|
|
|
|
THE
IMPACT OF PALLIATIVE CARE PROGRAMMING IN NURSING HOMES.
N. Strumpf , University of Pennsylvania
School of Nursing, 420 Guardian Drive, Philadelphia, PA
19104
Click
here to download powerpoint
presentation. |
| |
|
| |
PARTICIPANTS:
(for
information about presenters, click
here)
N. Strumpf, H.Tuch, P. Parmelee, & D. Stillman. (University
of PA & Genesis ElderCare, Kennett Sq, PA 19348). Palliative
Care in Nursing Homes: Response to Physical and Emotional
Symptoms.
D. Stillman, S. Cunningham, & E. Capezuti. (University
of PA & Emory University, Atlanta, GA). The
Effects of a Palliative Care Program on Nursing Home Staff
Attitudes Toward End-of-Life Care.
P. Parmelee, H. Tuch, N. Strumpf, D. Stillman, & A.
Lewis (University of PA and Genesis ElderCare). Quality
of Death in Nursing Homes: Evaluation of a Palliative Care
Intervention.
H. Tuch & N. Strumpf. (University of PA & Genesis
ElderCare). What Will it Take to
Improve Palliative Care in Nursing Homes?
DISCUSSANT:
M. Mezey (NewYork University, Division of Nursing, NY, NY
10012).
Data will be presented from a 3 year study of palliative
care (PC) in six nursing homes, sponsored by The Robert
Wood Johnson Foundation as part of a broader initiative
to promote excellence in end-of-life care. We examined the
impact of staff training, nurse consultation, and an interdisciplinary
team in 4 intervention and 2 control homes. The homes averaged
135 beds. There were 3 rural and 3 urban homes, all part
of a large elder care network. Key findings from the papers
will be discussed: 1) Documentation concerning physical
and emotional symptoms was problematic; physical symptoms
(notably pain) were more likely to be treated than emotional
symptoms; 2) Staff in intervention homes showed greater
awareness of specific end-of-life problems and valued palliative
care teams; 3) PC programming was associated with clear
differences in planning for death, life-sustaining interventions,
and pain management; and 4) Until palliative care is effectively
reimbursed and monitored, sustained improvement in end-of-life
care for nursing home residents is unlikely.
|
| |
|
| |
PALLIATIVE
CARE IN NURSING HOMES: ASSESSMENT AND TREATMENT OF PHYSICAL
AND EMOTIONAL SYMPTOMS. N. Strumpf, H.Tuch, P. Parmelee,
& D. Stillman, University of PA and Genesis Health
Ventures.
Recent
studies point out that pain is frequently reported by
nursing home residents, often goes unrecognized, and is
routinely under treated. We explored the ongoing impact,
over an 18 month period, of a systematic palliative care
program in six nursing homes (2 control, 4 intervention)
on the assessment and treatment of physical and emotional
symptoms. An investigator-generated symptom tracking form
was used to review health care records monthly for evidence
of any documented assessment and/or treatment plan on
consented participants (N=151). Preliminary analyses indicate
that there were no significant differences in assessment
and treatment of symptoms between those residents judged
appropriate for palliative care and those who were not,
nor between intervention and control homes. Assessment
and treatment were more likely to be recorded for physical
rather then emotional symptoms, and consistent documentation
of an assessment linked to a treatment plan was often
missing. Since nurse specialist field notes and other
data suggest that in the intervention homes, staff were
attending to physical symptoms (especially pain), ongoing
issues of accurate documentation in health records are
discussed.
|
| |
|
| |
QUALITY
OF DEATH IN NURSING HOMES: EVALUATION OF A PALLIATIVE CARE
INTERVENTION. P. Parmelee, H. Tuch, N. Strumpf, D. Stillman,
A. Lewis. Genesis Health Ventures & Univ. of PA School
of Nursing.
This presentation explores how implementing a palliative
care (PC) program affected "quality of death"
in long-term care, i.e., care received and symptoms experienced
during the last days of life. Data were collected for all
deaths in 9 Maryland SNFs from 04/99 - 12/00. For each,
nursing staff reported advance directives and PC planning;
cause & site of death; routine, palliative, and life-sustain-ing
treatments; acute syndromes & symptoms; cognition &
mood; pain, suffering, and the moment of death. Logistic
regression identified differences among centers receiving
3 levels of PC programming: full implementation & consultation,
brief education only, and no intervention. PC programming
was associated with clear differences in planning for death,
life-sustaining interventions, and pain management. PC sites
also identified more symptoms of physical and emotional
suffering, perhaps due to heightened sensitivity to those
issues. Results are discussed in terms of effects of active
PC training upon quality of death. Methodological issues
are also explored in terms of effects of conducting intervention
research upon overall quality of care in SNFs.
|
| |
|
| |
WHAT
WILL IT TAKE TO IMPROVE PALLIATIVE CARE IN A NURSING HOME?
H.Tuch & N.Strumpf. Genesis ElderCare & University
of PA.
Nearly 20% of all deaths in the US occur in nursing homes,
about 500,000 people annually. The medical literature raises
significant concerns about the quality of end-of-life care
that is currently provided to these residents. Our experience,
derived form a 3-year project supported by the Robert Wood
Johnson Foundation ("Palliative Care in the Nursing
Home"), will be described within the context of policy
changes we believe necessary to improve palliative care
in nursing home settings. Specific reimbursement mechanisms
tied to the RAI and RUGS categories, diminishing regulatory
barriers, changes in staff training and support, increased
community involvement, and changes in institutional processes
and culture will be addressed.
Palliative care should be considered skilled care, reimbursed
appropriately and monitored effectively. In the absence
of systemic change, meaningful or sustained improvement
in palliative care in the nursing home is unlikely.
|
| |
|
| |
|
THE
EFFECTS OF ORGANIZATION OF CARE ON NURSE SENSITIVE OUTCOMES
FOR OLDER ADULTS. E. Sullivan-Marx,
UPenn, School of Nursing, Philadelphia, PA 19104-4217.
Click
here to download powerpoint
presentation. |
| |
|
| |
PARTICIPANTS
M.
Bourbonniere, N. Strumpf, L. Evans, & G. Maislin. (University
of Pennsylvania, Philadelphia, PA) Organizational Variables
and Physical Restraint Use Among Hospitalized Nursing Home
Residents
E. Sullivan-Marx, G. Maislin, & J. Carson (University
of Pennsylvania, Philadelphia, PA) Hospital Staffing,
Physical Restraint, & Patient Outcomes
L. Kurlowicz (University of Pennsylvania, School of Nursing,
Philadelphia, PA) Geropsychiatric Liaison Nursing Consultation
for Older Hospitalized Patients and Their Nurses
J. Sochalski (University of Pennsylvania, School of Nursing,
Philadelphia, PA) Outcomes of Geriatric Rehabilitation
for Frail Elders
A. S. Beeber & K.L. Schumacher (University of Pennsylvania,
School of Nursing, Philadelphia, PA) From Hospital to
Home: A Case Analysis of a Critical Transition for Older
Adults with Cancer and Their Family Caregivers
DISCUSSANT:
J.Kayser-Jones
(University of California San Francisco, San Francisco,
CA)
Although
innovative clinical interventions in hospitals and specialized
units of care have demonstrated improvement in outcomes
of care for older adults, in reality the majority of older
adults experience health care in systems that are not organized
for their specific needs. The organization of nursing care
directly impacts patient outcomes yet little is known about
the effects of organization of care pertaining to older
adults who are acutely ill. Understanding the relationship
between delivery of care and outcomes that are sensitive
to nursing care is particularly relevant to frail, vulnerable
older adults. Both nurses and advanced practice nurses can
influence care for older adults at risk for poor outcomes
but their ability to affect improvement in outcomes is dependent
on a responsive organization. In this symposium, we present
five research papers that examine and discuss organizational
relationships between nursing care and nurse sensitive patient
outcomes for frail vulnerable older adults who have experienced
acute illness. |
| |
|
| |
ORGANIZATIONAL
VARIABLES AND PHYSICAL RESTRAINT USE AMONG HOSPITALIZED
NURSING HOME RESIDENTS M. Bourbonniere, N. Strumpf,
L. Evans, & G. Maislin, School of Nursing, University
of Pennsylvania, Philadelphia, PA 19146
Existing research suggests that nurses, physicians, patients,
and families consider registered nurse (RN) staffing a critical
factor in preventing physical restraint use, although studies
have not addressed potential relationships among these variables.
Using data from a study designed to test the impact of an
advanced practice nurse intervention on restraint use among
hospitalized nursing home residents, this analysis examines
relationships between RN skill mix, patient-RN ratios, patient-total
staff ratios and physical restraint use, controlling for
cognitive status, treatment interference, behavioral phenomena,
fall risk, and acuity on admission. 171 nursing home residents,
with a mean age of 84.9 years, were admitted to one of eleven
medical-surgical units of a large urban hospital. Rate of
restraint was 26%. Hospital staffing varied considerably.
RN skill mix ranged from 25% to 100% (Mean=65%); patient
to RN ratios ranged from 0.5 to 16 (Mean=6.7); and patient
to total nursing staff ratios ranged from 0.4 to 7.7 (Mean=4.1).
Univariate analyses indicate a significant relationship
between patient-RN ratios and restraint use. Discussion
will focus on issues related to care of frail elders in
restructured environments. (NINR 1 F31 NR07532-01) |
| |
|
| |
HOSPITAL
STAFFING, PHYSICAL RESTRAINT, & PATIENT OUTCOMES
E. Sullivan-Marx, G. Maislin, & J. Carson (School of
Nursing, University of Pennsylvania, Philadelphia, PA)
We examined the effects of hospital staffing (RN-patient
ratios and staff mix) on physical restraint use and discharge
outcomes using a retrospective case cohort design to conduct
a secondary analysis of 9222 hip fracture patients in 20
urban teaching hospitals in PA, NJ, VA, and TX from 1983-1993.
Rate of restraint use for hospitalized hip fracture patients
was 31.5%. Mean age of subjects was 82.6, 80% were women,
and 87.4% were white, 22.3% were admitted from nursing homes,
and 62.6% were independent in activities of daily living
prior to fracture. Data on nurse staffing were obtained
from the American Hospital Association Annual Hospital Survey.
Higher nurse patient ratios and greater RN skill mix were
associated with lower physical restraint use in bivariate
analysis (p<.0001). We used a mixed model to test the
effects of staffing on restraint use, and of restraint use
on patient outcomes, controlling for year, hospital, age,
gender, race, cognitive impairment, type of fracture, pre
fracture functional status, and severity of illness. Patients
who were not restrained had significantly (p<.0001) lower
inpatient mortality, lower death at 30 days postoperatively,
fewer pressure ulcers, and were more independent in feeding
and grooming. Better hospital staffing and lower restraint
use contributed to better outcomes but the effect was not
significant. Discussion focuses on testing models of organization
on nurse sensitive outcomes and effect of organization on
physical restraint use. (NINR 1 KO1 NR 00157-01)
|
| |
|
| |
DEPRESSION
AMONG OLDER AFRICAN AMERICANS USERS OF AN ACADEMIC
OUTPATIENT REHABILITATION PROGRAM L. H. Kurlowicz, Ph.D.,
RN, CS, L. K. Evans, DNSc, RN, FAAN, and S. M. Marcus, Ph.D.,
School of Nursing, University of Pennsylvania, Philadelphia,
PA.
Using depression measures containing a range of somatic
items, prevalence estimates of depression in clinical samples
of older African Americans range from 11% to 33%. The tendency
of this group to report somatic symptoms over sadness raises
questions about the assessment of depression, especially
among those with multiple medical comorbidities. The purpose
of this study was to explore the prevalence of depression
among older African American users of an academic outpatient
rehabilitation program using a depression tool with a low
somatic item content. Correlates of depression in this population
also were explored. Medical records of 150 older, urban,
African Americans seen over a two-year period were examined.
Depression was assessed on admission using the 30-item Geriatric
Depression Scale {GDS}. Using a GDS cut-off score for depression
of 11 or greater, 30% of the sample (mean age = 75.5 + 7.16,
range = 65-95, 75% female) scored positive for depression.
Nine percent also reported having suicidal thoughts within
the previous week. Consistent with existing literature,
depressed patients, compared to the non-depressed group,
were significantly younger, more suicidal, were more likely
to rate their general health as poor, had higher mean ratings
of pain, & limited their social activities more often.
Six GDS items also were found to have little ability to
discriminate between depressed and non-depressed patients:
satisfaction with life, getting bored easily, prefer staying
at home, find life exciting, getting started on new projects,
& full of energy. Whether this is related to the generally
high levels of medically associated disability in this sample,
or cultural beliefs or preferences, is unclear.
|
| |
|
| |
OUTCOMES
OF GERIATRIC REHABILITATION FOR FRAIL ELDERS.
J. Sochalski, PhD, RN, FAAN, School of Nursing, University
of Pennsylvania, Philadelphia, PA.
The aim of this study was to assess the contribution of
the Collaborative Assessment and Rehabilitation for Elders
(CARE) Program--a comprehensive, outpatient, short-term
intensive rehabilitation program-- to improvements in levels
of function and to reductions in the use of inpatient care
among frail elders experiencing functional decline. The
study sample comprised 308 patients enrolled in CARE between
October 1993 and April 1997. Data sources included CARE
Program records, hospital discharge records for the each
patient obtained from a statewide inpatient database, and
the National Death Index. Significant improvement was found
in functional status (measured by change in FIM scores)
for patients who completed their plans of care (t=10.37,
p < .001), as compared to those patients who did not
complete their plans (t=1.29, p=ns). A significant decline
was noted in the number
of inpatient days in the year after CARE as compared with
days in the year before CARE admission. Geriatric rehabilitation
services have demonstrated their effectiveness in reversing
or halting declining functional status, and this study showed
the additional benefit of reduction in inpatient care. Appropriate
referral appears to be key to improved outcomes for those
participating in these programs. (NINR K07-NR00090; NIA
R03--AG16802)
|
| |
|
| |
FROM
HOSPITAL TO HOME: A CASE ANALYSIS OF CRITICAL TRANSITIONS
FOR OLDER ADULTS WITH CANCER AND THEIR FAMILY CAREGIVERS
A. S. Beeber ; K. L. Schumacher; (University of Pennsylvania,
School of Nursing, Philadelphia, PA 19104)
The transition from hospital to home poses challenging care
issues and causes stress for cancer patients and their caregivers.
These predicaments are magnified when the person with cancer
is older. In a study discerning caregiver skill among family
members of persons with cancer and the development of a
caregiving assessment tool (Family Caregiving Skill Profile),
caregivers were interviewed about their experiences. Through
a case analysis derived from these qualitative data, the
experience of the caregiving for an older adult with cancer
and the transition from hospital to home is examined. Changes
in the structure of care for older adults, including short
hospital stays and changes in nurse staffing, have led to
decreased support for caregivers and patients upon discharge.
This often results in feelings of uncertainty and unpreparedness
by caregivers and patients during this critical transition.
Discussion will include issues around the post-discharge
critical time period, cancer symptom management in older
adults, patient and family stress, coping strategies, and
caregiver skill. The implications of these findings for
research and practice will also be discussed. (NINR #R01
NR05126, John A. Hartford Foundation's Building Academic
Geriatric Nursing Capacity Scholarship Program through AAN) |
| |
|
| |
Source:
The Gerontologist, Vol. 41, Special Issue, 1, October
2001 |
|
|
