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Gruneir A, Chamberlain SA, Jensen C, Cummings G, Hoben M, Boamah S, Bosco C, Ekhlas S, Bolt SR, Rappon T, Berta WB, Squires J, Estabrooks CA. Burnout Among Nursing Home Care Aides and the Effects on Resident Outcomes. Med Care Res Rev 2024; 81:233-244. [PMID: 38158788 PMCID: PMC11092296 DOI: 10.1177/10775587231220072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 11/24/2023] [Indexed: 01/03/2024]
Abstract
While burnout among health care workers has been well studied, little is known about the extent to which burnout among health care workers impacts the outcomes of their care recipients. To test this, we used a multi-year (2014-2020) survey of care aides working in approximately 90 nursing homes (NHs); the survey focused on work-life measures, including the Maslach Burnout Inventory (MBI) and work-unit identifier. Resident Assessment Instrument Minimum Data Set (RAI-MDS 2.0) data were obtained on all residents in the sampled NHs during this time and included a unit identifier for each resident. We used multi-level models to test associations between the MBI emotional exhaustion and cynicism sub-scales reported by care aides and the resident outcomes of antipsychotics without indication, depressive symptoms, and responsive behaviors among residents on units. In 2019/2020, our sample included 3,547 care aides and 10,117 residents in 282 units. The mean frequency of emotional exhaustion and cynicism across units was 43% and 50%, respectively. While residents frequently experienced antipsychotics without indication 1,852 (18.3%), depressive symptoms 2,089 (20.7%), and responsive behaviors 3,891 (38.5%), none were found to be associated with either emotional exhaustion or cynicism among care aides.
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Affiliation(s)
| | | | | | | | - Matthias Hoben
- University of Alberta, Edmonton, Canada
- York University, Toronto, Ontario, Canada
| | | | | | | | | | - Tim Rappon
- McMaster University, Hamilton, Ontario, Canada
| | | | - Janet Squires
- Ottawa Health Research Institute, Ontario, Canada
- University of Ottawa, Ontario, Canada
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Morain S, Largent E. Think Pragmatically: Investigators' Obligations to Patient-Subjects When Research is Embedded in Care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:10-21. [PMID: 35435790 PMCID: PMC9576818 DOI: 10.1080/15265161.2022.2063435] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Growing interest in embedded research approaches-where research is incorporated into clinical care-has spurred numerous studies to generate knowledge relevant to the real-world needs of patients and other stakeholders. However, it also has presented ethical challenges. An emerging challenge is how to understand the nature and extent of investigators' obligations to patient-subjects. Prior scholarship on investigator duties has generally been grounded upon the premise that research and clinical care are distinct activities, bearing distinct duties. Yet this premise-and its corresponding implications-are challenged when research and clinical care are deliberately integrated. After presenting three case studies from recent pragmatic clinical trials, we identify six differences between explanatory trials and embedded research that limit the application of existing scholarship for ascertaining investigator duties. We suggest that these limitations indicate a need to account for the implications of usual care and to move beyond a narrow focus on the investigator-subject dyad, one that better reflects the team- and institution-based nature of contemporary health systems.
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Singh S, Molina E, Meyer E, Min SJ, Fischer S. Post-Acute Care Outcomes and Functional Status Changes of Adults with New Cancer Discharged to Skilled Nursing Facilities. J Am Med Dir Assoc 2022; 23:1854-1860. [PMID: 35337793 PMCID: PMC9912689 DOI: 10.1016/j.jamda.2022.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Older hospitalized adults with an existing diagnosis of cancer rarely receive cancer treatment after discharge to a skilled nursing facility (SNF). It is unclear to what degree these outcomes may be driven by cumulative effects of previous cancer treatment and their complications vs an absolute functional threshold from which it is not possible to return. We sought to understand post-acute care outcomes of adults newly diagnosed with cancer and explore functional improvement during their SNF stay. DESIGN Retrospective cohort study, 2011-2013. SETTING AND PARTICIPANTS Surveillance, Epidemiology, and End Results - Medicare database of patients with new stage II-IV colorectal, pancreatic, bladder, or lung cancer discharged to SNF. METHODS Primary outcome was time to death after hospital discharge. Covariates include cancer treatment receipt and hospice use. A Minimum Data Set (MDS)-Activities of Daily Living (ADL) score was calculated to measure changes in ADLs during SNF stay. Patient groups of interest were compared descriptively using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Logistic regression was used to compare patient groups. RESULTS A total of 6791 cases were identified. Forty-six percent of patients did not receive treatment or hospice, 25.0% received no treatment but received hospice, 20.8% received treatment but no hospice, and 8.5% received both treatment and hospice. Only 43% of decedents received hospice. Patients who received treatment but not hospice had the best survival. There were limited improvements in MDS-ADL scores in the subset of patients for whom we have complete data. Those with greater functional improvement had improved survival. CONCLUSIONS AND IMPLICATIONS The majority of patients did not receive future cancer treatment or hospice care prior to death. There was limited improvement in MDS-ADL scores raising concern this population might not benefit from the rehabilitative intent of SNFs.
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Affiliation(s)
- Sarguni Singh
- Division of Hospital Medicine, University of Colorado Denver, Aurora, CO, USA.
| | | | | | - Sung-Joon Min
- Division of Health Care Policy & Research, University of Colorado Denver, Aurora, Colorado
| | - Stacy Fischer
- Division of General Internal Medicine, University of Colorado Denver, Aurora, Colorado
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Abstract
As the late Robert Kane observed, the term nursing home is often a misnomer. Most U.S. nursing homes lack adequate nursing staff, and they are typically not very homelike in either their physical structure or culture. These problems were magnified during the pandemic. The underlying reasons for these longstanding issues are that most state Medicaid payment systems reimburse nursing homes at a relatively low level and the government does not hold nursing homes accountable for spending dollars on direct resident care. To encourage increased staffing and more homelike models of care, policymakers need to reform how nursing homes are paid and hold facilities accountable for how they spend government dollars. With these reforms, the term nursing home will become more appropriate in the United States.
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Affiliation(s)
- David C Grabowski
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston MA 02115, USA
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Lin L, Liu X, McGilton KS, Yuan Y, Li H, Dong B, Xie C, Wang H, Li H, Tian L. Level of nurse supportive supervision and its influencing factors in long-term care facilities. Geriatr Nurs 2021; 42:1316-1322. [PMID: 34560526 DOI: 10.1016/j.gerinurse.2021.08.018] [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: 06/03/2021] [Revised: 08/28/2021] [Accepted: 08/31/2021] [Indexed: 11/17/2022]
Abstract
Quality of care provided by personal support workers (PSWs) in long-term care facilities (LTCFs) is associated with the supportive supervisory performance of registered nurses (RNs). To determine the level of supportive supervision of RNs and its influencing factors in LTCFs in East China, a cross-sectional survey was conducted in 12 LTCFs using self-designed sociodemographic questionnaires and the Chinese version of the Supportive Supervisory Scale. A total of 643 PSWs supervised by 260 RNs were surveyed. The average supportive supervision score was 59.60 ± 7.53, representing a moderate level of supervisory support. Supportive supervision was found to be positively correlated with the PSW's years of working, the RN's education, position, number of years in nursing, having access to managerial training as well as the RN/PSW ratio in the unit (p < 0.05). These factors can be modified to potentially influence the supportive capacity of nurse supervisors in LTCFs.
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Affiliation(s)
- Lu Lin
- The First Affiliated Hospital of Soochow University, No. 188 Shizi Road, Suzhou 215006, People's Republic of China; School of Nursing, Medical College of Soochow University, No. 188 Shizi Street, Suzhou 215006, People's Republic of China
| | - Xiaoming Liu
- The First Affiliated Hospital of Soochow University, No. 188 Shizi Road, Suzhou 215006, People's Republic of China
| | - Katherine S McGilton
- Toronto Rehabilitation Institute-UHN, Toronto, ON, Canada; University of Toronto, ON, Canada
| | - Yang Yuan
- School of Nursing, Medical College of Soochow University, No. 188 Shizi Street, Suzhou 215006, People's Republic of China
| | - Haixia Li
- Suzhou Kowloon Hospital, Shanghai Jiao Tong University School of Medicine, Suzhou 215006, People's Republic of China
| | - Bei Dong
- School of Nursing, Medical College of Soochow University, No. 188 Shizi Street, Suzhou 215006, People's Republic of China
| | - Congyan Xie
- School of Nursing, Medical College of Soochow University, No. 188 Shizi Street, Suzhou 215006, People's Republic of China
| | - Hong Wang
- Suzhou Kowloon Hospital, Shanghai Jiao Tong University School of Medicine, Suzhou 215006, People's Republic of China
| | - Huiling Li
- School of Nursing, Medical College of Soochow University, No. 188 Shizi Street, Suzhou 215006, People's Republic of China.
| | - Li Tian
- The First Affiliated Hospital of Soochow University, No. 188 Shizi Road, Suzhou 215006, People's Republic of China; School of Nursing, Medical College of Soochow University, No. 188 Shizi Street, Suzhou 215006, People's Republic of China.
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Downer B, Reistetter TA, Kuo YF, Li S, Karmarkar A, Hong I, Goodwin JS, Ottenbacher KJ. Relationship Between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery After Hip Replacement. Arch Phys Med Rehabil 2021; 102:1717-1728.e7. [PMID: 33812884 PMCID: PMC8429053 DOI: 10.1016/j.apmr.2021.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/19/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016. DESIGN Pre (January 1, 2015-June 30, 2016) vs post (July 1, 2016-December 31, 2017) design. SETTING Skilled nursing facilities (n=12,829). PARTICIPANTS Medicare fee-for-service beneficiaries (N=106,832) discharged from acute hospitals to SNF after hip replacement between January 1, 2015 and December 31, 2017. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The 5- and 14-day minimum data set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10 days and any improvement between the 5- and 14-day assessments. RESULTS The average adjusted change per 10 days for the quality measure total score for patients admitted before July 2016 and after July 2016 was 1.00 points (standard error, 0010) and 1.06 points (standard error, 0.010), respectively (P<.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (standard error, 0.06) had any improvement in the quality measure total score compared with 45.5% (standard error, 0.23) of patients admitted after July 2016 (P<.01). This was a relative increase of 2.5%. The adjusted change per 10 days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016. CONCLUSIONS Patients admitted to a SNF after a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.
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Affiliation(s)
- Brian Downer
- University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, Galveston, TX; University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX.
| | - Timothy A Reistetter
- University of Texas Health Science Center at San Antonio, School of Health Professions, Department of Occupational Therapy, San Antonio, TX
| | - Yong-Fang Kuo
- University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX; University of Texas Medical Branch, Preventive Medicine and Population Health, Office of Biostatistics, Galveston, TX
| | - Shuang Li
- University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX
| | - Amol Karmarkar
- Virginia Commonwealth University, School of Medicine, Department of Physical Medicine and Rehabilitation, Richmond, VA
| | - Ickpyo Hong
- Yonsei University, College of Health Sciences, Department of Occupational Therapy, Seoul, Korea
| | - James S Goodwin
- University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX; University of Texas Medical Branch, Department of Internal Medicine, Division of Geriatrics, Galveston, TX
| | - Kenneth J Ottenbacher
- University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, Galveston, TX; University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX
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Walker K, Shearkhani S, Bai YQ, McGilton KS, Berta WB, Wodchis WP. The Impact of the Long-term Care Homes Act and Public Reporting on Physical Restraint and Potentially Inappropriate Antipsychotic Use in Ontario's Long-term Care Homes. J Gerontol A Biol Sci Med Sci 2020; 75:813-819. [PMID: 31356654 DOI: 10.1093/gerona/glz143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We report on the impact of two system-level policy interventions (the Long-Term Care Homes Act [LTCHA] and Public Reporting) on publicly reported physical restraint use and non-publicly reported potentially inappropriate use of antipsychotics in Ontario, Canada. METHODS We used interrupted time series analysis to model changes in the risk-adjusted use of restraints and antipsychotics before and after implementation of the interventions. Separate analyses were completed for early ([a] volunteered 2010/2011) and late ([b] volunteered March 2012; [c] mandated September 2012) adopting groups of Public Reporting. Outcomes were measured using Resident Assessment Instrument Minimum Data Set (RAI-MDS) data from January 1, 2008 to December 31, 2014. RESULTS For early adopters, enactment of the LTCHA in 2010 was not associated with changes in physical restraint use, while Public Reporting was associated with an increase in the rate (slope) of decline in physical restraint use. By contrast, for the late-adopters of Public Reporting, the LTCHA was associated with significant decreases in physical restraint use over time, but there was no significant increase in the rate of decline associated with Public Reporting. As the LTCHA was enacted, potentially inappropriate use of antipsychotics underwent a rapid short-term increase in the early volunteer group, but, over the longer term, their use decreased for all three groups of homes. CONCLUSIONS Public Reporting had the largest impact on voluntary early adopters while legislation and regulations had a more substantive positive effect upon homes that delayed public reporting.
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Affiliation(s)
- Kevin Walker
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario, Canada
| | - Sara Shearkhani
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario, Canada
| | - Yu Qing Bai
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario, Canada
| | - Katherine S McGilton
- Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada
| | - Whitney B Berta
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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Xu H, Intrator O. Medicaid Long-term Care Policies and Rates of Nursing Home Successful Discharge to Community. J Am Med Dir Assoc 2020; 21:248-253.e1. [DOI: 10.1016/j.jamda.2019.01.153] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/23/2019] [Accepted: 01/29/2019] [Indexed: 11/28/2022]
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Akinleye DD, McNutt LA, Lazariu V, McLaughlin CC. Correlation between hospital finances and quality and safety of patient care. PLoS One 2019; 14:e0219124. [PMID: 31419227 PMCID: PMC6697357 DOI: 10.1371/journal.pone.0219124] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 06/17/2019] [Indexed: 11/19/2022] Open
Abstract
Background Hospitals under financial pressure may struggle to maintain quality and patient safety and have worse patient outcomes relative to well-resourced hospitals. Poor predictive validity may explain why previous studies on the association between finances and quality/safety have been equivocal. This manuscript employs principal component analysis to produce robust measures of both financial status and quality/safety of care, to assess our a priori hypothesis: hospital financial performance is associated with the provision of quality care, as measured by quality and safety processes, patient outcomes, and patient centered care. Methods This 2014 cross-sectional study investigated hospital financial condition and hospital quality and safety at acute care hospitals. The hospital financial data from the Centers for Medicare and Medicaid Services (CMS) cost report were used to develop a composite financial performance score using principal component analysis. Hospital quality and patient safety were measured with a composite quality/safety performance score derived from principal component analysis, utilizing a range of established quality and safety indicators including: risk-standardized inpatient mortality, 30-day mortality, 30-day readmissions for select conditions, patient safety indicators from inpatient admissions, process of care chart reviews, CMS value-based purchasing total performance score and patient experience of care surveys. The correlation between the composite financial performance score and the composite quality/safety performance score was calculated using linear regression adjusting for hospital characteristics. Results Among the 108 New York State acute care facilities for which data were available, there is a clear relationship between hospital financial performance and hospital quality/safety performance score (standardized correlation coefficient 0.34, p<0.001). The composite financial performance score is also positively associated with the CMS Value Based Purchasing Total Performance Score (standardized correlation coefficient 0.277, p = 0.002); while it is negatively associated with 30 day readmission for all outcomes (standardized correlation coefficient -0.236, p = 0.013), 30-day readmission for congestive heart failure (standardized correlation coefficient -0.23, p = 0.018), 30 day readmission for pneumonia (standardized correlation coefficient -0.209, p = 0.033), and a decrease in 30-day mortality for acute myocardial infarction (standardized correlation coefficient -0.211, p = 0.027). Used alone, operating margin and total margin are poor predictors of quality and safety outcomes. Conclusions Strong financial performance is associated with improved patient reported experience of care, the strongest component distinguishing quality and safety. These findings suggest that financially stable hospitals are better able to maintain highly reliable systems and provide ongoing resources for quality improvement.
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Affiliation(s)
- Dean D Akinleye
- School of Public Health, State University of New York, University at Albany, Albany, NY, United States of America
| | - Louise-Anne McNutt
- Institute for Health and the Environment, State University of New York, University at Albany, Albany, NY, United States of America
| | - Victoria Lazariu
- School of Public Health, State University of New York, University at Albany, Albany, NY, United States of America
| | - Colleen C McLaughlin
- Albany College of Pharmacy and Health Sciences, Albany, NY, United States of America
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Travers JL, Teitelman AM, Jenkins KA, Castle NG. Exploring social-based discrimination among nursing home certified nursing assistants. Nurs Inq 2019; 27:e12315. [PMID: 31398775 DOI: 10.1111/nin.12315] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Certified nursing assistants (CNAs) provide the majority of direct care to nursing home residents in the United States and, therefore, are keys to ensuring optimal health outcomes for this frail older adult population. These diverse direct care workers, however, are often not recognized for their important contributions to older adult care and are subjected to poor working conditions. It is probable that social-based discrimination lies at the core of poor treatment toward CNAs. This review uses perspectives from critical social theory to explore the phenomenon of social-based discrimination toward CNAs that may originate from social order, power, and culture. Understanding manifestations of social-based discrimination in nursing homes is critical to creating solutions for severe disparity problems among perceived lower-class workers and subsequently improving resident care delivery.
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Affiliation(s)
- Jasmine L Travers
- National Clinician Scholars Program, Yale University Schools of Medicine and Nursing, New Haven, CT, USA
| | - Anne M Teitelman
- Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Kevin A Jenkins
- Perelman School of Medicine, University of Pennsylvania School of Social Policy and Practice, Philadelphia, PA, USA
| | - Nicholas G Castle
- Department of Health Policy, Management and Leadership, West Virginia University, Morgantown, WV, USA
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McGarry BE, Joyce NR, McGuire TG, Mitchell SL, Bartels SJ, Grabowski DC. Association between High Proportions of Seriously Mentally Ill Nursing Home Residents and the Quality of Resident Care. J Am Geriatr Soc 2019; 67:2346-2352. [PMID: 31355443 DOI: 10.1111/jgs.16080] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/11/2019] [Accepted: 06/15/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To examine the association between the quality of care delivered to nursing home residents with and without a serious mental illness (SMI) and the proportion of nursing home residents with SMI. DESIGN Instrumental variable study. Relative distance to the nearest nursing home with a high proportion of SMI residents was used to account for potential selection of patients between high- and low-SMI facilities. Data were obtained from the 2006-2010 Minimum Data Set assessments linked with Medicare claims and nursing home information from the Online Survey, Certification, and Reporting database. SETTING Nursing homes with high (defined as at least 10% of a facility's population having an SMI diagnosis) and low proportions of SMI residents. PARTICIPANTS A total of 58 571 Medicare nursing residents with an SMI diagnosis (ie, schizophrenia or bipolar disorder) and 558 699 individuals without an SMI diagnosis who were admitted to the same nursing homes. MEASUREMENTS Outcomes were nursing home quality measures: (1) use of physical restraints, (2) any hospitalization in the last 3 months, (3) use of an indwelling catheter, (4) use of a feeding tube, and (5) presence of pressure ulcer(s). RESULTS For individuals with SMI, admission to a high-SMI facility was associated with a 3.7 percentage point (95% confidence interval [CI] = 1.4-6.0) increase in the probability of feeding tube use relative to individuals admitted to a low-SMI facility. Among individuals without SMI, admission to a high-SMI facility was associated with a 1.7 percentage point increase in the probability of catheter use (95 CI = .03-3.47), a 3.8 percentage point increase in the probability of being hospitalized (95% CI = 2.16-5.44), and a 2.1 percentage point increase in the probability of having a feeding tube (95% CI = .43-3.74). CONCLUSION Admission to nursing homes with high concentrations of residents with SMI is associated with worse outcomes for both residents with and without SMI. J Am Geriatr Soc 67:2346-2352, 2019.
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Affiliation(s)
- Brian E McGarry
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Nina R Joyce
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Thomas G McGuire
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Susan L Mitchell
- Hebrew Senior Life Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Stephen J Bartels
- The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Shin JH, Shin IS. The effect of registered nurses on nursing home residents’ outcomes, controlling for organizational and health care market factors. Geriatr Nurs 2019; 40:296-301. [DOI: 10.1016/j.gerinurse.2018.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/21/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
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The Relationship Between Quality of Care, Physical Therapy, and Occupational Therapy Staffing Levels in Nursing Homes in 4 Years' Follow-up. J Am Med Dir Assoc 2019; 20:462-469. [DOI: 10.1016/j.jamda.2019.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/15/2022]
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Trajectory of Physical Functioning Among Persons Living With HIV in Nursing Homes. J Am Med Dir Assoc 2019; 20:497-502. [PMID: 30846372 DOI: 10.1016/j.jamda.2019.01.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE(S) To examine the change in physical functional status among persons living with HIV (PLWH) in nursing homes (NHs) and how change varies with age and dementia. DESIGN Retrospective cohort study. SETTING NHs in 14 states in the United States. PARTICIPANTS PLWH who were admitted to NHs between 2001 and 2010 and had stays of ≥90 days (N = 3550). MEASUREMENTS We linked Medicaid Analytic eXtract (MAX) and Minimum Data Set (MDS) data for NH residents in the sampled states and years and used them to determine HIV infection. The main outcome was improvement in physical functional status, defined as a decrease of at least 4 points in the activities of daily living (ADL) score within 90 days of NH admission. Independent variables of interest were age and dementia (Alzheimer's disease or other dementia). Multivariate logistic regression was used, adjusting for individual-level covariates. RESULTS The average age on NH admission of PLWH was 58. Dementia prevalence ranged from 14.5% in the youngest age group (age <40 years) to 38.9% in the oldest group (age ≥70 years). Overall, 44% of the PLWH experienced ADL improvement in NHs. Controlling for covariates, dementia was related to a significantly lower likelihood of ADL improvement among PLWH in the oldest age group only: the adjusted probability of improvement was 40.6% among those without dementia and 29.3% among those with dementia (P < .01). CONCLUSIONS/RELEVANCE PLWH, especially younger persons, may be able to improve their ADL function after being admitted into NHs. However, with older age, PLWH with dementia are more physically dependent and vulnerable to deterioration of physical functioning in NHs. More and/or specialized care may be needed to maintain physical functioning among this population. Findings from this study provide NHs with information on care needs of PLWH and inform future research on developing interventions to improve care for PLWH in NHs.
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Blankart CR, Foster AD, Mor V. The effect of political control on financial performance, structure, and outcomes of US nursing homes. Health Serv Res 2018; 54:167-180. [PMID: 30294780 PMCID: PMC6338305 DOI: 10.1111/1475-6773.13061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective To evaluate the effect of partisan political control on financial performance, structure, and outcomes of for‐profit and not‐for‐profit US nursing homes. Data Sources/Study Setting Nineteen‐year panel (1996‐2014) of state election outcomes, financial performance data from nursing home cost reports, operational and aggregate resident characteristics from OSCAR of 13 737 nursing homes. Study Design A linear panel model was estimated to identify the effect of Democratic and Republican political control on next year's outcomes. Nursing home outcomes were defined as yearly facility revenues, expenses, and profits; the number of Medicaid, Medicare, and private‐pay residents; staffing levels; and selected resident outcomes. Principal Findings Democratic political control leads to an increase in financial flows to for‐profit nursing homes, boosting profits without producing observable improvements in resident outcomes. Republican political control leads to lower revenues and profits of for‐profit nursing homes. A shift from Medicaid to more profitable private‐pay residents following Republican political control is observed for all nursing homes. Financial performance of not‐for‐profit nursing homes is not significantly affected by changes in political control. Conclusion Political control of the two legislative chambers—but not of the governorship—shapes the structure of the nursing home industry as seen in provider behavior.
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Affiliation(s)
- Carl Rudolf Blankart
- KPM Center for Public Management, University of Bern, Bern, Switzerland.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Andrew D Foster
- Department of Economics, Brown University, Providence, Rhode Island
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
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16
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Escrig-Pinol A, Corazzini KN, Blodgett MB, Chu CH, McGilton KS. Supervisory relationships in long-term care facilities: A comparative case study of two facilities using complexity science. J Nurs Manag 2018; 27:311-319. [DOI: 10.1111/jonm.12681] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/20/2018] [Accepted: 06/10/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Astrid Escrig-Pinol
- Toronto Rehabilitation Institute, EnCOAR Team; University Health Network; Toronto ON Canada
- University of Toronto; Dalla Lana School of Public Health; Toronto ON Canada
| | | | - Meagan B. Blodgett
- Toronto Rehabilitation Institute, EnCOAR Team; University Health Network; Toronto ON Canada
| | - Charlene H. Chu
- Toronto Rehabilitation Institute, EnCOAR Team; University Health Network; Toronto ON Canada
| | - Katherine S. McGilton
- Toronto Rehabilitation Institute, EnCOAR Team; University Health Network; Toronto ON Canada
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17
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Zullo AR, Zhang T, Banerjee G, Lee Y, McConeghy KW, Kiel DP, Daiello LA, Mor V, Berry SD. Facility and State Variation in Hip Fracture in U.S. Nursing Home Residents. J Am Geriatr Soc 2018; 66:539-545. [PMID: 29336024 PMCID: PMC5849498 DOI: 10.1111/jgs.15264] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To quantify the variation in hip fracture incidence across U.S. nursing home (NH) facilities and states and examine how hip fracture incidence varies according to facility- and state-level characteristics. DESIGN Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. SETTING U.S. NHs with 100 or more beds. PARTICIPANTS Long-stay NH residents between May 1, 2007, and April 30, 2008, from 1,481 facilities and 46 U.S. states (N = 201,892). MEASUREMENTS Incident hip fractures were ascertained using Medicare Part A diagnostic codes. Each resident was followed for up to 2 years. RESULTS The mean adjusted incidence rate of hip fractures for all facilities was 3.13 (95% confidence interval (CI) = 3.01-3.26) per 100 person-years (range 1.20, 95% CI = 1.15-1.26 to 6.40, 95% CI = 6.07-6.77). Facilities with the highest rates of hip fracture had greater percentages of residents taking psychoactive medications (top tertile 27.2%, bottom tertile 24.8%), and fewer nursing (top tertile 3.43, bottom tertile 3.53) and direct care (top tertile 3.22, bottom tertile 3.29) hours per day per resident. The combination of state and facility characteristics explained 6.7% of the variation in hip fracture, and resident characteristics explained 7.6%. CONCLUSION Much of the variation in hip fracture incidence remained unexplained, although these findings indicate that potentially modifiable state and facility characteristics such as psychoactive drug prescribing and minimum staffing requirements could be addressed to help reduce the rate of hip fracture in U.S. NHs.
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Affiliation(s)
- Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI
| | - Tingting Zhang
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Geetanjoli Banerjee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Kevin W. McConeghy
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI
| | - Douglas P. Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Lori A. Daiello
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Sarah D. Berry
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Institute for Aging Research, Hebrew SeniorLife, Boston, MA
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18
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Goldberg EM, Keohane LM, Mor V, Trivedi AN, Jung HY, Rahman M. Preferred Provider Relationships Between Medicare Advantage Plans and Skilled Nursing Facilities Reduce Switching Out of Plans: An Observational Analysis. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2018; 55:46958018797412. [PMID: 30175669 PMCID: PMC6122232 DOI: 10.1177/0046958018797412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/03/2018] [Accepted: 08/07/2018] [Indexed: 12/03/2022]
Abstract
Unlike traditional Medicare, Medicare Advantage (MA) plans contract with specific skilled nursing facilities (SNFs). Patients treated in an MA plan's preferred SNF may benefit from enhanced coordination and have a lower likelihood of switching out of their plan. Using 2011-2014 Medicare enrollment data, the Medicare Healthcare Effectiveness Data and Information Set, and the Minimum Data Set, we examined Medicare enrollees who were newly admitted to SNFs in 2012-2013. We used the Centers for Medicare & Medicaid Services star rating to distinguish between MA plans and show how SNF concentration experienced by patients varies between patients in plans with different star ratings. We found that highly rated MA plans steer their patients to a smaller number of SNFs, and these patients are less likely to switch out of their plans. Strengthening the MA plan-SNF relationship may lower disenrollment rates for SNF beneficiaries, imparting benefits to both patients and payers.
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Affiliation(s)
| | | | - Vincent Mor
- Brown University, Providence, RI,
USA
- Providence VA Medical Center, RI,
USA
| | - Amal N. Trivedi
- Brown University, Providence, RI,
USA
- Providence VA Medical Center, RI,
USA
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19
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Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial. THE LANCET RESPIRATORY MEDICINE 2017; 5:738-746. [DOI: 10.1016/s2213-2600(17)30235-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 05/23/2017] [Accepted: 05/30/2017] [Indexed: 02/04/2023]
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20
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Kramer DB, Reynolds MR, Normand SL, Parzynski CS, Spertus JA, Mor V, Mitchell SL. Nursing Home Use After Implantable Cardioverter-Defibrillator Implantation in Older Adults: Results from the National Cardiovascular Data Registry. J Am Geriatr Soc 2017; 65:340-347. [PMID: 28198561 DOI: 10.1111/jgs.14520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To evaluate the incidence and characteristics of nursing home (NH) use after implantable cardioverter-defibrillator (ICD) implantation. DESIGN Cohort study. SETTING Medicare beneficiaries in the National Cardiovascular Data Registry-ICD Registry. PARTICIPANTS Individuals aged 65 and older receiving ICDs between January 1, 2006, and March 31, 2010 (N = 192,483). MEASUREMENTS Proportion of ICD recipients discharged to NHs directly after device placement, cumulative incidence of long-term NH admission, and factors associated with immediate discharge to a NH and time to long-term NH admission. RESULTS Over 4 years, 40.6% of the cohort died, and 35,939 (18.7%) experienced at least one NH admission, including 4.0% directly discharged to a NH after ICD implantation and 2.8% admitted to long-term NH care during follow-up. The cumulative incidence of long-term NH admission, accounting for the competing risk of death, was 1.7% at 1 year, 3.8% at 3 years, and 4.6% at 4 years; 20.1% of individuals admitted to a NH died there. Factors most strongly associated with direct NH discharge and time to long-term NH care were older age (adjusted odds ratio (AOR) = 2.09, 95% confidence interval (CI) = 2.01-2.17 per 10-year increment; adjusted hazard ratio (AHR) = 1.88, 95% CI = 1.80-1.97, respectively), dementia (AOR = 2.60, 95% CI = 2.25-3.01; AHR = 2.50, 95% CI = 2.14-2.93, respectively), and Medicare Part A claim for NH stay in prior 6 months (AOR = 3.96, 95% CI = 3.70-4.25; AHR = 2.88, 95% CI = 2.65-3.14, respectively). CONCLUSION Nearly one in five individuals are admitted to NHs over a median of 1.6 years of follow-up after ICD implantation. Understanding these outcomes may help inform the clinical care of these individuals.
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Affiliation(s)
- Daniel B Kramer
- Hebrew SeniorLife Institute for Aging Research, Boston, MA.,Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA
| | - Matthew R Reynolds
- Harvard Clinical Research Institute, Boston, MA.,Lahey Hospital and Medical Center, Burlington, MA
| | - Sharon-Lise Normand
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Department of Biostatistics, Havard TH Chan School of Public Health, Boston, MA
| | - Craig S Parzynski
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, Yale University, New Haven, Connecticut
| | | | - Vincent Mor
- Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, Rhode Island
| | - Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, MA.,Harvard Medical School, Boston, MA
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21
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Li Y, Harrington C, Mukamel DB, Cen X, Cai X, Temkin-Greener H. Nurse Staffing Hours At Nursing Homes With High Concentrations Of Minority Residents, 2001-11. Health Aff (Millwood) 2017; 34:2129-37. [PMID: 26643634 DOI: 10.1377/hlthaff.2015.0422] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recent increases in state Medicaid payments to nursing homes have the potential to reduce disparities in nurse staffing between facilities with high and low concentrations of racial/ethnic minority residents. Analyses of nursing home and state policy survey data for the period 2001-11 suggest that registered nurse and licensed practical nurse staffing levels increased slightly during this period, regardless of racial/ethnic minority resident concentration. Adjusted disparities in registered nurse hours per resident day between nursing homes with high and low concentrations of minority residents persisted, although they were reduced. Certified nursing assistant hours per patient day increased in nursing homes with low concentrations of minorities but decreased in homes with high concentrations, creating a new disparity. Overall, increases in state Medicaid payment rates to nursing homes were associated with improvements in staffing and reduced staffing disparities across facilities, but the adoption of case-mix payments had the opposite effect. Further reforms in health care delivery and payment are needed to address persistent disparities in care between nursing homes serving higher proportions of minority residents and those serving lower proportions, and to prevent unintended exacerbations of such disparities.
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Affiliation(s)
- Yue Li
- Yue Li is an associate professor in the Department of Public Health Sciences at the University of Rochester, in New York
| | - Charlene Harrington
- Charlene Harrington is a professor of nursing at the University of California, San Francisco
| | - Dana B Mukamel
- Dana B. Mukamel is a professor in the Department of Medicine, University of California, Irvine
| | - Xi Cen
- Xi Cen is a PhD candidate in the Department of Public Health Sciences at the University of Rochester
| | - Xueya Cai
- Xueya Cai is a research associate professor in the Department of Biostatistics and Computational Biology at the University of Rochester
| | - Helena Temkin-Greener
- Helena Temkin-Greener is a professor in the Department of Public Health Sciences at the University of Rochester
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22
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Lepore M, Leland NE. Nursing Homes That Increased The Proportion Of Medicare Days Saw Gains In Quality Outcomes For Long-Stay Residents. Health Aff (Millwood) 2017; 34:2121-8. [PMID: 26643633 DOI: 10.1377/hlthaff.2015.0303] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nursing homes are increasingly providing rehabilitative care to short-stay residents under Medicare's skilled nursing facility coverage, which is much more generous than Medicaid's coverage for long-stay residents. This shift creates the potential for both beneficial and detrimental effects on outcomes for such residents. Examining nationwide facility-level nursing home data for the period 2007-10, we found that increasing the proportion of Medicare-covered patient days in a nursing home was significantly associated with improvements in the quality of the three outcomes we considered for long-stay residents. We saw significant decreases in the percentages of long-stay residents with daily pain (from 5.1 percent to 3.4 percent), with worsening pressure ulcers (from 2.5 percent to 2.0 percent), and with a decline in performing activities of daily living (from 15.9 percent to 14.9 percent). These findings reinforce previous research indicating that quality outcomes tend to be superior in nursing homes with greater financial resources. They also bolster arguments for financial investments in nursing homes, including increases in Medicaid payment rates, to support better care for long-stay residents.
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Affiliation(s)
- Michael Lepore
- Michael Lepore is a senior health policy and health services researcher in the Aging, Disability, and Long-Term Care program at RTI International in Washington, D.C., and an adjunct assistant professor in the Department of Health Services, Policy, and Practice at Brown University, in Providence, Rhode Island
| | - Natalie E Leland
- Natalie E. Leland is an assistant professor with a joint appointment in the Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy and the Davis School of Gerontology at the University of Southern California, in Los Angeles, and an adjunct assistant professor in the Department of Health Services, Policy, and Practice at Brown University
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23
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Li Y, Harrington C, Temkin-Greener H, You K, Cai X, Cen X, Mukamel DB. Deficiencies In Care At Nursing Homes And Racial/Ethnic Disparities Across Homes Fell, 2006-11. Health Aff (Millwood) 2016; 34:1139-46. [PMID: 26153308 DOI: 10.1377/hlthaff.2015.0094] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite the increased use of nursing homes by minority residents, nursing home care remains highly segregated. Compared to whites, racial/ethnic minorities tend to be cared for in facilities with limited clinical and financial resources, low nurse staffing levels, and a relatively high number of care deficiency citations. We assessed the trends from 2006 to 2011 in those citations and in disparities across facilities with four different concentrations of racial/ethnic minority residents. We found that the number of health care-related deficiencies and the percentage of facilities with serious deficiencies decreased over time for all four facility groups. From 2006 to 2011 the average annual number of health care-related deficiencies declined from 7.4 to 6.8 for facilities with low minority concentrations (<5 percent) and from 10.6 to 9.4 for facilities with high minority concentrations (≥35 percent). In multivariable analyses, across-site disparities in health care-related deficiencies and in life-safety deficiencies narrowed over time. We also found that increasing the Medicaid payment rate might help improve both overall quality and disparities, but state case-mix payment approaches might worsen both. These results suggest the need to reevaluate quality improvement and cost containment efforts to better foster the quality and equity of nursing home care.
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Affiliation(s)
- Yue Li
- Yue Li is an associate professor in the Department of Public Health Sciences at the University of Rochester Medical Center, in New York
| | - Charlene Harrington
- Charlene Harrington is a professor of nursing at the University of California, San Francisco
| | - Helena Temkin-Greener
- Helena Temkin-Greener is a professor in the Department of Public Health Sciences at the University of Rochester Medical Center
| | - Kai You
- Kai You is a PhD candidate in public health sciences at the University of Rochester
| | - Xueya Cai
- Xueya Cai is a research assistant professor of biostatistics and computational biology at the University of Rochester
| | - Xi Cen
- Xi Cen is a PhD candidate in public health sciences at the University of Rochester
| | - Dana B Mukamel
- Dana B. Mukamel is a professor in the Department of Medicine at the University of California, Irvine
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24
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Gruneir A, Bronskill SE, Newman A, Bell CM, Gozdyra P, Anderson GM, Rochon PA. Variation in Emergency Department Transfer Rates from Nursing Homes in Ontario, Canada. Healthc Policy 2016; 12:76-88. [PMID: 28032826 PMCID: PMC5221713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Nursing home (NH) residents are frequently transferred to the emergency department (ED) but there is little data on inter-facility variation, which has implications for intervention planning and implementation. OBJECTIVES To describe variation in ED transfer rates (TRs) across NHs and the association with NH characteristics. DESIGN/SETTING Retrospective cohort study using linked administrative data from Ontario. PARTICIPANTS 71,780 residents of 604 NHs in 2010 and followed for one year. MEASUREMENTS Funnel plots were used to identify high transfer NHs and logistic regression to test the association with NH location, size, ownership and historical ED transfer rate. RESULTS One-year ED transfer rates ranged from 4.3% to 58.6% (mean 28.4%); 115 (19%) NHs were considered high. Being within five minutes of an ED, larger size and high historical ED transfer rate were associated with being a high ED transfer home. CONCLUSION There was substantial variation across NHs. Consideration of characteristics such as proximity to an ED may be important in the development and targeting of different interventions for NHs.
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Affiliation(s)
- Andrea Gruneir
- Assistant Professor, Department of Family Medicine, University of Alberta, Edmonton, AB
| | | | - Alice Newman
- Analyst, Institute for Clinical Evaluative Sciences, Toronto, ON
| | - Chaim M. Bell
- Professor, Department of Medicine, Mount Sinai Hospital/University of Toronto, Toronto, ON
| | - Peter Gozdyra
- Medical Geographer, Institute for Clinical Evaluative Sciences, Toronto, ON
| | - Geoffrey M. Anderson
- Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Paula A. Rochon
- Senior Scientist, Women's College Research Institute, Women's College Hospital, Toronto, ON
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25
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Bowblis JR, Applebaum R. How Does Medicaid Reimbursement Impact Nursing Home Quality? The Effects of Small Anticipatory Changes. Health Serv Res 2016. [PMID: 27581748 DOI: 10.1111/1475‐6773.12553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE In 2006, Ohio changed its Medicaid reimbursement methodology for nursing homes (NHs) to promote more efficient staffing levels. This study examines the impacts of this policy change on quality. RESEARCH DESIGN AND SUBJECTS Ohio NHs were categorized based on their anticipated change in reimbursement under a new reimbursement system initiated in 2006. Linear regressions were utilized to determine how quality changed from 2006 to 2010 relative to a group of NHs that were not anticipated to experience any significant change in reimbursement. We examine resident outcomes constructed from the Minimum Data Set, deficiency citations, staffing levels, and satisfaction scores for residents and families as measures of quality. PRINCIPAL FINDINGS Nursing homes in the group receiving increased reimbursement showed an increase in nursing and nursing aide staffing levels. NHs in the group receiving a reduction in reimbursement did lower staffing levels. None of the nonstaffing quality outcomes were impacted by changes in Medicaid reimbursement. CONCLUSION Increased Medicaid reimbursement was found to increase staffing levels, but it had a limited effect, at least in the short run, on an array of nonstaffing quality outcomes.
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26
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Bowblis JR, Applebaum R. How Does Medicaid Reimbursement Impact Nursing Home Quality? The Effects of Small Anticipatory Changes. Health Serv Res 2016; 52:1729-1748. [PMID: 27581748 DOI: 10.1111/1475-6773.12553] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE In 2006, Ohio changed its Medicaid reimbursement methodology for nursing homes (NHs) to promote more efficient staffing levels. This study examines the impacts of this policy change on quality. RESEARCH DESIGN AND SUBJECTS Ohio NHs were categorized based on their anticipated change in reimbursement under a new reimbursement system initiated in 2006. Linear regressions were utilized to determine how quality changed from 2006 to 2010 relative to a group of NHs that were not anticipated to experience any significant change in reimbursement. We examine resident outcomes constructed from the Minimum Data Set, deficiency citations, staffing levels, and satisfaction scores for residents and families as measures of quality. PRINCIPAL FINDINGS Nursing homes in the group receiving increased reimbursement showed an increase in nursing and nursing aide staffing levels. NHs in the group receiving a reduction in reimbursement did lower staffing levels. None of the nonstaffing quality outcomes were impacted by changes in Medicaid reimbursement. CONCLUSION Increased Medicaid reimbursement was found to increase staffing levels, but it had a limited effect, at least in the short run, on an array of nonstaffing quality outcomes.
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27
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Campbell LJ, Cai X, Gao S, Li Y. Racial/Ethnic Disparities in Nursing Home Quality of Life Deficiencies, 2001 to 2011. Gerontol Geriatr Med 2016; 2:2333721416653561. [PMID: 27819015 PMCID: PMC5066711 DOI: 10.1177/2333721416653561] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/04/2016] [Accepted: 05/09/2016] [Indexed: 11/16/2022] Open
Abstract
Objectives: Racial/ethnic disparities in nursing homes (NHs) are associated with lower quality of care, and state Medicaid payment policies may influence NH quality. However, no studies analyzing disparities in NH quality of life (QoL) exist. Therefore, this study aims to estimate associations at the NH level between average number of QoL deficiencies and concentrations of racial/ethnic minority residents, and to identify effects of state Medicaid payment policies on racial/ethnic disparities. Method: Multivariable Poisson regression with NH random effects was used to determine the association between NH minority concentration in 2000 to 2010 and average number of QoL deficiencies in 2001 to 2011 at the NH level, and the effect of state NH payment policies on QoL deficiencies and racial/ethnic disparities in QoL deficiencies across NH minority concentrations. Results: Racial/ethnic disparities in QoL between high and low minority concentration NHs decrease over time, but are not eliminated. Case mix payment was associated with an increased disparity between high and low minority concentration NHs in QoL deficiencies. Discussion: NH managers and policy makers should consider initiatives targeting minority residents or low-performing NHs with higher minority concentrations for improvement to reduce disparities and address QoL deficiencies.
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Affiliation(s)
| | - Xueya Cai
- University of Rochester Medical Center, NY, USA
| | - Shan Gao
- University of Rochester Medical Center, NY, USA
| | - Yue Li
- University of Rochester Medical Center, NY, USA
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28
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Harrington C, Schnelle JF, McGregor M, Simmons SF. The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes. Health Serv Insights 2016. [PMID: 27103819 DOI: 10.4137/hsi.s38994.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.
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Affiliation(s)
- Charlene Harrington
- R.N. Professor Emeritus of Nursing and Sociology, Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - John F Schnelle
- Hamilton Professor of Medicine and Director of the Center for Quality Aging, Department of Medicine, Division of Geriatrics, Vanderbilt University, Nashville, TN, USA.; Division of General Internal Medicine and Public Health, Center for Quality Aging, Vanderbilt University, Nashville, TN, USA.; Department of Veterans Affairs, Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Margaret McGregor
- Clinical Associate Professor, Director of Community Geriatrics, University of British Columbia Department of Family Practice, Vancouver, BC, USA
| | - Sandra F Simmons
- Division of General Internal Medicine and Public Health, Center for Quality Aging, Vanderbilt University, Nashville, TN, USA.; Department of Veterans Affairs, Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.; Associate Professor, Department of Medicine, Division of Geriatrics, Vanderbilt University, Nashville, TN, USA
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29
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Implementation of a nursing home quality improvement project to reduce resident pain: a qualitative case study. J Nurs Care Qual 2016; 30:261-8. [PMID: 25407787 DOI: 10.1097/ncq.0000000000000099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article describes the experiences of staff members working within nursing homes that successfully implemented a quality improvement project aimed at reducing resident pain. Interviews were conducted with 24 nursing home employees from within 8 facilities participating in the quality improvement project. Findings were organized using the Consolidated Framework for Implementation Research. Interdisciplinary communication, supportive leadership, training, and nursing assistant participation facilitated implementation. Increased documentation, resistance to change, and difficulty measuring outcomes were perceived challenges.
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30
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Harrington C, Schnelle JF, McGregor M, Simmons SF. The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes. Health Serv Insights 2016; 9:13-9. [PMID: 27103819 PMCID: PMC4833431 DOI: 10.4137/hsi.s38994] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/08/2016] [Accepted: 03/14/2016] [Indexed: 11/05/2022] Open
Abstract
Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.
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Affiliation(s)
- Charlene Harrington
- R.N. Professor Emeritus of Nursing and Sociology, Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - John F Schnelle
- Hamilton Professor of Medicine and Director of the Center for Quality Aging, Department of Medicine, Division of Geriatrics, Vanderbilt University, Nashville, TN, USA.; Division of General Internal Medicine and Public Health, Center for Quality Aging, Vanderbilt University, Nashville, TN, USA.; Department of Veterans Affairs, Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Margaret McGregor
- Clinical Associate Professor, Director of Community Geriatrics, University of British Columbia Department of Family Practice, Vancouver, BC, USA
| | - Sandra F Simmons
- Division of General Internal Medicine and Public Health, Center for Quality Aging, Vanderbilt University, Nashville, TN, USA.; Department of Veterans Affairs, Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.; Associate Professor, Department of Medicine, Division of Geriatrics, Vanderbilt University, Nashville, TN, USA
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Nezamodini ZS, Khodamoradi F, Malekzadeh M, Vaziri H. Nursing Errors in Intensive Care Unit by Human Error Identification in Systems Tool: A Case Study. ACTA ACUST UNITED AC 2016. [DOI: 10.17795/jjhs-36055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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You K, Li Y, Intrator O, Stevenson D, Hirth R, Grabowski D, Banaszak-Holl J. Do Nursing Home Chain Size and Proprietary Status Affect Experiences With Care? Med Care 2016; 54:229-34. [PMID: 26765147 PMCID: PMC4752885 DOI: 10.1097/mlr.0000000000000479] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
BACKGROUND In 2012, over half of nursing homes were operated by corporate chains. Facilities owned by the largest for-profit chains were reported to have lower quality of care. However, it is unknown how nursing home chain ownerships are related with experiences of care. OBJECTIVES To study the relationship between nursing home chain characteristics (chain size and profit status) with patients' family member reported ratings on experiences with care. DATA SOURCES AND STUDY DESIGN Maryland nursing home care experience reports, the Online Survey, Certification, And Reporting (OSCAR) files, and Area Resource Files are used. Our sample consists of all nongovernmental nursing homes in Maryland from 2007 to 2010. Consumer ratings were reported for: overall care; recommendation of the facility; staff performance; care provided; food and meals; physical environment; and autonomy and personal rights. We identified chain characteristics from OSCAR, and estimated multivariate random effect linear models to test the effects of chain ownership on care experience ratings. RESULTS Independent nonprofit nursing homes have the highest overall rating score of 8.9, followed by 8.6 for facilities in small nonprofit chains, and 8.5 for independent for-profit facilities. Facilities in small, medium, and large for-profit chains have even lower overall ratings of 8.2, 7.9, and 8.0, respectively. We find similar patterns of differences in terms of recommendation rate, and important areas such as staff communication and quality of care. CONCLUSIONS Evidence suggests that Maryland nursing homes affiliated with large-for-profit and medium-for-profit chains had lower ratings of family reported experience with care.
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Affiliation(s)
- Kai You
- Department of Economics, University at Albany, State University of New York
| | - Yue Li
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - Orna Intrator
- Department of Public Health Sciences, Division of Health Policy and Outcomes Research, University of Rochester Medical Center
| | - David Stevenson
- Department of Health Policy, Vanderbilt University School of Medicine
| | - Richard Hirth
- Department of Health Management and Policy, University of Michigan
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Gravenstein S, Dahal R, Gozalo PL, Davidson HE, Han LF, Taljaard M, Mor V. A cluster randomized controlled trial comparing relative effectiveness of two licensed influenza vaccines in US nursing homes: Design and rationale. Clin Trials 2016; 13:264-74. [PMID: 26908539 DOI: 10.1177/1740774515625976] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Influenza, the most important viral infection affecting older adults, produces a substantial burden in health care costs, morbidity, and mortality. Influenza vaccination remains the mainstay in prevention and is associated with reduced rates of hospitalization, stroke, heart attack, and death in non-institutional older adult populations. Influenza vaccination produces considerably lower antibody response in the elderly compared to young adults. Four-fold higher vaccine antigen (high-dose) than in the standard adult vaccine (standard-dose) elicits higher serum antibody levels and antibody response in ambulatory elderly. PURPOSE To describe the design considerations of a large clinical trial of high-dose compared to standard-dose influenza vaccine in nursing homes and baseline characteristics of participating nursing homes and long-stay (more than 90 days) residents over 65 years of age. METHODS The high-dose influenza vaccine intervention trial is multifacility, cluster randomized controlled trial with a 2×2 factorial design that compares hospitalization rates, mortality, and functional decline among long-stay nursing home residents in facilities randomized to receive high-dose versus standard-dose influenza vaccine and also randomized with or without free staff vaccines provided by study organizers. Enrollment focused on nursing homes with a large long-stay resident population over 65 years of age. The primary outcome is the resident-level incidence of hospitalization with a primary diagnosis of pulmonary and influenza-like illness, based upon Medicare inpatient hospitalization claims. Secondary outcomes are all-cause mortality based upon the vital status indicator in the Medicare Vital Status file, all-cause hospitalization directly from the nursing home Minimum Data Set discharge records, and the probability of declining at least 4 points on the 28-point Activities of Daily Living Scale. RESULTS Between February and September 2013, the high-dose influenza vaccine trial recruited and randomized 823 nursing homes. The analysis sample includes 53,035 long-stay nursing home residents over 65 years of age, representing 57.7% of the participating facilities' population. Residents are mainly women (72.2%), white (75.5%), with a mean age of 83 years. Common conditions include hypertension (79.2%), depression (55.1%), and diabetes mellitus (34.4%). The prevalence of circulatory and pulmonary disorders includes heart failure (20.5%), stroke (20.1%), and asthma/chronic obstructive pulmonary disease (20.2%). CONCLUSIONS This high-dose influenza vaccine trial uniquely offers a paradigm for future studies of clinical and programmatic interventions within the framework of efforts designed to test the impact of changes in usual treatment practices adopted by health care systems. TRIAL REGISTRATION NCT01815268.
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Affiliation(s)
- Stefan Gravenstein
- Center for Geriatrics and Palliative Care, University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, OH, USA Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, RI, USA Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Roshani Dahal
- Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, RI, USA
| | - Pedro L Gozalo
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | | | - Lisa F Han
- Insight Therapeutics LLC, Norfolk, VA, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada. Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Vincent Mor
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA Providence Veterans Administration Medical Center, Providence, RI USA
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A Critical Review of Research on Hospitalization from Nursing Homes; What is Missing? AGEING INTERNATIONAL 2015. [DOI: 10.1007/s12126-015-9232-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Holup AA, Gassoumis ZD, Wilber KH, Hyer K. Community Discharge of Nursing Home Residents: The Role of Facility Characteristics. Health Serv Res 2015. [PMID: 26211390 DOI: 10.1111/1475-6773.12340] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Using a socio-ecological model, this study examines the influence of facility characteristics on the transition of nursing home residents to the community after a short stay (within 90 days of admission) or long stay (365 days of admission) across states with different long-term services and supports systems. DATA SOURCE Data were drawn from the Minimum Data Set, the federal Online Survey, Certification, and Reporting (OSCAR) database, the Area Health Resource File, and the LTCFocUs.org database for all free-standing, certified nursing homes in California (n = 1,127) and Florida (n = 657) from July 2007 to June 2008. STUDY DESIGN Hierarchical generalized linear models were used to examine the impact of facility characteristics on the probability of transitioning to the community. PRINCIPAL FINDINGS Facility characteristics, including size, occupancy, ownership, average length of stay, proportion of Medicare and Medicaid residents, and the proportion of residents admitted from acute care facilities are associated with discharge but differed by state and whether the discharge occurred after a short or long stay. CONCLUSION Short- and long-stay nursing home discharge to the community is affected by resident, facility, and sometimes market characteristics, with Medicaid consistently influencing discharge in both states.
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Affiliation(s)
- Amanda A Holup
- Florida Policy Exchange Center on Aging, School of Aging Studies, University of South Florida, Tampa, FL
| | - Zachary D Gassoumis
- Davis School of Gerontology, University of Southern California, Los Angeles, CA
| | - Kathleen H Wilber
- Davis School of Gerontology, University of Southern California, Los Angeles, CA
| | - Kathryn Hyer
- Florida Policy Exchange Center on Aging, School of Aging Studies, University of South Florida, Tampa, FL
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Rodríguez-Martín B, Stolt M, Katajisto J, Suhonen R. Nurses' characteristics and organisational factors associated with their assessments of individualised care in care institutions for older people. Scand J Caring Sci 2015; 30:250-9. [DOI: 10.1111/scs.12235] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 03/09/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Beatriz Rodríguez-Martín
- Faculty of Occupational Therapy, Logopedia and Nursing; University of Castilla-La Mancha Talavera de la Reina Toledo Spain
- Social and Health Care Research Center, University of Castilla-La Mancha; Cuenca Spain
| | - Minna Stolt
- University of Turku; Department of Nursing; Turku Finland
| | - Jouko Katajisto
- University of Turku; Department of Mathematics and Statistics; Turku Finland
| | - Riitta Suhonen
- University of Turku; Department of Nursing; Turku Finland
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Foster AD, Lee YS. Staffing subsidies and the quality of care in nursing homes. JOURNAL OF HEALTH ECONOMICS 2015; 41:133-147. [PMID: 25814437 PMCID: PMC4417439 DOI: 10.1016/j.jhealeco.2015.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 02/03/2015] [Accepted: 02/09/2015] [Indexed: 06/04/2023]
Abstract
Concerns about the quality of state-financed nursing home care has led to the wide-scale adoption by states of pass-through subsidies, in which Medicaid reimbursement rates are directly tied to staffing expenditure. We examine the effects of Medicaid pass-through on nursing home staffing and quality of care by adapting a two-step FGLS method that addresses clustering and state-level temporal autocorrelation. We find that pass-through subsidies increases staffing by about 1% on average and 2.7% in nursing homes with a low share of Medicaid patients. Furthermore, pass-through subsidies reduce the incidences of pressure ulcer worsening by about 0.9%.
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Affiliation(s)
- Andrew D Foster
- Department of Economics, Brown University, Providence, RI 02912, USA.
| | - Yong Suk Lee
- Freeman Spogli Institute of International Studies, Stanford University, Stanford CA 94305, USA.
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Abrahamson K, Miech E, Davila HW, Mueller C, Cooke V, Arling G. Pay-for-performance policy and data-driven decision making within nursing homes: a qualitative study. BMJ Qual Saf 2015; 24:311-7. [PMID: 25749027 DOI: 10.1136/bmjqs-2014-003362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 02/19/2015] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Health systems globally and within the USA have introduced nursing home pay-for-performance (P4P) programmes in response to the need for improved nursing home quality. Central to the challenge of administering effective P4P is the availability of accurate, timely and clinically appropriate data for decision making. We aimed to explore ways in which data were collected, thought about and used as a result of participation in a P4P programme. METHODS Semistructured interviews were conducted with 232 nursing home employees from within 70 nursing homes that participated in P4P-sponsored quality improvement (QI) projects. Interview data were analysed to identify themes surrounding collecting, thinking about and using data for QI decision making. RESULTS The term 'data' appeared 247 times in the interviews, and over 92% of these instances (228/247) were spontaneous references by nursing home staff. Overall, 34% of respondents (79/232) referred directly to 'data' in their interviews. Nursing home leadership more frequently discussed data use than direct care staff. Emergent themes included using data to identify a QI problem, gathering data in new ways at the local level, and measuring outcomes in response to P4P participation. Alterations in data use as a result of policy change were theoretically consistent with the revised version of the Promoting Action on Research Implementation in Health Services framework, which posits that successful implementation is a function of evidence, context and facilitation. CONCLUSIONS Providing a reimbursement context that facilitates the collection and use of reliable local evidence may be an important consideration to others contemplating the adaptation of P4P policies.
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Affiliation(s)
| | - Edward Miech
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Christine Mueller
- School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Valerie Cooke
- Minnesota Department of Human Services, Minneapolis, Minnesota, USA
| | - Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana, USA
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Wysocki A, Thomas KS, Mor V. Functional Improvement Among Short-Stay Nursing Home Residents in the MDS 3.0. J Am Med Dir Assoc 2015; 16:470-4. [PMID: 25659622 DOI: 10.1016/j.jamda.2014.11.018] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 09/29/2014] [Accepted: 11/24/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To examine the completeness of the activities of daily living (ADL) items on admission and discharge assessments and the improvement in ADL performance among short-stay residents in the newly adopted Minimum Data Set (MDS) 3.0. DESIGN Retrospective analysis of MDS admission and discharge assessments. SETTING Nursing homes from July 1, 2011, to June 30, 2012. PARTICIPANTS New nursing home residents admitted from acute hospitals with corresponding admission and discharge assessments between July 1, 2011, and June 30, 2012, who had a length of stay of 100 days or less. MEASUREMENTS ADL self-performance items, including bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, at admission and discharge. RESULTS The ADL self-performance items are complete at both admission and discharge, with less than 1% missing for any item. More than 60% of residents improved over the course of their post-acute stay. New short-stay nursing home residents with conditions such as cognitive impairment, delirium, dementia, heart failure, and stroke showed less improvement in ADL performance during their stay. CONCLUSION The discharge assessment data in the MDS 3.0 provide new information to researchers and providers to examine and track ADL performance. Nursing homes can identify and track patients who require more intensive therapies or targeted interventions to achieve functional improvement during their stay. Future research can examine facility-level measures to better understand how ADL improvement varies across facilities.
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Affiliation(s)
| | - Kali S Thomas
- School of Public Health, Brown University, Providence RI; Providence VA Medical Center, Providence, RI
| | - Vincent Mor
- School of Public Health, Brown University, Providence RI; Providence VA Medical Center, Providence, RI
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Hyer K, Thomas KS, Johnson CE, Harman JS, Weech-Maldonado R. Do Medicaid incentive payments boost quality? Florida's direct care staffing adjustment program. J Aging Soc Policy 2013; 25:65-82. [PMID: 23256559 DOI: 10.1080/08959420.2012.705629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents--the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.
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Affiliation(s)
- Kathryn Hyer
- Florida Policy Exchange Center on Aging, School of Aging Studies, University of South Florida, Tampa, Florida 33612, USA.
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Abstract
OBJECTIVES To examine the prevalence of obesity and its relationship with pressure ulcers among nursing home (NH) populations, and whether such relationship varies with certified nursing assistant (CNA) level in NHs. DATA AND STUDY POPULATION: The 1999-2009 nationwide Minimum Data Sets were linked with Online Survey of Certification and Reporting records. We identified newly admitted NH residents who became long-stayers and followed them up to 1 year. ANALYSES The outcome variable was presence of pressure ulcers during the 1-year follow-up period. Residents were categorized as normal [18.5 ≤ body mass index (BMI)<30 kg/m2], mild obesity (30 ≤ BMI <35 kg/m2), and moderate or severe obesity (BMI ≥ 35 kg/m2). Pooled and stratified analyses were performed to examine the relationship between obesity and pressure ulcers, and how it varied by facility CNA level. RESULTS The prevalence of obesity increased from 16.9% to 25.8% among newly admitted NH residents over the last decade. Obesity was associated with higher risks of pressure ulcers among long-stay residents. The relationship between obesity and pressure ulcers persisted after accounting for individual health conditions at the baseline and facility-level variations. Further, the within-facility relationship between obesity and pressure ulcers varied by facility CNA levels. The odds of pressure ulcers were 18.9% higher for residents with moderate or severe obesity than for nonobese residents within NHs with low CNA levels. The percents for medium and high CNA level facilities were 14.0% and 12.8%, respectively. CONCLUSION To prepare for the growing obesity epidemic in NHs, policies should focus on strategies to improve care provided for obese residents.
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Affiliation(s)
- Shubing Cai
- Center for Gerontology and Health Care Research, Brown University, Providence, RI 02912, USA.
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Li Y, Cai X, Ye Z, Glance LG, Harrington C, Mukamel DB. Satisfaction with Massachusetts nursing home care was generally high during 2005-09, with some variability across facilities. Health Aff (Millwood) 2013; 32:1416-25. [PMID: 23918486 PMCID: PMC3784993 DOI: 10.1377/hlthaff.2012.1416] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since 2005 Massachusetts has publicly reported results from biennial surveys of satisfaction with nursing homes, completed by responsible parties for residents, to promote consumer-centered care. Our analysis of the results from 2005, 2007, and 2009 revealed generally high satisfaction with care, which remained stable over time. On a scale of 1 to 5 (from very dissatisfied to very satisfied), average satisfaction with overall care was 4.22-4.31, and satisfaction that overall residents' needs were met was 4.09-4.16. Around 90 percent of respondents would recommend the facility. Satisfaction ratings varied considerably across facilities, with higher scores associated with higher nursing staffing levels, fewer deficiency citations, and nonprofit or government ownership. Scores for six domains of care were, in general, closely associated with satisfaction scores. However, family members seemed less satisfied with the physical and social activities available to residents and with the food and meals served than with such attributes as the physical environment. Our findings suggest that including the consumer's perspective would improve the Centers for Medicare and Medicaid Services' current nursing home reporting efforts. However, refinements may be necessary to detect the impact of consumer reporting on the quality of patient-centered care.
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Affiliation(s)
- Yue Li
- Department of Public Health Sciences, University of Rochester, NY, USA.
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Rodríguez-Martín B, Martínez-Andrés M, Cervera-Monteagudo B, Notario-Pacheco B, Martínez-Vizcaíno V. Perception of quality of care among residents of public nursing-homes in Spain: a grounded theory study. BMC Geriatr 2013; 13:65. [PMID: 23809066 PMCID: PMC3701483 DOI: 10.1186/1471-2318-13-65] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Accepted: 06/10/2013] [Indexed: 11/25/2022] Open
Abstract
Background The quality of care in nursing homes is weakly defined, and has traditionally focused on quantify nursing homes outputs and on comparison of nursing homes’ resources. Rarely the point of view of clients has been taken into account. The aim of this study was to ascertain what means “quality of care” for residents of nursing homes. Methods Grounded theory was used to design and analyze a qualitative study based on in-depth interviews with a theoretical sampling including 20 persons aged over 65 years with no cognitive impairment and eight proxy informants of residents with cognitive impairment, institutionalized at a public nursing home in Spain. Results Our analysis revealed that participants perceived the quality of care in two ways, as aspects related to the persons providing care and as institutional aspects of the care’s process. All participants agreed that aspects related to the persons providing care was a pillar of quality, something that, in turn, embodied a series of emotional and technical professional competences. Regarding the institutional aspects of the care’s process, participants laid emphasis on round-the-clock access to health care services and on professional’s job stability. Conclusions This paper includes perspectives of the nursing homes residents, which are largely absent. Incorporating residents’ standpoints as a complement to traditional institutional criteria would furnish health providers and funding agencies with key information when it came to designing action plans and interventions aimed at achieving excellence in health care.
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Abstract
CONTEXT Understanding Medicaid performance relative to private payers and among other states may lead to better value. DESIGN, SETTING, AND PARTICIPANTS Hospital Quality Alliance data from 2007-2008 were used to create composite "all-or-none" quality scores for nearly 900,000 nonelderly adult patients hospitalized with acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia. MAIN OUTCOME MEASURES Differences in the quality of care received by Medicaid compared with privately insured patients at the national and state levels. RESULTS Nationally, 88% of Medicaid beneficiaries received all appropriate processes of care when hospitalized for AMI, compared with 73% for CHF and 77% for pneumonia. Private patients received higher quality of care than Medicaid patients, but differences were small (1.3 percentage point difference, pneumonia; 2.7, AMI; 2.9, CHF; all P<0.05). At the state level, the differences averaged <3 percentage points across all conditions, but some states (2-8 states depending on the condition) exhibited significant (P<0.05) differences of >5 percentage points in favor of private patients. Two states exhibited significantly better quality of care for their Medicaid patients in excess of 5 percentage points. Quality scores for both Medicaid and private patients varied significantly by state but were highly correlated (correlations for AMI=0.80, CHF=0.84, pneumonia=0.80; all P<0.001). CONCLUSIONS Small national differences in quality between hospitalized Medicaid and private patients are promising, although merit close monitoring as states are forced to curb Medicaid reimbursements. Although quality for Medicaid patients varied by state, high correlations with private patients suggest that the factors driving quality have more to do with geographic factors in the delivery of hospital services than with state-established Medicaid policies.
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Eliopoulos C. Affecting culture change and performance improvement in Medicaid nursing homes: The Promote Understanding, Leadership, and Learning (PULL) Program. Geriatr Nurs 2013; 34:218-23. [DOI: 10.1016/j.gerinurse.2013.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 02/25/2013] [Indexed: 11/27/2022]
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Miller SC, Looze J, Shield R, Clark MA, Lepore M, Tyler D, Sterns S, Mor V. Culture change practice in U.S. Nursing homes: prevalence and variation by state medicaid reimbursement policies. THE GERONTOLOGIST 2013; 54:434-45. [PMID: 23514674 DOI: 10.1093/geront/gnt020] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE OF THE STUDY To estimate the prevalence of culture change practice in U.S. nursing homes (NHs) and examine how state Medicaid policies may be associated with this prevalence. DESIGN AND METHODS In 2009/2010, we conducted a survey of a stratified proportionate random sample of NH directors of nursing (DONs) and administrators (NHAs) at 4,149 U.S. NHs; contact was achieved with 3,695. Cooperation rates were 62.6% for NHAs and 61.5% for DONs. Questions focused on NH (physical) environment, resident-centered care, and staff empowerment domains. Domain scores were created and validated, in part, using qualitative interviews from 64 NHAs. Other NH covariate data were from Medicare/Medicaid surveys (Online Survey, Certification and Reporting), aggregated resident assessments (Minimum Data Set), and Medicare claims. Medicaid policies studied were a state's average NH reimbursement rate and pay-for-performance (P4P) reimbursement (including and not including culture change performance measures). Multivariate generalized ordered logit regressions were used. RESULTS Eighty-five percent of DONs reported some culture change implementation. Controlling for NH attributes, a $10 higher Medicaid rate was associated with higher NH environment scores. Compared with NHs in non-P4P states, NHs in states with P4P including culture change performance measures had twice the likelihood of superior culture change scores across all domains, and NHs in other P4P states had superior physical environment and staff empowerment scores. Qualitative interviews supported the validity of survey results. IMPLICATIONS Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended.
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Affiliation(s)
- Susan C Miller
- *Address correspondence to Susan C. Miller, Center for Gerontology & Health Care Research, Department of Health Services, Policy and Practice, Warren Alpert Medical School, Brown University, 121 South Main Street, G-S121-6, Providence, RI 02912. E-mail:
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Bowblis JR, Hyer K. Nursing home staffing requirements and input substitution: effects on housekeeping, food service, and activities staff. Health Serv Res 2013; 48:1539-50. [PMID: 23445455 DOI: 10.1111/1475-6773.12046] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To study the effect of minimum nurse staffing requirements on the subsequent employment of nursing home support staff. DATA SOURCES Nursing home data from the Online Survey Certification and Reporting (OSCAR) System merged with state nurse staffing requirements. STUDY DESIGN Facility-level housekeeping, food service, and activities staff levels are regressed on nurse staffing requirements and other controls using fixed effect panel regression. DATA EXTRACTION METHOD OSCAR surveys from 1999 to 2004. PRINCIPAL FINDINGS Increases in state direct care and licensed nurse staffing requirements are associated with decreases in the staffing levels of all types of support staff. CONCLUSIONS Increased nursing home nurse staffing requirements lead to input substitution in the form of reduced support staffing levels.
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Affiliation(s)
- John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, E. High Street, Oxford, OH 45056, USA.
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Brown LM, Dosa DM, Thomas K, Hyer K, Feng Z, Mor V. The effects of evacuation on nursing home residents with dementia. Am J Alzheimers Dis Other Demen 2013; 27:406-12. [PMID: 22930698 DOI: 10.1177/1533317512454709] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In response to the hurricane-related deaths of nursing home residents, there has been a steady increase in the number of facilities that evacuate under storm threat. This study examined the effects of evacuation during Hurricane Gustav on residents who were cognitively impaired. METHODS Nursing homes in counties located in the path of Hurricane Gustav were identified. The Minimum Data Set resident assessment files were merged with the Centers for Medicare enrollment file to determine date of death for residents in identified facilities. Difference-in-differences analyses were conducted adjusting for residents' demographic characteristics and acuity. RESULTS The dataset included 21,255 residents living in 119 at risk nursing homes over three years of observation. Relative to the two years before the storm, there was a 2.8 percent increase in death at 30 days and a 3.9 percent increase in death at 90 days for residents with severe dementia who evacuated for Hurricane Gustav, controlling for resident demographics and acuity. CONCLUSIONS The findings of this research reveal the deleterious effects of evacuation on residents with severe dementia. Interventions need to be developed and tested to determine the best methods for protecting this at risk population when there are no other options than to evacuate the facility.
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Affiliation(s)
- Lisa M Brown
- School of Aging Studies, University of South Florida, Tampa, FL 33612, USA.
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