A Substance Misuse Intervention Program in Postacute Care: Who Declines Participation?

OBJECTIVES: Alcohol and substance misuse has been under-acknowledged and underidentified in older adults. However, promising treatment approaches exist (e.g., brief interventions) that can support older adults with at-risk alcohol and substance use. Postacute rehabilitation settings of Skilled Nursing Facilities (SNFs) can offer such programs, but little is known about patient characteristics that are associated with the likelihood of participating in interventions offered in postacute rehabilitation care. Thus, the objective of this study was to identify individual patient characteristics (predisposing, enabling, and need-related factors) associated with participation in a brief alcohol and substance misuse intervention at a SNF. METHODS: This cross-sectional study analyzed medical record data of postacute care patients within a SNF referred to a substance misuse intervention. Participants were 271 patients with a history of substance misuse, 177 of whom enrolled in the intervention and 94 refused. Data collected upon patient admission were used to examine predisposing, enabling, and need-related factors related to likelihood of program participation. RESULTS: Older age and ethnic minority status were associated with a reduction in likelihood to participate, while widowhood increased the likelihood of participation. CONCLUSION: Upon referral to a substance misuse intervention, clinicians in SNFs should be cognizant that some patients may be more likely to refuse intervention, and additional efforts should be made to engage patients at-risk for refusal.

Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care.

BACKGROUND: Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization. OBJECTIVE: We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF. DESIGN: Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making. PARTICIPANTS: Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities. MAIN MEASURES: We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame. KEY RESULTS: The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome. CONCLUSIONS: Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.

The perspective of allied health staff on the role of nurses in subacute care.

AIMS AND OBJECTIVES: To explore allied health staff perceptions on the role of nurses in subacute care wards. BACKGROUND: A consequence of earlier discharge from acute hospitals is higher acuity of patients in subacute care. The impact on nurses' roles and required skill mix remains unknown. In the same way, nurses' integration into the rehabilitation team is ambiguous. DESIGN: Descriptive qualitative inquiry. METHODS: Semistructured interviews conducted with 14 allied health staff from one subacute care facility in Melbourne, Australia. Interviews were audio-recorded and transcribed verbatim. Analysis using the framework approach. RESULTS: Three main themes were evident: (a) the changing context of care: patient acuity, rapid patient discharge and out-dated buildings influenced care; (b) generalist as opposed to specialist rehabilitation nurses: a divide between traditional nursing roles of clinical and personal care and a specialist rehabilitation role; and (c) interdisciplinary relations and communication demonstrated lack of respect for nurses and integrating holistic care into everyday routines. CONCLUSIONS: Allied health staff had limited understanding of nurses' role in subacute care, and expectations varied. Power relationships appeared to hamper teamwork. Failure to include nurses in team discussions and decision-making could hinder patient outcomes. Progressing patients to levels of independence involves both integrating rehabilitation into activities of daily living with nurses and therapy-based sessions. Promotion of the incorporation of nursing input into patient rehabilitation is needed with both nurses and allied health staff. RELEVANCE TO CLINICAL PRACTICE: Lack of understanding of the nurses' role contributes to lack of respect for the nursing contribution to rehabilitation. Nurses have a key role in rehabilitation sometimes impeded by poor teamwork with allied health staff. Processes in subacute care wards need examination to facilitate more effective team practices inclusive of nurses. Progressing patients' independence in rehabilitation units involves activities of daily living with nurses as much as therapy-based sessions.

How Receptive Are Patients With Late Stage Cancer to Rehabilitation Services and What Are the Sources of Their Resistance?

OBJECTIVE: To describe the proportion and characteristics of patients with late stage cancer that are and are not receptive to receiving rehabilitation services, and the rationale for their level of interest. DESIGN: Prospective mixed-methods study. SETTING: Comprehensive cancer center in a quaternary medical center. PARTICIPANTS: Adults with stage IIIC or IV non-small cell or extensive stage small cell lung cancer (N=311). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Telephone-acquired responses to the administration of (1) the Activity Measure for Post Acute Care Computer Adaptive Test (AM-PAC-CAT); (2) numerical rating scales for pain, dyspnea, fatigue, general emotional distress, and distress associated with functional limitations; (3) a query regarding receptivity to receipt of rehabilitation services, and (4) a query about rationale for nonreceptivity. RESULTS: Overall, 99 (31.8%) of the study's 311 participants expressed interest in receiving rehabilitation services: 38 at the time of enrollment and an additional 61 during at least 1 subsequent contact. Participants expressing interest were more likely to have a child as primary caregiver (18.18% vs 9.91%, P=.04) and a musculoskeletal comorbidity (42.4% vs 31.6%, P=.05). Function-related distress was highly associated with receptivity, as were lower AM-PAC-CAT scores. Reasons provided for lack of interest in receiving services included a perception of their limited benefit, being too busy, and prioritization below more pressing tasks/concerns. CONCLUSIONS: One-third of patients with late stage lung cancer are likely to be interested in receiving rehabilitation services despite high levels of disability and related distress. These findings suggest that patient misperception of the role of rehabilitation services may be a barrier to improved function and quality of life. Efforts to educate patients on the benefits of rehabilitation and to more formally integrate rehabilitation as part of comprehensive care may curb these missed opportunities.

Motor and Cognitive Functional Status Are Associated with 30-day Unplanned Rehospitalization Following Post-Acute Care in Medicare Fee-for-Service Beneficiaries.

BACKGROUND: The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood. OBJECTIVE: To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care. DESIGN: This was a retrospective cohort study. SETTING: Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013. PARTICIPANTS: Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406). INTERVENTIONS: Not applicable. MAIN MEASURES: Thirty-day unplanned rehospitalization following post-acute rehabilitation. KEY RESULTS: The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %). CONCLUSIONS: The functional domains identified in the IMPACT Act were associated with 30-day unplanned rehospitalization following post-acute care in this large national sample. Further research is needed to better understand and improve the functional measures, and to determine if their association with rehospitalizations varies across post-acute settings, patient populations, or episodes of care.

Trends in Receipt of Help at Home After Hospital Discharge Among Older Adults in the US.

Importance: With declining use of institutional postacute care, more patients are going directly home after hospital discharge. The consequences on the amount of help needed at home after discharge are unknown. Objective: To estimate trends in the frequency and duration of receipt of help with activities of daily living (ADLs) among older adults discharged home. Design, Setting, and Participants: Repeated cross-sectional study of a national sample of community-dwelling older adults who returned home after hospital discharge from 2011 to 2017. Participants included respondents to National Health and Aging Trends Study (NHATS), an annual population-based, nationally representative survey of Medicare beneficiaries, who were 69 years or older and were discharged from an acute care hospital to home during the years of the study. A nationally representative sample was estimated using NHATS' analytic weights. Unweighted frequencies and weighted and unweighted percentages are reported. The analysis was conducted from September 2020 to October 2021. Exposures: Discharge from an acute care hospitalization. Main Outcomes and Measures: Receipt of help with ADLs during the 3 months after hospital discharge. Results: Of the 3591 survey participants who were discharged home from an acute care hospital during the study period, 53.3% were female, 54.8% were married or living with a partner, and the mean (SD) age was 78.5 (7.0) years. Of these, 1710 (44.1%) reported receiving help within 3 months of discharge. Compared with people not receiving help, those receiving help were older (mean [SD] years, 79.7 [7.5] years vs 77.6 [6.3] years), had worse self-rated health at baseline (47.1% with fair or poor health vs 26.5%) and were more likely to have dementia (21.8% vs 5.5%). The percentage of respondents who reported receiving help increased during the study period from 38.1% of hospital discharges in 2011 to 51.5% in 2017. For those who were independent in their ADLs before hospitalization, the percentage receiving help after discharge more than doubled over the study period increasing from 9.3% receiving help in 2011 to 31.8% in 2017. Among patients who did not receive Medicare-reimbursed home health, the percentage receiving help also increased from 22.1% to 28.1%. Among those who received help after discharge, the need for help slowly declined to prehospitalization levels over the ensuing 9 months. Conclusions and Relevance: In this cross-sectional study, older adults' receipt of help at home after hospital discharge increased from 2011 to 2017, including patients relying on non-Medicare funded sources of care. As payers steer patients away from inpatient postacute care facilities, policymakers will need to pay attention to this shifting burden of care.

Effectiveness of a rapid response service for frail older people.

AIM: Many innovative community-based intermediate care services have been initiated to address the care needs of older people with chronic health conditions, but there is little evidence about their outcomes or how they are best configured and delivered. This study aimed to evaluate one practice innovation, a rapid response service (RRS). METHOD: This study focused on the RRS's clinical and therapeutic achievements, and patients' satisfaction with its care. A mixed design of quantitative and qualitative methods was used. RESULTS: Patients were satisfied with staff attitudes; being treated at home or in a home-like environment; and receiving a quick response to their needs and access to services/ help. Aspects of care that they were dissatisfied with were inconvenient facilities and insufficient equipment or material supplies; arrangements for their care and recovery; lack of communication; inappropriate medical care; and insufficient or limited duration of care. CONCLUSION: The RRS provided holistic assessments for a previously under-served group of older people with chronic health problems and disabilities, and identified and responded to several unmet needs, partly through its own treatment and partly by referring patients to other health and social services.

Caregivers' Perceptions Managing Functional Needs Among Older Adults Receiving Post-Acute Home Health Care.

Caregivers play important roles in managing the physical functioning (PF) needs of older adults transitioning home after a hospitalization. Training and support of caregivers in the post-acute home health care (HHC) setting should incorporate caregivers' perspectives. To explore caregivers' experiences managing PF needs in the post-acute HHC setting, semi-structured telephone interviews of 20 caregivers were conducted. Conventional content analysis revealed patient-, caregiving task-, caregiver-, and home environment-related themes consistent with the Theory of Dependent Care. Caregivers highlighted the dynamics and contributors of PF needs for older patients in the post-acute HHC setting and depicted the enormity of caregiving tasks needed to manage older patients' PF needs. Caregivers also described their perceived roles and challenges in managing PF deficits, including a sense of isolation when they were the sole caregiver. Findings from this research can guide nursing efforts to target caregiver training and support during this critical care transition. [Res Gerontol Nurs. 2019; 12(4):174-183.].

The validity, reliability, and responsiveness of the modified Iowa Level of Assistance scale in hospitalized older adults in subacute care.

OBJECTIVE: The objective of this study was to investigate the psychometric properties of the Modified Iowa Level of Assistance scale in hospitalized older adults in subacute care. DESIGN: A cohort, measurement-focused study. PARTICIPANTS AND SETTING: Fifty-eight older adults, aged 65 years and older, were recruited from a subacute rehabilitation hospital. METHODS: Inter-rater reliability was established by having two physiotherapists independently assess each participant within 24-h of each other. Construct validity was established using "known-groups" validity, while concurrent validity was also examined by correlating modified Iowa Level of Assistance scores with the Elderly Mobility Scale. Responsiveness was assessed by examining the difference in modified Iowa Level of Assistance scores from admission to discharge. RESULTS: The mean age of participants was 82.8 years (SD 7.5; range 68-97). The modified Iowa Level of Assistance scale was found to be reliable, valid, and responsive in this sample of hospitalized older adults. It had excellent inter-rater reliability (intraclass correlation coefficient [2,1] 0.96; 95% confidence intervals (CI) 0.93, 0.98) and no systematic differences across the range of scores. The scale displayed a mean difference between two known groups of 11.4 points and correlated significantly and negatively with the Elderly Mobility Scale (Spearman's rho - 0.90). The modified Iowa Level of Assistance score also changed significantly over the course of the hospital admission with an effect size of 1.2. CONCLUSIONS: The modified Iowa Level of Assistance scale is a valid measure with excellent inter-rater reliability in hospitalized older adults. It is responsive to functional change during hospital admission and may be useful for routine outcome assessment for hospitalized older adults in subacute care. Implications for Rehabilitation The mILOA scale is a valid, reliable, and responsive outcome measure that can be used to quantify the gait and mobility impairments in hospitalized older adults in subacute care. For optimal reliability and responsiveness, consistent administration of the mILOA scale will be required particularly for higher level mobility tasks such as negotiating a step.

Evaluating a respiratory intermediate care team.

This article examines the work of a respiratory intermediate care team. Findings from an audit and a patient satisfaction postal questionnaire are presented to assess the effectiveness of the team's work and evaluate the effect of specialist nursing teams on hospital bed days and patient preference. From the evaluation it is apparent that the respiratory intermediate care team is an effective means of saving hospital bed days through prevention of admission and early discharge in patients with chronic respiratory disease. The results of the patient satisfaction postal questionnaire show that the majority of patients find hospital-at-home style care favourable because they feel well-supported at home to self-manage their condition. This outcome is important because it indicates that specialist nursing teams in primary care are valuable to patients and save the NHS money.

Minor depression and rehabilitation outcome for older adults in subacute care.

During recent years, numerous studies have found an association between minor depressive symptoms and physical functioning for older adults recuperating from illness or injury Whereas earlier research has focused on the effects of minor depression during rehabilitation in acute or long-term settings, this study examined 209 patients receiving subacute physical therapy. The dependent measures were total score changes on the Functional Independence Measure (FIM) obtained at admission, discharge, and 3-month follow-up. The independent measure was minor depressive symptoms, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, obtained within 5 days of admission. A binary logistic regression analysis was conducted with dichotomized FIM scores and the presence/absence of minor depressive symnptoms. The results indicated a statistically significant relationship between FIM score change and minor depression from admission to discharge, but not from discharge to follow-up.

Prognostic social factors in the subacute phase after a stroke for the discharge destination from the hospital stroke-unit. A systematic review of the literature.

PURPOSE: The objective of our study was to identify prognostic social factors in the subacute phase after stroke for the discharge destination from the hospital stroke-unit. METHODS: A systematic literature search was performed, designed in accordance with the Cochrane Collaboration criteria. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria. RESULTS: Characteristics of the social situation that proved to be important for prediction of the discharge destination are marital status and social support. Quantity and methodological quality of the research studies were insufficient, and the number of possible social prognostic factors investigated was limited by the absence of a conceptual framework of social subdomains in the studies, including an unambiguous definition of the prognostic social factors within these subdomains. CONCLUSIONS: A great need exists for research into the prognostic qualities of the following social factors: the ability to provide support, presence, and readiness of the homefront; the availability of professional care, personal financial means, membership of societies and clubs, frequency of contacts with close relatives and friends; the quality of the patient's residence with regard to the adaptation to the needs and abilities of the patient. A commitment about the aforementioned conceptual framework is mandatory.

Controversial issues in the care and maintenance of vascular access devices in the long-term/subacute care client.

The aging population provides a unique challenge for the initiation and maintenance of infusion therapy. This article will highlight three common but controversial issues that have been observed by this author in the long-term/subacute care realm of infusion therapy: 1) the failure to maintain a sterile dressing over the catheter insertion site; 2) the use of heparin to maintain patency of the peripheral infusion device; and 3) the routine replacement of peripheral i.v. catheters. Several factors that contribute to the controversies will be discussed, along with some associated negative and positive outcomes.

Providing continuity of care for patients transferred from ICU.

Patients requiring treatments previously only undertaken in critical care units are now being nursed in other ward areas. A study was carried out to determine the difficulties that are faced by ward nurses caring for this highly dependent patient group. Staff and patient stress were problems experienced and there was a call for closer liaison between ICU and ward staff.

An ethnographic study of intermediate care services in Wales: the hidden work.

AIM: To explore the perceptions of staff working in and referring to community-based intermediate care teams in Wales. BACKGROUND: Central and devolved governments have high expectations of intermediate care to promote independence and quality of life for older people and to solve the system pressures within the acute hospital sector. Developing an evidence base of the effectiveness of a model of care that is characterized by diversity and difference in practice is problematic. METHOD: Fourth generation ethnographic evaluation involving focus groups, non-participant observations and semi-structured interviews with people working within and referring to intermediate care teams. PRELIMINARY FINDINGS: Strong evidence of interprofessional working demonstrated by shared responsibility, coordinated rather than parallel services, understanding of other organizations and recognition and resolution of conflict areas. This generated work which traditional measures would not identify. IMPLICATIONS FOR NURSING MANAGEMENT: Evaluation is inherent in the work of healthcare professionals and managers. Managers need to aware of the systems and structures within which they are required to manage. This is important for intermediate care services as the heterogeneity contributes to the challenges encountered by managers when seeking to describe services and measure their effectiveness. Applying an appropriate evaluation framework will facilitate both.

Needs of family caregivers caring for stroke patients: based on the rehabilitation treatment phase and the treatment setting.

The objective of the study was to identify the needs of family members across rehabilitation treatment phases and treatment settings. Participants were 123 family caregivers in rehabilitation settings in South Korea that replied to the survey. The needs were measured by the Family Needs Questionnaire (FNQ) and the t-test and one-way ANOVA were used to analyze collected data. In the comparison of two rehabilitation phases, the family caregivers caring for their patients in the acute rehabilitation phase perceived the need for health information as more important than those in the postacute phase. In addition, the family caregivers caring for patients in the acute rehabilitation phase were less satisfied with community network support and family support than those in the postacute phase. In the comparison of treatment settings, family caregivers caring for their patients in outpatient clinic services showed the lowest satisfaction of their needs in four areas (health information, emotional support, instrumental support, and professional support) compared with those in inpatient facilities or day hospitals. Findings are discussed within the context of the empirical and theoretical literature and implications for social work practice are considered.

Does intermediate care minimize relocation stress for patients leaving the ICU?

Relocation stress is a phenomenon in which physical and psychological disturbances are experienced following transfer from one environment to another [Carpenito LJ. (2000). Nursing Diagnosis. Application to Clinical Practice, 8th edn]. The purpose of this review was to identify whether a period of intermediate care minimizes the problems associated with relocation stress after discharge from the intensive care unit (ICU) and before transfer to the ward. Methods of retrieving the literature involved identifying key terms, utilizing a range of databases and applying specific criteria in order to delineate the boundaries of the search. Using electronic and manual search methods, 11 studies were selected, both primary and secondary research. Following tabulation and critiquing of the studies, the findings of the review suggest that the factors which contribute towards relocation stress are the loss of one-to-one nursing, a reduction of visible monitoring equipment, lack of continuity of care and inadequate preparation of the patient for the transfer. The evidence also indicates that in order to minimize these factors, early planning and preparation of the patient for transfer are required, incorporating strategies of gradual reduction in nursing attention and monitoring equipment and the provision of information. Although the benefits of intermediate care are established as being advanced monitoring, appropriate nurse-to-patient ratio, heightened demonstration of expert knowledge and skill, there is no sufficient evidence to indicate a period of intermediate care that can ease the transition from the ICU to the ward.