Examining the Use of Text Messages Among Multidisciplinary Care Teams to Reduce Avoidable Hospitalization of Nursing Home Residents with Dementia: Protocol for a Secondary Analysis

Background Reducing avoidable nursing home (NH)–to-hospital transfers of residents with Alzheimer disease or a related dementia (ADRD) has become a national priority due to the physical and emotional toll it places on residents and the high costs to Medicare and Medicaid. Technologies supporting the use of clinical text messages (TMs) could improve communication among health care team members and have considerable impact on reducing avoidable NH-to-hospital transfers. Although text messaging is a widely accepted mechanism of communication, clinical models of care using TMs are sparsely reported in the literature, especially in NHs. Protocols for assessing technologies that integrate TMs into care delivery models would be beneficial for end users of these systems. Without evidence to support clinical models of care using TMs, users are left to design their own methods and protocols for their use, which can create wide variability and potentially increase disparities in resident outcomes. Objective Our aim is to describe the protocol of a study designed to understand how members of the multidisciplinary team communicate using TMs and how salient and timely communication can be used to avert poor outcomes for NH residents with ADRD, including hospitalization. Methods This project is a secondary analysis of data collected from a Centers for Medicare & Medicaid Services (CMS)–funded demonstration project designed to reduce avoidable hospitalizations for long-stay NH residents. We will use two data sources: (1) TMs exchanged among the multidisciplinary team across the 7-year CMS study period (August 2013-September 2020) and (2) an adapted acute care transfer tool completed by advanced practice registered nurses to document retrospective details about NH-to-hospital transfers. The study is guided by an age-friendly model of care called the 4Ms (What Matters, Medications, Mentation, and Mobility) framework. We will use natural language processing, statistical methods, and social network analysis to generate a new ontology and to compare communication patterns found in TMs occurring around the time NH-to-hospital transfer decisions were made about residents with and without ADRD. Results After accounting for inclusion and exclusion criteria, we will analyze over 30,000 TMs pertaining to over 3600 NH-to-hospital transfers. Development of the 4M ontology is in progress, and the 3-year project is expected to run until mid-2025. Conclusions To our knowledge, this project will be the first to explore the content of TMs exchanged among a multidisciplinary team of care providers as they make decisions about NH-to-hospital resident transfers. Understanding how the presence of evidence-based elements of high-quality care relate to avoidable hospitalizations among NH residents with ADRD will generate knowledge regarding the future scalability of behavioral interventions. Without this knowledge, NHs will continue to rely on ineffective and outdated communication methods that fail to account for evidence-based elements of age-friendly care. International Registered Report Identifier (IRRID) DERR1-10.2196/50231

ICSC POWELL, K ADRD; 2) Estimate the effects of the 4Ms found in TMs on avoidable NH-to-hospital transfers; and 3) Compare communication patterns of interdisciplinary teams making transfer decisions about residents with and without ADRD. A potential impact of this work is to decrease avoidable hospitalizations, and ultimately, morbidity and mortality in NH residents with ADRD by identifying evidence-based elements of high-quality care for older adults (4Ms). Another potential impact is the development of a structured language allowing for timely and seamless portability of information across the complete spectrum of care, optimizing the health of individuals and populations.

PUBLIC HEALTH RELEVANCE:
In this project we examine how interdisciplinary communication using text messaging can improve delivery of age-friendly care to nursing home (NH) residents and prevent avoidable NH-to-hospital transfer. This study will provide information needed for the development and testing of interventions using convenient, low-cost technologies, like text messaging, to ultimately reduce morbidity and mortality in residents with Alzheimer's disease or a related dementia.

CRITIQUE 1
Significance: 3 Investigator(s): 2 Innovation: 3 Approach: 3 Environment: 2 Overall Impact: This study using a retrospective design will examine how interdisciplinary communication using text messaging (TM) can improve delivery of care to nursing home (NH) residents and prevent avoidable hospitalization. The investigators will identify documentation of the 4Ms (Matters, Medications, Mentation, and Mobility) in health information, estimate the effects of the 4Ms in TMs on avoidable hospitalizations, and compare communication patterns of teams making transfer decisions about NH residents with and without Alzheimer's Disease or a related dementia (ADRD). Pilot data revealed the most common messages sent and received were about patient updates (vital signs, lab results), confirmation of information , and questions about residents. Study team conducted 3 preliminary studies that revealed 1) timely communication will reduce NH to hospital transfers, 2) unknown how TM was used by different members of team, and 3) there were differences in low and high hospital transfer among NH residents (low transfer rates had more decision-making interactions). Inclusion across the lifespan has adequately been addressed. Sex as a biological variable has been discussed. The timeline is appropriate. The strengths of this proposal include: 1) preliminary data from investigative team, 2) examination of communication to reduce hospitalization, 3) investigators have collaborated previously. The weaknesses of this proposal include: 1) Limited to the previous data set (MOQI study), 2) Unclear how common for NHs to have access to TM. Considering the strengths and weaknesses of this proposal, the overall impact is moderate.

Strengths
• 2/3 of 1.7 million US nursing home (NH) residents have cognitive impairment (e.g. Alzheimer's disease or a related dementia [ADRD]) at are at high risk for hospitalization.
• Early illness recognition and treatment could prevent hospitalization and reducing morbidity/mortality in residents with ADRD.
• NHs use antiquated communication methods to share health information. ICSC POWELL, K • Potential of the development of a structure language that allows timely information across the spectrum of care.

Weaknesses
• Unclear how common for NHs to have access to TM

Strengths
• PI is a new and early stage nurse researcher and has Senior researcher/mentor on study • Several investigators on team have worked on prior studies and published together.
• Investigator with expertise in computer engineering is on the team.
• A biostatistician is on the team.

Weaknesses
• None noted by reviewer.

Strengths
• Use of the 4M framework to analyze communication patterns.
• The examination of TM communication between providers in a field where phone/fax are the status quo.

Weaknesses
• TM has been examined before, but in a different discipline.

Strengths
• The proposal is guided by the 4M framework.
• Thorough development of 4M taxonomy • Use of the MOQI dataset (investigators have ready access) • Plan to triangulate findings by using multiple data sources and methods

Weaknesses
• Limited to the previous data set (MOQI study)

Strengths
• University of Missouri and Columbia University have the capabilities and support to successfully complete this proposal.

CRITIQUE 2
Significance: 2 Investigator(s): 1 Innovation: 2 Approach: 4 Environment: 1 Overall Impact: The goal of this study is to use NLP and social network analysis to study textmessages prior to hospital transfers for nursing home patients. The team proposes use standardized vocabularies, clinical expertise and NLP to document 4Ms in text-message communications (Aim 1), examine the associations between the 4Ms and transfers (Aim 2), compare communications prior to transfers for ADRD patients vs. non ADRD patients (Aim 3). This study leverages text messages from a multi-years MOQI study funded by AHRQ. Strengths of this study include a strong investigative team, rich text-message data set, focus on a significant and potentially modifiable aspect of healthcare costs for NH, strong preliminary data. The main limitation is potential for lack of generalizability due to poor use of text messages and no descriptive information about the NH included in this study (how representative). In addition, it is not clear why the communication patterns are only being applied to the analysis comparing ADRD vs. non ADRD. Finally, it would be helpful to have a greater understanding of how results of this study could be applied to new interventions. In summary, this application has the ICSC POWELL, K potential to advance interventions to improve team communication around NH to hospital transfers and has only a few minor limitations.

Strengths
• This project focuses on a costly and potentially modifiable healthcare problem.
• The authors identify that improving communication among the team has the potential to improve outcomes, patient quality of life and reduce costs.
• The research is founded on a strong scientific premise and supported by a strong literature of team based care in other settings.

Weaknesses
• The concept of avoidable transfers is not entirely clear in this project (appears that it is rated by APRNs after the event).
• Communication is only one aspect of care, other things such as staffing ratio, SES or other factors may also play a role.
• It would be helpful to have more information about how this data could be use in an intervention, especially considering the NH in this study appear to be already participating in an intervention.

Strengths
• Dr. Powell is an early-stage investigator and well-suited to be the PI for this project • Co-investigators Popescu, Mehr, Lee and Alexander provide appropriate expertise to support the project.

Weaknesses
• None noted by reviewer.

Strengths
• Application of NLP and social network analysis to NH transfers is novel.

Weaknesses
• Results of this study are an incremental step toward improving team communication to prevent NH transfers 4. Approach:

Strengths
• Rich existing dataset available for this study.
• Preliminary data analysis from only 6 months demonstrates the team's expertise and also support the proposed relationships.
Weaknesses ICSC POWELL, K • Possible lack of generalizability of the NH enrolled in the prior study. It appears they were participating in an intervention. In addition, the text message may lack generalizability because as the authors point out, NH teams are often not communicating by text.
• Not clear why the team's interaction is only being compared between the ADRD and non ADRD samples, why not compare also between the preventable and non-preventable transfers?

Strengths
• Appropriate for completing the proposed study

Weaknesses
• None noted by reviewer. Overall Impact: The majority of nursing home residents in the U.S. have a cognitive impairment and are at high risk of hospital transfer, and reducing hospital transfer is important due to health and financial reasons. This proposed project plans to investigate how interdisciplinary communication using text messaging can improve care delivery to nursing home residents with Alzheimer's disease or a related dementia (ADRD), and prevent avoidable hospital transfer. The study team offers adequate expertise and experience for successfully carrying out the proposed research. The environment and institutional support is excellent. Research design, methods and timeline are well presented. One concern is that the PI may need to demonstrate her independent role in leading such an significant project due to her limited experience in working with ADRD patients.

Strengths
• Two-thirds of nursing home residents in the U.S. have a cognitive impairment and are at high risk of hospital transfer.
• Reducing hospitalizations for nursing home residents is important due to health and financial concerns.
• This proposed project will examine how interdisciplinary communication using text messaging can improve care delivery to nursing home residents with Alzheimer's disease or a related dementia (ADRD), and prevent avoidable nursing home-to-hospital transfer.

Weaknesses
• None noted by reviewer.

Strengths
• PI is a new and early-stage nurse researcher with an interest in health information sharing.
• PI has served as postdoc or co-I on grants, and has a good track record of publications.
• Co-Is have commentary areas of expertise and are well suit for this project.

Weaknesses
• PI's work mostly overlaps with the postdoc mentor.
• PI has a limited experience in studying the ADRD population.

Strengths
• This study will build upon previous work by using an innovative conceptual framework to examine the content of text messages and leveraging advanced methods.

Weaknesses
• None noted by reviewer.

Strengths
• Approach is well presented with a clear plan.
• Data collection and analysis is well presented.

Weaknesses
• Scenically relevant preliminary work is presented, although is placed in the significance section.

Strengths
• Institutional support and commitment is strong.

Weaknesses
• None noted by reviewer. Footnotes for 1 R01 AG078281-01; PI Name: Powell, Kimberly Ryan NIH has modified its policy regarding the receipt of resubmissions (amended applications).See Guide Notice NOT-OD-18-197 at https://grants.nih.gov/grants/guide/notice-files/NOT-OD-18-197.html. The impact/priority score is calculated after discussion of an application by averaging the overall scores (1-9) given by all voting reviewers on the committee and multiplying by 10. The criterion scores are submitted prior to the meeting by the individual reviewers assigned to an application, and are not discussed specifically at the review meeting or calculated into the overall impact score. Some applications also receive a percentile ranking. For details on the review process, see http://grants.nih.gov/grants/peer_review_process.htm#scoring.

Interdisciplinary Clinical Care in Specialty Care Settings Study Section Healthcare Delivery and Methodologies Integrated Review Group CENTER FOR SCIENTIFIC REVIEW ICSC 02/17/2022 -02/18/2022
Notice of NIH Policy to All Applicants: Meeting rosters are provided for information purposes only. Applicant investigators and institutional officials must not communicate directly with study section members about an application before or after the review. Failure to observe this policy will create a serious breach of integrity in the peer review process, and may lead to actions outlined in NOT-OD-14-073 at https://grants.nih.gov/grants/guide/notice-files/NOT-OD-14-073.html, NOT-OD-15-106 at https://grants.nih.gov/grants/guide/notice-files/NOT-OD-15-106.html, and NOT-OD-18-115 at https://grants.nih.gov/grants/guide/notice-files/NOT-OD-18-115.html, including removal of the application from immediate review.