Quality of mental health care for nursing home residents: a literature review

Barriers and facilitators to caring for individuals with serious persistent mental illness in long-term care

OBJECTIVE

Many older adults in the United States with serious persistent mental illness reside in long-term facilities, and evidence suggests increasing numbers of long-term care residents with serious persistent mental illness. Healthcare professionals in these settings may face challenges in providing care to these residents. The purpose of this study was to describe health care professionals' perceptions of the barriers and facilitators to caring for long-term care residents with serious persistent mental illness.

METHODS

A qualitative descriptive design was employed.

RESULTS

Ten healthcare professionals working in long-term care were interviewed. Themes that emerged from the interviews were: coming to know the individual and their unique needs takes time; offering choices and being flexible facilitates trust; respecting the inherent worth of each individual promotes caring.

CONCLUSIONS

Caring for individuals with serious persistent mental illness in long-term care requires an individualized, person-centered approach.

Mental health in nursing homes: The role of immigration in the long-term care workforce

One-fourth of nursing home residents are diagnosed with anxiety disorders and approximately half live with depression. Nursing homes have long struggled with staffing shortages, and the lack of care has further heightened the risk of poor mental health. A key solution to both problems could be immigration. Prior studies have documented how immigrant labor could strengthen the long-term care workforce. We add to this picture by exploring the impact of immigrant inflows on the mental health outcomes of nursing home residents. Using a nationally representative dataset and a shift-share instrumental variable approach, we find empirical evidence that immigration reduces diagnoses of depression and anxiety, the use of antidepressant and antianxiety drugs, and self-assessed symptoms of depression. The results are robust to several sensitivity tests. We further find that the effect is more substantial in facilities with lower direct care staff hours per resident and with likely more immigrants without citizenship. Language barriers tend to be a minor issue when providing essential care. The findings suggest that creating a policy framework that directs immigrant labor to the long-term care sector can mutually benefit job-seeking immigrants and nursing home residents.

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

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

Prototype development of the Mental Health benchmarking Industry Tool for residential aged Care (MHICare Tool): a protocol paper of a two-stage sequential and mixed methods codesign study

OBJECTIVES

Current mental health practices for people living in residential aged care (RAC) facilities are poor. In Australia, there are no mechanisms to monitor and promote mental health for people living in RAC, including those who experience changed behaviours and psychological symptoms. The aim of this study is to improve current practices and mental health outcomes for people living in RAC facilities by codesigning a Mental Health benchmarking Industry Tool for residential aged Care (MHICare Tool).

METHODS

A two-stage sequential and mixed methods codesign methodology will be used. Stage 1 will include qualitative interviews and focus groups to engage with residents, family/care partners and RAC staff to ascertain mental healthcare practices and outcomes of greatest significance to them. Adapted concept mapping methods will be used to rank identified issues of concern in order of importance and changeability, and to generate draft quality indicators. Stage 2 will comprise a Delphi procedure to gain the wider consensus of expert panel views (aged care industry, academic, clinical) on the performance indicators to be included, resulting in the codesigned MHICare Tool.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the University of Queensland Human Research Ethics Committee (HREC/2019002096). This project will be carried out according to the National Statement on Ethical Conduct in Human Research (2007). The study's findings will be published in peer-reviewed journals and disseminated at national and international conferences and through social media.

CONCLUSION

This protocol reports structured methods to codesign and develop a mental health performance indicator tool for use in Australian RAC.

Compliance with CBT referral in nursing home residents diagnosed with depression: Results from a feasibility study

Objectives

Patient-level factors that influence compliance with a recommendation for CBT in nursing home residents diagnosed with depression were identified.

Methods

Within a cluster-randomized trial on stepped care for depression in nursing homes (DAVOS-study, Trial registration: DRKS00015686), participants received an intake interview administered by a licensed psychotherapist. If psychotherapy was required, patients were offered a referral for CBT. Sociodemographic characteristics, severity of depression, loneliness, physical health, antidepressant medication, prior experience with psychotherapy, and attitudes towards own aging were assessed. A binary regression determined predictors of compliance with referral.

Results

Of 123 residents receiving an intake interview, 80 were recommended a CBT. Forty-seven patients (58.8 %) followed the recommendation. The binary logistic regression model on compliance with recommended CBT was significant, χ2(9) = 21.64, p = .010. Significant predictors were age (Odds Ratio (OR) = 0.9; 95 % Confidence Interval (CI) = 0.82, 0.99; p = .024) and depression (OR = 1.33; 95 % CI = 1.08, 1.65; p = .008).

Conclusion

Within the implemented setting compliance rate was comparable to other age groups. Future interventions should include detailed psychoeducation on the benefits of psychotherapy on mild depressive symptoms in older age and evidence-based interventions to address the stigma of depression. Interventions such as reminiscence-based methods or problem-solving could be useful to increase compliance with referral, especially in very old patients (80+). Language barriers and a culturally sensitive approach should be considered when screening residents.

SARS-CoV-2 vaccination prevalence by mental health diagnosis: a population-based cross-sectional study in Ontario, Canada

BACKGROUND

Since the onset of the COVID-19 pandemic, there has been concern about the impact of SARS-CoV-2 infection among individuals with mental illnesses. We analyzed the SARS-CoV-2 vaccination status of Ontarians with and without a history of mental illness.

METHODS

We conducted a population-based cross-sectional study of all community-dwelling Ontario residents aged 19 years and older as of Sept. 17, 2021. We used health administrative data to categorize Ontario residents with a mental disorder (anxiety, mood, substance use, psychotic or other disorder) within the previous 5 years. Vaccine receipt as of Sept. 17, 2021, was compared between individuals with and without a history of mental illness.

RESULTS

Our sample included 11 900 868 adult Ontario residents. The proportion of individuals not fully vaccinated (2 doses) was higher among those with substance use disorders (37.7%) or psychotic disorders (32.6%) than among those with no mental disorders (22.9%), whereas there were similar proportions among those with anxiety disorders (23.5%), mood disorders (21.5%) and other disorders (22.1%). After adjustment for age, sex, neighbourhood income and homelessness, individuals with psychotic disorders (adjusted prevalence ratio 1.19, 95% confidence interval [CI] 1.18-1.20) and substance use disorders (adjusted prevalence ratio 1.35, 95% CI 1.34-1.35) were more likely to be partially vaccinated or unvaccinated relative to individuals with no mental disorders.

INTERPRETATION

Our study found that psychotic disorders and substance use disorders were associated with an increased prevalence of being less than fully vaccinated. Efforts to ensure such individuals have access to vaccinations, while challenging, are critical to ensuring the ongoing risks of death and other adverse consequences of SARS-CoV-2 infection are mitigated in this high-risk population.

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study

OBJECTIVE

We investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities.

DESIGN

Repeated cross-sectional study.

SETTING AND PARTICIPANTS

Linked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019.

METHODS

Counts and proportions were calculated to describe the sociodemographic characteristics and clinical comorbidities. Relative changes and trend tests were calculated to quantify the longitudinal changes in the characteristics of residents of assisted living facilities between 2013 and 2019. A Sankey plot was graphed to display transitions between different care settings (ie, hospital admission, nursing home admission, died, or remained in the assisted living facility) each year from 2013 to 2019.

RESULTS

There was a 34% relative increase in the resident population size of assisted living facilities (56,9752019 vs 42,6002013). These older adults had a mean age of 87 years, and women accounted for nearly two-thirds of the population across all years. The 5 clinical comorbidities that had the highest relative increases were renal disease (24.3%), other mental health conditions (16.8%), cardiac arrhythmias (9.6%), diabetes (8.5%), and cancer (6.9%). Nearly 20% of the original cohort from 2013 remained in an assisted living facility at the end of 2019, and approximately 10% of that cohort transitioned to a nursing home in any year from 2013 to 2019.

CONCLUSIONS AND IMPLICATIONS

Residents of assisted living facilities are an important older adult population that has progressively increased in clinical complexity within less than a decade. Clinicians and policy makers should advocate for the implementation of on-site medical care that is aligned with the needs of these older adults.

Successes and challenges towards improving quality of primary health care services: a scoping review

BACKGROUND

Quality health services build communities' and patients' trust in health care. It enhances the acceptability of services and increases health service coverage. Quality primary health care is imperative for universal health coverage through expanding health institutions and increasing skilled health professionals to deliver services near to people. Evidence on the quality of health system inputs, interactions between health personnel and clients, and outcomes of health care interventions is necessary. This review summarised indicators, successes, and challenges of the quality of primary health care services.

METHODS

We used the preferred reporting items for systematic reviews and meta-analysis extensions for scoping reviews to guide the article selection process. A systematic search of literature from PubMed, Web of Science, Excerpta Medica dataBASE (EMBASE), Scopus, and Google Scholar was conducted on August 23, 2022, but the preliminary search was begun on July 5, 2022. The Donabedian's quality of care framework, consisting of structure, process and outcomes, was used to operationalise and synthesise the findings on the quality of primary health care.

RESULTS

Human resources for health, law and policy, infrastructure and facilities, and resources were the common structure indicators. Diagnosis (health assessment and/or laboratory tests) and management (health information, education, and treatment) procedures were the process indicators. Clinical outcomes (cure, mortality, treatment completion), behaviour change, and satisfaction were the common indicators of outcome. Lower cause-specific mortality and a lower rate of hospitalisation in high-income countries were successes, while high mortality due to tuberculosis and the geographical disparity in quality care were challenges in developing countries. There also exist challenges in developed countries (e.g., poor quality mental health care due to a high admission rate). Shortage of health workers was a challenge both in developed and developing countries.

CONCLUSIONS

Quality of care indicators varied according to the health care problems, which resulted in a disparity in the successes and challenges across countries around the world. Initiatives to improve the quality of primary health care services should ensure the availability of adequate health care providers, equipped health care facilities, appropriate financing mechanisms, enhance compliance with health policy and laws, as well as community and client participation. Additionally, each country should be proactive in monitoring and evaluation of performance indicators in each dimension (structure, process, and outcome) of quality of primary health care services.

Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter?

OBJECTIVE

To examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

The study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017.

METHODS

2010-2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a "choice" set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies.

RESULTS

Among the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01).

CONCLUSIONS AND IMPLICATIONS

Black individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.

Specialty care after transition to long-term care in nursing home

BACKGROUND

Nursing home residents face many barriers to accessing specialist physician outpatient care. However, little data exists on how specialty care use changes when individuals transition to a nursing home in the US.

METHODS

We studied specialist outpatient visits for new long-term care (LTC) residents within 1 year before and after their transition to nursing home residence using the Minimum Data Set v3.0 (MDS) and a 20% sample of Medicare fee-for-service claims in 2014-2018. To focus on residents requiring specialty care at baseline, we limited the cohort to residents with specialty care in the 13-24 months before LTC transition. We then measured the proportion of residents receiving at least one visit in the 12 months before the transition and the 12 months after the transition. We also examined subgroups of residents with a prior diagnosis likely requiring long-term specialty care (e.g., multiple sclerosis). Finally, we examined whether there was continuity of care within the same specialty care provider.

RESULTS

Among 39,288 new LTC transitions identified in 2016-2017, 17,877 (45.5%) residents had a prior specialist visit 13-24 months before the transition. Among them, the proportion of residents with specialty visits decreased consistently in all specialties in the 12 months after the transition, ranging from a relative decrease of 14.4% for orthopedics to 67.9% for psychiatry. The relative decrease among patients with a diagnosis likely requiring specialty care ranged from 0.9% for neurology in patients with multiple sclerosis to 67.1% for psychiatry in patients with severe mental illness. Among residents who continued visiting a specialist, 78.9% saw the same provider as before the transition.

CONCLUSIONS

The use of specialty care falls significantly after patients transition to a nursing home. Further research is needed to understand what drives this drop in use and whether interventions, such as telemedicine can ameliorate potential barriers to specialty care.

Health profiles of older nursing home residents by suicidal ideation: A latent class analysis

OBJECTIVES

Identify the health profiles of older nursing home residents with and without at-admission self-reported suicidal ideation (SI) and examine the association between the identified profiles and self-reported SI at 90 days.

METHODS

Using the Minimum Data Set 3.0 and the ninth Patient Health Questionnaire-9 (PHQ-9) item, we identified 15,277 older residents with and 562,184 without self-reported SI at nursing home admission. Latent class analysis, using frailty, cognitive impairment, palliative care index, pain, and remaining PHQ-9 items as indicators, identified health profiles by at-admission SI and the BCH method estimated their association with SI at 90 days.

RESULTS

Profiles identified for residents without at-admission SI were: (1) frail and depressedNoSI (prevalence: 33.9%); (2) frail and severe cognitive impairmentNoSI (38.1%); (3) pre-frailNoSI (28.0%). Residents in the frail and depressedNoSI group had greater odds [adjusted OR: 2.80; 95% Confidence Interval: 2.60-3.00] while those in the frail and severe cognitive impairmentNoSI group had lower odds [aOR: 0.79; 95% CI: 0.71-0.86] of 90-day SI than those in the pre-frailNoSI group. Profiles identified for residents with at-admission SI were: (1) frail and all depressive symptomsSI (22.8%); (2) frail and some depressive symptomsSI (32.2%); (3) frail and severe cognitive impairmentSI (22.9%); (4) pre-frailSI (22.0%). Compared to those in the pre-frailSI group, residents in the frail and all depressive symptomsSI group had greater odds of continuing reporting SI at 90 days [aOR: 1.22; 95% CI:1.09-1.35].

CONCLUSIONS

Findings indicated unique health profiles of nursing home residents at higher risk of new onset of or continued SI.

Nursing Home-Sensitive Hospitalizations and the Relevance of Telemedicine: A Scoping Review

The aging of society is increasing the number of hospitalizations of nursing home residents. Telemedicine might help reduce the frequency of these potentially risk-associated hospitalizations. This scoping review looked for evidence of a change in the rate of hospitalization and, if mentioned, any cost savings and/or staff acceptance of the use of telemedicine in a nursing home setting. To identify available evidence, the electronic databases PubMed, Livivo, EBSCO and JSTOR were searched (without time or regional constraints) for comparative primary research studies on this topic in peer-reviewed journals. A total of 1127 articles were retrieved and 923 titles and abstracts were screened, with 16 studies published between 2001 and 2022 being included. Telemedicine consultation reduced the hospitalization of nursing home residents in 14/16 and care costs in 8/11 articles. Staff satisfaction was mentioned positively in five studies. Most studies used telemedicine involving medical diagnostic technologies (10), (electronic) health records (9), specialists (9) and specialized nursing staff (11). Few studies had a higher level of evidence: only one randomized clinical trial was included. There is the need for high credibility studies, using guidelines on protocol and reporting, to better understand the hindering and facilitating factors of telemedicine provision in the healthcare of nursing home residents.

Strategies for Implementing Group Mental Health Interventions in a VA Community Living Center

Objectives: Group mental health interventions are difficult to implement into rehabilitation facilities, but no one has studied the specific barriers. This mixed-methods project systematically examined the implementation of a mental health (MH) group intervention in a VA community living center (CLC) for residents on subacute rehabilitation units, using the Promoting Action on Research Implementation in Health Services (PARIHS) implementation framework.Methods: We implemented a group MH intervention, tracking team referrals, attendance rates, and reasons for declining to participate. We conducted qualitative interviews with attendees.Results: Individual barriers to attendance included acute illness (n = 67, 20%), attitudes toward MH (n = 50; 15%), and perceived busyness (n = 19; 6%). Facility barriers included competing appointments (n = 69; 21%). Interviews demonstrated challenges to implementation, including stigma toward mental health (Theme: Challenges and Supports to Implementation). Attendees found the group relatable, and noted that both positive and negative group dynamics contributed to their experience (Themes: Content Relevance and Group Dynamics).Conclusions: The results provide insight into implementing a group MH treatment into the CLC setting, with implications for the MH care of older adults residing in CLCs.Clinical Implications: 1) Group leaders should consider matching attendees for ability levels (physical or cognitive). 2) At the facility level, leaders may take steps to address stigma toward MH by adopting approaches (e.g., music) or framing MH issues (e.g., use of language) in a way that is approachable. 3) Modifiable barriers at the individual and facility level could be addressed to encourage ease of implementation.

Association of Psychiatric Diagnoses and Medicaid Coverage with Length of Stay Among Inpatients Discharged to Skilled Nursing Facilities

BACKGROUND

Inpatients with psychiatric diagnoses often require higher levels of care in skilled nursing facilities (SNFs) and are more likely to be covered by Medicaid, which reimburses SNFs at significantly lower rates than Medicare and commercial payors.

OBJECTIVE

To characterize factors affecting length of stay in inpatients discharged to SNFs.

DESIGN

A retrospective cross-sectional study design using 2016-2018 data from National Inpatient Sample.

PARTICIPANTS

Inpatients aged ≥ 40 who were discharged to SNFs.

EXPOSURES

Primary discharge diagnosis (medical, psychiatric, or substance use) and primary payor.

MAIN OUTCOMES AND MEASURES

Length of stay, categorized non-exclusively as >3 days, >7 days, or > 14 days.

RESULTS

Among 9,821,155 inpatient discharges to SNFs between 2016 and 2018, 95.7% had medical primary discharge diagnoses, 3.3% psychiatric diagnoses, and 1.0% substance use diagnoses; Medicare was the most common primary payor (83.3%), followed by private insurance (7.9%), Medicaid (6.6%), and others (2.2%). Median length of stay for all patients was 5.0 days (interquartile range [IQR], 3.0-8.0), 5.0 (IQR, 3.0-8.0) for those with medical diagnoses, 8.0 (IQR, 4.0-15.0) for psychiatric diagnoses, and 5.0 (IQR, 3.0-8.0) for substance use diagnoses. After multivariable adjustment, compared to patients with medical diagnoses, patients with psychiatric diagnoses were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to Medicare patients, Medicaid patients were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to patients with medical diagnoses, those with psychiatric diagnoses were also more likely to have lengths of stay 1 times, 1.5 times, and 2 times greater than the national geometric mean length of stay for that diagnosis-related group (p < 0.001).

CONCLUSIONS

Patients discharged to SNFs after inpatient hospitalization for psychiatric diagnoses and with Medicaid coverage were more likely to have longer lengths of stay than patients with medical diagnoses and those with Medicare coverage, respectively.

Loss, Unresolved Trauma and Gaps in Staff Knowledge: A Qualitative Study on Older Adults Living in Residential Aged Care

Despite the prevalence of mental health concerns among those who live in residential aged care, many residential aged care facilities (RACFs) provide little by way of psychological support. Drawing on qualitative data obtained from interviews with residents from across 15 RACFs in Victoria, Australia, this article adds to understandings about the diversity and impact of mental health challenges experienced by residents, and gaps in the knowledge of staff about how to address such. Thus, it also offers evidence of the urgent need for RACFs to provide residents both better access to specialist mental health practitioners and training to care staff on mental health issues.

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.

Quality of Nursing Homes Admitting Working-Age Adults With Serious Mental Illness

OBJECTIVE

This cross-sectional study examined the association between nursing home quality and admission of working-age persons (ages 22-64 years) with serious mental illness.

METHODS

The study used 2015 national Minimum Data Set 3.0 and Nursing Home Compare (NHC) data. A logistic mixed-effects model estimated the likelihood (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]) of a working-age nursing home resident having serious mental illness, by NHC health inspection quality rating. The variance partition coefficient (VPC) was calculated to quantify the variation in serious mental illness attributable to nursing home characteristics. Measures included serious mental illness (i.e., schizophrenia, bipolar disorder, and other psychotic disorders), health inspection quality rating (ranging from one star, below average, to five stars, above average), and other sociodemographic and clinical covariates.

RESULTS

Of the 343,783 working-age adults newly admitted to a nursing home in 2015 (N=14,307 facilities), 15.5% had active serious mental illness. The odds of a working-age resident having serious mental illness was lowest among nursing homes of above-average quality, compared with nursing homes of below-average quality (five-star vs. one-star facility, AOR=0.78, 95% CI=0.73-0.84). The calculated VPC from the full model was 0.11.

CONCLUSIONS

These findings indicate an association between below-average nursing homes and admission of working-age persons with serious mental illness, suggesting that persons with serious mental illness may experience inequitable access to nursing homes of above-average quality. Access to alternatives to care, integration of mental health services in the community, and improving mental health care in nursing homes may help address this disparity.

Prevalence of depression and its related factors among older adults in Indonesian nursing homes

Background

Depression is one of the most severe mental disorders experienced by older adults worldwide. The prevalence of depression among older adults in nursing homes is three-time higher than in the community. Therefore, knowing the incident rates of depression and its related factors would help provide appropriate intervention and prevention programs in the future.

Objectives

The study aimed to determine the prevalence of depression and compare the difference in depression status according to the sociodemographic characteristic of the older adults in the Indonesian nursing homes.

Methods

A descriptive cross-sectional study design was used in this study, which involved 116 participants selected using convenience sampling from five different general nursing homes in Bandung City, Indonesia. The Short Form (SF) of the Geriatric Depression Scale (GDS) was used to evaluate depression among older adults in nursing homes. The t-test and one-way ANOVA were used for data analysis.

Results

Of the total participants, 56.9% had depression, which 7.8% with mild depression, 37.1% with moderate depression, and 12% with severe depression. In addition, there were significant differences in depression according to age, gender, marital status, educational background, ethnicity, disease history, duration of stay, and the visitor frequency among the older adults in nursing homes (p <.001).

Conclusion

A high rate of depression among older adults in Indonesian nursing homes was identified. Therefore, attention to caring for more specific needs, such as the psychosocial needs of older adults in nursing homes, is urgent.

Geropsychiatric Nursing Leadership in Long-Term Care

Geropsychiatric nursing (GPN) leaders in long-term care settings have a 25-year tradition of innovation that has strikingly improved mental health and quality of life for older adult residents. The impact of the Coronavirus disease of 2019 (COVID-19) on the mental health of older adult residents and today's evolving health care systems requires additional GPN leaders well-prepared to advocate, plan, and deliver care for this vulnerable population. In this article, the authors discuss GPN leadership in the context of its history, the role of professional organizations, and educational competencies. A leadership exemplar is provided as well as recommendations for clinical practice and research.

The Diagnosis of Schizophrenia Among Nursing Home Residents With ADRD: Does Race Matter?

OBJECTIVE

To examine racial differences in the frequency of schizophrenia diagnosis codes used among nursing home (NH) residents with Alzheimer's Disease and Related Dementias (ADRD), pre and post the implementation of public reporting of antipsychotic use in NHs.

METHODS

The 2011-2017 Minimum Data Set and Medicare Master Beneficiary Summary File were linked. We identified long-stay NH residents (i.e., those who had quarterly or annual assessments) with ADRD aged 55 years and older (N = 7,734,348). Outcome variable was defined as the diagnosis of schizophrenia documented in the MDS assessments. Main variables of interest included individual race (black versus white), the percent of blacks in a NH and time trend. Multivariate regressions were estimated.

RESULTS

The frequency of schizophrenia diagnosis codes among NH residents with ADRD steadily increased over the study period, and blacks experienced a greater increase than their white counterparts. For example, the overall likelihood of having schizophrenia diagnosis increased 1.9 percentage points (95% confidence interval [CI]: 0.019, 0.020, p < 0.01) from 2011 to 2017 among whites, while blacks had an addition 1.3 percentage points increase (95% CI: 0.011, 0.015, p < 0.01). The increase in the likelihood of having schizophrenia diagnosis code was higher in NHs with higher percent of blacks: the increase from 2011 to 2017 was 2.6 percentage point (95% CI: 0.023, 0.029, p < 0.01) higher in NHs with the highest percent of blacks, compared to NHs with lowest percent of blacks. Racial differences in the growth of schizophrenia diagnosis also existed within a NH after accounting for NH factors.

CONCLUSION

Following the implementation of public reporting of antipsychotic use in NH, black residents experienced a greater increase in the likelihood of having schizophrenia diagnosis than white NH residents. NHs with a higher proportion of blacks had a greater increase in schizophrenia diagnosis, and blacks experienced an increased likelihood of schizophrenia diagnosis than whites within a NH. Further research is needed to determine a causal relationship between the federal policy mandating public reporting and disparities in schizophrenia diagnostic coding.

Collaborative identification and prioritisation of mental health nursing care process metrics and indicators: a Delphi consensus study

BACKGROUND

The Irish Office of Nursing & Midwifery Services Director (ONMSD) commissioned the development an updated suite of mental health nursing metrics and indicators for implementation in Irish mental health clinical settings. While measuring care processes does offer the potential to improve care quality, the choice of which mental health nursing metrics to measure presents a significant challenge, both in Ireland and internationally. The provision of safe and high-quality mental health nursing care stems from nurses' expertise, skills and overall capacity to provide recovery focused care across a range of health care settings. Accordingly, efforts to measure what mental health nurses do depends on the identification of those care processes that contribute to mental health nursing practice. This paper reports on the identification, development and prioritisation of a national suite of Quality Care Metrics (QCM), along with their associated indicators, for mental health nursing care processes in Ireland.

METHODS

The study was undertaken over four phases; i) a systematic literature review to identify mental health care process metrics and their associated indicators of measurement; ii) a two-round, online Delphi survey of mental health nurses to develop consensus on the suit of mental health nursing care process metrics; iii) a two-round online Delphi survey of mental health nurses to develop consensus on the indicators to be used to measure the agreed metrics; and iv) a face-to-face consensus meeting with mental health nurses and service user representatives to develop consensus on the final suite of metrics and indicators.

RESULTS

Following these four phases 9 metrics and their 71 associated indicators were agreed for inclusion in the final suite of Mental Health Nursing QCM. These metrics are applicable across the life span and the range of mental health nursing health care settings.

CONCLUSION

The development of this suite of Mental Health Nursing QCM and their indicators represents an opportunity for the measurement of safe and high-quality mental health nursing care for application in Ireland and internationally. This initial development of metrics and indicators should be followed by a rigorous baseline review of QCM uptake and implementation amongst mental health nurses as part of an ongoing evaluation.

Incidence and outcomes of COVID-19 first wave pandemic in a French nursing home with residents suffering from severe mental illnesses

During the first wave of COVID-19, nearly 50% of France's fatalities occurred in nursing homes. Older people with mental health disorders are considered to be more prone to infections when epidemics arise. To test this hypothesis, we conducted a retrospective descriptive and comparative study of the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a cohort of elderly residents with or without severe mental illness (SMI) living in a French nursing home facility. This was done during the first lockdown from March 17th until May 11th, 2020. Our study included 72 participants of 75 residents, of whom 58 contracted COVID-19, 14 developed a severe form requiring hospitalisation, and 14 died. The disease was significantly less frequent in residents with SMI 15(62%) than those without SMI 43 (89.6%). In regression analysis, a higher level of autonomy was significantly associated with a lower disease incidence. Once contracted, residents with or without SMI differed significantly neither on morbidity nor mortality. The period of survival did not either significantly differ between the two groups. As a potential explanation, we suggested that pathological social withdrawal added to stigmatisation could have protected SMI residents from contracting the disease.

Abuse and Neglect in Nursing Homes: The Role of Serious Mental Illness

BACKGROUND AND OBJECTIVES

Nursing homes (NH) are serving a large number of residents with serious mental illness (SMI). We analyze the highest ("High-SMI") quartile of NHs based on the proportion of residents with SMI and compare NHs on health deficiencies and the incidence of deficiencies given for resident abuse, neglect, and involuntary seclusion.

RESEARCH DESIGN AND METHODS

We used national Certification and Survey Provider Enhanced Reports (CASPER) data for all freestanding certified NHs in the continental United States from 2014 to 2017 (14,698 NHs; 41,717 recertification inspections; 246,528 deficiencies). Differences in the number of deficiencies, a weighted deficiency score, the deficiency grade, and the facility characteristics associated with deficiencies for abuse, neglect, and involuntary seclusion were examined in High-SMI. Incidence rate ratios (IRR) and odds ratios (OR) were reported with 95% confidence intervals.

RESULTS

High-SMI NHs did not receive more deficiencies or a greater weighted deficiency score per recertification inspection. Deficiencies given to High-SMI NHs were associated with a wider scope, especially Pattern (IRR:1.03;[1.00, 1.07]) and Widespread (IRR:1.07;[1.02, 1.11]). High-SMI NHs were more likely to be cited for resident abuse and neglect (OR:1.49;[1.23, 1.81]) and the policies to prohibit and monitor for abuse and neglect (OR:1.18;[1.08, 1.30]) in comparison to all other NHs.

DISCUSSION AND IMPLICATIONS

Although resident abuse, neglect, and involuntary seclusion are rarely cited, these deficiencies are disproportionately found in High-SMI NHs. Further work is needed to disentangle the antecedents to potential resident abuse and neglect in those with mental healthcare needs.

Process of Deinstitutionalization of Aging Individuals With Severe and Disabling Mental Disorders: A Review

BACKGROUND

For more than 60 years, psychiatric services has gradually gone from an asylum model to a community model. This change has led to the emergence of a deinstitutionalization movement. This movement seems to have left behind long-term hospitalized aging individuals with severe and disabling mental disorders. The objective of this article is to conduct a review on the challenges and issues associated with the process of deinstitutionalization among hospitalized aging individuals with severe and disabling mental disorders.

METHODS

Using PRISMA statement, the research methodology was carried out in English and French in 16 databases with a combination of 3 lists of keywords. The selection process was then followed by a thematic analysis which aimed at categorizing by theme and classifying the writings selected.

RESULTS

A total of 83 articles published between 1978 and 2019 were selected and organized into six categories: (a) a forgotten population in research and health policies, (b) an economic presentation of the deinstitutionalization process, (c) an improvement in quality of life and global functioning for deinstitutionalized patients (d) from stigmatization to the rejection of elderly psychiatric inpatients from deinstutionalization process, (e) a difficult community-based care offer and a difficult epistemological identification, (f) from the lack of community services to the phenomenon of transinstitutionalization. The current state of scientific research, institutional policies and clinical practices associated with the deinstitutionalization process of SVPTSIH are then commented.

CONCLUSIONS

Recommendations are proposed to researchers and professionals concerned with the support of long-term hospitalized aging individuals with severe and disabling mental disorders.

Serious Mental Illness in the Nursing Home Literature: A Scoping Review

Nursing homes (NH) and other institutional-based long-term care settings are not considered an appropriate place for the care of those with serious mental illness, absent other medical conditions or functional impairment that warrants skilled care. Despite policy and regulatory efforts intended to curb the unnecessary placement of people with serious mental illness (SMI) in these settings, the number of adults with SMI who receive care in NHs has continued to rise. Through a scoping review, we sought to summarize the available literature describing NH care for adults with SMI from 2000 to 2020. We found that SMI was operationalized and measured using a variety of methods and diagnoses. Most articles focused on a national sample, with the main unit of analysis being at the NH resident-level and based on analysis of secondary data sets. Understanding current evidence about the use of NHs by older adults with SMI is important to policy and practice, especially as we continue to grapple as a nation with how to provide quality care for older adults with SMI.

Characteristics of Working-Age Adults With Schizophrenia Newly Admitted to Nursing Homes

OBJECTIVES

Persons aged <65 years account for a considerable proportion of US nursing home residents with schizophrenia. Because they are often excluded from psychiatric and long-term care studies, a contemporary understanding of the characteristics and management of working-age adults (22-64 years old) with schizophrenia living in nursing homes is lacking. This study describes characteristics of working-age adults with schizophrenia admitted to US nursing homes in 2015 and examines variations in these characteristics by age and admission location. Factors associated with length of stay and discharge destination were also explored.

DESIGN

This is a cross-sectional study using the Minimum Data Set 3.0 merged to Nursing Home Compare.

SETTING AND PARTICIPANTS

This study examines working-age (22-64 years) adults with schizophrenia at admission to a nursing home.

METHODS

Descriptive statistics of resident characteristics (sociodemographic, clinical comorbidities, functional status, and treatments) and facility characteristics (ownership, geography, size, and star ratings) were examined overall, stratified by age and by admission location. Generalized estimating equation models were used to explore the associations of age, discharge to the community, and length of stay with relevant resident and facility characteristics. Coefficient estimates, adjusted odds ratios, and 95% CIs are presented.

RESULTS

Overall, many of the 28,330 working-age adults with schizophrenia had hypertension, diabetes, and obesity. Those in older age subcategories tended to have physical functional dependencies, cognitive impairments, and clinical comorbidities. Those in younger age subcategories tended to exhibit higher risk of psychiatric symptoms.

CONCLUSIONS AND IMPLICATIONS

Nursing home admission is likely inappropriate for many nursing home residents with schizophrenia aged <65 years, especially those in younger age categories. Future psychiatric and long-term care research should include these residents to better understand the role of nursing homes in their care and should explore facility-level characteristics that may impact quality of care.

Social Service Directors' Roles and Self-Efficacy in Suicide Risk Management in US Nursing Homes

Nursing home (NH) residents have many risk factors for suicide in later life and transitions into and out of NHs are periods of increased suicide risk. The purpose of this study was to describe NH social service directors (SSDs) roles in managing suicide risk and to identify factors that influence self-efficacy in this area. This study used data from the 2019 National Nursing Home Social Services Directors survey (n = 924). One-fifth (19.7%) of SSDs reported a lack of self-efficacy in suicide risk management, as indicated by either needing significant preparation time or being unable to train others on intervening with residents at risk for suicide. Ordinal logistic regression identified SSDs who were master's prepared, reported insufficient social service staffing as a minor barrier (versus a major barrier) to psychosocial care, and those most involved in safety planning for suicide risk were more likely to report self-efficacy for training others. Implications include the need for targeted training of NH social service staff on suicide prevention, such as safety planning as an evidence-based practice. Likewise, sufficient staffing of qualified NH social service providers is critically important given the acute and chronic mental health needs of NH residents.

Reliability and Validity Testing of the Quantified Quality of Interaction Schedule

BACKGROUND AND PURPOSE

The purpose of this study was to test the reliability and validity of the Quality of Interactions Schedule (QuIS) using a quantification scoring approach.

METHODS

Baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) study was used.

RESULTS

A total of 553 residents participated. There was evidence of inter-rater reliability with Kappa scores of .86 to 1.00 and internal consistency based on the Rasch analysis (item reliability of .98). There was some support for validity based on item fit and hypothesis testing as resistiveness to care was significantly associated with total QuIS scores.

CONCLUSION

This study supports the use of the quantified QuIS to evaluate the quality of interactions over time and to test interventions to improve interactions.

Ageing with schizophrenia: an update

PURPOSE OF REVIEW

The aim of this review was to summarize the recent literature on the clinical symptoms, functioning, outcomes and treatments for older adults with chronic schizophrenia.

RECENT FINDINGS

The number and proportion of older adults with schizophrenia is rapidly increasing. Schizophrenia is a heterogeneous disorder and older adults with schizophrenia display significant variability in symptom severity, quality of life and overall outcomes. Many achieve stable disease remission, some display persistent nonremission and others experience fluctuating symptoms. Depression is commonly reported, and although rates of suicide are higher when compared with age-matched peers, the excess mortality seen in this population is mainly attributed to natural causes of death. Cognitive decline and reduced illness awareness have important implications for functional status and quality of life. Antipsychotics remain essential in the treatment regimen, although elderly patients with chronic disease may be good candidates for gradual dose reduction. Interdisciplinary treatment approaches as well as nonpharmacologic psychosocial interventions play a critical adjunctive role in the treatment of older adults with schizophrenia.

SUMMARY

Research focusing on schizophrenia in late life is sparse. Too often, older patients are eliminated from research studies or averaged in with all age groups. Thus, there continues to be gaps in our understanding of modifiable predictors of remission and recovery, and the most efficacious and safest treatment approaches for this age group.

Risk of Nursing Home Use among Older Americans: The Impact of Psychiatric History and Trajectories of Cognitive Function

OBJECTIVE

Mental illness and cognitive functioning may be independently associated with nursing home use. We investigated the strength of the association between baseline (1998) psychiatric history, eight-year cognitive function trajectories, and prospective incidence of nursing home use over a ten-year period while accounting for relevant covariates in U.S. adults aged 65 and older. We hypothesized that self-reported baseline history of psychiatric, emotional or nervous problems would be associated with greater risk of nursing home use, and that cognition trajectories with the greatest decline would be associated with subsequent higher risk of nursing home use.

METHODS

We used eight waves (1998-2016) of Health and Retirement Study data for adults aged 65 years and older. Latent class mixture modeling identified four distinct cognitive function trajectory classes (1998-2006): low-declining, medium-declining, medium-stable, high-declining. Participants from the 1998 wave (N = 5628) were classified into these four classes. Competing risks regression analysis modeled the sub-hazard of nursing home use between 2006 and 2016 as a function of baseline psychiatric history and cognitive function trajectories.

RESULTS

Psychiatric history was independently associated with greater risk of nursing home use (SHR 1.26, 95% CI 1.06-1.51, p<.01), net the effects of life course variables. Further, "low declining" (SHR 2.255, 95% CI 1.70-2.99, p<.001) and "medium declining" (2.103, 95% CI 1.69-2.61, p<.001) trajectories predicted increased risk of nursing home use.

DISCUSSION

Evidence of these associations can be used to educate policymakers and providers about the need for appropriate psychiatric training for staff in community-based and residential long-term care programs.

Personal, social and cultural factors affecting elders' transitions to long term care: Certified nursing assistant perspectives

A focus group methodology was employed to elicit information from Certified Nursing Assistants (CNAs) about their views of the personality, social, institutional and cultural factors that affect the success or failure of elders' adaptation to nursing home life. The focus group (N = 6) was conducted in one long-term care facility. CNAs identified three themes that represent the process of successful adaptation to the nursing home. Emotional displacement was followed by a period of assimilation and acceptance. Resident personality, social, institutional and cultural characteristics that may affect each stage of the process are described. This study supports previous findings regarding the contribution of social-environmental elements in the adjustment process. CNA perceptions of factors that assist elders during the transition process proved to be a valuable source of information.

Psychiatric and behavioral problems and well-being in gerontopsychiatric nursing home residents

OBJECTIVES

Gerontopsychiatric nursing home residents are residents with a chronic mental condition (not dementia), in combination with one or more physical disorders. Psychiatric and behavioral problems are common within this population. The objective of this study is to examine these behaviors and their relationship to the level of both observed and self-rated well-being in the gerontopsychiatric population.

METHOD

Both gerontopsychiatric residents, and their primary formal caregiver in several nursing homes in The Netherlands were asked to participate in a structured interview concerning psychiatric and behavioral problems and resident well-being. Psychiatric and behavioral problems were measured with the Neuropsychiatric Inventory Questionnaire (NPI-Q) and the Cohen Mansfield Agitation Index (CMAI). Well-being was measured through the self-rated Laurens Well-being Inventory for Gerontopsychiatry (LWIG), and the observer rated Laurens Well-being Observations for Gerontopsychiatry (LWOG).

RESULTS

A total of 126 residents participated in the study with ages varying from 42 to 90. Different types of chronic mental disorders such as schizophrenia spectrum disorder, bipolar disorders and personality disorders were prevalent in the population. Most psychiatric and behavioral problems are associated with lower observed and self-rated well-being. For irritability and affective problem behaviors the relationship with well-being was the most evident.

CONCLUSION

In daily care practice the relationship between well-being and psychiatric and behavioral problems should be taken into account in care planning and treatment. To further explore the direction and details of this relationship, more research is needed.

A Rising Tide Lifts "Related" Boats-Post-Acute Care Quality Improvement is Associated with Improvement in Long-Term Care Quality in Nursing Homes

OBJECTIVES

To examine the relationship between post-acute care (PAC) quality improvement and long-term care (LTC) quality changes.

DESIGN

Observational study using national nursing home data from Nursing Home Compare linked to Brown University's LTCFocus data.

SETTING AND PARTICIPANTS

Free-standing nursing homes serving PAC and LTC residents in the United States.

METHODS

This study used pooled cross-sectional analysis with nursing home-level data from 2005 to 2010 (12,150 unique nursing homes). We used fixed effects models to examine the association between a 1-year change in PAC quality and a 1-year change in LTC quality, with a specific focus on related care domains.

RESULTS

Strong and positive associations were found between related PAC and LTC care domains, particularly between the PAC and LTC influenza vaccination care domains (β = 0.30, P < .001) and the PAC and LTC pneumococcal vaccination care domains (β = 0.55, P < .001). Meanwhile, model results showed PAC quality changes essentially had no associations with unrelated LTC care domains.

CONCLUSIONS AND IMPLICATIONS

This is the first study that examines the association of changes in quality between 2 overlapping but different care domains (ie, PAC and LTC) using multiple quality measures. Our findings indicate that nursing homes can manage concurrent quality improvement in PAC and LTC, particularly on care domains that are related. More research is needed to examine the mechanism that enables such concurrent quality improvement.

The Conceptualization of Mental Health Service Quality Assessment: Consumer Perspective

This review synthesises theoretical approaches and methodological considerations in mental health service quality assessment from consumers-perspective. We searched published articles from databases: EMBASE, MEDLINE, CIHNAL, Scopus, Web of Science, and PsycINFO. Of the 30 included papers, 16 contained instruments used to mental health quality assessment and 14 focused on theoretical constructs. The review finds that mental health quality assessment is explained and measured using constructs that focus on structure, process and outcome. The methodological issues that need critical consideration are the context and cultural norms of services, outcome perspectives, evaluator, sources of information as well as the selection of consumers and instruments. The review recommends that researchers and clinicians should consider the theoretical constructs and methodological issues in mental health quality assessment.

Assessment of Anxiety in Long-Term Care Residents: Issues and Strategies

The experience of clinically significant anxiety and anxiety disorders represent significant and often debilitating problems for many residents in long-term care (LTC) settings. However, anxiety problems often go undetected and untreated in this growing population. The purposes of this paper are to examine the prevalence and impact of anxiety problems among residents in LTC facilities, describe the efficacy of the current instruments that are used to detect anxiety in these settings, and provide clinical guidance for the thorough assessment of anxiety. Regarding measurement tools, the GAI, GAI-SF, GAS-LTC, and the BADS are the only self-report measures designed for older adults that have been successfully validated for use with older adults living in LTC settings. Clinicians should focus on ways to educate LTC directors and staff to emphasize the importance of screening and assessing for anxiety, using validated measures, to improve the assessment and treatment of anxiety in their residents.

Using the Delphi Method to Identify Risk Factors Contributing to Adverse Events in Residential Aged Care Facilities

Purpose

This study aimed to identify risk factors associated with adverse events in residential aged care facilities in China.

Patients and Methods

After compiling a list of risk factors for adverse events generated from in-depth interviews with managers of residential aged care facilities, a three-round Delphi method was used to reach consensus. The synthesized risk factors were presented on a Likert scale to the expert panelists three times to validate their responses.

Results

The list identified 67 items as risk factors for adverse events, attached to four first-level indexes (ie, environmental facility, nursing staff, older adults' characteristics, and management factors). The experts' authority coefficient was 0.87. The positive coefficients were 82.76%, 91.67%, and 100%, and the coordination coefficients were 0.154, 0.297, and 0.313 in the first, second, and third rounds, respectively.

Conclusion

Using a Delphi method, this study established a consensus on risk factors contributing to adverse events and developed a risk assessment grade for use in future aged care practice and research. The resulting list is useful in prioritizing risk-reduction activities and assessing intervention or education strategies for preventing adverse events in residential aged care facilities.

Impact

This study fills the gap in risk identification in the Chinese residential aged care system to ensure provision of best-practice care to this vulnerable population. Nursing staff and management factors at the top of the list are not only the most common causes of adverse events but also the core elements in creating a secure and error-free environment. This list was intended to support predictive and prevention-oriented decision-making by managers and nursing supervisors to reduce preventable adverse events.

Quality Concerns in Nursing Homes That Serve Large Proportions of Residents With Serious Mental Illness

Background and Objectives

Nursing homes (NHs) are serving greater proportions of residents with serious mental illness (SMI), and it is unclear whether this affects NH quality. We analyze the highest and lowest quartiles of NHs based on the proportion of residents with SMI and compare these NHs on facility characteristics, staffing, and quality stars.

Research Design and Methods

National Certification and Survey Provider Enhanced Reports data were merged with NH Compare data for all freestanding certified NHs in the continental United States in 2016 (N = 14,460). NHs were categorized into “low-SMI” and “high-SMI” facilities using the lowest and highest quartiles, respectively, of the proportion of residents in the NH with SMI. Bivariate analyses and logistic models were used to examine differences in organizational structure, payer mix, resident characteristics, and staffing levels associated with high-SMI NHs. Linear models examined differences in quality stars.

Results

High-SMI facilities were found to report lower direct-care staffing hours, have a greater Medicaid-paying resident census, were more likely to be for-profit, and scored lower on all NH Compare star ratings in comparison to all other NHs.

Discussion and Implications

As the SMI population in NHs continues to grow, a large number of residents have concentrated in a few NHs. These are uniquely different from typical NHs in terms of facility characteristics, staffing, and care practices. While further research is needed to understand the implications of these trends, public policymakers and NH providers need to be aware of this population’s unique—and potentially unmet—needs.

A Canadian Cohort Study to Evaluate the Outcomes Associated with a Multicenter Initiative to Reduce Antipsychotic Use in Long-Term Care Homes

OBJECTIVES

To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels.

DESIGN

Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories.

SETTING AND PARTICIPANTS

Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study.

MEASURES

Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use.

INTERVENTION

Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis.

RESULTS

At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms.

CONCLUSIONS/IMPLICATIONS

The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.

Citizen and stakeholder led priority setting for long-term care research: identifying research priorities within the Translating Research in Elder Care (TREC) Program

BACKGROUND

The Translating Research in Elder Care (TREC) program is a longitudinal partnered program of research in Western Canada that aims to improve the quality of care and quality of life for residents and quality of worklife for staff in long-term care settings. This program of research includes researchers, citizens (persons living with dementia and caregivers of persons living in long-term care), and stakeholders (representatives from provincial and regional health authorities, owner-operators of long-term care homes). The aim of this paper is to describe how we used priority setting methods with citizens and stakeholders to identify ten priorities for research using the TREC data.

METHODS

We adapted the James Lind Alliance Priority Setting Partnership method to ensure our citizens and stakeholders could identify priorities within the existing TREC data. We administered an online survey to our citizen and stakeholder partners. An in-person priority setting workshop was held in March 2019 in Alberta, Canada to establish consensus on ten research priorities. The in-person workshop used a nominal group technique and involved two rounds of small group prioritization and one final full group ranking.

RESULTS

We received 72 online survey respondents and 19 persons (citizens, stakeholders) attended the in-person priority setting workshop. The workshop resulted in an unranked list of their ten research priorities for the TREC program. These priorities encompassed a range of non-clinical topics, including: influence of staffing (ratios, type of care provider) on residents and staff work life, influence of the work environment on resident outcomes, and the impact of quality improvement activities on residents and staff.

CONCLUSIONS

This modified priority setting approach provided citizens and stakeholders with an opportunity to identify their own research priorities within the TREC program, without the external pressures of researchers. These priorities will inform the secondary analyses of the TREC data and the development of new projects. This modified priority setting may be a useful approach for research teams trying to engage their non-academic partners and to identify areas for future research.

Restoring trust: COVID-19 and the future of long-term care in Canada

The Royal Society of Canada Task Force on COVID-19 was formed in April 2020 to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19. The Task Force established a series of working groups to rapidly develop policy briefings, with the objective of supporting policy makers with evidence to inform their decisions. This paper reports the findings of the COVID-19 Long-Term Care (LTC) working group addressing a preferred future for LTC in Canada, with a specific focus on COVID-19 and the LTC workforce. First, the report addresses the research context and policy environment in Canada’s LTC sector before COVID-19 and then summarizes the existing knowledge base for integrated solutions to challenges that exist in the LTC sector. Second, the report outlines vulnerabilities exposed because of COVID-19, including deficiencies in the LTC sector that contributed to the magnitude of the COVID-19 crisis. This section focuses especially on the characteristics of older adults living in nursing homes, their caregivers, and the physical environment of nursing homes as important contributors to the COVID-19 crisis. Finally, the report articulates principles for action and nine recommendations for action to help solve the workforce crisis in nursing homes.

Preventing and responding to depression, self-harm, and suicide in older people living in long term care settings: a systematic review

Objective: The well documented demographic shift to an aging population means that more people will in future be in need of long term residential care. Previous research has reported an increased risk of mental health issues and suicidal ideation among older people living in residential care settings. However, there is little information on the actual prevalence of depression, self-harm, and suicidal behavior in this population, how it is measured and how care homes respond to these issues. Method: This systematic review of international literature addressed three research questions relating to; the prevalence of mental health problems in this population; how they are identified and; how care homes try to prevent or respond to mental health issues. Results: Findings showed higher reported rates of depression and suicidal behavior in care home residents compared to matched age groups in the community, variation in the use of standardised measures across studies and, interventions almost exclusively focused on increasing staff knowledge about mental health but with an absence of involvement of older people themselves in these programmes. Conclusion: We discuss the implications of these findings in the context of addressing mental health difficulties experienced by older people in residential care and future research in this area.

Treatment fidelity evidence for BE-ACTIV - a behavioral intervention for depression in nursing homes

Objectives: Evidence-based depression therapies are difficult to implement in nursing homes. We present data for BE-ACTIV, a 10-week depression treatment designed for implementation in nursing homes, to address questions of treatment fidelity (delivery, receipt, and enactment) in that context. Method: Participants were 41 patients from 13 nursing homes in the treatment arm of a clinical trial, treated by graduate student therapists. Therapists and their supervisor rated their audio-recorded sessions for adherence to treatment protocol and session quality. Results: Delivery of core program elements averaged from 80-94% across all sessions; mean quality was 5.6 (SD 0.61) out of 6 points. Delivery of core components to nursing home activities staff who collaborated in the treatment was similarly high. Patients received an average of 7.32 sessions (SD 3.39); 17 completed 10 sessions. The theoretical basis of BE-ACTIV is behavioral activation; therapist-client dyads planned new pleasant events weekly, from a mean of 3.66 (SD 1.35) after the first session to a mean of between 5 and 6 activities a week across sessions 6-9, with a similar progression in percent activities completed. Activities enactment was significantly related to the likelihood of remission at post-treatment, and of maintaining improvement at 3-month follow-up. Treatment receipt and enactment were also related to improved mood from baseline to 3 months. Conclusion: Results demonstrate delivery, receipt, and successful enactment of BE-ACTIV core components in diverse nursing homes and patients, and support the theoretical premise of the intervention. These findings support further implementation work for the BE-ACTIV intervention.

Thirty-Year Trends in Nursing Home Composition and Quality Since the Passage of the Omnibus Reconciliation Act

OBJECTIVE

In 1987, the Omnibus Reconciliation Act (OBRA) called for a dramatic overhaul of the nursing home (NH) quality assurance system. This study examines trends in facility, resident, and quality characteristics since passage of that legislation.

METHODS

We conducted univariate analyses of national data on US NHs from 3 sources: (1) the 1985 National Nursing Home Survey (NNHS), (2) the 1992-2015 Online Survey Certification and Reporting (OSCAR) Data, and (3) LTCfocUS data for 2000-2015. We examined changes in NH characteristics, resident composition, and quality.

SETTING AND PARTICIPANTS

US NH facilities and residents between 1985 and 2015.

RESULTS

The proportion of NHs that are Medicare and Medicaid certified, members of chains, and operating not-for-profit has increased over the past 30 years. There have also been reductions in occupancy and increases in the share of residents who are racial or ethnic minorities, admitted for post-acute care, in need of physical assistance with daily activities, primarily supported by Medicare, and diagnosed with a psychiatric condition such as schizophrenia. With regard to NH quality, direct care staffing levels have increased. The proportion of residents physically restrained has decreased dramatically, coupled with changes in inappropriate antipsychotic (chemical restraint) use.

CONCLUSIONS AND IMPLICATIONS

Together with changes in the long-term care market, the NHs of today look very different from NHs 30 years ago. The 30th anniversary of OBRA provides a unique opportunity to reflect, consider what we have learned, and think about the future of this and other sectors of long-term care.

Suicide among Nursing Home Residents: Development of Recommendations for Prevention Using a Nominal Group Technique

This research aimed to develop and prioritize recommendations for prevention of suicide among nursing home residents. The study employed a nominal group technique, comprising three rounds, including two forums and a follow-up survey to prioritize recommendations for prevention. Participants included experts and stakeholders in aged care, geriatric psychiatry, suicide prevention, and public policy. The study was conducted and described in accordance with the consolidated criteria for reporting qualitative studies (COREQ). Nine participants (n = 6 males, 66%) developed eleven recommendations for prevention. The top three prioritized recommendations included expanding state and national suicide prevention frameworks, aligning nursing home life with community living, and improving residents' access to mental health services. The recommendations provide a foundation for suicide prevention strategies in Australian nursing homes and contribute to the limited international knowledge base on prevention of suicide among nursing home residents.

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Nursing Home Star Ratings and New Onset of Depression in Long-Stay Nursing Home Residents

OBJECTIVES

To examine the association between nursing home (NH) quality and new onset of depression and severity of depressive symptoms in a national cohort of long-stay NH residents in the United States.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

129,837 long-stay residents without indicators of depression admitted to 13,921 NHs.

METHODS

NH quality was measured by Nursing Home Compare star ratings (overall, health inspection, staffing, quality measures) closest to admission. Study outcomes at 90 days from the Minimum Data Set 3.0 included depression diagnosis and severity of depressive symptoms (minimal; mild; moderate; moderately severe/severe). Symptoms were measured by resident self-report Patient Health Questionnaire (PHQ-9) or a staff-report observational version (PHQ-9-OV). Logistic and multinomial logistic models with generalized estimating equations were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

At 90 days postadmission, 14.1% of residents had a new diagnosis of depression, and odds did not differ across star ratings. Nearly 90% of these residents had minimal depressive symptoms, with only 8.5% reporting mild symptoms and 2.6% with moderate to severe symptoms. Using minimal depressive symptoms as the reference, residents in NHs with 5-star overall ratings were 12% less likely than those in 3-star NHs to experience mild (95% CI: 0.81-0.96) and 31% less likely to experience moderate symptoms (95% CI: 0.58-0.82). In NHs with 1-star staffing compared to 3-star, residents had 37% higher odds of moderate symptoms (95% CI: 1.14-1.64) and 57% higher odds of moderately severe to severe depressive symptoms (95% CI: 1.17-2.12). The odds of any above-minimal depressive symptoms decreased as quality measure ratings increased.

CONCLUSIONS/IMPLICATIONS

Lower NH quality ratings were associated with more severe depressive symptoms. Further investigation is warranted to identify potential mechanisms for a targeted intervention to improve quality and provide more equitable care.