Substance Use Disorder Care in Skilled Nursing Facilities: Characterizing Resident Experiences.

OBJECTIVES: Patients with substance use disorder (SUD) may face many challenges when being cared for in skilled nursing facilities (SNFs), such as stigma and inadequate access to treatment. This study aims to learn from the perspectives of SNF residents with SUD. METHODS: Nineteen semistructured interviews were conducted at 5 SNFs in the Chicago Metropolitan Area. Additionally, Likert-type responses and substance use screening tests were collected. Qualitative data were analyzed using Dedoose version 9.0.107 (Sociocultural Research Consultants, LLC, Los Angeles, CA). RESULTS: Qualitative analyses identified 4 themes: (1) the SNF can be a positive site for recovery, (2) barriers to recovery in SNFs are variable, (3) lived experiences with SUD care and harm reduction are heterogeneous, and (4) the needs of residents with SUD encompass multiple domains. Results highlighted the variability of access to counseling and SUD treatment, as well as the prevalence of stigma, substance use, and overdose in SNFs. Results revealed the need for access to social work support, activities, counseling services, and improved staff knowledge of treating SUD. CONCLUSIONS: SNF residents living with SUD experience variable quality of care and may have difficulty accessing counseling and medical treatments for SUD, depending on the available resources in the facility to which they were admitted. The quality of care for residents living with SUD requires further study as more patients with SUD require SNF care.

Fact Check: Assessing the Response of ChatGPT to Alzheimer's Disease Statements with Varying Degrees of Misinformation.

Background: There are many myths regarding Alzheimer's disease (AD) that have been circulated on the Internet, each exhibiting varying degrees of accuracy, inaccuracy, and misinformation. Large language models such as ChatGPT, may be a useful tool to help assess these myths for veracity and inaccuracy. However, they can induce misinformation as well. The objective of this study is to assess ChatGPT's ability to identify and address AD myths with reliable information. Methods: We conducted a cross-sectional study of clinicians' evaluation of ChatGPT (GPT 4.0)'s responses to 20 selected AD myths. We prompted ChatGPT to express its opinion on each myth and then requested it to rephrase its explanation using a simplified language that could be more readily understood by individuals with a middle school education. We implemented a survey using Redcap to determine the degree to which clinicians agreed with the accuracy of each ChatGPT's explanation and the degree to which the simplified rewriting was readable and retained the message of the original. We also collected their explanation on any disagreement with ChatGPT's responses. We used five Likert-type scale with a score ranging from -2 to 2 to quantify clinicians' agreement in each aspect of the evaluation. Results: The clinicians (n=11) were generally satisfied with ChatGPT's explanations, with a mean (SD) score of 1.0(±0.3) across the 20 myths. While ChatGPT correctly identified that all the 20 myths were inaccurate, some clinicians disagreed with its explanations on 7 of the myths.Overall, 9 of the 11 professionals either agreed or strongly agreed that ChatGPT has the potential to provide meaningful explanations of certain myths. Conclusions: The majority of surveyed healthcare professionals acknowledged the potential value of ChatGPT in mitigating AD misinformation. However, the need for more refined and detailed explanations of the disease's mechanisms and treatments was highlighted.

Geriatrics Fellows Learning Online And Together (Geri-a-FLOAT): A sustainable model of learning and support.

BACKGROUND: Geriatrics Fellows Learning Online And Together (Geri-a-FLOAT) is a virtual curriculum designed to convene fellows nationwide for learning and peer support. This paper presents the expansion and evaluation of the program from the "Wave 1" pilot to the "Wave 2" year-long curriculum. METHODS: Kern's six-step approach to curriculum development was used to develop the Wave 2 curriculum. Participation was collected via Zoom. Post-session web-based surveys evaluated participant satisfaction regarding speaker, content, and overall session quality; intent-to-change; and a free-response section. A one-year follow-up survey sent to participants with valid e-mail addresses assessed sustained knowledge, skills, and behavior change. RESULTS: Nineteen sessions were held with mean (SD) of 23 (13) participants per session, totaling 182 unique participants. Fifteen of 19 sessions were evaluated with 96 evaluations completed (mean [SD] 6 [4] evaluations per session). Mean (SD) ratings per session that were excellent or above average was 100% (0) for content, 99% (4) for speaker, and 99% (4) overall. Mean (SD) evaluations per session noting intent to change was 90% (14). Respondents reported helpful aspects as sharing resources and examples, perspectives and experiences of others, professional connections, and collaborative discussion. Of 127 participants with valid e-mail addresses, 40 (response rate = 31%) completed the one-year follow-up survey. Mean (SD) respondents reporting some or significant sustained impact was 89% (7) across all learning outcomes. CONCLUSIONS: This virtual, national curriculum for geriatrics fellows was well-received and associated with high rates of self-reported, sustained impact one-year post curriculum. Geri-a-FLOAT may be a model to standardize education and build collaboration and peer support across a discipline.

Barriers to Care for Nursing Home Residents With Substance Use Disorders: A Qualitative Study.

OBJECTIVES: Over the past decade, the numbers of older adults with opioid and substance use disorders (OUD/SUD) have increased. As this population enters nursing homes (NHs) in increasing numbers, it is crucial to consider their capacity to manage issues related to OUD/SUD. This study aimed to examine current NH protocols for care coordination of residents with OUD/SUD as well as facility-related barriers to providing care to this vulnerable population within the NH. METHODS: Twenty-four semistructured interviews were conducted with NH staff including directors of nursing, administrators, nurses, and physicians in July 2020. Staff were recruited from 11 different post-acute care and long-term care facilities located in urban and suburban communities of Chicago. Interviews were conducted virtually (via teleconference platform or by telephone) and subsequently coded using ATLAS.ti 8 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) using constant comparative method. RESULTS: Qualitative analyses identified 3 themes around NH barriers to care for residents with SUD/OUD: (1) staff preparedness, (2) staff perceptions of addiction, and (3) overall lack of resources. Results revealed a strong need for the development of consistent policies, as well as standardized, educational interventions for NH staff that target SUD/OUD management in this vulnerable population. CONCLUSIONS: The evaluation and impact of persons with SUD/OUD entering NHs are an important topic that requires further study. More resources and staff training are necessary to ensure that residents with SUD/OUD have access to appropriate care within these settings.

Management and outcomes of a COVID-19 outbreak in a nursing home with predominantly Black residents.

BACKGROUND/OBJECTIVES: Few studies present clinical management approaches and outcomes of coronavirus disease 2019 (COVID-19) outbreaks in skilled nursing facilities (SNFs). We describe outcomes of a clinical management pathway for a large COVID-19 outbreak in an urban SNF with predominantly racial minority (>90% black), medically complex, older residents. DESIGN: Single-center, retrospective, and observational cohort study (March 1, 2020-May 31, 2020). SETTING AND PARTICIPANTS: All subacute and long-term care residents at an urban SNF between March 1, 2020 and May 31, 2020 (Chicago, IL). INTERVENTION: A multicomponent management pathway was developed to manage a large COVID-19 outbreak in an SNF. MEASUREMENTS: Chart review was used to extract demographics, comorbidities, symptoms, lab results, and clinical outcomes over 12 weeks, which were summarized and compared between residents with and without COVID-19. RESULTS: A multicomponent clinical management pathway was used to care for residents with COVID-19, which included frequent scheduled clinical and laboratory evaluation, use of intravenous fluids, supplemental oxygen, antibiotics when indicated, and goals-of-care discussions. Of the 204 residents, 172 (84.3%) tested positive for SARS-CoV-2 during the 3-month period, with 50.5% symptomatic, 9.3% presymptomatic, and 24.5% asymptomatic, with a 30-day mortality rate of 15.7%. Predominant symptoms were low-grade fever >99 °F, anorexia, delirium, and fatigue. While in the facility, approximately one-quarter of residents experienced hypernatremia [Na > 145 mEq/L] (24.5%), acute kidney injury [Cr > 0.03 mg/dL or 1.5× baseline] (29.7%), or leukopenia [WBC < 4.8 1000/mm3 ] (39.4%). CONCLUSION: We present the first available clinical strategy guiding the medical management of a COVID-19 syndrome in an urban SNF, caring for largely black residents, which may lead to improved mortality.

Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care.

An outbreak of SARS-CoV-2 in a skilled nursing facility (SNF) can be devastating for residents and staff. Difficulty identifying asymptomatic and presymptomatic cases and lack of vaccination or treatment options make management challenging. We created, implemented, and now present a guide to rapidly deploy point-prevalence testing and 3-tiered cohorting in an SNF to mitigate an outbreak. We outline key challenges to SNF cohorting.

"Ms. B changes doctors": using a comic and patient transition packet to engineer patient-oriented clinic handoffs (EPOCH).

BACKGROUND: Few patient-centered interventions exist to improve year-end residency clinic handoffs. AIM: Our purpose was to assess the impact of a patient-centered transition packet and comic on clinic handoff outcomes. SETTING: The study was conducted at an academic medicine residency clinic. PARTICIPANTS: Participants were patients undergoing resident clinic handoff 2011-2013 PROGRAM DESCRIPTION: Two months before the 2012 handoff, patients received a "transition packet" incorporating patient-identified solutions (i.e., a new primary care provider (PCP) welcome letter with photo, certificate of recognition, and visit preparation tool). In 2013, a comic was incorporated to stress the importance of follow-up. PROGRAM EVALUATION: Patients were interviewed by phone with response rates of 32 % in 2011, 43 % in 2012 and 36 % in 2013. Most patients who were interviewed were aware of the handoff post-packet (95 %). With the comic, more patients recalled receiving the packet (44 % 2012 vs. 64 % 2013, p< 0.001) and correctly identified their new PCP (77 % 2012 vs. 98 % 2013, p< 0.001). Among patients recalling the packet, most (70 % 2012; 65 % 2013) agreed it helped them establish rapport. Both years, fewer patients missed their first new PCP visit (43 % in 2011, 31 % in 2012 and 26 % in 2013, p< 0.001). DISCUSSION: A patient-centered transition packet helped prepare patients for clinic handoffs. The comic was associated with increased packet recall and improved follow-up rates.

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety.

PURPOSE: Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff. METHOD: In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes. RESULTS: Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P<.01), more verbal handoffs (80% versus 38%, P<.01), more patients aware of the handoff (100% versus 74%, P=.01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P=.03), and more ownership of patients before the first visit (56% versus 26%, P=.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P<.01), and more tests were followed up appropriately (67% versus 46%, P=.02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P=.06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P=.06). CONCLUSIONS: Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

What do patients think about year-end resident continuity clinic handoffs? A qualitative study.

BACKGROUND: Although Internal Medicine year-end resident clinic handoffs affect numerous patients, little research has described patients' perspectives of the experience. OBJECTIVE: To describe patients' perceptions of positive and negative experiences pertaining to the year-end clinic handoff; to rate patient satisfaction with aspects of the clinic handoff and identify whether or not patients could name their new physicians. DESIGN: Qualitative study design using semi-structured interviews. PARTICIPANTS: High-risk patients who underwent a year-end clinic handoff in July 2011. MEASUREMENTS: Three months post-handoff, telephone interviews were conducted with patients to elicit their perceptions of positive and negative experiences. An initial coding classification was developed and applied to transcripts. Patients were also asked to name their primary care physician (PCP) and rate their satisfaction with the handoff. RESULTS: In all, 103 telephone interviews were completed. Patient experiences regarding clinic handoffs were categorized into four themes: (1) doctor-patient relationships (i.e. difficulty building rapport); (2) clinic logistics (i.e. difficulty rescheduling appointments); (3) process of the care transition (i.e. patient unaware transition occurred); and (4) patient safety-related issues (i.e. missed tests). Only 59 % of patients could correctly name their new PCP. Patients who reported that they were informed of the clinic transition by letter or by telephone call from their new PCP were more likely to correctly name them (65 % vs. 32 % p = 0.007), report that their new doctor assumed care for them immediately (81 % [68/84] vs. 53 % [10/19], p = 0.009) and report satisfaction with communication between their old and new doctors (80 % [67/84] vs. 58 % [11/19], p = 0.04). Patients reported positive experiences such as learning more about their new physician through personal sharing, which helped them build rapport. Patients who reported being aware of the medical education mission of the clinic tended to be more understanding of the handoff process. CONCLUSIONS: Patients face unique challenges during year-end clinic handoffs and provide insights into areas of improvement for a patient-centered handoff.