Ensuring Quality Care Through Evidence-Based Practices

As the number and diversity of older adults in the United States increase, so does the demand on the healthcare service industry to provide quality long-term care (LTC) for this population. LTC providers are continually searching for ways in which the care provided to their residents can be improved. The implementation of evidence-based strategies, such as those presented in this issue of Annals of Long-Term Care: Clinical Care and Aging^®, can lead to better outcomes for older adults living in LTC settings.

The inclusion of nurse practitioners (NPs) on the care team has been associated with fewer hospitalizations and emergency department transfers; improved health status, behavior, and satisfaction with care; and increased quality of care among LTC residents. Karen Devereaux Melillo, PhD, et al. evaluated whether the primary care practice model influences the process of care for LTC nursing facility residents. The results of this study validate the key role of NPs in the care of older adults.

The overprescribing of medications to older adults living in LTC settings is an important issue, as it can lead to adverse health outcomes and increased costs. Often, alternative approaches to pharmacotherapy can be used that can provide superior outcomes. One example of this is the treatment of insomnia and other sleep problems, which are common among older adults, including those living in LTC settings. Hypnotic or soporific medications are widely used in LTC patients with impaired sleep, but the literature shows that these medications only provide a modest benefit in terms of improving sleep quality of older adults. As a result, a number of recent clinical guidelines and statements have expressly recommended against their use in this population. As an alternative, a variety of nonpharmacological approaches have shown efficacy in older adults, including cognitive-behavioral therapy for insomnia; interventions targeting circadian rhythms, such as timed exposure to bright light; and complementary and alternative interventions, such as yoga and tai chi. Juan C. Rodriguez Tapia, MD, and colleagues discuss these non-pharmacological interventions and provide recommendations for how these approaches can be translated for use in LTC settings.

Another important issue for the provision of quality care is the capacity of staff to tend to residents’ psychosocial needs. Because the care staff is often preoccupied with daily tasks and with attending to current residents, it is crucial to seek the support of another partner in the continuum of care who is able to provide an intermediary role in the form of attending to the social needs and interpersonal engagement of new residents. This is particularly important during the transition of older adults to institutionalized care settings. Andrew Perrella, MD, reviews the challenges related to transitions to LTC and discusses how volunteers can aid these transitions to fill the gap in the continuity of care. Previous studies have shown that volunteers are an integral part of the long-term care team and are uniquely positioned to tend to the needs of transitioning older adults.

Finally, the medical management of older adults with multiple chronic conditions is a difficult and complex issue. One example is how best to provide quality care to smokers living in LTC settings. The medical evidence shows that smokers who undergo certain medical procedures experience poorer outcomes, such as respiratory and cardiac complications, compared with non-smokers. Therefore, some physicians feel strongly that it is their ethical duty to refuse to provide certain medical care to patients who are smokers. They may also consider it a waste of health care system resources to treat conditions with interventions that may not be as effective in smokers as in non-smokers. Ultimately, the potential denial of needed treatments to elderly smokers may compromise the quality of life for these individuals. At the same time, one could make a similar argument about any patient with chronic illnesses influenced by lifestyle choices such as diet and exercise. Helen Senderovich, MD, MCFPC, and Michael Gordon, MD, MSc, FRCPC, explore this ethical conundrum facing physicians and discuss whether there is any ethical rationale upon which they can refuse to provide medical care to smokers unless the patient is willing to forgo their tobacco use.

The articles in this issue explore how the implementation of evidence-based strategies can enable LTC facilities to ensure they are using the best practices for the care of residents.