Posttraumatic Stress Disorder in Older Veterans admitted to VA Community Living Centers: Prevalence and Risk Correlates.

OBJECTIVES: To examine prevalence and risk correlates for post-traumatic stress disorder (PTSD) occurring during or after admission to a Veterans Administration (VA) skilled nursing facility. DESIGN: Retrospective cohort analysis of electronic health record information extracted from the VA Corporate Data Warehouse. SETTING: United States VA skilled nursing facility. PARTICIPANTS: 57,414 Veterans age 60+ with an admission during five fiscal years, 2018-2022, excluding those who died within six months of admission or were still admitted. MEASUREMENTS: The dependent variable was PTSD diagnosis during or six-months following the admission. Risk correlates examined were: age, gender, race, rurality, clinical complexity, prior dementia diagnosis, length of stay, and facility size; odds ratios (OR) and confidence intervals (CI) are provided for each correlate. RESULTS: 19.1% of Veterans had a diagnosis of PTSD, associated with younger age (age 60-69 compared to age 80+; OR: 2.92, 95% CI: 2.70-3.14; age 70-79 compared to age 80+ OR: 4.51, 95% CI: 4.20-4.84); female gender (OR: 1.65, 95% CI: 1.50-1.82); minoritized race (OR: 1.17, 95% CI: 1.12-1.23); higher clinical complexity (OR:1.22, 95% CI: 1.17-1.28). As compared to Veterans who had a prior PTSD diagnosis, Veterans with newly diagnosed PTSD were more likely to be older (age 60 group OR= 0.59, 95% CI:0.51-0.70; age 70 group OR= 0.54, 95% CI:0.46-0.62,), rural (OR=1.14, 95% CI:1.04-1.24) and admitted to a larger facility (OR=1.22, 95% CI:1.12-1.33). CONCLUSIONS: PTSD is a significant concern for older Veterans admitted to VA skilled nursing facilities, supporting the need for trauma-informed care, particularly for those most at risk.

Discharge to Skilled Nursing Facility Is a Risk Factor for Readmission: A Nationwide Propensity-Matched Study.

INTRODUCTION: General surgery procedures place stress on geriatric patients, and postdischarge care options should be evaluated. We compared the association of discharge to a skilled nursing facility (SNF) versus home on patient readmission. METHODS: We retrospectively reviewed the Nationwide Readmission Database (2016-2019) and included patients ≥65 y who underwent a general surgery procedure between January and September. Our primary outcome was 30-d readmissions. Our secondary outcome was predictors of readmission after discharge to an SNF. We performed a 1:1 propensity-matched analysis adjusting for patient demographics and hospital course to compare patients discharged to an SNF with patients discharged home. We performed a sensitivity analysis on patients undergoing emergency procedures and a stepwise regression to identify predictors of readmission. RESULTS: Among 140,056 included patients, 33,916 (24.2%) were discharged to an SNF. In the matched population of 19,763 pairs, 30-d readmission was higher in patients discharged to an SNF. The most common diagnosis at readmission was sepsis, and a greater proportion of patients discharged to an SNF were readmitted for sepsis. In the sensitivity analysis, emergency surgery patients discharged to an SNF had higher 30-d readmission. Higher illness severity during the index admission and living in a small or fringe county of a large metropolitan area were among the predictors of readmission in patients discharged to an SNF, while high household income was protective. CONCLUSIONS: Discharge to an SNF compared to patients discharged home was associated with a higher readmission. Future studies need to identify the patient and facility factors responsible for this disparity.

Factors Associated with Discharge to Skilled Nursing Facility Following Gunshot Wounds.

INTRODUCTION: Firearm injury is a public health crisis. Most victims are minorities in underserved neighborhoods. Measuring firearm injury by mortality underestimates its impact, as most victims survive to discharge. This study was done to determine if race and insurance status are associated with discharge disposition for gunshot wound (GSW)-related trauma. METHODS: Using the 2019 Trauma Quality Improvement Program database, we identified GSW patients with Abbreviated Injury Scale (AIS) = 1-3. Exclusion criteria included patients who died in hospital and routine home discharge. We compared discharge patterns of patients based on demographics (age, gender, race, ethnicity, payor, AIS, hospital designation, and length of stay [LOS]) and injury severity. Multivariable logistic regression models identified factors associated with discharge disposition. RESULTS: Our sample included 2437 patients with GSWs. On univariable analysis, Black patients were more likely to discharge to home with home health (64.1% Black versus 34.7% White; P < 0.001). White patients were more likely to discharge to skilled nursing facility (SNF) (51.4% White versus 44.6% Black; P < 0.001). Controlling for age, race, Latin ethnicity, primary payor, LOS, AIS severity, and injury severity score factors independently associated with discharge to SNF included age (0.0462, P < 0.001), Medicaid (1.136, P < 0.0003), Medicare (1.452, P < 0.001), and LOS (0.03745, P < 0.001). CONCLUSIONS: Postacute care following traumatic injuries is essential to recovery. Black GSW victims are more likely to be discharged to home health than White patients, who are more likely to be discharged to SNF. Targeted programs to reduce barriers to appropriate aftercare are necessary to eliminate this bias and improve the care of underserved populations.

In the presence of death and dying: death attitudes and compassion fatigue among certified nursing assistants in skilled care.

OBJECTIVES: Certified Nursing Assistants (CNAs) are responsible for 80-90% of direct-to-resident care in skilled nursing facilities (SNFs), and may develop close, family-like relationships with their residents. With SNFs becoming a common place of death for older adults, CNAs now find themselves engaging in end-of-life caregiving with limited training and institutional support for emotional outcomes. This study aimed to understand and evaluate the relations between bereavement, death exposure, and compassion fatigue among CNAs, hypothesizing that (a) experiential avoidance moderates the relation between death exposure and negative death attitudes and (b) death attitudes moderate the relation between death exposure and compassion fatigue. METHOD: One hundred and ten CNAs across all shifts from four skilled nursing facilities in the southeastern United States participated in surveys and, potentially, focus groups. RESULTS: Results failed to find support for death exposure being related either to experiential avoidance or negative death attitudes. However, results supported the relation between negative death attitudes and compassion fatigue. CONCLUSION: Implications highlight the need to develop interventions focusing on palliative skills-based training and emotional support of CNAs in their role as end-of-life caregivers. By reducing compassion fatigue, it may be possible to decrease job turnover and increase quality-of-care for residents.

Validation of a Discharge Risk Calculator for Rural Patients Following Total Joint Arthroplasty.

BACKGROUND: As the volume of total joint arthroplasty in the US continues to grow, new challenges surrounding appropriate discharge surface. Arthroplasty literature has demonstrated discharge disposition to postacute care facilities carries major risks regarding the need for revision surgery, patient comorbidities, and financial burden. To quantify, categorize, and mitigate risks, a decision tool that uses preoperative patient variables has previously been published and validated using an urban patient population. The aim of our investigation was to validate the same predictive model using patients in a rural setting undergoing total knee arthroplasty (TKA) and total hip arthroplasty. METHODS: All TKA and THA procedures that were performed between January 2012 and September 2022 at our institution were collected. A total of 9,477 cases (39.6% TKA, 60.4% THA) were included for the validation analysis. There were 9 preoperative variables that were extracted in an automated fashion from the electronic medical record. Included patients were then run through the predictive model, generating a risk score representing that patient's differential risk of discharge to a skilled nursing facility versus home. Overall accuracy, sensitivity and specificity were calculated after obtaining risk scores. RESULTS: Score cutoff equally maximizing sensitivity and specificity was 0.23, and the proportion of correct classifications by the predictive tool in this study population was found to be 0.723, with an area under the curve of 0.788 - both higher than previously published accuracy levels. With the threshold of 0.23, sensitivity and specificity were found to be 0.720 and 0.723, respectively. CONCLUSIONS: The risk calculator showed very good accuracy, sensitivity, and specificity in predicting discharge location for rural patients undergoing TKA and THA, with accuracy even higher than in urban populations. The model provides an easy-to-use interface, with automation representing a viable tool in helping with shared decision-making regarding postoperative discharge plans.

Discharge to a Skilled Nursing Facility After Hip Fracture Results in Higher Rates of Periprosthetic Joint Infection.

BACKGROUND: Femoral neck fractures (FNFs) in elderly patients are associated with major morbidity and mortality. The influence of postoperative discharge location on recovery and outcomes after arthroplasty for hip fractures is not well understood. METHODS: A multisite retrospective cohort from 9 academic centers identified patients who had FNF treated with hemiarthroplasty or total hip arthroplasty between 2010 and 2019. Patients who had diagnoses of dementia, stroke, age > 80 years, or high energy fracture were excluded. Discharge location was identified, including home-based health services (HHS), inpatient rehabilitation (IPR), or a skilled nursing facility (SNF). Rates of reoperation, periprosthetic joint infection (PJI), and mortality were compared between cohorts. Multivariate logistic regressions were performed, adjusting for age, American Society of Anesthesiologists (ASA) score, body mass index, sex, and tobacco use. Statistical significance was defined as P < .05. RESULTS: A total of 672 patients (315 HHS, 144 IPR, and 213 SNF) were included in this study. The average follow-up was 30 months. The SNF cohort was significantly older (P < .0001) with higher ASA scores (P < .0001) than the HHS cohort. In a logistic regression model adjusting for age, ASA score, and body mass index, the SNF cohort had higher mortality rates than the HHS cohort (P = .0296) and were more likely to have PJI within 90 days (odds ratio = 4.55, 95% confidence interval = 1.40, 4.74) and within 1 year (odds ratio = 3.08, 95% confidence interval = 1.08, 8.78). Time to PJI was significantly shorter in the SNF cohort (SNF 38 versus HHS 231 days, P = .0155). No differences were seen in dislocation or reoperation rates between the SNF and HHS cohorts. No differences were seen in complication rates between the IPR and HHS cohorts. CONCLUSIONS: Discharge to a SNF after arthroplasty for FNF is associated with increased mortality and higher rates of PJI. Hip fracture care pathways that uniformly discharge patients to SNFs may need to be re-evaluated, and surgeons should consider discharge to home with HHS when possible.

Length of Stay and Discharge Disposition After Total Hip Arthroplasty: A Large Multicenter Propensity Matched Comparison of Robotic-Assisted and Manual Techniques.

BACKGROUND: Robotic-arm assistance continues to gain popularity in total hip arthroplasty (THA) for its potential to improve component placement accuracy and patient outcomes. Nonetheless, there is limited data on the impact of robotic-assisted THA (RA-THA) on hospital length of stay (LOS) and discharge location. This study thus aimed to compare LOS, discharge location, and readmission rate for propensity-matched cohorts of RA-THA versus manual THA (M-THA). METHODS: A retrospective review of a multi-hospital database was performed to identify patients who underwent THA between January 2016 and December 2021 from surgeons who performed both RA-THA and M-THA at 77 geographically diverse hospitals. The RA-THA and M-THA cohorts were 1-to-1 matched based on patient sex, age, and body mass index, resulting in 8,536 patients per cohort. Insurance type, LOS, same-day discharge, discharge disposition, and 90-day all-cause readmission rate were compared using Mann-Whitney U and Chi-square tests. RESULTS: Average LOS was significantly shorter for RA-THA patients (1.39 ± 0.85 days) than for M-THA patients (1.48 ± 0.91 days, P < .001). Compared to 5.6% of M-THA patients, 5.3% of RA-THA patients underwent same-day discharge (P = .38). There were statistically significant differences in discharge disposition between cohorts, with more RA-THA cases discharged home without home healthcare compared to M-THA (47.9 versus 45.5%, P = .001) and fewer RA-THA cases discharged to a skilled nursing facility compared to M-THA (5.6 versus 6.9%, P = .001). The 90-day all-cause readmission rate for RA-THA cases was 3.0%, compared to 3.4% for M-THA cases (P = .26). CONCLUSIONS: Compared to M-THA, RA-THA had a shorter average LOS, a similar percentage of patients with same-day discharge, fewer patients who had skilled nursing facility discharge, and a similar all-cause 90-day readmission rate. These results may be of interest to surgeons participating in bundled payment programs and engaging in cost savings.

Patient disposition after discharge following primary total hip arthroplasty: home versus skilled nursing facility-a study based on national inpatient sample database.

INTRODUCTION: In view of the shortened length of hospital stay following THA, an increasing proportion of patients have required transfer to "extended-care" (ECF) or "skilled nursing" facilities (SNF) over the past years. As a result, the expenditure related to postoperative care facility has been acknowledged as a crucial component of total economic burden associated with THA. In this context, the clinical and demographic factors leading to the need for transfer of patients to SNF following primary THA need to be clearly understood. METHODS: The NIS database was utilised to identify the patients, who underwent primary THA between 2016 and 2019. The patients were then grouped under two categories: group A-patients who required post-THA transfer to SNF; and group B-those who were discharged home. The details regarding patients' demographic profile, medical comorbidities and complication profile during the perioperative period were recorded; and compared between groups A and B. RESULTS: Based on the database, 368,431 patients underwent primary THA between 2016 and 2019; among whom, 67,498 (18.3%) were transferred to SNF (group A) following the surgery. Among the various comorbidities evaluated [on multivariate analysis (MVA)], uncomplicated DM (OR 1.45; p < 0.001), CKD (OR 1.47; p < 0.001), cirrhosis (OR 1.83; p < 0.001), Parkinson's disease (OR 3.94; p < 0.001), previous H/O dialysis (OR 2.84; p < 0.001), colostomy (OR 2.03; p < 0.001) or organ transplant (OR 1.42; p < 0.001); morbid obesity (OR 1.72; p < 0.001), cocaine abuse (OR 1.76; p < 0.001); and legal blindness (OR 2.58; p < 0.001) were associated with significantly greater need for post-THA transfer to SNF. Among the systemic complications reviewed (on MVA), pneumonia (odds ratio 3.2; p < 0.001), DVT (odds ratio 2.58; p < 0.001), higher need for blood transfusions (odds ratio 2.55; p < 0.001), ARF (odds ratio 2.32; p < 0.001), MI (odds ratio 2.2; p < 0.001), anaemia (odds ratio 1.65; p = 0.002) and PE (odds ratio 1.56; p < 0.001) significantly raised the probability of need for higher discharge destinations. In addition, prosthesis-related local complications such as prosthetic dislocation (OR 1.59; p < 0.001), fracture (OR 2.64; p < 0.001) or early peri-prosthetic infection (PPI; OR 1.71; p = 0.01) also necessitated specialised facilities of care following THA. CONCLUSION: We could observe that 0.2% of patients required transfer to SNF following primary THA. Comorbidities such as Parkinson's disease, previous H/O dialysis, legal blindness and H/O colostomy had the highest odds of necessitating patient disposition to SNF. The occurrence of one or more systemic complications including pneumonia, DVT, ARF, MI, PE, and blood loss anaemia (or need for blood transfusion) or local prosthesis-related complications (dislocation, fracture or infections) substantially increased the chances of requiring transfer to a specialised care facility.

Content validity index for the readiness for hospital discharge scale in the skilled nursing facility setting.

OBJECTIVES: The purpose of this study was to determine the appropriateness of using the Readiness for Hospital Discharge Scale (RHDS) in the skilled nursing facility (SNF) setting as a discharge outcome measure. METHODS: Six experts consisting of nurses and physical therapists from two different SNFs in the Midwest were selected to participate in the study. The content validity of the scale was determined by using item and scale content validity index scores to determine the appropriateness of the scale in the SNF setting. RESULTS: The scale content validity index score for the RHDS was 0.96 with an item content validity index score range of 0.83 to 1.0. Kendall's Coefficient of Concordance was 0.278 and the statistical significance had a p-value of 0.031. CONCLUSIONS: The results of this study indicate that the RHDS has good content validity and is an appropriate measure to determine patient discharge readiness in the SNF setting.

Spillover effect of the Patient Drive Payment Model on skilled nursing facility therapy delivery among Medicare Advantage enrollees.

In a multi-payer health care system, economic theory suggests that different payers can impose spillover effects on one another. This study aimed to evaluate the spillover effect of the Patient Driven Payment Model (PDPM) on Medicare Advantage (MA) enrollees, despite it being designed for Traditional Medicare (TM) beneficiaries. We applied a regression discontinuity approach by comparing therapy utilization before and after the implementation of PDPM in October 2019 focusing on patients newly admitted to skilled nursing facilities. The results showed that both TM and MA enrollees experienced a decrease in individual therapy minutes and an increase in non-individual therapy minutes. The estimated reduction in total therapy use was 9 min per day for TM enrollees and 3 min per day for MA enrollees. The effect of PDPM on MA beneficiaries varied depending on the level of MA penetration, with the smallest effect in facilities with the highest MA penetration quartile. In summary, the PDPM had directionally similar effects on therapy utilization for both TM and MA enrollees, but the magnitudes were smaller for MA beneficiaries. These results suggest that policy changes intended for TM beneficiaries may spillover to MA enrollees and should be assessed accordingly.

Prediction of rehospitalization and mortality risks for skilled nursing facilities using a dimension reduction approach.

BACKGROUND: Hospitals are incentivized to reduce rehospitalization rates, creating an emphasis on skilled nursing facilities (SNFs) for post-hospital discharge. How rehospitalization rates vary depending on patient and SNF characteristics is not well understood, in part because these characteristics are high-dimensional. We sought to estimate rehospitalization and mortality risks by patient and skilled nursing facility (SNF) leveraging high-dimensional characteristics. METHODS: Using 1,060,337 discharges from 13,708 SNFs of Medicare patients residing or visiting a provider in Wisconsin, Iowa, and Illinois, factor analysis was performed to reduce the number of patient and SNF characteristics. K-means clustering was applied to SNF factors to categorize SNFs into groups. Rehospitalization and mortality risks within 60 days of discharge was estimated by SNF group for various values of patient factors. RESULTS: Patient and SNF characteristics (616 in total) were reduced to 12 patient factors and 4 SNF groups. Patient factors reflected broad conditions. SNF groups differed in beds and staff capacity, off-site services, and physical and occupational therapy capacity; and in mortality and rehospitalization rates for some patients. Patients with cardiac, orthopedic, and neuropsychiatric conditions are associated with better outcomes when assigned to SNFs with greater on-site capacity (i.e. beds, staff, physical and occupational therapy), whereas patients with conditions related to cancer or chronic renal failure are associated with better outcomes when assigned to SNFs with less on-site capacity. CONCLUSIONS: Risks of rehospitalization and mortality appear to vary significantly by patient and SNF, with certain SNFs being better suited for some patient conditions over others.

Factors Influencing Admission Decisions in Skilled Nursing Facilities: Retrospective Quantitative Study.

BACKGROUND: Occupancy rates within skilled nursing facilities (SNFs) in the United States have reached a record low. Understanding drivers of occupancy, including admission decisions, is critical for assessing the recovery of the long-term care sector as a whole. We provide the first comprehensive analysis of financial, clinical, and operational factors that impact whether a patient referral to an SNF is accepted or denied, using a large health informatics database. OBJECTIVE: Our key objectives were to describe the distribution of referrals sent to SNFs in terms of key referral- and facility-level features; analyze key financial, clinical, and operational variables and their relationship to admission decisions; and identify the key potential reasons behind referral decisions in the context of learning health systems. METHODS: We extracted and cleaned referral data from 627 SNFs from January 2020 to March 2022, including information on SNF daily operations (occupancy and nursing hours), referral-level factors (insurance type and primary diagnosis), and facility-level factors (overall 5-star rating and urban versus rural status). We computed descriptive statistics and applied regression modeling to identify and describe the relationships between these factors and referral decisions, considering them individually and controlling for other factors to understand their impact on the decision-making process. RESULTS: When analyzing daily operation values, no significant relationship between SNF occupancy or nursing hours and referral acceptance was observed (P>.05). By analyzing referral-level factors, we found that the primary diagnosis category and insurance type of the patient were significantly related to referral acceptance (P<.05). Referrals with primary diagnoses within the category "Diseases of the Musculoskeletal System" are least often denied whereas those with diagnoses within the "Mental Illness" category are most often denied (compared with other diagnosis categories). Furthermore, private insurance holders are least often denied whereas "medicaid" holders are most often denied (compared with other insurance types). When analyzing facility-level factors, we found that the overall 5-star rating and urban versus rural status of an SNF are significantly related to referral acceptance (P<.05). We found a positive but nonmonotonic relationship between the 5-star rating and referral acceptance rates, with the highest acceptance rates found among 5-star facilities. In addition, we found that SNFs in urban areas have lower acceptance rates than their rural counterparts. CONCLUSIONS: While many factors may influence a referral acceptance, care challenges associated with individual diagnoses and financial challenges associated with different remuneration types were found to be the strongest drivers. Understanding these drivers is essential in being more intentional in the process of accepting or denying referrals. We have interpreted our results using an adaptive leadership framework and suggested how SNFs can be more purposeful with their decisions while striving to achieve appropriate occupancy levels in ways that meet their goals and patients' needs.

Effectiveness of Coronavirus Disease 2019 (COVID-19) mRNA Vaccines Against Infection During an Outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Beta (B.1.351) Variant in a Skilled Nursing Facility: Virginia, March-April 2021.

In April 2021, we assessed mRNA vaccine effectiveness (VE) in the context of a COVID-19 outbreak in a skilled nursing facility. Among 28 cases, genomic sequencing was performed on 4 specimens on 4 different patients, and all were classified by sequence analysis as the Beta (B.1.351) variant. Adjusted VE among residents was 65% (95% confidence interval: 25-84%). These findings underscore the importance of vaccination for prevention of COVID-19 in skilled nursing facilities.

Investigation of a Severe Acute Respiratory Syndrome Coronavirus 2 Delta (B.1.617.2) Variant Outbreak Among Residents of a Skilled Nursing Facility and Vaccine Effectiveness Analysis: Maricopa County, Arizona, June-July 2021.

BACKGROUND: Short-term rehabilitation units present unique infection control challenges because of high turnover and medically complex residents. In June 2021, the Maricopa County Department of Public Health was notified of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta outbreak in a skilled nursing facility short-term rehabilitation unit. We describe the outbreak and assess vaccine effectiveness (VE). METHODS: Facility electronic medical records were reviewed for residents who spent > 1 night on the affected unit between June 10 and July 23, 2021, to collect demographics, SARS-CoV-2 test results, underlying medical conditions, vaccination status, and clinical outcomes. Coronavirus disease 2019 VE estimates using Cox proportional hazards models were calculated. RESULTS: Forty (37%) of 109 short-stay rehabilitation unit residents who met inclusion criteria tested positive for SARS-CoV-2. SARS-CoV-2-positive case-patients were mostly male (58%) and White (78%) with a median age of 65 (range, 27-92) years; 11 (27%) were immunocompromised. Of residents, 39% (10 cases, 32 noncases) received 2 doses and 9% (4 cases, 6 noncases) received 1 dose of messenger RNA (mRNA) vaccine. Among nonimmunocompromised residents, adjusted 2-dose primary-series mRNA VE against symptomatic infection was 80% (95% confidence interval, 15-95). More cases were hospitalized (33%) or died (38%) than noncases (10% hospitalized; 16% died). CONCLUSIONS: In this large SARS-CoV-2 Delta outbreak in a high-turnover short-term rehabilitation unit, a low vaccination rate and medically complex resident population were noted alongside severe outcomes. VE of 2-dose primary-series mRNA vaccine against symptomatic infection was the highest in nonimmunocompromised residents. Health departments can use vaccine coverage data to prioritize facilities for assistance in preventing outbreaks.

Estimating COVID-19 Vaccine Effectiveness for Skilled Nursing Facility Healthcare Personnel, California, USA.

We estimated real-world vaccine effectiveness among skilled nursing facility healthcare personnel who were regularly tested for SARS-CoV-2 infection in California, USA, during January‒March 2021. Vaccine effectiveness for fully vaccinated healthcare personnel was 73.3% (95% CI 57.5%-83.3%). We observed high real-world vaccine effectiveness in this population.

The design and conduct of a pragmatic cluster randomized trial of an advance care planning program for nursing home residents with dementia.

BACKGROUND/AIMS: A significant number of people with Alzheimer's disease or related dementia diagnoses will be cared for in nursing homes near the end of life. Advance care planning (ACP), the process of eliciting and documenting patient-centered preferences for care, is considered essential to providing high quality care for this population. Nursing homes are currently required by regulations to offer ACP to residents and families, but no training requirements exist for nursing home staff, and approaches to fulfilling this regulatory and ethical responsibility vary. As a result, residents may receive care inconsistent with their goals, such as unwanted hospitalizations. Pragmatic trials offer a way to develop and test ACP in real-world settings to increase the likelihood of adoption of sustainable best practices. METHODS: The "Aligning Patient Preferences-a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support (APPROACHES)" project is designed to pragmatically test and evaluate a staff-led program in 137 nursing homes (68 = intervention, 69 = control) owned by two nursing home corporations. Existing nursing home staff receive standardized training and implement the ACP Specialist program under the supervision of a corporate lead. The primary trial outcome is the annual rate of hospital transfers (admissions and emergency department visits). Consistent with the spirit of a pragmatic trial, study outcomes rely on data already collected for quality improvement, clinical, or billing purposes. Configurational analysis will also be performed to identify conditions associated with implementation. RESULTS: Partnerships with large corporate companies enable the APPROACHES trial to rely on corporate infrastructure to roll out the intervention, with support for a corporate implementation lead who is charged with the initial introduction and ongoing support for nursing home-based ACP Specialists. These internal champions connect the project with other company priorities and use strategies familiar to nursing home leaders for the initiation of other programs. Standardized data collection across nursing homes also supports the conduct of pragmatic trials in this setting. DISCUSSION: Many interventions to improve care in nursing homes have failed to demonstrate an impact or, if successful, maintain an impact over time. Pragmatic trials, designed to test interventions in real-world contexts that are evaluated through existing data sources collected routinely as part of clinical care, are well suited for the nursing home environment. A robust program that increases access to ACP for nursing home residents has the potential to increase goal-concordant care and is expected to reduce hospital transfers. If successful, the ACP Specialist Program will be primed for rapid translation into nursing home practice to reduce unwanted, burdensome hospitalizations and improve the quality of care for residents with dementia.

A validated preoperative risk prediction tool for discharge to skilled nursing or rehabilitation facility following anatomic or reverse shoulder arthroplasty.

BACKGROUND: As bundled payment models continue to spread, understanding the primary drivers of cost excess helps providers avoid penalties and ensure equal health care access. Recent work has shown discharge to rehabilitation and skilled nursing facilities (SNFs) to be a primary cost driver in total joint arthroplasty, and an accurate preoperative risk calculator for shoulder arthroplasty would not only help counsel patients in clinic during shared decision-making conversations but also identify high-risk individuals who may benefit from preoperative optimization and discharge planning. METHODS: Anatomic and reverse total shoulder arthroplasty cohorts from 2 geographically diverse, high-volume centers were reviewed, including 1773 cases from institution 1 (56% anatomic) and 3637 from institution 2 (50% anatomic). The predictive ability of a variety of candidate variables for discharge to SNF/rehabilitation was tested, including case type, sociodemographic factors, and the 30 Elixhauser comorbidities. Variables surviving parameter selection were incorporated into a multivariable logistic regression model built from institution 1's cohort, with accuracy then validated using institution 2's cohort. RESULTS: A total of 485 (9%) shoulder arthroplasties overall were discharged to post-acute care (anatomic: 6%, reverse: 14%, P < .0001), and these patients had significantly higher rates of unplanned 90-day readmission (5% vs. 3%, P = .0492). Cases performed for preoperative fracture were more likely to require post-acute care (13% vs. 3%, P < .0001), whereas revision cases were not (10% vs. 10%, P = .8015). A multivariable logistic regression model derived from the institution 1 cohort demonstrated excellent preliminary accuracy (area under the receiver operating characteristic curve [AUC]: 0.87), requiring only 11 preoperative variables (in order of importance): age, marital status, fracture, neurologic disease, paralysis, American Society of Anesthesiologists physical status, gender, electrolyte disorder, chronic pulmonary disease, diabetes, and coagulation deficiency. This model performed exceptionally well during external validation using the institution 2 cohort (AUC: 0.84), and to facilitate convenient use was incorporated into a freely available, online prediction tool. A model built using the combined cohort demonstrated even higher accuracy (AUC: 0.89). CONCLUSIONS: This validated preoperative clinical decision tool reaches excellent predictive accuracy for discharge to SNF/rehabilitation following shoulder arthroplasty, providing a vital tool for both patient counseling and preoperative discharge planning. Further, model parameters should form the basis for reimbursement legislation adjusting for patient comorbidities, ensuring no disparities in access arise for at-risk populations.

Barriers to Aging in Place for Rural, Institutionalized Older Adults: A Qualitative Exploration.

OBJECTIVES: Although the majority of older adults wish to "age in place" in their communities, rural contexts pose challenges to maintaining long-term independence. The purpose of this study was to develop an understanding of the experiences of rural older adults who live in Skilled Nursing Facilities (SNFs) and thus have not aged in place. By retrospectively analyzing their pre-institution care situation, we aim to generate foundational knowledge on the barriers to aging in place in rural settings. METHODS: A series of individual and group interviews was conducted in SNFs across seven rural communities. A grounded, thematic analysis was used to interpret interview findings, and coding was informed by the socio-ecological model (SEM). RESULTS: Participants were 32 adults with a mean age of 72 years (SD = 5.7 years) and an average SNF residence of 3.9 years. Two themes emerged as primary barriers to successful aging in place: (1) Caregiver-related support issues and (2) Present focus, or lack of advanced care-planning. CONCLUSIONS: Findings suggest the importance of specifically supporting caregivers, to ease burden and allow for increased agency for rural older adults. A lack of access to caregiver supports and other services limits the ability of community-dwelling rural older adults to age in place or plan for the future. CLINICAL IMPLICATIONS: Existing networks of rural community resources and innovative solutions should be leveraged to improve access to services for older adults and their informal caregivers.

Behavioral Health Services with Short-Stay Residents in Skilled Nursing Facilities: A Qualitative Study of Clinicians and Administrators.

OBJECTIVES: The perspectives of professionals involved in behavioral health (BH) services with short-stay residents in skilled nursing facilities (SNFs) are rarely captured in the literature. This study examines the real-world experiences of BH clinicians and administrators in post-acute/subacute care units in SNFs. METHODS: This qualitative study used semi-structured interviews with 18 clinicians (e.g., psychologists and social workers) and five administrators (e.g., directors of social services or BH company executives) involved in BH services with short-stay SNF residents. Interviews were recorded, transcribed, and analyzed by two independent coders using conventional thematic content analysis. RESULTS: Three themes emerged from the data: (1) BH needs are high among short-stay residents and families during post-acute care transitions; (2) BH services offer multiple unique opportunities to enhance post-acute/subacute care in SNFs; and (3) barriers to providing optimal BH care exist at multiple levels and require action from BH clinicians and stakeholders. CONCLUSIONS: Variability in clinician roles and barriers to optimized care suggest the need for future research targeting best practices and implementation strategies for BH services with short-stay SNF residents. CLINICAL IMPLICATIONS: Results identified multiple ways in which BH services may enhance resident, family, and staff outcomes, as well as the milieu in SNFs.

Forced to Choose: When Medicare Policy Disrupts End-of-Life Care.

In the last six months of life, 30% of Medicare beneficiaries use the skilled nursing facility (SNF) benefit for post-acute care after a hospital stay. Frequently, the circumstances that indicate a need for SNF care are the same as those of a worsening illness trajectory such as functional decline and falls, unstable health conditions, and pain and other symptoms. The following case example and narrative discussion describes the national implications of this issue and the need for Medicare policy changes that allow for concurrent rehabilitative care and hospice services.