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

Assisted living residents with dementia: Disparities in mental health services pre and during COVID-19

BACKGROUND

Little is known about mental health among Medicare beneficiaries with Alzheimer's disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL residents with ADRD, pre and during the COVID pandemic, focusing on race/ethnicity and Medicare/Medicaid dual status.

METHODS

A CY2018 cohort of AL residents with ADRD was identified. Outcome was any quarterly in-person or telemedicine mental health visit based on national CY2019-2020 Medicare claims. Key independent variables were individual race/ethnicity and dual status and the AL-level proportion of dual residents. We estimated a linear probability model with random effects and robust standard errors. Quarterly indicators captured service use before and after the onset of the pandemic.

RESULTS

The study included 102,758 fee-for-service Medicare beneficiaries with ADRD in 13,400 ALs. One in five residents had any mental health visits prior to the COVID-19 pandemic. Black residents, and those with dual Medicare/Medicaid eligibility, were significantly less likely to use mental health services prior to and during the pandemic. There were no significant differences in visits via telemedicine by race/ethnicity or individual dual status. Residents in AL communities with a higher proportion of duals had a lower likelihood of visits before and during the pandemic.

CONCLUSIONS/IMPLICATIONS

Mental health service use among AL residents with ADRD was low and declining prior to the pandemic. Telehealth allowed for mental health visits to continue during the pandemic, albeit at a lower level. Residents in ALs with a higher proportion of duals were less likely to have in-person or telehealth visits. The results suggest that some ALs may find it difficult to assure mental health service provision to this vulnerable population.

State-level nursing home in-service dementia training requirements and inappropriate psychotropic medication use

BACKGROUND

Although non-pharmacological interventions, which are staff intensive, are recommended for behavioral symptoms of dementia, psychotropics are often prescribed in nursing homes (NHs), with insufficient nurse staffing levels and dementia care training. Since 2017, deficiency citations can be assigned for inappropriate psychotropics use (F-758 tag). Some states require in-service dementia training above federal minimums, but it is unknown whether extra dementia training requirements were related to fewer F-758 citations for residents with dementia and whether nurse staffing influenced the relationship between receiving F-758 citations and having additional state-level dementia training requirements.

PURPOSE

To relate F-758 citation occurrence to extra in-service dementia training regulations and to explore how the relationships are affected by nurse staffing levels.

METHOD

Generalized linear mixed models were used to examine F-758 citation occurrence in relation to state-level in-service dementia training regulations. Stratification was also conducted to compare the effects in NHs with low versus high nurse staffing.

FINDINGS

Requiring in-service dementia training with extra hours was inversely related to receiving F-758 tags. That relationship was also noted in NHs with lower registered nurse and certified nurse assistant staffing.

DISCUSSION

In-service dementia training may be helpful in reducing inappropriate psychotropics use, particularly in facilities with lower nurse staffing.

Post-acute care transitions and outcomes among Medicare beneficiaries with dementia: Associations with race/ethnicity and dual status

OBJECTIVE

To evaluate how post-acute care (PAC) transitions affect minority older adults with Alzheimer's disease or related dementia (ADRD), and the extent to which dual Medicare-Medicaid eligibility may attenuate or exacerbate disparities in PAC outcomes. We examined: (1) PAC referrals by race/ethnicity and dual status; (2) individual, hospital, and market-level factors associated with PAC; (3) the association between PAC and outcomes.

DATA SOURCES/STUDY SETTING

We used the following secondary data: Master Beneficiary Summary File (MBSF), Medicare Provider Analysis and Review (MedPAR), Minimum Data Set (MDS), Area Health Resource File (AHRF), hospital Provider of Services (POS) file, and the area deprivation index (ADI).

STUDY DESIGN

This observational study consisted of 619,262 community-residing Medicare fee-for-service (FFS) beneficiaries with ADRD who had a hospital stay in 2017.

DATA COLLECTION/EXTRACTION METHODS

PAC discharge was to skilled nursing facilities (SNF), home health care (HHC) agencies or home without services. Outcomes were 30-day readmission and death. Multinomial logistic regressions with hospital random effects (RE), stratified by dual eligibility, were fit.

PRINCIPAL FINDINGS

Dual-related differences were significantly larger than race/ethnicity differences in PAC transitions. For example, the difference in the probability of SNF transitions between White and Black patients was 3.2% and 6.8%-points for non-duals and duals, respectively. The difference between non-dual/dual White patients was 21.6% points, and among Black patients 18.0%-points. The adjusted risk of 30-day readmission was 5.6 percentage point higher among non-duals discharged to SNF, compared to home, but such risk among duals was not statistically significantly different. The adjusted probabilities of 30-day mortality were larger for duals and non-duals who transitioned to SNF, compared to those discharged home.

CONCLUSIONS

PAC referrals and the resulting outcomes for Medicare beneficiaries with ADRD are associated with multi-level variables that need to be incorporated in discharge decision making.

Serious Mental Illness in Nursing Homes: Stakeholder Perspectives on the Federal Preadmission Screening Program

The federal Preadmission Screening and Resident Review (PASRR) program was enacted in the 1980s amid concerns surrounding the quality of nursing home (NH) care. This program is meant to serve as a tool to assist with level of care determinations for NH applicants with serious mental illness (SMI) and was intended to limit the growth in the number of NH residents with SMI. Despite this policy effort, the prevalence of SMI in NHs has continued to increase, and little is known about the mechanisms driving the heterogeneous and suboptimal administration of the PASRR program, absent routine evaluative efforts. We conducted 20 semi-structured interviews with state and national stakeholders to identify factors affecting PASRR program administration and NH care for residents with SMI. Stakeholders expressed concern regarding fragmentation, specifically lack of clarity in the value of assessments beyond a regulatory requirement. Additionally, they cited variable program administration as contributing to fragmented communication patterns and inconsistent training across jurisdictions. Given the number of people with SMI currently residing in NHs, policy and practice should take a person-centered approach to assess how PASRR can be better used to support resident needs.

Reliability and Validity of the Cornell Scale for Depression in Dementia and Invariance Between Black Versus White Residents in Nursing Homes

OBJECTIVES

The purpose of this study was to expand on prior work testing invariance on several depression measures in community-based older adults and explore the psychometric properties and evidence of invariance between racial groups based on the Cornell Scale for Depression in Dementia.

DESIGN

This was a descriptive measurement study.

SETTING AND PARTICIPANTS

This was a secondary data analysis using baseline data from 2 studies: Testing the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms Associated with Dementia and the study Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents with Dementia. Combined, 67 nursing homes participated from 2 states and 889 residents were recruited. The mean age of the participants was 86.58 (SD 10.31) and most were women (72%) and White (70%).

METHODS

This was a descriptive study, and a Rasch analysis was done to establish reliability based on internal consistency and evidence of differential item functioning (DIF) across races. Validity was based on item fit and model testing with structural equation modeling to compare models between White and Black participants.

RESULTS

There was evidence of internal consistency (alpha coefficient of 0.98) and no significant evidence of DIF. The item related to suicide had a high logit and did not significantly load onto the measurement model for Black individuals. There was not a good spread of the items across the concept of depression. The model had a better fit with the items when used with White versus Black participants.

CONCLUSIONS AND IMPLICATIONS

The findings indicate that it would be helpful to add some additional items that reflect depressive symptoms among this population. Further, the findings serve as a reminder that this measure may be biased toward identification of symptoms of depression among White versus Black residents.

Relationship between environmental factors and responsive behaviours in long-term care homes: a secondary data analysis

OBJECTIVE

Responsive behaviours (eg, wandering, resisting care and verbal abuse) are a continuing issue for staff and individuals living in long-term care (LTC) homes. The LTC environment can influence responsive behaviours and is a factor in determining the quality of life for those living there. The ways in which the quality of the environment might influence responsive behaviours has not been investigated yet. We hypothesised that better quality environments would be associated with reduced rates of responsive behaviours. We used a tool that simultaneously encompasses human and structural elements of the environment, a novel approach in this field of research.

DESIGN

Cross-sectional study, using data collected from September 2014 to May 2015 as part of the Translating Research in Elder Care research programme.

SETTING

A representative, stratified (size, owner-operator model and health region) random sample of 76 LTC homes in British Columbia, Alberta, Manitoba.

PARTICIPANTS

13 224 individuals (67.3% females) living in participating LTC homes.

OUTCOME MEASURES

Quality of care unit work environment was assessed using the observable indicators of quality (OIQ) tool. Responsive behaviours were assessed using routinely collected Resident Assessment Instrument-Minimum Data Set V.2.0 data.

RESULTS

Adjusted regression coefficients of overall Aggressive Behaviour Scale score and interpersonal communication were 0.02 (95% CI -0.011 to 0.045), grooming 0.06 (95% CI -0.032 to 0.157), environment-basics 0.067 (95% CI 0.024 to 0.110), odour -0.066 (95% CI -0.137 to -0.004), care delivery -0.007 (95% CI -0.033 to 0.019), environment-access -0.027 (95% CI -0.062 to 0.007), environment-homelike -0.034 (95% CI -0.065 to -0.002) and total OIQ score 0.003 (95% CI -0.004 to 0.010).

CONCLUSIONS

We found small associations between the environmental quality and responsive behaviours in Western Canadian LTC homes. Higher scores on homelikeness were associated with decreased responsive behaviours. Higher scores on basic environmental quality were associated with increased responsive behaviours.

Serious Mental Illness in Nursing Homes: Roles and Perceived Competence of Social Services Directors

Providing nursing home psychosocial care to persons with serious mental illnesses (SMI) requires understanding of comorbidities and attention to resident rights, needs and preferences. This quantitative study reports how 924 social service directors (SSDs) taking part in the National Nursing Home Social Service Director survey identified their roles and competence, stratified by the percentage of residents with SMI. More than 70% of SSDs, across all categories of homes, reported the social services department was "always" involved in conducting depression screening, biopsychosocial assessments and PASRR planning. SSDs in homes with lower concentrations of residents with SMI reported less involvement in anxiety screening. Those employed in homes with higher concentrations of residents with SMI reported lower involvement conducting staff interventions for resident aggression or making referrals. More than one-fifth of SSDs lacked confidence in their ability to compare/contrast dementia, depression, and delirium or to develop care plans for residents with SMI. SSDs' perceived competence in developing care plans for residents with SMI was associated with education and involvement in care planning. About one-quarter of social services directors reported not being prepared to train a colleague on how to develop care plans for residents with SMI. Training in SMI could enhance psychosocial care.