Benchmarking Site of Death and Hospice Use: A Case Study of Veterans Cared by Department of Veterans Affairs Home-based Primary Care.

OBJECTIVE: The objective of this study was to examine site of death and hospice use, identifying potential disparities among veterans dying in Department of Veterans Affairs (VA) Home Based Primary Care (VA-HBPC). METHODS: Administrative data (2008, 2012, and 2016) were compiled using the VA Residential-History-File which tracks health care service location, daily. Outcomes were site of death [home, nursing home (NH), hospital, inpatient hospice]; and hospice use on the day of death. We compared VA-HBPC rates to rates of 2 decedent benchmarks: VA patients and 5% Traditional Medicare non-veteran males. Potential age, race, urban/rural residence and living alone status disparities in rates among veterans dying in VA-HBPC in 2016 were examined by multinomial logistic regression. RESULTS: In 2016, 7796 veterans died in VA-HBPC of whom 62.1% died at home, 11.8% in NHs, 14.7% in hospitals and 11.4% in inpatient hospice. Hospice was provided to 60.9% of veterans dying at home and 63.9% of veterans dying in NH. Over the 2008-2012-2016 period, rates of VA-HBPC veterans who died at home and rates of home death with hospice increased and were higher than both benchmarks. Among VA-HBPC decedents, younger/older veterans were more/less likely to die at home and less/more likely to die with hospice. Race/ethnicity and urban/rural residence were unrelated to death at home but veterans living alone were less likely to die at home. CONCLUSIONS: Results reflect VA-HBPC's primary goal of supporting its veterans at home, including at the end-of-life, surpassing other population benchmarks with some potential disparities remaining.

Interdisciplinary Team Perspectives on Mental Health Care in VA Home-Based Primary Care: A Qualitative Study.

OBJECTIVES: This qualitative study describes the structure and processes of providing care to U.S. Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) enrollees with mental health care needs; explains the role of the HBPC psychologist; and describes how mental health treatment is integrated into care from the perspective of HBPC team members. DESIGN: HBPC programs were selected for in-person site visits based on initial surveys and low hospitalization rates. SETTING: Programs varied in setting, geographic locations, and primary care model. PARTICIPANTS: Eight site visits were completed. During visits, key informants including HBPC program directors, medical directors, team members, and other key staff involved with the HBPC program participated in semi-structured individual and group interviews. MEASUREMENTS: Recorded interviews, focus groups, and field observation notes. RESULTS: Qualitative thematic content analysis revealed four themes: 1) HBPC Veterans have not only complex physical needs but also co-occurring mental health needs; 2) the multi-faceted role of psychologists on HBPC teams, that includes providing care for Veterans and support for colleagues; 3) collaboration between medical and mental health providers as a means of caring for HBPC Veterans with mental health needs; and 4) gaps in providing mental health care on HBPC teams, primarily related to a lack of team psychiatrists and/or need for specialized medication management for psychiatric illness. CONCLUSIONS: Mental health providers are essential to HBPC teams. Given the significant mental health care needs of HBPC enrollees and the roles of HBPC mental health providers, HBPC teams should integrate both psychologists and consulting psychiatrists.

Pharmacy Diabetes Management of a Veteran Population in a Long-Term Care Setting: A Program Evaluation.

BACKGROUND: The benefits of an outpatient pharmacy diabetes clinic has been established, with improved patient outcomes and reduced total costs of care. We describe the benefits of an inpatient clinical pharmacy diabetes service within a Department of Veterans Affairs long-term care facility. METHODS: Patients were referred to the pharmacy diabetes monitoring program between February 2016 and August 2016. During this time, clinical pharmacy specialists managed all pharmacotherapy relating to diabetes care as well as all fingerstick monitoring frequencies and laboratory monitoring to achieve a prespecified, patient-specific A1C goal. The primary endpoints were optimization of blood glucose fingerstick monitoring frequency and cessation of sliding-scale insulin. Secondary end points were achievement of A1C goal, reduction of hypoglycemic/hyperglycemic events, and reduction of total insulin injections per day. RESULTS: At the time of discharge or end of the observation period, fingerstick frequency had been reduced by a mean of 7.7 fingersticks/patient/week (35.6% total reduction, median 17.5; interquartile range [IQR] 5.5-21; P = 0.002). All eight patients initially prescribed sliding-scale insulin upon referral had their sliding scale stopped by the end of observation. Total injections per day had been reduced from baseline with a mean reduction of 0.55 injections/patient/day (16.5% total reduction; P < 0.05). A1C also showed improvement from baseline, though this was not statistically significant (median 7.75%, IQR 6.8-8.3; P = 0.1). Total hyperglycemic events were reduced from 36 prior to enrollment to 23 post-observation period, while hypoglycemic events decreased from 8 before enrollment to 4 post-observation period. CONCLUSION: Type 2 diabetes mellitus patients managed by clinical pharmacy specialists at a Veterans Affairs long-term care facility significantly decreased weekly fingerstick blood monitoring frequency, number of insulin injections per day, and ceased sliding-scale insulin use. A1C and hypoglycemic and hyperglycemic events remained stable. Our results are limited because of a small sample size.

High-Intensity Telemedicine Decreases Emergency Department Use by Senior Living Community Residents.

BACKGROUND: The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents. MATERIALS AND METHODS: We performed a prospective cohort study over 3.5 years. Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls. Consenting patients at intervention facilities could access telemedicine for acute illness care. Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses. The primary outcome was the rate of ED use. RESULTS: We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group; 1,058 subjects served as controls. Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home. Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction). Primary care use and mortality were not significantly different. CONCLUSIONS: High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.

Reducing Emergency Department Utilization Through Engagement in Telemedicine by Senior Living Communities.

BACKGROUND: High-intensity telemedicine has been shown to reduce the need for emergency department (ED) care for older adult senior living community (SLC) residents with acute illnesses. We evaluated the effect of SLC engagement in the telemedicine program on ED use rates. MATERIALS AND METHODS: We performed a secondary analysis of data from a prospective cohort study evaluating the effectiveness of high-intensity telemedicine for SLC residents. We compared the annual rate of change in ED use among subjects who resided in SLC units that were more engaged in telemedicine services with that among subjects who resided in SLC units that were less engaged in telemedicine and control subjects who lived at facilities without access to telemedicine services. RESULTS: During the study, subjects had 503 telemedicine visits, with 362 (72.0%) in the more engaged SLCs and 141 (28.0%) in the less engaged SLCs. For subjects residing in more engaged SLCs, ED use decreased at an annualized rate of 28% (rate ratio [RR] = 0.72; 95% confidence interval [CI], 0.58-0.89), whereas in the less engaged (RR = 0.962; 95% CI, 0.776-1.19) and control (RR = 0.909, 95% CI, 0.822-1.07) groups there was no significant change in ED use (p = 0.036 for group × time interaction). CONCLUSIONS: Individuals residing in more engaged SLCs experienced a greater decrease in ED use compared with subjects residing in less engaged SLCs or those without access to high-intensity telemedicine for acute illnesses. We identified potential factors associated with more engaged SLCs, but further research is needed to understand resident and staff engagement and how to increase it.

Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center.

OBJECTIVE: We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. METHODS: We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. RESULTS: We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales -level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) -may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. CONCLUSIONS: Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.

"Geriatricizing" hospitalists: identifying educational opportunities.

The objective of this study was to identify differences between geriatricians and hospitalists in caring for hospitalized older adults, so as to inform faculty development programs that have the goal of improving older patient care. Eleven hospitalists and 13 geriatricians were surveyed regarding knowledge, confidence, and practice patterns in caring for hospitalized older adults, targeting areas previously defined as central to taking care of older hospitalized patients. Overall, geriatricians had more confidence and more knowledge in caring for older hospitalized adults. The areas in which hospitalists expressed the least confidence were in caring for patients with dementia, self-care issues, and care planning. Geriatricians reported more routine medication reviews, functional and cognitive assessments, and fall evaluations. Geriatricians and hospitalists differ in their approach to older adults. Where these differences reflect lack of knowledge or experience, they set the stage for developing curricula to help narrow these gaps.

Development of telehealth principles and guidelines for older adults: A modified Delphi approach.

The COVID-19 pandemic elevated telehealth as a prevalent care delivery modality for older adults. However, guidelines and best practices for the provision of healthcare via telehealth are lacking. Principles and guidelines are needed to ensure that telehealth is safe, effective, and equitable for older adults. The Collaborative for Telehealth and Aging (C4TA) composed of providers, experts in geriatrics, telehealth, and advocacy, developed principles and guidelines for delivering telehealth to older adults. Using a modified Delphi process, C4TA members identified three principles and 18 guidelines. First, care should be person-centered; telehealth programs should be designed to meet the needs and preferences of older adults by considering their goals, family and caregivers, linguistic characteristics, and readiness and ability to use technology. Second, care should be equitable and accessible; telehealth programs should address individual and systemic barriers to care for older adults by considering issues of equity and access. Third, care should be integrated and coordinated across systems and people; telehealth should limit fragmentation, improve data sharing, increase communication across stakeholders, and address both workforce and financial sustainability. C4TA members have diverse perspectives and expertise but a shared commitment to improving older adults' lives. C4TA's recommendations highlight older adults' needs and create a roadmap for providers and health systems to take actionable steps to reach them. The next steps include developing implementation strategies, documenting current telehealth practices with older adults, and creating a community to support the dissemination, implementation, and evaluation of the recommendations.

Integrating Principles of Safety Culture and Just Culture Into Nursing Homes: Lessons From the Pandemic.

Decades of concerns about the quality of care provided by nursing homes have led state and federal agencies to create layers of regulations and penalties. As such, regulatory efforts to improve nursing home care have largely focused on the identification of deficiencies and assignment of sanctions. The current regulatory strategy often places nursing home teams and government agencies at odds, hindering their ability to build a culture of safety in nursing homes that is foundational to health care quality. Imbuing safety culture into nursing homes will require nursing homes and regulatory agencies to acknowledge the high-risk nature of post-acute and long-term care settings, embrace just culture, and engage nursing home staff and stakeholders in actions that are supported by evidence-based best practices. The response to the COVID-19 pandemic prompted some of these actions, leading to changes in nursing survey and certification processes as well as deployment of strike teams to support nursing homes in crisis. These actions, coupled with investments in public health that include funds earmarked for nursing homes, could become the initial phases of an intentional renovation of the existing regulatory oversight from one that is largely punitive to one that is rooted in safety culture and proactively designed to achieve meaningful and sustained improvements in the quality of care and life for nursing home residents.

COVID-19 Vaccination in VA Home Based Primary Care: Experience of Interdisciplinary Team Members.

OBJECTIVES: Describe how Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) team members discussed the COVID-19 vaccine with Veteran patients and their caregivers; describe HBPC team members' experiences providing care during the pandemic; identify facilitators and barriers to vaccinating HBPC Veterans during the COVID-19 pandemic. DESIGN: Online survey that included 3 open-ended COVID-19 vaccine-related questions. SETTING AND PARTICIPANTS: HBPC Program Directors from 145 VA Medical Centers were invited to participate and share the survey invitation with team members. The survey was open from March to May 2021. We collected N = 573 surveys from 73 sites. METHODS: We analyzed demographic data using descriptive frequencies and open-ended questions using thematic analysis. RESULTS: Respondents from all HBPC roles were included in the study: Registered Nurses, Psychologists, Advanced Registered Nurse Practitioners, Social Workers, Dieticians, Occupational Therapists, Pharmacists, Physical Therapists, HBPC Program Directors, HBPC Medical Directors, MDs, Physician Assistants, Other. Qualitative thematic analysis revealed 3 themes describing VA HBPC team members' experiences discussing and administering the COVID-19 vaccine: communication and education, advocating for prioritization of HBPC Veterans to receive the vaccine, and logistics of delivering and administering the vaccine. CONCLUSIONS AND IMPLICATIONS: Our study findings highlight the multifaceted experiences of VA HBPC team members discussing and administering initial doses of the COVID-19 vaccine to primarily homebound Veterans. Although the VA's HBPC program offers an example of a singular health care system, insights from more than 70 sites from across the United States reveal key lessons around the internal and external structures required to successfully support programs and their staff in providing these key activities. These lessons include proactively addressing the needs of homebound populations in national vaccine rollouts and developing vaccine education and training programs for HBPC team members specifically aligned to HBPC program needs. These lessons can extend to non-VA organizations who care for similar homebound populations.

Care Transitions to the Community from Veterans Affairs Nursing Homes: Experiences of Social Connection and Disconnection.

OBJECTIVE: This study aimed to further knowledge of older Veterans' experiences with transitioning to the community from Veterans Affairs nursing homes (Community Living Centers or CLCs) with emphasis on social functioning. DESIGN: A qualitative study design was used in addition to administration of standardized depression and mental status screens. SETTING AND PARTICIPANTS: Veterans (n = 18) and caregivers (n = 14) were purposively sampled and recruited from 2 rural CLCs in Upstate New York. METHODS: Semistructured interviews were completed with Veterans in the CLC prior to discharge (to explore experiences during the CLC stay and expectations regarding discharge and returning home) and in the home 2-4 weeks postdischarge (to explore daily routines and perceptions of overall health, mental health, and social functioning). Caregivers participated in 1 interview, completed postdischarge. The 9-item Patient Health Questionnaire and the Brief Interview for Mental Status were administered postdischarge. RESULTS: Thematic analysis of verbatim transcriptions revealed 3 inter-related themes: (1) Veterans may experience improved social connectedness in CLCs by nature of the unique care environment (predominantly male, shared military experience); (2) Experiences of social engagement and connectedness varied after discharge and could be discordant with Veterans' expectations for recovery prior to discharge; and (3) Veterans may or may not describe themselves as "lonely" after discharge, when physically isolated. Veterans lacked moderate to severe cognitive impairment (Brief Interview for Mental Status: range = 14-15); however, they reported a wide range in depressive symptom severity postdischarge (9-item Patient Health Questionnaire: mean = 4.9, SD = 6.1, median/mode = 3, range = 0-23). CONCLUSIONS AND IMPLICATIONS: This study identified a potential for increased social isolation and disengagement after discharge from Veterans Affairs nursing homes. Nursing homes should integrate social functioning assessment for their residents, while extending care planning and transitional care to address patient-centered social functioning goals.

Assessing Social Functioning During COVID-19 and Beyond: Tools and Considerations for Nursing Home Staff.

Social functioning is defined as how a person operates in their unique social environment (ie, engagement in activities, connectedness with others, and contributions to social roles). Healthy social functioning is important for nursing home residents as they are at increased risk for loneliness and isolation. Social functioning has long been an underacknowledged aspect of nursing home residents' health, but now, with the COVID-19 pandemic, residents' risk for decreased social functioning is increased. Several reliable and well-validated tools are available to supplement routine care planning and delivery and track and improve changes in social functioning over time. The overarching aim of this article is to provide resources and recommendations for interdisciplinary team assessment related to social functioning for nursing home residents. We describe 2 domains of social functioning measures, care-planning measures and outcome measures, and provide recommendations for how to integrate said measures into practice. Healthy social functioning is needed to maintain nursing home residents' well-being and quality of life. Measures and recommendations outlined in this article can be used by nursing home staff to understand residents' social preferences and address social functioning during COVID-19 and beyond.

Factors Associated With Hospitalization by Veterans in Home-Based Primary Care.

OBJECTIVES: This study examined the extent to which program site-based and Veteran characteristics were associated with potentially avoidable hospitalizations or other hospitalization of Veterans enrolled in the Veterans Affairs (VA) Home-Based Primary Care (HBPC). DESIGN: Retrospective claims-based study. SETTING AND PARTICIPANTS: HBPC programs that responded to a national survey of HBPC programs (n = 189) in fiscal year (FY) 2016 were studied. Veterans in the analysis cohort were identified as having been enrolled in VA-HBPC in FY2016 who had not received care by VA-HBPC within 1 year prior to their first HBPC enrollment in FY2016 (N = 8497). METHODS: Multinomial logistic regression analysis with 5 outcome categories within the 6 months following the first HBPC enrollment date: (1) any potentially avoidable hospitalizations for ambulatory care-sensitive conditions (ACSC) as identified by AHRQ Prevention Quality Indicator (PQI), (2) any other hospitalizations for non-ACSC conditions, (3) died during study period, (4) discharged from HBPC, or (5) remained at home with HBPC. Average marginal effects (AME) of veteran-level and VA-HBPC-level covariates are reported for each of the outcome categories. RESULTS: More frail Veterans and Veterans 85 years old or older were more likely to have potentially preventable ACSC hospitalizations (AME = 5.4%, 1.8%, respectively). Veterans who were younger than 75 years, functionally impaired, bed-bound, or frail were more likely to have non-ACSC hospitalization (AME = 3.0%, 2.2%, 3.5%, and 9.0%, respectively). Veterans with low frailty index scores were less likely to have non-ACSC hospitalizations (AME = -17.1%). Six-month hospitalization patterns were not associated with reported HBPC site characteristics. CONCLUSIONS AND IMPLICATIONS: Within the framework of the national VA HBPC program, variations in the structural model used at HBPC sites are not significantly associated with hospitalizations. Tailoring of HBPC care, based on individual patient factors and clinical judgment rather than standard protocols, may be central to the success of HBPC in reducing ACSC hospitalizations.

Perceived Effectiveness of Home-Based Primary Care Teams in Veterans Health Administration.

BACKGROUND AND OBJECTIVES: Previous studies have shown that staff perception of team effectiveness is related to better health outcomes in various care settings. This study focused on the Veterans Health Administration's Home-Based Primary Care (HBPC) program. We examined variations in HBPC interdisciplinary teamwork (IDT) and identified modifiable team and program characteristics that may influence staff perceptions of team effectiveness. RESEARCH DESIGN: We used a broadly validated survey instrument to measure perceived team effectiveness, workplace conditions/resources, group culture, and respondents' characteristics. Surveys were initiated in January and completed in July, 2016. METHODS: Team membership rosters (n = 249) included 2,852 IDT members. The final analytical data set included 1,403 surveys (49%) from 221 (89%) teams. A generalized estimating equation model with logit link function, weighted by survey response rates, was used to examine factors associated with perceived team effectiveness. RESULTS: Respondents who served as primary care providers (PCPs) were 8% more likely (p = .0044) to view team's performance as highly effective compared to other team members. Teams with nurse practitioners serving as team leader reported 6% higher likelihood of high-perceived team effectiveness (p = .0234). High team effectiveness was 13% more likely in sites where the predominant culture was characterized as group/developmental, and 7%-8% more likely in sites with lower environmental stress and better resources and staffing, respectively. CONCLUSIONS AND IMPLICATIONS: Team effectiveness is an important indirect measure of HBPC teams' function. HBPC teams should examine their predominant culture, workplace stress, resources and staffing, and PCP leadership model as part of their quality improvement efforts.

Dedicated to the Mission: Strategies US Department of Veterans Affairs Home-Based Primary Care Teams Apply to Keep Veterans at Home.

BACKGROUND/OBJECTIVES: The US Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) Program provides interdisciplinary, long-term primary care for frail, disabled, or chronically ill veterans. This research identifies strategies used by HBPC teams to support veterans in their homes, rather than in institutionalized care. DESIGN: Focus groups and semistructured interviews were conducted with HBPC interdisciplinary team (IDT) members, including program directors, medical directors, and key staff, from September 2017 to March 2018. Field observations were gathered during visits to veterans' homes and IDT meetings. SETTING: In-person site visits were conducted at eight HBPC Programs across the United States. Sites varied in location, setting, and primary care model. PARTICIPANTS: A total of 105 HBPC professionals. MEASUREMENT: Qualitative thematic content analysis. RESULTS: Four main strategies drive and support the shared mission of IDTs to support veterans at home: fostering frequent communication among IDT members, veterans, caregivers, and outside agencies; development of longitudinal, trusting, reliable relationships within IDTs and with veterans and caregivers; ongoing, consistent education for IDT members and veterans and caregivers; and collaboration within and outside IDTs. Adhering to this mission meant providing timely and efficient care that kept veterans in their homes and minimized the need for acute hospitalizations and nursing home placement. CONCLUSION: HBPC IDTs studied worked together across disciplines to effectively create a dedicated culture of caring for veterans, caregivers, and themselves, leading to keeping veterans at home. Focusing on the strategies identified in this research may be useful to achieve similar positive outcomes when caring for medically complex, homebound patients within and outside the VA. J Am Geriatr Soc 67:2511-2518, 2019.

Telehealth in Home-Based Primary Care: Factors and Challenges Associated With Integration Into Veteran Care.

OBJECTIVES: To describe the structural characteristics and challenges associated with home telehealth (HT) use in the US Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) program. DESIGN: We designed a national survey to collect information about HBPC program structural characteristics. The survey included eight organizational and service domains, one of which was HT. HBPC program directors were surveyed online using REDCap. PARTICIPANTS: We received 232 surveys from 394 HBPC sites (59% response rate). METHODS: HBPC structural domains were compared between sites using and not using HT technology. Open-ended responses were analyzed using content analysis. RESULTS: A total of 127 sites (76%) used HT, which was more likely when HBPC sites were aligned organizationally with the VA's Geriatrics and Extended Care Services division, when there were more disciplines on the HBPC team, and when primary care providers made home visits. Program directors overwhelmingly viewed HT as contributing to managing veterans' complex chronic conditions (81%), yet HT data were not readily integrated into care planning (24%). Challenges to HT use included veterans' acceptance and adherence, device issues, and collaboration between HBPC teams and HT staff. CONCLUSION: Corresponding to HBPC's complexity, HT use is primarily a self-organizing process that shapes the patterns of integration at each site. Although HT technology is compatible with core structures of the HBPC model, usability varies, and overall is low. To optimize HT use in HBPC, there are opportunities to redesign systems to mitigate challenges to adoption. As the Centers for Medicare and Medicaid Services' strives to increase access to both HBPC and telehealth benefits, evidenced by the continuation of its successful Independence at Home demonstration and the final changes in the proposed rule in April 2019 incorporating additional telehealth benefits for beneficiaries, this information will be relevant to VA and non-VA alike. J Am Geriatr Soc 67:1928-1933, 2019.

Standards for the Use of Telemedicine for Evaluation and Management of Resident Change of Condition in the Nursing Home.

OBJECTIVES: This document offers guidance to clinicians and facilities on the use of telemedicine to deliver medically necessary evaluation and management of change of condition for nursing home residents. SETTINGS AND PARTICIPANTS: Members of the telemedicine workgroup of AMDA-The Society for Post-Acute Long-Term Medicine-developed this guideline through both telephonic and face-to-face meetings between April 2017 and September 2018. The guideline is based on the currently available research, experience, and expertise of the workgroup's members, including a summary of a recently completed systematic mixed studies literature review to determine evidence for telemedicine to reduce emergency department visits or hospitalizations of nursing home residents. RESULTS: Research and experience to date support the use of telemedicine as a tool in change of condition assessment and management as a means of reducing unnecessary emergency department visits and hospitalization. Telemedicine-delivered care should be integrated into the primary care of the resident and delivered by providers with competency in post-acute long-term care. The development and sustainability of telemedicine programs is heavily dependent on financial implications. Quality measures should be defined for telemedicine programs in nursing homes. CONCLUSIONS/IMPLICATIONS: Telemedicine programs in nursing homes can contribute to the delivery of timely, high quality medical care, which reduces unnecessary hospitalization. Reimbursement for telemedicine-driven care should be based upon medical necessity of visits to care and the maintenance of quality standards. More studies are needed to understand which telemedicine tools and processes are most effective in improving outcomes for nursing home residents.

High-Intensity Telemedicine Reduces Emergency Department Use by Older Adults With Dementia in Senior Living Communities.

OBJECTIVES: Individuals with dementia have high rates of emergency department (ED) use for acute illnesses. We evaluated the effect of a high-intensity telemedicine program that delivers care for acute illnesses on ED use rates for individuals with dementia who reside in senior living communities (SLCs; independent and assisted living). DESIGN: We performed a secondary analysis of data for patients with dementia from a prospective cohort study over 3.5 years that evaluated the effectiveness of high-intensity telemedicine for acute illnesses among SLC residents. SETTING AND PARTICIPANTS: We studied patients cared for by a primary care geriatrics practice at 22 SLCs in a northeastern city. Six SLCs were selected as intervention facilities and had access to patient-to-provider high-intensity telemedicine services to diagnose and treat illnesses. Patients at the remaining 15 SLCs served as controls. Participants were considered to have dementia if they had a diagnosis of dementia on their medical record problem list, were receiving medications for the indication of dementia, or had cognitive testing consistent with dementia. MEASURES: We compared the rate of ED use among participants with dementia and access to high-intensity telemedicine services to control participants with dementia but without access to services. RESULTS: Intervention group participants had 201 telemedicine visits. In participants with dementia, it is estimated that 1 year of access to telemedicine services is associated with a 24% decrease in ED visits (rate ratio 0.76, 95% confidence interval 0.61, 0.96). CONCLUSIONS/IMPLICATIONS: Telemedicine in SLCs can effectively decrease ED use by individuals with dementia, but further research is needed to confirm this secondary analysis and to understand how to best implement and optimize telemedicine for patients with dementia suffering from acute illnesses.

National Structural Survey of Veterans Affairs Home-Based Primary Care Programs.

OBJECTIVES: To describe the current structural and practice characteristics of the Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) program. DESIGN: We designed a national survey and surveyed HBPC program directors on-line using REDCap. PARTICIPANTS: We received 236 surveys from 394 identified HBPC sites (60% response rate). MEASUREMENTS: HBPC site characteristics were quantified using closed-ended formats. RESULTS: HBPC program directors were most often registered nurses, and HBPC programs primarily served veterans with complex chronic illnesses that were at high risk of hospitalization and nursing home care. Primary care was delivered using interdisciplinary teams, with nurses, social workers, and registered dietitians as team members in more than 90% of the sites. Most often, nurse practitioners were the principal primary care providers (PCPs), typically working with nurse case managers. Nearly 60% of the sites reported dual PCPs involving VA and community-based physicians. Nearly all sites provided access to a core set of comprehensive services and programs (e.g., case management, supportive home health care). At the same time, there were variations according to site (e.g., size, location (urban, rural), use of non-VA hospitals, primary care models used). CONCLUSION: HBPC sites reflected the rationale and mission of HBPC by focusing on complex chronic illness of home-based veterans and providing comprehensive primary care using interdisciplinary teams. Our next series of studies will examine how HBPC site structural characteristics and care models are related to the processes and outcomes of care to determine whether there are best practice standards that define an optimal HBPC structure and care model or whether multiple approaches to HBPC better serve the needs of veterans.

Pioneering a Nursing Home Quality Improvement Learning Collaborative: A Case Study of Method and Lessons Learned.

OBJECTIVES: To describe the development of a nursing home (NH) quality improvement learning collaborative (QILC) that provides Lean Six Sigma (LSS) training and infrastructure support for quality assurance performance improvement change efforts. DESIGN: Case report. SETTING/PARTICIPANTS: Twenty-seven NHs located in the Greater Rochester, NY area. INTERVENTION: The learning collaborative approach in which interprofessional teams from different NHs work together to improve common clinical and organizational processes by sharing experiences and evidence-based practices to achieve measurable changes in resident outcomes and system efficiencies. MEASUREMENTS: NH participation, curriculum design, LSS projects. RESULTS: Over 6 years, 27 NHs from urban and rural settings joined the QILC as organizational members and sponsored 47 interprofessional teams to learn LSS techniques and tools, and to implement quality improvement projects. CONCLUSIONS: NHs, in both urban and rural settings, can benefit from participation in QILCs and are able to learn and apply LSS tools in their team-based quality improvement efforts.