Evaluation of geriatric home healthcare depression assessment and care management: are OASIS-C depression requirements enough?

OBJECTIVE: Research is scarce on how depression is identified and treated among Medicare home healthcare (HHC) patients age 65+ with disability. The Centers for Medicare & Medicaid Services (CMS) recently incorporated depression screening into the OASIS-C HHC assessment. Our study objectives were to evaluate and characterize depression care management (DCM) in an HHC agency after CMS increased its depression requirements and to determine if there was an association of DCM with disability (activities of daily living [ADLs]) outcomes. METHODS: The authors conducted a retrospective chart review of 100 new Medicare HHC admissions patients age 65+ (mean age: 81.7) who screened positive for depression and had disability and multimorbidity. Clinical and administrative records were examined and descriptive analyses used. Multivariate regression analyses investigated the association of six DCM components with ADLs improvement. RESULTS: Depression was recognized in care plans of 60% of patients. Documentation of only one nurse care management activity, antidepressant use, indicated the use of evidence-based standards of depression assessment and DCM. Depression measures were not administered at discharge, recertification, or transfer. Forty percent of patients had a formal depression diagnosis by the referring physician in the chart, and 65% were receiving an antidepressant. Having a depression care plan and depression medication were significantly associated with a large ADLs improvement. CONCLUSION: Despite the association of depression care plans with patient disability improvement, inadequate compliance to evidence-based DCM was found. Medicare and HHC agencies must ensure compliance to DCM, including follow-up depression assessment for patients with positive screens.

Short of breath and dying: state of the science on opioid agents for the palliation of refractory dyspnea in older adults.

The purpose of this narrative literature review was to describe the state of the science on the effectiveness of opioid medications to palliate dyspnea in older adults with advanced disease. A three-stage critical appraisal process was used to evaluate articles published between 2000-2011 that were retrieved from the CINAHL, Ovid MEDLINE, and PsycINFO databases. Low-dose opioid medication use was associated with statistically significant reductions in dyspnea intensity scores in the majority of studies included in the analysis. Many recent articles on this topic shed light on the importance but underuse of opioid agents to palliate dyspnea, particularly in older adults with advanced chronic illnesses, such as heart failure and chronic obstructive pulmonary disease. ADRA (Assess, Document, Re-assess, Advocate) is a proposed framework that gerontological nurses can use to ensure patients receive adequate symptom management for refractory dyspnea.

Barriers and facilitators to optimize function and prevent disability worsening: a content analysis of a nurse home visit intervention.

AIMS: This paper is a report of an analysis of how to better understand the results of the nurse home visit intervention in the Medicare Primary and Consumer-Directed Care Demonstration in terms of facilitators and barriers to disability improvement/maintenance as compared with disability worsening. BACKGROUND: There is a lack of literature describing how nurse home visit interventions are able to maintain/improve disability among older persons with disability. The present study is one of only six reporting beneficial disability outcomes. METHODS: Cases were purposefully sampled to represent change in the disability construct leading to selection of ten cases each of disability maintenance/improvement (no change or decrease in total Activities of Daily Living score from baseline) and worsening (an increase in total Activities of Daily Living score from baseline). Data from nurses' progress notes and case studies (collected in March 1998-June 2002) were analysed using qualitative descriptive analysis (May 2009). These results remain relevant because the present study is one of the few studies to identify select nurse activities instrumental in postponing/minimizing disability worsening. RESULTS/FINDINGS: Three primary themes captured the facilitators and barriers to effective disability maintenance/improvement: (1) building and maintaining patient-centred working relationships, (2) negotiating delivery of intervention components and (3) establishing balance between patients' acute and chronic care needs. Sub-themes illustrate nurse, patient and system factors associated with effective disability maintenance/improvement (e.g. nurse caring, communicating, facilitating interdisciplinary communication) and barriers associated with disability worsening (e.g. dementia, depression and recurring acute illnesses). CONCLUSION: This study provides new insights about the facilitators and barriers to effective disability maintenance/improvement experienced by patients receiving home visits. Potential opportunities exist to integrate these insights into best-practice models of nurse home visiting.

Randomized controlled trial of CARE: an intervention to improve outcomes of hospitalized elders and family caregivers.

In this randomized controlled trial we tested the efficacy of an intervention program (CARE: Creating Avenues for Relative Empowerment) for improving outcomes of hospitalized older adults and their family caregivers (FCGs). FCG-patient dyads (n = 407) were randomized into two groups. The CARE group received a two-session empowerment-educational program 1-2 days post-admission and 1-3 days pre-discharge. The attention control group received a generic information program during the same timeframe. Follow-up was at 2 weeks and 2 months post-discharge. There were no statistically significant differences in patient or FCG outcomes. However, inconsistent evidence of role outcome differences suggests that CARE may benefit certain FCG subgroups instead of being a one-size-fits-all intervention strategy. Closer examination of CARE's mechanisms and effects is needed.

Which components of a primary care affiliated home visiting nurse program are associated with disability maintenance/improvement?

A process evaluation of a primary care affiliated home visiting nurse intervention was performed to determine which intervention components were associated with disability maintenance/improvement. This secondary analysis (N = 238) used data recorded in intervention databases and patient interviews among community-dwelling elders with disability. Intervention components were examined in descriptive, correlational, bivariate, and logistic regression analyses. Results demonstrated that two structure components--physician-patient-family-nurse conference visits and intervention (education) materials--and three process components--disease management activities, goal setting, and medication management activities--were linked to maintaining/improving activities of daily living disability status. Confirmation of these findings may help home care nurses to delay disability worsening.

Claiming our core: appraising qualitative evidence for nursing questions about human response and meaning.

The growing acceptance of evidence-based practice (EBP) principles in nursing raises the possibility that only question domains central to medical practice--therapy, harm, prognosis, and medical diagnosis--and "best evidence" appropriate to those domains will be valued. We propose incorporation of 2 additional question domains--human response and meaning--as particularly important for nursing practice, and we argue that the strongest evidence for these questions arises from qualitative research traditions. We discuss the evaluation and application of qualitative evidence for practice and identify unresolved issues for further discussion within the discipline.

Meaning and practice of palliative care for nursing home residents with dementia at end of life.

OBJECTIVE: To describe the meaning and practice of palliative care (PC) for nursing home (NH) residents with dementia at end of life (EOL). DESIGN: Concurrent mixed methods (quantitative retrospective chart review and qualitative field study). SETTING: Three NHs with varying approaches to EOL care: in-house non-Medicare hospice, Medicare hospice by outside agency, and Medicare hospice by outside agency plus specialized staff and comfort care unit. RESULTS: Residents' course fluctuated between curative and comfort care, with a noticeable increase in symptoms right before death. Hospice care was short. Most died of complications of dementia. Families found care decisions based on residents' uncertain disease course difficult. CONCLUSION: The role of PC for NH residents with dementia at EOL is complex and poorly understood. As they are in a residential setting, decisions need to be made about how residents live, as well as how they die, thus balancing quality of living/comfort with disease management.

Everyday ethics in assisted living facilitites: a framework for assessing resident-focused issues.

This article describes and illustrates a framework that may be used when assessing the moral basis of everyday issues that can affect residents of assisted living facilities. The "taxonomy of everyday ethical issues" was an outcome of ethnographic research focused on care of nursing home residents with dementia. However, in this article it is shown to be equally relevant for conceptualizing issues affecting cognitively intact as well as cognitively impaired residents across these two settings. The taxonomy is grounded in some of the more common cultural characteristics of congregate living arrangements for elderly individuals who have needs for varying levels of compensatory and therapeutic oversight by a staff of service providers.

Home health care nurse perceptions of geriatric depression and disability care management.

PURPOSE OF THE STUDY: Psychosocial interventions alone or combined with antidepressant medication can effectively treat mild to moderate geriatric depression. However, most home health care patients with depression and disability do not receive these interventions. Moreover, relatively little is known about home health care nurse views about depression management. Therefore, our research purpose was to provide a deeper understanding about how home health care nurses perceive and experience depression detection and evaluation within the context of caring for geriatric patients with disabilities. DESIGN AND METHODS: This qualitative descriptive study involved 2 focus groups and 16 semistructured interviews with nurses providing care to geriatric home health care patients followed by observation during 25 nurse home visits to geriatric patients who had depression and disability. FINDINGS: Nurses demonstrated confidence in caring for elderly patients with disabilities. However, they expressed different views about the nature of depression and the integration of depression and disability care in daily practice. Evidence points to a need for advanced training that supports an enhanced role for generalist homecare nurses in providing depression care management for this vulnerable geriatric population. IMPLICATIONS: Policy challenges are associated with ways in which home health care is fiscally organized primarily to address patients' physical and acute skilled care needs and not depression.

Home health care nurse interactions with homebound geriatric patients with depression and disability.

Building therapeutic nurse-patient relationships is pivotal to the provision of optimum nurse care management for geriatric home health care (HHC) patients. However, little is known about which strategies most effectively treat older adult HHC patients with concomitant depression and disability. This qualitative descriptive study was conducted in two parts to explore the issue further. The first part involved interviews regarding HHC nurse perceptions of geriatric depression and disability care management. The second part, which is the focus of the current analysis, describes HHC nurses' use of care management and therapeutic during home visits. Observation of nurse-patient interactions involved 25 nurses home visits to HHC patients 60 and older who had depression and disability. Drawing on clinical knowledge and interpersonal skills, nurses built relationships and fostered trust. However, despite their disabilities to make these connections, multiple missed opportunities occurred for nurses to engage in more productive interactions. Four training components to support improvement of nurse-patient therapeutic relationships are described and recommended.

The significance of losing things for nursing home residents with dementia and their families.

This article examines the significance of losing things as part of an individual's whole experience with the material aspects of life. The data on which this report is based were drawn from a broader ethnographic study of everyday ethics affecting nursing home residents with dementia. Combined anthropological methods of participant observation and in-depth interviewing were used to gather information about ordinary daily issues for residents, family members, and nursing home staff. Findings are described as themes related to personal possessions and concerns surrounding them. Discussion comprises an interpretive analysis of meanings drawn from the research and represented as ethical considerations and practice implications--general principles and strategies.

Navigating tensions: integrating palliative care consultation services into an academic medical center setting.

CONTEXT: Despite rapid proliferation of hospital-based palliative care consultation services (PCCSs) across the country, there is little description of the dynamic processes that the PCCS and the non-PCCS hospital cultures experience during the institutionalization of a successful PCCS. OBJECTIVES: To describe the institutionalization of a new PCCS in a quaternary care academic medical center (AMC) and highlight two themes, cost and quality, that pervaded the dynamics involved from the inception to the successful integration of the service. METHODS: Ethnography using longitudinal field observations, in-depth interviews, and the collection of artifacts. The study was performed in a 750-bed quaternary care AMC in the northeastern region of the U.S. Participants were a purposefully selected sample (n=79) of 1) senior-level institutional administrators, including clinical leaders in nursing, medicine, and social work, 2) clinicians who used the PCCS, either commonly or rarely, and 3) members of the PCCS core and extended teams. RESULTS: Key infrastructure components that contributed to the successful integration of the PCCS included top level interprofessional administrative buy-in to the quality and cost arguments for PCCS, PCCS leadership selection, robust data collection strategies emphasizing quality outcome data, the adoption of the "physician referral only" rule, and incremental and sustainable growth. The PCCS service grew an average of 23% per year from 2003 to 2009. CONCLUSION: An in-depth understanding of the dynamic interaction of the infrastructures and processes of a successful institutionalization, in their unique complexity, may help other PCCSs identify and negotiate attributes of their own circumstances that will increase their chances for successful and sustainable implementation.

Meaning and practice of palliative care for hospitalized older adults with life limiting illnesses.

Objective. To illustrate distinctions and intersections of palliative care (PC) and end-of-life (EOL) services through examples from case-centered data of older adults cared for during a four-year ethnographic study of an acute care hospital palliative care consultation service. Methods. Qualitative narrative and thematic analysis. Results. Description of four practice paradigms (EOL transitions, prognostic uncertainty, discharge planning, and patient/family values and preferences) and identification of the underlying structure and communication patterns of PC consultation services common to them. Conclusions. Consistent with reports by other researchers, study data support the need to move beyond equating PC with hospice or EOL care and the notion that EOL is a well-demarcated period of time before death. If professional health care providers assume that PC services are limited to assisting with and helping patients and families prepare for dying, they miss opportunities to provide care considered important to older individuals confronting life-limiting illnesses.

The Family Preferences Index: helping family members who want to participate in the care of a hospitalized older adult.

Family members are an important but often underappreciated resource in caring for hospitalized older adults. The Family Preferences Index is a 14-item approach to exploring caregivers' personal choices for participating in the care of hospitalized older adult family members. It can be administered as a structured interview or as a questionnaire. Higher scores indicate a greater preference to participate in care. The nurse can use the responses to the index to plan care that builds a partnership with the family. To watch a free video demonstrating the use of the index, go to http://links.lww.com/A296.