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Two-thirds of older adults have multimorbidity (MM), or co-occurrence of two or more medical conditions. Mild cognitive impairment (CI) is found in almost 20% of older adults and can lead to further cognitive decline and increased mortality. Older adults with MM are the primary users of home health care services and are at high risk for CI development; however, there is no validated cognitive screening tool used to assess the level of CI in home health users. Given the prevalence of MM and CI in the home health setting, we conducted a review of the literature to understand this association. Due to the absence of literature on CI in home health users, the review focused on the association of MM and CI in community-dwelling older adults. Search terms included home health, older adults, cognitive impairment, and multimorbidity and were applied to the databases PubMed, CINAHL, and PsychInfo leading to eight studies eligible for review. Results show CI is associated with MM in older adults of increasing age, among minorities, and in older adults with lower levels of education. Heart disease was the most prevalent disease associated with increased CI. Sleep disorders, hypertension, arthritis, and hyperlipidemia were also significantly associated with increased CI. The presence of MM and CI was associated with increased risk for death among older adults. Further research and attention are needed regarding the use and development of a validated cognitive assessment tool for home health users to decrease adverse outcomes in the older adult population.

Information does not yet exist on the characteristics and outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) who are discharged to the home setting. Using rich data from home health care (HHC), the authors describe characteristics of COVID-19 survivors upon admission to HHC, the home visits they received, and the extent of recovery among those discharged from HHC. They also profile the risk factors associated with rehospitalization and death., Background: Little is known about recovery from coronavirus disease 2019 (COVID-19) after hospital discharge. Objective: To describe the home health recovery of patients with COVID-19 and risk factors associated with rehospitalization or death. Design: Retrospective observational cohort. Setting: New York City. Participants: 1409 patients with COVID-19 admitted to home health care (HHC) between 1 April and 15 June 2020 after hospitalization. Measurements: Covariates and outcomes were obtained from the mandated OASIS (Outcome and Assessment Information Set). Cox proportional hazard models were used to estimate the hazard ratio (HR) of risk factors associated with rehospitalization or death. Results: After an average of 32 days in HHC, 94% of patients were discharged and most achieved statistically significant improvements in symptoms and function. Activity-of-daily-living dependencies decreased from an average of 6 (95% CI, 5.9 to 6.1) to 1.2 (CI, 1.1 to 1.3). Risk for rehospitalization or death was higher for male patients (HR, 1.45 [CI, 1.04 to 2.03]); White patients (HR, 1.74 [CI, 1.22 to 2.47]); and patients with heart failure (HR, 2.12 [CI, 1.41 to 3.19]), diabetes with complications (HR, 1.71 [CI, 1.17 to 2.52]), 2 or more emergency department visits in the past 6 months (HR, 1.78 [CI, 1.21 to 2.62]), pain daily or all the time (HR, 1.46 [CI, 1.05 to 2.05]), cognitive impairment (HR, 1.49 [CI, 1.04 to 2.13]), or functional dependencies (HR, 1.09 [CI, 1.00 to 1.20]). Eleven patients (1%) died, 137 (10%) were rehospitalized, and 23 (2%) remain on service. Limitations: Care was provided by 1 home health agency. Information on rehospitalization and death after HHC discharge is not available. Conclusion: Symptom burden and functional dependence were common at the time of HHC admission but improved for most patients. Comorbid conditions of heart failure and diabetes, as well as characteristics present at admission, identified patients at greatest risk for an adverse event. Primary Funding Source: No direct funding.

Limited functional status is a common health problem in patients living with heart failure (HF), which often requires rehospitalization.Home-based transitional telehealth programs (TTPs) focused on health monitoring, education, promotion of self-management, and multidisciplinary team consultation have been shown to improve functional status and satisfaction with care while reducing rehospitalization rates in this population. Nonetheless, these variables and outcomes have yet to be assessed in a Thai patient with HF. Thus, the aim of this study was to investigate the effectiveness of a TTP on functional status, rehospitalization, and satisfaction with care in Thai patients with HF. Eligible participants (N = 146) were randomly assigned to either the control or TTP group. The TTP included in-hospital discharge planning and 6-week telemonitoring via a mobile phone application to provide follow-up home care. Data on the outcome variables were collected at 6 and 8 weeks post-enrollment and analyzed by descriptive statistics, independent t-tests, repeated measures ANOVA, and Z-tests. Functional status and satisfaction with care scores in the TTP group were significantly higher than those of the control group, and rehospitalization rates in the TTP group were significantly lower than those of the control group at 6 and 8 weeks post-enrollment. Thus, the TTP effectively improved functional status, increased satisfaction with care, and reduced rehospitalization rates in Thai patients with HF. TTP implementation could be considered to improve the quality of transitional care in Thailand.

Home health care is one of the fastest growing health care sectors in the United States. However, little is known of differences in trends in quality performance between rural and urban home health agencies over time. This study aimed to examine disparities in quality performance between rural and urban home health agencies between 2014 and 2018.This is a cohort study using 2014-2018 national Home Health Compare data and Providers of Service Profile data, including 7,908 home health agencies, of which 1,537 were rural agencies. Quality performance measures included timely initiation of care, hospitalization, and emergency department (ED) visits. Two-level hierarchical regression models were used to identify rural-urban differences in these quality indicators over time when controlling organizational characteristics.Rural agencies were less likely to be for-profit and accredited, and more likely to be hospital-based, serve both Medicare and Medicaid beneficiaries, and have hospice programs. Rural agencies consistently outperformed on timely initiation of care over time, and urban agencies consistently outperformed on hospitalization and ED visits over time. These gaps between rural and urban agencies were steady over time except the gap in hospitalization, which slightly narrowed over time (Coef. = 0.11, P = .001 for urban and year interaction term).Significant differences exist in quality of care between rural and urban home health agencies and such differences have not been significantly narrowed over time. To reduce rural-urban disparities, policy makers should take into account unique challenges faced by urban and rural agencies when making policy decisions.

This study investigated the impact of an interprofessional mock code on students' comfort and competency related to Parkinson's disease (PD) medication administration during care transitions.Patients with PD are at increased risk for medication errors during hospitalization. Individualization of PD medication creates vulnerability during care transitions.Four interprofessional groups took part in this study: baccalaureate degree senior nursing students (n = 113), master's level nurse anesthesia students (n = 35), doctor of osteopathic medicine fourth-year students (n = 32), and doctor of clinical psychology fourth-year students (n = 22). Groups participated in an unfolding case study simulation involving a mock code with a focus on the omission of time-sensitive PD medication. Pre- and postsimulation test results were compared.Findings indicated an increased understanding among three of the four groups relating to medication timing during care transitions.All groups improved with respect to perceived comfort and competency.

During the pandemic, have you been looked down upon or dismissed by other healthcare professionals because you're ‘just’ a dental nurse? Melissa O'Connor addresses dentistry's damaged reputation and suggests dental nurses are the powerhouses of any practice

Background This protocol is based on home health care (HHC) best practice evidence showing the value of coupling timely post-acute care visits by registered nurses and early outpatient provider follow-up for sepsis survivors. We found that 30-day rehospitalization rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing visit within 2 days of hospital discharge, at least 1 more nursing visit the first week, and an outpatient provider follow-up visit within 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors who transitioned to HHC received this timely visit protocol. The opportunity exists for many more sepsis survivors to benefit from timely home care and outpatient services. This protocol aims to achieve this goal. Methods Guided by the Consolidated Framework for Implementation Research, this Type 1 hybrid pragmatic study will test the effectiveness of the Improving Transitions and Outcomes of Sepsis Survivors (I-TRANSFER) intervention compared to usual care on 30-day rehospitalization and emergency department use among sepsis survivors receiving HHC. The study design includes a baseline period with no intervention, a six-month start-up period followed by a one-year intervention period in partnership with five dyads of acute and HHC sites. In addition to the usual care/control periods from the dyad sites, additional survivors from national data will serve as control observations for comparison, weighted to produce covariate balance. The hypotheses will be tested using generalized mixed models with covariates guided by the Andersen Behavioral Model of Health Services. We will produce insights and generalizable knowledge regarding the context, processes, strategies, and determinants of I-TRANSFER implementation. Discussion As the largest HHC study of its kind and the first to transform this novel evidence through implementation science, this study has the potential to produce new knowledge about the impact of timely attention in HHC to alleviate symptoms and support sepsis survivor’s recovery at home. If effective, the impact of this intervention could be widespread, improving the quality of life and health outcomes for a growing, vulnerable population of sepsis survivors. A national advisory group will assist with widespread results dissemination.

Sepsis survivors have the second highest readmission rate among Medicare beneficiaries, next to heart failure. I-TRANSFER is an implementation science study to improve transitions and reduce readmissions among sepsis survivors transitioning from acute to home health care (HHC). A total of 63 semi-structured interviews were conducted with stakeholders among 12 hospitals and 5 affiliated home health agencies (HHAs). The purpose of this secondary analysis was to: 1) examine how the sepsis diagnosis is reflected in HHC documentation, 2) identify barriers in sepsis information transfer to HHC, 3) recommend a documentation strategy to enhance information transfer and HHC documentation. We analyzed the diagnosis coding within a national OASIS dataset and eight I-TRANSFER interviews with hospitalists, documentation specialists, and HHC coders. Findings include: a) sepsis diagnoses were nearly invisible in HHC records being documented for only 10% of 165,000 sepsis survivors transitioned to HHC, b) sepsis information in referral documentation can be unclear to HHC coders, c) the lack of sepsis diagnosis documentation might make HHC clinicians unaware of the patient’s risk for readmission, d) HHC coders recommended improved language in the acute care discharge summary to link the need for HHC to sepsis, thereby supporting the use of ICD-10 sepsis ‘A’ codes in HHC. The use of terms, such as “History of Sepsis” or “Sepsis Resolved,” leads to HHC using non-specific codes, thus is not recommended. We highlight the need for new ICD-10 codes for “Sepsis Aftercare” and “Post-Sepsis Syndrome” to clearly communicate and document the needs of sepsis survivors.

Heart failure (HF) affects approximately 26 million people globally resulting in morbidity, mortality, and rehospitalization. With 30-day rehospitalization rates ranging from 19% to 25%, HF is burdensome for patients and challenging for clinicians to manage. HF costs in the U.S. exceeded $30 billion in 2012, projected to exceed $70 billion by 2030, and produce estimated social care costs of 12 billion in 2020. Therefore, reducing HF readmissions should be a global priority. A technology-based platform may assist in the goal of reducing readmissions. This platform may accomplish this goal by providing several digital tools that can assist the clinician in the care process, while simultaneously enabling patients with self-care through more effective communication in all care settings. Digital twins (DT) and the nursing Avatar (NA) are two such tools. The DT is a virtual, real-time digital representation of a physical object/process. It originated from NASA to improve physical model simulation of spacecraft in 2010 (Wickramasinghe et al., 2021). It is possible to achieve similar benefits in healthcare by developing suitable DT of patients in specific clinical contexts (Wickramasinghe et al., 2021; Lui et al., 2019). So to, the NA was studied by Bickmore, et al (2209) and found ultimately to be the preferred discharge communication method. As such, we proffer the development of digital twins and NA for HF patients to support better provider decision and patient communication. This will result in HF care being more precise, consistent, reproducible, and personalized resulting in improved diagnosis, treatment, and care outcomes.

In North Dakota, 28% of adults over age 65 report falling each year, resulting in substantial morbidity and mortality. Evidence-based fall prevention programs can benefit quality of life and maintenance of daily living activities, particularly for community-dwelling older adults. The Stepping On fall prevention program, a national evidence-based program, is designed to educate older adults about risk factors for falls, safety strategies, and coping behaviors. The program consists of seven weekly community-based workshops conducted in a small-group setting by two trained facilitators. The Stepping On program was introduced in North Dakota in March 2012. Since that time, 132 workshops have taken place in rural communities across the state, serving 1,502 participants. The number of workshops and participants steadily grew between 2012 and 2019. In the year 2012-13, 127 individuals participated in ten workshops. By 2019, before the program was suspended during the pandemic, 199 individuals participated in 16 workshops; 24 workshops had previously been held in 2018. The current study discusses the implementation process as the program scaled up and expanded to more locations. The feasibility and sustainability of conducting the program in isolated rural areas, challenges encountered, and lessons learned will also be discussed. It is important that residents in rural communities have access to evidence-based programs like Stepping On so they can experience the benefits.

Mobility limitations in older adults are associated with negative outcomes including fear of falls (FOF) and poorer quality of life. However, self-reported symptoms contributing to mobility difficulty have not been fully explored as an area for intervention. The study aimed to identify the prevalence of self-reported symptom causes of difficulty walking and stair-climbing. In addition, we examined associations between symptoms and FOF in a population-based cohort of community-dwelling older adults in the MOBILIZE Boston Study. Of the 243 older adults who reported difficulty with walking one quarter of a mile or climbing stairs, 67% were women, 72% were white, average age=79.4y (SD=5.7). FOF was measured with the Tinetti Falls Efficacy Scale. Pain was most commonly reported as the primary symptom responsible for mobility difficulty (38.4%) followed by endurance (21.1%), multiple symptoms (15.6%), weakness (13.2%), balance (8.7%), other symptoms (2.9%). Factorial ANCOVA determined gender differences in associations between symptoms and FOF, adjusting for age. In pairwise comparisons, women who identified balance as their primary symptom had higher FOF than women identifying endurance (p=.017), pain (p=.015), other (p=.017), or multiple (p=.050) symptoms. There were no FOF differences for women identifying balance compared to weakness as the primary issue (p=.395). Men who identified balance as their primary symptom had higher FOF than those who identified pain (p=.036); no other FOF differences were noted in men identifying balance compared to other symptoms. Understanding common symptoms experienced by older adults, and symptoms associated with greatest FOF, will assist in developing tailored interventions for mobility improvement.

There are no national, empirically derived clinical decision support tools to assist the interprofessional home health team in determining readiness for discharge from skilled home health. Eliciting patient and family caregiver perspectives around readiness for home health discharge is integral to developing tools that address their needs in this decision-making process. The purpose of this study was to describe the factors home health patients and their family caregivers perceive as critical when determining readiness for discharge from services. A qualitative descriptive study was conducted among skilled home health recipients and their family caregivers who were either recently discharged or recertified for additional care from two different Medicare-certified skilled home health agencies. Nine themes emerged: self-care ability, functional status, status of condition(s) and symptoms, presence of a caregiver, support for the caregiver, connection to community resources/support, safety needs of the home environment addressed, adherence to the prescribed regimen, and care coordination.

Background: Type 1 diabetes (T1DM) is a chronic autoimmune disease that affects the body’s production of the hormone insulin. T1DM is diagnosed during childhood and adolescence and may have significant impacts on mental health. Understanding the impact of T1DM on mental health during adolescence may increase our understanding of the mental health needs of young adults with T1DM. Purpose: To describe the lived experiences of young adults with T1DM and how it relates to their mental health status during adolescence. Methods: A qualitative explorative study using semi-structured interviews. A purposive sample of young adults with T1DM were recruited through social media and through an announcement in the monthly, national newsletter of the College Diabetes Network. Participants were interviewed individually via Apple Facetime and Google Hangouts. Self-reported demographic and clinical information was also collected. Professionally transcribed data were analyzed using thematic analysis. Results: The sample was comprised of 18 young adults, the mean age was 20.4 years ± 1.21. Average age of diagnosis was 9.7 years ± 3.76. The interviews generated 4 major themes: (1) isolation, (2) maturity, (3) social support, and (4) challenges experienced by participants. Conclusions/Implications: The young adults in this study report many positive and negative influences on mental health during adolescence. Many participants agreed that while they had support through family and friends, they felt they would best be reached by other people with T1DM. Participants also identified a lack of resources for managing T1DM in adolescence and negative judgement from healthcare providers regarding lifestyle/food choices. This research provides information about the importance of addressing mental health needs of young adults with T1DM during adolescence. Continued education for educators and health care providers regarding the importance of using person-centered non-judgement language is essential. Disclosure M. Ottignon: None. M. OConnor: None. C. Whitehouse: None.

Background: Caregivers play a crucial role in the management of older adults with type 2 diabetes mellitus (T2DM). Caregivers often lack support and experience caregiver burden. Purpose: The purpose of the study was to investigate the needs and experience of caregivers of recently hospitalized older adults with T2DM. Methods: Qualitative interviews were conducted using a semi-structured interview guide with open-ended questions that highlighted the caregivers’ experience caring for a recently hospitalized older adult with T2DM. All interviews were digitally recorded and professionally transcribed. Once transcribed, transcripts were uploaded to ATLAS.ti to organize and retrieve data. Transcripts were analyzed using qualitative content analysis. Results: A total of 20 caregivers were interviewed. Most of the subjects were caregivers for a family member, with a majority of subjects caring for their parents. Participants were mostly female (75%), above age 50, and non-Hispanic Black (80%). The main themes that emerged from the qualitative data were: (1) the role itself, (2) challenges, (3) role preparation, and (4) additional comorbid diagnoses. Conclusion: Our findings provide an understanding of experience, tasks, and needs of caregivers for older adults with T2DM. This study revealed that many caregivers feel that care taking is an obligation and a full-time role. A majority of caregivers indicated they did not receive education regarding caring for someone with DM, despite being solely responsible for providing care. Although many of the caregivers did not identify T2DM as the main concern due to additional comorbid conditions, the most pertinent patient and caregiver challenges identified include diet, multiple responsibilities, and time-management. This study identifies the importance of inclusion of family caregivers when providing education. Disclosure A. Danner: None. M. OConnor: None. C. Whitehouse: None.

Few studies have explored racial/ethnic differences in health care outcomes among patients receiving home health care (HHC), despite known differences in other care settings. We conducted a retrospective cohort study examining racial/ethnic disparities in rehospitalization and emergency room (ER) use among post-acute patients served by a large northeastern HHC agency between 2013 and 2014 ( N = 22,722). We used multivariable binomial logistic regression to describe the relationship between race/ethnicity and health care utilization outcomes, adjusting for individual-level factors that are conceptually related to health service use. Overall rates of rehospitalization and ER visits were 10% and 13%, respectively. African American and Hispanic patients experienced higher odds of ER visits or rehospitalization during their HHC episode. Racial/ethnic differences in utilization were mediated by enabling factors, such as caregiver availability, and illness-level factors, such as illness severity, functional status, and symptoms. Intervention targets may include early risk assessment, proactive management of clinical conditions, rehabilitative therapy, and caregiver training.

Nutrition is often considered the foundation of health and an important indicator of well-being. Older adults living in the community are particularly at high risk of poor nutrition due to social i...

Older adults are at increased risk for loneliness and social isolation. Research on loneliness identifies increased rates of depression, increased cognitive decline, and poor cardiovascular health outcomes. The COVID-19 pandemic forced many older adults into social isolation for protection against this insidious virus. Mandated lockdowns and personal decisions to shelter-in-place produced a tremendous increase in rates of loneliness, especially among older adults. Identifying a need for communication and relationships, we created Villanova ReachOut, a program that partners interprofessional students (N= 66) with older adults (N=53) through weekly telephone or video calls. To assess the impact of our program we developed a five question survey administered via phone to older adults and a 13-item survey for volunteers to assess training, satisfaction, needs and impact of the program. Of the older adults (n=16) who completed the survey, 78.6% believe the program helped them feel less isolated throughout the pandemic and 93.8% indicated they looked forward to weekly calls with their partner . Volunteers who completed the survey (N=25), overwhelmingly stated they enjoy and look forward to their calls (100%) and their communication skills have improved (92%). Volunteers reported being paired up with an older adult for weekly conversation had a positive impact on their personal and professional development. Findings from our program evaluation provide rich data in descriptions of positive impact for both the older adult and volunteer. These findings also support the need for programs that engage in intergenerational dialogue, specifically targeting older adults and the potential older adult workforce.

An interprofessional mock code simulation was designed to educate students from four healthcare disciplines on the care of a patient with Parkinson's disease (PD) during a care transition. This interprofessional education initiative facilitated students learning about, from, and with each other. The simulation consisted of an unfolding patient with Parkinson's disease (PD) that involved an incomplete medication reconciliation and an omission of time-sensitive PD medication, resulting in a full code. The simulation explored quality improvement strategies for safe and timely medication administration and reconciliation during a care transition for a patient with PD. The simulation was conducted in the Learning Resource Simulation Center with small groups of students from two separate institutions and four separate schools or college programs rotating throughout the semester. The student participants consisted of the following: Baccalaureate Degree Senior Nursing Students; Master's level Senior Nurse Anesthesia Students; Fourth-Year Doctor of Osteopathic Medicine Students; and Fourth-Year Doctor of Psychology Students. The objectives of the interprofessional mock code simulation were as follows: 1) learners shall understand the roles and responsibilities of members of a healthcare team by participating in an interprofessional simulation of a patient with Parkinson's disease during a mock code scenario; 2) learners shall recognize the harm that occurs from incomplete medication reconciliation specific to Parkinson's disease during care transitions such as disorientation, garbled speech, severely limited breathing capacity and even death; and 3) learners from four different healthcare disciplines will evaluate their comfort and competence specific to working as part of an interprofessional healthcare team during a mock code simulation. The simulation demonstrated an increase in knowledge among all the interprofessional healthcare team members regarding PD medication safety. This PD unfolding case study simulation training also helped students and future professionals feel comfortable and competent while working together during a patient code situation in the acute care setting. This simulation holds great potential for dissemination among all faculty disciplines to improve the quality and safety of the PD population during care transitions. A complete copy of the IPE simulation is available upon request from the primary author.

Research on attitudes toward dementia has often focused on younger and older adults; few studies have also included the age groups of established and middle adulthood. The current study utilized data from community-dwelling adults aged 18-95 (n=567) residing in two Midwestern states. Participants were divided into four age groups: emerging/young adulthood (ages 18-29), established adulthood (ages 30-45), middle adulthood (ages 46-64), and older adulthood (age 65+). ANOVA models were used to examine age group differences on the following outcomes: factual knowledge about dementia (total score on 14 true-false questions); attitudes toward dementia (total score on the 20-item Dementia Attitudes Scale); and a single item, “I am afraid of losing my memory” (rated on a 5-point scale). The effect of age group was significant in all models (p

By 2030, older adults are projected to outnumber children. This growth among older adults presents both opportunities and challenges on how to care for this unprecedented older adult population. In 2010, there were 7.2 family caregivers for every person 80 and older; this is expected to fall to 3 by 2050. Many older adults are at risk of becoming an elder orphan - someone aging alone with no family available to address their caregiving needs. This underscores the urgent need for the education of nurses who are prepared to care for older adults with complex social and health needs, many of whom are suffering from three to five chronic conditions. This symposium highlights cutting-edge research designed to transform nursing education to better prepare students to advance the health of older adults. Our first presentation describes ageism among undergraduate students and innovative curricula to positively influence their preference for working with older adults. Next, the groundbreaking tool-kit that encourages self-reflection on beliefs about aging and reframes how students view older adults. Third, the qualitative results of a collaborative learning experience designed to introduce students earlier and more often to older adults. Finally, findings from a student-led study investigating the unique needs of caregivers of older adults with diabetes highlights the importance of funding students to conduct research related to older adults. Our symposium ends with a discussion of how these approaches are transforming nursing education to adequately prepare nurses to improve the health and health care of older adults.

In November 2016, the Centers for Medicare and Medicaid Services published a report commissioned from Abt Associates titled “Medicare Home Health Prospective Payment System: Case-Mix Methodology Refinements, Overview of the Home Health Groupings Model.” The report presents a proposal to dramatically change Medicare payment for home health care. Based on Medicare claims and home health patient assessment data from 2013, the proposal and its approach raise issues and questions about whether historical practice patterns in home health care provide optimal grounding for a redesign of the home health payment system of the future.

Falls are the leading cause of injuries among older adults, particularly in the more vulnerable home health care (HHC) population. Existing standardized fall risk assessments often require supplemental data collection and tend to have low specificity. We applied a random forest algorithm on readily available HHC data from the mandated Outcomes and Assessment Information Set (OASIS) with over 100 items from 59,006 HHC patients to identify factors that predict and quantify fall risks. Our ultimate goal is to build clinical decision support for fall prevention. Our model achieves higher precision and balanced accuracy than the commonly used multifactorial Missouri Alliance for Home Care fall risk assessment. This is the first known attempt to determine fall risk factors from the extensive OASIS data from a large sample. Our quantitative prediction of fall risks can aid clinical discussions of risk factors and prevention strategies for lowering fall incidence.

Care of the older adult can be complex and frequently influenced by ageism. Nursing students do not have the frequent opportunity to provide care for older adults. The purpose of this pilot study was to expose sophomore nursing students to older adults earlier and more often in the undergraduate curriculum by providing a unique clinical experience at St. Thomas of Villanova Monastery, a residential facility for retired Augustinian priests. This study examines the experience of students’ participation in this clinical experience. Qualitative content analysis of 12 student logs was conducted. Themes that emerged included: age-related changes, environmental considerations, psychosocial needs and changes, and consideration of gerontology as a career choice and existing bias. Students gained a valuable understanding of the unique age-related changes that older adults are experiencing. Early experiences are vital in the curriculum and provide enhanced engagement in gerontology.

Education and mentorship of undergraduate students extends beyond the classroom and clinical setting into research. This presentation will discuss the experience of the student and research mentor as well as provide findings from an important qualitative research study. Through a university funded grant, a student nurse partnered with faculty to investigate the needs and experience of caregivers of recently hospitalized older adults with diabetes. Caregivers play a vital role in caring for older adults, often they do not receive the education necessary to achieve optimal health outcomes. Qualitative interviews of 20 caregivers were conducted. The main themes that emerged from the data were: the role itself, challenges, preparation, and additional comorbid diagnoses. These findings provide an understanding of experience, tasks, and needs of caregivers for older adults with diabetes. This research experience provided exposure and education that is essential to developing future aging research scientists.

A lack of readiness for discharge from skilled home health can result in adverse events among older adults. The purpose of the current study was to explore interprofessional home health clinician perceptions of the factors they consider important to determine readiness for discharge among skilled home health recipients. A qualitative descriptive study was conducted using four focus groups among 32 interprofessional clinicians from one large skilled home health agency and two telephone interviews with home visiting physicians. A semi-structured interview guide was followed. Qualitative content analysis was used for manifest coding and then thematic analysis. Five themes emerged: (a) patient safety , (b) long-term plan is in place , (c) reached maximum self-care potential , (d) presence of a willing and able caregiver , and (e) patient attributes . The goal of this line of inquiry is to develop an evidence-based home health discharge decision support tool to provide a standardized approach in determining readiness for discharge from skilled home health services. [Res Gerontol Nurs. 2016; 9(6):269–277.]

Models of care coordination can significantly improve health outcomes for older adults with chronic illnesses if they can engage participants. The purpose of this study was to examine the impact of nursing contact on the rate of participants’ voluntary disenrollment from a care coordination program. In this retrospective cohort study using administrative data for 1,524 participants in the Health Quality Partners Medicare Care Coordination Demonstration Program, the rate of voluntary disenrollment was approximately 11%. A lower risk of voluntary disenrollment was associated with a greater proportion of in-person (vs. telephonic) nursing contact (Hazard Ratio [HR] 0.137, confidence interval [CI] [0.050, 0.376]). A higher risk of voluntary disenrollment was associated with lower continuity of nurses who provided care (HR 1.964, CI [1.724, 2.238]). Findings suggest that in-person nursing contact and care continuity may enhance enrollment of chronically ill older adults and, ultimately, the overall health and well-being of this population

In 2000, the John A. Hartford Foundation established the Building Academic Geriatric Nursing Capacity Program initiative, acknowledging nursing's key role in the care of the growing population of older adults. This program has supported 249 nurse scientists with pre- and postdoctoral awards. As a result of the program's success, several Building Academic Geriatric Nursing Capacity Program awardees formed an alumni organization to continue to advance the quality care of older adults. This group of Building Academic Geriatric Nursing Capacity Program awardees joined others receiving support from the John A. Hartford Foundation nursing initiatives to grow a formal organization, the Hartford Gerontological Nursing Leaders (HGNL). The purpose of this article is to present the development, accomplishments, and challenges of the HGNL, informing other professional nursing organizations that are experiencing similar accomplishments and challenges. This article also demonstrates the power of a funding initiative to grow an organization dedicated to impact gerontological health and health care through research, practice, education, and policy.

Chronically ill older adults are at risk for avoidable adverse events especially during care transitions, the transfer to one care setting or one level of care to another. Because of the expected increase in the older adult population, increased demand for transitional care is anticipated. Despite the consistent call for expanded competencies in care transitions, nursing education has not incorporated these concepts into nursing curricula. To fill this gap, Villanova University developed patient care scenarios and simulations incorporating standardized patients to demonstrate the needs, risks, and potential complications associated with transitioning patients from acute care to home.

Heart failure is difficult to manage and increasingly common with many individuals experiencing frequent hospitalizations. Little is known about patient factors consistently associated with hospital readmission. A literature review was conducted to identify heart failure patient characteristics, measured before discharge, that contribute to variation in hospital readmission rates. Database searches yielded 950 potential articles, of which 34 studies met inclusion criteria. Patient characteristics generally have a very modest effect on all-cause or heart failure–related readmission within 7 to 180 days of index hospital discharge. A range of cardiac diseases and other comorbidities only minimally increase readmission rates. No single patient characteristic stands out as a key contributor across multiple studies underscoring the challenge of developing successful interventions to reduce readmissions. Interventions may need to be general in design with the specific intervention depending on each patient’s unique clinical profile.

The implementation of the Home Health Prospective Payment System in 2000 led to a dramatic reduction in home health length of stay and number of skilled nursing visits among Medicare beneficiaries. While policy leaders have focused on the rising costs of home health care, its potential underutilization, and the relationship between service use and patient outcomes including hospitalization rates have not been rigorously examined. A secondary analysis of five Medicare-owned assessment and claims data sets for the year 2009 was conducted among two independently randomly selected samples of Medicare-reimbursed home health recipients (each n = 31,485) to examine the relationship between home health length of stay or number of skilled nursing visits and hospitalization rates within 90 days of discharge from home health. Patients who had a home health length of stay of at least 22 days or received at least four skilled nursing visits had significantly lower odds of hospitalization than patients with shorter home health stays and fewer skilled nursing visits. Additional study is needed to clarify the best way to structure home health services and determine readiness for discharge to reduce hospitalization among this chronically ill population. In the mean time, the findings of this study suggest that home health providers should consider the benefits of at least four SNV and/or a home health LOS of 22 days or longer. © 2015 Wiley Periodicals, Inc.

Every day interprofessional health care teams evaluate patients’ needs and make decisions regarding their care often without empirically derived decision support tools to assist in making these common but important decisions. Chronically ill older adults often experience uncoordinated care transitions and are particularly vulnerable for poor outcomes. The purpose of clinical decision support is to provide evidenced-based and timely information to clinicians to inform decisions about health care and patient needs. Clinical decision support has the potential to lower costs, improve efficiency of care transitions and promote effectiveness of health care services. Clinical decision support is an understudied but emerging area of research and application is expected to become more common as evidence-based practice develops. This symposium highlights three cutting-edge and developing areas of clinical decision support including one application that suggests referral to post-acute care following an inpatient hospitalization and two applications in skilled home health.

Medicare relies upon an interprofessional team of home health (HH) clinicians to evaluate beneficiary needs and to decide to discharge from skilled HH or recertify patients for an additional 60-days. However, there are no national, empirically derived decision support tools to assist in making these important decisions and getting it wrong can result in adverse events after discharge. Two studies, one quantitative and one qualitative informed the research questions of what factors are associated with poor HH discharge outcomes and readiness for discharge. The quantitative OASIS data elements were found to not be helpful predictors for identifying which patients are likely to have adverse outcomes. However, the qualitative interview themes identified patient safety, independence and caregiver availability as critical for determining readiness for a safe discharge. These findings inform the development of an evidence-based discharge decision support tool to provide a standardized approach to determine readiness for discharge from HH.

Objective: To examine activities of daily living (ADL) disability outcomes among racially/ethnically diverse elders receiving home care (HC) after hospitalization. Method: We conducted a retrospective cohort analysis of single-agency, 2013-2014 Outcome and Assessment Information Set data from older adults who received post-hospitalization HC ( n = 20,674). We measured overall change in ADL disability by summing the difference of standardized admission and discharge scores from nine individual ADL. Associations between race/ethnicity and overall ADL change scores were modeled using general linear regression, adjusting for covariates consistent with the Disablement Model. Results: Overall, patients experienced improvement in ADL disability from HC admission to discharge. However, Asian, African American, and Hispanic patients experienced significantly less improvement compared with non-Hispanic Whites (all p < .001), even after controlling for covariates. Discussion: Racial/ethnic disparities exist in ADL disability improvement among HC patients. Research is needed to clarify mechanisms underlying these disparities. Disablement Model factors may be targets for clinical intervention.

Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong-Lo-Mendell-Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p < 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community-dwelling older adults.

Frontloading of skilled nursing visits is one way home health providers have attempted to reduce hospital readmissions among skilled home health patients. Upon review of the frontloading evidence, visit intensity emerged as being closely related. This state of the science presents a critique and synthesis of the published empirical evidence related to frontloading and visit intensity. OVID/Medline, PubMed, and Scopus were searched. Seven studies were eligible for inclusion. Further research is required to define frontloading and visit intensity, identify patients most likely to benefit, and to provide a better understanding of how home health agencies can best implement these strategies.

Hospitalization among older adults receiving skilled home health services continues to be prevalent. Frontloading of skilled nursing visits, defined as providing 60% of the planned skilled nursing visits within the first two weeks of home health episode, is one way home health agencies have attempted to reduce the need for readmission among this chronically ill population. This was a retrospective observational study using data from five Medicare-owned, national assessment and claim databases from 2009. An independent randomized sample of 4500 Medicare-reimbursed home health beneficiaries was included in the analyses. Propensity score analysis was used to reduce known confounding among covariates prior to the application of logistic analysis. Although whether skilled nursing visits were frontloaded or not was not a significant predictor of 30-day hospital readmission (p = 0.977), additional research is needed to refine frontloading and determine the type of patients who are most likely to benefit from it.

The purpose of this study was to explore participants’ experience in the Health Quality Partners (HQP) Care Coordination Program that contributed to their continued engagement. Older adults with multiple chronic conditions often have limited engagement in health care services and face fragmented health care delivery. This can lead to increased risk for disability, mortality, poor quality of life, and increased health care utilization. A qualitative descriptive design with two focus groups was conducted with a total of 20 older adults enrolled in HQP’s Care Coordination Program. Conventional content analysis was the analytical technique. The overarching theme resulting from the analysis was “in our corner,” with subthemes “opportunities to learn and socialize” and “dedicated nurses,” suggesting that these are the primary contributing factors to engagement in HQP’s Care Coordination Program. Study findings suggest that nurses play an integral role in patient engagement among older adults enrolled in a care coordination program.

Older adults who experience new or worsening difficulties performing activities of daily living (ADL) after hospitalization have poorer prognoses within a year after discharge. Past research suggests racial/ethnic disparities exist in the development and progression of ADL disability. However, little research exists examining ADL disability disparities among racially/ethnically diverse older adults after hospitalization. Understanding differences in ADL disability across racial/ethnic groups may lead to targeted interventions reducing disparities and promoting ADL performance. This study’s purpose was to determine if differences exist in ADL disability trajectories among racially/ethnically diverse adults age 65 years and older receiving home care following hospitalization. We used 2013–2014 Outcome and Assessment Information Set data (n=21,473) from a large non-profit home care agency to examine overall change in ADL disability, which was measured by summing the difference of admission and discharge scores from nine individual ADL. Associations between race/ethnic groups and overall ADL change scores were examined using general linear regression models, adjusting for personal, environmental, and health-related factors from the International Classification of Functioning, Disability and Health framework. On home care admission, Asians, African-Americans, and Hispanics had poorer individual ADL scores compared to Non-Hispanic Whites (all p

This article presents a summary and critique of the published empirical evidence between the years 2002 and 2011 regarding rehospitalization among Medicare-reimbursed, skilled home health recipients. The knowledge gained will be applied to a discussion regarding ACH among geriatric home health recipients and areas for future research. The referenced literature in MEDLINE, PubMed and Cochrane databases was searched using combinations of the following search terms: home care and home health and Medicare combined with acute care hospitalization, rehospitalization, hospitalization, and adverse events and limited to studies conducted in the United States. Twenty-five research studies published in the last eight years investigated hospitalization among patients receiving Medicare-reimbursed, skilled home health. Empirical findings indicate telehomecare can reduce hospitalizations and emergency room use. The identification of risk factors for hospitalization relate to an elder’s sociodemographic, clinical and functional status that can be identified upon admission and interventions taken in order to reduce hospitalizations. Disease management, frontloading nurse visits, the structure of home health services and OBQI are also among the interventions identified to reduce hospitalizations. However, the body of evidence is limited by a paucity of research and the over reliance on small sample sizes. Few published studies have explored methods that effectively reduce hospitalization among Medicare-reimbursed skilled home health recipients. Further research is needed to clarify the most effective ways to structure home health services to maximize benefits and reduce hospitalization among this chronically ill geriatric population.

A disease management study conducted in home care with 303 patients with diabetes, heart failure, or both revealed information deficits that make disease and quality management difficult. Nurses used a guideline checklist to indicate the amount and type of information available to them on admission and by the end of the episode of care. Nurses reported having data on 7% to 94% of the data elements. Whether a lipid profile had been done, the HbA1C (glycosolated hemoglobin test, also called a hemoglobin A1C) levels, or ejection fractions were known for 7%, 17%, and 18%, respectively. When nurses reported information related to ACE-I use (N = 183), they reported that 76% of patients were on ACE-I (angiotensin-converting enzyme inhibitor) or acceptable alternative for heart failure. But no information was reported on ACE-I use for 12% of the patients (N = 24). Potential solutions to these deficits in information and quality include increased use of guidelines in home care, guideline checklists, information transfer forms, nurse activism to request information, and the adoption of the electronic health record.