Publications

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An Integrated Healthcare Model for our County's Most Vulnerable Patients: Making an Impact with PACT (Post-Acute Care Transition)

JAMDA
March 1, 2020
Safe hospital discharge remains a high priority for maintaining quality of care in medical systems. The PACT initiative grew from a growing need to care for a challenging population - patients who are hospitalized for complex medical conditions but...

AI Predicts Post-Acute Care Need

JAMDA
March 1, 2020
Discharge delays due to non-medical reasons are important causes of unnecessary extended inpatient lengths of stay that contribute to rising costs and strained bed capacities. Appropriate post-acute care (PAC) placement is a critical component of...

Addressing Population Health Care Transitions by Utilizing Swingbed Post-Acute Care

JAMDA
March 1, 2020
Ste Genevieve County Memorial Hospital (SGCMH) has a swing bed hospital-based program for Transitional Care (skilled nursing). Recently, SGCMH implemented an innovative care model, standardized triage process, and collaboration with select tertiary...

A Multidisciplinary Process to Improve Quality Indicators in a Veterans Affairs Community Living Center

JAMDA
March 1, 2020
Quality Indicators (QIs) are an important part of Long-Term Care Quality improvement initiatives and 1 of 3 domains of the overall star rating developed by Centers for Medicare/Medicaid (CMS). At the Corporal Michael J Cresencz Veterans Affairs...

Utilizing the Huddle for Meaningful Conversations about Goals of Care and Advance Directives

JAMDA
March 1, 2020
Oftentimes, the conversations that are needed the most to understand patient care goals, especially in the context of serious illness or end of life, are often not talked about. Patients’ goals of care and advance directives tend to happen too late...

Staff Education on a Urinary Tract Infection Algorithm in a Skilled Nursing Facility

JAMDA
March 1, 2020
A nation-wide initiative has been established for antibiotic stewardship in an effort to reduce over-treatment and over-diagnosis of infections. In our Skilled Nursing Facility (SNF), there are minimal guidelines for ordering urinalyses (UAs) in...

Impacts of UTI Protocol Initiation on Long-Term Care Nursing Staff

JAMDA
March 1, 2020
Concerns of urinary tract infections (UTI) are widespread in long-term care (LTC) settings. Non-specific symptoms can lead to unnecessary testing and inappropriate antibiotic use. There have been numerous protocols developed to standardize diagnosis...

ECHO™-Skilled Nursing Facilities: Telementoring for Nurses in Skilled Nursing Facility Leadership Positions

JAMDA
March 1, 2020
It is common for nurses with limited specialized training in geriatrics to care for older adults at skilled nursing facilities (SNFs). In SNFs on the south side of Chicago, prior needs assessments have identified a gap in knowledge in geriatrics...

Choosing Wisely in Post-Acute and Long-Term Care: Evaluating internal medicine residents knowledge gaps

JAMDA
March 1, 2020
In 2013, the Choosing Wisely Campaign launched 5 recommendations pertaining to the care of patients in the post-acute and long-term setting. This was done in an effort to educate clinicians, patients, and other providers about potentially...

Avoid the ER! Using Simulation-Based Mastery Learning to Teach Common Procedures Needed in Post-Acute Care

JAMDA
March 1, 2020
Hospitalized older patients are increasingly complex and often require procedures after discharge that lead to burdensome transitions of care. Post-acute care providers practicing in the skilled nursing facility or long-term care setting have often...