Regional Workshops to Widely Disseminate an Innovative Practice

Abstract The second stage of the CMS Region IV project involved a series of 20 half-day workshops and five follow-up webinars to introduce Go to the Hospital or Stay Here?, the training resources available (12 videos, 5 case studies and Best Practices summary), and strategies for implementation. Altogether 1124 representatives from long-term care facilities, state agencies, ombudsman groups and hospitals attended these interactive workshops. Polled participants reported that resident and family insistence on transfer to the hospital was a major barrier to successful reduction of acute care transfers for them. Those who implemented the Guide facility-wide reported an average 28% reduction in transfers. Primary barriers to facility-wide implementation were lack of leadership, making a choice to absorb the cost of financial penalties and failure to distinguish the goal of Guide use from those of existing transfer reduction programs. The facilities found the workshops helpful preparation for effective implementation of the Guide.


EFFECTS OF A NOVEL APPROACH TO REDUCING COSTLY HOSPITALIZATIONS OF NURSING HOME RESIDENTS
Chair: Ruth Tappen Co-Chair: David Wolf Discussant: Karen Southard The reduction of preventable hospitalizations from long term care facilities has been identified by CMS as an important measure of quality, both in terms of resident outcomes and nursing home performance. As many as one-quarter of individuals admitted to nursing homes from acute care are rehospitalized within the month placing them at high risk for increased falls, delirium, skin breakdown, nosocomial infection and the like and costing an estimate $4.3 billion annually. To address this well documented threat to care quality, CMS has imposed significant penalties for excessive readmissions on facilities with high rehospitalization rates. An important contributor to these preventable readmissions is resident and family insistence on the transfer. Early efforts to reduce potentially preventable hospitalization of nursing home residents focused on developing systems to identify and respond to acute changes in condition before hospitalization becomes necessary. Reports from facility staff, however, brought to our attention the additional problem of resident and family insistence on transfer despite provider recommendations to the contrary. A series of funded studies to understand this problem, develop a solution and test the effectiveness of this solution will be reported by an interdisciplinary team. We begin with description of the development and clinical trial of Go to the Hospital or Stay Here?, an evidence-based, patient-centered decision aid, with individual residents and families, followed by a pilot test of facility-wide implementation; then an eight state regional dissemination supported by CMS and participating states and finally a discussion of best practices for effective implementation of the Guide. With the exception of guides for making end of life choices, there are very few if any patient decision aids created for residents of long-term care facilities. Further, only half of patient decision aids produced for any purpose have actually been field tested with patients and even fewer have been evaluated by providers other than the developers of the decision aid. Development of Go to the Hospital or Stay Here? was based on expert experience combined with extensive input from over 270 long-term care residents, their families and their caregivers. The initial clinical trial of this decision aid is reported in this presentation. Increased knowledge, reduced decisional conflict, increased preference for care in the nursing home when possible and a high rating of the helpfulness of the Guide were found in those who received the Guide (n=97) compared to those who did not (n=95).

PILOT STUDY TO IMPLEMENT A RESIDENT AND FAMILY DECISION GUIDE
David Wolf, 1 and Janet Sopcheck, 2 1. Bellarmine University,Louisville,Kentucky,United States,2. Florida Atlantic University,Boca Raton,Florida,United States In this first stage of an 8 state initiative designed to assist nursing homes in reducing unnecessary hospital readmissions, 16 nursing homes were identified and invited by CMS and state agency advisors to participate in the pilot study of the effects of intervention (use of the Guide). Selected facilities received an online orientation to the project and onsite visit from project team leadership prior to launch. Pre and post implementation data were uploaded to a secure section of the project website by the facilities. Three facilities withdrew due to change in top management and a fourth facility provided incomplete data resulting in data for analysis from 12 pilot facilities. Results show the average reduction in readmissions was 31.2% for the project period as compared with the 3-month pre-project period. This presentation will include facility reports of the effect of Guide use on resident and family decision making.

REGIONAL WORKSHOPS TO WIDELY DISSEMINATE AN INNOVATIVE PRACTICE Debra Hain, and Armiel Suriaga, Florida Atlantic University, Boca Raton, Florida, United States
The second stage of the CMS Region IV project involved a series of 20 half-day workshops and five follow-up webinars to introduce Go to the Hospital or Stay Here?, the training resources available (12 videos, 5 case studies and Best Practices summary), and strategies for implementation. Altogether 1124 representatives from long-term care facilities, state agencies, ombudsman groups and hospitals attended these interactive workshops. Polled participants reported that resident and family insistence on transfer to the hospital was a major barrier to successful reduction of acute care transfers for them. Those who implemented the Guide facility-wide reported an average 28% reduction in transfers. Primary barriers to facility-wide implementation were lack of leadership, making a choice to absorb the cost of financial penalties and failure to distinguish the goal of Guide use from those of existing transfer reduction programs. The facilities found the workshops helpful preparation for effective implementation of the Guide.

UTILIZING IMPLEMENTATION SCIENCE TO ACCELERATE ADOPTION OF A PROGRAM TO PREVENT AVOIDABLE TRANSFERS Karen Southard, 1 and Suzie Kaye, 2 1. The Carolinas Center for Medical Excellence (CCME), Columbia, South Carolina, United States, 2. Florida Atlantic University, Boca Raton, Florida, United States
The research team combined their long-term care management experience with feedback from the 16 pilot nursing homes and several hundred workshop and webinar participants' reports to identify the most effective strategies for implementation of the Guide and smaller Trifold. The learning framework employed to develop these Best Practices was directed to two distinct audiences 1) the licensed staff of the facility and 2) the residents of the facilities and their families. Critical elements identified included: when and how to distribute the Guide; how the Guide can be used to support difficult conversations e.g. about end of life choices; and effective and efficient ways to train staff. The framework for discussion during the symposium will be achievement of organizational readiness and the relevance of the four E's of implementation science as it applies to long term care organizations.

ENGAGING PHARMACISTS IN INTERPROFESSIONAL PROGRAMS TO SUPPORT OLDER RESIDENTS OF HUD-ASSISTED HOUSING Chair: Patricia Slattum Discussant: Elvin Price
Medications are one of the pillar 4Ms of an age-friendly healthcare system. Ensuring that benefits of a medication regimen outweigh the risks and that medications are not contributing to meaningful outcomes such as functional or cognitive decline is a challenge for our healthcare system, particularly for older persons experiencing adverse social determinants of health, health disparities or uncoordinated care. More fully engaging pharmacists in the older person's health care team is one strategy to improve clinical, humanistic and economic outcomes. This workshop reports findings on medication management capacity among older residents of five low-income apartment buildings in urban Richmond, VA, indicating that this population experiences challenges in managing medications as measured by MedMaIDE. The second presentation describes a pilot partnership between an independent community pharmacy and a local area agency on aging to provide medication coaching to residents of six affordable housing buildings in Seattle, WA, demonstrating feasibility of engaging pharmacists in the healthcare team and resulting in an average of five interventions per resident. The third presentation describes an interprofessional educational intervention based in two low-income apartment buildings for older persons in underserved West Baltimore, MD involving pharmacy students, to better prepare pharmacists to engage in interprofessional team care and meet the needs of a low income culturally diverse older adult population. Discussion will focus on barriers and opportunities to more fully engage pharmacists to support urban residents of low-income housing buildings to optimize medication outcomes and reduce medication-related harm. MMC is an essential component of safe and independent living. This cross-sectional study was designed to assess MMC among low-income older persons residing in HUD-subsidized housing, located at one of five apartment buildings in urban Richmond, VA. Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) was used to measure MMC during individual, face-to-face interviews. Of the 107 participants, 89% were African-American with an average age of 68.5 years (±7.2), an average of 4.9 (±2.9) comorbidities and using approximately 8 (±4.1) medications on a regular basis. The mean deficit in MMC was 3 (±2.0). The most difficult skill was naming all of the medications (69.2%) followed by stating the indication (46.7%) and knowing how or when all of the medications should be taken or identifying existing refills (38.3%). Many older residents of low-income housing experience challenges in managing medications.