Anticoagulation risks in older adult, long-term care patients are known to be high, especially in those with frequent transitions between care environments. Introduction of collaborative practice agreements (CPA) in specific settings is encouraged in the United States and has provided an additional option for the care of medically challenging patients. The aim of this study was to investigate the time in therapeutic range (TTR) in a Medicare Part A sponsored long-term care environment managed by pharmacists through a collaborative practice agreement in South-Central Appalachia. A retrospective review of all warfarin patient admissions from a large long-term care pharmacy’s anticoagulant clinic was conducted for residents over an 18-month period. For all patients (n = 104), the overall TTR was 46.7% (INR 43% in range). Average management duration was 19.5 days per patient. Further studies are required to optimize CPA and transition strategies for complex, advanced age warfarin patients.

The Centers for Medicare and Medicaid are requiring long-term care facilities (LTCFs) to implement antibiotic stewardship programs (ASPs) to alleviate overuse of antibiotics in the nursing home population. Current research shows that the benefits of ASPs include improved patient outcomes, reduced adverse events related to Clostridium difficile (C-diff) infection, improvement in rates of antibiotic susceptibilities, and optimized resource utilization. This project addressed the problem of antibiotic overuse and misuse in the geriatric population and whether the implementation of an ASP reduced the overuse of antibiotics, C-diff infection, and resistance rates in the LTCF. Application of the Johns Hopkins nursing model and Centers for Disease Control framework informed this project. An ASP was implemented by the organization. This project evaluated the program preASP and postASP over a 10-month period. A descriptive analysis was used to compare the number of new antibiotic starts, C-diff cases, and resistant cases before and after ASP implementation. The total number of cases of resistance declined from 12 to 10 cases after the ASP was implemented, which was a 16.67% decline. The number of monthly new antibiotic orders for the time period evaluated declined from 120 to 110 respectively, which was an 8.3% change. There was no change in the number of C-diff infections. The results demonstrated that implementing the ASP led to a decline in antibiotic misuse, overuse, and resistance cases. This project supports social change by expanding the healthcare team's knowledge regarding the project problem and informing future interventions to be implemented to help reduce antibiotic overuse and misuse in the geriatric population.

Clinical evidence-based practice guidelines providing recommendations for health care decision making have become vital components of long-term health care practice in the United States. Frequently changing guidelines have complicated nurse practitioners' (NPs) efforts to implement evidence-based practice into the daily care that they provide to patients. The purpose of this project was to develop an evidence-based practice guideline for doctoral-prepared NPs working in long-term care facilities. This project is important because practitioners use practice guidelines to provide patients with the most appropriate, evidence-based care. Kolcaba's comfort theory was used to guide this project. Kolcaba's theory holds that comfort exists in 3 forms: relief, ease, and transcendence. Comfort theory, with its emphasis on physical, psychospiritual, sociocultural, and environmental aspects of comfort, will lead to a proactive, diverse, and multifaceted approach to providing patient care. A complete practice guideline was developed for doctoral-prepared NPs. For the review of the scholarly evidence, an electronic search that yielded 34 articles was completed. Twenty-six of these articles were excluded because the articles were more than 20 years old and/or focused on a specialty. Findings from the 8 articles were used to develop the practice guideline, which was reviewed by an advisory committee of 7 experts. The AGREE tool was used by the advisory committee to provide feedback on the quality of the practice guideline. Implementation of the practice guideline will take place in a facility in Indiana that currently uses 3 NPs. A doctoral-prepared NP will evaluate the practice guideline annually for patient trends including hospital readmission and infection rates.

When family members no longer have the capacity to meet Alzheimer's Disease (AD) caregiving demands at home, a move to a nursing home or other formal care facility becomes the only solution. Recognizing this as a time of transition, three research questions were identified: (1) What do family caregivers to AD individuals experience as they shift their caregiving from home to formal care settings? (2) How does caregiving in formal care differ from caregiving at home? and (3) How do family caregivers perceive the relationships that develop between families and formal care staff? Specific attention was paid to the experiences of spouses and adult children. Using a qualitative approach, two specific bodies of data were investigated. First, transcripts of a series of 30 focus groups with 179 caregivers, and second, ten follow-up interviews were analyzed. Both spouses and adult children overwhelmingly identified physical exhaustion and often emotional exhaustion as the pervasive common experience. After reaching this state, caregivers identified the pivotal nature of events in contributing to placement. These kinds of events turn out to be more like turning points than crises. Caregivers in this study identified five themes that were influential in their decision-making process. In order of their importance to the caregivers, they were: events, the health care system, caregiver-care receiver relationship, support, and options and availability. A male spouse caregiver was likely to cite a turning point event centered on an incontinence problem, while for a female spouse caregiver, it was an AD safety issue. The health care system was usually a negative influence and served to delay the placement decision. Immediately, after placement, family caregivers noted shifts in control, involvement and personal reorganization. Family caregivers frequently noted the development of a caregiving relationship with staff. The individuals whom the family caregivers mentioned most often were the aides. Their bottom line was that staff deliver quality care, which they equated with caring about the resident rather than only taking care of them. The findings from this study have implications for theory development, family caregivers, formal care staff, and health care policy.

Dying is a normal life process. Palliative care is the means in which health care professionals care for individuals with either life limiting or terminal illness at or near the end of life. It is important to deliver palliative care across all health care contexts - from acute care to residential care. Nurses within the specialty of palliative care or who have had palliative care education consider all aspects of caring for individuals - physical, psychological, social, and spiritual. Quality of life (QoL) is important at all stages of life. Older persons with life limiting illness residing in long term care homes may have different factors that influence their QoL than younger persons in good health. The purpose of this study was to describe factors affecting quality of life for older persons with life limiting illness who reside in long term care (LTC) homes. It was also of interest to discover what nursing strategies are used to promote quality of life for this population. A literature review of sixteen articles was carried out. Articles which were relevant to the literature review’s aim were retrieved from CINAHL and PubMed databases. Twelve articles were retrieved from the databases and four articles were found using a manual search. A systematic process of reviewing each article, reading and re-reading them to analyze the method and results was undertaken. Deductive reasoning was used to develop themes with inspiration from the World Health Organization’s domains of quality of life. Results were categorized into categories of sociodemographic characteristics, psychological/spiritual, physical health/independence, environment, and nursing strategies. It was found that being female and married positively affected one’s quality of life. Visits from family and friends positively affected QoL. Of interest was that having a higher education negatively affected one’s quality of life. Having a lower cognitive function and more comorbidities negatively affected one’s quality of life. Living in a smaller long term care home and also long term care homes with more leisure activities positively affected one’s quality of life. Nursing strategies to positively affect quality of life in long term care homes included education of staff in palliative care by a palliative care consult team, and assessment and treatment of older persons’ pain. In conclusion, QoL must be emphasized in LTC homes since the world’s population is aging and more complex symptoms within an increase in co-morbidities require expert nursing. QoL is affected by social factors such as visits from family and friends. It is affected by nurses’ attention to pain management and their caring nature in supporting residents’ dignity. QoL is also affected by demographic characteristics which staff and managers must be aware of in order to support the resident in optimizing QoL in a LTC home. Nurses, nurse specialists and managers at LTC homes need to prioritize their work in order to positively affect QoL for older persons with life limiting illness.

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An evidence-based clinical practice guideline was developed to prevent and manage constipation in long-term care (LTC) residents, a vulnerable population not specifically addressed in previous guidelines. A literature review was completed, and evidence was evaluated and included in initial draft recommendations. The guideline was reviewed for content validity using a Delphi committee of clinical experts in gastroenterology, geriatrics, and pharmacy. The updated guideline was presented to an interdisciplinary team that reviewed its clinical applicability. Overall, interdisciplinary team members agreed or strongly agreed the guideline was clinically applicable (n=30). Finally, the guideline was evaluated by a group of doctorally-prepared practicing nurse practitioners using the Appraisal of Guidelines for Research and Evaluation II instrument. Appraiser scores were 85% or higher in every domain, indicating the guideline was perceived as high in quality. Development of this guideline signifies an initial step in the management and prevention of constipation in LTC residents.

Research acknowledges that older adults residing in long-term care facilities are at risk for social isolation, depression, and functional decline (Mezuk et al., 2014; Ouyang et al., 2015). The health risks associated with long-term care facilities may lead to poor health outcomes and poor quality of life. However, current evidence-based literature demonstrates ways in which to counteract the health risks associated with long-term care facilities through a holistic approach addressing the social, emotional, and physical health of an individual as they relate to quality of life. The aim of this doctoral project is to create an evidence-based and theory-driven program that supports older adults in long-term care facilities. The project explores the various factors impacting quality of life and provides recommendations and a potential solution to improving overall quality of life of older adults in long-term care facilities. E.D.U.C.A.T.E is a 7-step web-based resource for occupational therapy practitioners that utilizes a health and wellness approach and empowerment principles to improve quality of life of older adults residing in long-term care facilities. The objectives of E.D.U.C.A.T.E. are to foster occupational therapy practitioners employing a health and wellness approach to practice, increase older adults’ participation in meaningful occupations and social engagements, and increase older adults’ feelings of self-efficacy through an empowerment approach. By following the 7-step resource, occupational therapy practitioners may promote overall quality of life of older adults by addressing the social, emotional, and physical components impacting health outcomes. In order for this program to be implemented, additional information is included related to program evaluation, funding plans, and dissemination plans.

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