Diabetes care distinguishes the broad spectrum of services and settings that enable the patient-centered continuum of caring and treatment. The acute character of comorbidities, especially among older patients, predefine the need for the quality care provided in skilled nursing facilities (SNF). The study proposal is aimed at shaping the research issue by answering how Quality Improvement (QI) intervention may improve the readmission rate of diabetes patients in SNFs.
Diabetes Care in Skilled Nursing Facilities. Background and Significance of the Problem
Diabetes complications can lead to patients requiring very costly and sophisticated health care services. The continuous diabetes care is a challenge for the national health care system. Though the importance of care coordination is acknowledged, fragmentary functioning units still cause non-effective resource allocation and necessitate advanced nurses’ managerial skills in particular (ANA, 2012). On the way, safe transitions to and from SNFs constitute the most apparent problem indicating the quality of care and care outcomes. SNFs refer to the health care chains with the biggest readmissions rate and gaps in health care delivery (Neuman, Wirtalla, & Werner, 2014). Alongside this, the facilities take care of a significant number of older patients with chronic diseases who are the most vulnerable to the timely delivery of vital services (Munshi et al., 2016). Still, the reviewed studies argue a significant part of readmissions are preventable and unnecessary (Munshi et al., 2016; Neuman et al., 2014; Ouslander et al., 2016).
Statement of the Problem and Purpose of the Study
Accordingly, the problem manifests in the controversy and gaps of the SNFs performance that result in prolonged stays, the development of comorbidities, and acute readmissions. The readmissions are primarily related to chronic diseases’ comorbidities (Neuman et al., 2014). Provision of timely responses to the disease course changes and comprehensive management of post-cute situations pose the biggest challenges for continuous treatment. The research problem concerns the care coordination of the SNFs with related facilities that are detected to be the primary reason for acute care errors (Jacobs, 2011; Ouslander et al., 2016; Samal et al., 2016). Consequently, the purpose of the current study is to discover the significance of quality improvements in care coordination to decrease acute readmissions. The organization of efficient health care management and fluent transitions between facilities are the tasks that can be solved with the scope of advanced nurse’s skills (ANA, 2012). The search for optimization tools involves a literature review.
Recent studies imply that there is an urgent need to implement the necessary changes in the facilities’ organization, as well as the innovative programs to guide them. Still, the findings are mainly fragmentary and do not provide a holistic view of quality care and safe transitions, especially in cases of diabetes. Consequently, the literature review aims at detecting the reasons for readmissions, current options for safe transitions, quality improvements in the SNF organizations, and the state of diabetes in the light of the readmission problem.
The SNFs are found to have significantly high readmission rates leading to costly and complicated rehabilitation, especially among patients with chronic diseases (Jacobs, 2011; Meehan et al., 2015; Neuman et al., 2014). In particular, Neuman et al. (2014) consider SNF staffing and facility performance ratings to be the primary issues leading to readmissions. However, when adjusted to the patient factors, the correlation turns out to be insignificant and controversial. The report by Li, Cai, Yin, Glance, and Mukamel (2012) supports the existence of a relationship between the SNF’s volume and the readmissions rate after 30- and 90-day discharges. They contribute to the issue of optimal organization of facilities and the work overload of nurse practitioners. Another case study by Jacobs (2011) distinguishes incomprehensive discharge planning to be a significant obstacle to the multilevel management of SNF patients. The discharge orders refer to another option that influences the decisions for readmissions. Unclear discharge orders complicate nurse case management and care coordination. The reports by Ritt and Taylor (2016) and Samal et al. (2016) found the coordination gaps to be sufficient in reinforcing the readmission problem. Additionally, safe transitions are an essential component of care coordination.
Topics of transitional care refer to the most promising factors in improving the quality of continuous care. The qualitative and quantitative studies exploring the SNFs’ functioning deal with transitions as the main coordination gaps. The reports indicate the narrow diagnoses and limited coordination between facilities are the most common reasons for unnecessary patient transfers. Toles et al. (2016) distinguish three groups of issues shaping effective one-way transitions. Organizational support, staff interactions for the preparation of safe transitions, and evidence for planning and decision making in the delivery of transitional care services are all influencing the quality of transitions. The need for evidence-based transitional care services is emphasized (Toles, et al., 2016). Furthermore, the literature describes the safe and unnecessary transitions that have to be addressed.
The reviewed literature indicates the importance of avoidable transitions in reducing the readmission rate or safe transitions to provide holistic care. They are supposed to constitute nearly a quarter (23%) of all the transitions (Ouslander et al., 2016). Unnecessary transitions are closely related to fiscal limitations and the lack of multidisciplinary staff and technical resources. The partial character of the SNF care services appears to be the apparent barrier to treating the acute changes of nonspecific origin. The SNF staff experiences a lack of skills while managing multiple symptoms of geriatric diseases (Ouslander et al., 2016). Besides, nurses suffer from low confidence in the preparation of self-care management of patients and their families to decrease the readmissions and facilitate safe transitions (Jacobs, 2011; Toles, et al., 2016). Accordingly, the modifiable strategies should be used to advance such nurse skills as self-management education, transitional services, and comprehensive assessment of acute changes.
In turn, the identified components facilitate safe transitions. Safe transitions are referred to as the markers of the quality of SNFs performance. They include the health management services to provide the flawless continuum of care (Toles et al., 2016). Li et al. (2012) identify the hospital-based facilities to be better at the provision of safe transitional services. Additionally, quality improvements (QI) of the SNF’s functioning are observed to be valuable interventions in reinforcing the facilities’ functions in the chain of health care processes.
QI programs enable a broad spectrum of options to manage the performance weaknesses and coordination gaps of SNFs. They include the development and maximal implementation of health information technologies (HIT) (Samal et al., 2016). HITs contribute to the care coordination while facilitating patient monitoring, timely feedbacks between the SNF and emergency departments, and control of the transitional processes. Recently, the Quality Improvement Organization (QIO) support has become another working instrument used to improve the SNFs’ coordination of care (Meehan et al., 2015; Ouslander, 2016). The support manifests in guiding the changes, leading to the congruence of system resources and patient needs (Samal et al., 2016).
The Interventions to Reduce Acute Care Transfers (INTERACT) options of QIO refer to the assistance in implementing QIs in the organizational, technical, and human resources’ domains. The INTERACT program is found to be important and easy to understand for the staff members. The studies of Meehan et al. (2015) and Ouslander (2016) show that these improvements are effective at targeting avoidable readmissions, technical assistance of care management, and staff education. Still, the representativeness of findings is limited because of the insufficient number of facilities implementing QIs. Moreover, the patient factor is often underestimated when assessing the potential of QIs (Meehan et al., 2015; Neuman et al., 2016; Ouslander, 2016; Ritt & Taylor, 2016). The latter means that the QI activities should involve the needs of patients and their families. The analyzed studies mention that geriatric care is the focus of QIs. The recognition of the problem is impossible without disseminating the complexity of chronic conditions of geriatric patients and treating them systematically (Ritt & Taylor, 2016). Diabetes is one of the most severe and rapidly growing chronic diseases that result in frequent acute readmissions. Accordingly, there exists a need to analyze the targeted population.
According to the reviewed studies, older patients with chronic conditions are the ones who require early health care planning, timely response to acute changes, and a minimum of transitions (Munshi et al.2016; Neuman et al., 2014). Moreover, Ritt and Taylor (2016) consider chronic patients with multiplied comorbidities to be the most susceptible to the coordination of care while treated only fragmentary. Neuman et al. (2014) determine this group to be at the highest risk of acute exacerbations and mortality because of complicated readmissions. Early communication of changes in the disease course and related comorbidities refers to the field of QI tasks. Additionally, the researchers exploring the quality of the SNF care recognize that additional quantitative studies are necessary to generate the interventions that will fit the specific needs of older patients with chronic conditions (Munshi et al., 2016; Neuman et al., 2014; Ritt and Taylor, 2016).
Summary of the Evidence for the Proposed Study
The literature review contributes to the explicit understanding of the readmission problem that can be solved by addressing the SNFs’ performances and coordination of care. In particular, staffing, interoperability, and care organization are considered to be the most apparent reasons for readmissions. Therefore, unnecessary and safe transitions constitute the topics of increased interest and concern the control of acute readmissions. The analyzed literature contributes to the significance of the transition management that is ineffective and fragmentary in the SNFs. Comprehensive planning of discharge and transitions refers to the options to be improved. Moreover, QI programs are found to be the most valuable source of solutions for this issue. the chronic and multifaceted nature of diabetes care predisposes the inclusion of older diabetes population in the group with the highest SNF readmission rate. The lack of evidence concerning the quality of diabetes care in the SNFs in current literature highlights the importance of the initiated research and determines the research questions that need to be answered.
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Research Question, Hypothesis, and Variables with Operational Definitions
The care coordination problem requires the identification of several research components. Assuming that quality improvements are necessary to improve care coordination, the first research question is designated to discover whether the coordination gaps depend on the SNFs structure, as well as financial, staff, and technical resources. The first question leads to another research question that requires defining the relationship between coordination gaps and patient outcomes. Coordination gaps that are measured with the performance indicators available at Medicare’s Nursing Home Compare serve as an independent variable for the first question and a dependent one for the second. In the first case, facility characteristics that can be used as structural parameters of the unit from the Medicare Online Survey, Certification, and Reporting Files become a dependent variable (Neuman et al., 2014). Patient outcomes are involved in assessing the quality of care in the SNF as an independent variable for the second question while using hospitalization indicators according to Hospital Readmission Reduction Program algorithms (Neumann et al., 2014). Finally, the research involves exploring the significance of the QI intervention in decreasing the readmission rate. The statements serve as a background for the main research question. The latter is how the QI program is implemented among older diabetes patients in the SNF as compared to the facilities without QI tools. The rate of acute readmissions within one year is measured. Accordingly, the research hypothesis includes the suggestion that QI options implemented in SNFs improve the care organization and diabetes patient outcomes. The null hypothesis predicts that no correlation exists between QI intervention and readmission rates.
Research questions and hypotheses consider applying the QI tools and readmission rates for identifying study variables. Meehan et al. (2015) propose the Interventions to Reduce Acute Care Transfers (INTERACT) program to improve the QI structure in the SNF. These tools are a priority for the current investigation. The level of use of the QI program in care coordination is the most apparent measurable independent variable. The latter means utilizing free available programs provided by the Quality Improvement Organization to detect and follow the changes in acute patients’ health (Meehan et al., 2015). The use of optimizing tools is determined while evaluating the frequency and the structure of health care processes assisted by the INTERACT tools. The project is directed to decrease the readmission rates of post-acute diabetes patients discharged from SNFs. Hence, the readmission rate is the dependent variable that can be modified. The readmissions from SNFs and after home discharges within the 30-day period related to diabetes exacerbations are involved in the assessment of the readmission rates. The exploration of the distribution and dynamics of study variables relies on the model of transitions.
Overview and Guiding Propositions(s) Described in Theory
The quality of skilled nursing facilities (SNF) functioning is highly dependent on the transitional services that could be essential in preventing readmissions. The transitions suggest changes for all members of health care processes. In order to understand the nature of transitions and address the problematic issues in the transitional processes, the theory of transition is applied. The theory deals with the challenging experience of transitions, the success of which is shaped by appropriate responses to changes together with professional support and empowerment. Consequently, the theory contributes to generating a nursing plan of assistance on all the stages of transitions. Hence, the model takes into consideration the paradigms of role supplementation to deliver the clients’ roles, lived experience to discover the real nature of transitions, and the feminist post-colonialist framework to shape an effective allocation of resources (Meleis, 2015, p. 363). The propositions concern health changes, developmental and situational transitions, and organizational functioning that provide positive changes in the member’s roles, supportive behavior, and the passage of health status with the help of preventive and therapeutic options (Meleis, 2015, p. 364). The proposed interventions determine the significance of the theory’s applicability to the current study.
Application of Theory to the Study Project’s Focus
The transitions theory offers guidelines to support healthy processes and facilitate outcome responses. In the case of SNFs, the options for nursing include generating an assessment plan to find the relationships of possible and projected changes with resources and the mastery of roles. According to the theory, the primary function of an advanced nurse during an intervention is to develop or strengthen the roles of patients, caregivers, and staff to optimize collaborations (Meleis, 2015, p. 368). Further, a nurse practitioner should search for the evidence to detect the transition properties, milestones, and instruments to fill the gaps in the transition process. Finally, the theory identifies the ways in which to mobilize the staff, as well as technical and social resources that are essential for the quality care of SNFs. The theory becomes significant while strengthened by strict methodology
The care coordination gaps and transition processes are considered to be the primary triggers of the problem. These indicators are the first subjects of the SNFs’ exploration. The SNFs with the implemented quality improvement (QI) programs and without them will be detected to provide the performance comparison. Performance indicators that are accessible for the Medicare-covered institutions constitute other subjects for inclusion. Besides, the study focuses on the diabetes population, which includes older patients who are the most vulnerable to the readmissions process. Consequently, only the SNF settings where diabetes-related exacerbations with older patients are recorded will be included in the study.
According to the expected and limited sample and setting, the purposive sampling procedure will be involved. The data for inclusion and comparison will be analyzed in the Medicare’s Nursing Home Compare and Medicare Online Survey, Certification, and Reporting Files databases (Neuman et al., 2014). The detected SNFs with the best and worst performance characteristics refer to the primary units of the sample. Moreover, the SNFs in which the QI programs have been implemented at least one year before the study will serve as the setting for selecting the intervention group for distinguishing the comparative evidence.
The research is designed to find quantitative evidence to answer how quality improvements in SNFs influence the readmissions rate of older patients with diabetes post-acute conditions. Accordingly, the study is interested in the report of the pre-post intervention of QI tools in SNF organizations, which, however, cannot be controlled by nurse researchers due to the affiliation policy and limited financial and human resources. Moreover, the sample will not be randomly assigned since an insufficient number of SNFs utilize QI programs (Meehan et al., 2015). The validity of the research will be strengthened by the pretest comparison of the intervention and control of SNFs groups.
The quasi-experimental design of the interventional study predefines the non-randomized approach that may be accompanied by a systematic error. Since only a limited number of SNFs were included, the SNF structure and resources as extraneous variables may modify the SNF performance. The latter is considered to show the level of care coordination. Similarly, the individual patient characteristics, including the disease severity, duration, the set of comorbidities, and emotional status, will constitute the possible confounding variables (Neuman et al., 2014). To prevent and minimize the effect of extraneous issues, statistical control will be used. The units with no statistically significant effects detected in the process statistical assessment will be included in the interventional research.
Statistical control is an appropriate quantitative instrument to measure and improve internal and external validity while excluding the units vulnerable to the lack of accommodation and resources. In this particular case, the statistical procedure ANCOVA enables researches to determine the effects of SNFs’ resources on the performance and distinguish the existence of bias. Besides, the patients’ characteristics are to be tested to find out whether they can mediate the relationships between the QI program functioning in SNFs and readmission rate with the help of ANCOVA measurements (Houser, 2012, p. 404). Pretest and posttest comparison procedure of performances of the SNFs with QI options and without them will constitute another tool to strengthen the internal validity. The reliability of the QI instruments in improving the readmission rates will be supported by correlation analysis of the subjects’ stability over time. Statistically significant results of correlation indicate the reliability of the instruments involved.
Description of the Intervention
The research explores the effects of QI programs applied to SNFs with Medicare beneficiaries. Accordingly, the intervention concerns itself with facilitating timely and effective responses to acute and post-acute events using QI tools to improve the care coordination and transition processes. Events within the 30-day period after discharge are included. QI programs are the most efficient in educational interventions and technical support in the implementation of the Interventions to Reduce Acute Care Transfers resources that are significant in the long-term perspective (Ouslander et al., 2016). Hence, one year after an intervention is the time for conducting the post-test measurements. In the light of the problem, the position of a nurse case manager plays the determinant role in delivering the options to the team and creating an efficient professional relationship between the providers and consumers of quality changes. Additionally, the range of skills of a nurse practitioner contributes to collecting the appropriate set of patients and facility-related data.
Data Collection Procedures
The data collection procedure consists of the diabetes patients’ data bank and the SNFs description. Statistical reports of the American Diabetes Association and Centers for Disease Control and Prevention constitute the primary sources used to find geographical peculiarities and disparities in diabetes management in the population older than 65. The selection of the most severe comorbidities in the diabetes records of the aforementioned organizations is another step of the collection procedure necessary to provide the subjects of the diabetes-related readmission events in SNFs. Based on the gathered information, the second part of the procedure directed to collect the information on the functioning and performance of SNFs in the detected states and affiliations is possible.
Data Analysis Plans
The plan for data analysis of the demographic variables involves addressing the study population, demographic structure, and measurement instruments to detect the statistical features of a study sample. The population consists of the skilled nursing facilities’ older patients diagnosed with diabetes. Special attention is paid to these patients since they are observed due to the increasing frequency of acute exacerbations in SNFs (Neuman et al., 2014). Accordingly, diabetes patients with acute exacerbations in SNFs make the study population group. The demographic characteristics are categorized. Nominal measurements of frequencies are used for the gender, family status, and ethnic origin of study subjects.
Together with the demographic data, the patients’ physical parameters need to be analyzed to provide a research background. The mean, outliers, and skewness parameters constitute descriptive statistics for ratio measurements of the aforementioned study variables (Burns, Grove, Gray, & Burns, 2011, p. 191). These baseline characteristics are processed through multiple covariance statistical procedures to determine and fix the effect of demographic features on diabetes patients’ characteristics. Other baseline study variables for ratio measurements are the SNFs’ performance and the level of QI tools usage. The next step of the plan for data analysis of study variables refers to the pre- and post-test assessment of the relationship between the previously mentioned study variables and the readmission rate in control and intervention groups. In cases of the normal distribution, parametrical chi-square and t-tests are applied to distinguish the statistical significance of relations. In the other case, a non-parametrical test is used for inferential statistical analysis. A significant relationship between readmission rates and high levels of use of INTERACT tools in SNFs in the process of acute care is the evidence needed for the nurse case manager’s practice. The evidence is collected while committing to ethical standards.
Professional Code of Ethics considers the ethical conduct of a nurse researcher to be manifested in developing patient awareness of the research participants. The latter means that the study project aims at improving the quality of care with apparent benefits for the patients or public health in general. Moreover, the ethically guided nurse researcher recognizes the humanistic designation of nursing research that avoids bringing harm to the participants. By committing to these issues, the research project should include preparing the project application to the Institutional Review Board for ethical approval. The application requires agreement and assurance documents for the ethical and professional behavior of the principal investigator while working with human subjects and maintaining the confidentiality of personal data (Appendix A). To protect the human rights of all participants, informed consent is attached and has to be signed by all the participants before the intervention. The consent form contains a short research description and information about benefits and possible risks for the patients written out in lay language contributing to participant awareness and understanding (Appendix B).
Limitation of Proposed Study
The proposed study has several limitations. Participant recruitment was intentional after preliminary selection of SNFs the data about which is available from Medicare’s Nursing Home Compare. Accordingly, not all types of skilled nursing facilities are analyzed. Moreover, only participants covered by Medicare insurance are involved, limiting the generalizability and scope of the findings. Another limitation concerns the range of QI tools recommended by the QIOs that can be different for SNFs. As a result, the variables may become a potential confounder. Still, care coordination is found to be a significant factor when related to QI programs, but not the range of tools (Meehan et al., 2015). Despite the limitations, the study offers valuable implications for practice.
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Implications for Practice
The research provides the evidence necessary for reducing the rate of acute diabetes-related readmissions that are frequent among older people. In particular, the tools to improve the performance of SNFs in order to provide continuous and comprehensive transitional services are evaluated. The findings contribute to the validity of QI tools for improving care coordination in SNF, leading to timely and effective responses to acute episodes. Moreover, the study reveals the significance and values of organizational and technical advances in SNFs in response to quality health care offered to diabetes patients who experience complicated and costly readmissions. Finally, the results of the study imply that there is a need to perceive the SNF’s structures as complex and multilevel systems, the functioning of which depends on the character of relationships inside the affiliation as well as with outer chains of holistic diabetes care.
Altogether, skilled nursing facilities in the diversity of specialized units are found to be the determinant setting requiring innovations. The review of literature established a comprehensive view on the problem of the quality of diabetes care in skilled nursing facilities and distinguishing the evidence for change options. The broad scope of domains involved in the care coordination problem and significance of the issue on the national level contribute to the necessity of interventional studies. The research operates with measurable variables that enable scientists to evaluate the relationship between the SNF structure and performance and the diabetes patients’ health care outcomes. As a result, the research question manifests in exploring how QI interventions can decrease the post-acute readmissions of older diabetes patients. For these purposes, a quasi-experimental design with statistical pre-post procedures is suggested. The outcomes of the analysis imply the need for the implementation of QI tools in SNFs designated for advances in staffing, technical assistance, care of patients, and collaboration with related facilities.