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Yang MT, Temkin-Greener H, Veazie P, Cai S. Home Health Quality among Hospitalized Older Adults with Alzheimer's Disease and Related Dementia: Association with Race/Ethnicity and Dual Eligibility before and during the COVID Pandemic. J Am Med Dir Assoc 2024; 25:105057. [PMID: 38843869 DOI: 10.1016/j.jamda.2024.105057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVES During the COVID-19 pandemic, home health agencies (HHAs) discharges following acute hospitalizations increased. This study examined whether racial and ethnic minoritized and socioeconomically disadvantaged patients (ie, Medicare-Medicaid dual-eligible) were differentially discharged to below-average quality HHAs before and during the COVID-19 pandemic. We focused on post-acute patients with Alzheimer's disease and related dementias (ADRD), who are generally frail and have high care needs. DESIGN Cohort study. SETTING AND PARTICIPANTS We linked 2019 to 2021 Medicare data with Area Deprivation Index (ADI), Home Health Compare, and COVID-19 infection data. We included Medicare beneficiaries with ADRD who were hospitalized for non-COVID-19 conditions and discharged to HHAs between January 2019 and November 2021. The final analytical sample included 426,766 qualified hospitalization events. METHODS The outcome variable was whether a patient received care from a below-average quality HHA, defined by an average Quality of Patient Care Star Rating lower than 3.0. Key independent variables included individual race, ethnicity, and Medicare-Medicaid dual status. Linear probability models with county fixed effects were estimated, sequentially adjusting for the individual- and community-level covariates. Sensitivity analysis using various definitions of below-average quality HHAs was conducted. RESULTS Before the pandemic, Black and Hispanic individuals had significantly higher probabilities of discharge to below-average quality HHAs compared with white individuals (3.4 and 3.9 percentage points, respectively). Dual-eligible individuals were also 2.5 percentage points more likely to be discharged to below-average quality HHAs. During the pandemic, disparities in being discharged to below-average quality HHAs persisted among racial and ethnic minoritized patients and increased among duals. Findings were consistent with and without adjusting for individual covariates and across different definitions of below-average quality HHA. CONCLUSIONS AND IMPLICATIONS Persistent disparities were observed in being discharged to below-average quality HHAs by race, ethnicity, and dual status. Further research is needed to identify factors contributing to these ongoing inequalities.
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Affiliation(s)
- Ming-Ting Yang
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.
| | - Helena Temkin-Greener
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Peter Veazie
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Shubing Cai
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
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Dayama N, Pradhan R, Davlyatov G, Weech-Maldonado R. Electronic Health Record Implementation Enhances Financial Performance in High Medicaid Nursing Homes. J Multidiscip Healthc 2024; 17:2577-2589. [PMID: 38803618 PMCID: PMC11129737 DOI: 10.2147/jmdh.s457420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction The nursing home (NH) industry operates within a two-tiered system, wherein high Medicaid NHs which disproportionately serve marginalized populations, exhibit poorer quality of care and financial performance. Utilizing the resource-based view of the firm, this study aimed to investigate the association between electronic health record (EHR) implementation and financial performance in high Medicaid NHs. A positive correlation could allow high Medicaid NHs to leverage technology to enhance efficiency and financial health, thereby establishing a business case for EHR investments. Methods Data from 2017 to 2018 were sourced from mail surveys sent to the Director of Nursing in high Medicaid NHs (defined as having 85% or more Medicaid census, excluding facilities with over 10% private pay or 8% Medicare), and secondary sources like LTCFocus.org and Centers for Medicare & Medicaid Services cost reports. From the initial sample of 1,050 NHs, a 37% response rate was achieved (391 surveys). Propensity score inverse probability weighting was used to account for potential non-response bias. The independent variable, EHR Implementation Score (EIS), was calculated as the sum of scores across five EHR functionalities-administrative, documentation, order entry, results viewing, and clinical tools-and reflected the extent of electronic implementation. The dependent variable, total margin, represented NH financial performance. A multivariable linear regression model was used, adjusting for organizational and market-level control variables that may independently affect NH financial performance. Results Approximately 76% of high Medicaid NHs had implemented EHR either fully or partially (n = 391). The multivariable regression model revealed that a one-unit increase in EIS was associated with a 0.12% increase in the total margin (p = 0.05, CI: -0.00-0.25). Conclusion The findings highlight a potential business case -long-term financial returns for the initial investments required for EHR implementation. Nonetheless, policy interventions including subsidies may still be necessary to stimulate EHR implementation, particularly in high Medicaid NHs.
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Affiliation(s)
- Neeraj Dayama
- Department of Healthcare Management and Leadership, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Rohit Pradhan
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Ganisher Davlyatov
- Department of Health Administration & Policy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Robert Weech-Maldonado
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, USA
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McMahan C, Shieu B, Trinkoff A, Castle N, Wolf DG, Handler S, Harris JA. Factors Associated With the Ability of US Nursing Homes to Accept Residents With Severe Obesity. J Am Med Dir Assoc 2024; 25:912-916.e3. [PMID: 38640960 DOI: 10.1016/j.jamda.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVES Severe obesity in nursing home (NH) residents is associated with specialized care needs, limited mobility, and challenges in daily living. The COVID-19 pandemic strained NH resources and exacerbated staffing shortages. This study aimed to assess the ability of US NHs to accept and care for residents with severe obesity post-COVID, as well as associated NH factors. DESIGN Cross-sectional nationwide survey of NH administrators (2021-2022). SETTING AND PARTICIPANTS 290 NHs from a national sample (n = 224) and a targeted sample in Massachusetts and New Jersey (n = 66). METHODS A survey designed to assess how NHs approach admitting and caring for people with severe obesity before and after COVID was fielded from 2021 to 2022. Responses were linked to facility information from the Certification and Survey Provider Enhanced Reports, Minimum Data Set, Nursing Home Compare, Area Health Resources File, and US Diabetes Surveillance System. Multivariable logistic regression was used to assess the effect of organizational and survey response variables. RESULTS Of the 2503 surveys sent to US NHs, 1923 were sent to the national NH stratified sample, and 580 were sent to the MA/NJ sample. Overall, 12% (301 of 2503) of NHs surveyed responded. The response rates were similar between the 2 samples. Of 290 NHs with complete data, 34% reported being unlikely to accept residents with severe obesity after COVID-19, compared with 25% before the pandemic (P < .001). The main barriers to acceptance were staffing shortages and difficulties meeting equipment and space needs. NHs with higher proportions of Black residents were more likely to admit individuals with severe obesity. CONCLUSIONS AND IMPLICATIONS The decline in acceptance of residents with severe obesity during and after COVID-19 highlights potential challenges that this population faces in accessing care. Our results also raise concerns that an intersection of disparities may exist in Black patients with severe obesity.
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Affiliation(s)
- Cynthia McMahan
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Bianca Shieu
- School of Nursing, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Alison Trinkoff
- Department of Family and Community Health, University of Maryland School of Nursing, Baltimore, MD, USA
| | - Nicholas Castle
- Department of Health Policy and Management, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - David G Wolf
- College of Business and Management, Lynn University, Boca Raton, FL, USA
| | - Steven Handler
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Technology Enhancing Cognition and Health - Geriatrics Research Education and Clinical Center (TECH-GRECC), Veterans Administration Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John A Harris
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Research Institute, Pittsburgh, PA, USA
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Bhattacharyya KK, Molinari V, Peterson L, Fauth EB, Andel R. Do nursing homes with a higher proportion of residents with dementia have greater or fewer complaints? Aging Ment Health 2024; 28:448-456. [PMID: 37921356 DOI: 10.1080/13607863.2023.2277265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023]
Abstract
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.
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Affiliation(s)
| | - Victor Molinari
- School of Aging Studies, University of South Florida, Tampa, FL, USA
| | - Lindsay Peterson
- School of Aging Studies, University of South Florida, Tampa, FL, USA
| | - Elizabeth B Fauth
- Alzheimer's Disease and Dementia Research Center, Utah State University, Logan, UT, USA
- Department of Human Development and Family Studies, Utah State University, Logan, UT, USA
| | - Ross Andel
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
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Scroggins S, Little G, Okala O, Ellis M, Shacham E. The Relationship of Vaccine Uptake and COVID-19 Infections Among Nursing Home Staff and Residents in Missouri: A Measure of Risk by Community Mobility. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2024; 30:176-182. [PMID: 37831663 DOI: 10.1097/phh.0000000000001824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
BACKGROUND As the COVID-19 pandemic progressed across the United States, older adults living in nursing home (NH) facilities were disproportionately affected because of living in communal spaces with close proximity to others, age-related medical conditions, and constant contact with staff who may support multiple clients and facilities. While these populations are particularly at risk, there has been limited research focused on the management of the potential vectors of COVID-19 infection. METHODS Data from the Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting system assessing weekly observations of COVID-19 case counts among NH residents and COVID-19 vaccination rates among NH staff and residents in the states of Missouri and Illinois (n = 877) from May 24, 2021, to August 28, 2021, were used. This ecological study, using results from the CMS COVID-19 reporting system, local COVID-19 rates, and NH-level demographic characteristics, conducted a zero inflation mode to determine the association between NH staff vaccine uptake and COVID-19 cases among NH residents. RESULTS Among the total 11 195 weekly observations within the NH facilities, zero cases of COVID-19 were reported during 10 683 (95%) of those weeks, supporting the use of a zero-inflated model. Results show that staff vaccination rates were significantly associated with a decrease in COVID-19 mortality. This study identified that for every percentage increase in staff vaccine coverage, the rate of COVID-19 among residents decreased by 2%. DISCUSSION These findings suggest that NH staff vaccination rates are significantly associated with the rate of COVID-19 outbreaks among NH residents. Community median income was associated with an increased likelihood of infection. Future research that explores associations with employment benefits and staff mobility, particularly in vulnerable populations, should be implemented in future vaccination strategic planning.
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Affiliation(s)
- Stephen Scroggins
- Department of Behavioral Science and Health Equity, College for Public Health and Social Justice (Drs Scroggins and Shacham, and Ms Little and Mr Okala), Saint Louis University, St Louis, Missouri; and Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri (Dr Ellis)
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McCreedy EM, Dewji A, Dionne L, Zhu E, Baier RR, Reddy A, Olson MB, Rudolph JL. Pragmatic Implementation of a Music Intervention in Nursing Homes Before and During COVID-19. J Am Med Dir Assoc 2024; 25:314-320. [PMID: 38036026 PMCID: PMC10872256 DOI: 10.1016/j.jamda.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/23/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVES We conducted 2 trials of a music intervention for managing behaviors in nursing home (NH) residents with dementia, before (2019) and during (2021) the pandemic. In this report, we compare adherence fidelity across the trials using the Framework for Implementation Fidelity (FIF). DESIGN Cross-sectional, descriptive implementation comparison. SETTING AND PARTICIPANTS Fifty-four NHs randomized to receive the intervention (27 pre-COVID, 27 during COVID) METHODS: We compare the trials on the following FIF criteria: coverage (number of residents receiving the intervention); duration (minutes of music received per exposed day); frequency (percentage of residents with nursing staff use of music in the past week); and details of content (adherence to core components of the intervention). We report NH-level performance in each domain and compare characteristics of NHs in the bottom (low) and top (high) terciles of adherence. RESULTS Across FIF domains, adherence fidelity was lower during COVID compared with pre-COVID: coverage, residents exposed (COVID: 7.5, SD 5.6; pre-COVID: 12.7, SD 3.6); duration, music minutes per exposed day (COVID: 2.5, SD 5.1; pre-COVID: 27.1, SD 23.9); frequency, percentage of residents with nursing use of intervention in the past week (COVID: 15.0, SD 31.5; pre-COVID 40.4, SD 25.6); and details of content, compliance with core components of the intervention (COVID: 8.3, SD 1.9; pre-COVID 9.6, SD 2.0). In both trials, high-adherence fidelity NHs had better nursing staff ratios, greater percentages of Medicare residents, and lower percentages of Black residents, compared with low-fidelity NHs. CONCLUSIONS AND IMPLICATIONS Adherence fidelity was worse in the COVID vs pre-COVID trial, despite adaptations between trials intended to reduce staff burden and increase clinical targeting of the intervention. Results may point to the long-term effects of COVID on quality improvement capacity in NHs and/or a lack of available resources in most NHs to implement complex behavioral interventions without direct research support.
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Affiliation(s)
- Ellen M McCreedy
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA.
| | - Aleena Dewji
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Laura Dionne
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, RI, USA
| | - Enya Zhu
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Rosa R Baier
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA
| | - Ann Reddy
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA
| | - Miranda B Olson
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA
| | - James L Rudolph
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; US Department of Veterans Affairs Medical Center, Providence, RI, USA
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Orewa GN, Davlyatov G, Pradhan R, Lord J, Weech-Maldonado R. High Medicaid Nursing Homes: Contextual Factors Associated with the Availability of Specialized Resources Required to Care for Obese Residents. J Aging Soc Policy 2024; 36:156-173. [PMID: 38011172 DOI: 10.1080/08959420.2023.2284061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 10/18/2023] [Indexed: 11/29/2023]
Abstract
Obesity is an increasingly important concern in the delivery of high-quality nursing home care. Obese nursing home residents require specialized equipment and resources. As high Medicaid nursing homes have limited financial ability, they may lack the necessary resources to address the needs of obese residents. Moreover, there are variations in the availability of obesity-related specialized resources across these facilities. This study aims to investigate the organizational and market factors associated with the availability of obesity-related specialized resources in high-Medicaid nursing homes. Survey and secondary data sources for the study period 2017-2018 were utilized. The survey data were merged with Brown University's Long Term Care Focus (LTCFocus), Nursing Home Compare, and Area Health Resource File datasets. The dependent variable was the composite score of obesity-related specialized resources, ranging from 0-19. An ordinary least square regression with propensity score weights (to adjust for potential survey non-response bias), along with appropriate organizational/market level control variables were used for our analysis. Our results suggest that payer-mix (>Medicare residents) and a higher proportion of obese residents were positively associated with the availability of obesity-related specialized resources. Policymakers should consider implementing incentives, such as increased Medicaid payments, to assist high Medicaid nursing homes in addressing the specific needs of obese residents.
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Affiliation(s)
- Gregory N Orewa
- Department of Public Health, College of Health, Community and Policy, University of Texas, San Antonio, USA
| | - Ganisher Davlyatov
- Department of Health Administration and Policy, Hudson School of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Rohit Pradhan
- Department of Health Administration, College of Health Professions, Texas State University, San Marcos, USA
| | - Justin Lord
- Department of Health Administration, College of Business, Louisiana State University, Shreveport, USA
| | - Robert Weech-Maldonado
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
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Yin C, Mpofu E, Brock K, Ingman S. Nursing Home Residents' COVID-19 Infections in the United States: A Systematic Review of Personal and Contextual Factors. Gerontol Geriatr Med 2024; 10:23337214241229824. [PMID: 38370579 PMCID: PMC10870703 DOI: 10.1177/23337214241229824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 12/22/2023] [Accepted: 01/15/2024] [Indexed: 02/20/2024] Open
Abstract
Background: This mixed methods systemic review synthesizes the evidence about nursing home risks for COVID-19 infections. Methods: Four electronic databases (PubMed, Web of Science, Scopus, and Sage Journals Online) were searched between January 2020 and October 2022. Inclusion criteria were studies reported on nursing home COVID-19 infection risks by geography, demography, type of nursing home, staffing and resident's health, and COVID-19 vaccination status. The Mixed Methods Appraisal Tool (MMAT) was used to assess the levels of evidence for quality, and a narrative synthesis for reporting the findings by theme. Results: Of 579 initial articles, 48 were included in the review. Findings suggest that highly populated counties and urban locations had a higher likelihood of COVID-19 infections. Larger nursing homes with a low percentage of fully vaccinated residents also had increased risks for COVID-19 infections than smaller nursing homes. Residents with advanced age, of racial minority, and those with chronic illnesses were at higher risk for COVID-19 infections. Discussion and implications: Findings suggest that along with known risk factors for COVID-19 infections, geographic and resident demographics are also important preventive care considerations. Access to COVID-19 vaccinations for vulnerable residents should be a priority.
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Affiliation(s)
- Cheng Yin
- University of North Texas, Denton, USA
| | - Elias Mpofu
- University of North Texas, Denton, USA
- University of Sydney, Australia
- University of Johannesburg, South Africa
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Felix HC, Brown CC, Narcisse MR, Vincenzo JL, Andersen JA, Bradway CW, Weech-Maldonado R. Characteristics of United States nursing homes with high percentages of stage 2-4 pressure injuries among high-risk nursing home residents with obesity. WOUND PRACTICE AND RESEARCH 2023; 31:174-181. [PMID: 38737330 PMCID: PMC11084039 DOI: 10.33235/wpr.31.4.174-181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
Obesity rates in nursing homes (NHs) are increasing. Residents with obesity are at risk for poor outcomes such as pressure injuries (PIs) due to special care needs such as bariatric medical equipment and special protocols for skin care. PIs among resident populations is a sign of poor quality NH care. The purpose of this retrospective observational study was to identify characteristics of NHs with high rates of stage 2-4 PIs among their high-risk residents with obesity. Resident assessment data were aggregated to the NH level. NH structure and process of care and antecedent conditions of the residents and environment measures were used in bivariate comparisons and multivariate logistic regression models to identify associations with NHs having high rates of stage 2-4 PIs among high-risk residents with obesity. We identified three characteristics for which the effect on the odds was at least 10% for clinical significance - for-profit status, large facilities, and the hours of certified nursing assistants (CNAs) per patient day (HRPPD). This study identified several NH characteristics that are associated with higher risk for PIs, which can be targeted with evidence-based interventions to reduce the risk of these adverse safety events occurring.
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Affiliation(s)
- Holly C Felix
- Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 820, Little Rock, AR 72205, USA
| | - Clare C Brown
- Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 820, Little Rock, AR 72205, USA
| | - Marie-Rachelle Narcisse
- Warren Alpert Medical School, Brown University, 222 Richmond Street, Providence, RI, 02903 USA
| | - Jennifer L Vincenzo
- College of Health Professions, University of Arkansas for Medical Sciences, 1125 N. College Avenue, Fayetteville, AR 72703, USA
| | - Jennifer A Andersen
- College of Medicine, University of Arkansas for Medical Sciences, 2708 South 48th Street, Springdale, AR 72762, USA
| | - Christine W Bradway
- School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Fagin Hall, Room 312, Philadelphia, PA 19104-4217, USA
| | - Robert Weech-Maldonado
- School of Health Professions, University of Alabama at Birmingham, 1720 2nd Avenue South, SHPB 558, Birmingham, AL 35294, USA
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FABIUS CHANEED, OKOYE SAFIYYAHM, WU MINGCHEMJ, JOPSON ANDREWD, CHYR LINDAC, BURGDORF JULIAG, BALLREICH JEROMIE, SCERPELLA DANNY, WOLFF JENNIFERL. The Role of Place in Person- and Family-Oriented Long-Term Services and Supports. Milbank Q 2023; 101:1076-1138. [PMID: 37503792 PMCID: PMC10726875 DOI: 10.1111/1468-0009.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/13/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023] Open
Abstract
Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and well-being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state-level LTSS-relevant environmental characteristics stand to improve the health and well-being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions. CONTEXT Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them. METHODS We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status. FINDINGS We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations. CONCLUSIONS We present a framework and analyses describing the variable relationships between LTSS-relevant environmental factors and person-reported care experiences. LTSS-relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state- and community-based policies and practices that support aging in place.
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Templeton ZS, Apathy NC, Konetzka RT, Skira MM, Werner RM. The health effects of nursing home specialization in post-acute care. JOURNAL OF HEALTH ECONOMICS 2023; 92:102823. [PMID: 37839286 PMCID: PMC10841893 DOI: 10.1016/j.jhealeco.2023.102823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 09/19/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023]
Abstract
Nursing homes serve both long-term care and post-acute care (PAC) patients, two groups with distinct financing mechanisms and requirements for care. We examine empirically the effect of nursing home specialization in PAC using 2011-2018 data for Medicare patients admitted to nursing homes following a hospital stay. To address patient selection into specialized nursing homes, we use an instrumental variables approach that exploits variation over time in the distance from the patient's residential ZIP code to the closest nursing home with different levels of PAC specialization. We find that patients admitted to nursing homes more specialized in PAC have lower hospital readmissions and mortality, longer nursing home stays, and higher Medicare spending for the episode of care, suggesting that specialization improves patient outcomes but at higher costs.
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Travers JL, Castle N, Weaver SH, Perera UG, Wu B, Dick AW, Stone PW. Environmental and structural factors driving poor quality of care: An examination of nursing homes serving Black residents. J Am Geriatr Soc 2023; 71:3040-3048. [PMID: 37306117 PMCID: PMC10592533 DOI: 10.1111/jgs.18459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 04/17/2023] [Accepted: 04/29/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Poor quality of care in nursing homes (NHs) with high proportions of Black residents has been a problem in the US and even more pronounced during the COVID-19 pandemic. Federal and state agencies are devoting attention to identifying the best means of improving care in the neediest facilities. It is important to understand environmental and structural characteristics that may have led to poor healthcare outcomes in NHs serving high proportions of Black residents pre-pandemic. METHODS We conducted a cross-sectional observational study using multiple 2019 national datasets. Our exposure was the proportion of Black residents in a NH (i.e., none, <5%, 5%-19.9%, 20-49.9%, ≥50%). Healthcare outcomes examined were hospitalizations and emergency department (ED) visits, both observed and risk-adjusted. Structural factors included staffing, ownership status, bed count (0-49, 50-149, or ≥150), chain organization membership, occupancy, and percent Medicaid as a payment source. Environmental factors included region and urbanicity. Descriptive and multivariable linear regression models were estimated. RESULTS In the 14,121 NHs, compared to NHs with no Black residents, NHs with ≥50% Black residents tended to be urban, for-profit, located in the South, have more Medicaid-funded residents, and have lower ratios of registered-nurse (RN) and aide hours per resident per day (HPRD) and greater ratios of licensed practical nurse HPRD. In general, as the proportion of Black residents in a NH increased, hospitalizations and ED visits also increased. DISCUSSION/IMPLICATIONS As lower use of RNs has been associated with increased ED visits and hospitalizations in NHs generally, it is likely low RN use largely drove the differences in hospitalizations and ED visits in NHs with greater proportions of Black residents. Staffing is an area in which state and federal agencies should take action to improve the quality of care in NHs with larger proportions of Black residents.
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Affiliation(s)
- Jasmine L. Travers
- Rory Meyers College of Nursing, New York University, 433 1st Avenue, New York, NY 10010, USA
| | | | - Susan H. Weaver
- New Jersey Collaborating Center for Nursing, Newark, NJ, 07102, USA
| | - Uduwanage G. Perera
- Columbia University School of Nursing, 560 West 168 St. New York, NY 10032, USA
| | - Bei Wu
- Rory Meyers College of Nursing, New York University, 433 1st Avenue, New York, NY 10010, USA
| | | | - Patricia W. Stone
- Columbia University School of Nursing, 560 West 168 St. New York, NY 10032, USA
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13
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Chen R, Charpignon ML, Raquib RV, Wang J, Meza E, Aschmann HE, DeVost MA, Mooney A, Bibbins-Domingo K, Riley AR, Kiang MV, Chen YH, Stokes AC, Glymour MM. Excess Mortality With Alzheimer Disease and Related Dementias as an Underlying or Contributing Cause During the COVID-19 Pandemic in the US. JAMA Neurol 2023; 80:919-928. [PMID: 37459088 PMCID: PMC10352932 DOI: 10.1001/jamaneurol.2023.2226] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/27/2023] [Indexed: 07/20/2023]
Abstract
Importance Adults with Alzheimer disease and related dementias (ADRD) are particularly vulnerable to the direct and indirect effects of the COVID-19 pandemic. Deaths associated with ADRD increased substantially in pandemic year 1. It is unclear whether mortality associated with ADRD declined when better prevention strategies, testing, and vaccines became widely available in year 2. Objective To compare pandemic-era excess deaths associated with ADRD between year 1 and year 2 overall and by age, sex, race and ethnicity, and place of death. Design, Setting, and Participants This time series analysis used all death certificates of US decedents 65 years and older with ADRD as an underlying or contributing cause of death from January 2014 through February 2022. Exposure COVID-19 pandemic era. Main Outcomes and Measures Pandemic-era excess deaths associated with ADRD were defined as the difference between deaths with ADRD as an underlying or contributing cause observed from March 2020 to February 2021 (year 1) and March 2021 to February 2022 (year 2) compared with expected deaths during this period. Expected deaths were estimated using data from January 2014 to February 2020 fitted with autoregressive integrated moving average models. Results Overall, 2 334 101 death certificates were analyzed. A total of 94 688 (95% prediction interval [PI], 84 192-104 890) pandemic-era excess deaths with ADRD were estimated in year 1 and 21 586 (95% PI, 10 631-32 450) in year 2. Declines in ADRD-related deaths in year 2 were substantial for every age, sex, and racial and ethnic group evaluated. Pandemic-era ADRD-related excess deaths declined among nursing home/long-term care residents (from 34 259 [95% PI, 25 819-42 677] in year 1 to -22 050 [95% PI, -30 765 to -13 273] in year 2), but excess deaths at home remained high (from 34 487 [95% PI, 32 815-36 142] in year 1 to 28 804 [95% PI, 27 067-30 571] in year 2). Conclusions and Relevance This study found that large increases in mortality with ADRD as an underlying or contributing cause of death occurred in COVID-19 pandemic year 1 but were largely mitigated in pandemic year 2. The most pronounced declines were observed for deaths in nursing home/long-term care settings. Conversely, excess deaths at home and in medical facilities remained high in year 2.
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Affiliation(s)
- Ruijia Chen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Marie-Laure Charpignon
- Institute for Data, Systems, and Society, Massachusetts Institute of Technology, Cambridge
| | - Rafeya V. Raquib
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Jingxuan Wang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Erika Meza
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Hélène E. Aschmann
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Michelle A. DeVost
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Alyssa Mooney
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco
| | - Kirsten Bibbins-Domingo
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco
- Editor in Chief, JAMA
| | - Alicia R. Riley
- Department of Sociology, University of California, Santa Cruz, Santa Cruz
| | - Mathew V. Kiang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Yea-Hung Chen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Andrew C. Stokes
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - M. Maria Glymour
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
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14
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Shireman TI, Fashaw-Walters S, Zhang T, Zullo AR, Gerlach LB, Coe AB, Daiello L, Lo D, Strominger J, Bynum JPW. Federal Nursing Home Policies on Antipsychotics had Similar Impacts by Race and Ethnicity for Residents With Dementia. J Am Med Dir Assoc 2023; 24:1283-1289.e4. [PMID: 37127131 PMCID: PMC10523862 DOI: 10.1016/j.jamda.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/15/2023] [Accepted: 03/20/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups. DESIGN Retrospective, cross-sectional trends study. SETTING AND PARTICIPANTS National long-stay nursing home residents with dementia from 2011 to 2017. METHODS We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015). RESULTS Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = -0.8807, P = .0023) and the slope declined further after the Partnership (β = -0.6611, P < .0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P = .4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (β = -0.0428, P = .0312) and Hispanic residents (β = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = -0.086, P = .0275) and post-Five Star Rating (β = -0.0775, P < .0001) declined faster among Hispanic residents. CONCLUSIONS AND IMPLICATIONS We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives.
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Affiliation(s)
- Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Shekinah Fashaw-Walters
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Lori Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Julie P W Bynum
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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15
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Cole CS, Blackburn J, Carpenter JS, Chen CX, Hickman SE. Pain and Associated Factors in Nursing Home Residents. Pain Manag Nurs 2023; 24:384-392. [PMID: 37003932 PMCID: PMC10440293 DOI: 10.1016/j.pmn.2023.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Understanding factors associated with risk of pain allows residents and clinicians to plan care and set priorities, however, factors associated with pain in nursing home residents has not been conclusively studied. AIM To evaluate the association between pain and nursing home (NH) resident demographic and clinical characteristics. DESIGN Retrospective analysis of Minimum Data Set 3.0 records of nursing home residents residing in 44 Indiana NHs between September 27, 2011 and December 27, 2019 (N = 9,060). RESULTS Pain prevalence in this sample of NH residents was 23.7%. Of those with pain, 28.0% experienced moderate to severe/frequent pain and 54.6% experienced persistent pain. Risk factors for moderate to severe/frequent pain include female sex; living in a rural setting; intact, mildly, or moderately impaired cognition; arthritis; contracture; anxiety; and depression. In contrast, stroke and Alzheimer's disease and Alzheimer's-disease related dementias (AD/ADRD) were associated with decreased risk of reporting moderate to severe/frequent pain, likely representing both the under-assessment and under-reporting of pain among cognitively impaired NH residents. Risk factors for persistent pain included age <70, Black race, living in a rural location, intact cognition, contracture, and depression. CONCLUSIONS Pain remains a pressing problem for NH residents. In this study, we identified demographic and clinical factors associated with moderate to severe frequent pain and persistent pain. Residents with a diagnosis of AD/ADRD were less likely to report pain, likely representing the difficulty of evaluating pain in these residents. It is important to note that those with cognitive impairment may not experience any less pain, but assessment and reporting difficulties may make them appear to have less pain. Knowledge of factors associated with pain for NH residents has the potential for improving the ability to predict, prevent, and provide better pain care in NH residents.
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Affiliation(s)
- Connie S Cole
- School of Nursing, Indiana University, Indianapolis, Indiana; School of Medicine, University of Colorado, Aurora, Colorado; RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University, Indianapolis, Indiana.
| | - Justin Blackburn
- Richard Fairbanks School of Public Health, Indiana University Purdue University, Indianapolis, Indiana
| | | | - Chen X Chen
- School of Nursing, Indiana University, Indianapolis, Indiana
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, Indiana; RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana
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16
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Cai S, Yan D, Wang S, Temkin-Greener H. Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter? J Am Med Dir Assoc 2023; 24:712-717. [PMID: 36870366 PMCID: PMC10182813 DOI: 10.1016/j.jamda.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE To examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies. DESIGN Retrospective cross-sectional study. SETTING AND PARTICIPANTS The study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017. METHODS 2010-2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a "choice" set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies. RESULTS Among the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01). CONCLUSIONS AND IMPLICATIONS Black individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.
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Affiliation(s)
- Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Di Yan
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sijiu Wang
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, IL, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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17
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Long-Term Care and the COVID-19 Pandemic: Lessons Learned. Nurs Clin North Am 2023; 58:35-48. [PMID: 36731958 PMCID: PMC9606037 DOI: 10.1016/j.cnur.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
US nursing homes and other long-term care (LTC) communities such as assisted living and adult day care services have been disproportionally affected by COVID-19. Nurses and health care workers provided care and services despite health concerns for themselves and family members. Nurses on the frontline were called to act with extraordinary tenacity, skill, flexibility, and creativity to prevent infection; prevent complications; and optimize function, health, and well-being. The purpose of this article is to provide an overview of the challenges posed by the COVID-19 pandemic and the strategies prioritized and implemented by nurse and interdisciplinary colleagues in LTC settings.
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18
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Bowblis JR, Brunt CS, Xu H, Grabowski DC. Understanding Nursing Home Spending And Staff Levels In The Context Of Recent Nursing Staff Recommendations. Health Aff (Millwood) 2023; 42:197-206. [PMID: 36745835 DOI: 10.1377/hlthaff.2022.00692] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
To provide context for evaluating proposed nursing home staff regulations, we examined the proportion of facility revenues spent on nursing staff, as well as nursing staff levels in hours worked and paid per resident day, in 2019. Nationally, the median proportion of revenues spent on nursing staff was 33.9 percent, and median nursing staff levels were 3.67 hours worked and 4.08 hours paid per resident day. Facilities with higher shares of Medicaid residents spent a larger share of revenues on nursing staff but had lower staffing levels. States varied significantly with respect to median spending on nursing staff (26.8-44.0 percent of revenues) and median nursing staff levels (3.2-5.6 hours worked and 3.6-5.7 hours paid per resident day). These findings indicate that raising the proportion of revenues spent by nursing homes on nursing staff to a regulated minimum would not guarantee the achievement of adequate nursing staff levels unless it was paired with other regulatory mechanisms.
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Affiliation(s)
| | | | - Huiwen Xu
- Huiwen Xu, University of Texas Medical Branch, Galveston, Texas
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19
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Ying M, Thirukumaran CP, Temkin-Greener H, Joynt Maddox KE, Holloway RG, Li Y. Association of Skilled Nursing Facility Participation in Voluntary Bundled Payments With Postacute Care Outcomes for Joint Replacement. Med Care 2023; 61:109-116. [PMID: 36630561 DOI: 10.1097/mlr.0000000000001799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE The Medicare Bundled Payments for Care Improvement (BPCI) model 3 of 2013 holds participating skilled nursing facilities (SNFs) responsible for all episode costs. There is limited evidence regarding SNF-specific outcomes associated with BPCI. OBJECTIVE To examine the association between SNF BPCI participation and patient outcomes and across-facility differences in these outcomes among Medicare beneficiaries undergoing lower extremity joint replacement (LEJR). DESIGN, SETTING, AND PARTICIPANTS Observational difference-in-differences (DID) study of 2013-2017 for 330 unique persistent-participating SNFs, 146 unique dropout SNFs, and 14,028 unique eligible nonparticipating SNFs. MAIN OUTCOME MEASURES Rehospitalization within 30 and 90 days after SNF admission, and rate of successful discharge from the SNF to the community. RESULTS Total 636,355 SNF admissions after LEJR procedures were identified for 582,766 Medicare patients [mean (SD) age, 76.81 (9.26) y; 424,076 (72.77%) women]. The DID analysis showed that for persistent-enrollment SNFs, no BPCI-related changes were found in readmission and successful community discharge rates overall, but were found for their subgroups. Specifically, under BPCI, the 30-day readmission rate decreased by 2.19 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, and by 1.75 percentage-points for non-Medicaid-dependent SNFs in the persistent-participating group relative to those in the nonparticipating group; and the rate of successful community discharge increased by 4.44 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, whereas such relationship was not detected among non-White-serving SNFs, leading to increased between-facility differences (differential DID=-7.62). BPCI was not associated with readmission or successful community discharge rates for dropout SNFs, overall, or in subgroup analyses. CONCLUSIONS Among Medicare patients receiving LEJR, BPCI was associated with improved outcomes for White-serving/non-Medicaid-dependent SNFs but not for other SNFs, which did not help reduce or could even worsen the between-facility differences.
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Affiliation(s)
- Meiling Ying
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Caroline P Thirukumaran
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Helena Temkin-Greener
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine
- Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO
| | - Robert G Holloway
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Yue Li
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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20
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Engeda JC, Karmarkar EN, Mitsunaga TM, Raymond KL, Oh P, Epson E. Resident racial and ethnic composition, neighborhood-level socioeconomic status, and COVID-19 infections in California SNFs. J Am Geriatr Soc 2023; 71:157-166. [PMID: 36196970 PMCID: PMC9874461 DOI: 10.1111/jgs.18076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 07/18/2022] [Accepted: 08/30/2022] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Joseph C. Engeda
- California Department of Public HealthHealthcare‐Associated Infections ProgramRichmondCaliforniaUSA,Public Health and Scientific ResearchSocial & Scientific SystemsDurhamNorth CarolinaUSA
| | - Ellora N. Karmarkar
- California Department of Public HealthHealthcare‐Associated Infections ProgramRichmondCaliforniaUSA
| | - Tisha M. Mitsunaga
- California Department of Public HealthHealthcare‐Associated Infections ProgramRichmondCaliforniaUSA
| | - Kristal L. Raymond
- California Department of Public HealthOffice of Health EquitySacramentoCaliforniaUSA
| | - Peter Oh
- California Department of Public HealthOffice of Health EquitySacramentoCaliforniaUSA
| | - Erin Epson
- California Department of Public HealthHealthcare‐Associated Infections ProgramRichmondCaliforniaUSA
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21
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Mueller CA, Alexander GL, Ersek M, Ferrell BR, Rantz MJ, Travers JL. Calling all nurses-Now is the time to take action on improving the quality of care in nursing homes. Nurs Outlook 2023; 71:101897. [PMID: 36621418 DOI: 10.1016/j.outlook.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/18/2022] [Accepted: 11/08/2022] [Indexed: 01/09/2023]
Abstract
For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee's vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments. This paper outlines concrete and specific actions nurses and nursing organizations can take to ensure the recommendations are implemented.
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Affiliation(s)
| | | | - Mary Ersek
- Veteran Experience Center, University of Pennsylvania Schools of Nursing and Medicine, Department of Veterans Affairs, Philadelphia, PA
| | - Betty R Ferrell
- City of Hope National Medical Center, Division of Nursing Research & Education, Duarte, CA
| | - Marilyn J Rantz
- University of Missouri, Sinclair School of Nursing, Columbia, MO
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22
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Hicks NM, Heid AR, Abbott KM, Leser K, Van Haitsma K. Preference Importance Ratings among African American and White Nursing Home Residents. Clin Gerontol 2023; 46:111-121. [PMID: 34962458 PMCID: PMC9237178 DOI: 10.1080/07317115.2021.2007436] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The Preferences for Everyday Living Inventory (PELI-NH) assesses psychosocial preferences of nursing home (NH) residents. This study explored the association of race with importance ratings of self-dominion preferences (i.e., preferences for control). METHODS PELI-NH interviews were conducted with 250 NH residents. Tests of mean differences compared African American (n = 57) and White (n = 193) residents on demographic (age, gender, education, length of stay) and clinical attributes (self-rated health, depressive symptoms, anxiety, functional limitations, hearing, vision, cognition). Stepwise multiple regression accounted first for associations of demographic and clinical attributes then for the unique association of race with total importance of self-dominion preferences to determine whether African American and White residents differ. For between group demographic/clinical differences, interaction effects were tested. RESULTS African Americans were younger and more functionally impaired. After accounting for the effects of gender (female), age (younger), anxiety (greater), and functional impairment (less) with higher reports of importance of self-dominion preferences, race was significant. There were no significant moderating effects. CONCLUSIONS African American residents reported greater importance of self-dominion preferences than Whites. CLINICAL IMPLICATIONS Cultural sensitivity is critical; it may be more important to provide opportunities for autonomous decision-making for African American than for White residents.
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Affiliation(s)
- Nytasia M. Hicks
- Miami University, Department of Sociology and Gerontology, Oxford, OH, USA
| | | | | | - Kendall Leser
- College of Education, Health & Society, Miami University, Oxford, OH, USA
| | - Kimberly Van Haitsma
- The Polisher Research Institute at The Madlyn and Leonard Abramson Center for Jewish Life, Horsham, PA, USA and The Pennsylvania State University, University Park, PA, USA
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Inoue M, Li MH, Layman S, Tompkins CJ, Ihara ES. Characteristics of Nursing Facilities and Staff Willingness to Implement a Non-Pharmacological Intervention. Gerontol Geriatr Med 2022; 8:23337214221146410. [PMID: 36582661 PMCID: PMC9793045 DOI: 10.1177/23337214221146410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 12/25/2022] Open
Abstract
While non-pharmacological interventions could positively impact mood and behaviors of nursing-home residents who are living with dementia, some facilities are more willing to adopt such interventions than others. This study investigated the characteristics of Medicaid-funded nursing facilities that were associated with their willingness to implement a non-pharmacological intervention, personalized music. Using the publicly-available dataset (aka LTCfocus) from Brown University, this study examined characteristics of nursing homes in Virginia that have implemented or are in the process of implementing a personalized music intervention (n = 59) and that have decided not to implement it (n = 216). The findings indicate that nursing facilities with a higher proportion of long-term residents are more likely to implement the intervention. The findings can inform future research recruitment strategies. In addition, a greater understanding of the use of non-pharmacological interventions in relation to the characteristics of nursing facilities offers insight to policymakers and public health officials regarding resource allocations to facilities.
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Affiliation(s)
- Megumi Inoue
- George Mason University, Fairfax, VA,
USA,Megumi Inoue, Department of Social Work,
George Mason University, 4400 University Drive, MSN: 1F8, Fairfax, VA 22030,
USA.
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24
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TYLER DENISEA, FENG ZHANLIAN, GRABOWSKI DAVIDC, BERCAW LAWREN, SEGELMAN MICAH, KHATUTSKY GALINA, WANG JOYCE, GASDASKA ANGELA, INGBER MELVINJ. CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned. Milbank Q 2022; 100:1243-1278. [PMID: 36573335 PMCID: PMC9836234 DOI: 10.1111/1468-0009.12594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 12/28/2022] Open
Abstract
Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone. CONTEXT In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only). METHODS Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. FINDINGS Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations. CONCLUSIONS Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.
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25
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O’Neill ET, Bosco E, Persico E, Silva JB, Riester MR, Moyo P, van Aalst R, Loiacono MM, Chit A, Gravenstein S, Zullo AR. Correlation of long-term care facility vaccination practices between seasons and resident types. BMC Geriatr 2022; 22:835. [PMID: 36333667 PMCID: PMC9635204 DOI: 10.1186/s12877-022-03540-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Background Influenza vaccination varies widely across long-term care facilities (LTCFs) due to staff behaviors, LTCF practices, and patient factors. It is unclear how seasonal LTCF vaccination varies between cohabitating but distinct short-stay and long-stay residents. Thus, we assessed the correlation of LTCF vaccination between these populations and across seasons. Methods The study design is a national retrospective cohort using Medicare and Minimum Data Set (MDS) data. Participants include U.S. LTCFs. Short-stay and long-stay Medicare-enrolled residents age ≥ 65 in U.S. LTCFs from a source population of residents during October 1st-March 31st in 2013–2014 (3,042,881 residents; 15,683 LTCFs) and 2014–2015 (3,143,174, residents; 15,667 LTCFs). MDS-assessed influenza vaccination was the outcome. Pearson correlation coefficients were estimated to assess seasonal correlations between short-stay and long-stay resident vaccination within LTCFs. Results The median proportion of short-stay residents vaccinated across LTCFs was 70.4% (IQR, 50.0–82.7%) in 2013–2014 and 69.6% (IQR, 50.0–81.6%) in 2014–2015. The median proportion of long-stay residents vaccinated across LTCFs was 85.5% (IQR, 78.0–90.9%) in 2013–2014 and 84.6% (IQR, 76.6–90.3%) in 2014–2015. Within LTCFs, there was a moderate correlation between short-stay and long-stay vaccination in 2013–2014 (r = 0.50, 95%CI: 0.49–0.51) and 2014–2015 (r = 0.53, 95%CI: 0.51–0.54). Across seasons, there was a moderate correlation for LTCFs with short-stay residents (r = 0.54, 95%CI: 0.53–0.55) and a strong correlation for those with long-stay residents (r = 0.68, 95%CI: 0.67–0.69). Conclusions In LTCFs with inconsistent influenza vaccination across seasons or between populations, targeted vaccination protocols for all residents, regardless of stay type, may improve successful vaccination in this vulnerable patient population. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03540-3.
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Affiliation(s)
- Emily T. O’Neill
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Elliott Bosco
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Erin Persico
- grid.20431.340000 0004 0416 2242University of Rhode Island College of Pharmacy, Kingston, RI USA
| | - Joe B. Silva
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Melissa R. Riester
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Patience Moyo
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Robertus van Aalst
- grid.417555.70000 0000 8814 392XSanofi, Swiftwater, PA USA ,grid.4494.d0000 0000 9558 4598Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Ayman Chit
- grid.417555.70000 0000 8814 392XSanofi, Swiftwater, PA USA ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | - Stefan Gravenstein
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA ,grid.413904.b0000 0004 0420 4094Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI USA ,grid.40263.330000 0004 1936 9094Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI USA
| | - Andrew R. Zullo
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA ,grid.413904.b0000 0004 0420 4094Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI USA ,grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University School of Public Health, Providence, RI USA
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Laws MB, Beeman A, Haigh S, Wilson IB, Shield RR. Changes in Nursing Home Populations Challenge Practice and Policy. Policy Polit Nurs Pract 2022; 23:238-248. [PMID: 35957612 PMCID: PMC10155416 DOI: 10.1177/15271544221118315] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
U.S. nursing homes (NH) have a growing prevalence of individuals with severe mental illness (SMI) and substance use disorders (SUD), and an associated increasing proportion of people under 65. We explored how Directors of Nursing (DONs) perceive challenges and strategies in caring for these populations. We conducted semi-structured telephone interviews with 32 DONs from diverse facilities around the U.S. Participants reported that people with SUD and SMI often present behavioral challenges requiring resource intensive responses, while regulations constrain optimal medication treatment. Younger individuals are considered more demanding of staff and impatient with traditional NH activities designed for older people. Some NHs report they screen out people with behavioral health disorders; they tend to be concentrated in NHs in economically disadvantaged communities. Individuals may remain in NHs because suitable settings for discharge are unavailable. These developments constitute a back door "re-institutionalization" of people with behavioral health disorders, and a growing crisis.
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Affiliation(s)
- M. Barton Laws
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Aly Beeman
- Youth Development Labs (YLabs), Kigali, Rwanda
| | | | - Ira B. Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Renée R. Shield
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
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Bartlett VL, Ross JS, Balasuriya L, Rhee TG. Association of Psychiatric Diagnoses and Medicaid Coverage with Length of Stay Among Inpatients Discharged to Skilled Nursing Facilities. J Gen Intern Med 2022; 37:3070-3079. [PMID: 35048298 PMCID: PMC9485316 DOI: 10.1007/s11606-021-07320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Inpatients with psychiatric diagnoses often require higher levels of care in skilled nursing facilities (SNFs) and are more likely to be covered by Medicaid, which reimburses SNFs at significantly lower rates than Medicare and commercial payors. OBJECTIVE To characterize factors affecting length of stay in inpatients discharged to SNFs. DESIGN A retrospective cross-sectional study design using 2016-2018 data from National Inpatient Sample. PARTICIPANTS Inpatients aged ≥ 40 who were discharged to SNFs. EXPOSURES Primary discharge diagnosis (medical, psychiatric, or substance use) and primary payor. MAIN OUTCOMES AND MEASURES Length of stay, categorized non-exclusively as >3 days, >7 days, or > 14 days. RESULTS Among 9,821,155 inpatient discharges to SNFs between 2016 and 2018, 95.7% had medical primary discharge diagnoses, 3.3% psychiatric diagnoses, and 1.0% substance use diagnoses; Medicare was the most common primary payor (83.3%), followed by private insurance (7.9%), Medicaid (6.6%), and others (2.2%). Median length of stay for all patients was 5.0 days (interquartile range [IQR], 3.0-8.0), 5.0 (IQR, 3.0-8.0) for those with medical diagnoses, 8.0 (IQR, 4.0-15.0) for psychiatric diagnoses, and 5.0 (IQR, 3.0-8.0) for substance use diagnoses. After multivariable adjustment, compared to patients with medical diagnoses, patients with psychiatric diagnoses were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to Medicare patients, Medicaid patients were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to patients with medical diagnoses, those with psychiatric diagnoses were also more likely to have lengths of stay 1 times, 1.5 times, and 2 times greater than the national geometric mean length of stay for that diagnosis-related group (p < 0.001). CONCLUSIONS Patients discharged to SNFs after inpatient hospitalization for psychiatric diagnoses and with Medicaid coverage were more likely to have longer lengths of stay than patients with medical diagnoses and those with Medicare coverage, respectively.
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Affiliation(s)
| | - Joseph S Ross
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Lilanthi Balasuriya
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA.
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Hugunin J, Chen Q, Baek J, Clark RE, Lapane KL, Ulbricht CM. Quality of Nursing Homes Admitting Working-Age Adults With Serious Mental Illness. Psychiatr Serv 2022; 73:745-751. [PMID: 34911354 PMCID: PMC9200905 DOI: 10.1176/appi.ps.202100356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This cross-sectional study examined the association between nursing home quality and admission of working-age persons (ages 22-64 years) with serious mental illness. METHODS The study used 2015 national Minimum Data Set 3.0 and Nursing Home Compare (NHC) data. A logistic mixed-effects model estimated the likelihood (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]) of a working-age nursing home resident having serious mental illness, by NHC health inspection quality rating. The variance partition coefficient (VPC) was calculated to quantify the variation in serious mental illness attributable to nursing home characteristics. Measures included serious mental illness (i.e., schizophrenia, bipolar disorder, and other psychotic disorders), health inspection quality rating (ranging from one star, below average, to five stars, above average), and other sociodemographic and clinical covariates. RESULTS Of the 343,783 working-age adults newly admitted to a nursing home in 2015 (N=14,307 facilities), 15.5% had active serious mental illness. The odds of a working-age resident having serious mental illness was lowest among nursing homes of above-average quality, compared with nursing homes of below-average quality (five-star vs. one-star facility, AOR=0.78, 95% CI=0.73-0.84). The calculated VPC from the full model was 0.11. CONCLUSIONS These findings indicate an association between below-average nursing homes and admission of working-age persons with serious mental illness, suggesting that persons with serious mental illness may experience inequitable access to nursing homes of above-average quality. Access to alternatives to care, integration of mental health services in the community, and improving mental health care in nursing homes may help address this disparity.
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Affiliation(s)
- Julie Hugunin
- Clinical and Population Health Research Program, Morningside Graduate School of Biomedical Sciences (Hugunin, Chen, Baek, Clark, Lapane), and Department of Population and Quantitative Health Sciences (Hugunin, Chen, Baek, Clark, Lapane, Ulbricht), UMass Chan Medical School, University of Massachusetts, Worcester; National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (Ulbricht)
| | - Qiaoxi Chen
- Clinical and Population Health Research Program, Morningside Graduate School of Biomedical Sciences (Hugunin, Chen, Baek, Clark, Lapane), and Department of Population and Quantitative Health Sciences (Hugunin, Chen, Baek, Clark, Lapane, Ulbricht), UMass Chan Medical School, University of Massachusetts, Worcester; National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (Ulbricht)
| | - Jonggyu Baek
- Clinical and Population Health Research Program, Morningside Graduate School of Biomedical Sciences (Hugunin, Chen, Baek, Clark, Lapane), and Department of Population and Quantitative Health Sciences (Hugunin, Chen, Baek, Clark, Lapane, Ulbricht), UMass Chan Medical School, University of Massachusetts, Worcester; National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (Ulbricht)
| | - Robin E Clark
- Clinical and Population Health Research Program, Morningside Graduate School of Biomedical Sciences (Hugunin, Chen, Baek, Clark, Lapane), and Department of Population and Quantitative Health Sciences (Hugunin, Chen, Baek, Clark, Lapane, Ulbricht), UMass Chan Medical School, University of Massachusetts, Worcester; National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (Ulbricht)
| | - Kate L Lapane
- Clinical and Population Health Research Program, Morningside Graduate School of Biomedical Sciences (Hugunin, Chen, Baek, Clark, Lapane), and Department of Population and Quantitative Health Sciences (Hugunin, Chen, Baek, Clark, Lapane, Ulbricht), UMass Chan Medical School, University of Massachusetts, Worcester; National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (Ulbricht)
| | - Christine M Ulbricht
- Clinical and Population Health Research Program, Morningside Graduate School of Biomedical Sciences (Hugunin, Chen, Baek, Clark, Lapane), and Department of Population and Quantitative Health Sciences (Hugunin, Chen, Baek, Clark, Lapane, Ulbricht), UMass Chan Medical School, University of Massachusetts, Worcester; National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (Ulbricht)
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Travers JL, Dick AW, Wu B, Grabowski D, Robison J, Agarwal M, Perera GU, Stone PW. A Profile of Black and Latino Older Adults Receiving Care in Nursing Homes: 2011-2017. J Am Med Dir Assoc 2022; 23:1833-1837.e2. [PMID: 35594945 DOI: 10.1016/j.jamda.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 04/10/2022] [Accepted: 04/14/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify if disparate trends in the access and use of nursing home (NH) services among Black and Latino older adults compared with White older adults persist. Access was operationalized as the NHs that served Black, Latino, and White residents. Use was operationalized as the utilization of NH services by Black, Latino, and White residents. DESIGN This was an observational study analyzing facility-level data from LTCfocus for 2011 to 2017. SETTING AND PARTICIPANTS All NH residents present in US NHs participating in the Centers for Medicare and Medicaid Services program on the first Thursday in April in the years 2011 to 2017. NHs with fewer than 4500 bed-days per year are excluded in the LCTfocus dataset. Black, Latino, and White were the racial/ethnic groups of interest. METHODS We calculated the mean percentage of each racial/ethnic group in NHs (Black, Latino, White) annually along with the number of NHs that provided care for these groups. We conducted a simple trend analysis using ordinary least squares to estimate the change in NH access and use by racial/ethnic group over time. RESULTS Our NH sample ranged from 15,564 in 2011 to 14,956 in 2017. Latino older residents' use of NHs increased by 20.47% and Black residents increased by 11.42%, whereas there was a 1.36% decrease in White residents' use of NHs. In this 7-year span, there was a 4.44% and 6.41% decline in the number of NHs that serve any Black and Latino older adults, respectively, compared with a 2.26% decline in NHs that serve only White older adults (access). CONCLUSIONS AND IMPLICATIONS Our findings reveal a continued disproportionate rise in Black and Latino older adults' use of NHs while the number of NHs that serve this population have declined. This work can inform federal and state policies to ensure access to long-term care services and supports in the community for all older adults and prevent inappropriate NH closures.
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Affiliation(s)
- Jasmine L Travers
- Rory Meyers College of Nursing, New York University, New York, NY, USA.
| | | | - Bei Wu
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | | | | | - Mansi Agarwal
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
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Cai S, Wang S, Yan D, Conwell Y, Temkin-Greener H. The Diagnosis of Schizophrenia Among Nursing Home Residents With ADRD: Does Race Matter? Am J Geriatr Psychiatry 2022; 30:636-646. [PMID: 34801382 PMCID: PMC8983437 DOI: 10.1016/j.jagp.2021.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/01/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To examine racial differences in the frequency of schizophrenia diagnosis codes used among nursing home (NH) residents with Alzheimer's Disease and Related Dementias (ADRD), pre and post the implementation of public reporting of antipsychotic use in NHs. METHODS The 2011-2017 Minimum Data Set and Medicare Master Beneficiary Summary File were linked. We identified long-stay NH residents (i.e., those who had quarterly or annual assessments) with ADRD aged 55 years and older (N = 7,734,348). Outcome variable was defined as the diagnosis of schizophrenia documented in the MDS assessments. Main variables of interest included individual race (black versus white), the percent of blacks in a NH and time trend. Multivariate regressions were estimated. RESULTS The frequency of schizophrenia diagnosis codes among NH residents with ADRD steadily increased over the study period, and blacks experienced a greater increase than their white counterparts. For example, the overall likelihood of having schizophrenia diagnosis increased 1.9 percentage points (95% confidence interval [CI]: 0.019, 0.020, p < 0.01) from 2011 to 2017 among whites, while blacks had an addition 1.3 percentage points increase (95% CI: 0.011, 0.015, p < 0.01). The increase in the likelihood of having schizophrenia diagnosis code was higher in NHs with higher percent of blacks: the increase from 2011 to 2017 was 2.6 percentage point (95% CI: 0.023, 0.029, p < 0.01) higher in NHs with the highest percent of blacks, compared to NHs with lowest percent of blacks. Racial differences in the growth of schizophrenia diagnosis also existed within a NH after accounting for NH factors. CONCLUSION Following the implementation of public reporting of antipsychotic use in NH, black residents experienced a greater increase in the likelihood of having schizophrenia diagnosis than white NH residents. NHs with a higher proportion of blacks had a greater increase in schizophrenia diagnosis, and blacks experienced an increased likelihood of schizophrenia diagnosis than whites within a NH. Further research is needed to determine a causal relationship between the federal policy mandating public reporting and disparities in schizophrenia diagnostic coding.
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Affiliation(s)
- Shubing Cai
- Department of Public Health Sciences (SC, DY, HTG), University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Sijiu Wang
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637
| | - Di Yan
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry; 265 Crittenden Blvd., CU 420644, Rochester, NY 14642
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 300 Crittenden Blvd, Rochester, NY 14642
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry; 265 Crittenden Blvd., CU 420644, Rochester, NY 14642
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Estrada LV, Levasseur JL, Maxim A, Benavidez GA, Pollack Porter KM. Structural Racism, Place, and COVID-19: A Narrative Review Describing How We Prepare for an Endemic COVID-19 Future. Health Equity 2022; 6:356-366. [PMID: 35651360 PMCID: PMC9148659 DOI: 10.1089/heq.2021.0190] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 12/17/2022] Open
Abstract
Background: Place is a social determinant of health, as recently evidenced by COVID-19. Previous literature surrounding health disparities in the United States often fails to acknowledge the role of structural racism on place-based health disparities for historically marginalized communities (i.e., Black and African American communities, Hispanic/Latinx communities, Indigenous communities [i.e., First Nations, Native American, Alaskan Native, and Native Hawaiian], and Pacific Islanders). This narrative review summarizes the intersection between structural racism and place as contributors to COVID-19 health disparities. Methods: This narrative review accounts for the unique place-based health care experiences influenced by structural racism, including health systems and services and physical environment. We searched online databases for peer-reviewed and governmental sources, published in English between 2000 and 2021, related to place-based U.S. health inequities in historically marginalized communities. We then narrate the link between the historical trajectory of structural racism and current COVID-19 health outcomes for historically marginalized communities. Results: Structural racism has infrequently been named as a contributor to place as a social determinant of health. This narrative review details how place is intricately intertwined with the results of structural racism, focusing on one's access to health systems and services and physical environment, including the outdoor air and drinking water. The role of place, health disparities, and structural racism has been starkly displayed during the COVID-19 pandemic, where historically marginalized communities have been subject to greater rates of COVID-19 incidence and mortality. Conclusion: As COVID-19 becomes endemic, it is crucial to understand how place-based inequities and structural racism contributed to the COVID-19 racial disparities in incidence and mortality. Addressing structurally racist place-based health inequities through anti-racist policy strategies is one way to move the United States toward achieving health equity.
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Affiliation(s)
- Leah V. Estrada
- Center for Health Policy, Columbia University School of Nursing, New York, New York, USA
| | - Jessica L. Levasseur
- Nicholas School of the Environment, Duke University, Durham, North Carolina, USA
| | - Alexandra Maxim
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Gabriel A. Benavidez
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina, USA
| | - Keshia M. Pollack Porter
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Abstract
As the late Robert Kane observed, the term nursing home is often a misnomer. Most U.S. nursing homes lack adequate nursing staff, and they are typically not very homelike in either their physical structure or culture. These problems were magnified during the pandemic. The underlying reasons for these longstanding issues are that most state Medicaid payment systems reimburse nursing homes at a relatively low level and the government does not hold nursing homes accountable for spending dollars on direct resident care. To encourage increased staffing and more homelike models of care, policymakers need to reform how nursing homes are paid and hold facilities accountable for how they spend government dollars. With these reforms, the term nursing home will become more appropriate in the United States.
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Affiliation(s)
- David C Grabowski
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston MA 02115, USA
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Shen K. Relationship between nursing home COVID-19 outbreaks and staff neighborhood characteristics. PLoS One 2022; 17:e0267377. [PMID: 35439279 PMCID: PMC9017897 DOI: 10.1371/journal.pone.0267377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/05/2022] [Indexed: 11/18/2022] Open
Abstract
The COVID-19 pandemic has been particularly deadly for residents of nursing homes and other long-term care facilities. This paper analyzes COVID-19 deaths at nursing homes during the first wave of the pandemic in the United States during the spring and early summer 2020. By combining data on facility-level COVID-19 deaths during this period with data on the neighborhoods where nursing home staff reside for a sample of eighteen states, this paper finds that staff neighborhood characteristics were a large and significant predictor of COVID-19 nursing home deaths. Even after controlling for the county where a facility is located, one standard deviation increases in average staff neighborhood (Census tract) population density, public transportation use, and non-white share were associated with 1.3 (p < .001), 1.4 (p < .001), and 0.9 (p < .001) additional deaths per 100 beds, respectively. These effects are larger than all facility management or quality variables, and larger than the effect of the nursing home’s own neighborhood characteristics. These results suggest COVID-19 outbreaks in staff communities can have large consequences for the facilities where they work, even in highly-rated facilities, and that disparities in nursing home outbreaks may be related to differences in the types of neighborhoods nursing home staff live in.
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Affiliation(s)
- Karen Shen
- Department of Economics, Harvard University, Cambridge, MA, United States of America
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34
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Explaining spatial accessibility to high-quality nursing home care in the US using machine learning. Spat Spatiotemporal Epidemiol 2022; 41:100503. [DOI: 10.1016/j.sste.2022.100503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/18/2022] [Accepted: 03/21/2022] [Indexed: 11/19/2022]
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35
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Estrada LV, Harrison JM, Dick AW, Luchsinger JA, Dhingra L, Stone PW. Examining Regional Differences in Nursing Home Palliative Care for Black and Hispanic Residents. J Palliat Med 2022; 25:1228-1235. [PMID: 35143358 PMCID: PMC9347389 DOI: 10.1089/jpm.2021.0416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Leah V Estrada
- Center for Health Policy, Columbia University School of Nursing, New York, New York, USA
| | | | | | - José A Luchsinger
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA.,Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Patricia W Stone
- Center for Health Policy, Columbia University School of Nursing, New York, New York, USA
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36
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Hawk T, White EM, Bishnoi C, Schwartz LB, Baier RR, Gifford DR. Facility characteristics and costs associated with meeting proposed minimum staffing levels in skilled nursing facilities. J Am Geriatr Soc 2022; 70:1198-1207. [PMID: 35113449 DOI: 10.1111/jgs.17678] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 11/10/2021] [Accepted: 11/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Federal minimum nurse staffing levels for skilled nursing facilities (SNFs) were proposed in 2019 U.S. Congressional bills. We estimated costs and personnel needed to meet the proposed staffing levels, and examined characteristics of SNFs not meeting these thresholds. METHODS This was a cross-sectional analysis of 2019Q4 payroll data, the Hospital Wage Index, and other administrative data for 14,964 Medicare and Medicaid-certified SNFs. We examined characteristics of SNFs not meeting proposed minimum thresholds: 4.1 total nursing hours per resident day (HPRD); 0.75 registered nurse (RN) HPRD; 0.54 licensed practical nurse (LPN) HPRD; and 2.81 certified nursing assistant (CNA) HPRD. For SNFs falling below the thresholds, we calculated the additional HPRD needed, along with the associated full-time equivalent (FTE) personnel and salary costs. RESULTS In 2019, 25.0% of SNFs met the minimum 4.1 total nursing HPRD, while 31.0%, 84.5%, and 10.7% met the RN, LPN, and CNA thresholds, respectively. Only 5.0% met all four categories. In adjusted analyses, factors most strongly associated with SNFs not meeting the proposed minimums were: higher Medicaid census, larger bed size, for-profit ownership, higher county SNF competition; and, for RNs specifically, higher community poverty and lower Medicare census. Rural SNFs were less likely to meet all categories and this was explained primarily by county SNF competition. We estimate that achieving the proposed federal minimums across SNFs nationwide would require an estimated additional 35,804 RN, 3509 LPN, and 116,929 CNA FTEs at $7.25 billion annually in salary costs based on current wage rates and prepandemic resident census levels. CONCLUSIONS Achieving proposed minimum nurse staffing levels in SNFs will require substantial financial investment in the workforce and targeted support of low-resource facilities. Extensive recruitment and retention efforts are needed to overcome supply constraints, particularly in the aftermath of the COVID-19 pandemic.
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Affiliation(s)
- Terry Hawk
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, District of Columbia, USA
| | - Elizabeth M White
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Courtney Bishnoi
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, District of Columbia, USA
| | - Lindsay B Schwartz
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, District of Columbia, USA
| | - Rosa R Baier
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island, USA
| | - David R Gifford
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, District of Columbia, USA.,Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
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Werner RM, Konetzka RT. Reimagining Financing and Payment of Long-Term Care. J Am Med Dir Assoc 2022; 23:220-224. [PMID: 34942158 PMCID: PMC8695540 DOI: 10.1016/j.jamda.2021.11.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/19/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Rachel M Werner
- Department of Medicine, Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - R Tamara Konetzka
- Department of Public Health Sciences, Department of Medicine, The University of Chicago Biological Sciences, Chicago, IL, USA.
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38
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Sloane PD. The Uncertain Future of Nursing Home Post-Acute Care. J Am Med Dir Assoc 2022; 23:190-192. [DOI: 10.1016/j.jamda.2021.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 02/04/2023]
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Shippee TP, Fabius CD, Fashaw-Walters S, Bowblis JR, Nkimbeng M, Bucy TI, Duan Y, Ng W, Akosionu O, Travers JL. Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports. J Am Med Dir Assoc 2022; 23:214-219. [PMID: 34958742 PMCID: PMC8821413 DOI: 10.1016/j.jamda.2021.12.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
| | - Chanee D. Fabius
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - John R. Bowblis
- Miami University, Farmer School of Business and Scripps Gerontology Center, Oxford, Ohio, USA
| | - Manka Nkimbeng
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Taylor I. Bucy
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Yinfei Duan
- University of Alberta Faculty of Nursing, Edmonton, Alberta, Canada
| | - Weiwen Ng
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Odichinma Akosionu
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Jasmine L. Travers
- New York University Rory Meyers College of Nursing, New York, New York, USA
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40
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Fashaw-Walters SA, Rahman M, Gee G, Mor V, White M, Thomas KS. Out Of Reach: Inequities In The Use Of High-Quality Home Health Agencies. Health Aff (Millwood) 2022; 41:247-255. [PMID: 35130066 PMCID: PMC8883595 DOI: 10.1377/hlthaff.2021.01408] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Patients receiving home health services from high-quality home health agencies often experience fewer adverse outcomes (for example, hospitalizations) than patients receiving services from low-quality agencies. Using administrative data from 2016 and regression analysis, we examined individual- and neighborhood-level racial, ethnic, and socioeconomic factors associated with the use of high-quality home health agencies. We found that Black and Hispanic home health patients had a 2.2-percentage-point and a 2.5-percentage-point lower adjusted probability of high-quality agency use, respectively, compared with their White counterparts within the same neighborhoods. Low-income patients had a 1.2-percentage-point lower adjusted probability of high-quality agency use compared with their higher-income counterparts, whereas home health patients residing in neighborhoods with higher proportions of marginalized residents had a lower adjusted probability of high-quality agency use. Some 40-77 percent of the disparities in high-quality agency use were attributable to neighborhood-level factors. Ameliorating these inequities will require policies that dismantle structural and institutional barriers related to residential segregation.
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Affiliation(s)
| | | | - Gilbert Gee
- Gilbert Gee, University of California Los Angeles, Los Angeles, California
| | - Vincent Mor
- Vincent Mor, Brown University and Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | | | - Kali S Thomas
- Kali S. Thomas, Brown University and Providence Veterans Affairs Medical Center
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41
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Larrabee Sonderlund A, Charifson M, Schoenthaler A, Carson T, Williams NJ. Racialized economic segregation and health outcomes: A systematic review of studies that use the Index of Concentration at the Extremes for race, income, and their interaction. PLoS One 2022; 17:e0262962. [PMID: 35089963 PMCID: PMC8797220 DOI: 10.1371/journal.pone.0262962] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/09/2022] [Indexed: 11/19/2022] Open
Abstract
Extensive research shows that residential segregation has severe health consequences for racial and ethnic minorities. Most research to date has operationalized segregation in terms of either poverty or race/ethnicity rather than a synergy of these factors. A novel version of the Index of Concentration at the Extremes (ICERace-Income) specifically assesses racialized economic segregation in terms of spatial concentrations of racial and economic privilege (e.g., wealthy white people) versus disadvantage (e.g., poor Black people) within a given area. This multidimensional measure advances a more comprehensive understanding of residential segregation and its consequences for racial and ethnic minorities. The aim of this paper is to critically review the evidence on the association between ICERace-Income and health outcomes. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct a rigorous search of academic databases for papers linking ICERace-Income with health. Twenty articles were included in the review. Studies focused on the association of ICERace-Income with adverse birth outcomes, cancer, premature and all-cause mortality, and communicable diseases. Most of the evidence indicates a strong association between ICERace-Income and each health outcome, underscoring income as a key mechanism by which segregation produces health inequality along racial and ethnic lines. Two of the reviewed studies examined racial disparities in comorbidities and health care access as potential explanatory factors underlying this relationship. We discuss our findings in the context of the extant literature on segregation and health and propose new directions for future research and applications of the ICERace-Income measure.
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Affiliation(s)
- Anders Larrabee Sonderlund
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Mia Charifson
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Antoinette Schoenthaler
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, New York, New York, United States of America
| | - Traci Carson
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, New York, New York, United States of America
| | - Natasha J. Williams
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, New York, New York, United States of America
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Dufour AB, Kosar C, Mor V, Lipsitz LA. The Effect of Race and Dementia Prevalence on a COVID-19 Infection Control Intervention in Massachusetts Nursing Homes. J Gerontol A Biol Sci Med Sci 2022; 77:1361-1365. [PMID: 35020886 PMCID: PMC8807187 DOI: 10.1093/gerona/glab355] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Indexed: 12/13/2022] Open
Abstract
Background Nursing home (NH) residents, especially those who were Black or with dementia, had the highest infection rates during the COVID-19 pandemic. A 9-week COVID-19 infection control intervention in 360 Massachusetts NHs showed adherence to an infection control checklist with proper personal protective equipment (PPE) use and cohorting was associated with declines in weekly infection rates. NHs were offered weekly webinars, answers to infection control questions, resources to acquire PPE, backup staff, and SARS-CoV-2 testing. We asked whether the effect of this intervention differed by racial and dementia composition of the NHs. Methods Data were obtained from 4 state audits using infection control checklists, weekly infection rates, and Minimum Data Set variables on race and dementia to determine whether adherence to checklist competencies was associated with decline in average weekly rates of new COVID-19 infections. Results Using a mixed-effects hurdle model, adjusted for county COVID-19 prevalence, we found the overall effect of the intervention did not differ by racial composition, but proper cohorting of residents was associated with a greater reduction in infection rates among facilities with ≥20% non-Whites (n = 83). Facilities in the middle (>50%–62%; n = 121) and upper (>62%; n = 115) tertiles of dementia prevalence had the largest reduction in infection rates as checklist scores improved. Cohorting was associated with greater reductions in infection rates among facilities in the middle and upper tertiles of dementia prevalence. Conclusions Adherence to proper infection control procedures, particularly cohorting of residents, can reduce COVID-19 infections, even in facilities with high percentages of high-risk residents (non-White and dementia).
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Affiliation(s)
- Alyssa B Dufour
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine and Division of Gerontology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Cyrus Kosar
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vincent Mor
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration Medical Center, Research Service, Providence, Rhode Island, USA
| | - Lewis A Lipsitz
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine and Division of Gerontology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Robinson-Lane SG, Block L, Bowers BJ, Cacchione PZ, Gilmore-Bykovskyi A. The Intersections of Structural Racism and Ageism in the Time of COVID-19: A Call to Action for Gerontological Nursing Science. Res Gerontol Nurs 2022; 15:6-13. [PMID: 35044863 PMCID: PMC8856583 DOI: 10.3928/19404921-20211209-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The health consequences of systemic racism and ageism have received growing attention as the coronavirus disease 2019 pandemic has illuminated long-standing inadequacies and injustices that are structurally engrained in our health systems. The current State of the Science Commentary addresses the intersecting influences of systemic racism and ageism, and other "-isms" that conspire to create disparate health outcomes for older adults from historically excluded and marginalized backgrounds. We focus specifically on the long-term care sector as a representative microcosm of structural inequities, while recognizing that these unjust barriers to health are widespread, endemic, and pervasive. We present a call to action for gerontological nursing science to engage deeply and robustly in these realities, and the ethical and scientific imperative they present to ensure that all older adults encounter just conditions for maximizing their health and well-being. [Research in Gerontological Nursing, 15(1), 6-13.].
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Affiliation(s)
| | | | | | - Pamela Z. Cacchione
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Andrea Gilmore-Bykovskyi
- School of Nursing, Madison, Wisconsin, USA,University of Wisconsin-Madison Center for Health Disparities Research, Madison, Wisconsin, USA
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Ying M, Temkin-Greener H, Thirukumaran CP, Maddox KEJ, Holloway RG, Li Y. Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance. Med Care 2022; 60:83-92. [PMID: 34812788 PMCID: PMC8665005 DOI: 10.1097/mlr.0000000000001659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents. OBJECTIVE The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance. DESIGN, SETTING, AND PARTICIPANTS A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs. MAIN OUTCOME MEASURES Inflation-adjusted operating expenses, revenues, profit, and profit margin. RESULTS BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures. CONCLUSIONS BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.
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Affiliation(s)
- Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Helena Temkin-Greener
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
| | - Caroline Pinto Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY
| | - Karen E. Joynt Maddox
- Cardiovascular Division, School of Medicine, Washington University in St. Louis, St. Louis, MO
- Center for Health Economics and Policy, Washington University Institute for Public Health, St. Louis, MO
| | - Robert G. Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center, Rochester, NY
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Berridge C, Grigorovich A. Algorithmic harms and digital ageism in the use of surveillance technologies in nursing homes. FRONTIERS IN SOCIOLOGY 2022; 7:957246. [PMID: 36189442 PMCID: PMC9525107 DOI: 10.3389/fsoc.2022.957246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/26/2022] [Indexed: 05/10/2023]
Abstract
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.
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Affiliation(s)
- Clara Berridge
- School of Social Work, University of Washington, Seattle, WA, United States
- *Correspondence: Clara Berridge
| | - Alisa Grigorovich
- Recreation and Leisure Studies, Brock University, St. Catharines, ON, Canada
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Tzeng HM, Downer B, Haas A, Ottenbacher KJ. Association Between Cognitive Status and Falls With and Without Injury During a Skilled Nursing Facility Short Stay. J Am Med Dir Assoc 2022; 23:128-132.e2. [PMID: 34237256 PMCID: PMC8712356 DOI: 10.1016/j.jamda.2021.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To examine the relationship between cognitive status and falls with and without injury among older adults during the first 18 days of a skilled nursing facility (SNF) and determine if this association is mediated by limitations in activities of daily living (ADL) and impaired balance. DESIGN Cohort study of Medicare fee-for-service beneficiaries admitted to an SNF between October 1, 2016, and September 31, 2017. SETTINGS AND PARTICIPANTS 815,927 short-stay nursing home residents admitted to an SNF within 3 days of hospital discharge. METHODS Cognitive status at SNF admission was classified as intact, mild, moderate, or severe impairment. Residents were classified as having no falls, a fall without injury, and a fall with a minor or major injury. We used ordinal logistic regression to model the association between cognitive status and falls adjusting for resident and facility characteristics. A causal mediation analysis was used to test for the mediating effects of ADL limitations and impaired balance on the association between cognitive status and falls with an injury. RESULTS Mild, moderate, and severe cognitive impairment were associated with 1.72 (95% CI: 1.68-1.75), 2.72 (95% CI: 2.66-2.78), and 2.61 (95% CI: 2.48-2.75) higher odds of being in a higher fall severity category, respectively, compared to being cognitively unimpaired. Greater ADL limitations and impaired balance were significantly associated with falls, but each mediated the association between cognitive status and falls by less than 2%. CONCLUSIONS AND IMPLICATIONS Older adults with cognitive impairment are more likely to experience a fall during an SNF stay. ADL limitations and impaired balance are risk factors for falls but may not contribute to the increased fall risk for SNF residents with cognitive impairment. Continued research is needed to better understand the risk factors for falls among SNF residents with cognitive impairment.
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Affiliation(s)
- Huey-Ming Tzeng
- School of Nursing, University of Texas Medical Branch, Galveston, TX, USA; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA
| | - Brian Downer
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA; Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX, USA.
| | - Allen Haas
- Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Kenneth J Ottenbacher
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA; Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX, USA
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Mitchell SG, Nordeck CD, Lertch E, Ross TE, Welsh C, Schwartz RP, Gryczynski J. Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization. Subst Abus 2022; 43:848-854. [PMID: 35179452 PMCID: PMC9793431 DOI: 10.1080/08897077.2021.2007512] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.
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Affiliation(s)
| | - Courtney D. Nordeck
- Friends Research Institute, Inc., Baltimore, MD,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | - Christopher Welsh
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
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Mathuba W, Deer R, Downer B. Racial and ethnic differences in the improvement in daily activities during a nursing home stay. J Am Geriatr Soc 2021; 70:1244-1251. [PMID: 34882305 DOI: 10.1111/jgs.17600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Improving independence in daily activities is an important outcome of postacute nursing home care. We investigated racial and ethnic differences in the improvement in activities of daily living (ADL) during a skilled nursing facility (SNF) stay among Medicare fee-for-service beneficiaries with a hip fracture, joint replacement, or stroke. METHODS This was a retrospective study of Medicare beneficiaries admitted to a SNF between 01/01/2013 and 9/30/2015. The final sample included 428,788 beneficiaries admitted to a SNF within 3 days of hospital discharge for a hip fracture (n = 118,790), joint replacement (n = 245,845), or stroke (n = 64,153). Data from residents' first and last Minimum Data Set were used to calculate ADL total scores for self-performance in dressing, personal hygiene, toileting, locomotion on the unit, transferring, bed mobility, and eating. Residents were dichotomized according to having had any improvement in the ADL total score. Multivariable logistic regression models that included a random intercept for the facility were used to estimate the adjusted odds ratios for any improvement in ADL function among black and Hispanic residents compared to white residents. RESULTS A total of 299,931 residents (69.9%) had any improvement in ADL function. Black residents (OR:0.94; 95% CI: 0.91-0.98) but not Hispanic residents (OR: 0.98; 95% CI: 0.94-1.03) had significantly lower odds to have any improvement in ADL function. Analyses stratified by the reason for prior hospitalization indicated that black residents discharged for hip fracture (OR: 0.87; 95% CI: 0.80-0.93) and stroke (OR: 0.87; 95% CI: 0.83-0.93), but not joint replacement (OR: 1.02; 95% CI: 0.97-1.06) had significantly lower odds for any ADL improvement compared to white residents. CONCLUSIONS Our findings are evidence for racial disparities in the improvement in ADL function during a SNF stay. Future research should investigate systemic factors that may contribute to disparities in the improvement in ADL function during a SNF stay.
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Affiliation(s)
- Warona Mathuba
- University of Texas Medical Branch School of Medicine, Galveston, Texas, USA
| | - Rachel Deer
- Department of Nutrition, Metabolism & Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas, USA.,University of Texas Medical Branch, Sealy Center on Aging, Galveston, Texas, USA
| | - Brian Downer
- Department of Nutrition, Metabolism & Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas, USA.,University of Texas Medical Branch, Sealy Center on Aging, Galveston, Texas, USA
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Kapoor A, Sadiq H, Patel J, Zhang N, Mazor K, Crawford S, Chen Z, Gurwitz J, McManus D, Hanchate A. Disparities in Anticoagulation Use by Race and Ethnicity in Long-Term Care Residents With Atrial Fibrillation. J Am Heart Assoc 2021; 10:e023428. [PMID: 34816732 PMCID: PMC9075411 DOI: 10.1161/jaha.121.023428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alok Kapoor
- University of Massachusetts Medical SchoolWorcesterMA
- University of Massachusetts Memorial Medical CenterWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Hammad Sadiq
- University of Massachusetts Medical SchoolWorcesterMA
| | - Jay Patel
- University of Massachusetts Medical SchoolWorcesterMA
| | - Ning Zhang
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
- Department of Health Policy and PromotionSchool of Public Health and Health SciencesUniversity of Massachusetts AmherstAmherstMA
| | - Kathleen Mazor
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Sybil Crawford
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Zhiyong Chen
- University of Massachusetts Medical SchoolWorcesterMA
- Zem Data Science, LLCNorth PotomacMD
| | - Jerry Gurwitz
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - David McManus
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Amresh Hanchate
- Department of Social Sciences and HealthWake Forest School of MedicineWinston‐SalemNC
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Sharma H, Hefele JG, Xu L, Conkling B, Wang XJ. First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance. Med Care 2021; 59:1099-1106. [PMID: 34593708 DOI: 10.1097/mlr.0000000000001648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions. OBJECTIVE The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP. RESEARCH DESIGN We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis. RESULTS The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312. CONCLUSIONS SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.
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Affiliation(s)
- Hari Sharma
- Department of Health Management and Policy, The University of Iowa, Iowa City, IA
| | | | - Lili Xu
- Department of Health Management and Policy, The University of Iowa, Iowa City, IA
| | | | - Xiao Joyce Wang
- McCormack Graduate School of Policy and Global Studies, University of Massachusetts, Boston, MA
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