Increasing Primary Care Utilization of Medication-Assisted Treatment (MAT) for Opioid Use Disorder.

BACKGROUND: With increasing prevalence of opioid use disorders (OUDs) there is an urgent need for OUD trained front line primary care providers (PCPs) who can help improve patient adherence to addiction treatment. Unfortunately, most physicians have had limited training for treating patients with addiction, leaving clinicians under prepared. To address this need, we created a Medication-Assisted Treatment (MAT) training program specifically designed for PCPs. INTERVENTION: A 4-hour PCP focused buprenorphine office-based implementation training was designed to supplement the 8-hour SAMHSA DATA 2000 waiver training. The intent of the supplemental training is to increase PCP likelihood of implementing MAT through practical evidenced-based implementation, addressing barriers reported by waivered PCPs. METHODS: We developed and validated a new pre- and postsurvey instrument that assesses changes in participants knowledge, skills, and attitudes. Data were entered into REDCap, and composite scales were created and analyzed to determine pre-post differences. RESULTS: A total of 183 participants completed pre-post evaluations. Pre-post comparisons indicated substantial improvement in learner levels of confidence in implementing MAT care processes and in their interactions with MAT patients (df = 4, F = 203.518, P < .001). Participants described themselves as more comfortable identifying patients who would benefit from MAT (t = 15.04, P < .001), more competent in implementing MAT (t = 21.27, P < .001) and more willing (t = 15.56, P < .001) to implement MAT after training. CONCLUSION: Evidence suggests that a new MAT training program that supplements the SAMHSA waiver training increases confidence and willingness to implement MAT among PCPs. Efforts to replicate this success to allow for further generalization and policy recommendations are warranted.

A multi-step education model for advancing competencies in geriatrics and interprofessional collaboration for health students.

At a time when the older adult population is increasing exponentially and health care agencies are fraught with crisis-level short-handedness and burnout, addressing the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers is more crucial than ever. A multi-step education model was designed to advance competencies in geriatrics and Interprofessional Collaborative Practice (IPCP) for health profession students focused on each element of the Quadruple Aim. The goals of this education were to equip students with knowledge and experience to provide team-based care for older adults and achieve satisfaction with the education program. The education steps consisted of online didactics, team icebreaker, skills practice, professional huddles, and interprofessional simulation with debriefing. Over 2,300 students and 87 facilitators from 16 professions completed the training over three years. A positive statistically significant increase was found between pre- and post-measures of IPCP competency, knowledge, and attitudes. Additionally, high satisfaction with the education was reported by students and facilitators. By providing positive geriatric education and experiences for health students to work in interprofessional teams, it can translate into future improvements in older adult population health, health care provider job satisfaction, and reduced health care costs.

Multi-Site Study of Provider Self-Efficacy and Beliefs in Explaining Judgments About Need and Responsibility for Advance Care Planning.

BACKGROUND AND OBJECTIVES: We examined the impact of advance care planning (ACP) self-efficacy and beliefs in explaining skilled nursing facility (SNF) provider judgments about resident need and provider responsibility for initiating ACP conversations. RESEARCH DESIGN AND METHODS: This observational multi-site study of 348 registered nurses, licensed practical nurses, and social workers within 29 SNFs used an anonymous survey in which providers judged vignettes with assigned situational features of a typical SNF resident. Mixed modeling was used to analyze the vignette responses. RESULTS: Providers who had more negative beliefs about ACP were less likely to judge residents in need of ACP and less likely to feel responsible for ensuring ACP took place. Self-efficacy did not have a significant impact on judgments of need, but did significantly increase judgments of responsibility for ensuring ACP conversations. Providers with the highest levels of ACP self-efficacy were most likely to feel responsible for ensuring ACP conversations. In an exploratory analysis, these relationships remained the same whether responding to high or low risk residents (i.e., based on risk of hospitalization, type of diagnosis, functional status, and rate of declining health). DISCUSSION AND IMPLICATIONS: Both negative beliefs about ACP and self-efficacy in one's ability to conduct ACP discussions were associated with professional judgments regarding ACP. The findings illustrate the importance of addressing negative beliefs about ACP and increasing provider ACP self-efficacy through education and policies that empower nurses and social workers.

Effects of pharmacy interventions at transitions of care on patient outcomes.

PURPOSE: An interdisciplinary group developed a care transitions process with a prominent pharmacist role. METHODS: The new transitions process was initiated on a 32-bed medical/surgical unit. Demographics, reconciliation data, information on medication adherence barriers, medication recommendations, and time spent performing interventions were prospectively collected for 284 consecutive patients over 54 days after the pharmacy participation was completely implemented. Outcome data, including 30-day readmission rates and length of stay, were retrospectively collected. RESULTS: When comparing metrics for all intervention patients to baseline metrics from the same months of the previous year, the readmission rate was decreased from 21.0% to 15.3% and mean length of stay decreased from 5.3 days to 4.4 days. Further improvement to a 10.2% readmission rate and a 3.6-day average length of stay were observed in the subgroup of intervention patients who received all components of the pharmacy intervention. Additionally, greater improvements were observed in intervention-period patients who received the full pharmacy intervention, as compared to those receiving only parts of the pharmacy intervention, with a 10.2-percentage-point lower readmission rate (10.2% vs 20.4%, P = 0.016) and a 1.7-day shorter length of stay (3.6 days vs 5.3 days; 95% confidence interval, 0.814-2.68 days; P = 0.0003). For patients receiving any component of the pharmacy intervention, an average of 9.56 medication recommendations were made, with a mean of 0.89 change per patient deemed to be required to avoid harm and/or increased length of stay. CONCLUSION: A comprehensive pharmacy intervention added to a transitions intervention resulted in an average of nearly 10 medication recommendations per patient, improved length of stay, and reduced readmission rates.

Advance Care Planning in Skilled Nursing Facilities: A Multisite Examination of Professional Judgments.

BACKGROUND AND OBJECTIVES: Lack of advance care planning (ACP) may increase hospitalizations and impact the quality of life for skilled nursing facility (SNF) residents, especially African American residents who may be less likely to receive ACP discussions. We examined the professional judgments of SNF providers to see if race of SNF residents and providers, and risk for hospitalization for residents influenced professional judgments as to when ACP was needed and feelings of responsibility for ensuring ACP discussions. RESEARCH DESIGN AND METHODS: Nurses and social workers (n = 350) within 29 urban SNFs completed surveys and rated vignettes describing eight typical SNF residents. Linear mixed modeling was used to examine factors that impacted ratings of need for ACP and responsibility for ensuring ACP. RESULTS: Neither the race of the provider, resident, nor the interaction of the two were associated with either outcome variable. In contrast, providers rated (on a 9-point scale) residents at high risk for hospitalization as more in need of ACP (estimate = 0.86, confidence interval [CI] 0.65, 1.07) and felt more responsible for ensuring ACP (estimate = 0.60, CI 0.42, 0.78). DISCUSSION AND IMPLICATIONS: Research on ACP is continuing to evolve and these results show the primacy of disease trajectory variables on providers' judgments about ACP. Differences between providers indicate a need for stronger policies and education. Further, research comparing rural, suburban, and urban SNFs is needed to explore possible forms of structural racism such as residential and SNF segregation.

Interprofessional education model for geriatric falls risk assessment and prevention.

BACKGROUND: One in three people over the age of 65 fall every year, with 1/3 sustaining at least moderate injury. Falls risk reduction requires an interprofessional health team approach. The literature is lacking in effective models to teach students how to work collaboratively in interprofessional teams for geriatric falls prevention. The purpose of this paper is to describe the development, administration and outcome measures of an education programme to teach principles of interprofessional care for older adults in the context of falls prevention. METHODS: Students from three academic institutions representing 12 health disciplines took part in the education programme over 18 months (n=237). A mixed method one-group pretest and post-test experimental design was implemented to measure the impact of a multistep education model on progression in interprofessional collaboration competencies and satisfaction. RESULTS: Paired t-tests of pre-education to posteducation measures of Interprofessional Socialization and Valuing Scale scores (n=136) demonstrated statistically significant increase in subscales and total scores (p<0.001). Qualitative satisfaction results were strongly positive. DISCUSSION: Results of this study indicate that active interprofessional education can result in positive student attitude regarding interprofessional team-based care, and satisfaction with learning. Lessons learnt in a rapid cycle plan-do-study-act approach are shared to guide replication efforts for other educators. CONCLUSION: Effective models to teach falls prevention interventions and interprofessional practice are not yet established. This education model is easily replicable and can be used to teach interprofessional teamwork competency skills in falls and other geriatric syndromes.

CE: Original Research: Advance Care Planning: An Exploration of the Beliefs, Self-Efficacy, Education, and Practices of RNs and LPNs.

: Objective: This study compared the advance care planning (ACP)-related beliefs, sense of self-efficacy, education, and practices of RNs and LPNs. METHODS: Data were extrapolated from a larger multisite study that was conducted across seven counties in one midwestern state. The sample consisted of RNs and LPNs working in 29 urban skilled nursing facilities in zip code areas with greater than 10% African American residents. The survey tool, a self-administered written questionnaire, gathered data on participants' demographics and ACP-related beliefs, sense of self-efficacy, education, and practices. The two main outcome variables were the percentage of residents with whom a nurse discussed ACP and the timing of the most recent such discussion. RESULTS: A total of 136 RNs and 178 LPNs completed the survey. Multivariate mixed-model analysis of the two main outcome variables showed that negative beliefs were not significantly associated with the percentage of residents with whom nurses discussed ACP but were significantly associated with the timing of the most recent ACP discussion. Having higher levels of ACP-related self-efficacy and education were significantly and positively associated with both outcome variables. RNs and LPNs did not differ significantly in their ACP-related beliefs, but RNs reported significantly higher levels of self-efficacy and education than LPNs did. CONCLUSIONS: There has been a paucity of research comparing RNs and LPNs regarding their ACP practices in skilled nursing facilities. Better education and policies that empower nurses to take a more active role are critical to increasing conversations about ACP. Further research exploring how the complementary roles of RNs and LPNs can be used to improve ACP processes and inform ACP policies is needed.

Workplace Violence Training Using Simulation.

: Workplace violence in health care settings is increasing dramatically nationwide. In response, an interdisciplinary team at an Ohio health system developed and piloted a model of training to address workplace violence. The model included classroom learning, a code silver (person with a weapon or a hostage situation) simulation training, and hands-on self-defense techniques. Based on data collected in the pilot, the team revised the model to offer a more comprehensive approach; the new, revised training program is known as Violence: enABLE Yourself to Respond. The team designed four distinct five-minute simulation scenarios depicting a range of threats from "escalating behavior" to "active shooter" and enacted them with standardized participants (health care personnel trained to perform specific behaviors in educational scenarios). Immediately after each simulation, the instructors facilitated a debriefing of the participants. Participants' pre- and post-training program self-evaluations of how prepared they felt to react to violent situations, as well as experts' evaluations of the participants' performance in simulations, provided evidence of the effectiveness of the model. Analysis of the data demonstrated a statistically significant positive difference in both participants' perception of their preparedness and experts' evaluation of their performance. The combination of classroom learning and simulation training is an effective, evidence-based method to prepare employees to respond when a situation escalates to violence, including the use of a weapon. This approach was designed for acute care but can be adapted to other settings. Skills learned can be used in both personal and professional life.

Development of a Scale to Assess Physician Advance Care Planning Self-Efficacy.

BACKGROUND: Although patients prefer that physicians initiate advance care planning (ACP) conversations, few physicians regularly do so. Physicians may be reluctant to initiate ACP conversations because they lack self-efficacy in their skills. Yet, no validated scale on self-efficacy for ACP exists. Our objective was to develop a scale that measures physicians' ACP self-efficacy (ACP-SE) and to investigate the validity of the tool. METHODS: Electronic questionnaires were administered to a random sample of family medicine physicians (n = 188). Exploratory factor analysis was performed to determine whether the scale was multidimensional. An initial assessment of the scale's validity was also conducted. RESULTS: The exploratory factor analysis indicated that a single factor was appropriate using all 17 items. A single, unidimensional scale was created by averaging the 17 items, yielding good internal consistency (Cronbach α = 0.95). The average scale score was 3.94 (standard deviation = 0.71) on a scale from 1 to 5. The scale was moderately correlated with a global single-item measure of self-efficacy for ACP ( r = .79, P < .001), and the scale differentiated between physician groups based on how much ACP they were doing, how recently they had an ACP conversation, formal training on ACP, and knowledge of ACP. In a multivariate analysis, the ACP-SE scale was a strong predictor of the percentage of patients with chronic life-limiting diseases with whom the physician discussed ACP. CONCLUSION: The final ACP-SE scale included 17 items and demonstrated high internal consistency.

Patient-reported Chiari malformation type I symptoms and diagnostic experiences: a report from the national Conquer Chiari Patient Registry database.

Chiari malformation (CM) is a condition in which cerebellar tonsillar ectopia may manifest with various clinical presentations. This study reports from the only national, online patient registry available, the symptoms, comorbid neurocognitive and psychological conditions, and diagnostic experiences of patients living with CM type I (CM I). The current research is one component of a large investigation designed to collect information from individuals with CM through the online Conquer Chiari Patient Registry questionnaire. Analyses included descriptive statistics to study body system impact and patient diagnostic experiences. Participants were 768 individuals with CM I and were predominantly female (86.8 %) and Caucasian (93.8 %) with an average age of 35 years. Pain was the most frequently reported symptom (76.69 %) experienced prior to diagnosis with headaches implicated most often (73.44 %). Neurocognitive comorbidities included memory difficulties (43.88 %) and aphasia (43.75 %) and psychological disorders such as depression (31.77 %) and anxiety disorders (19.92 %) were reported. Average time to diagnosis from first physician visit to diagnosis was 3.43 years, and only 8.46 % of patients had previous awareness of CM. CM I diagnosis was found incidentally for 24.87 % of participants. Common misdiagnoses were classified as psychological (19.26 %) and neurological (19.26 %). Fear was the most frequent emotion elicited at the time of correct diagnosis (42.19 %). CM I can be a challenging condition for patients and physicians, during both the search for diagnosis and management of symptoms. Patient and physician education about CM I may permit early intervention and the prevention of further deterioration and patient suffering.

Factors that influence physical function and emotional well-being among Medicare-Medicaid enrollees.

Dually enrolled Medicare-Medicaid older adults are a vulnerable population. We tested House's Conceptual Framework for Understanding Social Inequalities in Health and Aging in Medicare-Medicaid enrollees by examining the extent to which disparities indicators, which included race, age, gender, neighborhood poverty, education, income, exercise (e.g., walking), and physical activity (e.g., housework) influence physical function and emotional well-being. This secondary analysis included 337 Black (31%) and White (69%) older Medicare-Medicaid enrollees. Using path analysis, we determined that race, neighborhood poverty, education, and income did not influence physical function or emotional well-being. However, physical activity (e.g., housework) was associated with an increased self-report of physical function and emotional well-being of ß = .23, p < .001; ß = .17, p < .01, respectively. Future studies of factors that influence physical function and emotional well-being in this population should take into account health status indicators such as allostatic load, comorbidity, and perceived racism/discrimination.

The impact of Chiari malformation on daily activities: A report from the national Conquer Chiari Patient Registry database.

BACKGROUND: Chiari malformation (CM) is characterized by herniation of the cerebellar tonsils into the cervical spine. While ample literature on CM exists for clinical and procedural aspects of the disease, few studies have measured the impact CM has on daily activities. OBJECTIVE: The objective of this study was to measure the impact that CM has on daily living activities. METHODS: Data was analyzed from 798 CM patients gathered by the national Conquer Chiari Patient Registry database. RESULTS: Results indicate CM is associated with negative impact on daily living and physical activities for patients, even those exhibiting mild symptoms. Participants with severe symptoms experience the greatest deficit with regards to daily living such as difficulty walking, driving, housecleaning and food preparation. CONCLUSIONS: As 96.1% of CM patients report impact in one or more areas of daily living, CM is classified as a disability according to 42 U.S. CODE § 12101 (Americans with Disabilities Act). The degree of self-reported CM symptom severity is strongly related to the frequency and extent of limitations in both physical and daily activities.

Results of the promoting effective advance care planning for elders (PEACE) randomized pilot study.

The specific aim of the PEACE pilot study was to determine the feasibility of a fully powered study to test the effectiveness of an in-home geriatrics/palliative care interdisciplinary care management intervention for improving measures of utilization, quality of care, and quality of life in enrollees of Ohio's community-based long-term care Medicaid waiver program, PASSPORT. This was a randomized pilot study (n=40 intervention [IG], n=40 usual care) involving new enrollees into PASSPORT who were >60 years old. This was an in-home interdisciplinary chronic illness care management intervention by PASSPORT care managers collaborating with a hospital-based geriatrics/palliative care specialist team and the consumer's primary care physician. This pilot was not powered to test hypotheses; instead, it was hypothesis generating. Primary outcomes measured symptom control, mood, decision making, spirituality, and quality of life. Little difference was seen in primary outcomes; however, utilization favored the IG. At 12 months, the IG had fewer hospital visits (50% vs. 55%, P=0.65) and fewer nursing facility admissions (22.5% vs. 32.5%, P=0.32). Using hospital-based specialists interfacing with a community agency to provide a team-based approach to care of consumers with chronic illnesses was found to be feasible. Lack of change in symptom control or quality of life outcome measures may be related to the tools used, as these were validated in populations closer to the end of life. Data from this pilot study will be used to calculate the sample size needed for a fully powered trial.

The after discharge care management of low income frail elderly (AD-LIFE) randomized trial: theoretical framework and study design.

Interdisciplinary care management is advocated for optimal care of patients with many types of chronic illnesses; however, few models exist that have been tested using randomized trials. The purpose of this report is to describe the theoretical basis for the After Discharge Management of Low Income Frail Elderly (AD-LIFE) trial, which is an ongoing 2-group randomized trial (total n = 530) to test a chronic illness management and transitional care intervention. The intervention is based on Wagner's chronic illness care model and involves comprehensive posthospitalization nurse-led interdisciplinary care management for low income frail elders with chronic illnesses, employs evidence-based protocols that were developed using the Assessing Care of Vulnerable Elders (ACOVE) guidelines, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. The primary aim of the AD-LIFE trial is to test a chronic illness management intervention in vulnerable patients who are eligible for Medicare and Medicaid. This model, with its standardized, evidence-based medical and psychosocial intervention protocols, will be easily transportable to other sites interested in optimizing outcomes for chronically ill older adults. If the results of the AD-LIFE trial demonstrate the superiority of the intervention, then this data will be important for health care policy makers.

A randomized trial testing the superiority of a postdischarge care management model for stroke survivors.

OBJECTIVE: We sought to evaluate whether comprehensive postdischarge care management for stroke survivors is superior to organized acute stroke department care with enhanced discharge planning in improving a profile of health and well-being. METHODS: This was a randomized trial of a comprehensive postdischarge care management intervention for patients with ischemic stroke and National Institutes of Health Stroke Scale scores greater than or equal to 1 discharged from an acute stroke department. An advanced practice nurse performed an in-home assessment for the intervention group from which an interdisciplinary team developed patient-specific care plans. The advanced practice nurse worked with the primary care physician and patient to implement the plan during the next 6 months. The intervention and usual care groups were compared using a global and closed hypothesis testing strategy. Outcomes fell into 5 domains: (1) neuromotor function, (2) institution time or death, (3) quality of life, (4) management of risk, and (5) stroke knowledge and lifestyle. RESULTS: Treatment effect was near 0 SD for all except the stroke knowledge and lifestyle domain, which showed a significant effect of the intervention (P = .0003). CONCLUSIONS: Postdischarge care management was not more effective than organized stroke department care with enhanced discharge planning in most domains in this population. The intervention did, however, fill a postdischarge knowledge gap.

Effectiveness of Chloraprep in reduction of blood culture contamination rates in emergency department.

Contaminated blood cultures result in increased healthcare utilization. Poor skin preparation is usually the cause of contamination. Our study results showed a significant decrease in contamination rates using 2% chlorhexidine and 70% isopropanol (Chloraprep) versus tincture of iodine. Adoption of this technique throughout our institution is expected to result in a savings of 875000 dollars per year, as well as decreased discomfort for the patient.

Evaluating pain management delivered by direct care nurses.

It is difficult to assess the effectiveness of the delivery of pain management care because pain management is a complex process. This article describes a quality assurance study that was conducted on a surgical unit at a community teaching hospital, which is a member of a 1200 licensed inpatient beds multihospital system, to determine the effectiveness of pain management at the unit level. For the study, a Chart Audit Analysis Tool was developed and used to review second postoperative day charts of patients who had undergone a major abdominal surgery. The Chart Audit Analysis Tool quantifies by weighted indicators 2 outcomes measures, nurses' care delivery and pharmacologic management. The Chart Audit Analysis Tool, along with the results of a test of the nurses' knowledge and attitudes about pain management, provides nurse managers a quick and easy method to identify strengths and weaknesses of pain management at the unit level.