Addressing Systemic Racism in Nursing Homes: A Time for Action

"I feel like a caged pig in here": Language, Race, and Ethnic Identity in a Case Study Hmong Nursing Home Resident Quality of Life

Racial disparities in nursing home (NH) quality of life (QOL) are well established, yet, little is understood about actual experiences shaping QOL for Black, indigenous, and people of color (BIPOC) residents in NHs. This gap extends to BIPOC residents with limited English proficiency (LEP). Drawing on Kane's (2001) and Zubristky's (2013) QOL frameworks, this case study examined QOL experiences for Hmong NH residents, an ethnic and refugee group from Southeast Asia, in a NH with a high proportion of BIPOC residents. Methods include four months of observation, interviews with eight Hmong residents and five NH staff, and one community focus group. Thematic analysis revealed significant challenges in QOL. Exacerbated by language barriers and racism, many residents reported neglect, limited relationships, lack of meaningful activities, and dissatisfaction with food. These experiences fostered a sense of resignation and diminished QOL among Hmong residents, highlighting the need for additional supports for this group.

Empowering a person-centered long-term care workforce

Currently there is a crisis in the long-term care workforce, as many workers experience poor pay, a lack of training, burnout, low quality working conditions, and physical strain, which is leading to a workforce shortage. To address this, the Alzheimer's Association Dementia Care Provider Roundtable (AADCPR) convened a panel of direct care workers to discuss and provide direction on their view of the current state of the workforce. From this panel, five touchpoints for hiring and retaining direct care workers were highlighted: high quality jobs; recruitment and reputation management; onboarding; retention; and training and career advancement. In addition, the DCPR put together a set of standards to follow to meet these needs, which includes promoting staff dementia education opportunities, creating recommendations around peer mentoring programs specific to dementia care, and increasing inclusion of direct care workers in decision-making and plans of care. HIGHLIGHTS: Presents the current state of workforce in long-term care. Provides five touchpoints that long-term and home and community-based services should implement for hiring and retaining direct care workers. Recommends a set of standards to follow to meet the needs of the workforce within long-term care.

Post-acute care transitions during COVID-19: Racial, ethnic, and socioeconomic differences in older adults with Alzheimer's disease and related dementia

BACKGROUND

Differences in the post-acute care (PAC) destinations among racial, ethnic, and socioeconomic groups have been documented before the COVID-19 pandemic. Yet, the pandemic's impact on these differences remains unknown. We examined the impact of the COVID-19 pandemic on PAC destinations and its variation by individual race, ethnicity, and socioeconomic status among community-dwelling older adults with Alzheimer's disease and related dementia (ADRD).

METHODS

We linked 2019-2021 national data (Medicare claims, Minimum Data Set, Master Beneficiary Summary File) and several publicly available datasets, including Provider of Services File, Area Deprivation Index, Area Health Resource File, and COVID-19 infection data. PAC discharge destinations included skilled nursing facilities (SNFs), home health agencies (HHA), and homes without services. Key variables of interest included individual race, ethnicity, and Medicare-Medicaid dual status. The analytic cohort included 830,656 community-dwelling Medicare fee-for-service beneficiaries with ADRD who were hospitalized between 2019 and 2021. Regression models with hospital random effects and state-fixed effects were estimated, stratified by the time periods, and adjusted for the individual, hospital, and county-level covariates.

RESULTS

SNF discharges decreased while home and HHA discharges increased during the pandemic. The trend was more prominent among racial and ethnic minoritized groups and even more so among dual-eligible beneficiaries. For instance, the reduction in the probabilities of SNF admissions between the pre-pandemic period and the 2nd year of COVID was 4.6 (White non-duals), 18.5 (White duals), 8.7 (Black non-duals), and 20.1 (Black duals) percentage-point, respectively. We also found that non-duals were more likely to replace SNF with HHA services, while duals were more likely to be discharged home without HHA.

CONCLUSIONS

The COVID-19 pandemic significantly impacted PAC destinations for individuals with ADRD, especially among socioeconomically disadvantaged and racial and ethnic minoritized populations. Future research is needed to understand if and how these transitions may have affected health outcomes.

Addressing Equity and Justice in Age-Friendly Communities: Considerations for LGBTQ+ Older Adults of Color

BACKGROUND AND OBJECTIVES

This research critically examined the concept of age-friendliness from the perspectives of older Black lesbian women living in New York City (NYC). The primary aim was to extend existing age-friendly frameworks to more inclusively meet the needs of older lesbian, gay, bisexual, transgender, and queer adults of color, promoting greater equity and justice.

RESEARCH DESIGN AND METHODS

Applying principles from critical participatory action research, we collected and analyzed data from 5 focus groups consisting of 5 older Black lesbian women. Participants shared their daily experiences living in NYC and proposed ideas to enhance the age-friendliness of the city to better accommodate their unique needs and experiences.

RESULTS

Participants called for greater attention to the interaction between identities and structures in relation to age-friendly communities. Historic and contemporary experiences of violence and discrimination, as well as the ever-shifting political context were identified as a key factor shaping their aging experiences. The need for affirming spaces with positive representation of their layered identities was emphasized in the context of age-friendly interventions.

DISCUSSION AND IMPLICATIONS

While dominant age-friendly frameworks are universally accepted for improving the health and wellbeing of older adults, the specific challenges of aging with multiple intersecting marginalized identities necessitate a critical perspective. Gerontology needs to take seriously how privilege and oppression operate within society, shaping health and aging trajectories of vulnerable and underserved populations.

Utilization and Potential Disparities in Access to Physical Therapy for Spine Pain in the Long-Term Care Population

OBJECTIVE

To determine the frequency of physical therapy (PT) services and potential disparities in receiving PT among Medicare fee-for-service beneficiaries with a history of spine pain who live in long-term care (LTC) settings.

DESIGN

Secondary cross-sectional analysis of Medicare administrative data on beneficiaries with a history of spine pain from 2017-2019. We identified LTC residents using a validated algorithm, then identified and described PT episodes that occurred after the LTC index date. To identify potential disparities in access to PT services, we performed multivariable logistic regression to determine resident demographic, clinical, and community factors associated with receiving PT.

SETTING

Not applicable.

PARTICIPANTS

Medicare fee-for-service LTC residents aged ≥65 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Receiving PT services.

RESULTS

Of the 999,495 LTC residents with a history of spine pain, 49.6% received PT. Only 12.1% of PT episodes specifically treated spine pain. The odds of receiving PT were higher for residents with pain in multiple spine regions or neuropathic pain (OR, 1.27; 95% confidence interval CI, 1.26-1.29) and for residents with inpatient admissions (OR, 1.76; 95% CI, 1.75-1.78). Odds of receiving PT were lower for residents from minoritized racial and ethnic groups, and for residents with dementia (OR, 0.89; 95% CI, 0.88-0.90), depression (OR, 0.95; 95% CI, 0.94-0.96), or who lived in urban or more socioeconomically deprived areas.

CONCLUSIONS

Although nearly half of LTC residents with histories of spine pain received PT services, most PT was not for spine pain. There are potential disparities in access to PT for LTC residents from minoritized groups living in urban and more deprived areas. Further work should examine PT outcomes and remove barriers to PT for LTC residents with histories of spine pain.

Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes

OBJECTIVES

This study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons.

METHODS

Our comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs.

RESULTS

The study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons.

CONCLUSIONS AND IMPLICATIONS

Our analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity.

Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents

Importance

Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs).

Objective

To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents.

Design, Setting, and Participants

This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022.

Exposure

Race and ethnicity of NH residents.

Main Outcomes and Measures

Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate.

Results

Of 2 098 385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39 873 (1.9%) were Asian, 229 112 (10.9%) were Black or African American, 99 304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1 713 670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1 355 143 (64.6%) were female; 128 997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]).

Conclusions and Relevance

In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.

Patient Characteristics and Treatment Patterns for Speech-Language Pathology Services in Skilled Nursing Facilities

PURPOSE

Skilled nursing facility (SNF) care has historically been influenced by systemic issues that could impact speech-language pathology (SLP) service provision. However, there has been little study specifically on factors associated with SLP service provision in SNFs. Large administrative data sets are rarely analyzed in SLP research but can be used to understand real-world SLP services. This study investigated associations between patient and facility characteristics and SLP services.

METHOD

Mixed-effects logistic regression models were used to evaluate factors associated with SLP service provision in 2018 Medicare administrative data representing 833,653 beneficiaries.

RESULTS

Beneficiaries had higher odds of receiving SLP services when they had neurologic diagnosis (odds ratio [OR] = 3.32), had SLP-related functional impairments (ORs = 1.19-3.41), and received other rehabilitative services (ORs = 3.11-3.78). Beneficiaries had lower odds of receiving SLP services when they received care from SNFs located in hospitals versus freestanding (OR = 0.45), with need for interpreter services (OR = 0.76) and with thresholding (OR = 0.68), a financially motivated practice. Direction of association varied across racial and ethnic groups and measures of location. Odds of being provided SLP services decreased with increasing communication impairment severity.

CONCLUSIONS

The results suggest that clinicians are identifying patients with diagnoses most likely to warrant SLP services. However, association disparities and weakening association of service provision with increasing impairment severity have concerning clinical implications. Health services research methods can be used to further explore SLP practices in SNFs to support equitable service provision.

End-of-Life Planning and the Influence of Socioeconomic Status among Black Americans: A Systematic Review

Purpose

The purpose of this systematic review is to explore end-of-life (EOL) care planning and the impact of socioeconomic status (SES) among people who identify as Black or African American.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were used to guide and inform this systematic review process. The following academic electronic databases with publications that reflected the interdisciplinary fields related to the research objective were searched APA PsycINFO, CINHAL, PubMed, Scopus, and Social Work Abstracts.

Results

After the authors conducted the search, 14 articles (from 13 studies) ultimately met the criteria for inclusion. The results substantiated significant concerns highlighted in previous literature regarding SES and its relation to EOL planning, but also revealed an absence of original work and interventions to increase engagement in EOL planning among Black and African American populations.

Conclusion

Black individuals deserve an equitable EOL experience. Researchers, practitioners, and policymakers need to move towards advocacy and action to meet this important need.

Proposing A Racism-Conscious Approach To Policy Making And Health Care Practices

Racial and ethnic health inequities are driven by multiple social and political factors. Race-neutral policies that overlook the role of racism in policy and in disparities may also contribute to inequities. In response, one broad policy-making approach has been to craft race-based policies that attempt to improve outcomes explicitly for specific racial groups. However, race-based policies can be politically infeasible. We propose a racism-conscious approach to policy making and health care practices that addresses racism and advances health equity. Using postacute and long-term care policies as a backdrop, we identify five key steps to creating racism-conscious policies that rest on continuous community engagement and policy evaluation. The proposed racism-conscious framework can be used to develop a new health policy or to redesign an existing policy, and it can work for federal, state, local, and organizational policies, practices, or both.

Accuracy of infection reporting in US nursing home ratings

OBJECTIVE

To assess the accuracy of nursing home-reported data on urinary tract infections (UTIs), which are publicly reported on Nursing Home Care Compare, and pneumonia, which are not publicly reported.

DATA SOURCES AND STUDY SETTING

We used secondary data for 100% of Medicare fee-for-service beneficiaries in the United States between 2011 and 2017.

STUDY DESIGN

We identified Medicare fee-for-service beneficiaries who were nursing home residents between 2011 and 2017 and admitted to a hospital with a primary diagnosis of UTI or pneumonia. After linking these hospital claims to resident-level nursing home-reported assessment data in the Minimum Data Set, we calculated the percentages of infections that were appropriately reported and assessed variation by resident- and nursing home-level characteristics. We developed a claims-based nursing home-level measure of hospitalized infections and estimated correlations between this and publicly reported ratings.

DATA EXTRACTION METHODS

Medicare fee-for-service beneficiaries who were nursing home residents and hospitalized for UTI or pneumonia during the study period were included.

PRINCIPAL FINDINGS

Reporting rates were low for both infections (UTI: short-stay residents 29.1% and long-stay residents 19.2%; pneumonia: short-stay residents 66.0% and long-stay residents 70.6%). UTI reporting rates increased when counting additional assessments, but it is unclear whether these reports are for the same versus a newly developed UTI. Black residents had slightly lower reporting rates, as did nursing homes with more Black residents. Correlations between our claims-based measure and publicly reported ratings were poor.

CONCLUSIONS

UTI and pneumonia were substantially underreported in data used for national public reporting. Alternative approaches are needed to improve surveillance of nursing home quality.

Caring for aging parents in the last years of life

BACKGROUND

Adult children provide a large portion of end-of-life caregiving for older adults and make up the majority of caregivers for adults with dementia. Yet research has been limited to the hours of care that primary caregivers provide, neglecting the other ways adult children provide caregiving support. This study aims to describe the caregiving support adult children provide to their parents at the end of life and characterize differences by race and ethnicity and dementia status.

METHODS

We conducted a retrospective study using survey responses from the Health and Retirement Study between 2002 and 2018. The sample population (n = 8040) included decedents aged 65 with at least one living adult child at their time of death. Caregiving support was defined as providing financial support, providing help with basic or instrumental activities of daily living (ADLs or IADLs), or coresiding with the care recipient. Respondents were stratified by self-identified race and ethnicity as Hispanic, non-Hispanic White, or non-Hispanic Black. Respondents were further stratified by dementia and marital status.

RESULTS

Black and Hispanic respondents without dementia were more likely to report receiving financial help from (28.0% and 25.9%) or coresiding with their adult children (38.9% and 49.7%) compared to White respondents (15.0% receiving financial help and 23.3% coresiding) (p < 0.05). Among respondents with dementia, 47.1% of both Black and Hispanic respondents reported coresiding with their adult children, compared to only 24.6% of White respondents (p < 0.05). Notably, married Black and Hispanic respondents reported significantly higher rates of all support types compared to married White respondents (p < 0.05).

CONCLUSIONS

The majority of older adults at the end of life receive some form of care and support from their adult children, with Black and Hispanic older adults receiving particularly high rates of care and support from their adult children regardless of dementia or marital status.

The Role of Trust in Older Adult Service Provision at the Onset of the COVID-19 Pandemic

The COVID-19 pandemic caused near immediate service delivery adaptation among social service and healthcare sectors. Findings from in-depth interviews with 45 senior leaders of social services and healthcare organizations serving older adults in Washington State elucidate the role of trust in service provision at the onset of the pandemic. First, a history of trust facilitated service adaptation. Intentional outreach, programs, and culturally responsive services sustained trust with service recipients. Providing services and information in an older adult's preferred language built trust. Community networks facilitated and reflected trust between organizations and older adults. Finally, mistrust was prevalent for clients who perceived a high risk of experiencing negative consequences from accessing services. Our findings support the need for culturally and linguistically diverse services. To improve trust, the aging network should strengthen and expand partnerships with community-based organizations who have established trust through history, intentionality, and relevance to their service populations..

Constructing Discrimination Rights: Comparisons Among Staff in Long-Term Care Health Facilities

BACKGROUND AND OBJECTIVES

Despite increased attention to racial and gender justice in the workplace in recent years, discrimination complaints remain vastly underreported. Building on legal consciousness theory-which explains how individuals invoke (or do not invoke) legal principles to define everyday experiences-this study examines how long-term care facility staff understand experiences of discrimination by residents and why staff fails to report discrimination.

RESEARCH DESIGN AND METHODS

This qualitative comparative study uses in-depth semistructured ethnographic interviews to compare experiences among facility staff (n = 80) at three levels (floor staff, mid-management, and upper-management). The qualitative content analysis incorporated both inductive and deductive coding approaches.

RESULTS

Findings reveal extensive unreported instances of discrimination from residents. Staff at all levels rarely invoked discrimination concepts to describe interactions between residents and staff. Floor staff framed residents' discriminatory behavior as a condition of employment or attributed resident behavior to their health or cognitive status. Mid-management framed experiences around staff safety. Upper-management acknowledged staff rights without invoking discrimination rhetoric.

DISCUSSION AND IMPLICATIONS

By avoiding naming experiences as discrimination and blaming residents, most floor staff never reached the claiming process that would result in a report or complaint of discrimination. Managers' framings also shaped how front-line staff and managers named, blamed, and claimed experiences of discrimination and help explain why staff may be hesitant to report discrimination by residents. These findings suggest the need for new and targeted policy and practice approaches that address the nuances accompanying how staff understands workplace experiences as discrimination.

Black and white proxy experiences and perceptions that influence advanced dementia care in nursing homes: The ADVANCE study

BACKGROUND

Regional, facility, and racial variability in intensity of care provided to nursing home (NH) residents with advanced dementia is poorly understood.

MATERIALS AND METHODS

Assessment of Disparities and Variation for Alzheimer's disease NH Care at End of life (ADVANCE) is a multisite qualitative study of 14 NHs from four hospital referral regions providing varied intensity of advanced dementia care based on tube-feeding and hospital transfer rates. This report explored the perceptions and experiences of Black and White proxies (N = 44) of residents with advanced dementia to elucidate factors driving these variations. Framework analyses revealed themes and subthemes within the following a priori domains: understanding of advanced dementia and care decisions, preferences related to end-of-life care, advance care planning, decision-making about managing feeding problems and acute illness, communication and trust in NH providers, support, and spirituality in decision-making. Matrix analyses explored similarities/differences by proxy race. Data were collected from June 1, 2018 to July 31, 2021.

RESULTS

Among 44 proxies interviewed, 19 (43.1%) were Black, 36 (81.8%) were female, and 26 (59.0%) were adult children of residents. In facilities with the lowest intensity of care, Black and White proxies consistently reported having had previous conversations with residents about wishes for end-of-life care and generally better communication with providers. Black proxies held numerous misconceptions about the clinical course of advanced dementia and effectiveness of treatment options, notably tube-feeding and cardiopulmonary resuscitation. Black and White proxies described mistrust of NH staff but did so towards different staffing roles. Religious and spiritual beliefs commonly thought to underlie preferences for more intense care among Black residents, were rarely, but equally mentioned by race.

CONCLUSIONS

This report refuted commonly held assumptions about religiosity and spirituality as drivers of racial variations in advanced dementia care and revealed several actionable facility-level factors, which may help reduce these variations.

"I Have a Lotta Sad Feelin'" - Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

OBJECTIVE

To investigate mental health needs and barriers to seeking mental health support in Medicaid-funded Assisted Living Facility (M-ALF).

DESIGN

A multimethod, qualitative-dominant descriptive design using questionnaires and semistructured interviews.

SETTING AND PARTICIPANTS

The study occurred at a M-ALF in the Bronx, New York. A researcher in residence recruited 13 residents (11 Black or African American, 2 Asian) using purposive sampling.

METHODS

Demographic data and mental health indicators (depression, anxiety, stress, hopelessness) were measured with questionnaires (Center for Epidemiological Studies Depression Scale, Edmonton Symptom Assessment System, Perceived Stress Scale, Beck Hopelessness Survey) and analyzed with descriptive statistics. Interviews were conducted between June and November 2021, transcribed, and analyzed using conventional content analysis.

RESULTS

Thirteen residents (mean age: 73.4 years, mean length of stay: 3.5 years; range: 1.0-7.5) completed data collection. Quantitatively indicators of unmet mental health were common. Qualitatively, residents reported barriers to mental health access to address depression, anxiety, and substance use. This was accompanied by concerns surrounding loss of autonomy, mistrust for M-ALF organizational support, isolation and uncertainty about how to receive mental health support. Perspectives were shaped by past experiences with institutional living, serious illness, and being unhoused. Themes and subthemes were (1) mental health need (unmet mental health need, depression, and anxiety and seeking support through non-mental health resources) and (2) barriers to mental health support (dissatisfaction with M-ALF care, perceived threats to autonomy, desire for autonomy that leads to diminished care seeking).

CONCLUSION AND IMPLICATIONS

Residents of M-ALF have mental health needs for which care is stymied by loss of autonomy, lack of resources, and the M-ALF environment. Residents use unconventional resources to address needs that may be neither efficient nor effective. Novel mental health interventions and processes are needed to improve mental health access and should prioritize residents' desire for autonomy and the unique circumstances of living in M-ALF.

Long-Term Care Research in the Context of COVID-19 Pandemic: A Bibliometric Analysis

Despite the increasing awareness of long-term care (LTC) research after the outbreak of COVID-19 pandemic, little attention was given to quantitatively describe the evolution of the research field during this period. A total of 1024 articles retrieved from the Web of Science Core Collection database were systematically analyzed using CiteSpace visualization software. The overall characteristics analysis showed that, in the context of the pandemic, attention to LTC research increased significantly-over 800 articles were published in the past two years. The USA, Canada, Italy, and England formed the leading LTC research group, which was consistent with the conclusions of existing bibliometric studies on LTC research before the outbreak. A rigorous analysis based on a dual perspective of references and keywords was applied to reveal that, compared with previous studies, in the context of the pandemic, the focus shifted from the mental and physical health status of older adults in need of LTC to the impact of the pandemic on those of older adults in LTC facilities, from the prevention of general epidemics to the prevention and response of significant public health emergencies, from providing and paying for LTC to strategies for LTC facilities to improve the quality of LTC and well-being of their residents during the pandemic. These findings can provide help and reference for academics, civil folks, and LTC practitioners, as well as help with the sustainable development of LTC research in the context of COVID-19 pandemic.

Spatial and racial covid-19 disparities in U.S. nursing homes

In many parts of the world nursing home residents have experienced a disproportionate risk of exposure to COVID-19 and have died at much higher rates than other groups. There is a critical need to identify the factors driving COVID-19 risk in nursing homes to better understand and address the conditions contributing to their vulnerability during public health crises. This study investigates the characteristics associated with COVID-19 cases and deaths among residents in U.S. nursing homes from 2020 to 2021, with a focus on geospatial and racial inequalities. Using data from the Centers for Medicare and Medicaid Services and LTCFocus, this paper uses zero-inflated negative binomial regression models, Kruskal-Wallis tests, and Local Moran's I to generate statistical and geospatial results. Our analysis reveals that majority Hispanic facilities have alarmingly high COVID-19 cases and deaths, suggesting that these facilities have the greatest need for policy improvements in staffing and financing to reduce racial inequalities in nursing home care. At the same time we also detect COVID-19 hot spots in rural areas with predominately White residents, indicating a need to rethink public messaging strategies in these areas. The top states with COVID-19 hot spots are Kentucky, Pennsylvania, Illinois, and Oklahoma. This research provides new insights into the socio-spatial contexts and inequities that contribute to the vulnerability of nursing home residents during a pandemic.

Quality at nursing homes with high proportion of residents with cognitive impairment

INTRODUCTION

There is limited data on staffing ratings at nursing homes (NHs) serving residents with dementia, despite staffing impacting quality of care.

METHODS

Residents' cognitive impairment status, staffing rating, and facility characteristics were obtained for 11,469 NHs, using data from the Centers for Medicare & Medicaid Services and Long-term Care: Facts on Care in the U.S. The association between the proportion of residents with cognitive impairment and nurse staffing rating was analyzed using multiple logistic regression in a cross-sectional study design.

RESULTS

NHs with a high proportion of residents with cognitive impairment were 41% less likely to have a high staffing rating or high RN staffing rating (95% CI: 0.52-0.67) compared to NHs with a low proportion.

DISCUSSION

NHs that serve a higher proportion of residents with cognitive impairment have lower staffing ratings, and this disparity is more pronounced in NHs with more minority residents. Increasing staffing levels is a necessary policy measure to improve care in these facilities.

Resident racial and ethnic composition, neighborhood-level socioeconomic status, and COVID-19 infections in California SNFs

BACKGROUND

In California, >29,000 residents in skilled nursing facility (SNFs) were diagnosed with novel coronavirus disease 2019 (COVID-19) between March 2020 and November 2020. Prior research suggests that SNFs serving racially and ethnically minoritized residents often have fewer resources and lower quality of care. We performed a cross-sectional analysis of COVID-19 incidence among residents in California SNFs, assessing the association of SNF-level racial and ethnic compositions and facility- and neighborhood-level (census tract- and county-level) indicators of socioeconomic status (SES).

METHODS

SNFs were grouped based on racial and ethnic composition using data from the Centers for Medicare and Medicaid Services; categories included SNFs with ≥88% White residents, SNFs with ≥32% Black or Latinx residents, SNFs with ≥32% Asian residents, or SNFs not serving a high proportion of any racial and ethnic composition (mixed). SNF resident-level COVID-19 infection data were obtained from the National Healthcare Safety Network from May 25, 2020 to August 16, 2020. Multilevel mixed-effects negative binomial regressions were used to estimate incidence rate ratios (IRR) for confirmed COVID-19 infections among residents.

RESULTS

Among 971 SNFs included in our sample, 119 (12.3%) had ≥88% White residents; 215 (22.1%) had ≥32% Black or Latinx residents; 78 (8.0%) had ≥32% Asian residents; and 559 (57.6%) were racially and ethnically mixed. After adjusting for confounders, SNFs with ≥32% Black or Latinx residents (IRR = 2.40 [95% CI = 1.56, 3.68]) and SNFs with mixed racial and ethnic composition (IRR = 2.12 [95% CI = 1.49, 3.03]) both had higher COVID-19 incidence rates than SNFs with ≥88% White residents. COVID-19 incidence rates were also found to be higher in SNFs with low SES neighborhoods compared to those in high SES neighborhoods.

CONCLUSION

Public health personnel should consider SNF- and neighborhood-level factors when identifying facilities to prioritize for COVID-19 outbreak prevention and control.

The Weltanschauung of Howard Rachlin: Interdependencies among behaviors and contexts

Through his broad perspectives and curiosity, Howard Rachlin took behaviorism, added critical perspectives and behavioral economics, and contributed substantially to developing behaviorism as an approach to addressing complex human actions and engagements. This essay describes the influence of Rachlin's work in three areas that reflect this broader growth of the field: 1) teleological behaviorism as a response to essentialist thinking about behavior, typified by Ryle's category mistake and including concepts in psychopathology; 2) self-control as choices among rewards differing by amount and delay and the application of this model to clinical and preventive interventions; and 3) behavioral economic modeling of social support as a commodity substitutable for other commodities of interest such as nicotine. These and the body of Rachlin's work suggest a view not only of interdependencies among behaviors, patterns of behavior, and their consequences, but more broadly, of interdependencies among different settings and their effects on behavior, leading to a behaviorism of systems and contexts. Replacing essentialist discourse of individuals, individual behaviors, and discrete influences, a world view or Weltanschauung emerges of diffuse interdependencies across patterns, individuals, settings, systems, probabilities, and consequences.

Implementation of a CMS Nursing Facility Initiative: Differences by Racial Minority Resident Population

Objectives: The CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: Payment Reform (NFI 2) provided billing opportunities to incentivize participating facilities to keep long-stay residents onsite for acute care, rather than hospitalizing them. We examined cross-facility differences in NFI 2 implementation by racial composition of facility resident populations. Methods: We analyzed Medicare claims in conjunction with in-person and telephone interviews among facility staff to assess NFI 2 engagement in relation to racial minority resident population. Results: Participating facilities with larger racial minority resident populations faced additional barriers to NFI 2 implementation. These facilities submitted fewer NFI 2 claims, reported more challenges engaging resident families, and experienced greater facility staff and leadership instability, compared to facilities with predominantly white resident populations. Discussion: Addressing structural differences within facilities with larger populations of racial minority residents may encourage future development of targeted programs to support diverse nursing facilities.

Use of hospitals in the New York City Metropolitan Region, by race: how separate? How equal in resources and quality?

BACKGROUND

Although racial and ethnic minorities disproportionately use some hospitals, hospital-based racial and ethnic composition relative to geographic region and its association with quality indicators has not been systematically analyzed.

METHODS

We used four race and ethnicity categories: non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and Asian/Pacific Islander/Alaskan Native/American Indian (API/AIAN), as well as a combined non-NHW category, from the 2010 (latest year publicly available) Medicare Institutional Provider & Beneficiary Summary public use file for 84 hospitals in the New York City region. We assessed the relative distribution of race and ethnicity across hospitals grouped at different geographic levels (region, county, hospital referral region [HRR], or hospital service areas [HSA]) using the dissimilarity index. Hospital characteristics included quality star ratings, essential professional services and diagnostic/treatment equipment, bed size, total expenses, and patients with dual Medicare and Medicaid enrollment. We assessed Spearman's rank correlation between hospital-based racial and ethnic composition and quality/structural measures.

RESULTS

Dissimilarity Index decreases from region (range 30.3-40.1%) to county (range 13.7-23.5%), HRR (range 10.5-27.5%), and HSA (range 12.0-16.9%) levels. Hospitals with larger non-NHW patients tended to have lower hospital ratings and higher proportions of dually-enrolled patients. They were also more likely to be safety net hospitals and non-federal governmental hospitals.

CONCLUSIONS

In the NYC metropolitan region, there is considerable hospital-based racial and ethnic segregation of Medicare patients among non-NHW populations, extending previous research limited to NHB. Availability of data on racial and ethnic composition of hospitals should be made publicly available for researchers and consumers.

Having Hard Conversations About Racism Within Nursing Education: A Collaborative Process of Developing an Antiracism Action Plan

BACKGROUND

Multiple events that occurred in the United States in early 2020 prompted a widespread response to address racism that exists within systemic and social structures. Third-year psychiatric nursing students at a small Western Canadian university answered the call to action by initiating a process to address racism within clinical and educational settings in their faculty.

METHODS

The researchers used collaborative autoethnography to examine the experience of students and faculty working collaboratively to create a Faculty of Health Studies antiracism action plan.

RESULTS

The reflections of the student and faculty researchers highlighted three major themes: what inspired the work of creating an antiracism action plan, doing the work, and lessons learned.

CONCLUSION

Engaging in this research provided an opportunity to critically reflect on the process of students and faculty working together in establishing an antiracism action plan. [J Nurs Educ. 2022;61(8):461-468.].

Evidence to inform policy and practice: Mechanisms to address racial/ethnic disparities in nursing home quality of life

Background and Objectives

Abundant evidence documents racial/ethnic disparities in access, quality of care, and quality of life (QoL) among nursing home (NH) residents who are Black, Indigenous and people of color (BIPOC) compared to White residents. BIPOC residents are more likely to be admitted to lower quality NHs and to experience worse outcomes. Yet, little is known about processes for differences in QoL among residents receiving care in high proportion BIPOC NHs. This study presents an examination of the processes for racial/ethnic disparities in QoL in high-proportion BIPOC facilities while highlighting variability in QoL between these facilities.

Research Design and Methods

Guided by the Minority Health and Health Disparities Research Framework and the Zubritsky framework for QoL in NHs, we employ a concurrent mixed-methods approach involving in-depth case studies of six high-proportion BIPOC NHs in Minnesota (96 resident interviews; 61 staff interviews; 614 hours of observation), coupled with state-wide survey data on residents’ QoL linked to resident clinical Minimum Data Set assessments.

Results

Quantitative findings show that BIPOC residents experience lower QoL than White residents across various domains. Qualitative findings reveal variability in BIPOC residents’ QoL between high proportion BIPOC facilities. In some facilities, BIPOC residents experienced worse QoL based on their race/ethnicity, while in others BIPOC residents QoL was not directly affected by their race/ethnicity or they had mixed experiences.

Discussion and Implications

The findings highlight variability in racial/ethnic disparities in QoL across NHs with a high proportion of BIPOC residents. We identify health equity initiatives, including engaging with community BIPOC organizations and volunteers, and providing more resources to high-proportion BIPOC facilities to support staff training, additional staffing, and culturally-specific programming. Given the increasing racial/ethnic diversity of NHs, ensuring equity in QoL for BIPOC residents is an urgent priority for NHs to remain relevant in the future.

Association of Nursing Home Organizational Culture and Staff Perspectives With Variability in Advanced Dementia Care: The ADVANCE Study

IMPORTANCE

Regional, facility, and racial and ethnic variability in intensity of care provided to nursing home residents with advanced dementia is well documented but poorly understood.

OBJECTIVE

To assess the factors associated with facility and regional variation in the intensity of care for nursing home residents with advanced dementia.

DESIGN, SETTING, AND PARTICIPANTS

In the ADVANCE (Assessment of Disparities and Variation for Alzheimer Disease Nursing Home Care at End of Life) qualitative study, conducted from June 1, 2018, to July 31, 2021, nationwide 2016-2017 Medicare Minimum Data Set information identified 4 hospital referral regions (HRRs) with high (n = 2) and low (n = 2) intensity of care for patients with advanced dementia based on hospital transfer and tube-feeding rates. Within those HRRs, 14 facilities providing relatively high-intensity and low-intensity care were recruited. A total of 169 nursing home staff members were interviewed, including administrators, directors of nursing, nurses, certified nursing assistants, social workers, occupational therapists, speech-language pathologists, dieticians, medical clinicians, and chaplains.

MAIN OUTCOMES AND MEASURES

Data included 275 hours of observation, 169 staff interviews, and abstraction of public nursing home material (eg, websites). Framework analyses explored organizational factors and staff perceptions across HRRs and nursing homes in the following 4 domains: physical environment, care processes, decision-making processes, and implicit and explicit values.

RESULTS

Among 169 staff members interviewed, 153 (90.5%) were women, the mean (SD) age was 47.6 (4.7) years, and 54 (32.0%) were Black. Tube-feeding rates ranged from 0% in 5 low-intensity facilities to 44.3% in 1 high-intensity facility, and hospital transfer rates ranged from 0 transfers per resident-year in 2 low-intensity facilities to 1.6 transfers per resident-year in 1 high-intensity facility. The proportion of Black residents in facilities ranged from 2.9% in 1 low-intensity facility to 71.6% in 1 high-intensity facility, and the proportion of Medicaid recipients ranged from 45.3% in 1 low-intensity facility to 81.3% in 1 high-intensity facility. Factors distinguishing facilities providing the lowest-intensity care from those providing the highest-intensity care facilities included more pleasant physical environment (eg, good repair and nonmalodorous), standardized advance care planning, greater staff engagement in shared decision-making, and staff implicit values unfavorable to tube feeding. Many staff perceptions were ubiquitous (eg, adequate staffing needs), with no distinct pattern across nursing homes or HRRs. Staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in advance care planning and favored more aggressive care. Except in nursing homes providing the lowest-intensity care, many staff believed that feeding tubes prolonged life and had other clinical benefits.

CONCLUSIONS AND RELEVANCE

This study found that variability in the care of patients with advanced dementia may be reduced by addressing modifiable nursing home factors, including enhancing support for low-resource facilities, standardizing advance care planning, and educating staff about evidence-based care and shared decision-making. Given pervasive staff biases toward proxies of Black residents, achieving health equity for nursing home residents with advanced dementia must be the goal behind all efforts aimed at reducing disparities in their care.

Examining Structural Disparities in U.S. Nursing Homes: A National Survey of Health Information Technology Maturity (Preprint)

Background

There are 15,632 nursing homes (NHs) in the United States. NHs continue to receive significant policy attention due to high costs and poor outcomes of care. One strategy for improving NH care is use of health information technology (HIT). A central concept of this study is HIT maturity, which is used to identify adoption trends in HIT capabilities, use and integration within resident care, clinical support, and administrative activities. This concept is guided by the Nolan stage theory, which postulates that a system such as HIT moves through a series of measurable stages. HIT maturity is an important component of the rapidly changing NH landscape, which is being affected by policies generated to protect residents, in part because of the pandemic.

Objective

The aim of this study is to identify structural disparities in NH HIT maturity and see if it is moderated by commonly used organizational characteristics.

Methods

NHs (n=6123, >20%) were randomly recruited from each state using Nursing Home Compare data. Investigators used a validated HIT maturity survey with 9 subscales including HIT capabilities, extent of HIT use, and degree of HIT integration in resident care, clinical support, and administrative activities. Each subscale had a possible HIT maturity score of 0-100. Total HIT maturity, with a possible score of 0-900, was calculated using the 9 subscales (3 x 3 matrix). Total HIT maturity scores equate 1 of 7 HIT maturity stages (stages 0-6) for each facility. Dependent variables included HIT maturity scores. We included 5 independent variables (ie, ownership, chain status, location, number of beds, and occupancy rates). Unadjusted and adjusted cumulative odds ratios were calculated using regression models.

Results

Our sample (n=719) had a larger proportion of smaller facilities and a smaller proportion of larger facilities than the national nursing home population. Integrated clinical support technology had the lowest HIT maturity score compared to resident care HIT capabilities. The majority (n=486, 60.7%) of NHs report stage 3 or lower with limited capabilities to communicate about care delivery outside their facility. Larger NHs in metropolitan areas had higher odds of HIT maturity. The number of certified beds and NH location were significantly associated with HIT maturity stage while ownership, chain status, and occupancy rate were not.

Conclusions

NH structural disparities were recognized through differences in HIT maturity stage. Structural disparities in this sample appear most evident in HIT maturity, measuring integration of clinical support technologies for laboratory, pharmacy, and radiology services. Ongoing assessments of NH structural disparities is crucial given 1.35 million Americans receive care in these facilities annually. Leaders must be willing to promote equal opportunities across the spectrum of health care services to incentivize and enhance HIT adoption to balance structural disparities and improve resident outcomes.

Examining Regional Differences in Nursing Home Palliative Care for Black and Hispanic Residents

Background: Approximately one-quarter of all deaths in the United States occur in nursing homes (NHs). Palliative care has the potential to improve NH end-of-life care, but more information is needed on the provision of palliative care in NHs serving Black and Hispanic residents. Objective: To determine whether palliative care services in United States NHs are associated with differences in the concentrations of Black and Hispanic residents, respectively, and the impact by region. Design: We conducted a cross-sectional analysis. The outcome was NH palliative care services (measured by an earlier national survey); total scores ranged from 0 to 100 (higher scores indicated more services). Other data included the Minimum Data Set and administrative data. The independent variables were concentration of Black and Hispanic residents (i.e., <3%, 3-10%, >10%), respectively, and models were stratified by region (i.e., Northeast, Midwest, South and West). We compared unadjusted, weighted mean palliative care services by the concentration of Black and Hispanic residents and computed NH-level multivariable linear regressions. Setting/Subjects: Eight hundred sixty-nine (weighted n = 15,020) NHs across the United States. Results: Multivariable analyses showed fewer palliative care services provided in NHs with greater concentrations of Black and Hispanic residents. Fewer palliative care services were reported in NHs in the Northeast, for which >10% of the resident population was Black, and NHs in the West for which >10% was Hispanic versus NHs with <3% of the population being Black and Hispanic (-13.7; p < 0.001 and -9.3; p < 0.05, respectively). Conclusion: We observed differences in NH palliative care by region and with greater concentration of Black and Hispanic residents. Our findings suggest that greater investment in NH palliative care services may be an important strategy to advance health equity in end-of-life care for Black and Hispanic residents.

Structural Racism In Historical And Modern US Health Care Policy

The COVID-19 pandemic has illuminated and amplified the harsh reality of health inequities experienced by racial and ethnic minority groups in the United States. Members of these groups have disproportionately been infected and died from COVID-19, yet they still lack equitable access to treatment and vaccines. Lack of equitable access to high-quality health care is in large part a result of structural racism in US health care policy, which structures the health care system to advantage the White population and disadvantage racial and ethnic minority populations. This article provides historical context and a detailed account of modern structural racism in health care policy, highlighting its role in health care coverage, financing, and quality.

Reimagining Financing and Payment of Long-Term Care

The COVID-19 pandemic revealed fundamental problems with the structure of long-term care financing and payment in the United States. The piecemeal system that exists suffers from several key problems, including underfunding, fragmentation across types and sites of care, and substantial variation in payment across states and populations. These problems result in inefficient allocation of resources, limited access to care, substandard quality, and inequities in both access and quality. We propose a new federal benefit for long-term care, most likely as part of the Medicare program. Essential features of this benefit include taxpayer subsidies, along the lines of other Medicare benefits, and coverage across the range of long-term care services, including both residential and home- and community-based care. A new federal benefit has the most potential to break down administrative barriers and improve resource allocation, to ensure adequate payment rates across all states, to expand access to care by spreading risk across the entire Medicare population, and to improve equity by extending coverage to all Medicare beneficiaries who want it. A new federal benefit is politically challenging, requiring bold action by Congress, and entails the risks of administrative challenges and unintended consequences. However, in this case, retaining the status quo remains the far greater risk.

Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports

Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of these disparities, manifesting via racially segregated care, low Medicaid reimbursement, and lack of livable wages for staff, along with other policies and processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance, public reporting of quality of care, and culture change in nursing homes and integrated home- and community-based service (HCBS) programs as possible mechanisms for addressing racial and ethnic disparities. We developed a set of recommendations for LTSS based on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates, especially for providers serving high proportions of Medicaid-eligible and BIPOC older adults; (2) reconsider the design of pay-for-performance programs as they relate to providers who serve underserved groups; (3) include culturally sensitive measures, such as quality of life, in public reporting of quality of care, and develop and report health equity measures in outcomes of care for BIPOC individuals; (4) implement culture change so services are more person-centered and homelike, alongside improvements in staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices, with special attention to family caregivers; (7) and increase promotion of integrated HCBS programs that can be targeted to BIPOC consumers, and implement models that value community health workers. Multipronged solutions may help diminish the role of systemic racism in existing racial disparities in LTSS, and these recommendations provide steps for action that are needed to reimagine how long-term care is delivered, especially for BIPOC populations.

A Call to Address RN, Social Work, and Advanced Practice Registered Nurses in Nursing Homes: Solutions From the Missouri Quality Initiative

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.

Algorithmic harms and digital ageism in the use of surveillance technologies in nursing homes

Ageism has not been centered in scholarship on AI or algorithmic harms despite the ways in which older adults are both digitally marginalized and positioned as targets for surveillance technology and risk mitigation. In this translation paper, we put gerontology into conversation with scholarship on information and data technologies within critical disability, race, and feminist studies and explore algorithmic harms of surveillance technologies on older adults and care workers within nursing homes in the United States and Canada. We start by identifying the limitations of emerging scholarship and public discourse on "digital ageism" that is occupied with the inclusion and representation of older adults in AI or machine learning at the expense of more pressing questions. Focusing on the investment in these technologies in the context of COVID-19 in nursing homes, we draw from critical scholarship on information and data technologies to deeply understand how ageism is implicated in the systemic harms experienced by residents and workers when surveillance technologies are positioned as solutions. We then suggest generative pathways and point to various possible research agendas that could illuminate emergent algorithmic harms and their animating force within nursing homes. In the tradition of critical gerontology, ours is a project of bringing insights from gerontology and age studies to bear on broader work on automation and algorithmic decision-making systems for marginalized groups, and to bring that work to bear on gerontology. This paper illustrates specific ways in which important insights from critical race, disability and feminist studies helps us draw out the power of ageism as a rhetorical and analytical tool. We demonstrate why such engagement is necessary to realize gerontology's capacity to contribute to timely discourse on algorithmic harms and to elevate the issue of ageism for serious engagement across fields concerned with social and economic justice. We begin with nursing homes because they are an understudied, yet socially significant and timely setting in which to understand algorithmic harms. We hope this will contribute to broader efforts to understand and redress harms across sectors and marginalized collectives.

The Imperative to Reimagine Assisted Living

Assisted living (AL) has existed in the United States for decades, evolving in response to older adults' need for supportive care and distaste for nursing homes and older models of congregate care. AL is state-regulated, provides at least 2 meals a day, around-the-clock supervision, and help with personal care, but is not licensed as a nursing home. The key constructs of AL as originally conceived were to provide person-centered care and promote quality of life through supportive and responsive services to meet scheduled and unscheduled needs for assistance, an operating philosophy emphasizing resident choice, and a residential environment with homelike features. As AL has expanded to constitute half of all long-term care beds, the increasing involvement of the real estate, hospitality, and health care sectors has raised concerns about the variability of AL, the quality of AL, and standards for AL. Although the intent to promote person-centered care and quality of life has remained, those key constructs have become mired under tensions related to models of AL, regulation, financing, resident acuity, and the workforce. These tensions have resulted in a model of care that is not as intended, and which must be reimagined if it is to be an affordable care option truly providing quality, person-centered care in a suitable environment. Toward that end, 25 stakeholders representing diverse perspectives conferred during 2 half-day retreats to identify the key tensions in AL and discuss potential solutions. This article presents the background regarding those tensions, as well as potential solutions that have been borne out, paving the path to a better future of assisted living.

Transforming Direct Care Jobs, Reimagining Long-Term Services and Supports

The diverse array of individuals who receive long-term services and supports share one common experience, which is the need for assistance with personal care and/or other daily activities. The direct care workers (including nursing assistants, home health aides, and personal care aides) who provide this assistance play a critical role in keeping individuals safe, supporting their health and well-being, and helping prevent adverse outcomes. Yet despite decades of research, advocacy, and incremental policy and practice reform, direct care workers remain inadequately compensated, supported, and respected. Long-standing direct care job quality concerns are linked to high turnover and job vacancy rates in this workforce, which in turn compromise the availability and quality of essential care for older adults and people with disabilities-which has never been more evident than during the COVID-19 pandemic. This special article makes the case for transforming direct care jobs and stabilizing this workforce as a centerpiece of efforts to reimagine long-term services and supports system in the United States, as a public health priority, and as a social justice imperative. Drawing on research evidence and examples from the field, the article demonstrates that a strong, stable direct care workforce requires: a competitive wage and adequate employment benefits for direct care workers; updated training standards and delivery systems that prepare these workers to meet increasingly complex care needs across settings, while also enhancing career mobility and workforce flexibility; investment in well-trained frontline supervisors and peer mentors to help direct care workers navigate their challenging roles; and an elevated position for direct care workers in relation to the interdisciplinary care team. The article concludes by highlighting federal and state policy opportunities to achieve direct care job transformation, as well as discussing research and practice implications.

U.S. Nursing Home Quality Ratings Associated with COVID-19 Cases and Deaths

Objectives

To inform future policies and disaster preparedness plans in the vulnerable nursing home setting, we need greater insight into the relationship between nursing homes’ (NHs’) quality and the spread and severity of COVID-19 in NH facilities. We therefore extend current evidence on the relationships between NH quality and resident COVID-19 infection rates and deaths, taking into account NH structural characteristics and community characteristics.

Design

Cross-sectional study.

Setting and Participants

15,390 Medicaid- and Medicare-certified NHs.

Methods

We obtained and merged the following data sets: (1) COVID-19 weekly data reported by each nursing home to the Centers for Disease Control and Prevention’s National Healthcare Safety Network, (2) Centers for Medicare & Medicaid Services Five Star Quality Rating System, (3) county-level COVID-19 case counts, (4) county-level population data, and (5) county-level sociodemographic data.

Results

Among 1-star NHs, there were an average of 13.19 cases and 2.42 deaths per 1000 residents per week between May 25 and December 20, 2020. Among 5-star NHs, there were an average of 9.99 cases and 1.83 deaths per 1000 residents per week. The rate of confirmed cases of COVID-19 was 31% higher among 1-star NHs compared with 5-star NHs [model 1: incidence rate ratio (IRR) 1.31, 95% confidence interval (CI) 1.23-1.39], and the rate of COVID-19 deaths was 30% higher (IRR 1.30, 95% CI 1.20, 1.41). These associations were only partially explained by differences in community spread of COVID-19, case mix, and the for-profit status and size of NHs.

Conclusions and Implications

We found that COVID-19 case and death rates were substantially higher among NHs with lower star ratings, suggesting that NHs with quality much below average are more susceptible to the spread of COVID-19. This relationship, particularly with regard to case rates, can be partially attributed to external factors: lower-rated NHs are often located in areas with greater COVID-19 community spread and serve more socioeconomically vulnerable residents than higher-rated NHs.