Purpose: To document and disseminate a comprehensive analysis of senior population health on a national and state-by-state basis across ~35 measures.

Rationale: According to the United States Census Bureau, adults aged 65 and older now comprise more than 15 percent of the total population.1 By 2030, that number will climb significantly to 20 percent.2 Adults aged 65 and older are the largest consumers of health care, and this poses challenges to policy-makers, Medicare, Medicaid and Social Security in addition to the effect on families, communities, and healthcare providers including advanced practice registered nurses (APRNs).

Theoretical framework: America’s Health Rankings® Senior Report was built upon the World Health Organization (WHO) definition of health. The model reflects that determinants of health directly influence health outcomes.

Methods: This descriptive study draws data from more than a dozen government agencies and leading research organizations to create a focused, uniquely rich dataset for measuring health at the state level. A composite variable focused on social isolation in older adults will include analysis of measures from the AARP Foundation Isolation Framework Report (2012) and the American Community Survey (ACS). Quantitative analysis included descriptive statistics and standard formulas to determine a score for each state and rankings on key measures.

Results: These data from the 2020 America’s Health Rankings Senior Report are pending and anticipated to be released in late April.

Application to practice: Continued population growth, coupled with more complex medical conditions and social isolation threaten to further strain the healthcare system. APRNs caring for older adults can take an active role in improving overall health outcomes for their populations by leveraging these data. In addition, APRNs have to opportunity to collaborate with additional inter-professional teams to drive policy change and promote the health of older adults.

References
1. U.S. Census Bureau https://www.census.gov/newsroom/facts-for-features/2017/cb17-ff08.html. Accessed February 14, 2020
2. https://www.census.gov/prod/2010pubs/p25-1138.pdf. Accessed February 14, 2020

Patients who transition from hospital to skilled nursing facilities frequently require home healthcare services upon discharge to home. Medicare requires a physician-signed face-to-face (F2F) form. In an academic-medical setting, non-physician providers (NPP) prepared an electronic discharge summary and incorporated the F2F into the summary, which was routed to physician for signature. This process was started in October 2016. Patients who discharged two years prior to the change (pre-group) and two years after the change (post-group) were reviewed to determine if the change improved the time to start of care of home care services. Total number of patients who discharged during this period was 382. Also reviewed was 30-day and 60-day emergency room visits and rehospitalizations for these patients.

Results of this study did not show statistically significant difference in time to start of home care services in comparing the pre- and post-groups, but, however, did show the odds of being re-hospitalized within 30 days was 57% lower among the post-implementation group. Similarly, the odds of having an ED visit within 30 days were 60% lower among this same group. Factors that can contribute to this association are standardization of the discharge process among NPPs, increased emphasis on the discharge summary itself as a handoff communication tool and increased comfort in the referral process.

Health care in the US is moving towards value-based care. The Center for Medicare and Medicaid Innovation (CMMI) continues to develop a growing portfolio and testing various payment and service delivery models that aim to achieve better care for patients, better health for communities, and lower costs through improvement of the healthcare system.

This presentation highlights drivers of value-based care by highlighting Medicare spending on older adults, in general, and on chronic disease and multiple co-morbidities, in particular.

By 2030, all baby boomers will reach the age of 65, raising the number of older adults to 77M by 2034. Medicare spent more than $7B as of 2017 and is projected to reach unsustainable expenditures of $6T in 2027. 17% of Medicare beneficiaries account for 53% of spending and 81% of hospital readmission according to a 2017 Medicare data. The Lewin Group (2010) reports the cost of care for individuals with both chronic condition and functional limitations are double those with chronic conditions alone.
Furthermore, this presentation shows Medicare fee-for-service (FFS) payment reforms as relates to technology, value-based care, cost, and value.

Medicare value-based programs include end-stage renal disease quality incentive program (ESRD QIP), hospital value-based purchasing program (VBP), hospital readmission reduction program (HRRP), value modifier (VM), and hospital-acquired conditions (HAC) reduction program (HAC), skilled nursing facility value-based program (SNFVBP), home health value-based program (HHVBP), among others.

Focus on the details and resources is given to the forthcoming 2021 CMMI program that affects FFS practices, including home-based primary care (HBPC) practices: primary care first (PCF) and seriously ill population (SIP).

Practices will be able to participate in one of three PCF components: PCF-general, SIP, and hybrid PCF+SIP. PCF-general is for advanced primary care practices and assumes the financial risk in exchange for reduced administrative burden and performance-based payments. The SIP component promotes care for high-need, seriously ill population for those who lack a primary care practitioner or effective care coordination. CMS uses claims data to identify beneficiaries who meet the requirements.

Due to the coronavirus (COVID-19) public health emergency, healthcare providers were able to use telehealth services to treat COVID-19 (and for other medically reasonable purposes) from offices, hospitals, and places of residence (like homes, nursing homes, and assisted living facilities) as of March 6, 2020.

Under the new developments, HIPAA rules were relaxed, and providers were allowed to do telehealth visits, even using FaceTime and billing using the same code as face-to-face (F2F) systems.

CMS issued flexibilities around telehealth. Clinicians were allowed to bill immediately for dates of service starting March 6, 2020. Telehealth services were paid under the physician fee schedule at the same amount as in-person services. Medicare coinsurance and deductible still applied for these services. Additionally, the Health and Human Services (HHS) Office of Inspector General (OIG) provided flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

Using a HIPAA-compliant platform, a home-based primary care (HBPC) practice shares its experience using telehealth in continuing to provide medical care visit for homebound seniors, including documentation of the visits. Experiences such as this may have a potential for telehealth visits to become part of the mainstream program within Medicare, especially where vulnerable homebound older adults are concerned.

Membership engagement is as challenging as it is rewarding. Engagement starts with the encouragement for members to interact and share their experiences as an organization. To continue to keep members of the Northern California Chapter of GAPNA (NCCGPNA) engaged, a membership engagement survey was rolled out in line with the annual continuing education conference in February 2020.

The survey was rolled out online as well as on printed questionnaires with about 45% of members responding.

Survey results showed that the majority of respondents are certified as gerontological nurse practitioners (GNP), followed by family nurse practitioners (FNP). Among these respondents, the top three specialty areas were palliative care, house calls, and skilled nursing facility.

The members surveyed ranked professional collaboration as the benefit of membership and providing continuing education (CE) as the highest-ranked activity that members think the organization should be engaged in. When asked as to the kind of CEs, the respondents responded with neurology, hospice/palliative care, and wound care as the top three.

When asked how the organization can help improve the recruitment of new members, the respondents ranked meetings in groups and members bringing colleagues as the method of choice.

The chapter will use this information to further engage members in the coming years. This survey will be an ongoing check on member engagement so that the organization can continue addressing the perceived need of the members.

Patients with a new ostomy require a tremendous amount of education and support in relation to lifestyle changes and ostomy care. Inpatient and short-term resources are readily available, but long-term care and community resources are scarce. A need for continued support was identified. Working with an IT department and a clinical manager, an outpatient clinic for ostomy patients was created. The nurse practitioner for the clinic was integrated into the existing ERAS program (enhanced recovery after surgery) as the ostomy educator and resource. Patients were introduced to a “world nurse” that would be available at all times for support and to answer questions. A “world nurse” is a first-line resource for questions and concerns outside of the hospital setting. To evaluate the effectiveness of this program, patients were surveyed in regards to clinic experience. The goal was to assure patient problems and concerns were identified and addressed in a timely fashion and that patients had an ongoing contact and resource for continued ostomy care. To date, over 20 surveys have been received, rating patient experience as “very well” with respect to resolving problems and increasing ability and confidence to preform self-care. 

Purpose: A continuum of study to evaluate the effectiveness of a 20-day post-discharge hospital ostomate follow-up program, as conducted by the "world" ostomy nurse practitioner, to assess the effectiveness of the nurse practitioner role as a resource in the community and to identify problems ostomates continue to face after discharge from a level one trauma center in Southeast Michigan.

Patients receive limited education during hospitalization due to the global push to decrease hospital length of stay. Following hospitalization, patients transition home for additional ostomy education and support from the visiting home nurse. Some patients refuse homecare due to economics and a variety of other reasons. Eventually, all patients are discharged back into their community. For ostomates, the "world" ostomy nurse practitioner is the first-line resource for questions and concerns outside the hospital setting.

The 20-day ostomate follow-up program interviewed 91 discharged patients. Interview results indicated the educational level of the ostomate and the perceived quality of ostomy care, current problems with self-care, any skin breakdown, leaking pouches, the understanding of the use of convexity to secure the pouching seal, hydration and nutrition goals, and education and access to ostomy medical supplies. It also examined the individual perceived awareness of the "world" ostomy nurse practitioner as a community resource available to all ostomates.

The goal of such a follow-up program is to provide access to the "world" ostomy clinician in the community, as well as empower ostomates in ostomy self-care to identify normal verses abnormal peristomal skin, resolve acute skin care issues with available tools, seek professional assistance for complicated skin issues, understand the topographical nature and anatomy of the peristomal skin and stoma, recognize change, and obtain the correct ostomy supplies in a timely manner.

Purpose: To evaluate the educational efficacy and overall reduction in hospital readmissions of new ostomates that received preoperative ostomy education, resources and post-operative access to the “world” ostomy nurse practitioner through the enhanced recovery after surgery (ERAS) program. The goal of the ERAS program is to provide pre-operative surgical optimization and pre-abiliation. Focus is placed on pre-operative health optimization, patient education, and resource guidance to assist patients in making educated and informed decisions in their surgical venture; giving patients the ability to independently access the provided and available resources if encountering a variety of ostomy-related issues or complications. This education and resource guidance aims to decrease overall preoperative anxiety and increase patient confidence in ostomy self-care, furthermore preventing emergency room visits and consequential hospitalizations. Patient education and provision of access to continuing care resources is vital to the success of the program. In this institutional study, 71 ERAS patients received preoperative education by the “world” ostomy nurse practitioner and stoma clinic resources during the study window of January-September 2019. 53% of patients were seniors, over age 60, demonstrating a potentially vulnerable patient population. Of the 71 patients seen in the ERAS clinic, 66 patients had colorectal surgery resulting in ostomy placement. 54% of the new ostomates utilized the “world” ostomy nurse practitioner via phone or clinic visit with problems that would have otherwise resulted in a potential emergency room visit and possible readmission for hospitalization.

Outcome: The results of this study provide statistical support that enrollment in the ERAS program to provide new ostomates with pre-operative education, support, and resources to increase independence in ostomy self-care, reduces overall post-operative emergency room visits and consequential hospitalization.

Objective: Identify older adults who are at high risk for readmission following a skilled nursing facility stay that would benefit from a nurse practitioner visit within 72 hours of skilled nursing facility discharge. This improvement project aims to decrease 30-day hospital readmission rates following a skilled nursing facility stay by 20% through implementation of transitional care services. Additionally, information obtained during implementation will be provided to stakeholders in the skilled nursing facility as well as home-based primary care to inform of any gaps in care identified.

Methods: This improvement project will be completed at one facility in North Carolina and will include older adults considered at high risk for readmission following a skilled nursing facility. Risk will be determined through use of the LACE index and electronic frailty index (or Rockwood Clinical Frailty Scale if needed). Patients who meet criteria will be seen for a transitional visit in their home within 72 hours by a nurse practitioner. This visit will focus on medication reconciliation, physical exam findings, assurance that appropriate follow-up is in place, disease self-management education, environmental hazard assessment, confirmation that therapy services have been initiated, and DME received.

Results: Project is currently being implemented. Anticipate a reduction in 30-day readmission following a skilled nursing facility stay in high-risk older adults.

Clinical relationship: It is estimated that approximately 22% of older adults are seen in the emergency department or require hospital admission within 30 days following a skilled nursing facility discharge. Literature is limited in regards to transitional care following a skilled nursing facility stay. Literature that is available support the benefits of utilizing nurse practitioners for care transitions which has been shown to cut costs, decrease readmissions, and improve outcomes.

Impact or significance: This improvement project will provide support for the use of nurse practitioners for transitional care following a skilled nursing facility stay. The findings from this improvement project can be generalized to any high-risk older adult transitioning from a skilled nursing facility to home.

Estimates indicate approximately 15-20 percent of older adults aged 65 and older suffer from depression. This translates to nearly 7 million adults currently residing in the United States. Depression and dementia are two of the most common neurological disorders occurring in the older adult, and research supports the idea that depressive symptoms are a risk factor for dementia. The symptoms of depression have been shown to accelerate decline in cognitive functions and memory. The presence of both depression and cognitive impairment were found to be independent predictors of one-year mortality in medically ill older adults. However, these two illnesses are not the processes of aging and remain treatable conditions. If symptoms of depression are identified and treated in a timely manner, an individual’s quality of life and functional abilities can be significantly improved. However, many providers lack adequate knowledge related to screening for depressive symptoms and treatment options in the older adult, often selecting inappropriate depression screening tools. The purpose of this presentation is to educate advanced practice providers on age-appropriate screening tools to identify depressive symptoms in the older adult.