Intended and unintended consequences of minimum staffing standards for nursing homes

Mental health in nursing homes: The role of immigration in the long-term care workforce

One-fourth of nursing home residents are diagnosed with anxiety disorders and approximately half live with depression. Nursing homes have long struggled with staffing shortages, and the lack of care has further heightened the risk of poor mental health. A key solution to both problems could be immigration. Prior studies have documented how immigrant labor could strengthen the long-term care workforce. We add to this picture by exploring the impact of immigrant inflows on the mental health outcomes of nursing home residents. Using a nationally representative dataset and a shift-share instrumental variable approach, we find empirical evidence that immigration reduces diagnoses of depression and anxiety, the use of antidepressant and antianxiety drugs, and self-assessed symptoms of depression. The results are robust to several sensitivity tests. We further find that the effect is more substantial in facilities with lower direct care staff hours per resident and with likely more immigrants without citizenship. Language barriers tend to be a minor issue when providing essential care. The findings suggest that creating a policy framework that directs immigrant labor to the long-term care sector can mutually benefit job-seeking immigrants and nursing home residents.

Home time and state regulations among Medicare beneficiaries in assisted living communities

BACKGROUND

Home time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed nurse staffing.

METHODS

Medicare beneficiaries who entered AL communities in 2018 were identified, and their home time in the year following admission was measured. Home time was calculated as the percentage of time spent at home per day being alive. Resident characteristics and state regulations in DCW staffing, DCW training, and licensed staffing were measured. We used a multivariate linear regression model with AL-level fixed effects to estimate the relationship between person-level characteristics and home time. Linear regression models adjusting for resident characteristics were used to estimate the association between state regulations and residents' home time.

RESULTS

The study sample included 59,831 new Medicare beneficiary residents in 12,143 ALs. In the year following AL admission, residents spent 94% (standard deviation = 14.6) of their time at home. Several resident characteristics were associated with lower home time: Medicare-Medicaid dual eligibility, having more chronic conditions, and specific chronic conditions, for example, dementia. In states with greater regulatory specificity for DCW training and staffing, and lower specificity for licensed staffing, residents had longer adjusted home time.

CONCLUSION/IMPLICATIONS

Home time varied substantially among AL residents depending on resident characteristics and state-level regulatory specificity. AL residents eligible for Medicare and Medicaid had substantially shorter home time than the Medicare-only residents, largely due to longer time spent in nursing homes. State AL regulatory specificity for DCWs and licensed staff also impacted AL residents' home time. These findings may guide AL operators and state legislators in efforts to improve this important quality of life metric.

Nursing Home Staffing: Share Of Immigrant Certified Nursing Assistants Grew As US-Born Staff Numbers Fell, 2010-21

Nursing homes have long faced a shortage of direct care workers, a problem that was magnified during the COVID-19 pandemic. Using nationally representative data from three sources, we found that much of the certified nursing assistant (CNA) workforce in US nursing homes is filled by immigrant labor. The number of native-born CNAs has been declining rapidly since the mid-2010s, whereas the number of foreign-born CNAs has remained relatively constant. During the first two years of the COVID-19 pandemic, the share of immigrant CNAs employed by nursing homes surged, which can be explained by a simultaneous drop in the share of native-born staff. Staffing shortages observed during the pandemic would have been worse if not for foreign-born CNAs remaining in the workforce. However, the share of foreign-born CNAs varied considerably across states, from less than 1 percent in West Virginia to more than 70 percent in Hawaii. In an analysis of prepandemic data, we found that nursing homes in regions with a higher share of immigrant CNAs were associated with more direct care staff hours per resident day and better nursing home quality performance. With the growing demand for long-term care, creating pathways for job-seeking immigrants to fill the gaps in direct care will be crucial to meeting future staffing needs.

Assessing the impact of enforcement and compliance with minimum staffing standards on the quality of care in nursing homes: Evidence from the Centers for Medicare and Medicaid Services' staff star rating downgrade policy

Policymakers have historically attempted to influence quality in nursing homes through the imposition of minimum staffing standards and through the public dissemination of quality on websites like Care Compare. One current Federal standard necessitates a registered nurse (RN) on duty for at least eight consecutive hours each day. In 2018, the Centers for Medicare and Medicaid Services announced that they would incentivize compliance with this requirement by downgrading nursing homes with 7+ days without an RN present during the quarter by one star on their Care Compare staffing domain quality rating. This study evaluates the impact of this new enforcement mechanism. Using an intent-to-treat sample of nursing homes at risk for downgrade with difference-in-differences and event study models, it finds that the policy increased compliance and staffing levels. Using the policy to instrument for full compliance, it finds that the daily presence of an RN causally improves several quality dimensions.

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Paying for the view? How nursing home prices affect certified staffing ratios

Many countries limit public and private reimbursement for nursing care costs for social or financial reasons. Still, quality varies across nursing homes. We explore the causal link between case-mix adjusted nurse staffing ratios as an indicator of care quality and different price components in Swiss nursing homes. The Swiss reimbursement system limits and subsidizes the care price at the cantonal level, which implicitly limits staffing ratios, while the residents cover the nursing home-specific lodging price privately. To estimate causal effects, we exploit (i) the exogeneity of the Swiss care price regulation, (ii) nursing-home fixed effects estimations and (iii) instrumental variables for the lodging price. Our estimates show a positive impact of prices on certified staffing ratios. We find that a 10% increase in care prices increases certified staffing ratios by 3-4%. A comparable 10% increase in lodging prices raises certified staffing ratios by 1.5-10% (depending on the model). Our findings highlight that price limits for nursing care impose a limit on staffing ratios. Furthermore, our results indicate that providers circumvent price limits by increasing lodging prices that are privately covered. Thus, this cost shifting implicitly shifts the financial burden to the residents.

More than just staffing? Assessing evidence on the complex interplay among nurse staffing, other features of organisational context and resident outcomes in long-term care: a systematic review protocol

INTRODUCTION

Especially in acute care, evidence points to an association between care staffing and resident outcomes. However, this evidence is more limited in residential long-term care (LTC). Due to fundamental differences in the population of care recipients, organisational processes and staffing models, studies in acute care may not be applicable to LTC settings. We especially lack evidence on the complex interplay among nurse staffing and organisational context factors such as leadership, work culture or communication, and how these complex interactions influence resident outcomes. Our systematic review will identify and synthesise the available evidence on how nurse staffing and organisational context in residential LTC interact and how this impacts resident outcomes.

METHODS AND ANALYSIS

We will systematically search the databases MEDLINE, EMBASE, CINAHL, Scopus and PsycINFO from inception for quantitative research studies and systematically conducted reviews that statistically modelled interactions among nurse staffing and organisational context variables. We will include original studies that included nurse staffing and organisational context in LTC as independent variables, modelled interactions between these variables and described associations of these interactions with resident outcomes. Two reviewers will independently screen titles/abstracts and full texts for inclusion. They will also screen contents of key journals, publications of key authors and reference lists of all included studies. Discrepancies at any stage of the process will be resolved by consensus. Data extraction will be performed by one research team member and checked by a second team member. Two reviewers will independently assess the methodological quality of included studies using four validated checklists appropriate for different research designs. We will conduct a meta-analysis if pooling is possible. Otherwise, we will synthesise results using thematic analysis and vote counting.

ETHICS AND DISSEMINATION

Ethical approval is not required as this project does not involve primary data collection. The results of this study will be disseminated via peer-reviewed publications and conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42021272671.

The Need for an Economically Feasible Nursing Home Staffing Regulation: Evaluating an Acuity-Based Nursing Staff Benchmark

Background and Objectives

Despite concerns about the adequacy of nursing home (NH) staffing, the federal agency responsible for NH certification and regulation has never adopted an explicit quantitative nursing staff standard. A prior study has proposed a benchmark for this purpose based on the 1995/97 Staff Time Measurement (STM) studies. This article aims to assess the extent to which NHs staff to this proposed STM benchmark, the extent to which regulators already implicitly apply the STM benchmark, and compute the additional operating expenses NHs would incur to adhere to the STM benchmark.

Research Design and Methods

Using NH Compare Archive data, the STM benchmark was compared to staffing levels reported by the facility and whether NHs received a nursing staff deficiency. Using financial information from Medicare Cost Reports, the additional annual operating expenses required to staff to the STM benchmark were calculated for each state and nationwide.

Results

The vast majority of NHs did not staff to the STM benchmark; 80.2% for registered nurses and 60.0% for total nursing staff. Deficiency patterns showed that NH regulators were not using the STM benchmark to determine sufficiency of nursing staff. Implementing the STM benchmark as a regulatory standard would increase operating expenses for 59.1% of NHs, at an average annual cost of half-million dollars per facility. The nationwide increase in operating expense is estimated to be at least $4.9 billion per year.

Discussion and Implications

Without clear guidance on the staffing level needed to be sufficiently staffed, most NHs are subject to a community standard of care, which some have argued could be associated with suboptimal staffing levels. Implementing an acuity-based benchmark could result in improved staffing levels but also comes with significant economic costs. The STM benchmark is not economically feasible at current Medicare and Medicaid reimbursement levels.

Facility characteristics and costs associated with meeting proposed minimum staffing levels in skilled nursing facilities

BACKGROUND

Federal minimum nurse staffing levels for skilled nursing facilities (SNFs) were proposed in 2019 U.S. Congressional bills. We estimated costs and personnel needed to meet the proposed staffing levels, and examined characteristics of SNFs not meeting these thresholds.

METHODS

This was a cross-sectional analysis of 2019Q4 payroll data, the Hospital Wage Index, and other administrative data for 14,964 Medicare and Medicaid-certified SNFs. We examined characteristics of SNFs not meeting proposed minimum thresholds: 4.1 total nursing hours per resident day (HPRD); 0.75 registered nurse (RN) HPRD; 0.54 licensed practical nurse (LPN) HPRD; and 2.81 certified nursing assistant (CNA) HPRD. For SNFs falling below the thresholds, we calculated the additional HPRD needed, along with the associated full-time equivalent (FTE) personnel and salary costs.

RESULTS

In 2019, 25.0% of SNFs met the minimum 4.1 total nursing HPRD, while 31.0%, 84.5%, and 10.7% met the RN, LPN, and CNA thresholds, respectively. Only 5.0% met all four categories. In adjusted analyses, factors most strongly associated with SNFs not meeting the proposed minimums were: higher Medicaid census, larger bed size, for-profit ownership, higher county SNF competition; and, for RNs specifically, higher community poverty and lower Medicare census. Rural SNFs were less likely to meet all categories and this was explained primarily by county SNF competition. We estimate that achieving the proposed federal minimums across SNFs nationwide would require an estimated additional 35,804 RN, 3509 LPN, and 116,929 CNA FTEs at $7.25 billion annually in salary costs based on current wage rates and prepandemic resident census levels.

CONCLUSIONS

Achieving proposed minimum nurse staffing levels in SNFs will require substantial financial investment in the workforce and targeted support of low-resource facilities. Extensive recruitment and retention efforts are needed to overcome supply constraints, particularly in the aftermath of the COVID-19 pandemic.

Nursing Home Residents With Dementia: Association Between Place of Death and Patient Safety Culture

BACKGROUND AND OBJECTIVES

Nursing homes (NHs) care for 70% of Americans dying with dementia. Many consider deaths in NHs rather than hospitals as preferable for most of these residents. NH characteristics such as staff teamwork, communication, and other components of patient safety culture (PSC), together with state minimum NH nurse staffing requirements, may influence location of death. We examined associations between these variables and place of death (NH/hospital) among residents with dementia.

RESEARCH DESIGN AND METHODS

Cross-sectional study of 11,957 long-stay NH residents with dementia, age 65+, who died in NHs or hospitals shortly following discharge from one of 800 U.S. NHs in 2017. Multivariable logistic regression systematically estimated effects of PSC on odds of in-hospital death among residents with dementia, controlling for resident, NH, county, and state characteristics. Logistic regressions also determined moderating effects of state minimum NH nurse staffing requirements on relationships between key PSC domains and location of death.

RESULTS

Residents with dementia in NHs with higher PSC scores in communication openness had lower odds of in-hospital death. This effect was stronger in NHs located in states with higher minimum NH nurse staffing requirements.

DISCUSSION AND IMPLICATIONS

Promoting communication openness in NHs across nursing disciplines may help avoid unnecessary hospitalization at the end of life, and merits particular attention as NHs address nursing staff mix while adhering to state staffing requirements. Future research to better understand unintended consequences of staffing requirements is needed to improve end-of-life care in NHs.

Considering the new minimum staffing standards for Australian residential aged care

ObjectiveTo compare the historical staffing patterns and organisational characteristics of Australian residential aged care facilities (RACFs) against the new minimum staffing standards recommended by the Royal Commission into Aged Care Quality and Safety (RCACQS).MethodRetrospective data analysis was used to compare the staffing levels and characteristics of 1705 RACFs (for 4 years, 2016-19) with the three new mandatory staffing requirements. De-identified datasets were provided by the RCACQS, obtained under its legal authority.ResultsOnly 3.8% of RACFs have staffing levels at or above all three requirements. Although many (79.7%) already meet the requirement to have a registered nurse (RN) on-site for morning and afternoon shifts, few have staffing levels above requirements for total direct care per resident per day (10.4%) or care provided by an RN per resident per day (11.1%). Historical levels of on-site RNs, total direct care, and RN care vary significantly across facilities of different size, location and provider scale.ConclusionThe new staffing standards, to be mandatory by 2023, prescribe minimum requirements significantly higher than existing levels, particularly in care per resident per day. Each of the three requirements will likely have a differential effect for different types of RACFs.What is known about the topic?International evidence suggests that introducing mandatory minimum staffing standards tends to increase the amount of care provided by staff in residential aged care facilities (RACFs). However, the impact of staffing standards is influenced by the stringency of the minimum threshold relative to existing staffing levels, the capacity of organisations to increase their staffing levels, and the specific way the regulation is formulated.What does this paper add?This paper explores the potential implications of the three national minimum staffing standards, to be in force by October 2023, specifying total direct care, care received by a registered nurse (RN), and an RN on-site. By examining the existing staffing levels of Australian RACFs, it identifies the extent to which facilities already meet the new standards and the characteristics of facilities with staffing levels above and below the three requirements (individually and in combination).What are the implications for practitioners?The study informs both policy and practice in relation to the likely effects of implementing the national minimum staffing standards for residential aged care in Australia. It demonstrates that the new minimum thresholds are likely to require substantial increases in staffing across the sector, both in terms of all direct care workers and RNs. It also shows that the three requirements are likely to have a differential effect for RACFs of different size, location and chain affiliation, thereby guiding policy about the future needs for Australia's aged care workforce.

The relationship between quality and staffing in long-term care: A systematic review of the literature 2008-2020

BACKGROUND

Higher staffing levels in long-term care have been associated with better outcomes for residents in several landmark studies. However previous systematic reviews found mixed results, calling into question the effectiveness of higher levels of staff. With persistent concerns about quality, rising resident acuity, and a growing demographic of seniors requiring more services, understanding the relationship between quality and long-term care staffing is a growing concern.

OBJECTIVES

This review considered the following question: What is the influence of nursing and personal care staffing levels (registered nurse, licensed practical nurse, and nursing assistant) and / or skill mix on long-term care residents, measured by quality of care indicators?

DESIGN

Preferred Reporting Items for Systematic Review and Meta-analysis Protocols guided the report of this systematic review.

DATA SOURCES

Published articles focused on quality and nursing and personal care staffing in long-term care in peer-reviewed databases (MEDLINE, CINAHL, and AGELINE) and several Cochrane databases to retrieve studies published between January 2008 and June 2020.

REVIEW METHODS

A systematic review was conducted. 11,096 studies were identified, of which 34 were included in this review. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to evaluate study quality and risk of bias, and five quality measures were selected for in-depth analyses: pressure ulcers, hospitalizations, physical restraints, deficiencies and catherization.

RESULTS

This review confirms previous review findings that evidence on the relationships between quality and long-term care staffing level and skill mix, remain mixed. Higher staffing levels and skill mix generally supported better rather than worse outcomes. Significant and consistent findings were more evident when staffing levels were further analyzed by indicator and staffing category. For example, registered nurses were consistently associated with significantly fewer pressure ulcers, hospitalizations, and urinary tract infections. Few studies examined the impact of total nursing and personal care hours compared to the impact of specific categories or classes of nursing staff on outcomes.

CONCLUSIONS

Evidence on the relationship between quality and long-term care staffing remains mixed, however some categories of nursing staff may be more effective at improving the quality of certain indicators. Study quality has improved minimally over the last decade. Although research continues to standardize units of measurement, and longitudinal and instrumental variable analyses are increasingly being used, very few studies controlled for endogeneity, conducted adequate risk-adjustment, and used resident-level data. Additional strides must still be made to improve the rigor of long-term care staffing research.

Larger Nursing Home Staff Size Linked To Higher Number Of COVID-19 Cases In 2020

Staff in skilled nursing facilities (SNFs) are essential health care workers, yet they can also be a source of COVID-19 transmission. We used detailed staffing data to examine the relationship between a novel measure of staff size (that is, the number of unique employees working daily), conventional measures of staffing quality, and COVID-19 outcomes among SNFs in the United States without confirmed COVID-19 cases by June 2020. By the end of September 2020, sample SNFs in the lowest quartile of staff size had 6.2 resident cases and 0.9 deaths per 100 beds, compared with 11.9 resident cases and 2.1 deaths per 100 beds among facilities in the highest quartile. Staff size, including staff members not involved in resident care, was strongly associated with SNFs' COVID-19 outcomes, even after facility size was accounted for. Conventional staffing quality measures, including direct care staff-to-resident ratios and skill mix, were not significant predictors of COVID-19 cases or deaths. Reducing the number of unique staff members without decreasing direct care hours, such as by relying on full-time rather than part-time staff, could help prevent outbreaks.

The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review

Aim

Aim of this study is to systematically review and synthesize available evidence to identify the association between nurse staffing methodologies and nurse and patient outcomes.

Design

Systematic review and narrative synthesis.

Data sources

A search of MEDLINE (EBSCO), CINAHL (EBSCO) and Web of Science was conducted for studies published in English between January 2000 and January 2020.

Review methods

The reporting of this review and narrative synthesis was guided by the preferred reporting items for systematic and meta‐analysis guidelines (PRISMA) statement and data synthesis guided by the Synthesis Without Meta‐analysis (SWiM) guideline. The quality of each article was assessed using the Mixed Methods Appraisal Tool.

Results

Twenty‐two studies met the inclusion criteria. Twenty‐one used the mandated minimum nurse‐to‐patient ratio methodology and one study assessed the number of nurse hours per patient day staffing methodology. Both methodologies were mandated. All studies that reported on nurse outcomes demonstrated an improvement associated with the implementation of mandated minimum nurse‐to‐patient ratio, but findings related to patient outcomes were inconclusive.

Conclusions

Evidence on the impact of specific nurse staffing methodologies and patient and nurse outcomes remains highly limited. Future studies that examine the impact of specific staffing methodologies on outcomes are required to inform this fundamental area of management and practice.

Presenteeism Among Nurses in Switzerland and Portugal and Its Impact on Patient Safety and Quality of Care: Protocol for a Qualitative Study

Background

Nurses dispense direct care in a wide variety of settings and are considered the backbone of the health care system. They often work long hours, face emotional stress, and are at a high risk of psychosocial and somatic illnesses. Nurses sometimes fall sick but work regardless, leading to presenteeism and subsequent risks to quality of care and patient safety due to the increased likelihood of patients falling, medication errors, and staff-to-patient disease transmission.

Objective

This study aims to understand presenteeism among frontline nurses and nurse managers in acute, primary, and long-term health care settings and to contribute to the development of future interventional studies and recommendations.

Methods

A qualitative study based on online focus group discussions will explore the perceptions of, attitudes to, and experiences with presenteeism among frontline nurses and nurse managers. Using a pilot-tested interview guide, 8 focus group discussions will involve nurses working in acute care hospitals, primary care settings, and long-term residential care facilities in Switzerland’s French-speaking region and Portugal’s Center region. The data collected will be examined using a content analysis approach via NVivo 12 QSR International software.

Results

The University of Applied Sciences and Arts Western Switzerland’s School of Health Sciences and the Polytechnic of Leiria’s School of Health Sciences in Portugal have both approved funding for the study. The research protocol has been approved by ethics committees in both countries. Study recruitment commenced in February 2021. The results of the data analysis are expected by September 2021.

Conclusions

This present study aims to gain more insight into the dilemmas facing nurses as a result of all causes of presenteeism among frontline nurses and nurse managers in different health care settings. The researchers will prepare manuscripts on the study’s findings, publish them in relevant peer-reviewed journals, exhibit them in poster presentations, and give oral presentations at appropriate academic and nonscientific conferences. Regarding further knowledge transfer, researchers will engage with stakeholders to craft messages focused on the needs of nurses and nurse managers and on disseminating our research findings to deal with the issue of nursing presenteeism.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27963

End-of-Life Care among Nursing Home Residents with Dementia Varies by Nursing Home and Market Characteristics

OBJECTIVES

Nursing homes (NHs) are critical end-of-life (EOL) care settings for 70% of Americans dying with Alzheimer's disease/related dementias (ADRD). Whether EOL care/outcomes vary by NH/market characteristics for this population is unknown but essential information for improving NH EOL care/outcomes. Our objectives were to examine variations in EOL care/outcomes among decedents with ADRD and identify associations with NH/market characteristics.

DESIGN

Cross-sectional.

OUTCOMES

Place-of-death (hospital/NH), presence of pressure ulcers, potentially avoidable hospitalizations (PAHs), and hospice use at EOL. Key covariates were ownership, staffing, presence of Alzheimer's units, and market competition.

SETTING AND PARTICIPANTS

Long-stay NH residents with ADRD, age 65 + years of age, who died in 2017 (N = 191,435; 14,618 NHs) in NHs or hospitals shortly after NH discharge.

METHODS

National Medicare claims, Minimum Data Set, public datasets. Descriptive analyses and multivariable logistic regressions.

RESULTS

As ADRD severity increased, adjusted rates of in-hospital deaths and PAHs decreased (17.0% to 6.3%; 11.2% to 7.0%); adjusted rates of dying with pressure ulcers and hospice use increased (8.2% to 13.5%; 24.5% to 40.7%). Decedents with moderate and severe ADRD had 16% and 13% higher likelihoods of in-hospital deaths in for-profit NHs. In NHs with Alzheimer's units, likelihoods of in-hospital deaths, dying with pressure ulcers, and PAHs were significantly lower. As ADRD severity increased, higher licensed nurse staffing was associated with 14%‒27% lower likelihoods of PAHs. Increased NH market competition was associated with higher likelihood of hospice use, and lower likelihood of in-hospital deaths among decedents with moderate ADRD.

CONCLUSIONS AND IMPLICATIONS

Decedents with ADRD in NHs that were nonprofit, had Alzheimer's units, higher licensed nurse staffing, and in more competitive markets, had better EOL care/outcomes. Modifications to state Medicaid NH payments may promote better EOL care/outcomes for this population. Future research to understand NH care practices associated with presence of Alzheimer's units is warranted to identify mechanisms possibly promoting higher-quality EOL care.

Nursing Staff Time and Care Quality in Long-Term Care Facilities: A Systematic Review

BACKGROUND AND OBJECTIVES

In long-term care (LTC) facilities, nursing staff are important contributors to resident care and well-being. Despite this, the relationships between nursing staff coverage, care hours, and quality of resident care in LTC facilities are not well understood and have implications for policy-makers. This systematic review summarizes current evidence on the relationship between nursing staff coverage, care hours, and quality of resident care in LTC facilities.

RESEARCH DESIGN AND METHODS

A structured literature search was conducted using four bibliographic databases and gray literature sources. Abstracts were screened by two independent reviewers using Covidence software. Data from the included studies were summarized using a pretested extraction form. The studies were critically appraised, and their results were synthesized narratively.

RESULTS

The systematic searched yielded 15,842 citations, of which 54 studies (all observational) were included for synthesis. Most studies (n = 53, 98%) investigated the effect of nursing staff time on resident care. Eleven studies addressed minimum care hours and quality of care. One study examined the association between different nursing staff coverage models and resident outcomes. Overall, the quality of the included studies was poor.

DISCUSSION AND IMPLICATIONS

Because the evidence was inconsistent and of low quality, there is uncertainty about the direction and magnitude of the association between nursing staff time and type of coverage on quality of care. More rigorously designed studies are needed to test the effects of different cutoffs of care hours and different nursing coverage models on the quality of resident care in LTC facilities.

Developing scaled tools for residential and nursing home inspection: feasibility study

Purpose

This study explored the feasibility of developing scaled inspection tools for use during external inspection of health and social care facilities to give improved accuracy in identifying facilities “at risk”, a tool for risk-adjusted frequency of inspection, and greater consistency of judgements.

Design/methodology/approach

This paper summarises the development through working groups and workshops involving 20 experienced inspectors (nurses and social workers) of the Regulation and Quality Improvement Authority who inspect the 206 nursing and 182 residential care homes in Northern Ireland. A brief evaluation survey, including response to a case vignette, gathered inspectors' views after using the tools for six months.

Findings

Eight two-dimensional Scaled Inspection Tools were created, each embodying a scale of performance (seriousness of risk issue) and a scale of the ability of the facility to manage that issue, each axis comprising four points. The Scaled Inspection Tools were used for on-site inspections during 2017–18. Evaluative comments were generally positive. The case vignette seemed to highlight greater risk aversion amongst newer inspectors.

Research limitations/implications

The creation of scaled inspection tools adds credibility to the potential for developing risk-based governance in service regulation. Further testing of domains and their scope is required.

Practical implications

Prompts for each domain were found essential to guide inspectors. Despite the challenge of change, inspectors became enthusiastic about use for evaluating risks, and managers about improvements in consistency of inspection.

Social implications

Knowledge derived from statistical approaches needs to be incorporated into inspection and regulation, just as in other aspects of professional practice.

Originality/value

Scaled inspection tools, with two orthogonal axes corresponding to seriousness of risk and ability to manage the risk (inverse of likelihood of harm), proved acceptable and intuitive in use. The study gives credibility to the possibility of developing screening and surveillance approaches to risk-based governance in service regulation.

Standards in Regulating Quality of Adult Community Health and Social Care: Systematic Narrative Review

PURPOSE

The growing range and complexity of community care services require robust approaches to ensuring quality.

METHOD

This review collated studies on the use of standards in regulating community health and social care using Social Care Online, MEDLINE and CINAHL databases. Studies were appraised by two reviewers and synthesized by study themes.

RESULTS

Sixteen studies were synthesized under three themes: standards in quality assurance and quality improvement; effectiveness of standards; and design of regulatory standards. Standards facilitate providers in self-regulation and enable regulators to support and monitor improvement. Effectiveness of standards depends on their language and interpretation, and on organizational factors. There was little evidence of scales within quality standards.

DISCUSSION

There is continuing debate about self-regulation versus external regulation. Social care service regulation requires more research.

CONCLUSION

Regulatory organizations should take note of wider initiatives toward evidence-based practice in the design of quality standards.

Quality Concerns in Nursing Homes That Serve Large Proportions of Residents With Serious Mental Illness

Background and Objectives

Nursing homes (NHs) are serving greater proportions of residents with serious mental illness (SMI), and it is unclear whether this affects NH quality. We analyze the highest and lowest quartiles of NHs based on the proportion of residents with SMI and compare these NHs on facility characteristics, staffing, and quality stars.

Research Design and Methods

National Certification and Survey Provider Enhanced Reports data were merged with NH Compare data for all freestanding certified NHs in the continental United States in 2016 (N = 14,460). NHs were categorized into “low-SMI” and “high-SMI” facilities using the lowest and highest quartiles, respectively, of the proportion of residents in the NH with SMI. Bivariate analyses and logistic models were used to examine differences in organizational structure, payer mix, resident characteristics, and staffing levels associated with high-SMI NHs. Linear models examined differences in quality stars.

Results

High-SMI facilities were found to report lower direct-care staffing hours, have a greater Medicaid-paying resident census, were more likely to be for-profit, and scored lower on all NH Compare star ratings in comparison to all other NHs.

Discussion and Implications

As the SMI population in NHs continues to grow, a large number of residents have concentrated in a few NHs. These are uniquely different from typical NHs in terms of facility characteristics, staffing, and care practices. While further research is needed to understand the implications of these trends, public policymakers and NH providers need to be aware of this population’s unique—and potentially unmet—needs.

The cyclicality of informal care

This paper measures the cyclicality of an important input into elderly health: informal care. Using independent survey measures of informal caregiving and care receipt over the past two decades, we find that informal care from adult children to their elderly parents is countercyclical. By contrast, informal care from spouses is procyclical among individuals in their sixties. We find little corresponding change in the use of formal care, highlighting the potential for unmet care needs across the business cycle. These findings suggest that informal health inputs may play an important role in the interpretation of the cyclicality of elderly mortality.

The Impact of the Long-term Care Homes Act and Public Reporting on Physical Restraint and Potentially Inappropriate Antipsychotic Use in Ontario's Long-term Care Homes

BACKGROUND

We report on the impact of two system-level policy interventions (the Long-Term Care Homes Act [LTCHA] and Public Reporting) on publicly reported physical restraint use and non-publicly reported potentially inappropriate use of antipsychotics in Ontario, Canada.

METHODS

We used interrupted time series analysis to model changes in the risk-adjusted use of restraints and antipsychotics before and after implementation of the interventions. Separate analyses were completed for early ([a] volunteered 2010/2011) and late ([b] volunteered March 2012; [c] mandated September 2012) adopting groups of Public Reporting. Outcomes were measured using Resident Assessment Instrument Minimum Data Set (RAI-MDS) data from January 1, 2008 to December 31, 2014.

RESULTS

For early adopters, enactment of the LTCHA in 2010 was not associated with changes in physical restraint use, while Public Reporting was associated with an increase in the rate (slope) of decline in physical restraint use. By contrast, for the late-adopters of Public Reporting, the LTCHA was associated with significant decreases in physical restraint use over time, but there was no significant increase in the rate of decline associated with Public Reporting. As the LTCHA was enacted, potentially inappropriate use of antipsychotics underwent a rapid short-term increase in the early volunteer group, but, over the longer term, their use decreased for all three groups of homes.

CONCLUSIONS

Public Reporting had the largest impact on voluntary early adopters while legislation and regulations had a more substantive positive effect upon homes that delayed public reporting.

Capacity constraints and time allocation in public health clinics

Unlike in the production of most goods, changes in capacity for labor-intensive services only affect outcomes of interest insofar as service providers change the way they allocate their time in response to those capacity changes. In this paper, we examine how public sector service providers respond to unexpected capacity constraints in the specific context of public health clinics. We exploit an exogenous reduction in public health clinic capacity to quantify the trade-off between patients treated and time spent with each patient, which we treat as a proxy for a quality versus quantity decision. We provide evidence that these small and generally insignificant effects on nurse time favor public sector employees prioritizing quality of each interaction over clearing the patient queue.

Factors Relating to the Quality of Care for Nursing Home Residents in Korea: Using the Delphi Method

PURPOSE

This study identified factors related to the quality of care in nursing homes, and elicited consensus opinions from experts on nursing homes.

METHODS

A Delphi questionnaire was developed based on a review of the literature using the keywords "nursing homes," "workforce," and "quality of care." A total of two Delphi surveys were conducted with 14 experts. The important and urgent factors related to the quality of care for nursing home residents emerged.

RESULTS

A consensus was achieved on the important and urgent factors relating to the quality of care. The related factors were grouped into four sections: Organizational Characteristics, Staffing Characteristics, the Long-Term Care Market and Legal and Policy Issues, and Nursing Processes. In total, 23 items were important factors and 26 items were urgent factors relating to the quality of care. In addition, the unanimous advocacy by the experts for increased hours per resident day for registered nurses (RNs, 41 minutes 59 seconds) was much higher than the current hours per resident day of RNs in Korea.

CONCLUSION

To provide optimal care for residents in nursing homes in Korea, the mandatory and essential placement of RNs with professional knowledge and skills is paramount.

Reassessing the labor market effects of California's minimum nurse staffing regulations

California implemented hospital-unit level licensed nurse minimum staffing regulations in 2004, with more stringent regulations applying for certain units in 2005 and 2008. All analyses agree that there were significant increases in Registered Nurse (RN) staffing levels, especially in hospitals with lower preregulation staffing. Analyses of the labor market effects of the regulations, however, come to mixed conclusions. I revisit the labor market effects of the regulations using different data and a different analytical model for RN wages. For the analysis of growth of RN employment, I use information from the National Sample Survey of Registered Nurses, the largest and most complete source of information on nurse employment, and find that RN employment grew significantly faster in California than in other states after the regulations were implemented. For the analysis of changes in RN wages, I apply a panel difference-in-difference-in-difference model to wage averages in Metropolitan Statistical Areas, controlling for MSA-, occupation-, and time-fixed effects, and all their two-way interactions. Analysis of changes in the differential between RN wages and wages in four other selected occupations indicates significant growth in RN wages after the regulations were implemented.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Variation in Licensed Nurse Staffing Characteristics by State Requirements in Residential Care

Research on licensed nurses in assisted living and residential care communities (RCCs) is sparse compared to that on licensed nurses in nursing homes. RCCs are state-regulated; thus, staffing requirements vary considerably. The current study analyzed variation in characteristics of licensed nurses by state-specific requirements for licensed nurses in RCCs. A significantly higher percentage of RCCs with one or more RNs (68.87%) and licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) (56.85%) were found among states with licensed nurse requirements compared to states with no such requirements (37.35% and 29.08%, respectively; p < 0.05). LPN/LVN hours were higher among RCCs in states with licensed nurse requirements compared to RCCs in states with no such requirements (17 minutes and 8 minutes, respectively; p < 0.05). The findings provide the first evidence of variation in characteristics of licensed nurses by state-specific requirements for licensed nurses. [Res Gerontol Nurs. 2019; 12(1):27-33.].

Staffing in Ontario's Long-Term Care Homes: Differences by Profit Status and Chain Ownership

Ontario has the highest proportion of for-profit nursing homes in Canada. These facilities, which are known in Ontario as long-term care (LTC) homes, offer 24-hour custodial as well as nursing care to individuals who cannot live independently. Increasingly, they are also operating as members of multi-facility chains. Using longitudinal data (1996-2011) from the Residential Care Facilities Survey (n = 627), our analysis revealed discernible differences in staffing levels by profit status and chain affiliation. We found for-profit LTC homes - especially those owned by a chain organization - provided significantly fewer hours of care, after adjusting for variation in the residents' care needs. Findings from this study offer new information on the impact of organizational structure on staffing levels in Ontario's LTC homes and have implications for other jurisdictions where a growing presence of private, chain-affiliated operators has been observed.