A Critical Review of Research on Hospitalization from Nursing Homes; What is Missing?

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis

AIM

To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life.

DESIGN

Systematic review, without meta-analysis, with vote counting based on direction of effect.

DATA SOURCES

Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies.

REVIEW METHODS

Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness.

RESULTS

Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result.

CONCLUSION

This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed.

IMPACT

The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.

Nurse Staffing and Skill Mix Patterns in Relation to Resident Care Outcomes in US Nursing Homes

OBJECTIVES

The purpose of this study was to identify patterns of nurse staffing and skill mix and estimate the impact of these patterns on rehospitalization and emergency department (ED) visits in nursing home (NH) residents. We also estimated the relative contribution of unique staffing patterns on variations in hospital and ED use rates.

DESIGN

Retrospective secondary data analysis at the facility level, using administrative data.

SETTING AND PARTICIPANTS

Data from Medicare/Medicaid certified NHs in the 2018 Certification and Survey Provider Enhanced Reporting System were merged with the NH Compare Claims-Based Quality Measures file, for those facilities with complete data available (N = 14,325).

METHODS

Cluster analysis was performed to identify groups of NHs with similar nursing skill mix patterns, using measures that captured hours per resident day (HPRD) for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). We estimated the impact of cluster assignment on unplanned rehospitalization and ED visits using multivariate generalized estimating equations. Plots were generated to visualize simulation models that showed the relative contribution of unique staffing strategies to the outcomes, while holding other factors constant.

RESULTS

We identified 3 nursing skill mix clusters: high-RN, high-LPN, and high-CNA, relative to national staffing averages. After controlling for regional and organizational characteristics, residents in NHs in the high-RN cluster had significantly lower rehospitalization and ED use compared with those in the high-LPN cluster, with a similar nonsignificant trend for the high-CNA vs high-LPN clusters. Though the high-RN cluster had CNA HPRD similar to the high-CNA cluster, it relied much less on LPN staffing. Whereas NHs in the high-LPN cluster had proportionally fewer hours of care by both CNAs and RNs.

CONCLUSIONS AND IMPLICATIONS

NHs that emphasize LPN care in place of either RN or CNA care appears to exhibit higher rates of unplanned rehospitalization and ED visits among residents.

Operationalizing the Disablement Process for Research on Older Adults: A Critical Review

Self-care disability is difficulty with or dependence on others to perform activities of daily living, such as eating and dressing. Disablement is worsening self-care disability measured over time. The disablement process model (DPM) is often used to conceptualize gerontology research on self-care disability and disablement; however, no summary of variables that align with person-level DPM constructs exists. This review summarizes the results of 88 studies to identify the nature and role of variables associated with disability and disablement in older adults according to the person-level constructs (e.g., demographic characteristics, chronic pathologies) in the DPM. It also examines the evidence for cross-sectional applications of the DPM and identifies common limitations in extant literature to address in future research. Researchers can apply these results to guide theory-driven disability and disablement research using routinely collected health data from older adults.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: Protocol for a systematic review

AIM

To synthesize the evidence relating to the ability of specialist care home support services to prevent the hospital admission of older care home residents, including hospital admission at the end-of-life.

DESIGN

Systematic review and narrative synthesis.

METHODS

Ten electronic databases will be searched from 2010 - 31 December 2018 using predetermined search terms. All studies of specialist healthcare services to meet care home residents' physical healthcare needs which provide outcome data on hospital admission or place of death compared with usual care will be included. Two reviewers will independently assess studies' eligibility and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool. Data will be extracted by one reviewer and checked by a second according to predetermined categories. Data will be synthesized in evidence tables and narrative. Funder: National Institute for Health Research School for Social Care Research, November 2016.

DISCUSSION

Care of older people in care home settings is a key aspect of nursing nationally and internationally. This review will increase understanding of the extent to which different models of specialist healthcare support for care homes are associated with key resident outcomes.

IMPACT

Standard healthcare support for care home residents is often inadequate, resulting in avoidable hospital admissions and lack of resident choice as to place of death. Although a range of specialist healthcare services are emerging, little is known about their relative effectiveness. This paper marshalls evidence of relevance to commissioners investing in healthcare provision to care homes to meet NHS targets.

One patient, two worlds - coordination between nursing home and hospital doctors

BACKGROUND

Increasingly poor health in the nursing home population and transfer of responsibilities to the municipal health services place great demands on collaboration between primary and secondary health services. The article presents the opinions of nursing home and hospital doctors with regard to treatment of nursing home patients and their descriptions of the coordination between doctors at the two levels.

MATERIAL AND METHOD

This qualitative study was conducted in a Norwegian county in 2011 – 12. The results are based on manifest content analysis of ten focus group interviews with a total of 46 nursing home doctors, and eight focus group interviews with 41 hospital doctors from the medical departments in the public county hospital.

RESULTS

From their respective standpoints, both groups of doctors were concerned about unnecessary admissions and overtreatment in hospitals. They had widely differing approaches to patient treatment and communicated that little coordination took place in the treatment of nursing home patients. Both groups described strikingly little communication between the doctors in the context of transfer between the levels.

INTERPRETATION

Preconceived notions, negative experiences and lack of communication may reduce trust and prevent proper dialogue about patients. This may cause both over- and undertreatment, as well as give rise to erroneous expectations. The municipal health services and the hospitals share the responsibility for appropriate coordination and treatment of individual patients from nursing homes.