Background: The use of opioid medications has the potential to provide relief of chronic, severe non-cancer pain. However, there is a significant risk of abuse and misuse. Urine drug screening is used to monitor patients on chronic opioid therapy for compliance and to detect illicit drug use. Although the literature supports the use of urine drug screening, there is little evidence to identify the testing frequency.

Methods: A quality improvement project was performed to assess the previously implemented protocol for urine drug screening frequency. A retrospective chart review was performed utilizing the pain clinic’s electronic health record over a predefined, 24-month period. Data was gathered on 311 patients over the age of 18 who met the inclusion criteria. Descriptive statistics was performed on the demographic variables, including age, gender, smoking status, diagnosis, marital status, and prescribed medication.

Results: Chi-square analysis found a statistically significant main effect between the four independent groups and the rates of positive drug screens, p = 0.002. Statistically significant differences were not detected between the once-per-year group and the twice-per-year group, p = 0.96, nor between the three-times-per-year group and the once-per-year group, p = 0.82. There was a significant difference between the four- times-per-year group and the once-per-year group, p = 0.014.

Conclusion: Participants that had four drug screens over the year were 3.05 times more likely (95% CI 1.26 – 7.40) to have a positive drug screen over the course of a year versus those that received just one drug screen a year. The findings support the clinic’s policy of performing urine drug testing four times a year to monitor opioid therapy compliance. It is recommended that a nurse be assigned to oversee the coordination of the monitoring process and that urine drug screen results are reviewed and the appropriate intervention is completed.  

For over twenty years, bisphosphonates have been the primary treatment of osteoporosis. These medications were associated with a potential for gastrointestinal side effects which necessitated specific dosing directions. In more recent years, bisphosphonates became associated with more serious side effects of atypical femoral fracture and osteonecrosis of the jaw. In an effort to reduce the risk of these rare events, drug holidays of up to five years were recommended. However, there is lack of consensus on the appropriate timing and duration of drug holidays. This presentation will offer a review of the current recommendations for bisphosphonate drug holidays.

Mary DiGiulio discloses that she receives royalties from McGraw Hill for prior editions of Medical-Surgical Nursing Demystified and Health Assessment Demystified.

Purpose: Receiving a diagnosis of dementia is only the beginning of how the disease will impact a patient and his/her support system. There are 5.5 million persons with dementia in the United States, and 81% of them live in the community.

Rationale: Clinicians seeing patients with home-based primary care programs are in a unique position to assess the medical and social effects of dementia on patients and support systems. Quality improvement metrics are implemented to document basic minimum standards but do not always translate into improved quality of care for patients.

Supporting literature: The 2019 Merit-based Incentive Payment System (MIPS) clinical quality measure for dementia requires documented safety concern screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks, as well as documentation of recommendations. No standardized safety screening tool exists for this measure.

Interventions: Two clinicians developed questions for a dementia safety screening tool (DSST) that was integrated into the charting system to ensure data was recorded in a reportable manner. The DSST records if a patient has 24-hour supervision, transfers independently, and has any of eight other risk factors such as fall risk, food insecurity, medication safety hazards, etc. After clinicians learned to use the DSST, a monthly report was generated to analyze use and flag patients for intervention. A workflow was developed for the practice’s registered nurse case managers (RNCM) and licensed clinical social workers (LCSW) to intervene for these at-risk patients.

Outcomes: Clinicians screened 85% of established patients with dementia in four months. One identified risk factor triggers an interprofessional coordination with standardized interventions via phone or house call based on risks identified.

Applicability to practice: The DSST is quick and easy to use, which increased buy-in from clinicians. Increasingly, clinicians are tasked to check a box in the patients’ electronic health records but doing so does not always improve patient care. The DSST is the first step of a standardized process in which high-risk patients receive interprofessional coordination, improving the quality of care for our homebound patients. 

This presentation will describe the development of educational materials to increase the number of providers trained in the provision of age-friendly care using the 4Ms framework: what matters, medication, mentation, and mobility. Convenient care clinics are becoming the provider of choice for episodic care even for older adults. Case Western Reserve University Frances Payne Bolton School of Nursing (FPB) partnered with CVS Health MinuteClinic and the Institute for Healthcare Improvement (IHI) in a project funded by The John A. Hartford Foundation to facilitate this educational development. The professional development team (PD) was responsible for the creation of instructional modules to develop competence in implementing age-friendly care for adults 65 and older in the MinuteClinic setting. The time constraints of providers were an important consideration and an understanding of the usual process of the MinuteClinic was essential. An assessment of the current options offered by the MinuteClinic for continuing education of their providers informed the development of materials. The overall objective was to delineate the 4Ms assessment elements and follow-up action steps for the implementation of age-friendly care. The PD team included the lead faculty from FPB, a MinuteClinic field educator, and a consultant from IHI, along with other implementation team members. Weekly meetings were held to discuss progress and next steps. The team developed products focused on age-friendly content including grand rounds, video vignettes with experts to address gerontological topics in more depth, and an orientation video comparing standard care to 4Ms care in the convenient care setting. All of these products were designed to be viewed in 10 minutes or less to promote their utilization within a busy clinic day. We will share examples of the resources which are accessible to all providers on the AFHSResourcePortal.com. 

Depression affects more than 6.5 million Americans ages 65 and over ("Older Adults," 2015). The diagnosis and treatment of late life depression (LLD) is complicated, due to factors such as comorbidities, clinical presentation, adverse drug effects, drug interactions, and psychosocial factors (Lill, 2015). Late-life depression has a profound negative impact on the quality of life. Unutzer et al (2000) found that individuals with clinically significant depressive symptoms at baseline had significantly lower quality adjusted life years (QALYs) over a 4-year study period than non-depressed individuals, even after adjusting for differences in age, gender, and other chronic medical conditions (Unutzer et al., 2000). Since the care of patients with multiple chronic diseases accounts for the majority of healthcare costs, effective approaches to managing such complex care in primary care are needed (Katon et al., 2010). At the same time, implementing and sustaining these interventions in real-world settings has presented significant challenges.

In the absence of collaborative depression care management programs, primary care practices often struggle to balance active chronic disease management with proactive screening for depression and other comorbidities.

A multimodal intervention was developed to facilitate the delivery of an evidence-based collaborative depression care management protocol (DCP) in primary care. Pre- and post-survey design and modified chart review were utilized to assess effectiveness of the intervention. The intervention was delivered to a primary care team comprising primary care providers, triage staff, nursing staff, and clinic billing personnel.
Results suggested 79.06% increase in participants’ self-rated knowledge and 75 % increase in participants’ confidence level regarding primary care of the elderly, identifying signs of LLD, and ability to deliver DCP. The post-intervention depression screening rate was 51.9%, which was significantly higher than the benchmark of 25%.
An evidence-based collaborative DCP model highlights the unique opportunity to provide depression screening and identification in geriatric primary care, thus positively impacting chronic disease management and utilization of healthcare cost in a vulnerable population.

Over half of older adults in the United States fall annually, nearly 1/3 fall multiple times. Falls are the most frequent cause of trauma-related death in older adults. Medical costs are $50 billion annually. Fear of falling can be equally debilitating, when individuals become less active and spiral into functional decline.

Published studies have integrated the Center for Disease Control’s STEADI (stop elderly accidents, deaths, and injuries) fall prevention fundamentals of screening, assessment, and intervention into the workflow of primary care clinics. Achieving only a 60% adoption of the most important components, clinicians showed significant reduction in fall-related injuries. Incorporating these complex interventions requires time, expertise, and resources, which can be in short supply in primary care clinics.

Based on STEADI principles, a nurse practitioner (NP) and physical therapist (PT) created and implemented a multi-component falls prevention clinic for older adults. Referrals were received from primary care providers and emergency service personnel for patients with a recent history of a fall, or at high-fall risk. Patients underwent a comprehensive falls risk assessment and mobility testing. The NP developed patient-specific plans of care based on the assessment, made recommendations to the primary care provider around high-risk medications, and made referrals to specialists as appropriate. At 6 weeks patients were called; using motivation interviewing the NP was able to troubleshot barriers to compliance. Participants returned at 12 weeks to repeat gait and balance testing, and discuss continued exercise through home or community-based programs.

Early results from our work are extremely encouraging. Data analysis of pre-/post- measures using Wilcoxon Signed Ranks test reveals statistically significant improvement for both objective and subjective outcomes, including Dynamic Gait Index (difference: median=1.0, IQR=0,2, p=0.0004), Activities-Specific Balance Confidence Scale (difference: median=4.7, IQR=-1.0,14.0, p=0.0006), and Timed Up and Go (difference: median=-2.0, IQR: -3.70,0.39, p=0.0051). Participants described the impact they perceived, with excerpts from the satisfaction survey below:
• “I became more observant of my environment so have been less likely to fall.”
• “I felt reassured gaining better balance and control.”

This is an NP-driven fee for service model of care resulting in falls risk reduction for older adults.

Polypharmacy (typically defined as the concomitant use of 5 or more medications) affects 40-50% of older adults in the US and is associated with geriatric syndromes, a higher risk of medication non-adherence, and adverse drug events. Medication non-adherence is a common frustrating issue for clinicians who provide care for older adult patients. Simultaneously, patients often find medication regimens to be complicated and confusing. This may contribute to medication non-adherence, which may further lead to adverse drug events and negative health outcomes. The more medications a patient is taking, the higher the risk for non-adherence. Graduates of adult-gerontology primary care nurse practitioner (AGPCNP) programs must have an advanced understanding of barriers to and enablers of medication adherence to improve chronic care management and health outcomes for older adult patients (AACN Essentials VIII and IX). AGPCNP curricula must include learning activities that support student understanding and practice of patient-centered care that acknowledges culture, values, beliefs, socioeconomic means, and cognitive abilities (AGPCNP Independent Practice Competencies 3a, 3d, 3e, and 4). 38 AGPCNP students enrolled in an advanced health assessment course were given a one-month supply of five mock medications that are commonly prescribed for older adults. Students were instructed to follow directions on each of the bottles for approximately one month. A private messaging system was available for questions about medications or if refills were needed. At the conclusion of this month-long activity, a debriefing session was held, at which time students returned medication bottles. All returned bottles contained mock medications, but pill counts were not analyzed. Approximately 52.6% of students estimated adhering to the medication regimen 0-24% of the time, whereas 26.3% students reported an adherence rate of 25-50%. The most commonly cited barrier to adherence (55.3%) was “forgetfulness.” Pill boxes were ranked as the most effective adherence aid, but 57.9 % of students reported using no aids. Nearly all students (89.5%) reported that the exercise “very much” increased awareness of challenges patients face when managing medications, and 97% cited an increased awareness of ways to improve medication adherence. Students endorsed implementation of this simulation activity in future iterations of the course. 

Recent changes in healthcare focus on providing care of patients in the community-based setting with a goal of decreasing hospitalizations. Caring for older patients is complicated by the presence of multiple chronic medical conditions such as heart failure, hypertension, diabetes, and COPD, requiring closer monitoring to prevent hospitalizations. Advances in technology are bringing the monitoring of specific physiological parameters to the patient home. Remote patient monitoring (RPM) is the collection of data, such as blood pressure, oxygen saturation, weight, and blood glucose, by the patient in the home and transmitting this data to a provider for review. Gilchrist’s elder medical care (EMC) program currently utilizes the use of RPM for homebound patients requiring closer monitoring of one or more chronic medical conditions. The goal of the program is to identify decline in the patient and treat the patient in the home, limiting the potential for hospitalization. Patients are identified for inclusion in the program by the primary care provider and enrolled in the program for a minimum of sixty (60) days. The program is administered in conjunction with a third-party provider who receives the transmissions and reports any physiological parameters outside set ranges, known as alerts. The use of technology, such as RPM, will continue to increase as payment for monitoring services increase. Studies indicate that patients, especially younger patients, accept various forms of telemonitoring for delivery of their care. Utilization of RPM in the home has promise to identify patient decline in a timely manner which can help promote positive outcomes. 

In this quantitative pilot study, the context of education among healthcare providers in a long-term care facility was carried out with keen attention to understanding the knowledge base on the COPD management protocol. The major study objective was seeing if educating the nursing staff about the COPD management protocols and the use of the COPD assessment tool (CAT) would help reduce COPD exacerbation rates among residents in the facility. COPD exacerbation symptoms examined in the study were dyspnea leading to hospitalizations, increased cough, and change in sputum. The rates were obtained for October to December 2018 and then compared to the rates 30- days post-educational intervention implementation. The theoretical framework for the research is based on the transtheoretical model which gives much attention to the stages of behavior change among nursing staff and how these stages could be controlled and managed. The model is used as the framework for the practitioner educational program on how well they could implement the COPD protocols to improve patient outcomes. Participants were 15 nurses engaged in direct patient care in the nursing facility. After signing informed consent, they were given a pre-test, followed by the education on COPD exacerbation symptoms and use of the CAT tool in assessing early COPD symptoms. COPD exacerbation knowledge and knowledge of the CAT tool improved as indicated by positive changes in the post test scores. Additionally, there were reductions in dyspnea leading to hospitalizations, increase in cough, and changes in sputum. The educational intervention had a statistically significant impact in increasing participants COPD management and CAT tool knowledge by 6.83% from pre-intervention. This shows education and use of an assessment tool in monitoring early COPD exacerbation can lead to reduction in exacerbation rates among residents in long-term care facilities.

Purpose: Delirium increases the risk for long-term cognitive decline and mortality. This exploratory study evaluates the use of a limited lead EEG device for objective identification of delirium with the aim of early initiation of treatment.

Background: Current assessment for delirium is completed using a bedside clinical screening tool. Unfortunately, due to challenges with bedside screening, only 20% of delirious patients are accurately identified. Full EEG monitoring is the true gold standard for delirium detection but is not a feasible option. This study aims to address this practice gap by evaluating use of a nurse friendly limited lead EEG device for delirium identification in the ICU.

Methodology: Pragmatic sampling of critically ill older adults requiring mechanical ventilation (n=20) was used in this prospective observational study to evaluate differences in EEG waveforms of delirious patients versus those without delirium. EEG waves are compared for changes in rate and frequency of awake to sleep waves.

Results: Analyses includes EEG spectral wave analysis using MatLAB. Inferential statistics conducted using SPSS v24. Findings will be used to determine additional research on the effectiveness of EEG-based delirium detection.