Developing a Set of Indicators to Assess End-of-Life Care in Massachusetts Nursing Homes: Final Report

Nursing homes are often the final residence for many people. Studies have estimated that as many as 20 to 25 percent of deaths due to chronic illness in the U.S. occur in nursing homes. In recognition of the trend of increasing utilization of nursing homes as a setting for the end of life, and the opportunities and challenges for end-of-life care in nursing homes, in July 2004, Commonwealth Medicine (a division of the UMass Medical School) awarded an internal grant to the study team to develop a set of indicators that can be used to assess and evaluate the appropriateness of end-of-life care for residents of nursing homes in Massachusetts. The indicators and the results of the analysis are a basis from which future research can be conducted, and from which quality improvement programs can be initiated. This report presents the project’s results. The project was guided by an advisory group of researchers, nursing home administrators, directors of nursing, geriatricians, advocates, and policy makers. First, a comprehensive literature review was conducted to inform the project. Second, a set of indicators were developed within seven domains of end of life care: 1) structure and processes of care; 2) physical and emotional aspects of care; 3) advanced care planning; 4) ethical and legal aspects of care; 5) aggressive care near death; 6) family satisfaction; and 7) provider continuity, skill, and satisfaction. Third, the indicators were prioritized by the advisory group using a structured prioritization process in order to determine which indicators had the most relevance to assessing end-of-life care in the nursing home setting. Fourth, baseline data were collected for a small set of indicators. Data were collected from Massachusetts Medicaid claims data and a family survey. A total of 44 indicators were developed in the seven domains. The indicators within each domain were prioritized and the results of the structured prioritization process are provided in the body of the report. Baseline data were collected for five of the indicators: death in hospital; overall hospice use; length of stay on hospice; total Medicaid resource use at the end of life; and family satisfaction. This project sets forth a slate of indicators that can be used by nursing homes, coalitions, community groups, state agencies, and researchers to evaluate the quality of end-of-life care in nursing homes. With long histories of providing care to this vulnerable population, nursing homes can be well-positioned in the future to provide symptom management, advance care planning support, appropriate care to the imminently dying, and emotional support to staff and other residents. However, nursing homes face many challenges to providing high-quality end-of-life care. With continuing attention on the strengths of nursing homes and the needs of dying residents, improvements in the processes of care and the policy environment to support high-quality end-of-life care are possible. Moreover, the indicators presented in this report can provide the critical tools in evaluating the success of future interventions to improve the end-of-life care for nursing home residents

Lesson in a pill box: teaching about the challenges of medication adherence

BACKGROUND AND OBJECTIVES: Medication mismanagement is a serious health issue affecting elders and people with disabilities, who often manage multiple medications. This project\u27s goal was to educate medical and nursing students about the challenges patients face when managing complex medication regimens. METHODS: A total of 104 first-year medical students and 40 second-year nursing students were randomly assigned to participate in a 1-week regimen of mock prescriptions or to read a description of the regimen and make predictions about what the experience would be like had they participated. RESULTS: Quantitative results in combination with qualitative information suggest that the students taking the mock prescriptions gained important insights into the difficulty of managing a complicated medication regimen. DISCUSSION: This mock prescription exercise, well accepted by students and faculty, was easily incorporated into the curriculum and provided an experiential opportunity for students to learn of the difficulties of medication adherence

Meeting Students Where They Are: Educating Students with Varying Life Experiences About the Health Care Needs of Persons with Disabilities

Purpose: Medical students enter preclinical years with varying levels of experience with individuals with disabilities. Previous experience has been shown to have a significant impact on attitudes toward this population and, hence, has the potential to impact patient care (Tervo et. al, 2002). This study examined the impact of a one-day Interclerkship on students’ self-reports regarding specific components of their attitudes, by level and type of previous disability experience. Methodology: Students met with individuals with physical or cognitive disabilities and their families in small groups to discuss their health care needs and experiences. Students also viewed a short film regarding effective methods of communication with and modifications to the clinical encounter for individuals with physical disabilities. Afternoon workshops covered a wide array of topics including assistive technology, sexuality/childbirth, mental health, community resources and bladder management. Students reported levels of experience cognitive/physical: friends, relatives, schoolmates k-12 and college. 153 (77%) students over two years completed pre-and post-Interclerkship self-assessments that rated attitudes about medical care for patients with disabilities, using a 14-item 5-point Likert scale; means were compared by paired t-test. Students also provided course feedback. Results: There was a highly significant (pConclusions: A single-day Interclerkship improved the attitudes of students’ reporting all levels and types of disability experience

Meeting Challenges in Caring for Patients with Disabilities: An Interclerkship Course

Purpose: People with disabilities use healthcare services more than those without disabilities, yet healthcare systems often fail these individuals. Understanding the needs of those with physical and cognitive disabilities is crucial in providing them with appropriate healthcare. A one-day Interclerkship introduced third-year medical students to key challenges for physicians who care for disabled patients: (1) building trust and confidence, (2) communication, (3) anticipating secondary medical conditions, (4) appropriately modifying clinical encounters, and (5) identifying appropriate community resources. Methodology: Essential elements of patient-centered care for disabled individuals were presented in plenary sessions. In small groups, students met with individuals with physical or development disabilities, their families and their community advocates, discussing healthcare and access concerns. Other workshops, taught by clinical and community experts, addressed assistive technology, parenting challenges, mental health, community resources, sexuality, and end-of-life care. Sixty-seven (69%) students completed pre-and post-Interclerkship self-assessments that rated knowledge, skills, and attitudes about medical care for disabled patients, using a 14-item 5-point Likert scale; means were compared by paired t-test. Students also provided course feedback. Results: There was a highly significant (p80% of the students agreed or strongly agreed that the Interclerkship addressed a topic essential to physician training, providing knowledge and skills not obtained elsewhere. Conclusions: A single-day Interclerkship successfully improved third year medical students self-assessed knowledge, attitudes and skills on providing appropriate medical care for disabled patient. Presented at the AAMC (Association of American Colleges) Annual Meeting, RIME (Research in Medical Education) Program, November 2006

Twelve-Month Diagnosed Prevalence of Mental Illness, Substance Use Disorders, and Medical Comorbidity in Massachusetts Medicare and Medicaid Members Aged 55 and Over, 2005

This report describes the 12-month diagnosed prevalence of behavioral health disorders (BHDs) among Massachusetts Medicare and Medicaid (MassHealth) members 55 years of age and older during calendar year 2005. Although population-based estimates of prevalence of BHDs among the elderly are available in only a few selected studies, none of them describe Massachusetts. With an expected rise in the number of elderly people with psychiatric disorders, a better understanding of the prevalence of mental illness and addictions in this population is needed to plan for services and supports

Leveraging the PASRR process to divert and transition elders with mental illness from nursing facilities

This study examines how some states use Pre-Admission Screening and Resident Review (PASRR) processes to provide opportunities for nursing facility diversion and/or transition for elders with mental illness and highlights potential promising practices from selected states. Document reviews and interviews were conducted with key informants across 13 states. Key themes presented are 1) philosophies of diversion/transition embedded into PASRR processes, 2) questions on screening tools used to promote diversion/transition, 3) PASRR authorities\u27 collaboration with other initiatives to promote diversion/transition, and 4) the extent to which states used PASRR to help identify mental health supports needed by nursing facility residents. Findings provide policy-relevant information to help states consider enhancement of their PASRR processes to further support nursing facility diversion and transition for persons with mental illness and improved mental health services for those in nursing facilities

Elders with Serious Mental Illness: Lost Opportunities and New Policy Options

This article reviews key federal Medicaid policies affecting older adults with serious, long-term mental illness: (a) the Medicaid exclusion of coverage for Institutions for Mental Diseases, (b) the Preadmission Screening and Resident Review Process, and (c) the Medicaid Home and Community Based Services waiver policy. Documenting the incentives and restrictions in these policies provides an historical context for understanding the current gaps in treatment for elders with mental illness. New federal options under the Deficit Reduction Act may provide opportunities for reducing the institutional bias for older adults with mental illness and for improving mental health services for elders under Medicaid

Commentary: Defining Disability in Health Care Education

According to the 2008 American Community Survey, about 12% of the population of the United States is living with one or more disabling conditions. These conditions impact lives in a variety of ways, some with more or less direct impact on an individual\u27s health and access to health care services. Although it has been 20 years since the passage of the Americans with Disabilities Act, people with disabilities still experience health disparities and a lack of access to the appropriate care. This commentary is part of a collection of articles that describe various aspects of incorporating content into the medical school curriculum to enhance the preparation of today\u27s medical students to meet the needs of people with disabilities. The authors briefly describe the scope of the problem and define the population of people with disabilities that constitutes the focus of the work described in the other articles in this collection

Commentary: defining disability in health care education

According to the 2008 American Community Survey, about 12% of the population of the United States is living with one or more disabling conditions. These conditions impact lives in a variety of ways, some with more or less direct impact on an individual\u27s health and access to health care services. Although it has been 20 years since the passage of the Americans with Disabilities Act, people with disabilities still experience health disparities and a lack of access to the appropriate care. This commentary is part of a collection of articles that describe various aspects of incorporating content into the medical school curriculum to enhance the preparation of today\u27s medical students to meet the needs of people with disabilities. The authors briefly describe the scope of the problem and define the population of people with disabilities that constitutes the focus of the work described in the other articles in this collection