A function-based targeting system effectively and efficiently identifies older people at risk of functional decline and death. Self-reported diagnoses and conditions, when added to the system, do not enhance predictive ability. The function-based targeting system relies on self-report and is easily transported across care settings.

OBJECTIVES:To examine the frequency and reasons for potentially avoidable hospitalizations of nursing home (NH) residents. DESIGN: Medical records were reviewed as a component of a project designed to develop and pilot test clinical practice tools for reducing potentially avoidable hospitalization. SETTING: NHs in Georgia. PARTICIPANTS: In 10 NHs with high and 10 with low hospitalization rates, 10 hospitalizations were randomly selected, including long-and short-stay residents. MEASUREMENTS: Ratings using a structured review by expert NH clinicians. RESULTS: Of the 200 hospitalizations, 134 (67.0%) were rated as potentially avoidable. Panel members cited lack of on-site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, problems with quality of care in assessing acute changes, and uncertain benefits of hospitalization as causes of these potentially avoidable hospitalizations. CONCLUSION: In this sample of NH residents, experienced long-term care clinicians commonly rated hospitalizations as potentially avoidable. Support for NH infrastructure, clinical practice and communication tools for health professionals, increased attention to reducing the frequency of medically futile care, and financial and other incentives for NHs and their affiliated hospitals are needed to improve care, reduce avoidable hospitalizations, and avoid unnecessary healthcare expenditures in this population. J Am Geriatr Soc 58:627-635, 2010.Key words: nursing homes; avoidable hospitalizations; transfers; quality H ospitalization of nursing home (NH) residents can cause discomfort for residents, anxiety for their loved ones, morbidity due to iatrogenic events, and excess healthcare costs. Many of these hospitalizations may be preventable through better care in the NH or inappropriate, because the transfer exposes NH residents to additional risks associated with hospitalization, 1 without substantial potential benefit for the residents' clinical course or quality of life. Previous in-depth research on the overall frequency and costs of potentially avoidable hospitalizations of nursing home residents is limited. One study found that, in 2004, 23% of the $972 million spent on hospitalizations of long-stay NH residents in the state of New York were for ambulatory care-sensitive diagnoses (ACSDs), a proxy measure for potentially unnecessary hospitalizations. 2ACSDs include diagnoses such as angina pectoris, heart failure, chronic obstructive pulmonary disease, pneumonia, urinary tract infection, cellulitis, diabetes mellitus, and dehydration. 3 This is an underestimate of the overall costs of these hospitalizations, because short-stay residents, in whom hospitalizations are more common than long-stay residents, were excluded from this analysis. A study of hospital admissions from Canadian long-term care facilities found 55% to be due to a modified list of ACSD. 4 In an analysis of hospital transfers from eight Los Angeles NHs, experienced physicians using a structured implicit record re...

Care for vulnerable elders falls short of acceptable levels for a wide variety of conditions. Care for geriatric conditions is much less optimal than care for general medical conditions.

Inappropriate transfers are a potentially large problem. Some inappropriate transfers may be associated with poor quality of care in SNFs. This study demonstrates that structured implicit review meets criteria for reliable assessment of inappropriate transfer rates. Structured implicit review may be a valuable tool for identifying inappropriate transfers from SNFs to EDs and hospitals.

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OBJECTIVES:To systematically document the implementation, components, comparators, adherence, and effectiveness of published fall prevention approaches in U.S. acute care hospitals. DESIGN: Systematic review. Studies were identified through existing reviews, searching five electronic databases, screening reference lists, and contacting topic experts for studies published through August 2011. SETTING: U.S. acute care hospitals. PARTICIPANTS: Studies reporting in-hospital falls for intervention groups and concurrent (e.g., controlled trials) or historic comparators (e.g., before-after studies). INTERVENTION: Fall prevention interventions. MEASUREMENTS: Incidence rate ratios (IRR, ratio of fall rate postintervention or treatment group to the fall rate preintervention or control group) and ratings of study details. RESULTS: Fifty-nine studies met inclusion criteria. Implementation strategies were sparsely documented (17% not at all) and included staff education, establishing committees, seeking leadership support, and occasionally continuous quality improvement techniques. Most interventions (81%) included multiple components (e.g., risk assessments (often not validated), visual risk alerts, patient education, care rounds, bed-exit alarms, and postfall evaluations). Fifty-four percent did not report on fall prevention measures applied in the comparison group, and 39% neither reported fidelity data nor described adherence strategies such as regular audits and feedback to ensure completion of care processes. Only 45% of concurrent and 15% of historic control studies reported sufficient data to compare fall rates. The pooled postintervention incidence rate ratio (IRR) was 0.77 (95% confidence interval = 0.52-1.12, P = .17; eight studies; I 2 : 94%). Meta-regressions showed no systematic association between implementation intensity, intervention complexity, comparator information, or adherence levels and IRR. CONCLUSION: Promising approaches exist, but better reporting of outcomes, implementation, adherence, intervention components, and comparison group information is necessary to establish evidence on how hospitals can successfully prevent falls. J Am Geriatr Soc 61:483-494, 2013.Key words: fall prevention; implementation; hospital; systematic review I n-hospital falls are a significant clinical, legal, and regulatory problem, but information on effective fall reduction is lacking. The Centers for Medicare and Medicaid Services no longer reimburses hospitals for in-hospital falls with trauma.1 As the U.S. population ages, fall prevention is more relevant than ever; older, frail individuals are more prone to falls, and the consequences of falls are more severe. 2,3Preventing falls in U.S. acute care hospitals poses particular challenges, given that patients are acutely ill and average only 4.9 days in the hospital. 4 This compressed acuity places a greater burden on staff to keep patients safe, so results from fall prevention interventions in longterm care facilities may not apply to acute care settings. Similarly, resu...

word count: 324 ABSTRACT COVID-19 continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguidedly use age as an arbitrary criterion, which inappropriately disfavors older adults.This statement represents the official policy position of the American Geriatrics Society (AGS). It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations to consider when developing strategies for allocating scarce resources during an emergency involving older adults. Members of the AGS Ethics Committee collaborated with interprofessional experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care) to conduct a structured literature review and examine relevant reports. The resulting recommendations defend a particular view of distributive justice that maximizes relevant clinical factors and de-emphasizes or eliminates factors placing arbitrary, disproportionate weight on advanced age. The AGS positions include: (1) avoiding age per se as a means for excluding anyone from care; (2) assessing comorbidities and considering the disparate impact of social determinants of health; (3) encouraging decision makers to focus primarily on potential shortterm (not long-term) outcomes; (4) avoiding ancillary criteria such as -life-years saved‖ and -long-term predicted life expectancy‖ that might disadvantage older people; (5) forming and staffing triage committees tasked with allocating scarce resources; (6) developing institutional resource allocation strategies that are transparent and applied uniformly; and (7) facilitating appropriate advance care planning. The statement includes recommendations that should be Accepted Article 5 immediately implemented to address resource allocation strategies during COVID-19, aligning with AGS positions. The statement also includes recommendations for post-pandemic review.Such review would support revised strategies to ensure that governments and institutions have equitable emergency resource allocation strategies, avoid future discriminatory language and practice, and have appropriate guidance to develop national frameworks for emergent resource allocation decisions.consequences of severe illness, hospitalization and death. The extent to which this disproportionate impact is due to factors such as the disease itself, versus the response of health care systems to the disease, is unknown. Concerns about potential shortages of ventilators, ICU beds, and hospital bedsboth now and in the fall when resource shortages caused by any surge in COVID-19 will likely be intensified due to influenza -have focused attention on how decisions to allocate these scarce resources are being made. Many of the initially av...