Objective. To develop a conceptual model that explained common and divergent care processes in Green House (GH) nursing homes with high and low hospital transfer rates. Data Sources/Settings. Eighty-four face-to-face, semistructured interviews were conducted with direct care, professional, and administrative staff with knowledge of care processes in six GH organizations in six states. Study Design/Data Collection. The qualitative grounded theory method was used for data collection and analysis. Data were analyzed using open, axial, and selective coding. Data collection and analysis occurred iteratively. Principal Findings. Elements of the GH model created significant opportunities to identify, communicate, and respond to early changes in resident condition. Staff in GH homes with lower hospital transfer rates employed care processes that maximized these opportunities. Staff in GH homes with higher transfer rates failed to maximize, or actively undermined, these opportunities. Conclusions. Variations in how the GH model was implemented across GH homes suggest possible explanations for inconsistencies found in past research on the care outcomes, including hospital transfer rates, in culture change models. The findings further suggest that the details of culture change implementation are important considerations in model replication and policies that create incentives for care improvements. Key Words. Medical decision making, nursing, qualitative research, long-term care, nursing homes, culture change Evidence suggests that between 25 percent and 70 percent of hospital transfers from nursing homes are "potentially avoidable" (Ouslander and Maslow 2012; U.S. Department of Health and Human Services [USDHHS] 2013;Ouslander et al. 2014). Older adults from long-term care settings are particularly vulnerable to the risks of hospitalization, which include hospital-acquired complications, morbidity, mortality, and excess health care expenditure
Preparing future nurses to care for the growing population of older adults has become a national priority. The demand for long term care services is expected to double between 2000 and 2040, yet the field remains stigmatized as an undesirable place for highly-skilled nurses to work. Recent efforts to increase student preparation in geriatrics have been shown to improve student attitudes toward working with older adults and increase knowledge, but long term care settings remain unattractive to students. This paper reports on development, implementation and evaluation of The Wisconsin Long Term Care Clinical Scholars Program, a nursing home internship for baccalaureate nursing students. The program couples a paid nursing home work experience with an evidence-based long term care nursing curriculum. The program increased student preparation and interest in working with older adults and in nursing homes, while concurrently increasing the capacity of nursing homes to provide a positive student experience.
The authors examined mental illness and psychotropic medications use among nursing home residents. Data were drawn from the Texas Long-Term Care Reimbursement Project, a 1986 study of nearly 2,000 residents in 49 nursing homes. The study measured the use of antipsychotics and other psychotropic medications, physical health conditions, mental illness diagnoses, behavior, and nursing and other direct-care time for sampled residents. The findings indicated that 45% of the sample was receiving an antipsychotic or other psychotropic medication. Although psychotropics were prescribed more extensively for those with a psychiatric diagnosis, nearly one half of persons without a psychiatric diagnosis were receiving psychotropic medications at the time of the survey. Moreover, psychotropics were quite prevalent among those with unstable medical conditions and/or severe activities of daily living impairment. Neither a mental illness diagnosis, evidence of a behavioral problem, nor use of psychotropics was significantly correlated with the amount of nursing or other direct-care time received by residents. The findings raise concerns about the widespread prescribing of these medications, especially among residents who have no supporting psychiatric diagnosis and/or who have physical health conditions making them vulnerable to adverse drug effects.
Key PointsQuestionDoes external facilitation improve adoption and effects of a complex antibiotic stewardship intervention in nursing homes?FindingsThis trial protocol describes a cluster-randomized hybrid type 2 effectiveness-implementation clinical trial of implementation of a multicomponent toolkit focused on improving the recognition and management of suspected urinary tract infection (UTI) in nursing homes. The trial seeks to evaluate whether delivery of external facilitation—coaching, collaborative learning, and peer comparison feedback—to implement this toolkit results in higher rates of toolkit adoption and reduced rates of urine testing and initiation of antibiotics for treatment of suspected UTI.MeaningIf successful, external facilitation could become an effective approach for improving spread and adoption of antibiotic stewardship interventions, as well as other quality improvement initiatives, in the nursing home setting.
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