Publications

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Telemedicine Coverage Impacts Hospital Transfers in High Acuity Nursing Home

JAMDA
May 1, 2023
Providing direct clinical provider encounters during off hours via telemedicine with the goal of reducing hospital transfers by 15%.

Reduction of Non-Beneficial Life-Sustaining Treatments in a Nursing Home

JAMDA
May 1, 2023
Decrease number of non-beneficial medical treatments (NBT) for nursing home (NH) residents with advanced life-limiting illnesses and also enrollment in palliative care by 30% over a 12-month period via an interdisciplinary team (IDT) approach to...

Reduction in Hospitalization, A Formidable Goal!

JAMDA
May 1, 2023
Hospital readmission of nursing home patients continues to pose a safety and quality of life as well as a cost issue. The purpose of this initiative is to promote evidence-based strategies in reducing avoidable hospitalizations.

Post-SNF Follow-Up Calls and Appointments Trend Toward Decreased Readmissions

JAMDA
May 1, 2023
To assess whether scheduled and attended follow-up appointments and follow-up phone calls after skilled nursing facility (SNF) discharge decrease 30-day readmissions post-SNF discharge, and subsequently improve patient outcomes and help decrease the...

Palliative Care Clinical Activation Report to Identify Palliative Needs

JAMDA
May 1, 2023
To review the use of a Palliative Care Clinical Activation Report (PCAR©) to identify high-risk patients for a palliative care program.

Optimizing Osteoporosis Intervention After Fragility Fracture in Post-Acute Long-Term Care

JAMDA
May 1, 2023
To provide education to patients, family, and subacute rehabilitation providers, initiating interventions, and to assist with transition to community healthcare providers for further care. This is especially paramount given current aging population...

Medication-Reconciliation Quality Improvement With a Reverse Hand-Off at a Nursing-Home

JAMDA
May 1, 2023
By the end of November 2022, we will increase the rate of reverse hand-offs performed by accepting providers at the skilled nursing facility by 50% as a process measure.

Long-Term Care Referral Process for Veterans with a Mental Health Diagnosis

JAMDA
May 1, 2023
This study aimed to improve the referral process for veterans with a mental health diagnosis who are seeking long-term care with their local Veterans Affairs Medical Facility (VAMC) through a needs and gaps analysis of a VAMC in New England. Hackman...

Life Storytelling To Improve Person-Centered Care in Long-Term Care

JAMDA
May 1, 2023
To assess whether introducing patient life stories at 1 skilled nursing facility (SNF) can improve person-centered care by increasing knowledge about patients’ personal histories and improving patient/family-provider relationships.

Improving Communication Skills Amongst Clinicians Through Formal Evidence Based Training

JAMDA
May 1, 2023
To conduct a quality improvement project assessing whether training using the VitalTalk program will lead to improved knowledge, skills and attitudes regarding communicating with patients and families about serious illness.