Advance Directives in the Nursing Home Setting: An Initiative to Increase Completion and Reduce Potentially Avoidable Hospitalizations

Journal of Social Work in End-of-Life and Palliative Care

Volumn 17, Issue 1, 2021, Pages 19-34

  Galambos, Colleen ^a   Rantz, Marilyn ^b   Popejoy, Lori ^b   Ge, Bin ^c   Petroski, Greg ^c  

^a UNIVERSITY OF WISCONSIN MILWAUKEE   (United States)

^b UNIVERSITY OF MISSOURI   (United States)

^c University of Missouri   (United States)

Author keywords

Advance care planning; advance directives; end of life; nursing homes; rehospitalizations

Indexed keywords

ADULT; ADVANCE CARE PLANNING; ARTICLE; DOCUMENTATION; FEMALE; HOSPITAL READMISSION; HOSPITALIZATION; HUMAN; HUMAN EXPERIMENT; LIVING WILL; MALE; NURSING HOME; RESIDENT; STATISTICAL SIGNIFICANCE; AGED; MEDICARE; UNITED STATES;

ADVANCE DIRECTIVES; AGED; HOSPITALIZATION; HUMANS; MEDICARE; NURSING HOMES; SKILLED NURSING FACILITIES; UNITED STATES;

EID: 85099869341     PISSN: 15524256     EISSN: 15524264     Source Type: Journal    
DOI: 10.1080/15524256.2020.1863895     Document Type: Article

References (29)

1. Alexander, G. L., Rantz, M., Galambos, C., Vogelsmeier, A., Flesner, M., Popejoy, L., … Elvin, M., (2015). Preparing nursing homes for the future of health information exchange. Applied Clinical Informatics, 6 (2), 248–266. doi: 10.4338/ACI-2014-12-RA-0113
2. Bern-Klug, M., (2014). A conceptual model of family surrogate end-of-life decision-making process in the nursing home setting: Goals of care as guiding stars. Journal of Social Work in End-of-Life & Palliative Care, 10 (1), 59–79. doi: 10.1080/15524256.2013.877863
3. Bern-Klug, M., & Kramer, K. W. O., (2013). Core functions of nursing home social services Departments in the United States. Journal of the American Medical Directors Association, 14 (1), 75.e1–e7. doi: 10.1016/j.jamda.2012.09.004
4. Blacker, S., Head, B. A., Jones, B. L., Remke, S. S., & Supiano, K., (2016). Advancing hospice and palliative care social work leadership in interprofessional education and practice. Journal of Social Work in End-of-Life & Palliative Care, 12 (4), 316–330. doi: 10.1080/15524256.2016.1247771
5. Centers for Medicare and Medicaid Services. (2015a). Initiative to reduce avoidable hospitalizations among nursing facility residents. Retrieved from http://innovations.cms.gov/initiatives/rahnfr/.
6. Centers for Medicare and Medicaid Services. (2015b). Nursing home data compendium, 2015 Edition. Washington, DC.: U.S. Department of Health and Human Services.
7. Ersek, M., & Carpenter, J. G., (2013). Geriatric palliative care in long-term care settings with a focus on nursing homes. Journal of Palliative Medicine, 16 (10), 1180–1187. doi: 10.1089/jpm.2013.9474
8. Galambos, C., Starr, J., Rantz, M., & Petroski, G., (2016). Analysis of advance directive documentation to support palliative care Activities in Nursing Homes. Health & Social Work, 41 (4), 228–234. doi: 10.1093/hsw/hlw042
9. Garrido, M. M., Balboni, T. A., Maciejewski, P. K., Bao, Y., & Prigerson, H. G. (2015). Quality of Life and Cost of Care at the End of Life: The Role of Advance Directives. Journal of Pain and Symptom Management, 49 (5), 828–835. doi: 10.1016/j.jpainsymman.2014.09.015
10. Gazarian, P. K., Cronin, J., Dalto, J. L., Baker, K. M., Friel, B. J., Bruce-Baiden, W., & Rodriguez, L. Y., (2019). A systematic evaluation of advance care planning patient educational resources. Geriatric Nursing, 40 (2), 174–180. 2. doi: 10.1016/j.gerinurse.2018.09.011
11. Giuffrida, J., (2015). Palliative care in your nursing home: Program development and innovation in transitional care. Journal of Social Work in End-of-Life & Palliative Care, 11 (2), 167–177. doi: 10.1080/15524256.2015.1074143
12. Houben, C. H., Spruit, M. A., Groenen, M. T., Wouters, E. F., & Janssen, D. J., (2014). Efficacy of advance care planning: A systematic review and meta-analysis. Journal of the American Medical Directors Association, 15 (7), 477–489. doi: 10.1016/j.jamda.2014.01.008
13. Isaacson, M., (2017). Wakanki Ewastepikte: An advance directive education project with American Indian elders. Journal of Hospice & Palliative Nursing, 19 (6), 580–587. doi: 10.1097/NJH.0000000000000392
14. Miller, S. C., Lima, J. C., Intrator, O., Martin, E., Bull, J., & Hanson, L., (2016). Palliative care consultations in nursing homes and reductions in acute care use and potentially burdensome End-of-Life Transitions. Journal of the American Geriatrics Society, 64 (11), 2280–2287. DOI: 10.11111/jgs.14469.
15. National Health Care Decisions Day (2020, September 10). National Health Care Decisions Day. Retrieved from https://theconversationproject.org/nhdd/.
16. Obermeyer, Z., Makar, M., Abujaber, S., Dominici, F., Block, S., & Cutler, D. M., (2014). Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA, 312 (18), 1888–1896. doi: 10.1001/jama.2014.14950
17. Ouslander, J. G., Bonner, A., Herndon, L., & Shutes, J. (2014). The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care. Journal of the American Medical Directors Association, 15 (3), 162–170. doi: 10.1016/j.jamda.2013.12.005
18. Pollack, K. M., Morhaim, D., & Williams, M. A., (2010). The public's perspectives on advance directives: Implications for state legislative and regulatory policy. Health Policy, 96 (1), 57–63. doi: 10.1016/j.healthpol.2010.01.004
19. Rantz, M. J., Alexander, G., Galambos, C., Vogelsmeier, A., Popejoy, L., Flesner, M., … Koopman, R. J., (2014). Initiative to test a multidisciplinary model with advanced practice nurses to reduce avoidable hospitalizations among nursing facility residents. Journal of Nursing Care Quality, 29 (1), 1–8. doi: 10.1097/NCQ.0000000000000033
20. Rantz, M., Birtley, N. M., Flesner, M., Crecelius, C., & Murray, C., (2017). Call to action: APRNs in U.S. nursing homes to improve care and reduce costs. Nursing Outlook, 65 (6), 689–696. doi: 10.1016/j.outlook.2017.08.011
21. Rantz, M. J., Flesner, M. K., Franklin, J., Galambos, C., Pudlowski, J., Pritchett, A., … Lueckenotte, A., et al. (2015). Better care, better quality: Reducing avoidable hospitalizations of nursing home residents. Journal of Nursing Care Quality, 30 (4), 290–297. doi: 10.1097/NCQ0000000000000145
22. Rantz, M. J., Popejoy, L., Vogelsmeier, A., Galambos, C., Alexander, G., Flesner, M., … Petroski, G., (2017). Successfully reducing hospitalizations of nursing home residents: Results of the Missouri Quality Initiative. Journal of the American Medical Directors Association, 18 (11), 960–966. doi: 10.1016/j.jamda.2017.05.027
23. Research Triangle Institute International. (2017). Evaluation of the initiative to reduce avoidable hospitalizations among nursing home facility residents: Annual Report, Project Year 4. Retrieved from https://innovation.cms.gov/Files/reports/irahnfr-finalyrfourevalrpt.pdf.
24. Song, M. K., Ward, S., Fine, J. P., Hanson, L. C., Lin, F. C., Hladik, G. A., … Bridgman, J. C., (2015). Advance care planning and end-of-life decision making in dialysis: A randomized controlled trial targeting patients and their surrogates. American Journal of Kidney Diseases, 66 (5), 813–822. Doi.org/10.1053/j.ajkd.2015.05.018. doi: 10.1053/j.ajkd.2015.05.018
25. Stein, G., Cagle, J., & Christ, G., (2017). Social work involvement in advance care planning: Findings from a large survey of social workers in hospice and palliative care settings. Journal of Palliative Medicine, 20 (3), 253–259. doi: 10.1089/jpm.2016.0352
26. The Conversation Project. (2020). Your conversation starter kit. Retrieved form https://theconversationproject.org/wp-content/uploads/2017/02/ConversationProject-ConvoStarterKit-English.pdf.
27. U.S. Department of Health and Human Services, Office of Inspector General (USDHHS, OIG). (2013). Medicare nursing home resident hospitalization rates merit additional monitoring. Retrieved from https://oig.hhs.gov/oei/reports/oei-06-11-00040.pdf.
28. Vasilevskis, E. E., Ouslander, J. G., Mixon, A. S., Bell, S. P., Jacobsen, M. L., Saraf, A. A., … Schnelle, J., (2017). Potentially avoidable readmissions of patients discharged to post-acute care: Perspectives of hospital and skilled nursing facility staff. Journal of the American Geriatrics Society, 65 (2), 269–276. doi: 10.1111/jgs.14557
29. Walsh, E. G., Wiener, J. M., Haber, S., Bragg, A., Freiman, M., & Ouslander, J. G., & (2012). Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs. Journal of the American Geriatrics Society, 60 (5), 821–829. doi: 10.1111/j.1532-5415.2012.03920.x