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OBJECTIVES: To assess the feasibility of a multifaceted strategy to translate evidence-based guidelines for treating nursing home-acquired pneumonia (NHAP) into practice using a small intervention trial. DESIGN: Pre-posttest with untreated control group. SETTING: Two Colorado State Veterans Homes (SVHs) during two influenza seasons. PARTICIPANTS: Eighty-six residents with two or more signs of lower respiratory tract infection. INTERVENTION: Multifaceted, including a formative phase to modify the intervention, institutional-level change emphasizing immunization, and availability of appropriate antibiotics; interactive educational sessions for nurses; and academic detailing. MEASUREMENTS: Subjects' SVH medical records were reviewed for guideline compliance retrospectively for the influenza season before the intervention and prospectively during the intervention. Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test. RESULTS: At the intervention facility, compliance with five of the guidelines improved: influenza vaccination, timely physician response to illness onset, x-ray for patients not being hospitalized, use of appropriate antibiotics, and timely antibiotic initiation for unstable patients. Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year. CONCLUSION: Multifaceted, evidence-based, NHAP guideline implementation improved care processes in a SVH. Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents. [ABSTRACT FROM AUTHOR]

Objectives: To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates., Design: Quasi-experimental design whereby subjects receiving the intervention (n=158) were compared with control subjects derived from administrative data (n=1,235)., Setting: A large integrated delivery system in Colorado., Participants: Community-dwelling adults aged 65 and older admitted to the study hospital with one of nine selected conditions., Intervention: Intervention subjects received tools to promote cross-site communication, encouragement to take a more active role in their care and assert their preferences, and continuity across settings and guidance from a transition coach., Measurements: Rates of postdischarge hospital use at 30, 60, and 90 days. Intervention subjects' care experience was assessed using the care transitions measure., Results: The adjusted odds ratio comparing rehospitalization of intervention subjects with that of controls was 0.52 (95% confidence interval (CI)=0.28-0.96) at 30 days, 0.43 (95% CI=0.25-0.72) at 90 days, and 0.57 (95% CI=0.36-0.92) at 180 days. Intervention patients reported high levels of confidence in obtaining essential information for managing their condition, communicating with members of the healthcare team, and understanding their medication regimen., Conclusion: Supporting patients and caregivers to take a more active role during care transitions appears promising for reducing rates of subsequent hospitalization. Further testing may include more diverse populations and patients at risk for transitions who are not acutely ill.

Objectives: To compare the effectiveness of Cooperative Health Care Clinic ((CHCC) group outpatient model for chronically ill, older health maintenance organization (HMO) patients) with usual care., Design: Two-year, randomized, controlled trial conducted with recruitment from February 1995 through July of 1996., Setting: Nonprofit group model HMO., Participants: Two hundred ninety-four adults (145 intervention and 149 usual care), aged 60 and older (mean age 74.1) with 11 or more outpatient visits in the prior 18 months, one or more self-reported chronic conditions, and expressed interest in participating in a group clinic., Intervention: Monthly group meetings held by patients' primary care physicians., Measurement: Differences in clinic visits, inpatient admissions, emergency room visits, hospital outpatient services, professional services, home health, and skilled nursing facility admissions; measures of patient satisfaction, quality of life, self-efficacy, and activities of daily living (ADLs)., Results: Outpatient, pharmacy services, home health, and skilled nursing facility use did not differ between groups, but CHCC patients had fewer hospital admissions (P=.012), emergency visits (P=.008), and professional services (P=.005). CHCC patients' costs were $41.80 per member per month less than those of control patients. CHCC patients reported higher satisfaction with their primary care physician (P=.022), better quality of life (P=.002), and greater self-efficacy (P=.03). Health status and ADLs did not differ between groups., Conclusion: The CHCC model resulted in fewer hospitalizations and emergency visits, increased patient satisfaction, and self-efficacy, but no effect on outpatient use, health, or functional status., (Copyright 2004 American Geriatrics Society)

Objectives: To determine factors that predict site of death (hospital vs nursing home (NH)), related costs, and geographic variation in site of death of NH residents admitted under the Medicare Part A Benefit., Design: Retrospective cohort study., Setting: NHs located in the United States (N=13,146)., Participants: All persons admitted to skilled nursing facilities (SNFs) in 2001 who died in a SNF (n=101,307) or hospital (n=51,187)., Measurements: Patient, facility, and geographic characteristics associated with death in a hospital and receipt of Medicare payment., Results: Absence of a do-not-resuscitate order, non-Caucasian ethnicity, greater functional independence, and higher cognitive status correlated with hospital as the site of death. Rural, hospital-based, and government-owned facilities had the lowest in-hospital death rates. Site of death varied widely from state to state. Of those who died in a hospital, 24.2% (12,410) died within 24 hours of transfer. The average daily combined stay Medicare payment for those who died in the hospital was $969, versus $300 for those who died in a NH., Conclusion: Patient and facility characteristics predict site of death of Medicare NH patients, but in-hospital death rather than NH death varies geographically and is associated with higher daily Medicare payment.

Objectives: To evaluate effects on patient outcomes of Outcome-Based Quality Improvement (OBQI), a continuous quality improvement methodology for home health care (HHC)., Design: A quasi-experimental design with prospective pre/post and study/control components within two multiyear demonstration trials (occurring from 1995 to 2000) in which 73 home health agencies implemented OBQI, receiving several annual cycles of outcome reports to evaluate and enhance patient outcomes., Setting: New York and 27 other states., Participants: The study involved 157,548 predominantly older adult patients admitted over 3 years to 54 OBQI agencies from 27 states in the National Demonstration Trial, 105,917 patients admitted over 4 years to 19 OBQI agencies in the New York State Trial, and 248,621 patients admitted over 3 years to non-OBQI control agencies in the 27 demonstration states., Intervention: As a clinical management and administrative intervention, OBQI involves collecting, encoding, and transmitting patient-level health status data to a central source that provides each OBQI agency with a risk-adjusted outcome report comparing the agency's patient outcomes with those from a reference population and with its own outcomes from the prior period. Target outcomes are selected and focused plans of action implemented to change care behaviors. Outcome changes are evaluated through the next report cycle., Measurements: Outcome measures include hospitalization rates and improvement and stabilization outcome rates in functional, physiological, emotional/behavioral, and cognitive health., Results: For the National and New York State Demonstration Trials, the risk-adjusted relative rates of decline in hospitalization of 22% and 26%, respectively, for OBQI patients over the 3-year and 4-year demonstration periods were significant (P <.001) and unparalleled by considerably smaller rates of decline for the non-OBQI patients in the 27 states. The risk-adjusted rates of improvement in OBQI target outcome measures of health status averaged 5% to 7% per year in both demonstration trials and were significantly greater (P <.05) than analogous improvement rates for nontarget comparison outcomes, which averaged about 1% per year., Conclusion: It is feasible to integrate the programmatic, data collection, data transmission, and outcome enhancement components of OBQI into the day-to-day operations of home health agencies. The aggregate findings and the agency-level evidence available from site-specific communications suggest that OBQI had a pervasive effect on outcome improvement for home health patients. OBQI appears to warrant expansion and refinement in HHC and experimentation in other healthcare settings.

Objectives: To evaluate change in pressure ulcer prevalence in long-term nursing home residents since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87)., Design: Cross-sectional comparison of two time periods., Setting: Ninety-two nursing homes scheduled for a quality-of-care survey randomly selected from 22 representative states., Participants: Four thousand six hundred seventy-nine residents who had resided in the facility for at least 100 days were evaluated: 2,336 during 1992-1994 and 2,343 during 1997-1998., Measurements: Trained registered nurses collected data on pressure ulcer prevalence, stage, and risk factors from medical record review during on-site evaluations. Risk-adjusted differences were estimated using logistic regression., Results: Unadjusted prevalence rates for all stages of pressure ulcers (8.52% vs 8.54%, P =.983) and those rated stage 2 or greater (5.31% vs 5.63%, P =.624) did not differ between the two time periods. After adjustment for urinary incontinence, immobility, poor nutrition, and history of previous pressure ulcers, the relative odds of having a pressure ulcer in 1992/4 versus 1997/8 was 1.06 (95% confidence interval (CI) = 0.84-1.34) for all stages and 1.21 (95% CI = 0.92-1.60) for stages 2 and greater., Conclusions: No change in pressure ulcer prevalence was demonstrated since implementation of OBRA '87 in this nationally derived sample of long-term nursing home residents.

Objectives: To determine what precipitates rehospitalization for residents who become acutely ill in the first 90 days of a nursing home (NH) admission., Design: NH medical record review comparing acutely ill Medicare admissions transferred back to hospital with those not transferred., Setting: Sixty skilled nursing facilities in five states during 1994., Participants: Six hundred thirty-six residents who became acutely ill with urinary tract infection (UTI), pneumonia, or congestive heart failure (CHF) during the first 90 days of their nursing home admission were identified from 2,414 random NH Medicare admissions, excluding those with orders not to be hospitalized., Measurements: Diagnosis, age, gender, advance care directives, nursing shift during which problem occurred, comorbidity, symptoms, and signs of acutely ill NH residents transferred to the hospital or emergency department were compared with those not transferred., Results: Rates of hospitalization varied markedly by acute illness: 11 of residents with UTI, 46 with pneumonia, and 58 with an exacerbation of CHF (P< .001). In stratified multivariate analysis, older age decreased the odds of rehospitalization only for CHF. Male gender increased odds of hospitalization for pneumonia (odds ratio (OR) = 2.94) and decreased odds of hospitalization for CHF (OR = 0.28). Do not resuscitate orders were negatively associated with hospitalization only for pneumonia (OR = 0.23), whereas weekend and evening/night shifts increased odds of hospitalization for UTI. Each illness had its own set of symptoms, signs, and comorbidities associated with hospitalization., Conclusions: Whether an acutely ill NH Medicare patient was rehospitalized depended primarily on the particular illness. The relative importance of age, gender, shift, advance care directives, symptom severity, signs, and comorbid illnesses varied by diagnosis.

Objectives: To determine the impact of the prospective payment system (PPS) for skilled nursing facilities (SNFs) on therapy use and community discharge rates., Design: Quasi-experimental study examining the predemonstration (1994) to demonstration (1997) change in amount of therapy provided, and in community discharge rates at PPS participating and nonparticipating facilities., Setting: Eighteen PPS participating and 17 nonparticipating SNFs in five states., Participants: Two thousand sixty-seven admissions to 18 PPS participating and 17 nonparticipating SNFs in five states., Measurements: We compared changes in number of physical and occupational therapy visits per stay for patients receiving therapy and likelihood of being located in the community 60 days after admission between 1994 and 1997. Analyses were stratified by functional category and risk adjusted using multivariate methods., Results: Demographics and percentage of patients in each stratum were similar in participating and nonparticipating sites and between 1994 and 1997. Amount of therapy received by the highest-functioning patients increased in participating sites (19.3 to 26.5 visits per stay, P = .005), but not in nonparticipating sites (23.3 to 18.2, P = .98). After adjusting for covariates, likelihood of community discharge for the highest-functioning patients did not change between participating and nonparticipating sites., Conclusions: The highest-functioning patients treated under the SNF PPS demonstration experienced great increases in therapy, without any improvement in rate of community discharge.

Objective: Older persons with general medical and surgical conditions increasingly receive posthospital rehabilitation care in nursing homes and rehabilitation hospitals. This study describes the characteristics of such patients, contrasted with patients with traditional rehabilitation diagnoses of hip fracture and stroke., Design: Prospective cohort study., Setting: Seventeen skilled nursing facilities and six rehabilitation hospitals in seven states., Participants: Medicare patients age 65 or older receiving posthospital rehabilitation., Methods: A total of 290 medical/surgical patients were compared with 336 hip fracture and 429 stroke patients. Data were collected prospectively from charts, nursing assessments, and patient interviews. Patient characteristics associated with functional recovery and mortality were estimated using multivariate regression., Results: Medical/surgical patients had greater premorbid activities of daily living (ADL) (P < .001) and instrumental activities of daily living (IADL) (P < .01) disability, but suffered less decline with the acute event than hip fracture or stroke patients (P < .001). Medical/surgical patients were more likely to recover premorbid ADL function (P < .05) but 1-year mortality was significantly greater (30% vs. 14% hip fracture; 18% stroke; P < .001). Predictors of functional recovery and mortality differed between the three groups. Among medical/surgical patients, premorbid ADL difficulty, cognitive impairment, a pressure ulcer at rehabilitation admission, and depression were associated with failure to recover premorbid function whereas increasing comorbidity and incontinence were associated with mortality., Conclusions: Medical/surgical patients represent a unique rehabilitation population. They experienced greater premorbid functional disability, less acute decline, but greater mortality than patients with traditional rehabilitation diagnoses. Further study of this distinct rehabilitation population may help identify patients most likely to benefit from rehabilitation.

Objectives: To compare treatment and outcomes for older persons with stroke in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) systems., Design: Inception cohort stratified by payer and followed for 1 year., Setting: Six HMOs and five FFS systems with large Medicare populations in the West, Midwest, and Eastern United States., Participants: A total of 429 randomly selected stroke patients receiving rehabilitation in nursing homes or rehabilitation hospitals (RHs) from June 1993 to June 1995., Measurements: Improvement in activities of daily living (ADLs) during rehabilitation, and ADL recovery, community residence, and utilization until 12 months after stroke. Outcomes were adjusted for premorbid function, marital status, comorbid illness, posthospital function, cognition, psychological problems, and stroke deficits., Results: At baseline, HMO patients were more likely to be married, and less likely to be blind or have psychiatric diagnoses. HMO patients had shorter hospitalizations (P < .001), were less likely to be admitted to RHs (13% vs 85%, P < .001), and received fewer therapy and physician specialist visits (P < .001) but more home health visits (P < .001). During rehabilitation, FFS patients made greater improvement in ADLs (difference, 0.73 ADLs; 95% CI, .37-1.09). At 1 year, there was no difference in ADL recovery (difference, -0.24 ADL; 95% CI, -0.64-0.16), but FFS patients were more likely to reside in the community (adjusted OR, 1.8; 95% CI, 1.1-3.1), and HMO patients were more likely to reside in nursing homes (adjusted OR, 2.4; 95% CI, 1.1-5.5)., Conclusion: Study findings suggest that short-term functional outcomes and eventual community residence rates are poorer for Medicare HMO patients with stroke than for stroke patients receiving FFS care, consistent with the lower intensity of rehabilitation (in nursing homes vs RHs) and less specialty physician care.

Objectives: To develop and validate a clinical prediction rule for nursing home residence 6 months after a hip fracture., Design: Two prospective cohort studies, a development study (DS) and a validation study (VS)., Setting: The DS included hip fracture patients admitted to 92 rehabilitation units or skilled nursing facilities; the VS included hip fracture patients from 11 integrated healthcare systems., Participants: A total of 344 community-dwelling hip fracture patients aged 65 and older participated in the DS; 239 similar patients were enrolled in the VS., Intervention: None., Measurements: The acute hospital record, nursing evaluations, and patient questionnaires provided information about demographics, physical and neuropsychological function, and comorbidity. Residence 6 months after fracture was determined by phone interview. Multivariate analysis identified predictors for a risk score to assess the likelihood of nursing home residence., Results: 18.7% of patients in the DS resided in nursing homes 6 months after hip fracture. The four independent risk factors for institutionalization were (1) being unmarried (OR = 6.7 [95% CI 2.4 to 19]), (2) incontinence (OR = 2.3 [CI 1.2 to 4.7]), (3) dependence in ambulation (OR = 5.0 [CI 2.1 to 12.3]), and (4) cognitive impairment (OR = 6.6 [CI 3.3 to 13.2]). Of patients with all four risk factors, 73.2% were institutionalized at 6 months, compared with 0% of patients with no risk factors. In the VS, 6.1% of patients resided in nursing homes after 6 months, with a range from 50.0% of patients with four risk factors to 0% of those with no risk factors. Areas under receiver-operating characteristic curves for the prediction rule were 0.84 +/- .03 in the DS, and 0.81 +/- .06 in the VS., Conclusion: A clinical prediction rule using four easily measurable characteristics can identify individuals at high or low risk of nursing home residence 6 months after hip fracture.

The objective of this project was to describe geriatric care provided under Medicare-risk contracts in HMOs with established Medicare programs. These findings provided the basis for an invitational workshop, sponsored by the National Institute on Aging and the Robert Wood Johnson Foundation, to formulate a research agenda for geriatric care in HMOs. The case study method involved site visits to seven HMOs by a physician with expertise in geriatrics, a managed care specialist, and a program development specialist. Representatives from the HMOs included senior executive officials, physicians recognized for providing and promoting geriatric care, research and program development staff, and various clinical staff including pharmacists, geriatric nurse practitioners, nurses, and social workers. The most frequently encountered geriatric care programs were categorized by the following six objectives: (1) identifying high risk patients, (2) assessing multi-problem patients, (3) treating multi-problem patients, (4) rehabilitating patients following acute events, (5) reducing medication problems, and (6) providing long-term care and home health care. Unique programs identified from these site visits included screening methods for new enrollees, approaches to comprehensive geriatric assessment, use of skilled nursing facilities for intensive rehabilitation and postacute care, and drug profiling and review. Utilization of geriatric nurse specialists and programs aimed at coordination with social services were pervasive in many of these HMOs. Workshop participants proposed several research and demonstration projects in all six areas. Overall consensus emerged that HMOs with Medicare-risk contracts provide a valuable setting for experimentation in geriatric care. Given the current health policy emphasis on managed care and capitated payment methodologies, geriatric care research in HMOs should be a high priority.

In a prospective study, 46 patients discharged from a teaching hospital to a "teaching unit" nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P less than .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P less than .01). Long-term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.