Publications

Members only publications are marked with a lock icon:
Filter By

Evaluation of the Skilled Nursing Facility (SNF) Transitional Care Management Program (TCMP) Using Decision Support on Post-Acute Discharge SNF Length of Stay and Subsequent Hospital Readmissions

JAMDA
March 1, 2019
Accounting for both significant total medical expense and variation, managing Skilled Nursing Facility (SNF) post-acute care (PAC) utilization has become a major focus area for accountable care organizations (ACOs). In 2017 our healthcare system...

Effects of Physiatric Consultation in Post-acute Care

JAMDA
March 1, 2019
Physiatry-directed rehabilitation teams are assumed to improve patient outcomes, reduce hospital readmissions, and lead to appropriate lengths of stay in inpatient rehabilitation settings. However, there is no evidence to support these assumptions...

Utilizing Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) to Improve Ineffective Communication in Long-Term Care Settings

JAMDA
March 1, 2019
Ineffective communication remains a major factor contributing to medical errors and sentinel events in health care that lead to fatalities and billions in malpractice cost. Nurses have a leading role in communicating valuable patient information to...

The Impact of Quality Improvement Coaching on Skilled Nursing Facilities to Improve Transitions

JAMDA
March 1, 2019
Plan-Do-Study-Act (PDSA) is widely accepted as an effective Quality Improvement (QI) methodology in Skilled Nursing Facilities (SNF). Accountable care organizations (ACOs) are interested in promoting this methodology in collaborative endeavors with...

The Care Aligned Program (CAP): Reducing Avoidable Hospitalizations Without Focusing on Hospitalizations

JAMDA
March 1, 2019
Reducing avoidable hospitalizations is a common concern for nursing home residents as debility, functional decline, morbidity and mortality are inevitable complications of hospitalization. Therefore, nursing homes and hospitals across the country...

Teaming up to Reduce Catheter-Associated Urinary Tract Infections

JAMDA
March 1, 2019
Indwelling urinary catheters are a frequent cause of infection, which may result in hospitalization and increased morbidity and mortality. Catheter-associated urinary tract infection (CAUTI) and its complications are linked to increased health care...

Significance of STEADI Screening in Early Identification of Geriatric Patients with Undiagnosed Depression

JAMDA
March 1, 2019
Each year, the health care system loses billions of dollars due to falls in the geriatric population, causing significant morbidity and mortality. Clinical depression is relatively uncommon among older US adults, but depressive symptomatology has...

Readmissions? Not with Your Nurse Practitioner in Charge!

JAMDA
March 1, 2019
Deaconess Health System developed a post-acute embedded Nurse Practitioner (NP) program in partnered skilled nursing facilities (SNF) to improve patient transitions and coordination of care. This model has improved patient care, lowered 30-day...

Quality Improvement Project to Enhance Knowledge of Post-Acute Care Interdisciplinary Team of Hospice Services

JAMDA
March 1, 2019
Hospice services provided to residents of post-acute and long-term care (PALTC) facilities are associated with higher resident and family satisfaction and lower health care costs. One barrier to timely hospice enrollment is limited understanding of...

Proof of Concept: Nursing Home Specialist in Action. the Impact of Full-time Physician Services in Post-Acute Care

JAMDA
March 1, 2019
Post-Acute Care skilled nursing facilities have become a key component to improving quality of care and reducing health care costs nationwide. Several models have been considered to address the complex care and expense that post-acute care...