End-of-life care in nursing homes: the importance of CNA staff communication

High-Quality Nursing Home and Palliative Care-One and the Same

Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches' effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.

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

BACKGROUND AND OBJECTIVES

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

DISCUSSION AND IMPLICATIONS

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

The relationship between caregivers' perceptions of end-of-life care in long-term care and a good resident death

OBJECTIVE

Quality end-of-life (EOL) care is critical for dying residents and their family/friend caregivers. While best practices to support resident comfort at EOL in long-term care (LTC) homes are emerging, research rarely explores if and how the type of care received at EOL may contribute to caregivers' perceptions of a good death. To address this gap, this study explored how care practices at EOL contributed to caregivers' perceptions of a good resident death.

METHOD

This study used a retrospective cross-sectional survey design. Seventy-eight participants whose relative or friend died in one of five LTC homes in Canada completed self-administered questionnaires on their perceptions of EOL care and perceptions of a good resident death.

RESULTS

Overall, caregivers reported positive experiences with EOL care and perceived residents to have died a good death. However, communication regarding what to expect in the final days of life and attention to spiritual issues were often missing components of care. Further, when explored alongside direct resident care, family support, and rooming conditions, staff communication was the only aspect of EOL care significantly associated with caregivers' perceptions of a good resident death.

SIGNIFICANCE OF RESULTS

The findings of this study suggest that the critical role staff in LTC play in supporting caregivers' perceptions of a good resident death. By keeping caregivers informed about expectations at the very end of life, staff can enhance caregivers' perceptions of a good resident death. Further, by addressing spiritual issues staff may improve caregivers' perceptions that residents were at peace when they died.

An Evaluation of the Communication at End-of-Life Education Program for Personal Support Workers in Long-Term Care

Background: Communication skills are crucial for personal support workers (PSWs) to foster therapeutic relationships with the residents and their families in the long-term care (LTC) setting. Aim: To evaluate the impact of the Communication at End-of-Life (CEoL) Education Program on the competency and confidence of PSWs working in LTC to communicate about palliative and end-of-life care, and factors affecting their involvement in palliative and end-of-life care. Setting/Participants: PSWs from 35 LTC homes in Ontario, Canada, who participated in the CEoL Education Program between January and March 2019. Design: Mixed-methods evaluation using pre- (n = 178) and post-workshop (n = 113) surveys capturing the attitudes and beliefs toward death and dying; relationships with residents and families; and PSWs' participation in end-of-life care. Follow-up interviews were conducted between February and March 2019 with 21 PSWs to examine facilitators and barriers that affected their confidence in engaging in palliative care. Results: We observed significant improvements in all three domains, with the greatest increase (11%, p < 0.001) in the proportion of participants who responded "Often" or "Always" in the participation in end-of-life care domain. Specifically, we observed PSWs' elevated confidence in speaking with families of the residents about end-of-life, discussing goals and plans with the residents, and realizing that a "good death" is possible. Time constraints and staff shortages were recurrent themes that hindered many participants' ability to provide resident-centered care. Conclusions: This evaluation demonstrates that CEoL Education Program was associated with improved PSW competency and confidence in supporting palliative and end-of-life care in LTC settings.

Community Discharge Among Post-Acute Nursing Home Residents: An Association With Patient Safety Culture?

OBJECTIVES

We examined whether better patient safety culture (PSC) in skilled nursing facilities was associated with higher likelihood of successful community discharge for post-acute care residents.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Medicare beneficiaries who were newly admitted for post-acute care (N = 53,929) to skilled nursing facilities participating in PSC survey (N = 818).

METHODS

Facility-level PSC scores were obtained from a national, random survey conducted in 2017. Survey data was linked to Minimum Dataset 3.0, Medicare Provider Analysis and Review, Master Beneficiary Summary File, Nursing Home Compare File, Payroll-Based Journal, and Areal Health Resources File. Successful discharge to community was the outcome of interest. Facility-level PSC scores were the key covariate. We controlled for individual-level, facility-level, and area-level characteristics. Separate logistic regression models for each of the 12 PSC domains and for the overall score were fit.

RESULTS

Post-acute care residents who were successfully discharged to community were more likely to be female (63.7%), white (87.1%), Medicare-only (88.1%), cognitively intact (87.8%), and admitted following a surgery (40.9%) The multivariable analyses showed that teamwork (odds ratio 1.09, P = .02) and supervisor expectations and actions promoting resident safety (odds ratio 1.11, P = .01) were significantly associated with the increased likelihood of successful community discharge.

CONCLUSIONS AND IMPLICATIONS

This is the first study to analyze the relationship between patient safety culture and successful discharge among post-acute care residents. Our results suggest that nursing home leaders may want to focus their quality and safety improvement efforts on specific PSC domains (eg, teamwork) as means for improving community discharge for post-acute care residents.

Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis

Starting in 2016, Centers for Medicare and Medicaid Services implemented the first phase of a 3-year multi-phase plan revising the manner in which nursing homes are regulated. In this revision, attention was placed on the importance of certified nursing assistants (CNAs) to resident care and the need to empower these frontline workers. Phase II mandates that CNAs be included as members of the nursing home interdisciplinary team that develops care plans for the resident that are person-centered and comprehensive and reviews and revises these care plans after each resident assessment. While these efforts are laudable, there are no direct guidelines for how to integrate CNAs in the interdisciplinary team. We recommend the inclusion of direct guidelines, in which this policy revision clarifies the expected contributions from CNAs, their responsibilities, their role as members of the interdisciplinary team, and the expected patterns of communication between CNAs and other members of the interdisciplinary team.

The Role, Education, and Experience of Health Care Assistants in End-of-Life Care in Long-Term Care: A Scoping Review

The changing age profile of the human population globally means that the requirement for residential long-term care (LTC) for older adults is escalating, with an associated increase in deaths in these facilities. Health care assistants (HCAs), whose main role is provision of direct care to residents, comprise the largest staff cohort in residential care for older adults. The purpose of this scoping review was to explore three key areas related to HCAs: their role and responsibilities, end-of-life (EOL) education, and their views and experiences of caring for residents at EOL. The literature search included five databases and 32 studies were ultimately reviewed. Key issues were as follows: HCAs feel marginalized and undervalued, they need and desire EOL education, and resident deaths impact negatively on them. The changing care needs for older adults with complex comorbidities at EOL in LTC will place an increased onus on HCAs' skills, knowledge, and personal and professional development. [Journal of Gerontological Nursing, 46(1), 21-29.].

Hospice care education needs of nursing home staff in South Korea: a cross-sectional study

Background

While the importance of hospice care education in nursing homes is recognized, the volume of research on the specific educational needs of caregivers in hospice care in nursing homes is still lacking. This study aimed to assess educational needs in hospice care among the nursing home staff in South Korea, and to examine factors related to their education needs.

Methods

This is a cross-sectional descriptive study. A total of 324 nursing staff members recruited from 15 nursing homes in South Korea participated in this cross-sectional study. Measurements included demographic information, organizational characteristics, education experiences in hospice care, and educational needs in hospice care based on questionnaires developed by Whittaker and colleagues. Data were analyzed using descriptive statistics, t-test, ANOVA, and multiple regression techniques.

Results

In the present study, 70.6% (n = 218) of respondents reported that they had previous experience with education in hospice care and expressed their continued need for further education. The provision of care in the last days of a patient’s life was the most frequent issue identified by nursing home staff for further education. Factors predicting educational needs in hospice care included provision of hospice care services in nursing homes and the existence of hospice care team meetings in the institution. Multiple regression analysis resulted in 14.3% of explained variance in the educational needs of nursing home staff in hospice care.

Conclusions

Nursing home staff members showed high levels of need for training in hospice care. Therefore, it is imperative for nursing home administrators to initiate and support well-suited hospice care education for multi-level care workers on an ongoing basis.

Family perceptions of care at the end of life in UK nursing care homes

Background

Over a fifth of the population of developed countries die in care homes. While studies are emerging on the outcomes of care in the last few weeks of life, few report on the experience as perceived by the family members.

Methods

As part of a wider study to improve the delivery of end-of-life care, bereaved relatives of residents who had died in a care home/hospital were sent the Family Perception of Care Scale questionnaire to evaluate their experience of care provision for their relative in the last month of life. The Family Perception of Care Scale questionnaire was posted to bereaved relatives, from 37 nursing care homes in south-east England, 3-6 months following the resident's death. The questionnaires were posted over a 14-month period from 1 October 2009 to 31 November 2010.

Results

A total of 869 questionnaires were posted, with a 42% response rate. A global question within the Family Perception of Care Scale looking at the overall satisfaction with the quality of end-of-life care (Q24) indicated that bereaved relatives were satisfied with the care provided. Qualitative responses from family members highlighted some excellent care, although issues in relation to medical input, professional teamwork, last days of life and spiritual care remain problematic. Results provide an important insight into care provision at the end of life within these care homes.

Conclusion

While some issues can be addressed through education, relationships and value-based issues are likely to be more difficult to address in light of increasing pressure of healthcare support for UK care homes.

WE'RE THE EYES AND THE EARS, BUT WE DON'T HAVE A VOICE: PERSPECTIVES OF HOSPICE AIDES

Hospice aides are integral to the delivery of home hospice care and play an essential role in the effective communication and collaboration of the hospice interdisciplinary team. Despite their critical role, little is known about hospice aides' perceptions of their role in providing hospice services. This qualitative study explores hospice aides' perspectives of their work, their relationships with patients, families and interdisciplinary team members, and their contributions to end-of-life care. Two focus groups of hospice aides (N = 13), and 16 hours of observation of in-home caregiving were conducted. Focus group data were inductively and iteratively coded, and three themes were identified: 1) "We're the eyes and ears", 2) "We're kept out of the loop", and 3) "We have no voice." Aides described themselves as front-line providers based on the close relationships they formed with patients and family members, yet felt under-recognized by members of the hospice team. Observational field notes were reexamined with themes to confirm convergence of qualitative and observational data. Better understanding of their role could enhance integration of aides into patient- and family-centered team interactions, leading to both improved patient and family outcomes and retention and support of this critical component of the hospice workforce.

Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial

BACKGROUND

Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested.

OBJECTIVE

Test the impact of PCTeams on end-of-life outcomes.

RESEARCH DESIGN

Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect.

SUBJECTS

In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents).

MEASURES

Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions.

RESULTS

Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations.

CONCLUSIONS

The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.

Improving palliative care through teamwork (IMPACTT) in nursing homes: Study design and baseline findings

BACKGROUND

The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life.

METHODS/DESIGN

This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention.

DISCUSSION

Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more "skilled" care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services.

Caring for Dying Patients in the Nursing Home: Voices From Frontline Nursing Home Staff

CONTEXT

Nursing homes are an important site for end-of-life care, yet little is known about the perspectives of the frontline staff who provide a majority of this care.

OBJECTIVE

To describe, from the staff perspective, positive/negative experiences related to caring for dying residents.

METHODS

Qualitative analysis using survey data from staff working in 52 Indiana nursing homes.

RESULTS

A total of 707 frontline staff who provide nursing, nurse aide, and social work services responded to open-ended prompts. Study data included responses to open-ended prompts asking participants to describe one positive experience and one negative experience caring for a dying patient. A thematic content analysis was conducted using the constant-comparative method. Respondents were largely female (93%), white (78%), 31-50 years (42%), and 53% had >5 years of nursing home work experience. Experiences were described from three perspectives: 1) first-hand experiences, 2) observed experiences of dying patients, and 3) observed experiences of family members. Selected themes for positive experiences include the following: creating close bonds; good patient care; involvement of hospice; being prepared; and good communication. Selected themes for negative experiences consisted of the following: challenging aspects of care; unacknowledged death; feeling helpless; uncertainty; absent family; painful emotions; and family discord.

CONCLUSION

Findings reveal the richness and many complexities of providing end-of-life care in nursing homes and have implications for improving staff knowledge, coordination of care with hospice, and social support for patients.

Work environment characteristics associated with quality of care in Dutch nursing homes: A cross-sectional study

BACKGROUND

A lack of relationship between direct care staffing levels and quality of care, as found in prior studies, underscores the importance of considering the quality of the work environment instead of only considering staff ratios. Only a few studies, however, have combined direct care staffing with work environment characteristics when assessing the relationship with quality of care in nursing homes.

OBJECTIVES

To examine the relationship between direct care staffing levels, work environment characteristics and perceived quality of care in Dutch nursing homes.

DESIGN

Cross-sectional, observational study in cooperation with the Dutch Prevalence Measurement of Care Problems.

SETTINGS

Twenty-four somatic and 31 psychogeriatric wards from 21 nursing homes in the Netherlands.

PARTICIPANTS

Forty-one ward managers and 274 staff members (registered nurses or certified nurse assistants) from the 55 participating wards.

METHODS

Ward rosters were discussed with managers to obtain an insight into direct care staffing levels (i.e, total direct care staff hours per resident per day). Participating staff members completed a questionnaire on work environment characteristics (i.e., ward culture, team climate, communication and coordination, role model availability, and multidisciplinary collaboration) and they rated the quality of care in their ward. Data were analyzed using multilevel linear regression analyses (random intercept). Separate analyses were conducted for somatic and psychogeriatric wards.

RESULTS

In general, staff members were satisfied with the quality of care in their wards. Staff members from psychogeriatric wards scored higher on the statement 'In the event that a family member had to be admitted to a nursing home now, I would recommend this ward'. A better team climate was related to better perceived quality of care in both ward types (p≤0.020). In somatic wards, there was a positive association between multidisciplinary collaboration and agreement by staff of ward recommendation for a family member (p=0.028). In psychogeriatric wards, a lower score on market culture (p=0.019), better communication/coordination (p=0.018) and a higher rating for multidisciplinary collaboration (p=0.003) were significantly associated with a higher grade for overall quality of care. Total direct care staffing, adhocracy culture, hierarchy culture, as well as role model availability were not significantly related to quality of care.

CONCLUSIONS

Our findings suggest that team climate may be an important factor to consider when trying to improve quality of care. Generating more evidence on which work environment characteristics actually lead to better quality of care is needed.

"Sometimes I've gone home feeling that my voice hasn't been heard": a focus group study exploring the views and experiences of health care assistants when caring for dying residents

Background

In most developed countries, Health Care Assistants comprise a significant, and growing, proportion of the residential aged care workforce. Despite the fact that they provide the majority of direct care for residents, little is known about a key care aspect of their work, namely their experience of caring for dying residents.

Methods

Twenty-six Health Care Assistants working in aged residential care facilities in Auckland, New Zealand participated in six focus group discussions. Focus groups were designed to explore the experiences of Health Care Assistants caring for imminently dying residents in aged care facilities and to identify barriers and facilitators to their work in this area. The focus groups were digitally recorded, transcribed verbatim and analysed using a general inductive approach.

Results

Participants confirmed that Health Care Assistants provide the majority of hands on care to dying residents and believed they had a valuable role to play at this time due to their unique ‘familial’ relationship with residents and families. However, it was apparent that a number of barriers existed to them maximising their contribution to supporting dying residents, most notably the lack of value placed on their knowledge and experience by other members of the multidisciplinary team. Whilst a need for additional palliative and end of life care education was identified, a preference was identified for hands on education delivered by peers, rather than the didactic education they currently receive.

Conclusion

Given ageing populations internationally coupled with a constrained health budget, the role of Health Care Assistants in most developed countries is likely to become even more significant in the short to medium term. This study makes a unique contribution to the international literature by identifying the barriers to caring for dying residents experienced by this valuable sector of the aged care workforce. These data have the potential to inform new, innovative, interventions to address the urgent need identified to improve palliative and end of life care management in aged care internationally.

End-of-Life Care in Nursing Homes: From Care Processes to Quality

BACKGROUND/OBJECTIVE

Nursing homes (NHs) are an important setting for the provision of palliative and end-of-life (EOL) care. Excessive reliance on hospitalizations at EOL and infrequent enrollment in hospice are key quality concerns in this setting. We examined the association between communication-among NH providers and between providers and residents/family members-and two EOL quality measures (QMs): in-hospital deaths and hospice use.

DESIGN AND METHODS

We developed two measures of communication by using a survey tool implemented in a random sample of U.S. NHs in 2011-12. Using secondary data (Minimum Data Set, Medicare, and hospice claims), we developed two risk-adjusted quality metrics for in-hospital death and hospice use. In the 1201 NHs, which completed the survey, we identified 54,526 residents, age 65+, who died in 2011. Psychometric assessment of the two communication measures included principal factor and internal consistency reliability analyses. Random-effect logistic and weighted least-square regression models were estimated to develop facility-level risk-adjusted QMs, and to assess the effect of communication measures on the quality metrics.

RESULTS

Better communication with residents/family members was statistically significantly (p = 0.015) associated with fewer in-hospital deaths. However, better communication among providers was significantly (p = 0.006) associated with lower use of hospice.

CONCLUSIONS

Investing in NHs to improve communication between providers and residents/family may lead to fewer in-hospital deaths. Improved communication between providers appears to reduce, rather than increase, NH-to-hospice referrals. The actual impact of improved provider communication on residents' EOL care quality needs to be better understood.

Communication with Residents and Families in Nursing Homes at the End of Life

Communication with residents and their families is important to ensure that the end-of-life experience is in accordance with resident's wishes. A secondary analysis was conducted to determine: (a) who should communicate with the resident/family about death and dying; (b) when communication should occur around death and dying, obtaining a "DNR" order, and obtaining a hospice referral; and (c) what differences exist in communication about death and dying between Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and unlicensed staff. Greater than 90% of staff (N=2,191) reported that the physician or social worker should communicate about death and dying with residents/families, but only 53% thought that direct care staff should talk with them. Weighted scores for "When communication should occur about death and dying and obtaining a 'DNR' Order" revealed significantly (p < .01) lower scores for unlicensed staff than RNs and LPNS (i.e., licensed staff), indicating that licensed staff were more likely to initiate conversations on admission or at the care-planning meeting, or when the resident's family requested it. No differences were found between staff on communication about obtaining a hospice referral. The identified gaps in perception about who should be communicating can assist in developing appropriate interventions that need future testing. The potential for training regarding communication strategies and techniques could lead to higher satisfaction with end-of-life care for residents and their families.

Family Caregiving and the Site of Care: Four Narratives About End-of-Life Care for Individuals with Dementia

Little is known about end-of-life care for individuals with Alzheimer's disease and other dementias. Four case studies are presented, using data collected by qualitative interviews conducted with family caregivers who were closely involved with end-of-life care for relatives with dementia. The case studies are formatted in two pairs, with one reflecting two deaths occurring at home and the other pair representing two deaths in the nursing home. The cases reveal a range of end-of-life experiences, suggesting that there is not just one "good" path. The extent of care needed, the responsiveness of the individual, the health of the caregiver(s), and the residence and support situations, can all intersect in a variety of ways that make no one scenario the answer for all. Although most people say they would prefer to die at home, in some situations the nursing home can be a satisfactory choice, particularly if hospice is involved. These narrative case studies give the reader insight into the variety of the end-of-life experiences and suggest the environment should be considered as part of the care provision.

Preparedness for Resident Death in Long-Term Care: The Experience of Front-Line Staff

CONTEXT

Although resident death is a common occurrence in long-term care, little attention has focused on how prepared certified nursing assistants (CNAs), who provide most of residents' daily care, are for this experience.

OBJECTIVES

To identify characteristics of the resident, CNA, and care context associated with CNAs' preparedness for resident death and to determine differential patterns for emotional versus informational preparedness.

METHODS

One hundred forty CNAs completed semistructured, in-person interviews concerning their experiences regarding resident death. The associations of CNA characteristics (e.g., personal end-of-life [EOL] care preferences), CNAs' perceptions of resident status (e.g., knowledge of resident's condition), and the caregiving context (e.g., support from coworkers and hospice involvement) with emotional and informational preparedness were examined by the use of bivariate and multivariate analyses.

RESULTS

CNAs who reported that their resident was "aware of dying" or "in pain" expressed greater levels of both emotional and informational preparedness. CNAs who endorsed an EOL care preference of wanting all possible treatments regardless of chances for recovery were likely to report lesser emotional preparedness. More senior CNAs, both in regard to age and tenure, reported greater preparedness levels. Greater support from coworkers and hospice involvement also were associated with greater levels of both facets of preparedness, the latter in particular when hospice care was viewed positively by the CNA.

CONCLUSION

Having more information about resident status and more exchange opportunities within the care team around EOL-related challenges may help CNAs feel more prepared for resident death and strengthen their ability to provide good EOL care.

Massage, Music, and Art Therapy in Hospice: Results of a National Survey

CONTEXT

Complementary and alternative medicine (CAM) provides clinical benefits to hospice patients, including decreased pain and improved quality of life. Yet little is known about the extent to which U.S. hospices employ CAM therapists.

OBJECTIVES

To report the most recent national data regarding the inclusion of art, massage, and music therapists on hospice interdisciplinary teams and how CAM therapist staffing varies by hospice characteristics.

METHODS

A national cross-sectional survey of a random sample of hospices (n = 591; 84% response rate) from September 2008 to November 2009.

RESULTS

Twenty-nine percent of hospices (169 of 591) reported employing an art, massage, or music therapist. Of those hospices, 74% employed a massage therapist, 53% a music therapist, and 22% an art therapist, and 42% expected the therapist to attend interdisciplinary staff meetings, indicating a significant role for these therapists on the patient's care team. In adjusted analyses, larger hospices compared with smaller hospices had significantly higher odds of employing a CAM therapist (adjusted odds ratio 6.38; 95% CI 3.40, 11.99) and for-profit hospices had lower odds of employing a CAM therapist compared with nonprofit hospices (adjusted odds ratio 0.52; 95% CI 0.32, 0.85). Forty-four percent of hospices in the Mountain/Pacific region reported employing a CAM therapist vs. 17% in the South Central region.

CONCLUSION

Less than one-third of U.S. hospices employ art, massage, or music therapists despite the benefits these services may provide to patients and families. A higher proportion of large hospices, nonprofit hospices, and hospices in the Mountain/Pacific region employ CAM therapists, indicating differential access to these important services.

End-of-Life Care in Nursing Homes with Greater versus Less Palliative Care Knowledge and Practice

BACKGROUND

Many older adults in nursing homes (NHs) lack palliative care (PC) access; but little is known about whether access to PC knowledge and practice (beyond hospice) impacts residents' care.

OBJECTIVE

The study objective was to evaluate how differing levels of NH PC knowledge and practice are associated with residents' end-of-life health care use.

METHODS

In 2009/10 we surveyed a stratified random sample of U.S. NHs and asked directors of nursing (DONs) PC knowledge and practice questions from Thompson and colleagues' validated PC Survey. This study includes 1981 NHs with complete survey responses and the 58,876 residents who died in these facilities between July 2009 and June 2010. Medicare resident assessment (minimum data set [MDS]) and claims data from July 2009 through June 2010 were used to determine outcomes and a NH's hospice use. Multivariate logistic regressions examined whether residing in NHs with higher PC scores was associated with documented six-month prognoses and receipt of aggressive treatments, including hospital and emergency room (ER) use in the last 30 days of life.

RESULTS

Controlling for NH hospice use, being in a NH with higher PC care knowledge scores was associated with residents having a higher likelihood of documented six-month prognoses and lower likelihoods of having feeding tubes, injections, restraints, suctioning, and end-of-life hospital and ER use. Being in a NH with higher PC practice scores was associated with a lower likelihood of having feeding tubes and ER visits.

CONCLUSION

Policies and advocacy promoting the development of NH PC knowledge and practices could potentially improve care and reduce hospital and ER use.

Nursing home practices following resident death: the experience of Certified Nursing Assistants

This study examined certified nursing assistants' (CNAs) experiences of nursing home practices following resident death. Participants were 140 CNAs who had experienced recent resident death. In semi-structured, in-person interviews, CNAs were asked about their experiences with the removal of the resident's body, filling the bed with a new resident, and how they were notified about the death. The facilities' practice of filling the bed quickly was most often experienced as negative. Responses to body removal and staff notification varied, but negative experiences were reported by a substantial minority. Being notified prior to returning to work was associated with a more positive experience. Learning about the death by walking into a room to find the bed empty or already filled was the most negative experience. Study findings suggest that more mindful approaches to the transitions related to resident deaths would be valued by CNAs and could improve their work experience.

Hospice in the nursing home: perspectives of front line nursing home staff

OBJECTIVE

Use of hospice has been associated with improved outcomes for nursing home residents and attitudes of nursing home staff toward hospice influences hospice referral. The objective of this study is to describe attitudes of certified nursing assistants (CNAs), nurses, and social workers toward hospice care in nursing homes.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a survey of 1859 staff from 52 Indiana nursing homes.

MEASUREMENTS

Study data include responses to 6 scaled questions and 3 open-ended qualitative prompts. In addition, respondents who cared for a resident on hospice in the nursing home were asked how often hospice: (1) makes their job easier; (2) is responsive when a patient has symptoms or is actively dying; (3) makes care coordination smooth; (4) is needed; (5) taught them something; and (6) is appreciated by patients/families. Responses were dichotomized as always/often or sometimes/never.

RESULTS

A total of 1229 surveys met criteria for inclusion. Of the respondents, 48% were CNAs, 49% were nurses, and 3% were social workers; 83% reported caring for a nursing home patient on hospice. The statement with the highest proportion of always/often rating was 'patient/family appreciate added care' (84%); the lowest was 'hospice makes my job easier' (54%). More social workers responded favorably regarding hospice responsiveness and coordination of care compared with CNAs (P = .03 and P = .05, respectively).

CONCLUSIONS

A majority of staff responded favorably regarding hospice care in nursing homes. About one-third of nursing home staff rated coordination of care lower than other aspects, and many qualitative comments highlighted examples of when hospice was not responsive to patient needs, representing important opportunities for improvement.

Analyzing the Interprofessional Working of a Home-Based Primary Care Team

De plus en plus, les équipes interprofessionnelles sont chargées de fournir la prestation de services de soins de santé intégrés. Cependant, les équipes efficaces ne sont pas le fruit du hasard, mais nécessitent une planification minutieuse et une attention soutenue au processus de développer l’équipe. Basée sur une étude de cas portant sur des entretiens, l’observation participante, et une enquête, nous avons identifié les attributs clés pour le travail interprofessionnel efficace (TIE) dans le cadre de soins primaires à domicile (SPD). Reconnaissant l’importance d’un modèle théorique qui reflète la nature multi-dimensionnelle de la recherche sur l’efficacité de l’équipe, nous avons utilisé le modèle de l’efficacité de l’équipe integrée pour analyser nos résultats. Ces résultats indiquaient qu’une vision commune, des objectifs communs, le respect et la confiance entre les membres de l’équipe—ainsi que la communication continue, la direction efficace et des mécanismes de résolution des conflits—sont essentiels pour le développement d’une equipe de TIE qui fonctionne très bien. L’ambiguité et l’incertitude qui entoure le cadre de la prestation de services (à domicile), ainsi que la négociation des relations extérieures dans le domaine SPD, nécessitent la recherche plus approfondie.

Hospice for nursing home residents: does ownership type matter?

BACKGROUND

Currently, more than half of all nursing home residents use hospice at some point. Studies have shown benefits to hospice enrollment for patients; however, the literature on ownership differences in hospice care in general has indicated that for-profit hospices offer a narrower scope of services and employ fewer professional staff. Although nursing home staffing patterns have been shown to be essential to quality of care, the literature has not explored differences in number of patients per staff member for hospice care within nursing homes.

METHODS

We hypothesized that for-profit hospices would have a higher number of patients per staff member for home care workers (HCWs), registered nurses (RNs), and medical social workers (MSWs), and this relationship would be moderated by the proportion of hospice users living in nursing homes. Using data from the National Hospice Survey, a random sampling of all Medicare-certified hospices operating between September 2008 and November 2009, we identified 509 hospices that served individuals living in a nursing home, with 89 hospices having 50% or greater of their clients living in a nursing home.

RESULTS

Adjusted analysis indicated a higher number of patients per staff member for HCWs and RNs among for-profit hospices. Moreover, compared with nonprofit hospices, for-profit hospices with a high proportion of nursing home residents had 36 more patients per HCW (p=0.011) and 24 more patients per RN (p=0.033).

CONCLUSIONS

Staffing is an important indicator of hospice quality, thus our findings may be useful for anticipating potential impacts of the growth in for-profit hospice on nursing home residents.

Hospice utilization in nursing homes: association with facility end-of-life care practices

OBJECTIVES

Hospice care provided to nursing home (NH) residents has been shown to improve the quality of end-of-life (EOL) care. However, hospice utilization in NHs is typically low. This study examined the relationship between facility self-reported EOL practices and residents' hospice use and length of stay.

DESIGN

The study was based on a retrospective cohort of NH residents. Medicare hospice claims, Minimum Data Set, Online Survey, Certification, and Reporting system and the Area Resource File were linked with a survey of directors of nursing (DON) regarding institutional EOL practice patterns (EOLC Survey).

SETTING AND PARTICIPANTS

In total, 4,540 long-term-care residents who died in 2007 in 290 facilities which participated in the EOLC Survey were included in this study.

MEASUREMENTS

We measured NHs' tendency to offer hospice to residents and to initiate aggressive treatments (hospital transfers and feeding tubes) for EOL residents based on DON's responses to survey items. Residents' hospice utilization was determined using Medicare hospice claims.

RESULTS

The prevalence of hospice use was 18%. The average length of stay was 93 days. After controlling for individual risk factors, facilities' self-reported practice measures associated with residents' likelihood of using hospice were tendency to offer hospice (p = .048) and tendency to hospitalize (p = .002). Residents in NHs reporting higher tendency to hospitalize tended to enroll in hospice closer to death.

CONCLUSION

Residents' hospice utilization is not only associated with individual and facility characteristics but also with NHs' self-reported EOL care practices. Potential interventions to effect greater use of hospice may need to focus on facility-level care processes and practices.

Caregivers' desired patterns of communication with nursing home staff- just TALKKK!

Individuals with cognitive impairment often represent a significant percentage of the residents in a nursing home nurse's care. With years of experience caring for their placed family members, caregivers of these residents are often experts in knowing the resident's needs, habits, behaviors, and moods. Caregivers often wish to convey this insider knowledge to nursing home staff. Furthermore, communication with caregivers promotes trust that personalized, safe, and effective care occurs when they are not there. Based on an interpretive study of the experiences of caregivers who place a family member with Alzheimer's disease in the nursing home, six preferred patterns of communication are presented in this article. The six patterns are represented by the acronym TALKKK (tell them; ask them; listen to them; know their family member by relating and communicating; be knowledgeable about dementia, its progression, dementia-specific care, and commonly used medications; and share that knowledge with them).

The effect of Medicaid nursing home reimbursement policy on Medicare hospice use in nursing homes

OBJECTIVE

To understand how changes in Medicaid nursing home (NH) reimbursement policy and rates affect a NH's approach to end-of-life care (ie, its use of hospice).

METHODS

This longitudinal study merged US NH decedents' (1999 to 2004) resident assessment data (MDS) with Part A claims data to determine the proportion of a NH's decedents using hospice. Freestanding NHs across the 48 contiguous US states were included. A NH-level analytic file was merged with NH survey (ie, OSCAR) and area resource file data, and with annual data on state Medicaid NH rates, case-mix reimbursement policies, and hospice certificate of need (CON). NH fixed-effect (within) regression analysis examined the effect of changing state policies, controlling for differing time trends in CON and case-mix states and for facility-level and county-level attributes. Models were stratified by urban/rural status.

RESULTS

A $10 increase in the Medicaid rate resulted in a 0.41% [95% confidence interval (CI): 0.275, 0.553] increase in hospice use in urban NHs and a 0.37% decrease (95% CI: -0.676, -0.063) in rural NHs not adjacent to urban areas. There was a nonstatistically significant increase in rural NHs adjacent to urban areas. Introduction of case-mix reimbursement resulted in a 2.14% (95% CI: 1.388, 2.896) increase in hospice use in urban NHs, with comparable increases in rural NHs.

CONCLUSIONS

This study supports and extends previous research by showing changes in Medicaid NH reimbursement policies affect a NH's approach to end-of-life care. It also shows how policy changes can have differing effects depending on a NH's urban/rural status.