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Pesonen T, Väisänen V, Aaltonen M, Edgren J, Corneliusson L, Ruotsalainen S, Sinervo T. Determinants of received care time among Finnish home care clients and assisted living facility residents: a time-motion study. BMC Geriatr 2024; 24:754. [PMID: 39266978 PMCID: PMC11391809 DOI: 10.1186/s12877-024-05355-w] [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: 05/22/2023] [Accepted: 09/03/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND Ageing populations and care workforce shortages across Europe are causing challenges for care services for older people. Therefore, it is paramount that limited care resources are allocated optimally, based on the clients' care needs. Multiple functioning-related factors have been identified that determine the amount of care time clients receive, while organizational and other factors remain largely unexplored. The aim was to examine how various individual and organizational factors are associated with clients' received care time in different care settings. METHODS Cross-sectional observational study design with data from time and motion study, registers, and surveys was used. In total, 1477 home care clients and 1538 residents from assisted living facilities with 24/7 service participated, from 61 Finnish care units. Linear mixed-effect modeling was used to examine the association between individual and organizational-level variables and received care time. RESULTS Physical functioning was the strongest predictor of received care time in both care settings. In home care, greater pain, more unstable health, and higher team autonomy were associated with increased care time. In assisted living, depressive mood and higher staffing level of the organization were associated with care time. Clients who received informal care also received significantly more care time from nurses in both care settings. CONCLUSIONS Physical functioning was the main driver of received care time. Interventions that maintain or improve physical functioning can help restrain the growing need of care resources, although it is important to ensure that each client receives care according to their holistic care needs.
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Affiliation(s)
- Tiina Pesonen
- Finnish Institute for Health and Welfare, Helsinki, Finland.
| | - Visa Väisänen
- Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
| | - Mari Aaltonen
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Johanna Edgren
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | | | - Timo Sinervo
- Finnish Institute for Health and Welfare, Helsinki, Finland
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Rickert J. On Patient Safety: The Danger of Private Equity Involvement in Healthcare. Clin Orthop Relat Res 2024; 482:936-939. [PMID: 38662944 PMCID: PMC11124759 DOI: 10.1097/corr.0000000000003096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/01/2024] [Indexed: 05/26/2024]
Affiliation(s)
- James Rickert
- President, The Society for Patient Centered Orthopedics, Bloomington, IN, USA
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3
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Williams D, Fernandez R, Stevenson D, Unruh M, Braun RT. Nursing home finances associated with real estate investment trust and private equity investments. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae037. [PMID: 38756179 PMCID: PMC11034530 DOI: 10.1093/haschl/qxae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/04/2024] [Accepted: 04/03/2024] [Indexed: 05/18/2024]
Abstract
In 2021, real estate investment trusts (REITs) and private equity (PE) held investments in 1915 (16%) and 1569 (13%) US nursing homes (NHs), respectively. We created a database of REIT and PE investments in NHs, merged it with Medicare Cost Report data (2011-2019), and used a difference-in-differences approach within an event-study framework to compare NH spending and financial performance before and after REIT or PE investment to NHs that did not receive REIT or PE investment. REIT investments were associated with higher total wages (3%), total nursing wages (3%; both logged, per resident day [PRD]), and current ratio (81%). PE investments were associated with lower net patient service revenue (7%), total expenses (7%), and total wages (8%; all logged, PRD). The impact of REIT and PE investments in NHs may vary in different market conditions, as may occur in the current environment of low, falling NH profits, potentially higher minimum staffing requirements, and rising interest rates. Therefore, it is important for stakeholders to understand the impact of these large, growing investments on the financial performance of NHs.
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Affiliation(s)
- Dunc Williams
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC 29425-9620, United States
- Center for Telehealth—Telehealth Center of Excellence, Medical University of South Carolina, Charleston, SC 29425-9620, United States
| | - Rahul Fernandez
- Population Health Sciences, Division of Health Policy and Economics, Cornell University, New York, NY 10065, United States
| | - David Stevenson
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN 37232, United States
- The Geriatric Research, Education and Clinical Center (GRECC), Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN 37212-2637, United States
| | - Mark Unruh
- Population Health Sciences, Division of Health Policy and Economics, Cornell University, New York, NY 10065, United States
| | - Robert Tyler Braun
- Population Health Sciences, Division of Health Policy and Economics, Cornell University, New York, NY 10065, United States
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Sutton N, Ma N, Yang JS, Lin J. Quality effects of home acquisitions in residential aged care. Australas J Ageing 2024; 43:158-166. [PMID: 38317602 DOI: 10.1111/ajag.13268] [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] [Received: 04/11/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 02/07/2024]
Abstract
OBJECTIVE The recent consolidation of the Australian residential aged care market has raised concerns about the potential adverse effects of acquisition activity on quality of care (QoC). We examined changes in QoC outcomes within acquired homes and the influence of the acquiring providers' characteristics on these post-acquisition outcomes. METHODS A retrospective observational study was conducted using de-identified data sets obtained under the legal authority of the Royal Commission into Aged Care Quality and Safety. Regression analysis was used to investigate post-acquisition changes in QoC outcomes for 225 Australian home acquisitions between 2015 and 2019. The outcomes were analysed for the first two full financial years before and after the acquisition. RESULTS After controlling for other factors, we find acquired homes were associated with significantly worse QoC outcomes in the 2 years after acquisition, with higher rates of hospitalisations and reported complaints to the regulator. However, these results were driven by homes acquired by providers that were smaller in scale, for-profit or had comparatively poorer average quality across the other homes they operated. CONCLUSIONS Our finding that homes' QoC on average declines in the first 2 years following acquisition, are consistent with studies in other countries and points to the potential risks that consolidation poses to the care delivered to older people in Australia during that period.
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Affiliation(s)
- Nicole Sutton
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Nelson Ma
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jin Sug Yang
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jiali Lin
- University of Technology Sydney, Sydney, New South Wales, Australia
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Rhodes A, Novak AC, Caprio TV, Zanjani F, Marrs S, Gendron T, Waters L. Special Focus Facilities vs Special Focus Facility Candidates: What is the Difference? J Am Med Dir Assoc 2024; 25:390-395. [PMID: 37951582 DOI: 10.1016/j.jamda.2023.10.005] [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: 07/04/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES This study compares Special Focus Facilities (SFFs) and Special Focus Facility Candidate Facilities (SFFcs) on organizational traits and quality outcomes to evaluate the effectiveness of the SFF program as a quality improvement intervention and inform potential areas for program reform. DESIGN This is a retrospective analysis. SETTINGS AND PARTICIPANTS Using data from the Centers for Medicare and Medicaid Services archives for 2020, this retrospective study analyzed 247 nursing facilities (50 SFFs and 197 SFFcs). METHODS Variables of interest were staffing, profit status, facility size, certification status, number of residents, and complaint citations: t tests, χ2, Fisher's Exact test, and multivariate analysis of variance were used to compare the 2 groups. RESULTS From an organizational perspective, SFFs and SFFcs are minimally different. Both groups had similar facility size, profit status, hospital affiliation, continuing care retirement community status, and Medicare/Medicaid certification. Large and for-profit facilities were overrepresented in both groups. SFFs and SFFcs exhibited statistical differences in the number of complaint deficiencies. The groups had no significant difference in staffing levels, category, severity of complaints, or incident reports. CONCLUSIONS AND IMPLICATION The study's findings suggest that the SFF program, while resource-intensive, is minimally impactful. The similarities between SFFs and SFFcs raise questions about the program's effectiveness in improving nursing facility care. Previous adjustments to the program may not have successfully achieved the desired quality improvements. This research highlights the need to further evaluate the SFF program's effectiveness as a quality improvement intervention. It also underscores the importance of addressing biases and subjectivity in state survey agency processes, which affect the enrollment of nursing facilities. The study underscores the flaws within the nursing home monitoring system and the 5-star quality rating system, especially when comparing small samples between states.
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Affiliation(s)
- Annie Rhodes
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA.
| | | | - Thomas V Caprio
- University of Rochester Medical Center: Home Care and Medicine Hospice Program, Rochester, NY, USA
| | - Faika Zanjani
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA
| | - Sarah Marrs
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA
| | - Tracey Gendron
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA
| | - Leland Waters
- Department of Gerontology, Virginia Commonwealth University, Richmond, VA, USA
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Chen AC, Skinner RJ, Braun RT, Konetzka RT, Stevenson DG, Grabowski DC. New CMS Nursing Home Ownership Data: Major Gaps And Discrepancies. Health Aff (Millwood) 2024; 43:318-326. [PMID: 38437601 DOI: 10.1377/hlthaff.2023.01110] [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: 03/06/2024]
Abstract
Nursing home ownership has become increasingly complicated, partly because of the growth of facilities owned by institutional investors such as private equity (PE) firms and real estate investment trusts (REITs). Although the ownership transparency and accountability of nursing homes have historically been poor, the Biden administration's nursing home reform plans released in 2022 included a series of data releases on ownership. However, our evaluation of the newly released data identified several gaps: One-third of PE and fewer than one-fifth of REIT investments identified in the proprietary Irving Levin Associates and S&P Capital IQ investment data were present in Centers for Medicare and Medicaid Services (CMS) publicly available ownership data. Similarly, we obtained different results when searching for the ten top common owners of nursing homes using CMS data and facility survey reports of chain ownership. Finally, ownership percentages were missing in the CMS data for 82.40 percent of owners in the top ten chains and 55.21 percent of owners across all US facilities. Although the new data represent an important step forward, we highlight additional steps to ensure that the data are timely, accurate, and responsive. Transparent ownership data are fundamental to understanding the adequacy of public payments to provide patient care, enable policy makers to make timely decisions, and evaluate nursing home quality.
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Affiliation(s)
- Amanda C Chen
- Amanda C. Chen, Harvard University, Cambridge, Massachusetts
| | | | | | | | - David G Stevenson
- David G. Stevenson, Vanderbilt University and Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
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7
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Matthews S, Roxas R. Private equity and its effect on patients: a window into the future. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2023; 23:673-684. [PMID: 35604628 PMCID: PMC9125965 DOI: 10.1007/s10754-022-09331-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 04/08/2022] [Indexed: 05/17/2023]
Affiliation(s)
- Sajith Matthews
- Department of Internal Medicine, Wayne State University School of Medicine, 4201 St. Antoine St, UHC 5A, 48201 Detroit, MI United States
| | - Renato Roxas
- Department of Internal Medicine, Wayne State University School of Medicine, 4201 St. Antoine St, UHC 5A, 48201 Detroit, MI United States
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Felix HC, Brown CC, Narcisse MR, Vincenzo JL, Andersen JA, Weech-Maldonado R, Bradway CW. Characteristics of Nursing Homes with High Rates of Urinary Tract Infections among Their Residents with Obesity. UROLOGIC NURSING 2023; 46:273-303. [PMID: 38774393 PMCID: PMC11105761 DOI: 10.7257/2168-4626.2023.43.6.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Nursing home residents with obesity are at high risk for contracting urinary tract infections. In this research study, we found nursing homes in multi-facility chain organizations, for-profit status, nursing home size, obesity rate of resident population, and market competition were significantly associated with rates of urinary tract infections among residents with obesity.
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Affiliation(s)
- Holly C Felix
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Clare C Brown
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Marie-Rachelle Narcisse
- Warren Alpert Medical School of Brown University and a Research Scientist at Bradley Hospital, Providence, RI
| | - Jennifer L Vincenzo
- College of Health Professions, University of Arkansas for Medical Sciences, Fayetteville, AR
| | - Jennifer A Andersen
- Center for Community Health and Research, College of Medicine, University of Arkansas for Medical Sciences, Fayetteville, AR
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Borsa A, Bejarano G, Ellen M, Bruch JD. Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review. BMJ 2023; 382:e075244. [PMID: 37468157 DOI: 10.1136/bmj-2023-075244] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To review the evidence on trends and impacts of private equity (PE) ownership of healthcare operators. DESIGN Systematic review. DATA SOURCES PubMed, Web of Science, Embase, Scopus, and SSRN. ELIGIBILITY CRITERIA FOR STUDY SELECTION Empirical research studies of any design that evaluated PE owned healthcare operators. MAIN OUTCOME MEASURES The main outcome measures were impact of PE ownership on health outcomes, costs to patients or payers, costs to operators, and quality. The secondary outcome measures were trends and prevalence of PE ownership of healthcare operators. DATA SYNTHESIS Studies were classified as finding either beneficial, harmful, mixed, or neutral impacts of PE ownership on main outcome measures. Results across studies were narratively synthesized and reported. Risk of bias was evaluated using ROBINS-I (Risk Of Bias In Non-randomised Studies of Interventions). RESULTS The electronic search identified 1778 studies, with 55 meeting the inclusion criteria. Studies spanned eight countries, with most (n=47) analyzing PE ownership of healthcare operators in the US. Nursing homes were the most commonly studied healthcare setting (n=17), followed by hospitals and dermatology settings (n=9 each); ophthalmology (n=7); multiple specialties or general physician groups (n=5); urology (n=4); gastroenterology and orthopedics (n=3 each); surgical centers, fertility, and obstetrics and gynecology (n=2 each); and anesthesia, hospice care, oral or maxillofacial surgery, otolaryngology, and plastics (n=1 each). Across the outcome measures, PE ownership was most consistently associated with increases in costs to patients or payers. Additionally, PE ownership was associated with mixed to harmful impacts on quality. These outcomes held in sensitivity analyses in which only studies with moderate risk of bias were included. Health outcomes showed both beneficial and harmful results, as did costs to operators, but the volume of studies for these outcomes was too low for conclusive interpretation. In some instances, PE ownership was associated with reduced nurse staffing levels or a shift towards lower nursing skill mix. No consistently beneficial impacts of PE ownership were identified. CONCLUSIONS Trends in PE ownership rapidly increased across almost all healthcare settings studied. Such ownership is often associated with harmful impacts on costs to patients or payers and mixed to harmful impacts on quality. Owing to risk of bias and frequent geographic focus on the US, conclusions might not be generalizable internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022329857.
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Affiliation(s)
- Alexander Borsa
- Department of Sociomedical Sciences, Columbia University, New York, NY, USA
| | - Geronimo Bejarano
- Department of Epidemiology, University of Texas School of Public Health (UTHealth), Austin, TX, USA
| | - Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Health Policy Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Joseph Dov Bruch
- Department of Public Health Sciences, University of Chicago, Chicago, IL 60637, USA
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Matays J, Scruth E, Kawar LN, Cluff SC, Fogli A, Salas M, Harrington C. Advocating for the Vulnerable: The Clinical Nurse Specialist and Nursing Home Reform. CLIN NURSE SPEC 2023; 37:124-132. [PMID: 37058703 DOI: 10.1097/nur.0000000000000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
INTRODUCTION Nursing homes have been disproportionally affected by the COVID-19 pandemic, particularly because of resident vulnerability, inadequate staffing, and poor quality of care. CURRENT STATE Despite billions of dollars in funding, nursing homes often do not meet minimum federal staffing requirements and are frequently cited for infection prevention and control deficiencies. These factors significantly contributed to resident and staff deaths. For-profit nursing homes were associated with more COVID-19 infections and deaths. Nearly 70% of US nursing homes are for-profit ownership, where quality measures and staffing levels are often lower than their nonprofit counterparts. Nursing home reform is urgently needed to improve staffing and care quality in these facilities. Some states, such as Massachusetts, New Jersey, and New York, have made legislative progress in establishing standards for nursing home spending. The Biden Administration has also announced initiatives, through the Special Focus Facilities Program, to improve nursing home quality and the safety of residents and staff. Concurrently, the "National Imperative to Improve Nursing Home Quality" report from the National Academies of Science, Engineering, and Medicine made specific staffing recommendations, including an increase in direct care registered nurse coverage. CONCLUSION There is an urgent need to advocate for nursing home reform by partnering with congressional representatives or supporting nursing home legislation to improve care for this vulnerable patient population. Adult-gerontology clinical nurse specialists have an opportunity to leverage their advanced knowledge and unique skill set to lead and facilitate change to improve quality of care and patient outcomes.
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Affiliation(s)
- Jennie Matays
- Author Affiliations: Critical Care Clinical Nurse Specialist (Dr Matays), Kaiser Permanente, South Sacramento, Sacramento, California; Executive Director (Dr Scruth), Clinical Quality Programs, Data Analytics, and Tele Critical Care, NCAL Safety, Quality, and Regulatory Services-Kaiser Foundation Hospital and Health Plan, Oakland, California; Nurse Scientist (Dr Kawar), Kaiser Permanente, Southern California Patient Care Services, Regional Nursing Research Program, Pasadena, California; Outpatient Palliative Care RN Case Manager (Ms Cluff), Kaiser Permanente East Bay, Oakland, California; Geriatric Clinical Nurse Specialist (Ms Fogli), Kaiser Permanente, Walnut Creek Medical Center, California; Clinical Nurse Specialist (Ms Salas), Kaiser Permanente Antioch Medical Center, California; and Professor Emerita (Dr Harrington), Department of Social and Behavioral Sciences, University of California San Francisco
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Ying M, Temkin-Greener H, Thirukumaran CP, Joynt Maddox KE, Holloway RG, Li Y. Skilled Nursing Facility Participation in Bundled Payments Was Related to Small Increases in Nurse Staffing Levels. J Appl Gerontol 2023; 42:456-463. [PMID: 36321398 DOI: 10.1177/07334648221137060] [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] [Indexed: 02/18/2023] Open
Abstract
Medicare implemented Bundled Payments for Care Improvement (BPCI) Model 3 in 2013, in which participating skilled nursing facilities (SNFs) were accountable for episode costs. We performed comparative interrupted time series analyses to evaluate associations between SNF BPCI participation and nurse staffing levels, using Medicare claims, resident assessments, and facility-level and market-level files of 2010-2017. For persistent-participating SNFs, BPCI was associated with improved certified nursing assistant (CNA) staffing levels (differential change = .03 hours, p = .025). However, BPCI was not related to changes in registered nurse (RN) and all licensed nurse hours, and nurse skill mix. Among drop-out SNFs, BPCI was associated with increased RN staffing levels (differential change = .02 hours, p = .009), leading to a higher nurse skill ratio (0.51 percentage points, p = .016) than control SNFs. Bundled payments for care improvement had no impact on CNA and all licensed nurse staffing levels. In conclusion, BPCI was associated with statistically significant but small increases in nurse staffing levels.
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Affiliation(s)
- Meiling Ying
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Urology, Dow Division of Health Services Research, 12266University of Michigan Medical School, Ann Arbor, MI, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Caroline P Thirukumaran
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Orthopaedics, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, 12275Washington University School of Medicine, St Louis, MI, USA
- Center for Health Economics and Policy, 12275Institute for Public Health at Washington University in St Louis, St. Louis, Missouri, USA
| | - Robert G Holloway
- Department of Neurology, 6923University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, 6923University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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12
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Braun RT, Williams D, Stevenson DG, Casalino LP, Jung HY, Fernandez R, Unruh MA. The Role Of Real Estate Investment Trusts In Staffing US Nursing Homes. Health Aff (Millwood) 2023; 42:207-216. [PMID: 36696597 DOI: 10.1377/hlthaff.2022.00278] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In 2021 real estate investment trusts (REITs) held investments in 1,806 US nursing homes. REITs are for-profit public or private corporations that invest in income-producing properties. We created a novel database of REIT investments in US nursing homes, merged it with Medicare cost report data (2013-19), and used a difference-in-differences approach within an event study framework to compare staffing before and after a nursing home received REIT investment with staffing in for-profit nursing homes that did not receive REIT investment. REIT investment was associated with average relative staffing increases of 2.15 percent and 1.55 percent for licensed practical nurses (LPNs) and certified nursing assistants (CNAs), respectively. During the postinvestment period, registered nurse (RN) staffing was unchanged, but event study results showed a 6.25 percent decrease in years 2 and 3 after REIT investment. After the three largest REIT deals were excluded, REIT investments were associated with an overall 6.25 percent relative decrease in RN staffing and no changes in LPN and CNA staffing. Larger deals resulted in increases in LPN and CNA staffing, with no changes in RN staffing; smaller deals appeared to replace more expensive and skilled RN staffing with less expensive and skilled staff.
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Affiliation(s)
| | - Dunc Williams
- Dunc Williams, Medical University of South Carolina, Charleston, South Carolina
| | - David G Stevenson
- David G. Stevenson, Vanderbilt University and Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
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13
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Lindmark T, Engström M, Trygged S. Psychosocial Work Environment and Well-Being of Direct-Care Staff Under Different Nursing Home Ownership Types: A Systematic Review. J Appl Gerontol 2023; 42:347-359. [PMID: 36214292 PMCID: PMC9841825 DOI: 10.1177/07334648221131468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/15/2022] [Accepted: 09/19/2022] [Indexed: 01/15/2023] Open
Abstract
This systematic review investigated the psychosocial work environment and well-being of direct-care staff under different nursing home ownership types. Databases searched: Scopus, Web of Science, Cinahl, and PubMed, 1990-2020. Inclusion criteria: quantitative or mixed-method studies; population: direct-care staff in nursing homes; exposure: for-profit and non-profit ownership; and outcomes: psychosocial work environment and well-being. In total, 3896 articles were screened and 17(n = 12,843 participants) were assessed using the Joanna Briggs Institute Critical Appraisal tools and included in the narrative synthesis. The results were inconsistent, but findings favored non-profit over for-profit settings, for example, regarding leaving intentions, organizational commitment, and stress-related outcomes. There were no clear differences concerning job satisfaction. Job demands were higher in non-profit nursing homes but alleviated by better job resources in one study. The result highlights work environment issues, with regulations concerning for-profit incentives being discussed in terms of staff benefits.
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Affiliation(s)
- Tomas Lindmark
- Faculty of Health and Occupational Studies, Department of Social Work, University of Gävle, Gävle, Sweden
| | - Maria Engström
- Faculty of Health and Occupational Studies, Department of Caring Science, University of Gävle, Gävle, Sweden
| | - Sven Trygged
- Faculty of Health and Occupational Studies, Department of Social Work, University of Gävle, Gävle, Sweden
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14
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Kusmaul N, Becker TD, Hector P, Bern-Klug M, Smith KM. High Interest in Pursuing Trauma-Informed Care in Nursing Home Social Services Directors. J Appl Gerontol 2023:7334648231153729. [PMID: 36703571 DOI: 10.1177/07334648231153729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
This study explored nursing home social services directors' interest in pursuing trauma-informed care (TIC) training, and individual and organizational characteristics associated with their interest. Data from the 2019 National Nursing Home Social Services Directors Survey, a national cross-sectional survey, were used. Measures sought information on participants' interest in TIC training, sociodemographic characteristics, and characteristics of employing nursing homes. Descriptive statistics and multivariate binary logistic regression analyses were used. Of the 924 respondents, 880 (95.2%) were included in the analysis. Most (71.7%) expressed high interest in TIC training. Younger age, fewer years of nursing home social services experience, being degreed and licensed in social work, and being a person of color were associated with greater odds of high interest in TIC training. Neither nursing home ownership nor social services staffing ratio was significantly associated with interest in TIC training. As policy requires TIC in nursing homes, these findings present a first step towards understanding implementation.
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Affiliation(s)
- Nancy Kusmaul
- 14701University of Maryland, Baltimore County, Baltimore, MD, USA
| | - Todd D Becker
- 115980University of Maryland, Baltimore, Baltimore, MD, USA
| | - Paige Hector
- Paige Ahead Healthcare Education & Consulting, Tucson, AZ, USA
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15
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Dunbar P, Keyes LM, Browne JP. Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research. PLoS One 2023; 18:e0278007. [PMID: 37053186 PMCID: PMC10101495 DOI: 10.1371/journal.pone.0278007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/13/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services. METHODS Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes. RESULTS The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance. CONCLUSION The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.
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Affiliation(s)
- Paul Dunbar
- Health Information and Quality Authority, Mahon, Cork, Ireland
| | - Laura M Keyes
- Health Information and Quality Authority, Mahon, Cork, Ireland
| | - John P Browne
- School of Public Health, University College Cork, Cork, Ireland
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16
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Patwardhan S, Sutton M, Morciano M. Effects of chain ownership and private equity financing on quality in the English care home sector: retrospective observational study. Age Ageing 2022; 51:6936404. [PMID: 36571782 PMCID: PMC9792077 DOI: 10.1093/ageing/afac222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/21/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND the structure of care homes markets in England is changing with the emergence of for-profit homes organised in chains and financed by private equity. Previous literature shows for-profit homes were rated lower quality than not-for-profit homes when inspected by the national regulator, but has not considered new forms of financing. OBJECTIVES to examine whether financing and organisation of care homes is associated with regulator assessments of quality. METHODS retrospective observational study of the Care Quality Commission's ratings of 10,803 care homes providing services to older people as of January 2020. We used generalised ordered logistic models to assess whether ratings differed between not-for-profit and for-profit homes categorised into three groups: (i) chained ownership, financed by private equity; (ii) chained ownership, not financed by private equity and (iii) independent ownership. We compared Overall and domain (caring, effective, responsive, safe, well-led) ratings adjusted for care home size, age and location. RESULTS all three for-profit ownership types had lower average overall ratings than not-for-profit homes, especially independent (6.8% points (p.p.) more likely rated as 'Requires Improvement/Inadequate', 95% CI: 4.7-8.9) and private equity chains (6.6 p.p. more likely rated as 'Requires Improvement/Inadequate', 95% CI: 2.9-10.2). Independent homes scored better than private equity chains in the safe, effective and responsive domains but worst in the well-led domain. DISCUSSION private equity financing and independent for-profit ownership are associated with lower quality. The consequences of the changing care homes market structure for quality of services should be monitored.
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Affiliation(s)
- Sharvari Patwardhan
- Health Organization, Policy and Economics (HOPE) research group, School of Health Science, Oxford Road, M13 9PL, Manchester, UK
| | - Matthew Sutton
- Health Organization, Policy and Economics (HOPE) research group, School of Health Science, Oxford Road, M13 9PL, Manchester, UK
| | - Marcello Morciano
- Address correspondence to: Morciano Marcello, The University of Manchester, UK.
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17
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Franzosa E, Wyte-Lake T, Tsui EK, Reckrey JM, Sterling MR. Essential but Excluded: Building Disaster Preparedness Capacity for Home Health Care Workers and Home Care Agencies. J Am Med Dir Assoc 2022; 23:1990-1996. [PMID: 36343702 PMCID: PMC9634621 DOI: 10.1016/j.jamda.2022.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
COVID-19 has demonstrated the essential role of home care services in supporting community-dwelling older and disabled individuals through a public health emergency. As the pandemic overwhelmed hospitals and nursing homes, home care helped individuals remain in the community and recover from COVID-19 at home. Yet unlike many institutional providers, home care agencies were often disconnected from broader public health disaster planning efforts and struggled to access basic resources, jeopardizing the workers who provide this care and the medically complex and often marginalized patients they support. The exclusion of home care from the broader COVID-19 emergency response underscores how the home care industry operates apart from the traditional health care infrastructure, even as its workers provide essential long-term care services. This special article (1) describes the experiences of home health care workers and their agencies during COVID-19 by summarizing existing empiric research; (2) reflects on how these experiences were shaped and exacerbated by longstanding challenges in the home care industry; and (3) identifies implications for future disaster preparedness policies and practice to better serve this workforce, the home care industry, and those for whom they care.
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Affiliation(s)
- Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Geriatric Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY, USA,Address correspondence to Emily Franzosa DrPH, Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY
| | - Tamar Wyte-Lake
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Emma K. Tsui
- Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Jennifer M. Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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18
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Del Piero J, Parikh R, Weng CY. Driving forces and current trends in private equity acquisitions within ophthalmology. Curr Opin Ophthalmol 2022; 33:347-351. [PMID: 35838270 DOI: 10.1097/icu.0000000000000880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Private equity investment in ophthalmology has dramatically increased over the past 20 years. Despite a massive influx in private equity investment in ophthalmology, little is known regarding if and how private equity investment might affect practice behavior. This review seeks to discuss why private equity investment may be expanding in ophthalmology and explore recent data on demographic and billing trends before and after private equity acquisition. RECENT FINDINGS Recent publications have identified ophthalmology and optometry practices acquired by private equity from 2012 to 2021. Practice demographics and provider billing habits before and after private equity acquisition were analyzed from 2012 to 2019 and 2012 to 2017, respectively, using Internal Revenue Service, United States Census, and Medicare fee-for-service data. SUMMARY Private equity investment in ophthalmology is increasing and may be because of a growing demand from an aging population, fragmented network of healthcare practices, and potential for ancillary billable services. Private equity practices acquired between 2012 and 2019 were mostly in metropolitan areas with higher proportions of private insurance coverage. Ophthalmologists and optometrists in practices acquired between 2012 and 2016 showed increased utilization of diagnostic testing and cataract surgery in the year following private equity acquisition compared with the year prior to private equity acquisition.
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Affiliation(s)
- Juliet Del Piero
- Baylor College of Medicine, Cullen Eye Institute, Houston, Texas
| | - Ravi Parikh
- Manhattan Retina and Eye
- New York University School of Medicine, New York, New York, USA
| | - Christina Y Weng
- Baylor College of Medicine, Cullen Eye Institute, Houston, Texas
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19
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Exploitation, Freedom, and Coercion: The Integration of Applied Behavior Analysis in a Capitalist System. BEHAVIOR AND SOCIAL ISSUES 2022. [DOI: 10.1007/s42822-022-00100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Gozalo PL, Inrator O, Phibbs CS, Kinosian B, Allen SM. Successful Discharge of Short Stay Veterans from VA Community Living Centers. J Aging Soc Policy 2022; 34:690-706. [PMID: 35959862 DOI: 10.1080/08959420.2022.2111169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007-2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed the patient and facility rates of successful discharge to the community (SDC) of these short-stay Veterans. We found large variation in inter- as well as intra- facility SDC rates across the rehabilitation and skilled nursing short-stay cohorts. We discuss how our results can help guide VHA policy directed at delivering high-quality short-stay CLC care for Veterans.
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Affiliation(s)
- Pedro L Gozalo
- Research Health Scientist, U.S. Department of Veterans Affairs Medical Center, Center of Innovation in Long-Term Services and Supports, Providence, Rhode Island, USA.,Professor, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Orna Inrator
- Professor, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Research Health Scientist, Geriatrics & Extended Care Data & Analysis Center (GEC DAC), Canandaigua VA Medical Center, Canandaigua, New York, USA
| | - Ciaran S Phibbs
- Research Health Scientist, Health Economics Resource Center, Palo Alto VA Health Care System, Palo Alto, California, USA.,Associate Professor, Center for Innovation to Implementation, Stanford University School of Medicine, Palo Alto, California, USA.,Research Health Scientist, Geriatrics and Extended Care Data and Analysis Center, Palo Alto VA Health Care System, Palo Alto, California, USA
| | - Bruce Kinosian
- Associate Professor, Division of Geriatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Research Health Scientist, Geriatrics & Extended Care Data & Analysis Center (GEC DAC), Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Susan M Allen
- Research Health Scientist, U.S. Department of Veterans Affairs Medical Center, Center of Innovation in Long-Term Services and Supports, Providence, Rhode Island, USA.,Professor, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
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21
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Nursing Homes: Affiliation to Large Chains, Quality and Public–Private Collaboration. Healthcare (Basel) 2022; 10:healthcare10081431. [PMID: 36011087 PMCID: PMC9408552 DOI: 10.3390/healthcare10081431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 11/20/2022] Open
Abstract
The objective of this paper was to estimate the influence of being affiliated with an NH chain on perceived consumer quality, and whether this relationship is affected by maintaining a collaboration agreement with public administrations. We used a combination of theoretical foundations: (1) From the consumer perspective, we focussed on online reviews of the quality of nursing homes (NHs); (2) from the industrial organisation literature, we proposed arguments regarding the advantages and disadvantages of belonging to a chain; (3) the theory of transaction costs was used to explain public–private collaboration. The study was carried out on a sample of 642 chain-affiliated Spanish NHs, with data from quality scores downloaded from the website topMayores.es. We distinguished between the six largest chains and the rest. We applied linear regression models. The results show that NHs affiliated with one of the largest NH chains obtained worse quality scores in the assessment made by users, although quality scores improved for the largest chains of NHs involved in an agreement with the public administration.
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22
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Yoon JM, Trinkoff AM, Galik E, Storr CL, Lerner NB, Brandt N, Zhu S. Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia. J Am Med Dir Assoc 2022; 23:1772-1779. [PMID: 35568094 DOI: 10.1016/j.jamda.2022.04.006] [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] [Received: 11/17/2021] [Revised: 03/14/2022] [Accepted: 04/02/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia. DESIGN A mixed-methods study was performed. SETTING AND PARTICIPANTS During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica. METHODS Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ2 tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports. RESULTS Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on PRN psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001). CONCLUSIONS AND IMPLICATIONS This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.
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Affiliation(s)
- Jung Min Yoon
- Stony Brook University School of Nursing, Stony Brook, NY, USA.
| | | | - Elizabeth Galik
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Carla L Storr
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Nancy B Lerner
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Nicole Brandt
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Shijun Zhu
- University of Maryland School of Nursing, Baltimore, MD, USA
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23
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Hass Z, Abrahamson K, Arling G. Ownership Change and Care Quality: Lessons from Minnesota’s Experience with Value-Based Purchasing. Innov Aging 2022; 6:igac022. [PMID: 35712326 PMCID: PMC9196681 DOI: 10.1093/geroni/igac022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Minnesota’s implementation of a new nursing home value-based reimbursement (VBR) system in 2016 presented an opportunity to compare the response of nursing homes (NHs) to financial incentives to improve their quality and efficiency. The state substantially increased reimbursement for care-related costs and tied this rate increase to a composite quality score. Coinciding with rate increases of the new VBR system was an increase in ownership changes, with new owners being primarily for-profit entities from outside of Minnesota, including several private equity firms. Our objective was to examine NHs that underwent a change in ownership to determine their cost and quality response to the change. Research Design and Methods Our sample consists of 342 Minnesota NHs that submitted Medicaid cost reports each year from 2013 to 2019. A time differential two-way fixed-effects difference-in-difference model is used to assess changes in quality metrics by comparing measures in years prior to and years following the sale for NHs that changed ownership versus NHs with consistent ownership. Nursing home characteristics, revenue, and spending patterns are examined to understand differences in performance. Results Those NHs with ownership change experienced a decline in quality scores with notable changes to expenditure patterns. They performed worse on Minnesota Department of Health inspection scores and had nonsignificant declines in measures of quality of life and clinical care. They had declining staff dental and medical benefits and occupancy rates, greater revenue growth from Medicare Part B, and larger increases in administrative management fees. Discussion and Implications Minnesota like many other states has given wide latitude for nursing home ownership changes, without specific oversight for the quality of care and expenditure patterns of new owners. Recommendations include strict guidelines for the transparency of ownership structures, quality performance targets, rigorous financial auditing, and enhanced regulatory oversight.
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Affiliation(s)
- Zachary Hass
- Schools of Nursing and Industrial Engineering, Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Kathleen Abrahamson
- School of Nursing, Center for Aging and the Life Course, Purdue University, West Lafayette, Indiana, USA
| | - Greg Arling
- School of Nursing, Center for Aging and the Life Course, Purdue University, West Lafayette, Indiana, USA
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24
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Cerullo M, Lin YL, Rauh-Hain JA, Ho V, Offodile AC. Financial Impacts And Operational Implications Of Private Equity Acquisition Of US Hospitals. Health Aff (Millwood) 2022; 41:523-530. [PMID: 35377756 DOI: 10.1377/hlthaff.2021.01284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although private equity acquisition of short-term acute care hospitals purportedly improves efficiency and cost-effectiveness, financial performance after acquisition remains unexamined. We compared changes in the financial performance of 176 hospitals acquired during 2005-14 versus changes in matched control hospitals. Acquisition was associated with a $432 decrease in cost per adjusted discharge and a 1.78-percentage-point increase in operating margin. The majority of acquisitions-134 members of the Hospital Corporation of America, acquired in 2006-were associated with a $559 decrease in cost per adjusted discharge but no change in operating margin. Conversely, non-HCA hospitals exhibited a 3.27-percentage-point increase in operating margin without a concomitant change in cost per adjusted discharge. When we examined markers of hospital capacity, operational efficiency, and costs, we found that private equity acquisition was associated with decreases in total beds, ratio of outpatient to inpatient charges, and staffing (total personnel and nursing full-time equivalents and total full-time equivalents per occupied bed). Therefore, financial performance improved after acquisition, whereas patient throughput and inpatient utilization increased and staffing metrics decreased. Future research is needed to identify any unintended trade-offs with safety and quality.
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Affiliation(s)
- Marcelo Cerullo
- Marcelo Cerullo, Duke University Hospital, Durham, North Carolina
| | - Yu-Li Lin
- Yu-Li Lin, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Vivian Ho
- Vivian Ho, Rice University and Baylor College of Medicine, Houston, Texas
| | - Anaeze C Offodile
- Anaeze C. Offodile II , University of Texas MD Anderson Cancer Center and Rice University
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25
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Bowblis JR. The Need for an Economically Feasible Nursing Home Staffing Regulation: Evaluating an Acuity-Based Nursing Staff Benchmark. Innov Aging 2022; 6:igac017. [PMID: 35712323 PMCID: PMC9196696 DOI: 10.1093/geroni/igac017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Indexed: 11/21/2022] Open
Abstract
Background and Objectives Despite concerns about the adequacy of nursing home (NH) staffing, the federal agency responsible for NH certification and regulation has never adopted an explicit quantitative nursing staff standard. A prior study has proposed a benchmark for this purpose based on the 1995/97 Staff Time Measurement (STM) studies. This article aims to assess the extent to which NHs staff to this proposed STM benchmark, the extent to which regulators already implicitly apply the STM benchmark, and compute the additional operating expenses NHs would incur to adhere to the STM benchmark. Research Design and Methods Using NH Compare Archive data, the STM benchmark was compared to staffing levels reported by the facility and whether NHs received a nursing staff deficiency. Using financial information from Medicare Cost Reports, the additional annual operating expenses required to staff to the STM benchmark were calculated for each state and nationwide. Results The vast majority of NHs did not staff to the STM benchmark; 80.2% for registered nurses and 60.0% for total nursing staff. Deficiency patterns showed that NH regulators were not using the STM benchmark to determine sufficiency of nursing staff. Implementing the STM benchmark as a regulatory standard would increase operating expenses for 59.1% of NHs, at an average annual cost of half-million dollars per facility. The nationwide increase in operating expense is estimated to be at least $4.9 billion per year. Discussion and Implications Without clear guidance on the staffing level needed to be sufficiently staffed, most NHs are subject to a community standard of care, which some have argued could be associated with suboptimal staffing levels. Implementing an acuity-based benchmark could result in improved staffing levels but also comes with significant economic costs. The STM benchmark is not economically feasible at current Medicare and Medicaid reimbursement levels.
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Affiliation(s)
- John R Bowblis
- Address correspondence to: John R. Bowblis, PhD, Department of Economics and Scripps Gerontology Center, Miami University, 800 E. High St., Oxford, OH 45056, USA. E-mail:
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26
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Fogel AL, Hogan S, Dover J. Surgical Dermatology and Private Equity: A Review of the Literature and Discussion. Dermatol Surg 2022; 48:339-343. [PMID: 34985045 DOI: 10.1097/dss.0000000000003363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While there has been substantial investment in dermatology by private equity (PE), the relevance of this trend to the dermatologic surgeon has not been assessed. OBJECTIVE The literature on PE investment in medicine was reviewed to provide interdisciplinary data relevant to the dermatologic surgeon. MATERIALS AND METHODS The PubMed database was queried for all peer-reviewed articles containing the term "private equity" and identified 70 unique articles across 18 medical specialties, comprising 20 original research articles and 50 commentary articles. RESULTS Significant PE growth across multiple medical specialties occurred in the 2010s. Private equity ownership was associated with higher levels of nonphysician providers relative to physicians. Pooled data suggest that PE ownership is associated with lower staffing levels, particularly for non-revenue-generating staff, as well as potentially lower levels of medical supplies on hand. Data on financial performance suggests that PE-ownership results in higher profits, revenues, and costs. Surveys of physicians demonstrate concern about autonomy, ethics, and career prospects. CONCLUSION For the dermatologic surgeon, issues related to consolidation, provider scope of practice, support staff availability, and supply management are important due to the nature of procedural intervention and the increased risk of adverse events.
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Affiliation(s)
- Alexander L Fogel
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Sara Hogan
- Division of Dermatology, University of California Los Angeles, Los Angeles, California
| | - Jeffrey Dover
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
- Skin Care Physicians, Boston, Massachusetts
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27
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Kingsley DE, Harrington C. Financial and Quality Metrics of A Large, Publicly Traded U.S. Nursing Home Chain in the Age of Covid-19. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2022; 52:212-224. [PMID: 35118905 DOI: 10.1177/00207314221077649] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nursing homes faced serious challenges with large COVID-19 resident infection rates and deaths during the pandemic. This descriptive case study examined the structure, operations, strategies, care outcomes, and owners of The Ensign Group Inc. the second largest U.S. for-profit chain, between 2007 and 2021. Ensign, as a holding company, has a complex organizational structure that uses more than 430 corporate entities to manage its 228 nursing homes and senior living facilities. With mostly Medicare and Medicaid revenues and favorable government COVID-19 relief, Ensign grew rapidly, even during the pandemic, to $2.5 billion (all amounts in U.S. Dollars) in revenues with a market capitalization of $4.5 billion and strong profits and financial metrics in 2020 to 2021. The company used real estate purchasing, debt financing, and spin-off companies, and tax arbitrage to optimize shareholder value. Before and during the pandemic, its 198 nursing homes had low registered nurse and total nurse staffing levels and regulatory violations with below-average ratings, and they had high COVID-19 infection rates during the pandemic. Ensign's small board, executives, and institutional investors protected and enhanced shareholder interests rather than ensuring that its nursing homes met professional standards and regulatory requirements.
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Affiliation(s)
- David E Kingsley
- Department of Health Policy & Management, 12251University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Charlene Harrington
- Social & Behavioral Sciences, University of California, San Francisco, CA, USA
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28
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Zimmerman S, Carder P, Schwartz L, Silbersack J, Temkin-Greener H, Thomas KS, Ward K, Jenkens R, Jensen L, Johnson AC, Johnson J, Johnston T, Kaes L, Katz P, Klinger JH, Lieblich C, Mace B, O'Neil K, Pace DD, Scales K, Stone RI, Thomas S, Williams PJ, Williams KB. The Imperative to Reimagine Assisted Living. J Am Med Dir Assoc 2022; 23:225-234. [PMID: 34979136 PMCID: PMC8826534 DOI: 10.1016/j.jamda.2021.12.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
Assisted living (AL) has existed in the United States for decades, evolving in response to older adults' need for supportive care and distaste for nursing homes and older models of congregate care. AL is state-regulated, provides at least 2 meals a day, around-the-clock supervision, and help with personal care, but is not licensed as a nursing home. The key constructs of AL as originally conceived were to provide person-centered care and promote quality of life through supportive and responsive services to meet scheduled and unscheduled needs for assistance, an operating philosophy emphasizing resident choice, and a residential environment with homelike features. As AL has expanded to constitute half of all long-term care beds, the increasing involvement of the real estate, hospitality, and health care sectors has raised concerns about the variability of AL, the quality of AL, and standards for AL. Although the intent to promote person-centered care and quality of life has remained, those key constructs have become mired under tensions related to models of AL, regulation, financing, resident acuity, and the workforce. These tensions have resulted in a model of care that is not as intended, and which must be reimagined if it is to be an affordable care option truly providing quality, person-centered care in a suitable environment. Toward that end, 25 stakeholders representing diverse perspectives conferred during 2 half-day retreats to identify the key tensions in AL and discuss potential solutions. This article presents the background regarding those tensions, as well as potential solutions that have been borne out, paving the path to a better future of assisted living.
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Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paula Carder
- Institute on Aging, College of Urban and Public Affairs and School of Public Health, Oregon Health and Science University-Portland State University, Portland, OR, USA
| | - Lindsay Schwartz
- Center for Health Policy Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, DC, USA
| | - Johanna Silbersack
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kali S Thomas
- US Department of Veterans Affairs Medical Center, and Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kimberly Ward
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Liz Jensen
- Direct Supply Innovation & Technology Center, Milwaukee, WI, USA
| | - Alfred C Johnson
- National Association for Regulatory Administration, Madison, WI, USA
| | | | | | - Loretta Kaes
- American Assisted Living Nurses Association, Napa Valley, CA, USA
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, FL, USA
| | | | | | - Beth Mace
- National Investment Center for Seniors Housing and Care, Annapolis, MD, USA
| | | | - Douglas D Pace
- Mission Partnerships, Alzheimer's Association, Washington, DC, USA
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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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Braun RT, Jung HY, Casalino LP, Myslinski Z, Unruh MA. Association of Private Equity Investment in US Nursing Homes With the Quality and Cost of Care for Long-Stay Residents. JAMA HEALTH FORUM 2021; 2:e213817. [PMID: 35977267 PMCID: PMC8796926 DOI: 10.1001/jamahealthforum.2021.3817] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022] Open
Abstract
Question Is private equity acquisition of nursing homes associated with the quality or cost of care for long-stay nursing home residents? Findings In this cohort study with difference-in-differences analysis of 9864 US nursing homes, including 9632 residents in 302 nursing homes acquired by private equity firms and 249 771 residents in 9562 other for-profit nursing homes without private equity ownership, private equity acquisition of nursing homes was associated with higher costs and increases in emergency department visits and hospitalizations for ambulatory sensitive conditions. Meaning This study suggests that more stringent oversight and reporting on private equity ownership of nursing homes may be warranted. Importance Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. Objective To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. Design, Setting, and Participants In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity–acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Exposure Private equity acquisitions of 302 nursing homes between 2013 and 2017. Main Outcomes and Measures This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care–sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Results Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity–acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (−0.2 percentage points; 95% CI, −1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, −1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, −0.4 to 1.3 percentage points; P = .30). Conclusions and Relevance This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.
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Affiliation(s)
- Robert Tyler Braun
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Hye-Young Jung
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Zachary Myslinski
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Mark Aaron Unruh
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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Cerullo M, Yang KK, Roberts J, McDevitt RC, Offodile AC. Private Equity Acquisition And Responsiveness To Service-Line Profitability At Short-Term Acute Care Hospitals. Health Aff (Millwood) 2021; 40:1697-1705. [PMID: 34724425 DOI: 10.1377/hlthaff.2021.00541] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
As private equity firms continue to increase their ownership stake in various health care sectors in the US, questions arise about potential impacts on the organization and delivery of care. Using a difference-in-differences approach, we investigated changes in service-line provision in private equity-acquired hospitals. Relative to nonacquired hospitals, private equity acquisition was associated with a higher probability of adding specific profitable hospital-based services (interventional cardiac catheterization, hemodialysis, and labor and delivery), profitable technologies (robotic surgery and digital mammography), and freestanding or satellite emergency departments. Moreover, private equity acquisition was associated with an increased probability of providing services that were previously categorized as unprofitable but that have more recently become areas of financial opportunity (for example, mental health services). Finally, private equity-acquired hospitals were less likely to add or continue services that have unreliable revenue streams or that may face competition from nonprofit hospitals (for example, outpatient psychiatry), although fewer shifts were noted among unprofitable services. This may reflect a prevailing shift by acute care hospitals toward outpatient settings for appropriate procedures and synergies with existing holdings by private equity firms.
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Affiliation(s)
- Marcelo Cerullo
- Marcelo Cerullo is a resident in the General Surgery Residency Program, Duke University Hospital, in Durham, North Carolina
| | - Kelly Kaili Yang
- Kelly Kaili Yang is a graduate student in the Department of Economics, Duke University, in Durham, North Carolina
| | - James Roberts
- James Roberts is a professor in and chair of the Department of Economics, Duke University, and a research associate with the National Bureau of Economic Research
| | - Ryan C McDevitt
- Ryan C. McDevitt is a professor in the Fuqua School of Business, Duke University
| | - Anaeze C Offodile
- Anaeze C. Offodile II is an assistant professor in the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, in Austin, Texas, and a nonresident fellow in Domestic Health Policy at the Baker Institute for Public Policy, Rice University, in Houston, Texas. He is the current Gilbert Omenn Fellow of the National Academy of Medicine
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32
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Wang X, Simons K, Gammonley D, Roberts AR, Bern-Klug M. Social Service Directors' Roles and Self-Efficacy in Suicide Risk Management in US Nursing Homes. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2021; 64:791-810. [PMID: 34420479 DOI: 10.1080/01634372.2021.1936331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 06/13/2023]
Abstract
Nursing home (NH) residents have many risk factors for suicide in later life and transitions into and out of NHs are periods of increased suicide risk. The purpose of this study was to describe NH social service directors (SSDs) roles in managing suicide risk and to identify factors that influence self-efficacy in this area. This study used data from the 2019 National Nursing Home Social Services Directors survey (n = 924). One-fifth (19.7%) of SSDs reported a lack of self-efficacy in suicide risk management, as indicated by either needing significant preparation time or being unable to train others on intervening with residents at risk for suicide. Ordinal logistic regression identified SSDs who were master's prepared, reported insufficient social service staffing as a minor barrier (versus a major barrier) to psychosocial care, and those most involved in safety planning for suicide risk were more likely to report self-efficacy for training others. Implications include the need for targeted training of NH social service staff on suicide prevention, such as safety planning as an evidence-based practice. Likewise, sufficient staffing of qualified NH social service providers is critically important given the acute and chronic mental health needs of NH residents.
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Affiliation(s)
- Xiaochuan Wang
- School of Social Work, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida, USA
| | - Kelsey Simons
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Denise Gammonley
- School of Social Work, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida, USA
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Bach-Mortensen AM, Verboom B, Movsisyan A, Degli Esposti M. A systematic review of the associations between care home ownership and COVID-19 outbreaks, infections and mortality. NATURE AGING 2021; 1:948-961. [PMID: 37118328 DOI: 10.1038/s43587-021-00106-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/02/2021] [Indexed: 04/30/2023]
Abstract
Social care markets often rely on the for-profit sector to meet service demand. For-profit care homes have been reported to suffer higher rates of coronavirus disease 2019 (COVID-19) infections and deaths, but it is unclear whether these worse outcomes can be attributed to ownership status. To address this, we designed and prospectively registered a living systematic review protocol ( CRD42020218673 ). Here we report on the systematic review and quality appraisal of 32 studies across five countries that investigated ownership variation in COVID-19 outcomes among care homes. We show that, although for-profit ownership was not consistently associated with a higher risk of a COVID-19 outbreak, there was evidence that for-profit care homes had higher rates of COVID-19 infections and deaths. We also found evidence that for-profit ownership was associated with personal protective equipment (PPE) shortages. Variation in COVID-19 outcomes is not driven by ownership status alone, and factors related to staffing, provider size and resident characteristics were also linked to poorer outcomes. However, this synthesis finds that for-profit status and care home characteristics associated with for-profit status are linked to exacerbated COVID-19 outcomes.
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Affiliation(s)
| | - Ben Verboom
- Institute for Medical Information Processing, Biometry and Epidemiology, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Ani Movsisyan
- Institute for Medical Information Processing, Biometry and Epidemiology, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
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34
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Peterson LJ, Bowblis JR, Jester DJ, Hyer K. The Relationship Between Staffing Levels and Consumer Complaints in Nursing Homes. J Aging Soc Policy 2021; 34:742-754. [PMID: 34396928 DOI: 10.1080/08959420.2021.1962173] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
While research tends to find an association of nurse staffing with quality in nursing homes, few studies examine complaints as a quality measure or account for ancillary staff. This study used federal nursing home complaint data to examine how key explanatory variables including nursing and ancillary staffing were associated with numbers of complaints and the likelihood of receiving a complaint. Results support that nursing home staffing is associated with quality. While direct care staffing was associated with fewer complaints, larger effects were found for social service and activities staffing. Increasing ancillary staffing may be a cost-effective way to reduce complaints.
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Affiliation(s)
- Lindsay J Peterson
- Florida Policy Exchange Center of Aging, School of Aging Studies, University of South Florida, Tampa, Florida
| | - John R Bowblis
- Department of Economics and Scripps Gerontology Center, Miami University, Oxford, Ohio, USA
| | - Dylan J Jester
- Florida Policy Exchange Center of Aging, School of Aging Studies, University of South Florida, Tampa, Florida
| | - Kathryn Hyer
- Florida Policy Exchange Center of Aging, School of Aging Studies, University of South Florida, Tampa, Florida
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35
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Peters MD, Marnie C, Butler A. Delivering, funding, and rating safe staffing levels and skills mix in aged care: Authors' response. Int J Nurs Stud 2021; 128:104042. [PMID: 34340828 DOI: 10.1016/j.ijnurstu.2021.104042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Micah Dj Peters
- University of South Australia, Clinical & Health Sciences, Rosemary Bryant AO Research Centre, Australia; Australian Nursing and Midwifery Federation (ANMF) National Policy Research Unit (Federal Office), Australia.
| | - Casey Marnie
- University of South Australia, Clinical & Health Sciences, Rosemary Bryant AO Research Centre, Australia; Australian Nursing and Midwifery Federation (ANMF) National Policy Research Unit (Federal Office), Australia
| | - Annie Butler
- Federal Office, Australian Nursing and Midwifery Federation (ANMF), Australia
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36
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Hua J, Cui M, Geng G, Yang W, Xi Q, Qian X. A cross-sectional study using the national standard to examine differences between public and private non-profit nursing homes in China. Jpn J Nurs Sci 2021; 18:e12435. [PMID: 34132485 DOI: 10.1111/jjns.12435] [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: 12/25/2020] [Revised: 03/22/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022]
Abstract
AIM Most studies on nursing home quality focus on developed countries, with little coverage in developing countries. Our study aimed to compare the differences between Chinese public and private non-profit nursing homes using the latest national standard. METHODS A cross-sectional study was conducted including 232 nursing homes in Jiangsu and Zhejiang provinces, China. We conducted statistical analyses (chi-square and independent sample t test) to investigate differences in public and private non-profit nursing homes. We fitted a binary logistic regression model with whether or not the nursing home received a 3-star or higher rating as the dependent variable, and the ownership type as explanatory variable, after adjusting for nursing home characteristics. RESULTS Of the 232 nursing homes included in the study sample, 44.8% were public nursing homes and 55.2% were private non-profit nursing homes. The t test analysis comparing the measures of nursing homes yielded significant results for 4 measures, 3 of which (overall rating, environment, and services) favored private non-profit nursing homes. A regression analysis using whether or not the nursing home received a 3-star or higher rating as the dependent variable showed that when adjusting for nursing home characteristics, private non-profit nursing homes were more likely to have a 3 or higher star compared with public nursing homes (odds ratio = 1.961, 95% confidence interval: 1.056-3.643). CONCLUSION These results suggested that private non-profit nursing homes performed better than public nursing homes when using the Chinese national standard for nursing homes.
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Affiliation(s)
- Jianing Hua
- School of Medical, Nantong University, Nantong, China
| | - Min Cui
- School of Medical, Nantong University, Nantong, China
| | - Guiling Geng
- School of Medical, Nantong University, Nantong, China
| | - Wenwen Yang
- School of Medical, Nantong University, Nantong, China
| | - Qun Xi
- School of Medical, Nantong University, Nantong, China
| | - Xiangyun Qian
- Department of Infection, The Third People's Hospital of Nantong, Nantong, China
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37
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Dunbar P, Browne JP, O'Connor L. Determinants of regulatory compliance in health and social care services: a systematic review protocol. HRB Open Res 2021; 4:13. [PMID: 34258511 PMCID: PMC8258703 DOI: 10.12688/hrbopenres.13214.3] [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] [Accepted: 06/14/2021] [Indexed: 11/20/2022] Open
Abstract
Background: The delivery of high quality health and social care services is a fundamental goal for health systems worldwide. Identifying the determinants of quality is a complex task as there are a myriad of variables to choose from. Researchers in this field have assessed a range of organisational and environmental factors (for example: staff composition, facility ownership, facility size) for an association with various quality metrics. Less attention has been paid to the determinants of compliance with quality regulation. Identifying the determinants of compliance has the potential to improve regulatory processes and can inform quality improvement initiatives undertaken by service providers and policy makers. This protocol describes a systematic review which will review literature from a wide range of study designs and sources to develop an overview of the determinants of regulatory compliance in health and social care services. Methods: A wide range of study designs and grey literature will be sought for this review. Searches will be conducted using PubMed, MEDLINE, PsycInfo, SocINDEX and CINAHL databases. The studies included in the review will be subject to quality appraisal with reference to the collection of tools available from the Joanna Briggs Institute. Data extraction will be informed by the Consolidated Framework for Implementation Research (CFIR). A narrative synthesis will be conducted on the barriers, facilitators and factors associated with compliance, with reference to the concepts mapped onto the CFIR. GRADE-CERQual will be used to grade the overall body of evidence. Conclusion: The findings of this review will be useful to regulators to inform regulatory policy and practice. Service providers and policy makers may also use the findings to inform quality improvement initiatives aimed at improving compliance and quality across a range of health and social care services.
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Affiliation(s)
- Paul Dunbar
- Health Information and Quality Authority, Cork, T12 Y2XT, Ireland
| | - John P Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Laura O'Connor
- Health Information and Quality Authority, Cork, T12 Y2XT, Ireland
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38
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Gunn V, Somani R, Muntaner C. Health care workers and migrant health: Pre- and post-COVID-19 considerations for reviewing and expanding the research agenda. J Migr Health 2021; 4:100048. [PMID: 34405193 PMCID: PMC8352207 DOI: 10.1016/j.jmh.2021.100048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 05/11/2021] [Accepted: 05/20/2021] [Indexed: 11/24/2022] Open
Abstract
The main purpose of this article is to review several ways in which health care workers could either impact migrant health or be directly impacted by migration and, based on this, suggest the expansion of the current research agenda on migration and health to address a range of topics that are currently either neglected, insufficiently researched, or researched from different perspectives. To ground this suggestion and emphasize the complexity and significance of migrant health research, we start by briefly reviewing several migration-related notions including the process of migration and its key facilitators and benefits; existing barriers to the provision of migrant health care; and the intricate links between health systems, health professionals, and migrant health. The three areas of research examined in this article address (i) the specific role of health workers in providing care to migrants and refugees and their capacity to do so, (ii) the health problems experienced by health workers who become migrants or refugees, and (iii) the precarious employment conditions experienced by both migrant and non-migrant health care workers. After summarizing the current available evidence on these topics, we discuss key information gaps and strategies to address them, while also incorporating several relevant COVID-19 pandemic considerations and research implications. Expanding the focus of research studies on migration and health could not only enhance the results of current strategies by supplying additional information to support their implementation but also spearhead the development of new solutions to the migrant health problem.
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Affiliation(s)
- Virginia Gunn
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada
- Karolinska Institute, Sweden
| | - Rozina Somani
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada
- Collaborative Specialization in Global Health, Dalla Lana School of Public Health, University of Toronto, Canada
| | - Carles Muntaner
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Canada
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39
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Dunbar P, Browne JP, O'Connor L. Determinants of regulatory compliance in health and social care services: a systematic review protocol. HRB Open Res 2021; 4:13. [DOI: 10.12688/hrbopenres.13214.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 11/20/2022] Open
Abstract
Background: The delivery of high quality health and social care services is a fundamental goal for health systems worldwide. Identifying the determinants of quality is a complex task as there are a myriad of variables to choose from. Researchers in this field have assessed a range of organisational and environmental factors (for example: staff composition, facility ownership, facility size) for an association with various quality metrics. Less attention has been paid to the determinants of compliance with quality regulation. Identifying the determinants of compliance has the potential to improve regulatory processes and can inform quality improvement initiatives undertaken by service providers and policy makers. This protocol describes a systematic review which will review literature from a wide range of study designs and sources to develop an overview of the determinants of regulatory compliance in health and social care services. Methods: A wide range of study designs and grey literature will be sought for this review. Searches will be conducted using PubMed, MEDLINE, PsycInfo, SocINDEX and CINAHL databases. The studies included in the review will be subject to quality appraisal with reference to the collection of tools available from the Joanna Briggs Institute. Data extraction will be informed by the Consolidated Framework for Implementation Research (CFIR). A narrative synthesis will be conducted on the barriers, facilitators and factors associated with compliance, with reference to the concepts mapped onto the CFIR. GRADE-CERQual will be used to grade the overall body of evidence. Conclusion: The findings of this review will be useful to regulators to inform regulatory policy and practice. Service providers and policy makers may also use the findings to inform quality improvement initiatives aimed at improving compliance and quality across a range of health and social care services.
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40
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Gonzalez L. Long-Term Care Options in Florida: Their Availability by County Demographics. J Racial Ethn Health Disparities 2021; 9:698-707. [PMID: 33751483 DOI: 10.1007/s40615-021-01005-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/18/2021] [Accepted: 02/21/2021] [Indexed: 11/29/2022]
Abstract
Older people express a preference for home and community-based care over skilled nursing, realizing that preference, however, is dependent upon having those options available. The present exploratory study uses publicly available data to understand if the geographic availability of long-term care options-skilled nursing, assisted living, home health, and homemaker/companion services-are equally distributed by demographics in Florida. Regression analyses showed that the percent 65 and older and the percent in poverty in a county were not related to long-term care availability or quality. Findings indicate that Hispanic older people have less access to nursing home beds, greater access to home health and homemaker/companion agencies, and tend to live in counties with a greater number of assisted living facility (ALF) deficiencies while Black older people have greater access to homemaker services. Rural counties had lower rates of home health and homemaker/companion agencies and fewer ALF deficiencies. The 65 and older population would benefit from the increased availability of long-term care options near the communities in which they live.
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Affiliation(s)
- Lori Gonzalez
- Research Faculty III, Florida State University, Claude Pepper Center, Tallahassee, FL, 32306, USA.
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41
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Dunbar P, Browne JP, O'Connor L. Determinants of regulatory compliance in health and social care services: a systematic review protocol. HRB Open Res 2021; 4:13. [DOI: 10.12688/hrbopenres.13214.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 11/20/2022] Open
Abstract
Background: The delivery of high quality health and social care services is a fundamental goal for health systems worldwide. The measurement of quality in health and social care services is a complex task as there are a myriad of determinants and outcome measures to choose from. Researchers in this field have assessed a range of organisational and environmental factors (for example: staff composition, facility ownership, facility size) for an association with various measurements for quality. Compliance with regulations is one such quality measure. Compliance with regulations is variable and the determinants of this variability are under-investigated. Identifying the determinants of compliance has the potential to improve regulatory processes and can inform quality improvement initiatives undertaken by service providers and policy makers. This protocol describes a systematic review which will review literature from a wide range of study designs and sources to develop an overview of the determinants of regulatory compliance in health and social care services. Methods: A wide range of study designs and grey literature will be sought for this review. Searches will be conducted using PubMed, MEDLINE, PsycInfo, SocINDEX and CINAHL databases. The studies included in the review will be subject to quality appraisal with reference to the collection of tools available from the Joanna Briggs Institute. Data extraction will be informed by the Consolidated Framework for Implementation Research (CFIR). A narrative synthesis will be conducted with reference to the CFIR and Normalisation Process Theory (NPT). GRADE-CERQual will be used to grade the overall body of evidence. Conclusion: The findings of this review will be useful to regulators to inform regulatory policy and practice. Service providers and policy makers may also use the findings to inform quality improvement initiatives aimed at improving compliance and quality across a range of health and social care services.
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Pittman T. Care Deficiencies and Super-Organization of American Nursing Homes in Hospital Referral Region. Front Public Health 2021; 8:582405. [PMID: 33553087 PMCID: PMC7854530 DOI: 10.3389/fpubh.2020.582405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/18/2020] [Indexed: 11/21/2022] Open
Abstract
Super-organization has been associated with worse care quality in nursing homes. Previous research on the chain ownership of American nursing homes excluded government facilities in public-private partnerships, and focused on corporate entities. This longitudinal study proposes a novel method of demarcating the latent ownership networks of for-profit, government and non-profit nursing homes in the United States through use of open data and social network analysis. Facility characteristics and care quality measures were analyzed from an ecological cohort of 9,001 American nursing homes that had a registered organization for owner, and were reimbursed through Medicare or Medicaid. Information was obtained from the Nursing Home Compare open datasets at five semi-annual processing dates from March 2016 to March 2018. Ownership networks of American nursing homes were constructed using the exact legal name of registered organizations. As hospital discharge is a routine admission source of nursing home residents, hospital referral region was actualized to demarcate focal area. Utilizing Bayesian hierarchical models, the association between nursing home super-organization in hospital referral region (inferred by degree-based centrality and Herfindahl-Hirschman Index) to scope of cited care deficiencies (denoted by Total Weighted Health Survey Score) was explored. The percentage of nursing homes having super-organization increased from 56.8 to 56.9% over the 2-year period. During this interval, the mean size of nursing home ownership group in hospital referral region increased from 3.11 to 3.23 facilities. Overall, super-organization in hospital referral region was not associated with care deficiencies in American nursing homes. However, being part of an ownership group with more facilities was beneficial for care quality among nursing homes with super-organization.
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Affiliation(s)
- Tyler Pittman
- Biostatistics Department, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Gopal R, Han X, Yaraghi N. Compress the curve: a cross-sectional study of variations in COVID-19 infections across California nursing homes. BMJ Open 2021; 11:e042804. [PMID: 33408208 PMCID: PMC7789209 DOI: 10.1136/bmjopen-2020-042804] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Nursing homes' residents and staff constitute the largest proportion of the fatalities associated with COVID-19 epidemic. Although there is a significant variation in COVID-19 outbreaks among the US nursing homes, we still do not know why such outbreaks are larger and more likely in some nursing homes than others. This research aims to understand why some nursing homes are more susceptible to larger COVID-19 outbreaks. DESIGN Observational study of all nursing homes in the state of California until 1 May 2020. SETTING The state of California. PARTICIPANTS 713 long-term care facilities in the state of California that participate in public reporting of COVID-19 infections as of 1 May 2020 and their infections data could be matched with data on ratings and governance features of nursing homes provided by Centers for Medicare & Medicaid Services (CMS). MAIN OUTCOME MEASURE The number of reported COVID-19 infections among staff and residents. RESULTS Study sample included 713 nursing homes. The size of outbreaks among residents in for-profit nursing homes is 12.7 times larger than their non-profit counterparts (log count=2.54; 95% CI, 1.97 to 3.11; p<0.001). Higher ratings in CMS-reported health inspections are associated with lower number of infections among both staff (log count=-0.19; 95% CI, -0.37 to -0.01; p=0.05) and residents (log count=-0.20; 95% CI, -0.27 to -0.14; p<0.001). Nursing homes with higher discrepancy between their CMS-reported and self-reported ratings have higher number of infections among their staff (log count=0.41; 95% CI, 0.31 to 0.51; p<0.001) and residents (log count=0.13; 95% CI, 0.08 to 0.18; p<0.001). CONCLUSIONS The size of COVID-19 outbreaks in nursing homes is associated with their ratings and governance features. To prepare for the possible next waves of COVID-19 epidemic, policy makers should use these insights to identify the nursing homes who are more likely to experience large outbreaks.
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Affiliation(s)
- Ram Gopal
- Warwick Business School, University of Warwick, Coventry, UK
| | - Xu Han
- Gabelli School of Business, Fordham University, New York, New York, USA
| | - Niam Yaraghi
- Miami Herbert Business School, University of Miami, Coral Gables, Florida, USA
- Governance Studies, The Brookings Institution, Washington, DC, USA
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Trinca V, Chaudhury H, Slaughter SE, Lengyel C, Carrier N, Keller H. Making the Most of Mealtimes (M3): Association Between Relationship-Centered Care Practices, and Number of Staff and Residents at Mealtimes in Canadian Long-Term Care Homes. J Am Med Dir Assoc 2020; 22:1927-1932.e1. [PMID: 33338445 DOI: 10.1016/j.jamda.2020.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 10/07/2020] [Accepted: 11/13/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine if (1) number of staff or residents, when considering home-level factors and presence of family/volunteers, are associated with relationship-centered care practices at mealtimes in general and dementia care units in long-term care (LTC); and (2) the association between number of staff and relationship-centered care is moderated by number of residents and family/volunteers, profit status or chain affiliation. DESIGN Secondary analysis of the Making the Most of Mealtimes (M3) cross-sectional multisite study. SETTING AND PARTICIPANTS Thirty-two Canadian LTC homes (Alberta, Manitoba, Ontario, and New Brunswick) and 639 residents were recruited. Eighty-two units were included, with 58 being general and 24 being dementia care units. METHODS Trained research coordinators completed the Mealtime Scan (MTS) for LTC at 4 to 6 mealtimes in each unit to determine number of staff, residents, and family or volunteers present. Relationship-centered care was assessed using the Mealtime Relational Care Checklist. The director of care or food services manager completed a home survey describing home sector and chain affiliation. Multivariable analyses were stratified by type of unit. RESULTS In general care units, the number of residents was negatively (P = .009), and number of staff positively (P < .001) associated with relationship-centered care (F9,48 = 5.48, P < .001). For dementia care units, the associations were nonsignificant (F5,18 = 2.74, P = .05). The association between staffing and relationship-centered care was not moderated by any variables in either general or dementia care units. CONCLUSION AND IMPLICATIONS Number of staff in general care units may increase relationship-centered care at mealtimes in LTC. Number of residents or staff did not significantly affect relationship-centered care in dementia care units, suggesting that other factors such as additional training may better explain relationship-centered care in these units. Mandating minimum staffing and additional training at the federal level should be considered to ensure that staff have the capacity to deliver relationship-centered care at mealtimes, which is considered a best practice.
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Affiliation(s)
- Vanessa Trinca
- University of Waterloo Department of Kinesiology, Waterloo, Ontario, Canada
| | - Habib Chaudhury
- Simon Fraser University, Department of Gerontology, Vancouver, British Columbia, Canada
| | - Susan E Slaughter
- University of Alberta, Faculty of Nursing, Edmonton, Alberta, Canada
| | - Christina Lengyel
- University of Manitoba, Department of Food and Human Nutritional Sciences, Winnipeg, Manitoba, Canada
| | - Natalie Carrier
- Université de Moncton, Faculté des sciences de la santé et des services communautaires, Moncton, New Brunswick, Canada
| | - Heather Keller
- University of Waterloo Department of Kinesiology, Waterloo, Ontario, Canada; Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada.
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Cohen L. The Culling: Pandemic, Gerocide, Generational Affect. Med Anthropol Q 2020; 34:542-560. [DOI: 10.1111/maq.12627] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Lawrence Cohen
- Departments of Anthropology and of South and Southeast Asian Studies University of California Berkeley
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Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. Risque d’éclosions de COVID-19 et de décès de résidents dans les foyers de soins de longue durée à but lucratif. CMAJ 2020; 192:E1662-E1672. [PMID: 33257337 PMCID: PMC7721392 DOI: 10.1503/cmaj.201197-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 11/01/2022] Open
Abstract
CONTEXTE: Les foyers de soins de longue durée (SLD) ont jusqu’à présent été l’épicentre de la pandémie de maladie à coronavirus 2019 (COVID-19) au Canada. Selon des études antérieures, les soins offerts dans les foyers de SLD à but lucratif sont de qualité inférieure pour toute une gamme d’indicateurs de résultats et de processus, ce qui soulève la question suivante: les conséquences de la COVID-19 ont-elles été pires dans les foyers à but lucratif que dans ceux à but non lucratif? MÉTHODES: Une étude de cohorte rétrospective basée sur l’ensemble des foyers de SLD en Ontario a été menée pour la période du 29 mars au 20 mai 2020 à partir de la base de données sur les éclosions de COVID-19 alimentée par le ministère des Soins de longue durée de l’Ontario. Des méthodes logistiques hiérarchiques et basées sur des données de comptage ont été utilisées pour modéliser les associations entre le statut financier des foyers de SLD (à but lucratif, à but non lucratif ou municipal) et les éclosions de COVID-19 dans ces derniers, l’ampleur des éclosions (nombre de résidents infectés) et le nombre de décès de résidents attribuables à la COVID-19. RÉSULTATS: L’analyse portait sur les 623 foyers de SLD de l’Ontario, qui comptent 75 676 résidents. Parmi ces foyers, 360 (57,7 %) sont à but lucratif; 162 (26,0 %) sont à but non lucratif; et 101 (16,2 %) sont des foyers municipaux. Au total, 190 (30,5 %) éclosions de COVID-19 ont été enregistrées dans des foyers de SLD. Elles ont touché 5218 résidents et entraîné 1452 décès, ce qui représente un taux de létalité général de 27,8 %. Les probabilités d’une éclosion dans un foyer ont été associées à l’incidence de la COVID-19 dans la circonscription sanitaire entourant celui-ci (rapport de cotes [RC] ajusté 1,91; intervalle de confiance [IC] à 95 % 1,19–3,05), au nombre de résidents dans l’établissement (RC ajusté 1,38; IC à 95 % 1,18–1,61) et à l’application des anciennes normes d’aménagement (RC ajusté 1,55; IC à 95 % 1,01–2,38), mais pas au statut financier d’un foyer. Comparativement au statut « à but non lucratif », le statut « à but lucratif » a été associé à l’ampleur d’une éclosion dans un foyer de SLD (risque relatif [RR] 1,96; IC à 95 % 1,26–3,05) ainsi qu’au nombre de décès de résidents (RR ajusté 1,78; IC à 95 % 1,03–3,07). Ces associations s’expliquent par une plus grande prévalence des anciennes normes d’aménagement dans les foyers de SLD à but lucratif ainsi qu’à l’appartenance à une chaîne de propriétés. INTERPRÉTATION: Le statut « à but lucratif » est associé à l’ampleur d’une éclosion de COVID-19 et au nombre de décès de résidents dans un foyer de SLD, mais pas au risque d’éclosion. Deux principaux facteurs expliquent les différences entre les foyers à but lucratif et non lucratif, soit l’application des anciennes normes d’aménagement et l’appartenance à une chaîne de propriétés. Ceux-ci devraient être au coeur des futures mesures et politiques de lutte contre les infections.
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Affiliation(s)
- Nathan M Stall
- Division de médecine interne générale et de gériatrie (Stall), Système de santé Sinaï et Réseau universitaire de santé; Institut de recherche du Women's College (Stall, Rochon), Hôpital Women's College; Département de médecine (Stall, Rochon) et Institut des politiques, de la gestion et de l'évaluation de la santé (Stall, Rochon), Université de Toronto, Toronto (Ontario); Département des méthodes, des données et de l'incidence de la recherche en santé (Jones, Costa), Université McMaster, Hamilton (Ontario); Prévention et contrôle des infections (Brown), Santé publique Ontario; École de santé publique Dalla Lana (Brown), Université de Toronto, Toronto (Ontario); Chaire de l'Institut Schlegel en épidémiologie clinique et en vieillissement (Costa), Université McMaster; Centre de soins intégrés (Costa), Système de soins de santé St-Joseph, Hamilton (Ontario)
| | - Aaron Jones
- Division de médecine interne générale et de gériatrie (Stall), Système de santé Sinaï et Réseau universitaire de santé; Institut de recherche du Women's College (Stall, Rochon), Hôpital Women's College; Département de médecine (Stall, Rochon) et Institut des politiques, de la gestion et de l'évaluation de la santé (Stall, Rochon), Université de Toronto, Toronto (Ontario); Département des méthodes, des données et de l'incidence de la recherche en santé (Jones, Costa), Université McMaster, Hamilton (Ontario); Prévention et contrôle des infections (Brown), Santé publique Ontario; École de santé publique Dalla Lana (Brown), Université de Toronto, Toronto (Ontario); Chaire de l'Institut Schlegel en épidémiologie clinique et en vieillissement (Costa), Université McMaster; Centre de soins intégrés (Costa), Système de soins de santé St-Joseph, Hamilton (Ontario)
| | - Kevin A Brown
- Division de médecine interne générale et de gériatrie (Stall), Système de santé Sinaï et Réseau universitaire de santé; Institut de recherche du Women's College (Stall, Rochon), Hôpital Women's College; Département de médecine (Stall, Rochon) et Institut des politiques, de la gestion et de l'évaluation de la santé (Stall, Rochon), Université de Toronto, Toronto (Ontario); Département des méthodes, des données et de l'incidence de la recherche en santé (Jones, Costa), Université McMaster, Hamilton (Ontario); Prévention et contrôle des infections (Brown), Santé publique Ontario; École de santé publique Dalla Lana (Brown), Université de Toronto, Toronto (Ontario); Chaire de l'Institut Schlegel en épidémiologie clinique et en vieillissement (Costa), Université McMaster; Centre de soins intégrés (Costa), Système de soins de santé St-Joseph, Hamilton (Ontario)
| | - Paula A Rochon
- Division de médecine interne générale et de gériatrie (Stall), Système de santé Sinaï et Réseau universitaire de santé; Institut de recherche du Women's College (Stall, Rochon), Hôpital Women's College; Département de médecine (Stall, Rochon) et Institut des politiques, de la gestion et de l'évaluation de la santé (Stall, Rochon), Université de Toronto, Toronto (Ontario); Département des méthodes, des données et de l'incidence de la recherche en santé (Jones, Costa), Université McMaster, Hamilton (Ontario); Prévention et contrôle des infections (Brown), Santé publique Ontario; École de santé publique Dalla Lana (Brown), Université de Toronto, Toronto (Ontario); Chaire de l'Institut Schlegel en épidémiologie clinique et en vieillissement (Costa), Université McMaster; Centre de soins intégrés (Costa), Système de soins de santé St-Joseph, Hamilton (Ontario)
| | - Andrew P Costa
- Division de médecine interne générale et de gériatrie (Stall), Système de santé Sinaï et Réseau universitaire de santé; Institut de recherche du Women's College (Stall, Rochon), Hôpital Women's College; Département de médecine (Stall, Rochon) et Institut des politiques, de la gestion et de l'évaluation de la santé (Stall, Rochon), Université de Toronto, Toronto (Ontario); Département des méthodes, des données et de l'incidence de la recherche en santé (Jones, Costa), Université McMaster, Hamilton (Ontario); Prévention et contrôle des infections (Brown), Santé publique Ontario; École de santé publique Dalla Lana (Brown), Université de Toronto, Toronto (Ontario); Chaire de l'Institut Schlegel en épidémiologie clinique et en vieillissement (Costa), Université McMaster; Centre de soins intégrés (Costa), Système de soins de santé St-Joseph, Hamilton (Ontario)
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Lepore MJ, Lima JC, Miller SC. Nursing Home Culture Change Practices and Survey Deficiencies: A National Longitudinal Panel Study. THE GERONTOLOGIST 2020; 60:1411-1423. [PMID: 32478393 PMCID: PMC7681213 DOI: 10.1093/geront/gnaa063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Nursing home (NH) adoption of culture change practices has substantially increased in recent decades. We examined how increasing adoption of culture change practices affected the prevalence of health, severe health, and quality of life (QoL) deficiencies. RESEARCH DESIGN AND METHODS Novel data on culture change practice adoption from a nationally representative NH panel (N = 1,585) surveyed in 2009/2010 and 2016/2017 were used to calculate change in practice adoption scores in 3 culture change domains (resident-centered care, staff empowerment, physical environment). These data were linked to data on health, severe health, and QoL deficiencies and facility-level covariates. Multinomial logistic regression models, with survey weights and inverse probability of treatment weighting, examined how increased culture change practice adoption related to change in deficiencies. RESULTS We generally observed less increase in deficiencies when culture change practices increased. However, after weighting and controlling for baseline deficiencies and culture change scores, we found few statistically significant effects. Still, results show increased physical environment practices resulted in a higher likelihood of decreases or no change (vs increases) in QoL deficiencies; increased resident-centered care practices resulted in decreases or no change (vs increases) in health deficiencies; and increased staff empowerment practices resulted in a higher likelihood of no change (vs increases) in severe health deficiencies. DISCUSSION AND IMPLICATIONS This study provides some evidence that culture change practices can help reduce the risk of increasing some types of deficiencies, but the impact of increases in each culture change domain related differently to different types of deficiencies.
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Affiliation(s)
- Michael J Lepore
- LiveWell Institute, Southington, Connecticut
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Julie C Lima
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Susan C Miller
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
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Gonzalez L. Will For-Profits Keep Up the Pace in the United States? The Future of the Program of All-Inclusive Care for the Elderly and Implications for Other Programs Serving Medically Vulnerable Populations. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2020; 51:195-202. [PMID: 33019864 DOI: 10.1177/0020731420963946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Program of All-Inclusive Care for the Elderly (PACE) has provided, for more than 4 decades, high-quality, cost-effective medical and social care to older people in the United States under nonprofit ownership. Recent rulings by the Centers for Medicare & Medicaid Services (CMS), however, will fundamentally change the initial intent and operation of the program. CMS's final rule (4168-F) removes the provision that PACE operators be nonprofit. This article provides the legislative background for the final ruling and critiques the study that was used to justify the removal of the nonprofit provision. Although the Balanced Budget Act of 1997 listed a number of requirements for evaluating for-profit PACE programs, the secretary of the Department of Health and Human Services did not follow them before establishing for-profit PACE sites as permanent providers. It also argues that the ruling was made without much evidence that for-profit compared to nonprofit operators can provide a similar level of quality of care, access, and cost-effectiveness and urges policymakers to increase regulatory accountability, given what we know about other shifts in profit status and health care.
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Affiliation(s)
- Lori Gonzalez
- Claude Pepper Center, 375481Florida State University, Tallahassee, FL, USA
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Braun RT, Yun H, Casalino LP, Myslinski Z, Kuwonza FM, Jung HY, Unruh MA. Comparative Performance of Private Equity-Owned US Nursing Homes During the COVID-19 Pandemic. JAMA Netw Open 2020; 3:e2026702. [PMID: 33112402 PMCID: PMC7593807 DOI: 10.1001/jamanetworkopen.2020.26702] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE It is not known whether nursing homes with private equity (PE) ownership have performed better or worse than other nursing homes during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE To evaluate the comparative performance of PE-owned nursing homes on COVID-19 outcomes. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of 11 470 US nursing homes used the Nursing Home COVID-19 Public File from May 17, 2020, to July 2, 2020, to compare outcomes of PE-owned nursing homes with for-profit, nonprofit, and government-owned homes, adjusting for facility characteristics. EXPOSURE Nursing home ownership status. MAIN OUTCOMES AND MEASURES Self-reported number of COVID-19 cases and deaths and deaths by any cause per 1000 residents; possessing 1-week supplies of personal protective equipment (PPE); staffing shortages. RESULTS Of 11 470 nursing homes, 7793 (67.9%) were for-profit; 2523 (22.0%), nonprofit; 511 (5.3%), government-owned; and 543 (4.7%), PE-owned; with mean (SD) COVID-19 cases per 1000 residents of 88.3 [2.1], 67.0 [3.8], 39.8 [7.6] and 110.8 [8.1], respectively. Mean (SD) COVID-19 deaths per 1000 residents were 61.9 [1.6], 66.4 [3.0], 56.2 [7.3], and 78.9 [5.9], respectively; mean deaths by any cause per 1000 residents were 78.1 [1.3], 91.5 [2.2], 67.6 [4.5], and 87.9 [4.8], respectively. In adjusted analyses, government-owned homes had 35.5 (95% CI, -69.2 to -1.8; P = .03) fewer COVID-19 cases per 1000 residents than PE-owned nursing homes. Cases in PE-owned nursing homes were not statistically different compared with for-profit and nonprofit facilities; nor were there statistically significant differences in COVID-19 deaths or deaths by any cause between PE-owned nursing homes and for-profit, nonprofit, and government-owned facilities. For-profit, nonprofit, and government-owned nursing homes were 10.5% (9.1 percentage points; 95% CI, 1.8 to 16.3 percentage points; P = .006), 15.0% (13.0 percentage points; 95% CI, 5.5 to 20.6 percentage points; P < .001), and 17.0% (14.8 percentage points; 95% CI, 6.5 to 23.0 percentage points; P < .001), respectively, more likely to have at least a 1-week supply of N95 masks than PE-owned nursing homes. They were 24.3% (21.3 percentage points; 95% CI, 11.8 to 30.8 percentage points; P < .001), 30.7% (27.0 percentage points; 95% CI, 17.7 to 36.2 percentage points; P < .001), and 29.2% (25.7 percentage points; 95% CI, 16.1 to 35.3 percentage points; P < .001) more likely to have a 1-week supply of medical gowns than PE-owned nursing homes. Government nursing homes were more likely to have a shortage of nurses (6.9 percentage points; 95% CI, 0.0 to 13.9 percentage points; P = .049) than PE-owned nursing homes. CONCLUSIONS AND RELEVANCE In this cross-sectional study, PE-owned nursing homes performed comparably on staffing levels, resident cases, and deaths with nursing homes with other types of ownership, although their shortages of PPE may warrant monitoring.
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Affiliation(s)
- Robert Tyler Braun
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Hyunkyung Yun
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P. Casalino
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Zachary Myslinski
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Farai M. Kuwonza
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Hye-Young Jung
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Mark Aaron Unruh
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths. CMAJ 2020; 192:E946-E955. [PMID: 32699006 PMCID: PMC7828970 DOI: 10.1503/cmaj.201197] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes. METHODS We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19. RESULTS The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7%) were for profit, 162 (26.0%) were nonprofit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.19-3.05), the number of residents (adjusted OR 1.38, 95% CI 1.18-1.61), and older design standards of the home (adjusted OR 1.55, 95% CI 1.01-2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95% CI 1.26-3.05) and the number of resident deaths (adjusted RR 1.78, 95% CI 1.03-3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership. INTERPRETATION For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.
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Affiliation(s)
- Nathan M Stall
- Division of General Internal Medicine and Geriatrics (Stall), Sinai Health System and the University Health Network; Women's College Research Institute (Stall, Rochon), Women's College Hospital; Department of Medicine (Stall, Rochon) and Institute of Health Policy, Management and Evaluation (Stall, Rochon), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Costa), McMaster University, Hamilton, Ont.; Infection Prevention and Control (Brown), Public Health Ontario; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont.; Schlegel Chair in Clinical Epidemiology and Aging (Costa), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.
| | - Aaron Jones
- Division of General Internal Medicine and Geriatrics (Stall), Sinai Health System and the University Health Network; Women's College Research Institute (Stall, Rochon), Women's College Hospital; Department of Medicine (Stall, Rochon) and Institute of Health Policy, Management and Evaluation (Stall, Rochon), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Costa), McMaster University, Hamilton, Ont.; Infection Prevention and Control (Brown), Public Health Ontario; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont.; Schlegel Chair in Clinical Epidemiology and Aging (Costa), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Kevin A Brown
- Division of General Internal Medicine and Geriatrics (Stall), Sinai Health System and the University Health Network; Women's College Research Institute (Stall, Rochon), Women's College Hospital; Department of Medicine (Stall, Rochon) and Institute of Health Policy, Management and Evaluation (Stall, Rochon), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Costa), McMaster University, Hamilton, Ont.; Infection Prevention and Control (Brown), Public Health Ontario; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont.; Schlegel Chair in Clinical Epidemiology and Aging (Costa), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Paula A Rochon
- Division of General Internal Medicine and Geriatrics (Stall), Sinai Health System and the University Health Network; Women's College Research Institute (Stall, Rochon), Women's College Hospital; Department of Medicine (Stall, Rochon) and Institute of Health Policy, Management and Evaluation (Stall, Rochon), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Costa), McMaster University, Hamilton, Ont.; Infection Prevention and Control (Brown), Public Health Ontario; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont.; Schlegel Chair in Clinical Epidemiology and Aging (Costa), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Andrew P Costa
- Division of General Internal Medicine and Geriatrics (Stall), Sinai Health System and the University Health Network; Women's College Research Institute (Stall, Rochon), Women's College Hospital; Department of Medicine (Stall, Rochon) and Institute of Health Policy, Management and Evaluation (Stall, Rochon), University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Jones, Costa), McMaster University, Hamilton, Ont.; Infection Prevention and Control (Brown), Public Health Ontario; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont.; Schlegel Chair in Clinical Epidemiology and Aging (Costa), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
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