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Mukamel DB, Saliba D, Ladd H, Konetzka RT. The Relationship between Nursing Home Staffing and Health Outcomes Revisited. J Am Med Dir Assoc 2024; 25:105081. [PMID: 38878798 DOI: 10.1016/j.jamda.2024.105081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Nursing homes make staffing decisions in conjunction with choosing quality goals, potentially leading to endogeneity bias between staffing and quality. We use instrumental variables (IVs) to explore it. DESIGN Retrospective statistical analysis of 2017-2019 Payroll-Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term Care Focus. SETTINGS AND PARTICIPANTS A total of 11,261 nursing homes nationally. METHODS We estimated separate models for each of 6 quality measures as dependent variables, and registered nurses (RNs), certified nurse assistants (CNAs), and licensed practical nurses (LPNs) as independent variables, including other control variables associated with quality. The models were estimated using both ordinary least squares (OLS) and 2-stage least squares (2SLS) methods, the latter accounting for endogeneity. The IVs were defined as the average staffing of competing nursing homes in the same market as the index facility. RESULTS Estimated coefficients for the quality measures in the 2SLS models were up to 5 times larger than in the OLS models. The 2SLS estimates for antipsychotic medications use increased with higher RN staffing [0.279 (0.004 to 0.553)] and decreased with higher CNAs [-0.125 (-0.198 to -0.052)]. Hospitalizations decreased with more RNs [-1.328 (-1.673 to -0.983)] and LPN staffing [-0.483 (-0.755 to -0.211])] and increased with CNA [0.201 (0.109 to 0.293)] staffing. Emergency room visits decreased with higher RNs [-1.098 (-1.500 to -0.696)] and increased with CNAs [0.191 (0.084 to 0.298)]. Long-stay activities of daily living [-0.313 (-0.416 to -0.209)] and short-stay functioning [-0.481 (-0.598 to -0.364)] improved only with higher CNA staffing and pressure sores improved only with increased RN staffing [-0.436 (-0.836 to -0.035)]. CONCLUSIONS AND IMPLICATIONS Our findings demonstrate the importance of accounting for endogeneity in studies of staffing and quality. Endogeneity changes conclusions about significance, direction, and magnitude of the relationship between staffing and specific quality measures. These findings highlight the need to further study and understand the nuanced relationship between different staffing types and different health outcomes such as the difference between the relationship of RN and CNA hours per resident day to antipsychotic quality measures.
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Affiliation(s)
- Dana B Mukamel
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, CA, USA.
| | - Debra Saliba
- UCLA Borun Center at David Geffen School of Medicine, Los Angeles, CA, USA; Veterans Administration GRECC, Los Angeles, CA, USA; RAND Health, Santa Monica, CA, USA
| | - Heather Ladd
- Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, CA, USA
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Pot AM, Kok J, Schoonmade LJ, Bal RA. Regulation of long-term care for older persons: a scoping review of empirical research. Int Psychogeriatr 2024; 36:289-305. [PMID: 37700601 DOI: 10.1017/s1041610223000704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
OBJECTIVE Not only care professionals are responsible for the quality of care but other stakeholders including regulators also play a role. Over the last decades, countries have increasingly invested in regulation of Long-Term Care (LTC) for older persons, raising the question of how regulation should be put into practice to guarantee or improve the quality of care. This scoping review aims to summarize the evidence on regulatory practices in LTC for older persons. It identifies empirical studies, documents the aims and findings, and describes research gaps to foster this field. DESIGN A literature search (in PubMed, Embase, Cinahl, APA PsycInfo and Scopus) was performed from inception up to December 12th, 2022. Thirty-one studies were included. RESULTS All included studies were from high-income countries, in particular Australia, the US and Northwestern Europe, and almost all focused on care provided in LTC facilities. The studies focused on different aspects of regulatory practice, including care users' experiences in collecting intelligence, impact of standards, regulatory systems and strategies, inspection activities and policies, perception and style of inspectors, perception and attitudes of inspectees and validity and reliability of inspection outcomes. CONCLUSION With increasingly fragmented and networked care providers, and an increasing call for person-centred care, more flexible forms of regulatory practice in LTC are needed, organized closer to daily practice, bottom-up. We hope that this scoping review will raise awareness of the importance of regulatory practice and foster research in this field, to improve the quality of LTC for older persons, and optimize their functional ability and well-being.
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Affiliation(s)
- Anne Margriet Pot
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
- Optentia, North-West University, Vanderbijlpark, South Africa
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Josje Kok
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Linda J Schoonmade
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Roland A Bal
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
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3
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Davila H, Mills WL, Clark V, Hartmann CW, Sullivan JL, Mohr DC, Baughman AW, Berlowitz DR, Pimentel CB. Quality Improvement Efforts in VA Community Living Centers Following Public Reporting of Performance. J Aging Soc Policy 2024; 36:118-140. [PMID: 37014929 DOI: 10.1080/08959420.2023.2196913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 01/12/2023] [Indexed: 04/06/2023]
Abstract
For two decades, the U.S. government has publicly reported performance measures for most nursing homes, spurring some improvements in quality. Public reporting is new, however, to Department of Veterans Affairs nursing homes (Community Living Centers [CLCs]). As part of a large, public integrated healthcare system, CLCs operate with unique financial and market incentives. Thus, their responses to public reporting may differ from private sector nursing homes. In three CLCs with varied public ratings, we used an exploratory, qualitative case study approach involving semi-structured interviews to compare how CLC leaders (n = 12) perceived public reporting and its influence on quality improvement. Across CLCs, respondents said public reporting was helpful for transparency and to provide an "outside perspective" on CLC performance. Respondents described employing similar strategies to improve their public ratings: using data, engaging staff, and clearly defining staff roles vis-à-vis quality improvement, although more effort was required to implement change in lower performing CLCs. Our findings augment those from prior studies and offer new insights into the potential for public reporting to spur quality improvement in public nursing homes and those that are part of integrated healthcare systems.
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Affiliation(s)
- Heather Davila
- Center for Access and Delivery Research & Evaluation, Iowa City Department of Veterans Affairs (VA) Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Whitney L Mills
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Valerie Clark
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Jennifer L Sullivan
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI, USA
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, MA, USA
| | - Amy W Baughman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School,Boston, MA, USA
| | - Dan R Berlowitz
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Camilla B Pimentel
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
- New England Geriatric Research Education and Clinical Center, VA Bedford Healthcare System, Bedford, MA, USA
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Abstract
To improve the quality of nursing home care, reliable estimates of outcomes are essential. Obtaining such estimates requires optimal use of limited data, especially for small homes. We analyze the variation in mortality and hospital admissions across nursing homes in the Netherlands during the years 2010-2013. We use administrative data on all nursing home clients. We apply mixed-effects survival models, empirical Bayes estimation, and machine-learning techniques to optimally use the available longitudinal data. We find large differences in both outcomes across nursing homes, yet the estimates are surrounded by substantial uncertainty. We find no correlation between performance on mortality and avoidable hospital admissions, suggesting that these are related to different aspects of quality. Hence, caution is needed when evaluating the performance of individual nursing homes, especially when the number of outcome indicators is limited.
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Affiliation(s)
| | - Pieter Bakx
- Erasmus University Rotterdam, The Netherlands
| | - Albert Wong
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
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5
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Brunt CS. Assessing the impact of enforcement and compliance with minimum staffing standards on the quality of care in nursing homes: Evidence from the Centers for Medicare and Medicaid Services' staff star rating downgrade policy. HEALTH ECONOMICS 2023; 32:235-276. [PMID: 36403199 DOI: 10.1002/hec.4619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 06/16/2023]
Abstract
Policymakers have historically attempted to influence quality in nursing homes through the imposition of minimum staffing standards and through the public dissemination of quality on websites like Care Compare. One current Federal standard necessitates a registered nurse (RN) on duty for at least eight consecutive hours each day. In 2018, the Centers for Medicare and Medicaid Services announced that they would incentivize compliance with this requirement by downgrading nursing homes with 7+ days without an RN present during the quarter by one star on their Care Compare staffing domain quality rating. This study evaluates the impact of this new enforcement mechanism. Using an intent-to-treat sample of nursing homes at risk for downgrade with difference-in-differences and event study models, it finds that the policy increased compliance and staffing levels. Using the policy to instrument for full compliance, it finds that the daily presence of an RN causally improves several quality dimensions.
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Affiliation(s)
- Christopher S Brunt
- Department of Economics, Georgia Southern University, Statesboro, Georgia, USA
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Morantz A, Ross L. Intermediate Care Facilities for Individuals With Intellectual Disabilities: Does Ownership Type Affect Quality of Care? INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2022; 60:212-225. [PMID: 35640607 DOI: 10.1352/1934-9556-60.3.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/06/2021] [Indexed: 06/15/2023]
Abstract
Because many large, state-owned Intermediate Care Facilities for Individuals With Intellectual Disabilities (ICF/IIDs) have closed or downsized, their average size has fallen markedly, as has the number that are publicly owned. We probe the relationship between ownership type and four measures of care quality in ICF/IIDs. Data on deficiency citations suggest that for-profits underperform other ownership types, although data on complaints show no clear pattern. Meanwhile, data on staffing ratios and restrictive behavior management practices, based mostly on facility self-reports, generally tell the opposite story. Our results lend some credence to concerns regarding inadequate care in for-profit ICF/IIDs, while underscoring the importance of requiring ICF/IID operators to report more comprehensive, longitudinal data that are less prone to error and reporting bias.
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Affiliation(s)
| | - Leslie Ross
- Leslie Ross, University of California, San Francisco
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7
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Cronin CJ, Evans WN. Nursing home quality, COVID-19 deaths, and excess mortality. JOURNAL OF HEALTH ECONOMICS 2022; 82:102592. [PMID: 35104669 PMCID: PMC8776351 DOI: 10.1016/j.jhealeco.2022.102592] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 01/10/2022] [Accepted: 01/18/2022] [Indexed: 05/04/2023]
Abstract
The COVID-19 pandemic in the US has been particularly devastating for nursing home residents. A key question is how have some nursing homes been able to effectively protect their residents, while others have not? Using data on the universe of US nursing homes, we examine whether establishment quality is predictive of COVID-19 mortality. Higher-quality nursing homes, as measured by CMS overall five-star rating, have substantially lower COVID-19 mortality through September of 2020. Quality does not predict the ability to prevent any COVID-19 resident or staff cases, but higher-quality establishments prevent the spread of resident infections conditional on having one. Preventing COVID-19 cases and deaths may come at some cost, as high-quality homes have substantially higher non-COVID deaths. The positive correlation between establishment quality and non-COVID mortality is strong enough that high-quality homes also have more total deaths than their low-quality counterparts and this relationship has grown with time. As of late April 2021, five-star homes have experienced 8.4 percent more total deaths than one-star homes.
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Downer B, Reistetter TA, Kuo YF, Li S, Karmarkar A, Hong I, Goodwin JS, Ottenbacher KJ. Relationship Between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery After Hip Replacement. Arch Phys Med Rehabil 2021; 102:1717-1728.e7. [PMID: 33812884 PMCID: PMC8429053 DOI: 10.1016/j.apmr.2021.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/19/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016. DESIGN Pre (January 1, 2015-June 30, 2016) vs post (July 1, 2016-December 31, 2017) design. SETTING Skilled nursing facilities (n=12,829). PARTICIPANTS Medicare fee-for-service beneficiaries (N=106,832) discharged from acute hospitals to SNF after hip replacement between January 1, 2015 and December 31, 2017. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The 5- and 14-day minimum data set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10 days and any improvement between the 5- and 14-day assessments. RESULTS The average adjusted change per 10 days for the quality measure total score for patients admitted before July 2016 and after July 2016 was 1.00 points (standard error, 0010) and 1.06 points (standard error, 0.010), respectively (P<.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (standard error, 0.06) had any improvement in the quality measure total score compared with 45.5% (standard error, 0.23) of patients admitted after July 2016 (P<.01). This was a relative increase of 2.5%. The adjusted change per 10 days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016. CONCLUSIONS Patients admitted to a SNF after a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.
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Affiliation(s)
- Brian Downer
- University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, Galveston, TX; University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX.
| | - Timothy A Reistetter
- University of Texas Health Science Center at San Antonio, School of Health Professions, Department of Occupational Therapy, San Antonio, TX
| | - Yong-Fang Kuo
- University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX; University of Texas Medical Branch, Preventive Medicine and Population Health, Office of Biostatistics, Galveston, TX
| | - Shuang Li
- University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX
| | - Amol Karmarkar
- Virginia Commonwealth University, School of Medicine, Department of Physical Medicine and Rehabilitation, Richmond, VA
| | - Ickpyo Hong
- Yonsei University, College of Health Sciences, Department of Occupational Therapy, Seoul, Korea
| | - James S Goodwin
- University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX; University of Texas Medical Branch, Department of Internal Medicine, Division of Geriatrics, Galveston, TX
| | - Kenneth J Ottenbacher
- University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, Galveston, TX; University of Texas Medical Branch, Sealy Center on Aging, Galveston, TX
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9
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Lepore M, Barch DH. Medicare Usage Changes in Nursing Homes and Their Impacts on Long-Stay Resident Outcomes. J Appl Gerontol 2021; 41:826-830. [PMID: 34009055 DOI: 10.1177/07334648211013635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Medicare provides skilled nursing facility (SNF) coverage for short-stay rehabilitation in nursing homes (NHs) at a better rate than Medicaid covers long-term NH care. National trends of increasing Medicare days culminated in 2010/2011 with a reduction to the SNF rates. Before the cuts, NHs that increased SNF days also improved outcomes for long-stay residents, including pain, pressure ulcer, and functional decline outcomes, suggesting spillover effects of SNF days. We replicated the prior study to determine how changes in SNF days and long-stay outcomes related following the rate cut. From 2011 to 2014, SNF days decreased and all three study outcomes improved. Spillover effects were not consistently observed. Decreasing SNF days was associated with increasing percentages of long-stay residents with daily pain and with decreasing percentages of long-stay residents getting pressure ulcers. Research on these associations in more recent years is needed to determine whether they persist and to inform practice.
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10
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Johnson H. Restorative Quality Improvement: Novel Application of Six Sigma in a Skilled Nursing Facility. J Nurs Care Qual 2021; 36:67-73. [PMID: 32541424 DOI: 10.1097/ncq.0000000000000492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Six Sigma is a quality improvement (QI) method used in hospitals, but not typically in nursing homes (NHs), to reduce service variability and expenditures. LOCAL PROBLEM The existing QI process for functional maintenance program (FMP) charting/auditing in an urban NH allowed variability and lost revenue. METHODS A single-group pre/posttest design with analysis of variance and t-test analysis was used to implement Six Sigma for the FMP process. INTERVENTION Phases of Define, Measure, Analyze, Improve, and Control addressed performance objectives of FMP capacity; staff retention; congruence between prescribed, performed, and charted FMPs; and month-end summaries of resident status on FMPs. RESULTS With the existing staff, capability was increased by 17 residents ($200 000 revenue) and 90% to 100% charting congruence was achieved. Limited success was attributed to lack of skill diffusion, team communication, manager availability, and project prioritization. CONCLUSIONS Six Sigma was moderately successful when applied in a single NH for QI.
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Affiliation(s)
- Hannah Johnson
- College of Health and Human Services, Northern Illinois University, DeKalb
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11
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Salerno S, Dahlerus C, Messana J, Wisniewski K, Tong L, Hirth RA, Affholter J, Gremel G, Wu Y, Zhu J, Roach J, Balovlenkov Rn E, Andress J, Li Y. Evaluating national trends in outcomes after implementation of a star rating system: Results from dialysis facility compare. Health Serv Res 2020; 56:123-131. [PMID: 33184854 DOI: 10.1111/1475-6773.13600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To examine which factors are driving improvement in the Dialysis Facility Compare (DFC) star ratings and to test whether nonclinical facility characteristics are associated with observed longitudinal changes in the star ratings. DATA SOURCES Data were collected from eligible patients in over 6,000 Medicare-certified dialysis facilities from three annual star rating and individual measure updates, publicly released on DFC in October 2015, October 2016, and April 2018. STUDY DESIGN Changes in the star rating and individual quality measures were investigated across three public data releases. Year-to-year changes in the star ratings were linked to facility characteristics, adjusting for baseline differences in quality measure performance. DATA COLLECTION Data from publicly reported quality measures, including standardized mortality, hospitalization, and transfusion ratios, dialysis adequacy, type of vascular access for dialysis, and management of mineral and bone disease, were extracted from annual DFC data releases. PRINCIPAL FINDINGS The proportion of four- and five-star facilities increased from 30.0% to 53.4% between October 2015 and April 2018. Quality improvement was driven by the domain of care containing the dialysis adequacy and hypercalcemia measures. Additionally, independently owned facilities and facilities belonging to smaller dialysis organizations had significantly lower odds of year-to-year improvement than facilities belonging to either of the two large dialysis organizations (Odds Ratio [OR]: 0.736, 95% Confidence Interval [CI]: 0.631-0.856 and OR: 0.797, 95% CI: 0.723-0.879, respectively). CONCLUSIONS The percentage of four- and five-star facilities has increased markedly over a three-year time period. These changes were driven by improvement in the specific quality measures that may be most directly under the control of the dialysis facility.
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Affiliation(s)
- Stephen Salerno
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Claudia Dahlerus
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph Messana
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Karen Wisniewski
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Lan Tong
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard A Hirth
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jordan Affholter
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Garrett Gremel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - YiFan Wu
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Ji Zhu
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jesse Roach
- The Centers for Medicare & Medicaid Services, Baltimore, Maryland, USA
| | | | - Joel Andress
- The Centers for Medicare & Medicaid Services, Baltimore, Maryland, USA
| | - Yi Li
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan, USA
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Siegel EO, Young HM. Assuring Quality in Nursing Homes: The Black Box of Administrative and Clinical Leadership—A Scoping Review. THE GERONTOLOGIST 2020; 61:e147-e162. [DOI: 10.1093/geront/gnaa175] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Indexed: 01/18/2023] Open
Abstract
Abstract
Background and Objectives
Licensed nursing home administrators (NHA) and directors of nursing (DON) are responsible for nursing home quality and assuring optimal performance and job satisfaction/retention of their nursing home workforce. NHA/DON-focused studies have generated important foundational knowledge over the last three decades; yet, targeted research is needed to understand and apply the complexities of the black box of this top management team. This scoping review identifies, reviews, synthesizes, and maps the topical areas of research in NHA/DON positions in U.S. nursing homes.
Research Design and Methods
We conducted searches of 5 databases, yielding 3,479 records; screening/review yielded 88 unique records. We used thematic analysis to code the primary foci of the studies and the variables associated with the concepts of interest.
Results
Most papers (n = 40) focused on role characteristics, 23 examined approaches to management and leadership, 24 focused on perceptions about the role, and the remaining 12 examined role structure. The role-related themes linked to outcomes (n = 42), processes (n = 27), and structures (n = 30).
Discussion and Implications
We highlight important gaps for future research and offer a call to action for research, policy, practice, and education collaborations to accelerate the rate of research and translate the findings into best practices for NHA/DON to lead and manage the nursing home workforce and build capacity to ensure person-centered, high-quality care. Based on foundational descriptive studies, it is time to use what is known to design and implement interventions that enhance the capacity of NHA/DON to improve the structures, processes, and outcomes of nursing homes.
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Affiliation(s)
- Elena O Siegel
- Betty Irene Moore School of Nursing, University California, Davis, Sacramento, USA
| | - Heather M Young
- Betty Irene Moore School of Nursing, University California, Davis, Sacramento, USA
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Tamara Konetzka R, Yan K, Werner RM. Two Decades of Nursing Home Compare: What Have We Learned? Med Care Res Rev 2020; 78:295-310. [PMID: 32538264 DOI: 10.1177/1077558720931652] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Approximately two decades ago, federally mandated public reporting began for U.S. nursing homes through a system now known as Nursing Home Compare. The goals were to provide information to enable consumers to choose higher quality nursing homes and to incent providers to improve the quality of care delivered. We conduct a systematic review of the literature on responses to Nursing Home Compare and its effectiveness in meeting these goals. We find evidence of modest but meaningful response by both consumers and providers. However, we also find evidence that some improvement in scores does not reflect true quality improvement, that disparities by race and income have increased, that risk-adjustment of the measures is likely inadequate, and that several key domains of quality are not represented. Our results support moderate success of Nursing Home Compare in achieving intended goals but also reveal the need for continued refinement.
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Affiliation(s)
| | - Kevin Yan
- The University of Chicago, Chicago, IL, USA
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14
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Shetty KD, Tolpadi AA, Robbins MW, Taylor EA, Campbell KN, Damberg CL. Nursing Home Responses to Performance‐based Accountability: Results of a National Survey. J Am Geriatr Soc 2020; 68:1979-1987. [DOI: 10.1111/jgs.16466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 03/13/2020] [Accepted: 03/24/2020] [Indexed: 12/01/2022]
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15
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Davila H, Johnson DR, Sullivan JL. Prioritizing LTSS Quality: Exploring the Views of Older Adults, Families, and Professionals. J Aging Soc Policy 2020; 33:247-267. [PMID: 32286922 DOI: 10.1080/08959420.2020.1750542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We conducted a cross-sectional survey involving 349 older adults, family members, and long-term services and supports (LTSS) professionals in Minnesota to assess their views on priorities for residential LTSS quality. We found considerable agreement among the three groups on the highest priorities to ensure the wellbeing of older adults who use LTSS: safety, dignity, and staffing. Relationships were also viewed as a high priority. However, older adults prioritized the physical environment over professionals, and they expressed more varied opinions on priorities overall. Older adults also consistently rated autonomy/choice as less important than other quality domains, a finding worth further exploration.
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Affiliation(s)
- Heather Davila
- Postdoctoral Fellow, Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - David R Johnson
- Professor, Department of Organizational Leadership, Policy, and Development, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jennifer L Sullivan
- Investigator, Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA, USA.,Research Assistant Professor, Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
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Gaudet Hefele J. Nursing home quality: what matters to patients. BMJ Qual Saf 2020; 29:401-404. [DOI: 10.1136/bmjqs-2019-010338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/19/2019] [Accepted: 12/22/2019] [Indexed: 11/03/2022]
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Perraillon MC, Konetzka RT, He D, Werner RM. Consumer Response to Composite Ratings of Nursing Home Quality. AMERICAN JOURNAL OF HEALTH ECONOMICS 2019; 5:165-190. [PMID: 31579236 PMCID: PMC6774377 DOI: 10.1162/ajhe_a_00115] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Health care report cards are intended to address information asymmetries and enable consumers to choose providers of better quality. However, the form of the information may matter to consumers. Nursing Home Compare, a website that publishes report cards for nursing homes, went from publishing a large set of indicators to a composite rating in which nursing homes are assigned one to five stars. We evaluate whether the simplified ratings motivated consumers to choose better-rated nursing homes. We use a regression discontinuity design to estimate changes in new admissions six months after the publication of the ratings. Our main results show that nursing homes that obtained an additional star gained more admissions, with heterogeneous effects depending on baseline number of stars. We conclude that the form of quality reporting matters to consumers, and that the increased use of composite ratings is likely to increase consumer response.
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Affiliation(s)
| | | | - Daifeng He
- Swarthmore College, Department of Economics
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18
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Sharma H, Perraillon MC, Werner RM, Grabowski DC, Konetzka RT. Medicaid and Nursing Home Choice: Why Do Duals End Up in Low-Quality Facilities? J Appl Gerontol 2019; 39:981-990. [PMID: 30957619 DOI: 10.1177/0733464819838447] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We provide empirical evidence on the relative importance of specific observable factors that can explain why individuals enrolled in both Medicare and Medicaid (duals) are concentrated in lower quality nursing homes, relative to those not on Medicaid. Descriptive results show that duals are 9.7 percentage points more likely than nonduals to be admitted to a low-quality (1-2 stars) nursing home. Using the Blinder-Oaxaca decomposition approach in a multivariate framework, we find that 35.4% of the difference in admission to low-quality nursing homes can be explained by differences in the distribution of observable characteristics. Differences in education and distance to high-quality nursing homes are important drivers, as are health status and race. Our findings highlight the need for creative policy solutions targeting the modifiable factors to reduce the disparity.
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19
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Snyder DJ, Kroshus TR, Keswani A, Garden EB, Koenig KM, Bozic KJ, Jevsevar DS, Poeran J, Moucha CS. Are Medicare's Nursing Home Compare Ratings Accurate Predictors of 90-Day Complications, Readmission, and Bundle Cost for Patients Undergoing Primary Total Joint Arthroplasty? J Arthroplasty 2019; 34:613-618. [PMID: 30630648 DOI: 10.1016/j.arth.2018.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/09/2018] [Accepted: 12/02/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Nursing Home Compare (NHC) ratings, created and maintained by Medicare, are used by both hospitals and consumers to aid in the skilled nursing facility (SNF) selection process. To date, no studies have linked NHC ratings to actual episode-based outcomes. The purpose of this study was to evaluate whether NHC ratings are valid predictors of 90-day complications, readmission, and bundle costs for patients discharged to an SNF after primary total joint arthroplasty (TJA). METHODS All SNF-discharged primary TJA cases in 2017 at a multihospital academic health system were queried. Demographic, psychosocial, and clinical variables were manually extracted from the health record. Medicare NHC ratings were then collected for each SNF. For patients in the Medicare bundle, postacute and total bundle cost was extracted from claims. RESULTS Four hundred eighty-eight patients were discharged to a total of 105 unique SNFs. In multivariate analysis, overall NHC rating was not predictive of 90-day readmission/major complications, >75th percentile postacute cost, or 90-day bundle cost exceeding the target price. SNF health inspection and quality measure ratings were also not predictive of 90-day readmission/major complications or bundle performance. A higher SNF staffing rating was independently associated with a decreased odds for >75th percentile 90-day postacute spend (odds ratio, 0.58; P = .01) and a 90-day bundle cost exceeding the target price (odds ratio = 0.69; P = .02) but was similarly not predictive of 90-day readmission/complications. CONCLUSION Results of our study suggest that Medicare's NHC tool is not a useful predictor of 90-day costs, complications, or readmissions for SNFs within our health system.
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MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/rehabilitation
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/rehabilitation
- Costs and Cost Analysis
- Female
- Humans
- Male
- Medicare/economics
- Medicare/standards
- Odds Ratio
- Patient Care Bundles/economics
- Patient Discharge
- Patient Readmission/economics
- Patient Readmission/statistics & numerical data
- Postoperative Complications/epidemiology
- Postoperative Complications/etiology
- Retrospective Studies
- Skilled Nursing Facilities/standards
- United States/epidemiology
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Affiliation(s)
- Daniel J Snyder
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas R Kroshus
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aakash Keswani
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Evan B Garden
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karl M Koenig
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Seton Medical Center, Austin, TX
| | - Kevin J Bozic
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Seton Medical Center, Austin, TX
| | - David S Jevsevar
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NY
| | - Jashvant Poeran
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Calin S Moucha
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
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Brauner D, Werner RM, Shippee TP, Cursio J, Sharma H, Konetzka RT. Does Nursing Home Compare Reflect Patient Safety In Nursing Homes? Health Aff (Millwood) 2018; 37:1770-1778. [PMID: 30395505 PMCID: PMC6405288 DOI: 10.1377/hlthaff.2018.0721] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The past several decades have seen significant policy efforts to improve the quality of care in nursing homes, but the patient safety movement has largely ignored this setting. In this study we compared nursing homes' performance on several composite quality measures from Nursing Home Compare, the most prominent recent example of a national policy aimed at improving the quality of nursing home care, to their performance on measures of patient safety in nursing homes such as pressure sores, infections, falls, and medication errors. Although Nursing Home Compare captures some aspects of patient safety, we found the relationship to be weak and somewhat inconsistent, leaving consumers who care about patient safety with little guidance. We recommend that Nursing Home Compare be refined to provide a clearer picture of patient safety and quality of life, allowing consumers to weight these domains according to their preferences and priorities.
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Affiliation(s)
- Daniel Brauner
- Daniel Brauner is an associate professor in the Department of Medicine, University of Chicago, in Illinois
| | - Rachel M Werner
- Rachel M. Werner is a professor of medicine in the Division of General Internal Medicine at the Perelman School of Medicine and a professor of health care management at the Wharton School of Business, both at the University of Pennsylvania, and core faculty at the Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, in Philadelphia
| | - Tetyana P Shippee
- Tetyana P. Shippee is an associate professor in the Division of Health Policy and Management, School of Public Health, University of Minnesota, in Minneapolis
| | - John Cursio
- John Cursio is a research assistant professor in the Department of Public Health Sciences, University of Chicago
| | - Hari Sharma
- Hari Sharma is an assistant professor in the Department of Health Management and Policy, University of Iowa, in Iowa City. At the time this research was conducted, Sharma was a doctoral student in the Department of Public Health Sciences, University of Chicago
| | - R Tamara Konetzka
- R. Tamara Konetzka ( ) is a professor in the Department of Public Health Sciences and in the Department of Medicine, University of Chicago
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Fuller RL, Goldfield NI, Hughes JS, McCullough EC. Nursing Home Compare Star Rankings and the Variation in Potentially Preventable Emergency Department Visits and Hospital Admissions. Popul Health Manag 2018; 22:144-152. [PMID: 30059266 PMCID: PMC6459266 DOI: 10.1089/pop.2018.0065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Measurement of the quality of US health care increasingly emphasizes clinical outcomes over clinical processes. Nursing Home Compare Star Ratings are provided by Medicare to help select better nursing home care. The authors determined the rates and types of 2 important clinical outcomes-potentially preventable hospital admissions and potentially preventable emergency department (ED) visits-for a subset of 439,011 long-term nursing homes residents residing in 12,883 nursing homes throughout the United States over a 2-year period (2010-2011) and compared them with the Star Rating system. This study found that (1) the likelihood of potentially preventable events increases with increasing burden of chronic illness, (2) the principle reasons for hospital admissions and ED visits (eg, septicemia, pneumonia, confusion, gastroenteritis) are not part of existing nursing home quality measures, (3) the rate of potentially preventable admissions and ED visits for nursing homes residents varies greatly both across and within states, with 5 states having in excess of 20% more than the national average for both, and (4) the Nursing Home Compare Stars measure has limited correlation with rates of these potentially preventable events. Nursing Home Compare Star rankings could benefit by incorporating outcomes measures such as preventable hospitalizations and ED visits, and by comparing nursing home performance on results drawn from across states rather than within them. Such reform could better help users find nursing homes of higher quality and stimulate homes to improve quality in ways that benefit residents.
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Affiliation(s)
- Richard L Fuller
- 1 3M Health Information Systems, Clinical and Economic Research , Silver Spring, Maryland
| | | | - John S Hughes
- 3 Yale University School of Medicine , New Haven, Connecticut
| | - Elizabeth C McCullough
- 1 3M Health Information Systems, Clinical and Economic Research , Silver Spring, Maryland
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