Systematic Review of Studies of Staffing and Quality in Nursing Homes

Association between skilled nursing facility quality indicators and hospital readmissions

IMPORTANCE

Hospital readmissions are common, costly, and potentially preventable. Little is known about the association between available skilled nursing facility (SNF) performance measures and the risk of hospital readmission.

OBJECTIVE

To measure the association between SNF performance measures and hospital readmissions among Medicare beneficiaries receiving postacute care at SNFs in the United States.

DESIGN AND PARTICIPANTS

Using national Medicare data on fee-for-service Medicare beneficiaries discharged to a SNF after an acute care hospitalization between September 1, 2009, and August 31, 2010, we examined the association between SNF performance on publicly available metrics (SNF staffing intensity, health deficiencies identified through site inspections, and the percentages of SNF patients with delirium, moderate to severe pain, and new or worsening pressure ulcers) and the risk of readmission or death 30 days after discharge to a SNF. Adjusted analyses controlled for patient case mix, SNF facility factors, and the discharging hospital.

MAIN OUTCOMES AND MEASURES

Readmission to an acute care hospital or death within 30 days of the index hospital discharge.

RESULTS

Of 1,530,824 patients discharged, 357,752 (23.3%; 99% CI, 23.3%-23.5%) were readmitted or died within 30 days; 72,472 died within 30 days (4.7%; 99% CI, 4.7%-4.8%), and 321,709 were readmitted (21.0%; 99% CI, 20.9%-21.1%). The unadjusted risk of readmission or death was lower at SNFs with better staffing ratings. SNFs ranked lowest (19.2% of all SNFs) had a 30-day risk of readmission or death of 25.5% (99% CI, 25.3%-25.8%) vs 19.8% (99% CI, 19.5%-20.1%) among those ranked highest. SNFs with better facility inspection ratings also had a lower risk of readmission or death. SNFs ranked lowest (20.1% of all SNFs) had a risk of 24.9% (99% CI, 24.7%-25.1%) vs 21.5% (99% CI, 21.2%-21.7%) among those ranked highest . Adjustment for patient factors, SNF facility factors, and the discharging hospital attenuated these associations; we observed small differences in the adjusted risk of readmission or death according to SNF facility inspection ratings (lowest vs highest rating: 23.7%; 99% CI: 23.7%, 23.7%; vs 23.0%; 99% CI: 23.0%, 23.1%). Other measures did not predict clinically meaningful differences in the adjusted risk of readmission or death.

CONCLUSIONS AND RELEVANCE

Among fee-for-service Medicare beneficiaries discharged to a SNF after an acute care hospitalization, available performance measures were not consistently associated with differences in the adjusted risk of readmission or death.

The Aged Residential Care Healthcare Utilization Study (ARCHUS): a multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities

OBJECTIVE

To assess effect of a complex, multidisciplinary intervention aimed at reducing avoidable acute hospitalization of residents of residential aged care (RAC) facilities.

DESIGN

Cluster randomized controlled trial.

SETTING

RAC facilities with higher than expected hospitalizations in Auckland, New Zealand, were recruited and randomized to intervention or control.

PARTICIPANTS

A total of 1998 residents of 18 intervention facilities and 18 control facilities.

INTERVENTION

A facility-based complex intervention of 9 months' duration. The intervention comprised gerontology nurse specialist (GNS)-led staff education, facility bench-marking, GNS resident review, and multidisciplinary (geriatrician, primary-care physician, pharmacist, GNS, and facility nurse) discussion of residents selected using standard criteria.

MAIN OUTCOME MEASURES

Primary end point was avoidable hospitalizations. Secondary end points were all acute admissions, mortality, and acute bed-days. Follow-up was for a total of 14 months.

RESULTS

The intervention did not affect main study end points: number of acute avoidable hospital admissions (RR 1.07; 95% CI 0.85-1.36; P = .59) or mortality (RR 1.11; 95% CI 0.76-1.61; P = .62).

CONCLUSIONS

This multidisciplinary intervention, packaging selected case review, and staff education had no overall impact on acute hospital admissions or mortality. This may have considerable implications for resourcing in the acute and RAC sectors in the face of population aging. Australian and New Zealand Clinical Trials Registry (ACTRN12611000187943).

[Impact of nurse, nurses' aid staffing and turnover rate on inpatient health outcomes in long term care hospitals]

PURPOSE

This study was conducted to explore the impact of registered nurse/nurses' aid (RN/NA) staffing and turnover rate on inpatient health outcomes in long term care hospitals.

METHODS

A secondary analysis was done of national data from the Health Insurance Review and Assessment Services including evaluation of long term care hospitals in October-December 2010 and hospital general characteristics in July-September 2010. Final analysis of data from 610 hospitals included RN/NA staffing, turnover rate of nursing staff and 5 patient health outcome indicators.

RESULTS

Finding showed that, when variables of organization and community level were controlled, patients per RN was a significant indicator of decline in ADL for patients with dementia, and new pressure ulcer development in the high risk group and worsening of pressure ulcers. Patients per NA was a significant indicator for new pressure ulcer development in the low risk group. Turnover rate was not significant for any variable.

CONCLUSION

To maintain and improve patient health outcomes of ADL and pressure ulcers, policies should be developed to increase the staffing level of RN. Studies are also needed to examine causal relation of NA staffing level, RN staffing level and patient health outcomes with consideration of the details of nursing practice.

Revisiting the relationship between nurse staffing and quality of care in nursing homes: an instrumental variables approach

This paper revisits the relationship between nurse staffing and quality of care in nursing homes using an instrumental variables approach. Most prior studies rely on cross-sectional evidence, which renders causal inference problematic and policy recommendations inappropriate. We exploit legislation changes regarding minimum staffing requirements in eight states between 2000 and 2001 as exogenous shocks to nurse staffing levels. We find that registered nurse staffing has a large and significant impact on quality of care, and that there is no evidence of a significant association between nurse aide staffing and quality of care. A comparison of the IV estimation to the OLS estimation of the first-difference model suggests that ignoring endogeneity would lead to an underestimation of how nurse staffing affects quality of care in nursing homes.

Dual Eligibility, Selection of Skilled Nursing Facility, and Length of Medicare Paid Postacute Stay

Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients' SNF length of stay. Using a set of fee-for-service beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid.

Variations in levels of care between nursing home patients in a public health care system

Background

Within the setting of a public health service we analyse the distribution of resources between individuals in nursing homes funded by global budgets. Three questions are pursued. Firstly, whether there are systematic variations between nursing homes in the level of care given to patients. Secondly, whether such variations can be explained by nursing home characteristics. And thirdly, how individual need-related variables are associated with differences in the level of care given.

Methods

The study included 1204 residents in 35 nursing homes and extra care sheltered housing facilities. Direct time spent with patients was recorded. In average each patient received 14.8 hours direct care each week. Multilevel regression analysis is used to analyse the relationship between individual characteristics, nursing home characteristics and time spent with patients in nursing homes. The study setting is the city of Trondheim, with a population of approximately 180 000.

Results

There are large variations between nursing homes in the total amount of individual care given to patients. As much as 24 percent of the variation of individual care between patients could be explained by variation between nursing homes. Adjusting for structural nursing home characteristics did not substantially reduce the variation between nursing homes. As expected a negative association was found between individual care and case-mix, implying that at nursing home level a more resource demanding case-mix is compensated by lowering the average amount of care. At individual level ADL-disability is the strongest predictor for use of resources in nursing homes. For the average user one point increase in ADL-disability increases the use of resources with 27 percent.

Conclusion

In a financial reimbursement model for nursing homes with no adjustment for case-mix, the amount of care patients receive does not solely depend on the patients’ own needs, but also on the needs of all the other residents.

Pressure ulcer multidisciplinary teams via telemedicine: a pragmatic cluster randomized stepped wedge trial in long term care

BACKGROUND

The study was conducted to determine the clinical and cost effectiveness of enhanced multi-disciplinary teams (EMDTs) vs. 'usual care' for the treatment of pressure ulcers in long term care (LTC) facilities in Ontario, Canada

METHODS

We conducted a multi-method study: a pragmatic cluster randomized stepped-wedge trial, ethnographic observation and in-depth interviews, and an economic evaluation. Long term care facilities (clusters) were randomly allocated to start dates of the intervention. An advance practice nurse (APN) with expertise in skin and wound care visited intervention facilities to educate staff on pressure ulcer prevention and treatment, supported by an off-site hospital based expert multi-disciplinary wound care team via email, telephone, or video link as needed. The primary outcome was rate of reduction in pressure ulcer surface area (cm2/day) measured on before and after standard photographs by an assessor blinded to facility allocation. Secondary outcomes were time to healing, probability of healing, pressure ulcer incidence, pressure ulcer prevalence, wound pain, hospitalization, emergency department visits, utility, and cost.

RESULTS

12 of 15 eligible LTC facilities were randomly selected to participate and randomized to start date of the intervention following the stepped wedge design. 137 residents with a total of 259 pressure ulcers (stage 2 or greater) were recruited over the 17 month study period. No statistically significant differences were found between control and intervention periods on any of the primary or secondary outcomes. The economic evaluation demonstrated a mean reduction in direct care costs of $650 per resident compared to 'usual care'. The qualitative study suggested that onsite support by APN wound specialists was welcomed, and is responsible for reduced costs through discontinuation of expensive non evidence based treatments. Insufficient allocation of nursing home staff time to wound care may explain the lack of impact on healing.

CONCLUSION

Enhanced multi-disciplinary wound care teams were cost effective, with most benefit through cost reduction initiated by APNs, but did not improve the treatment of pressure ulcers in nursing homes. Policy makers should consider the potential yield of strengthening evidence based primary care within LTC facilities, through outreach by APNs.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01232764.

Antimicrobial resistance and stewardship in long-term care settings

Infections and antimicrobial resistance (AMR) in long-term care facilities (LTCFs) are a public health challenge and a future infectious disease threat. More and more data show the dimension and impact of AMR and of inappropriate use of antimicrobials in this setting. Recently, the spread of carbapenemase-producing Enterobacteriaceae has provided new insights into the dangerous role the long-term care sector may play in the AMR problem in a community. Implementation of effective infection and surveillance control programs in LTCFs is challenging, due to scarce resources (personnel, expertise, diagnostic and supportive services), and no or poor coordination of medical care. However, interventions in LTCFs have been proven to be effective: inappropriate use of antibiotics for asymptomatic bacteriuria may be reduced; hand hygiene compliance may be improved; and the transmission of multidrug-resistant organisms may be halted. This paper reviews the most recent epidemiological information on this issue, providing references to valuable intervention programs.

The economics of dementia-care mapping in nursing homes: a cluster-randomised controlled trial

Background

Dementia-care mapping (DCM) is a cyclic intervention aiming at reducing neuropsychiatric symptoms in people with dementia in nursing homes. Alongside an 18-month cluster-randomized controlled trial in which we studied the effectiveness of DCM on residents and staff outcomes, we investigated differences in costs of care between DCM and usual care in nursing homes.

Methods

Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training, a DCM organizational briefing day and conducted the 4-months DCM-intervention twice during the study. A single DCM cycle consists of observation, feedback to the staff, and action plans for the residents. We measured costs related to health care consumption, falls and psychotropic drug use at the resident level and absenteeism at the staff level. Data were extracted from resident files and the nursing home records. Prizes were determined using the Dutch manual of health care cost and the cost prices delivered by a pharmacy and a nursing home. Total costs were evaluated by means of linear mixed-effect models for longitudinal data, with the unit as a random effect to correct for dependencies within units.

Results

34 units from 11 nursing homes, including 318 residents and 376 nursing staff members participated in the cost analyses. Analyses showed no difference in total costs. However certain changes within costs could be noticed. The intervention group showed lower costs associated with outpatient hospital appointments over time (p = 0^.05) than the control group. In both groups, the number of falls, costs associated with the elderly-care physician and nurse practitioner increased equally during the study (p<0^.02).

Conclusions

DCM is a cost-neutral intervention. It effectively reduces outpatient hospital appointments compared to usual care. Other considerations than costs, such as nursing homes’ preferences, may determine whether they adopt the DCM method.

Trial Registration

Dutch Trials Registry NTR2314

Real teams and their effect on the quality of care in nursing homes

BACKGROUND

Use of teams has shown to be an important factor for organizational performance. However, research has shown that a team has to meet certain criteria and operate in a certain way to realize the potential benefits of team organizing. There are few studies that have examined how teams operate in the nursing home sector and their effect on quality of care. This study investigates the relationship between teams that meet an academic definition of the team concept and quality of care in nursing homes.

METHODS

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilized to test our research question: (1) self-report questionnaires to 444 employees, (2) interviews with 40 ward managers, (3) self-report questionnaires to 40 ward managers, (4) telephone interviews with 378 relatives, and (5) 900 hours of field observations. Use of teams in nursing home wards was assessed by field observations and by interviews with ward mangers. Quality of care was assessed by data from surveys and interviews with relatives and staff and through field observations. All data were aggregated to the ward level and two-level analyses were used to assess the relationships.

RESULTS

The multi-level analyses showed that teams - as operationalized in the present study - were significantly positively related to two out of the three quality of care indices when controlled for ward size, days of sick leave and care level. One significant interaction effect was found between teams and days of sick leave, implying that the effect of teams decreased with higher numbers of days of sick leave.

CONCLUSIONS

The results suggest that teams are related to higher levels of quality of care in nursing homes. However, the study shows that there is a substantial difference between real, functional teams that meet an academic definition of the concept and quasi teams, the latter having a significantly lower effect on quality of care. Hence, nursing home leaders, directors and ward leaders should be aware of the substantial differences betweens dysfunctional - or quasi - teams and real teams, and encourage the development of real functional teams to take advantage of the potential benefits of team organizing.

Nursing Staffing and Quality of Life in Western New York Nursing Homes

This study investigated the relationship between nurse staffing and quality of life (QOL) in Western New York State nursing homes. This was a cross-sectional, correlational study. The independent variables were hours per resident day (HPRD), skill mix, and turnover rate of nursing staff. The outcomes were measured using the self-reported QOL instrument. No coefficients were statistically significant with registered nurses’ (RNs) HPRD. Certified nursing assistant (CNA) HPRD had a statistically significant positive impact on the spiritual well-being domain. There was a statistically negative relationship between the amount of licensed practical nurse (LPN) HPRD and food enjoyment; and the ratio of more RNs to fewer LPNs and CNAs had a statistically significant negative influence on the meaningful-activity, food-enjoyment, and security domains. The turnover of RNs had a statistically negative relationship with the sum of each domain. None of the coefficients was statistically significant with LPN turnover.

[Malnutrition and dementia in the elderly in German nursing homes. Results of a prevalence survey from the years 2008 and 2009]

BACKGROUND AND OBJECTIVE

Dementia is one of most challenging problems for the care of older people in Germany. Although malnutrition in nursing homes is also associated with dementia, few systematic studies have described health care structures in German nursing homes for people with dementia and their individual nutritional status. Therefore, the aim of this study was to determine dementia-specific differences concerning the nutrition situation for the elderly in German nursing homes.

METHODS

A cross-sectional multicenter study was performed using a standardized multilevel instrument (observation, questionnaire) developed at the University of Maastricht. Variables are indicators for malnutrition and its risks, quality indicators, care dependency and types of interventions.

RESULTS

In the 2008 and 2009 surveys, 53% of 4,777 participants (77.9% women, 22.1% men, mean age 82 years) were identified (based on care documentation) as having dementia. More than one third of this population (n = 759, 85.1% women, 14.1% men, mean age 85 years) was probably malnourished; thus, the prevalence rate in the group of people with dementia was 10% higher compared to the group without dementia. People with dementia showed a higher risk in all relevant risk indicators (weight history, body mass index, and food intake) for malnutrition compared to those without dementia. Furthermore, people with dementia had higher care dependency rates and required more assistance for eating and drinking.

CONCLUSION

The study results confirm the relationship between malnutrition and dementia. The use of standardized nutrition screening tools is not common practice in German nursing homes yet. However, the results suggest that with an increasing risk for malnutrition combined with dementia the proportion of nursing interventions also increases, which means that nurses must react adequately. Nevertheless, the interventions concerning malnutrition should be improved especially with respect to preventive measurements.

A staff training and management intervention in VA long-term care: impact on feeding assistance care quality

Efforts to translate efficacious interventions into long-term care practice have had limited success due to the lack of consideration of key translational intervention components. A multi-faceted intervention was implemented in two veteran affairs facilities to improve feeding assistance care. There were three study phases: baseline, intervention, and follow-up. During each phase, trained research staff conducted standardized observations of 12 meals/participant to assess feeding assistance care quality. The staff received three initial training sessions followed by six consecutive weeks of feedback sessions wherein the observation-based care process measures were shared with the staff. There were significant, but modest, improvements in mealtime feeding assistance care processes, and most of the improvements were maintained during follow-up. A multi-faceted intervention resulted in significant, but modest, improvements in mealtime feeding assistance care quality. Organizational (staff schedules, communication) and environmental (dining location) barriers were identified that interfered with improvement efforts.

Relationship between structural characteristics and outcome quality indicators at health care facilities for the elderly requiring long-term care in Japan from a nationwide survey

AIM

To clarify the performance situation of selected quality indicators: falls, pressure ulcers and dehydration, at health care facilities for the elderly in Japan, and what structural characteristics are related to them.

METHODS

The operational population consisted of 1057 institutionalized users (approximately 10 randomly selected per facility) from a survey answered by the care staff. The facilities were divided into two groups according to their prevalence of negative outcomes (falls, pressure ulcers, dehydration): the best 25% (the very good performers) and the remaining 75% (not so good performers). Logistic regression analysis was carried out to examine the relationship between the structure characteristics of the facilities and their performance regarding each quality indicator.

RESULTS

After controlling for sex, years of operation and average age of the users, our results showed a beneficial significant relationship between falls and the total number of nurses per 100 users with an adjusted odds ratio (AOR) of 0.77 (95% CI 0.59-0.98); In contrast, for pressure ulcers, harmful associations between a higher number of registered nurses (AOR 1.23, 95% CI 1.01-1.05) and the availability of 24-h nurse staffing (AOR 4.95, 95% CI 1.19-24.91) were found; regarding dehydration, we did not find any related staffing characteristics.

CONCLUSION

Nursing staff might be considered as a potentially related variable in the quality of care in health care facilities for the elderly. The present study is the first to show a relationship between structural characteristics and quality outcomes in health care facilities for the elderly.

Treatment of pain in European nursing homes: results from the Services and Health for Elderly in Long TERm Care (SHELTER) study

OBJECTIVE

To identify pharmacological and nonpharmacological pain management approaches and associated factors in nursing home residents across Europe.

SETTING, PARTICIPANTS, AND MEASUREMENTS

Cross-sectional study with 4156 residents who were assessed using the interRAI instrument for Long Term Care Facilities (interRAI LTCF), including pharmacological and nonpharmacological pain management modalities. Those reporting pain were included in the analyses (n = 1900). A deeper analysis was performed for the subsample of residents who reported "current pain," defined as pain at least 1 day within the past 3 days (n = 838), and those who reported "current pain of moderate to severe intensity" (n = 590).

RESULTS

Up to 24% of residents who reported pain did not receive any pain medication and up to 11% received it only PRN (as-needed basis), independent of current pain-intensity levels; 61% did not receive any nonpharmacological treatment and 21% received neither pharmacological nor nonpharmacological pain modalities. Considerable differences could be demonstrated across European countries. Factors positively associated with pharmacological pain management were being of female gender, reporting cancer, and having moderate or severe pain. High turnover rates of regular staff and low-to-moderate physicians' availability were negatively associated. Factors positively associated with nonpharmacological treatment were fractures and need of assistance in activities of daily living. Dementia, large nursing home facilities, above-average and high turnover rates of nursing staff, a low physicians' availability, and severe pain intensity were negatively associated.

CONCLUSION

Despite some advances in recent years, pain treatment in European nursing home residents remains to be suboptimal and requires further improvement.

Inappropriate use of psychotropic drugs in older individuals: implications for practice

Frailty at old age and institutionalization in nursing homes are often associated with multiple chronic diseases (multimorbidity) requiring multiple medications (polypharmacy). Among these chronic conditions, mental health problems (e.g., dementia, depression and insomnia) are common. Psychotropic drugs are frequently used as a treatment approach for these conditions, and the prevalence of their use is high among community-dwelling older adults, but even higher in nursing homes. Furthermore, within the problem of polypharmacy and inappropriate prescribing, psychotropic drugs (defined in this article as antipsychotics, benzodiazepines and antidepressants) constitute a significant proportion. The use of psychotropics in older adults remains controversial given the risk of adverse effects, in contrast to the limited effectiveness. Guidelines advise a thorough risk–benefit analysis before the initiation of psychotropics, in addition to time-limited use and discontinuation. In the future, serious efforts should be undertaken to tackle the burden of inappropriate psychotropic prescribing in older adults by incorporating a multidisciplinary approach and by offering credible alternatives.

The impact of the Worksite Heart Health Improvement Project on work ability: a pilot study

OBJECTIVE

To test the efficacy of the Worksite Heart Health Improvement Project (WHHIP).

METHODS

The WHHIP was a quasi-experimental, 6-month pilot performed in two long-term care facilities. Thirty-nine minority female nursing assistants participated in this study. The 3-month WHHIP intervention focused on reducing cardiovascular disease risk by increasing physical activity and reducing the amount of salt and fat consumed. The intervention included three components: environmental and policy assessment; education; and ongoing motivation. The control site received education only. Measures were collected at baseline, 3 months, and 6 months and included work ability, job stress, and job satisfaction.

RESULTS

Generalized estimating equations showed that the treatment group demonstrated significant improvements in work ability (P = 0.049).

CONCLUSIONS

There was preliminary evidence that the WHHIP improved work ability, and future research should assess the impact of improved work ability on patients.

Supporting and promoting personhood in long term care settings: contextual factors

The need for personhood-focused long-term care (LTC) is well-documented. A myriad of sociocultural, political, nursing/professional and organisational contexts facilitate or hinder registered nurses (RNs)' capacity to ensure personhood-focused LTC. Complexities derive from the countless interrelated aspects of these contexts, blurring clear distinctions of causality, responsibility and accountability. Context-related complexities were highlighted at a recent international conference attended by invited experts in LTC leadership from six countries (Canada, USA, England, Northern Ireland, New Zealand and Sweden). The group was convened to explore the value and contributions of RNs in LTC (McGilton, , International Journal of Older People Nursing 7, 282). The purpose of this paper is to expand the discussion of personhood-focused care beyond RNs, to contexts that influence the RN's capacity to ensure personhood-focused practices are embedded in LTC settings. Consistent with key topics covered at the international conference, we selected four major contexts for discussion in this paper: (i) sociocultural, (ii) public policy/financing/regulation, (iii) nursing/professional and (iv) organisational. For each context, we provide a brief description, literature and examples from a few countries attending the conference, potential impact on personhood-focused practices and RN strategies to facilitate personhood-focused care. The knowledge gained from attending to the influence of contextual factors on the RN's role in facilitating personhood-focused practices provides critical insights and directions for interventions aimed to maximise RN role effectiveness in LTC. In practice, understanding linkages between the various contexts offers indispensable insight for LTC nurse leaders charged with managing day-to-day operations and leading quality improvement initiatives that promote personhood-focused practices.

Attitudes of long-term care staff toward dementia and their related factors

BACKGROUND

Attitudes of residential care staff toward residents with dementia affect the quality of care. We examined the attitude of frontline residential care staff toward residents with dementia, and how the presence of specialized care units or programs may affect staff attitude.

METHODS

Staff working in nursing homes participated in a survey which covered demographic data, current state of dementia care in workplace, opinion regarding dementia care, and perceived importance of dementia behaviors.

RESULTS

1,047 nurses and personal care workers participated. 78.8% respondents reported difficulties in managing dementia residents. Those who ranked positive symptoms as more important were 4.5 times more likely to report difficulties, independent of experience. Independent factors associated with positive attitudes toward further training were working in a non-profit home (OR 2.4, 95% CI 1.1, 5.0; p = 0.024) and having a dementia program or unit in the current workplace (OR 1.8, 95% CI 0.985, 3.302; p = 0.056). Only having a dementia program or unit in the current workplace was associated with a positive attitude toward commitment to stay in dementia care (OR 1.9, 95% CI 1.1, 3.2; p = 0.021), adjusted for gender, type of home, post, dementia prevalence in workplace, and work experience.

CONCLUSION

The majority of long-term care staff felt dementia care difficult yet hold positive attitude toward further training and were committed to stay in dementia care. Having a specialized dementia care unit or program in the current workplace was associated with commitment to stay in dementia care and was marginally associated with positive attitude toward further training.

Older Persons' Transitions in Care (OPTIC): a study protocol

BACKGROUND

Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to: 1. define successful and unsuccessful elements of transitions from multiple perspectives; 2. develop and test a practical tool to assess transition success; 3. assess transition processes in a discrete set of transfers in two study sites over a one year period; 4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and 5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH - ED transitions.

METHODS/DESIGN

This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases).

DISCUSSION

Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.

Prevalence and potentially reversible factors associated with anorexia among older nursing home residents: results from the ULISSE project

OBJECTIVE

The principal aims of the present study were to explore the prevalence of anorexia and the factors correlated to anorexia in a large population of older people living in nursing home. Secondary, we evaluated the impact of anorexia on 1-year survival.

METHODS

Data are from baseline evaluation of 1904 participants enrolled in the Un Link Informatico sui Servizi Sanitari Esistenti per l'Anziano study, a project evaluating the quality of care for older persons living in an Italian nursing home. All participants underwent a standardized comprehensive evaluation using the Italian version of the inter Resident Assessment Instrument Minimum Data Set (version 2.0) for Nursing Home. We defined anorexia as the presence of lower food intake. The relationship between covariates and anorexia was estimated by deriving ORs and relative 95% CIs from multiple logistic regression models including anorexia as the dependent variable of interest. Hazard ratios and 95% CIs for mortality by anorexia were calculated.

RESULTS

More than 12% (240 participants) of the study sample suffered from anorexia, as defined by the presence of decreased food intake or the presence of poor appetite. Participants with functional impairment, dementia, behavior problems, chewing problems, renal failure, constipation, and depression, those treated with proton pump inhibitors and opioids had a nearly 2-fold increased risk of anorexia compared with participants not affected by these syndromes. Furthermore, participants with anorexia had a higher risk of death for all causes compared with nonanorexic participants (hazard ratio 2.26, 95% CI: 2.14-2.38).

CONCLUSIONS

The major finding is that potentially reversible causes, such as depression, pharmacologic therapies, and chewing problems, were strongly and independently associated with anorexia among frail older people living in nursing home. Furthermore, anorexia was associated with higher rate of mortality, independently of age and other clinical and functional variables.

The relationship of California's Medicaid reimbursement system to nurse staffing levels

BACKGROUND

Policy initiatives at the Federal and state level are aimed at increasing staffing in nursing homes. These include direct staffing standards, public reporting, and financial incentives.

OBJECTIVE

To examine the impact of California's Medicaid reimbursement for nursing homes which includes incentives directed at staffing.

RESEARCH DESIGN

Two-stage limited-information maximum-likelihood regressions were used to model the relationship between staffing [registered nurses (RNs), licensed practical nurses, and certified nursing assistants hours per resident day] and the Medicaid payment rate, accounting for the specific structure of the payment system, endogeneity of payment and case-mix, and controlling for facility and market characteristics.

SAMPLE

A total of 927 California free-standing nursing homes in 2006.

MEASURES

The model included facility characteristics (case-mix, size, ownership, and chain affiliation), market competition and excess demand, labor supply and wages, unemployment, and female employment. The instrumental variable for Medicaid reimbursement was the peer group payment rate for 7 geographical market areas, and the instrumental variables for resident case-mix were the average county revenues for professional therapy establishments and the percent of county population aged 65 and over.

RESULTS

Consistent with the rate incentives and rational expectation behavior, expected nursing home reimbursement rates in 2008 were associated with increased RN staffing levels in 2006 but had no relationship with licensed practical nurse and certified nursing assistant staffing. The effect was estimated at 2 minutes per $10 increase in rate.

CONCLUSIONS

The incentives in the Medicaid system impacted only RN staffing suggesting the need to improve the state's rate setting methodology.

Measuring nursing care time and tasks in long-term services and supports: one size does not fit all

BACKGROUND

Although most staff in long-term care services and support (LTSS) are nursing care personnel, a method for measuring the provision of nursing care has not yet been developed.

PURPOSE/METHODS

We sought to understand the challenges of measuring nursing care across different types of LTSS using a qualitative approach that included the triangulation of data from three unique sources.

RESULTS

Six primary challenges to measuring nursing care across LTSS emerged. These included (a) level of detail about time of day, amount of time, or type of tasks varied by type of nursing and organization; (b) time and tasks were documented across clinical records and administrative databases; (c) data existed in both paper and electronic formats; (d) several sources of information were needed to create the fullest picture of nursing care; (e) data were inconsistently available for contracted providers; and (f) documentation of informal caregiving was unavailable. Differences were observed between assisted living facilities and home- and community-based services compared with nursing homes. Differences were also observed across organizations within a setting. A commonality across settings and organizations was the availability of an electronically stored care plan specifying individual needs, but not necessarily how these would be met.

CONCLUSIONS

Findings demonstrate the variability of data availability and specificity across three distinct LTSS settings. This study is an initial step toward establishing a process for measuring the provision of nursing care across LTSS in order to explore the range of nursing care needs of LTSS recipients and how these needs are currently fulfilled.

The affordable care act and long-term care: comprehensive reform or just tinkering around the edges?

The Patient Protection and Affordable Care Act (ACA) includes several provisions that aim to improve prevailing deficiencies in the nation's long-term care system. But just how effective is the ACA likely to be in addressing these challenges? Will it result in meaningful or marginal reform? This special issue of Journal of Aging & Social Policy seeks to answer these questions. The most prominent long-term care provision is the now-suspended Community Living Assistance Services and Supports Act. Others include incentives and options for expanding home- and community-based care, a number of research and demonstration projects in the areas of chronic care coordination and the dually eligible, and nursing home quality reforms. There are also elements that seek to improve workforce recruitment and retention, in addition to benefit improvements and spending reductions under Medicare. This article reviews the basic problems plaguing the long-term care sector and the provisions within the ACA meant to address them. It also includes a brief overview of issue content.

The effect of state regulatory stringency on nursing home quality

OBJECTIVE

To test the hypothesis that more stringent quality regulations contribute to better quality nursing home care and to assess their cost-effectiveness.

DATA SOURCES/SETTING

Primary and secondary data from all states and U.S. nursing homes between 2005 and 2006.

STUDY DESIGN

We estimated seven models, regressing quality measures on the Harrington Regulation Stringency Index and control variables. To account for endogeneity between regulation and quality, we used instrumental variables techniques. Quality was measured by staffing hours by type per case-mix adjusted day, hotel expenditures, and risk-adjusted decline in activities of daily living, high-risk pressure sores, and urinary incontinence.

DATA COLLECTION

All states' licensing and certification offices were surveyed to obtain data about deficiencies. Secondary data included the Minimum Data Set, Medicare Cost Reports, and the Economic Freedom Index.

PRINCIPAL FINDINGS

Regulatory stringency was significantly associated with better quality for four of the seven measures studied. The cost-effectiveness for the activities-of-daily-living measure was estimated at about 72,000 in 2011/ Quality Adjusted Life Year.

CONCLUSIONS

Quality regulations lead to better quality in nursing homes along some dimensions, but not all. Our estimates of cost-effectiveness suggest that increased regulatory stringency is in the ballpark of other acceptable cost-effective practices.

The relationships among licensed nurse turnover, retention, and rehospitalization of nursing home residents

PURPOSE

Individuals receiving postacute care in skilled nursing facilities often require complex, skilled care provided by licensed nurses. It is believed that a stable set of nursing personnel is more likely to deliver better care. The purpose of this study was to determine the relationships among licensed nurse retention, turnover, and a 30-day rehospitalization rate in nursing homes (NHs).

DESIGN AND METHODS

We combined two data sources: NH facility-level data (including characteristics of the facility, the market, and residents) and the Florida Nursing Home Staffing Reports (which provide staffing information for each NH) for 681 Florida NHs from 2002 to 2009. Using a two-way fixed effects model, we examined the relationships among licensed nurse turnover rates, retention rates, and 30-day rehospitalization rates.

RESULTS

Results indicate that an NH's licensed nurse retention rate is significantly associated with the 30-day rehospitalization rate (est. = -.02, p = .04) controlling for demographic characteristics of the patient population, residents' preferences for hospitalization, and the ownership characteristics of the NH. The NHs experiencing a 10% increase in their licensed nurse retention had a 0.2% lower rehospitalization rate, which equates to 2 fewer hospitalizations per NH annually. Licensed nurse turnover is not significantly related to the 30-day rehospitalization rate.

IMPLICATIONS

These findings highlight the need for NH administrators and policy makers to focus on licensed nurse retention, and future research should focus on the measures of staff retention for understanding the staffing/quality relationship.

Understanding nursing home worker conceptualizations about good care

This study explored how direct care workers in nursing homes conceptualize good care and how their conceptualizations are influenced by external factors surrounding their work environment and the relational dynamics between them and residents. Study participants were drawn from a local service employees' union, and in-depth interviews were conducted. Data were analyzed using a grounded theory approach, and the results revealed that direct care workers equated good care, such as resident cleanliness, comfort, and happiness as a desirable outcome of care activities. Good care also meant affectionate, respectful, and patient attitudes of direct care workers toward residents in care delivery processes. Nursing home workers internalized the perspectives of residents and other professionals about what constitutes good care, and then drew their own conclusions about how to balance, combine, and compromise those diverse demands. It is important to communicate accurate and consistent messages about what comprises good nursing home care to nursing home workers and build a working environment where workers' conceptualizations about good care can be executed without organizational barriers.

The impact of organizational factors on the urinary incontinence care quality in long-term care hospitals: a longitudinal correlational study

BACKGROUND

With the rapid increase in the number of long-term care hospitals in Korea, care quality has become an important issue. Urinary incontinence is an important condition affecting many residents' quality of life. Thus, it is important that urinary incontinence be amenable to improving conditions with appropriate interventions, since a change in urinary incontinence status can reflect care quality in long-term care facilities if patient level factors are adjusted.

OBJECTIVES

We aim to examine the impact of organizational factors on urinary incontinence care quality defined as the improvement of urinary incontinence status or maintenance of continent status post-admission to Korean long-term care hospitals. DESIGN AND DATA: This is a longitudinal correlation study. Data came from two sources: monthly patient assessment reports using the Patient Assessment Instrument and the hospital information system from the Health Insurance Review and Assessment Services. The final analysis includes 5271 elderly adults without indwelling urinary catheter or urostomy who were admitted to 534 Korean long-term care hospitals in April 2008.

METHODS

Multi-level logistic analysis was used to explore the organizational factors that influence urinary incontinence care quality controlling for patient level factors.

RESULTS

With respect to the organizational factors, the findings showed that location and RN/total nursing staff ratio variables were statistically significant, controlling for risk factors at the patient level. The odds of urinary incontinence improvement from admission in urban long-term care hospitals were 1.28 times higher than rural long-term care hospitals. In addition, when a long-term care hospital increased one standard deviation (0.19) in the RN ratio, the odds of urinary incontinence status improvement or maintenance of continence status from admission increased about 1.8 times.

CONCLUSIONS

The most significant finding was that a higher RN to patient ratio and urban location were associated with better resident outcomes of urinary incontinence among organizational factors. For a better understanding of how these significant organizational factors influence positive care outcomes and provide more practical implications, studies should examine concrete care process measures as well as structure and outcome measures based on systematic conceptual models.

Nursing practice environment and registered nurses' job satisfaction in nursing homes

PURPOSE

 Recruiting and retaining registered nurses (RNs) in nursing homes is problematic, and little research is available to guide efforts to make nursing homes a more attractive practice environment for RNs. The purpose of this study was to examine relationships between aspects of the nursing practice environment and job satisfaction among RNs in nursing homes. 

DESIGN AND METHODS

 The sample included 863 RNs working as staff RNs in 282 skilled nursing facilities in New Jersey. Two-level hierarchical linear modeling was used to account for the RNs nested by nursing homes. 

RESULTS

 Controlling for individual and nursing home characteristics, staff RNs' participation in facility affairs, supportive manager, and resource adequacy were positively associated with RNs' job satisfaction. Ownership status was significantly related to job satisfaction; RNs working in for-profit nursing homes were less satisfied. 

IMPLICATIONS

 A supportive practice environment is significantly associated with higher job satisfaction among RNs working in nursing homes. Unlike other nursing home characteristics, specific dimensions of the nursing practice environment can be modified through administrative actions to enhance RN job satisfaction.

Improving direct-care compensation in nursing homes: Medicaid wage pass-through adoption, 1999-2004

Because states play such a prominent role in the U.S. health care system, they have long grappled with how to best control health care costs while maintaining high quality of care. There are many policy tools available to address efficiency and quality concerns--from pure state regulation to market-oriented competition designs. Given public discourse and official party platforms, one would assume that states controlled by Democrats would be more likely to adopt regulatory reforms. This study examines whether party control, as well as other economic and political factors, is associated with adopting wage pass-through (WPT) policies, which direct a portion of Medicaid reimbursement or its increase toward nursing home staff in an effort to reduce staff turnover, thereby increasing efficiency and the quality of care provided. Contrary to expectations, results indicate that states with Republican governors were against WPT adoption only when for-profit industry pressure increased; otherwise, they were more likely to favor adoption than their Democratic counterparts. This suggests a more complex relationship between partisanship and state-level policy adoption than is typically assumed. Results also indicate that state officials reacted predictably to prevailing political and economic conditions affecting state fiscal-year decisions but required sufficient governing capacity to successfully integrate WPTs into existing reimbursement system arrangements. This suggests that WPTs represent a hybrid between comprehensive and incremental policy change.

Resident characteristics related to the lack of morning care provision in long-term care

PURPOSE

The purpose of this study was to examine usual long-term care (LTC) practices related to 3 aspects of morning care and determine if there were resident characteristics related to the lack of care.

DESIGN AND METHODS

Participants were 169 long-stay residents in 4 community LTC facilities who required staff assistance with either transfer out of bed, dressing, and/or incontinence care and were able to respond to structured interview questions about their morning care preferences. Trained research staff conducted standardized observations during 4 consecutive morning hours once per week per participant for 3 consecutive months during usual LTC conditions and interviewed participants about their morning care preferences using a structured interview protocol once per month during this same time period.

RESULTS

Overall, 40% of the observations showed a lack of morning care provision, including any staff-resident communication about care, during the 4-hr observation period. Participants rated by staff as more physically dependent and requiring 2 staff for transfer were more likely to not receive morning care. Even when care in a particular area was absent, the majority of participants expressed a stable preference for care to remain the "same" (range of proportions was .75 to .87 for the 3 targeted care areas) and infrequently made requests for care.

IMPLICATIONS

Efforts to promote resident-directed care should consider staffing issues related to missed care occurrences and resident issues related to level of dependency on staff as well as reduced expectations for care, which can lead to resident acceptance of low care frequencies.

Nursing home deficiency citations for physical restraints and restrictive side rails

This article examines whether nursing home facility-level characteristics are associated with the likelihood of receiving deficiency citations for physical restraints, including restrictive side rails. Data from the on-line survey certification of automated records were used to calculate odds ratios for facility-level characteristics associated with these deficiency citations. Repeat records from 2000 to 2007 were combined to produce longitudinal data. The results of this study show that restraint/side rail deficiency citations were negatively associated with higher staffing levels of registered nurses and licensed practical nurses (p ≤ .001) and higher Medicaid reimbursement rates (p ≤ .01). Citations were positively associated with greater nurse aide staffing (p ≤ .01) and higher quality-of-care deficiency citation percentiles (p ≤ .001). The extent of physical restraint and restrictive side rail misuse within nursing homes appears to vary according to various facility characteristics. It is less clear how internal processes within a facility bring about these observed patterns of variation.