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Skilled nursing facilities (SNFs) are organizations that represent complex adaptive systems, offering barriers to the implementation of quality improvement (QI) initiatives. The current article describes the authors' efforts to use the approach of reflective adaptive process to implement a new model of care (i.e., the Skilled Heart Unit Program) for effective heart failure (HF) care in one SNF. A team of stakeholders from the local hospital system and a local SNF was convened to design and implement this new model. Evaluation of the implementation processes confirmed the value of the implementation approach, which centered on team-based approaches, staff engagement, and flexibility of processes to respect the SNF's needs and culture. Interviews with facility staff and the administrator revealed their perceptions that the strategy resulted in better HF care, enhanced teamwork between staff and clinicians, and improved staff job satisfaction. This work provides a unique blueprint of strategic QI implementation for patients with HF in the SNF setting. [Journal of Gerontological Nursing, 47(5), 26-33.] [ABSTRACT FROM AUTHOR]

The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care ( OPTIMISTIC) project aims to reduce avoidable hospitalizations of long-stay residents enrolled in 19 central Indiana nursing facilities. This clinical demonstration project, funded by the Centers for Medicare and Medicaid Services Innovations Center, places a registered nurse in each nursing facility to implement an evidence-based quality improvement program with clinical support from nurse practitioners. A description of the model is presented, and early implementation experiences during the first year of the project are reported. Important elements include better medical care through implementation of Interventions to Reduce Acute Care Transfers tools and chronic care management, enhanced transitional care, and better palliative care with a focus on systematic advance care planning. There were 4,035 long-stay residents in 19 facilities enrolled in OPTIMISTIC between February 2013 and January 2014. Root-cause analyses were performed for all 910 acute transfers of these long stay residents. Of these transfers, the project RN evaluated 29% as avoidable (57% were not avoidable and 15% were missing), and opportunities for quality improvement were identified in 54% of transfers. Lessons learned in early implementation included defining new clinical roles, integrating into nursing facility culture, managing competing facility priorities, communicating with multiple stakeholders, and developing a system for collecting and managing data. The success of the overall initiative will be measured primarily according to reduction in avoidable hospitalizations of long-stay nursing facility residents. [ABSTRACT FROM AUTHOR]

Objectives To evaluate whether race influences agreement between screening results and documentation of cognitive impairment and delirium. Design Secondary data analysis. Setting An urban, public hospital and healthcare system. Participants Hospitalized older adults aged 65 and older admitted to general inpatient medical services evaluated for cognitive impairment (n = 851) and evaluated for delirium (n = 424). Measurements Cognitive impairment and delirium were measured in each participant using the Short Portable Mental Status Questionnaire ( SPMSQ) and the Confusion Assessment Method ( CAM), respectively, as the reference identification method. Clinical documentation of cognitive impairment and delirium was defined according to the presence of International Classification of Diseases, Ninth Revision ( ICD-9), codes from within 1 year before hospitalization through discharge for cognitive impairment or from hospital admission through discharge for delirium. Results Two hundred ninety-four participants (34%) had cognitive impairment based on SPMSQ performance, and 163 (38%) had delirium based on CAM results. One hundred seventy-one (20%) of those with cognitive impairment had an ICD-9 code for cognitive impairment, whereas 92 (22%) of those with delirium had an ICD-9 code for delirium. After considering age, sex, education, socioeconomic status, chronic comorbidity, and severity of acute illness, of those who screened positive on the SPMSQ, African Americans had a higher adjusted odds ratio ( AOR) than non-African Americans for clinical documentation of cognitive impairment ( AOR = 1.66, 95% confidence interval ( CI) = 0.95-2.89), and of those who screened negative on the SPMSQ, African Americans had higher odds of clinical documentation of cognitive impairment ( AOR = 2.10, 95% CI = 1.17-3.78) than non-African Americans. There were no differences in clinical documentation rates of delirium between African Americans and non-African Americans. Conclusion Racial differences in coding for cognitive impairment may exist, resulting in higher documentation of cognitive impairment in African Americans screening positive or negative for cognitive impairment. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effect of cognitive impairment on rehospitalization in older adults. Design One-year longitudinal study. Setting Medical service of an urban, 340-bed public hospital in Indianapolis between July 2006 and March 2008. Participants Individuals aged 65 and older admitted to the medical service (N = 976). Measurements Rehospitalization was defined as any hospital admission after the index admission. Participant demographics, discharge destination, Charlson Comorbidity Index, Acute Physiology Score, and prior hospitalizations were measured as the confounders. Participants were considered to have cognitive impairment if they had two or more errors on the Short Portable Mental Status Questionnaire. Results After adjusting for confounders, a significant interaction between cognitive impairment and discharge location was found to predict rehospitalization rate ( P = .008) and time to 1-year rehospitalization ( P = .03). Participants with cognitive impairment discharged to a facility had a longer time to rehospitalization (median 142 days) than participants with no cognitive impairment (median 98 days) (hazard ratio ( HR) = 0.77, 95% confidence interval ( CI) = 0.58-1.02, P = .07), whereas participants with cognitive impairment discharged to home had a slightly shorter time to rehospitalization (median 182 days) than those without cognitive impairment (median 224 days) ( HR = 1.15, 95% CI = 0.92-1.43, P = .23). These two nonsignificant HRs in opposite directions were significantly different from each other ( P = .03). Conclusion Discharge destination modifies the association between cognitive impairment and rehospitalization. Of participants discharged to a facility, those without cognitive impairment had higher rehospitalization rates, whereas the rates were similar between cognitively impaired and intact participants discharged to the community. [ABSTRACT FROM AUTHOR]

Background: The US Institute of Medicine has recommended an integrated, locally sensitive collaboration among the various members of the community, health care systems, and research organizations to improve dementia care and dementia research. Methods: Using complex adaptive system theory and reflective adaptive process, we developed a professional network called the "Indianapolis Discovery Network for Dementia" (IDND). The IDND facilitates effective and sustainable interactions among a local and diverse group of dementia researchers, clinical providers, and community advocates interested in improving care for dementia patients in Indianapolis, Indiana. Results: The IDND was established in February 2006 and now includes more than 250 members from more than 30 local (central Indiana) organizations representing 20 disciplines. The network uses two types of communication to connect its members. The first is a 2-hour face-to-face bimonthly meeting open to all members. The second is a web-based resource center (http://www.indydiscoverynetwork.org). To date, the network has: (1) accomplished the development of a network website with an annual average of 12,711 hits per day; (2) produced clinical tools such as the Healthy Aging Brain Care Monitor and the Anticholinergic Cognitive Burden Scale; (3) translated and implemented the collaborative dementia care model into two local health care systems; (4) created web-based tracking software, the Enhanced Medical Record for Aging Brain Care (eMR-ABC), to support care coordination for patients with dementia; (5) received more than USD$24 million in funding for members for dementia-related research studies; and (6) adopted a new group-based problem-solving process called the "IDND consultancy round." Conclusion: A local interdisciplinary "think-tank" network focused on dementia that promotes collaboration in research projects, educational initiatives, and quality improvement efforts that meet the local research, clinical, and community needs relevant to dementia care has been built. [ABSTRACT FROM AUTHOR]