Improving safety and preventing falls using an evidence-based, front-line staff huddling practice: protocol for a pragmatic trial to increase quality of care in State Veterans Homes.

INTRODUCTION: Falls in nursing homes are a major cause for decreases in residents' quality of life and overall health. This study aims to reduce resident falls by implementing the LOCK Falls Programme, an evidence-based quality improvement intervention. The LOCK Falls Programme involves the entire front-line care team in (1) focusing on evidence of positive change, (2) collecting data through systematic observation and (3) facilitating communication and coordination of care through the practice of front-line staff huddles. METHODS AND ANALYSIS: The study protocol describes a mixed-methods, 4-year hybrid (type 2) effectiveness-implementation study in State Veterans Homes in the USA. The study uses a pragmatic stepped-wedge randomised trial design and employs relational coordination theory and the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to guide implementation and evaluation. A total of eight State Veterans Homes will participate and data will be collected over an 18-month period. Administrative data inclusive of all clinical assessments and Minimum Data Set assessments for Veterans with a State Veterans Home admission or stay during the study period will be collected (8480 residents total). The primary outcome is a resident having any fall. The primary analysis will be a partial intention-to-treat analysis using the rate of participants experiencing any fall. A staff survey (n=1200) and qualitative interviews with residents (n=80) and staff (n=400) will also be conducted. This research seeks to systematically address known barriers to nursing home quality improvement efforts associated with reducing falls. ETHICS AND DISSEMINATION: This study is approved by the Central Institutional Review Board (#167059-11). All participants will be recruited voluntarily and will sign informed consent as required. Collection, assessment and managing of solicited and spontaneously reported adverse events, including required protocol alterations, will be communicated and approved directly with the Central Institutional Review Board, the data safety monitoring board and the Office of Research and Development. Study results will be disseminated through peer-reviewed publications and conference presentations at the Academy Health Annual Research Meeting, the Gerontological Society of America Annual Scientific Meeting and the American Geriatrics Society Annual Meeting. Key stakeholders will also help disseminate lessons learnt. TRIAL REGISTRATION NUMBER: NCT05906095.

Home and Community-Based Service Use Varies by Health Care Team and Comorbidity Level of Veterans with Dementia.

Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients' type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients' non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs.

Quality Improvement Efforts in VA Community Living Centers Following Public Reporting of Performance.

For two decades, the U.S. government has publicly reported performance measures for most nursing homes, spurring some improvements in quality. Public reporting is new, however, to Department of Veterans Affairs nursing homes (Community Living Centers [CLCs]). As part of a large, public integrated healthcare system, CLCs operate with unique financial and market incentives. Thus, their responses to public reporting may differ from private sector nursing homes. In three CLCs with varied public ratings, we used an exploratory, qualitative case study approach involving semi-structured interviews to compare how CLC leaders (n = 12) perceived public reporting and its influence on quality improvement. Across CLCs, respondents said public reporting was helpful for transparency and to provide an "outside perspective" on CLC performance. Respondents described employing similar strategies to improve their public ratings: using data, engaging staff, and clearly defining staff roles vis-à-vis quality improvement, although more effort was required to implement change in lower performing CLCs. Our findings augment those from prior studies and offer new insights into the potential for public reporting to spur quality improvement in public nursing homes and those that are part of integrated healthcare systems.

The Impact of COVID-19 on Hypertension and Hypertension Medication Adherence Among Underrepresented Racial and Ethnic Groups: A Scoping Review.

PURPOSE OF REVIEW: To conduct a scoping review of articles which examined the impact of COVID-19 on HTN and HTN medication adherence among underrepresented racial/ethnic minorities. RECENT FINDINGS: Seven studies were included in this review and impact of COVID-19 was examined at 4 levels: patient, provider, health system and society. The results indicated that patient level factors, such as high unemployment and inequitable access to telemedicine due to society factors- lack of access to high-speed Internet and variation in the offering of telehealth by health systems, were most impactful on adherence. Additionally, provider level clinical inertia may have further impacted adherence to HTN medication. Our review showed that the COVID-19 pandemic did not introduce new barriers but exacerbated preexisting barriers. Ongoing efforts are needed to change policies at the state and local levels to dismantle inequities in underrepresented communities to ensure access to health care with telemedicine to promote health equity.

Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population.

BACKGROUND: Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations. OBJECTIVE: To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs). METHODS: We conducted semistructured interviews with staff, patients, and family members at 1 CLC to assess their understanding of penicillin allergies and receptiveness to verifying the allergy. We also asked staff about the proposed allergy assessment strategy, including willingness to delabel by history and feasibility of performing oral challenges or skin testing on their unit. RESULTS: From 24 interviews (11 front-line staff, 4 leadership, 3 patients, 6 family members), we identified several facilitators or barriers. Staff recognized the importance of allergy verification and were willing to support and assist in implementing verification strategies. The CLC residents were willing to have their allergy status verified. However, some family members expressed reluctance to verifying their relative's allergy status owing to safety concerns. Front-line staff also expressed concern over having the necessary resources, including time and expertise, to implement the strategy. Staff suggested involving clinical pharmacists and educating staff, patients, and family members as ways to overcome these barriers. CONCLUSIONS: Concerns about safety and staff resources are important potential barriers to implementing verification strategies. Involvement of pharmacists and education of both staff and patients and family members will be important components of any successful intervention.

Factors Differentiating Nursing Homes With Strong Resident Safety Climate: A Qualitative Study of Leadership and Staff Perspectives.

The current qualitative study assessed leadership and staff perceptions related to resident safety at Department of Veterans Affairs (VA) nursing homes with a range of safety climates. We recruited a purposive sample of six VA nursing homes from geographically diverse regions of the United States and with diverse overall safety climate ratings. We conducted semi-structured phone interviews with 43 senior and middle level nursing home leaders and frontline providers (medical and nursing). We performed a thematic analysis of interview data to assess participant perceptions of factors that influence resident safety at higher and lower safety climate sites. Analyses identified two factors that differentiated VA nursing homes with high safety climate ratings from those with medium or low ratings: (1) communication about resident safety, particularly the important role of accessibility of physicians and managers; and (2) leadership support for and responsiveness to resident safety issues raised by frontline staff. Findings from high safety climate nursing homes underscore the importance of leadership accessibility, communication, support, and follow through regarding resident safety concerns. These results may provide a basis for designing safety climate interventions, such as those designed to improve communication, teamwork, and quality improvement structures and processes. [Journal of Gerontological Nursing, 49(2), 13-17.].

A Spotlight on Adaptation: Preimplementation of Montessori-Based Activity Programming in Long-Term Care Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME).

BACKGROUND AND OBJECTIVES: Effectively adapting evidence-based interventions for nursing home (NH) implementation is a critical, yet underexamined, component of improving care quality. Montessori-based activity programming (MAP) is an evidence-based intervention that promotes person-centered care, engages persons living with dementia, and mitigates distress behaviors. Currently, there is sparse evidence of MAP in Department of Veterans Affairs NHs (i.e., community living centers [CLCs]). CLCs differ significantly from community NHs and require adaptations to support MAP use and sustainability. This study uses the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to track changes made to MAP as an exemplar for clinicians and implementation scientists. This work fills a gap in adapting interventions through a detailed examination of the adaptation process in NHs. RESEARCH DESIGN AND METHODS: Qualitative and quantitative data were collected across 8 CLCs (e.g., advisory panel, staff interviews, training evaluations, field notes, and fidelity assessments). We used an iterative, rapid content analytic approach to triangulate findings and identify needed adaptations for the CLC setting. RESULTS: Thirty-six adaptations were made. Most adaptions occurred during the preimplementation phase, were reactive, focused on training/evaluation, and involved researchers, intervention developers, and practitioners. All were fidelity-consistent with MAP. The most common goal across adaptations was increased reach/engagement of the intervention. DISCUSSION AND IMPLICATIONS: CLCs and community NHs can use findings to support intervention adaptation, and adapt and implement MAP to improve meaningful engagement for persons living with dementia and other residents. Future research should further evaluate and standardize FRAME for diverse users of complex interventions.

Preferences of Older Adult Veterans With Heart Failure for Engaging With Mobile Health Technology to Support Self-care: Qualitative Interview Study Among Patients With Heart Failure and Content Analysis.

BACKGROUND: Heart failure (HF) affects approximately 6.5 million adults in the United States, disproportionately afflicting older adults. Mobile health (mHealth) has emerged as a promising tool to empower older adults in HF self-care. However, little is known about the use of this approach among older adult veterans. OBJECTIVE: The goal of this study was to explore which features of an app were prioritized for older adult veterans with HF. METHODS: Between January and July 2021, we conducted semistructured interviews with patients with heart failure aged 65 years and older at a single facility in an integrated health care system (the Veterans Health Administration). We performed content analysis and derived themes based on the middle-range theory of chronic illness, generating findings both deductively and inductively. The qualitative questions captured data on the 3 key themes of the theory: self-care maintenance, self-care monitoring, and self-care management. Qualitative responses were analyzed using a qualitative data management platform, and descriptive statistics were used to analyze demographic data. RESULTS: Among patients interviewed (n=9), most agreed that a smartphone app for supporting HF self-care was desirable. In addition to 3 a priori themes, we identified 7 subthemes: education on daily HF care, how often to get education on HF, support of medication adherence, dietary restriction support, goal setting for exercises, stress reduction strategies, and prompts of when to call a provider. In addition, we identified 3 inductive themes related to veteran preferences for app components: simplicity, ability to share data with caregivers, and positive framing of HF language. CONCLUSIONS: We identified educational and tracking app features that can guide the development of HF self-care for an older adult veteran population. Future research needs to be done to extend these findings and assess the feasibility of and test an app with these features.

Osteoclasts and Macrophages-Their Role in Bone Marrow Cavity Formation During Mouse Embryonic Development.

The formation of the bone marrow cavity is a prerequisite for endochondral ossification. In reviews and textbooks, it is occasionally reported that osteoclasts are essential for bone marrow cavity formation removing hypertrophic chondrocytes. Mice lacking osteoclasts or having functionally defective osteoclasts have osteopetrotic bones, yet they still form a bone marrow cavity. Here, we investigated the role of osteoclasts and macrophages in bone marrow cavity formation during embryogenesis. Macrophages can assist osteoclasts in matrix removal by phagocytosing resorption byproducts. Rank-deficient mice, lacking osteoclasts, and Pu.1-deficient mice, lacking monocytes, macrophages, and osteoclasts, displayed a delay in bone marrow cavity formation and a lengthening of the zone of hypertrophic chondrocytes. F4/80-positive monocyte/macrophage numbers increased by about fourfold in the bone marrow cavity of E18.5 Rank-deficient mice. Based on lineage-tracing experiments, the majority of the excess F4/80 cells were derived from definitive hematopoietic precursors of the fetal liver. In long bones of both Rank-/- and Pu.1-/- specimens, Mmp9-positive cells were still present. In addition to monocytes, macrophages, and osteoclasts, Ctsb-positive septoclasts were lost in Pu.1-/- specimens. The mineralization pattern was altered in Rank-/- and Pu.1-/- specimens, revealing a significant rise in transverse-oriented mineralized structures. Taken together, our findings imply that early on during bone marrow cavity formation, osteoclasts facilitate the entry of blood vessels and later the turnover of hypertrophic chondrocytes, whereas macrophages appear to play no major role. Furthermore, the absence of septoclasts in Pu.1-/- specimens suggests that septoclasts are either derived from Pu.1-dependent precursors or require PU.1 activity for their differentiation. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Engaging veterans in the research process: a practical guide.

Aims: Provide guidance for engaging military veterans in various research teams to help overcome veterans' lack of trust in research. Methods: We draw from our combined experience to present four case studies of veteran research on sensitive topics to illustrate successful engagement with veterans. Results: For each case example, we describe veterans' contributions at different phases of research. We then share practical guidance for realizing benefits and overcoming challenges of engaging veterans in research at each phase. In our experience, successful engagement has built trust by aligning research with participants' own experience as veterans. Conclusion: Investigators wishing to engage veterans in research may benefit from the lessons presented through these case studies.

Mice Lacking Wnt9a or Wnt4 Are Prone to Develop Spontaneous Osteoarthritis With Age and Display Alteration in Either the Trabecular or Cortical Bone Compartment.

Osteoarthritis (OA) is a common degenerative disease of the joint, with a complex multifactorial not yet fully understood etiology. Over the past years, the Wnt signaling pathway has been implicated in osteoarthritis. In a recent genomewide association study (GWAS), the chromosomal location on chromosome 1, linked to the Wnt3a-Wnt9a gene locus, was identified as the most significant locus associated with a thumb osteoarthritis endophenotype. Previously, it was shown that WNT9a is involved in maintaining synovial cell identity in the elbow joint during embryogenesis. Here, we report that the conditional loss of Wnt9a in the Prx1-Cre expressing limb mesenchyme or Prg4-CreER expressing cells predispositions the mice to develop spontaneous OA-like changes with age. In addition, the trabecular bone volume is altered in these mice. Similarly, mice with a conditional loss of Wnt4 in the limb mesenchyme are also more prone to develop spontaneously OA-like joint alterations with age. These mice display additional alterations in their cortical bone. The combined loss of Wnt9a and Wnt4 increased the likelihood of the mice developing osteoarthritis-like changes and enhanced disease severity in the affected mice. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Home Health Aides' Increased Role in Supporting Older Veterans and Primary Healthcare Teams During COVID-19: a Qualitative Analysis.

BACKGROUND: Home health aides are important but often overlooked members of care teams, providing functional and emotional support to patients. These services became increasingly important during the COVID-19 pandemic as older adults faced disruptions in in-person medical services and family caregiving. Understanding how aides supported healthcare teams is important for informing emergency planning and better integrating home health services with primary care. OBJECTIVE: To describe aides' roles in supporting veterans and working with primary care teams during COVID-19 and identify COVID-related changes in tasks. DESIGN: Semi-structured interviews. PARTICIPANTS: Eight home health aides, 6 home health agency administrators, and 9 primary care team members (3 RNs, 3 social workers, 3 MDs) serving veterans at a large, urban, Veterans Affairs medical center. APPROACH: Combined deductive and inductive analysis to identify a priori concepts (aide roles; changes in tasks and new tasks during COVID-19) and emergent ideas. Aide, administrator, and provider interviews were analyzed separately and compared and contrasted to highlight emergent themes and divergent perspectives. KEY RESULTS: Participants reported an increase in the volume and intensity of tasks that aides performed during the pandemic, as well as the shifting of some tasks from the medical care team and family caregivers to the aide. Four main themes emerged around aides' roles in the care team during COVID-19: (1) aides as physically present "boots on the ground" during medical and caregiving disruptions, (2) aides as care coordination support, (3) aides as mental health support, and (4) intensification of aides' work. CONCLUSIONS: Home health aides played a central role in coordinating care during the COVID-19 pandemic, providing hands-on functional, medical, and emotional support. Integrating aides more formally into healthcare teams and expanding their scope of practice in times of crisis and beyond may improve care coordination for older veterans.

Nursing Home Residents' Relocation to Another Facility: an Exploratory Study of Family Caregiver Experiences.

Over time, family caregivers for older adults may face care transitions for their loved ones. The move from home to residential care facility is a much-studied transition. Yet we know little of family caregiver experiences when their loved ones move from one facility to another. We interviewed family caregivers of nursing home residents and inquired about caregiver experiences in prior facilities and factors that prompted moving to another facility. Our analysis identified three themes: 1) A precursor of moving to another facility was caregivers' assessment of poor fit between their family member and the facility; 2) Executing a move was demanding for the caregiver in instrumental and emotional ways; 3) Once in the new facility, caregivers adapted their caregiving to the capacity of the new facility and fostered resident-facility fit (not interfering with good care and supplementing facility care). Findings suggest that family caregivers continually assess and respond to emerging problems with resident-facility fit, which sometimes escalate and necessitate a move to another facility. Nursing home social workers are well-positioned to help families address emerging care problems, so they do not escalate. Doing so can promote care continuity, which benefits both the resident and the family caregiver.

Strategies for Implementing Group Mental Health Interventions in a VA Community Living Center.

Objectives: Group mental health interventions are difficult to implement into rehabilitation facilities, but no one has studied the specific barriers. This mixed-methods project systematically examined the implementation of a mental health (MH) group intervention in a VA community living center (CLC) for residents on subacute rehabilitation units, using the Promoting Action on Research Implementation in Health Services (PARIHS) implementation framework.Methods: We implemented a group MH intervention, tracking team referrals, attendance rates, and reasons for declining to participate. We conducted qualitative interviews with attendees.Results: Individual barriers to attendance included acute illness (n = 67, 20%), attitudes toward MH (n = 50; 15%), and perceived busyness (n = 19; 6%). Facility barriers included competing appointments (n = 69; 21%). Interviews demonstrated challenges to implementation, including stigma toward mental health (Theme: Challenges and Supports to Implementation). Attendees found the group relatable, and noted that both positive and negative group dynamics contributed to their experience (Themes: Content Relevance and Group Dynamics).Conclusions: The results provide insight into implementing a group MH treatment into the CLC setting, with implications for the MH care of older adults residing in CLCs.Clinical Implications: 1) Group leaders should consider matching attendees for ability levels (physical or cognitive). 2) At the facility level, leaders may take steps to address stigma toward MH by adopting approaches (e.g., music) or framing MH issues (e.g., use of language) in a way that is approachable. 3) Modifiable barriers at the individual and facility level could be addressed to encourage ease of implementation.

Music for your mental health? The development and evaluation of a group mental health intervention in subacute rehabilitation.

Objectives: Short-stay residents of nursing homes experience high rates of mental health (MH) distress compared to community dwelling counterparts, yet MH interventions are difficult to implement and sustain. We modified a music therapy framework to Effective Music in Psychotherapy. Using the modified model, we integrated music listening into MH group intervention and evaluated MH outcomes. This pilot study reports the development and evaluation of the Mental Health and Music Group for short-stay nursing homes residents.Method: The group was developed and refined to be non-sequential and non-cumulative, specific to the needs of short-stay nursing home residents. Pre-/post-session ratings examined affect, quality of life, and pain. Leaders monitored engagement across and between sessions. Qualitative interviews were conducted with a selection of attendees.Results: Findings indicated decreases in irritation and worry, and increases in mood, energy, and self-as-a-whole from pre- to post-session. There were no changes in pain, perception of physical health or life-as-a-whole, energetic, sad, or happy affect, or differences in engagement. Qualitative interviews demonstrated benefits of group modality and music to group cohesion and highlighted the relevance of music for mental health outcomes.Conclusion: The Mental Health and Music group was designed around a framework of Effective Music in Psychotherapy, for short-stay nursing home settings, and demonstrated promising results. Future research can solidify the interventions generalizeability to medical and rehabilitation settings addressing the specific population needs and preferences.Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2021.1935463 .

Organizational readiness to change as a leverage point for improving safety: a national nursing home survey.

BACKGROUND: A stronger safety climate in nursing homes may reduce avoidable adverse events. Yet efforts to strengthen safety climate may fail if nursing homes are not ready to change. To inform improvement efforts, we examined the link between organizational readiness to change and safety climate. METHODS: Seven safety climate domains and organizational readiness to change were measured with validated Community Living Center/CLC Employee Survey of Attitudes about Resident Safety and Organizational Readiness to Change Assessment. Safety climate domains comprised of safety priorities, supervisor commitment to safety, senior management commitment to safety, safety attitudes, environmental safety, coworker interactions around safety, and global rating of CLC. We specified models with and without readiness to change to explain CLC- and person-level variance in safety climate domains. RESULTS: One thousand three hundred ninety seven workers (frontline staff and managers) responded from 56 US Veterans Health Administration CLCs located throughout the US. Adding readiness to change reduced baseline CLC-level variance of outcomes (2.3-9.3%) by > 70% for interpersonal domains (co-workers, supervisors, and senior management). Readiness to change explained person-level variance of every safety climate domain (P < 0.05), especially for interpersonal domains. CONCLUSIONS: Organizational readiness to change predicted safety climate. Safety climate initiatives that address readiness to change among frontline staff and managers may be more likely to succeed and eventually increase resident safety.

De-implementing and sustaining an intervention to eliminate nursing home resident bed and chair alarms: interviews on leadership and staff perspectives.

BACKGROUND: Improving nursing home quality of care relies partly on reducing or stopping ineffective or harmful practices, a process known as de-implementation. We know little about de-implementation in this setting. Relatively recent policy changes reclassified resident position-change (bed and chair) alarms, which monitor resident movement, as restraints. This created an optimal environment in which to study impressions of an alarm de-implementation and sustainment intervention. METHODS: This cross-sectional interview study focused on understanding participants' experience of a quality improvement program in the Department of Veterans Affairs Community Living Centers (nursing homes). The program's goal was to improve resident outcomes and staff communication and teamwork through, among other foci, eliminating resident position-change alarms. The Community Living Centers were located in geographically dispersed areas of the continental United States. Interview participants were leadership and staff members from seven Community Living Centers. We conducted in-depth, semi-structured qualitative interviews using a convenience sample and used a thematic analytic approach. RESULTS: We conducted seventeen interviews. We identified five main themes: Initiating De-implementation (compelling participants with evidence, engaging local leadership, and site-level education and training), Changing Expectations (educating staff and family members), Using Contrasting Approaches (gradual or abrupt elimination of alarms), Witnessing Positive Effects of De-implementation (reduction in resident falls, improved resident sleep, reduction in distressing behaviors, and increased resident engagement), and Staying the Course (sustainment of the initiative). CONCLUSIONS: Findings highlight how participants overcame barriers and successfully eliminated resident position-change alarms and sustained the de-implementation through using convincing evidence for the initiative, local leadership involvement and support, and staff and family member education and engagement. These findings and the resulting three-phase process to support nursing homes' de-implementation efforts expand the de-implementation science knowledge base and provide a promising framework for other nursing home-based de-implementation initiatives.