<0.05), gait speed (r=0.59, p<0.05), handgrip strength (r=0.71, p<0.05), Instrumental ADLs (r=0.44, p<0.05) and life space mobility (r=0.54, p<0.05).There was a weak inverse correlation between post-dialysis step counts (4-hour blocks after a dialysis session) and post-dialysis interval fatigue [r=-0.19 (n=102, p=0.06).ConclusionsPhysical activity assessment via accelerometer is feasible for older adults receiving hemodialysis. Step count variability correlated with physical function, so it may be a novel measure of physical resilience. Further studies are needed to validate this measure

Transitional care of older adults in skilled nursing facilities: A systematic review

Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1,082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients

MDS Coordinator Relationships and Nursing Home Care Processes

The purpose of this study was to describe how Minimum Data Set (MDS) Coordinators' relationship patterns influence nursing home care processes. The MDS Coordinator potentially interacts with staff across the nursing home to coordinate care processes of resident assessment and care planning. We know little about how MDS Coordinators enact this role or to what extent they may influence particular care processes beyond paper compliance. Guided by complexity science and using two nursing home case studies as examples (pseudonyms Sweet Dell and Safe Harbor), we describe MDS Coordinators' relationship patterns by assessing the extent to which they used and fostered the relationship parameters of good connections, new information flow, and cognitive diversity in their work. Sweet Dell MDS Coordinators fostered new information flow, good connections, and cognitive diversity, which positively influenced assessment and care planning. In contrast, Safe Harbor MDS Coordinators did little to foster good connections, information flow, or cognitive diversity with little influence on care processes. This study revealed that MDS Coordinators are an important new source of capacity for the nursing home industry to improve quality of care. Findings suggest ways to enhance this capacity

Transitional care in skilled nursing facilities: a multiple case study

Abstract Background Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement. Methods In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services. Results Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions. Conclusions Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care

Certified Nursing Assistants' Explanatory Models of Nursing Home Resident Depression

In this study, we explored how Certified Nursing Assistants (CNAs) understood resident depression. Interviews with 18 CNAs, working in two nursing homes were guided by Kleinman’s Explanatory Models of Illness framework. Interview data were content analyzed and CNAs’ descriptions of depression were compared to the MDS 2.0 Mood Screen and to DSM-IV-TR Depression Criteria. CNAs identified causes, signs, and symptoms of depression, but they were unsure about the duration and normalcy of depression in residents. Although they had no formal training, CNAs felt responsible for detecting depression and described verbal and non-verbal approaches that they used for emotional care of depressed residents. CNAs hold potential to improve the detection of depression and contribute to the emotional care of residents. Attention to knowledge deficits and facility barriers may enhance this capacity

Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies

Medication discrepancies are unintended differences between medication regimens (ie, between a patient’s home regimen and medications prescribed on admission to the hospital)

Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge

The primary objective of this study was to describe the time to first acute-care use (e.g., emergency department use without hospitalization or rehospitalization)for older adults who discharged to home after receiving post-acute care in skilled nursing facilities (SNFs). The secondary objective was to identify predictors of patients' first acute-care use

Staff perceptions of staff-family interactions in nursing homes

Each year thousands of older adults are admitted to nursing homes. Following admission, nursing home staff and family members must interact and communicate with each other. This study examined relationship and communication patterns between nursing home staff members and family members of nursing home residents, as part of a larger multi-method comparative case study. Here, we report on 6- month case studies of two nursing homes where in-depth interviews, shadowing experiences, and direct observations were completed. Staff members from both nursing homes described staff-family interactions as difficult, problematic and time consuming, yet identified strategies that when implemented consistently, influenced the staff-family interaction positively. Findings suggest explanatory processes in staff-family interactions, while pointing toward promising interventions

Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers

Abstract Background Little is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC. Methods In eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports. Results Staff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using “train the trainer” approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability. Conclusions When designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability. Trial registration ClinicalTrial.gov, NCT0063667

CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes

<p>Abstract</p> <p>Background</p> <p>Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures.</p> <p>Methods/design</p> <p>Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model.</p> <p>Discussion</p> <p>By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00636675">NCT00636675</a></p