JAMDA xxx (2017) 1e5
JAMDA journal homepage: www.jamda.com
Implementation of a Person-Centered Medical Care Model in a Skilled Nursing Facility: A Pilot Evaluation Kathleen Abrahamson PhD, RN a, *, Jaclyn Myers PharmD a, Arif Nazir MD, FACP, CMD b a b
Purdue University, West Lafayette, IN Signature HealthCARE, Louisville, KY
a b s t r a c t Keywords: Person-centered skilled nursing facility (SNF) implementation
Objectives: The objective of this study was to evaluate the feasibility and impact of implementing a person-centered medical care model for post-acute care residents within a skilled nursing facility (SNF). Design: A mixed-method (qualitative and quantitative) pilot evaluation. Setting: An 89-bed SNF located within a large midwestern city. Participants: Forty SNF post-acute patients admitted to the facility during a 6-month period were enrolled in the pilot evaluation. The patients were 75% women, 57% African American, and had an average age of 73. To meet inclusion criteria, patients must have been admitted to the facility for rehabilitation with a plan for community discharge, and be cognitively able to consent as indicated by a cognitive screening tool or assent to participation with family member consent. Intervention: The person-centered medical care model included (1) biweekly interdisciplinary care plan meetings, scheduled at a time of patients’ preference and held in the patient’s room; (2) patient selection of health-related goals that guide team discussions; (3) use of lay-language that facilitated patient understanding; (4) team accountability to the patient for patient care preferences; and (5) monthly careteam meetings to exchange feedback regarding the team’s performance and the model. Measurement: Evaluation data included admission and discharge Patient Activation Measure surveys; admission and discharge Care of Chronic Conditions surveys; admission and biweekly modiﬁed Castle Satisfaction Surveys; admission and discharge Patient and Caregiver Engagement surveys; and semistructured interviews with a sample of staff, family members, and patients. Results: A signiﬁcant (P < .01) improvement was noted between admission and discharge on both the Care for Chronic Conditions and the Patient Activation Measure surveys. Patient satisfaction surveys trended toward higher ratings over time on most questions, with signiﬁcant improvement in 2 questions addressing satisfaction with their medical provider. Interviews revealed a perception that the model encouraged an environment of respect and honesty in patient communications, and an overall positive experience. The challenges of scheduling and time were noted by respondents. Conclusions: Implementation of person-centered medical care within an SNF was feasible, yet required changing care processes to better address individual goals and facilitate communication among patients, providers, and SNF staff. Overall pilot results indicated that patients and staff members viewed the person-centered care experience positively. Further research is needed to examine long-term effects of the model on resident outcomes. Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Approximately 20% of hospitalized Medicare beneﬁciaries are discharged to a skilled nursing facility (SNF) for ongoing care and rehabilitation.1 These post-acute patients commonly enter the SNF
The authors declare no conﬂicts of interest. This project was funded by the Indiana Clinical and Translational Science Institute of Indiana, and a quality improvement award from AMDA Foundation. * Address correspondence to Kathleen Abrahamson, PhD, RN, Associate Professor of Nursing, Purdue University, 502 N. University Street, West Lafayette, IN 47907. E-mail address: [email protected]
(K. Abrahamson). http://dx.doi.org/10.1016/j.jamda.2017.03.001 1525-8610/Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
with unresolved acute health issues and multiple functional and psychosocial needs. The increased clinical demands that result from increased numbers of post-acute admissions have not been paralleled by changes in SNF care delivery models. For example, SNF regulations require a minimum of 1 physician visit a month, which may be insufﬁcient to provide high-quality, evidence-based care. An Ofﬁce of the Inspector General report2 noted that more than 30% of patients risk harm from poor care within 30 days of their admission to an SNF. Multicomponent, interdisciplinary interventions have improved care in hospital settings, but are yet to
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be widely implemented to improve the quality of SNF care.3e5 The current study was a pilot examination of the Patient-Oriented Interdisciplinary Sub-acute Care (POISe-Care) model. The POISe-Care model introduced an interdisciplinary team care method into the traditional SNF care processes with the intention of changing the way in which subacute SNF care was delivered. The interdisciplinary team consisted of a physician and/or advanced nurse practitioner, physical and/or occupational therapists, social workers, nurses, nursing assistants, and activities and food service personnel. Patients directed the care decision process by selecting the day and time for the meeting in their room and providing the care team with their top 3 goals to be achieved during the SNF stay. The interdisciplinary team used lay terminology to facilitate patient and caregiver understanding, spoke directly to the patient while addressing the patient in the ﬁrst person, and viewed the patient as team leader, or “CEO” of his or her own care. Team development was a central feature of the model. A “real team,” as opposed to a quasi-team, is one that has a clear task, and in which members have clear roles, speciﬁc authority to manage their own work processes, and high membership stability.6 The current environment in a typical SNF suffers from poor organizational support, absence of clear leadership, lack of understanding of staff roles and tasks, misaligned aims and priorities, and vertical management structures.7 As a result, only 16% of SNF staff members organize in a manner consistent with the concept of real teams7; this despite evidence that team-driven care promotes positive health and safety outcomes, enhanced continuity of care and patient trust, group problem solving, and staff satisfaction.8 Additionally, existing research indicates that having a prescribing provider (physician or advanced practice nurse [APN]) as part of the team increases the probability of improved health outcomes.9 Currently, a prescribing clinician’s availability in interdisciplinary care planning is rare, with fewer than 5% of care plans having any physician or APN involvement.10 The POISe-Care Model was developed on this evidence, with the goal of integrating more effective team work into the patient-centered model. Further detail about this model is available in the article by Nazir et al.11 The objective of this study was to evaluate the feasibility and impact of the POISe-Care model. It was predicted that the evaluation would provide positive evidence of model success to support a larger translation of the POISe-Care model into practice. Methods Study Design Evaluation participants were selected from patients admitted to the intervention facility, a for-proﬁt SNF that is located within a large midwestern city and has an average daily census of more than 20 short-stay residents. The facility had a Centers for Medicare and Medicaid Services quality rating of 4 of 5 stars at the time of POISeCare model implementation. Participant inclusion criteria included the following: (1) admitted to the facility for skilled rehabilitation with a plan for community discharge, and (2) able to consent to participation as indicated by a cognitive screening tool or able to positively assent to participation with the consent of a guardian or power of attorney. Participants were excluded from the evaluation if they were (1) unable to communicate in English; (2) diagnosed with a terminal illness, deﬁned as less than 6 months to live with comfort care only; or (3) cognitively impaired without an available surrogate. All short-stay patients at the intervention facility received person-centered medical care through the POISe-Care model; a patient did not need to consent to provide data for this study to
receive care using the innovative model. Study participants received the POISe-Care model of medical care, described previously, as part of their routine care. All patients were informed of their right to refuse any aspect of the model and/or to participate in data collection. Data Complimentary data were collected concurrently from multiple sources to address the complexities surrounding implementation of a new model of medical care within an SNF, and equal weight was given to each form of data. Demographic, health, and functional information was extracted from the patient Minimum Data Set data. Additional data were collected from participating patients by using the Assessment for Care of Chronic Conditions scale at admission and discharge, the Insignia Patient Activation Measure at admission and discharge, and a modiﬁed Castle Satisfaction survey at admission, every 2 weeks, and again at discharge. Family caregivers were given the Preparedness for Caregiving Scale on admission and at discharge. The modiﬁed Castle Satisfaction survey data were collected from patients by facility staff as part of the POISe model process and used to encourage discussion at POISe-Care meetings. All other surveys were completed by a study research associate. Survey data were analyzed using SPSS version 23 (IBM SPSS Statistics, IBM Corporation, Chicago, IL) to determine descriptive statistics and comparison of means between survey administration time periods. Semistructured interviews addressing perceptions of model implementation, feasibility, and impact were conducted by a study research associate with staff members, patients, and patient family members until such a point in which data saturation was reached. Institutional review board approval was received before the beginning of data collection. Results Study Sample Of the 64 eligible patients admitted during the study period, 13 refused participation, 12 did not remain in the facility to meet the minimum 2-week participation window, and data were collected from 39 enrolled participants. The mean age of enrolled participants was 73.4 years (range 42e100 years); 75% were women; and 95% had Medicare coverage, 44% were Medicaid eligible, and 5% were privately paying for their stay. Twenty (50%) of the participants identiﬁed a primary caregiver. Consistent with the patient population of the intervention nursing home, more than half of the participants (57%) self-identiﬁed as African American, 41% selfidentiﬁed as white, and 2.5% as Hispanic/Latino. The 3 most common medical diagnoses were diabetes (50%), kidney disease (38%), and heart failure (33%). The average number of prescribed medications on admission per study participant was 10.7 scheduled, 2.5 as needed. Among the 39 study participants, 85% had reported pain in the previous 5 days, 63% had fallen within the 2 months before the nursing home admission, and 2 residents fell within the ﬁrst 5 days of their nursing home admission. With regard to physical function, 15% could walk without assistance or with only supervision, 90% required some assistance with dressing and grooming, and 92% required some physical assistance with toileting. Seventy-six percent of enrolled patients were cognitively intact on the Brief Interview for Mental Status cognition scale, and 87% demonstrated no sign of depression using the Patient Health Questionnaire-9 scale. Sample characteristics are displayed in Table 1.
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Of the 15 caregivers who completed the admission Preparedness for Caregiving Scale, more than half considered themselves very well prepared to care for the resident at home (53%), make caregiving activities pleasant (53%), respond to emergencies (60%), and get information when they need it (53%). Analysis of change between admission and discharge of caregiver data could not be accurately reported because of the small sample size and the high level of missing discharge data. Table 4 displays caregiver responses to the Preparedness for Caregiving Scale. A modiﬁed version of the Caste Satisfaction survey was administered to residents on admission and every 2 weeks subsequently by facility staff. The satisfaction survey was used to guide discussion surrounding aspects of care during the bedside POISe-Care meetings. The survey dealt with the domains of activities, privacy, safety/security, caregivers, physical environment, meals, and general satisfaction. Change in average score for each survey question was examined, with the understanding that because of community discharge/differences in length of stay, patients completed differing numbers of surveys completed decreases at each time period (eg, some residents have only 2 surveys completed, others have more with a maximum possible number of surveys at 6). Although the trend was upward on most questions, examining each question separately by using all available survey time periods demonstrated no signiﬁcant difference over time for any survey question. However, when only admission and discharge satisfaction surveys are included in the analysis, so that each resident is equally represented in the data, a comparison of means demonstrated a trend toward improved satisfaction on the questions asking about whether the physician or nurse practitioner understands their needs (P < .058) and satisfaction with the physician or nurse practitioner (P < .048).
Table 1 Characteristics of the Study Sample (n ¼ 40) Baseline Characteristics, n ¼ 40 Average age Average total scheduled medications Average total of as-needed medications Women Hispanic ethnicity African American Payment source: Medicaid Payment source: Medicare
73.4 (range 42e100) 10.7 (range 4e20) 2.5 (range 0e7) 75% 2.5% 55.0% 43.6% 94.9%
Survey Findings In response to the admission Insignia Patient Activation Measure (n ¼ 39), 87% agreed or strongly agreed that they were the person who is responsible for taking care of their health, 92% agreed or strongly agreed that taking an active role in their health care was the most important thing they could do for their health, 90% agreed or strongly agreed they were conﬁdent about speaking to their doctor, and 85% agreed or strongly agreed that they would be able to follow through on medical plans at home. Conversely, 46% disagreed with the statement that they knew what each of their prescribed medicines did for their health. A paired t-test analysis of mean Patient Activation Measure scores for those who completed the measure both at admission and discharge (n ¼ 34) found a signiﬁcant difference moving toward increased activation for health between assessments (P < .00). Responses for the Insignia Patient Activation Measure are noted in Table 2. On admission to the facility, more than half of the patients who completed the Assessment for Care of Chronic Conditions (n ¼ 38) responded that they did not remember ever being given a written list of things they should do to improve their health (60%), or a treatment plan (53%). However, many patients noted the following: being asked for their ideas about the treatment plan (29%), given choices to think about (34%), and being shown how self-care can improve their condition (32%) most of the time or always. Similarly, a paired t-test analysis indicated a signiﬁcant increase in conﬁdence scores on the Care for Chronic Conditions scale (n ¼ 35) between admission and discharge assessments (P < .02). Table 3 displays the admission responses for the Assessment for Care of Chronic Conditions survey.
Interviews Semistructured interviews were conducted with 12 stakeholders (6 residents, 4 staff members, and 2 family members of residents). The interviews were approximately 30 minutes in length, were recorded and transcribed, and focused on perceptions of the POISe-Care model implementation, feasibility, and impact. Analysis for key themes was completed by 2 project investigators by using NVIVO 9 software (QSR International, Melbourne, Australia), and 3 major themes were
Table 2 Admission Insignia: Patient Activation Measure Results and Change at Discharge N/A, % When all is said and done, I am the person who is responsible for taking care of my health. Taking an active role in my own health care is the most important thing that affects my health. I know what each of my prescribed medications do. I am conﬁdent that I can tell whether I need to go to the doctor or whether I can take care of a health problem myself. I am conﬁdent that I can tell a doctor concerns I have even when he or she does not ask. I am conﬁdent that I can follow through on medical treatments I may need to do at home. I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising. I know how to prevent problems with my health. I am conﬁdent I can ﬁgure out solutions when new problems arise when my health. I am conﬁdent I can maintain lifestyle changes, like eating right and exercising, even during times of stress. N/A, not applicable. *Difference is signiﬁcant P < .01 based on paired t test.
Disagree Strongly, %
Agree Strongly, %
Mean Change at Discharge
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Table 3 Admission Assessment for Care of Chronic Conditions Results Admission Assessment for Care of Chronic Conditions (n ¼ 38 Unless Otherwise Indicated) and Mean Change at Discharge
Asked for my ideas when we made a treatment plan. Given choices about treatment to think about. Asked to talk about any problems with my medicines or their effects. Given a written list of things I should do to improve my health. (n ¼ 37) Satisﬁed that my care was well-organized. (n ¼ 37) Shown how what I did to take care of myself inﬂuenced my condition. Asked to talk about my goals in caring for my condition. (n ¼ 37) Helped to set speciﬁc goals to improve my eating or exercise. Given a copy of my treatment plan. Encouraged to go to a speciﬁc group or class to help me cope with my chronic condition. Asked questions, either directly or on a survey, about my health habits. Sure that my doctor or nurse thought about my values, beliefs, and traditions when they recommended treatments to me. Helped to make a treatment plan that I could carry out in my daily life. Helped to plan ahead so I could take care of my condition even in hard times. Asked how my chronic condition affects my life.
None of the Time, %
A Little of the Time, %
Some of the Time, %
Most of the Time, %
Mean Change at Discharge
23.7 28.9 15.8
21.1 18.4 13.2
26.3 18.4 28.9
10.5 18.4 18.4
18.4 15.8 23.7
2.86 2.83 3.17
0.80y 0.69* 0.63
*Difference is signiﬁcant P < .05 based on paired t test. y Difference is signiﬁcant P < .01 based on paired t test.
discovered: the importance of honesty and respect in nursing home care, time and schedule challenges, and overall satisfaction with the patient-centered model of care. Resident interviews, in particular, had a heavy emphasis on honesty and respect in caregiving. “If you are upfront with me, then I am deﬁnitely going to work to do my best to do what is going to be best for me.” When asked, none of the residents interviewed expressed it to be a burden to participate in the rounds. However, 3 of 4 of the staff member interviews expressed a concern with time in terms of interference with other caregiving tasks and time to schedule meetings.
“Most of our families work, so getting that (meeting) timeframe down pat for them to participate has been a challenge.” Overall, the interviews were very positive with regard to perceptions of the model. Interview participants volunteered for the interview, so self-selection bias may have inﬂuenced the positivity of our ﬁndings. However, despite this limitation, the overall analyzed text predominately reﬂected positive impressions of the model’s impact on care.
“I deﬁnitely think a facility needs to be adequately staffed to do this model because you need to pull people off of the (caregiving role) ﬂoor.”
“I would encourage it (the POISe-Care model) 100% just because it truly makes a difference and it empowers our residents to own what is going on and to want more.” “So, those were really good meetings and I just really have to admit that I just really love what they were doing for my Mom. That was really cool.”
Table 4 Preparedness for Caregiving Scale (n ¼ 15 Caregivers) Not at All Prepared, % How well prepared do you think you are to take care of your family member’s physical needs? How well prepared do you think you are to take care of his or her emotional needs? How well prepared do you think you are to ﬁnd out about and set up services for him or her? How well prepared do you think you are for the stress of caregiving? How well prepared do you think you are to make caregiving activities pleasant for both you and your family member? How well prepared do you think you are to respond to and handle emergencies that involve him or her? How well prepared do you think you are to get the help and information you need from the health care system? Overall, how well prepared do you think you are to care for your family member?
Not Too Well Prepared, %
Somewhat Well Prepared, %
Pretty Well Prepared, %
Very Well Prepared, %
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Discussion Overall, implementation of the POISe-Care model was viewed favorably by the staff, residents, and family members queried. A signiﬁcant (P < .01) improvement was noted between admission and discharge on both the Care for Chronic Conditions and the Patient Activation Measure surveys. Patient satisfaction surveys trended toward higher ratings over time on most questions, with signiﬁcant improvement in 2 questions addressing satisfaction with their medical provider. Interviews revealed a perception that the model encouraged an environment of respect and honesty in patient communications, and an overall positive experience. Patient-centeredness was a central feature of this model. Despite their value in improving quality of care, integration of patient and caregiver input into SNF usual care is challenging.12 The current usual team care in SNFs is organized around the routines of the team rather than centering on the patient. The inclusion of patient and family caregivers into the team has potential to increase access to patients’ backgrounds, preferences, and priorities for care. Moreover, such approaches encourage the integration of patient values and beliefs into the medical decision-making process.13 Feedback from patients facilitates within-team alignment of perceptions and expectations with those of patients and families, and consistent interactions through the bedside meetings were designed to ensure that team members are accountable to the patient for patient-directed outcomes. Structured communication tools were used to ensure feedback from patients, accountability of the team to the patient as team leader, and adherence to agreed-on team processes. Patients also provided feedback in the form of surveys (Patient Activation Measure, modiﬁed Castle Satisfaction survey, Care of Chronic Conditions survey) to assess their satisfaction with care and conﬁdence in self-care. Monthly interdisciplinary team meetings, separate from the biweekly patient-oriented meetings, provided a venue for within-team feedback and process improvement. The interdisciplinary team was accountable to report on progress made toward patient goals and care preferences, and patients received a document entitled the “CEO Report,” which provided information from the meeting to share with family or refresh their memory as needed. Changes in the health care environment have placed increased focus on patient and caregiver perspectives, satisfaction, and valued outcomes.14,15 Despite a number of limitations to our pilot study, it has been demonstrated that it is feasible to implement a person-centered model of medical care within an SNF. Preliminary staff interviews demonstrate a high level of satisfaction despite concerns regarding staff time, and patients were receptive to the model, reporting positive satisfaction overall. As the clearest testament of model feasibility, the pilot facility continues to carry out the model and is working to expand implementation beyond the pilot unit. Although time and scheduling were noted as model challenges, the positive staff response and continuation of the model demonstrate that streamlining care by focusing speciﬁcally on patient priorities is an efﬁcient means to deliver care. An additional beneﬁt appears to be increased satisfaction with medical providers. Of note is the survey ﬁnding that although most patients felt conﬁdent in their ability to return home successfully, fewer than half reported understanding their medications. Further investigation is needed to understand the mechanism behind this lack of understanding and conﬁdence regarding medications, and how evidence-based interventions may improve this problem.
It is worth noting that, because most nursing homes operate on relatively tight stafﬁng margins and ﬂat organizational structures that may not ﬂex easily to the individualized bedside meeting schedule required for this model, further more expansive study is needed to how this model translates to other facilities, and to gather satisfaction and outcomes data on a large sample of SNF patients. Also, the patient participant sample was predominately cognitively intact, and the facility had a leadership team, including a physician, that championed this change. Dissemination into environments with more heavily impaired patients and/or signiﬁcant stafﬁng concerns may be more challenging. However, we believe that aspects of this model, such as use of lay-language, patient-centric goal setting, and “patient as CEO” level accountability are transferable to most SNF settings. Importantly, the ﬁndings from this analysis support further exploration into the beneﬁts of a team-based, person-centered model of medical care within the SNF setting, and future research would beneﬁt from analysis of patient outcomes, such as health status, utilization, and satisfaction within the community after discharge. Conclusions It was feasible to implement a person-centered model of medical care within an SNF setting, despite time and resource constraints. Resident surveys and stakeholder interviews indicated a high level of satisfaction with the model. Further research is needed to link the resident experience with clinical outcomes, such as length of stay, hospitalizations, and health status. Additionally, future use of case-control or quasi-experimental methods would provide valuable evidence for model translation. References 1. Mor V, Intrator O, Feng Z, Grabowski DC. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Milwood) 2010;29:57e64. 2. Ofﬁce of the United States Inspector General. Adverse events in skilled nursing facilities: National incidence among Medicare beneﬁciaries. OEI-06-11-00370. Washington, DC: U.S. Department of Health and Human Services; 2014. 3. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340: 669e676. 4. Milisen K, Foreman MD, Abraham IL, et al. A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. J Am Geriatr Soc 2001;49:523e532. 5. Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: A systematic review. Ann Intern Med 2013;158:375e380. 6. Havig AK, Skogstad A, Veenstra M, Romoren TI. Real teams and their effect on the quality of care in nursing homes. BMC Health Serv Res 2013;13:499. 7. Temkin-Greener H, Cai S, Katz P, et al. Daily practice teams in nursing homes: Evidence from New York state. Gerontologist 2009;49:68e80. 8. Pierce JL, Kostova T, Dirks KT. Toward a theory of psychological ownership in organizations. Acad Manage Rev 2001;26:298e310. 9. Nazir A, Unroe K, Tegeler M, et al. Systematic review of interdisciplinary interventions in nursing homes. J Am Med Dir Assoc 2013;14:471e478. 10. Delleﬁeld ME. Interdisciplinary care planning and the written care plan in nursing homes: A critical review. Gerontologist 2006;46:128e133. 11. Nazir A, Bernard B, Myers J, Abrahamson K. Can patients be the CEO of their skilled nursing stay? Description of a person-centered model of sub-acute care. J Am Med Dir Assoc 2015;16:905e907. 12. O’Shea F, Weathers E, McCarthy G. Family care experiences in nursing home facilities. Nurs Older People 2014;26:26e31. 13. Van Haitsma K, Abbott KM, Heid AR, et al. The consistency of self-reported preferences for everyday living: Implications for person-centered care delivery. J Gerontol Nurs 2014;40:34e46. 14. Beattie M, Lauder W, Atherton I, Murphy DJ. Instruments to measure patient experience of health care quality in hospitals: A systematic review protocol. Syst Rev 2014;3:4. 15. Xyrichis A, Ream E. Teamwork: A concept analysis. J Adv Nurs 2008;61: 232e241.