“Sometimes People Don't Fit in Boxes”: Attitudes Toward the Minimum Data Set Among Clinical Leadership in VA Nursing Homes

Effects of Mental Health Disorders on Nursing Home Residents' Nine-Month Pain Trajectories

OBJECTIVE

To determine the key classes of nursing home residents' nine-month pain trajectories, the influence of residents' mental health disorders on membership in these classes, and nine-month health-related outcomes associated with pain trajectory class membership.

METHODS

Four times over a nine-month period, the MDS 3.0 resident assessment instrument was used to record the demographic characteristics, mental health disorder diagnoses, pain characteristics, and health and functioning outcomes of 2,539 Department of Veterans Affairs Community Living Center (VA CLC) residents. Growth mixture modeling was used to estimate the key classes of residents' nine-month pain trajectories, the influence of residents' mental health disorders on their pain trajectory class membership, and the associations of class membership with residents' health and functioning outcomes at nine-month follow-up.

RESULTS

Four-class solutions best described nursing home residents' nine-month trajectories of pain frequency, severity, and interference. Residents with dementia and severe mental illness diagnoses were less likely, and those with depressive disorder, PTSD, and substance use disorder diagnoses more likely, to belong to adverse nine-month pain trajectory classes. Membership in adverse pain frequency and pain severity trajectory classes, and in trajectory classes characterized by initially high but steeply declining pain interference, portended more depressive symptoms but better cognitive and physical functioning at nine-month follow-up.

CONCLUSIONS

Nursing home residents' mental health disorder diagnoses help predict their subsequent pain frequency, severity, and interference trajectories. This may be clinically useful information for improving pain assessment and treatment approaches for nursing home residents.

Mental health disorder, pain, and pain treatment among long-term care residents: Evidence from the Minimum Data Set 3.0

Objective: This study evaluated: (a) associations between long-term care residents' mental health disorder diagnoses and their pain self-reports and pain treatments, and (b) the extent to which communication, cognitive, and physical functioning problems help explain disparities in the pain and pain treatments of long-term care residents with and without mental health disorders. Method: Minimum Data Set 3.0 records of 8,300 residents of Department of Veterans Affairs Community Living Centers were used to determine statistically unadjusted and adjusted cross-sectional associations between residents' mental health diagnoses and their pain and pain treatments. Results: Residents diagnosed with dementia and serious mental illness (SMI) were less likely, and those diagnosed with depressive disorder, post-traumatic stress disorder (PTSD), and substance use disorder (SUD) were more likely, to report recent, severe, and debilitating pain. Among residents affirming recent pain, those with dementia or SMI diagnoses were twice as likely to obtain no treatment for their pain and significantly less likely to receive as-needed pain medication and non-pharmacological pain treatments than were other residents. Those with either depressive disorder or PTSD were more likely, and those with SUD less likely, to obtain scheduled pain medication. In general, these associations remained even after statistically adjusting for residents' demographic characteristics, other mental health disorder diagnoses, and functioning. Conclusion: Long-term care residents with mental health disorders experience disparities in pain and pain treatment that are not well-explained by their functioning deficits. They may benefit from more frequent, thorough pain assessments and from more varied and closely tailored pain treatment approaches.

The Influence of Supportive Supervisory Practices and Health Care Aides' Self-Determination on the Provision of Person-Centered Care in Long-Term Care Facilities

Person-centred care (PCC) is recognized as best practice in long-term care (LTC). Using a cross-sectional design, we examined the relationship between supportive supervisory practices and health care aides' (HCAs) self-determination on HCAs' perceived ability to provide PCC. A total of 131 HCAs from four LTC facilities participated in the study. There were strong, positive associations between HCAs' self-determination and their perceived ability to provide PCC, r = .59, p < .0001, and how supportive their supervisors were, r = .50, p < .0001. Mediation analysis using structural equation modeling found the direct effect of self-determination on PCC was 73% of its total effect on PCC; its indirect effect mediated through supervisory support was 27% of its total effect on PCC. Improving supportive supervisory relationships that encourage and enable HCAs' self-determination in LTC settings may be an important and effective means by which to increase the provision of PCC.

The Influence of Organizational Systems on Information Exchange in Long-Term Care Facilities: An Institutional Ethnography

Person-centered care is heavily dependent on effective information exchange among health care team members. We explored the organizational systems that influence resident care attendants' (RCAs) access to care information in long-term care (LTC) settings. We conducted an institutional ethnography in three LTC facilities. Investigative methods included naturalistic observations, in-depth interviews, and textual analysis. Practical access to texts containing individualized care-related information (e.g., care plans) was dependent on job classification. Regulated health care professionals accessed these texts daily. RCAs lacked practical access to these texts and primarily received and shared information orally. Microsystems of care, based on information exchange formats, emerged. Organizational systems mandated written exchange of information and did not formally support an oral exchange. Thus, oral information exchanges were largely dependent on the quality of workplace relationships. Formal systems are needed to support structured oral information exchange within and between the microsystems of care found in LTC.

Comprehensive Care Plan Development Using Resident Assessment Instrument Framework: Past, Present, and Future Practices

Development of the comprehensive care plan (CCP) is a requirement for nursing homes participating in the federal Medicare and Medicaid programs, referred to as skilled nursing facilities. The plan must be developed within the context of the comprehensive interdisciplinary assessment framework-the Resident Assessment Instrument (RAI). Consistent compliance with this requirement has been difficult to achieve. To improve the quality of CCP development within this framework, an increased understanding of complex factors contributing to inconsistent compliance is required. In this commentary, we examine the history of the comprehensive care plan; its development within the RAI framework; linkages between the RAI and registered nurse staffing; empirical evidence of the CCP's efficacy; and the limitations of extant standards of practices in CCP development. Because of the registered nurse's educational preparation, professional practice standards, and licensure obligations, the essential contributions of professional nurses in CCP development are emphasized. Recommendations for evidence-based micro and macro level practice changes with the potential to improve the quality of CCP development and regulatory compliance are presented. Suggestions for future research are given.

Affirming the Value of the Resident Assessment Instrument: Minimum Data Set Version 2.0 for Nursing Home Decision-Making and Quality Improvement

Background: We examined the agreement over time of the physical functioning domains of the Resident Assessment Instrument: Minimum Data Set Version 2.0 (RAI-MDS) and the Functional Independence Measure (FIM) in nursing home residents with dementia. Methods: We completed a secondary analysis of data from a longitudinal quasi-experimental study of residents who could transfer independently or with the assistance of one person. FIM assessments were completed at up to three time points by researchers using interviews. RAI-MDS assessments, completed by nursing home staff, were matched to the FIM assessment by nearest time. FIM and RAI-MDS assessments were correlated based on time between assessments using Pearson’s correlation. Items for activities of daily living (ADL) from the RAI-MDS were rescaled using two previously published crosswalks. Motor and ADL subscales were also used, containing eight and six items, respectively. Results: A total of 362 paired interviews and assessments were collected from 130 residents. The mean scores and standard deviations were as follows: FIM: 19.64 (7.60); William’s RAI-MDS crosswalk: 18.04 (5.25); and Velozo’s RAI-MDS crosswalk: 18.09 (6.50). Using both crosswalks, most items showed medium (r > 0.3) or large (r > 0.5) correlations, even at greater than 41 days between assessments. Subscales showed large correlations for all time intervals for both crosswalks. Conclusions: The RAI-MDS remains stable when data are collected greater than 41 days from the FIM assessment. These findings should add confidence in the RAI-MDS data and its clinical utility.

A systematic review of the effectiveness of advanced practice nurses in long-term care

AIM

To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living in long-term care residential settings.

BACKGROUND

Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted.

DESIGN

Quantitative systematic review.

DATA SOURCES

Twelve electronic databases were searched (1966-2010); leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group.

REVIEW METHODS

Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria.

RESULTS

Four prospective studies conducted in the USA and reported in 15 papers were included. Long-term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services.

CONCLUSION

Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long-term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.

The match between institutional elderly care management research and management challenges - a systematic literature review

BACKGROUND

Elderly care practice and its management together with policy and research play a crucial role in responding to increasing challenges in institutional care for elderly people. Successful dialogue between these is necessary. The purpose of this systematic literature review is to compare how institutional elderly care management research meets the care challenges currently emphasized in international long-term care policy documents.

METHODS

This paper was based on a systematic literature review. After screening 1971 abstracts using inclusion/exclusion criteria, 58 refereed articles published between 2000 and 2010 remained for analysis. The articles were analyzed using theory-based content analysis by comparing the results to the framework based on analysis of international long-term care management policy documents.

RESULTS

The current challenges of long-term care management identified from policy documents were Integrated Care Management, Productivity Management, Quality Management, Workforce Management and ICT Management. The research on institutional elderly care management responded somewhat to the challenges mentioned in policy documents. However, some of the challenges were studied broadly and some were paid only minor attention. Further, only few studies focused on the core items of challenges addressed in policy documents.

CONCLUSIONS

Institutional care management research needs to focus more on challenges in integrated care, productivity, ICT and division of labor. Managers, researchers and policy-makers should assume more active collaborative roles in processes of research, policymaking and policy implementation. In addition managers' and policymakers' scientific literacy needs to be enhanced.

Making the investment count: revision of the Minimum Data Set for nursing homes, MDS 3.0

BACKGROUND

The Minimum Data Set (MDS) is a potentially powerful tool for implementing standardized assessment in nursing homes (NHs). Its content has implications for residents, families, providers, researchers, and policymakers, all of whom have expressed concerns about the reliability, validity, and relevance of MDS 2.0. Some argue that because MDS 2.0 fails to include items that rely on direct resident interview, it fails to obtain critical information and effectively disenfranchises many residents from the assessment process.

PURPOSE

Design a major revision of the MDS, MDS 3.0, and evaluate whether the revision improves reliability, validity, resident input, clinical utility, and decreases collection burden.

DESIGN AND METHODS

In the form design phase, we gathered information from a wide range of experts, synthesized existing literature, worked with a national consortium of VA researchers to revise and test eight sections, pilot tested a draft MDS 3.0 and revised the draft based on results from the pilot. In the national validation and evaluation phase, we tested MDS 3.0 in 71 community NHs and 19 VHA NHs, regionally distributed throughout the United States. The sample was selected based on scheduled MDS 2.0 assessments. Comatose residents were excluded. A total 3822 residents of community NHs in eight states were included. The evaluation was designed to test and analyze inter-rater agreement (reliability) between research nurses and between facility staff and research nurses, validity of key sections, response rates for interview items, anonymous feedback on changes from participating nurses, and time to complete the MDS assessment.

RESULTS

The reliability for research nurse to research nurse and for research nurse to facility staff was good or excellent for most items. Response rates for the resident interview sections were high: 90% for cognitive, 86% for mood, 85% for preferences, and 87% for pain. Staff survey responses showed increased satisfaction with clinical relevance, validity and clarity compared with MDS 2.0. The test version of the MDS 3.0 took 45% less time for facilities to complete.

IMPLICATIONS

Improving the reliability, accuracy, and usefulness of the MDS has profound implications for NH care and public policy. Enhanced accuracy supports the primary legislative intent that MDS be a tool to improve clinical assessment and supports the credibility of programs that rely on MDS.

Clinical practice in nursing homes as a key for progress

With the aging of the world's population there has become a major need for the development of nursing homes throughout the world. While some countries provide high quality care for the disabled elderly, in others this is not the case. Education of a medical director has been shown to improve the quality of the nursing home. Physicians need to have knowledge of how to implement continuous quality improvement and culture change. Key medical issues include moving to a restraint free environment, subsyndromal delirium, behavioral disturbances, weight loss, pain management, pressure ulcers, falls, hip fractures, polypharmacy, depression and frailty.

Neglecting the importance of the decision making and care regimes of personal support workers: a critique of standardization of care planning through the RAI/MDS

PURPOSE

The Resident Assessment Instrument-Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the decision making and care practices of personal support workers (PSWs) in relation to the RAI/MDS standardized process.

DESIGN AND METHODS

This qualitative study utilized focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) in two nursing homes in central Canada.

RESULTS

PSWs evidenced unique occupational contributions to assessment via proximal familiarity and biographical information as well as to individualizing care by empathetically linking their own bodily experiences and forging bonds of fictive kinship with residents. These contributions were neither captured by RAI/MDS categories nor relayed to the interdisciplinary team. Causal factors for PSW exclusion included computerized records, low status, and poor interprofessional collaboration. Intraprofessional collaboration by PSWs aimed to compensate for exclusion and to individualize care.

IMPLICATIONS

Exclusive institutional reliance on the RAI/MDS undermines quality care because it fails to capture residents' preferences and excludes input by PSWs. Recommendations include incorporating PSW knowledge in care planning and documentation and examining PSWs' nascent occupational identity and their role as interprofessional brokers in long-term care.

The basis for improving and reforming long-term care. Part 3: essential elements for quality care

There is a pervasive effort to reform nursing homes and improve the care they provide. Many people are trying to educate and inform nursing homes and their staff, practitioners, and management about what to do and not do, and how to do it. But only some of that advice is sound. After more than 3 decades of such efforts, and despite evidence of improvement in many facets of care, there are still many issues. Despite improvements, the overall public, political, and health professional perception of nursing homes is often still negative. To date, no tactic or approach has succeeded nationwide in consistently facilitating good performance or correcting poor performance. Only some of the current efforts to try to improve nursing home quality and to measure it are on target. Many of the measures used to assess the quality of performance have limited value in guiding overall quality improvement. Before we can reform nursing homes, we must understand what needs to be reformed. This series of articles has focused on what is needed for safe, effective, efficient, and person-centered care. Ultimately, all efforts to improve nursing home care quality must be matched against the critical elements needed to provide desirable care. Based on the discussions in the previous 2 articles, this third article in this 4-part series considers 5 key elements of care processes and practices that can help attain multiple desirable quality objectives.