Identifying Patterns of Skilled Nursing Facility Readmission

Design/Methodology: Case Report- 78 year old male with past medical his-

tory of Hypertension, Hyperlipedemia, who is a long term resident in ex-

tended care facility was sent to ER for evaluation of his multiple somatic

complaints. He described his mood as terrible, sad at times with suicidal

thoughts. He had an existing diagnosis ofMajor Depressive disorder for which

he was started with SSRI for 1 year with no improvement. The patient repeat-

edly says ‘‘I am feeling awful.’’ Social history revealed that he is a widower,

had university level education and recently retired as a teacher. On exa-

mination he was alert and oriented, but appears apathetic. Mood appeared

alternating between labile and constricted as patient was tearful at one mo-

ment and started laughing withinminutes.MMSE revealed 20/30 with 3/3 re-

call with abnormal Clock drawing test and verbal Fluency of 7. Advanced

neurocognitive evaluation showed that patient lacked initiation and perse-

verence. He was not able to do Trail B test. The patient hospital stay was re-

markable for multiple episodes of disinhibited behavior, being sexually

preoccupied, grabbing nursing staff and making inappropriate gestures.

Rest of the physical examination, laboratory data was unremarkable. CT

scan of head was suggestive of diffuse cortical atrophy with mild microvascu-

lar ischemic changes.

Results:Patientwas started onDepakote 125mgbid for his behavior abnormal-

ity. Ritalin 2.5mg bid was added to pre-existing dose of celexa 40mg. His mood

variability improved significantly but sexual impulsivity is still persisting.

Conclusion/Discussion: FTD can often bemisdiagnosed and treated as a psy-

chiatric disorder. In this case FTD was not picked up at its early stage and pa-

tient was been treated for sole major depression. FTD is a chronic and

progressive disorder which becomes resistant to treatment if it is not recog-

nized early. This case illustrates the difficulty faced by the clinician in recog-

nizing a relatively common condition like Fronto temporal dementia if it is

complicated or superimposed by Major depressive syndrome. Early recogni-

tion and diagnosis offers improved quality of life and as our case demonstrates

may decrease burden on nursing staff and caregiver.

Disclosures:All authors have stated there are no disclosures to be made that

are pertinent to this abstract.

Hartmans’ Pouch Mucocele Misdiagnosed as an Ovarian Tumor in an 86Year Old Nursing Home Resident

Presenting Author: S. L. Oakes, MD, University of Texas Health Science

Center Family and Community Medicine

Author(s): S. L. Oakes, MD, S. Kanjee, MD; and D. V. Espino, MD

Introduction/Objective: An end sigmoid colostomy resulting in aHartmann’s

pouch is the procedure of choice when permanent fecal diversion is required.

The distal portion of the rectosigmoid colon is exteriorized resulting in a mu-

cinous fistula. This procedure can lead to the development of a mucocele

which may be misdiagnosed unless a complete evaluation is done.

Design/Methodology: Case report.Results:An 86-year old female with past medical history of atrial fibrillation,

stroke with left hemiparesis, moderate Alzheimer’s who underwent hemico-

lectomy for ischemic bowel disease was admitted to the nursing home. On ad-

mission, the nursing home staff noted that she was draining a large amount of

mucus from her rectum associated with intermittent, moderate abdominal

pain. An abdominal CT scan revealed a cystic pelvic lesion which was highly

suggestive of a primary ovarian cancer. The senior interventional radiologist

differed with the initial interpretation and instead inserted a rectal tube

which drained 200 cc of gelatinous material. A follow-up CT scan revealed

resolution of the lesion. Further history taken from the family indicated

that the patient had required daily rectal ‘‘drainage’’ of mucous material by

abdominal pressure done by her in-home care provider prior to her nursing

home admission. Finally, a post drainage sigmoidoscopy revealed old un-

excreted pills in the Hartmann’s pouch that most likely contributed to the

increased mucous production.

Conclusion/Discussion: It has been noted that following colon resection us-

ing the Hartmann’s procedure the rectal mucosa continues to secrete mucus.

This is rarely a clinical problem as the mucus passes through the rectum.

However, on occasion, a mucocele can occur. This is a rare event as only

four English language case reports have been published. Of note was the ini-

tial diagnosis of ovarian cancer, which may have been erroneously discussed

POSTER ABSTRACTS

with her family had the workup been stopped there. As with all patients, this

case demonstrates the need to attempt a tissue diagnosis and and/or endo-

scopic evaluation for all but the most obvious suspected tumors.



Identifying Hospice Eligible Nursing Home Residents: The HospiceEligibility Prediction (HELP) Tool

Presenting Author: Cari R. Levy, MD, PhD, CMD, Denver VA Medical

Center Medicine

Author(s):Cari R. Levy, MD, PhD, CMD, Lauren Pointer; and Evelyn Hutt

Introduction/Objective: Nursing homes are the site of death for 25% of

Americans. Research indicates that end-of-life care in nursing homes is sub-

optimal but improves if hospice is involved. Precision in estimating life expec-

tancy is necessary if hospices are to enroll patients with a life expectancy of 6-

months or less. Tools are needed to aid in accurate estimation of prognosis

among nursing home residents who often havemultiple co-morbid conditions

contributing to mortality risk rather than a single disease entity.

Design/Methodology:A series of logistic regressions were applied to a cohort

of VA nursing home residents (N528,865) in FY 2003-2005 to identify Min-

imum Data Set variables predictive of 6-month mortality.

Results: Fifteen resident-level variables were selected for the final predictive

model with a c-index of 0.845. This model was then tested on a validation

cohort (N58660) with a c-index of 0.851. The c-index was 0.845 when

the model was applied to the entire VA CLC cohort (developmental + val-

idation cohort). After assigning aHELP tool probability for hospice eligibility

to all residents in the cohort, 62.6% were not in hospice and not eligible,

15.9% were in hospice and eligible, 14.7% were not in hospice but eligible

and 6.8% were in hospice but not eligible.

Conclusion/Discussion:Hospice eligibility was incorrectly assessed for 1 in 5

residents. The HELP tool may improve accuracy in assessing hospice eligibil-

ity for nursing home residents.



Identifying Patterns of Skilled Nursing Facility Readmission

Presenting Author: Yanping Ye, MD, UTHSC at San Antonio

Author(s): Yanping Ye, MD, Ughanmwan Efeovbokhan;

and Robert W. Parker, MD

Introduction/Objective: One-fourth of the Medicare beneficiaries who are

discharged from an acute hospital to a Skilled Nursing Facility (SNF) are re-

admitted within 30 days. Re-hospitalization of SNF patients can be costly,

disruptive to patients and families, and interrupt their plan of care. In addi-

tion, hospitalization of frail elders can lead to a variety of complications in-

cluding delirium, iatrogenic illness, de-conditioning, poly-pharmacy, and

pressure ulcers. Identifying and decreasing readmissions decreases patient

mortality and lowers health care costs. In this study, we sought to conduct

a preliminary review of re-hospitalization events within 30 days after dis-

charge to one of our 5 community based Skilled Nursing Facilities, and iden-

tify indicators that could be targeted to reduce re-admissions.

Design/Methodology: SNF data were obtained from EMR between January

2010 and September 2010, and the readmission events were recorded if pa-

tients were re-hospitalized within 30 days after they were discharged to the

SNF. Data included date of readmission, SNF Length of Stay (LOS), SNF ad-

mission diagnosis, reason for re-admission, and number of visits by either phy-

sician or GNP prior to readmission. Hospital discharge summaries were

reviewed for verifying readmission diagnosis.

Results: There were total 79 readmissions recorded during this period. Fif-

teen patients (22%) expired after re-hospitalization. Among those patients,

ten (67%) were on hospice prior to their death. The most common reasons

to be on hospice are pulmonary disease, mental status change and cardiac

conditions. Among the surviving patients, forty four patients were discharged

to home, four patients are staying in SNF; two patients were at assisted living

B13

facilities, nine patients were in long term care. Overall, patients spent aver-

age 11 days in the SNF, and received two E&Mvisits before being readmitted

to hospitals. Wednesday and Thursday were the most common days of read-

mission (18% each). The most common reasons for readmission were cardiac

related diseases (16.46%); pulmonary related diseases (15.19%); mental sta-

tus change (13.92%); gastrointestinal (11.39%) problems and abnormal labs

(8.89%). In addition, comparing the admission and re-admission diagnosis,

we found that patients with mental status change, pulmonary disease, GI

problem, cardiac condition and infection were at high risk of re-hospitalized

with the same diagnosis.

Conclusion/Discussion: Patients with cardiac diseases, pulmonary diseases

and mental status change are most likely to be readmitted, and they are at

higher risk to die or be placed on hospice thereafter. Patients with underlying

atrial fibrillation, CHF are at increased risk for readmission due to cardiac

condition even after surgical procedures. This indicates that standardized pro-

tocols for managing post surgical care patients and monitoring of chronic dis-

eases is necessary. Currently, CNAs are trained to use early warning signs to

recognize patients’ change of conditions, and RNs are trained to use SBAR

(Surrounding, Background, Assessment and Request) form for improving

communication with on-call providers. The INTERACT (Intervention to

Reduce Acute Care Transfer) care pathway tools are being implemented in

the SNF. These quality improvement programs emphasizing communication

and standardized protocols may reduce the 30-day readmission rate and thus

improve the patient care.



Table 2. Prevention of Spread Measures

�There should be high suspicion index for any patient in-house having diarrhea, orother symptoms such as abdominal pain and vomiting in conjunction with

fever.

� Any patient suspected of infection should be placed on report and staff from

Infection Control and the Medical Director or Attending Physician of the unit

informed

� All such patients should be confined to their rooms and placed on contact

isolation until further notice.

� All staff and visitors entering the rooms of these residents must wash their handsbefore entering and again upon leaving the room.

� Housekeeping should clean all fomites, (e.g. door handles, toilet seats, walls)

with a 10% bleach solution as soon as possible.

� Roommates should be asked to pay attention to hand washing and remain on theunits as far as is possible

Impact of F-Tag 309 Survey Interpretive Guidelines on Persistent PainManagement Among Nursing Home Residents

Presenting Author: Kate Lapane, PhD, MS, Virginia Commonwealth

University

Author(s): Kate Lapane, PhD, MS, Brian Quilliam, PhD, RPh,

Wing Chow, PharmD, MPH; and Myoung Kim, PhD, MS, MBA

Introduction/Objective: Introduction: InMarch 2009, the Centers for Medi-

care & Medicaid Services implemented new guidelines which direct sur-

veyors to investigate whether facilities are following proper pain

management practices. Objective: To estimate the extent to which imple-

mentation of F-Tag 309 improved recognition and management of pain

among nursing home residents

Design/Methodology: Design: Quasi-experimental. Setting: One hundred

seventy-four for profit nursing homes in nineteen U.S. states. Partici-

pants: Residents with at least two Minimum Data Set (MDS) assessments

living in one of the included nursing homes in operation during January

2007 through March 30, 2009 (before F-Tag implementation; n58,449)

and between March 31, 2009 and December 2009 (after F-Tag imple-

mentation; n51,400). Intervention: Implementation of F-Tag 309

into the surveyors’ interpretative guidelines Measurements: MDS assess-

ments provided information on pain, analgesics, cognitive, functional,

and emotional status. Separate logistic regression models adjusting for

clustering effects of residents residing in nursing homes provided esti-

mates of the relationship between the implementation of F-Tag 309

and prevalence of pain as well as use of analgesics and adjuvant medica-

tions for pain.

Results: Pain was more likely to be documented post-F-Tag (persistent:

25.6%, Intermittent: 30.0%) relative to pre-F-tag (persistent: 25.2%,

Intermittent: 25.7%, p50.0009). Residents were more likely to have persis-

tent or intermittent pain recognized after the implementation of F-Tag 309

(Adjusted odds ratio (AOR): 1.15; 95% Confidence Interval (CI): 1.01-

1.31). Among all residents, increases in use of any analgesic was observed

in the post-F-Tag 309 era (AOR: 1.43; 95% CI: 1.26-1.62) with greater im-

provements in use of analgesics for residents experiencing intermittent pain

(AOR: 1.51; 95% CI: 1.18-1.92). Increases in opioid use (Post F-Tag 309:

43.3% vs. Post: 34.5%; p\0.0001) and use of medications potentially used

as adjuvants for pain (Post: 72.7% vs. Pre: 64.6%; p\0.0001) increased

with F-Tag 309 implementation.

Conclusion/Discussion: Use of directed language as part of the surveyor’s

interpretive guidelines may be a viable approach to stimulating improve-

B14

ments in pain management. Pain recognition did not change in persons

with severe cognitive impairments with the F-Tag 309 implementation

suggesting that different pain assessment tools may be required for these

residents.

Disclosures: Kate Lapane, PhD, MS and Brian Quilliam, PhD, RPh received

funds for project consulting from Ortho-McNeil Janssen Scientific Affairs

Wing Chow, PharmD, MPH and Myoung Kim, PhD, MS, MBA are em-

ployees of Ortho-McNeil Janssen Scientific Affairs.

Improving Noroviral Gastroenteritis Attack Rate and Clinical Outcomesin a Skilled Nursing Facility

Presenting Author: Louis M. Mudannayake, MD, CMD, Cobble Hill Health

Center

Author(s): Louis M. Mudannayake, MD, CMD

Introduction/Objective: Noroviral Gastroenteritis is the leading cause of in-

fective gastroenteritis in the US and worldwide. Nursing home patients can

have significantMORBIDITY andMORTALITY secondary to infective nor-

ogastroenteritis. My objective was to limit attack rates and improve clinical

outcomes in a noroviral gastroenteritis outbreak in a Skilled Nursing Facility

in Brooklyn, New York.

Design/Methodology:This is a retrospective study of a norovirus gastroenter-itis outbreak in a 360 bed Long TermCare Facility fromDecember 26, 2008 –

February 5, 2009. Using an INTERDISCIPLINARY Team there was

a proactive approach to prevention of spread and treatment of patients during

a norogastroenteritis outbreak in Brooklyn, New York

Table 1. Interdisciplinary Team Approach to Noro GastroenteritisOutbreak

Department Role

LTC Medicine
� Early recognition of potentially infected
patients.

� Immediate isolation and administration of

oral rehydration salts (ORS)

Housekeeping
� Early cleaning of fomites.
� Containment of infected material

Social Service
� Educating families of involved patient or
prevention on prevention of spread

measure

Therapeutic Recreation
� Early recognition of potentially infected
patients. Assist nursing with administration

of ORS

Dietary
� Ensuring adequate stocked ORS in house and
delivery to affected units

Medical Director
� Coordination of efforts in conjunction with
Infection Control Nurse

� Education of all Departments

JAMDA – March 2011

Documents

Identifying Patterns of Skilled Nursing Facility Readmission