Black nursing home residents, those under age 65 more likely to have repeat transfers to hospital, SSON study finds

Study also found those with ‘full-code’ status regarding end-of-life care more likely to have repeat transfers than those with ‘do-not-resuscitate’ status.

Story originally published July 1, 2022, at Show Me Mizzou
For more information contact Brian Consiglio, 573-882-9144, consigliob@missouri.edu

Nursing homes transfer roughly 25% of their residents to the hospital at least once, at a cost of $14.3 billion to Medicare, according to a federal report by the Office of Inspector General.

But a new study by the University of Missouri discovered the number of repeat transfers are much higher for Black nursing home residents and those under age 65.

In one of the few studies to analyze the demographics of nursing home residents who get repeatedly transferred to the hospital, Amy Vogelsmeier, an associate professor in the MU Sinclair School of Nursing, found that Black nursing home residents, those under age 65 and those with “full-code” status were significantly more likely to be transferred to the hospital, at least four times or more in a given year.

“Since repeat hospitalization for nursing home residents can at times result in more harm than benefit, we wanted to look back to see if we could identify any patterns to potentially avoid the hospital transfer,” Vogelsmeier said. “For example, if a resident gets very sick and requires hospitalization, such as a blood infection from a urinary tract infection, how do we better prevent the urinary tract infection in the first place? In general, are there opportunities to better equip nursing homes with the right equipment and trained staff to better manage these conditions without the need for transfer?”

Vogelsmeier and colleagues analyzed a subset of data from the Missouri Quality Initiative, an eight-year, $35 million program funded by the Centers for Medicare and Medicaid that implemented advanced practice registered nurses (APRNs) full time into 16 Midwest nursing homes with higher hospitalization rates than the national average.

Due to the project’s implementation of APRNs, illnesses were detected early before there were significant declines in patient condition, reducing avoidable hospitalizations. Still, from 2017-2019 there were more than 1,400 residents who were transferred to the hospital at least once annually, 113 residents were transferred at least four times or more in a year, and 17 residents were transferred at least eight or more times during the three years.

“In addition to the financial burden and adverse health outcomes like hospital-acquired infections that can occur, transfers from a nursing home to the hospital can be traumatic, stressful and frightening for the mental health of frail adults,” Vogelsmeier said.

Vogelsmeier said younger adults may be admitted to nursing homes after traumatic brain injuries or strokes, as well as with serious early onset conditions, such as congestive heart failure or chronic pulmonary disease. These conditions, combined with potential serious mental health disorders, such as schizophrenia, and other comorbidities, often require nursing home levels of care for the resident.

“End-of-life conversations can be difficult, particularly with younger adults and their families, and sometimes there might be confusion regarding the ‘do-not-resuscitate’ designation,” Vogelsmeier said. “It simply means no resuscitation attempts will be made if you die, and does not mean withholding appropriate treatments. We want to focus on treatments that are evidence-based and right for the resident given their multiple chronic conditions; knowing that in almost all cases, nursing home residents will die even when cardiopulmonary resuscitation (CPR) is provided and suffer great harm from the intervention.”

Previous research has shown Black nursing home residents who get transferred to the hospital tend to have more chronic conditions, poorer health outcomes and live in nursing homes of poorer quality, possibly due to financial constraints.

“Other studies suggest Black residents and their families tend to be less likely to engage in conversations about goals of care and are more likely to seek aggressive treatment, but we don’t yet fully understand why that is,” Vogelsmeier. “It could be distrust in the health care system, it could be providers making assumptions that they don’t want to discuss these things, which could be rooted in structural racism, so these topics should be further investigated going forward to better ensure racial equity in the health care industry.”

Vogelsmeier added that APRNs play a critical role in coaching and mentoring nursing home staff, yet they were not always sought out or consulted within the decision-making process for residents in the study who were repeatedly transferred.

“Whether it is working with the nursing staff to build competencies or having difficult goals of care conversations, early involvement of APRNs plays a key role in guiding appropriate care and potentially reducing avoidable transfers,” Vogelsmeier said. “We learned from the COVID-19 pandemic how vulnerable nursing homes are, and more implementation of APRNs, registered nurses and licensed social workers in nursing homes can help remedy these vulnerabilities going forward.”

“Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity” was recently published in BMC Health Services Research. Funding for the study was provided by Centers for Medicare and Medicaid.

SSON Announces Interim Dean

Lori Popejoy, PhD, RN, FAAN is currently the associate dean for Innovation and Partnership and an associate professor in the Sinclair School of Nursing at the University of Missouri.  She obtained her BSN’93, MS(N)‘96 and PhD‘07 from the University of Missouri, and has been a faculty member in the school since 2007.  She was awarded the John A. Foundation Building Academic Nursing Capacity Scholarship from 2002 to 2004.  Her post-doctoral training was supported by the John A. Hartford Foundation, Claire M. Fagin Post-Doctoral Fellowship from 2009 to 2012. 

Dr. Popejoy is a health systems researcher. In her current position she is building opportunities with community partners to use cutting-edge research findings to manage the complex care needs of older adults across the care continuum. Her research focuses on understanding the complex issues surrounding the provision of care to elders in hospitals, nursing homes, community settings, home healthcare and primary care. When asked about her accomplishments thus far in her career she states, “My research with my colleagues has changed care-delivery systems in the United States. With the help of the John A. Hartford Foundation and the education I have received from the University of Missouri, we have made an impact for the care of older adults around the world.”  This research centers around the design, implementation and evaluation of nurse care coordination and transitional care practices in a variety of aging-in-place settings that have national and international implications for the care of older people.

In addition to aging-in-place, Dr. Popejoy’s work in nursing homes has been ongoing for over 20 years and has centered on improving nursing home capacity to manage increasingly complex resident care issues and improve outcomes. Her work is interdisciplinary including colleagues from the health-related disciplines, informatics, engineering, ethics and economics. She has more than 100 publications in refereed journals and has received funding from National Institutes of Health and the Agency for Healthcare Research & Quality.  She has served as co-director or co-lead on three studies with the Centers for Medicare and Medicaid Innovations (CMMI), funded for nearly 48 million dollars.

Dr. Popejoy is excited to take the position of Interim Dean of the Sinclair School of Nursing. She hopes to continue the strategic initiatives that have made the school a highly respected academic and top-ranked school in the United States. ““We have exciting times ahead. We are moving into our new building this fall and it will bring more opportunities for research, collaboration and experiential learning. The Sinclair School of Nursing is positioned to grow and flourish with our strong history of excellence and innovation.”

When Dr. Popejoy is not blazing trails at the Sinclair School of Nursing, you will find her enjoying life outdoors with her husband, daughter, son-in-law and three grandchildren. She loves to travel, kayak, fly fish, hike, garden and stay engaged in the Columbia community where she has lived for 41 years.

SSON study finds health benefits of ‘aging in place’ at TigerPlace

Care at independent living facility helps older adults avoid declines in physical, mental and cognitive health outcomes.

First published May 27, 2022 by Show-Me Mizzou. For more information contact: Brian Consiglio, 573-882-9144, consigliob@missouri.edu

The American Association of Retired Persons (AARP) found the majority of older adults want to stay in their own home as they age. However, given the natural decline in health that comes with aging, some older adults may have to move into a nursing home or assisted-living facility to receive more intensive levels of care.

To help older adults live independently as they ‘age in place,’ researchers at the University of Missouri analyzed eight years of health data from 2011 – 2019 for more than 190 residents at TigerPlace, a senior living facility developed in partnership between the MU Sinclair School of Nursing and Americare Senior Living.

Researchers found that because registered nurse care coordinators were able to identify illnesses early and quickly in residents and provide them with appropriate care and services, most of the older adults living at TigerPlace were able to stay healthier longer, which allowed them to comfortably ‘age in place’ and reduced their need to be transferred to a nursing home for more intensive levels of care.

TigerPlace combines the convenience and privacy of individual apartments with many recreational and socialization opportunities, such as sports bars, fitness centers, live music performances, pet therapy visits, dominoes, Bible study, bingo, volunteer opportunities and programs with local churches.

The residents at TigerPlace received health assessments from registered nurse care coordinators every six months related to cognitive functioning, completing daily tasks, depression, the risk of falling and physical functioning. Additionally, some residents chose to use noninvasive motion, bed, and depth sensors to trend level of activity, respiratory and heart rate, and fall detection. Changes in activity, new or increased falls, and assessment were used to identify illnesses, such as pneumonia or a urinary tract infection, as early as possible so interventions could be provided quickly.

“The benefits of both the regular health assessments and use of non-invasive sensors helped to keep them steady as they age comfortably,” said Lori Popejoy, lead author on the study and an associate professor in the MU Sinclair School of Nursing. “The goal is to identify slight declines in health as early as possible so the right services can be put into place, whether it is connecting them with a doctor, beginning therapy or starting treatment to depression, whatever is needed based off the assessments.”

Popejoy added the exercise and socialization opportunities available at TigerPlace help improve both physical and mental health outcomes, as well as reduce the risk of falls by improving muscle mass and strength. The average age of study participants was 84.

“The residents are able to use these services to enhance their quality of life in retirement, which allows them to live longer independently,” Popejoy said. “For older adults that are still living at home and maybe starting to notice increased difficulty completing daily activities, or for those who are struggling with social isolation, moving to a facility like TigerPlace can be very helpful for living a healthier life longer and possibly avoiding the need to ever move to a nursing home.”

The research study was interdisciplinary in nature, involving collaboration among nursing students, medical students, social workers, engineers and information technology professionals.

With May being ‘Older Americans Month,’ Popejoy has dedicated her career to improving the quality of care for older adults. She has provided hands-on clinical care in a variety of health care settings, from hospitals and nursing homes to community centers and home health care agencies.

“Longitudinal analysis of aging in place at TigerPlace: Resident function and well-being” was recently published in Geriatric Nursing.

Karry Weston – PhD Spotlight

Karry Weston, BSN ’02, MS(N) has multiple awards already as a doctoral student at the Sinclair School of Nursing. She has been awarded the PhD Scholarly Achievement Award, the Graduate and Professional Council Research Development Award and the AgriSafe Nurse Scholar Award.

One of the most prestigious of her awards comes in the shape of a highly competitive F31 predoctoral research training grant from the National Institutes of Health (NIH) and the National Institute of Nursing Research (NINR) to study the Impact of Rural Habitus on First-Time Mothers’ Feeding Choices. The story of Weston’s work in maternal health care was showcased in a recent article in Show Me Mizzou. Read the article below and see why this Mizzou Nurse and the communities she serves have a bright future.

 

Originally published May 5, 2022 on Show Me Mizzou. For more information, contact: Brian Consiglio, 573-882-9144, consigliob@missouri.edu.

NIH grant will help research lack of breastfeeding in rural Missouri

Two-year grant aims to help nurses talk with rural mothers about newborn care, feeding options.

Karry Weston, a nurse and doctoral student at the University of Missouri Sinclair School of Nursing, has worked in maternal child health for almost 20 years, helping to deliver babies and care for newborns. Among her main focusses are educating mothers about their newborns and postpartum care, including their decision to breastfeed or use formula.

While researching the benefits of breastfeeding, Weston discovered a lack of information involving mothers living in rural communities. Being from rural Missouri herself, Weston is passionate about educating women in rural areas about the benefits of breastfeeding to promote infant health.

“Research shows that across the United States, rural women breastfeed much less than both suburban women and urban women,” Weston said. “So, why is that? I feel like there has got to be something culturally about that, that is causing that decision, especially if we’re giving them the same education.”

To better understand the factors that may impact rural mothers’ decisions of whether or not to breastfeed their babies, the National Institutes of Health (NIH) and National Institute of Nursing Research (NINR) awarded Weston a $66,000 grant, which runs through March 2024.

“I want to look more at how being from a rural area, the way we are raised and the influences we have, how that eventually affects health care decisions,” Weston said. “In this case, I want to study the factors that may influence the choice to breastfeed your newborn or formula feed your newborn.”

Weston said while formula is a safe, healthy and convenient option, studies show natural breastfeeding is linked to numerous health benefits for both mother and child, which includes improving the mother’s recovery after giving birth. In addition to being packed with nutrients and strengthening the baby’s immune system, breastmilk also may help lower the baby’s risk of developing obesity and diabetes.

With the help of the grant, Weston plans to interview at least 30 rural Missouri mothers, with the goal of finding women with a wide variety of perspectives about the feeding choices for their newborns. The Women, Infants and Children (WIC) clinic in Moberly, Missouri, is supporting the grant and will help Weston recruit mothers for her research.

“I feel that as health care professionals, we cannot create interventions or education until we truly understand the culture,” Weston said. “I live in a rural community, so these are my people. I understand that sometimes there’s a different dynamic, too, on the way things are done and the way people make decisions. So, I think it would really help researchers to look more into that.”

Weston hopes with the help of this grant, she can improve the understanding of rural communities for the entire health care industry, not just maternal care.

“I feel like we need to tailor our resources and our approach with rural communities,” Weston said. “This type of research could translate beyond breastfeeding one day. It could potentially translate to diabetes research or to cardiac health research. It could really go anywhere — I’m just starting with breastfeeding.”

Weston is mentored by Linda Bullock of the MU Sinclair School of Nursing and Kevin Everett of the MU School of Medicine.