The Impact of Dementia Special Care Units on Quality of Care: An Instrumental Variables Analysis

Factors Influencing Hospitalization of Nursing Home Residents in Korea Using Regularized Negative Binomial Regression

The appropriateness of hospitalization for nursing home (NH) residents is still up for debate, with determining factors including timeliness, available treatment, healthcare staff, medication options in hospitals, and safety issues. Although the factors leading to hospitalization have been studied expansively, research on staffing is limited. Thus, this study aimed to investigate organizational predictors, nurse staffing, and government incentives and find important factors to hospitalization due to infection or disease among NH residents in Korea. A cross-sectional design was used, and data were collected via survey from a total of 51 NHs from August 27, 2021 to March 25, 2022. A total of 32 explanatory variables were included. The response variable was the count of hospitalized residents due to infection or disease. We analyzed data using least absolute shrinkage and negative binomial regression. We found that registered nurses' increased hours per resident day were related to decreased hospitalizations due to infection or disease. Appropriate retention and recruitment of nurse staffing with professional leadership should be performed to increase the quality of care for NH residents.

Do nursing homes with a higher proportion of residents with dementia have greater or fewer complaints?

Objectives: Nursing home (NH) residents' capacity to communicate deteriorates with dementia. Consequently, NHs with high proportions of people living with dementia (PLWD) may receive fewer resident complaints, and/or investigating complaints may be challenging. We assessed NHs' proportion of PLWD in relation to total and substantiated complaints. Methods: Data were from the ASPEN Complaints/Incident Tracking System and the Certification and Survey Provider Enhanced Reports (2017). NHs (N = 15,499) were categorized based on high (top-10%), medium (middle-80%), and low (bottom-10%) dementia prevalence. Negative binomial Poisson regression assessed complaint patterns in relation to NHs' high/low (vs. medium) proportions of PLWD and other facility/resident characteristics. Results: Compared to NHs with medium-dementia prevalence, NHs with low proportions of PLWD had higher total (average marginal effect [AME] = 0.16, p < 0.001) and substantiated (AME = 0.30, p < 0.001) complaints, whereas NHs with high proportions of PLWD had fewer total (AME= -0.07; p < 0.05) and substantiated (AME= -0.11, p < 0.05) complaints. Also, NHs' profit status, chain-affiliation, size, staffing, and resident ethnicity were associated with total and substantiated complaints. Conclusion: The association between high proportions of PLWD and lower NH complaints suggests either that these NHs have higher overall quality or that complaints are underreported. Regardless, surveyors and families may need more involvement in monitoring higher dementia prevalence facilities.

Dementia, nurse staffing, and health outcomes in nursing homes

OBJECTIVE

To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality.

DATA SOURCES AND STUDY SETTING

A national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus.

STUDY DESIGN

Retrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.

DATA COLLECTION/EXTRACTION METHODS

Hospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.

PRINCIPAL FINDINGS

We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome.

CONCLUSIONS

These findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.

Evaluation of Measurement Properties of Supportive Environment Assessment Scales for Dementia Special Care Units: A COSMIN Systematic Review

OBJECTIVES

To identify, critically appraise, compare, and summarize the measurement properties of existing instruments that assess the supportive environment of dementia special care units (DSCUs).

DESIGN

Systematic review of measurement properties consistent with Consensus-based standards for the selection of health measurement instruments (COSMIN) guidelines.

SETTINGS AND PARTICIPANTS

PubMed, Embase, Web of Science, CINAHL, CNKI, Wanfang, VIP, and SinoMed were searched from inception to July 21, 2023. Studies that (1) measured the supportive environment for DSCUs using any type of assessment instrument and (2) evaluated 1 or more psychometric properties of a DSCU's supportive environment assessment instruments were included.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias.

RESULTS

Fourteen studies were identified that reported the psychometric properties of 8 assessment instruments. The Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH) exhibited relatively better results on methodological risk of bias and quality of the psychometric properties. None of the instruments reported the evaluations on hypothesis testing, cross-cultural validity/measurement invariance, measurement error, or responsiveness. Based on the summary of 32 dimensions from 8 assessment instruments, this review established 7 functional constructs for the supportive environment for DSCUs: safety maintenance, space design, external resources, sensory stimulation, humanistic care, residual function development, and professional care. In addition, this study also initially developed a conceptual framework for the supportive environment of DSCUs.

CONCLUSION AND IMPLICATIONS

TESS-NH received the rating of "best methodological quality" and outperformed other weakly recommended scales. Further studies should pay attention to developing or revalidating scales for assessing the supportive environment of DSCUs in large multicenter samples following the COSMIN methodology. Furthermore, the conceptual framework for the DSCU supportive environment will provide a theoretical reference for facilitating their hierarchical establishment and governance within diverse long-term care facilities by state authorities.

Hospital Proximity and Emergency Department Use among Assisted Living Residents

OBJECTIVES

To examine the relationship between AL communities' distance to the nearest hospital and residents' rates of emergency department (ED) use. We hypothesize that when access to an ED is more convenient, as measured by a shorter distance, assisted living (AL)-to-ED transfers are more common, particularly for nonemergent conditions.

DESIGN

Retrospective cohort study, where the main exposure of interest was the distance between each AL and the nearest hospital.

SETTING AND PARTICIPANTS

2018-2019 Medicare claims were used to identify fee-for-service Medicare beneficiaries aged ≥55 years residing in AL communities.

METHODS

The primary outcome of interest was ED visit rates, classified into those that resulted in an inpatient hospital admission and those that did not (ie, ED treat-and-release visits). ED treat-and-release visits were further classified, based on the NYU ED Algorithm, as (1) nonemergent; (2) emergent, primary care treatable; (3) emergent, not primary care treatable; and (4) injury-related. Linear regression models adjusting for resident characteristics and hospital referral region fixed effects were used to estimate the relationship between distance to the nearest hospital and AL resident ED use rates.

RESULTS

Among 540,944 resident-years from 16,514 AL communities, the median distance to the nearest hospital was 2.5 miles. After adjustment, a doubling of distance to the nearest hospital was associated with 43.5 fewer ED treat-and-release visits per 1000 resident years (95% CI -53.1, -33.7) and no significant difference in the rate of ED visits resulting in an inpatient admission. Among ED treat-and-release visits, a doubling of distance was associated with a 3.0% (95% CI -4.1, -1.9) decline in visits classified as nonemergent, and a 1.6% (95% CI -2.4%, -0.8%) decline in visits classified as emergent, not primary care treatable.

CONCLUSIONS AND IMPLICATIONS

Distance to the nearest hospital is an important predictor of ED use rates among AL residents, particularly for visits that are potentially avoidable. AL facilities may rely on nearby EDs to provide nonemergent primary care to residents, potentially placing residents at risk of iatrogenic events and generating wasteful Medicare spending.

Dementia Care Is Widespread In US Nursing Homes; Facilities With The Most Dementia Patients May Offer Better Care

More than three million US nursing home residents were diagnosed with Alzheimer's disease and related dementias (ADRD) between 2017 and 2019. This number is expected to increase as the population ages and ADRD prevalence increases. People with ADRD require specialized care from trained staff. This study addressed two questions: Are residents with ADRD concentrated in nursing homes where they are the majority? If not, what are the implications for their quality of care and life? We answered the first question by determining the ADRD census for each nursing home in the country during the period 2017-19. Using the Minimum Data Set and Medicare claims, we compared characteristics of nursing homes with high and low ADRD census along several dimensions, including staffing, resident outcomes, and resident characteristics. We found that residents with ADRD were dispersed throughout all nursing homes, with fewer than half residing in nursing homes where residents with ADRD accounted for 60-90 percent of the census. Furthermore, only facilities exceeding 90 percent of residents with ADRD seemed to offer better care. These findings raise concerns about the quality of care and life for the majority of residents with ADRD, suggesting that current National Institutes of Health dementia research initiatives and the Biden administration's policies to improve nursing home care should be coordinated.

Measuring Nursing Home Performance Using Administrative Data

To improve the quality of nursing home care, reliable estimates of outcomes are essential. Obtaining such estimates requires optimal use of limited data, especially for small homes. We analyze the variation in mortality and hospital admissions across nursing homes in the Netherlands during the years 2010-2013. We use administrative data on all nursing home clients. We apply mixed-effects survival models, empirical Bayes estimation, and machine-learning techniques to optimally use the available longitudinal data. We find large differences in both outcomes across nursing homes, yet the estimates are surrounded by substantial uncertainty. We find no correlation between performance on mortality and avoidable hospital admissions, suggesting that these are related to different aspects of quality. Hence, caution is needed when evaluating the performance of individual nursing homes, especially when the number of outcome indicators is limited.

Care delivery approaches and perceived barriers to improving quality of care: A national survey of skilled nursing facilities

BACKGROUND

Nursing home quality of care is a persistent challenge, with recent reports calling for increased reforms to improve quality and safety. Less is known about the clinical approaches currently used and the barriers perceived by skilled nursing facilities (SNFs) to provide care for their short-stay residents.

METHODS

We conducted a nationally representative survey of SNFs from October 2020 to May 2021 to understand their care delivery approaches and perceived barriers. Our primary outcomes were the reported number of 23 separate care delivery approaches and the reported number of 12 separate barriers to reduce spending or improve care for SNF short-stay residents. We also performed stratified analyses by facility participation in bundled payments and other SNF characteristics.

RESULTS

We received 377 responses from 693 SNFs contacted (response rate = 54%). SNFs reported an average of 16.8 care delivery approaches and an average of 5.0 barriers. While there were some differences observed in SNF characteristics, such as by bundled payments participation or ownership type, there were common care delivery approaches and barriers shared by most facilities. Care management practices, including reviewing the patient census and medication reconciliation on discharge, were the most common delivery approaches reported. SNFs were less likely to ensure the completion of a follow-up appointment with a primary care provider or track repeat emergency room visits. Issues concerning staffing, such as staff turnover and/or burnout, and lack of resources to provide patients social support, mental health, and substance use services, were the most cited barriers to care delivery.

CONCLUSIONS

Nationally, SNFs implemented a wide array of care delivery approaches, but challenges with staffing and limited resources to address patients' social and mental health needs were dominant. Individual SNFs may have limited ability to address these key barriers, so the involvement of many stakeholders across the entire healthcare system may be necessary.

A qualitative study exploring nursing home care environments where nurse practitioners work

Research is needed to support the growing nurse practitioner workforce to assure higher quality care for older adults in nursing homes. Nursing homes with optimal care environments that support nurse practitioner roles, increased visibility, independence, and relationships are better positioned to support care of older adults. This study reports findings of thirteen qualitative interviews with nurse practitioners to explore facets of nursing home care environments and adapt a tool to measure care environments. Our team incorporated deductive and inductive coding to identify three major emerging themes impacting care environments: 1) nurse practitioner practice in nursing homes, 2) overall goals of practice, 3) workplace challenges. Themes were derived from seven overarching categories and 33 codes describing aspects of NH care environment important to nurse practitioners. Some of the most highly important survey items measured nurse practitioner and physician relationships. Less important items measured relationships between nurse practitioners and administration.

The Impact of Nurse Practitioner-Led Primary Care on Quality and Cost for Medicaid-Enrolled Patients in States With Pay Parity

Studies have established that nurse practitioners (NPs) deliver primary care comparable to physicians in quality and cost, but most focus on Medicare, a program that reimburses NPs less than physicians. In this retrospective cohort study, we evaluated the quality and cost implications of receiving primary care from NPs compared to physicians in 14 states that reimburse NPs at the Medicaid fee-for-service (FFS) physician rate (i.e., pay parity). We linked national provider and practice data with Medicaid data for adults with diabetes and children with asthma (2012-2013). We attributed patients to primary care NPs and physicians based on 2012 evaluation & management claims. Using 2013 data, we constructed claims-based primary care quality measures and condition-specific costs of care for FFS enrollees. We estimated the effect of NP-led care on quality and costs using: (1) weighting to balance observable confounders and (2) an instrumental variable (IV) analysis using differential distance from patients' residences to primary care practices. Adults with diabetes received comparable quality of care from NPs and physicians at similar cost. Weighted results showed no differences between NP- and physician-attributed patients in receipt of recommended care or diabetes-related hospitalizations. For children with asthma, costs of NP-led care were lower but quality findings were mixed: NP-led care was associated with lower use of appropriate medications and higher rates of asthma-related emergency department visits but similar rates of asthma-related hospitalization. IV analyses revealed no evidence of differences in quality between NP- and physician-led care. Our findings suggest that in states with Medicaid pay parity, NP-led care is comparable to physician-led care for adults with diabetes, while associations between NP-led care and quality were mixed for children with asthma. Increased use of NP-led primary care may be cost-neutral or cost-saving, even under pay parity.

Nursing factors associated with length of stay and readmission rate of the elderly residents from nursing home based on LTCfocus database

OBJECTIVES

Nursing factors have been found to be associated with a reduction in readmission rates. Nevertheless, few attentions have been given to the effect of nursing factors on nursing home (NH) residents. This study was to assess the impact of nursing factors on the hospital readmissions and length of stay (LOS) of the elderly residents from the NH.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Data were extracted from the NH of the LTCFocus.org data set between 2011 and 2018. The study included residents aged ≥55 years who were admitted to NH in the United States, following a hospitalization event. The nursing factors included facility-level data elements and medical care personnel. An unsupervised machine learning algorithm (K-means) was used to cluster NH according to readmission rate and LOS. Multivariate logistic regression analysis was performed.

RESULTS

This study consisted of 107,000 NH-year observations. The median readmission rate was 17%, with a median LOS was 28.00 days. Three clusters were identified: cluster 1 was a high readmission rate with high LOS, cluster 2 was a low readmission rate with low LOS, and cluster 3 was a high readmission rate with low LOS. Multifacility and admission/bed were associated with a reduction in readmission rate and LOS in both cluster 1 vs cluster 2 and cluster 3 vs cluster 2. The special care unit and registered nurses' ratio were associated with decreased readmission rate and LOS in cluster 1 vs cluster 2. Total beds and Alzheimer unit decreased the readmission rate and LOS, whereas certified nursing assistant increased the readmission rate and LOS in cluster 3 vs cluster 2. NH for profit was associated with elevated readmission rate and LOS in cluster 1 vs cluster 2 and decreased readmission rate and LOS in cluster 3 vs cluster 2. Based on the subgroup analysis, the certified nursing assistant decreased readmission rate and LOS in cluster 1 vs cluster 2 and increased readmission rate and LOS in cluster 3 vs cluster 2 (all P < 0.005).

CONCLUSION

This study indicates the importance of the improvement of nurse number and level and the inputs of facility characteristics in NH.

Maximizing Well-Being in the Context of Long-Term Services and Supports: A Q Methodological Approach

OBJECTIVES

The goal of this study was to investigate diversity in stakeholders' perspectives on how best to maximize older adults' well-being when they use long-term services and supports (LTSS).

METHODS

We used Q methodology, an exploratory method, to investigate preference patterns among a purposive sample of older adults, family members, and leadership professionals (n = 57). Participants categorized 52 items related to 9 domains of LTSS quality relevant to well-being into categories of importance. We used factors analysis and qualitative methods to identify groups of individuals who identified similar priorities.

RESULTS

The analysis identified four shared viewpoints, each prioritizing different aspects of well-being: 1) physical health and safety; 2) independence; 3) emotional well-being; and 4) social engagement. Individual and contextual factors, including stakeholder role, care needs, and expectations for LTSS, appeared to influence participants' perspectives.

CONCLUSIONS

Distinct viewpoints on how to maximize well-being when older adults use LTSS exist. Our results affirm the importance of person-centered care yet demonstrate that shared preference patterns LTSS exist.

CLINICAL IMPLICATIONS

Engaging with older adults' values and preferences is critical to improving their experiences with LTSS. Better understanding common preference patterns could help providers deliver person-centered care more efficiently and effectively.

Memory care reduces nursing home admissions among assisted-living residents with dementia

INTRODUCTION

We compare nursing-home and hospital admissions among residents with Alzheimer's disease and related dementias (ADRD) in memory-care assisted living to those in general assisted living.

METHODS

Retrospective study of Medicare beneficiaries with ADRD in large (>25 bed) assisted-living communities. We compared admission to a hospital, to a nursing home, and long-term (>90 day) admission to a nursing home between the two groups, using risk differences and survival analysis.

RESULTS

Residents in memory-care assisted living had a lower adjusted risk of hospitalization (risk difference = -1.8 percentage points [P = .014], hazard ratio = 0.93 [0.87-1.00]), a lower risk of nursing-home admission (risk difference = -2.2 percentage points [P < .001], hazard ratio = 0.87 [-.79-0.95]), and a lower risk of a long-term nursing home admission (risk difference = -1.1 percentage points [P < .001], hazard ratio = 0.71 [0.57-0.88]).

DISCUSSION

Memory care is associated with reduced rates of nursing-home placement, particularly long-term stays, compared to general assisted living.

Factors Associated with Potentially Harmful Medication Prescribing in Nursing Homes: A Scoping Review

OBJECTIVES

To summarize current evidence regarding facility and prescriber characteristics associated with potentially harmful medication (PHM) use by residents in nursing homes (NHs), which could inform the development of interventions to reduce this potentially harmful practice.

DESIGN

Scoping review.

SETTING AND PARTICIPANTS

Studies conducted in the United States that described facility and prescriber factors associated with PHM use in NHs.

METHODS

Electronic searches of PubMed/MEDLINE were conducted for articles published in English between April 2011 and November 2021. PHMs were defined based on the Beers List criteria. Studies testing focused interventions targeting PHM prescribing or deprescribing were excluded. Studies were characterized by the strengths and weaknesses of the analytic approach and generalizability.

RESULTS

Systematic search yielded 1253 articles. Of these, 29 were assessed in full text and 20 met inclusion criteria. Sixteen examined antipsychotic medication (APM) use, 2 anticholinergic medications, 1 sedative-hypnotics, and 2 overall PHM use. APM use was most commonly associated with facilities with a higher proportion of male patients, younger patients, and patients with severe cognitive impairment, anxiety, depression, and aggressive behavior. The use of APM and anticholinergic medications was associated with low registered nurse staffing ratios and for-profit facility status. No studies evaluated prescriber characteristics.

CONCLUSIONS AND IMPLICATIONS

Included studies primarily examined APM use. The most commonly reported facility characteristics were consistent with previously reported indicators of poor NH quality and NHs with patient case mix more likely to use PHMs.

Nursing Home Alzheimer's Special Care Units: Geographic Location Matters

OBJECTIVES

Limited data suggest nursing home (NH) Alzheimer's special care units (ASCUs) may improve care and outcomes among residents with dementia. Unfortunately, information describing NH characteristics related to presence of ASCUs is lacking, especially whether location and neighborhood resources influence their presence. We examined locations of NHs with ASCUs and assessed whether neighborhood socioeconomic deprivation, region, and levels of rurality were associated with NH ASCUs.

DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

Contiguous United States; we used 2017 LTCfocus and NH Compare data to identify free-standing NHs and obtain addresses (N = 13,207 NHs).

METHODS

NH ZIP+4 codes were linked to the Area Deprivation Index (ADI) (within-state ranking of neighborhood deprivation). The 9 census-defined regions of the United States and Rural Urban Continuum codes categorized location. Descriptive analyses and binary logistic regression models, adjusting for NH characteristics, examined associations between NH ASCUs and location.

RESULTS

Nearly 15% of NHs had ASCUs. In adjusted models, odds of NH ASCUs were 58% to 69% lower in Pacific, Middle Atlantic, and Southern regions compared with the East North Central region (P values <.001). Odds of NH ASCUs increased 25% to 47% as rurality increased relative to NHs in the most metropolitan areas (P < .01); however, odds of NH ASCUs decreased 63% in the most rural areas (P < .001). ADI was not significantly associated with NH ASCUs. For-profit NHs had 42% lower and chain-affiliated NHs 34% higher odds of ASCUs (P < .001). NHs with higher total staffing hours had 29% higher odds of ASCUs; odds of ASCUs were 46% lower in NHs with more RN staffing hours (P < .001).

CONCLUSIONS AND IMPLICATIONS

Using a robust sample, region, rurality, ownership, and nursing hours significantly predicted NH ASCUs whereas ADI did not. Geographically tailored interventions should be considered to promote use of NH-based ASCUs.

Context, mechanisms and outcomes of dementia special care units: An initial programme theory based on realist methodology

Background

Dementia special care units represent a widely implemented care model in nursing homes. Their benefits must be thoroughly evaluated given the risk of exclusion and stigma. The aim of this study is to present an initial programme theory that follows the principles of realist methodology. The theory development was guided by the question of the mechanisms at play in the context of dementia special care units to produce or influence outcomes of interest in people with dementia.

Methods

The initial programme theory is based on qualitative interviews with dementia special care stakeholders in Germany and a realist review of complex interventions in dementia special care units. The interviews were analysed using content analysis techniques. For the realist review, a systematic literature search was conducted in four scientific databases; studies were appraised for quality and relevance. All data were analysed independently by two researchers. A realist informed logic model was developed, and context-mechanism-outcome (CMO) configurations were described.

Results

We reviewed 16 empirical studies and interviewed 16 stakeholders. In the interviews, contextual factors at the system, organisation and individual levels that influence the provision of care in dementia special care units were discussed. The interviewees described the following four interventions typical of dementia special care units: adaptation to the environment, family and public involvement, provision of activities and behaviour management. With exception of family and public involvement, these interventions were the focus of the reviewed studies. The outcomes of interest of stakeholders include responsive behaviour and quality of life, which were also investigated in the empirical studies. By combining data from interviews and a realist review, we framed three CMO configurations relevant to environment, activity, and behaviour management.

Discussion

As important contextual factors of dementia special care units, we discuss the transparency of policies to regulate dementia care, segregation and admission policies, purposeful recruitment and education of staff and a good fit between residents and their environment.

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.

Factors associated with Emergency Medical Dispatcher request and residents' inappropriate transfers from Nursing Homes to Emergency Department

PURPOSE

In the last decades, the amount of emergency department (ED) transfers of nursing home (NH) residents has disproportionally increased in western countries. The main role of emergency medical dispatcher (EMD) among this population is to refer residents to EDs in the most appropriate way. The aim of this study was to assess risk factors of inappropriate transfers from NH to ED after EMD request.

METHODS

This research was a secondary analysis of a prospective observational multicenter study carried out in 17 EDs entitled FINE aimed to assess potentially inappropriate transfer prevalence among this population. Inappropriate transfers were determined in the FINE study threw a standardized approach by a unique expert team.

RESULTS

Overall, 572/1037 (55.2%) of residents were transferred to the ED after an EMD's decision. Among them, 92/572 (16.1%) transfers was defined as inappropriate. The average age was 87.3 years old (SD = 0.3). The main reason for ED transfer were falls (217/572, 37.9%). In multivariate analysis, the presence of a Special Care Unit in NH was significantly associated with a high rate of inappropriate transfer (OR 1.78; 95 CI [1.07-2.93]; p = 0.02) whereas a medical examination by a general practitioner before the transfer (OR 0.55; 95 CI [0.33-0.83]; p = 0.02) and a prompt access to psychiatric advice (OR 0.54; 95 CI [0.33-0.84]; p = 0.007) were associated with a low rate of potentially inappropriate transfer.

CONCLUSION

Promoting onsite medical assessment and partnership thanks to available geriatrician's advice may help the emergency medical dispatcher to improve the appropriateness of residents' transfer from Nursing Home to the emergency department.

Engagement in purposeful activities and social interactions amongst persons with dementia in special care units compared to traditional nursing homes: An observational study

Background

Persons with dementia spend most time of their day not engaging in activities or social interactions. A care concept of a dementia special care unit that promotes activities and social interaction through a household‐like design and individualised stimuli is studied.

Aim

To evaluate the main outcomes of the care concept of a dementia special care unit, namely, engagement in activities and social interactions.

Methods

We conducted an observational study as part of a theory‐driven evaluation. The Maastricht Daily Life Observation Tool was used to collect momentary assessments multiple times per participant, including engagement in activity, type of activity, engagement in social interaction, interaction partners, location, agitation and mood. Thirty‐three residents of the dementia special care units that implemented the care concept and 54 residents with dementia of two traditional nursing homes participated in the study, resulting in 2989 momentary assessments.

Results

Residents of both settings did not engage in activities or social interaction in approximately half of the observations. Compared to residents of traditional nursing homes, residents of special care units had a significantly higher chance for engagement in activities and social interaction in the afternoon but not in the morning or evening.

Conclusion

The care concept of the special care unit facilitated engagement but had its limitations. Further research is needed to develop and evaluate appropriate interventions to enhance engagement of persons with dementia.

Dementia specific care structures in nursing homes-Study protocol of a telephone-based survey study in a nationwide random sample

AIM

To describe a study protocol for a survey study in German nursing homes that (1) plans to enhance a typology of care units (2) and investigates the association between different care unit types and the provision of dementia-specific interventions based on a stratified randomized sample.

BACKGROUND

Many nursing homes in Germany provide Dementia Special Care Units. Existing definitions often do no justice to the complexity of their context. In this study, we define context as structural and organizational variables. It is necessary to define an empirical based set of indicators to characterize care units with respect to dementia care.

DESIGN

Observational survey study with a cross-sectional design.

METHODS

We will use a stratified random nationwide sample of 160 German nursing homes. Stratification variables are federal state and the existence of a Dementia Special Care Unit. The sampling frame from which the participating nursing homes are selected is a list with the total population of German nursing homes (n = 11.658). Data will be gathered on the level of the nursing homes and one of their care units via computer-assisted telephone interviews with a standardized questionnaire. The distribution of the assessed variables (contextual characteristics) will be described in absolute and relative frequencies for the whole sample in the first step in order to describe dementia-specific care structures. In the second step, factor analysis of mixed data (FAMD) with hierarchical clustering (HC) will be applied to analyze relationships between variables. The study was ethically approved in October 2018.

DISCUSSION

The typology can be used in future studies to define the context of care units in nursing homes. This may improve the interpretation of findings from future studies that investigated interventions in nursing homes.

IMPACT

The typology will visualize and describe the complexity of contextual characteristics of several care units.

Definition and Measurement of Physical and Chemical Restraint in Long-Term Care: A Systematic Review

This systematic review aimed to identify thematic elements within definitions of physical and chemical restraint, compare explicit and implicit definitions, and synthesize reliability and validity of studies examining physical and/or chemical restraint use in long-term care. Studies were included that measured prevalence of physical and/or chemical restraint use, or evaluated an intervention to reduce restraint use in long-term care. 86 papers were included in this review, all discussed physical restraint use and 20 also discussed chemical restraint use. Seven themes were generated from definitions including: restraint method, setting resident is restrained in, stated intent, resident capacity to remove/control, caveats and exclusions, duration, frequency or number, and consent and resistance. None of the studies reported validity of measurement approaches. Inter-rater reliability was reported in 27 studies examining physical restraint use, and only one study of chemical restraint. Results were compared to an existing consensus definition of physical restraint, which was found to encompass many of the thematic domains found within explicit definitions. However, studies rarely applied measurement approaches that reflected all of the identified themes of definitions. It is necessary for a consensus definition of chemical restraint to be established and for measurement approaches to reflect the elements of definitions.

End-of-Life Care among Nursing Home Residents with Dementia Varies by Nursing Home and Market Characteristics

OBJECTIVES

Nursing homes (NHs) are critical end-of-life (EOL) care settings for 70% of Americans dying with Alzheimer's disease/related dementias (ADRD). Whether EOL care/outcomes vary by NH/market characteristics for this population is unknown but essential information for improving NH EOL care/outcomes. Our objectives were to examine variations in EOL care/outcomes among decedents with ADRD and identify associations with NH/market characteristics.

DESIGN

Cross-sectional.

OUTCOMES

Place-of-death (hospital/NH), presence of pressure ulcers, potentially avoidable hospitalizations (PAHs), and hospice use at EOL. Key covariates were ownership, staffing, presence of Alzheimer's units, and market competition.

SETTING AND PARTICIPANTS

Long-stay NH residents with ADRD, age 65 + years of age, who died in 2017 (N = 191,435; 14,618 NHs) in NHs or hospitals shortly after NH discharge.

METHODS

National Medicare claims, Minimum Data Set, public datasets. Descriptive analyses and multivariable logistic regressions.

RESULTS

As ADRD severity increased, adjusted rates of in-hospital deaths and PAHs decreased (17.0% to 6.3%; 11.2% to 7.0%); adjusted rates of dying with pressure ulcers and hospice use increased (8.2% to 13.5%; 24.5% to 40.7%). Decedents with moderate and severe ADRD had 16% and 13% higher likelihoods of in-hospital deaths in for-profit NHs. In NHs with Alzheimer's units, likelihoods of in-hospital deaths, dying with pressure ulcers, and PAHs were significantly lower. As ADRD severity increased, higher licensed nurse staffing was associated with 14%‒27% lower likelihoods of PAHs. Increased NH market competition was associated with higher likelihood of hospice use, and lower likelihood of in-hospital deaths among decedents with moderate ADRD.

CONCLUSIONS AND IMPLICATIONS

Decedents with ADRD in NHs that were nonprofit, had Alzheimer's units, higher licensed nurse staffing, and in more competitive markets, had better EOL care/outcomes. Modifications to state Medicaid NH payments may promote better EOL care/outcomes for this population. Future research to understand NH care practices associated with presence of Alzheimer's units is warranted to identify mechanisms possibly promoting higher-quality EOL care.

Understanding the Relationship Between Nursing Home Experience With Human Immunodeficiency Virus and Patient Outcomes

BACKGROUND

As the population with human immunodeficiency virus (HIV) continues to age, the need for nursing home (NH) care is increasing.

OBJECTIVES

To assess whether NH's experience in treating HIV is related to outcomes.

RESEARCH DESIGN

We used claims and assessment data to identify individuals with and without HIV who were admitted to NHs in 9 high HIV prevalent states. We classified NHs into HIV experience categories and estimate the effects of NH HIV experience on patient's outcomes. We applied an instrumental variable using distances between each individual's residence and NHs with different HIV experience.

SUBJECTS

In all, 5,929,376 admissions for those without HIV and 53,476 admissions for residents with HIV.

MEASURES

Our primary outcomes were 30-day hospital readmissions, likelihood of becoming a long stay resident, and 180-day mortality posthospital discharge.

RESULTS

Residents with HIV tended to have poorer outcomes than residents without HIV, regardless of the NH they were admitted to. Residents with HIV admitted to high HIV experience NHs were more likely to be readmitted to the hospital than those admitted to NHs with lower HIV experience (19.6% in 0% HIV NHs, 18.7% in 05% HIV NHs and 22.9% in 5%-50% HIV NHs).

CONCLUSIONS

Residents with HIV experience worse outcomes in NHs than residents without HIV. Increased HIV experience was not related to improved outcomes.

Prevalence and variability in use of physical and chemical restraints in residential aged care facilities: A systematic review and meta-analysis

BACKGROUND

Use of physical and chemical restraints are common in residential aged care facilities worldwide. Restraint use can pose harm to residents even causing deaths.

OBJECTIVE

To synthesize the prevalence and variability in physical and chemical restraint use, and examine factors that may contribute to this variability of prevalence rates.

METHODS

Six health science databases were searched from inception up to 21st January 2020. Quantitative studies investigating restraint use in residential aged care facilities that reported data from year 2000 onwards were included. Meta-analyses of binomial data using a random effect model were performed to pool proportions of physical or chemical restraints with 95% confidence intervals. Univariable meta-regression analyses were used to assess factors that may contribute to the variability in physical and chemical restraint prevalence. Multiple meta-regression analyses were performed where possible to construct models of factors contributing to these variations.

RESULTS

Eighty-five papers were included. The pooled proportion of physical and chemical restraint use in residential aged care facilities were 33% and 32% respectively. Bedrails (44%) and benzodiazepines (42%) were the most prevalent forms of physical and chemical restraint respectively. Studies from North America (lower prevalence) [coefficient (95% CI): -0.15 (-0.27, -0.03)], measurement approaches using direct observation (higher prevalence) [0.17 (0.02, 0.33)] and a combination of multiple measurement approaches (higher prevalence) [0.17 (0.05, 0.29)] explained 25.5% of variability in the prevalence of physical restraint. Multiple meta-regression analyses were not performed to identify factors that may explain the observed variability in chemical restraint prevalence due to the small number of studies with data available.

CONCLUSION

Variability in prevalence of physical restraint could be explained partly by different measurement approaches and geographical regions. Valid and reliable measurement approaches across different regions is required to understand cultural differences due to geographical region effects on the prevalence of physical restraint use.

Severe Behavioral Health Manifestations in Nursing Homes: Associations with Service Availability?

BACKGROUND/OBJECTIVES

Despite high prevalence of behavioral health (BH) manifestations among nursing home (NH) residents, availability of BH services in this care setting is often inadequate. Our objective was to examine associations between availability of BH services and the presence of severe depression, suicidal ideation (SI), and severe aggressive behaviors (ABs) among NH residents.

DESIGN

Cross-sectional.

SETTING/PARTICIPANTS

This study used 2017 survey data about BH service availability obtained from 1,051 NHs. The Minimum Data Set (MDS) was used to identify long-stay residents in these facilities (N = 101,238) and the prevalence of BH manifestations. Descriptive statistics and multivariable logistic regressions were used.

MEASUREMENTS

We constructed measures of three severe BH manifestations based on the MDS: presence of depression, SI, and ABs. Three independent measures of service availability based on survey items asked about degrees of inadequate (1) staff BH education, (2) coordination/collaboration between facility/community providers, and (3) facility infrastructure (ie, ability to make referrals/transport residents to services).

RESULTS

Odds of severe depression were 21% higher (odds ratio [OR] = 1.21; P < .001) when NHs reported inadequate BH staff education. Residents with SI had 13% higher odds (OR = 1.13; P = .027) of living in NHs that reported inadequate coordination between facility and community providers. Severe ABs were 10% more likely among residents in NHs reporting inadequate facility infrastructure (OR = 1.10; P = .002) and 7% more likely in facilities with self-reported inadequate coordination between facility/community providers (OR = 1.07; P = .019). Several facility-level factors (eg, staffing, training, turnover) were also statistically significantly associated with these severe BH manifestations.

CONCLUSION

Residents in NHs reporting inadequate BH services were more likely to experience adverse severe BH manifestations even after controlling for individual and facility-level risk factors. Higher nurse staffing and more staff psychiatric training were associated with lower prevalence of severe BH manifestations. Policy changes and modifications to Medicaid NH reimbursements may be warranted to better incentivize NHs to improve provision of BH services.

The Changing Adoption of Culture Change Practices in U.S. Nursing Homes

BACKGROUND AND OBJECTIVES

The study aimed to: (i) describe whether culture change (CC) practice implementation related to physical environment, resident-centered care, and staff empowerment increased within the same nursing homes (NHs) over time; and (ii) identify factors associated with observed increases.

RESEARCH DESIGN AND METHODS

This was a nationally representative panel study of 1,584 U.S. NHs surveyed in 2009/2010 and 2016/2017. Survey data were merged with administrative, NH, and market-level data. Physical environment, staff empowerment, and resident-centered care domain scores were calculated at both time points. Multivariate logistic regression models examined factors associated with domain score increases.

RESULTS

Overall, 22% of NHs increased their physical environment scores over time, 32% their staff empowerment scores, and 44% their resident-centered care scores. However, 32%-68% of NHs with below median baseline scores improved their domain scores over time compared with only 11%-21% of NHs with baseline scores at or above the median. Overall, NHs in states with Medicaid pay-for-performance (with CC components), in community care retirement communities, with special care units and higher occupancy had significantly higher odds of increases in physical environment scores. Only baseline domain scores were associated with increases in staff empowerment and resident-centered care scores.

DISCUSSION AND IMPLICATIONS

This is the first nationally representative panel study to assess NH CC adoption. Many NHs increased their CC practices, though numerous others did not. While financial incentives and indicators of financial resources were associated with increase in physical environment scores, factors associated with staff empowerment and resident-centered care improvements remain unclear. Studies are needed to assess whether the observed increases in CC adoption are associated with greater quality of life and care gains for residents and whether there is a threshold effect beyond which the efficacy of additional practice implementation may be less impactful.

Social interactions of persons with dementia living in special care units in long-term care: A mixed-methods systematic review

BACKGROUND

Special care units are a well-utilized approach in the long-term care for persons with dementia. A therapeutic goal of such settings is to provide meaningful engagement and a sense of community that is crucial for the overall quality of life. In recent years, several studies followed this notion by investigating residents' social interactions and the influence of the environment on these interactions.

AIMS

This review aims to synthesize the literature on the social interactions of persons with dementia living in special care units.

DESIGN

A mixed-methods systematic review was conducted.

METHODS

Literature was searched in PubMed, CINAHL, PsycINFO, the Cochrane Library and Web of Science databases. Additionally, reference lists of relevant articles were searched. Studies were screened, data were extracted and the quality was appraised. Separate syntheses were conducted for qualitative and quantitative studies, which were subsequently merged in the final mixed-methods synthesis.

RESULTS

In total, 18 articles were included, investigating large-scale, small-scale and homelike special care units and green care farms. Residents in special care units experience few social interactions but more than those in the comparative groups. Opportunities to interact are only marginally seized. Interactions typically occur in small groups and are facilitated by familiarity and the organizational environment. Residents mainly rely on staff members to create social interaction, for example initiating or facilitating resident-to-resident interaction.

CONCLUSION

Although the evidence base is increasing, it is still fragmented and built on different concepts, interventions, control groups and measurements. Nevertheless, the first conclusions suggest a positive impact of special care units on residents' social interactions. Although the review yielded a more comprehensive picture of residents' social life, further high-quality research built on a sound theoretical background is needed.

Exploring the prevalence and management of wounds for people with dementia in long-term care

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long-term care (LTC). A scoping literature review, a cross-sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence-based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia-specific facilities and a lack of research in this area limits evidence in guiding practice.

Collecting self-report research data with people with dementia within care home clinical trials: Benefits, challenges and best practice

One-third of people with dementia live in care home settings and in order to deliver better evidence-based care, robust research including clinical trials is required. Concerns have been raised by researchers about the capacity of care home residents with dementia to participate in clinical trials. This includes self-report measures, completion of which researchers have suggested may be unreliable or impossible and may cause distress for residents. Many trials, therefore, utilise only proxy completed outcome measures. This is despite evidence that individuals with mild through to advanced dementia can reliably report on outcomes, if appropriate measures and approaches to data collection are used. However, little has been written about best practice in data collection with this group. This study aimed to explore the experiences of researchers working on dementia trials in care homes and identify best practices to assist design of future trials. Thirty-three researchers completed an online, qualitative questionnaire outlining their experiences and the perceived benefits and challenges of data collection with people with dementia. We identified five main benefits: (1) improving the delivery of person-centred care, (2) hearing the voice of people with dementia, (3) residents spending time with researchers, (4) improving researcher understanding, and (5) having an evidence base from multiple sources. We also identified five main challenges: (1) effective communication, (2) fluctuating capacity, (3) causing distress to residents, (4) time pressures, and (5) staff availability. Researchers also made suggestions about how these can be overcome. We recommend that the challenges identified could be overcome using appropriate methods for collecting data. Thorough training for researchers on data collection with people with dementia was identified as important for ensuring successful data collection.

Association between High Proportions of Seriously Mentally Ill Nursing Home Residents and the Quality of Resident Care

OBJECTIVES

To examine the association between the quality of care delivered to nursing home residents with and without a serious mental illness (SMI) and the proportion of nursing home residents with SMI.

DESIGN

Instrumental variable study. Relative distance to the nearest nursing home with a high proportion of SMI residents was used to account for potential selection of patients between high- and low-SMI facilities. Data were obtained from the 2006-2010 Minimum Data Set assessments linked with Medicare claims and nursing home information from the Online Survey, Certification, and Reporting database.

SETTING

Nursing homes with high (defined as at least 10% of a facility's population having an SMI diagnosis) and low proportions of SMI residents.

PARTICIPANTS

A total of 58 571 Medicare nursing residents with an SMI diagnosis (ie, schizophrenia or bipolar disorder) and 558 699 individuals without an SMI diagnosis who were admitted to the same nursing homes.

MEASUREMENTS

Outcomes were nursing home quality measures: (1) use of physical restraints, (2) any hospitalization in the last 3 months, (3) use of an indwelling catheter, (4) use of a feeding tube, and (5) presence of pressure ulcer(s).

RESULTS

For individuals with SMI, admission to a high-SMI facility was associated with a 3.7 percentage point (95% confidence interval [CI] = 1.4-6.0) increase in the probability of feeding tube use relative to individuals admitted to a low-SMI facility. Among individuals without SMI, admission to a high-SMI facility was associated with a 1.7 percentage point increase in the probability of catheter use (95 CI = .03-3.47), a 3.8 percentage point increase in the probability of being hospitalized (95% CI = 2.16-5.44), and a 2.1 percentage point increase in the probability of having a feeding tube (95% CI = .43-3.74).

CONCLUSION

Admission to nursing homes with high concentrations of residents with SMI is associated with worse outcomes for both residents with and without SMI. J Am Geriatr Soc 67:2346-2352, 2019.

Use of instrumental variables for endogenous treatment at the provider level

Health economists are often interested in the effects of provider-level attributes (e.g., nonprofit status or quality rating) on patient outcomes, but estimation is subject to selection bias due to correlation with other omitted provider-level attributes that also affect patient outcomes. Recently, researchers have attempted to use patient-level instrumental variables, such as differential distance, to solve this problem of a provider-level endogenous treatment variable in settings where patients are nested within providers. However, to satisfy validity assumptions, an instrumental variable for a provider attribute must be at the provider level or a larger unit of aggregation, not at the patient level. A patient-level instrument cannot predict variation in a provider attribute separately from other, potentially unmeasured, provider attributes. In this paper, we explain this misapplication, review the extent of this problem in recent literature, and offer alternative approaches to avoid this misapplication of patient-level instrumental variables.