Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

Reducing Hospitalizations From Long-Term Care Settings

Authors: Konetzka RT, Spector W, Limcangco MR

Journal: Medical Care Research and Review (2008); 65(1):40–66

DOI: 10.1177/1077558707307569

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✅ PICO Analysis

Type of Study:

Narrative systematic review of 55 empirical studies (RCTs and observational) evaluating interventions to reduce hospitalisations from long-term care (LTC) settings

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P – Population

• Setting:Older adults (≥65 years) receiving long-term care services in:
  • Nursing homes
  • Assisted living facilities
  • Home health and community-based care settings
• Characteristics:
  • Frail older adults with complex comorbidities and functional impairments
  • Participants often at risk of hospitalisation due to avoidable or discretionary conditions such as infections, CHF, COPD, pressure ulcers, or falls

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I – Intervention

• Interventions reviewed were grouped into six categories:
  1. Increased Staffing:
     • Use of nurse practitioners, physician assistants, or RNs to provide more skilled on-site care
  2. Improved Care Transitions:
     • From hospital to home or nursing facility
     • Includes discharge planning, home follow-up, and telemonitoring
  3. Substitution of Home Health for Hospital Days:
     • “Hospital-at-home” models, early discharge with intensive home support
  4. Prevention of High-Risk Clinical Problems:
     • Use of pharmaceuticals, pressure ulcer prevention, respiratory care, wound care
  5. System-Level Quality Improvement:
     • Use of standardised assessment instruments (e.g., MDS, OASIS)
     • Hospice integration in nursing homes
  6. Policy/Payment Reform:
     • Alignment of financial incentives (e.g. risk-based Medicare contracting, Medicaid rate increases)

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C – Comparison

• Comparisons varied by study, but included:
  • Standard/usual care vs. intervention group
  • Pre/post intervention data within the same facility
  • Control groups receiving no intervention or alternative intervention
• Both randomised controlled trials and strong quasi-experimental designs were included, with sample sizes >20 and risk adjustment strategies

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O – Outcomes

Person-Centred Outcomes:

• Reduced exposure to hospital-associated complications (e.g. delirium, infections)
• Better alignment of treatment with resident preferences, especially with palliative and hospice care models

Process Outcomes:

• Reduced hospital transfer rates (emergency and planned)
• Improved continuity of care during transitions
• Increased documentation and care planning through standardised tools (e.g., RAI, MDS-HC, OASIS)

System-Level Outcomes:

• Hospitalisation metrics:
  • Reduction in admissions and readmissions (22%–80% in some studies)
  • Shorter hospital length of stay
  • Fewer hospital days and ICU use near end of life
• Cost-effectiveness:
  • Savings of up to $1,000 per patient (e.g. hospital-to-home transitions)
  • Evercare model showed 48% reduction in hospitalisations and significant Medicare savings

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Summary of Promising Interventions:

The five strategies with the strongest evidence base for reducing hospitalisations from LTC settings were:

1. Use of nurse practitioners and physician assistants for on-site primary care
2. Increasing registered nurse staffing ratios in nursing homes
3. Improving the hospital-to-home transition, especially for CHF and COPD patients
4. Substituting home health care for hospital days through “hospital-at-home” models
5. Aligning financial incentives via Medicare risk contracting or increased Medicaid rates 

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