Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents

Journal of the American Geriatrics Society

Volumn 67, Issue 8, 2019, Pages 1649-1655

  Hickman, Susan E ^a   Unroe, Kathleen T ^a,b   Ersek, Mary ^c,d   Stump, Timothy E ^a   Tu, Wanzhu ^a,b   Ott, Monica ^a   Sachs, Greg A ^a,b  

^a INDIANA UNIVERSITY   (United States)

^b INDIANA UNIVERSITY CENTER FOR AGING RESEARCH   (United States)

^c VETERANS AFFAIRS MEDICAL CENTER   (United States)

^d UNIVERSITY OF PENNSYLVANIA   (United States)

Author keywords

advance care planning; nursing facility; nursing home; palliative care

Indexed keywords

ADVANCE CARE PLANNING; AGED; ARTICLE; COGNITION; CONTROLLED STUDY; FEMALE; FUNCTIONAL STATUS; HOSPITALIZATION; HUMAN; MAJOR CLINICAL STUDY; MALE; NURSE; NURSING HOME PATIENT; HEALTH SERVICE; HOME FOR THE AGED; NURSING HOME; PROGRAM EVALUATION; TOTAL QUALITY MANAGEMENT; VERY ELDERLY;

ADVANCE CARE PLANNING; AGED; AGED, 80 AND OVER; FEMALE; HOMES FOR THE AGED; HOSPITALIZATION; HUMANS; MALE; MEDICAL OVERUSE; NURSING HOMES; PROGRAM EVALUATION; QUALITY IMPROVEMENT;

EID: 85064770997     PISSN: 00028614     EISSN: 15325415     Source Type: Journal    
DOI: 10.1111/jgs.15927     Document Type: Article

References (41)

1. Advance Care Planning for Older Adults. American Geriatrics Society (online). http://www.americangeratrics.org. Accessed October 5, 2018.
2. Carr D, Luth AL. Advance care planning: contemporary issues and future directions. Innov Aging. 2017;1:1-10.
3. Rietjens JAC, Sudore RL, Connolly M, et al. Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care. Lancet Oncol. 2017;18:e543-e551.
4. Pizzo P, Walker D, Bomba P. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: Institute of Medicine; 2014.
5. Cohen AB, Knobf MT, Fried TR. Do not hospitalize orders in nursing homes: call the family instead of calling the ambulance. J Am Geriatr Soc. 2017;65:1573-1577.
6. Sudore RL, Heyland DL, Lum HD, et al. The outcomes that define successful advance care planning: a Delphi panel consensus. J Pain Symptom Manage. 2018;55:245-255.
7. Hanson LC, Zimmerman S, Song M-K, et al. Effect of the goals of care intervention for advanced dementia: a randomized clinical trial. JAMA Intern Med. 2017;177(1):24-31.
8. Hickman SE, Nelson CA, Moss A, Tolle SW, Perrin N, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the Physician Orders for Life-Sustaining Treatment (POLST) form. J Am Geriatr Soc. 2011;59:2091-2099.
9. Mitchell SL, Palmer JA, Volandes AE, Hanson LC, Habtermarian D, Shaffer ML. Level of care preferences among nursing home residents with advanced dementia. J Pain Symptom Manage. 2017;54:340-345.
10. Ouslander JG, Lamb G, Perloe M, et al. Potentially avoidable hospitalizations of nursing facility residents: frequency, causes, and costs. J Am Geriatr Soc. 2010;58(4):627-635.
11. Grabowski DC, Stewart KA, Broderick SM, Coots LA. Predictors of nursing home hospitalization: a review of the literature. Med Care Res Rev. 2008;65(1):3-39.
12. Nicholas LH, Langa KM, Iwashyna TJ, Weir DR. Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA. 2011;306(13):1447-1453.
13. Hammes BJ, Rooney BL, Gundrum JD, Hickman SE, Hager H. The POLST program: a retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. J Palliat Med. 2012;15:1-9.
14. Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program. J Am Geriatr Soc. 2010;58(7):1241-1248.
15. Levy C, Morris M, Kramer A. Improving end-of-life outcomes in nursing homes by targeting residents at high-risk of mortality for palliative care: program description and evaluation. J Palliat Med. 2008;11(2):217-225.
16. Martin RS, Hayes B, Gregorevic K, Lim WK. The effects of advance care planning interventions on nursing home residents: a systematic review. J Am Med Dir Assoc. 2016;17(4):284-293.
17. Ouslander JG, Naharci I, Engstrom G, et al. Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: lessons learned for reducing unnecessary hospitalizations. J Am Med Dir Assoc. 2016;17(3):256-262.
18. Unroe KT, Nazir A, Holtz LR, et al. The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care approach: preliminary data from the implementation of a Centers for Medicare and Medicaid Services nursing facility demonstration project. J Am Geriatr Soc. 2015;63(1):165-169.
19. Hickman SE, Unroe KT, Ersek M, Buente BB, Sachs GA. An interim analysis of an advance care planning intervention in the nursing home setting. J Am Geriatr Soc. 2016;64:2385-2392.
20. Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care: The OPTIMISTIC Project. 2019; https://www.optimistic-care.org/. Accessed January 10, 2019.
21. Ingber MJ, Feng Z, Khatutsky G, et al. Initiative to reduce avoidable hospitalizations among nursing facility residents shows promising results. Health Aff (Millwood). 2017;36:441-450.
22. Ersek M, Hickman SE, Thomas AC, Bernard B, Unroe KT. Stakeholder perspectives on the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project. Gerontologist. 2017;58:1177-1187.
23. Kelly K, Ersek M, Virani R, Malloy P, Ferrell B. End-of-Life Nursing Education Consortium. Geriatric training program: improving palliative care in community geriatric care settings. J Gerontol Nurs. 2008;34:28-35.
24. Respecting Choices Advanced Steps. Respecting Choices (online). Available at http://www.respectingchoices.org. Accessed December 6, 2018.
25. Morris JN, Fries BE, Morris SA. Scaling ADLs within the MDS. J Gerontol A Biol Sci Med Sci. 1999;54(11):M546-M553.
26. Thomas KS, Dosa D, Wysocki A, Mor V. The Minimum Data Set 3.0 Cognitive Function Scale. Med Care. 2017;55(9):e68-e72.
27. The Indiana Physician Orders for Scope of Treatment (POST) Program. Indiana Patient Preferences Coalition (online). Available at http://www.indianapost.org. Accessed December 6, 2018.
28. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381.
29. Unroe KT, Carnahan JL, Hickman SE, Sachs GA, Hass Z, Arling G. The complexity of determining whether a nursing home transfer is avoidable at time of transfer. J Am Geriatr Soc. 2018;66(5):895-901.
30. SAS Institute Inc. SAS/STAT® 14.2 User's Guide. Cary, NC: SAS Institute Inc; 2018.
31. Kane RL, Huckfeldt P, Tappen R, et al. Effects of an intervention to reduce hospitalizations from nursing homes: a randomized implementation trial of the INTERACT program. JAMA Intern Med. 2017;177(9):1257-1264.
32. Hickman SE, Keevern E, Hammes BJ. Use of the physician orders for life-sustaining treatment program in the clinical setting: a systematic review of the literature. J Am Geriatr Soc. 2015;63(2):341-350.
33. Ng CWL, Cheong S, Govinda Raj A, Teo W, Leong I. End-of-life care preferences of nursing home residents: results of a cross-sectional study. Palliat Med. 2016;30(9):843-853.
34. Givens JL, Sudore RL, Marshall GA, Dufour AB, Kopits I, Mitchell SL. Advance care planning in community-dwelling patients with dementia. J Pain Symptom Manage. 2018;55(4):1105-1112.
35. Molloy DW, Guyatt GH, Russo R, et al. Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial. JAMA. 2000;283(11):1437-1444.
36. Morrison RS, Chichin E, Carter J, Burack O, Lantz M, Meier DE. The effect of a social work intervention to enhance advance care planning documentation in the nursing home. J Am Geriatr Soc. 2005;53(2):290-294.
37. Unroe KT, Fowler NR, Carnahan JL, et al. Improving nursing facility care through an innovative payment demonstration project: Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care phase 2. J Am Geriatr Soc. 2018;66(8):1625-1631.
38. Kahwati LC, Lewis MA, Williams PA, Kane H. Using qualitative comparative analysis to understand and quantify translation and implementation. Transl Behav Med. 2014;4:201-208.
39. Sinuff T, Dodek P, You JJ, et al. Improving end-of-life communciation and decision making: the development of a conceptual framework and quality indicators. J Pain Symptom Manage. 2015;49:1070-1080.
40. Unroe KT, Hickman SE, Torke AM, Group ARCW. Care consistency with documented care preferences: methodologic considerations for implementing the “measuring what matters” quality indicator. J Pain Symptom Manage. 2016;52(4):453-458.
41. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.