Fall-related Injuries and Opioid Administration Among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers.

OBJECTIVES: Opioid use is associated with fall-related injuries (FRI) among older adults, especially those with dementia. We examined FRI following changes in national opioid safety initiatives over 3 regulatory periods [preinitiatives baseline (period 1): October 2012 to June 2013; post-Veteran Affairs (VA) opioid safety initiative (period 2): January 2014 to November 2015; post-VA and CDC opioid prescribing guidelines (period 3): March 2017 to September 2018] among Department of VA Community Living Center (CLC) long-stay residents with dementia. DATA: VA provided and purchased care records, Medicare claims, CLC Minimum Data Set (MDS) assessments. VA bar-code medication administration data, VA outpatient prescription refill data, and Medicare Part D data were used to capture medication from inpatient, outpatient, and Medicare sources. SETTINGS AND PARTICIPANTS: A total of 12,229 long-stay CLC residents with dementia between October 2012 and September 2018. METHODS: We applied Veteran-regulatory period level (1) generalized linear model to examine the unadjusted and adjusted trends of FRI, and (2) difference-in-difference model with propensity score weighting to examine the relationship between opioid safety initiatives and FRI in 3 regulatory periods. We applied propensity score weighting to enable the cohorts in periods 2 and 3 had similar indications for opioid administration as in period 1. RESULTS: FRI prevalence per month among CLC residents with Alzheimer disease and related dementias decreased from 3.1% in period 1 to 1.6% and 1.2% in periods 2 and 3, and the adjusted probability of FRI was 17% and 40% lower in periods 2 and 3 compared with period 1. The any, incident, and continued opioid administration were significantly associated with higher FRI, whereas the differences in FRI probabilities between opioid and nonopioid users had no significant changes over the 3 regulatory periods. CONCLUSIONS: FRI was reduced among CLC residents with Alzheimer disease and related dementias receiving care in VA CLCs over the 3 regulatory periods, but the FRI reduction was not significantly associated with opioid safety initiatives. Other interventions that potentially targeted falls are likely to have helped reduce these fall events. Future studies could examine whether opioid use reduction ultimately benefitted nursing home residents by focusing on other possible outcomes or whether such reduction only resulted in more untreated pain.

Differential Effects of an Emergency Department-to-Home Care Transitions Intervention in an Older Adult Population: A Latent Class Analysis.

BACKGROUND: Older adults frequently return to the emergency department (ED) within 30 days of a visit. High-risk patients can differentially benefit from transitional care interventions. Latent class analysis (LCA) is a model-based method used to segment the population and test intervention effects by subgroup. OBJECTIVES: We aimed to identify latent classes within an older adult population from a randomized controlled trial evaluating the effectiveness of an ED-to-home transitional care program and test whether class membership modified the intervention effect. RESEARCH DESIGN: Participants were randomized to receive the Care Transitions Intervention or usual care. Study staff collected outcomes data through medical record reviews and surveys. We performed LCA and logistic regression to evaluate the differential effects of the intervention by class membership. SUBJECTS: Participants were ED patients (age 60 y and above) discharged to a community residence. MEASURES: Indicator variables for the LCA included clinically available and patient-reported data from the initial ED visit. Our primary outcome was ED revisits within 30 days. Secondary outcomes included ED revisits within 14 days, outpatient follow-up within 7 and 30 days, and self-management behaviors. RESULTS: We interpreted 6 latent classes in this study population. Classes 1, 4, 5, and 6 showed a reduction in ED revisit rates with the intervention; classes 2 and 3 showed an increase in ED revisit rates. In class 5, we found evidence that the intervention increased outpatient follow-up within 7 and 30 days (odds ratio: 1.81, 95% CI: 1.13-2.91; odds ratio: 2.24, 95% CI: 1.25-4.03). CONCLUSIONS: Class membership modified the intervention effect. Population segmentation is an important step in evaluating a transitional care intervention.

Multimethod Process Evaluation of a Community Paramedic Delivered Care Transitions Intervention for Older Emergency Department Patients.

OBJECTIVE: We assessed fidelity of delivery and participant engagement in the implementation of a community paramedic coach-led Care Transitions Intervention (CTI) program adapted for use following emergency department (ED) visits. METHODS: The adapted CTI for ED-to-home transitions was implemented at three university-affiliated hospitals in two cities from 2016 to 2019. Participants were aged ≥60 years old and discharged from the ED within 24 hours of arrival. In the current analysis, participants had to have received the CTI. Community paramedic coaches collected data on program delivery and participant characteristics at each transition contact via inventories and assessments. Participants provided commentary on the acceptability of the adapted CTI. Using a multimethod approach, the CTI implementation was assessed quantitatively for site- and coach-level differences. Qualitatively, barriers to implementation and participant satisfaction with the CTI were thematically analyzed. RESULTS: Of the 863 patient participants, 726 (84.1%) completed their home visits. Cancellations were usually patient-generated (94.9%). Most planned follow-up visits were successfully completed (94.6%). Content on the planning for red flags and post-discharge goal setting was discussed with high rates of fidelity overall (95% and greater), while content on outpatient follow-up was lower overall (75%). Differences in service delivery between the two sites existed for the in-person visit and the first phone follow-up, but the differences narrowed as the study progressed. Participants showed a 24.6% increase in patient activation (i.e., behavioral adoption) over the 30-day study period (p < 0.001).Overall, participants reported that the program was beneficial for managing their health, the quality of coaching was high, and that the program should continue. Not all participants felt that they needed the program. Community paramedic coaches reported barriers to CTI delivery due to patient medical problems and difficulties with phone visit coordination. Coaches also noted refusal to communicate or engage with the intervention as an implementation barrier. CONCLUSIONS: Community paramedic coaches delivered the adapted CTI with high fidelity across geographically distant sites and successfully facilitated participant engagement, highlighting community paramedics as an effective resource for implementing such patient-centered interventions.

Older Adults Receiving Rehabilitation Services Are More Likely to Get Bathing and Toileting Equipment Installed.

IMPORTANCE: Adaptive equipment, such as shower grab bars and modified toilet seating, is effective but underused in the United States. To change this, a better understanding of how equipment ends up being installed is needed. We hypothesized that rehabilitation services were a major mechanism. OBJECTIVE: To examine the association between receipt of rehabilitation services and installation of adaptive equipment. DESIGN: Observational cohort of the National Health and Aging Trends Study in 2015 and 2016. SETTING: Community. PARTICIPANTS: A total of 416 community-dwelling adults age 65 yr or older who needed bathing equipment and 454 who needed toileting equipment. OUTCOMES AND MEASURES: Study outcomes were the installation of bathing or toileting equipment. The primary independent variable was the receipt of rehabilitation services between 2015 and 2016. RESULTS: Among older adults who needed equipment in 2015, 34.3% had bathing equipment and 19.2% had toileting equipment installed by 2016. In multivariate logistic regression analyses, rehabilitation services were associated with installation of bathing (odds ratio [OR] = 5.07, 95% confidence interval [CI] [2.60, 9.89]) and toileting equipment (OR = 2.67, 95% CI [1.48, 4.84]). CONCLUSIONS AND RELEVANCE: A minority of those in need have adaptive equipment installed within a year. In the current health care system, rehabilitation providers play a major role in equipment installation. What This Article Adds: Rehabilitation providers are involved in the installation of adaptive bathroom equipment among older persons who need it. Still, most in need of equipment do not have it after a year, suggesting that further work is needed to increase access to rehabilitation providers and develop other avenues for obtaining equipment.

Implementation considerations of deprescribing interventions: A scoping review.

Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.

Scalar Assessment of the Family Caregiver Activation in Transitions Tool: An Exploratory Factor Analysis.

The Family Caregiver Activation in Transitions (FCAT) tool in its current, non-scalar form is not pragmatic for clinical use as each item is scored and intended to be interpreted individually. The purpose of the current study was to create a scalar version of the FCAT to facilitate better care communications between hospital staff and family caregivers. We also assessed the scale's validity by comparing the scalar version of the measure against patient health measures. Data were collected from 463 family caregiver-patient dyads from January 2016 to July 2019. An exploratory factor analysis was performed on the 10-item FCAT, resulting in a statistically homogeneous six-item scale focused on current caregiving activation factors. The measure was then compared against patient health measures, with no significant biases found. The six-item scalar FCAT can provide hospital staff insight into the level of caregiver activation occurring in the patient's health care and help tailor care transition needs for family caregiver-patient dyads. [Journal of Gerontological Nursing, 48(12), 35-42.].

The invisible gap: Older adults' communication with health care providers about concomitant use of alcohol and medications.

The purpose of this study was to assess the impact of a new educational intervention, Communicating with your Health Care Providers, which was designed to assist older adults in communicating with their physicians and other health care providers and improving their knowledge about concomitant alcohol and medication risks. A randomized control trial was conducted in older adult centers in an urban community. Participants were assigned to either the intervention group or a control group that received traditional services. The intervention group received educational material about health, physical and other aging changes, medication use and possible adverse interactions between alcohol and medications, as well as strategies to initiate communication with physicians and other health care providers. The outcomes measured were: (1) interest in communicating with physicians and health care providers; (2) perception of the importance of communication; and (3) knowledge about concomitant alcohol and medication use. MANCOVA tests indicated that the intervention group had greater knowledge about the risks of combining alcohol with prescription medications than the control group, as well as greater interest in having health care discussions with their physicians and other health care providers. These findings may be translated into future educational programming for community centers.

Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis.

BACKGROUND: Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents. OBJECTIVES: To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents. RESEARCH DESIGN: We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors. SUBJECTS: Privately owned, free-standing NHs in the United States (N=13,260). RESULTS: Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (ß=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED. CONCLUSIONS: Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.

Is well-being prior to receiving rehabilitation services associated with postrehabilitation mental health and functioning?

OBJECTIVES: Millions of older adults receive rehabilitation services every year, which aim to restore, maintain, or limit decline in functioning. We examine whether lower reported well-being prior to receiving rehabilitation services is associated with increased odds of worsening anxiety symptoms, depressive symptoms, and impairment in self-care and household activities following rehabilitation. METHODS: Data come from the National Health and Aging Trends Study (NHATS), an annual survey of a nationally representative sample of Medicare beneficiaries aged 65 years and older. Our sample consists of 811 NHATS participants who, in the 2015 interview, had information on well-being and, in the 2016 interview, reported receiving rehabilitation services in the prior year. RESULTS: In multivariable logistic regression analyses, compared to the highest quartile, those in the lowest quartile of well-being at baseline have increased odds of having worsening depressive symptoms (OR = 9.25, 95% CI: 3.78-22.63) and worsening impairments in self-care activities (OR = 2.39, 95% CI: 1.12-5.11). CONCLUSION: Our findings suggest that older adults with the lowest levels of baseline well-being may be susceptible to having worsening depressive symptoms and impairment in self-care activities following rehabilitation services. Examination on whether consideration of well-being during the rehabilitation process could lead to better mental health and functional outcomes following rehabilitation is needed.

Pain Management in Home Health Care: Relationship With Dementia and Facility Admissions.

BACKGROUND: Pain is common yet under-studied among older Medicare home health (HH) patients with Alzheimer's disease and related dementias (ADRD). AIMS: Examine (1) the association between ADRD and severe pain in Medicare HH patients; and (2) the impact of severe pain and ADRD on unplanned facility admissions in this population. DESIGN: Analysis of the Outcome and Assessment Information Set (OASIS) and Medicare claims data. SETTINGS/PARTICIPANTS: 6,153 patients ≥65 years receiving care from a nonprofit HH agency in 2017. METHODS: Study outcomes included presence of severe pain and time-to-event measures of unplanned facility admissions (hospital, nursing home, or rehabilitation facilities). ADRD was identified using ICD-10 diagnosis codes and cognitive impairment symptoms. Logistic regression and Cox proportional hazard models were used to examine, respectively, the association between ADRD and severe pain, and the independent and interaction effects of severe pain and ADRD on unplanned facility admission. RESULTS: Patients with ADRD (n = 1,525, 24.8%) were less likely to have recorded severe pain than others (16.4% vs. 23.6%, p < .001). Adjusting for demographics, comorbidities, mental and physical functional status, and use of HH services, having severe pain was related to a 35% increase (hazard ratio [HR] = 1.35, p = .002) in the risk of unplanned facility admission, but the increase in such risk was the same whether or not the patient had ADRD. CONCLUSIONS: HH patients with ADRD may have under-recognized pain. Severe pain is a significant independent predictor of unplanned facility admissions among HH patients.

Construction and Validation of Risk-adjusted Rates of Emergency Department Visits for Long-stay Nursing Home Residents.

BACKGROUND: Long-stay nursing home (NH) residents are at high risk of having emergency department (ED) visits, but current knowledge regarding risk-adjusted ED rates is limited. OBJECTIVES: To construct and validate 3 quarterly risk-adjusted rates of long-stay residents' ED use: any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED). RESEARCH DESIGN: The authors calculated quarterly NH risk-adjusted ED rates from 2011 Q2 to 2013 Q3 national Medicare claims and Minimum Data Set data. Using random-effect linear regressions, the authors validated these rates against Nursing Home Compare overall 5-star quality ratings and examined their associations with hospitalization rates to provide a quality context. SUBJECTS: Resident-quarter observations (7.3 million) from 15,235 unique NHs. RESULTS: Risk-adjusted rates of any ED, outpatient ED, and PAED averaged 9.7%, 3.4%, and 3.2%, respectively. Compared with NHs with 1 or 2 stars overall rating, NHs with ≥3 stars were significantly associated with lower rates of any ED visit, outpatient ED, and PAED (ß, -0.23%, -0.16%, and -0.11%, respectively; all P<0.01). Pearson Correlation coefficients between hospitalization rates and rates of any ED visit, outpatient ED, and PAED were 0.74, 0.31, and 0.46, respectively. CONCLUSIONS: The moderately negative associations of 5-star ratings with ED rates provide supportive evidence to their validity. Outpatient ED and PAED were moderately correlated to hospitalizations suggesting they provided more information about quality than any ED.

The association of patient-reported improvement and rehabilitation characteristics with mortality.

This study aims to investigate the association of patient-reported improvement and rehabilitation characteristics with mortality among older adults who received rehabilitation. To do so, a national sample of Medicare beneficiaries from the National Health and Aging Trends Study was examined. Among those who reported receiving rehabilitation services in the 2015 interview (N = 1,188), 4.2% were deceased at the 2016 follow-up interview. Mortality was more common among those who had received rehabilitation in nursing home or inpatient and in-home settings compared to outpatient rehabilitation settings. In multivariable analyses accounting for demographics and health status, patient-reported worsening of functioning during rehabilitation (OR=15.69; 95% CI: 1.84-133.45) and cardiovascular disease (OR=4.15; 95% CI: 1.41-12.17) were associated with mortality. Among older adults who received rehabilitation, 1 in 25 were deceased at follow-up. That patient-reported functioning is associated with mortality suggests that more systematically including patient-reported outcomes in rehabilitation care may be clinically pertinent.

Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial.

BACKGROUND: Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. OBJECTIVE: Test the impact of PCTeams on end-of-life outcomes. RESEARCH DESIGN: Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect. SUBJECTS: In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). MEASURES: Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. RESULTS: Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations. CONCLUSIONS: The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.

A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

BACKGROUND: Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role. METHODS: This single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults' ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged≥ 60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit. DISCUSSION: This is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits. TRIAL REGISTRATION: ClinicalTrials.gov Registration: NCT02520661 . Trial registration date: August 13, 2015.

Prototype End-of-Life Quality Measures Based on MDS 3 Data.

BACKGROUND: The Nursing Home Compare (NHC) report card does not include end-of-life (EOL) quality measures (QMs). OBJECTIVES: To develop and examine the properties of EOL QMs. SUBJECTS: A total of 39,590 nursing home decedents in 626 facilities in New York State in fiscal year 2012. DESIGN: Statistical analyses of Minimum Data Set 3 data, including multivariable regression analyses and descriptive statistics. MEASURES: Death in the hospital, number of hospitalizations, pain, and depression during the last 90 days before death. RESULTS: Overall, 32% of residents died in the hospital. They averaged 0.49 hospitalizations in the last 90 days before death, 10% reported moderate to severe pain, and 17% had depressive symptoms. The EOL QMs exhibited variation across facilities similar to that observed for other QMs. They showed low or moderate correlations. The pain and depression QMs were significantly better among nursing homes ranked by NHC as 4 and 5 stars compared with those ranked as 1 and 2 stars for most dimensions. The hospitalizations QMs were significantly better among nursing homes ranked by NHC as 4 and 5 stars compared with those ranked as 1 and 2 stars only when compared on the staffing dimension. CONCLUSIONS: The Minimum Data Set 3 includes much information that can be used to assess quality of EOL care in nursing homes. The prototype measures we developed could be improved if information about advance directives and the nonclinical aspects of care, such as comfort and emotional support for both the resident and the family and respect for resident and family preferences, were collected.

A multisite geriatric education program for rural providers in the Veteran Health Care System (GRECC-Connect).

Older patients who live in rural areas often have limited access to specialty geriatric care, which can help in identifying and managing geriatric conditions associated with functional decline. Implementation of geriatric-focused practices among rural primary care providers has been limited, because rural providers often lack access to training in geriatrics and to geriatricians for consultation. To bridge this gap, four Geriatric Research, Education, and Clinical Centers, which are centers of excellence across the nation for geriatric care within the Veteran health system, have developed a program utilizing telemedicine to connect with rural providers to improve access to specialized geriatric interdisciplinary care. In addition, case-based education via teleconferencing using cases brought by rural providers was developed to complement the clinical implementation efforts. In this article, the authors review these educational approaches in the implementation of the clinical interventions and discuss the potential advantages in improving implementation efforts.

Special Focus Facilities vs Special Focus Facility Candidates: What is the Difference?

OBJECTIVES: This study compares Special Focus Facilities (SFFs) and Special Focus Facility Candidate Facilities (SFFcs) on organizational traits and quality outcomes to evaluate the effectiveness of the SFF program as a quality improvement intervention and inform potential areas for program reform. DESIGN: This is a retrospective analysis. SETTINGS AND PARTICIPANTS: Using data from the Centers for Medicare and Medicaid Services archives for 2020, this retrospective study analyzed 247 nursing facilities (50 SFFs and 197 SFFcs). METHODS: Variables of interest were staffing, profit status, facility size, certification status, number of residents, and complaint citations: t tests, χ2, Fisher's Exact test, and multivariate analysis of variance were used to compare the 2 groups. RESULTS: From an organizational perspective, SFFs and SFFcs are minimally different. Both groups had similar facility size, profit status, hospital affiliation, continuing care retirement community status, and Medicare/Medicaid certification. Large and for-profit facilities were overrepresented in both groups. SFFs and SFFcs exhibited statistical differences in the number of complaint deficiencies. The groups had no significant difference in staffing levels, category, severity of complaints, or incident reports. CONCLUSIONS AND IMPLICATION: The study's findings suggest that the SFF program, while resource-intensive, is minimally impactful. The similarities between SFFs and SFFcs raise questions about the program's effectiveness in improving nursing facility care. Previous adjustments to the program may not have successfully achieved the desired quality improvements. This research highlights the need to further evaluate the SFF program's effectiveness as a quality improvement intervention. It also underscores the importance of addressing biases and subjectivity in state survey agency processes, which affect the enrollment of nursing facilities. The study underscores the flaws within the nursing home monitoring system and the 5-star quality rating system, especially when comparing small samples between states.

Implementation of a 4Ms approach in age-friendly oral health care at an Academic Specialty Care Dental Clinic.

BACKGROUND: Implementing the Age-Friendly Health System (AFHS) framework into dental care provides a significant opportunity to link oral health to healthy aging. This project aimed to implement the AFHS 4Ms (what matters, medications, mentation, and mobility) in the provision of oral health care. This article describes the planning, integration, training development, and outcome measurements supporting a 4Ms approach at an academic dental clinic. METHODS: The Eastman Institute for Oral Health (EIOH) implemented screening instruments based on the 4Ms framework recommended for ambulatory care clinics by the Institute for Health Care Improvement (IHI). These ambulatory instruments were integrated into the workflows of a Specialty Care Clinic through the development of a plan-do-study-act cycle, utilization of available clinic resources, and creation of interdisciplinary collaborations. RESULTS: This project demonstrated the feasibility of implementing an AFHS checklist and tracking forms in dental practice by integrating available resources and prioritizing the 4Ms elements. This effort necessitated interdisciplinary collaborations between dental, medical, and social service professionals. It also created a new age-friendly focused education and training curriculum for dental residents and faculty. CONCLUSIONS: This pilot project is the first to establish dental standards for AFHS implementation, adapting the 4Ms assessment and metrics to oral health. This AFHS underscores key oral health processes, including assessment, planning, and personalized oral health care, adapted to the unique needs of the older adult population, especially those with cognitive impairment.

Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home.

OBJECTIVES: Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients. DESIGN: Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. SETTING AND PARTICIPANT: Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MEASURES: Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. RESULTS: We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. CONCLUSIONS AND IMPLICATIONS: Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.