Care home medicine

Care homes are changing, with improved standards and expanding roles, and it is vital that their residents are not excluded or discriminated against by health and social services. Staff are keen to be educated, and investment of time and money is rewarded with improved outcomes in many areas.

Beset by obstacles: a review of Australian policy development to support ageing in place for people with intellectual disability

BACKGROUND

Australian government policy regards people with intellectual disability (ID) as citizens with equal rights, which means that they should have access to the same opportunities as the wider community. Ageing in place is central to aged care policy in Australia for the general population.

METHOD

This paper reviews policy to support the provision of similar opportunities to age in place for people with ID, and the reasons for its slow development.

RESULTS

Due to lifestyle patterns earlier in the life course, many people with ID experience a mid-life disruption to their accommodation, and may live in a group home as they age or may move prematurely to residential aged care. The absence of mechanisms to adjust disability funding as needs change, and the existence of policy that denies residents in group homes access to community-based aged care, forces disability services to "go it alone" to support ageing in place.

CONCLUSION

Despite a national priority to improve the interface between the disability and aged care sectors, administrative and funding characteristics continue to obstruct the development of implementation strategies to support ageing in place for people with ID, which remain at the stage of an exploration of the issues.

Patient Characteristics and End-of-Life Health Care Utilization Among Medicare Beneficiaries in 1989 and 1999

OBJECTIVE

To evaluate the association of institutional residence and chronic disability with end-of-life Medicare utilization in 1989 and 1999.

RESEARCH DESIGN

Retrospective study of nationally representative survey data linked to Medicare claims.

SUBJECTS

Medicare beneficiaries who completed the National Long-Term Care Survey in 1989 or 1999 and died within 1 year.

MEASURES

Medicare utilization [hospital, hospice, and skilled nursing facility (SNF)] in the last year of life and at death among the nondisabled, chronically disabled, and institutionalized.

RESULTS

Medicare utilization over the last year of life was similar in 1989 and 1999 for the proportion hospitalized in all groups (eg, 76% vs. 73% among the nondisabled); there were significant increases in SNF use (eg, 9% vs. 20% among the nondisabled). Comparisons at the time of death were somewhat different, with significant increases in hospice use in all groups (eg, 4% vs. 22% in the nondisabled); there was a significant decrease in the proportion dying in the hospital only for the nondisabled group (53% vs. 40%). Utilization was similar for the nondisabled and chronically disabled, but was lower in the institutionalized (eg, proportion hospitalized in the last year of life was 51% in the institutionalized, 73% in the nondisabled, and 77% in the disabled group in 1999).

CONCLUSIONS

Despite dramatic growth in hospice use, hospital and SNF utilization generally did not decline. Institutional residence, which is not usually included in analyses of Medicare claims, was strongly associated with utilization. This may affect the usefulness of claims-based efficiency indicators.

[Involuntary hospital admissions of mentally ill patients--how specific are differences among the German Federal States?]

OBJECTIVE

Estimates for the proportion of involuntary admissions and coercive measures applied in general mental health care and in residential care for the elderly were developed. Sector-specific rates and quotas for Germany as a whole and for the sixteen Federal States were calculated, and the change of these indicators between 1993 and 2003 analysed.

METHODS

Statistical modeling of epidemiologic and juridical data ("Amtsgerichtsstatistik") was performed.

RESULTS

Against an overall increase of involuntary admissions into psychiatric hospitals per 100,000 population, the overall German percentage of involuntary admissions on all admissions into inpatient mental health care remained rather stable between 1993 and 2003. The number of legal coercive measures during inpatient stays has risen. On a Federal State level, these indicators varied considerably across the states and over time.

CONCLUSION

An overall increase of involuntary admissions was not detected from the calculations. Detailed analyses of the increase of coercive measures during psychiatric inpatient stays are still needed. The implementation of a detailed reporting routine of these indicators is strongly recommended.

Quality improvement in nursing homes in Texas: results from a pressure ulcer prevention project

BACKGROUND

Pressure ulcer prevalence, cost, associated mortality, and potential for litigation are major clinical problems in nursing homes despite guidelines for prevention and treatment.

OBJECTIVE

To improve the use of pressure ulcer prevention procedures at nursing homes in Texas through implementation of process of care system changes in collaboration with a state quality improvement organization (QIO).

DESIGN

Preintervention and postintervention measurement of performance for process of care quality indicators and of pressure ulcer incidence rates.

SETTING

Twenty nursing homes in Texas.

PARTICIPANTS

Quality improvement teams at participating nursing homes.

MEASUREMENT

Data were abstracted from medical records on performance measures (quality indicators) and pressure ulcer incidence rates between November 2000 and August 2002. Descriptive and inferential statistics were used.

INTERVENTIONS

Process of care system changes consisting of tools and education to prevent pressure ulcers were introduced to participating nursing homes.

RESULTS

Participating nursing homes showed statistically significant improvement in 8 out of 12 quality indicators. Pressure ulcer incidence rates also decreased, although not quite significantly. Furthermore, facilities with the greatest improvement in quality indicator scores had significantly lower pressure ulcer incidence rates than the facilities with the least improvement in quality indicator scores (S = 131.0, P = .03). This suggests that the interventions positively affected not only the process of care but also led to a decrease in pressure ulcer incidences.

CONCLUSIONS

These results show that nursing homes in a collaborative effort with a QIO were able to improve their processes of care. Although significant improvement was noted on most of the quality indicators, opportunity remains for further improvement. Furthermore, these results suggest that implementation of process of care system changes by nursing homes in a collaborative relationship with a QIO may yield improvements in measures of patient outcome (eg, pressure ulcer incidence).

New evidence of racial differences in access and their effects on the use of nursing homes among older adults

BACKGROUND

Historical disparities in rates of nursing home placement between blacks and whites have been well documented, and are thought to result from more extensive and supportive social networks, cultural aversion, and poorer geographic access among African Americans. A few recent studies, however, suggest that these racial disparities may no longer exist. We used comprehensive data to assess whether racial differences in nursing home placement remain, and if so, to identify the reasons for them.

METHODS

Data on 6242 black and white self-respondents to the Survey of Assets and Health Dynamics Among the Oldest Old cohort who were 70 years old or older at baseline (1993) were used. Placement status was ascertained at each biennial follow-up through 2004, and discrete-time hazards models were estimated.

RESULTS

After adjusting for baseline covariates, it was found that blacks were 26% (lambda = 0.74, P < 0.001) less likely to use a nursing home over an 11-year period than whites. Moreover, the supply of skilled nursing beds was more salient for nursing home placement for blacks than whites, as was the increasing supply of assisted living beds.

CONCLUSIONS

The racial gap in nursing home placement remains, despite the increased supply of nursing home beds and the emergence of assisted living facilities as the preferred alternative. As the supply of skilled nursing beds increases, in part due to whites choosing assisted living facilities, the racial gap in the risks of nursing home placement may be lessening. Blacks, however, remain less likely to be placed in a nursing home than whites.

The links between health-related behaviors and life satisfaction in elderly individuals who prefer institutional living

Background

Life satisfaction among residents of institutions is becoming an important issue in a rapidly aging population. The aim of this cross-sectional study was to investigate the links between life satisfaction and health-related behaviors amongst functionally independent elderly people who prefer institutional living in İstanbul, Turkey.

Methods

The socio-demographic characteristics, health-related behaviors, leisure-time activities and fall histories of 133 residents of an institution in Istanbul were assessed by a structured questionnaire during face-to-face interviews. A validated life-satisfaction index questionnaire (LSI-A) was completed.

Results

The mean age of the study group was 73.9 ± 8.0 (range 60–90 years). Within the group, 22.6% had never married and 14.3% had university degrees. The majority (71.4%) were in the low income bracket. The overall mean LSI-A score was 20.3 ± 5.9. Participants who declared moderate/high income levels had a significantly higher mean LSI-A score than those in the low-income bracket (p = 0.009). Multivariate analysis of the data suggested that leisure-time activities and participation in regular physical activities are significant predictors of LSI-A scores (R²: 0.112; p = 0.005 and p = 0.02, respectively).

Conclusion

The findings imply that regular physical activity and leisure-time activities are significantly related to life satisfaction among residents in institutions. Participation in physical activity and leisure-time activity programs may help to improve the life satisfaction of elderly people living in institutions.

Quality improvement nursing facilities: a nursing leadership perspective

The purposes of this study were to characterize the state of quality improvement (QI) in nursing facilities and to identify barriers to improvement from nursing leaders' perspectives. The study employed a non-experimental descriptive design, using closed- and open-ended survey questions in a sample of 51 nursing facilities in a midwestern state. Only two of these facilities had active QI programs. Furthermore, turnover and limited training among these nursing leaders represented major barriers to rapid implementation of such programs. This study is consistent with earlier findings that QI programs are limited in nursing homes.