Hypertension is extremely common in the geriatric population, with estimates as high as 75%. Among nursing home residents, the prevalence is even higher. Asymptomatic hypertension, an acute increase in blood pressure without end-organ involvement, is common in this patient population and results in many cases being transported and evaluated in an emergency department (ED). Many of these cases do not need ED evaluation. The Geriatric Emergency Department Accreditation and Improved Care of Nursing Home Residents and ED Task Force, with representatives from the American College of Emergency Physicians and The Post-Acute and Long-Term Care Medical Association, present best practice recommendations for the management of acute blood pressure elevation without symptoms of hypertensive emergency in older patients, especially those residing in nursing homes.

Objectives Microtransitions are brief, nonurgent transitions in care, such as room changes, recreational outings, and outpatient medical visits. Microtransitions occur at least as frequently as major transitions (eg, hospitalizations, discharges, etc.) and carry similar risks for adverse clinical outcomes if not properly managed. Post-acute and long-term care (PALTC) staff may be challenged to implement certain best practice recommendations for microtransitions. The objective of this study was to explore barriers and facilitators to successful execution of these recommendations in PALTC. Design Mixed-methods study. Setting and Participants A total of 39 panelists from the PALTmed modified Delphi study on best practices for microtransitions in care. Methods Through 3 surveys and a focus group, panelists described implementation of best practice recommendations for microtransitions within PALTC settings. Panelist feedback was thematically analyzed to identify barriers and facilitators of successful microtransitions at patient, staff, and systems levels. Panelists’ views on regulations related to microtransitions were explored using content analysis and a four-question quantitative survey. Results Patient-level themes included safety and resident rights. Panelists emphasized that many microtransition-related standards of care are inconsistently implemented. Staff-level themes included burden, importance of communication, and training. Systems-level themes included staffing, regulation, material resource, and liability concerns, as well as “already standard of care.” Most panelists agreed that microtransition needs vary by facility characteristics and patient-specific needs and would not benefit from federal (71.4%) or state regulations (74.3%). There was consensus (91.4%) that regularly updated best-practice recommendations are advisable. Conclusions and Implications The care coordination required for successful execution of a microtransition is complex. Using best practice recommendations during microtransitions for PALTC residents may mitigate adverse event risk. However, ethical, liability, and regulatory barriers may limit effective implementation. Regulations around microtransitions may do more harm than good when it comes to improving patient care. Future research on interventions to facilitate adoption of best practices are needed.

It is hard to judge if persons with dementia are experiencing unbearable suffering.• Asking patients to judge how much suffering future conditions would cause helps clarify their end-of-life wishes.• Attempts to treat suffering with palliative care must occur before ceasing assisted feeding and hydrating.Suffering must be severe and irreversible, meaning that attempts to reduce suffering by non-burdensome treatment failed.• Asking all concerned-the patient, family members, and providershonors the complexity of suffering and decision-making.• Considering loved ones' suffering as a significant contributor to patients' suffering is innovative.• "Bi-directional empathic suffering" (Terman's new term) is based on personal interactions and targets an important aspect of the complexity of suffering.We agree that providers should be sensitive to decision-makers' increased feelings of guilt due to focusing on bidirectional empathic suffering.Yet its appreciation could also reduce decision-makers' emotional burden by justifying suffering as severe enough to allow patients to die of their underlying disease.• It is unfortunate that US statutes usually neglect the burdens of nonprofessional caregivers.The protocol we recommend (detailed elsewhere 2 ) strives to reduce the complexity of making end-of-life decisions by sharing the process among (A) the patient's judgments formed during advance care planning (ACP), (B) designated proxies/agents and others who are members of the Patient Decision Committee that the patient established during ACP, and (C) the physician/provider.The committee's main function is

Caring for the Ages is the official newspaper of AMDA and provides long-term care professionals with timely and relevant news and commentary about clinical developments and about the impact of health care policy on long-term care medicine.

BACKGROUND:Nursing home residents are at high risk for infection, hospitalization, and colonization with multidrug-resistant organisms. METHODS:We performed a cluster-randomized trial of universal decolonization as compared with routine-care bathing in nursing homes. The trial included an 18-month baseline period and an 18-month intervention period. Decolonization entailed the use of chlorhexidine for all routine bathing and showering and administration of nasal povidone-iodine twice daily for the first 5 days after admission and then twice daily for 5 days every other week. The primary outcome was transfer to a hospital due to infection. The secondary outcome was transfer to a hospital for any reason. An intention-to-treat (as-assigned) difference-in-differences analysis was performed for each outcome with the use of generalized linear mixed models to compare the intervention period with the baseline period across trial groups. RESULTS:Data were obtained from 28 nursing homes with a total of 28,956 residents. Among the transfers to a hospital in the routine-care group, 62.2% (the mean across facilities) were due to infection during the baseline period and 62.6% were due to infection during the intervention period (risk ratio, 1.00; 95% confidence interval [CI], 0.96 to 1.04). The corresponding values in the decolonization group were 62.9% and 52.2% (risk ratio, 0.83; 95% CI, 0.79 to 0.88), for a difference in risk ratio, as compared with routine care, of 16.6% (95% CI, 11.0 to 21.8; P<0.001). Among the discharges from the nursing home in the routine-care group, transfer to a hospital for any reason accounted for 36.6% during the baseline period and for 39.2% during the intervention period (risk ratio, 1.08; 95% CI, 1.04 to 1.12). The corresponding values in the decolonization group were 35.5% and 32.4% (risk ratio, 0.92; 95% CI, 0.88 to 0.96), for a difference in risk ratio, as compared with routine care, of 14.6% (95% CI, 9.7 to 19.2). The number needed to treat was 9.7 to prevent one infection-related hospitalization and 8.9 to prevent one hospitalization for any reason. CONCLUSIONS:In nursing homes, universal decolonization with chlorhexidine and nasal iodophor led to a significantly lower risk of transfer to a hospital due to infection than routine care. (Funded by the Agency for Healthcare Research and Quality; Protect ClinicalTrials.gov number, NCT03118232.).

AMDA e The Society for Post-Acute and Long-Term Care Medicine is the only medical specialty society representing the community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants, and other practitioners in the post-acute and long-term care continuum.We advance our mission through timely professional development, evidence-based clinical guidance, and tireless advocacy on behalf of our members, patients, families, and staff.

Standardized observation of bed baths and showers for 100 residents in 8 nursing homes revealed inadequate cleansing of body sites (88%-100% failure) and >90% process failure involving lather, firm massage, changing dirty wipes or cloths, and following clean-to-dirty sequence. Insufficient water warmth affected 86% of bathing opportunities. Bathing training and adequate resources are needed.

Kristine P. Nguyen BS1, Raveena D. Singh MA1, Raheeb Saavedra AS1, Shruti K. Gohil MDMPH1, John T. Billimek PhD2, Steven P. Tam MD3, Karl E. Steinberg MD4, Lori Porter5 and Susan S. Huang MD, MPH1 1Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine, California, USA, 2Department of Family Medicine, University of California, Irvine School of Medicine, Irvine, California, USA, 3Division of Geriatrics and Gerontology, University of California, Irvine School of Medicine, Irvine, California, USA, 4Shiley Haynes Institute for Palliative Care, California State University, San Marcos, San Marcos, California, USA and 5National Association of Health Care Assistants. Carl Junction, Missouri, USA

Benjamin Franklin wrote in a letter to Jean Baptiste Le Roy in 1789, “Our new Constitution is now established, and has an appearance that promises permanency; but in this world nothing can be said to be certain, except death and taxes.” Before Franklin, in 1716 Christopher Bullock had written in his book The Cobbler of Preston, “’Tis impossible to be sure of any thing but Death and Taxes.” “Death and taxes” is a commonly used phrase to express two inevitable things in life, but I believe there are other inevitable experiences, and one of them is pain. Since this issue of Caring has a special focus on pain and it’s a topic of perennial interest to our readers who try to ameliorate pain in our patients, we’ll consider the subject of physical pain. Also, the clinical practice guideline and pocket guide of AMDA – The Society for Post-Acute and Long-Term Care Medicine have been recently updated (available at https://bit.ly/painCPG), and they are great resources for PALTC clinicians. Pain can be physical, emotional, psychosocial, spiritual, existential, or dwell in other categories, and it may combine multiple domains — resulting in what Dame Cicely Saunders called “total pain.” Some of us may privately quip, “These fibromyalgia patients are a total pain,” but the fact remains that each patient’s subjective pain experience is something that we as clinicians can commiserate with and attempt to ameliorate, but we are not living the experience ourselves. We must have the grace to acknowledge that we don’t fully understand all the factors — including past trauma — that play into an individual patient’s lived experience and perception of pain. While there are physiological correlates of pain, physical pain is largely a subjective phenomenon. Pain scales, while still widely used and certainly of some clinical utility, are not reliable in all patients who can self-report a pain score. Some patients may rate an acute hip fracture a “2,” while others who are lying comfortably in bed dozing off, with a respiratory rate of 10, will say their pain is “11 out of 10.” Of course, part of our sacred responsibility to our patients is to alleviate suffering, and we generally take what our patients tell us about their pain to be accurate. Some patients are very averse to pain and prefer aggressive measures to minimize or avoid it (including opioids and other potentially sedating, habituating, or otherwise harmful medications). Other patients want to avoid being overly sedated and don’t mind some level of pain if they can remain alert, awake, and cognitively intact. Still others (just to be clear, not including me) believe they derive a redemptive value from suffering and do not want any medical intervention. As prescribers, we need to be respectful of our patients’ preferences for pain treatments, practice person-centered care, and use a shared decision-making process. Especially for patients nearing the end of life, we should not be overly stingy with opioids. With chronic pain, the peer-reviewed evidence for the efficacy of opioids has been disappointing, but I suspect all of us prescribers have had patients in whom opioids have been a godsend, the difference between constant misery and a reasonably tolerable existence. For most nursing home residents, concerns about self-administration of escalating doses and possible overdoses do not loom as large as in the community because we have nurses both administering the medications and monitoring for adverse events. Specific medications may be particularly useful in neuropathic pain, including serotonin-norepinephrine reuptake inhibitors (SNRIs) like duloxetine, anticonvulsants like gabapentinoids, and — if tolerated — tricyclic antidepressants or methadone. Corticosteroids can be exceptionally useful for a variety of pain etiologies but carry significant risks. Patients with severe pain and a history of substance use disorders can present special challenges, and it may be necessary to obtain consultation from specialists in addiction, pain, or palliative medicine. Medications that are less commonly prescribed for typical pain such as buprenorphine, methadone, and even (puzzlingly) low-dose naltrexone have proven especially useful in some of my more difficult clinical scenarios. We are quick to pull out the (virtual) prescription pad and medicate our patients for pain because that’s what we were trained to do. But we may sometimes forget to consider other approaches. Combining modalities can yield better results than a single strategy. A good body of evidence exists for nonpharmacological interventions in many kinds of physical (somatic and neuropathic) pain, and these should be part of every treatment plan. Many of these techniques are available to residents of PALTC settings, including some manual techniques (via physical therapy), cognitive behavioral therapy, and mindfulness techniques. Even simple things like demonstrating a deep breathing and visualization exercise at the bedside may empower patients with an easy tool to distract them from pain, especially for people who spend as much time in bed as many of our PALTC residents. And whatever the scientific evidence may be, there is certainly little harm in utilizing prayer if that resonates with our patients. Active listening and acknowledging the emotional toll of pain on our patients can also strengthen the therapeutic alliance. Being able to articulate that we are sorry the patient is suffering; that we will continue to walk the path with them and seek out solutions together; that we wish we could completely relieve all their pain (but recognize this is probably an unrealistic goal); that we realize it must be difficult for them to bear the pain at times; and that we acknowledge that they are trying — all of these types of statements can serve to relieve at least some of our patients’ stress and anxiety, if not the pain itself. Pain is indeed inevitable, and it’s especially common in our care setting, but it does not have to become all-encompassing or make our patients’ lives miserable. Even though patients with severe, chronic, or seemingly disproportionate pain may be a challenge to us as clinicians, it’s important for us to treat each case as a unique and precious soul — and to use shared decision-making and all the tricks in our bag to practice truly compassionate, person-centered care when trying to ameliorate and palliate their pain. And we should always be willing to ask for help when we feel we are falling short. Dr. Steinberg was the 2021–2022 president of AMDA – The Society for Post-Acute and Long-Term Care Medicine and is editor emeritus of Caring for the Ages. The author’s views are his own and do not represent those of the Society nor any other entity.

Background Assessing chronic obstructive pulmonary disease (COPD) severity is challenging in nursing home (NH) residents due to incomplete symptom assessments and exacerbation history. Objective The objective of this study was to predict COPD severity in NH residents using the Minimum Data Set (MDS), a clinical assessment of functional capabilities and health needs. Methods A cohort analysis of prospectively collected longitudinal data was conducted. Residents from geographically varied Medicare-certified NHs with age ≥60 years, COPD diagnosis, and ≥6 months NH residence at enrollment were included. Residents with severe cognitive impairment were excluded. Demographic characteristics, medical history, and MDS variables were extracted from medical records. The care provider–completed COPD Assessment Test (CAT) and COPD exacerbation history were used to categorize residents by Global Initiative for Chronic Lung Disease (GOLD) A to D groups. Multivariate multinomial logit models mapped the MDS to GOLD A to D groups with stepwise selection of variables. Results Nursing home residents (N = 175) were 64% women and had a mean age of 77.9 years. Among residents, GOLD B was most common (A = 13.1%; B = 44.0%; C = 5.7%; D = 37.1%). Any long-acting bronchodilator (LABD) use and any dyspnea were significant predictors of GOLD A to D groups. The predicted MDS-GOLD group (A = 6.9%; B = 52.6%; C = 4.6%; D = 36.0%) showed good model fit (correctly predicted = 60.6%). Nursing home residents may underuse group-recommended LABD treatment (no LABD: B = 53.2%; C = 80.0%; D = 40.0%). Conclusion and Relevance The MDS, completed routinely for US NH residents, could potentially be used to estimate COPD severity. Predicted COPD severity with additional validation could provide a map to evidence-based treatment guidelines and may help to individualize treatment pathways for NH residents.

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Background: The terminal illness of late-stage (advanced) Alzheimer's and related dementias is progressively cruel, burdensome, and can last years if caregivers assist oral feeding and hydrating. Options to avoid prolonged dying are limited since advanced dementia patients cannot qualify for Medical Aid in Dying. Physicians and judges can insist on clear and convincing evidence that the patient wants to die-which many advance directives cannot provide. Proxies/agents' substituted judgment may not be concordant with patients' requests. While advance directives can be patients' last resort to attain a peaceful and timely dying consistent with their lifelong values, success depends on their being effective and acceptable. A single flaw can provide opponents justification to refuse the directive's requests to cease assisted feeding. Aim: This article considers 24 common advance directive flaws in four categories. Process flaws focus on how patients express their end-of-life wishes. Content flaws reflect drafters' selection of conditions and interventions, and how they are described. Inherent flaws can make advance directives unacceptable to authorities concerned about premature dying. Strategies are needed to compel physicians to write needed orders and to prevent third parties from sabotaging these orders after they are implemented. The article includes excerpts from "dementia-specific" directives or supplements that exemplify each flaw-mostly from the US and Europe. No directive critiqued here included an effective strategy to resolve this long-debated bioethical conflict: the past directive requests "Cease assisted feeding" but the incapacitated patient apparently expresses the desire to "Continue assisted feeding." Some opponents to the controversial request, cease assisted feeding, use this conflict as a conceptual wedge to practice hard paternalism. This article proposes a protocol to prevent this conflict from emerging. These strategies may prevent authorities from requiring patients to fulfill authorities' additional clinical criteria as a prerequisite to honor the requests in patients directives. Conclusion: This critique of flaws may serve as a guide to drafting and to selecting effective and acceptable advance directives for dementia. It also poses several bioethical and clinical questions to those in authority: Does your paternalistic refusal to honor patients' wishes respect their self-determination? Protect vulnerable patients from harm? Force patients to endure prolonged suffering? Violate the principles of bioethics? Violate the very foundation of patient-centered care?

Patients living with advanced dementia (PLADs) face several challenges to attain the goal of avoiding prolonged dying with severe suffering. One is how to determine when their current suffering becomes severe enough to cease all life-sustaining treatments, including the controversial request, to withdraw assistance with oral feeding and hydrating. This article broadens the concept of suffering by including suffering that cannot be observed contemporaneously and that loved ones experience. It presents four paradigm shifts. One asks patients completing advance care planning to judge possible future conditions: Which conditions would cause severe suffering? To decide when to allow patients to die, treating providers need only assess if patients reached previously judged conditions.Will this protocol: Prevent prolonged dying with suffering for PLADs? Deter early-stage dementia patients from committing preemptive suicide? Sway decision-making surrogates from withholding life-sustaining treatments from middle-stage dementia patients? Provoke providers’ opposition to relinquish their traditional, unilateral authority to determine patients’ suffering?

On October 6, 2021, Governor Gavin Newsom signed California’s AB 749 into law after it sailed through the state’s Assembly and Senate with minimal opposition. The bill requires almost all nursing facility medical directors to be certified through the American Board of Post-Acute and Long-Term Care Medicine (APBLM) by 2027. The California Association of Long Term Care Medicine (CALTCM), which is the state affiliate of AMDA – The Society for Post-Acute and Long-Term Care Medicine, was the sponsoring organization for this bill. In 1974, in response to identified quality of care problems, the federal government began to require that all skilled nursing facilities have a physician serve as medical director and be responsible for the medical care provided. One year later, a group of concerned medical directors formed the California Medical Directors Association (now called CALTCM) and immediately began to promote education for physicians practicing in long-term care. Since this organization’s inception it has emphasized the concept of effective, informed, engaged medical direction in its educational offerings. Medical director certification has been around since 1991, when the Society formed the American Medical Directors Certification Program (AMDCP), now called the ABPLM. Many CALTCM leaders have pursued the certification and recertification. Yet there are only a little over 100 active certified medical directors (CMD) in California, which has over 1,200 skilled nursing facilities. In 2001, the Maryland Office of Health Care Quality implemented detailed requirements for nursing home medical directors that were supposed to encourage Maryland medical directors to become certified. Unfortunately, these requirements have not been fully enforced or monitored, so there has not been an opportunity to assess the effectiveness of mandatory certification. In 2009, Frederick Rowland, MD, PhD, CMD, published a seminal study in JAMDA demonstrating that facilities with certified medical directors had at least a 15% improvement in quality measures, and the study methodology actually lent itself to undervaluing the impact of certified medical directors (J Am Med Dir Assoc 2009;10:431-435). To date, this has been the only study of its kind. A number of other published papers and an Office of Inspector General report have discussed the value and importance of competent and engaged medical directors — which seems intuitively obvious, but it would be desirable to devise and implement additional research providing evidence. The Society and ABPLM will be working on this actively as AB 749 rolls out. The pandemic had a devastating impact on nursing homes across the country, and when the governor of California proposed that nursing homes accept COVID-19 patients from hospitals, similar to the mandate from Governor Andrew Cuomo of New York, CALTCM’s Board immediately took action. The Board passed several resolutions in a very short period of time, one of which strongly stated that nursing homes should not be required to accept COVID-19 patients. Another resolution advocated that every nursing home in California be required to have a full-time infection preventionist. CALTCM members soon found themselves quoted in news articles and interviewed on television regarding the pandemic. This definitely had the effect of raising the profiles of CALTCM and the Society. During the summer of 2020, a political affairs consultant contacted CALTCM with the idea of working with the organization to influence regulatory and legislative initiatives in California. The CALTCM Board engaged some members of its dormant Public Policy Committee and began developing ideas for legislation. This ultimately led to a proposed “Nursing Home Safety Act” with five proposals:•Required 24/7 on-site registered nurse (RN) coverage. It is essential that an RN be available at all times to adequately assess the residents with multiple medical conditions and a high degree of frailty. Although licensed vocational nurses can monitor patients’ health, they lack the educational preparation and regulatory authority to perform comprehensive nursing assessments.•A minimum of 0.75 RN hours per resident day. COVID-19 has demonstrated that sufficient nursing staff must be available to handle clinical situations as they arise.•Medical director certification. As the clinical leader of a nursing home, the medical director needs the skills and tools to be an integral part of the leadership team. Certified medical directors receive additional education and training related to the complexities of nursing home operations and regulations as well as the principles of geriatric medicine and bioethics that are essential to providing appropriate care to an aging population.•Full related-party transparency. Corporations who operate nursing facilities can siphon off funds by using third-party vendors that they themselves own; these related-party vendor charges may be above fair market value or their services may be neither appropriate nor necessary (Health Affairs Blog, Feb. 11, 2021; https://bit.ly/3rmMLhd). The scarce financial resources of nursing homes must be effectively and appropriately utilized, so full transparency for these related-party transactions is needed to effectively determine the true amount of resources necessary to ensure the adequate funding of operations.•Administrative costs ceiling. The bill would place a ceiling on the combined administrative costs and profits of each nursing home and its related parties, including parent companies, at 15% of net revenues per year. Nursing homes cannot be operated and financed like an apartment complex; they provide for the health care needs of a complex and vulnerable population, so there must be a balance among profit, quality of care, and safety. In the fall of 2020, discussions with the legislative staff for Assemblymember Adrin Nazarian, chair of the Committee on Aging and Long-Term Care, led to the development of AB 749. There was surprise and dismay among many legislators when they learned that despite the acuity level of skilled nursing facility residents, there was no requirement beyond a medical license to be a medical director — and that beyond the medical director, nursing facilities do not have a mandatory mechanism to evaluate the performance of other attending practitioners. This bill, by virtue of being part of a package of nursing home quality improvement bills, quickly garnered the support of AARP, the Service Employees International Union (SEIU), and California Advocates for Nursing Home Reform. CALTCM developed a trusting and collaborative relationship with Mr. Nazarian’s staff and let them shepherd the bill through the legislative process. As part of the process, some minor amendments were made, including waiving the requirement for hospital-based nursing facilities and — happily — incorporating a request from the California Department of Public Health to add language authorizing them to collect data on all nursing home medical directors, including their certification status and/or the progress of their path to certification. AB 749 sunsets in 10 years, so it will be important to demonstrate the tangible benefits of mandatory certification. The Society is working on methods to collect data that will provide ongoing support for this requirement, and we hope that in the meantime other states can use AB 749 as a springboard to mobilize similar legislative efforts. The Society’s state-based policy and advocacy workgroup, led by Carl (Christian) Bergman, MD, CMD, is working with CALTCM and the Society’s Board and Public Policy Committee to create templates and mentoring. It will be most important to find a champion in state legislative bodies to promote the cause of requiring minimal standards for nursing home medical direction. Dr. Steinberg is president of AMDA – The Society for Post-Acute and Long-Term Care Medicine and editor emeritus of Caring for the Ages. Dr. Wasserman is a geriatrician and chair of CALTCM’s Public Policy Committee. He is medical director at Eisenberg Village, Los Angeles Jewish Home. He was formerly the CEO overseeing the largest nursing home chain in California and was Executive, Care Continuum for HSAG, the QIN-QIO in California. He can be reached at [email protected] , or can be found on Twitter (@wassdoc).

Abstract Background Nursing home (NH) residents are at high infection and hospital readmission risk. Colonization with multidrug-resistant organisms (MDROs) is common. In ICU and post-hospital discharge settings, decolonization has reduced infection rates. However, the effectiveness of this strategy in NHs is unclear. Methods We performed a cluster randomized trial of 1:1 universal decolonization (decol) vs standard of care bathing (control) in 28 California NHs. After an 18 month baseline evaluation of hospitalization rates due to infection and MDRO prevalence, NHs were randomized to decol or control. Decol consisted of 1) chlorhexidine bathing; 2) nasal povidone iodine bid on admission x 5d and then M-F biweekly x 18 mo. Primary outcome was the probability that a transfer to a hospital was due to infection. Secondary outcome was the probability that a NH discharge was to a hospital. Results Four of 28 NHs dropped from the trial (3 decol, 1 control). Mean facility baseline of hospital transfers due to infection was 58% and 57% in the control and decol groups. In the intervention period, proportions were 57% and 48% in the control and decol groups. When accounting for clustering within NHs, hospital transfers due to infection had an OR of 0.91 (95% CI: 0.82-1.02) in the control group and an OR of 0.73 (95% CI: 0.56-0.95) in the decol group when comparing intervention to baseline period. For the primary outcome, decol had a 18% greater impact v. control (P=0.005, Fig. A). Baseline proportion of NH discharges due to hospitalization was 37% and 39% in the control and decol groups. In the intervention period, proportions were 36% and 33%. When accounting for clustering within NHs, the proportion of discharges due to hospitalization had an OR of 1.14 (95% CI: 1.06-1.22) in the control group and 0.91 (CI: 0.77-1.07) in the decol group when comparing the intervention period to the baseline period. For the secondary outcome, decol had a 23% greater impact v. control (P< 0.0001, Fig. B). In this figure, each nursing home is represented by a circle. The size of the circle represents the amount of contributed patient days to the trial. The groups represent “as randomized” categories. Panel A) compares the probability that a transfer to a hospital was due to infection; panel B) compares the probability that a nursing home discharge was to a hospital. The y-axis represents the odds ratio of these probabilities comparing the baseline to the intervention period. The p values represent the significance of the difference between groups (the trial effect). Conclusion Universal NH decolonization with chlorhexidine and nasal iodophor significantly reduced the proportion of transfers to hospitals due to infection and discharges due to hospitalization. Our findings suggest that NH decolonization reduces serious infections and can decrease morbidity in this vulnerable population. Disclosures Loren G. Miller, MD, MPH, Medline (Grant/Research Support, Other Financial or Material Support, Contributed product) Stryker (Other Financial or Material Support, Contributed product) Xttrium (Other Financial or Material Support, Contributed product) James A. McKinnell, MD, Medline (Grant/Research Support) Raveena Singh, MA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Gabrielle Gussin, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Ken Kleinman, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Raheeb Saavedra, AS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Lauren Heim, MPH, Medline (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Stryker (Sage) (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product) Xttrium (Other Financial or Material Support, Conducted clinical trials and studies in which participating hospitals and nursing homes received contributed antiseptic product) Shruti K. Gohil, MD, MPH, Medline (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Molnycke (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Stryker (Sage) (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Susan S. Huang, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)

In palliative and end-of-life care, people with serious illness and their families experience a number of transitions—in functional status, physical location, cognitive abilities, and goals of care. This chapter focuses on care transitions in location and treatment preferences and discusses some pitfalls of transitions, along with telemedicine as a palliative care tool to reduce the burden of transitions. Medication reconciliation between sites of care and interprofessional coordination of care among various clinicians and teams are important elements of safe, effective care transitions. Respecting a patient’s autonomy while optimizing safety can be a challenge, and care decisions in times of transition should be person centered, holistic, and compassionate.