A Strategy for Identifying and Disseminating Best Practice Innovations in the Care of Patients with Multiple Chronic Conditions or End-of-Life Care Needs.

Patients with multiple chronic conditions and those with end-of-life care needs experience high health care costs and needs for skilled coordination and well-trained staff. Focusing on these populations presents an opportunity to improve the patient experience toward the goal of more patient-centered care and reduced costs. Although innovative programs that provide better care to these patient populations have been developed, these innovations are often localized and not actively disseminated to other settings. This paper describes a quality-improvement project aimed at developing a process to identify best practices implemented in community-based clinical settings, develop a platform to share and disseminate these best practices, and facilitate the adoption of successful practices across other similar settings. The facilitation process involved structured coaching by clinicians and researchers experienced with practice change and quality improvement. The coaching component ensured that implementation teams receive guidance in the planning and adoption process, stay on track with implementation, and have access to timely support in addressing unanticipated barriers.

Implementing toileting trials in nursing homes: evaluation of a dissemination strategy.

OBJECTIVES: This study sought to improve incontinence care in nursing homes (NHs) by administering and evaluating a webinar course that provided extended instruction to help NHs implement toileting trials in accordance with recommended procedures. Of particular interest was: 1) whether the course design would prompt NH staffs to implement the recommended protocol, and 2) whether participants preferred this course design to other models. DESIGN: The study collected descriptive evaluation data. SETTING: The setting was comprised of seven NHs. PARTICIPANTS: Participants were staff members, typically nurses, from enrolled NHs who attended at least three of the six webinars that comprised the course. MEASURES: Data was collected using a course evaluation and implementation survey. RESULTS: Staff in the participating nursing homes attended an average of 4.85 webinars, with an average of nine staff members attending each webinar (range: 3-20). Twelve of 16 responding participants said they preferred the webinar course to other course designs. All respondents said they would recommend the course and take a similar course again. All facilities submitted some evidence that staff providers had completed implementation assignments. Most facilities reported plans to sustain use of the recommended protocol. CONCLUSION: This study found limited evidence that the webinar course prompts NHs to implement a recommended toileting trial protocol and is preferred to other training program designs.

Charles bonnet syndrome: treating nonpsychiatric hallucinations.

Charles Bonnet syndrome (CBS) is characterized by recurrent or persistent complex visual hallucinations that occur in visually impaired individuals with intact cognition and no evidence of psychiatric illness. Patients usually retain insight into the unreal nature of their hallucinations.3,4 CBS is often misdiagnosed, and predominantly affects elderly patients with vision changes (e.g., age-related macular degeneration, glaucoma, and cataract). While many require only the assurance of the benign nature of the hallucinations, nonpharmacological and pharmacological interventions have been reported to be useful in the treatment of CBS. This case involves an 83-year-old female, with a two-year history of CBS, who presented to the clinic with worsening visual hallucinations over the past few months. She was starting to lose insight into her hallucinations secondary to her new diagnosis of dementia. Several pharmacological agents were explored to determine the most appropriate choice for our patient. Ultimately, this patient was started on donepezil (reported to be successful in a CBS case report), which helped improve her cognitive function. At future follow-up visits, her hallucinations improved and her cognitive function stabilized. Pharmacists should be aware of CBS and its treatment options to properly assist physicians in the medication-selection process to alleviate distress experienced by patients with CBS. In patients who may benefit from pharmacological treatment, physicians should weigh the risks and benefits of the different treatment options. Donepezil can be a favorable option in CBS patients with Alzheimer's type dementia.

The Impact of a Primary Care Telepsychiatry Program on Outcomes of Managed Care Older Adults.

OBJECTIVE: The goal of this study was to assess the outcomes of a primary-based telepsychiatry intervention program for older managed care enrollees with depression/anxiety and with limited access to in-person psychiatric care. DESIGN: A pre-post design was used to examine service use (n = 218) and severity of depression (n = 204). Enrollment, claims, and depression and anxiety score data were obtained from the medical group. The implementation process and self-reported outcomes were examined. SETTING AND PARTICIPANTS: The program was funded by the Senior Care Action Network (SCAN) group and implemented by a large medical group serving older adults who were identified as needing outpatient psychiatric care, including those with psychiatric hospitalizations, depression/anxiety disorders, comorbid substance use disorders, or other multiple comorbidities. METHODS: Poisson regressions were used to examine changes in predicted rates of outpatient services, emergency department visits, and hospitalizations up to 24 months prior and 24 months following the first telepsychiatry visit. Changes in predicted severity of depression up to 2 quarters prior and 3 quarters following the first telepsychiatry visit were examined. RESULTS: The number of outpatient services declined significantly by 0.24 per patient per 6-month time frame following the first telepsychiatry visit. The number of emergency department visits and hospitalizations also declined after the first visit (0.07 and 0.03 per patient per 6-month time frame, respectively). Depression severity scores also declined in the quarters following the first visit (1.52). The medical group reported improvements in both wait time for appointments and no-show rates with the integration of telepsychiatry in primary care. CONCLUSIONS AND IMPLICATIONS: The telepsychiatry program lowered service use, depression severity, and increased better access to psychiatry care. The findings highlight the potential benefits of sustaining and expanding the telepsychiatry program by SCAN and other plans facing a limited supply of psychiatrists.

Team-Based Interprofessional Competency Training for Dementia Screening and Management.

As many as 50% of people satisfying diagnostic criteria for dementia are undiagnosed. A team-based training program for dementia screening and management was developed targeting four professions (medicine, nursing, pharmacy, social work) whose scope of practice involves dementia care. An interprofessional group of 10 faculty members was trained to facilitate four interactive competency stations on dementia screening, differential diagnoses, dementia management and team care planning, and screening for and managing caregiver stress. Registrants were organized into teams of five members, with at least one member of each profession per team. The teams rotated through all stations, completing assigned tasks through interprofessional collaboration. A total of 117 professionals (51 physicians, 11 nurses, 20 pharmacists, 24 social workers, 11 others) successfully completed the program. Change scores showed significant improvements in overall competence in dementia assessment and intervention (very low = 1; very high = 5; average change 1.12, P < .001), awareness of importance of dementia screening (average change 0.85, P < .001), and confidence in managing medication (average change 0.86, P < .001). Eighty-seven participants (82.9%) reported feeling confident or very confident using the dementia toolkit at their home institution. In a survey administered 3 months after the session, 48 respondents reported that they had changed their approach to administering the Mini-Cog test (78%), differential diagnosis (49%), assessment of caregiver stress (74%), and accessing community support and services (69%). In conclusion, team-based interprofessional competency training is a team teaching model that can be used to enhance competency in dementia screening and management in medical, nursing, pharmacy, and social work practitioners.

A standardized quality assessment system to evaluate pain detection and management in the nursing home.

CONTEXT: Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain. OBJECTIVE: Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain. DESIGN: Descriptive. SETTING: Thirty nursing homes (NHs). PARTICIPANTS: Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator. MEASUREMENTS: Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware. RESULTS: Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview. CONCLUSIONS: Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.

Assessing the Usability of Web-Based Alcohol Education for Older Adults: A Feasibility Study.

BACKGROUND: Older adults can experience unfavorable health effects from drinking at relatively low consumption levels because of age-related physiological changes and alcohol's potentially adverse interactions with declining health, increased medication-use and diminishing functional status. At the same time, alcohol use in older adults may be protective against heart disease, stroke, and other disorders associated with aging. We developed "A Toast to Health in Later Life! Wise Drinking as We Age," a web-based educational intervention to teach older adults to balance drinking risks and benefits. OBJECTIVE: To examine the intervention's feasibility in a sample of community-dwelling current drinkers ≥55 years of age and examine its effects on their quantity and frequency of alcohol use, adherence to standard drinking guidelines, and alcohol-related risks. METHODS: Participants were recruited in person, by mail and by telephone between September and October 2014 from a community-based social services organization serving Los Angeles County. Once enrolled, participants were randomly assigned to the intervention or to a control group. The conceptual frameworks for the intervention were the Health Belief Model, models of adult learning, and the US Department of Health and Human Services guidelines for designing easy-to-use websites. The intervention's content focuses on the relationship between drinking and its effects on older adults' medical conditions, use of medications, and ability to perform daily activities. It also addresses quantity and frequency of alcohol use, drinking and driving and binge drinking. The control group did not receive any special intervention. Data on alcohol use and risks for both groups came from the online version of the Alcohol-Related Problems Survey and were collected at baseline and four weeks later. Data on usability were collected online from the intervention group immediately after it completed its review of the website. RESULTS: The 49 intervention and 47 control participants did not differ at baseline in age, ethnicity, medication use, medical conditions, or alcohol use and both groups were mostly female, college-educated, and in good health. Of the intervention participants, 94% (46/49) had little or no difficulty using the website, with 67% (33/49) reporting that they will change the way they think about drinking because of their exposure to the education. At the 4-week follow-up, the intervention group reported drinking less (P=.02). No changes between groups were found in quantity and frequency, adherence to recommended guidelines, or risk status. CONCLUSIONS: Community-dwelling older adults are receptive to online alcohol education. To be most effective, the education should be included as a component of a larger effort consisting of screening and counseling preferably in a health care setting.

Improving the quality of nursing home care and medical-record accuracy with direct observational technologies.

Nursing home medical-record documentation of daily-care occurrence may be inaccurate, and information is not documented about important quality-of-life domains. The inadequacy of medical record data creates a barrier to improving care quality, because it supports an illusion of care consistent with regulations, which reduces the motivation and ability of providers to identify areas for improvement. Observational protocols designed for use by survey and quality-assurance staff can provide the independent information necessary for improving both medical record accuracy and residents' quality of life. Unfortunately, observational protocols currently used in survey and quality-assurance activities are not designed in a manner that is consistent with the scientific principles that guide observational measurement. The purpose of this article is to describe the steps to develop a standardized and scientifically defensible observational system to assess nursing home care quality.

The effect of megestrol acetate on oral food and fluid intake in nursing home residents: a pilot study.

OBJECTIVES: The objective of this study was to evaluate the effect of megestrol acetate (Megace OS; Bristol-Myers Squibb, Princeton, NJ) on the oral food and fluid intake of nursing home (NH) residents under two conditions: usual NH care and optimal mealtime feeding assistance. DESIGN AND SETTING: We conducted a prospective, preliminary trial in four NHs. PARTICIPANTS: Participants (n = 17) were recruited from a larger study designed to assess nutritional care quality. Eligibility for the Megace OS trial required participants to consistently eat less than 75% of most meals under both usual NH care and optimal feeding assistance conditions at baseline. INTERVENTION: Megace OS, an oral liquid suspension of megestrol acetate, was given daily in a 400-mg dose for 63 days. MEASUREMENTS: Each participant's oral food and fluid intake was monitored weekly for 1 day (three meals) during which research staff conducted direct observations of usual NH care (weeks 1, 3, and 5 and day 63) or provided optimal feeding assistance (weeks 2, 4, and 6). Average total percent intake was compared from baseline across the assessment weeks of the trial under the two mealtime care conditions. RESULTS: Megace OS had a significant effect on oral food and fluid intake only under the optimal mealtime feeding assistance condition, in which average total percent eaten increased from 50% (+/-15%) at baseline to 63% (+/-14%) post-63 days of the trial. There was no change in participants' oral food and fluid intake under the usual NH care condition (average total percent intake at baseline 43% +/- 12% vs. 43% +/- 20% post-63 days). CONCLUSION: The results of this preliminary study suggest that Megace OS is not an effective nutritional intervention to increase oral intake under usual NH care conditions, which is often characterized by inadequate feeding assistance. However, Megace OS in combination with optimal mealtime feeding assistance does significantly increase oral intake in a frail NH sample at high risk for weight loss.

A standardized quality assessment system to evaluate pain detection and management in the nursing home.

CONTEXT: Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain. OBJECTIVE: Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain. DESIGN: Descriptive. SETTING: Thirty nursing homes (NHs). PARTICIPANTS: Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator. MEASUREMENTS: Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware. RESULTS: Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview. CONCLUSIONS: Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.

A Practice Improvement Education Program Using a Mentored Approach to Improve Nursing Facility Depression Care-Preliminary Data.

Depression is common in nursing facility residents. Depression data obtained using the Minimum Data Set (MDS) 3.0 offer opportunities for improving diagnostic accuracy and care quality. How best to integrate MDS 3.0 and other data into quality improvement (QI) activity is untested. The objective was to increase nursing home (NH) capability in using QI processes and to improve depression assessment and management through focused mentorship and team building. This was a 6-month intervention with five components: facilitated collection of MDS 3.0 nine-item Patient Health Questionnaire (PHQ-9) and medication data for diagnostic interpretation; education and modeling on QI approaches, team building, and nonpharmacological depression care; mentored team meetings; educational webinars; and technical assistance. PHQ-9 and medication data were collected at baseline and 6 and 9 months. Progress was measured using team participation measures, attitude and care process self-appraisal, mentor assessments, and resident depression outcomes. Five NHs established interprofessional teams that included nursing (44.1%), social work (20.6%), physicians (8.8%), and other disciplines (26.5%). Members participated in 61% of eight offered educational meetings (three onsite mentored team meetings and five webinars). Competency self-ratings improved on four depression care measures (P = .05 to <.001). Mentors observed improvement in team process and enthusiasm during team meetings. For 336 residents with PHQ-9 and medication data, depression scores did not change while medication use declined, from 37.2% of residents at baseline to 31.0% at 9 months (P < .001). This structured mentoring program improved care processes, achieved medication reductions, and was well received. Application to other NH-prevalent syndromes is possible.

The minimum data set weight-loss quality indicator: does it reflect differences in care processes related to weight loss?

OBJECTIVES: To determine whether nursing homes (NHs) that score differently on prevalence of weight loss, according to a Minimum Data Set (MDS) quality indicator, also provide different processes of care related to weight loss. DESIGN: Cross-sectional. SETTING: Sixteen skilled nursing facilities: 11 NHs in the lower (25th percentile-low prevalence) quartile and five NHs in the upper (75th percentile-high prevalence) quartile on the MDS weight-loss quality indicator. PARTICIPANTS: Four hundred long-term residents. MEASUREMENTS: Sixteen care processes related to weight loss were defined and operationalized into clinical indicators. Trained research staff conducted measurement of NH staff implementation of each care process during assessments on three consecutive 12-hour days (7 a.m. to 7 p.m.), which included direct observations during meals, resident interviews, and medical record abstraction using standardized protocols. RESULTS: The prevalence of weight loss was significantly higher in the participants in the upper quartile NHs than in participants in the lower quartile NHs based on MDS and monthly weight data documented in the medical record. NHs with a higher prevalence of weight loss had a significantly larger proportion of residents with risk factors for weight loss, namely low oral food and fluid intake. There were few significant differences on care process measures between low- and high-weight-loss NHs. Staff in low-weight-loss NHs consistently provided verbal prompting and social interaction during meals to a greater proportion of residents, including those most at risk for weight loss. CONCLUSION: The MDS weight-loss quality indicator reflects differences in the prevalence of weight loss between NHs. NHs with a lower prevalence of weight loss have fewer residents at risk for weight loss and staff who provide verbal prompting and social interaction to more residents during meals, but the adequacy and quality of feeding assistance care needs improvement in all NHs.

Does an exercise and incontinence intervention save healthcare costs in a nursing home population?

OBJECTIVES: To determine whether an intervention that combines low-intensity exercise and incontinence care offsets some of its costs by reducing the incidence of selected health conditions in nursing home residents. DESIGN: Randomized, controlled trial with the incidence and costs of selected, acute conditions compared between a 6-month baseline and an 8-month intervention phase. SETTING: Four nursing homes. PARTICIPANTS: One hundred ninety incontinent, long-stay nursing home residents. INTERVENTION: Low-intensity, functionally oriented exercise and incontinence care were provided every 2 hours from 8:00 a.m. to 4:00 p.m. for 5 days a week for 8 months. MEASUREMENTS: Predefined acute conditions hypothesized to be related to physical inactivity, incontinence, or immobility were abstracted from residents' medical records by blinded observers during a 6-month baseline period and throughout the 8-month intervention. Conditions included those in the dermatological, genitourinary, gastrointestinal, respiratory and cardiovascular systems; falls; pain; and psychiatric and nutritional disturbances. Costs were determined using Current Procedural Terminology Center and Medicare allowable cost reimbursement at a rate of 80%. RESULTS: The intervention group had significantly better functional outcomes than the control group (strength, mobility endurance, urinary and fecal incontinence) and a reduction of 10% in the incidence of the acute conditions, which was not significant. There were no significant differences between groups in the cost of assessing and treating these acute conditions between baseline and intervention. CONCLUSION: The intervention, which is consistent with federal and clinical practice guidelines, significantly improved functional outcomes but did not reduce the incidence and costs of selected acute health conditions. The cost of implementing these labor-intensive interventions for frail nursing home residents will have to be justified based on functional and quality-of-life outcomes and are unlikely to be offset by savings in medical care costs in this population.

The minimum data set pressure ulcer indicator: does it reflect differences in care processes related to pressure ulcer prevention and treatment in nursing homes?

OBJECTIVES: To determine whether nursing homes (NHs) that score in the extreme quartiles of pressure ulcer (PU) prevalence as reported on the Minimum Data Set (MDS) PU quality indicator provide different PU care. DESIGN: Descriptive, cohort. SETTING: Sixteen NHs. PARTICIPANTS: Three hundred twenty-nine NH residents at risk for PU development as determined by the PU Resident Assessment Protocol of the MDS. MEASUREMENTS: : Sixteen care process quality indicators (10 specific to PU care processes, five related to nutrition, and one related to incontinence management) were scored using medical record data, direct human observation, interviews, and data from wireless thigh movement monitors. RESULTS: There were no differences between homes with low- and high-PU prevalence rates reported on the MDS PU quality indicator on most care processes. NHs with high PU prevalence rates used pressure-reduction surfaces more frequently and were better at documentation of four wound characteristics when PUs were present. No measure of PU care processes was better in low-PU NHs. Neither low- nor high-PU prevalence NHs routinely repositioned residents every 2 hours, even though 2-hour repositioning was documented in the medical record for nearly all residents. CONCLUSION: The assumption that homes with fewer PUs and thus low PU prevalence according to the MDS PU quality indicator are providing better PU care was not supported in this sample. NHs that scored low on the MDS PU quality indicator did not provide significantly better care than NHs that scored high. All NHs could improve PU prevention, as evidenced by the poor performance on prevention care processes by low- and high-PU NHs. The MDS PU quality indicator is not a useful measure of the quality of PU care in NHs and can be misleading if not presented with an explanation of the meaning of the indicator.

A standardized quality assessment system to evaluate incontinence care in the nursing home.

OBJECTIVES: To demonstrate the reliability and feasibility of a standardized protocol to assess and score urinary incontinence care in nursing homes. DESIGN: Descriptive. SETTING: Eighteen nursing homes (NHs). PARTICIPANTS: Four hundred twenty-six incontinent residents. MEASUREMENTS: Resident interview data were used to score three quality indicators, and usable data were retrieved from 117 (27%) of 426 incontinent residents in 18 homes who were selected for interview based on evidence that they could accurately describe the care they received. Medical record data were used to score six quality indicators for a subset of 58 participants in five homes. RESULTS: Zero to 98% of the participants were scored as receiving care consistent with the intent of the indicator across the nine indicators. All NHs failed to provide chart documentation of an assessment to determine an incontinent resident's appropriateness for a scheduled toileting program (0% passed). The absence of an assessment to determine a resident's potential responsiveness to toileting assistance may explain why 103 incontinent residents who were documented on the Minimum Data Set as being on a scheduled toileting program reported that they received the same number of toileting assists per day (1.3) as the group of 114 incontinent residents who were not on a scheduled toileting program (1.0). The received toileting assistance frequencies reported by both groups were too low to maintain continence. CONCLUSION: The standardized quality assessment system generated scores for nine incontinence quality indicators with good interrater reliability and provided explicit scoring rules that can facilitate replication. The focus of the indicators on care processes that are under the control of NH staff make the protocol useful for external survey and internal quality improvement purposes.

Prescription analgesic and antidepressant utilization and cost among elderly Medicaid beneficiaries before and after nursing home admission.

OBJECTIVES: The objectives of this study were to describe changes in prescription analgesic and antidepressant medications and to track the costs associated with these medication changes when elderly Medicaid beneficiaries move from the community to a nursing home setting. DESIGN: Retrospective analysis of Medicaid long-term care and drugs claims data for fiscal year 2000 from three different states. SETTING: Long-term care facilities in three different states. PARTICIPANTS: We studied 1321 elderly Medicaid beneficiaries newly admitted to a nursing home during the study period. MEASUREMENTS: Pain medications were grouped into four different categories and all antidepressants were grouped into one category. For each medication category, we obtained the number of unique patients for whom it was prescribed, the number of days it was prescribed, and the amount paid by Medicaid. We then calculated the percentage of subjects prescribed and the amount paid per day for each medication class before and after nursing home admission. RESULTS: Except for skeletal muscle relaxants, 21% to 39% of beneficiaries already had claims linked to each medication class while still living in the community. After nursing home admission, the percentage of beneficiaries exposed to each medication class increased by 2% to 33%. Cost per day of therapy increased by 10% to 83%. There was significant variation among the states in utilization and cost per day of therapy. CONCLUSIONS: We draw three major conclusions: (1) community-dwelling elderly Medicaid beneficiaries in this study use more prescription analgesics and antidepressants than community-dwelling elders in prior studies; (2) there is a significant increase in medication utilization and cost on nursing home admission; and (3) significant variability in medication use and cost exists among the three states examined. Further investigation to elucidate the reasons for these differences could assist legislators in formulating sound public policy to contain Medicaid expenditures without sacrificing patient care.

The effect of megestrol acetate on oral food and fluid intake in nursing home residents: a pilot study.

OBJECTIVES: The objective of this study was to evaluate the effect of megestrol acetate (Megace OS; Bristol-Myers Squibb, Princeton, NJ) on the oral food and fluid intake of nursing home (NH) residents under two conditions: usual NH care and optimal mealtime feeding assistance. DESIGN AND SETTING: We conducted a prospective, preliminary trial in four NHs. PARTICIPANTS: Participants (n = 17) were recruited from a larger study designed to assess nutritional care quality. Eligibility for the Megace OS trial required participants to consistently eat less than 75% of most meals under both usual NH care and optimal feeding assistance conditions at baseline. INTERVENTION: Megace OS, an oral liquid suspension of megestrol acetate, was given daily in a 400-mg dose for 63 days. MEASUREMENTS: Each participant's oral food and fluid intake was monitored weekly for 1 day (three meals) during which research staff conducted direct observations of usual NH care (weeks 1, 3, and 5 and day 63) or provided optimal feeding assistance (weeks 2, 4, and 6). Average total percent intake was compared from baseline across the assessment weeks of the trial under the two mealtime care conditions. RESULTS: Megace OS had a significant effect on oral food and fluid intake only under the optimal mealtime feeding assistance condition, in which average total percent eaten increased from 50% (+/- 15%) at baseline to 63% (+/- 14%) post-63 days of the trial. There was no change in participants' oral food and fluid intake under the usual NH care condition (average total percent intake at baseline 43% +/- 12% vs. 43% +/- 20% post-63 days). CONCLUSION: The results of this preliminary study suggest that Megace OS is not an effective nutritional intervention to increase oral intake under usual NH care conditions, which is often characterized by inadequate feeding assistance. However, Megace OS in combination with optimal mealtime feeding assistance does significantly increase oral intake in a frail NH sample at high risk for weight loss.

Incidence and costs of acute medical conditions in long-stay incontinent nursing home residents.

OBJECTIVES: To determine the incidence of acute medical conditions in incontinent nursing home residents, and associated costs of diagnostic testing and treatment DESIGN: Prospective, cohort study. SETTING: Three community nursing homes. PARTICIPANTS: 161 long-stay residents with urinary incontinence in (mean age 86 years, 77% female, 92% white). MEASUREMENTS: Acute medical conditions were identified prospectively through medical record review based on standardized criteria. All diagnostic testing and treatment provided for these conditions were recorded, and related costs in the nursing home were assigned based on 1997-1998 Medicare and Medicaid reimbursement. RESULTS: The highest incidences of illness were for dermatological conditions (107 episodes per 1000 patient-weeks, involving 70% of subjects), respiratory illnesses (29 per 1000 patient-weeks, 47% of subjects) and gastrointestinal illnesses (24 per 1000 patient-weeks, 36% of subjects). Among episodes with an incidence of at least 5 per 1000 patient-weeks, the illness events with the highest median diagnostic testing and treatment costs per episode were pneumonia, acute bronchitis, and depression. Only 42 out of the total 1071 episodes identified resulted in a hospitalization. Significant predictors of higher illness incidence included greater baseline comorbidity and higher number of routine medications (model adjusted R-square = 0.319, P = 0.021). CONCLUSION: Acute illness is very common among incontinent nursing home residents, and is generally diagnosed and treated at the nursing home site, with variation among conditions in associated costs. Important policy implications include resource allocation (including appropriate staffing patterns), educational and quality improvement activities, and future research and guideline development for the optimal management of medical conditions in the nursing home setting.

Incidence and costs of acute medical conditions in long-stay incontinent nursing home residents.

OBJECTIVES: To determine the incidence of acute medical conditions in incontinent nursing home residents, and associated costs of diagnostic testing and treatment DESIGN: Prospective, cohort study. SETTING: Three community nursing homes. PARTICIPANTS: 161 long-stay residents with urinary incontinence in (mean age 86 years, 77% female, 92% white). MEASUREMENTS: Acute medical conditions were identified prospectively through medical record review based on standardized criteria. All diagnostic testing and treatment provided for these conditions were recorded, and related costs in the nursing home were assigned based on 1997-1998 Medicare and Medicaid reimbursement. RESULTS: The highest incidences of illness were for dermatological conditions (107 episodes per 1000 patient-weeks, involving 70% of subjects), respiratory illnesses (29 per 1000 patient-weeks, 47% of subjects) and gas-trointestinal illnesses (24 per 1000 patient-weeks, 36% of subjects). Among episodes with an incidence of at least 5 per 1000 patient-weeks, the illness events with the highest median diagnostic testing and treatment costs per episode were pneumonia, acute bronchitis, and depression. Only 42 out of the total 1071 episodes identified resulted in a hospitalization. Significant predictors of higher illness incidence included greater baseline comorbidity and higher number of routine medications (model adjusted R-square = 0.319, P = 0.021). CONCLUSION: Acute illness is very common among incontinent nursing home residents, and is generally diagnosed and treated at the nursing home site, with variation among conditions in associated costs. Important policy implications include resource allocation (including appropriate staffing patterns), educational and quality improvement activities, and future research and guideline development for the optimal management of medical conditions in the nursing home setting.