Longitudinal Evaluation of a Statewide Quality Improvement Program for Nursing Homes.

OBJECTIVES: The National Academies of Sciences, Engineering, and Medicine (NASEM) Nursing Home Quality report recommends that states "develop and operate state-based…technical assistance programs…to help nursing homes…improve care and…operations." The Quality Improvement Program for Missouri (QIPMO) is one such program. This longitudinal evaluation examined and compared differences in quality measures (QMs) and nursing home (NH) characteristics based on intensity of QIPMO services used. DESIGN: A descriptive study compared key QMs of clinical care, facility-level characteristics, and differing QIPMO service intensity use. QIPMO services include on-site clinical consultation by expert nurses; evidence-based practice information; teaching NHs use of quality improvement (QI) methods; and guiding their use of Centers for Medicare and Medicaid Services (CMS)-prepared QM comparative feedback reports to improve care. SETTING AND PARTICIPANTS: All Missouri NHs (n = 510) have access to QIPMO services at no charge. All used some level of service during the study, 2020-2022. METHODS: QM data were drawn from CMS's publicly available website (Refresh April 2023) and NH characteristics data from other public websites. Service intensity was calculated using data from facility contacts (on-site visits, phone calls, texts, emails, webinars). NHs were divided into quartiles based on service intensity. RESULTS: All groups had different beginning QM scores and improved ending scores. Group 2, moderate resource intensity use, started with "worse" overall score and improved to best performing by the end. Group 4, most resource intensity use, improved least but required highest service intensity. CONCLUSIONS AND IMPLICATIONS: This longitudinal evaluation of QIPMO, a statewide QI technical assistance and support program, provides evidence of programmatic stimulation of statewide NH quality improvements. It provides insight into intensity of services needed to help facilities improve. Other states should consider QIPMO success and develop their own programs, as recommended by the NASEM report so their NHs can embrace QI and "initiate fundamental change" for better care for our nation's older adults.

Smart Technology for Aging and Reducing Disability (STAReD): Study protocol for a randomized pragmatic clinical trial.

BACKGROUND: There is a critical need to improve quality of life for community-dwelling older adults with disabilities. Prior research has demonstrated that a smart, in-home sensor system can facilitate aging in place for older adults living in independent living apartments with care coordination support by identifying early illness and injury detection. Self-management approaches have shown positive outcomes for many client populations. Pairing the smart, in-home sensor system with a self-management intervention for community-dwelling older adults with disabilities may lead to positive outcomes. METHODS: This study is a prospective, two-arm, randomized, pragmatic clinical trial to compare the effect of a technology-supported self-management intervention on disability and health-related quality of life to that of a health education control, for rural, community-dwelling older adults. Individuals randomized to the self-management study arm will receive a multidisciplinary (nursing, occupational therapist, and social work) self-management approach coupled with the smart-home sensor system. Individuals randomized to the health education study arm will receive standard health education coupled with the smart-home sensor system. The primary outcomes of disability and health-related quality of life will be assessed at baseline and post-intervention. Generalizable guidance to scale the technology-supported self-management intervention will be developed from qualitatively developed exemplar cases. CONCLUSION: This study has the potential to impact the health and well-being of rural, community-dwelling older adults with disabilities. We have overcome barriers including recruitment in a rural population and supply chain issues for the sensor system. Our team remains on track to meet our study aims.

Exploring Hospital Transfers for Long-Stay Nursing Home Residents With End-Stage Renal Disease.

BACKGROUND: Nursing home residents with end-stage renal disease (ESRD) are an understudied, yet growing population within nursing homes. PURPOSE: To describe hospital transfers for nursing home residents diagnosed with ESRD and receiving hemodialysis. METHODS: Data were analyzed for residents with ESRD transferred to the hospital between October 2016 and September 2020 (n = 219). Descriptive statistics, bivariate analyses, logistic regression, and content analysis were used for analysis. RESULTS: Clinical factors associated with transfers included abnormal vitals, altered mental state, and pain. Other factors included lack of care planning and advance directives, provider communication, resident/family preferences, missing/refusing dialysis, and facility resources. The odds of an observation/emergency department only visit was 2.02 times larger when transferred from the dialysis clinic. CONCLUSIONS: Advance care planning and coordinated care between nursing home and dialysis clinics are needed along with proactive planning when residents miss dialysis or experience a condition change at the dialysis clinic.

Ambulatory Care Coordination Data Gathering and Use.

Care coordination is a crucial component of healthcare systems. However, little is known about data needs and uses in ambulatory care coordination practice. Therefore, the purpose of this study was to identify information gathered and used to support care coordination in ambulatory settings. Survey respondents (33) provided their demographics and practice patterns, including use of electronic health records, as well as data gathered and used. Most of the respondents were nurses, and they described varying practice settings and patterns. Although most described at least partial use of electronic health records, two respondents described paper documentation systems. More than 25% of respondents gathered and used most of the 72 data elements, with collection and use often occurring in multiple locations and contexts. This early study demonstrates significant heterogeneity in ambulatory care coordination data usage. Additional research is necessary to identify common data elements to support knowledge development in the context of a learning health system.

Factors associated with avoidable hospital transfers among residents in Swiss nursing homes.

Unplanned hospitalizations from nursing homes (NHs) may be considered potentially avoidable and can result in adverse resident outcomes. There is little information about the relationship between a clinical assessment conducted by a physician or geriatric nurse expert before hospitalization and an ensuing rating of avoidability. This study aimed to describe characteristics of unplanned hospitalizations (admitted residents with at least one night stay, emergency department visits were excluded) and to examine this relationship. We conducted a cohort study in 11 Swiss NHs and retrospectively evaluated data from the root cause analysis of 230 unplanned hospitalizations. A telephone assessment by a physician (p=.043) and the need for further medical clarification and treatment (p=<0.001) were the principal factors related to ratings of avoidability. Geriatric nurse experts can support NH teams in acute situations and assess residents while adjudicating unplanned hospitalizations. Constant support for nurses expanding their clinical role is still warranted.

Understanding Formal Caregiver Burden in Nursing Assistants in Nursing Homes: A Mixed Methods Approach.

The current study aimed to describe formal caregiver burden of nursing assistants in nursing homes. A descriptive, cross-sectional, convergent mixed methods approach identified attributes of formal caregiver burden using phenomenological interviews and established self-report measures. Themes included nursing assistants' experiences of stress, close relationships, extensive assistance of residents, balancing needs and routines, and feeling accomplished. Self-report measures demonstrated moderate stress, moderate caring behaviors, responsibility, and competence. MDS 3.0 results showed moderate cognitive impairment, minimal depressive symptoms, and decreased functional status of residents. The mixed methods synthesis confirmed the presence of five attributes of formal caregiver burden: perceived stress, caring for another, dependency of the older adult, responsibility, and competence. Burnout was not confirmed. Future investigation of attributes among a larger, diverse sample of nursing assistants, residents, and nursing homes will advance knowledge and inform research design and methods of interventions. [Research in Gerontological Nursing, 16(5), 231-240.].

Access for Cancer Caregivers to Education and Support for Shared Decision Making (ACCESS) intervention: a cluster cross-over randomised clinical trial.

OBJECTIVES: The purpose of this study was to test an intervention named ACCESS (Access for Cancer Caregivers to Education and Support for Shared Decision Making). The intervention uses private Facebook support groups to support and educate caregivers, preparing them to participate in shared decision-making during web-based hospice care plan meetings. The overall hypothesis behind the study was that family caregivers of hospice patients with cancer would experience lower anxiety and depression as a result of participating in an online Facebook support group and shared decision-making with hospice staff in a web-based care plan meeting. METHODS: This is a cluster cross-over randomised three-arm clinical trial where one group participated in both the Facebook group and the care plan team meeting. A second group participated only in the Facebook group and the third group was a control group and received usual hospice care. RESULTS: There were 489 family caregivers who participated in the trial. There were no statistically significant differences between the ACCESS intervention group and the Facebook only or the control group on any outcome. The participants in the Facebook only group, however, experienced a statistically significant decrease in depression compared with the enhanced usual care group. CONCLUSIONS: While the ACCESS intervention group did not experience significant improvement in outcomes, caregivers assigned to the Facebook only group showed significant improvement in depression scores from baseline as compared with the enhanced usual care control group. Further research is needed to understand the mechanisms of action leading to reduced depression.

Evaluating the implementation fidelity to a successful nurse-led model (INTERCARE) which reduced nursing home unplanned hospitalisations.

BACKGROUND: Implementation fidelity assesses the degree to which an intervention is delivered as it should be. Fidelity helps to determine if the outcome(s) of an intervention are attributed to the intervention itself or to a failure of its implementation. Little is known about how fidelity impacts the intended outcome(s) and what elements or moderators can affect the fidelity trajectory over time. We exemplify the meaning of implementation fidelity with INTERCARE, a nurse-led care model that was implemented in eleven Swiss nursing homes (NHs) and showed effectiveness in reducing unplanned hospital transfers. INTERCARE comprises six core elements, including advance care planning and tools to support inter- and interprofessional communication, which were introduced with carefully developed implementation strategies. METHODS: A mixed-methods convergent/triangulation design was used to investigate the influence of implementation fidelity on unplanned transfers. A fidelity questionnaire measuring the degree of fidelity to INTERCARE's core components was fielded at four time points in the participating NHs. Two-monthly meetings were conducted with NHs (September 2018-January 2020) and structured notes were used to determine moderators affecting fidelity (e.g., participant responsiveness). We used the fidelity scores and generalized linear mixed models to analyze the quantitative data. The Framework method was used for the qualitative analysis. The quantitative and qualitative findings were integrated using triangulation. RESULTS: A higher overall fidelity score showed a decreasing rate of unplanned hospital transfers post-intervention (OR: 0.65 (CI = 0.43-0.99), p = 0.047). A higher fidelity score to advance care planning was associated with lower unplanned transfers (OR = 0.24 (CI 0.13-0.44), p = < 0.001) and a lower fidelity score for communication tools (e.g., ISBAR) to higher rates in unplanned transfers (OR = 1.69 (CI 1.30-2.19), p = < 0.003). In-house physicians with a collaborative approach and staff's perceived need for nurses working in extended roles, were important moderators to achieve and sustain high fidelity. CONCLUSION: Implementation fidelity is challenging to measure and report, especially in complex interventions, yet is crucial to better understand how such interventions may be tailored for scale-up. This study provides both a detailed description of how fidelity can be measured and which ingredients highly contributed to reducing unplanned NH transfers. TRIAL REGISTRATION: The INTERCARE study was registered at clinicaltrials.gov Protocol Record NCT03590470.

Health Literacy of Surrogates and Communication Issues in Palliative Care Conversations in Critical Care: An Integrative Review.

Worldwide, 56.8 million persons are estimated to require palliative care. Critically ill patients benefit from palliative care by improving their quality of life through symptom management. Resistance to palliative care exists from surrogate decision-makers because of low health literacy and communication issues with providers. This research reviewed the literature to identify how health literacy and health care communication influenced palliative care conversations with decision-making surrogates and health outcomes of critically ill patients. The review included articles between 2011 and 2022 using the terms communication, health literacy, palliative care, critical care, intensive care, ICU, surrogate decision maker, family, and caregiver in PubMed, CINAHL, and Google Scholar. Fourteen articles were included. Quality was assessed through Joanna Briggs Institute appraisal tools. Health literacy of surrogates was not found to be significant for patient outcomes. However, there were significant differences between clinician and surrogate communication influenced by surrogates' previous health care experiences. Early communication about prognosis was important for surrogates. Structured communication approaches were preferred by surrogates. Limitations of the review included primarily White participants, small variability of research sites, and a few number of articles. Future research needs to study the effects of surrogate health literacy of critically ill patients on willingness to accept palliative care.

Discharge process challenges of an academic vascular surgery service: A qualitative study.

Vascular surgery patients have a high incidence of unplanned hospital readmissions and complications. Previous research has not fully examined specific elements of the hospital discharge process for vascular surgery patients to identify issues that may contribute to readmissions. The objective of this qualitative descriptive study was to explore challenges identified by healthcare providers and patients regarding the discharge process from an academic vascular surgery service. Data were collected from eight focus group interviews and analyzed for relevant themes. Patients and healthcare providers identified several challenges within the standard discharge process, including ineffective communication, insufficient time for discharge education, and limitations accessing providers with post-discharge concerns. These obstacles may be ameliorated in part by specialized coordinators, caregiver support, and use of adaptive strategies outside of the current discharge process. The discharge challenges described by study participants likely contribute to adverse post-hospitalization outcomes, including unplanned hospital readmissions. A multifaceted approach that incorporates standardized discharge processes, as well as informal problem-solving strategies, is recommended to improve hospital discharge and outcomes for vascular surgery patients.

Informal Family Caregiving of Patients with Diabetic Extremity Wounds: An Integrative Review.

Annually, 26 million people worldwide develop diabetic extremity wounds, adversely impacting the lives of patients and their family caregivers, who provide vital health assistance to these patients. This integrative review synthesized scientific literature of informal caregiving experiences for patients with diabetic extremity wounds. Five databases were searched for relevant English-language quantitative or qualitative research; ten studies were included in the final analysis. The caregiving experience included disrupted routines, frustration, guilt, poor health care communication, helplessness, and anxiety. Increased caregiver burden and decreased quality of life were associated with higher patient amputation level, worsening wound appearance and patient pain, poor health care communication, lack of social support and/or caregiving help, and lack of caregiver employment outside the home. Future research opportunities include further exploration of caregiver tasks and priorities, caregiving experiences in settings lacking family support structures and equitable health system access, and relationships between the caregiver experience and patient health system utilization.

Interventions to Prevent Readmissions in Hospitalized Peripheral Vascular Surgery Patients: A Systematic Review.

A large proportion of peripheral vascular patients worldwide experience unplanned hospital readmissions after inpatient vascular surgery. This review was conducted to identify acute care and post-discharge interventions that may help in reducing unplanned vascular surgery readmissions. A computer-based search of four databases was conducted July 2021 for original research reports published 2000 to 2021. Eight studies met inclusion criteria, with interventions including multidisciplinary care teams, advance practice provider discharge coordination, individualized case management, home care nursing, early primary care provider or telephone follow-up, and telehealth driven follow up evaluated. Some reductions in readmission rates were associated with most interventions but were inconsistent across studies. Further research is necessary to clarify and validate these findings, incorporate patient perspectives, and explore the role of technology-based interventions. This work is key to improving the patient's experience, reduce healthcare costs, and strengthen the quality of vascular surgery care.

A qualitative study evaluating the discharge process for vascular surgery patients to identify significant themes for organizational improvement.

OBJECTIVE: Transition from the hospital to an outpatient setting is a multifaceted process requiring coordination among a variety of services and providers to ensure a high-quality discharge. Vascular surgery patients comprise a complex population that experiences high unplanned readmission rates. We performed a qualitative study to identify themes for process improvement for vascular surgery patients. A validated discharge process, RED (Re-Engineered Discharge), was used to identify additional actionable themes to create a more efficient discharge process tailored specifically to the vascular surgery population. METHODS: A prospective, qualitative analysis at a tertiary center using a semi-structured focus group interview guide was performed to evaluate the current discharge process and identify opportunities for improvement. Focus groups were Zoom recorded, transcribed into electronic text files, and were loaded into Dedoose qualitative software for analysis using a directed content analysis approach. Two researchers independently thematically coded each transcript, starting with accepted discharge components to identify new thematic categories. Prior to analysis, all redundancy of codes was resolved, and all team members agreed on text categorization and coding. RESULTS: Eight focus groups with a total of 38 participants were conducted. Participants included physicians (n = 13), nursing/ancillary staff (n = 14), advanced nurse practitioners (n = 2), social worker/dietitian/pharmacist (n = 3), and patients (n = 6). Transcript analyses revealed facilitators and barriers to the discharge process. In addition to traditional RED components, unique concepts pertinent to vascular surgery patients included patient complexity, social determinants of health, technology literacy, complexity of ancillary services, discharge appropriateness, and use of advanced nurse practitioners for continuity. CONCLUSIONS: Specific themes were identified to target and enhance the future vRED (vascular Re-Engineered Discharge) bundle. Thematic targets for improvement include increased planning, organization, and communication prior to discharge to address vascular surgery patients' multiple comorbidities, extensive medication lists, and need for complex ancillary services at the time of discharge. Other thematic barriers discovered to improve include provider awareness of patient health literacy, patient understanding of complex discharge instructions, patient technology barriers, and intrinsic social determinants of health in this population. To address these discovered barriers, organizational targets to improve include enhanced social support, the use of advanced nurse practitioners for education reinforcement, and increased coordination. These results provide a framework for future quality improvement targeting the vascular surgery discharge process.

Digital Methodology for Mobile Clinical Decision Support Development in Long-Term Care.

The global COVID-19 pandemic has driven innovations in methods to sustain initiatives for the design, development, evaluation, and implementation of clinical support technology in long-term care settings while removing risk of infection for residents, family members, health care workers, researchers and technical professionals. We adapted traditional design and evaluation methodology for a mobile clinical decision support app - designated Mobile Application Information System for Integrated Evidence ("MAISIE") - to a completely digital design methodology that removes in-person contacts between the research team, developer, and nursing home staff and residents. We have successfully maintained project continuity for MAISIE app development with only minor challenges while working remotely. This digital design methodology can be implemented in projects where software can be installed without in-person technical support and remote work is feasible. Team skills, experience, and relationships are key considerations for adapting to digital environments and maintaining project momentum.

Health economic evaluation of a nurse-led care model from the nursing home perspective focusing on residents' hospitalisations.

BACKGROUND: Health economic evaluations of the implementation of evidence-based interventions (EBIs) into practice provide vital information but are rarely conducted. We evaluated the health economic impact associated with implementation and intervention of the INTERCARE model-an EBI to reduce hospitalisations of nursing home (NH) residents-compared to usual NH care. METHODS: The INTERCARE model was conducted in 11 NHs in Switzerland. It was implemented as a hybrid type 2 effectiveness-implementation study with a multi-centre non-randomised stepped-wedge design. To isolate the implementation strategies' costs, time and other resources from the NHs' perspective, we applied time-driven activity-based costing. To define its intervention costs, time and other resources, we considered intervention-relevant expenditures, particularly the work of the INTERCARE nurse-a core INTERCARE element. Further, the costs and revenues from the hotel and nursing services were analysed to calculate the NHs' losses and savings per resident hospitalisation. Finally, alongside our cost-effectiveness analysis (CEA), a sensitivity analysis focused on the intervention's effectiveness-i.e., regarding reduction of the hospitalisation rate-relative to the INTERCARE costs. All economic variables and CEA were assessed from the NHs' perspective. RESULTS: Implementation strategy costs and time consumption per bed averaged 685CHF and 9.35 h respectively, with possibilities to adjust material and human resources to each NH's needs. Average yearly intervention costs for the INTERCARE nurse salary per bed were 939CHF with an average of 1.4 INTERCARE nurses per 100 beds and an average employment rate of 76% of full-time equivalent per nurse. Resident hospitalisation represented a total average loss of 52% of NH revenues, but negligible cost savings. The incremental cost-effectiveness ratio of the INTERCARE model compared to usual care was 22'595CHF per avoided hospitalisation. As expected, the most influential sensitivity analysis variable regarding the CEA was the pre- to post-INTERCARE change in hospitalisation rate. CONCLUSIONS: As initial health-economic evidence, these results indicate that the INTERCARE model was more costly but also more effective compared to usual care in participating Swiss German NHs. Further implementation and evaluation of this model in randomised controlled studies are planned to build stronger evidential support for its clinical and economic effectiveness. TRIAL REGISTRATION: clinicaltrials.gov ( NCT03590470 ).

Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity.

BACKGROUND: Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. METHODS: This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. RESULTS: Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. CONCLUSIONS: Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

Development and Pilot Analysis of the Nursing Home Health Information Technology Maturity Survey and Staging Model.

The current research includes a psychometric test of a nursing home (NH) health information technology (HIT) maturity survey and staging model. NHs were assembled based on HIT survey scores from a prior study representing NHs with low (20%), medium (60%), and high (20%) HIT scores. Inclusion criteria were NHs that completed at least two annual surveys over 4 years. NH administrators were excluded who participated in the Delphi panel responsible for instrument recommendations. Recruitment occurred from January to May 2019. Administrators from 121 of 429 facilities completed surveys. NHs were characteristically for-profit, medium bed size, and metropolitan. A covariance matrix demonstrated that all dimensions and domains were significantly correlated, except HIT capabilities and integration in administrative activities. Cronbach's alpha was very good (0.86). Principal component analysis revealed all items loaded intuitively onto four components, explaining 80% variance. The HIT maturity survey and staging model can be used to assess nine dimensions and domains, total HIT maturity, and stage, leading to reliable assumptions about NH HIT. [Research in Gerontological Nursing, 15(2), 93-99.].

Longitudinal analysis of aging in place at TigerPlace: Resident function and well-being.

This paper reports on a longitudinal eight-year analysis (2011-2019) of trajectory of function and well-being residents of TigerPlace Aging in Place (AIP) model of care. Residents were routinely assessed using standard health assessment instruments. Average scores from each measure were examined for changes or trends in resident function; decline over time was calculated. Scores for depression, mental health subscale Short Form Health Survey-12 (SF-12) remained stable over time. Mini Mental State Exam declined to mild dementia range (21-24). Physical measures SF-12 physical health subscale, ADLs, and IADLs declined slightly, while fall risk increased over time. When yearly trends in AIP were modeled with a referent group there was no significant worsening of functioning. The length of stay for TigerPlace residents continued to remain stable at nearly 30 months. Residents maintained function in the environment of their choice longer at cost less than nursing homes, and just above residential care cost.

Positive effect of the INTERCARE nurse-led model on reducing nursing home transfers: A nonrandomized stepped-wedge design.

BACKGROUND: Unplanned nursing home (NH) transfers are burdensome for residents and costly for health systems. Innovative nurse-led models of care focusing on improving in-house geriatric expertise are needed to decrease unplanned transfers. The aim was to test the clinical effectiveness of a comprehensive, contextually adapted geriatric nurse-led model of care (INTERCARE) in reducing unplanned transfers from NHs to hospitals. METHODS: A multicenter nonrandomized stepped-wedge design within a hybrid type-2 effectiveness-implementation study was implemented in 11 NHs in German-speaking Switzerland. The first NH enrolled in June 2018 and the last in November 2019. The study lasted 18 months, with a baseline period of 3 months for each NH. Inclusion criteria were 60 or more long-term care beds and 0.8 or more hospitalizations per 1'000 resident care days. Nine hundred and forty two long-term NH residents were included between June 2018 and January 2020 with informed consent. Short-term residents were excluded. The primary outcome was unplanned hospitalizations. A fully anonymized dataset of overall transfers of all NH residents served as validation. Analysis was performed with segmented mixed regression modeling. RESULTS: Three hundred and three unplanned and 64 planned hospitalizations occurred. During the baseline period, unplanned transfers increased over time (ß1  = 0.52), after which the trend significantly changed by a similar but opposite amount (ß2  = -0.52; p = 0.0001), resulting in a flattening of the average transfer rate throughout the postimplementation period (ß1  + ß2  ≈ 0). Controlling for age, gender, and cognitive performance did not affect these trends. The validation set showed a similar flattening trend. CONCLUSION: A complex intervention with six evidence-based components demonstrated effectiveness in significantly reducing unplanned transfers of NH residents to hospitals. INTERCARE's success was driven by registered nurses in expanded roles and the use of tools for clinical decision-making.

Value Propositions for Health Information Exchange Toward Improving Nursing Home Hospital Readmission Rates.

The importance of health information technology use in nursing home (NH) care delivery is a major topic in research exploring methods to improve resident care. Topics of interest include how technology investments, infrastructure, and work-force development lead to better methods of nursing care delivery and outcomes. Value propositions, including perceived benefits, incentives, and system changes recognized by end-users, are important resources to inform NH leaders, policymakers, and stakeholders about technology. The purpose of the current research was to identify and disseminate value propositions from a community of stakeholders using a health information exchange (HIE). Researchers used a nominal group process, including 49 individual stakeholders participating in a national demonstration project to reduce avoidable hospitalizations in NHs. Stakeholders identified 41 total anticipated changes from using HIE. Ten stakeholder types were perceived to have experienced the highest impact from HIE in areas related to resident admissions, communication, and efficiency of care delivery. [Journal of Gerontological Nursing, 48(1), 15-20.].