Pain Management in Long-Term Care Communities: A Quality Improvement Initiative.

Pain is underrecognized and undertreated in the long-term care (LTC) setting. To improve the management of pain for LTC residents, the authors implemented a quality improvement (QI) initiative at one LTC facility. They conducted a needs assessment to identify areas for improvement and designed a 2-hour educational workshop for facility staff and local clinicians. Participants were asked to complete a survey before and after the workshop, which showed significant improvement in their knowledge of pain management and confidence in their ability to recognize and manage residents' pain. To measure the effectiveness of the QI initiative, the authors performed a chart review at baseline and at 3 and 8 months after the workshop and evaluated relevant indicators of adequate pain assessment and management. The post-workshop chart reviews showed significant improvement in how consistently employees documented pain characteristics (ie, location, intensity, duration) in resident charts and in their use of targeted pain assessments for residents with cognitive dysfunction. The proportion of charts that included a documented plan for pain assessment was high at baseline and remained stable throughout the study. Overall, the findings suggest a QI initiative is an effective way to improve pain care practices in the LTC setting.

Improving diabetes care and patient outcomes in skilled-care communities: successes and lessons from a quality improvement initiative.

OBJECTIVE: To improve the quality of care for residents of long term care (LTC) facilities who have diabetes by (1) improving glycemic control, (2) increasing comprehensive diabetes management, (3) reducing fragmented care, and (4) empowering patient-care teams to educate patients and families regarding this disease. DESIGN: Based on the Plan-Do-Study-Act principles of effective change, a baseline evaluation of contemporary care for residents with diabetes was conducted through focus-group interviews, a confidence survey, and chart review. Three live educational workshops provided guideline-recommended information addressing educational desires and needs of clinical staff, a tool for improving performance in key areas of need, and an opportunity for care teams to engage in dialogue about advances in diabetes with a national diabetes expert. Reassessment was performed via chart review twice at 3 and 5 months post education. Key lessons and tools for improvements were disseminated to other LTC communities through a CME-certified publication activity and follow-up teleconferences. SETTING: Two skilled-nursing LTC communities. PARTICIPANTS: Physicians, administrators, nurses, certified nursing assistants, and nutrition staff. INTERVENTION: Three live continuing education/continuing medical education-certified workshops attended by 83 health care professionals. MEASUREMENTS: Twenty-five comprehensive clinical indicators of diabetes care and overall health were assessed for all residents with a diabetes diagnosis at baseline (n = 35), 3 months (n = 40), and 5 months (n = 27) post education. RESULTS: The primary objective of improving glycemic control we reached through a statistically significant 18% reduction in the percentage of residents experiencing hypoglycemia from baseline to 3 months post education (31% at baseline, 13% at 3 months, P = .046). Low levels of hypoglycemia (11%) were maintained at 5 months post education. Positive changes in an additional 3 measures of patient health include improved daily blood glucose levels, reduced ranges of HbA1c, and improved low-density lipoprotein cholesterol concentrations. Improvements in 4 measures of clinician performance were also observed, namely comprehensive foot evaluations, referrals to specialists for foot care and eye exams, and improved use of physical activity. CONCLUSION: Diabetes care, particularly in elder adults, is complex and requires a multidisciplinary approach. Focused quality improvement activities within LTC communities offer care providers the information and tools required to make effective changes that have the ability to promote improved patient care. These efforts must be multidisciplinary and effectively engage all stakeholders.