Use of electronic health record data to examine administrations of pro re nata analgesics during hip fracture post-acute care.

PURPOSE: Medications prescribed to older adults in US skilled nursing facilities (SNF) and administrations of pro re nata (PRN) "as needed" medications are unobservable in Medicare insurance claims. There is an ongoing deficit in our understanding of medication use during post-acute care. Using SNF electronic health record (EHR) datasets, including medication orders and barcode medication administration records, we described patterns of PRN analgesic prescribing and administrations among SNF residents with hip fracture. METHODS: Eligible participants resided in SNFs owned by 11 chains, had a diagnosis of hip fracture between January 1, 2018 to August 2, 2021, and received at least one administration of an analgesic medication in the 100 days after the hip fracture. We described the scheduling of analgesics, the proportion of available PRN doses administered, and the proportion of days with at least one PRN analgesic administration. RESULTS: Among 24 038 residents, 57.3% had orders for PRN acetaminophen, 67.4% PRN opioids, 4.2% PRN non-steroidal anti-inflammatory drugs, and 18.6% PRN combination products. The median proportion of available PRN doses administered per drug was 3%-50% and the median proportion of days where one or more doses of an ordered PRN analgesic was administered was 25%-75%. Results differed by analgesic class and the number of administrations ordered per day. CONCLUSIONS: EHRs can be leveraged to ascertain precise analgesic exposures during SNF stays. Future pharmacoepidemiology studies should consider linking SNF EHRs to insurance claims to construct a longitudinal history of medication use and healthcare utilization prior to and during episodes of SNF care.

Community Participation Transition After Stroke (COMPASS) Randomized Controlled Trial: Effect on Adverse Health Events.

OBJECTIVE: To compare adverse health events in intervention versus control group participants in the Community Participation Transition After Stroke trial to reduce barriers to independent living for community-dwelling stroke survivors. DESIGN: Randomized controlled trial. SETTING: Inpatient rehabilitation (IR) to home and community transition. PARTICIPANTS: Stroke survivors aged ≥50 years being discharged from IR who had been independent in activities of daily living prestroke (N=183). INTERVENTIONS: Participants randomized to intervention group (n=85) received home modifications and self-management training from an occupational therapist over 4 visits in the home. Participants randomized to control group (n=98) received the same number of visits consisting of stroke education. MAIN OUTCOME MEASURES: Death, skilled nursing facility (SNF) admission, 30-day rehospitalization, and fall rates after discharge from IR. RESULTS: Time-to-event analysis revealed that the intervention reduced SNF admission (cumulative survival, 87.8%; 95% confidence interval [CI], 78.6%-96.6%) and death (cumulative survival, 100%) compared with the control group (SNF cumulative survival, 78.9%; 95% CI, 70.4%-87.4%; P=.039; death cumulative survival, 87.3%; 95% CI, 79.9%-94.7%; P=.001). Thirty-day rehospitalization also appeared to be lower among intervention participants (cumulative survival, 95.1%; 95% CI, 90.5%-99.8%) than among control participants (cumulative survival, 86.3%; 95% CI, 79.4%-93.2%; P=.050) but was not statistically significant. Fall rates did not significantly differ between the intervention group (5.6 falls per 1000 participant-days; 95% CI, 4.7-6.5) and the control group (7.2 falls per 1000 participant-days; 95% CI, 6.2-8.3; incidence rate ratio, 0.78; 95% CI, 0.46-1.33; P=.361). CONCLUSIONS: A home-based occupational therapist-led intervention that helps stroke survivors transition to home by reducing barriers in the home and improving self-management could decrease the risk of mortality and SNF admission after discharge from rehabilitation.

A Mixed-Method Evaluation to Understand Clinician Perceptions of a Program to Implement High-Intensity Resistance Rehabilitation into Skilled Nursing Facilities.

OBJECTIVE: To assess rehabilitation clinicians' viewpoints regarding a multicomponent implementation program aimed at promoting high-intensity resistance rehabilitation (HIR), as well as practical implications for its use in Skilled Nursing Facility (SNF) rehabilitation. DESIGN: Prospective convergent mixed-method design. SETTING: Eight rural Skilled Nursing Facilities within the Department of Veterans Affairs Participants: Physical rehabilitation clinicians (physical and occupational therapists, physical and occupational therapy assistants, recreational therapists, and kinesiotherapists) who engaged with the implementation program (n=38). INTERVENTIONS: Clinicians engaged with the multicomponent implementation program to promote use of HIR in clinical practice. The program components included clinician training (i.e., virtual didactic modules with synchronous case discussions), provision of resources (e.g., equipment, job aids), and facilitated implementation (e.g., external implementation facilitator support, distributed tips and tricks). MAIN OUTCOME MEASURES: Acceptability of Intervention Measure, Training Acceptability Rating Scale, study-specific questionnaires, and qualitative focus groups exploring perceived acceptability, impact, feasibility, and effect on work experience. RESULTS: Questionnaires revealed high levels of implementation program acceptability and perceived impact, alongside moderate levels of feasibility. Focus group themes supported these findings, explaining high acceptability and impact through differentiation from other trainings and prolonged engagement. Feasibility results were explained qualitatively by facilitatory factors (i.e., team participation, reduced caseloads, training characteristics) and inhibitory factors (i.e., training timing, self-paced scheduling logistics, lack of protected time and space). There was no reported negative impact on clinician work experience. CONCLUSIONS: According to SNF clinician perspectives, a positive HIR implementation experience may be enhanced through implementation programs that provide prolonged engagement and self-paced structure with built-in accountability. Leadership and organizational support appear important to protect time and space for clinicians who experience competing priorities to successfully facilitate evidence uptake. Future work can evaluate the applicability across various contexts beyond rural VA SNFs.

Analysis of Patients' Dietary Status/Restrictions Following Instrumental Swallow Evaluations in Skilled Nursing Facilities.

Many residents in Skilled Nursing Facilities (SNFs) present with dysphagia and receive altered diets or liquids to minimize the risk of complications. Limited access to timely instrumental evaluations of swallow may impede the best management of these dysphagic residents. De-identified FEES reports completed by a mobile FEES company during a single month, January 2019, were reviewed. Descriptive statistics were used to summarize the pre-study diet/liquid levels and the post-study diet/liquid recommendations. FEES reports (n = 952) were reviewed. Before the FEES evaluation, 209 residents were receiving only non-oral nutrition. After the FEES evaluation, 76% of these residents were recommended to receive oral nutrition. Before the FEES evaluation, 442 (46%) residents were receiving thickened liquids, after the FEES evaluation, 244 (26%) were recommended to have a less restrictive liquid level. Before the FEES evaluation, 576 (60%) residents were receiving altered food texture, after the FEES evaluation, 413 (43%) were recommended to have a less restrictive food texture. The percentage of residents recommended to receive thin liquids increased from 32 to 68% and those recommended to receive a regular diet increased from 18 to 34%. These data indicate that access to instrumental swallow evaluations in the SNF setting generally resulted in lifting liquid and diet restrictions for many residents in the cohort reviewed and potentially improved their quality of life.

Rasch analysis of a palliative care self-efficacy instrument for nursing assistants.

This study used Rasch models to evaluate the psychometric properties of a self-efficacy instrument focused on psychosocial aspects of palliative care developed for nursing assistants (NAs). NAs from 6 skilled nursing facilities in Illinois, U.S. (n=102) were divided into intervention and control groups and answered 16 questions at baseline and 1-month follow-up. A total of 84 NAs completed assessments at both times. The rating scale structure improved when 3 instead of 5 response categories were used. After removing 4 items, the instrument demonstrated unidimensionality and local independence. A person-item threshold map indicated a ceiling effect. For the intervention group, 2 items and 1 item became easier and more difficult respectively post-training. With adjustments, the 12-item instrument became an adequate measure of palliative care self-efficacy. By using PCSE-NA as a tool to assess palliative care self-efficacy of NAs, geriatric nurses can identify weaknesses of and ways to improve training for NAs.

Long-Term Care Pharmacy Market Shares and Differences in Skilled Nursing Facilities Served.

Medications and pharmacy services are critical to post-acute care (PAC) in skilled nursing facilities (SNFs), yet little is known about the long-term care (LTC) pharmacies that provide them. We estimated the market shares of LTC pharmacies and how SNFs differed between pharmacies. This cross-sectional study used data from SNFs that provided PAC services in Rhode Island (RI) in 2019. We applied the parametric g-formula to compare SNF pharmacy-related deficiencies and medication use measures between LTC pharmacies while standardizing for SNF membership in a chain and number of beds. Among 75 SNFs, 68 (91%) were served by either Omnicare (n = 32, 43%) or PharMerica (n = 36, 48%), and 7 (9%) by other LTC pharmacies. After covariate adjustment, PharMerica SNFs had the lowest prevalences of any pharmacy-related deficiency (PharMerica, 63.2%; Omnicare, 80.2%; other LTC pharmacy, 69.1%) and antianxiety medication use (PharMerica, 9.7%; Omnicare, 13.6%; other LTC pharmacy, 13.5%), but estimates were imprecise. The RI market is highly concentrated between LTC pharmacies. If similarly high LTC pharmacy market concentration exists nationally, there is enormous promise for efficiently delivering interventions to improve medication management in SNFs. However, it may also present a risk of harm if policies do not maintain sufficient competition and innovation is stifled.

Little is known about long-term care pharmacies serving skilled nursing facilitiesThese pharmacies may have a strong influence on quality of care and outcomesTwo pharmacies dominate 91% of the Rhode Island skilled nursing facility marketSkilled beds, pharmacy deficiencies, and medication use may differ by pharmacyPharmacy market concentration creates opportunities for both big benefits and harms.

Evaluation of post-acute care and one-year outcomes among Medicare beneficiaries with hip fractures: a retrospective cohort study.

BACKGROUND: Post-acute care (PAC) services after hospitalization for hip fracture are typically provided in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or at home via home health care (HHC). Little is known about the clinical course following PAC for hip fracture. We examined the nationwide burden of adverse outcomes by PAC setting in the year following discharge from PAC for hip fracture. METHODS: This retrospective cohort included Medicare Fee-for-Service beneficiaries > 65 years who received PAC services in U.S. SNFs, IRFs, or HHC following hip fracture hospitalization between 2012 and 2018. Individuals who had a fall-related injury (FRI) during PAC or received PAC services in multiple settings were excluded. Primary outcomes included FRIs, all-cause hospital readmissions, and death in the year following discharge from PAC. Cumulative incidences and incidence rates for adverse outcomes were reported by PAC setting. Exploratory analyses examined risk ratios and hazard ratios between settings before and after inverse-probability-of-treatment-weighting, which accounted for 43 covariates. RESULTS: Among 624,631 participants (SNF, 67.78%; IRF, 16.08%; HHC, 16.15%), the mean (standard deviation) age was 82.70 (8.26) years, 74.96% were female, and 91.30% were non-Hispanic White. Crude incidence rates (95%CLs) per 1000 person-years were highest among individuals receiving SNF care for FRIs (SNF, 123 [121, 123]; IRF, 105 [102, 107]; HHC, 89 [87, 91]), hospital readmission (SNF, 623 [619, 626]; IRF, 538 [532, 544]; HHC, 418 [414, 423]), and death (SNF, 167 [165, 169]; IRF, 47 [46, 49]; HHC, 55 [53, 56]). Overall, rates of adverse outcomes generally remained higher among SNF care recipients after covariate adjustment. However, inferences about the group with greater adverse outcomes differed for FRIs and hospital readmissions based on risk ratio or hazard ratio estimates. CONCLUSIONS: In this retrospective cohort study of individuals hospitalized for hip fracture, rates of adverse outcomes in the year following PAC were common, especially among SNF care recipients. Understanding risks and rates of adverse events can inform future efforts to improve outcomes for older adults receiving PAC for hip fracture. Future work should consider calculating risk and rate measures to assess the influence of differential time under observation across PAC groups.

Hospitalists Improving Transitions of Care Through Virtual Collaborative Rounding with Skilled Nursing Facilities-the HiToC SNF Study.

BACKGROUND: Over one in five Medicare patients discharged to skilled nursing facilities (SNFs) are re-hospitalized within 30 days of discharge. Poor communication between the hospital and SNF upon hospital discharge is frequently cited as the most common cause of readmission. AIM: The goal of this program was to assess the ability of a weekly post-discharge hospitalist led virtual rounding program to augment the written discharge summary sent to SNFs. SETTING: Two academic hospitals and six SNFs in Baltimore, MD. PARTICIPANTS: Hospitalists and medical directors or directors of nursing from the partner SNF. PROGRAM DESCRIPTION: During weekly encounters, the hospitalist and SNF providers discussed the clinical status, discharge medications, treatment plan, and follow-up care of all discharged patients. The intervention took place from July 2021 to December 2021. PROGRAM EVALUATION: During the study, 544 patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists identified clinically significant errors in 124 discharge summaries. A survey of participating hospitalists and SNF medical and nursing leadership indicated the intervention was thought to improve care transitions. DISCUSSION: Our innovation was successful in identifying errors in discharge summaries and was thought to improve the transition of care by participating SNF and hospitalist providers.

A Comparison of Acute Ischemic Stroke Patients Discharged to Inpatient Rehabilitation vs a Skilled Nursing Facility: The Paul Coverdell National Acute Stroke Program.

OBJECTIVE: To compare the sociodemographic, clinical, and hospital related factors associated with discharge of acute ischemic stroke (AIS) survivors to inpatient rehabilitation (IRF) and skilled nursing facility (SNF) rehabilitation services. DESIGN: Retrospective descriptive study from the Paul Coverdell National Acute Stroke Program (PCNASP) participating hospitals during 2016 to 2019. SETTING: 9 Participating states from PCNASP in United States. PARTICIPANTS: 130,988 patients with AIS from 569 hospitals (N=337,857). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Discharge to IRF and SNF. RESULTS: Patients discharged to a SNF had longer length of hospital stay, more comorbidities, and higher modified Rankin scores compared with patients discharged to an IRF. Nine characteristics were associated with being less likely to be discharged to an IRF than an SNF: older age (85+ years old, adjusted odds ratio [AOR]=0.20 [confidence interval [CI]=0.18-0.21]), identifying as non-Hispanic Black (AOR=0.85 [CI=0.81-0.89]), identifying as Hispanic (AOR=0.80 [CI=0.74-0.87]), having Medicaid or Medicare (AOR=0.73 [CI=0.70-0.77]), being able to ambulate with assistance from another person (AOR=0.93 [CI=0.89-0.97]), being unable to ambulate (AOR=0.73 [CI=0.62-0.87]) and having comorbidities, prior stroke (AOR=0.69 [CI=0.66-0.73]), diabetes (AOR=0.85 [CI=0.82-0.88]), and myocardial infraction or coronary artery disease (AOR=0.94 [CI=0.90-0.97]). Four characteristics were associated with being more likely to be discharged to an IRF than an SNF: being a man (AOR=1.20 [CI=1.16-1.24]), and having a slight disability (Rankin Score 2) (AOR=1.41 [CI=1.29-1.54]), being at larger hospitals (200-399 beds: AOR=1.31 [CI=1.23-1.40]; 400+ beds: AOR=1.29 [CI=1.20-1.38]), and being at a hospital with stroke unit (AOR=1.12 [CI=1.07-1.17]). CONCLUSION: This study found differences in demographic, clinical, and hospital characteristics of AIS patients discharged for rehabilitation to an IRF vs SNF. The characteristics of patients receiving rehabilitation services may be helpful for researchers and hospitals making policies related to stroke discharge and practices that optimize patient outcomes. Populations experiencing inequities in access to rehabilitation services should be identified, and those who qualify for rehabilitation in IRF should receive this care in preference to rehabilitation in SNF.

Impact of COVID-19 on occupational injuries and illnesses among nursing care facility workers: Analysis of California workers' compensation data, 2019-2021.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic greatly affected healthcare workers, both physically and psychologically, by increasing their workload and stress. This may also have increased their risk of occupational injuries. This study analyzed workers' compensation (WC) claims among California nursing care facility workers during 2019-2021, to assess the impact of the pandemic on occupational injury risk. METHODS: This study used data from the California Workers' Compensation Information System. WC claims in prepandemic and pandemic periods were described and compared between nursing care facilities and other settings. Nursing facility cases were described by demographic, job, and injury characteristics. RESULTS: In 2019-2021, we identified 41,134 claims as nursing facility cases in California. Annual claims increased by 64.6% from 2019 to 2020 and then decreased in 2021, returning to levels similar to pre-COVID. In contrast, non-healthcare settings had decreases in claims during the pandemic. COVID-related claims accounted for 50.5% of claims in nursing facilities in 2020-2021; this proportion was much higher compared with other healthcare (35.7%) or nonhealthcare settings (14.3%). Non-COVID claims decreased during the pandemic but mental disorder or stress claims increased in nursing facilities, particularly in 2020 (+42.5%). CONCLUSIONS: Our findings show that nursing care facilities were more severely affected by the pandemic than other settings. We did not find evidence of an increased risk of occupational injuries during the pandemic, except for increased claims for stress or mental disorders. Our findings indicate a clear need to address psychological stress and mental health among nursing facility workers during a pandemic.

Seroprevalence of Severe Acute Respiratory Syndrome Coronavirus 2 Among Skilled Nursing Facility Residents and Staff Members-Los Angeles County, August-September 2020.

BACKGROUND: The prevalence of current or past coronavirus disease 2019 in skilled nursing facility (SNF) residents is unknown because of asymptomatic infection and constrained testing capacity early in the pandemic. We conducted a seroprevalence survey to determine a more comprehensive prevalence of past coronavirus disease 2019 in Los Angeles County SNF residents and staff members. METHODS: We recruited participants from 24 facilities; participants were requested to submit a nasopharyngeal swab sample for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing and a serum sample for detection of SARS-CoV-2 antibodies. All participants were cross-referenced with our surveillance database to identify persons with prior positive SARS-CoV-2 results. RESULTS: From 18 August to 24 September 2020, we enrolled 3305 participants (1340 residents and 1965 staff members). Among 856 residents providing serum samples, 362 (42%) had current or past SARS-CoV-2 infection. Of the 346 serology-positive residents, 199 (58%) did not have a documented prior positive SARS-CoV-2 PCR result. Among 1806 staff members providing serum, 454 (25%) had current or past SARS-CoV-2 infection. Of the 447 serology-positive staff members, 353 (79%) did not have a documented prior positive SARS-CoV-2 PCR result. CONCLUSIONS: Past testing practices and policies missed a substantial number of SARS-CoV-2 infections in SNF residents and staff members.

Sleep Management within Skilled Nursing Facilities: A Practice Survey.

A cross-sectional descriptive survey of 105 occupational therapy practitioners examined the practice patterns in sleep management within skilled nursing facilities. All participants viewed sleep as essential to address in their settings, since clients frequently reported inadequate sleep, daytime sleepiness, difficulty staying asleep, and situational interruption. Majority of the practitioners reported not screening, assessing, treating, or documenting sleep issues and lack the use of standardized assessments and evidence-based interventions for sleep. Results suggest that practitioners need more training, education, and advocacy skills to promote the role of occupational therapy in addressing sleep management in skilled nursing facilities.

Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study.

BACKGROUND AND PURPOSE: The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients. METHODS: We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies. RESULTS: In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%). CONCLUSIONS: This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.

Skilled Nursing and Inpatient Rehabilitation Facility Use by Medicare Fee-for-Service Beneficiaries Discharged Home After a Stroke: Findings From the COMPASS Trial.

OBJECTIVES: To examine the effect of a comprehensive transitional care model on the use of skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) care in the 12 months after acute care discharge home following stroke; and to identify predictors of experiencing a SNF or IRF admission following discharge home after stroke. DESIGN: Cluster randomized pragmatic trial SETTING: Forty-one acute care hospitals in North Carolina. PARTICIPANTS: 2262 Medicare fee-for-service beneficiaries with transient ischemic attack or stroke discharged home. The sample was 80.3% White and 52.1% female, with a mean (SD) age of 74.9 (10.2) years and a mean ± SD National Institutes of Health stroke scale score of 2.3 (3.7). INTERVENTION: Comprehensive transitional care model (COMPASS-TC), which consisted of a 2-day follow-up phone call from the postacute care coordinator and 14-day in-person visit with the postacute care coordinator and advanced practice provider. MAIN OUTCOME MEASURES: Time to first SNF or IRF and SNF or IRF admission (yes/no) in the 12 months following discharge home. All analyses utilized multivariable mixed models including a hospital-specific random effect to account for the non-independence of measures within hospital. Intent to treat analyses using Cox proportional hazards regression assessed the effect of COMPASS-TC on time to SNF/IRF admission. Logistic regression was used to identify clinical and non-clinical predictors of SNF/IRF admission. RESULTS: Only 34% of patients in the intervention arm received COMPASS-TC per protocol. COMPASS-TC was not associated with a reduced hazard of a SNF/ IRF admission in the 12 months post-discharge (hazard ratio, 1.20, with a range of 0.95-1.52) compared to usual care. This estimate was robust to additional covariate adjustment (hazard ratio, 1.23) (0.93-1.64). Both clinical and non-clinical factors (ie, insurance, geography) were predictors of SNF/IRF use. CONCLUSIONS: COMPASS-TC was not consistently incorporated into real-world clinical practice. The use of a comprehensive transitional care model for patients discharged home after stroke was not associated with SNF or IRF admissions in a 12-month follow-up period. Non-clinical factors predictive of SNF/IRF use suggest potential issues with access to this type of care.

Effect of an Interdisciplinary Stroke Consult Service on the Transition to Postacute Rehabilitation.

OBJECTIVE: To evaluate the effect of a physiatry-led stroke consult service on access and time to intensive postacute rehabilitation. DESIGN: Prospective observational study. SETTING: Urban Joint Commission Comprehensive Stroke Center. PARTICIPANTS: Adult (older than 18 years) acute stroke hospital discharges between January 1, 2018, and December 31, 2020 (N=1190). INTERVENTIONS: Weekday huddle rounds were interdisciplinary, which created a pathway to ensure patients with stroke received comprehensive rehabilitation care followed by a virtual rounding tool, allowing clinicians to evaluate plan of care facilitation using the electronic medical record. MAIN OUTCOME MEASURES: Proportion of acute stroke discharges to home, inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF) and onset days to IRF transfer. RESULTS: During the 3-year study period, sociodemographic characteristics, stroke severity at admission, and mortality rates did not change significantly. Discharges of patients with acute stroke patient to IRFs increased 5.9%, from 24.2% in 2018 to 30.1% in 2020. A total of 11% of patients were discharged to SNF in 2018 compared with 8.7% in 2020. Proportion of patients with acute stroke discharged to home decreased 4.9%, from 49.6% in 2018 to 44.7% (P=.0325). For patients with ischemic stroke, the average onset days to IRF transfer decreased 7.5% between 2018 and 2020, from 8 days to 7.4 days. For patients with hemorrhagic stroke, the average onset days decreased 17.5%, from 12 days in 2018 to 9.9 days in 2020. The decrease in onset days were not statistically significant for either stroke type (P=.3794). CONCLUSIONS: Implementation of huddle rounds and a virtual rounding tool by a physiatry-led stroke consult service significantly increased referrals to IRFs, with a concomitant decrease in referrals to SNFs or directly home. Next steps include validating model efficacy, with the goal of implementation at stroke centers in the United States.

A Postacute Care Function Process Quality Measure for the Collection of Standardized Self-Care and Mobility Data: Development, Implementation, and Quality Measure Scores.

OBJECTIVE: To describe the development of and quality measure scores for the cross-setting postacute care function process quality measure that requires the collection of standardized self-care and mobility data at admission and discharge and at least 1 function goal. DESIGN: Description of the development and implementation of the quality measure and the associated standardized self-care and mobility data elements. Descriptive analyses of quality measure scores for the first calendar year using data from the Minimum Data Set, the Inpatient Rehabilitation Facility Patient Assessment Instrument, the Long-Term Care Hospitals (LTCH) Continuity Assessment Record and Evaluation Data Set, and Outcome and Assessment Information Set. SETTING: 15,127 skilled nursing facilities (SNFs), 1129 inpatient rehabilitation facilities (IRFs), 414 LTCHs, and 10,352 home health agencies (HHAs) in the United States. PARTICIPANTS: In total there were 9,216,943 stays/quality episodes (N = 9,216,943), including 2,084,774 SNF Medicare fee-for-service patient stays, 493,209 IRF Medicare patient stays, 161,714 patient stays, and 6,477,246 Medicare and Medicaid quality episodes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Scores for the cross-setting postacute care function process quality measure. RESULTS: The mean process quality measure scores for SNFs, IRFs, LTCHs, and HHAs were 95.5%, 99.7%, 99.1%, and 95.8, respectively. The 10th percentile scores for SNFs, IRFs, LTCHs, and HHAs were 88.5%, 99.3%, 98.4%, and 89.4, respectively, indicating that at least 90% of postacute care providers submitted the standardized data for a large proportion of their patients. Mean quality measure scores did not vary by provider characteristics. CONCLUSIONS: Most SNFs, IRFs, LTCHs, and HHAs submitted the self-care and mobility data, resulting in high quality measure scores during the first year of implementation. The availability of the standardized self-care and mobility data across postacute care settings offers the opportunity to compare the characteristics and functional outcomes of patients treated in postacute care.

Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization.

Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.

Adapting the Connect-Home transitional care intervention for the unique needs of people with dementia and their caregivers: A feasibility study.

AIMS: After leaving skilled nursing facilities (SNF), 20% of people with dementia (PWD) are re-hospitalized within 30 days. We assessed fidelity, acceptability, preliminary outcomes, and mechanisms of the Connect-Home ADRD transitional care intervention. DESIGN: A feasibility study of Connect-Home ADRD. METHODS: The Connect-Home intervention was adapted for dementia-specific needs. PWD and caregiver dyads in 2 SNFs received transitional care. Data sources included interviews with PWD and caregivers and a review of health records. RESULTS: 19 of 34 eligible dyads (56%) were enrolled. The intervention was feasible (components delivered for >84% of dyads) and acceptable (dyads rated it very helpful and not difficult to use). Connect-Home ADRD adaptations included in-home support to manage symptoms of dementia and unplanned events, such as transition to hospice. IMPACT: Connect-Home ADRD is feasible, acceptable, and merits future research as an intervention to reduce rapid return to acute care following SNF stays.

A Multistate Comparison Study of COVID-19 Cases Among Accredited and Nonaccredited Nursing Homes.

Widely acknowledged is the disproportionate number of COVID-19 cases among nursing home residents. This observational study examined the relationship between accreditation status and COVID-19 case rates in states where the numbers and proportions of Joint Commission accredited facilities made such comparisons possible (Illinois (IL), Florida (FL), and Massachusetts (MA)). COVID-19 data were accessed from the Centers for Medicare & Medicaid Services (CMS) Nursing Home Compare Public Use File, which included retrospective COVID-19 data submitted by nursing homes to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network. The outcome variable was the total number of nursing home-identified COVID-19 cases from June 2020 to January 2021. Joint Commission accreditation status was the independent variable. Mediating factors included state, and county-level case rates. Increases in the county rate had a significant association with higher nursing home COVID-19 case rates (p < .001). After adjusting for county case rates, no differences were observed in the mean group case rates for accredited and nonaccredited nursing homes. However, comparing predicted case rates to actual case rates revealed that accredited nursing homes were more closely aligned with their predicted rates. Performance of the nonaccredited nursing homes was more variable and had proportionally more outliers compared to accredited nursing homes. Community prevalence of COVID-19 is the strongest predictor of nursing home cases. While accreditation status did not have an impact on overall mean group performance, nonaccredited nursing homes had greater variation in performance and a higher proportion of negative outliers. Accreditation was associated with more consistent performance during the COVID-19 pandemic, despite being located in counties with a higher prevalence of COVID-19.

Evaluating the Effectiveness of BREATHE for Nurse Practitioners During COVID Pandemic.

The current health care system incorporates multidimensional strategies of improving patients' care experiences, promoting the health of populations, and reducing per capita cost of health care. These strategies include reducing readmission rates by keeping patients in the community and out of the skilled nursing facilities. Unfortunately, patients' outcomes were severely threatened during the coronavirus disease 2019 pandemic due to staff burnout. This project evaluates the effectiveness of the BREATHE program on the perceived stress level of nurse practitioners during the coronavirus disease 2019 pandemic. Emotional exhaustion and depersonalization decreased 1 month after nurse practitioners completed the program.