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author:("roles, Mark")
1.  Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge 
Background/Objectives
The primary objective of this study was to describe the time to first acute-care use (e.g., emergency department use without hospitalization or rehospitalization)for older adults who discharged to home after receiving post-acute care in skilled nursing facilities (SNFs). The secondary objective was to identify predictors of patients' first acute-care use.
Design
Retrospective cohort study using administrative claims data.
Setting
SNFs providing post-acute care in North and South Carolina (N=1,474).
Participants
A cohort of Medicare beneficiaries aged 65 years and older (N=55,980) who were hospitalized, then transferred to a SNF for post-acute care, and subsequently discharged home (January 1, 2010, to August 31, 2011).
Measurements
Medicare institutional claims data (Part A and Part B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute-care use was explored. Cox proportional hazards regression models were used to describe patient, home care and nursing facility-level predictors.
Results
After SNF-to-home discharge, 22.1% of older adults had an episode of acute-care use within 30 days, including 7.25% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5 % of older adults had their first acute-care usewithin 90 days. Male gender, dual eligibility status, higher Charlson co-morbidity score, certain primary diagnoses at the index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient day were associated with higher risk for acute-care use.
Conclusion
Medicare patients have a high use of acute-care services after discharge from SNFs, and several factors associated with acute-care use are potentially modifiable. Findings suggest the need for interventions to support patients as they transition from SNFs to home.
doi:10.1111/jgs.12602
PMCID: PMC4128392  PMID: 24383890
care transitions; skilled nursing facilities; epidemiology
2.  Local interaction strategies and capacity for better care in nursing homes: a multiple case study 
Background
To describe relationship patterns and management practices in nursing homes (NHs) that facilitate or pose barriers to better outcomes for residents and staff.
Methods
We conducted comparative, multiple-case studies in selected NHs (N = 4). Data were collected over six months from managers and staff (N = 406), using direct observations, interviews, and document reviews. Manifest content analysis was used to identify and explore patterns within and between cases.
Results
Participants described interaction strategies that they explained could either degrade or enhance their capacity to achieve better outcomes for residents; people in all job categories used these ‘local interaction strategies’. We categorized these two sets of local interaction strategies as the ‘common pattern’ and the ‘positive pattern’ and summarize the results in two models of local interaction.
Conclusions
The findings suggest the hypothesis that when staff members in NHs use the set of positive local interaction strategies, they promote inter-connections, information exchange, and diversity of cognitive schema in problem solving that, in turn, create the capacity for delivering better resident care. We propose that these positive local interaction strategies are a critical driver of care quality in NHs. Our hypothesis implies that, while staffing levels and skill mix are important factors for care quality, improvement would be difficult to achieve if staff members are not engaged with each other in these ways.
doi:10.1186/1472-6963-14-244
PMCID: PMC4059721  PMID: 24903706
Nursing homes; Management; Staff interactions; Complexity science; Case study
3.  Staff Interaction Strategies that Optimize Delivery of Transitional Care in a Skilled Nursing Facility: a Multiple Case Study 
Family & community health  2012;35(4):334-344.
After hospitalization, 1.5 million older adults each year receive post-acute care in skilled nursing facilities (SNF). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from a SNF to home, have rarely been studied. Thus, we conducted a longitudinal, multiple case study of transitional care provided in an SNF to explore the care processes and staff interaction strategies that SNF staff members used to optimize delivery of on transitional care. Using qualitative data from 89 interviews, 118 field observations, and 70 chart or document reviews, we observed that transitional care services were not solely formalized processes, but rather were embedded in the interactions among older adult patients, their family caregivers and members of interdisciplinary care teams. We found, moreover, that staff member interactions with patients and family caregivers increased the capacity of patient care teams for optimizing patient-centered care, information exchange, and coordination of transitional care.
doi:10.1097/FCH.0b013e31826666eb
PMCID: PMC3967871  PMID: 22929379
Transitional Care; Skilled Nursing Facilities; Older Adults; Family Caregivers; Interactions
4.  Regulation and Mindful Resident Care in Nursing Homes 
Qualitative health research  2010;20(9):1283-1294.
Regulatory oversight is intended to improve the health outcomes of nursing home residents, yet evidence suggests that regulations can inhibit mindful staff behaviors that are associated with effective care. We explored the influence of regulations on mindful staff behavior as it relates to resident health outcomes, and offer a theoretical explanation of why regulations sometimes enhance mindfulness and other times inhibit it. We analyzed data from an in-depth, multiple case study including field notes, interviews, and documents collected in 8 nursing homes. We completed a conceptual/thematic description using the concept of mindfulness to reframe the observations. Shared facility mission strongly impacted staff perceptions of the purpose and utility of regulations. In facilities with a resident-centered culture, regulations increased mindful behavior, whereas in facilities with a cost-focused culture, regulations reduced mindful care practices. When managers emphasized the punitive aspects of regulation we observed a decrease in mindful practices in all facilities.
doi:10.1177/1049732310369337
PMCID: PMC2918733  PMID: 20479137
case studies; nursing homes; nursing; administration; nursing homes; older people
5.  Nutrition and the Cancer Survivor: Evidence to Guide Oncology Nursing Practice 
Seminars in oncology nursing  2008;24(3):171-179.
Objectives
To conduct a systematic review of scientific reports related to diet and cancer survivorship that have been published since the 2006 American Cancer Society’s Guide for Informed Choices on Nutrition and Physical Activity During and After Cancer Treatment and to integrate these findings into a consistent message that can be delivered by nurses in hopes of improving the health and well-being of cancer survivors.
Data Sources
Journal articles.
Conclusion
Cancer survivors represent a growing population at high risk for recurrence and other co-morbidities. Evidence continues to accumulate regarding the importance of weight management, and a healthful diet (plant-based, low saturated fat) in improving the overall health and promoting disease-free and overall survival in this population
Implications for Nursing Practice
Cancer survivors are eager for nutrition information and nurses are well-positioned to guide them regarding the importance of weight management and healthy food choices.
doi:10.1016/j.soncn.2008.05.005
PMCID: PMC2629487  PMID: 18687263

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