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BACKGROUND US nursing homes (NHs) have struggled to overcome a historic pandemic that laid bare limitations in the number and clinical expertise of NH staff. PROBLEM For nurse staffing, current regulations require only one registered nurse (RN) on duty 8 consecutive hours per day, 7 days per week, and one RN on call when a licensed practical/vocational nurse is on duty. There is no requirement for a degreed or licensed social worker, and advanced practice registered nurses (APRNs) in NHs cannot bill for services. APPROACH It is time to establish regulation that mandates a 24-hour, 7-day-a-week, on-site RN presence at a minimum requirement of 1 hour per resident-day that is adjusted upward for greater resident acuity and complexity. Skilled social workers are needed to improve the quality of care, and barriers for APRN billing for services in NHs need to be removed. CONCLUSIONS Coupling enhanced RN and social work requirements with access to APRNs can support staff and residents in NHs.

Objectives 1) Explain the financial benefit of potential revenue recapture (PRR) for non-billable days due to hospitalizations of nursing home (NH) residents using a six-year longitudinal analysis of 11 of 16 NHs participating in the Missouri Quality Initiative (MOQI); and 2) Discuss the work-flow benefits of early detection of changes in health status using qualitative data from all MOQI homes. Design A CMS funded demonstration project with full-time advanced practice registered nurses (APRN) and operations support team focused on reducing avoidable hospitalizations for long stay NH residents (2012–2020). Setting and Participants Setting was a sample of 11 of 16 US NHs participating in the CMS project. The NHs ranged in size between 121 and 321 beds located in urban and rural areas in one midwestern geographic region. Methods Financial and occupancy data were analyzed using descriptive methods. Data are readily available from most NH financial systems and include information about short and long stay residents to calculate non-billable days due to hospitalizations. Average hospital transfer rates per 1000 resident days were used. Qualitative data collected in MOQI informed the work-flow benefits analysis. Results There was over $2.6 million in actual revenue recapture due to hospitalization of long stay residents in the 11 participating NHs during five years, 2015–2019, with 2014 as baseline; savings to payers was more than $31 million during those same years. The PRR for both short and long stay residents combined totaled $32.5 million for six years (2014–2019); for each NH this ranged from $590,000 to over $5 million. On average, an additional $500,000 of revenue each year per 200 beds could have been recaptured by further reducing hospitalizations. Workflow improved for nurses and nursing assistants using INTERACT and focusing on early detection of health changes. Conclusions Reducing avoidable hospitalizations reduces costs to payers and increases revenue by substantially recapturing revenue lost each day of hospitalization. Implications Focusing nursing staff on early illness recognition and management of condition changes within NHs has benefits for residents as the stress of hospital transfer and resulting functional decline is avoided. Nurses and nursing assistants benefit from workflow improvements by focusing on early illness detection, managing most condition changes within NHs. NHs benefit financially from increased revenue by reducing empty bed days.

Care transitions (CT) are critical junctures in the healthcare delivery process. Effective transitions reduce the need for subsequent transfers between healthcare settings, including nursing homes. Understanding social services (SS) involvement in these processes in nursing homes is important from a quality and holistic care perspective. Using logistic regression, this study examines structural and relational factors identified with higher involvement of SS in care transitions and admissions. SS directors from 924 nursing homes were evaluated in relation to SS involvement in care transitions and admissions processes. Results suggest the level of SS involvement in care transitions and admissions are associated with structural factors such as size of facility, geographical location, ratio of FTE's to beds, ownership status, and standalone SS departments, as well as relational factors, including perceptions and utilization of SS staff by facility leadership, coworkers, and family. Additionally, SS staff with higher levels of expertise and with social work degrees are less involved in admissions tasks.

Nursing home (NH) residents have high psychosocial needs related to illness, disability, and changing life circumstances. The staff member with the most expertise in addressing psychosocial needs is the social worker. However, federal regulations indicate that only NHs with 120+ beds need hire a social services staff member and that a "qualified social worker" need not have a social work degree. Therefore, two-thirds of NHs are not required to employ a social services staff member and none are required to hire a degreed social worker. This is in stark contrast to NASW professional standards. Reporting findings from this nationally representative sample of 924 social services directors, we describe the NH social services workforce and document that most NHs do hire social services staff, although 42% of social services directors are not social work educated. 37% of NHs have a degreed and licensed social worker at the helm of social services. The odds of hiring a degreed and licensed social workers are higher for larger NHs, especially if not-for-profit and not part of a chain. NH residents deserve psychosocial care planned by staff with such expertise. Quality of psychosocial care impacts quality of life.

By 2030 more people in the United States will be older than age sixty-five than younger than age five. Our health care system is unprepared for the complexity of caring for a heterogenous population of older adults-a problem that has been magnified by the coronavirus disease 2019 (COVID-19) pandemic. Here, as part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we identify six vital directions to improve the care and quality of life for all older Americans. The next administration must create an adequately prepared workforce; strengthen the role of public health; remediate disparities and inequities; develop, evaluate, and implement new approaches to care delivery; allocate resources to achieve patient-centered care and outcomes, including palliative and end-of-life care; and redesign the structure and financing of long-term services and supports. If these priorities are addressed proactively, an infrastructure can be created that promotes better health and equitable, goal-directed care that recognizes the preferences and needs of older adults.

Advance directive (AD) completion can improve transitions between hospitals and skilled nursing facilities (SNF's). One Centers for Medicare and Medicaid Services (CMS) Innovations Demonstration Project, The Missouri Quality Initiative (MOQI), focused on improving AD documentation and use in sixteen SNF's. The intervention included education, training, consultation and improvements to discussion process, policy development, increased AD enactment, and increased community education and awareness activities. An analysis was conducted of data collected from annual chart inventories occurring over four years. Using a logistic mixed model, results indicated statistical significance (

Background: The COVID-19 pandemic disproportionately affected the older adult population, especially those in nursing homes (NHs). However, there is also evidence that some NHs fared better than others. Objectives: This study examines a set of nursing home related factors to understand whether these factors are associated with the number of COVID-19 cases. Design: We combined three datasets from the Centers for Medicare & Medicaid Services (CMS) – the Star Rating Dataset, the Provider Information Dataset, and the COVID-19 Nursing Home Dataset. Setting and Participants: 4390 NHs that responded to the CMS survey. Methods: Data used is from the period of Jan 1–Dec 27, 2020 for all 12 Midwestern states. The measures used were self-reported information on ratings, staff shortages, PPE shortage, number of beds, Registered Nurse (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA) hours per resident, star rating and ownership. Results: Of the 4390 NHs in 12 Midwestern states, high performing NHs were less likely to have more than 30 COVID-19 cases versus low-performing facilities for two of the CMS domains (health inspections, 520 NHs [27.6%] vs 1363 NHs [72.4%]; and staffing 773 NHs [41.1%] vs 1110 NHs [58.9%]). There was also a statistically significant association COVID-19 cases and star rating, NH ownership, NH size, RN, LPN, and CNA staffing in NHs (all p ≤ 0.01). NH ownership status persisted as a predictor of COVID 19 cases when controlled for NH size. Conclusions: Our study highlights two interesting findings. A) a statistically significant association between NH ownership structure and COVID-19 cases among residents - for-profit NHs had higher number of COVID-19 cases B) a statistically significant negative association between RN and CNA staffing and COVID-19 cases (i.e., more staffing hours of RNs and CNA correlated with a smaller number of COVID-19 cases) and a statistically significant positive association between LPN staffing and COVID-19 cases. We discuss ensuing policy implications for NHs.

The purpose of this article is to present six-year findings of the Missouri Quality Initiative (MOQI) to reduce unnecessary hospitalizations for long-stay nursing home residents. A CMS funded demonstration project analyzed over 6-years using a single group design. The setting was 16 Midwestern US nursing homes ranging in size between 121 and 321 beds located in urban and rural areas in one geographic region. The sample of eligible residents averaged from 1819 in 2014 to 1068 in 2019. Resident data were analyzed using descriptive methods of aggregate facilities’ hospital transfer rates per 1000 resident days and changes per year of average hospital transfer rates. Individual facility transfer rates were grouped by level of performance (best, mixed, and low). Leadership turnover and engagement were also described. Full-time advanced practice registered nurses (APRN) and an operations support team focused on reducing unnecessary hospitalizations for long-stay nursing home residents. Total transfers for 2014–2019 was 6913 and the average transfer rate per 1000 resident days declined from 2.48 in 2014 to a low of 1.89 in 2018 and slightly increased to 1.99 in 2019. Eleven nursing homes achieved sustained improvement, five did not. Differences in leadership turnover and engagement were noted by level of performance; however, three outlier facilities were identified. The MOQI intervention achieved improved outcomes over six-years in the majority of nursing homes in the project. The embedded APRN’s daily focus on project goals supported by a multi-disciplinary operations team facilitated success. Facility leadership stability and engagement in the project likely contributed to outcomes. Full-time presence of APRNs coupled with an operations’ support team improved nursing homes outcomes, however Medicare currently restricts APRNs hired by nursing homes from billing Medicare for direct care services. This unnecessary restriction of practice discourages nursing homes from hiring APRNs and should be abolished.

Background There is a need to adopt evidence-based approaches to discharge planning in the skilled nursing facility (SNF) short stay population. Purpose This article describes implementation of the Reengineered Discharge (RED) process in SNFs and makes recommendations for its future implementation. Methods The methods included a pre- and postanalysis of an 18-month RED implementation with a contemporaneous comparison of 4 Midwestern SNFs randomly assigned to 2 different RED implementation strategies. The Standard facilities received less implementation than Enhanced facilities. Results Standard SNFs made more improvements and were more satisfied with the improved process than Enhanced SNFs. Field notes revealed that corporate willingness to make process changes impacted the Standard group's capacity for change; both groups were heavily influenced by external forces, and turnover was an impediment to RED implementation. Conclusion This research revealed that discharge processes are similar across settings and that evidence-based programs such as RED can be adapted to the SNF setting.

To address the self-care needs of African American family caregivers, a community-engaged approach was used to develop and implement a half-day virtual self-care program. This study evaluates experiences of program attendees. All attendees were emailed an electronic survey containing Likert-type and open-ended questions. Responses were examined for patterns and key content-related categories using inductive content analysis. Eleven attendees responded to the survey. All 11 strongly agreed (64%) or agreed (36%) that the event met their expectations and/or needs. In addition to providing opportunity to take time to engage in self-care, the event created a virtual space for women to focus on themselves. Women spoke about three distinct ways the event met their needs: (1) learning and trying new things, (2) access to resources, and (3) having a shared experience. These findings suggest that virtual programs may be used as an additional resource to support the health of African American women caregivers.

While previous studies have evaluated the impact of education interventions on knowledge and attitudes about Alzheimer’s disease and other dementias (Kaf, Barboa, Fisher, & Snavely, 2011; Kimzey, Mastel-Smith, & Alfred, 2016; Yamashita, Kinney, & Lokon, 2011), there is little research about the impact on knowledge and attitudes about issues related to caregivers of those with dementia. This paper reports on the results of an education intervention to increase college students’ knowledge, and positive attitudes on memory loss, Alzheimer’s disease and other dementias, and related caregiver issues. The intervention consisted of a series of lectures and readings, including a caregiver memoir. The intervention was conducted in social work and nursing classes over two semesters. A questionnaire, using established scales that measured knowledge and attitudes about dementia and caregiving issues, was administered to the students using a pretest-posttest design. The educational intervention tested successfully increased knowledge and positive attitudes about Alzheimer’s disease, dementia, memory loss, and caregiving (p=.0001). This finding held across courses, grade levels, previous experience with older adults, knowledge of someone with memory loss, and relationships with caregivers and persons with memory loss. A memoir as a storytelling informational narrative, and structured lectures and readings served as effective learning tools that influenced both knowledge and attitude levels about Alzheimer’s disease, dementia, memory loss, and caregiving. Gains made in knowledge and attitude changes were true for both face- to- face and online teaching venues. Implications for training, classroom teaching, and workforce development will be discussed.

The importance of health information technology use in nursing home (NH) care delivery is a major topic in research exploring methods to improve resident care. Topics of interest include how technology investments, infrastructure, and work-force development lead to better methods of nursing care delivery and outcomes. Value propositions, including perceived benefits, incentives, and system changes recognized by end-users, are important resources to inform NH leaders, policymakers, and stakeholders about technology. The purpose of the current research was to identify and disseminate value propositions from a community of stakeholders using a health information exchange (HIE). Researchers used a nominal group process, including 49 individual stakeholders participating in a national demonstration project to reduce avoidable hospitalizations in NHs. Stakeholders identified 41 total anticipated changes from using HIE. Ten stakeholder types were perceived to have experienced the highest impact from HIE in areas related to resident admissions, communication, and efficiency of care delivery. [ Journal of Gerontological Nursing, 48 (1), 15–20.]

Objectives To measure the impact of advanced practice nurses (APRNs) on quality measures (QM) scores of nursing homes (NHs) in the CMS funded Missouri Quality Initiative (MOQI) that was designed to reduce avoidable hospitalizations of NH residents, improve quality of care, and reduce overall healthcare spending. Design A four group comparative analysis of longitudinal data from September 2013 thru December 2019. Setting NHs in the interventions of both Phases 1 (2012–2016) and 2 (2016–2020) of MOQI (n=16) in the St. Louis area; matched comparations in the same counties as MOQI NHs (n=27); selected Phase 2 payment intervention NHs in Missouri (n=24); NHs in the remainder of the state (n=406). Participants NHs in Missouri Intervention: Phase 1 of The Missouri Quality Initiative (MOQI), a Centers for Medicare and Medicaid (CMS) Innovations Center funded research initiative, was a multifaceted intervention in NHs in the Midwest, which embedded full-time APRNs in participating NHs to reduce hospitalizations and improve care of NH residents. Phase 2 extended the MOQI intervention in the original intervention NHs and added a CMS designed Payment Intervention; Phase 2 added a second group of NHs to receive the Payment. Intervention Only. Measurements Eight QMs selected by CMS for the Initiative were falls, pressure ulcers, urinary tract infections, indwelling catheters, restraint use, activities of daily living, weight loss, and antipsychotic medication use. For each of the monthly QMs (2013 thru 2019) an unobserved components model (UCM) was fitted for comparison of groups. Results The analysis of QMs reveals that that the MOQI Intervention + Payment group (group with the embedded APRNs) outperformed all comparison groups: matched comparison with neither intervention, Payment Intervention only, and remainder of the state. Conclusion These results confirm the QM analyses of Phase 1, that MOQI NHs with full-time APRNs are effective to improve quality of care.

Previous studies examined factors influencing an increase in good health and quality of life among American Indian Elders (AIEs). However, there is a lack of research regarding the role of technolo...

OBJECTIVES We explored the differences in potentially avoidable/unavoidable hospital transfers in a retrospective analysis of Interventions to Reduce Acute Care Transfers (INTERACT) Acute Transfer Tools (ACTs) completed by advanced practice registered nurses (APRNs) working in the Missouri Quality Improvement (QI) Initiative (MOQI). DESIGN Cross-sectional descriptive study of 3996 ACTs for 32.5 calendar months from 2014 to 2016. Univariate analyses examined differences between potentially avoidable vs unavoidable transfers. Multivariate logistic regression analysis of candidate factors identified those contributing to avoidable transfers. SETTING Sixteen nursing homes (NHs), ranging from 120 to 321 beds, in urban, metro, and rural communities within 80 miles of a large midwestern city. PARTICIPANTS A total of 5168 residents with a median age of 82 years. MEASUREMENTS Data from 3946 MOQI-adapted ACTs. RESULTS A total of 54% of hospital transfers were identified as avoidable. QI opportunities related to avoidable transfers were earlier detection of new signs/symptoms (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 1.61-3.42; P

In 1987, The Nursing Home Reform Act was enacted as part of the Omnibus Reconciliation Act of 1987 (OBRA 87). At that time, the Health Care Finance Administration (now Centers for Medicare and Medicaid Services) issued comprehensive regulations and survey processes to “ensure that residents of nursing homes receive quality care that will result in their highest practicable physical, mental, and social well-being.” Despite this landmark legislation, nursing homes struggle to provide quality care, and are additionally challenged by natural disasters and pandemics. This presentation will report on recommendations that examine, structures, policies, and care models that promote change and innovation, with a focus on safety, environmental modifications, patient centered approaches, and quality care. Dr. Colleen Galambos, a professor at University of Wisconsin-Milwaukee, with expertise in nursing home care delivery and quality improvement will present the care delivery recommendations from the NASEM report.

While most of the nursing home literature focuses on residents and nurses, there is a growing literature on social services staff and family members of nursing home residents. Social services staff include social workers as well as non-social workers with responsibility for assessing and care planning for resident psychosocial issues, as well as a host of other responsibilities including working with families. This symposium presents findings from the National Nursing Home Social Services Directors Survey (NNHSSDS), a cross-sectional (2019) nationally representative study (n=924) that collected data on social services staff characteristics, departmental role responsibilities, and training needs. In this session three papers developed from these data are presented to document the extent to which social services staff are involved with family members, their interest in receiving training on how they can support other staff in understanding resident abuse and exploitation (at the hands of family, fellow residents, or staff), and neglect. As demanding as the social services role is, many holding the position of social services director report they are thriving (not just surviving) in the role. A final paper describes which variables help to distinguish those who report they are thriving versus those who do not. Implications to be discussed include what administrators could do to make the social services director’s job more attractive. The RRF Foundation for Aging provided data collection support for the NNHSSDS.

As the population of older adults in the U.S. increases, the need for family caregivers will mirror this growth. Despite a greater intensity of caregiving, African American caregivers are less likely to access formal support services and engage in self-care practices. To address the self-care needs of African American family caregivers, a community-engaged approach was used to develop and implement a half-day virtual self-care program. The development of the program was guided by the Individual and Family Self-Management Theory. This study evaluates experiences of program attendees. The specific aims are to examine the acceptability and practicality of the virtual self-care program. Women who self-identified as African American and a caregiver (i.e., taking care of another adult) were personally invited to attend. All attendees were emailed an electronic survey containing Likert-type and open-ended questions. Responses were examined for patterns and key content-related categories using inductive content analysis. Eleven of the sixteen attendees responded to the survey. All eleven strongly agreed (64%) or agreed (36%) that the event met their expectations and/or needs. In addition to providing opportunity to take time to engage in self-care, the event created a virtual space for women to focus on themselves. Women spoke about three distinct ways the event met their needs: 1) learning and trying new things, 2) access to resources, and 3) having a shared experience. These findings suggest that virtual programs may be used as an additional resource to support the health of African American women who care for older adults.

Advance care planning involves a meaningful conversation about residents' end of life goals with the health-care team and documenting these wishes in advance directives; however, these conversations are not taking place early enough or with strategies that allow nursing home residents' preferences to be meaningfully integrated into care plans. This article outlines a new model that nursing home social workers can use to initiate advance care planning discussions called Take it to the Resident. This model was tested with 11 long-term stay nursing home residents. Data were collected through structured memos and field notes. Summative content analysis was utilized to analyze the data. Take it to the Resident facilitated a discussion about advance care planning and allowed residents to consider their wishes before engaging family members. Although discussions took place, some residents were hesitant to document their wishes formally through advance directives. The results of this study support the utility of continued testing of this model. Having empirically supported tools for nursing home social workers is critical to increasing advance care planning conversations and empowering residents to document their wishes.

The Re-Engineered Discharge (RED) program, designed for hospitals, is being trialed in skilled nursing facilities (SNFs) with promising results. This paper reports on the quantitative results of a multimethod study testing two different RED program implementation strategies in SNFs. A pretest-posttest design was used to compare utilization outcomes of two different RED implementation strategies (Enhanced and Standard) and overall group differences in four Midwestern SNFs. In the Standard group there were higher odds of being readmitted in the pre-intervention versus post-intervention period. After adjusting coefficients using Poisson regression, in the pre-intervention period the adjusted number of rehospitalizations for the Standard group was 45% higher at 30 days, 50% higher at 60 days ( p = .01), and 39% higher at 180 days ( p = .001). SNF RED may be a useful program to reduce rehospitalizations after discharge. Benefit of SNF RED is dependent on degree of adoption of the intervention.

Dear Editor, As the impacts of COVID-19 on nursing facilities became apparent, the members of the U.S. based National Nursing Home Social Work Network (NNHSWN) immediately considered what it could ...

The current study explored the perceptions of health care providers' use of electronic advance directive (AD) forms in the electronic health record (EHR). The Technology Acceptance Model (TAM) was used to guide the study. Of 165 surveys distributed, 151 participants (92%) responded. A moderately strong positive correlation was noted between perceived usefulness and actual system usage ( r = 0.70, p < 0.0001). Perceived ease of use and actual system usage also had a moderately strong positive correlation ( r = 0.70, p < 0.0001). In contrast, the strength of the relationship between behavioral intention to use and actual system usage was more modest ( r = 0.22, p < 0.004). There was a statistically significant difference in actual system usage of electronic ADs across six departments (χ 2 [5] = 79.325, p < 0.001). The relationships among primary TAM constructs found in this research are largely consistent with previous TAM studies, with the exception of behavioral intention to use, which is slightly lower. These data suggest that health care providers' perceptions have great influence on the use of electronic ADs. [ Journal of Gerontological Nursing, 45 (1), 17–21.]

In current standard practice, without a structured process for delirium follow up, older individuals and their family caregivers seemed to be lost, as they transitioned from hospital to home. The aim of this study was to pilot test a theoretical post-hospital model of care (DDEFY delirium) to mitigate the complications in patients who had hospital delirium. This is a pilot feasibility randomized controlled trial for patients with hospital delirium. The intervention was carried out by a delirium transitions nurse with personalized interdisciplinary team recommendations. DDEFY delirium intervention encompasses: Diagnose cognitive disorder; review Drugs; Educate patient/family; assess Function; Your health goals. During COVID-19 pandemic a virtual intervention group was created. Thus, three groups were analyzed: control, intervention, and virtual intervention. Among the 35 participants (mean age 80 years (SD10), 40% Black, 46% female), 40% had a diagnosis of dementia, mean Charles Deyo score was 6.4, mean number of medications 11.4 (3.2), and a mean anticholinergic medication burden was 2.4. The intervention group and virtual intervention group rates were: recruitment: 44.6 %vs8.8%, feasibility: 97%vs97%, fidelity:100%vs100%, 30-day readmission 28.6%vs0%, and 30-day ED visits: 0 vs.1. There were no differences in 30-day readmission rates between control vs intervention (p=1.0), control vs virtual intervention (p=.53), nor comparing all 3 groups (p=.49). The results of this pilot study determined that delivering DDEFY intervention to patients with delirium is feasible. Lessons learned from conducting this study will help us design a larger trial with modifications for older patients with delirium who transition from hospital to home.

COVID-19 has been devastating for Nursing Homes (NHs). The concentration of older adults with underlying chronic conditions inevitably made the setting highly vulnerable leading to high rates of mortality for residents. However, some nursing homes fared better than others. This study examines several quality measures and organizational factors to understand whether these factors are associated with COVID-19 cases in Wisconsin. We combined three datasets from Centers for Medicare & Medicaid Services (CMS) – the Star Rating dataset, Provider Information dataset and COVID-19 Nursing Home dataset. Data used is from the period of Jan 1 – Oct 25, 2020 for the state of Wisconsin. The analysis includes 331 free-standing NHs with no missing values from the data sets. The variables used were self-reported information on nursing home ratings, staff shortage, staff reported hours, occupancy rate, number of beds and ownership. Of the 331 NHs examined, shortages were reported of 25.4%, 31.1%, 3.2% and 15.6% of licensed nurse staff (25.4%), nurse aides (31.1%), clinical staff, (3.2%) and other staff (15.6%) Additionally, there was a significant (p

This qualitative study is part of a larger randomized prospective intervention study that examined the clinical and cost effectiveness of using sensor data from an environmentally embedded sensor system for early illness recognition. It explored the perceptions of older adults and family members on the sensor system's usefulness, impact on daily routine, privacy, and sharing of health information. This study was conducted in 13 assisted-living facilities in Missouri, and 55 older adults were interviewed. Data were collected over five points in time with a total of 188 interviews. From these five participant interview iterations, the following themes emerged: (1) understanding and purpose, (2) daily life and benefits, (3) impact on privacy, and (4) sharing of information. Three themes emerged from one round of family interviews: (1) benefits of bed sensors, (2) family involvement/staff interaction, and (3) privacy protection versus sensor benefits. The sensor suite was regarded as helpful in maintaining independence, health, and physical functioning. Responses suggest that the willingness to adopt the sensor suite was motivated by both a decline in functional status and a desire to remain independent. Participants were willing to share their health data with providers and select family members. Recommendations for future practice are provided.

As part of an intervention to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions, 1,877 resident records were reviewed for advance directive (AD) documentation. At the initial phases of the intervention, 50 percent of the records contained an AD. Of the ADs in the resident records, 55 percent designated a durable power of attorney for health care, most often a child (62 percent), other relative (14 percent), or spouse (13 percent). Financial power of attorney documents were sometimes found within the AD, even though these documents focused on financial decision making rather than health care decision making. Code status was the most prevalent health preference documented in the record at 97 percent of the records reviewed. The intervention used these initial findings and the philosophical framework of respect for autonomy to develop education programs and services on advance care planning. The role of the social worker within an interdisciplinary team is discussed.

This paper examines the evidence to support the need to translate current research into health care practices about social isolation and loneliness (SIL) among older adults. The health care system may be in the best position to identify those at highest risk—namely, older adults, whose only interactions are with members of the health care system. This paper reviews recommendations related to periodic assessments, including the use of validated tools to identify those at highest risk. Through this identification, clinicians and health care researchers may be able to use these findings to better target meaningful clinical and public health interventions. Additionally, a critical step toward preventing, mitigating, or eliminating negative health impacts will be to improve awareness about the problem and impact of SIL within the older adult population. This paper reviews recommendations for improving overall awareness by including SIL in national health strategies and public campaigns. Part of a symposium sponsored by Loneliness and Social Isolation Interest Group.

Social isolation and loneliness (SIL) are serious yet underappreciated public health risks for many older adults (AARP, 2018a). Strong evidence suggests that, for older adults, social isolation and loneliness are associated with an increased likelihood of early death, dementia, heart disease, and more (AARP, 2018b, Holt-Lunstad and Smith, 2016). While all ages may experience SIL, older adults are at increased risk because they are more likely to face predisposing factors such as living alone, the loss of family or friends, chronic illness, and sensory impairments. Health care providers may be in the best position to identify older individuals who are at highest risk for SIL – individuals for whom the health care system may be the only point of contact with their broader community. The National Academies of Sciences, Engineering, and Medicine (NASEM) developed a consensus study report on this issue. This symposium presents the study recommendations. Dr. Holt-Lunstad examines the recommendations to develop a more robust evidence base for effective assessment, prevention, and intervention strategies for social isolation and loneliness. Dr. Galambos examines the recommendations to translate current research into health care practices and to improve awareness of the health and medical impacts of SIL. Dr. Lustig examines the recommendations to strengthen ongoing education and training and to strengthen ties between the health care system and community-based resources. Dr. Demiris examines the role of technology across all of these recommendations. Loneliness and Social Isolation Interest Group Sponsored Symposium

This article describes our recommendation for adapting hospital-based RED (Reengineered Discharge) processes to skilled nursing facilities (SNFs). Using focus groups, the SNFs’ discharge processes were assessed twice additionally, research staff then recorded field notes documenting discussions about facility discharge processes as they related to RED processes. Data were systematically analyzed using thematic analysis to identify recommendations for adapting RED to the SNF setting including (a) rapidly identifying, involving, and preparing family/caregivers to implement a patient focused SNF discharge plan; (b) reconnecting patients quickly to primary care providers; and (c) educating patients at discharge about their target health condition, medications, and impact of changes on other chronic health needs. Limited SNF staff capacity and corporate-level policies limited adoption of some key RED components. Transitional care processes such as RED, developed to avoid discharge problems, can be adapted for SNFs to improve their discharges.

The Missouri Quality Initiative’s (MOQI) aim to reduce potentially avoidable hospitalizations among long stay nursing facility residents was achieved through: (1) condition management; (2) early illness detection; (3) use of INTERACT and Quality Improvement; (4) end-of-life and care transitions discussions; (5) improved communication using health information technology. Advanced Practice Registered Nurses (APRN’s) were embedded in each facility supported by a team including a master’s prepared social work care transitions coach (CTC). The MOQI achieved a 40% reduction in all cause hospitalizations and a 57.7% reduction in potentially avoidable hospitalizations (p=001); all cause visits were reduced by 54.1%, and potentially avoidable ED visits reduced by 65.3% (p=0.001). Highlights of the model and use of the CTC, discussion of results, integration of social service departments, and implications for practice will be presented.

Re-engineered (RED) Discharge Process has been effective in hospitals but little tested in SNFs. This study tested the effect of an 18-month adapted RED implementation in four Midwestern SNFs on 30, 60, 180 day hospital, SNF, and emergency department (ED) readmissions. The sample included 1026 SNF residents discharged to the community during 2013 (n = 526) and 2015 (n = 500). We used Medicare claims Data and Minimum Data Set (3.0) File to identify SNF admissions and readmissions to SNF, acute care, or ED. Data were linked across all four facilities by year and compared using appropriate statistics for descriptive, comparison, and regression tests. Residents discharged in 2013 had statistically significantly higher Charlson Comorbidity Scores 4.65 vs 3.97 in 2015 (p < 0.01), while those discharged in 2015 had significantly worse cognitive status, mood, and ADL self-performance. Overall, rates and number of 30, 60-day, 180 rehospitalization, SNF readmission, ED visits with rehospitalization were lower for all 2015 compared to 2013, but not statistically significantly different, except for the number of 180-day rehospitalizations in 2015. Likewise, the only statistically significantly different result was in the regression model was 180 day rehospitalizations. However, in the two facilities that had the best uptake of the intervention, numbers of readmissions were lower at 60 and 180 days (p=.0106 and .0013, respectively for regression results). SNF RED may be a useful tool for SNFs to use to reduce rehospitalizations after discharge; however, benefit depends on the degree of adoption of the intervention.

In July of 2015, the Federal Register published for public comment proposed rule changes for nursing homes certified to receive Medicare and/or Medicaid. If the final rules are similar to the proposed rules, they will represent the largest change in federal rules governing nursing homes since the Nursing Home Reform Act which was part of OBRA 1987. The proposed changes have the potential to enhance the quality of care and quality of life of nursing home residents. Many of the proposed changes would directly affect the practice of social work and would likely expand the role for nursing home social workers. This article discusses the role that members of the National Nursing Home Social Work Network (NNHSW Network) played in developing and submitting a response to CMS. The article provides the context for the publication of the proposed rules, describes the process used by the NNHSW Network to develop and build support for comments on these rules, and also includes the actual comments submitted to CMS. Social work education programs and continuing education programs throughout the country will continue to have an important role to play in helping to prepare social work students and practitioners for a career in long-term care.