Improving medication management after a hospitalization with pharmacist home visits and electronic personal health records: an observational study.

BACKGROUND: Substantial opportunity exists to improve medication management in the period following a hospital discharge. The objective of this study was to assess and improve medication management during care transitions through pharmacist home visits and the use of an electronic personal health record (ePHR) system. METHODS: Recently discharged patients aged 50 years or older and having a chronic medical condition were offered the opportunity to meet with a pharmacist in the home setting to review medication instructions and receive a demonstration of an ePHR system. Patients agreeable to using the ePHR system were offered pharmacist support with setting up the ePHR system, having emphasis on documenting and reviewing medication regimens. Medication-related problems identified by the pharmacist during the visit were categorized according to ePHR use and by other characteristics. RESULTS: Thirty recently discharged patients with chronic disease were visited by a pharmacist over a 6-month period. The percentage of medication-related problems identified by the pharmacist was greater among those patients who agreed to use the ePHR system, as compared with patients whose visit did not include use of the ePHR (75% versus 40%, respectively; P=0.06). Differing types of medication-related problems were identified, including therapy duplications, lack of use of clinically important therapies, and patient nonadherence. CONCLUSION: For some patients, the home setting can be a suitable venue for medication review and education after discharge from hospital. Assisting patients with setting up the ePHR system may enhance pharmacists' ability to identify and resolve medication-related problems that may lead to rehospitalization.

Distance learning: a strategy for improving incontinence care in nursing homes.

PURPOSE: This article describes a distance learning model designed to help nursing homes implement incontinence management best practices. A basic premise is that translating research into practice requires both a feasible intervention and a dissemination strategy responsive to the target audience's needs. DESIGN AND METHODS: Over 8 months, nurse supervisors from 14 nursing homes in nine states learned how to implement prompted voiding during monthly 60- to 90-min teleconferences. Supervisors completed field assignments that required them to implement prompted voiding. Descriptive evaluation data were collected using a resident data form, pre- and posttraining quizzes, and a project evaluation survey. RESULTS: Nursing home staff attended an average of 6.5 teleconferences; on average, three staff members typically attended each teleconference. Eighty-nine percent of all survey respondents (N = 28) reported that they (a) would participate in a similar project and (b) would recommend the course to colleagues. Average scores on the quiz increased 16% (p < .05) from pre- to posttraining. Collectively, participating facilities assessed a total of 261 incontinent residents and reported maintaining 117 (44.8%) on prompted voiding, for an average of 10 residents per facility. IMPLICATIONS: The intervention implementation results were promising for a management strategy often described as challenging to maintain. The distance learning model worked as expected. Given its strengths and relatively few weaknesses, it appears to be a feasible, effective, and low-cost strategy for translating research into nursing home practice.

Identifying star performers: the relationship between ambitious targets and nursing home quality improvement.

Setting Targets--Achieving Results (STAR) is a Web-based tool that helps nursing home leadership select annual performance goals, or targets, for a subset of publicly reported quality measures. Previous results demonstrate that nursing homes whose staff implement STAR targets demonstrate greater improvement on the related outcomes. In this analysis, the authors hypothesized that nursing homes whose staff select the most ambitious targets (reflecting large improvement over their current performance) may be more successful in their related quality improvement efforts than homes with less-ambitious targets (reflecting lesser improvement). The authors analyzed data from 7,091 Medicare- or Medicaid-certified nursing homes that set STAR targets in 2005 or 2006 for two quality measures: the proportion of residents who were physically restrained daily and the proportion of high-risk residents with pressure ulcers. Targets were classified as ambitious or less ambitious based on the 75th and 50th rank-ordered percentiles, respectively. Improvement was calculated using four-quarter averages for baseline (the year ending when the target was set) and remeasurement (the subsequent year). The results indicate that nursing homes with ambitious targets demonstrate greater improvement than their peers selecting less-ambitious targets. With limited federal and local resources to assist providers with quality improvement, target values may be a used as a "flag" to help agencies allocate scarce resources to nursing homes committed to quality improvement efforts and with the organizational capacity to improve.

Ameliorating pain in nursing homes: a collaborative quality-improvement project.

OBJECTIVES: To evaluate a multifaceted intervention to improve pain-management processes of care and outcomes in nursing homes. DESIGN: Quasi-experimental, pretest/posttest. SETTING: Nursing homes in Rhode Island. PARTICIPANTS: Twenty-one facilities. INTERVENTION: This project used a multifaceted collaborative intervention involving audit and feedback of pain management, education, training, coaching using rapid-cycle quality-improvement techniques, and inter-nursing home collaboration. MEASUREMENTS: Pain-management processes of care and outcomes, measured using chart review and the Minimum Data Set. RESULTS: Of 21 facilities, 17 completed the project. Postintervention, nursing homes increased the use of appropriate pain assessments (3.9% vs 43.8%, P<.001), pain intensity scales (15.6% vs 73.9%, P<.001), and nonpharmacological treatments (40.5% vs 81.9%, P<.001). Prescriptions of World Health Organization Step II or Step III pain medications for residents with daily moderate or severe pain showed trends towards improvement (40.8% vs 50.6%, P=.057), but prescription of any pain medication (93.3% vs 94.6%, P=.710), change in pain medication (29.0% vs 30.1%, P=.386), and prescription of pain medications on a regularly scheduled basis (67.9% vs 69.5%, P=.370) did not. There was a 41.1% reduction in prevalence of pain (12.2% vs 7.2%, P=.032) between the pre- and postintervention time periods in the nursing homes that completed the project, whereas all the other facilities in Rhode Island (n=72) had only a 12.1% reduction (12.7% vs 11.2%, P=.286) during the same period. CONCLUSION: A multifaceted intervention improved pain-management process and outcome measures in nursing homes.

Is signed consent for influenza or pneumococcal polysaccharide vaccination required?

Each year, thousands of preventable deaths and hospitalizations result from complications of influenza and pneumococcal disease, mostly in elderly persons, despite the availability of vaccines. Obtaining signed consent prior to administering the vaccines represents an obstacle to achieving the Healthy People 2010 goals for vaccinating individuals against influenza and pneumococcal disease. Signed consent is neither legally mandated nor a guarantee that the patient (or proxy) has given informed consent. Nonetheless, many health care providers and institutions currently require signed consent before administering these vaccines. Rather, health care providers should use the Vaccine Information Sheets developed by the Centers for Disease Control and Prevention to inform patients about the risks and benefits associated with these vaccines. Requiring signed consent before administering these low-risk, high-benefit vaccines is inconsistent with the current practice of not requiring signed consent before prescribing other common treatments, eg, antibiotic treatment, whose risk levels are the same or higher.

Admission and continued-stay criteria for assisted living facilities.

As residents in assisted living facilities (ALFs) try to "age in place" but decline in health, the facilities, families, and residents must find a balance between protecting the health and safety of residents in ALFs and maintaining their desire to live independently. The assisted living industry incorporates resident autonomy into its goals, but with regard to resident health and safety, recent reports have found that ALF staff are struggling to provide adequate care for residents with increasingly complex needs. Moreover, state regulations are not consistent in obligating ALFs to prioritize adequate health care and protection for residents over resident autonomy, or vice versa. A set of admission and continued stay criteria for individuals residing in assisted living that could serve as a guideline for state regulations in addressing the balance between safety and autonomy in ALFs is recommended.

Approaches to quality improvement in nursing homes: lessons learned from the six-state pilot of CMS's Nursing Home Quality Initiative.

BACKGROUND: In November 2002, the Centers for Medicare & Medicaid Services (CMS) launched a Nursing Home Quality Initiative that included publicly reporting a set of Quality Measures for all nursing homes in the country, and providing quality improvement assistance to nursing homes nationwide. A pilot of this initiative occurred in six states for six months prior to the launch. METHODS: Review and analysis of the lessons learned from the six Quality Improvement Organizations (QIOs) that led quality improvement efforts in nursing homes from the six pilot states. RESULTS: QIOs in the six pilot states found several key outcomes of the Nursing Home Quality Initiative that help to maximize the potential of public reporting to leverage effective improvement in nursing home quality of care. First, public reporting focuses the attention of all stakeholders in the nursing home industry on achieving good quality outcomes on a defined set of measures, and creates an incentive for partnership formation. Second, publicly reported quality measures motivate nursing home providers to improve in certain key clinical areas, and in particular to seek out new ways of changing processes of care, such as engaging physicians and the medical director more directly. Third, the lessons learned by QIOs in the pilot of this Initiative indicate that certain approaches to providing quality improvement assistance are key to guiding nursing home providers' desire and enthusiasm to improve towards a using a systematic approach to quality improvement. CONCLUSION: The Nursing Home Quality Initiative has already demonstrated the potential of public reporting to foster collaboration and coordination among nursing home stakeholders and to heighten interest of nursing homes in quality improvement techniques. The lessons learned from this pilot project have implications for any organizations or individuals planning quality improvement projects in the nursing home setting.