2023 GAPNA Annual Conference

P01 - PLAN: Preparing and Living for Aging Now a Multi-Methods Study Investigating Older Adults’ Readiness to Plan for Aging and Frailty

Erica Frechman, PhD, AGPCNP-BC, ACHPN, NEA-BC, FPCN, Wake Forest University School of Medicine

Tags: frailty healthy aging planning community

Updated: 08/21/23

Background: Understanding aging through a holistic lens is essential to promote healthy aging in light of population aging and increased life expectancies that are often accompanied by the risk of chronic conditions, frailty, and disability. Planning for aging and frailty (PAF) encompasses five domains of aging (communication/socialization, environmental, financial, physical care, cognitive status) and serves as a proactive way for adults to prepare and plan across the life course. The purpose of this study was to examine the stages of change, experiences (personal and experiences with others), and associations between contextual factors and stages of change for readiness to PAF. And to explore how people perceive the concept of PAF and identify the facilitators and barriers involve in the planning process.

Methods: This study utilized a multi-methods design. Community-dwelling adults age 50-80 years old were recruited from a senior center, two YMCA sites, and ResearchMatch.org. Participants (N=252) completed a survey assessing stages of change for PAF, functional status, frailty, health status, social support, and demographics. Qualitative methods utilized semi-structured phone interviews with participants (N=20).

Results: The distribution of stages of change in readiness across domains of PAF were varied with highest levels of planning in action/maintenance stage in financial (68.7%) and lowest level in cognitive status (28.2%). More participants reported having experiences with others in all domains as compared to having personal. Older participants (³ 70) vs. younger (50-69) reported statistically significant greater planning in action/maintenance stages for all domains (p < .05) except cognitive status. Factors most indicative of planning were older age, marital status, living situation, social support, and vulnerability.

Conventional qualitative content analysis revealed categories of codes in the perception domain (internal, external, and future-oriented), facilitators domain (internal, external, and systems), and barriers domain (internal, systems). The depth of one’s self-identity, life experiences, and societal influences emerged.

Conclusion: PAF is an innovative concept that takes a comprehensive look at the aging process through the promotion of planning. Geriatric APRNs are uniquely positioned to provide education, guidance, and advocacy to older adults that may want to age in place and require guidance in navigating their later years.

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

P02 - Use of Admission MDS Data to Capture Unrecognized Cognitive Impairment in Heart Failure and the Implications for Discharge Planning

Garden Paquin, MSN, RN | Candace C. Harrington, PhD, DNP, APRN, AGPCNP-BC, CNE, FAAN

Tags: heart failure skilled nursing facility cognitive impairment discharge planning

Updated: 08/31/23

Background: Up to 80% of skilled nursing facility residents with heart failure (HF) also have comorbid cognitive impairment (CI). Concurrent HF with CI complicates residents’ self-care after discharge from short-term rehabilitation. More research exploring the characteristics of skilled nursing facility residents with comorbid HF and CI is needed.

Purpose: This study aimed to compare the clinical characteristics of HF residents with and without CI admitted for short-term rehabilitation in one of five skilled nursing facilities within the same organization in a midwest metropolitan city.

Method: Following institutional review board exemption from the University of Louisville (22.0241), we conducted a secondary data analysis of 2021-2022 admission MDS data with primary or secondary diagnoses for HF (n = 32) using ICD-10 diagnosis reports. Data were analyzed for comorbid conditions, complexity of care, caregiver involvement, and discharge planning using Fisher’s exact tests and measures of central tendency. MDS records indicating delirium or serious mental illness were excluded.

Results: Eleven (34%) brief interview of mental status (BIMS) scores indicated HF with CI; cognitive impairment. Of those, seven (64%) were undiagnosed, with average BIM scores indicative of moderate CI (M = 10, SD 2.4) in comparison to those with diagnosed CI (M = 7, SD 6.4). We found no statistically or clinically significant differences between the two groups’ complexity of symptoms or care. Family member involvement overall was low (n=5, 16%), but was higher for residents with CI (n = 4, 36%) than without CI (n = 1, 5%), p = .037. Although 97% planned to return to the community, none of the records indicated a need for referrals to community agencies.

Implications: These findings support the value of underutilized MDS data for planning medical and nursing care. Missed opportunities to diagnose CI have implications for primary care following facility discharge and possibly 30-day hospital readmissions.

Limitations: Limitations of this study include the format of the MDS questionnaire (different scales of measures), limited sample size, and the quality of data originally entered. Although primary caregiver involvement is critical to outcomes, admission MDS data are not designed to capture residents’ sociocultural barriers critical to successful discharge planning.

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

P03 - Integrating Virtual SIM Clinic PC Spark– Advanced Health/Physical Assessment Experience

George Byron Peraza-Smith, DNP, A-GNP-C, GNP-BC, GS-C, CNE, FAANP | Christine Bouchard, MPH, APRN, ANP-BC, FMCSA

Tags: simulation assessment virtual reality gaming technology artificial intelligence

Updated: 08/21/23

This poster presentation addresses the NONPF Role Core Competency – NP domain 1: knowledge of practice (NP 1.3g: demonstrate clinical judgment to inform and improve NP practice – advanced assessment). Nurse practitioners have become one of the most in-demand healthcare professionals while coalescing at a time that the US population is aging. The traditional, campus-based ground nurse practitioner programs have been unable to keep pace with expanding demand. Online nurse practitioner programs have seen significant growth. Online education provides working adults the opportunity to flex their lives and work around their education. Online innovations are continuously being explored and developed to improve the learning experience. We are a large online university providing NP programs to residents in California, Florida, and Texas, including adult gerontology primary care and acute care nurse practitioner and family nurse practitioner programs. The university’s innovation lab partnered with PC Sparks to develop a tailored virtual SIM clinic using artificial intelligence (AI) gaming technology. The SIM clinic consists of 20 virtual patients with varying ages and chief complaints. Our NP programs implemented the virtual SIM clinic in our advanced health/physical assessment course to augment the course learning by providing students to practice history taking and physical assessment skills in a safe environment. The gaming technology uses a state-of-the-art conversation engine and interactive modeling for students to practice collecting health histories, performing assessments, and practicing documentation. This technology is cloud-based and students engage with virtual clinic patients on their personal devices, as well as using 3D virtual reality headsets. The course design team, innovation lab team, PC Spark, and nursing faculty worked together in creating the various patient cases. The virtual SIM clinic was placed into courses for in the January 2023 start. Preliminary data from the end of one term demonstrates positive outcomes and satisfaction from students. There were positive trends from pre- and post-implementation for OSCE scores, course grades, and student confidence in history and assessment skills. There will be data from 4 terms and data will be shared comparing pre- and post-implementation outcomes.

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

P04 - Education, Engagement, and Empowerment: The APRN Role in a Nursing Home QI Collaborative

Carole Bartoo, AGPCNP, GS-C | Anna H. Gallion, DNP, APRN, FNP-BC

Tags: quality improvement nursing homes COVID-19 education engagement

Updated: 08/21/23

The COVID-19 pandemic highlighted long-standing gaps in the ability of nursing homes (NHs) to engage in quality improvement (QI) as evidenced by The National Academies of Sciences, Engineering and Medicine (NASEM) report "The National Imperative to Improve Nursing Home Quality" (2022). The report warns the current system is ineffective and unsustainable, and their resulting goals emphasize an urgent need to reinforce, expand, and otherwise remake QI in NHs (NASEM, 2022). Adult gerontology primary care nurse practitioners (AGPCNP) can bridge gaps in NH QI as their competencies promote safety and risk reduction for the adult gerontology population (American Association of Colleges of Nursing, 2016). Skills in leadership make nurse practitioners (NPs) key to collaborative efforts including multiple stakeholders, especially in systemic QI where communication and interprofessional relationships are key to success. A project to boost NH QI during the COVID-19 pandemic offered an opportunity to test a unique role for NPs. From Fall 2021 through Spring 2023, the project paired four NP QI advisors from a nearby academic medical center with more than 30 NHs to meet three objectives: 1) educate NH QI leaders, mostly through one-on-one mentorship in QI methodology; 2) engage facilities by coaching through QI methodologies, including plan, do, study, act (PDSA) cycles; and 3) empower facilities to embed evidence-based QI into standard workflows. QI topics varied and were self-selected by facilities. Topics included fall prevention, medication reduction, infection control, and COVID vaccination, among others. NP advisors provided real-time guidance in the application of QI methodologies as projects progressed. Over the 18-month project, seven NHs completed multiple PDSA cycles, 11 completed at least one, and 16 participated but did not complete a PDSA cycle. More than 200 nursing continuing education credit hours were awarded. In post-project interviews, facilities highly valued the educational component and credited the project with facilitating their engagement in QI. Empowerment to embed QI was more difficult to assess; facility QI leaders expressed a desire for more time with their NP advisor which could facilitate this. This project exemplifies how geriatric-focused NPs are uniquely positioned to lead future change by educating, engaging, and empowering NH QI leaders.

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

P05 - Understanding Clinician Perspectives of Palliative Care Referral Criteria or Tools with Nursing Home Residents

Connie Cole, PhD, DNP, APRN, RN-BC

Tags: palliative care Nurse Practitioner nursing home identifying serious illness

Updated: 08/21/23

Objective: To describe the experience of nursing home staff, providers, and palliative care providers with identifying residents appropriate for receiving palliative care.
Design: Qualitative descriptive
Setting and participants: Nursing home staff (n=3), nursing home providers (n=10), and palliative care providers (n=4)
Methods: A semi-structured interview guide was used to elicit experiences identifying residents appropriate to receive palliative care. Interviews were recorded and professionally transcribed. Rapid qualitative analysis was conducted to code data and identify themes.

Results: Four themes emerged reflecting participant descriptions of criteria for palliative care referral for residents: 1) resident health status, 2) uncontrolled symptoms, and 3) resident and/or family support needs. “Barriers to palliative care” and “primary palliative care as a solution” emerged as additional themes. In most cases, participants cited resident health status of serious illness and global indicators of decline as well as uncontrolled symptoms in determining when palliative care was appropriate. Resident and family support needs such as conflicted goals of care and unrealistic expectations were also frequently cited as indications to receive palliative care. Most participants discussed barriers to palliative care in nursing homes, including the workforce challenges in accessing specialist palliative care, the lack of screening tools or defined criteria for identifying residents appropriate for palliative care, and lack of knowledge about palliative care among nursing home staff, residents, and families. Primary palliative care by nursing home providers was identified as one solution to meeting the needs of this vulnerable population.

Conclusions and implications: Findings describe the criteria currently in use for palliative care referral and barriers to palliative care provision for nursing home residents. Findings suggest that both education about palliative care and defined criteria are needed to facilitate timely entry into primary and specialty palliative care programs.

Learner outcome: Enhance the learners’ knowledge of palliative care referral criteria for use with nursing home residents and understanding of primary palliative care as one strategy to improve nursing home resident quality of life.

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

P06 - Risk Factors for Inpatient Facility Admission Among Home Healthcare Patients with Diabetes

Katelyn Webster-Dekker, PhD, RN

Tags: diabetes Home Health hospitalization inpatient transfer assisted living

Updated: 08/21/23

Aims: This study aimed to identify factors associated with inpatient facility admissions among adults 50 years and older with diabetes receiving home health care (HHC) at home or in assisted living (AL) and examine whether associated factors are similar or different between the two groups.

Rationale: There is a high risk for inpatient facility admissions among HHC patients with diabetes. HHC is primarily provided to patients in their own homes but is increasingly provided to patients residing in AL. Older adults living in different settings may have unique risk factors.

Conceptual framework and supporting literature: This study was guided by Anderson’s Behavioral Model of Health Services Use, which suggests that healthcare utilization is influenced by predisposing, enabling, and need factors.

Methods: This retrospective study of HHC patients with diabetes 50 years and older (n=5,308) used data from the outcome and assessment information set D (OASIS-D). Using logistic regression, we examined whether characteristics at the start of HHC were associated with having an inpatient admission while receiving HHC. Two separate models were completed for patients living at home and patients in assisted living.

Results: The mean age of the overall sample was 75.6 (SD 9.5) and patients were 57.5% female; 29.5% of patients had an inpatient admission while receiving HHC. Multiple prior hospitalizations, depression, limited cognitive function, decreased ability to perform activities of daily living, and an unhealed pressure ulcer or injury ≥ stage 2 were associated with having an inpatient admission in patients living at home receiving HHC. Multiple prior hospitalizations and decreased ability to perform activities of daily living were associated with having an inpatient admission in patients in AL receiving HHC.

Applicability to advanced practice nursing practice: This study aids in understanding risk factors for inpatient admissions among patients with diabetes living at home or in AL. The results may support identification of at-risk patients and inform targeted interventions to prevent inpatient admissions while receiving HHC.

Learning outcome: At the end of the presentation, attendees will be able to list factors associated with inpatient transfers in home health patients age ≥50 with diabetes.

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

P07 - Developing a “Best Possible Caregiving History” for Use in a Geriatric Emergency Department

Karen de Sola-Smith, PhD, MS, MA, NP, RN

Tags: age-friendly emergency department caregiver

Updated: 08/21/23

Background: Better discharge planning and care coordination could address many of the issues that present in a geriatric emergency department (ED; e.g., non-injurious falls, wandering behaviors), but this requires an understanding of a patient’s caregiving context to plan interventions. We thus sought to develop a method to standardize how we collect data on a patient’s caregiving context.

Methods: Using human-centered design, we are developing a process for collecting and displaying information about patient caregiving contexts, which we call the “best possible caregiving history” (BPCH). Using semi-structured interviews and focus groups, we queried key informants (ED social workers, geriatric nurses, physicians, and geriatricians) on what would be helpful for documenting caregiving contexts, ideated and developed several prototypes, and solicited feedback.

Results: From semi-structured interviews, major themes included preferences for organization by functional need, need for brief narrative with summarized information, and assessment of adequacy of caregiving. In feedback sessions, users wanted caregiving data to be systematized and organized but some struggled to see how the BPCH would be used and wondered who would collect the data. In response, we updated prototypes to mimic the local health record and iterated further on systematic BPCHs.

Conclusion: Human-centered design methods have helped us rapidly prototype and solicit feedback on a BPCH with potential users. Next prototypes will need to test systems for organizing caregiving data, test how to present when caregiving is insufficient and balance comprehensiveness with expedient data collection.

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

P08 - Palliative Care Services in the SNF Setting

Amy Quintero, GNP-BC

Tags: palliative care skilled nursing facility

Updated: 08/21/23

Background: Our healthcare delivery system is serving more than 550000+ patients in Texas and Florida. The SNF (skilled nursing facility) program started in 2008 in San Antonio, TX, and is one of several sub-specialty programs offered thru our organization. Currently there are four physicians and five APCs (advanced practice clinicians) that work in these facilities. Many of the patients in the SNF setting have palliative care needs. In 2019 the supportive care team (SCT) started to collaborate with the SNFs. Due to COVID, the program was on hold. It was reintroduced in October 2022 and has been instrumental for patients with high acuity and with multiple acute and chronic diagnosis.

Objective: The goal of this poster is to describe the referral process, criteria, and collaboration to identify palliative care needs in the SNF setting and the impact of the program.

Description: The SNF team rounds weekly to identify appropriate palliative care patients. Referring criteria include frequent hospitalizations; newly diagnosed cancers; acute on chronic medical conditions, such as heart failure; advanced COPD; functional decline; poor social support; and hospice appropriate patients that have declined hospice. Patients identified have a one-time visit by the SCT to make recommendations and evaluate appropriateness. If approved, further follow-up will be done in the home setting.

Results: Data was obtained using SNF referrals from October 2022 through December 2022. 160 members were admitted to one SNF. Of the 160, 44 were admitted to SCT. From the 44 patients admitted, 20 were admitted into the palliative home visiting program, 8 were admitted to a step-down home program, 10 were involuntary discharged, 4 returned to care of the primary care physician, and 2 were admitted into hospice care.

Conclusion: The PC program in the SNF setting has made a significant impact on our pts healthcare. In the three months of this program, 27% was referred to PCS. These patients will have an extra layer of support upon discharge from the SNF setting to prevent further hospitalization and further identify goals of care.

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

P09 - ADVANCED-Comfort: A Novel Model of Care to Promote Comfort and Quality of Life

Ruth Lopez, PhD, FAAN

Tags: quality of life end-of-life care dementia palliative care comfort

Updated: 08/21/23

Over 6 million Americans are living with Alzheimer’s disease and related dementias (dementia), a progressive terminal condition and the 6th leading cause of death in the United States. While people with late-stage dementia should receive comprehensive, person-centered care focused on maintaining comfort and quality of life, many experience pain, distressing symptoms, and interventions, such as feeding tubes and hospital transfers, that do not benefit them. Advanced directives frequently fall short of ensuring comfort and quality of life because they require families to abandon the goal of sustaining life or restoring function in exchange for a focus on comfort. The purpose of this presentation is to describe ADVANCED-Comfort, a novel model of care that represents a major paradigm shift in end-of-life care planning. The model suggests that rather than “giving up,” comfort is actively sought by conducting a thorough assessment and selecting personalized interventions to meet the needs of people living with late-stage dementia in 6Ms adapted from the age-friendly health systems framework (what matters, meaningful activities, mealtime, medications, mobility, make comfortable). Family members complete the ADVANCED-Comfort workbook, which solicits information about the person living with dementia through a series of questions focused on each the 6Ms. Thereafter, families can use the answer sheets to guide conversations with healthcare providers or they can display them in a prominent place to serve as personalized care plans made visible to all those that care for the individual with dementia. Results of initial empirical testing of the model will also be presented.

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

P11 - Meeting Social Determinants of Health Measures for Quality Care

Carolyn Monroe, MS, RN, APN-C, AHN-C

Tags: SDOH Medicare Advantage quadruple aim utilization healthcare equity

Updated: 08/21/23

This project tested the impact of an industry standard social determinants of health (SDOH) screening tool, Protocol for Responding to and Assessing Patient’s Assets, Risks and Experiences (PRAPARE)[1], on connecting SDOH resources with high-risk Medicare Advantage (MA) members to improve access, enhance quality, and reduce unnecessary healthcare expenditures.

Research shows unmet SDOH needs drive as much as 80% of health outcomes and result in increased utilization of emergency department (ED) visits and hospitalizations[2],[3]. Adoption of a standardized method to screen for and connect patients to SDOH resources can enhance outcomes and drive medical savings.

An educational program, document repository, quick reference guide, and project playbook were created. Staff in three primary care clinics adopted a uniform method of assessing patients using PRAPARE. Patients who screened positive for SDOH needs were matched with social support services through internal assets, community resources, or FindHelp.org[4]. At the completion of eight weeks, data was analyzed.

There were 270 eligible patients; 226 were screened and 64 (28%) patients were found to have at least one SDOH need. 94 of those who screened positive were immediately connected to SDOH resources by the clinic staff, and 6% were referred to social workers (SW) for enhanced assistance. Social work referrals increased from an average of seven to 19 referrals per month as did z-code documentation adherence in comparison to past performance.

The impact on ED utilization and inpatient admissions are in early phases of data collection, with plans to scale this streamlined and effective approach to additional primary care clinics already initiated. By implementing standardized screening tools and intervention methodologies, we can impact patient health outcomes, proactively address the upcoming social needs screening and intervention (SNS-E) quality measures and health equity index (HEI) financial ratings, thus advancing the quadruple aim.

[1] The PRAPARE Screening Tool - PRAPARE
[2] Medicaid’s Role in Addressing Social Determinants of Health. (n.d.). RWJF. https://www.rwjf.org/en/insights/our-research/2019/02/medicaid-s-role-in-addressing-social-determinants-of-health.html
[3] Beaton, T. HealthPayerIntelligence. (2018, March 28). Payers Form Coalition to Address Social Determinants of Health. https://healthpayerintelligence.com/news/payers-form-coalition-to-address-social-determinants-of-health
[4] findhelp.org by findhelp - Search and Connect to Social Care

Learning Objective:

After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.