Preventing Avoidable Rehospitalizations through Standardizing Management of Chronic Conditions in Skilled Nursing Facilities.

Objectives: This study evaluated the impact of standardized care protocols, as a part of a quality improvement initiative (J10ohns Hopkins Community Health Partnership, J-CHiP), on hospital readmission rates for patients with a diagnosis of congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) after being discharged to skilled nursing facilities (SNFs).

Design: A retrospective study comparing 30-day hospital readmission rates the year before and 2 years following the implementation of the care protocol interventions.

Settings And Participants: Patients discharged from Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center to the participating SNFs diagnosed with CHF and/or COPD.

Geriatric syndrome risk factors among hospitalized postacute Medicare patients.

Objectives: To assess the association of geriatric syndrome risk factors with postacute utilization among hospitalized Medicare patients (both Medicare Advantage [MA] and fee-for-service [FFS] cohorts) and to examine patterns of postacute care for MA and FFS cohorts with high geriatric syndrome risk.

Study Design: Secondary data analysis using encounter-level data from the State Inpatient Databases (SID) of the Healthcare Cost and Utilization Project.

Methods: The sample included 3.

Association of a Care Coordination Model With Health Care Costs and Utilization: The Johns Hopkins Community Health Partnership (J-CHiP).

Importance: The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland.

Objective: To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending.

Design, Setting, And Participants: Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score-weighted and matched comparison groups.

Implementation of a comprehensive program to improve coordination of care in an urban academic health care system.

Purpose Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue.

Patient Portal Use Among Older Adults: What Is Really Happening Nationwide?

Patient portals (PPs), secure websites that allow patients to access their electronic health records and other health tools, can benefit older adults managing chronic conditions. However, studies have shown a lack of PP use in older adults. Little is known about the way they use PPs in community settings and specific challenges they encounter.

A Call to Bridge Across Silos during Care Transitions.

Background: Older adults with complex medical conditions are vulnerable during care transitions. Poor care transitions can lead to poor patient outcomes and frequent readmissions to the hospital.

Factors Contributing To Suboptimal Care Transitions: Key factors related to ineffective care transitions, which can lead to suboptimal patient outcomes, include poor cross-site communication and collaboration; lack of awareness of patient wishes, abilities, and goals of care; and incomplete medication reconciliation.

Case Study: Johns Hopkins Community Health Partnership: A model for transformation.

To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patient's primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs.

Telephone Survey of Infection-Control and Antibiotic Stewardship Practices in Long-Term Care Facilities in Maryland.

Background: Multidrug-resistant organisms are an emerging and serious threat to the care of patients. Long-term care facilities are considered a reservoir of these organisms partly because of the over-prescribing of antibiotics. Antibiotic use is common in long-term care facilities.

The Effects of an Online Theory-Based Bone Health Program for Older Adults.

An estimated 10 million Americans age 50 and older have osteoporosis, and many experience associated fractures. Although several interventions have been shown to be effective in preventing osteoporosis, their impact on bone health among older adults was limited. The aim of this study was, therefore, to examine the effects of a theory-based online bone health program (Bone Power program) for a large number of older adults.

Where do we go from here? A small scale observation of transfer results from chronic to skilled ventilator facilities.

Purpose: Skilled nursing facility ventilator units (SNF) are a recent attempt to reduce the costs of an increasing number of patients who are in acute intensive care units and are not able to be liberated from ventilators. Transfers of such patients from long-term care chronic vent units (LTCVs) to SNFs in Maryland began in 2006. The safety of these transfers needs to be assessed.

Dissemination of a theory-based online bone health program: Two intervention approaches.

With the increasing nationwide emphasis on eHealth, there has been a rapid growth in the use of the Internet to deliver health promotion interventions. Although there has been a great deal of research in this field, little information is available regarding the methodologies to develop and implement effective online interventions. This article describes two social cognitive theory-based online health behavior interventions used in a large-scale dissemination study (N = 866), their implementation processes, and the lessons learned during the implementation processes.

Benzodiazepine discontinuation and patient outcome in a chronic geriatric medical/psychiatric unit: a retrospective chart review.

Aim: A substantial number of elderly patients take benzodiazepines (BZD) regularly despite concerns about toxicity and possible dependence, and there are relatively few data to guide clinicians' decisions regarding discontinuing benzodiazepines in the elderly.

Methods: We carried out a retrospective chart review of 75 elderly patients admitted to a chronic medical/psychiatric unit who were taking a standing dose of benzodiazepines on admission, comparing 40 patients who discontinued benzodiazepines versus 35 who did not discontinue.

Purpose: We examined the association of BZD discontinuation versus continuation with clinical outcomes on discharge, and further examined clinical characteristics associated with BZD discontinuation.

A theory-based online hip fracture resource center for caregivers: effects on dyads.

Background: Hip fracture is a serious injury for older adults, usually requiring surgical repair and extensive therapy. Informal caregivers can help older adults make a successful recovery by encouraging them to adhere to the therapy plans and improve their health behaviors. Few resources, however, are available for these caregivers to learn about how to assist their care receivers and cope with their unique caregiving situations.

Lactoferrin for the prevention of post-antibiotic diarrhoea.

Antibiotic-associated diarrhoea (AAD) is a common cause of morbidity and mortality. Older individuals in long-term care facilities are particularly vulnerable due to multisystem illnesses and the prevailing conditions for nosocomial infections. Lactoferrin, an antimicrobial protein in human breastmilk, was tested to determine whether it would prevent or reduce AAD, including Clostridium difficile in tube-fed long-term care patients.

Recruitment of Older Adult Patient-Caregiver Dyads for an Online Caregiver Resource Program: Lessons Learned.

Hip fracture is a significant health problem for older adults and generally requires surgery followed by intensive rehabilitation. Informal caregivers (CGs) can provide vital assistance to older adults recovering from hip fracture. Caregiving is a dyadic process that affects both CGs and care recipients (CRs).

Flu in 15: a novel 15-minute education program to promote acceptance of the influenza vaccine among health care workers.

Introduction And Rationale: A performance improvement project was undertaken to increase health care worker (HCW) influenza vaccination acceptance rates in the long-term care setting by using a novel 15-minute education intervention called the "Flu in 15." As a core principle, we taught that more Americans die from complications of influenza than hepatitis B, yet there remains individual reluctance and barriers to achieve high acceptance rates of influenza vaccination among HCWs.

Methods: During chance encounters we offered the Flu in 15 in-service to all HCWs at the Johns Hopkins Bayview Care Center including certified nursing assistants (also called geriatric nursing assistants), registered nurses, registered dieticians, environment staff, physical therapists, occupational therapists, speech therapists, respiratory therapists, social workers, and administrators.

An international model for geriatrics program development in China: the Johns Hopkins-Peking Union Medical College experience.

China has the world's largest and most rapidly growing older adult population. Recent dramatic socioeconomic changes, including a large number of migrating workers leaving their elderly parents and grandparents behind and the 4:2:1 family structure caused by the one-child policy, have greatly compromised the traditional Chinese family support for older adults. These demographic and socioeconomic factors, the improved living standards, and the quest for higher quality of life are creating human economic pressures.