Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?

Involuntary closures of for-profit care homes in England by the Care Quality Commission

Adult social care services in England are struggling, and sometimes failing, to supply the quality of care deserved by the most vulnerable people in society. The Care Quality Commission (CQC) is responsible for protecting the recipients of this crucial public service. Their strongest enforcement is the ability to cancel the registration-the legal right to operate-of a health or social care provider. Using novel data from the CQC, we show that the proportion of care home closures due to CQC enforcements, relative to all closures, is increasing. Since 2011, 816 care homes (representing 19 918 registered beds) have been involuntarily closed by the CQC. Our results show that effectively all involuntary closures (804/816) occurred in for-profit care homes. This data emphasises the need for a comprehensive assessment of the impact of for-profit provision on the quality and sustainability of adult social care in England.

For health or for profit? Understanding how private financing and for-profit delivery operate within Canadian healthcare (4H|4P): protocol for a multimethod knowledge mobilisation research project

INTRODUCTION

Privatisation through the expansion of private payment and investor-owned corporate healthcare delivery in Canada raises potential conflicts with equity principles on which Medicare (Canadian public health insurance) is founded. Some cases of privatisation are widely recognised, while others are evolving and more hidden, and their extent differs across provinces and territories likely due in part to variability in policies governing private payment (out-of-pocket payments and private insurance) and delivery.

METHODS AND ANALYSIS

This pan-Canadian knowledge mobilisation project will collect, classify, analyse and interpret data about investor-owned privatisation of healthcare financing and delivery systems in Canada. Learnings from the project will be used to develop, test and refine a new conceptual framework that will describe public-private interfaces operating within Canada's healthcare system. In Phase I, we will conduct an environmental scan to: (1) document core policies that underpin public-private interfaces; and (2) describe new or emerging forms of investor-owned privatisation ('cases'). We will analyse data from the scan and use inductive content analysis with a pragmatic approach. In Phase II, we will convene a virtual policy workshop with subject matter experts to refine the findings from the environmental scan and, using an adapted James Lind Alliance Delphi process, prioritise health system sectors and/or services in need of in-depth research on the impacts of private financing and investor-owned delivery.

ETHICS AND DISSEMINATION

We have obtained approval from the research ethics boards at Simon Fraser University, University of British Columbia and University of Victoria through Research Ethics British Columbia (H23-00612). Participants will provide written informed consent. In addition to traditional academic publications, study results will be summarised in a policy report and a series of targeted policy briefs distributed to workshop participants and decision/policymaking organisations across Canada. The prioritised list of cases will form the basis for future research projects that will investigate the impacts of investor-owned privatisation.

Association of Receipt of Paycheck Protection Program Loans With Staffing Patterns Among US Nursing Homes

Importance

Staffing shortages in nursing homes (NHs) threaten the quality of resident care, and the COVID-19 pandemic magnified critical staffing shortages within NHs. During the pandemic, the US Congress enacted the Paycheck Protection Program (PPP), a forgivable loan program that required eligible recipients to appropriate 60% to 75% of the loan toward staffing to qualify for loan forgiveness.

Objective

To evaluate characteristics of PPP loan recipient NHs vs nonloan recipient NHs and whether there were changes in staffing hours at NHs that received a loan compared with those that did not.

Design, Setting, and Participants

This economic evaluation used national data on US nursing homes that were aggregated from the Small Business Administration, Nursing Home Compare, LTCFocus, the Centers for Medicare & Medicaid Services Payroll Based Journal, the Minimum Data Set, the Area Deprivation Index, the Healthcare Cost Report Information System, and the US Department of Agriculture Rural-Urban Continuum Codes from January 1 to December 23, 2020.

Exposure

Paycheck Protection Program loan receipt status.

Main Outcome and Measures

Staffing variables included registered nurse, licensed practical nurse (LPN), and certified nursing assistant (CNA) total hours per week. Staffing hours were examined on a weekly basis before and after loan receipt during the study period. An event-study approach was used to estimate the staffing total weekly hours at NHs that received PPP loans compared with NHs that did not receive a PPP loan.

Results

Among 6008 US NHs, 1807 (30.1%) received a PPP loan and 4201 (69.9%) did not. The median loan amount was $664 349 (IQR, $407 000-$1 058 300). Loan recipients were less likely to be part of a chain (733 [40.6%] vs 2592 [61.7%]) and more likely to be for profit (1342 [74.3%] vs 2877 [68.5%]), be located in nonurban settings (159 [8.8%] vs 183 [4.4%]), have a greater proportion of Medicaid-funded residents (mean [SD], 60.92% [21.58%] vs 56.78% [25.57%]), and have lower staffing quality ratings (mean [SD], 2.88 [1.20] vs 3.03 [1.22]) and overall quality star ratings (mean [SD], 3.08 [1.44] vs 3.22 [1.44]) (P < .001 for all). Twelve weeks after PPP loan receipt, NHs that received a PPP loan experienced a mean difference of 26.19 more CNA hours per week (95% CI, 14.50-37.87 hours per week) and a mean difference of 6.67 more LPN hours per week (95% CI, 1.21-12.12 hours per week) compared with nursing homes that did not receive a PPP loan. No associations were found between PPP loan receipt and weekly RN staffing hours (12 weeks: mean difference, 1.99 hours per week; 95% CI, -2.38 to 6.36 hours per week).

Conclusions and Relevance

In this economic evaluation, a forgivable loan program that required funding to be appropriated toward staffing was associated with a significant increase in CNA and LPN staffing hours among NH PPP loan recipients. Because the PPP loans are temporary, federal and state entities may need to institute sufficient and sustainable support to mitigate NH staffing shortages.

Psychosocial Work Environment and Well-Being of Direct-Care Staff Under Different Nursing Home Ownership Types: A Systematic Review

This systematic review investigated the psychosocial work environment and well-being of direct-care staff under different nursing home ownership types. Databases searched: Scopus, Web of Science, Cinahl, and PubMed, 1990-2020. Inclusion criteria: quantitative or mixed-method studies; population: direct-care staff in nursing homes; exposure: for-profit and non-profit ownership; and outcomes: psychosocial work environment and well-being. In total, 3896 articles were screened and 17(n = 12,843 participants) were assessed using the Joanna Briggs Institute Critical Appraisal tools and included in the narrative synthesis. The results were inconsistent, but findings favored non-profit over for-profit settings, for example, regarding leaving intentions, organizational commitment, and stress-related outcomes. There were no clear differences concerning job satisfaction. Job demands were higher in non-profit nursing homes but alleviated by better job resources in one study. The result highlights work environment issues, with regulations concerning for-profit incentives being discussed in terms of staff benefits.

Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities

BACKGROUND

Implementation of new skilled nursing facility (SNF) Medicare payment policy, the Patient Driven Payment Model (PDPM), resulted in immediate declines in physical and occupational therapy staffing. This study characterizes continuing impacts of PDPM in conjunction with COVID-19 on SNF therapy staffing and examines variability in staffing changes based on SNF organizational characteristics.

METHODS

We analyzed Medicare administrative data from a national cohort of SNFs between January 2019 and March 2022. Interrupted time series mixed effects regression examined changes in level and trend of total therapy staffing minutes/patient-day during PDPM and COVID-19 and by type of staff (therapists, assistants, contractors, and in-house staff). Secondary analyses examined the variability in staffing by organizational characteristics.

RESULTS

PDPM resulted in a -6.54% level change in total therapy staffing, with larger declines for assistants and contractors. Per-patient staffing fluctuated during COVID-19 as the census changed. PDPM-related staffing declines were larger in SNFs that were: Rural, for-profit, chain-affiliated, provided more intensive therapy, employed more therapy assistants, and admitted more Medicare patients before PDPM. COVID-19 resulted in larger staffing declines in rural SNFs but smaller early declines in SNFs that were hospital-based, for-profit, or received more relief funding.

CONCLUSIONS

SNFs that historically engaged in profit-maximizing behaviors (e.g., providing more therapy via lower-paid assistants) had larger staffing declines during PDPM compared to other SNFs. Therapy staffing fluctuated during COVID-19, but PDPM-related reductions persisted 2 years into the pandemic, especially in rural SNFs. Results suggest specific organizational characteristics that should be targeted for staffing and quality improvement initiatives.

Neglecting the care of older people in residential care settings: A national document analysis of complaints reported to the Finnish supervisory authority

Neglecting to provide older people with the care they need in residential care settings leads to human suffering and increased service needs. Research is lacking on neglect in older people's residential care and one way to assess the key issues is to study complaints. The aim of this study was to analyse official complaints related to allegations of neglect in residential care settings caring for older people in Finland. The data covered 317 complaints that were recorded in the national database in 2018 and 2019. The analysis of the complaints yielded 2,922 observations of neglect in older people's care in residential care settings. Based on our results, most of the complaints were made by family members when the patients were alive and their motivation was to improve the care their relative received, as well as the care of others, in the residential care home. The complaints focused on neglecting clinical care, including restricting older people's movements, not providing daily activities and not paying sufficient attention to their hygiene and secretions. Other complaints included issues relating to nutrition, medication, communication and issues that compromised their privacy, respect and dignity. Nearly three of four complaints identified staffing issues in relation to neglect and most of the complaints concerned private, rather than public, residential care homes. Although the complaints only concerned a small proportion of the annual care provided, more attention should be paid to care practices that prevent neglect in residential care and to multi-level monitoring for dignified care.

Delivering person-centred palliative care in long-term care settings: is humanism a quality of health-care employees or their organisations?

Reflecting on sustained calls for patient-centredness and culture change in long-term care, we evaluated the relative importance of personal and organisational predictors of palliative care, hypothesising the former as weaker predictors than the latter. Health-care employees (N = 184) from four Canadian long-term care homes completed a survey of person-centred care, self-efficacy, employee wellbeing and occupational characteristics. Using backward stepwise regression models, we examined the relative contributions of these variables to person-centred palliative care. Specifically, blocks of variables representing personal, organisational and occupational characteristics; palliative care self-efficacy; and employee wellbeing were simultaneously regressed on variables representing aspects of person-centred care. The change in R2 associated with the removal of each block was examined to determine each block's overall contribution to the model. We found that occupational characteristics (involvement in care planning), employee wellbeing (compassion satisfaction) and self-efficacy were reliably associated with person-centred palliative care (p < 0.05). Facility size was not associated, and facility profit status was less consistently associated. Demographic characteristics (gender, work experience, education level) and some aspects of employee wellbeing (burnout, secondary trauma) were also not reliably associated. Overall, these results raise the possibility that humanistic care is less related to intrinsic characteristics of employees, and more related to workplace factors, or to personal qualities that can be cultivated in the workplace, including meaningful role engagement, compassion and self-efficacy.

COVID-19 Cases and Deaths in Skilled Nursing Facilities in Cook County, Illinois

OBJECTIVE

The COVID-19 pandemic has had a devastating impact on older adults residing in skilled nursing facilities. This study examined the pathways through which community and facility factors may have affected COVID-19 cases and deaths in skilled nursing facilities.

METHODS

We used structural equation modeling to examine the number of COVID-19 cases and deaths in skilled nursing facilities in Cook County, Illinois, from January 1 through September 30, 2020. We used data from the Centers for Medicare & Medicaid Services, the Illinois Department of Public Health, and the Cook County Medical Examiner's Office to determine the number of resident COVID-19 cases and deaths, number of staff cases, facility-level characteristics, and community-level factors.

RESULTS

Poorer facility quality ratings and higher numbers of staff COVID-19 cases were associated with increased numbers of resident COVID-19 cases and deaths. For-profit ownership was associated with larger facilities and higher resident-to-staff ratios, which increased the number of staff COVID-19 cases. Furthermore, skilled nursing facilities with a greater percentage of White residents were in areas with lower levels of social vulnerability and were less likely to be for-profit and, thus, were associated with higher quality.

CONCLUSIONS

For-profit ownership was associated with lower facility quality ratings and increases in the number of staff COVID-19 cases, leading to increased resident COVID-19 cases and deaths. Establishing enforceable regulations to ensure quality standards in for-profit skilled nursing facilities is critical to prevent future outbreaks and reduce health disparities in facilities serving racial and ethnic minority populations.

Workplace Integrated Safety and Health Program Uptake in Nursing Homes: Associations with Ownership

Workers in nursing homes are at high risk of occupational injury. Understanding whether—and which—nursing homes implement integrated policies to protect and promote worker health is crucial. We surveyed Directors of Nursing (DON) at nursing homes in three US states with the Workplace Integrated Safety and Health (WISH) assessment, a recently developed and validated instrument that assesses workplace policies, programs, and practices that affect worker safety, health, and wellbeing. We hypothesized that corporate and for-profit nursing homes would be less likely to report policies consistent with Total Worker Health (TWH) approaches. For each of the five validated WISH domains, we assessed the association between being in the lowest quartile of WISH score and ownership status using multivariable logistic regression. Our sample included 543 nursing homes, 83% which were corporate owned and 77% which were for-profit. On average, DONs reported a high implementation of TWH policies, as measured by the WISH. We did not find an association between either corporate ownership or for-profit status and WISH score for any WISH domain. Results were consistent across numerous sensitivity analyses. For-profit status and corporate ownership status do not identify nursing homes that may benefit from additional TWH approaches.

Identifying Unexpected Deaths in Long-Term Care Homes

OBJECTIVES

Predicting unexpected deaths among long-term care (LTC) residents can provide valuable information to clinicians and policy makers. We study multiple methods to predict unexpected death, adjusting for individual and home-level factors, and to use as a step to compare mortality differences at the facility level in the future work.

DESIGN

We conducted a retrospective cohort study using Resident Assessment Instrument Minimum Data Set assessment data for all LTC residents in Ontario, Canada, from April 2017 to March 2018.

SETTING AND PARTICIPANTS

All residents in Ontario long-term homes. We used data routinely collected as part of administrative reporting by health care providers to the funder: Ontario Ministry of Health and Long-Term Care. This project is a component of routine policy development to ensure safety of the LTC system residents.

METHODS

Logistic regression (LR), mixed-effect LR (mixLR), and a machine learning algorithm (XGBoost) were used to predict individual mortality over 5 to 95 days after the last available RAI assessment.

RESULTS

We identified 22,419 deaths in the cohort of 106,366 cases (mean age: 83.1 years; female: 67.7%; dementia: 68.8%; functional decline: 16.6%). XGBoost had superior calibration and discrimination (C-statistic 0.837) over both mixLR (0.819) and LR (0.813). The models had high correlation in predicting death (LR-mixLR: 0.979, LR-XGBoost: 0.885, mixLR-XGBoost: 0.882). The inter-rater reliability between the models LR-mixLR and LR-XGBoost was 0.56 and 0.84, respectively. Using results in which all 3 models predicted probability of actual death of a resident at <5% yielded 210 unexpected deaths or 0.9% of the observed deaths.

CONCLUSIONS AND IMPLICATIONS

XGBoost outperformed other models, but the combination of 3 models provides a method to detect facilities with potentially higher rates of unexpected deaths while minimizing the possibility of false positives and could be useful for ongoing surveillance and quality assurance at the facility, regional, and national levels.

A systematic review of the associations between care home ownership and COVID-19 outbreaks, infections and mortality

Social care markets often rely on the for-profit sector to meet service demand. For-profit care homes have been reported to suffer higher rates of coronavirus disease 2019 (COVID-19) infections and deaths, but it is unclear whether these worse outcomes can be attributed to ownership status. To address this, we designed and prospectively registered a living systematic review protocol ( CRD42020218673 ). Here we report on the systematic review and quality appraisal of 32 studies across five countries that investigated ownership variation in COVID-19 outcomes among care homes. We show that, although for-profit ownership was not consistently associated with a higher risk of a COVID-19 outbreak, there was evidence that for-profit care homes had higher rates of COVID-19 infections and deaths. We also found evidence that for-profit ownership was associated with personal protective equipment (PPE) shortages. Variation in COVID-19 outcomes is not driven by ownership status alone, and factors related to staffing, provider size and resident characteristics were also linked to poorer outcomes. However, this synthesis finds that for-profit status and care home characteristics associated with for-profit status are linked to exacerbated COVID-19 outcomes.

Ownership, quality and prices of nursing homes in Australia: Why greater private sector participation did not improve performance

OBJECTIVE

This study examines whether greater private-sector participation in aged care can lead to better outcomes by comparing quality of care and prices of residential aged care facilities across three ownership types: government-owned, private not-for-profit and for- profit facilities. Australia, like many other countries, has been implementing market-oriented reforms aiming to promote greater consumer choice and increase the role of markets and private-sector participation in aged care.

METHODS

Using retrospective facility-level data, the study relates several measures of quality of care and a measure of price to ownership types while controlling for facility characteristics. The data covered six financial years (2013/14-2018/19) and contained 2,900 residential aged-care facilities, capturing almost all facilities in Australia. About 55% were private not-for-profit, 30% private for-profit and 15% government-owned.

RESULTS

Government-owned facilities provide higher quality of care in most quality measures and charge the lowest average price than private for-profit and not-for-profit facilities.

DISCUSSION

Reforms promoting private-sector participation in aged care are unlikely to result in effective competition to drive quality up or prices down unless sources of market failure are addressed. In Australia, the lack of public reporting of quality and the complex pricing structure are key issues that prevent market forces and consumer choice from working as intended.

Is there a future for nursing homes in Canada?

The high rates of nursing home deaths in the wake of COVID-19 have led to calls for their elimination and their replacement by home care. Based on years of research in Canada and abroad, this article argues that nursing homes are not just necessary, they provide significant benefits for those living in, working in, and visiting in them. In developing this argument, the article begins by setting out why long-term residential care is necessary before moving on to consider the benefits of such care, benefits that go beyond the clinical. It concludes by identifying factors that can make nursing homes a positive option while helping to avoid pandemic horrors in the future.

A Report of Information Technology and Health Deficiencies in U.S. Nursing Homes

OBJECTIVE

The aim of the study was to investigate the impact of nursing home (NH) information technology (IT) sophistication on publically reported health safety deficiency scores documented during standard inspections.

METHODS

The sample included 807 NHs from every U.S. state. A total of 2187 health inspections were documented in these facilities. A national IT sophistication survey describing IT capabilities, extent of IT use, and degree of IT integration in resident care, clinical support, and administrative activities in U.S. NHs was used. The relationship between NH health deficiencies and IT sophistication survey scores was examined, using weighted regression.

RESULTS

Controlling for registered nurse hours per resident day, deficiency scores decreased as total IT sophistication increased. Controlling for total IT sophistication score, deficiency scores decreased as registered nurse hours per resident day increased. Ownership status significantly influenced health deficiency scores.

CONCLUSIONS

These results highlight the necessity to understand benefits of implementing NH IT and demonstrating its impact on patient safety.

A cross-sectional study using the national standard to examine differences between public and private non-profit nursing homes in China

AIM

Most studies on nursing home quality focus on developed countries, with little coverage in developing countries. Our study aimed to compare the differences between Chinese public and private non-profit nursing homes using the latest national standard.

METHODS

A cross-sectional study was conducted including 232 nursing homes in Jiangsu and Zhejiang provinces, China. We conducted statistical analyses (chi-square and independent sample t test) to investigate differences in public and private non-profit nursing homes. We fitted a binary logistic regression model with whether or not the nursing home received a 3-star or higher rating as the dependent variable, and the ownership type as explanatory variable, after adjusting for nursing home characteristics.

RESULTS

Of the 232 nursing homes included in the study sample, 44.8% were public nursing homes and 55.2% were private non-profit nursing homes. The t test analysis comparing the measures of nursing homes yielded significant results for 4 measures, 3 of which (overall rating, environment, and services) favored private non-profit nursing homes. A regression analysis using whether or not the nursing home received a 3-star or higher rating as the dependent variable showed that when adjusting for nursing home characteristics, private non-profit nursing homes were more likely to have a 3 or higher star compared with public nursing homes (odds ratio = 1.961, 95% confidence interval: 1.056-3.643).

CONCLUSION

These results suggested that private non-profit nursing homes performed better than public nursing homes when using the Chinese national standard for nursing homes.

Long-Term Care Facility Workers' Perceptions of the Impact of Subcontracting on their Conditions of Work and the Quality of Care: A Qualitative Study in British Columbia

Subcontracting long-term care (LTC), whereby facilities contracted with third party agencies to provide care to residents, became widespread in British Columbia after 2002. This qualitative study aimed to understand the impact of subcontracting from the perspective of care workers. We interviewed 11 care workers employed in subcontracted facilities to explore their perceptions of caring and working under these conditions. Our overarching finding was one of loss. Care workers lost wages, benefits, security, and voice. Their working conditions worsened, with workload and turnover increasing, resulting in a loss of experienced staff and a loss of time to provide care. These findings call into question the promises of quality and flexibility that legitimated policies permitting subcontracting, while adding to the mounting evidence that subcontracting LTC harms both workers and residents.

Risque d’éclosions de COVID-19 et de décès de résidents dans les foyers de soins de longue durée à but lucratif

CONTEXTE:

Les foyers de soins de longue durée (SLD) ont jusqu’à présent été l’épicentre de la pandémie de maladie à coronavirus 2019 (COVID-19) au Canada. Selon des études antérieures, les soins offerts dans les foyers de SLD à but lucratif sont de qualité inférieure pour toute une gamme d’indicateurs de résultats et de processus, ce qui soulève la question suivante: les conséquences de la COVID-19 ont-elles été pires dans les foyers à but lucratif que dans ceux à but non lucratif?

MÉTHODES:

Une étude de cohorte rétrospective basée sur l’ensemble des foyers de SLD en Ontario a été menée pour la période du 29 mars au 20 mai 2020 à partir de la base de données sur les éclosions de COVID-19 alimentée par le ministère des Soins de longue durée de l’Ontario. Des méthodes logistiques hiérarchiques et basées sur des données de comptage ont été utilisées pour modéliser les associations entre le statut financier des foyers de SLD (à but lucratif, à but non lucratif ou municipal) et les éclosions de COVID-19 dans ces derniers, l’ampleur des éclosions (nombre de résidents infectés) et le nombre de décès de résidents attribuables à la COVID-19.

RÉSULTATS:

L’analyse portait sur les 623 foyers de SLD de l’Ontario, qui comptent 75 676 résidents. Parmi ces foyers, 360 (57,7 %) sont à but lucratif; 162 (26,0 %) sont à but non lucratif; et 101 (16,2 %) sont des foyers municipaux. Au total, 190 (30,5 %) éclosions de COVID-19 ont été enregistrées dans des foyers de SLD. Elles ont touché 5218 résidents et entraîné 1452 décès, ce qui représente un taux de létalité général de 27,8 %. Les probabilités d’une éclosion dans un foyer ont été associées à l’incidence de la COVID-19 dans la circonscription sanitaire entourant celui-ci (rapport de cotes [RC] ajusté 1,91; intervalle de confiance [IC] à 95 % 1,19–3,05), au nombre de résidents dans l’établissement (RC ajusté 1,38; IC à 95 % 1,18–1,61) et à l’application des anciennes normes d’aménagement (RC ajusté 1,55; IC à 95 % 1,01–2,38), mais pas au statut financier d’un foyer. Comparativement au statut « à but non lucratif », le statut « à but lucratif » a été associé à l’ampleur d’une éclosion dans un foyer de SLD (risque relatif [RR] 1,96; IC à 95 % 1,26–3,05) ainsi qu’au nombre de décès de résidents (RR ajusté 1,78; IC à 95 % 1,03–3,07). Ces associations s’expliquent par une plus grande prévalence des anciennes normes d’aménagement dans les foyers de SLD à but lucratif ainsi qu’à l’appartenance à une chaîne de propriétés.

INTERPRÉTATION:

Le statut « à but lucratif » est associé à l’ampleur d’une éclosion de COVID-19 et au nombre de décès de résidents dans un foyer de SLD, mais pas au risque d’éclosion. Deux principaux facteurs expliquent les différences entre les foyers à but lucratif et non lucratif, soit l’application des anciennes normes d’aménagement et l’appartenance à une chaîne de propriétés. Ceux-ci devraient être au coeur des futures mesures et politiques de lutte contre les infections.

Racial Capitalism Within Public Health-How Occupational Settings Drive COVID-19 Disparities

Epidemiology of the US coronavirus disease 2019 (COVID-19) outbreak focuses on individuals’ biology and behaviors, despite centrality of occupational environments in the viral spread. This demonstrates collusion between epidemiology and racial capitalism because it obscures structural influences, absolving industries of responsibility for worker safety. In an empirical example, we analyzed economic implications of race-based metrics widely used in occupational epidemiology. In the United States, White adults have better average lung function and worse hearing than Black adults. Impaired lung function and impaired hearing are both criteria for workers’ compensation claims, which are ultimately paid by industry. Compensation for respiratory injury is determined using a race-specific algorithm. For hearing, there is no race adjustment. Selective use of race-specific algorithms for workers’ compensation reduces industries’ liability for worker health, illustrating racial capitalism operating within public health. Widespread and unexamined belief in inherent physiological inferiority of Black Americans perpetuates systems that limit industry payouts for workplace injuries. We see a parallel in the epidemiology of COVID-19 disparities. We tell stories of industries implicated in the outbreak and review how they exemplify racial capitalism. We call on public health professionals to critically evaluate who is served and neglected by data analysis and to center structural determinants of health in etiological evaluation.

Will For-Profits Keep Up the Pace in the United States? The Future of the Program of All-Inclusive Care for the Elderly and Implications for Other Programs Serving Medically Vulnerable Populations

The Program of All-Inclusive Care for the Elderly (PACE) has provided, for more than 4 decades, high-quality, cost-effective medical and social care to older people in the United States under nonprofit ownership. Recent rulings by the Centers for Medicare & Medicaid Services (CMS), however, will fundamentally change the initial intent and operation of the program. CMS's final rule (4168-F) removes the provision that PACE operators be nonprofit. This article provides the legislative background for the final ruling and critiques the study that was used to justify the removal of the nonprofit provision. Although the Balanced Budget Act of 1997 listed a number of requirements for evaluating for-profit PACE programs, the secretary of the Department of Health and Human Services did not follow them before establishing for-profit PACE sites as permanent providers. It also argues that the ruling was made without much evidence that for-profit compared to nonprofit operators can provide a similar level of quality of care, access, and cost-effectiveness and urges policymakers to increase regulatory accountability, given what we know about other shifts in profit status and health care.

Severe Staffing And Personal Protective Equipment Shortages Faced By Nursing Homes During The COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic continues to devastate US nursing homes. Adequate personal protective equipment (PPE) and staffing levels are critical to protect nursing home residents and staff. Despite the importance of these basic measures, few national data are available concerning the state of nursing homes with respect to these resources. This article presents results from a new national database containing data from 98 percent of US nursing homes. We find that more than one in five nursing homes reports a severe shortage of PPE and any shortage of staff. Rates of both staff and PPE shortages did not meaningfully improve from May to July 2020. Facilities with COVID-19 cases among residents and staff, as well as those serving more Medicaid recipients and those with lower quality scores, were more likely to report shortages. Policies aimed at providing resources to obtain additional direct care staff and PPE for these vulnerable nursing homes, particularly in areas with rising community COVID-19 case rates, are needed to reduce the national COVID-19 death toll.

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths

BACKGROUND

Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes.

METHODS

We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19.

RESULTS

The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7%) were for profit, 162 (26.0%) were nonprofit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.19-3.05), the number of residents (adjusted OR 1.38, 95% CI 1.18-1.61), and older design standards of the home (adjusted OR 1.55, 95% CI 1.01-2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95% CI 1.26-3.05) and the number of resident deaths (adjusted RR 1.78, 95% CI 1.03-3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership.

INTERPRETATION

For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.

Prioritizing LTSS Quality: Exploring the Views of Older Adults, Families, and Professionals

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.

Educating Nursing Home Staff in Dementia Sensitive Communication: Impact on Antipsychotic Medication Use

OBJECTIVES

An educational program to enhance communication in nursing home dementia care increased person-centered communication by staff and resulted in reduced resident behavioral symptoms measured as resistiveness to care. The purpose of this analysis was to evaluate effects on resident antipsychotic medication use in participating nursing homes. The National Partnership to Improve Dementia Care set a goal of reducing antipsychotic medications in nursing homes by 15% during the study period.

DESIGN

A post hoc analysis of Nursing Home Compare data was used to evaluate change in antipsychotic medication rates in nursing homes receiving the communication education versus the corresponding statewide average change.

SETTING AND PARTICIPANTS

Eleven nursing homes participated in a cluster-randomized controlled trial from 2011 to 2013 in one Midwestern state.

MEASURES

Antipsychotic medication rates were abstracted from Nursing Home Compare data sets. Antipsychotic medication rates were compared for each participating nursing home for the 2 quarters before and the 2 quarters after the communication intervention. To control for other factors supporting reduction in antipsychotic use, changes in the participating nursing homes were compared to the state average change for the corresponding quarters using a 1-sample t test.

RESULTS

Antipsychotic medication use decreased on average by 4.88 percentage points (22.9%) in participating nursing homes compared to the state average decrease of 0.68 percentage points (2.7%) during the same period (P = .06).

CONCLUSIONS

A clinically meaningful reduction in antipsychotic medication usage occurred in the nursing homes that received communication education. Measurable changes in communication and behavioral symptoms were reflected in reductions in antipsychotic medication usage. Improving staff communication has the potential to reduce inappropriate antipsychotic medication use in long-term care.

Shaping attitudes: The association between prior contact with residential aged care and resistance to enter residential aged care

BACKGROUND

The ageing population is increasing, and negative attitudes towards older people are all too common and largely overlooked. However, little research has examined how ageist, prejudice, and discrimination, that often occur in healthcare settings, impact the community's perceptions of entering Residential Aged Care (RAC) in the future. In particular, studies have not investigated how contact with RAC influences individuals' attitudes towards RAC facilities, residents and staff. This study is the first to examine individuals' resistance towards living in RAC using the contact hypothesis, a theory of prejudice reduction.

AIMS

To explore how positive or negative contact with RAC residents and staff impacts individuals' behavioural intentions towards entering RAC in the future. To examine whether perceptions of trust, independence and RAC staff mediate the relationship between contact and behavioural intentions towards entering RAC in the future.

DESIGN

A cross-sectional survey design.

METHOD

Data were collected via online surveys using contact (positive or negative), trust, independence, perceptions of RAC staff and resistance levels (mild refusal or extreme refusal) measures. Participants (n = 373) from Australia and USA were recruited using social media, word of mouth and Amazons Mechanical Turk.

FINDINGS

Individuals who experienced negative contact with RAC residents and staff were more likely to report intense resistance to RAC, "I would rather die than enter RAC". Whereas, positive contact with RAC residents and staff was associated with reductions in the adverse appraisal of RAC staff; a diminished perception that individuals lost their independence, and an increased trust in RAC residents, facilities and staff. Participants from USA reported greater levels of resistance towards RAC in comparison with participants from Australia. This study demonstrates how interactions with RAC residents, facilities and staff are critical in shaping attitudes towards RAC.

IMPLICATIONS FOR PRACTICE

It is recommended that the public are exposed to opportunities where they can experience positive contact with RAC. RAC facilities can promote interaction between the public and RAC residents through encouraging participation in community partnership programs/intergenerational programs.

The Effect of Residential Aged Care Size, Ownership Model, and Multichain Affiliation on Resident Comfort and Symptom Management at the End of Life

CONTEXT

In most resource-rich countries, a large and growing proportion of older adults with complex needs will die while in a residential aged care (RAC) facility.

OBJECTIVES

This study describes the impact of facility size (small/large), ownership model (profit/nonprofit) and provider (independent/chain) on resident comfort, and symptom management as reported by RAC staff.

METHODS

This retrospective "after-death" study collected decedent resident data from a subsample of 51 hospital-level RAC facilities in New Zealand. Symptom Management at the End-of-Life in Dementia and Comfort Assessment in Dying at End of life with Dementia (SM-EOLD and CAD-EOLD, respectively) scales were used by RAC staff who were closely associated with 217 deceased residents. Data collection occurred from January 2016 to February 2017.

RESULTS

Results indicated that residents of large, nonprofit facilities experienced greater comfort at the end of life (CAD-EOLD) as indicated by a higher mean score of 37.21 (SD = 4.85, 95% CI = 34.4, 40.0) than residents of small for-profit facilities who recorded a lower mean score of 31.56 (SD = 6.20, 95% CI = 29.6, 33.4). There was also evidence of better symptom management for residents of chain facilities, with a higher mean score for symptom management (SM-EOLD total score) recorded for residents of chain facilities (mean = 28.07, SD = 7.64, 95% CI = 26.47, 29.66) than the mean score for independent facilities (mean = 23.93, SD = 8.72, 95% CI = 21.65, 26.20).

CONCLUSION

Findings suggest that there are differences in the quality of end-of-life care given in RAC based on size, ownership model, and chain affiliation.

Public/private ownership and quality of care: Evidence from Danish nursing homes

The involvement of private for-profit (FP) and not-for-profit (NFP) providers in the otherwise public delivery of welfare services is gradually changing the Nordic welfare state towards a more market-oriented mode of service delivery. This article examines the relationship between ownership and quality of care in public and private FP and NFP nursing homes in Denmark. The analysis draws on original survey data and administrative registry data (quality inspection reports) for the full population of almost 1000 nursing homes in Denmark. Quality is measured in terms of structural quality, process quality and outcome quality. We find that public nursing homes have a higher structural quality (in terms of, for instance, staffing), while FP providers perform better in terms of process quality (e.g. in the form of individualised care). NFP providers perform well in terms of structural criteria such as employment of full-time staff and receive fewer critical comments in the inspection reports. However, the results depend to some extent upon the method of data collection, which underlines the benefits of using multiple data sources to examine the relationship between ownership and the quality of care.

SCOPEOUT: sustainability and spread of quality improvement activities in long-term care- a mixed methods approach

BACKGROUND

Interventions to improve quality of care for residents of long-term care facilities, and to examine the sustainability and spread of such initiatives, remain a top research priority. The purpose of this exploratory study was to assess the extent to which activities initiated in a quality improvement (QI) collaborative study using care aide led teams were sustained or spread following cessation of the initial project and to identify factors that led to its success.

METHODS

This study used an exploratory mixed methods study design and was conducted in seven residential long-term care facilities in two Canadian provinces. Sustainability and spread of QI activities were assessed by a questionnaire over five time points for 18 months following the collaborative study with staff from both intervention with non-intervention units. Semi-structured interviews were conducted with care managers at six and 12 months. QI team success in applying the QI model was ranked as high, medium, or low using criteria developed by the research team. Descriptive statistics, bivariate analyses, and General Estimating Equations were used to analyze the data. Interview data were analyzed using thematic analysis.

RESULTS

In total, 683 surveys were received over the five time periods from 476 unique individuals on a facility unit. Seven managers were interviewed. A total of 533 surveys were analyzed. While both intervention and non-intervention units experienced a decline over time in all outcome measures, this decline was significantly less pronounced on intervention units. Facilities with medium and high success ranking had significantly higher scores in all four outcomes than facilities with a low success ranking. Care aides reported significantly less involvement of others in QI activities, less empowerment and less satisfaction with the quality of their work life than regulated care providers. Manager interviews provided evidence of sustainability of QI activities on the intervention units in four of the seven facilities up to 18 months following the intervention and demonstrated the need for continued staff and leadership engagement.

CONCLUSION

Sustainability of a QI project which empowers and engages care aides is possible and achievable, but requires ongoing staff and leadership engagement.

Marketization in Long-Term Care: A Cross-Country Comparison of Large For-Profit Nursing Home Chains

This article presents cross-country comparisons of trends in for-profit nursing home chains in Canada, Norway, Sweden, United Kingdom, and the United States. Using public and private industry reports, the study describes ownership, corporate strategies, costs, and quality of the 5 largest for-profit chains in each country. The findings show that large for-profit nursing home chains are increasingly owned by private equity investors, have had many ownership changes over time, and have complex organizational structures. Large for-profit nursing home chains increasingly dominate the market and their strategies include the separation of property from operations, diversification, the expansion to many locations, and the use of tax havens. Generally, the chains have large revenues with high profit margins with some documented quality problems. The lack of adequate public information about the ownership, costs, and quality of services provided by nursing home chains is problematic in all the countries. The marketization of nursing home care poses new challenges to governments in collecting and reporting information to control costs as well as to ensure quality and public accountability.