Publications

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Improving Post-Fall Evaluation in a Skilled Nursing Facility

JAMDA
June 1, 2026
The objective of this quality improvement (QI) project was to reduce fall-related complications, particularly fragility fractures, among residents and patients in skilled nursing facilities. This population is at high risk for falls and subsequent...

Improving Discussion of Chronic Care and End-of-Life Choices

JAMDA
June 1, 2026
Increase the discussion of choices in addressing chronic disease and end of life, measured by an increase in the number of Life Sustaining Treatment Initiative and Goals of Care Conversation notes written. This is relevant as individuals live longer...

Improving Continuity of Care in LTC through Standardized Communication

JAMDA
June 1, 2026
This project aims to enhance continuity of care for patients at a 180-bed skilled nursing facility in Colorado by streamlining communication processes with external medical providers with the goal to increase the documentation and therefore...

Improving AIMS Screening Through Interdisciplinary Staff Education in Long-Term Care

JAMDA
June 1, 2026
The objective of this quality improvement (QI) project was to evaluate whether a structured, evidence-based educational intervention impacted post-acute and long-term care (PALTC) clinical staff knowledge, confidence, and perceived clinical...

Implementing a Heart Failure Program within a Skilled Nursing Facility

JAMDA
June 1, 2026
To reduce 30-day HF readmissions in short-stay SNF patients (65+) by implementing the AHA Heart Failure Program. HF is a major cause of preventable readmissions and impacts quality of life and care costs. SMART Aim: Decrease 30-day HF readmissions...

Community-wide Strategies to Reduce Behavioral Incidents in Assisted Living

JAMDA
June 1, 2026
Adapt and implement the Safewards interventions in an assisted living (AL) community serving formerly homeless individuals to reduce aggressive incidents and calls to 911.

Care Coordination for Post-Acute and Long-Term Care Residents Receiving Hemodialysis

JAMDA
June 1, 2026
The objective of the project was to implement a shared PALTC–dialysis care coordination tool across six nursing homes in CMS ESRD Network 6, and within 6 months, achieve 90% documented tool completion while reducing missed or shortened dialysis...

Beyond the Indication: Deprescribing for Safer Aging

JAMDA
June 1, 2026
Within 90 days, reduce non-concordant acid-suppression therapy by ≥15% from baseline among SNF residents receiving PPIs/H2RBs by aligning prescribing with guideline-supported indications and durations. Sought to reduce resident pill burden and...

An End-of-Life Care Approach Defining a New Standard of Care

JAMDA
June 1, 2026
The Institute for Healthcare Improvement (IHI) Leadership Alliance established an End-of-Life Care/Ending-Life Care Accelerator to define a continuum of care for patients as they progress from curative care, to palliative care, to hospice care, to...

Advancing Education on Advanced Care Plan Discussions for Clinicians

JAMDA
June 1, 2026
Objective: to improve quality of ACP discussions, the confidence in clinician's ability to conduct ACP discussions, and documentation of ACP discussions. Who: Primary Care Providers (NPs and PAs) in nursing homes who have already undergone scripted...