Transitional care of people with dementia and caregivers in the ADRD-PC trial: A mixed methods study.

CONTEXT: People with late-stage Alzheimer's diseases and related dementias (ADRD) have high risk for post-acute complications and readmission; however, minimal research describes hospital transitional care. OBJECTIVE: Within the context of the ongoing ADRD-PC clinical trial, the purpose of this study was to describe the content and quality of transitional care of people with ADRD. METHODS: Descriptive mixed methods using data from a retrospective chart review and interviews with palliative care social workers and a nurse providing transitional care in the ADRD-PC clinical trial. RESULTS: Of 40 dyads of people with late-stage ADRD and their caregivers, palliative care plans were documented for 29 patients (73%); completed post-discharge calls in 72 hours were made for 39 (98%) caregivers and calls in 2 weeks were made for 33 (78%). The content of post-discharge care was promoting continuity, identifying resources, helping caregivers feel heard, troubleshooting problems, and providing grief support. Challenges during transitional care were limited time to engage caregivers in hospital-based palliative care, educate caregivers about palliative care plans, coordinate care after transfers to long term care, and the scarcity of community ADRD resources. Facilitators of high quality transitional care were continuity of staff who saw the patient or caregiver across hospital and post-acute contacts, caregiver understanding of goals of care, written palliative care plans, and resources for post-discharge care. CONCLUSION: Findings indicate high quality dementia-specific transitional care occurs when staff have resources, such as ADRD training and care planning template, to pull the hospital palliative care plan forward into the post-discharge destination, help families fit the plan to new circumstances, and manage strain and grief related to changes in health and function.

A streamlined approach to classifying and tailoring implementation strategies: recommendations to speed the translation of research to practice.

BACKGROUND: Implementation science emerged from the recognized need to speed the translation of effective interventions into practice. In the US, the science has evolved to place an ever-increasing focus on implementation strategies. The long list of implementation strategies, terminology used to name strategies, and time required to tailor strategies all may contribute to delays in translating evidence-based interventions (EBIs) into practice. To speed EBI translation, we propose a streamlined approach to classifying and tailoring implementation strategies. MAIN TEXT: A multidisciplinary team of eight scholars conducted an exercise to sort the Expert Recommendations for Implementing Change (ERIC) strategies into three classes: implementation processes (n = 25), capacity-building strategies (n = 20), and integration strategies (n = 28). Implementation processes comprise best practices that apply across EBIs and throughout the phases of implementation from exploration through sustainment (e.g., conduct local needs assessment). Capacity-building strategies target either general or EBI-specific knowledge and skills (e.g., conduct educational meetings). Integration strategies include "methods and techniques" that target barriers or facilitators to implementation of a specific EBI beyond those targeted by capacity building. Building on these three classes, the team collaboratively developed recommendations for a pragmatic, five-step approach that begins with the implementation processes and capacity-building strategies practice-settings are already using prior to tailoring integration strategies. A case study is provided to illustrate use of the five-step approach to tailor the strategies needed to implement a transitional care intervention in skilled nursing facilities. CONCLUSIONS: Our proposed approach streamlines the formative work required prior to implementing an EBI by building on practice partner preferences, expertise, and infrastructure while also making the most of prior research findings.

Health Trajectories of Skilled Nursing Facility Patients With Alzheimer's Disease and Related Dementias: Evidence for Practicing Nurses.

PURPOSE: Older adults with Alzheimer's disease and related dementias (ADRD) are at high risk for acute medical problems and their health trajectories frequently include hospital admission and care in a skilled nursing facility (SNF). Their health trajectories after SNF discharge are poorly understood. Therefore, in the current study, we sought to describe health trajectories and factors associated with hospital read-missions for older adults with ADRD during the 30 days following SNF discharge. METHOD: We conducted a secondary analysis of data from a clinical trial of transitional care of older adults with transitions from SNF to home and assisted living. A multiple case study design was used in the analysis of the health trajectories of 49 SNF patients with ADRD, 51% discharged from SNF to their own home, 34% discharged to a family member's home, and 15% transferred to assisted living. RESULTS: Within 30 days of discharge, 20% of patients with ADRD experienced new or recurrent acute needs and hospital readmission. CONCLUSION: Our findings suggest the need for nursing interventions to support patients with ADRD during care transitions, such as focusing care on the patient-caregiver dyad, providing transitional care, referring patients for palliative care consultation, and conducting nurse-led research to improve care transitions of these patients and their caregivers. [Journal of Gerontological Nursing, 50(4), 34-41.].

Life-Space of Older Adults after Discharge from Skilled Nursing Facilities.

OBJECTIVES: Describe (1) patient or caregiver perceptions of physical function in 30 days after skilled nursing facility (SNF) discharge indicated by Life-Space Assessment (LSA) scores, and (2) patient and caregiver factors associated with LSA scores. DESIGN: Secondary analysis of baseline and outcomes data from the cluster randomized trial of the Connect-Home transitional care intervention. SETTING AND PARTICIPANTS: Six SNFs in North Carolina. Patient and caregiver dyads with LSA scores (N = 245). METHODS: SNF patients or their caregivers serving as proxy reported the life-space of the SNF patient using the LSA tool, a measure of environmental and social factors that influence physical mobility. Simple scores for highest life-space attained depending on equipment and/or caregiver support range from 0 to 5, with higher scores indicating greater mobility. Multiple linear regression models for simple LSA scores and Composite Life-Space (0-120), adjusted for treatment, time via a COVID pandemic indicator, and treatment × COVID effect as fixed effects, were used to estimate the association of patient and caregiver variables and life-space. RESULTS: Patients had a mean age of 76.3 years, 62.6% were female, and 74.7% were white. Caregivers were commonly female (73.9%) and adult children of the patient (46.5%). The mean Composite Life-Space score was 22.6 (16.09). The mean Assisted Life-Space score (range: 0-5) was 1.6 (1.47), and 76.3% of patients could not move beyond their bedroom, house, and yard without assistance of another person. Higher Composite Life-Space scores were associated with lower levels of cognitive impairment and shorter SNF length of stay. CONCLUSIONS AND IMPLICATIONS: SNF patients and their caregivers reported very low LSA scores in 30 days after SNF care. Findings indicate the need for care redesign to promote recovery of physical function of older adults after SNF discharge, such as optimizing SNF rehabilitative therapy and adding postdischarge rehabilitative supports at home.

Novel Definitions of Wellness and Distress among Family Caregivers of Patients with Acute Cardiorespiratory Failure: A Qualitative Study.

Rationale: Family caregivers of patients with acute cardiorespiratory failure are at high risk for distress, which is typically defined as the presence of psychological symptoms such as anxiety, depression, or posttraumatic stress. Interventions to reduce caregiver distress and increase wellness have been largely ineffective to date. An incomplete understanding of caregiver wellness and distress may hinder efforts at developing effective support interventions. Objectives: To allow family caregivers to define their experiences of wellness and distress 6 months after patient intensive care unit (ICU) admission and to identify moderators that influence wellness and distress. Methods: Primary family caregivers of adult patients admitted to the medical ICU with acute cardiorespiratory failure were invited to participate in a semistructured interview 6 months after ICU admission as part of a larger prospective cohort study. Interview guides were used to assess caregiver perceptions of their own well-being, record caregiver descriptions of their experiences of family caregiving, and identify key stress events and moderators that influenced well-being during and after the ICU admission. This study was guided by the Chronic Traumatic Stress Framework conceptual model, and data were analyzed using the five-step framework approach. Results: Among 21 interviewees, the mean age was 58 years, 67% were female, and 76% were White. Nearly half of patients (47%) had died before the caregiver interview. At the time of the interview, 9 caregivers endorsed an overall sense of distress, 10 endorsed a sense of wellness, and 2 endorsed a mix of both. Caregivers defined their experiences of wellness and distress as multidimensional and composed of four main elements: 1) positive versus negative physical and psychological outcomes, 2) high versus low capacity for self-care, 3) thriving versus struggling in the caregiving role, and 4) a sense of normalcy versus ongoing life disruption. Postdischarge support from family, friends, and the community at large played a key role in moderating caregiver outcomes. Conclusions: Caregiver wellness and distress are multidimensional and extend beyond the absence or presence of psychological outcomes. Future intervention research should incorporate novel outcome measures that include elements of self-efficacy, preparedness, and adaptation and optimize postdischarge support for family caregivers.

Selecting outcomes for pragmatic clinical trials in dementia care: The IMPACT Collaboratory iLibrary.

BACKGROUND: Many interventions improve care and outcomes for people with Alzheimer's Disease and related dementias (ADRD), yet are never disseminated. Pragmatic trials facilitate the adoption and dissemination of best practices, but gaps in pragmatic outcome measurement are a critical obstacle. Our objectives are (1) to describe the development and structure of the IMbedded Pragmatic ADRD Clinical Trials Collaboratory (IMPACT) iLibrary of potential outcome measures for ADRD pragmatic trials, and (2) to assess their pragmatic characteristics. METHODS: We identified potential outcome measures from several sources: a database of administrative and clinical outcome measures from ADRD clinical trials registered in ClinicalTrials.gov, published reviews, and IMPACT pilot pragmatic trial outcome measures. The iLibrary reports (a) number of items, (b) completion time, (c) readability for diverse populations, (d) cost or copyright barriers to use, (e) method of administration, (f) assessor training burden, and (g) feasibility of data capture and interpretation in routine care; a summary of pragmatic characteristics of each outcome measure (high, moderate, low); items or descriptions of items; and links to primary citations regarding development or psychometric properties. RESULTS: We included 140 outcome measures in the iLibrary: 66 administrative (100% were pragmatic) and 74 clinical (52% were pragmatic). The most commonly addressed outcome domains from administrative assessments included physical function, quality of care or communication concerns, and psychological symptoms or distress behaviors. The most commonly addressed outcome domains from clinical assessments were psychological symptoms or distress behaviors, physical function, cognitive function, and health-related quality of life. CONCLUSIONS: Pragmatic outcome measures are brief, meaningful to diverse populations, easily scored and interpreted by clinicians, and available in electronic format for analysis. The iLibrary can facilitate the selection of measures for a wide range of outcomes relevant to people with ADRD and their care partners.

Characteristics of health care interventions in affordable senior housing: A scoping review.

AIMS: Older adults in affordable senior housing often experience chronic illness and unmet health care needs. This review describes studies reporting the characteristics and primary outcomes of health care interventions for older adults living in affordable senior housing. DESIGN: A scoping review METHODS: After a systematic search in three databases, a team of investigators screened 1,284 titles and abstracts and selected 31 records with reports on 28 studies for review. Narrative synthesis was used to describe studies of interventions in senior housing and primary outcomes. RESULTS: Studies typically used observational designs and added clinical staff, such as nurses and social workers, to provide health care interventions in groups (n = 15) or with individuals (n = 13). Outcomes were classified in four groups: wellness, symptom management, health care use, and physical function. A subset of 23 studies (82.1%) reported effective interventions. IMPACT: Findings identify innovative interventions to promote health in affordable senior housing.

Posttraumatic Stress Symptom Trajectories in Family Caregivers of Patients With Acute Cardiorespiratory Failure.

Importance: Overall, 1 in 3 family caregivers of patients who require intensive care unit (ICU) admission will experience significant posttraumatic stress symptoms (PTSSs), but little is known about how PTSSs evolve over time. Measuring PTSS trajectories could facilitate the development of targeted interventions to improve mental health outcomes for family caregivers of critically ill patients. Objective: To measure 6-month PTSS trajectories among caregivers of patients with acute cardiorespiratory failure. Design, Setting, and Participants: This prospective cohort study was conducted in the medical ICU of a large academic medical center among adult patients requiring (1) vasopressors for shock, (2) high-flow nasal cannula, (3) noninvasive positive pressure ventilation, or (4) invasive mechanical ventilation. Each patient was enrolled along with their primary caregiver, ie, the unpaid individual who provided the most physical, emotional, or financial support prior to ICU admission. Main Outcomes and Measures: Family caregiver PTSSs were assessed using the Impact of Events Scale-Revised within 48 hours of ICU admission, following ICU discharge, and 3 and 6 months after enrollment. Latent class growth analysis was used to measure PTSS trajectories. Preselected patient and caregiver characteristics measured at ICU admission were analyzed for association with trajectory membership. Six-month patient and caregiver outcomes were analyzed by caregiver trajectory. Results: Overall, 95 family caregivers were enrolled and provided baseline data; mean (SD) age was 54.2 (13.6) years, 72 (76%) were women, 22 (23%) were Black individuals, and 70 (74%) were White individuals. Three trajectories were identified: persistently low (51 caregivers [54%]), resolving (29 [31%]), and chronic (15 [16%]). Low caregiver resilience, prior caregiver trauma, high patient severity of illness, and good patient premorbid functional status were associated with the chronic trajectory. Caregivers with the chronic PTSS trajectory had worse 6-month health-related quality of life (mean [SD] total 36-item Short Form Survey score, persistently low trajectory: 104.7 [11.3]; resolving trajectory: 101.7 [10.4]; chronic trajectory: 84.0 [14.4]; P < .001) and reduced effectiveness at work (mean [SD] perceived effectiveness at work score, persistently low trajectory: 86.0 [24.2]; resolving trajectory: 59.1 [32.7]; chronic trajectory: 72.3 [18.4]; P = .009). Conclusions and Relevance: In this study, 3 distinct PTSS trajectories among ICU family caregivers were observed, with 16% of caregivers experiencing chronic PTSSs over the subsequent 6 months. Family caregivers with persistent PTSS had lower resilience, prior trauma, higher patient severity of illness, and higher baseline patient functional status compared with family caregivers with persistently low PTSS, with adverse effects on quality of life and work. Identifying these caregivers is an essential first step to develop interventions tailored to those with the greatest need for support.

Identifying unmet needs of older adults transitioning from home health care to independence at home: A qualitative study.

Health care practices to prepare older adults and their family caregivers for transitions from home health care (HHC) to independence at home are rarely studied. The objective of this multiple case study was to describe HHC patient and clinician perceptions of unmet needs after HHC discharge and recommendations to address them in future research. In this qualitative study, data were collected using chart-reviews and semi-structured interviews with paired patients (or caregivers as proxy) and HHC clinicians (N=17 pairs). We identified three themes: (1) low patient and caregiver engagement in care planning increased risk for preventable health events after HHC discharge, (2) limited continuity of care restricted patient and caregiver access to community-based services, and (3) gaps in patient and caregiver education influenced independent care of chronic illnesses after discharge. Findings suggest opportunities to improve care practices to prepare older adults and their caregivers for transitions from HHC to independence at home.

Comfort First: Development and pilot testing of a web-based video training to disseminate Comfort Matters dementia care.

BACKGROUND: Alzheimer's disease-related dementias (ADRD) are a leading cause of disability and death. In late-stage ADRD most people prioritize comfort, but care to achieve comfort is rare. Comfort Matters combines palliative and geriatric care practices for nursing home dementia care, but in-person training reaches few sites. To facilitate dissemination, we developed Comfort First, a web-based training toolkit with video demonstration of Comfort Matters practices. METHODS: We developed and pilot-tested Comfort First (NIA Intervention Stage 1). Stakeholder advisors representing nursing home residents, caregiver, and clinical perspectives guided development. Professional videographers filmed Comfort Matters staff to illustrate comfort-focused dementia care skills. Video training modules, supported by an implementation manual, address Understanding the Person with Dementia, Promoting Quality of Life and Comfort, Working as a Team, Responding When People with Dementia are Distressed, Addressing Pain, and Making Comfort First a Reality. We then delivered Comfort First to 3 nursing homes. Implementation and outcome evaluation assessed the number and clinically diverse roles of trained staff and post-test knowledge. RESULTS: Nursing home staff roles (n = 146) were diverse: certified nursing assistants (40%), nurses (19%), administrators (11%), activities staff (6%), therapy staff (5%) and other roles. Individual participants' knowledge scores ranged from 50-100%; however average post-test knowledge scores were high, ranging from 90% (Addressing Pain) to 99% (Promoting Quality of Life and Comfort, Making Comfort First a Reality). CONCLUSIONS: The Comfort First web-based training toolkit combines best practices in palliative care and geriatric care for ADRD, using video demonstrations to support broader dissemination of these skills. Initial evaluation demonstrates acceptability and knowledge uptake for staff in diverse clinical roles; future research should include evaluation of practice change. Consistent with the intent of its public funding, Comfort First will be widely disseminated at a minimal cost.

Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial.

BACKGROUND: Skilled nursing facility (SNF) patients and their caregivers who transition to home experience complications and frequently return to acute care. We tested the efficacy of the Connect-Home transitional care intervention on patient and caregiver preparedness for care at home, and other patient and caregiver-reported outcomes. METHODS: We used a stepped wedge, cluster-randomized trial design to test the intervention against standard discharge planning (control). The setting was six SNFs and six home health offices in one agency. Participants were 327 dyads of patients discharged from SNF to home and their caregivers; 11.1% of dyads in the control condition and 81.2% in the intervention condition were enrolled after onset of COVID-19. Patients were 63.9% female and mean age was 76.5 years. Caregivers were 73.7% female and mean age was 59.5 years. The Connect-Home intervention includes tools, training, and technical assistance to deliver transitional care in SNFs and patients' homes. Primary outcomes measured at 7 days included patient and caregiver measures of preparedness for care at home, the Care Transitions Measure-15 (patient) and the Preparedness for Caregiving Scale (caregiver). Secondary outcomes measured at 30 and 60 days included the McGill Quality of Life Questionnaire, Life Space Assessment, Zarit Caregiver Burden Scale, Distress Thermometer, and self-reported number of patient days in the ED or hospital in 30 and 60 days following SNF discharge. RESULTS: The intervention was not associated with improvement in patient or caregiver outcomes in the planned analyses. Post-hoc analyses that distinguished between pre- and post-pandemic effects suggest the intervention may be associated with increased patient preparedness for discharge and decreased number of acute care days. CONCLUSIONS: Connect-Home transitional care did not improve outcomes in the planned statistical analysis. Post-hoc findings accounting for COVID-19 impact suggest SNF transitional care has potential to increase patient preparedness and decrease return to acute care.

GEEMAEE: A SAS macro for the analysis of correlated outcomes based on GEE and finite-sample adjustments with application to cluster randomized trials.

BACKGROUND AND OBJECTIVES: Generalized estimating equations (GEE) are used to analyze correlated outcomes in marginal regression models with population-averaged interpretations of exposure effects. Limitations of popular software for GEE include: (i) user choice is restricted to a small set of within-cluster pairwise correlation (intra-class correlation; ICC) structures; and (ii) inference on ICC parameters is usually not possible because the precision of their estimates is not quantified. This is important because ICC values inform the design of cluster randomized trials. Beyond the standard GEE implementation, use of paired estimating equations (Prentice 1988) provides: (i) flexible specification of models for pairwise correlations and (ii) standard errors for ICC estimates. However, most GEEs give biased estimates of standard errors and correlations when the number of clusters is small (roughly, ≤40). Consequently, there is a need for software to provide GEE analysis with finite-sample bias-corrections. METHODS: The SAS macro GEEMAEE implements paired estimating equations to simultaneously estimate parameters in marginal mean and ICC models. It provides bias-corrected standard errors and uses matrix-adjusted estimating equations (MAEE) for bias-corrected estimation of correlations. Several built-in correlation matrix options, rarely found in software, are offered for multi-period, cluster randomized trials and similarly structured longitudinal observational data structures. Additional options include user-specified correlation structures and deletion diagnostics, namely Cooks' Distance and DBETA statistics that estimate the influence of observations, cluster-periods (when applicable) and clusters. RESULTS: GEEMAEE is illustrated for a binary and a count outcome in two stepped wedge cluster randomized trials and a binary outcome in a longitudinal study of disease surveillance. Use of MAEE resulted in larger values of correlation estimates compared to uncorrected estimating equations. Use of bias-corrected variance estimators resulted in (appropriately) larger values of standard errors compared to the usual sandwich estimators. Deletion diagnostics identified the clusters and cluster-periods having the most influence. CONCLUSIONS: The SAS macro GEEMAEE provides regression analysis for clustered or longitudinal responses, and is particularly useful when the number of clusters is small. Flexible specification and bias-corrected estimation of pairwise correlation parameters and standard errors are key features of the software to provide valid inference in real-world settings.

A general method for calculating power for GEE analysis of complete and incomplete stepped wedge cluster randomized trials.

Stepped wedge designs have uni-directional crossovers at randomly assigned time points (steps) where clusters switch from control to intervention condition. Incomplete stepped wedge designs are increasingly used in cluster randomized trials of health care interventions and have periods without data collection due to logistical, resource and patient-centered considerations. The development of sample size formulae for stepped wedge trials has primarily focused on complete designs and continuous responses. Addressing this gap, a general, fast, non-simulation based power procedure is proposed for generalized estimating equations analysis of complete and incomplete stepped wedge designs and its predicted power is compared to simulated power for binary and continuous responses. An extensive set of simulations for six and twelve clusters is based upon the Connect-Home trial with an incomplete stepped wedge design. Results show that empirical test size is well controlled using a t-test with bias-corrected sandwich variance estimator for as few as six clusters. Analytical power agrees well with a simulated power in scenarios with twelve clusters. For six clusters, analytical power is similar to simulated power with estimation using the correctly specified model-based variance estimator. To explore the impact of study design choice on power, the proposed fast GEE power method is applied to the Connect-Home trial design, four alternative incomplete stepped wedge designs and one complete design.

Adapting the Connect-Home transitional care intervention for the unique needs of people with dementia and their caregivers: A feasibility study.

AIMS: After leaving skilled nursing facilities (SNF), 20% of people with dementia (PWD) are re-hospitalized within 30 days. We assessed fidelity, acceptability, preliminary outcomes, and mechanisms of the Connect-Home ADRD transitional care intervention. DESIGN: A feasibility study of Connect-Home ADRD. METHODS: The Connect-Home intervention was adapted for dementia-specific needs. PWD and caregiver dyads in 2 SNFs received transitional care. Data sources included interviews with PWD and caregivers and a review of health records. RESULTS: 19 of 34 eligible dyads (56%) were enrolled. The intervention was feasible (components delivered for >84% of dyads) and acceptable (dyads rated it very helpful and not difficult to use). Connect-Home ADRD adaptations included in-home support to manage symptoms of dementia and unplanned events, such as transition to hospice. IMPACT: Connect-Home ADRD is feasible, acceptable, and merits future research as an intervention to reduce rapid return to acute care following SNF stays.

A Cross-Sectional, Correlational Study Comparing Individual Characteristics of Younger and Older Nursing Home Residents using Western Canadian Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0.

OBJECTIVE: To compare characteristics of nursing home (NH) residents by age categories in Western Canada. DESIGN: A cross-sectional, correlational analysis of secondary data. SETTING AND PARTICIPANTS: 89,231 residents living in Western Canada NHs in the provinces of Alberta, Manitoba, and British Columbia in 2016 and 2017. METHODS: Resident characteristics (age, sex, marital status, body mass index, medical diagnoses, cognitive function, physical function, depressive symptoms) came from the Resident Assessment Instrument-Minimum Data Set 2.0 and were analyzed using chi-square, analysis of variance, and post hoc pairwise tests. Human developmental stage age categories were used to create 5 age groups: 18-34, 35-50, 51-64, 65-80, and 81 years and older. RESULTS: The demographics, medical diagnoses, cognitive function, and physical function characteristics of NH residents among 5 age groups differed considerably (all P < .001). Residents aged 18-34 years were predominately male, never married, with a higher incidence of paralysis and traumatic brain injury. Residents aged 35-50 years had a higher incidence of stroke and multiple sclerosis, and residents aged 51-64 years mainly were morbidly obese and more prone to depression. Residents aged 65-80 years were predominately married and more prone to diabetes, and residents aged 81 years and older were predominately widowed, with a higher incidence of dementia compared with others. CONCLUSIONS AND IMPLICATIONS: Findings describe the uniqueness of younger NH age groups and indicate that the youngest NH residents often have the severe disability and a modest support system (as defined by partnered status) compared to older residents in NHs. Future studies must analyze longitudinal data that track the growth of, and changes in, residents' health and functional status.

Unique Care Needs of People with Dementia and Their Caregivers during Transitions from Skilled Nursing Facilities to Home and Assisted Living: A Qualitative Study.

OBJECTIVES: The purpose of the study was to describe unique care needs of people with dementia (PWD) and their caregivers during transitions from skilled nursing facilities (SNF) to home. DESIGN: A qualitative study using focus groups, semistructured interviews, and descriptive qualitative analysis. SETTING AND PARTICIPANTS: The study was set in one state, in 4 SNFs where staff had experience using a standardized transitional care protocol. The sample included 22 SNF staff, 4 home health nurses, 10 older adults with dementia, and their 10 family caregivers of whom 39 participated in focus groups and/or interviews. METHODS: Data collection included 4 focus groups with SNF staff and semistructured interviews with home health nurses, SNF staff, PWD, and their family caregivers. Standardized focus group and interview guides were used to elicit participant perceptions of transitional care. We used the framework analytic approach to qualitative analysis. A steering committee participated in interpretation of findings. RESULTS: Participants described 4 unique care needs: (1) PWD and caregivers may not be ready to fully engage in dementia care planning while in the SNF, (2) caregivers are not prepared to manage dementia symptoms at home, (3) SNF staff have difficulty connecting PWD and caregivers to community supports, and (4) caregivers receive little support to address their own needs. CONCLUSIONS AND IMPLICATIONS: Based on findings, recommendations are offered for adapting transitional care to address the needs of PWD and their caregivers. Further research is needed (1) to confirm these findings in larger, more diverse samples and (2) to adapt and test interventions to support successful community discharge of PWD and their caregivers.

Perceptions of ACT Team Members on the Implementation of Physical Health Services: A Qualitative Study.

BACKGROUND: Adults with severe mental illnesses have mortality rates 2.5 to 3 times higher than the general population, largely due to medical illnesses. Those with the most profound mental illnesses are served by assertive community treatment (ACT) teams that provide intensive mental health care; however, there are no clearly established models to integrate physical health treatment into ACT and this is a critical gap in the literature. AIMS: To describe perceptions of ACT team members regarding services provided for their clients to treat physical health, how those services can be improved, and what implementation strategies would likely be needed to promote uptake and sustainability of those services on ACT teams. METHOD: Qualitative interviews were conducted via Zoom using a semistructured interview guide with 19 employees from three ACT teams in a southeastern state. Interview transcripts were analyzed, using manifest content analysis, a form of qualitative analysis, to identify key themes in the interview transcripts. RESULTS: ACT team members described limited physical health services for their clients. They reported (1) system-level barriers to improving physical health care, such as inadequate tools and training; and (2) patient-level barriers, such as limited awareness of physical care needs. ACT team members reported the need for additional medical staff and strengthened relationships with primary care providers. They also recommended changes in policy, education, and quality monitoring to implement new physical health care services. CONCLUSIONS: Findings suggest intervention components and implementation strategies for improving physical health care of ACT consumers.

Quality improvement studies in nursing homes: a scoping review.

BACKGROUND: Quality improvement (QI) is used in nursing homes (NH) to implement and sustain improvements in patient outcomes. Little is known about how QI strategies are used in NHs. This lack of information is a barrier to replicating successful strategies. Guided by the Framework for Implementation Research, the purpose of this study was to map-out the use, evaluation, and reporting of QI strategies in NHs. METHODS: This scoping review was completed to identify reports published between July 2003 through February 2019. Two reviewers screened articles and included those with (1) the term "quality improvement" to describe their methods, or reported use of a QI model (e.g., Six Sigma) or strategy (e.g., process mapping) (2), findings related to impact on service and/or resident outcomes, and (3) two or more NHs included. Reviewers extracted data on study design, setting, population, problem, solution to address problem, QI strategies, and outcomes (implementation, service, and resident). Vote counting and narrative synthesis were used to describe the use of QI strategies, implementation outcomes, and service and/or resident outcomes. RESULTS: Of 2302 articles identified, the full text of 77 articles reporting on 59 studies were included. Studies focused on 23 clinical problems, most commonly pressure ulcers, falls, and pain. Studies used an average of 6 to 7 QI strategies. The rate that strategies were used varied substantially, e.g., the rate of in-person training (55%) was more than twice the rate of plan-do-study-act cycles (20%). On average, studies assessed two implementation outcomes; the rate these outcomes were used varied widely, with 37% reporting on staff perceptions (e.g., feasibility) of solutions or QI strategies vs. 8% reporting on fidelity and sustainment. Most studies (n = 49) reported service outcomes and over half (n = 34) reported resident outcomes. In studies with statistical tests of improvement, service outcomes improved more often than resident outcomes. CONCLUSIONS: This study maps-out the scope of published, peer-reviewed studies of QI in NHs. The findings suggest preliminary guidance for future studies designed to promote the replication and synthesis of promising solutions. The findings also suggest strategies to refine procedures for more effective improvement work in NHs.

Supporting the Dynamic Careers of Licensed Practical Nurses: A Strategy to Bolster the Long-Term Care Nurse Workforce.

As the U.S. population ages and the demand for long-term care increases, an insufficient number of licensed practical nurses (LPNs) is expected in the nursing workforce. Understanding the characteristics of LPN participation in the workforce is essential to address this challenge. Drawing on the theory of boundaryless careers, the authors examined longitudinal employment data from LPNs in North Carolina and described patterns in LPN licensure and career transitions. Two career patterns were identified: (a) the continuous career, in which LPNs were licensed in 75% or more of the years they were eligible to be licensed and (b) the intermittent career, in which lapses in licensure occurred. Findings indicated that LPNs who made job transitions were more likely to demonstrate continuous careers, as were Black LPNs. These findings suggest the importance of organizational support for LPN career transitions and support for diversity in the LPN workforce.

Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative.

Proctor's Framework for Implementation Research describes the role of implementation strategies and outcomes in the pathway from evidence-based interventions to service and client outcomes. This report describes the evaluation of a learning collaborative to implement a transitional care intervention in skilled nursing facilities (SNF). The collaborative protocol included implementation strategies to promote uptake of a transitional care intervention in SNFs. Using RE-AIM to evaluate outcomes, the main findings were intervention reach to 550 SNF patients, adoption in three of four SNFs that expressed interest in participation, and high fidelity to the implementation strategies. Fidelity to the transitional care intervention was moderate to high; SNF staff provided the five key components of the transitional care intervention for 64-93% of eligible patients. The evaluation was completed during the COVID-19 pandemic, which suggests the protocol was valued by staff and feasible to use amid serious internal and external challenges.