151
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Nazareno J. Welfare State Replacements: Deinstitutionalization, Privatization and the Outsourcing to Immigrant Women Enterprise. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2018; 48:247-266. [PMID: 29473439 DOI: 10.1177/0020731418759876] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The U.S. government has a long tradition of providing direct care services to many of its most vulnerable citizens through market-based solutions and subsidized private entities. The privatized welfare state has led to the continued displacement of some of our most disenfranchised groups in need of long-term care. Situated after the U.S. deinstitutionalization era, this is the first study to examine how immigrant Filipino women emerged as owners of de facto mental health care facilities that cater to the displaced, impoverished, severely mentally ill population. These immigrant women-owned businesses serve as welfare state replacements, overseeing the health and illness of these individuals by providing housing, custodial care, and medical services after the massive closure of state mental hospitals that occurred between 1955 and 1980. This study explains the onset of these businesses and the challenges that one immigrant group faces as owners, the meanings of care associated with their de facto mental health care enterprises, and the conditions under which they have operated for more than 40 years.
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Affiliation(s)
- Jennifer Nazareno
- 1 School of Public Health and Jonathan M. Nelson Center for Entrepreneurship, 6752 Brown University , Providence, Rhode Island, USA
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152
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Cornell PY, Grabowski DC, Cohen M, Shi X, Stevenson DG. Medical Underwriting In Long-Term Care Insurance: Market Conditions Limit Options For Higher-Risk Consumers. Health Aff (Millwood) 2018; 35:1494-503. [PMID: 27503976 DOI: 10.1377/hlthaff.2015.1133] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A key feature of private long-term care insurance is that medical underwriters screen out would-be buyers who have health conditions that portend near-term physical or cognitive disability. We applied common underwriting criteria based on data from two long-term care insurers to a nationally representative sample of individuals in the target age range (50-71 years) for long-term care insurance. The screening criteria put upper bounds on the current proportion of Americans who could gain coverage in the individual market without changes to medical underwriting practice. Specifically, our simulations show that in the target age range, approximately 30 percent of those whose wealth meets minimum industry standards for suitability for long-term care insurance would have their application for such insurance rejected at the underwriting stage. Among the general population-without considering financial suitability-we estimated that 40 percent would have their applications rejected. The predicted rejection rates are substantially higher than the rejection rates of about 20-25 percent of applicants in the actual market. In evaluating reforms for long-term care financing and their potential to increase private insurance rates, as well as to reduce financial pressure on public safety-net programs, policy makers need to consider the role of underwriting in the market for long-term care insurance.
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Affiliation(s)
- Portia Y Cornell
- Portia Y. Cornell is a PhD candidate in the Program in Health Policy at Harvard University, in Cambridge, Massachusetts
| | - David C Grabowski
- David C. Grabowski is a professor in the Department of Health Care Policy at Harvard Medical School, in Boston, Massachusetts
| | - Marc Cohen
- Marc Cohen is chief research and development officer at LifePlans Inc., in Waltham, Massachusetts
| | - Xiaomei Shi
- Xiaomei Shi is a senior statistician at LifePlans Inc
| | - David G Stevenson
- David G. Stevenson is an associate professor in the Department of Health Policy at the Vanderbilt University School of Medicine, in Nashville, Tennessee
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153
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Freedman VA, Spillman BC. Active Life Expectancy In The Older US Population, 1982-2011: Differences Between Blacks And Whites Persisted. Health Aff (Millwood) 2018; 35:1351-8. [PMID: 27503957 DOI: 10.1377/hlthaff.2015.1247] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Understanding long-range trends in longevity and disability is useful for projecting the likely impact of the baby-boom generation on long-term care utilization and spending. We examine changes in active life expectancy in the United States from 1982 to 2011 for white and black adults ages sixty-five and older. For whites, longevity increased, disability was postponed to older ages, the locus of care shifted from nursing facilities to community settings, and the proportion of life at older ages spent without disability increased. In contrast, for blacks, longevity increases were accompanied by smaller postponements in disability, and the percentage of remaining life spent active remained stable and well below that of whites. Older black women were especially disadvantaged in 2011 in terms of the proportion of years expected to be lived without disability. Public health measures directed at older black adults-particularly women-are needed to offset impending pressures on the long-term care delivery system as the result of population aging.
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Affiliation(s)
- Vicki A Freedman
- Vicki A. Freedman is a research professor in the Institute for Social Research at the University of Michigan, in Ann Arbor
| | - Brenda C Spillman
- Brenda C. Spillman is a senior fellow in the Health Policy Center at the Urban Institute, in Washington, D.C
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154
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Zimmermann J, Pfaff H. Influence of Nurse Staffing Levels on Resident Weight Loss Within German Nursing Homes. Res Gerontol Nurs 2018; 11:48-56. [DOI: 10.3928/19404921-20180109-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 11/22/2017] [Indexed: 11/20/2022]
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155
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Meyers DJ, Mor V, Rahman M. Medicare Advantage Enrollees More Likely To Enter Lower-Quality Nursing Homes Compared To Fee-For-Service Enrollees. Health Aff (Millwood) 2018; 37:78-85. [PMID: 29309215 PMCID: PMC5822393 DOI: 10.1377/hlthaff.2017.0714] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Unlike fee-for-service (FFS) Medicare, most Medicare Advantage (MA) plans have a preferred network of care providers that serve most of a plan's enrollees. Little is known about how the quality of care MA enrollees receive differs from that of FFS Medicare enrollees. This article evaluates the differences in the quality of skilled nursing facilities (SNFs) that Medicare Advantage and FFS beneficiaries entered in the period 2012-14. After we controlled for patients' clinical, demographic, and residential neighborhood effects, we found that FFS Medicare patients have substantially higher probabilities of entering higher-quality SNFs (those rated four or five stars by Nursing Home Compare) and those with lower readmission rates, compared to MA enrollees. The difference between MA and FFS Medicare SNF selections was less for enrollees in higher-quality MA plans than those in lower-quality plans, but Medicare Advantage still guided patients to lower-quality facilities.
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Affiliation(s)
- David J Meyers
- David J. Meyers ( ) is a doctoral student in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Vincent Mor
- Vincent Mor is a professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health, and a health scientist at the Providence Veterans Affairs Medical Center
| | - Momotazur Rahman
- Momotazur Rahman is an assistant professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health
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156
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Henning-Smith C, Kozhimannil K, Prasad S. Barriers to Nursing Home Care for Nonelderly Rural Residents. J Appl Gerontol 2017; 38:1708-1727. [PMID: 29249190 DOI: 10.1177/0733464817746772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rural residents experience higher disability, mortality, and poverty rates than their urban counterparts; they also have more barriers to accessing care, including nursing home care. Meanwhile, the proportion of nonelderly adult nursing home residents (<65 years old) is growing, yet little is known about this population and barriers they face trying to access care, especially in rural areas. This qualitative study uses data from 23 semistructured interviews with rural hospital discharge planners in five states to identify specific barriers to finding nursing home care for nonelderly rural residents. We grouped those barriers into three primary themes-payment status, fit, and medical complexity-as well as two minor themes-caregivers and bureaucratic processes-and discuss each in the article, along with potential policy and programmatic interventions to improve access to nursing home care for nonelderly rural residents.
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157
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Hefele JG, Ritter GA, Bishop CE, Acevedo A, Ramos C, Nsiah-Jefferson LA, Katz G. Examining Racial and Ethnic Differences in Nursing Home Quality. Jt Comm J Qual Patient Saf 2017; 43:554-564. [PMID: 29056175 DOI: 10.1016/j.jcjq.2017.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Identifying racial/ethnic differences in quality is central to identifying, monitoring, and reducing disparities. Although disparities across all individual nursing home residents and disparities associated with between-nursing home differences have been established, little is known about the degree to which quality of care varies by race//ethnicity within nursing homes. A study was conducted to measure within-facility differences for a range of publicly reported nursing home quality measures. METHODS Resident assessment data on approximately 15,000 nursing homes and approximately 3 million residents (2009) were used to assess eight commonly used and publicly reported long-stay quality measures: the proportion of residents with weight loss, with high-risk and low-risk pressure ulcers, with incontinence, with depressive symptoms, in restraints daily, and who experienced a urinary tract infection or functional decline. Each measure was stratified by resident race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic), and within-facility differences were examined. RESULTS Small but significant differences in care on average were found, often in an unexpected direction; in many cases, white residents were experiencing poorer outcomes than black and Hispanic residents in the same facility. However, a broad range of differences in care by race/ethnicity within nursing homes was also found. CONCLUSION The results suggest that care is delivered equally across all racial/ethnic groups in the same nursing home, on average. The results support the call for publicly reporting stratified nursing home quality measures and suggest that nursing home providers should attempt to identify racial/ethnic within-facility differences in care.
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158
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Bliss DZ, Mathiason MA, Gurvich O, Savik K, Eberly LE, Fisher J, Wiltzen KR, Akermark H, Hildebrandt A, Jacobson M, Funk T, Beckman A, Larson R. Incidence and Predictors of Incontinence-Associated Skin Damage in Nursing Home Residents With New-Onset Incontinence. J Wound Ostomy Continence Nurs 2017; 44:165-171. [PMID: 28267124 DOI: 10.1097/won.0000000000000313] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to determine the incidence and predictors of incontinence-associated dermatitis (IAD) in nursing home residents. METHODS Records of a cohort of 10,713 elderly (≥65 years) newly incontinent nursing home residents in 448 nursing homes in 28 states free of IAD were followed up for IAD development. Potential multilevel predictors of IAD were identified in 4 national datasets containing information about the characteristics of individual nursing home residents, nursing home care environment, and communities in which the nursing homes were located. A unique set of health practitioner orders provided information about IAD and the predictors of IAD prevention and pressure injuries in the extended perineal area. Analysis was based on hierarchical logistical regression. RESULTS The incidence of IAD was 5.5%. Significant predictors of IAD were not receiving preventive interventions for IAD, presence of a perineal pressure injury, having greater functional limitations in activities of daily living, more perfusion problems, and lesser cognitive deficits. CONCLUSION Findings highlight the importance of prevention of IAD and treatment/prevention of pressure injuries. A WOC nurse offers expertise in these interventions and can educate staff about IAD predictors, which can improve resident outcomes. Other recommendations include implementing plans of care to improve functional status, treat perfusion problems, and provide assistance with incontinence and skin care to residents with milder as well as greater cognitive deficits.
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Affiliation(s)
- Donna Z Bliss
- Donna Z. Bliss, PhD, RN, FAAN, FGSA, University of Minnesota School of Nursing, Minneapolis, Minnesota. Michelle A. Mathiason, MS, University of Minnesota School of Nursing, Minneapolis, Minnesota. Olga Gurvich, MS, University of Minnesota School of Nursing, Minneapolis, Minnesota. Kay Savik, MS, University of Minnesota School of Nursing, Minneapolis, Minnesota. Lynn E. Eberly, PhD, School of Public Health Division of Biostatistics, Minneapolis, Minnesota. Jessica Fisher, BSN, RN, University of Minnesota School of Nursing, Minneapolis, Minnesota. Kjerstie R. Wiltzen, BSN, BA, RN, University of Minnesota School of Nursing, Minneapolis, Minnesota. Haley Akermark, BSN, RN, University of Minnesota School of Nursing, Minneapolis, Minnesota. Amanda Hildebrandt, BA, University of Minnesota School of Nursing, Minneapolis, Minnesota. Megan Jacobson, BSN, RN, University of Minnesota School of Nursing, Minneapolis, Minnesota. Taylor Funk, BSN, RN, University of Minnesota School of Nursing, Minneapolis, Minnesota. Amanda Beckman, BSN, RN, University of Minnesota School of Nursing, Minneapolis, Minnesota. Reed Larson, BSN, RN, University of Minnesota School of Nursing, Minneapolis, Minnesota
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159
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Bliss DZ, Gurvich O, Savik K, Eberly LE, Harms S, Mueller C, Garrard J, Cunanan K, Wiltzen K. Racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Arch Gerontol Geriatr 2017; 72:187-194. [PMID: 28697432 PMCID: PMC5586547 DOI: 10.1016/j.archger.2017.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 06/14/2017] [Accepted: 06/16/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pressure ulcers increase the risk of costly hospitalization and mortality of nursing home residents, so timely healing is important. Disparities in healthcare have been identified in the nursing home population but little is known about disparities in the healing of pressure ulcers. PURPOSE To assess racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Multi-levels predictors, at the individual resident, nursing home, and community/Census tract level, were examined in three large data sets. METHODS Minimum Data Set records of older individuals admitted to one of 439 nursing homes of a national, for-profit chain over three years with a stages 2-4 pressure ulcer (n=10,861) were searched to the 90-day assessment for the first record showing pressure ulcer healing. Predictors of pressure ulcer healing were analyzed for White admissions first using logistic regression. The Peters-Belson method was used to assess racial or ethnic disparities among minority group admissions. RESULTS A significantly smaller proportion of Black nursing home admissions had their pressure ulcer heal than expected had they been part of the White group. There were no disparities in pressure ulcer healing disadvantaging other minority groups. Significant predictors of a nonhealing of pressure ulcer were greater deficits in activities of daily living and pressure ulcer severity. CONCLUSIONS Reducing disparities in pressure ulcer healing is needed for Blacks admitted to nursing homes. Knowledge of disparities in pressure ulcer healing can direct interventions aiming to achieve equity in healthcare for a growing number of minority nursing home admissions.
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Affiliation(s)
- Donna Z Bliss
- University of Minnesota, School of Nursing, Minneapolis, MN, United States.
| | - Olga Gurvich
- University of Minnesota, School of Nursing, Minneapolis, MN, United States
| | - Kay Savik
- University of Minnesota, School of Nursing, Minneapolis, MN, United States
| | - Lynn E Eberly
- School of Public Health, Division of Biostatistics, Minneapolis, MN, United States
| | - Susan Harms
- University of Minnesota, School of Nursing, Minneapolis, MN, United States; College of Pharmacy, Minneapolis, MN, United States
| | - Christine Mueller
- University of Minnesota, School of Nursing, Minneapolis, MN, United States
| | - Judith Garrard
- School of Public Health Division of Health Services Research and Policy, Minneapolis, MN, United States
| | - Kristen Cunanan
- School of Public Health, Division of Biostatistics, Minneapolis, MN, United States
| | - Kjerstie Wiltzen
- University of Minnesota, School of Nursing, Minneapolis, MN, United States
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160
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Race, Ethnicity, Health Insurance, and Mortality in Older Survivors of Critical Illness. Crit Care Med 2017; 45:e583-e591. [PMID: 28333761 DOI: 10.1097/ccm.0000000000002313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine whether minority race or ethnicity is associated with mortality and mediated by health insurance coverage among older (≥ 65 yr old) survivors of critical illness. DESIGN A retrospective cohort study. SETTING Two New York City academic medical centers. PATIENTS A total of 1,947 consecutive white (1,107), black (361), and Hispanic (479) older adults who had their first medical-ICU admission from 2006 through 2009 and survived to hospital discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We obtained demographic, insurance, and clinical data from electronic health records, determined each patient's neighborhood-level socioeconomic data from 2010 U.S. Census tract data, and determined death dates using the Social Security Death Index. Subjects had a mean (SD) age of 79 years (8.6 yr) and median (interquartile range) follow-up time of 1.6 years (0.4-3.0 yr). Blacks and Hispanics had similar mortality rates compared with whites (adjusted hazard ratio, 0.92; 95% CI, 0.76-1.11 and adjusted hazard ratio, 0.92; 95% CI, 0.76-1.12, respectively). Compared to those with commercial insurance and Medicare, higher mortality rates were observed for those with Medicare only (adjusted hazard ratio, 1.43; 95% CI, 1.03-1.98) and Medicaid (adjusted hazard ratio, 1.30; 95% CI, 1.10-1.52). Medicaid recipients who were the oldest ICU survivors (> 82 yr), survivors of mechanical ventilation, and discharged to skilled-care facilities had the highest mortality rates (p-for-interaction: 0.08, 0.03, and 0.17, respectively). CONCLUSIONS Mortality after critical illness among older adults varies by insurance coverage but not by race or ethnicity. Those with federal or state insurance coverage only had higher mortality rates than those with additional commercial insurance.
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161
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Gaudet Hefele J, Li Y, Campbell L, Barooah A, Wang J. Nursing home Facebook reviews: who has them, and how do they relate to other measures of quality and experience? BMJ Qual Saf 2017; 27:130-139. [PMID: 28780533 DOI: 10.1136/bmjqs-2017-006492] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND The growing use of social media creates opportunities for patients and families to provide feedback and rate individual healthcare providers. Whereas previous studies have examined this emerging trend in hospital and physician settings, little is known about user ratings of nursing homes (NHs) and how these ratings relate to other measures of quality. OBJECTIVE To examine the relationship between Facebook user-generated NH ratings and other measures of NH satisfaction/experience and quality. METHODS This study compared Facebook user ratings of NHs in Maryland (n=225) and Minnesota (n=335) to resident/family satisfaction/experience survey ratings and the Centers for Medicare and Medicaid (CMS) 5-star NH report card ratings. RESULTS Overall, 55 NHs in Maryland had an official Facebook page, of which 35 provided the opportunity for users to rate care in the facility. In Minnesota, 126 NHs had a Facebook page, of which 78 allowed for user ratings. NHs with higher aid staffing levels, not affiliated with a chain and located in higher income counties were more likely to have a Facebook page. Facebook ratings were not significantly correlated with the CMS 5-star rating or survey-based resident/family satisfaction ratings. CONCLUSIONS Given the disconnect between Facebook ratings and other, more scientifically grounded measures of quality, concerns about the validity and use of social media ratings are warranted. However, it is likely consumers will increasingly turn to social media ratings of NHs, given the lack of consumer perspective on most state and federal report card sites. Thus, social media ratings may present a unique opportunity for healthcare report cards to capture real-time consumer voice.
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Affiliation(s)
- Jennifer Gaudet Hefele
- Department of Gerontology, University of Massachusetts Boston, Boston, Massachusetts, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Lauren Campbell
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Adrita Barooah
- Department of Gerontology, University of Massachusetts Boston, Boston, Massachusetts, USA
| | - Joyce Wang
- Department of Gerontology, University of Massachusetts Boston, Boston, Massachusetts, USA
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162
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Black CL, Williams WW, Arbeloa I, Kordic N, Yang L, MaCurdy T, Worrall C, Kelman JA. Trends in Influenza and Pneumococcal Vaccination Among US Nursing Home Residents, 2006-2014. J Am Med Dir Assoc 2017; 18:735.e1-735.e14. [PMID: 28623156 PMCID: PMC5751715 DOI: 10.1016/j.jamda.2017.05.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Institutionalized adults are at increased risk of morbidity and mortality from influenza and pneumococcal infection. Influenza and pneumococcal vaccination have been shown to be effective in reducing hospitalization and deaths due to pneumonia and influenza in this population. OBJECTIVE To assess trends in influenza vaccination coverage among US nursing home residents from the 2005-2006 through 2014-2015 influenza seasons and trends in pneumococcal vaccination coverage from 2006 to 2014 among US nursing home residents, by state and demographic characteristics. METHODS Data were analyzed from the Centers for Medicare and Medicaid Services' (CMS's) Minimum Data Set (MDS). Influenza and pneumococcal vaccination status were assessed for all residents of CMS-certified nursing homes using data reported to the MDS by all certified facilities. RESULTS Influenza vaccination coverage increased from 71.4% in the 2005-2006 influenza season to 75.7% in the 2014-2015 influenza season and pneumococcal vaccination coverage increased from 67.4% in 2006 to 78.4% in 2014. Vaccination coverage varied by state, with influenza vaccination coverage ranging from 50.0% to 89.7% in the 2014-2015 influenza season and pneumococcal vaccination coverage ranging from 55.0% to 89.7% in 2014. Non-Hispanic black and Hispanic residents had lower coverage compared with non-Hispanic white residents for both vaccines, and these differences persisted over time. CONCLUSION Influenza and pneumococcal vaccination among US nursing home residents remains suboptimal. Nursing home staff can employ strategies such as provider reminders and standing orders to facilitate offering vaccination to all residents along with culturally appropriate vaccine promotion to increase vaccination coverage among this vulnerable population.
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Affiliation(s)
- Carla L Black
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Walter W Williams
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | | | - Chris Worrall
- Center for Medicare, Centers for Medicare & Medicaid Services, Baltimore, MD
| | - Jeffrey A Kelman
- Center for Medicare, Centers for Medicare & Medicaid Services, Baltimore, MD
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163
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Poey JL, Hermer L, Cornelison L, Kaup ML, Drake P, Stone RI, Doll G. Does Person-Centered Care Improve Residents' Satisfaction With Nursing Home Quality? J Am Med Dir Assoc 2017; 18:974-979. [PMID: 28754517 DOI: 10.1016/j.jamda.2017.06.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Person-centered care (PCC) is meant to enhance nursing home residents' quality of life (QOL). Including residents' perspectives is critical to determining whether PCC is meeting residents' needs and desires. This study examines whether PCC practices promote satisfaction with QOL and quality of care and services (QOC and QOS) among nursing home residents. DESIGN A longitudinal, retrospective cohort study using an in-person survey. SETTING Three hundred twenty nursing homes in Kansas enrolled or not enrolled in a pay-for-performance program, Promoting Excellent Alternatives in Kansas (PEAK 2.0), to promote PCC in nursing homes. PARTICIPANTS A total of 6214 nursing home residents in 2013-2014 and 5538 residents in 2014-2015, with a Brief Interview for Mental Status score ≥8, participated in face-to-face interviews. Results were aggregated to the nursing home level. MEASUREMENTS My InnerView developed a Resident Satisfaction Survey for Kansas composed of 32 questions divided into QOL, QOC, QOS, and global satisfaction subdomains. RESULTS After controlling for facility characteristics, satisfaction with overall QOL and QOC was higher in homes that had fully implemented PCC. Although some individual measures in the QOS domain (eg, food) showed greater satisfaction at earlier levels of implementation, high satisfaction was observed primarily in homes that had fully implemented PCC. CONCLUSION These findings provide evidence for the effectiveness of PCC implementation on nursing home resident satisfaction. The PEAK 2.0 program may provide replicable methods for nursing homes and states to implement PCC systematically.
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Affiliation(s)
- Judith L Poey
- Center on Aging, Kansas State University, Manhattan, KS.
| | - Linda Hermer
- Center for Applied Research, LeadingAge, Washington, DC
| | | | | | - Patrick Drake
- Center for Applied Research, LeadingAge, Washington, DC
| | - Robyn I Stone
- Center for Applied Research, LeadingAge, Washington, DC
| | - Gayle Doll
- Center on Aging, Kansas State University, Manhattan, KS
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164
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Zhang N, Rodriguez-Monguio R, Barenberg A, Gurwitz J. Are Obese Residents More Likely to Be Admitted to Nursing Homes That Have More Deficiencies in Care? J Am Geriatr Soc 2017; 64:1085-90. [PMID: 27225360 DOI: 10.1111/jgs.14105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether obese older adults who qualify for nursing home (NH) placement are as likely as nonobese adults to be admitted to NHs that provide adequate quality of care. DESIGN Retrospective study. SETTING NHs in New York State. PARTICIPANTS Individuals aged 65 and older newly admitted to a NH in New York State in 2006-07. MEASUREMENTS Total and healthcare-related deficiency citations for each facility were obtained from the Online Survey, Certification, and Reporting file. Bivariate and multivariate regression analyses were used to assess the association between obesity (body mass index (BMI) 30.0-39.9 kg/m(2) ) and morbid obesity (BMI ≥ 40.0 kg/m(2) ) separately and admission to facilities with more deficiencies. RESULTS NHs that admitted a higher proportion of morbidly obese residents were more likely to have more deficiencies, whether total or healthcare related. These NHs also had greater odds of having severe deficiencies, or falling in the top quartile ranking of total deficiencies. After sequentially controlling for the choice of facilities within the inspection region, resident characteristics, and facility covariates, the association between morbid obesity and admission to higher-deficiency NHs persisted. CONCLUSION Residents with morbid obesity were more likely to be admitted to NHs of poorer quality based on deficiency citations. The factors driving these disparities and their impact on the care of obese NH residents require further elucidation.
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Affiliation(s)
- Ning Zhang
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts.,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Rosa Rodriguez-Monguio
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Andrew Barenberg
- Department of Economics, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Jerry Gurwitz
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, Massachusetts
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165
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Bliss DZ, Gurvich OV, Eberly LE, Harms S. Time to and predictors of dual incontinence in older nursing home admissions. Neurourol Urodyn 2017; 37:229-236. [PMID: 28407296 DOI: 10.1002/nau.23279] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 03/12/2017] [Indexed: 11/07/2022]
Abstract
AIMS There are few studies of nursing home residents that have investigated the development of dual incontinence, perhaps the most severe type of incontinence as both urinary and fecal incontinence occur. To determine the time to and predictors of dual incontinence in older nursing home residents. METHODS Using a cohort design, records of older nursing home admissions who were continent or had only urinary or only fecal incontinence (n = 39,181) were followed forward for report of dual incontinence. Four national US datasets containing potential predictors at multiple levels describing characteristics of nursing home residents, nursing homes (n = 445), and socioeconomic and sociodemographic status of the community surrounding nursing homes were analyzed. A Cox proportional hazard regression with nursing home-specific random effect was used. RESULTS At 6 months after admission, 28% of nursing home residents developed dual incontinence, at 1 year 42% did so, and at 2 years, 61% had dual incontinence. Significant predictors for time to developing dual incontinence were having urinary incontinence, greater functional or cognitive deficits, more comorbidities, older age, and lesser quality of nursing home care. CONCLUSIONS The development of dual incontinence is a major problem among nursing home residents. Predictors in this study offer guidance in developing interventions to prevent and reduce the time to developing this problem which may improve the quality of life of nursing residents.
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Affiliation(s)
- Donna Z Bliss
- School of Nursing, University of Minnesota, Minneapolis, Minnesota
| | - Olga V Gurvich
- School of Nursing, University of Minnesota, Minneapolis, Minnesota
| | - Lynn E Eberly
- Division of Biostatistics, School of Public Health, Minneapolis, Minnesota
| | - Susan Harms
- School of Nursing, University of Minnesota, Minneapolis, Minnesota.,College of Pharmacy, Minneapolis, Minnesota
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166
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Konetzka RT, Perraillon MC. Use Of Nursing Home Compare Website Appears Limited By Lack Of Awareness And Initial Mistrust Of The Data. Health Aff (Millwood) 2017; 35:706-13. [PMID: 27044972 DOI: 10.1377/hlthaff.2015.1377] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In December 2008 the Centers for Medicare and Medicaid Services (CMS) launched a five-star rating system of nursing homes as part of Nursing Home Compare, a web-based report card detailing quality of care at all CMS-certified nursing homes. Questions remain, however, as to how well consumers use this rating system as well as other sources of information in choosing nursing home placement. We used a qualitative assessment of how consumers select nursing homes and of the role of information about quality, using semistructured interviews of people who recently placed a family member or friend in a nursing home. We found that consumers were receptive to using Internet-based information about quality as one source of information but that choice was limited by the need for specialized services, proximity to family or health care providers, and availability of Medicaid beds. Consumers had a positive reaction when shown Nursing Home Compare; however, its use appeared to be limited by lack of awareness and, to some extent, initial lack of trust of the data. Our findings suggest that efforts to expand the use of Nursing Home Compare should focus on awareness and trust. Useful additions to Nursing Home Compare might include measures of the availability of activities, information about cost, and consumer satisfaction.
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Affiliation(s)
- R Tamara Konetzka
- R. Tamara Konetzka is a professor in the Department of Public Health Sciences at the University of Chicago, in Illinois
| | - Marcelo Coca Perraillon
- Marcelo Coca Perraillon is an assistant professor in the Department of Health Systems, Management, and Policy at the Colorado School of Public Health, University of Colorado Anschutz Medical Campus, in Aurora
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167
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Fain KM, Castillo-Salgado C, Dore DD, Segal JB, Zullo AR, Alexander GC. Inappropriate Fentanyl Prescribing Among Nursing Home Residents in the United States. J Am Med Dir Assoc 2017; 18:138-144. [DOI: 10.1016/j.jamda.2016.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 11/28/2022]
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168
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Li Y, Harrington C, Mukamel DB, Cen X, Cai X, Temkin-Greener H. Nurse Staffing Hours At Nursing Homes With High Concentrations Of Minority Residents, 2001-11. Health Aff (Millwood) 2017; 34:2129-37. [PMID: 26643634 DOI: 10.1377/hlthaff.2015.0422] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recent increases in state Medicaid payments to nursing homes have the potential to reduce disparities in nurse staffing between facilities with high and low concentrations of racial/ethnic minority residents. Analyses of nursing home and state policy survey data for the period 2001-11 suggest that registered nurse and licensed practical nurse staffing levels increased slightly during this period, regardless of racial/ethnic minority resident concentration. Adjusted disparities in registered nurse hours per resident day between nursing homes with high and low concentrations of minority residents persisted, although they were reduced. Certified nursing assistant hours per patient day increased in nursing homes with low concentrations of minorities but decreased in homes with high concentrations, creating a new disparity. Overall, increases in state Medicaid payment rates to nursing homes were associated with improvements in staffing and reduced staffing disparities across facilities, but the adoption of case-mix payments had the opposite effect. Further reforms in health care delivery and payment are needed to address persistent disparities in care between nursing homes serving higher proportions of minority residents and those serving lower proportions, and to prevent unintended exacerbations of such disparities.
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Affiliation(s)
- Yue Li
- Yue Li is an associate professor in the Department of Public Health Sciences at the University of Rochester, in New York
| | - Charlene Harrington
- Charlene Harrington is a professor of nursing at the University of California, San Francisco
| | - Dana B Mukamel
- Dana B. Mukamel is a professor in the Department of Medicine, University of California, Irvine
| | - Xi Cen
- Xi Cen is a PhD candidate in the Department of Public Health Sciences at the University of Rochester
| | - Xueya Cai
- Xueya Cai is a research associate professor in the Department of Biostatistics and Computational Biology at the University of Rochester
| | - Helena Temkin-Greener
- Helena Temkin-Greener is a professor in the Department of Public Health Sciences at the University of Rochester
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169
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Lepore M, Leland NE. Nursing Homes That Increased The Proportion Of Medicare Days Saw Gains In Quality Outcomes For Long-Stay Residents. Health Aff (Millwood) 2017; 34:2121-8. [PMID: 26643633 DOI: 10.1377/hlthaff.2015.0303] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nursing homes are increasingly providing rehabilitative care to short-stay residents under Medicare's skilled nursing facility coverage, which is much more generous than Medicaid's coverage for long-stay residents. This shift creates the potential for both beneficial and detrimental effects on outcomes for such residents. Examining nationwide facility-level nursing home data for the period 2007-10, we found that increasing the proportion of Medicare-covered patient days in a nursing home was significantly associated with improvements in the quality of the three outcomes we considered for long-stay residents. We saw significant decreases in the percentages of long-stay residents with daily pain (from 5.1 percent to 3.4 percent), with worsening pressure ulcers (from 2.5 percent to 2.0 percent), and with a decline in performing activities of daily living (from 15.9 percent to 14.9 percent). These findings reinforce previous research indicating that quality outcomes tend to be superior in nursing homes with greater financial resources. They also bolster arguments for financial investments in nursing homes, including increases in Medicaid payment rates, to support better care for long-stay residents.
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Affiliation(s)
- Michael Lepore
- Michael Lepore is a senior health policy and health services researcher in the Aging, Disability, and Long-Term Care program at RTI International in Washington, D.C., and an adjunct assistant professor in the Department of Health Services, Policy, and Practice at Brown University, in Providence, Rhode Island
| | - Natalie E Leland
- Natalie E. Leland is an assistant professor with a joint appointment in the Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy and the Davis School of Gerontology at the University of Southern California, in Los Angeles, and an adjunct assistant professor in the Department of Health Services, Policy, and Practice at Brown University
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170
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Smith KM, Thomas KS, Johnson S, Meng H, Hyer K. Dietary Service Staffing Impact Nutritional Quality in Nursing Homes. J Appl Gerontol 2017; 38:639-655. [DOI: 10.1177/0733464816688309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To examine the relationship between dietary service staff and dietary deficiency citations in nursing homes (NHs). Method: 2007-2011 Online Survey and Certification and Reporting data for 14,881 freestanding NHs were used to examine the relationship between dietary service staff and the probability of receiving a dietary service–related deficiency citation. An unconditional logit model with random effects was employed. Results: Findings suggest that higher staffing levels for dietitians (odds ratio [OR] = .955; p < .01), dietary service personnel (OR = .996; p < .01), and certified nursing assistants (CNAs; OR = .981; p < .05) decrease the likelihood of receiving a dietary service deficiency citation. Conclusion: Higher levels of dietary service and CNA staffing levels have the potential to improve the quality of nutritional care in NHs. Findings help substantiate the Centers for Medicare and Medicaid Services’ proposed rules for more stringent Food and Nutrition Services in the NH setting and signify the need for further research relative to the impact of dietary service staff on nutritional and clinical outcomes.
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Affiliation(s)
| | - Kali S. Thomas
- U.S. Department of Veterans Affairs Medical Center, Providence, RI, USA
- Brown University, Providence, RI, USA
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171
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Kim LH, Leland NE. Rehabilitation Practitioners' Prioritized Care Processes in Hip Fracture Post-Acute Care. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2017; 34:155-168. [PMID: 28989216 DOI: 10.1080/02703181.2016.1267295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS Occupational and physical therapy in post-acute care (PAC) has reached the point where quality indicators for hip fracture are needed. This study characterizes the practitioners' prioritized hip fracture rehabilitation practices, which can guide future quality improvement initiatives. METHODS Ninety-two practitioners participating in a parent mixed methods study were asked to rank a series of evidence-based best practices across five clinical domains (assessment, intervention, discharge planning, caregiver training and patient education). RESULTS Prioritized practices reflected patient-practitioner collaboration, facilitating an effective discharge, and preventing adverse events. The highest endorsed care processes include: developing meaningful goals with patient input (84%) in assessment, using assistive devices in intervention (75%) and patient education (65%), engaging the patient and caregiver (50%) in discharge planning, and fall prevention (60%) in caregiver education. CONCLUSIONS Practitioners identified key care priorities. This study lays the foundation for future work evaluating the extent to which these practices are delivered in PAC.
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Affiliation(s)
- Lauren H Kim
- Davis School of Gerontology, University of Southern California
| | - Natalie E Leland
- Davis School of Gerontology, University of Southern California.,Chan Division of Occupational Science and Occupational Therapy.,Health Services Policy & Practice, Brown University
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172
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Li Y, Harrington C, Temkin-Greener H, You K, Cai X, Cen X, Mukamel DB. Deficiencies In Care At Nursing Homes And Racial/Ethnic Disparities Across Homes Fell, 2006-11. Health Aff (Millwood) 2016; 34:1139-46. [PMID: 26153308 DOI: 10.1377/hlthaff.2015.0094] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite the increased use of nursing homes by minority residents, nursing home care remains highly segregated. Compared to whites, racial/ethnic minorities tend to be cared for in facilities with limited clinical and financial resources, low nurse staffing levels, and a relatively high number of care deficiency citations. We assessed the trends from 2006 to 2011 in those citations and in disparities across facilities with four different concentrations of racial/ethnic minority residents. We found that the number of health care-related deficiencies and the percentage of facilities with serious deficiencies decreased over time for all four facility groups. From 2006 to 2011 the average annual number of health care-related deficiencies declined from 7.4 to 6.8 for facilities with low minority concentrations (<5 percent) and from 10.6 to 9.4 for facilities with high minority concentrations (≥35 percent). In multivariable analyses, across-site disparities in health care-related deficiencies and in life-safety deficiencies narrowed over time. We also found that increasing the Medicaid payment rate might help improve both overall quality and disparities, but state case-mix payment approaches might worsen both. These results suggest the need to reevaluate quality improvement and cost containment efforts to better foster the quality and equity of nursing home care.
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Affiliation(s)
- Yue Li
- Yue Li is an associate professor in the Department of Public Health Sciences at the University of Rochester Medical Center, in New York
| | - Charlene Harrington
- Charlene Harrington is a professor of nursing at the University of California, San Francisco
| | - Helena Temkin-Greener
- Helena Temkin-Greener is a professor in the Department of Public Health Sciences at the University of Rochester Medical Center
| | - Kai You
- Kai You is a PhD candidate in public health sciences at the University of Rochester
| | - Xueya Cai
- Xueya Cai is a research assistant professor of biostatistics and computational biology at the University of Rochester
| | - Xi Cen
- Xi Cen is a PhD candidate in public health sciences at the University of Rochester
| | - Dana B Mukamel
- Dana B. Mukamel is a professor in the Department of Medicine at the University of California, Irvine
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173
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Konetzka RT, Grabowski DC, Perraillon MC, Werner RM. Nursing home 5-star rating system exacerbates disparities in quality, by payer source. Health Aff (Millwood) 2016; 34:819-27. [PMID: 25941284 DOI: 10.1377/hlthaff.2014.1084] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Market-based reforms in health care, such as public reporting of quality, may inadvertently exacerbate disparities. We examined how the Centers for Medicare and Medicare Services' five-star rating system for nursing homes has affected residents who are dually enrolled in Medicare and Medicaid ("dual eligibles"), a particularly vulnerable and disadvantaged population. Specifically, we assessed the extent to which dual eligibles and non-dual eligibles avoided the lowest-rated nursing homes and chose the highest-rated homes once the five-star rating system began, in late 2008. We found that both populations resided in better-quality homes over time but that by 2010 the increased likelihood of choosing the highest-rated homes was substantially smaller for dual eligibles than for non-dual eligibles. Thus, the gap in quality, as measured by a nursing home's star rating, grew over time. Furthermore, we found that the benefit of the five-star system to dual eligibles was largely due to providers' improving their ratings, not to consumers' choosing different providers. We present evidence suggesting that supply constraints play a role in limiting dual eligibles' responses to quality ratings, since high-quality providers tend to be located close to relatively affluent areas. Increases in Medicaid payment rates for nursing home services may be the only long-term solution.
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Affiliation(s)
- R Tamara Konetzka
- R. Tamara Konetzka is an associate professor of health services research in the Department of Public Health Sciences at the University of Chicago, in Illinois
| | - David C Grabowski
- David C. Grabowski is a professor of health care policy at Harvard Medical School, in Boston, Massachusetts
| | - Marcelo Coca Perraillon
- Marcelo Coca Perraillon is a PhD candidate in the Department of Public Health Sciences at the University of Chicago
| | - Rachel M Werner
- Rachel M. Werner is an associate professor of medicine at the University of Pennsylvania, in Philadelphia
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174
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Kline N. Pathogenic Policy: Immigrant Policing, Fear, and Parallel Medical Systems in the US South. Med Anthropol 2016; 36:396-410. [PMID: 27849361 DOI: 10.1080/01459740.2016.1259621] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Medical anthropology has a vital role in identifying health-related impacts of policy. In the United States, increasingly harsh immigration policies have formed a multilayered immigrant policing regime comprising state and federal laws and local police practices, the effects of which demand ethnographic attention. In this article, I draw from ethnographic fieldwork in Atlanta, Georgia, to examine the biopolitics of immigrant policing. I underscore how immigrant policing directly impacts undocumented immigrants' health by producing a type of fear based governance that alters immigrants' health behaviors and sites for seeking health services. Ethnographic data further point to how immigrant policing sustains a need for an unequal, parallel medical system, reflecting broader social inequalities impacting vulnerable populations. Moreover, by focusing on immigrant policing, I demonstrate the analytical utility in examining the biopolitics of fear, which can reveal individual experiences and structural influents of health-related vulnerability.
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Affiliation(s)
- Nolan Kline
- a Department of Anthropology , Rollins College , Winter Park , Florida , USA
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175
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Fain KM, Alexander GC, Dore DD, Segal JB, Zullo AR, Castillo-Salgado C. Frequency and Predictors of Analgesic Prescribing in U.S. Nursing Home Residents with Persistent Pain. J Am Geriatr Soc 2016; 65:286-293. [PMID: 28198563 DOI: 10.1111/jgs.14512] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To quantify prescription analgesic use of elderly nursing home (NH) residents with persistent noncancer pain and to identify individual and facility traits associated with no treatment. DESIGN Cross-sectional study. SETTING Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims. PARTICIPANTS Individuals aged 65 and older with persistent noncancer pain were identified from a cross-section of all long-stay U.S. NH residents with an MDS assessment and Medicare Part D enrollment in 2008, excluding those who were terminally ill, those with Alzheimer's disease, and those with the most-severe cognitive impairment. MEASUREMENTS Residents with moderate to severe daily pain on consecutive assessments at least 90 days apart constituted the cohort with persistent pain. Part D dispensing for an opioid or nonsteroidal anti-inflammatory drug (NSAID) within 30 days of persistent pain onset was identified. Information on resident and facility characteristics was obtained from MDS and OSCAR records. Associations between resident and facility attributes and pain treatment were estimated using multilevel mixed-effects logistic regression analyses. RESULTS Of the study sample of 18,526 residents with persistent pain, 3,094 (16.7%) did not receive prescription analgesics, 12,815 (69.2%) received a prescription opioid, 485 (2.6%) received a prescription NSAID, and 2,132 (11.5%) received a prescription opioid and NSAID. After adjusting for potentially confounding covariates, residents who were older (≥95, odds ratio (OR) = 2.06, 95% confidence interval (CI) = 1.70-2.49), more cognitively impaired (moderately severe cognitive impairment, OR = 2.12, 95% CI = 1.71-2.62), or black (OR = 1.20, 95% CI = 1.03-1.39) or Asian (OR = 1.97, 95% CI = 1.22-3.20) were less likely to receive a prescription analgesic. CONCLUSION Through 2008, pain remained undertreated in NHs, especially in certain subpopulations, including cognitively impaired and older residents. Changes in pain management practice and policies may be necessary to target these vulnerable residents.
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Affiliation(s)
- Kevin M Fain
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - G Caleb Alexander
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - David D Dore
- Optum Epidemiology, Waltham, Massachusetts.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Jodi B Segal
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Carlos Castillo-Salgado
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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176
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Rahman M, Grabowski DC, Mor V, Norton EC. Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure? Health Serv Res 2016. [PMID: 27766639 DOI: 10.1111/1475‐6773.12603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity. SETTINGS Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization. STUDY DESIGN We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV. PRINCIPAL FINDINGS The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013. CONCLUSIONS Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Vincent Mor
- Department of Health Services Policy and Practice, Brown University, Providence, RI.,Health Services Research Program, Providence Veterans Administration Medical Center, Providence, RI
| | - Edward C Norton
- Department of Health Management and Policy and Department of Economics, University of Michigan, Ann Arbor, MI.,National Bureau of Economic Research, Cambridge, MA
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177
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Rahman M, Grabowski DC, Mor V, Norton EC. Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure? Health Serv Res 2016; 51:2158-2175. [PMID: 27766639 DOI: 10.1111/1475-6773.12603] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity. SETTINGS Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization. STUDY DESIGN We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV. PRINCIPAL FINDINGS The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013. CONCLUSIONS Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Vincent Mor
- Department of Health Services Policy and Practice, Brown University, Providence, RI.,Health Services Research Program, Providence Veterans Administration Medical Center, Providence, RI
| | - Edward C Norton
- Department of Health Management and Policy and Department of Economics, University of Michigan, Ann Arbor, MI.,National Bureau of Economic Research, Cambridge, MA
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178
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Bliss DZ, Gurvich OV, Mathiason MA, Eberly LE, Savik K, Harms S, Mueller C, Wyman JF, Virnig B. Prevention of Incontinence-Associated Skin Damage in Nursing Homes. West J Nurs Res 2016; 39:643-659. [PMID: 27586441 DOI: 10.1177/0193945916666065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Racial/ethnic disparities in preventing health problems have been reported in nursing homes. Incontinence is common among nursing home residents and can result in inflammatory-type skin damage, referred to as incontinence-associated skin damage (IASD). Little is known about the prevention of IASD and whether there are racial/ethnic disparities in its prevention. This study assessed the proportion of older nursing home residents receiving IASD prevention after developing incontinence after admission ( n = 10,713) and whether there were racial/ethnic disparities in IASD prevention. Predictors of preventing IASD were also examined. Four national data sets provided potential predictors at multiple levels. Disparities were analyzed using the Peters-Belson method; predictors of preventing IASD were assessed using hierarchical logistic regression. Prevention of IASD was received by 0.12 of residents and no racial/ethnic disparities were found. Predictors of preventing IASD were primarily resident-level factors including limitations in activities of daily living, poor nutrition, and more oxygenation problems.
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Affiliation(s)
- Donna Z Bliss
- 1 University of Minnesota School of Nursing, Minneapolis, MN, USA
| | - Olga V Gurvich
- 1 University of Minnesota School of Nursing, Minneapolis, MN, USA
| | | | - Lynn E Eberly
- 2 School of Public Health Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Kay Savik
- 1 University of Minnesota School of Nursing, Minneapolis, MN, USA
| | - Susan Harms
- 1 University of Minnesota School of Nursing, Minneapolis, MN, USA.,3 College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | | | - Jean F Wyman
- 1 University of Minnesota School of Nursing, Minneapolis, MN, USA
| | - Beth Virnig
- 4 School of Public Health Division of Health Services Research and Policy, University of Minnesota, Minneapolis, MN, USA
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179
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Bourbonniere M, Feng Z, Intrator O, Angelelli J, Mor V, Zinn JS. The Use of Contract Licensed Nursing Staff in U.S. Nursing Homes. Med Care Res Rev 2016; 63:88-109. [PMID: 16686074 DOI: 10.1177/1077558705283128] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The extent to which nursing homes rely on the use of contracted licensed staff, factors associated with this staffing practice, and the resultant effect on the quality of resident care has received little public attention. Merging the On-line Survey Certification and Reporting System database with the Area Resource File from 1992 through 2002, the authors regressed organizational and market-level variables on the use of 5 percent or more contract full-time equivalent registered nurses and licensed practical nurses. Since 1997, the proportion of facilities using 5 percent or more contract licensed staff more than tripled. Use of contract nurses was associated with more deficiency citations, characteristics of poorer facilities, and tight labor markets. Nursing homes increasingly rely on contract nurses. The failure of nursing homes to attract and retain a competent, stable workforce creates a vicious cycle of staffing practices, which may lead to decline in quality of care.
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180
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Abstract
This study uses a longitudinal California data set (1995 to 2000) to address two concerns about Medicaid nursing facility (NF) utilization. First, to consider the impact of national cost-control policies, the authors analyze data trends in Medicaid NF participants, days of care, and expenditures. Second, the authors investigate the percentage of Medicaid days of care (%MDOC) using a panel regression model to consider resident, facility, and county market predictors. The findings show that although statewide Medicaid NF participants, expenditures, and%MDOC remain stable, Medicaid market segmentation persistes, with program participants distributed unevenly among facilities. Factors associated positively with facility%MDOC are the proportion of minority residents, a larger facility size, for-profit status, the percentage of aged Black persons in the county, and market concentration. The factors associated negatively with%MDOC are the percentages of resident men, residents aged 85 or older, residents with Alzheimer’s disease, Medicaid reimbursement rates, and county wealth.
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181
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Bliss DZ, Gurvich OV, Eberly LE, Savik K, Harms S, Wyman JF, Mueller C, Virnig B, Wiltzen K. Racial disparities in primary prevention of incontinence among older adults at nursing home admission. Neurourol Urodyn 2016; 36:1124-1130. [PMID: 27376926 DOI: 10.1002/nau.23065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/11/2016] [Indexed: 11/08/2022]
Abstract
AIMS Maintaining continence of nursing home (NH) residents promotes dignity and well-being and may reduce morbidity and healthcare treatment costs. To determine the prevalence of older continent adults who received primary prevention of incontinence at NH admission, assess whether there were racial or ethnic disparities in incontinence prevention, and describe factors associated with any disparities. METHODS The design was an observational cross-sectional study of a nation-wide cohort of older adults free of incontinence at NH admission (n = 42,693). Four US datasets describing NH and NH resident characteristics, practitioner orders for NH treatment/care, and socioeconomic and sociodemographic status of the community surrounding the NHs were analyzed. Disparities were analyzed for four minority groups identified on the minimum data set using the Peters-Belson method and covariates at multiple levels. RESULTS Twelve percent of NH admissions received incontinence prevention. There was a significant disparity (2%) in incontinence prevention for Blacks (P < 0.05): Fewer Black admissions (8.6%) were observed to receive incontinence prevention than was expected had they been part of the White group (10.6%). The percentage of White admissions receiving incontinence prevention was 10.6%. Significant factors associated with disparity in receiving incontinence prevention were having greater deficits in ADL function and cognition and more comorbidities. No disparity disadvantaging the other minority groups was found. CONCLUSIONS Greater efforts for instituting incontinence prevention at the time of NH admission are needed. Eliminating racial disparities in incontinence prevention seems an attainable goal. Appropriate staff training, organizational commitment, and monitoring progress toward equitable outcomes can help achieve this goal. Neurourol. Urodynam. 36:1124-1130, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Donna Z Bliss
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | - Olga V Gurvich
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | | | - Kay Savik
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | - Susan Harms
- University of Minnesota School of Nursing, Minneapolis, Minnesota.,College of Pharmacy, Minneapolis, Minnesota
| | - Jean F Wyman
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | | | - Beth Virnig
- Division of Health Services Research and Policy of School of Public Health, Minneapolis, Minnesota
| | - Kjerstie Wiltzen
- University of Minnesota School of Nursing, Minneapolis, Minnesota
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182
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Noelker LS, Ejaz FK, Menne HL, Jones JA. The Impact of Stress and Support on Nursing Assistant Satisfaction With Supervision. J Appl Gerontol 2016. [DOI: 10.1177/0733464806290935] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This research applies a stress-and-social-support conceptual model to investigate the effects of personal and facility characteristics, job-related and personal stressors, and social support in the workplace on nursing assistant (NA) satisfaction with supervision. Survey data are from in-person interviews with 338 NAs employed at 22 skilled nursing facilities. Structural equation modeling was used to determine the model's goodness of fit. Results show that personal stressors (family, financial, and health concerns) have the greatest impact on satisfaction with supervision. Positive support in the workplace attenuated the effects of job-related stressors on the outcome. Findings suggest NAs'personal stressors require careful attention from supervisory and human resources staff because they directly affect worker satisfaction with supervision. Employee Assistance Programs and training for supervisors in team building, communication, and motivational skills are needed to promote more positive relationships with and among NAs.
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183
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Campbell LJ, Cai X, Gao S, Li Y. Racial/Ethnic Disparities in Nursing Home Quality of Life Deficiencies, 2001 to 2011. Gerontol Geriatr Med 2016; 2:2333721416653561. [PMID: 27819015 PMCID: PMC5066711 DOI: 10.1177/2333721416653561] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/04/2016] [Accepted: 05/09/2016] [Indexed: 11/16/2022] Open
Abstract
Objectives: Racial/ethnic disparities in nursing homes (NHs) are associated with lower quality of care, and state Medicaid payment policies may influence NH quality. However, no studies analyzing disparities in NH quality of life (QoL) exist. Therefore, this study aims to estimate associations at the NH level between average number of QoL deficiencies and concentrations of racial/ethnic minority residents, and to identify effects of state Medicaid payment policies on racial/ethnic disparities. Method: Multivariable Poisson regression with NH random effects was used to determine the association between NH minority concentration in 2000 to 2010 and average number of QoL deficiencies in 2001 to 2011 at the NH level, and the effect of state NH payment policies on QoL deficiencies and racial/ethnic disparities in QoL deficiencies across NH minority concentrations. Results: Racial/ethnic disparities in QoL between high and low minority concentration NHs decrease over time, but are not eliminated. Case mix payment was associated with an increased disparity between high and low minority concentration NHs in QoL deficiencies. Discussion: NH managers and policy makers should consider initiatives targeting minority residents or low-performing NHs with higher minority concentrations for improvement to reduce disparities and address QoL deficiencies.
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Affiliation(s)
| | - Xueya Cai
- University of Rochester Medical Center, NY, USA
| | - Shan Gao
- University of Rochester Medical Center, NY, USA
| | - Yue Li
- University of Rochester Medical Center, NY, USA
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184
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Schoenfeld AJ, Zhang X, Grabowski DC, Mor V, Weissman JS, Rahman M. Hospital-skilled nursing facility referral linkage reduces readmission rates among Medicare patients receiving major surgery. Surgery 2016; 159:1461-8. [PMID: 26830069 PMCID: PMC4821789 DOI: 10.1016/j.surg.2015.12.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/11/2015] [Accepted: 12/18/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND In the health reform era, rehospitalization after discharge may result in financial penalties to hospitals. The effect of increased hospital-skilled nursing facility (SNF) linkage on readmission reduction after surgery has not been explored. METHODS To determine whether enhanced hospital-SNF linkage, as measured by the proportion of surgical patients referred from a hospital to a particular SNF, would result in reduced 30-day readmission rates for surgical patients, we used national Medicare data (2011-2012) and evaluated patients who underwent 1 of 5 operative procedures (coronary artery bypass grafting [CABG], hip fracture repair, total hip arthroplasty, colectomy, or lumbar spine surgery). Initial evaluation was performed using regression modeling. Patient choice in SNF referral was adjusted for using instrumental variable (IV) analysis with distance between an individuals' home and the SNF as the IV. RESULTS A strong negative correlation (P < .001) was observed between the proportion of selected surgical discharges received by a SNF and the rate of hospital readmission. Increasing the proportion of surgical discharges decreased the likelihood of rehospitalization (regression coefficient, -0.04; 95% CI, -0.07 to -0.02). These findings were preserved in IV analysis. Increasing hospital-SNF linkage was found to reduce significantly the likelihood of readmission for patients receiving lumbar spine surgery, CABG, and hip fracture repair. CONCLUSION The benefits of increased hospital-SNF linkage seem to include meaningful reductions in hospital readmission after surgery. Overall, a 10% increase in the proportion of surgical referrals to a particular SNF is estimated to decrease readmissions by 4%. This may impact hospital-SNF networks participating in risk-based reimbursement models.
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Affiliation(s)
- Andrew J Schoenfeld
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Xuan Zhang
- Department of Health Services, Policy, and Practice, Brown University, Providence, RI
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University, Providence, RI; Health Services Research, Providence Veterans Administration Medical Center, Providence, RI
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University, Providence, RI
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185
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Schapira MM, Shea JA, Duey KA, Kleiman C, Werner RM. The Nursing Home Compare Report Card: Perceptions of Residents and Caregivers Regarding Quality Ratings and Nursing Home Choice. Health Serv Res 2016; 51 Suppl 2:1212-28. [PMID: 26867949 DOI: 10.1111/1475-6773.12458] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the perceived usefulness of publicly reported nursing home quality indicators. STUDY SETTING Primary data were collected from October 2013 to August 2014 among a convenience sample of persons (or family member) recently admitted or anticipating admission to a nursing home within 75 miles of the city of Philadelphia. STUDY DESIGN Structured interviews were conducted to assess the salience of data on the Medicare Nursing Home Compare website, including star ratings, clinical quality measures, and benchmarking of individual nursing home quality with state and national data. DATA COLLECTION Interviews were transcribed verbatim, independently coded by two reviewers, and agreement determined. A thematic analysis of transcripts was undertaken. PRINCIPAL FINDINGS Thirty-five interviews were completed. Eighty-three percent (n = 29) were caregivers and 17 percent (n = 6) were residents. Star ratings, clinical quality measures, and benchmarking information were salient to decision making, with preferred formats varying across participants. Participants desired additional information on the source of quality data. Confusion was evident regarding the relationship between domain-specific and overall star quality ratings. CONCLUSIONS The Nursing Home Compare website provides salient content and formats for consumers. Increased awareness of this resource and clarity regarding the definition of measures could further support informed decision making regarding nursing home choice.
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Affiliation(s)
- Marilyn M Schapira
- Division of General Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA
| | - Judy A Shea
- Division of General Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Katia A Duey
- Division of General Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Carly Kleiman
- Division of General Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rachel M Werner
- Division of General Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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186
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Gaugler JE. Understanding Quality of Care in Nursing Homes and Other Residential Settings. J Appl Gerontol 2016; 35:263-6. [DOI: 10.1177/0733464815623430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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187
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Zimmerman S, Bowers BJ, Cohen LW, Grabowski DC, Horn SD, Kemper P. New Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy, Practice, and Research. Health Serv Res 2015; 51 Suppl 1:475-96. [PMID: 26708381 DOI: 10.1111/1475-6773.12430] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To synthesize new findings from the THRIVE Research Collaborative (The Research Initiative Valuing Eldercare) related to the Green House (GH) model of nursing home care and broadly consider their implications. DATA SOURCES Interviews and observations conducted in GH and comparison homes, Minimum Data Set (MDS) assessments, Medicare data, and Online Survey, Certification and Reporting data. STUDY DESIGN Critical integration and interpretation of findings based on primary data collected 2011-2014 in 28 GH homes (from 16 organizations), and 15 comparison nursing home units (from 8 organizations); and secondary data derived from 2005 to 2010 for 72 GH homes (from 15 organizations) and 223 comparison homes. PRINCIPAL FINDINGS Implementation of the GH model is inconsistent, sometimes differing from design. Among residents of GH homes, adoption lowers hospital readmissions, three MDS measures of poor quality, and Part A/hospice Medicare expenditures. Some evidence suggests the model is associated with lower direct care staff turnover. CONCLUSIONS Recommendations relate to assessing fidelity, monitoring quality, capitalizing opportunities to improve care, incorporating evidence-based practices, including primary care providers, supporting high-performance workforce practices, aligning Medicare financial incentives, promoting equity, informing broad culture change, and conducting future research.
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Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Lauren W Cohen
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Susan D Horn
- Health System Innovation and Research Program, University of Utah School of Medicine, Salt Lake City, UT
| | - Peter Kemper
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, PA
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188
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Li Y, Cai X, Glance LG. Disparities in 30-Day Rehospitalization Rates Among Medicare Skilled Nursing Facility Residents by Race and Site of Care. Med Care 2015; 53:1058-65. [PMID: 26492217 PMCID: PMC4648673 DOI: 10.1097/mlr.0000000000000441] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To examine racial and site-of-care disparities in all-cause and potentially avoidable 30-day rehospitalization rates among a national cohort of Medicare skilled nursing facility (SNF) residents. METHODS We analyzed the 2012 Minimum Data Set, Medicare inpatient claims, and other data. Multivariable logistic regressions were used to adjust for resident demographic, functional, and diagnostic characteristics, as well as observed SNF and geographic factors. Conditional fixed effects for SNFs were further used to adjust for both observed and unobserved factors. Independent effects of black race and site-of-care groups were estimated, where sites were defined using proportions of black Medicare admissions to the SNF. RESULTS The 30-day all-cause and potentially avoidable rehospitalization rates were 21.9% and 8.8%, respectively, for black residents (n=120,508), and 17.7% and 7.9% for white residents (n=1,182,003). Racial disparities persisted after adjustment for resident characteristics. Moreover, risk-adjusted disparities were essentially related to the type of SNFs to which residents were admitted; after controlling for SNF sites, significant racial disparity disappeared for potentially available rehospitalizations. Black residents and white residents admitted to SNFs with high proportions of black admissions (>25%) were 31% and 19%, respectively, more likely to be rehospitalized than white residents admitted to SNFs caring for only a small percentage of black postacute residents (<3%). CONCLUSIONS Compared with white SNF residents, black SNF residents are more likely to be rehospitalized even after adjusting for patient risk factors. Black-white disparities, especially in potentially preventable rehospitalizations, are largely due to the fact that black residents tend to be admitted to the small number of SNFs with very high rehospitalization rates.
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Affiliation(s)
- Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center
| | - Laurent G. Glance
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
- Department of Anesthesiology, University of Rochester Medical Center
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189
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Bliss D, Harms S, Eberly LE, Savik K, Gurvich O, Mueller C, Wyman JF, Virnig B. Social Engagement After Nursing Home Admission: Racial and Ethnic Disparities and Risk Factors. J Appl Gerontol 2015; 36:1306-1326. [DOI: 10.1177/0733464815617285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Older adults admitted to nursing homes (NHs) are at risk for low social engagement, which has associations with medical, psychological, and social well-being. Minorities may be at a disadvantage for social engagement because of their racial or ethnic group identity. This study assessed whether there were racial/ethnic disparities in social engagement among older adults ( N = 15,927) at 1 year after their NH admission using multi-level predictors. No racial or ethnic-based disparities in social engagement were found; hence, an analysis of risk factors at NH admission that predicted low social engagement at 1 year for all residents was conducted. Significant risk factors for low social engagement were low social engagement at admission, deficits in activities in daily living and cognition, problems with vision and communication, and residing in an NH in an urban community. Results highlight the importance of initiating interventions to increase social engagement at the time of NH admission.
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Affiliation(s)
| | | | | | - Kay Savik
- University of Minnesota, Minneapolis, USA
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190
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Ellis ML, Molinari V, Dobbs D, Smith K, Hyer K. Assessing approaches and barriers to reduce antipsychotic drug use in Florida nursing homes. Aging Ment Health 2015; 19:507-16. [PMID: 25166458 DOI: 10.1080/13607863.2014.952710] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Antipsychotic medications have been federally regulated since 1987, yet research suggests they continue to be used inappropriately to alleviate behavioral symptoms associated with dementia. In 2012, the Centers of Medicare and Medicaid launched a new initiative to reduce antipsychotic medication in nursing homes by 15% nationally. The aim of this study was to examine qualitative data to explore strategies that have been implemented, to assess which strategies are evidence-based, and to make recommendations to improve upon practices to reduce antipsychotic medication use. METHOD A convenience sample of 276 nursing home professional staff members were surveyed about these topics using open-ended questions. RESULTS Theme-based content analysis yielded three main themes. The themes related to changes in practice included the following: (1) increased review of resident behavior and antipsychotic medication regimens; (2) reduction in antipsychotic medications or dosage; and (3) increased use of nonpharmacological interventions. The main themes relevant to needed assistance included the following: (1) education; (2) clinical support; and (3) increased financial resources and reimbursement. DISCUSSION Overall findings indicate that the majority of facilities are actively responding to the initiative, but challenges remain in education, finding mental health support, and in reimbursement.
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Affiliation(s)
- Michelle L Ellis
- School of Aging Studies, University of South Florida, Tampa, Florida; Florida Policy Exchange Center on Aging, University of South Florida, Tampa, Florida
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191
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Bliss DZ, Gurvich OV, Savik K, Eberly LE, Harms S, Wyman JF, Mueller C, Garrard J, Virnig B. Analysis of Racial and Ethnic Disparities as Possible Risk Factors for Development of Incontinence by Nursing Home Residents. Res Nurs Health 2015; 38:449-61. [PMID: 26340375 DOI: 10.1002/nur.21680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 11/10/2022]
Abstract
Incontinence is a common health problem among nursing home (NH) residents. Differences between black and white NH residents in incontinence prevalence have been reported. Although reducing health disparities is a principal objective of the national health care agenda, little is known about disparities in incidence of new incontinence in NHs. The purpose of this study was to assess whether there were racial/ethnic disparities in the time to development of incontinence in adults over age 65 who had been continent on NH admission. If no racial or ethnic disparities in time to incontinence were found, other predictors of time to incontinence would be explored. Three national databases were sources of data on 42,693 adults over 65 admitted to 446 for-profit NHs in a national chain. Multi-level predictors of time to any type of incontinence were analyzed, using Cox proportional hazards regression for white Non-Hispanic NH admissions and the Peters-Belson method for minority NH admissions: American Indians/Alaskan Natives, Asians/Pacific Islanders, Black non-Hispanics, and Hispanics. No racial/ethnic disparities in time to incontinence were found. Approximately 30% of all racial/ethnic groups had developed incontinence by 6 months. Those who developed incontinence sooner were older and had greater deficits in activities of daily living (ADL) and cognition. Results were consistent with past evidence and suggest that interventions to maintain continence from the time of admission should be applied across racial/ethnic groups.
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Affiliation(s)
- Donna Z Bliss
- School of Nursing, University of Minnesota, 5-140 Weaver-Densford Hall, 308 Harvard Street, Minneapolis, MN, 55455
| | - Olga V Gurvich
- School of Nursing, University of Minnesota, Minneapolis, MN
| | - Kay Savik
- School of Nursing, University of Minnesota, Minneapolis, MN
| | - Lynn E Eberly
- School of Public Health, University of Minnesota, Minneapolis, MN
| | - Susan Harms
- School of Nursing and Public Health, University of Minnesota, Minneapolis, MN
| | - Jean F Wyman
- School of Nursing, University of Minnesota, Minneapolis, MN
| | | | - Judith Garrard
- School of Nursing and Public Health, University of Minnesota, Minneapolis, MN
| | - Beth Virnig
- School of Nursing and Public Health, University of Minnesota, Minneapolis, MN
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192
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Eberly LE, Cunanan K, Gurvich O, Savik K, Bliss DZ, Wyman JF. Statistical Approaches to Assessing Health and Healthcare Disparities. Res Nurs Health 2015; 38:500-8. [PMID: 26340304 DOI: 10.1002/nur.21679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2015] [Indexed: 11/12/2022]
Abstract
Determining whether racial and ethnic disparities exist for a health-related outcome requires first specifying how outcomes will be measured and disparities calculated. We explain and contrast two common approaches for quantifying racial/ethnic disparities in health, with an applied example from nursing research. Data from a national for-profit chain of nursing homes in the US were analyzed to estimate racial/ethnic disparities in incidence of pressure ulcer within 90 days of nursing home admission. Two approaches were used and then compared: logistic regression and Peters-Belson. Advantages and disadvantages of each approach are given. Logistic regression can be used to quantify disparities as the odds of the outcome for one group relative to another. Peters-Belson can be used to quantify an overall disparity between groups as a risk difference and also provides the proportion of that disparity that is explained by available risk factors. Extensions to continuous outcomes, to survival outcomes, and to clustered data are outlined. Both logistic regression and Peters-Belson are easily implementable and interpretable and provide information on the predictors associated with the outcome. These disparity estimation methods have different interpretations, assumptions, strengths, and weaknesses, of which the researcher should be aware when planning an analytic approach.
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Affiliation(s)
- Lynn E Eberly
- Associate Professor, Division of Biostatistics, University of Minnesota, 420 Delaware St. SE, MMC 303, Minneapolis, MN, 55455
| | - Kristen Cunanan
- PhD Candidate, Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | - Olga Gurvich
- Senior Research Fellow, School of Nursing, University of Minnesota, Minneapolis, MN
| | - Kay Savik
- Senior Research Fellow, School of Nursing, University of Minnesota, Minneapolis, MN
| | - Donna Z Bliss
- Professor, School of Nursing, University of Minnesota, Minneapolis, MN
| | - Jean F Wyman
- Professor, School of Nursing, University of Minnesota, Minneapolis, MN
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193
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Rahman M, Galarraga O, Zinn JS, Grabowski DC, Mor V. The Impact of Certificate-of-Need Laws on Nursing Home and Home Health Care Expenditures. Med Care Res Rev 2015. [PMID: 26223431 DOI: 10.1177/1077558715597161] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Over the past two decades, nursing homes and home health care agencies have been influenced by several Medicare and Medicaid policy changes including the adoption of prospective payment for Medicare-paid postacute care and Medicaid-paid long-term home and community-based care reforms. This article examines how spending growth in these sectors was affected by state certificate-of-need (CON) laws, which were designed to limit the growth of providers and have remained unchanged for several decades. Compared with states without CON laws, Medicare and Medicaid spending in states with CON laws grew faster for nursing home care and more slowly for home health care. In particular, we observed the slowest growth in community-based care in states with CON for both the nursing home and home health industries. Thus, controlling for other factors, public postacute and long-term care expenditures in CON states have become dominated by nursing homes.
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Affiliation(s)
| | | | | | | | - Vincent Mor
- Brown University, Providence, RI, USA Providence Veterans Administration Medical Center, Health Services Research Program, Providence, RI, USA
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194
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Felix HC, Bradway C, Chisholm L, Pradhan R, Weech-Maldonado R. Prevalence of Moderate to Severe Obesity Among U.S. Nursing Home Residents, 2000–2010. Res Gerontol Nurs 2015; 8:173-8. [DOI: 10.3928/19404921-20150223-01] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 11/24/2014] [Indexed: 11/20/2022]
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195
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Shippee TP, Henning-Smith C, Rhee TG, Held RN, Kane RL. Racial Differences in Minnesota Nursing Home Residents' Quality of Life: The Importance of Looking Beyond Individual Predictors. J Aging Health 2015; 28:199-224. [PMID: 26112065 DOI: 10.1177/0898264315589576] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The aim of this study is to investigate racial differences in nursing home (NH) residents' quality of life (QOL) at the resident and facility levels. METHOD We used hierarchical linear modeling to identify significant resident- and facility-level predictors for racial differences in six resident-reported QOL domains. Data came from the following: (a) resident-reported QOL (n = 10,929), (b) the Minimum Data Set, and (c) facility-level characteristics from the Minnesota Department of Human Services (n = 376). RESULTS White residents reported higher QOL in five of six domains, but in full models, individual-level racial differences remained only for food enjoyment. On the facility level, higher percentage of White residents was associated with better scores in three domains, even after adjusting for all characteristics. DISCUSSION Racial differences in QOL exist on individual and aggregate levels. Individual differences are mainly explained by health status. The finding that facility racial composition predicts QOL more than individual race underscores the importance of examining NH structural characteristics and practices.
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Affiliation(s)
| | | | | | - Robert N Held
- Minnesota Department of Human Services, Minneapolis, USA
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196
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Herrin J, Kenward K, Joshi MS, Audet AMJ, Hines SJ. Assessing Community Quality of Health Care. Health Serv Res 2015; 51:98-116. [PMID: 26096649 DOI: 10.1111/1475-6773.12322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine the agreement of measures of care in different settings-hospitals, nursing homes (NHs), and home health agencies (HHAs)-and identify communities with high-quality care in all settings. DATA SOURCES/STUDY SETTING Publicly available quality measures for hospitals, NHs, and HHAs, linked to hospital service areas (HSAs). STUDY DESIGN We constructed composite quality measures for hospitals, HHAs, and nursing homes. We used these measures to identify HSAs with exceptionally high- or low-quality of care across all settings, or only high hospital quality, and compared these with respect to sociodemographic and health system factors. PRINCIPAL FINDINGS We identified three dimensions of hospital quality, four HHA dimensions, and two NH dimensions; these were poorly correlated across the three care settings. HSAs that ranked high on all dimensions had more general practitioners per capita, and fewer specialists per capita, than HSAs that ranked highly on only the hospital measures. CONCLUSION Higher quality hospital, HHA, and NH care are not correlated at the regional level; regions where all dimensions of care are high differ systematically from regions which score well on only hospital measures and from those which score well on none.
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Affiliation(s)
- Jeph Herrin
- Health Research & Educational Trust, Chicago, IL.,Yale University School of Medicine, New Haven CT, Charlottesville, VA
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Tyler DA, Shield RR, Miller SC. Diffusion of palliative care in nursing homes: lessons from the culture change movement. J Pain Symptom Manage 2015; 49:846-52. [PMID: 25499827 PMCID: PMC4441856 DOI: 10.1016/j.jpainsymman.2014.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 10/16/2014] [Accepted: 10/24/2014] [Indexed: 11/28/2022]
Abstract
CONTEXT Studies have found that nursing homes (NHs) that rely heavily on Medicaid funding are less likely to implement innovative approaches to care, such as palliative care (PC) or resident-centered approaches commonly referred to as "culture change" (CC). However, a nationally representative survey we previously conducted found that some high Medicaid facilities have implemented these innovative approaches. OBJECTIVES The purpose of this study was to identify the factors that enable some high Medicaid NHs to implement innovative approaches to care. METHODS We conducted telephone interviews with 16 NH administrators in four categories of facilities: 1) low PC and low CC, 2) low PC and high CC, 3) high PC and low CC, and 4) high PC and high CC. Interviews explored strategies used to overcome barriers to implementation and the resources needed for implementation. RESULTS We had expected to find differences between low and high NHs but instead found differences in NHs' experiences with CC and PC. Since the time of our national survey in 2009-2010, most previously low CC NHs had implemented at least some CC practices; however, we did not find similar changes around PC. Administrators reported numerous ways in which they had received information and assistance from outside entities for implementing CC. This was not the case for PC where administrators reported relying exclusively and heavily on hospices for both their residents' PC needs and information related to PC. CONCLUSION PC advocates could learn much from the CC model in which advocates have used multipronged efforts to institute reform.
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Affiliation(s)
- Denise A Tyler
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA; Health Services Research Program, Providence Veterans Administration Medical Center, Providence, Rhode Island, USA.
| | - Renée R Shield
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Susan C Miller
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
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198
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Hall RK, Toles M, Massing M, Jackson E, Peacock-Hinton S, O'Hare AM, Colón-Emeric C. Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities. Clin J Am Soc Nephrol 2015; 10:428-34. [PMID: 25649158 DOI: 10.2215/cjn.03510414] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Older adults with ESRD often receive care in skilled nursing facilities (SNFs) after an acute hospitalization; however, little is known about acute care use after SNF discharge to home. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study used Medicare claims for North and South Carolina to identify patients with ESRD who were discharged home from a SNF between January 1, 2010 and August 31, 2011. Nursing Home Compare data were used to ascertain SNF characteristics. The primary outcome was time from SNF discharge to first acute care use (hospitalization or emergency department visit) within 30 days. Cox proportional hazards models were used to identify patient and facility characteristics associated with the outcome. RESULTS Among 1223 patients with ESRD discharged home from a SNF after an acute hospitalization, 531 (43%) had at least one rehospitalization or emergency department visit within 30 days. The median time to first acute care use was 37 days. Characteristics associated with a shorter time to acute care use were black race (hazard ratio [HR], 1.25; 95% confidence interval [95% CI], 1.04 to 1.51), dual Medicare-Medicaid coverage (HR, 1.24; 95% CI, 1.03 to 1.50), higher Charlson comorbidity score (HR, 1.07; 95% CI, 1.01 to 1.12), number of hospitalizations during the 90 days before SNF admission (HR, 1.12; 95% CI, 1.03 to 1.22), and index hospital discharge diagnoses of cellulitis, abscess, and/or skin ulcer (HR, 2.59; 95% CI, 1.36 to 4.45). Home health use after SNF discharge was associated with a lower rate of acute care use (HR, 0.72; 95% CI, 0.59 to 0.87). There were no statistically significant associations between SNF characteristics and time to first acute care use. CONCLUSIONS Almost one in every two older adults with ESRD discharged home after a post-acute SNF stay used acute care services within 30 days of discharge. Strategies to reduce acute care utilization in these patients are needed.
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Affiliation(s)
- Rasheeda K Hall
- Durham Veterans Affairs Geriatric Research, Education, and Clinical Center, Durham, North Carolina; Divisions of Nephrology and
| | - Mark Toles
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark Massing
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eric Jackson
- Carolinas Center for Medical Excellence Inc, Cary, North Carolina
| | | | - Ann M O'Hare
- Hospital and Specialty Medicine and Health Services R&D Center of Excellence, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; and Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Cathleen Colón-Emeric
- Durham Veterans Affairs Geriatric Research, Education, and Clinical Center, Durham, North Carolina; Geriatrics, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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199
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Kasper JD, Freedman VA. Findings from the 1st round of the National Health and Aging Trends Study (NHATS): introduction to a special issue. J Gerontol B Psychol Sci Soc Sci 2015; 69 Suppl 1:S1-7. [PMID: 25342818 DOI: 10.1093/geronb/gbu125] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Judith D Kasper
- Johns Hopkins University Bloomberg School of Public Health Baltimore, Maryland Institute for Social Research, University of Michigan, Ann Arbor
| | - Vicki A Freedman
- Johns Hopkins University Bloomberg School of Public Health Baltimore, Maryland Institute for Social Research, University of Michigan, Ann Arbor
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200
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Rahman M, Foster AD. Racial segregation and quality of care disparity in US nursing homes. JOURNAL OF HEALTH ECONOMICS 2015; 39:1-16. [PMID: 25461895 PMCID: PMC4293270 DOI: 10.1016/j.jhealeco.2014.09.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 09/18/2014] [Accepted: 09/20/2014] [Indexed: 05/13/2023]
Abstract
In this paper, we examine the contributions of travel distance and preferences for racial homogeneity as sources of nursing home segregation and racial disparities in nursing home quality. We first theoretically characterize the distinctive implications of these mechanisms for nursing home racial segregation. We then use this model to structure an empirical analysis of nursing home sorting. We find little evidence of differential willingness to pay for quality by race among first-time nursing home entrants, but do find significant distance and race-based preference effects. Simulation exercises suggest that both effects contribute importantly to racial disparities in nursing home quality.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Box G-S121(6), Providence, RI 02912, United States.
| | - Andrew D Foster
- Department of Economics and Health Services Policy and Practice, Brown University, 64 Waterman street, Providence, RI 02912, United States.
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