Follow-up Psychiatric Care and Risk of Readmission in Patients with Serious Mental Illness in State Funded or Operated Facilities.

Receipt of outpatient treatment within 30 days of discharge from psychiatric hospitalization is an established quality indicator; however, there is scant, mixed evidence as to whether it reduces the risk of readmission. We evaluated this question in patients hospitalized for schizophrenic, bipolar or depressive disorders using the Mental Health Treatment Episode Data Set (MH-TEDS), comprising patients in state-funded or -operated facilities and programs. We performed a 6-month, retrospective longitudinal cohort study including 44,761 patients with schizophrenic disorders, 45,413 patients with bipolar disorders, and 74,995 patients with depressive disorders with an index hospitalization between 2014 and 2018, stratified by whether they had at least one outpatient treatment admission in the first 30 days post-discharge. We used multivariable logistic regression to assess risk of readmission during days 31-180. We found that less than 10 percent of patients in the three cohorts received the recommended follow-up outpatient care. Furthermore, we found that schizophrenic and bipolar patients who did receive such care were no less likely to be readmitted than those not receiving such care (AOR = 0.96, 95% CI 0.87-1.06; AOR 1.06, 955 CI 0.98-1.14), and patients with depressive disorders receiving such care were more likely to be readmitted (AOR = 1.14, 95% CI 1.07-1.22). Thus, few patients received follow-up outpatient care within 30 days of discharge. When it occurred, such outpatient care was either not linked to reduced readmissions or was associated with increased readmissions. These findings suggest the need for more effective care processes in state-funded or -operated facilities.

Initiating Aha moments when implementing person-centered care in nursing homes: a multi-arm, pre-post intervention.

BACKGROUND: Comprehensive adoption of culture change via person-centered care (PCC) practices in nursing homes has been slow. Change such as this, requires transformation of organizational culture, frequently generating resistance and slow moving change. This study examined how nursing homes perceive their adoption of PCC practices across seven domains and how these perceptions change in response to an educational intervention embedded in a statewide program, Promoting Excellent Alternatives in Kansas nursing homes (PEAK 2.0). Given perception is an important feature of the change process, it was hypothesized that pre-adopters engaging in PEAK 2.0's initial Foundation year (level 0) would have lower perceived PCC adoption following a year of education and exposure to PCC, whereas adopters (PEAK 2.0 level 1-5 homes) would have higher perceived PCC adoption following a year of participation in their respective level in the program. METHODS: A multi-arm, pre/post intervention study was conducted during the 2014 and 2015 years of the PEAK 2.0 program comparing pre-PCC adopters to adopters. Outcomes were self-ratings of perceived PCC implementation across seven domains of PCC at the beginning and end of the 2014-15 program year, after pre-adopters had received PCC education and adopters had implemented a year of PCC. Paired t-tests and mixed repeated-measures linear models, controlling for potential confounders, were employed to test the study hypotheses. RESULTS: Across all seven domains of PCC, pre-adopters rated their PCC implementation as significantly higher on pre-test (2014) than on post-test (2015). In contrast, adopters rated their PCC achievement as higher on post-test (2015) than on pre-test (2014). CONCLUSIONS: Pre-adopters' lower score following a year of education and exposure to PCC may reflect a shift in perceptions of PCC as a concept or a deeper conceptualization of PCC. Since perceptions or assumptions can serve as a source of resistance to change, redefinition or "unlearning" to make way for more accurate definitions of PCC could aid in reducing organizational resistance to implementation of PCC and thus improve the rate of adoption.

Person-Centered Care as Facilitated by Kansas' PEAK 2.0 Medicaid Pay-for-Performance Program and Nursing Home Resident Clinical Outcomes.

PURPOSE OF THE STUDY: Person-centered care (PCC) is intended to improve nursing home residents' quality of life, but the closer bonds it engenders between residents and staff may also facilitate improvements to residents' clinical health. Findings on whether adoption ameliorates resident clinical outcomes are conflicting, with some evidence of harm as well as benefit. To provide clearer evidence, the present study made use of Kansas' PEAK 2.0 Medicaid pay-for-performance (P4P) program, which incents the adoption of PCC. The program is distinctive in training facilities' staff on adopting PCC through a series of well-defined stages and providing regular feedback about their progress. DESIGN AND METHODS: A retrospective cohort study was performed with 349 Kansas facilities spread across several well-defined PCC adoption stages, ranging from nonadoption to comprehensive adoption. The outcomes were thirteen 2014-2016 Nursing Home Compare long-stay resident clinical measures and a composite measure incorporating only nonimputed data for those 13 outcomes. Observed facility demographic differences were controlled for with propensity score adjustment. Treatment effect analyses were run with each outcome, with the predictor variable of program stage. RESULTS: Seven of the 13 clinical measures plus the composite measure indicated better health for residents in homes at higher program stages, relative to those in nonparticipating homes, including a 49% lower prevalence of major depressive symptoms in strongly adopting facilities. IMPLICATIONS: The findings suggest that greater PCC adoption through PEAK participation is associated with better quality of care. Policymakers in other states may want to consider implementing a program modeled on PEAK 2.0.

The Kansas PEAK 2.0 Program Facilitates the Diffusion of Culture-Change Innovation to Unlikely Adopters.

Purpose of the Study: Recent studies have shown that nursing homes adopting culture change are disproportionately not-for-profit and CCRC-affiliated, with greater quality of care. Through the lens of diffusion-of-innovation theory, we examined whether Kansas' Medicaid pay-for-performance program PEAK 2.0, which incents the adoption of person-centered care (PCC) and worker empowerment, succeeded in its goal of spreading adoption to atypical- as well as typical-adopting nursing homes. Design and Methods: We conducted a retrospective cohort study of 349 nursing homes in the state during PEAK 2.0's existence, 2012-2016. We constructed a data set combining state program data, provider characteristics from CMS data sets, and other demographic information from the 2010 Census. With a series of logistic regression models, we tested whether program joiners differed from nonjoiners by profit status and other demographic factors, as well as quality-related and case-mix factors. Results: We found that in PEAK 2.0's first year, 2012, adopters were more likely to be not-for-profit and part of a CCRC, with higher occupancy rates and greater quality. However, by 2013 these associations became marginal, and in 2014 and 2015, we found no differences between program joiners and nonjoiners. Implications: The results show that by PEAK 2.0's third year, the program-with its large financial incentive and other potentially important characteristics-succeeded in attracting a large set of nursing homes whose demographics were representative of those in the state. This is important because other studies have found that the adoption of PCC is associated with improved health and well-being for residents.

Does Comprehensive Culture Change Adoption via the Household Model Enhance Nursing Home Residents' Psychosocial Well-being?

BACKGROUND AND OBJECTIVES: Several studies suggest that to substantially improve residents' psychosocial well-being, traditional-model nursing homes should redesign themselves as small, homelike "households" along with comprehensively adopting other aspects of "culture change," a set of reforms meant to improve residents' quality of life. But this evidence mainly comes from qualitative studies. This comparative, observational study tested quantitatively whether residents in a household-model nursing home that had comprehensively adopted culture change reforms displayed greater positive affect, increased cognitive engagement, more extensive social interactions with staff and greater use of the environment than did residents at partial culture-change-adopting facilities with traditional, institutional environments. RESEARCH DESIGN AND METHODS: Household-model residents were matched on clinical and demographic factors with residents at two institutional control facilities that had partially adopted culture change and were observed for 8 hours each. To provide potentially converging evidence, aides and nurses were also observed. Finally, a culture change implementation assessment was conducted. RESULTS: The implementation assessment showed that the household-model home had implemented culture change beyond national norms, whereas the control facilities were U.S.-typical partial adopters. It also revealed that household-model staff cared for residents in a more person-centered manner. Observation analyses revealed that household-model residents spent less time idle and less time stationary at wheelchair hubs. Moreover, although household-model residents did not spend the most time in the dining area overall, they spent the greatest percentage of time there talking with staff, displaying positive affect, and displaying active engagement. Finally, household-model residents and staff spent the most time in task-oriented interactions, including personal care. DISCUSSION AND IMPLICATIONS: These results suggest that the intended psychosocial benefits materialize in household-model facilities, particularly in the dining area and in resident-staff relationships. The findings raise the possibility that facilities may be able to achieve these outcomes without entirely redesigning their environment.

Does Person-Centered Care Improve Residents' Satisfaction With Nursing Home Quality?

OBJECTIVE: Person-centered care (PCC) is meant to enhance nursing home residents' quality of life (QOL). Including residents' perspectives is critical to determining whether PCC is meeting residents' needs and desires. This study examines whether PCC practices promote satisfaction with QOL and quality of care and services (QOC and QOS) among nursing home residents. DESIGN: A longitudinal, retrospective cohort study using an in-person survey. SETTING: Three hundred twenty nursing homes in Kansas enrolled or not enrolled in a pay-for-performance program, Promoting Excellent Alternatives in Kansas (PEAK 2.0), to promote PCC in nursing homes. PARTICIPANTS: A total of 6214 nursing home residents in 2013-2014 and 5538 residents in 2014-2015, with a Brief Interview for Mental Status score ≥8, participated in face-to-face interviews. Results were aggregated to the nursing home level. MEASUREMENTS: My InnerView developed a Resident Satisfaction Survey for Kansas composed of 32 questions divided into QOL, QOC, QOS, and global satisfaction subdomains. RESULTS: After controlling for facility characteristics, satisfaction with overall QOL and QOC was higher in homes that had fully implemented PCC. Although some individual measures in the QOS domain (eg, food) showed greater satisfaction at earlier levels of implementation, high satisfaction was observed primarily in homes that had fully implemented PCC. CONCLUSION: These findings provide evidence for the effectiveness of PCC implementation on nursing home resident satisfaction. The PEAK 2.0 program may provide replicable methods for nursing homes and states to implement PCC systematically.

Predictors of Intent to Leave the Job Among Home Health Workers: Analysis of the National Home Health Aide Survey.

Purpose: To identify agency policies and workplace characteristics that are associated with intent to leave the job among home health workers employed by certified agencies. Design and Methods: Data are from the 2007 National Home and Hospice Care Survey/National Home Health Aide Survey, a nationally representative, linked data set of home health and hospice agencies and their workers. Logistic regression with survey weights was conducted to identify agency and workplace factors associated with intent to leave the job, controlling for worker, agency, and labor market characteristics. Results: Job satisfaction, consistent patient assignment, and provision of health insurance were associated with lower intent to leave the job. By contrast, being assigned insufficient work hours and on-the-job injuries were associated with greater intent to leave the job after controlling for fixed worker, agency, and labor market characteristics. African American workers and workers with a higher household income also expressed greater intent to leave the job. Implications: This is the first analysis to use a weighted, nationally representative sample of home health workers linked with agency-level data. The findings suggest that intention to leave the job may be reduced through policies that prevent injuries, improve consistency of client assignment, improve experiences among African American workers, and offer sufficient hours to workers who want them.

Desvenlafaxine may accelerate neuronal maturation in the dentate gyri of adult male rats.

Adult hippocampal neurogenesis has been linked to the effects of anti-depressant drugs on behavior in rodent models of depression. To explore this link further, we tested whether the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine impacted adult hippocampal neurogenesis differently than its primary active SNRI metabolite desvenlafaxine. Adult male Long Evans rats (n = 5-6 per group) were fed vehicle, venlafaxine (0.5 or 5 mg) or desvenlafaxine (0.5 or 5 mg) twice daily for 16 days. Beginning the third day of drug treatment, the rats were given a daily bromodeoxyuridine (BrdU; 50 mg/kg) injection for 5 days to label dividing cells and then perfused 2 weeks after the first BrdU injection to confirm total new hippocampal cell numbers and their phenotypes. The high desvenlafaxine dose increased total new BrdU+ cell number and appeared to accelerate neuronal maturation because fewer BrdU+ cells expressed maturing neuronal phenotypes and more expressed mature neuronal phenotypes in the dentate gyri of these versus vehicle-treated rats. While net neurogenesis was not increased in the dentate gyri of rats treated with the high desvenlafaxine dose, significantly more mature neurons were detected. Our data expand the body of literature showing that antidepressants impact adult neurogenesis by stimulating NPC proliferation and perhaps the survival of neuronal progeny and by showing that a high dose of the SNRI antidepressant desvenlafaxine, but neither a high nor low venlafaxine dose, may also accelerate neuronal maturation in the adult rat hippocampus. These data support the hypothesis that hippocampal neurogenesis may indeed serve as a biomarker of depression and the effects of antidepressant treatment, and may be informative for developing novel fast-acting antidepressant strategies.

Toward the development of a sensitive, pre-clinical screen for neurological diseases from spontaneous neural coordination in juvenile and young-adult C57BK6 mice.

Spontaneous Frequency Bursts (SFBs) are a newly discovered form of long-distance neural coordination. They have several distinctive properties, including near-simultaneity of occurrence (+/-25-50 ms) across distant brain regions and high within- and across-site coherence in multiple low and high frequency bands, presumably requiring high axonal, dendritic and vascular integrity. We examined whether SFBs occurred in young and young-adult C57BK6 mice with properties similar to those seen in rats. We found that across the entorhinal and piriform cortices, SFBs occur robustly in young and young-adult mice under light anesthesia, and that their rate of occurrence dropped sharply as anesthetic levels increased, as in rats. Moreover, murine SFBs showed high cross-site coherence in multiple frequency bands, including those that require exquisite action potential timing to be maintained across long distances. We discuss our findings in light of SFBs potential as a pre-clinical biomarker for diseases affecting action potential firing and local field potential coherence, especially in high frequency ranges (20-30 Hz and beyond).

Cyber-workstation for computational neuroscience.

A Cyber-Workstation (CW) to study in vivo, real-time interactions between computational models and large-scale brain subsystems during behavioral experiments has been designed and implemented. The design philosophy seeks to directly link the in vivo neurophysiology laboratory with scalable computing resources to enable more sophisticated computational neuroscience investigation. The architecture designed here allows scientists to develop new models and integrate them with existing models (e.g. recursive least-squares regressor) by specifying appropriate connections in a block-diagram. Then, adaptive middleware transparently implements these user specifications using the full power of remote grid-computing hardware. In effect, the middleware deploys an on-demand and flexible neuroscience research test-bed to provide the neurophysiology laboratory extensive computational power from an outside source. The CW consolidates distributed software and hardware resources to support time-critical and/or resource-demanding computing during data collection from behaving animals. This power and flexibility is important as experimental and theoretical neuroscience evolves based on insights gained from data-intensive experiments, new technologies and engineering methodologies. This paper describes briefly the computational infrastructure and its most relevant components. Each component is discussed within a systematic process of setting up an in vivo, neuroscience experiment. Furthermore, a co-adaptive brain machine interface is implemented on the CW to illustrate how this integrated computational and experimental platform can be used to study systems neurophysiology and learning in a behavior task. We believe this implementation is also the first remote execution and adaptation of a brain-machine interface.

Chemoreception scientists gather under the Florida sun: The 31st Annual Association for Chemoreception Sciences meeting.

The 31st Annual Association for Chemoreception Sciences (AChemS) met in Sarasota, Florida April 22-26, 2009, attracting approximately 600 registrants and nearly 400 abstracts. In addition to poster and platform presentations, the program offered symposia, special lectures, and various National Institutes of Health (NIH)-sponsored workshops, including one on computational approaches to olfaction.