Preventing Avoidable Rehospitalizations through Standardizing Management of Chronic Conditions in Skilled Nursing Facilities.

OBJECTIVES: This study evaluated the impact of standardized care protocols, as a part of a quality improvement initiative (J10ohns Hopkins Community Health Partnership, J-CHiP), on hospital readmission rates for patients with a diagnosis of congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) after being discharged to skilled nursing facilities (SNFs). DESIGN: A retrospective study comparing 30-day hospital readmission rates the year before and 2 years following the implementation of the care protocol interventions. SETTINGS AND PARTICIPANTS: Patients discharged from Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center to the participating SNFs diagnosed with CHF and/or COPD. METHODS: The standardized protocols included medical provider or nurse assessments on SNF admission, multidisciplinary care planning, and medication management to avoid unplanned readmissions to the hospital. Descriptive analyses were conducted to illustrate the 30-day readmission rates before and after protocol implementation. RESULTS: There were 1128 patients in the pre-J-CHiP cohort and 2297 patients in the J-CHiP cohort. About half of the patients with a recorded diagnosis of CHF without COPD had the standardized protocol initiated, whereas 47% of the patients with a recorded diagnosis of COPD without CHF had the standardized protocol initiated. Of patients with recorded diagnoses of COPD and CHF, 49% had both protocols initiated. A reduction in the readmission rate was observed for patients with COPD protocols, from 23.5% in 2011 to 12.1% in 2015. However, fluctuations in the readmission rates were observed for patients who initiated the CHF protocols. CONCLUSIONS AND IMPLICATIONS: There were improvements in the readmission rates in this study, especially for patients who had initiated standardized care protocols in the SNFs. Our findings demonstrate great value in standardizing care management and strengthening collaboration with chronic care settings to facilitate a smooth transition of medically complex patients discharged from large health care systems. Future interventions could consider assessing nonclinical factors that may impact preventable hospital readmissions.

Geriatric syndrome risk factors among hospitalized postacute Medicare patients.

OBJECTIVES: To assess the association of geriatric syndrome risk factors with postacute utilization among hospitalized Medicare patients (both Medicare Advantage [MA] and fee-for-service [FFS] cohorts) and to examine patterns of postacute care for MA and FFS cohorts with high geriatric syndrome risk. STUDY DESIGN: Secondary data analysis using encounter-level data from the State Inpatient Databases (SID) of the Healthcare Cost and Utilization Project. METHODS: The sample included 3.1 million Medicare hospitalizations from the Florida SID (2010 to 2014). We used multivariate linear regression to examine the impact of a geriatric syndrome risk measure, assessed as high risk, moderate risk, or nonrisk, on outcomes in MA and FFS cohorts. Outcome measures included postacute destination and inpatient utilization. We then examined if this risk measure was associated with differences in outcomes between MA and FFS cohorts. RESULTS: Patients with high geriatric syndrome risk (in both MA and FFS cohorts) are less likely to be discharged to home or to home health care. They also have longer inpatient lengths of stay and higher inpatient costs. This risk measure also explains differences in postacute skilled nursing destination between MA and FFS cohorts. CONCLUSIONS: Geriatric syndrome risk factors not only play a role in postacute care and inpatient utilization in MA and FFS cohorts but also explain different utilizations between MA and FFS cohorts. This study's results can be applied to guide discharge planning among a group of high-risk patients and evaluate alternative delivery models for this high-cost, high-need cohort.

Patient Portal Use Among Older Adults: What Is Really Happening Nationwide?

Patient portals (PPs), secure websites that allow patients to access their electronic health records and other health tools, can benefit older adults managing chronic conditions. However, studies have shown a lack of PP use in older adults. Little is known about the way they use PPs in community settings and specific challenges they encounter. The aim of this study was to examine the current state of PP use in older adults, employing baseline data (quantitative and qualitative) from an ongoing nationwide online trial. The dataset includes 272 older adults (mean age, 70.0 years [50-92]) with chronic conditions. Findings showed that the majority of participants (71.3%) were using one or more PPs, but in limited ways. Their comments revealed practical difficulties with managing PPs, perceived benefits, and suggestions for improvement. Further studies with different older adult groups (e.g., clinic patients) will help develop and disseminate more usable PPs for these individuals.

The Effects of a Theory-Based Patient Portal e-Learning Program for Older Adults with Chronic Illnesses.

Introduction: The high prevalence of chronic illnesses is a serious public health problem in the United States, and more than 70 million older adults have at least one chronic illness. Patient portals (PPs) have an excellent potential to assist older adults in managing chronic illnesses; however, older adults' PP adoption rates have been low. Lack of support for older adults using PPs remains a critical gap in most implementation processes. The main aim of this study was to assess the impact of an older adult friendly Theory-based Patient portal e-Learning Program (T-PeP) on PP knowledge, selected health outcomes (health decision-making self-efficacy [SE] and health communication), PP SE and use, and e-health literacy in older adults. Materials and Methods: A two-arm randomized controlled trial was conducted with older adults (N = 272) who had chronic conditions. Participants were recruited online, and data were collected at baseline, 3 weeks, and 4 months. The main intervention effects were tested using linear mixed models. Results: The average age of participants was 70.0 ± 8.5 years, and 78.3% (n = 213) were white. At 3 weeks, the intervention group showed significantly greater improvement than the control group in all outcomes except PP use. At 4 months, the intervention effects decreased, but PP SE remained significant (p = 0.015), and the intervention group showed higher frequency of PP use than the control group (p = 0.029). Conclusion: The study findings showed that the T-PeP was effective in improving selected health and PP usage outcomes. Further studies are needed to test the long-term effects of T-PeP using more diverse samples.

Implementation of a comprehensive program to improve coordination of care in an urban academic health care system.

Purpose Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue. Design/methodology/approach J-CHiP targeted adults admitted to the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, patients discharged to participating skilled nursing facilities (SNFs), and high-risk Medicare and Medicaid patients receiving primary care in eight nearby outpatient sites. The primary drivers of the program were redesigned acute care delivery, seamless transitions of care and deployment of community care teams. Findings Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health plans, hand-offs and follow-up with primary care providers, Transition Guides, a patient access line and collaboration with SNFs. Community interventions involved forming multidisciplinary care coordination teams, integrated behavioral care and new partnerships with community-based organizations. Originality/value This paper offers a detailed description of the design and implementation of a complex program to improve care coordination for high-risk patients in an urban setting. The case studies feature findings from each intervention that promoted patient engagement, strengthened collaboration with community-based organizations and improved coordination of care.

A Call to Bridge Across Silos during Care Transitions.

BACKGROUND: Older adults with complex medical conditions are vulnerable during care transitions. Poor care transitions can lead to poor patient outcomes and frequent readmissions to the hospital. FACTORS CONTRIBUTING TO SUBOPTIMAL CARE TRANSITIONS: Key factors related to ineffective care transitions, which can lead to suboptimal patient outcomes, include poor cross-site communication and collaboration; lack of awareness of patient wishes, abilities, and goals of care; and incomplete medication reconciliation. Fundamental elements for effective care transitions put forth by The Joint Commission for effective care transitions include interdisciplinary coordination and collaboration of patient care in care transitions, shared accountability by all clinicians involved in care transitions, and provision of appropriate support and follow-up after discharge. REVIEW OF FOUR EXISTING MODELS OF CARE TRANSITIONS: Consideration of four existing care transitions models representing different health care settings-Care Transitions Intervention® Guided Care, Interventions to Reduce Acute Care Transfers (INTERACT®), Home Health Model of Care Transitions-revealed that they are important but limited in their impact on transitions across health care settings. PROPOSAL OF THE INTEGRATED CARE TRANSITIONS APPROACH: An innovative approach, Integrated Care Transitions Approach (ICTA), is proposed that incorporates the best practices of the four models discussed in this article and factors identified as essential for an effective care transition while addressing limitations of existing transitional care models. ICTA's four key characteristics and seven key elements are unique and stem from factors that help achieve effective care transitions.

Association of a Care Coordination Model With Health Care Costs and Utilization: The Johns Hopkins Community Health Partnership (J-CHiP).

Importance: The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland. Objective: To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending. Design, Setting, and Participants: Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score-weighted and matched comparison groups. The study spanned 2012 to 2016 and took place in acute care hospitals, primary care clinics, skilled nursing facilities, and community-based organizations. The ACI analysis compared outcomes of participants in Medicare and Medicaid during their 90-day postacute episode with those of a propensity score-weighted preintervention group at Johns Hopkins Community Health Partnership hospitals and a concurrent comparison group drawn from similar Maryland hospitals. The CI analysis compared changes in outcomes of Medicare and Medicaid participants with those of a propensity score-matched comparison group of local residents. Interventions: The ACI bundle aimed to improve transition planning following discharge. The CI included enhanced care coordination and integrated behavioral support from local primary care sites in collaboration with community-based organizations. Main Outcomes and Measures: Utilization measures of hospital admissions, 30-day readmissions, and emergency department visits; quality of care measures of potentially avoidable hospitalizations, practitioner follow-up visits; and total cost of care (TCOC) for Medicare and Medicaid participants. Results: The CI group had 2154 Medicare beneficiaries (1320 [61.3%] female; mean age, 69.3 years) and 2532 Medicaid beneficiaries (1483 [67.3%] female; mean age, 55.1 years). For the CI group's Medicaid participants, aggregate TCOC reduction was $24.4 million, and reductions of hospitalizations, emergency department visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 beneficiaries, respectively. The ACI group had 26 144 beneficiary-episodes for Medicare (13 726 [52.5%] female patients; mean patient age, 68.4 years) and 13 921 beneficiary-episodes for Medicaid (7392 [53.1%] female patients; mean patient age, 52.2 years). For the ACI group's Medicare participants, there was a significant reduction in aggregate TCOC of $29.2 million with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1000 beneficiary-episodes, respectively, and reduction in practitioner follow-up visits of 41 and 29 per 1000 beneficiary-episodes for 7-day and 30-day visits, respectively. For the ACI group's Medicaid participants, there was a significant reduction in aggregate TCOC of $59.8 million and the 90-day emergency department visit rate decreased by 133 per 1000 episodes, but hospitalizations increased by 49 per 1000 episodes and practitioner follow-up visits decreased by 70 and 182 per 1000 episodes for 7-day and 30-day visits, respectively. In total, the CI and ACI were associated with $113.3 million in cost savings. Conclusions and Relevance: A care coordination model consisting of complementary bundled interventions in an urban academic environment was associated with lower spending and improved health outcomes.

The Effects of an Online Theory-Based Bone Health Program for Older Adults.

An estimated 10 million Americans age 50 and older have osteoporosis, and many experience associated fractures. Although several interventions have been shown to be effective in preventing osteoporosis, their impact on bone health among older adults was limited. The aim of this study was, therefore, to examine the effects of a theory-based online bone health program (Bone Power program) for a large number of older adults. The 8-week program included learning modules, discussion boards, and other resources. Participants ( N = 866; M age = 62.5 years) were recruited online and randomized into a Bone Power or control group. At the end of the intervention, the Bone Power group showed significantly greater improvement over the control group in osteoporosis knowledge, self-efficacy/outcome expectations for calcium intake and exercise, and calcium intake and exercise behaviors. This study's findings suggest that online health programs can be effective in improving older adults' knowledge, beliefs, and health behaviors.

Case Study: Johns Hopkins Community Health Partnership: A model for transformation.

To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patient's primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs. The case study introduces: a) main program features including rationale, goals, intervention design, and partnership development; b) illness burden and social barriers of the population contributing to care challenges and opportunities; and c) lessons learned with steps that have been taken to engage both patients and providers more actively in the care model. Urban health systems, including academic medical centers, must continue to innovate in care delivery through programs like J-CHiP to meet the needs of their patients and communities.

Telephone Survey of Infection-Control and Antibiotic Stewardship Practices in Long-Term Care Facilities in Maryland.

BACKGROUND: Multidrug-resistant organisms are an emerging and serious threat to the care of patients. Long-term care facilities are considered a reservoir of these organisms partly because of the over-prescribing of antibiotics. Antibiotic use is common in long-term care facilities. Antibiotic stewardship programs have been shown to reduce antibiotic consumption in acute-care facilities. The purpose of our study is to investigate existing infection-control practices and antibiotic stewardship programs in long-term care facilities in Maryland. METHODS: We telephoned the infection-control personnel in 231 long-term care facilities in Maryland between February 2014 and July 2015 and reached 124 facilities (59%). RESULTS: Among the 124 facilities surveyed, there were 14,371 beds and 337 infection-control personnel with basic infection-control training. Close to 20% of facilities use silver- or antimicrobial-impregnated urinary catheters. Most facilities (97%) track urinary tract infections. Although all report to the health department in the case of an outbreak, only 63 (50.8 %) report directly to the Centers for Disease Control and Prevention. About 80% of facilities isolate patients with Clostridium difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococci with acute infections only. Eighty percent of facilities have basic guidance on choice of antibiotic, and 27% have a restricted formulary. Only 25% of facilities have an antibiotic approval process. Thirty-five percent of facilities have training for antibiotics prescribing. However, 17% of facilities did not know whether such training existed. CONCLUSIONS: Antibiotic stewardship programs in long-term care facilities are still in early development stages, but our results demonstrate that the majority of facilities are collecting data on prescribing antibiotics, and a surprising number have antibiotic approval and antibiotics prescribing training.

Where do we go from here? A small scale observation of transfer results from chronic to skilled ventilator facilities.

PURPOSE: Skilled nursing facility ventilator units (SNF) are a recent attempt to reduce the costs of an increasing number of patients who are in acute intensive care units and are not able to be liberated from ventilators. Transfers of such patients from long-term care chronic vent units (LTCVs) to SNFs in Maryland began in 2006. The safety of these transfers needs to be assessed. METHODS: We retrospectively followed up all patients designated as eligible by their insurance for transfer from our LTCV units to SNF from July 1, 2008 through June 30, 2010 looking only at survival. Those patients who refused transfer and appealed and remained in our LTCV were compared to those who were transferred to SNF ventilator units. The analysis was by Kaplan-Meier statistics. RESULTS: There was an increased mortality (P=.025) of those transferred to SNF ventilator facilities as compared to those remaining in the LTCV. CONCLUSION: We recognize that bias may occur in patients choosing to remain in our LTCV compared to those accepting transfers, the magnitude of the difference in mortality indicates the need for more comprehensive well designed analysis investigating the outcome of all transfers occurring to and from LTCVs.

Dissemination of a theory-based online bone health program: Two intervention approaches.

With the increasing nationwide emphasis on eHealth, there has been a rapid growth in the use of the Internet to deliver health promotion interventions. Although there has been a great deal of research in this field, little information is available regarding the methodologies to develop and implement effective online interventions. This article describes two social cognitive theory-based online health behavior interventions used in a large-scale dissemination study (N = 866), their implementation processes, and the lessons learned during the implementation processes. The two interventions were a short-term (8-week) intensive online Bone Power program and a longer term (12-month) Bone Power Plus program, including the Bone Power program followed by a 10-month online booster intervention (biweekly eHealth newsletters). This study used a small-group approach (32 intervention groups), and to effectively manage those groups, an eLearning management program was used as an upper layer of the Web intervention. Both interventions were implemented successfully with high retention rates (80.7% at 18 months). The theory-based approaches and the online infrastructure used in this study showed a promising potential as an effective platform for online behavior studies. Further replication studies with different samples and settings are needed to validate the utility of this intervention structure.

Benzodiazepine discontinuation and patient outcome in a chronic geriatric medical/psychiatric unit: a retrospective chart review.

AIM: A substantial number of elderly patients take benzodiazepines (BZD) regularly despite concerns about toxicity and possible dependence, and there are relatively few data to guide clinicians' decisions regarding discontinuing benzodiazepines in the elderly. METHODS: We carried out a retrospective chart review of 75 elderly patients admitted to a chronic medical/psychiatric unit who were taking a standing dose of benzodiazepines on admission, comparing 40 patients who discontinued benzodiazepines versus 35 who did not discontinue. PURPOSE: We examined the association of BZD discontinuation versus continuation with clinical outcomes on discharge, and further examined clinical characteristics associated with BZD discontinuation. RESULTS: Discontinuers had shorter length of stay without evidence of worse cognitive and functional outcome except a trend toward increased incidence of agitation. Logistic regression models suggested anxiety, higher age and higher dose of antidepressants at the beginning were significantly related to successful discontinuation during admission after regression. CONCLUSION: These data imply that BZD withdrawal during admission can be safe and feasible in many elderly frail patients, and that withdrawal might be associated with shorter duration of chronic hospitalization.

A theory-based online hip fracture resource center for caregivers: effects on dyads.

BACKGROUND: Hip fracture is a serious injury for older adults, usually requiring surgical repair and extensive therapy. Informal caregivers can help older adults make a successful recovery by encouraging them to adhere to the therapy plans and improve their health behaviors. Few resources, however, are available for these caregivers to learn about how to assist their care receivers and cope with their unique caregiving situations. OBJECTIVE: The study aims were to develop a comprehensive theory-based online hip fracture resource center (OHRC) for caregivers, Caring for Caregivers, and conducted a feasibility trial. METHODS: The OHRC included self-learning modules, discussion boards, Ask the Experts, and a virtual library. The feasibility of the intervention was assessed by usage and usability. The feasibility of the future trial was tested using a one-group pre-post design on 36 caregiver-care receiver dyads recruited from six hospitals. The caregivers used the OHRC for 8 weeks. The impact of the intervention was assessed on both caregivers (primary) and care receivers (secondary). The data were analyzed by descriptive statistics, paired t tests, and content analyses. RESULTS: On average, caregivers reviewed five modules and used the discussion board 3.1 times. The mean perceived usability score for the OHRC was 74.04 ± 7.26 (range, 12-84). Exposure to the OHRC significantly improved caregivers' knowledge about the care of hip fracture patients (t = 3.17, p = .004) and eHealth literacy (t = 2.43, p = .002). Changes in other caregiver outcomes (e.g., strain, coping, and social support) and care receiver outcomes (e.g., self-efficacy for exercise and osteoporosis medication adherence) were favorable but not significant. DISCUSSION: The findings suggest that the OHRC was user-friendly and could be beneficial for caregivers. Additional larger-scale trials are needed to assess the effectiveness of the intervention on outcomes.