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Kim H, Mahmood A, Chang CF, Dobalian A. Medicare skilled nursing facilities' occupancy and payer source: The moderating role of financial performance. SAGE Open Med 2024; 12:20503121241275368. [PMID: 39224891 PMCID: PMC11367703 DOI: 10.1177/20503121241275368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
Objectives While extensive research has focused on patient outcomes in skilled nursing facilities, a critical gap remains in understanding factors influencing their managerial performance, particularly occupancy rates. This study examines the occupancy rates of skilled nursing facilities and assesses the significance of two important drivers of managerial performance that have not received sufficient attention-the influence of payer mix and total profit margin. Specifically, we focused on the role played by a nursing home's financial performance (as assessed by profit margin) in influencing the relationship between payer mix and occupancy rate among skilled nursing facilities. Methods Data were extracted from the 2019 to 2020 Joint Annual Report of Nursing Homes for a sample of 612 skilled nursing facilities in Tennessee, USA. Regression analysis was performed by fitting a generalized estimating equation of occupancy rate. Results Compared to skilled nursing facilities in the lowest quartile of profit margin, for example, those in the highest quartile had approximately 18 percentage points higher occupancy rates per unit increase in resident days of care covered by traditional Medicare (β = 0.18, p = 0.0028). Similarly, skilled nursing facilities in the second highest quartile of profit margin had a higher occupancy rate by approximately 23 percentage points per unit increase in Medicare Advantage (β = 0.23, p = 0.0375) when compared to those in the lowest quartile of profit margin. Conclusions Skilled nursing facilities with stronger financial performance generally have higher occupancy rates, particularly notable in relation to an upswing in payer sources such as traditional Medicare and Medicare Advantage, when compared to skilled nursing facilities with weaker profitability. Given the increasingly larger role of Medicare in long-term care funding, policymakers and nursing home managers may find it useful to consider our findings when evaluating opportunities to enhance managerial performance of skilled nursing facilities.
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Affiliation(s)
- Hyunmin Kim
- School of Health Professions, The University of Southern Mississippi, Hattiesburg, MS, USA
| | - Asos Mahmood
- Center for Health System Improvement, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Medicine-General Internal Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cyril F. Chang
- Fogelman College of Business and Economics, The University of Memphis, Memphis, TN, USA
| | - Aram Dobalian
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH, USA
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Mukamel DB, Ladd H, Saliba D, Konetzka RT. Dementia, nurse staffing, and health outcomes in nursing homes. Health Serv Res 2024; 59:e14270. [PMID: 38156513 PMCID: PMC11250382 DOI: 10.1111/1475-6773.14270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Abstract
OBJECTIVE To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality. DATA SOURCES AND STUDY SETTING A national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus. STUDY DESIGN Retrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics. DATA COLLECTION/EXTRACTION METHODS Hospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded. PRINCIPAL FINDINGS We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome. CONCLUSIONS These findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.
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Affiliation(s)
- Dana B. Mukamel
- Department of Medicine, Division of General Internal MedicineUniversity of CaliforniaIrvineCaliforniaUSA
- Department of Medicine, iTEQC Research ProgramUniversity of CaliforniaIrvineCaliforniaUSA
| | - Heather Ladd
- Department of Medicine, iTEQC Research ProgramUniversity of CaliforniaIrvineCaliforniaUSA
| | - Debra Saliba
- Los Angeles Borun Center at David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
- Veterans Administration GRECCLos AngelesCaliforniaUSA
- RAND HealthSanta MonicaCaliforniaUSA
| | - R. Tamara Konetzka
- Department of Public Health SciencesThe University of ChicagoChicagoIllinoisUSA
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Mukamel DB, Saliba D, Ladd H, Konetzka RT. The Relationship between Nursing Home Staffing and Health Outcomes Revisited. J Am Med Dir Assoc 2024; 25:105081. [PMID: 38878798 DOI: 10.1016/j.jamda.2024.105081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Nursing homes make staffing decisions in conjunction with choosing quality goals, potentially leading to endogeneity bias between staffing and quality. We use instrumental variables (IVs) to explore it. DESIGN Retrospective statistical analysis of 2017-2019 Payroll-Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term Care Focus. SETTINGS AND PARTICIPANTS A total of 11,261 nursing homes nationally. METHODS We estimated separate models for each of 6 quality measures as dependent variables, and registered nurses (RNs), certified nurse assistants (CNAs), and licensed practical nurses (LPNs) as independent variables, including other control variables associated with quality. The models were estimated using both ordinary least squares (OLS) and 2-stage least squares (2SLS) methods, the latter accounting for endogeneity. The IVs were defined as the average staffing of competing nursing homes in the same market as the index facility. RESULTS Estimated coefficients for the quality measures in the 2SLS models were up to 5 times larger than in the OLS models. The 2SLS estimates for antipsychotic medications use increased with higher RN staffing [0.279 (0.004 to 0.553)] and decreased with higher CNAs [-0.125 (-0.198 to -0.052)]. Hospitalizations decreased with more RNs [-1.328 (-1.673 to -0.983)] and LPN staffing [-0.483 (-0.755 to -0.211])] and increased with CNA [0.201 (0.109 to 0.293)] staffing. Emergency room visits decreased with higher RNs [-1.098 (-1.500 to -0.696)] and increased with CNAs [0.191 (0.084 to 0.298)]. Long-stay activities of daily living [-0.313 (-0.416 to -0.209)] and short-stay functioning [-0.481 (-0.598 to -0.364)] improved only with higher CNA staffing and pressure sores improved only with increased RN staffing [-0.436 (-0.836 to -0.035)]. CONCLUSIONS AND IMPLICATIONS Our findings demonstrate the importance of accounting for endogeneity in studies of staffing and quality. Endogeneity changes conclusions about significance, direction, and magnitude of the relationship between staffing and specific quality measures. These findings highlight the need to further study and understand the nuanced relationship between different staffing types and different health outcomes such as the difference between the relationship of RN and CNA hours per resident day to antipsychotic quality measures.
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Affiliation(s)
- Dana B Mukamel
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, CA, USA.
| | - Debra Saliba
- UCLA Borun Center at David Geffen School of Medicine, Los Angeles, CA, USA; Veterans Administration GRECC, Los Angeles, CA, USA; RAND Health, Santa Monica, CA, USA
| | - Heather Ladd
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, CA, USA
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Tate K, Penconek T, Booth A, Harvey G, Flynn R, Lalleman P, Wolbers I, Hoben M, Estabrooks CA, Cummings GG. Contextually appropriate nurse staffing models: a realist review protocol. BMJ Open 2024; 14:e082883. [PMID: 38719308 PMCID: PMC11086385 DOI: 10.1136/bmjopen-2023-082883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Decisions about nurse staffing models are a concern for health systems globally due to workforce retention and well-being challenges. Nurse staffing models range from all Registered Nurse workforce to a mix of differentially educated nurses and aides (regulated and unregulated), such as Licensed Practical or Vocational Nurses and Health Care Aides. Systematic reviews have examined relationships between specific nurse staffing models and client, staff and health system outcomes (eg, mortality, adverse events, retention, healthcare costs), with inconclusive or contradictory results. No evidence has been synthesised and consolidated on how, why and under what contexts certain staffing models produce different outcomes. We aim to describe how we will (1) conduct a realist review to determine how nurse staffing models produce different client, staff and health system outcomes, in which contexts and through what mechanisms and (2) coproduce recommendations with decision-makers to guide future research and implementation of nurse staffing models. METHODS AND ANALYSIS Using an integrated knowledge translation approach with researchers and decision-makers as partners, we are conducting a three-phase realist review. In this protocol, we report on the final two phases of this realist review. We will use Citation tracking, tracing Lead authors, identifying Unpublished materials, Google Scholar searching, Theory tracking, ancestry searching for Early examples, and follow-up of Related projects (CLUSTER) searching, specifically designed for realist searches as the review progresses. We will search empirical evidence to test identified programme theories and engage stakeholders to contextualise findings, finalise programme theories document our search processes as per established realist review methods. ETHICS AND DISSEMINATION Ethical approval for this study was provided by the Health Research Ethics Board of the University of Alberta (Study ID Pro00100425). We will disseminate the findings through peer-reviewed publications, national and international conference presentations, regional briefing sessions, webinars and lay summary.
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Affiliation(s)
- Kaitlyn Tate
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Tatiana Penconek
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew Booth
- School of Medicine and Population Health, University of Sheffield, Sheffield, South Yorkshire, UK
| | - Gillian Harvey
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Rachel Flynn
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | | | - Inge Wolbers
- University of Applied Sciences Utrecht, Utrecht, Netherlands
| | - Matthias Hoben
- School of Health Policy and Management, York University, Toronto, Ontario, Canada
| | - Carole A Estabrooks
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Greta G Cummings
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Suen J, Dyer S, Shulver W, Ross T, Crotty M. A systematic review of typologies on aged care system components to facilitate complex comparisons. Health Serv Manage Res 2024; 37:123-134. [PMID: 37247254 DOI: 10.1177/09514848231179176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Objectives: Typologies are frequently utilised in analyses of the quality, funding, and efficiency of aged care systems. This review aims to provide a comprehensive resource identifying and critiquing existing aged care typologies. Methods: Systematic search of MEDLINE, Econlit, Google Scholar, greylit.org and Open Grey databases from inception to July 2020, including typologies of national, regional or provider aged care systems. Article screening, data extraction, and quality appraisal were conducted in duplicate. Results: 14 aged care typologies were identified; five applied to residential care, two to home care and seven to mixed settings; eight examined national systems and seven regional or provider systems. Five typologies classifying national financing or home care services, provider financing of staff and services and quality of residential care were considered high quality. The schematic provided summarises the focus area and aids in typology selection. Discussion: The aged care typologies identified cover a wide range of areas and contexts of aged care provision. This schematic, summary and critique will aid researchers, providers, and aged care policy makers to examine their own setting, compare it to other approaches to aged care provision and assist in identifying alternatives and important considerations, when undertaking aged care reform.
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Affiliation(s)
- Jenni Suen
- Flinders University, Bedford Park, AU-SA, Australia
| | - Suzanne Dyer
- Flinders University, Bedford Park, AU-SA, Australia
| | | | - Tyler Ross
- Flinders University, Bedford Park, AU-SA, Australia
| | - Maria Crotty
- Flinders University, Bedford Park, AU-SA, Australia
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Rhodes A, Novak AC, Caprio TV, Zanjani F, Marrs S, Gendron T, Waters L. Special Focus Facilities vs Special Focus Facility Candidates: What is the Difference? J Am Med Dir Assoc 2024; 25:390-395. [PMID: 37951582 DOI: 10.1016/j.jamda.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES This study compares Special Focus Facilities (SFFs) and Special Focus Facility Candidate Facilities (SFFcs) on organizational traits and quality outcomes to evaluate the effectiveness of the SFF program as a quality improvement intervention and inform potential areas for program reform. DESIGN This is a retrospective analysis. SETTINGS AND PARTICIPANTS Using data from the Centers for Medicare and Medicaid Services archives for 2020, this retrospective study analyzed 247 nursing facilities (50 SFFs and 197 SFFcs). METHODS Variables of interest were staffing, profit status, facility size, certification status, number of residents, and complaint citations: t tests, χ2, Fisher's Exact test, and multivariate analysis of variance were used to compare the 2 groups. RESULTS From an organizational perspective, SFFs and SFFcs are minimally different. Both groups had similar facility size, profit status, hospital affiliation, continuing care retirement community status, and Medicare/Medicaid certification. Large and for-profit facilities were overrepresented in both groups. SFFs and SFFcs exhibited statistical differences in the number of complaint deficiencies. The groups had no significant difference in staffing levels, category, severity of complaints, or incident reports. CONCLUSIONS AND IMPLICATION The study's findings suggest that the SFF program, while resource-intensive, is minimally impactful. The similarities between SFFs and SFFcs raise questions about the program's effectiveness in improving nursing facility care. Previous adjustments to the program may not have successfully achieved the desired quality improvements. This research highlights the need to further evaluate the SFF program's effectiveness as a quality improvement intervention. It also underscores the importance of addressing biases and subjectivity in state survey agency processes, which affect the enrollment of nursing facilities. The study underscores the flaws within the nursing home monitoring system and the 5-star quality rating system, especially when comparing small samples between states.
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Affiliation(s)
- Annie Rhodes
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA.
| | | | - Thomas V Caprio
- University of Rochester Medical Center: Home Care and Medicine Hospice Program, Rochester, NY, USA
| | - Faika Zanjani
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA
| | - Sarah Marrs
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA
| | - Tracey Gendron
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA
| | - Leland Waters
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA
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Scroggins S, Little G, Okala O, Ellis M, Shacham E. The Relationship of Vaccine Uptake and COVID-19 Infections Among Nursing Home Staff and Residents in Missouri: A Measure of Risk by Community Mobility. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2024; 30:176-182. [PMID: 37831663 DOI: 10.1097/phh.0000000000001824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
BACKGROUND As the COVID-19 pandemic progressed across the United States, older adults living in nursing home (NH) facilities were disproportionately affected because of living in communal spaces with close proximity to others, age-related medical conditions, and constant contact with staff who may support multiple clients and facilities. While these populations are particularly at risk, there has been limited research focused on the management of the potential vectors of COVID-19 infection. METHODS Data from the Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting system assessing weekly observations of COVID-19 case counts among NH residents and COVID-19 vaccination rates among NH staff and residents in the states of Missouri and Illinois (n = 877) from May 24, 2021, to August 28, 2021, were used. This ecological study, using results from the CMS COVID-19 reporting system, local COVID-19 rates, and NH-level demographic characteristics, conducted a zero inflation mode to determine the association between NH staff vaccine uptake and COVID-19 cases among NH residents. RESULTS Among the total 11 195 weekly observations within the NH facilities, zero cases of COVID-19 were reported during 10 683 (95%) of those weeks, supporting the use of a zero-inflated model. Results show that staff vaccination rates were significantly associated with a decrease in COVID-19 mortality. This study identified that for every percentage increase in staff vaccine coverage, the rate of COVID-19 among residents decreased by 2%. DISCUSSION These findings suggest that NH staff vaccination rates are significantly associated with the rate of COVID-19 outbreaks among NH residents. Community median income was associated with an increased likelihood of infection. Future research that explores associations with employment benefits and staff mobility, particularly in vulnerable populations, should be implemented in future vaccination strategic planning.
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Affiliation(s)
- Stephen Scroggins
- Department of Behavioral Science and Health Equity, College for Public Health and Social Justice (Drs Scroggins and Shacham, and Ms Little and Mr Okala), Saint Louis University, St Louis, Missouri; and Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri (Dr Ellis)
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8
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Blatter C, Osińska M, Simon M, Zúñiga F. The relationship between nursing home staffing and resident safety outcomes: A systematic review of reviews. Int J Nurs Stud 2024; 150:104641. [PMID: 37992653 DOI: 10.1016/j.ijnurstu.2023.104641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Resident safety is an important topic for nursing home practice with up to 33 % of residents subjected to an adverse event. In spite of a large evidence base examining the relationship between nursing home staffing and resident outcomes, the findings of several systematic reviews remain inconclusive and contradicting, possibly due to methodological shortcomings. OBJECTIVE The main aim of this review was to provide a comprehensive overview of the literature on nursing home staffing and its relationship with resident safety outcomes. DESIGN We undertook a systematic review of reviews. We searched Medline, CINAHL and Embase by the end of November 2022. Reviews were included if they assessed the relationship between nursing home staffing and resident safety outcomes using objective measures and data at resident level. Quality appraisal was conducted using the SIGN-checklist, but we did not exclude any reviews based on quality assessment. We used a narrative approach, tables and figures to summarize the findings. RESULTS We included 13 systematic reviews published between 2006 and 2022 building on primary evidence from 1977 to 2022. Twelve reviews investigated the relationship between nurse staffing and resident safety outcomes (187 unique primary studies), and one review focused on allied health professionals (28 primary studies). Five reviews originated as work to inform governmental recommendations on staffing. We found diverse approaches used to investigate the staffing-outcome relationship with regard to design, timeframe, operationalization, data-source and theoretical rationales guiding the studies. The most prominently reported resident safety outcomes were pressure ulcers and urinary tract infections. Commonly reported staffing measures included number and level of education of nursing home staff. Based on narrative summaries, staffing seems to have a favorable relationship with resident safety outcomes, but logic models explaining the mechanisms of this relationship were sparsely reported. CONCLUSIONS The existing literature shows methodological limitations that demand a change in research on the staffing-outcome relationship in the nursing home setting. Our work highlights the need for carefully designed primary studies that address the pertinent shortcomings by design, timeframe, operationalization, data-source and theoretical rationales. These future studies will allow to carefully examine the causal relationship between selected staffing measures and resident safety outcomes in further detail and serve as legitimate evidence bases to inform action plans for clinical practice and to evaluate staffing policies.
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Affiliation(s)
- Catherine Blatter
- Institute of Nursing Science, University of Basel, Switzerland. https://twitter.com/cathblatter
| | | | - Michael Simon
- Institute of Nursing Science, University of Basel, Switzerland. https://twitter.com/msimoninfo
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Chen M, Goodwin JS, Bailey JE, Bowblis JR, Li S, Xu H. Longitudinal Associations of Staff Shortages and Staff Levels with Health Outcomes in Nursing Homes. J Am Med Dir Assoc 2023; 24:1755-1760.e7. [PMID: 37263319 PMCID: PMC10826288 DOI: 10.1016/j.jamda.2023.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To examine whether facility-reported staff shortages and total staff levels were independently associated with changes in nursing home (NH) outcomes in 2020. DESIGN Longitudinal cohort study. SETTING AND PARTICIPANTS A total of 8466 NHs with staffing and outcome data. METHODS This study used NH COVID-19 Public File (2020), Nursing Home Compare (2019-2020), and Payroll-Based Journal data (2019-2020). Outcome measures included the percentage of long-stay residents in a facility with declines in activities in daily living (ADLs), decreases in mobility, weight loss, and pressure ulcers in 2020 Q2, 2020 Q3, and 2020 Q4. Independent variables were whether NHs reported any shortage of aides or licensed nurses and total staff hours per resident day (HPRD). Separate 2-level (NH, state) Hierarchical Generalized Linear Mixed models examined the association of facility-reported shortages and staff hours with key NH resident outcomes, controlling for NH characteristics and COVID-19 infections. RESULTS The weekly percentage of NHs reporting any staff shortage averaged 20%. Total staff HPRD increased slightly from 3.7 in 2019 to 3.8 in 2020. Health outcomes were stable during 2019 and 2020 Q1 but worsened substantially starting in 2020 Q2. For example, the percentage of residents with mobility loss increased from 16.2% in 2020 Q1 to 27.9% in 2020 Q4. Facility-reported staff shortages were associated with an increase in the proportion of residents with an ADL decline (0.54 percentage points), mobility loss (0.80 percentage points), weight loss (0.22 percentage points), and pressure ulcers (0.22 percentage points) (all P < .01). Total staff HPRD was not associated with changes in any outcomes (all P > .05). CONCLUSIONS AND IMPLICATIONS NHs reported worsened health outcomes among long-stay residents in 2020, with worse outcomes found among facilities that reported staff shortages but not among those with lower total staff levels. Facility-reported shortages provide important quality information during the COVID-19 pandemic.
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Affiliation(s)
- Ming Chen
- Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA; Institute of Health Outcomes and Policy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James S Goodwin
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA; Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - James E Bailey
- Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA; Institute of Health Outcomes and Policy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, OH, USA; Scripps Gerontology Center, Miami University, Oxford, OH, USA
| | - Shuang Li
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA
| | - Huiwen Xu
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA; School of Public and Population Health, University of Texas Medical Branch, Galveston, TX, USA.
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Dean A, McCallum J, Venkataramani A, Michaels D. Labor Unions and Staff Turnover in US Nursing Homes. JAMA Netw Open 2023; 6:e2337898. [PMID: 37831453 PMCID: PMC10576215 DOI: 10.1001/jamanetworkopen.2023.37898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/24/2023] [Indexed: 10/14/2023] Open
Abstract
This cross-sectional study examines the association between labor unions and health care staff turnover in the US using data from 2021.
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Affiliation(s)
- Adam Dean
- Deparment of Political Science, George Washington University, Washington, DC
| | - Jamie McCallum
- Department of Sociology, Middlebury College, Middlebury, Vermont
| | | | - David Michaels
- Deparment of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
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11
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Feng Z, Vadnais A, Huber B, Deutsch A, Li Q, Bercaw L, Ingber MJ, Segelman M, Khatutsky G, Sroczynski N, Xu L. Hospital Transfer Rates among Long-Stay Nursing Home Residents: Variation by Day of the Week. J Am Med Dir Assoc 2023; 24:1361-1362. [PMID: 37507100 DOI: 10.1016/j.jamda.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/30/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Lanlan Xu
- Centers for Medicare & Medicaid Services, Baltimore, MD, USA
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12
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Travers JL, McGarry BE, Friedman S, Holaday LW, Ross JS, Lopez L, Chen K. Association of Receipt of Paycheck Protection Program Loans With Staffing Patterns Among US Nursing Homes. JAMA Netw Open 2023; 6:e2326122. [PMID: 37498597 PMCID: PMC10375300 DOI: 10.1001/jamanetworkopen.2023.26122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 05/30/2023] [Indexed: 07/28/2023] Open
Abstract
Importance Staffing shortages in nursing homes (NHs) threaten the quality of resident care, and the COVID-19 pandemic magnified critical staffing shortages within NHs. During the pandemic, the US Congress enacted the Paycheck Protection Program (PPP), a forgivable loan program that required eligible recipients to appropriate 60% to 75% of the loan toward staffing to qualify for loan forgiveness. Objective To evaluate characteristics of PPP loan recipient NHs vs nonloan recipient NHs and whether there were changes in staffing hours at NHs that received a loan compared with those that did not. Design, Setting, and Participants This economic evaluation used national data on US nursing homes that were aggregated from the Small Business Administration, Nursing Home Compare, LTCFocus, the Centers for Medicare & Medicaid Services Payroll Based Journal, the Minimum Data Set, the Area Deprivation Index, the Healthcare Cost Report Information System, and the US Department of Agriculture Rural-Urban Continuum Codes from January 1 to December 23, 2020. Exposure Paycheck Protection Program loan receipt status. Main Outcome and Measures Staffing variables included registered nurse, licensed practical nurse (LPN), and certified nursing assistant (CNA) total hours per week. Staffing hours were examined on a weekly basis before and after loan receipt during the study period. An event-study approach was used to estimate the staffing total weekly hours at NHs that received PPP loans compared with NHs that did not receive a PPP loan. Results Among 6008 US NHs, 1807 (30.1%) received a PPP loan and 4201 (69.9%) did not. The median loan amount was $664 349 (IQR, $407 000-$1 058 300). Loan recipients were less likely to be part of a chain (733 [40.6%] vs 2592 [61.7%]) and more likely to be for profit (1342 [74.3%] vs 2877 [68.5%]), be located in nonurban settings (159 [8.8%] vs 183 [4.4%]), have a greater proportion of Medicaid-funded residents (mean [SD], 60.92% [21.58%] vs 56.78% [25.57%]), and have lower staffing quality ratings (mean [SD], 2.88 [1.20] vs 3.03 [1.22]) and overall quality star ratings (mean [SD], 3.08 [1.44] vs 3.22 [1.44]) (P < .001 for all). Twelve weeks after PPP loan receipt, NHs that received a PPP loan experienced a mean difference of 26.19 more CNA hours per week (95% CI, 14.50-37.87 hours per week) and a mean difference of 6.67 more LPN hours per week (95% CI, 1.21-12.12 hours per week) compared with nursing homes that did not receive a PPP loan. No associations were found between PPP loan receipt and weekly RN staffing hours (12 weeks: mean difference, 1.99 hours per week; 95% CI, -2.38 to 6.36 hours per week). Conclusions and Relevance In this economic evaluation, a forgivable loan program that required funding to be appropriated toward staffing was associated with a significant increase in CNA and LPN staffing hours among NH PPP loan recipients. Because the PPP loans are temporary, federal and state entities may need to institute sufficient and sustainable support to mitigate NH staffing shortages.
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Affiliation(s)
- Jasmine L. Travers
- Rory Meyers College of Nursing, New York University Grossman School of Medicine, New York
| | - Brian E. McGarry
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Steven Friedman
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Louisa W. Holaday
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph S. Ross
- Section of General Medicine and the National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Leo Lopez
- Institute for Public Health, University Health, University Medicine Associates, San Antonio, Texas
| | - Kevin Chen
- Office of Ambulatory Care and Population Health, New York City Health + Hospitals, New York
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University Grossman School of Medicine, New York
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13
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Joshi S. Staffing Shortages, Staffing Hours, and Resident Deaths in US Nursing Homes During the COVID-19 Pandemic. J Am Med Dir Assoc 2023:S1525-8610(23)00411-5. [PMID: 37253431 PMCID: PMC10165011 DOI: 10.1016/j.jamda.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Staffing shortages at nursing homes during the COVID-19 pandemic may have impacted care providers' staffing hours and affected residents' care and outcomes. This study examines the association of staffing shortages with staffing hours and resident deaths in nursing homes during the COVID-19 pandemic. DESIGN This study measured staffing hours per resident using payroll data and measured weekly resident deaths and staffing shortages using the Centers for Disease Control and Prevention's National Healthcare Safety Network data. Multivariate linear regressions with facility and county-week fixed effects were used to investigate the association of staffing shortages with staffing hours and resident deaths. SETTING AND PARTICIPANTS 15,212 nursing homes. MEASURES The primary outcomes included staffing hours per resident of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) and weekly total deaths per 100 residents. RESULTS Between May 31, 2020, and May 15, 2022, 18.4% to 33.3% of nursing homes reported staffing shortages during any week. Staffing shortages were associated with lower staffing hours per resident with a 0.009 decrease in RN hours per resident (95% CI 0.005-0.014), a 0.014 decrease in LPN hours per resident (95% CI 0.010-0.018), and a 0.050 decrease in CNA hours per resident (95% CI 0.043-0.057). These are equivalent to a 1.8%, 1.7%, and 2.4% decline, respectively. There was a positive association between staffing shortages and resident deaths with 0.068 (95% CI 0.048-0.088) total deaths per 100 residents. This was equivalent to an increase of 10.5%. CONCLUSION AND IMPLICATIONS Our results showed that self-reported staffing shortages were associated with a statistically significant decrease in staffing hours and with a statistically significant increase in resident deaths. These results suggest that addressing staffing shortages in nursing homes can save lives.
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Affiliation(s)
- Sushant Joshi
- USC Sol Price School of Public Policy, Los Angeles, CA, USA.
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14
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Wagg A, Hoben M, Ginsburg L, Doupe M, Berta W, Song Y, Norton P, Knopp-Sihota J, Estabrooks C. Safer Care for Older Persons in (residential) Environments (SCOPE): a pragmatic controlled trial of a care aide-led quality improvement intervention. Implement Sci 2023; 18:9. [PMID: 36991434 PMCID: PMC10054219 DOI: 10.1186/s13012-022-01259-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/20/2022] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The increased complexity of residents and increased needs for care in long-term care (LTC) have not been met with increased staffing. There remains a need to improve the quality of care for residents. Care aides, providers of the bulk of direct care, are well placed to contribute to quality improvement efforts but are often excluded from so doing. This study examined the effect of a facilitation intervention enabling care aides to lead quality improvement efforts and improve the use of evidence-informed best practices. The eventual goal was to improve both the quality of care for older residents in LTC homes and the engagement and empowerment of care aides in leading quality improvement efforts. METHODS Intervention teams participated in a year-long facilitative intervention which supported care aide-led teams to test changes in care provision to residents using a combination of networking and QI education meetings, and quality advisor and senior leader support. This was a controlled trial with random selection of intervention clinical care units matched 1:1 post hoc with control units. The primary outcome, between group change in conceptual research use (CRU), was supplemented by secondary staff- and resident-level outcome measures. A power calculation based upon pilot data effect sizes resulted in a sample size of 25 intervention sites. RESULTS The final sample included 32 intervention care units matched to 32 units in the control group. In an adjusted model, there was no statistically significant difference between intervention and control units for CRU or in secondary staff outcomes. Compared to baseline, resident-adjusted pain scores were statistically significantly reduced (less pain) in the intervention group (p=0.02). The level of resident dependency significantly decreased statistically for residents whose teams addressed mobility (p<0.0001) compared to baseline. CONCLUSIONS The Safer Care for Older Persons in (residential) Environments (SCOPE) intervention resulted in a smaller change in its primary outcome than initially expected resulting in a study underpowered to detect a difference. These findings should inform sample size calculations of future studies of this nature if using similar outcome measures. This study highlights the problem with measures drawn from current LTC databases to capture change in this population. Importantly, findings from the trial's concurrent process evaluation provide important insights into interpretation of main trial data, highlight the need for such evaluations of complex trials, and suggest the need to consider more broadly what constitutes "success" in complex interventions. TRIAL REGISTRATION ClinicalTrials.gov , NCT03426072, registered August 02, 2018, first participant site April, 05, 2018.
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Affiliation(s)
- Adrian Wagg
- Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Matthias Hoben
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Liane Ginsburg
- School of Health Policy & Management, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Malcolm Doupe
- Departments of Community Health Sciences, Emergency Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Whitney Berta
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Toronto, Canada
| | - Yuting Song
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Peter Norton
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Knopp-Sihota
- Faculty of Health Disciplines, Athabasca University & Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Carole Estabrooks
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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15
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Bryant NS, Cimarolli VR, Falzarano F, Stone R. Organizational Factors Associated with Certified Nursing Assistants' Job Satisfaction during COVID-19. J Appl Gerontol 2023:7334648231155017. [PMID: 36748259 PMCID: PMC9908517 DOI: 10.1177/07334648231155017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Given the instability of the nursing home (NH) certified nursing assistant (CNA) workforce and the challenging demands during COVID-19, it is important to understand the organizational factors that are correlated with job satisfaction which is a major predictor of CNA turnover. The purpose of this study was to determine the associations between quality of supervisor relationships, organizational supports, COVID-19 work-related stressors, and job satisfaction among CNAs in NHs. The results indicate that CNAs who reported a more optimal relationship with their supervisors, felt appreciated for the job they do and worked in NHs with lower COVID-19 resident infection rates tended to report higher rates of job satisfaction. The COVID-19 work-related stressors of increased workload demands and understaffing were associated with lower rates of job satisfaction. The study has practical implications for employers regarding how to support CNAs to improve job satisfaction especially during a crisis.
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Affiliation(s)
- Natasha S. Bryant
- LeadingAge, LTSS Center @UMass Boston, Washington, DC, USA,Natasha S. Bryant, LeadingAge LTSS Center @UMass Boston, 2519 Connecticut Avenue NW; Washington, DC 20008, USA.
| | | | - Francesca Falzarano
- Weill Cornell Medicine, Division of Geriatrics and Palliative Medicine, New York, NY, USA
| | - Robyn Stone
- LeadingAge, LTSS Center @UMass Boston, Washington, DC, USA
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16
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Vo QT, Koethe B, Holmes S, Simoni-Wastila L, Briesacher BA. Patient Outcomes After Delirium Screening and Incident Alzheimer's Disease or Related Dementias in Skilled Nursing Facilities. J Gen Intern Med 2023; 38:414-420. [PMID: 35970959 PMCID: PMC9905370 DOI: 10.1007/s11606-022-07760-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/29/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The extent to which a positive delirium screening and new diagnosis of Alzheimer's disease or related dementias (ADRD) increases the risk for re-hospitalization, long-term nursing home placement, and death remains unknown. OBJECTIVE To compare long-term outcomes among newly admitted skilled nursing facility (SNF) patients with delirium, incident ADRD, and both conditions. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of Medicare beneficiaries who entered a SNF from hospital with a minimum 14-day stay (n = 100,832) from 2015 to 2016. MAIN MEASURES Return to home, hospital readmission, admission to a long-term care facility, or death. KEY RESULTS Patients with delirium were as likely to be discharged home as patients diagnosed with ADRD (HR: 0.63, 95% CI: 0.59, 0.67; HR: 0.65, 95% CI: 0.64, 0.67). Patients with both delirium and ADRD were less likely to be discharged home (HR: 0.49, 95% CI: 0.47, 0.52) and showed increased risk of death (HR: 1.30, 95% CI: 1.17, 1.45). Patients with ADRD, regardless of delirium screening status, had increased risk for long-term nursing home care transfer (HR: 1.66, 95% CI: 1.63, 1.70; HR: 1.76, 95% CI: 1.69, 1.82). Patients with delirium and no ADRD showed increased risk of transfer to long-term nursing home care (HR: 1.25, 95% CI: 1.18, 1.33). The rate of deaths was higher among patients who screened positive for delirium without ADRD compared to the no delirium and no ADRD groups (HR: 2.35, 95% CI: 2.11, 2.61). CONCLUSION A positive delirium screening increased risk of death and transfer to long-term care in the first 100 days after admission regardless of incident ADRD diagnosis. Patients with delirium and/or ADRD also are less likely to be discharged home. Our study builds on the evidence base that delirium is important to address in older adults as it is associated with negative outcomes.
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Affiliation(s)
- Quynh T Vo
- Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA.
| | - Benjamin Koethe
- School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Sarah Holmes
- Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD, USA
- Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore School of Pharmacy, Baltimore, MD, USA
| | - Linda Simoni-Wastila
- Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore School of Pharmacy, Baltimore, MD, USA
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore School of Pharmacy, Baltimore, MD, USA
| | - Becky A Briesacher
- School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
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17
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Yan D, Temkin-Greener H, Cai S. Did the COVID-19 Pandemic Affect the Use of Antipsychotics Among Nursing Home Residents With ADRD? Am J Geriatr Psychiatry 2023; 31:124-140. [PMID: 36272888 PMCID: PMC9514966 DOI: 10.1016/j.jagp.2022.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To examine whether and how the COVID-19 pandemic affected the use of antipsychotics among residents with Alzheimer's disease and related dementias in nursing homes. DESIGN Observational study based on the Minimum Data Set and Medicare claims. SETTING Medicare- and/or Medicaid-certified nursing homes. PARTICIPANTS Nursing home residents diagnosed with Alzheimer's disease and related dementias between 2017 and 2020. MEASUREMENTS The main outcome variable was any antipsychotic use during a quarter. The secondary outcome was certified nursing assistants' staffing hours per bed per day in a quarter. We categorized nursing homes into quartiles based on the distribution of nursing home racial and/or ethnic composition. To explore the relationship between the COVID-19 pandemic and the frequency of antipsychotic use, we estimated a linear probability model with robust standard errors, individual and facility random effects. We used a similar model for certified nursing assistant hours. RESULTS About 23.7% of residents with ADRD had antipsychotic uses during the study period. The frequency of antipsychotic use declined from 23.7%-23.1% between the first quarter of 2017 (2017Q1) and the first quarter of 2020 (2020Q1) but increased to 24.8% by the last quarter of 2020 (2020Q4). Residents in all four racial and/or ethnic groups experienced an increase in antipsychotic use during the COVID-19 pandemic, but the extent of the increase varied by race and/or ethnicity. For example, while residents in the very-high minority nursing homes experienced a greater increase in antipsychotic use than did the residents of other nursing homes at the beginning of the pandemic, the increasing trend during the pandemic was smaller in the very-high minority nursing homes compared to the low-minority nursing homes (0.2 percentage points less, p<0.001, based on heteroskedasticity-robust t statistics, t = 3.67, df = 8,155,219). On average, the certified nursing assistant hours decreased from 1.8-1.7 hours per bed per day between 2017Q1 and 2020Q1, and further decreased to 1.5 hours per bed per day by 2020Q4. There was also a decreasing trend in staffing hours across all racial and/or ethnic groups during the pandemic. CONCLUSIONS AND RELEVANCE The COVID-19 pandemic was associated with an increase in the use of antipsychotics among nursing home residents with Alzheimer's disease and related dementias and decreased staffing of certified nursing assistants, especially among nursing homes with a high minority penetration. Future research is needed to explore means for reducing antipsychotic use, particularly in homes with a high penetration of minority residents.
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Affiliation(s)
- Di Yan
- University of Rochester School of Medicine and Dentistry.
| | | | - Shubing Cai
- University of Rochester School of Medicine and Dentistry
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18
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Xu L, Sharma H. Effect of Medicaid Expansion on Health Insurance for Low-Income Nursing Home Aides. J Appl Gerontol 2023; 42:231-240. [PMID: 36206172 DOI: 10.1177/07334648221132121] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
We examine how the Affordable Care Act Medicaid expansion affected the insurance coverage and the sources of coverage among low-income nursing home aides using the 2010-2019 American Community Survey data. Insurance coverage for low-income nursing home aides increased from about 60% to nearly 90% in expansion states but rose to only about 80% in nonexpansion states. Using a difference-in-differences regression design, we find that Medicaid expansion was associated with a 5.1 percentage-point increase in overall insurance coverage. Expansion states had a 12.2 percentage-point gain in Medicaid that was partially offset by a 6.4 percentage-point reduction in private insurance coverage. Our results show that ACA Medicaid expansion increased insurance coverage for low-income nursing home aides; however, there was substantial crowd-out of private insurance coverage in this population. Policymakers should consider expanding Medicaid while incentivizing affordable private health insurance options for low-income nursing home aides to improve insurance coverage.
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Affiliation(s)
- Lili Xu
- Department of Health Management and Policy, College of Public Health, 4083University of Iowa, Iowa City, IA, USA
| | - Hari Sharma
- Department of Health Management and Policy, College of Public Health, 4083University of Iowa, Iowa City, IA, USA
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19
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Abstract
IMPORTANCE Recent work suggests that instability in nursing home staffing levels may be an important marker of nursing home quality. Whether that association holds when controlling for average staffing levels is unknown. OBJECTIVE To examine whether staffing instability, defined as the percentage of days below average staffing levels, is associated with nursing home quality when controlling for average staffing levels. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study of 14 717 nursing homes used the merged Centers for Medicare & Medicaid Services Payroll Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term-Care Focus data for fiscal years 2017 to 2019. Statistical analysis was performed from February 8 to November 14, 2022. MAIN OUTCOMES AND MEASURES Linear, random-effect models with state fixed effects and robust SEs were estimated for 12 quality indicators as dependent variables, percentage of below-average staffing days as independent variables, controlling for average staffing hours per resident-day for registered nurses, licensed practical nurses, and certified nurse aides. Below-average staffing days were defined as those 20% below the facility average, by staffing type. Quality indicators included deficiency citations; long-stay residents receiving an antipsychotic; percentage of high-risk long-stay residents with pressure ulcers (2 different measures for pressure ulcers were used); and percentage of long-stay residents with activities of daily living decline, mobility decline, emergency department visits, and hospitalizations; and short-stay residents with new antipsychotic medication, mobility decline, emergency department visits, and rehospitalizations. RESULTS For the 14 717 nursing homes in this study, the mean (SD) percentage of days with below-average staffing was 30.2% (12.0%) for registered nurses, 16.4% (11.3%) for licensed practical nurses, and 5.1% (5.3%) for certified nurse aides. Mean (SD) staffing hours per resident-day were 0.44 (0.40) for registered nurses, 0.80 (0.32) for licensed practical nurses, and 2.20 (0.50) for certified nurse aides. In regression models that included average staffing, a higher percentage of below-average staffing days was significantly associated with worse quality for licensed practical nurses in 10 of 12 models, with the largest association for decline of activities of daily living among long-stay residents (regression coefficient, 0.020; P < .001). A higher percentage of below-average staffing days was significantly associated with worse quality for certified nurse aides in 9 of 12 models, with the largest association for short-stay functioning (regression coefficient, 0.030; P = .01). CONCLUSIONS AND RELEVANCE This study suggests that holding average staffing levels constant, day-to-day staffing stability, especially avoiding days with low staffing of licensed practical nurses and certified nurse aides, is a marker of better quality of nursing homes. Future research should investigate the causes and potential solutions for instability in staffing in all facilities, including those that may appear well-staffed on average.
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Affiliation(s)
- Dana B. Mukamel
- Public Health and Nursing, information Technology Enhancing Quality Care (iTEQC) Research Program, Division of General Internal Medicine, Department of Medicine, University of California, Irvine, Irvine
| | - Debra Saliba
- University of California, Los Angeles Borun Center at David Geffen School of Medicine, Los Angeles
- Geriatric Research, Education, and Clinical Centers, Veterans Administration, Los Angeles, California
- RAND, Santa Monica, California
| | - Heather Ladd
- iTEQC Research Program, Division of General Internal Medicine, Department of Medicine, University of California, Irvine, Irvine
| | - R. Tamara Konetzka
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
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20
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Dunbar P, Keyes LM, Browne JP. Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research. PLoS One 2023; 18:e0278007. [PMID: 37053186 PMCID: PMC10101495 DOI: 10.1371/journal.pone.0278007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/13/2023] [Indexed: 04/14/2023] Open
Abstract
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.
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Affiliation(s)
- Paul Dunbar
- Health Information and Quality Authority, Mahon, Cork, Ireland
| | - Laura M Keyes
- Health Information and Quality Authority, Mahon, Cork, Ireland
| | - John P Browne
- School of Public Health, University College Cork, Cork, Ireland
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21
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Tingvold L, Moholt JM, Førland O, Jacobsen FF, Tranvåg O. Intended, Unintended, Unanticipated? Consequences of Social Distancing Measures for Nursing Home Residents During the Covid-19 Pandemic. Glob Qual Nurs Res 2023; 10:23333936231176204. [PMID: 37261277 PMCID: PMC10227487 DOI: 10.1177/23333936231176204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 06/02/2023] Open
Abstract
During the outbreak of the COVID-19 pandemic, Norwegian health authorities introduced social distancing measures in nursing homes. The aim was to protect vulnerable residents from contracting the potentially deadly infection. Drawing on individual interviews with nursing home managers and physicians, and focus groups with nursing staff, we explore and describe consequences the social distancing measures had on nursing home residents' health and wellbeing. The analysis indicates that most residents became socially deprived, while some became calmer during the nursing home lockdown. Nursing home staff, physicians and managers witnessed that residents' health and functional capacity declined when services to maintain health, such as physiotherapy, were put on hold. In conclusion, we argue that although Norwegian health authorities managed to keep the infection rates low in nursing homes, this came at a high price for the residents however, as the social distancing measures also negatively impacted their health and wellbeing.
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Affiliation(s)
- Laila Tingvold
- Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
| | | | - Oddvar Førland
- Western Norway University of Applied Sciences, Bergen, Norway
| | | | - Oscar Tranvåg
- Western Norway University of Applied Sciences, Bergen, Norway
- Norwegian Research Centre for Women’s Health, University Hospital, Oslo, Norway
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22
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Mueller CA, Alexander GL, Ersek M, Ferrell BR, Rantz MJ, Travers JL. Calling all nurses-Now is the time to take action on improving the quality of care in nursing homes. Nurs Outlook 2023; 71:101897. [PMID: 36621418 DOI: 10.1016/j.outlook.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/18/2022] [Accepted: 11/08/2022] [Indexed: 01/09/2023]
Abstract
For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee's vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments. This paper outlines concrete and specific actions nurses and nursing organizations can take to ensure the recommendations are implemented.
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Affiliation(s)
| | | | - Mary Ersek
- Veteran Experience Center, University of Pennsylvania Schools of Nursing and Medicine, Department of Veterans Affairs, Philadelphia, PA
| | - Betty R Ferrell
- City of Hope National Medical Center, Division of Nursing Research & Education, Duarte, CA
| | - Marilyn J Rantz
- University of Missouri, Sinclair School of Nursing, Columbia, MO
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Yaraghi N, Henfridsson O, Gopal R. Impact of the COVID-19 pandemic on staff turnover at long-term care facilities: a qualitative study. BMJ Open 2022; 12:e065123. [PMID: 36521894 PMCID: PMC9755903 DOI: 10.1136/bmjopen-2022-065123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The objective of this research was to explore the lived experiences of long-term care facilities' staff during the COVID-19 pandemic and examine if and how the pandemic played a role in their decision to leave their jobs. DESIGN Qualitative study using thematic analysis of semistructured interviews. Interview transcripts were analysed using coding techniques based in grounded theory. PARTICIPANTS A total of 29 staff with various roles across 21 long-term care facilities in 12 states were interviewed. RESULTS The pandemic influenced the staff's decision to leave their jobs in five different ways, namely: (1) It significantly increased the workload; (2) Created more physical and emotional hazards for staff; (3) Constrained the facilities and their staff financially; (4) Deteriorated morale and job satisfaction among the staff and (5) Increased concerns with upper management's commitment to both general and COVID-19-specific procedures. CONCLUSIONS Staff at long-term care facilities discussed a wide variety of reasons for their decision to quit their jobs during the pandemic. Our findings may inform efforts to reduce the rate of turnover in these facilities.
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Affiliation(s)
- Niam Yaraghi
- Miami Herbert Business School, University of Miami, Coral Gables, Florida, USA
- Center for Technology Innovation, The Brookings Institution, Washington, District of Columbia, USA
| | - Ola Henfridsson
- Miami Herbert Business School, University of Miami, Coral Gables, Florida, USA
| | - Ram Gopal
- Warwick Business School, University of Warwick, Coventry, UK
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McHenry P, Mellor JM. The Impact of Recent State and Local Minimum Wage Increases on Nursing Facility Employment. JOURNAL OF LABOR RESEARCH 2022; 43:345-368. [PMID: 36415308 PMCID: PMC9673218 DOI: 10.1007/s12122-022-09338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
Various U.S. states and municipalities raised their mandated minimum wages between 2017 and 2019. In some areas, minimum wages became high enough to bind for more professional workers, such as lower paid staff at nursing facilities. We add to the small prior literature on the effects of minimum wages on nursing facility staffing using novel establishment-level data on daily hours worked; these data allow us to examine changes in staffing hours along margins previously unexplored in the minimum wage literature. We find no evidence that minimum wage increases reduced hours worked among lower-paid nurses in nursing facilities. In contrast, we find that increases in state and local minimum wages increased hours worked per resident day by nursing assistants; increases occurred for the average of all days throughout the month and on weekend days. We also find that a higher minimum wage increased the share of days in the month that facilities meet at least 75% of the minimum recommended levels of staffing for nursing assistants. These results lessen concerns that minimum wage hikes may reduce the quality of resident care at nursing facilities.
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Affiliation(s)
- Peter McHenry
- Department of Economics, William & Mary, P.O. Box 8795, Williamsburg, VA USA
| | - Jennifer M. Mellor
- Department of Economics and Schroeder Center for Health Policy, William & Mary, P.O. Box 8795, Williamsburg, VA USA
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Associations Between Daily Nurse Staffing Levels and Daily Hospitalizations and ED Visits in Nursing Homes. J Am Med Dir Assoc 2022; 23:1793-1799.e3. [PMID: 35948066 PMCID: PMC9955393 DOI: 10.1016/j.jamda.2022.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/27/2022] [Accepted: 06/30/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Although many prior studies have shown that high average levels of nurse staffing in nursing homes are associated with fewer hospitalizations, some studies have not, suggesting that the average nursing level may mask a more complex relationship. This study examines this issue by investigating the associations of daily staffing patterns and daily hospitalizations and emergency department (ED) visits. DESIGN Retrospective analyses of national Payroll Based Journal (PBJ) staffing data merged with the Minimum Data Set. SETTING AND PARTICIPANTS A total of 15,718 nursing homes nationally reporting PBJ data during 2017-2019, their staff, and residents. METHODS We estimated facility-day-level models as conditional facility fixed-effect Poisson regressions with robust standard errors. The dependent variables were daily numbers of hospitalization and ED visits and the independent variables of interest were the number of registered nurse (RN), licensed practical nurse (LPN), and certified nurse assistant (CNA) hours on the same and prior days. RESULTS The daily number of hospital transfers averaged 0.28 (SD 0.21). Daily total direct-care staffing hours averaged 288.7 (SD 188.2), with RNs accounting for 35.0, LPNs for 68.7, and CNAs for 185.0. Higher staffing was associated with more hospitalizations on the concurrent day. Higher staffing on the day prior was associated with fewer hospitalizations. The effect size was larger for RNs and LPNs (same day = ∼2%; prior day = approximately -0.7% to -0.9%) than for CNAs (same day <1%; prior day < -0.5%). ED visits not leading to hospitalizations, and analyses for subsamples exhibited similar findings. CONCLUSIONS AND IMPLICATIONS Our findings suggest that staff can address developing problems and prevent admissions the next day and identify emergent problems and hospitalize the same day. They also underscore the complex array of nursing home factors involved in hospitalization and ED visits, including the influence of daily staffing variation, suggesting the need for further research to better understand the associations between staffing and appropriate resident transfers to the hospital or the ED, and the potential implications for quality metrics in these domains.
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Carnahan JL, Unroe KT. Prioritizing nursing home staff and leadership consistency to improve quality. J Am Geriatr Soc 2022; 70:2472-2473. [PMID: 35770904 PMCID: PMC9489602 DOI: 10.1111/jgs.17938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022]
Abstract
This Editorial comments on the article by Zheng et al. in this issue.
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Affiliation(s)
- Jennifer L Carnahan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Kathleen T Unroe
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA
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Meulenbroeks I, Raban MZ, Seaman K, Westbrook J. Therapy-based allied health delivery in residential aged care, trends, factors, and outcomes: a systematic review. BMC Geriatr 2022; 22:712. [PMID: 36031624 PMCID: PMC9420184 DOI: 10.1186/s12877-022-03386-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background Allied health professionals in residential aged care facilities (RACFs) make important contributions to the physical and mental wellbeing of residents. Yet to date, health services research in RACFs has focused almost exclusively on nursing disciplines. This review aims to synthesise the current evidence on allied health services in RACF; specifically, how therapy-based allied health is delivered, what factors impact the quantity delivered, and the impact of services on resident outcomes and care quality. Methods Empirical peer-reviewed and grey literature focusing on allied health service delivery in RACFs from the past decade was identified through systematic searches of four databases and over 200 targeted website searches. Information on how allied health delivered, factors impacting service delivery, and impact on resident outcomes were extracted. The quality of included studies was appraised using the Mixed Methods Appraisal Tool (MMAT) and the AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) checklist. Results Twenty-eight unique studies were included in this review; 26 peer-reviewed and two grey literature studies. Sixteen studies discussed occupational therapy and 15 discussed physiotherapy, less commonly studied professional groups included dieticians (n = 9), allied health assistants (n = 9), and social workers (n = 6). Thirteen studies were assigned a 100% quality rating. Levels of allied health service provision were generally low and varied. Five studies examined the association between system level factors and allied health service provision, and seven studies examined facility level factors and service provision. Higher levels of allied health provision or access to allied health services, specifically physiotherapy, occupational therapy, and nutrition, were associated with reduced falls with injury, improved care quality, activities of daily living scores, nutritional status, and meal satisfaction in five studies. Conclusion Evidence on how allied health is delivered in RACFs, and its impact on resident health outcomes, is lacking globally. While there are some indications of positive associations between allied health staffing and resident outcomes and experiences, health systems and researchers will need commitment to consistent allied health data collection and health services research funding in the future to accurately determine how allied health is delivered in RACFs and its impact on resident wellbeing. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03386-9.
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Gozalo PL, Inrator O, Phibbs CS, Kinosian B, Allen SM. Successful Discharge of Short Stay Veterans from VA Community Living Centers. J Aging Soc Policy 2022; 34:690-706. [PMID: 35959862 DOI: 10.1080/08959420.2022.2111169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007-2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed the patient and facility rates of successful discharge to the community (SDC) of these short-stay Veterans. We found large variation in inter- as well as intra- facility SDC rates across the rehabilitation and skilled nursing short-stay cohorts. We discuss how our results can help guide VHA policy directed at delivering high-quality short-stay CLC care for Veterans.
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Affiliation(s)
- Pedro L Gozalo
- Research Health Scientist, U.S. Department of Veterans Affairs Medical Center, Center of Innovation in Long-Term Services and Supports, Providence, Rhode Island, USA.,Professor, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Orna Inrator
- Professor, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Research Health Scientist, Geriatrics & Extended Care Data & Analysis Center (GEC DAC), Canandaigua VA Medical Center, Canandaigua, New York, USA
| | - Ciaran S Phibbs
- Research Health Scientist, Health Economics Resource Center, Palo Alto VA Health Care System, Palo Alto, California, USA.,Associate Professor, Center for Innovation to Implementation, Stanford University School of Medicine, Palo Alto, California, USA.,Research Health Scientist, Geriatrics and Extended Care Data and Analysis Center, Palo Alto VA Health Care System, Palo Alto, California, USA
| | - Bruce Kinosian
- Associate Professor, Division of Geriatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Research Health Scientist, Geriatrics & Extended Care Data & Analysis Center (GEC DAC), Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Susan M Allen
- Research Health Scientist, U.S. Department of Veterans Affairs Medical Center, Center of Innovation in Long-Term Services and Supports, Providence, Rhode Island, USA.,Professor, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
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Lapane KL, Dubé CE, Jesdale BM, Bova C. Social Connectedness among Long-Stay Nursing Home Residents with Alzheimer's and Dementia: Exploring Individual and Facility-Level Variation. Dement Geriatr Cogn Disord 2022; 51:249-261. [PMID: 35785759 PMCID: PMC9501789 DOI: 10.1159/000525343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/13/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION This study sought to explore individual and facility-level variation in social connectedness among long-stay nursing home residents with Alzheimer's or other dementias (ADRD). METHODS We identified 721,074 long-stay residents with ADRD using 2016 Minimum Data Set 3.0 data. Social connectedness was defined using the social connectedness index (SCI) (high: SCI = 5, lower: 0 < SCI ≤ 4). Adjusted odds ratios (aOR) provided estimates of the associations between resident-level and facility-level characteristics, and high SCI was derived from logistic models. RESULTS The SCI Cronbach's alpha was 0.69; 78.6% had high SCI scores. Men were less likely than women to have higher SCI scores (aOR = 0.97; 95% CI: 0.97-0.98). Increasing age was associated with higher SCI scores (e.g., aOR [85-94 vs. 40-64 years]: 1.07; 95% CI: 1.06-1.07). Those with moderate cognitive impairment (aOR: 0.87) and severe cognitive impairment (aOR: 0.85) had reduced odds of SCI = 5 relative to those with mild/intact cognitive function. Residents living in homes with special care dementia units and with higher percentage of residents with dementia had decreased odds of high social connectedness. DISCUSSION/CONCLUSION Understanding resident- and nursing home-level variation in social connectedness may be important for targeting interventions that reduce isolation among residents with ADRD.
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Affiliation(s)
- Kate L. Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA,*Kate L. Lapane,
| | - Catherine E. Dubé
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Bill M. Jesdale
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Carol Bova
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, Massachusetts, USA
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The 2021 Update on Pressure Injuries: A Review of the Literature. Adv Skin Wound Care 2022; 35:422-428. [PMID: 35856612 DOI: 10.1097/01.asw.0000834588.32255.0d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
GENERAL PURPOSE To provide a review of the recent literature on the epidemiology and treatment of pressure injuries (PIs). TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will:1. Identify risk factors for developing PIs.2. Differentiate factors that could affect the healing of PIs.3. Select strategies that have an impact on the development of PIs. ABSTRACT Keeping up with the literature on pressure injuries is always a challenge for busy clinicians. In this article, the authors summarize six important articles published in 2021. Articles cover a range of topics including epidemiology, treatment, precision medicine, nurse staffing, and patient preferences for care. For each article, a description of the study results is provided along with a comment on why the results are important. This information is intended to help clinicians incorporate new data into their clinical practice.
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Predictors of patient safety activities among registered nurses and nurse aides in long-term care facilities: cross-sectional study. BMC Geriatr 2022; 22:541. [PMID: 35768765 PMCID: PMC9245202 DOI: 10.1186/s12877-022-03234-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 06/01/2022] [Indexed: 11/21/2022] Open
Abstract
Background In Korea, nurse aides (NAs) are legally permitted as substitutes for registered nurses (RNs) in long-term care (LTC) facilities, even though they have very different levels of education and qualification standards. Many studies in hospitals have shown better hospital nurse staffing, more educated nurses, and improved nurse work environments have been associated with lower hospital mortality and length of stay. There is research showing that a higher percentage of RNs with a bachelor’s degree corresponded to lower incidence rates of pressure ulcers in Korean LTC facilities. This study aimed to explore the factors that influence patient safety activities of the RNs and NAs working in LTC facilities and to identify the relationship between patient safety culture (PSC) and patient safety activities. Methods This study is a descriptive cross-sectional survey. The study participants were conveniently collected from 88 RNs and 71 NAs who worked at 33 LTC facilities for more than three months. The patient safety activities tool was developed by the researchers for residents of LTC facilities based on the tools developed by Park et al. (2012) for hospital nurses and the patient safety goals of the Joint Commission. The questionnaires were collected by email or mobile application and kept confidential. Data were analyzed using descriptive statistics, independent t-test, one-way ANOVA, Pearson correlation coefficients, and multiple regression analysis. Results The mean scores of PSC and patient safety activities were 4.03 ± 0.51 points and 4.29 ± 0.49 points out of 5, respectively. There was significant correlation between PSC and patient safety activities (r = .23, p = .004). Factors influencing patient safety activities among RNs and NAs in LTC facilities were RNs (β = .377, p < .001), organizational system of PSC (β = .314, p < .010), and work shift type (fixed night shift, on-call, 24-h shift) (β = -.264, p = .004), which explained about 36.0% of total variance (F = 5.69, p < .001). Conclusion The findings indicate that it is necessary to mandate RNs instead of NAs to enhance residents’ safety in LTC facilities. Additionally, the importance of an organizational safety system and effective working shift types to prevent residents’ safety accidents in LTC facilities is indicated. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03234-w.
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Choroschun K, Kennedy M, Hoben M. 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. BMJ Open 2022; 12:e061073. [PMID: 35732394 PMCID: PMC9226885 DOI: 10.1136/bmjopen-2022-061073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
| | - Megan Kennedy
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Matthias Hoben
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Hirose N, Morita K, Matsui H, Fushimi K, Yasunaga H. Association between nurse aide staffing and patient mortality after major cancer surgeries in acute care settings: A retrospective cohort study. Nurs Health Sci 2022; 24:283-292. [PMID: 35080800 DOI: 10.1111/nhs.12924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/09/2021] [Accepted: 01/17/2022] [Indexed: 11/29/2022]
Abstract
This study examined the association between adding nurse aides and patient mortality in acute care settings. We conducted a retrospective cohort study using a national healthcare administrative claims database. We identified patients who underwent planned surgery for six types of cancer from 2010 to 2017. Multivariable logistic analyses were used to examine the association between the nurse aide staffing level and patient outcomes. The primary outcomes were failure to rescue and 30-day hospital mortality. We examined 330 666 in-hospital patients. The median number of nurse aides per 100 occupied beds was 6.60 (interquartile range, 4.61-8.43). In the multivariable analysis, nurse aide staffing level was not significantly associated with failure to rescue or 30-day hospital mortality. The Japanese government provides economic incentives to hospitals that hire more nurse aides, expecting that a higher nurse aide staffing level will help licensed nurses concentrate on the tasks that need their specialties. However, our findings suggest that adding nurse aides may not be associated with lower rates of failure to rescue or 30-day hospital mortality in acute care settings.
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Affiliation(s)
- Naoki Hirose
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.,Global Health Nursing, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kojiro Morita
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Mukamel DB, Saliba D, Ladd H, Konetzka RT. Daily Variation in Nursing Home Staffing and Its Association With Quality Measures. JAMA Netw Open 2022; 5:e222051. [PMID: 35285921 PMCID: PMC9907340 DOI: 10.1001/jamanetworkopen.2022.2051] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Average staffing measures are a focus of nursing homes' quality assessments and reporting. They may, however, mask daily variation in staffing, additional information that could be important for understanding nursing home quality and relative ranking. OBJECTIVE To examine daily variation in staffing, its association with quality, and whether daily variation provides information regarding quality ranking of nursing homes over and above the information provided by average staffing levels. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study included registered nurses (RNs) and certified nurse aide (CNAs) at 13 339 certified nursing homes throughout the United States during 2017 to 2018. Retrospective analyses of the Payroll-Based Journal, Medicare Cost Reports, and Nursing Home Care Compare were conducted. Data were analyzed from January 2017 to December 2018. MAIN OUTCOMES AND MEASURES Three measures of daily variation, ie, coefficient of variation (COV), total outlier days (TOD), and low outlier days (LOD), were calculated for RNs and CNAs. The association between these measures and quality rankings and other facility characteristics were evaluated. RESULTS A total of 13 339 nursing homes were included in this study, with 9476 (71%) for-profit facilities. The mean (SD) hours-per-resident-day were 0.41 (0.29) for RNs and 2.16 (0.49) for CNAs, and a mean (SD) 55% (26%) of residents were Medicaid beneficiaries. Outcome measures were as follows: mean (SD) COV, 0.5 (0.6) for RNs and 0.1 (0.1) for CNAs; mean (SD) TOD, 220 (69) for RNs and 44 (45) for CNAs; and mean (SD) LOD, 116 (45) for RNs and 22 (24) for CNAs. All 3 variation measures, for both RNs and CNAs, were significantly associated with both the 5-Star Quality Measures (COV among RNs, -0.014 [95% CI, -0.021 to -0.007]; P < .001; COV among CNAs: -0.004 [95% CI, -0.006 to -0.003]; P < .001; TOD among RNs, -3.79 [95% CI, -4.59 to -2.99]; P < .001; TOD among CNAs, -2.52 [95% CI, -3.08 to -1.96]; P < .001; LOD among RNs, -2.46 [95% CI, -3.03 to -1.88]; P < .001; LOD among CNAs, -1.29 [95% CI, -1.58 to -0.99]; P < .001) and the 5-Star Survey rankings (COV among RNs,-0.026 [95% CI, -0.033 to -0.019]; P < .001; COV among CNAs: -0.006 [95% CI, -0.007 to -0.004]; P < .001; TOD among RNs, -5.10 [95% CI, -5.97 to -4.23]; P < .001; TOD among CNAs, -4.16 [95% CI, -4.77 to -3.55]; P < .001; LOD among RNs, -3.04 [95% CI, -3.65 to -2.44]; P < .001; LOD among CNAs, -1.97 [95% CI, -2.29 to -1.65]; P < .001) published in Nursing Home Care Compare. Low κ values, ranging from 0.23 to 0.63, indicated that the variation measures add information about ranking to the information provided by average staffing measure. CONCLUSIONS AND RELEVANCE These findings highlight the importance of reporting daily variation in staffing to improve understanding of the relationship between staffing and quality. They suggest that 2 facilities with the same average staffing achieve different quality of resident care and survey ratings in association with on the day-to-day variation in staffing. Measures of daily staffing may enhance the value of Nursing Home Care Compare for nursing homes and others engaged in quality improvement and consumers searching for high quality nursing homes.
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Affiliation(s)
- Dana B. Mukamel
- Department of Medicine, Division of General Internal Medicine, University of California, Irvine
| | - Debra Saliba
- UCLA Borun Center at David Geffen School of Medicine, Los Angeles, California
- Veterans Administration GRECC, Los Angeles, California
- RAND Health, Santa Monica, California
| | - Heather Ladd
- Department of Medicine, Division of General Internal Medicine, University of California, Irvine
| | - R. Tamara Konetzka
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois
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Camacho-Conde JA, Muñoz-Arbona DJ. A Survey of Basic Daily Living Assistance in Dependency Units during the Morning First Period at Nursing Homes with a Healthcare Dysfunction. NURSING REPORTS 2022; 12:125-139. [PMID: 35225899 PMCID: PMC8883999 DOI: 10.3390/nursrep12010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: It is important to evaluate the attention in the basic activities of daily life in the early hours of the day to evaluate the quality of care and to be able to increase the attention of human resources in case of observing an increase in dependency. The purpose was to improve healthcare quality in nursing homes, correctly identifying the work burden and incidents of daily planning, and completing the work plan by nursing assistant staffing. (2) Methods: The sample is based on 70 elderly people. The analysis used an observational trial every workday over a six-month period. An ad hoc sheet was prepared to collect socio-demographic data on each participant, and the Barthel Index was applied to the study subjects. A daily record of three basic activities of daily living (BADL), such as dressing, bathing, and eating, was kept. (3) Results: Our results showed a significant evolution in both units, but it was in the psychogeriatric unit in which higher compliance with the schedule and higher maintained stability was reached. (4) Conclusions: The use of some BADL registers helped us address situations of imbalance in terms of user assistance and establish an interdisciplinary communication with the nursing team as a way of achieving better organization and compliance with care protocols.
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Affiliation(s)
- José Antonio Camacho-Conde
- Department of Evolutionary and Educational Psychology, University of Granada, E-51005 Ceuta, Spain
- Correspondence:
| | - David Juan Muñoz-Arbona
- Teaching Technical Advisor for Inter-institutional Educational Programs, Provincial Office of the Ministry of Education in Ceuta, E-51005 Ceuta, Spain;
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Hawk T, White EM, Bishnoi C, Schwartz LB, Baier RR, Gifford DR. Facility characteristics and costs associated with meeting proposed minimum staffing levels in skilled nursing facilities. J Am Geriatr Soc 2022; 70:1198-1207. [PMID: 35113449 DOI: 10.1111/jgs.17678] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 11/10/2021] [Accepted: 11/21/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Terry Hawk
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, District of Columbia, USA
| | - Elizabeth M White
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Courtney Bishnoi
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, District of Columbia, USA
| | - Lindsay B Schwartz
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, District of Columbia, USA
| | - Rosa R Baier
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island, USA
| | - David R Gifford
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, District of Columbia, USA.,Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
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Briesacher BA, Olivieri‐Mui BL, Koethe B, Saczynski JS, Fick DM, Devlin JW, Marcantonio ER. Psychoactive medication therapy and delirium screening in skilled nursing facilities. J Am Geriatr Soc 2022; 70:1517-1524. [PMID: 35061246 PMCID: PMC9106820 DOI: 10.1111/jgs.17662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/14/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND A positive delirium screen at skilled-nursing facility (SNF) admission can trigger a simultaneous diagnosis of Alzheimer's Disease or related dementia (AD/ADRD) and lead to psychoactive medication treatment despite a lack of evidence supporting use. METHODS This was a nationwide historical cohort study of 849,086 Medicare enrollees from 2011-2013 who were admitted to the SNF from a hospital without a history of dementia. Delirium was determined through positive Confusion Assessment Method screen and incident AD/ADRD through active diagnosis or claims. Cox proportional hazard models predicted the risk of receiving one of three psychoactive medications (i.e., antipsychotics, benzodiazepines, antiepileptics) within 7 days of SNF admission and within the entire SNF stay. RESULTS Of 849,086 newly-admitted SNF patients (62.6% female, mean age 78), 6.1% had delirium (of which 35.4% received an incident diagnosis of AD/ADRD); 12.6% received antipsychotics, 30.4% benzodiazepines, and 5.8% antiepileptics. Within 7 days of admission, patients with delirium and incident dementia were more likely to receive an antipsychotic (relative risk [RR] 3.09; 95% confidence interval [CI] 2.99 to 3.20), or a benzodiazepine (RR 1.23; 95% CI 1.19 to 1.27) than patients without either condition. By the end of the SNF stay, patients with both delirium and incident dementia were more likely to receive an antipsychotic (RR 3.04; 95% CI 2.95 to 3.14) and benzodiazepine (RR 1.32; 95% CI 1.29 to 1.36) than patients without either condition. CONCLUSION In this historical cohort, a positive delirium screen was associated with a higher risk of receiving psychoactive medication within 7 days of SNF admission, particularly in patients with an incident AD/ADRD diagnosis. Future research should examine strategies to reduce inappropriate psychoactive medication prescribing in older adults admitted with delirium to SNFs.
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Affiliation(s)
- Becky A. Briesacher
- Bouvé College of Health Sciences, School of Pharmacy Northeastern University Boston Massachusetts USA
| | - Brianne L. Olivieri‐Mui
- Hebrew SeniorLife The Marcus Institute for Aging Research, Harvard Medical School Boston Massachusetts USA
| | - Benjamin Koethe
- Bouvé College of Health Sciences, School of Pharmacy Northeastern University Boston Massachusetts USA
| | - Jane S. Saczynski
- Bouvé College of Health Sciences, School of Pharmacy Northeastern University Boston Massachusetts USA
| | - Donna Marie Fick
- Center of Geriatric Nursing Excellence Penn State College of Nursing University Park Pennsylvania USA
| | - John W. Devlin
- Bouvé College of Health Sciences, School of Pharmacy Northeastern University Boston Massachusetts USA
| | - Edward R. Marcantonio
- Harvard Medical School, Divisions of General Medicine and Gerontology Beth Israel Deaconess Medical Center Boston Massachusetts USA
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Popejoy LL, Vogelsmeier AA, Canada KE, Kist S, Miller SJ, Galambos C, Alexander GL, Crecelius C, Rantz M. A Call to Address RN, Social Work, and Advanced Practice Registered Nurses in Nursing Homes: Solutions From the Missouri Quality Initiative. J Nurs Care Qual 2022; 37:21-27. [PMID: 34751164 PMCID: PMC8608010 DOI: 10.1097/ncq.0000000000000604] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND US nursing homes (NHs) have struggled to overcome a historic pandemic that laid bare limitations in the number and clinical expertise of NH staff. PROBLEM For nurse staffing, current regulations require only one registered nurse (RN) on duty 8 consecutive hours per day, 7 days per week, and one RN on call when a licensed practical/vocational nurse is on duty. There is no requirement for a degreed or licensed social worker, and advanced practice registered nurses (APRNs) in NHs cannot bill for services. APPROACH It is time to establish regulation that mandates a 24-hour, 7-day-a-week, on-site RN presence at a minimum requirement of 1 hour per resident-day that is adjusted upward for greater resident acuity and complexity. Skilled social workers are needed to improve the quality of care, and barriers for APRN billing for services in NHs need to be removed. CONCLUSIONS Coupling enhanced RN and social work requirements with access to APRNs can support staff and residents in NHs.
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Affiliation(s)
- Lori L. Popejoy
- Sinclair School of Nursing, University of Missouri, Columbia (Drs Popejoy, Vogelsmeier, Canada, Kist, and Rantz and Mr Miller); Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos); Columbia University School of Nursing, New York City, New York (Dr Alexander); Washington University School of Medicine, St Louis, Missouri (Dr Crecelius); and BJC Medical Group, St Louis, Missouri (Dr Crecelius)
| | - Amy A. Vogelsmeier
- Sinclair School of Nursing, University of Missouri, Columbia (Drs Popejoy, Vogelsmeier, Canada, Kist, and Rantz and Mr Miller); Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos); Columbia University School of Nursing, New York City, New York (Dr Alexander); Washington University School of Medicine, St Louis, Missouri (Dr Crecelius); and BJC Medical Group, St Louis, Missouri (Dr Crecelius)
| | - Kelli E. Canada
- Sinclair School of Nursing, University of Missouri, Columbia (Drs Popejoy, Vogelsmeier, Canada, Kist, and Rantz and Mr Miller); Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos); Columbia University School of Nursing, New York City, New York (Dr Alexander); Washington University School of Medicine, St Louis, Missouri (Dr Crecelius); and BJC Medical Group, St Louis, Missouri (Dr Crecelius)
| | - Shari Kist
- Sinclair School of Nursing, University of Missouri, Columbia (Drs Popejoy, Vogelsmeier, Canada, Kist, and Rantz and Mr Miller); Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos); Columbia University School of Nursing, New York City, New York (Dr Alexander); Washington University School of Medicine, St Louis, Missouri (Dr Crecelius); and BJC Medical Group, St Louis, Missouri (Dr Crecelius)
| | - Steven J. Miller
- Sinclair School of Nursing, University of Missouri, Columbia (Drs Popejoy, Vogelsmeier, Canada, Kist, and Rantz and Mr Miller); Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos); Columbia University School of Nursing, New York City, New York (Dr Alexander); Washington University School of Medicine, St Louis, Missouri (Dr Crecelius); and BJC Medical Group, St Louis, Missouri (Dr Crecelius)
| | - Colleen Galambos
- Sinclair School of Nursing, University of Missouri, Columbia (Drs Popejoy, Vogelsmeier, Canada, Kist, and Rantz and Mr Miller); Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos); Columbia University School of Nursing, New York City, New York (Dr Alexander); Washington University School of Medicine, St Louis, Missouri (Dr Crecelius); and BJC Medical Group, St Louis, Missouri (Dr Crecelius)
| | - Gregory L. Alexander
- Sinclair School of Nursing, University of Missouri, Columbia (Drs Popejoy, Vogelsmeier, Canada, Kist, and Rantz and Mr Miller); Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos); Columbia University School of Nursing, New York City, New York (Dr Alexander); Washington University School of Medicine, St Louis, Missouri (Dr Crecelius); and BJC Medical Group, St Louis, Missouri (Dr Crecelius)
| | - Charles Crecelius
- Sinclair School of Nursing, University of Missouri, Columbia (Drs Popejoy, Vogelsmeier, Canada, Kist, and Rantz and Mr Miller); Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos); Columbia University School of Nursing, New York City, New York (Dr Alexander); Washington University School of Medicine, St Louis, Missouri (Dr Crecelius); and BJC Medical Group, St Louis, Missouri (Dr Crecelius)
| | - Marilyn Rantz
- Sinclair School of Nursing, University of Missouri, Columbia (Drs Popejoy, Vogelsmeier, Canada, Kist, and Rantz and Mr Miller); Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos); Columbia University School of Nursing, New York City, New York (Dr Alexander); Washington University School of Medicine, St Louis, Missouri (Dr Crecelius); and BJC Medical Group, St Louis, Missouri (Dr Crecelius)
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Perruchoud E, Weissbrodt R, Verloo H, Fournier CA, Genolet A, Rosselet Amoussou J, Hannart S. The Impact of Nursing Staffs’ Working Conditions on the Quality of Care Received by Older Adults in Long-Term Residential Care Facilities: A Systematic Review of Interventional and Observational Studies. Geriatrics (Basel) 2021; 7:geriatrics7010006. [PMID: 35076476 PMCID: PMC8788263 DOI: 10.3390/geriatrics7010006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/22/2021] [Accepted: 12/25/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Little documentation exists on relationships between long-term residential care facilities (LTRCFs), staff working conditions and residents’ quality of care (QoC). Supporting evidence is weak because most studies examining this employ cross-sectional designs. Methods: Systematic searches of twelve bibliographic databases sought experimental and longitudinal studies, published up to May 2021, focusing on LTRCF nursing staff’s working conditions and the QoC they provided to older adults. Results: Of the 3577 articles identified, 159 were read entirely, and 11 were retained for inclusion. Higher nursing staff hours worked per resident per day (HPRD) were associated with significant reductions in pressure sores and urinary tract infections. Overall staff qualification levels and numbers of RNs had significant positive influences on QoC. Conclusions: To the best of our knowledge, this systematic review is the first to combine cohort studies with a quasi-experimental study to explore associations between LTRCF nursing staff’s working conditions and older adult residents’ QoC. Human factors (including HPRD, staff turnover, skill mix, staff ratios) and the specific working contribution of RNs had overwhelmingly significant influences on QoC. It seems essential that LTRCF supervisory and decision-making bodies should promote optimal working conditions for nursing staff because these have such a direct impact on residents’ QoC.
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Affiliation(s)
- Elodie Perruchoud
- Department of Nursing Sciences, School of Health Sciences, HES-SO Valais/Wallis, University of Applied Sciences and Arts Western Switzerland, Chemin de l’Agasse 5, CH-1950 Sion, Switzerland; (R.W.); (H.V.); (C.-A.F.); (A.G.); (S.H.)
- Correspondence: ; Tel.: +41-58-606-86-78
| | - Rafaël Weissbrodt
- Department of Nursing Sciences, School of Health Sciences, HES-SO Valais/Wallis, University of Applied Sciences and Arts Western Switzerland, Chemin de l’Agasse 5, CH-1950 Sion, Switzerland; (R.W.); (H.V.); (C.-A.F.); (A.G.); (S.H.)
| | - Henk Verloo
- Department of Nursing Sciences, School of Health Sciences, HES-SO Valais/Wallis, University of Applied Sciences and Arts Western Switzerland, Chemin de l’Agasse 5, CH-1950 Sion, Switzerland; (R.W.); (H.V.); (C.-A.F.); (A.G.); (S.H.)
- Service of Old Age Psychiatry, Department of Psychiatry, Lausanne University Hospital, Route de Cery 60, CH-1008 Lausanne, Switzerland
| | - Claude-Alexandre Fournier
- Department of Nursing Sciences, School of Health Sciences, HES-SO Valais/Wallis, University of Applied Sciences and Arts Western Switzerland, Chemin de l’Agasse 5, CH-1950 Sion, Switzerland; (R.W.); (H.V.); (C.-A.F.); (A.G.); (S.H.)
| | - Audrey Genolet
- Department of Nursing Sciences, School of Health Sciences, HES-SO Valais/Wallis, University of Applied Sciences and Arts Western Switzerland, Chemin de l’Agasse 5, CH-1950 Sion, Switzerland; (R.W.); (H.V.); (C.-A.F.); (A.G.); (S.H.)
| | - Joëlle Rosselet Amoussou
- Psychiatry Library, Education and Research Department, Lausanne University Hospital and University of Lausanne, Site de Cery, CH-1008 Lausanne, Switzerland;
| | - Stéphanie Hannart
- Department of Nursing Sciences, School of Health Sciences, HES-SO Valais/Wallis, University of Applied Sciences and Arts Western Switzerland, Chemin de l’Agasse 5, CH-1950 Sion, Switzerland; (R.W.); (H.V.); (C.-A.F.); (A.G.); (S.H.)
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Verdoorn BP, Evans TK, Hanson GJ, Zhu Y, Langhi Prata LGP, Pignolo RJ, Atkinson EJ, Wissler‐Gerdes EO, Kuchel GA, Mannick JB, Kritchevsky SB, Khosla S, Rizza SA, Walston JD, Musi N, Lipsitz LA, Kiel DP, Yung R, LeBrasseur NK, Singh RJ, McCarthy T, Puskarich MA, Niedernhofer LJ, Robbins PD, Sorenson M, Tchkonia T, Kirkland JL. Fisetin for COVID-19 in skilled nursing facilities: Senolytic trials in the COVID era. J Am Geriatr Soc 2021; 69:3023-3033. [PMID: 34375437 PMCID: PMC8447437 DOI: 10.1111/jgs.17416] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 01/19/2023]
Abstract
The burden of senescent cells (SnCs), which do not divide but are metabolically active and resistant to death by apoptosis, is increased in older adults and those with chronic diseases. These individuals are also at the greatest risk for morbidity and mortality from SARS-CoV-2 infection. SARS-CoV-2 complications include cytokine storm and multiorgan failure mediated by the same factors as often produced by SnCs through their senescence-associated secretory phenotype (SASP). The SASP can be amplified by infection-related pathogen-associated molecular profile factors. Senolytic agents, such as Fisetin, selectively eliminate SnCs and delay, prevent, or alleviate multiple disorders in aged experimental animals and animal models of human chronic diseases, including obesity, diabetes, and respiratory diseases. Senolytics are now in clinical trials for multiple conditions linked to SnCs, including frailty; obesity/diabetes; osteoporosis; and cardiovascular, kidney, and lung diseases, which are also risk factors for SARS-CoV-2 morbidity and mortality. A clinical trial is underway to test if senolytics decrease SARS-CoV-2 progression and morbidity in hospitalized older adults. We describe here a National Institutes of Health-funded, multicenter, placebo-controlled clinical trial of Fisetin for older adult skilled nursing facility (SNF) residents who have been, or become, SARS-CoV-2 rtPCR-positive, including the rationale for targeting fundamental aging mechanisms in such patients. We consider logistic challenges of conducting trials in long-term care settings in the SARS-CoV-2 era, including restricted access, consent procedures, methods for obtaining biospecimens and clinical data, staffing, investigational product administration issues, and potential solutions for these challenges. We propose developing a national network of SNFs engaged in interventional clinical trials.
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Affiliation(s)
- Brandon P. Verdoorn
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Geriatrics and GerontologyMayo ClinicRochesterMinnesotaUSA
| | - Tamara K. Evans
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
| | - Gregory J. Hanson
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Geriatrics and GerontologyMayo ClinicRochesterMinnesotaUSA
| | - Yi Zhu
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
| | | | - Robert J. Pignolo
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Geriatrics and GerontologyMayo ClinicRochesterMinnesotaUSA
| | - Elizabeth J. Atkinson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | | | - George A. Kuchel
- University of Connecticut Center on Aging, UConn HealthFarmingtonConnecticutUSA
| | | | - Stephen B. Kritchevsky
- Sticht Center for Healthy Aging and Alzheimer's PreventionWinston‐SalemNorth CarolinaUSA
| | - Sundeep Khosla
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Endocrinology, Department of MedicineMayo ClinicRochesterMinnesotaUSA
| | - Stacey A. Rizza
- Division of Infectious Diseases, Department of MedicineMayo ClinicRochesterMinnesotaUSA
| | - Jeremy D. Walston
- Department of Medicine, Division of Geriatric Medicine and GerontologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Nicolas Musi
- Barshop Institute for Longevity and Aging StudiesUniversity of Texas Health Science Center at San AntonioSan AntonioTexasUSA
| | - Lewis A. Lipsitz
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
- Division of GerontologyBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Douglas P. Kiel
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
- Division of GerontologyBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Raymond Yung
- Geriatrics Center and Institute of GerontologyUniversity of MichiganAnn ArborMichiganUSA
- VA Ann Arbor Geriatrics ResearchEducation and Clinical CenterAnn ArborMichiganUSA
- Department of Internal Medicine Division of Geriatric and Palliative MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Nathan K. LeBrasseur
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Department of Physical Medicine and RehabilitationMayo ClinicRochesterMinnesotaUSA
| | - Ravinder J. Singh
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Teresa McCarthy
- Institute on the Biology of Aging and Metabolism, Department of Biochemistry, Molecular Biology and BiophysicsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Michael A. Puskarich
- Institute on the Biology of Aging and Metabolism, Department of Biochemistry, Molecular Biology and BiophysicsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Laura J. Niedernhofer
- Institute on the Biology of Aging and Metabolism, Department of Biochemistry, Molecular Biology and BiophysicsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Paul D. Robbins
- Institute on the Biology of Aging and Metabolism, Department of Biochemistry, Molecular Biology and BiophysicsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | | | - Tamara Tchkonia
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
| | - James L. Kirkland
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Geriatrics and GerontologyMayo ClinicRochesterMinnesotaUSA
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Konetzka RT, White EM, Pralea A, Grabowski DC, Mor V. A systematic review of long-term care facility characteristics associated with COVID-19 outcomes. J Am Geriatr Soc 2021; 69:2766-2777. [PMID: 34549415 PMCID: PMC8631348 DOI: 10.1111/jgs.17434] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/04/2021] [Accepted: 08/08/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND/OBJECTIVES The coronavirus disease 2019 (COVID-19) pandemic has taken a disproportionate toll on long-term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID-19 cases and deaths. DESIGN Systematic review. SETTING Long-term care facilities (nursing homes and assisted living communities). PARTICIPANTS Thirty-six empirical studies of factors associated with COVID-19 cases and deaths in long-term care facilities published between January 1, 2020 and June 15, 2021. MEASUREMENTS Outcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably. RESULTS Larger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID-19 outcomes in long-term care facilities. Larger bed size and location in an area with high COVID-19 prevalence were the strongest and most consistent predictors of facilities having more COVID-19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID-19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5-star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID-19 outcomes. CONCLUSION Given the importance of community COVID-19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID-19 spread would have been critical for mitigating much of the morbidity and mortality long-term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5-Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID-19 presented a novel problem requiring extensive adaptation by both long-term care providers and policymakers.
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Affiliation(s)
- R. Tamara Konetzka
- Department of Public Health SciencesUniversity of ChicagoChicagoIllinoisUSA
| | - Elizabeth M. White
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Alexander Pralea
- Program in Liberal Medical EducationBrown UniversityProvidenceRhode IslandUSA
| | - David C. Grabowski
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusettsUSA
| | - Vincent Mor
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
- Providence Veterans Administration Medical Center Research ServiceProvidenceRhode IslandUSA
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Individual and organizational factors of nurses' job satisfaction in long-term care: A systematic review. Int J Nurs Stud 2021; 123:104073. [PMID: 34536909 DOI: 10.1016/j.ijnurstu.2021.104073] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/09/2021] [Accepted: 08/20/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND In long-term care facilities, nurses' job satisfaction predicts staff turnover, which adversely affects resident outcomes. Thus, it is important to develop a comprehensive understanding of factors affecting nurses' job satisfaction in long-term care facilities. OBJECTIVES To analyze factors associated with job satisfaction among nurses in nursing homes from individual and organizational perspectives utilizing a deductive approach. DESIGN Systematic literature review SETTING: Nursing homes. PARTICIPANTS Registered nurses and licensed practical nurses in nursing homes. METHODS A systematic literature review of seven online databases (EMBASE, CINAHL, PsychINFO, MEDLINE, PubMed, Scopus, and Web of Science) to July 23, 2020 was conducted. Studies were included if they examined factors associated job satisfaction in the target population and setting. Decision rules on how to determine factors important to nurse job satisfaction were developed a priori. Two team members independently screened the publications for inclusion, extracted data, and assessed included publications for methodological quality; conflicts were resolved through a consensus process and consultation of the third senior team member when needed. RESULTS Twenty-eight studies were included. Of these, 20 studies were quantitative, 6 were qualitative, and 2 were mixed methods. Factors associated with job satisfaction were grouped into two categories: individual and organizational. Individual factors significantly associated with job satisfaction were age, health status, self-determination/autonomy, psychological empowerment, job involvement, work exhaustion, and work stress. Individual factors identified as not important or equivocal were gender and experience as a nurse/in aged care. No organizational factors were identified as important for nurses' job satisfaction. Facility ownership, supervisor/manager support, resources, staffing level, and social relationships were identified as equivocal or not important. Findings from qualitative studies identified relationship with residents as an important factor for job satisfaction. CONCLUSIONS/IMPLICATIONS Factors identified as important to nurses' job satisfaction differ from those reported among care aides in nursing homes and nurses employed in acute care settings, suggesting that there is a need for unique approaches to enhance nurses' job satisfaction in nursing homes.
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Aloisio LD, Varin MD, Hoben M, Baumbusch J, Estabrooks CA, Cummings GG, Squires JE. To whom health care aides report: Effect on nursing home resident outcomes. Int J Older People Nurs 2021; 16:e12406. [PMID: 34247437 DOI: 10.1111/opn.12406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/10/2021] [Accepted: 06/21/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Health care aides (personal support workers and nursing assistants) provide ~80%-90% of direct care to residents in nursing homes; it is therefore important to understand whether supervision of health care aides affects quality of care. We sought to determine whether health care aide reporting practices are associated with resident outcomes in nursing homes. DESIGN AND METHODS We conducted a cross-sectional secondary analysis of survey data of 3991 health care aides from 322 units in 89 nursing homes in Western Canada. We then linked resident data from the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 database to care aide surveys at the unit level. We used hierarchical mixed models to determine if the proportion of health care aides reporting to a respective nursing leader role was associated with 13 practice sensitive quality indicators of resident care. RESULTS Most health care aides reported to a registered nurse (RN, 44.5%) or licenced practical nurse (LPN, 53.3%). Only 2.2% of health care aides reported to a care manager and were excluded from the analysis. Resident outcomes for only declining behavioural symptoms were more favourable when a higher proportion of health care aides (on a unit) reported to RNs, β = -0.004 (95% CI -0.006, -0.001, p = .004). The remaining indicators were not affected by care aide reporting practices. DISCUSSION AND IMPLICATIONS Resident outcomes as evaluated by the indicators appear largely unaffected by care aide reporting practices. LPNs' increasing scope of practice and changing work roles and responsibilities in nursing homes across Western Canada may explain the findings.
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Affiliation(s)
| | | | - Matthias Hoben
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | | | - Carole A Estabrooks
- Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, Canada
| | | | - Janet E Squires
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Nursing, University of Ottawa, Ottawa, ON, Canada
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Park C, Kim D, Briesacher BA. Association of Social Isolation of Long-term Care Facilities in the United States With 30-Day Mortality. JAMA Netw Open 2021; 4:e2113361. [PMID: 34132793 PMCID: PMC8209586 DOI: 10.1001/jamanetworkopen.2021.13361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/14/2021] [Indexed: 12/20/2022] Open
Abstract
Importance Long-term care (LTC) residents may be susceptible to social isolation if living in facilities located in neighborhoods lacking social connection. Objective To characterize the social isolation of residents living in LTC facilities in the US. Design, Setting, and Participants This cross-sectional study included 730 524 LTC residents from 14 224 LTC facilities in 8652 zip code tabulation areas (ZCTAs) in the US in 2011. A nationwide LTC database with ZCTA data was linked to population-level geographic data from the US Census Bureau. Statistical analysis was performed from January 2019 to December 2020. Exposures The primary variable of interest was the social isolation of LTC neighborhoods defined as the percentage of households in the ZCTA with individuals aged 65 years or older who lived alone and categorized into quartiles of social isolation. Main Outcomes and Measures Maps were generated to illustrate geographic variation of LTC facilities at the ZCTA level by the quartile of socially isolated neighborhoods. Generalized estimating equations were used to estimate the adjusted likelihood that LTC facilities were located in areas of highest social isolation. We also used multilevel logistic regression models to assess the association between the social isolation of neighborhoods of LTC facilities and 30-day all-cause mortality after LTC admission. Subgroup analyses were conducted by race and ethnicity. Results Among 33 120 ZCTAs in the US, 8652 (26.1%) had at least 1 LTC facility. Among the 730 524 LTC residents included in the study's 14 224 LTC facilities, 458 136 (62.71%) were female, 610 802 (83.61%) were non-Hispanic White, and 419 654 (57.45%) were aged 80 years or older. Location of LTC facilities was associated with increasing levels of social isolation (quartile 1 = 9.72% [n = 840]; quartile 2 = 18.60% [n = 1607]; quartile 3 = 32.23% [n = 2784]; quartile 4 = 39.45% [n = 3408]; P < .001). In multivariate models, LTC facilities were 8 times more likely to be located in ZCTAs with the highest percentages of older adults residing in single-occupancy households (odds ratio [OR], 8.46; 95% CI, 7.44-9.65; P < .001), compared with ZCTAs with the lowest percentages. This association held across ZCTAs with a majority population of African American and Hispanic individuals, although it was strongest in ZCTAs with a majority population of White individuals. LTC residents entering facilities in neighborhoods with the highest levels of social isolation among older adults had a 17% higher risk of 30-day mortality (OR, 1.17; 95% CI, 1.10-1.25; P < .001) compared with those in neighborhoods with the lowest levels of social isolation among older adults. Conclusions and Relevance This study found that LTC facilities were often located in socially isolated neighborhoods, suggesting the need for special attention and strategies to keep LTC residents connected to their family and friends for optimal health.
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Affiliation(s)
- Chanhyun Park
- Department of Pharmacy and Health Systems Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Daniel Kim
- Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- School of Public Policy and Urban Affairs, Northeastern University, Boston, Massachusetts
| | - Becky A. Briesacher
- Department of Pharmacy and Health Systems Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
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Mack DS, Baek J, Tjia J, Lapane KL. Geographic Variation of Statin Use Among US Nursing Home Residents With Life-limiting Illness. Med Care 2021; 59:425-436. [PMID: 33560713 PMCID: PMC8791012 DOI: 10.1097/mlr.0000000000001505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medically compromised nursing home residents continue to be prescribed statins, despite questionable benefits. OBJECTIVE To describe regional variation in statin use among residents with life-limiting illness. RESEARCH DESIGN Cross-sectional study using 2016 Minimum Data Set 3.0 assessments linked to Medicare administrative data and health service utilization area resource files. SETTING Nursing homes (n=14,147) within hospital referral regions (n=306) across the United States. SUBJECTS Long-stay residents (aged 65 y and older) with life-limiting illness (eg, serious illness, palliative care, or prognosis <6 mo to live) (n=361,170). MEASURES Prevalent statin use was determined by Medicare Part D claims. Stratified by age (65-75, 76 y or older), multilevel logistic models provided odds ratios with 95% confidence intervals. RESULTS Statin use was prevalent (age 65-75 y: 46.0%, 76 y or more: 31.6%). For both age groups, nearly all resident-level variables evaluated were associated with any and high-intensity statin use and 3 facility-level variables (ie, higher proportions of Black residents, skilled nursing care provided, and average number of medications per resident) were associated with increased odds of statin use. Although in residents aged 65-75 years, no associations were observed, residents aged 76 years or older located in hospital referral regions (HRRs) with the highest health care utilization had higher odds of statin use than those in nursing homes in HRRs with the lowest health care utilization. CONCLUSIONS Our findings suggest extensive geographic variation in US statin prescribing across HRRs, especially for those aged 76 years or older. This variation may reflect clinical uncertainty given the largely absent guidelines for statin use in nursing home residents.
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Affiliation(s)
- Deborah S. Mack
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jonggyu Baek
- Division of Biostatistics and Health Services Research, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jennifer Tjia
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kate L. Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Temkin-Greener H, Cen X, Li Y. Nursing Home Staff Turnover and Perceived Patient Safety Culture: Results from a National Survey. THE GERONTOLOGIST 2021; 60:1303-1311. [PMID: 32211874 DOI: 10.1093/geront/gnaa015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We examined the association between turnover of registered nurses (RNs) and certified nurse assistants (CNAs) and perceived patient safety culture (PSC) in nursing homes (NHs). RESEARCH DESIGN AND METHODS In 2017, we conducted PSC survey using the Agency for Healthcare Research and Quality- developed and -validated instrument for NHs. A random sample of 2,254 U.S. NHs was identified. Administrators, directors of nursing (DONs), and nurse unit leaders served as respondents. Responses were obtained for 818 facilities from 1,447 individuals. The instrument contained 42 items relating to 12 PSC domains and turnover rates. PSC domains were based on five-point Likert scale items. A positive response was defined as "agree" or "strongly agree" (4-5 on the Likert scale). For CNAs low turnover was defined as <35%, and for RNs <15%. Facility-level and market-competition characteristics were included. Bivariate comparisons employed analysis of variance and chi-square tests. In multivariable models, we fit separate linear regressions for the average positive PSC score and for each of the 12 PSC domains, including turnover rates, NH, and market factors. RESULTS In NHs with low turnover, the overall PSC scores were 4.04% (RNs) and 6.28% (CNAs) higher than in NHs with high turnover. Teamwork, staffing, and training/skills were associated with CNA but not RN turnover. DISCUSSION AND IMPLICATIONS The effect of turnover on PSC depends on who leaves and to a lesser extent on the organizational characteristics. In NHs, improvements in PSC may depend on the ability to retain a well-trained and skilled nursing staff.
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Affiliation(s)
| | - Xi Cen
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York
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Delivering, funding, and rating safe staffing levels and skills mix in aged care. Int J Nurs Stud 2021; 119:103943. [PMID: 33905991 DOI: 10.1016/j.ijnurstu.2021.103943] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/01/2021] [Accepted: 03/19/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Staffing levels and skill mix are critical issues within residential aged care. The positive impact of a sufficient number and skills mix of staff is upheld by abundant evidence within and beyond the sector. While being able to determine suitable staffing levels and skills mix to provide care to nursing home residents is vital, having an appropriate approach to funding the delivery of care is also critical. Beyond determining staffing levels and skills mix and funding care delivery, transparently rating the adequacy of staffing is also important to enable informed decision-making amongst consumers, policy makers, staff, and other stakeholders. There are existing tools for determining nursing home staffing levels and skills mix, funding care, and rating and reporting staffing, however there appears to be ongoing confusion regarding how these different tools might work together to achieve different things in order to ensure safe, quality care. OBJECTIVES In order to explain the importance of ensuring at least a minimum number (staffing level) of the right kind of staff (skills mix) to provide care to nursing home residents, in this paper we briefly explain key differences and interrelationships between three tools; one for determining staffing and skills mix, one for determining funding, and one for rating and reporting the level of staffing within a facility as a measure of quality. RESULTS Our explanation of the three existing tools has resulted in the development of a conceptual model for how minimum staffing levels and skills mix supports the delivery of safe, quality care and how this can be understood in relation to determining, funding, and rating staffing levels and skills mix. CONCLUSIONS Our conceptual model of how determining, funding, and rating staffing levels and skills mix relate to one another and fulfil different but related purposes can be used to demonstrate how minimum staffing levels and skills mix can be understood as foundational to ensuring respectful, safe, quality care.
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Kim D, Park C, Briesacher BA. Socially-isolated neighborhoods and the risk of all-cause mortality among nursing home residents in the United States: A multilevel study. Prev Med Rep 2021; 21:101285. [PMID: 33489720 PMCID: PMC7804969 DOI: 10.1016/j.pmedr.2020.101285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 12/03/2022] Open
Abstract
The total number of Americans age 65 and older is expected to nearly double by 2060, and the number of Americans admitted to nursing homes is likewise anticipated to escalate. Studies have found living alone to be an important risk factor for mortality. Yet little is known about possible spillover health effects of living in a community where many elderly residents live alone. Even less is known about whether these risks persist after entering nursing homes. Our study population consisted of 874,162 US elderly adults newly admitted to nursing homes in 2011, as identified from the 3.0 Minimum Data Set. Data on these individuals were linked to Medicare claims and 2010 Census data. In this cohort study, we estimated multivariable-adjusted hazard ratios for the associations between the quartiles of county-level percentage of households with those age 65 or older living alone and the individual-level risks of all-cause mortality until December 31, 2013, controlling for county-, nursing home facility-, and individual-level factors. Older adults in counties belonging to the highest quartile of elderly single-occupancy households had a 8% higher risk of dying (HR = 1.08; 95% CI = 1.04-1.12, p < 0.001) after entering nursing homes compared to those in counties belonging to the lowest quartile. There was evidence of a linear trend (p for trend < 0.001). Should these findings be confirmed in future studies, it would suggest that living arrangements in elderly communities may have spillover health effects onto their residents. Programs and interventions that modify such living arrangements may yield more favorable health trajectories among older Americans, who are increasingly aging in place and at growing risk of entering nursing homes.
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Affiliation(s)
- Daniel Kim
- Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States
- School of Public Policy and Urban Affairs, Northeastern University, Boston, MA, United States
| | - Chanhyun Park
- Department of Pharmacy & Health Systems Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States
| | - Becky A. Briesacher
- Department of Pharmacy & Health Systems Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States
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Daras LC, Vadnais A, Pogue YZ, DiBello M, Karwaski C, Ingber M, He F, Segelman M, Le L, Poyer J. Nearly One In Five Skilled Nursing Facilities Awarded Positive Incentives Under Value-Based Purchasing. Health Aff (Millwood) 2021; 40:146-155. [PMID: 33400571 DOI: 10.1377/hlthaff.2019.01244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare's Skilled Nursing Facility Value-Based Purchasing Program, which awards value-based incentive payments based on hospital readmissions, distributed its first two rounds of incentives during fiscal years 2019 and 2020. Incentive payments were based on achievement or improvement scores-whichever was better. Incentive payments were as low as -2.0 percent in both program years and as high as +1.6 percent in FY 2019 and +3.1 percent in FY 2020. In FY 2019, 26 percent of facilities earned positive incentives and 72 percent earned negative incentives, compared with 19 percent positive and 65 percent negative incentives in FY 2020. Larger, rural, and not-for-profit facilities were more likely to earn positive incentives, as were those with the highest registered nurse staffing levels. Although these findings indicate the potential to reward high-quality care at skilled nursing facilities, intended and unintended outcomes of this new value-based purchasing program should be monitored closely for possible program refinements, particularly in light of the disproportionate impacts of coronavirus disease 2019 (COVID-19) on nursing facilities.
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Affiliation(s)
- Laura Coots Daras
- Laura Coots Daras is a director at Insight Policy Research, in Arlington, Virginia
| | - Alison Vadnais
- Alison Vadnais is a research public health analyst in the Social, Statistical, and Environmental Sciences Unit at RTI International in Waltham, Massachusetts
| | - Ye Zhang Pogue
- Ye Zhang Pogue is a research public health analyst in the Social, Statistical, and Environmental Sciences Unit at RTI International in Waltham
| | - Michael DiBello
- Michael DiBello is a research public health analyst in the Social, Statistical, and Environmental Sciences Unit at RTI International in Waltham
| | - Christopher Karwaski
- Christopher Karwaski is a public health analyst in the Social, Statistical, and Environmental Sciences Unit at RTI International in Waltham
| | - Melvin Ingber
- Melvin Ingber is a principal scientist in the Social, Statistical, and Environmental Sciences Unit at RTI International in Research Triangle Park, North Carolina
| | - Fang He
- Fang He is a research economist in the Social, Statistical, and Environmental Sciences Unit at RTI International in Waltham
| | - Micah Segelman
- Micah Segelman is a researcher in the Social, Statistical, and Environmental Sciences Unit at RTI International in Washington, D.C
| | - Lang Le
- Lang Le is a program lead in the Division of Value, Incentives, and Quality Reporting at the Centers for Medicare and Medicaid Services, in Baltimore, Maryland
| | - James Poyer
- James Poyer is a senior technical advisor at the Centers for Medicare and Medicaid Services
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50
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Sugg MM, Spaulding TJ, Lane SJ, Runkle JD, Harden SR, Hege A, Iyer LS. Mapping community-level determinants of COVID-19 transmission in nursing homes: A multi-scale approach. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 752:141946. [PMID: 32889290 PMCID: PMC7446707 DOI: 10.1016/j.scitotenv.2020.141946] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 05/20/2023]
Abstract
Deaths from the COVID-19 pandemic have disproportionately affected older adults and residents in nursing homes. Although emerging research has identified place-based risk factors for the general population, little research has been conducted for nursing home populations. This GIS-based spatial modeling study aimed to determine the association between nursing home-level metrics and county-level, place-based variables with COVID-19 confirmed cases in nursing homes across the United States. A cross-sectional research design linked data from Centers for Medicare & Medicaid Services, American Community Survey, the 2010 Census, and COVID-19 cases among the general population and nursing homes. Spatial cluster analysis identified specific regions with statistically higher COVID-19 cases and deaths among residents. Multivariate analysis identified risk factors at the nursing home level including, total count of fines, total staffing levels, and LPN staffing levels. County-level or place-based factors like per-capita income, average household size, population density, and minority composition were significant predictors of COVID-19 cases in the nursing home. These results provide a framework for examining further COVID-19 cases in nursing homes and highlight the need to include other community-level variables when considering risk of COVID-19 transmission and outbreaks in nursing homes.
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Affiliation(s)
- Margaret M Sugg
- Department of Geography and Planning, Appalachian State University, P.O. Box 32066, Boone, NC 28608, United States of America.
| | - Trent J Spaulding
- Department of Nutrition and Healthcare Management, Appalachian State University, Boone, NC, United States of America
| | - Sandi J Lane
- Department of Nutrition and Healthcare Management, Appalachian State University, Boone, NC, United States of America
| | - Jennifer D Runkle
- Department of Geography and Planning, Appalachian State University, P.O. Box 32066, Boone, NC 28608, United States of America; North Carolina Institute of Climate Studies, North Carolina State University, 151 Patton Avenue, Asheville, NC 28801, United States of America.
| | - Stella R Harden
- Department of Geography and Planning, Appalachian State University, P.O. Box 32066, Boone, NC 28608, United States of America
| | - Adam Hege
- Department of Health and Exercise Science, Public Health Program, Appalachian State University, Boone, NC, United States of America
| | - Lakshmi S Iyer
- Department of Computer Information Systems, Appalachian State University, Boone, NC, United States of America
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