Background and method of the Striving to be Strong study a RCT testing the efficacy of a m-health self-management intervention.

BACKGROUND: Osteoporosis is a prevalent and debilitating condition affecting >50% of post-menopausal women. Yet, a low percentage of women regularly engage in health promoting behaviors associated with osteoporosis prevention. Complex, multidimensional, m-Health interventions hold promise to effect engagement in health behavior change related to calcium and vitamin D intake, balance, core and leg strength, and physical activity. METHODS: Striving to be Strong study (R01NR013913-01) tests the efficacy of a research and theory based, patient centered, dynamically tailored intervention delivered via smart phone apps. Ecological Momentary Assessments (EMAs) enhance immediate feedback and complement traditional measures. The desired outcomes are the maintenance of osteoporosis self-management behaviors and a decrease in the loss of bone density over time. The Individual and Family Self-management Theory provided the conceptual foundation for the study. The sample consists of 290 healthy women between the ages of 40 and 60 with an anticipated attrition of 33%. This three group repeated measures Randomized Clinical Trial spans a 12-month time period. Data collected occurs via web site, smart-phone app, self-report, observation, and measures. Proximal (engagement in osteoporosis health behaviors) and distal (serum vitamin D, DXA, and body composition) outcomes are collected for testing of the efficacy of the intervention and theory evaluation. DISCUSSION: Active and rigorous quality management processes continually evaluate enrollment and retention goals, functionality of the automated intervention delivery and data collection systems, EMAs, and dispersion of incentives.

Cost analysis of a home-based nurse care coordination program.

OBJECTIVES: To determine whether a home-based care coordination program focused on medication self-management would affect the cost of care to the Medicare program and whether the addition of technology, a medication-dispensing machine, would further reduce cost. DESIGN: Randomized, controlled, three-arm longitudinal study. SETTING: Participant homes in a large Midwestern urban area. PARTICIPANTS: Older adults identified as having difficulty managing their medications at discharge from Medicare Home Health Care (N = 414). INTERVENTION: A team consisting of advanced practice nurses (APNs) and registered nurses (RNs) coordinated care for two groups: home-based nurse care coordination (NCC) plus a pill organizer group and NCC plus a medication-dispensing machine group. MEASUREMENTS: To measure cost, participant claims data from 2005 to 2011 were retrieved from Medicare Part A and B Standard Analytical Files. RESULTS: Ordinary least squares regression with covariate adjustment was used to estimate monthly dollar savings. Total Medicare costs were $447 per month lower in the NCC plus pill organizer group (P = .11) than in a control group that received usual care. For participants in the study at least 3 months, total Medicare costs were $491 lower per month in the NCC plus pill organizer group (P = .06) than in the control group. The cost of the NCC plus pill organizer intervention was $151 per month, yielding a net savings of $296 per month or $3,552 per year. The cost of the NCC plus medication-dispensing machine intervention was $251 per month, and total Medicare costs were $409 higher per month than in the NCC plus pill organizer group. CONCLUSION: Nurse care coordination plus a pill organizer is a cost-effective intervention for frail elderly Medicare beneficiaries. The addition of the medication machine did not enhance the cost effectiveness of the intervention.

Integrated literature review of postdischarge telephone calls.

This systematic review of the literature assessed the impact of a postdischarge telephone call on patient outcomes. Nineteen articles met inclusion criteria. Data were extracted and an evidence table was developed. The content, timing, and professional placing the call varied across studies. Study strength was low and findings were inconsistent. Measures varied across studies, many sample sizes were small, and studies differed by patient population. Evidence is inconclusive for use of phone calls to decrease readmission, emergency department use, patient satisfaction, scheduled and unscheduled follow-up, and physical and emotional well-being. Among these studies, there was limited support for medication-focused calls by pharmacists but no support for decreasing readmission. Health care providers benefited from feedback but did not need to place the call to realize this benefit. Inpatient nurses were unable to manage the volume of calls. There was no standardized approach to the call, training, or documentation requirements.

Nurse care coordination and technology effects on health status of frail older adults via enhanced self-management of medication: randomized clinical trial to test efficacy.

BACKGROUND: Self-management of complex medication regimens for chronic illness is challenging for many older adults. OBJECTIVES: The purpose of this study was to evaluate health status outcomes of frail older adults receiving a home-based support program that emphasized self-management of medications using both care coordination and technology. DESIGN: This study used a randomized controlled trial with three arms and longitudinal outcome measurement. SETTING: Older adults having difficulty in self-managing medications (n = 414) were recruited at discharge from three Medicare-certified home healthcare agencies in a Midwestern urban area. METHODS: All participants received baseline pharmacy screens. The control group received no further intervention. A team of advanced practice nurses and registered nurses coordinated care for 12 months to two intervention groups who also received either an MD.2 medication-dispensing machine or a medplanner. Health status outcomes (the Geriatric Depression Scale, Mini Mental Status Examination, Physical Performance Test, and SF-36 Physical Component Summary and Mental Component Summary) were measured at baseline and at 3, 6, 9, and 12 months. RESULTS: After covariate and baseline health status adjustment, time × group interactions for the MD.2 and medplanner groups on health status outcomes were not significant. Time × group interactions were significant for the medplanner and control group comparisons. DISCUSSION: Participants with care coordination had significantly better health status outcomes over time than those in the control group, but addition of the MD.2 machine to nurse care coordination did not result in better health status outcomes.

Effects of the Serial Trial Intervention on discomfort and behavior of nursing home residents with dementia.

This study tested the effectiveness of the Serial Trial Intervention (STI), an innovative clinical protocol for assessment and management of unmet needs in people with late-stage dementia. A double-blinded randomized experiment was conducted in 14 nursing homes with 114 subjects. The treatment group had significantly less discomfort than the control group at posttesting and more frequently had behavioral symptoms return to baseline. The group of nurses using the STI also showed more persistence in assessing and intervening than control group nurses did. There was a statistically significant difference between the groups in the use of pharmacological, but not nonpharmacological, comfort treatments. Results suggest that the STI is effective and that effective treatment of discomfort is possible for people with late-stage dementia.

The Serial Trial Intervention: an innovative approach to meeting needs of individuals with dementia.

Individuals with dementia often use behaviors rather than specific verbal complaints to express the presence of a symptom or need. The Serial Trial Intervention uses systematic serial assessments and sequential trials of treatments to identify and treat unmet needs that may be the underlying cause of these behaviors. Because chronic pain is common and often under-treated in this population, a trial of analgesics is used when other approaches, including nonpharmacological treatments, have not been effective. A systematic approach to nursing assessment and treatment is needed to identify and treat discomfort and other unmet needs of individuals with dementia.

A model of consequences of need-driven, dementia-compromised behavior.

PURPOSE: To extend the original need-driven, dementia-compromised behavior (NDB) model by explaining the consequences of behavioral symptoms for the person with dementia. ORGANIZING CONSTRUCT AND METHODS: Literature is reviewed and the consequences of expressing needs through need-driven, dementia-compromised behaviors are posited. The consequences of need-driven, dementia-compromised behavior (C-NDB) theory is proposed as a framework to improve understanding of the person with dementia and the consequences of behavioral symptoms and unmet needs. FINDINGS: Instead of normative verbal communication, people with significant dementia commonly communicate need via non-normative behaviors, making it difficult for caregivers to know that the person has a need and the extent of such need. Not meeting needs of people with dementia affects the person with dementia, care factors, and contextual factors. Cascading effects occur in which not meeting the original need results in new needs and behavioral symptoms. CONCLUSIONS: This framework indicates the consequences of expressing need behaviorally rather than verbally and shows that caregiver actions might moderate the events that lead to many needs being unresolved. Suggestions are made regarding future research questions deduced from the model.

Effect of the BACE intervention on agitation of people with dementia.

PURPOSE: This study tests the effectiveness of the theoretically driven BACE (i.e., Balancing Arousal Controls Excesses) intervention in decreasing agitation in residents of long-term care with moderate or severe dementia. DESIGN AND METHODS: A pretest-posttest double-blinded experimental design with random assignment was used with a sample of 78 participants. The BACE intervention controls the daily activity schedule so that there is a balance between a person's high-arousal and low-arousal states. The outcome measure was observed agitation. RESULTS: When time spent in arousal imbalance at pretest was controlled for, a repeated measures analysis of covariance revealed a statistically significant Group x Time interaction, F(1, 69) = 4.26, p =.043, with a partial eta(2) =.06. The average change in agitation for the treatment group was a decrease of 8.43 points (SD = 12.01) from pretest to posttest, an effect size of.7. IMPLICATIONS: The results of this study support the theory that balancing arousal states by using an individualized approach is effective in decreasing agitation levels of people with dementia.