Nursing home leaders' perceptions of a research partnership.

BACKGROUND/OBJECTIVE: Partnerships between healthcare providers and researchers may accelerate the translation of interventions into widespread practice by testing them under real-world conditions, but depend on provider's willingness to engage with researchers and ability to fully implement an intervention. AIM: To understand nursing home leader's motivations for participating in a research study and perceptions of the process and value. METHODS: After a feasibility study of tuned lighting in a nursing home, we conducted semi-structured telephone interviews with six facility leaders. Interviews were audio-recorded, transcribed, and independently coded by four investigators. RESULTS: Three themes emerged: (1) The importance of the nursing home's culture and context: the facility had stable leadership, clear processes for prioritizing and implementing new initiatives, and an established interest in the study's topic. (2) The importance of leader's belief in the value of the intervention: leaders perceived research generally and the intervention specifically as positively impacting their facility and residents. (3) The importance of ongoing collaboration and flexibility throughout the study period: leaders served as champions to catalyze the project and overcome implementation barriers. CONCLUSION: Nursing home leader's perspectives about their participation in a feasibility study underscore the importance of establishing strong researcher-provider partnerships, understanding the environment in which the intervention will be implemented, and employing pragmatic methods that allow for flexibility in response to real-world implementation barriers. We recommend eliciting qualitative information to understand the environment in which an intervention will be implemented and to engage opinion leaders who can inform the protocol and champion its success.

Report on milestones for care and support under the U.S. National Plan to Address Alzheimer's Disease.

INTRODUCTION: Under the U.S. national Alzheimer's plan, the National Institutes of Health identified milestones required to meet the plan's biomedical research goal (Goal 1). However, similar milestones have not been created for the goals on care (Goal 2) and support (Goal 3). METHODS: The Alzheimer's Association convened a workgroup with expertise in clinical care, long-term services and supports, dementia care and support research, and public policy. The workgroup reviewed the literature on Alzheimer's care and support; reviewed how other countries are addressing the issue; and identified public policies needed over the next 10 years to achieve a more ideal care and support system. RESULTS: The workgroup developed and recommended 73 milestones for Goal 2 and 56 milestones for Goal 3. DISCUSSION: To advance the implementation of the U.S. national Alzheimer's plan, the U.S. government should adopt these recommended milestones, or develop similar milestones, to be incorporated into the national plan.

Design of a Nursing Home Infection Control Peer Coaching Program.

OBJECTIVE: To pilot test and refine an infection control peer coaching program, Infection Control Amplification in Nursing Centers (ICAN), in partnership with providers. DESIGN: Intervention design and pilot test. SETTING AND PARTICIPANTS: Infection preventionists (IPs) from 7 Connecticut nursing homes (NHs). METHODS: We codesigned and pilot tested the ICAN program with NH IPs. The initial program involved designating peer coaches to provide real-time feedback on infection control practices to coworkers and targeting coaches' observations using data from both observations shared by coaches in daily huddles and weekly audit data about hand hygiene, masking, and transmission-based precautions. IPs tested the initial program while providing feedback to the research team during weekly calls. We used information from the calls, participant surveys, and the pilot process to update the program. RESULTS: Despite IPs reporting that the initial program was highly aligned with facility priorities and needs, their weekly call attendance dropped as they dealt with short staffing and COVID-19-related outbreaks and none implemented all of the program's components as intended. Most IPs described making changes to increase feasibility and reduce burden on staff amid short staffing and other ongoing issues exacerbated by the SARS-CoV-2 pandemic. We used information from the IPs and the pilot to update the program, including shifting from having IPs lead implementation solo to using a team-based approach. The updated program retains peer coaches and audit data, while broadening the mode of feedback from huddles only to communication using one-on-one meetings or emails, huddles, or other strategies. It also provides NH staff with flexibility to tailor implementation of each to their needs and constraints. CONCLUSIONS AND IMPLICATIONS: Working with staff, we developed an infection control peer coaching program that may be of use to NH leaders seeking strategies to strengthen infection control practices. Future work should involve implementing and evaluating the updated program.

Facility characteristics and costs associated with meeting proposed minimum staffing levels in skilled nursing facilities.

BACKGROUND: Federal minimum nurse staffing levels for skilled nursing facilities (SNFs) were proposed in 2019 U.S. Congressional bills. We estimated costs and personnel needed to meet the proposed staffing levels, and examined characteristics of SNFs not meeting these thresholds. METHODS: This was a cross-sectional analysis of 2019Q4 payroll data, the Hospital Wage Index, and other administrative data for 14,964 Medicare and Medicaid-certified SNFs. We examined characteristics of SNFs not meeting proposed minimum thresholds: 4.1 total nursing hours per resident day (HPRD); 0.75 registered nurse (RN) HPRD; 0.54 licensed practical nurse (LPN) HPRD; and 2.81 certified nursing assistant (CNA) HPRD. For SNFs falling below the thresholds, we calculated the additional HPRD needed, along with the associated full-time equivalent (FTE) personnel and salary costs. RESULTS: In 2019, 25.0% of SNFs met the minimum 4.1 total nursing HPRD, while 31.0%, 84.5%, and 10.7% met the RN, LPN, and CNA thresholds, respectively. Only 5.0% met all four categories. In adjusted analyses, factors most strongly associated with SNFs not meeting the proposed minimums were: higher Medicaid census, larger bed size, for-profit ownership, higher county SNF competition; and, for RNs specifically, higher community poverty and lower Medicare census. Rural SNFs were less likely to meet all categories and this was explained primarily by county SNF competition. We estimate that achieving the proposed federal minimums across SNFs nationwide would require an estimated additional 35,804 RN, 3509 LPN, and 116,929 CNA FTEs at $7.25 billion annually in salary costs based on current wage rates and prepandemic resident census levels. CONCLUSIONS: Achieving proposed minimum nurse staffing levels in SNFs will require substantial financial investment in the workforce and targeted support of low-resource facilities. Extensive recruitment and retention efforts are needed to overcome supply constraints, particularly in the aftermath of the COVID-19 pandemic.

Feasibility of a Nursing Home Antibiotic Stewardship Intervention.

OBJECTIVE: To evaluate a bundled electronic intervention to improve antibiotic prescribing practices in US nursing homes. DESIGN: Prospective mixed-methods quality improvement intervention. SETTING AND PARTICIPANTS: Nursing staff and residents in 13 nursing homes, and residents in 8 matched-control facilities (n = 21 facilities total, from 2 corporations). METHODS: This study involved a 2-month design period (n = 5 facilities) focused on the acceptability and feasibility of a bundled electronic intervention consisting of 3 tools, followed by a 15-month implementation period (n = 8 facilities) during which we used rapid-cycle quality improvement methods to refine and add to the bundle. We used mixed-methods data from providers, intervention tools, and health records to assess feasibility and conduct a difference-in-difference analysis among the 8 intervention sites and 8 pair-matched controls. RESULTS: Nurses at 5 pilot sites reported that initial versions of the electronic tools were acceptable and feasible, but barriers emerged when 8 different facilities began implementing the tools, prompting iterative revisions to the training and bundle. The final bundle consisted of 3 electronic tools and training that standardized digital documentation to document and track a change in resident condition, infections, antibiotic prescribing, and antibiotic follow-up. By the end of the implementation phase, all 8 facilities were using at least 1 of the 3 tools. Early antibiotic discontinuation increased 10.5% among intervention sites, but decreased 10.8% among control sites. CONCLUSIONS AND IMPLICATIONS: The 3 tools in our bundled electronic intervention capture clinical and prescribing data necessary to assess changes in antibiotic use and were feasible for nurses to adopt. Achieving this required modifying the tools and training before the intervention reached its final form. Comparisons of rates of antibiotic use at intervention and control facilities showed promising improvement in antibiotic discontinuation, demonstrating that the intervention could be evaluated using secondary electronic health record data.

Providers' Perspectives on High-Quality Dementia Care in Long-Term Care.

OBJECTIVES: To understand dementia care providers' perspectives on high-quality care for persons living with dementia (PLWD) in long-term care (LTC). DESIGN: A qualitative study using a directed content analysis approach. SETTING AND PARTICIPANTS: Nine national LTC dementia care providers. METHODS: We facilitated 5 listening sessions centered around dementia care philosophies, models, and practices. Two researchers first mapped qualitative data to the Holistic Approach to Transformational Change (HATCh) model for dementia care using a directed content analysis approach. They then identified themes and subthemes emerging from the data using a conventional analysis approach. They coded data iteratively and solicited input from 3 additional researchers to reach consensus where needed. Member checks were performed to ensure the trustworthiness of the data during 2 follow-up listening sessions. RESULTS: The 9 participants described the importance of understanding the experiences of PLWDs in order to provide high-quality dementia care and to deliver such care with the residents and their preferences as the focus. They emphasized experiential education as essential for families and all staff, regardless of role. They noted the need to balance safety with resident choice, as well as the corresponding need for facility leadership and regulators to support such choices. The listening sessions revealed areas to foster person-centered care for PLWD, but also highlighted barriers to implementing this philosophy in LTC settings. CONCLUSIONS AND IMPLICATIONS: Emergent themes included care practices that center on resident preferences and are supported by staff with the experiential education and communication skills necessary to relate to and support PLWD. These findings provide contextual information for researchers seeking to identify and test interventions that reflect LTC providers' priorities for PLWD and emphasize the need to align research priorities with provider priorities.

Strategies associated with COVID-19 vaccine coverage among nursing home staff.

BACKGROUND: After the first of three COVID-19 vaccination clinics in U.S. nursing homes (NHs), the median vaccination coverage of staff was 37.5%, indicating the need to identify strategies to increase staff coverage. We aimed at comparing the facility-level activities, policies, incentives, and communication methods associated with higher staff COVID-19 vaccination coverage. METHODS: Design. Case-control analysis. SETTING: Nationally stratified random sample of 1338 U.S. NHs participating in the Pharmacy Partnership for Long-Term Care Program. PARTICIPANTS: Nursing home leadership. MEASUREMENT: During February 4-March 2, 2021, we surveyed NHs with low (<35%), medium (40%-60%), and high (>75%) staff vaccination coverage, to collect information on facility strategies used to encourage staff vaccination. Cases were respondents with medium and high vaccination coverage, whereas controls were respondents with low coverage. We used logistic regression modeling, adjusted for county and NH characteristics, to identify strategies associated with facility-level vaccination coverage. RESULTS: We obtained responses from 413 of 1338 NHs (30.9%). Compared with facilities with lower staff vaccination coverage, facilities with medium or high coverage were more likely to have designated frontline staff champions (medium: adjusted odds ratio [aOR] 3.6, 95% CI 1.3-10.3; high: aOR 2.9, 95% CI 1.1-7.7) and set vaccination goals (medium: aOR 2.4, 95% 1.0-5.5; high: aOR 3.7, 95% CI 1.6-8.3). NHs with high vaccination coverage were more likely to have given vaccinated staff rewards such as T-shirts compared with NHs with low coverage (aOR 3.8, 95% CI 1.3-11.0). Use of multiple strategies was associated with greater likelihood of facilities having medium or high vaccination coverage: For example, facilities that used ≥9 strategies were three times more likely to have high staff vaccination coverage than facilities using <6 strategies (aOR 3.3, 95% CI 1.2-8.9). CONCLUSIONS: Use of designated champions, setting targets, and use of non-monetary awards were associated with high NH staff COVID-19 vaccination coverage.

Rapid Changes in the Provision of Rehabilitation Care in Post-Acute and Long-Term Care Settings During the COVID-19 Pandemic.

OBJECTIVES: Little is known about how the COVID-19 pandemic has affected rehabilitation care in post-acute and long-term care. As part of a process to assess research priorities, we surveyed professionals in these settings to assess the impact of the pandemic and related research needs. DESIGN: Qualitative analysis of open-ended survey results. SETTING AND PARTICIPANTS: 30 clinical and administrative staff working in post-acute and long-term care. METHODS: From June 24 through July 10, 2020, we used professional connections to disseminate an electronic survey to a convenience sample of clinical and administrative staff. We conducted an inductive thematic analysis of the data. RESULTS: We identified 4 themes, related to (1) rapid changes in care delivery, (2) negative impact on patients' motivation and physical function, (3) new access barriers and increased costs, and (4) uncertainty about sustaining changes in delivery and payment. Rapid changes: Respondents described how infection control policies and practices shifted rehabilitation from group sessions and communal gyms to the bedside and telehealth. Negative impact: Respondents felt that patients' isolation, particularly in residential care settings, affected their motivation for rehabilitation and their physical function. Access and costs: Respondents expressed concerns about increased costs (eg, for personal protective equipment) and decreased patient volume, as well as access issues. Uncertainty: At the same time, respondents described how telehealth and Medicare waivers enabled new ways to connect with patients and wondered whether waivers would be extended after the public health emergency. CONCLUSIONS AND IMPLICATIONS: Survey results highlight rapid changes to rehabilitation in post-acute and long-term care during the height of the COVID-19 pandemic. Because staff vaccine coverage remains low and patients vulnerable in residential care settings, changes such as infection precautions are likely to persist. Future research should evaluate the impact on care, outcomes, and costs.

Omissions of Care in Nursing Homes: A Uniform Definition for Research and Quality Improvement.

Omission of care in US nursing homes can lead to increased risk for harm or adverse outcomes, decreased quality of life for residents, and increased healthcare expenditures. However, scholars and policymakers in long-term care have taken varying approaches to defining omissions of care, which makes efforts to prevent them challenging. Subject matter experts and a broad range of nursing home stakeholders participated in iterative rounds of engagement to identify key concepts and aspects of omissions of care and develop a consensus-based definition that is clear, meaningful, and actionable for nursing homes. The resulting definition is "Omissions of care in nursing homes encompass situations when care-either clinical or nonclinical-is not provided for a resident and results in additional monitoring or intervention or increases the risk of an undesirable or adverse physical, emotional, or psychosocial outcome for the resident." This concise definition is grounded in goal-concordant, resident-centered care, and can be used for a variety quality improvement purposes and for research.

Omissions of Care in Nursing Home Settings: A Narrative Review.

OBJECTIVES: This review aims to (1) examine existing definitions of omissions of care in the healthcare environment and associated characteristics and (2) outline adverse events that may be attributable to omissions of care among nursing home populations. DESIGN: Nonsystematic review. A literature search for published articles on care omissions in nursing home settings and related adverse events was performed using the databases PubMed, Web of Science, EBSCO Academic Search Premier, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) until January 2019. Articles were excluded if they were published in a language other than English or included samples that were not relevant to nursing home settings. SETTINGS AND PARTICIPANTS: Adult samples in nursing home settings or settings likely to include nursing homes as part of the continuum of care. MEASURES: Articles must provide a definition of missed or omitted care relevant to nursing home settings or include adverse events that can be attributed to care omissions. RESULTS: From a total of 2155 articles retrieved, 34 were retained for thematic synthesis. Key themes included broad agreement that any delay or failure of care is an omission; diverse views on including consideration of risks or occurrence of adverse events within the definition; diverse approaches to including components of care delivery systems in the definition; recognition that care in nursing homes includes both clinical and psychosocial care; and awareness that insufficient or inadequate resources to meet care demands can cause omissions. For research on adverse events attributable to omissions, 327 of 8385 articles were included for review. Nineteen adverse events were identified and omissions contributing to their incidence are highlighted. CONCLUSIONS/IMPLICATIONS: Definitions of omissions of care for nursing homes vary in scope and level of detail. Substantial evidence connects omissions of care with an array of adverse events in nursing home populations.

Critical review of resident assessment protocols.

OBJECTIVES: To evaluate the quality of all 18 federally mandated Resident Assessment Protocols (RAPs) by measuring their adherence to established criteria for clinical practice guidelines (CPGs). DESIGN: Analytical evaluation. SETTING: United States nursing homes. PARTICIPANTS: Eighteen federally mandated RAPs. MEASUREMENTS: Each RAP was evaluated using review criteria based on the 1992 Institute of Medicine criteria for measuring the quality of clinical practice guidelines. Criteria included measurements of RAP validity, reliability/reproducibility, clinical applicability, clinical flexibility, clarity/format, scheduled review, expertise needed to complete, multidisciplinary process, and resources needed to complete. Two reviewers, each a geriatrician with expertise in nursing home medicine, evaluated each RAP on the degree of compliance with each criterion using a 2-point scale for each criterion. RESULTS: Overall, no individual RAP met all of the review criteria. The Urinary Incontinence RAP best approximated all the review criteria. The Pressure Ulcer RAP received the lowest score. Notable deficiencies in most of the RAPs included poor validity, documentation, reliability, clinical flexibility, and clinical applicability. CONCLUSION: The RAPs synthesize large amounts of information into key points and recommendations. Nevertheless, RAPs perform poorly when held to formal standards expected for CPGs. Based on these findings, the authors and a technical expert panel convened by the Agency for Health Care Research and Quality generated recommendations that might improve the use and quality of future RAPs.

Quantitative proteomic analysis of proteins released by neoplastic prostate epithelium.

Prostate cancer is unusual among neoplasms in that it may be diagnosed at a curable stage through detection of a protein in serum, the serine protease prostate-specific antigen (PSA). PSA is secreted by both normal and neoplastic prostate epithelial cells in response to androgenic hormones and has found widespread use in cancer screening. Because PSA screening is controversial due to sensitivity and specificity issues, efforts continue to focus on the identification and characterization of additional markers that may be used for diagnostic and therapeutic purposes. In this study, we report the application of quantitative proteomic techniques that incorporate isotope coded affinity tag reagents and tandem mass spectrometry to comprehensively identify secreted and cell surface proteins from neoplastic prostate epithelium. LNCaP cells, a prostate tumor-derived cell line that secretes PSA in response to androgen exposure, were grown in a low protein-defined media under androgen-stimulated (A+) and -starved (A-) conditions. Proteomic analysis of the media identified in excess of 600 proteins, 524 of which could be quantified. Nine percent of the proteins had A+/A- ratios > 2.0, including PSA, and 2.5% had ratios < 0.5. A subset of these androgen-regulated proteins appeared to be expressed in abundance. Of these, selected mass spectrometry observations were confirmed by Western analysis. The findings suggest that androgen-mediated release of proteins may occur through the activation of proteolytic enzymes rather than exclusively through transcriptional or translational control mechanisms. On the basis of their known functional roles, several of the abundant androgen-regulated proteins may participate in the progression of neoplastic epithelial cell growth and should be considered as potential serum markers of neoplastic prostate diseases.

National Trends in Treatment Initiation for Nursing Home Residents With Diabetes Mellitus, 2008 to 2010.

OBJECTIVE: Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents. DESIGN AND SETTING: Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs. PARTICIPANTS: A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse. MEASUREMENTS: Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation. RESULTS: We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs -1.5 to -0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs -0.4 to -0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%-18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%-2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9-1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs -0.1 to 1.3). CONCLUSIONS: Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.

Is signed consent for influenza or pneumococcal polysaccharide vaccination required?

Each year, thousands of preventable deaths and hospitalizations result from complications of influenza and pneumococcal disease, mostly in elderly persons, despite the availability of vaccines. Obtaining signed consent prior to administering the vaccines represents an obstacle to achieving the Healthy People 2010 goals for vaccinating individuals against influenza and pneumococcal disease. Signed consent is neither legally mandated nor a guarantee that the patient (or proxy) has given informed consent. Nonetheless, many health care providers and institutions currently require signed consent before administering these vaccines. Rather, health care providers should use the Vaccine Information Sheets developed by the Centers for Disease Control and Prevention to inform patients about the risks and benefits associated with these vaccines. Requiring signed consent before administering these low-risk, high-benefit vaccines is inconsistent with the current practice of not requiring signed consent before prescribing other common treatments, eg, antibiotic treatment, whose risk levels are the same or higher.

Admission and continued-stay criteria for assisted living facilities.

As residents in assisted living facilities (ALFs) try to "age in place" but decline in health, the facilities, families, and residents must find a balance between protecting the health and safety of residents in ALFs and maintaining their desire to live independently. The assisted living industry incorporates resident autonomy into its goals, but with regard to resident health and safety, recent reports have found that ALF staff are struggling to provide adequate care for residents with increasingly complex needs. Moreover, state regulations are not consistent in obligating ALFs to prioritize adequate health care and protection for residents over resident autonomy, or vice versa. A set of admission and continued stay criteria for individuals residing in assisted living that could serve as a guideline for state regulations in addressing the balance between safety and autonomy in ALFs is recommended.

Ameliorating pain in nursing homes: a collaborative quality-improvement project.

OBJECTIVES: To evaluate a multifaceted intervention to improve pain-management processes of care and outcomes in nursing homes. DESIGN: Quasi-experimental, pretest/posttest. SETTING: Nursing homes in Rhode Island. PARTICIPANTS: Twenty-one facilities. INTERVENTION: This project used a multifaceted collaborative intervention involving audit and feedback of pain management, education, training, coaching using rapid-cycle quality-improvement techniques, and inter-nursing home collaboration. MEASUREMENTS: Pain-management processes of care and outcomes, measured using chart review and the Minimum Data Set. RESULTS: Of 21 facilities, 17 completed the project. Postintervention, nursing homes increased the use of appropriate pain assessments (3.9% vs 43.8%, P<.001), pain intensity scales (15.6% vs 73.9%, P<.001), and nonpharmacological treatments (40.5% vs 81.9%, P<.001). Prescriptions of World Health Organization Step II or Step III pain medications for residents with daily moderate or severe pain showed trends towards improvement (40.8% vs 50.6%, P=.057), but prescription of any pain medication (93.3% vs 94.6%, P=.710), change in pain medication (29.0% vs 30.1%, P=.386), and prescription of pain medications on a regularly scheduled basis (67.9% vs 69.5%, P=.370) did not. There was a 41.1% reduction in prevalence of pain (12.2% vs 7.2%, P=.032) between the pre- and postintervention time periods in the nursing homes that completed the project, whereas all the other facilities in Rhode Island (n=72) had only a 12.1% reduction (12.7% vs 11.2%, P=.286) during the same period. CONCLUSION: A multifaceted intervention improved pain-management process and outcome measures in nursing homes.

Physician leadership: enhancing the career development of academic physician administrators and leaders.

As the health care environment grows more complex, there is greater opportunity for physician administrative and management leadership. Although physicians in general, and academic physicians in particular, view management as outside their purview, the increased importance of physician administrative leadership represents an opportunity for academic physicians interested in working at the interface of clinical medicine, health care, finance, and management. These physicians are called academic physician administrators and leaders (APALs). APALs are clinician-administrators whose academic contributions include both scholarly work related to their administrative duties and administrative leadership of academically important programs. However, existing academic career development infrastructure, such as academic promotions, is oriented toward traditional clinician-educator and clinician-researcher faculty. The APAL career path differs from traditional academic pathways because APALs require unique skills, different mentors, and a more expansive definition of academic productivity. This article describes how academic medical institutions could enhance the career development of academic physicians in administrative and leadership positions.

Quality improvement for pressure ulcer care in the nursing home setting: the Northeast Pressure Ulcer Project.

OBJECTIVES: The objectives of this study were to evaluate the impact of a collaborative model of quality improvement in nursing homes on processes of care for the prevention and treatment of pressure ulcers. STUDY DESIGN: The study design was experimental. SETTING: We studied 29 nursing homes in New Jersey, Pennsylvania, and Rhode Island. PARTICIPANTS: Participants consisted of pressure ulcer quality improvement teams in 29 nursing homes. INTERVENTION: Quality improvement teams attended a series of workshops to review clinical guidelines and quality improvement principles and to share best practices, and worked one-on-one with mentors to implement quality improvement techniques and to collect data independently. MEASUREMENTS: We calculated process measures based on the Agency for Healthcare Research and Quality (AHRQ) guidelines. Process measures addressed each facility's processes of care for the prevention and treatment of pressure ulcers at baseline and after 12 months of intervention. Prevention measures focused on recent admissions and high-risk residents; treatment measures focused on patients newly diagnosed with pressure ulcers and all patients with pressure ulcers. RESULTS: Overall, 6 of 8 prevention process measures improved significantly, with percent difference between baseline and follow up ranging from 11.6% to 24.5%. Three of 4 treatment process measures improved significantly, with 5.0%, 8.9%, and 25.9% difference between baseline and follow up. For each process measure, between 5 and 12 facilities demonstrated significant improvement between baseline and follow up, and only 2 or fewer declined for each process measure. CONCLUSION: Improvement in processes of care after the use of a structured collaborative quality improvement approach is possible in the nursing home setting.