1
|
Dys S, Carder P. Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living. J Appl Gerontol 2023; 42:2198-2206. [PMID: 37268438 DOI: 10.1177/07334648231181517] [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: 06/04/2023] Open
Abstract
Individual state approaches to assisted living/residential care (AL/RC) licensing and oversight in the United States result in different practice standards and requirements, including psychotropic medication use. We examined 170 psychotropic medication deficiency citations issued to 152 Oregon AL/RC settings from 2015 to 2019. Applied thematic analysis resulted in the following themes: (1) documentation issues are primarily responsible for noncompliance, (2) unclear parameters place direct care workers in a role paradox, and (3) there is a persistent disconnect about when to seek qualified expertise before requesting psychotropic medications. AL/RC-specific mechanisms for medication prescription and administration are necessary to improve the structure and processes of care. Policymakers might consider how regulations unintentionally incentivize task-oriented versus person-centered care practices.
Collapse
Affiliation(s)
- Sarah Dys
- Institute on Aging, College of Urban and Public Affairs, Portland State University, Portland, OR, USA
| | - Paula Carder
- Institute on Aging, College of Urban and Public Affairs, Portland State University, Portland, OR, USA
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| |
Collapse
|
2
|
Wang X(J, Teno JM, Rosendaal N, Smith L, Thomas KS, Dosa D, Gozalo PL, Carder P, Belanger E. State Regulations and Assisted Living Residents' Potentially Burdensome Transitions at the End of Life. J Palliat Med 2023; 26:757-767. [PMID: 36580545 PMCID: PMC10278021 DOI: 10.1089/jpm.2022.0360] [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] [Accepted: 11/04/2022] [Indexed: 12/31/2022] Open
Abstract
Background: Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end-of-life care reported by bereaved family members. We examined the association between state RC/AL regulations relevant to end-of-life care delivery and the likelihood of residents experiencing potentially burdensome transitions. Methods: Retrospective cohort study combining RC/AL registries of states' regulations with Medicare claims data for residents in large RC/ALs (i.e., 25+ beds) in the United States on the 120th day before death (N = 129,153), 2017-2019. Independent variables were state RC/AL regulations relevant to end-of-life care, including third-party services, staffing, and medication management. Analyses included: (1) separate logistic regression models for each RC/AL regulation, adjusting for sociodemographic covariates; (2) separate logistic regression models with a Medicare fee-for-service (FFS) subgroup to control for comorbidities, and (3) multivariable regression analysis, including all regulations in both the overall sample and the Medicare FFS subgroup. Results: We found a lack of associations between potentially burdensome transitions and regulations regarding third-party services and staffing. There were small associations found between regulations related to medication management (i.e., requiring regular medication reviews, permitting direct care workers for injections, requiring/not requiring licensed nursing staff for injections) and potentially burdensome transitions. Conclusions: In this cross-sectional study, the associations of RC/AL regulations with potentially burdensome transitions were either small or not statistically significant, calling for more studies to explain the wide variation observed in end-of-life outcomes among RC/AL residents.
Collapse
Affiliation(s)
- Xiao (Joyce) Wang
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Joan M. Teno
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Nicole Rosendaal
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Lindsey Smith
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kali S. Thomas
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - David Dosa
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Pedro L. Gozalo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Paula Carder
- Institute on Aging, Portland State University, Portland, Oregon, USA
- School of Public Health, Oregon Health and Science University - Portland State University, Portland, Oregon, USA
| | - Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
3
|
Temkin-Greener H, Mao Y, Ladwig S, Cai X, Zimmerman S, Li Y. Variability and Potential Determinants of Assisted Living State Regulatory Stringency. J Am Med Dir Assoc 2021; 22:1714-1719.e2. [PMID: 33246841 PMCID: PMC8116343 DOI: 10.1016/j.jamda.2020.10.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/02/2020] [Accepted: 10/04/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We examined state variations in assisted living (AL) regulatory policies for admission/retention, staffing/training, medication management, and dementia care. Factors associated with domain-specific and overall regulatory stringency were identified. DESIGN This observational study used the following data sources: 2019 review of state AL regulations; 2019 national inventory of AL communities; 2014 Government Accountability Office survey of Medicaid agencies; 2016 Genworth Cost of Care Survey; and the 2018 Nursing Home Compare. SETTING AND PARTICIPANTS Final analyses included 46 states (excluding Alaska, Kentucky, Louisiana, and West Virginia) and the District of Columbia. METHODS For each regulatory domain of interest (dependent variables), we generated policy scores by conducting content analysis of state regulatory databases. States were assigned points for presence of each policy (eg, staff training). The number of points assigned to each policy was divided by the total possible number of policy-related points, producing state stringency scores (between 0% and 100%) for each policy domain. Independent variables included market-level characteristics (eg, AL monthly cost), state generosity (eg, proportion of Medicaid aged using AL services), quality of care (eg, percent of nursing homes with few deficiencies), and others. Descriptive analyses and multivariable logistic regression models with stepwise selection were used. RESULTS We found significant variations in all policy domains across states. No single policy appeared to clearly dominate a state's rank. AL bed supply, monthly AL cost, proportion of Medicaid beneficiaries receiving AL services, and other variables were significantly associated with regulatory stringency of the domains examined. CONCLUSIONS AND IMPLICATIONS There were substantial variations in regulatory stringency across states. Several market and state generosity measures were identified as potential determinants of stringency, but the direction of these associations appeared to depend on what was being regulated. Future studies should examine how regulatory stringency affects access to and care quality in ALs.
Collapse
Affiliation(s)
- Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.
| | - Yunjiao Mao
- Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Susan Ladwig
- Department of Medicine, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Sheryl Zimmerman
- School of Social Work, University of North Carolina, Chapel Hill, NC, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| |
Collapse
|
4
|
Abstract
Assisted living (AL) is a well-established alternative to nursing homes, promoting autonomy and choice in a residential environment. This article examines the opportunities that AL affords for older adults and areas for further research to optimize the fit between resident needs and the AL environment. The model of person-environment fit provides an organizing framework for our commentary. The environment of AL emphasizes choice, independence, and privacy. The acuity of health care needs in AL residents has evolved since its inception. Unlike earlier residents, many today live with multiple chronic conditions and need for functional supports. Regulated by states, there is high variability in oversight, staffing, and resources available in AL. Families play an important role in supporting residents, yet expectations for their engagement may not be clear. Descriptive research abounds but there is a need for more sophisticated approaches to understanding how the AL environment can provide optimal supports for older adults, across all states and across income and racial/ethnic groups. There are several methodological challenges to AL research, including the high variability among AL settings and across states, the lack of common data elements, and difficulty accessing representative samples. With the popularity of AL as an option, it will be important to continue to examine how this environment can evolve to meet the changing needs of the resident population, while balancing the elements of autonomy and affordability. [Research in Gerontological Nursing, 14(1), 5-12.].
Collapse
|
5
|
Dys S, Smith L, Tunalilar O, Carder P. Revisiting the Role of Physicians in Assisted Living and Residential Care Settings. Gerontol Geriatr Med 2020; 6:2333721420979840. [PMID: 33354590 PMCID: PMC7734500 DOI: 10.1177/2333721420979840] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/22/2020] [Accepted: 11/09/2020] [Indexed: 11/16/2022] Open
Abstract
As the United States population ages, a higher share of adults is likely to use long-term services and supports. This change increases physicians' need for information about assisted living and residential care (AL/RC) settings, which provide supportive care and housing to older adults. Unlike skilled nursing facilities, states regulate AL/RC settings through varying licensure requirements enforced by state agencies, resulting in differences in the availability of medical and nursing services. Where some settings provide limited skilled nursing care, in others, residents rely on resident care coordinators, or their own physicians to oversee chronic conditions, medications, and treatments. The following narrative review describes key processes of care where physicians may interact with AL/RC operators, staff, and residents, including care planning, managing Alzheimer's disease and related conditions, medication management, and end-of-life planning. Communication and collaboration between physicians and AL/RC operators are a crucial component of care management.
Collapse
Affiliation(s)
- Sarah Dys
- Oregon Health & Science University-Portland State University, Portland, OR, USA
- Portland State University, Portland, OR, USA
| | - Lindsey Smith
- Oregon Health & Science University-Portland State University, Portland, OR, USA
- Portland State University, Portland, OR, USA
| | | | - Paula Carder
- Oregon Health & Science University-Portland State University, Portland, OR, USA
- Portland State University, Portland, OR, USA
| |
Collapse
|
6
|
Carder PC. State Regulatory Approaches for Dementia Care in Residential Care and Assisted Living. THE GERONTOLOGIST 2018; 57:776-786. [PMID: 28077453 DOI: 10.1093/geront/gnw197] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 11/22/2016] [Indexed: 11/12/2022] Open
Abstract
Purpose This policy study analyzed states' residential care and assisted living (RC/AL) regulations for dementia care requirements. Estimates suggest that at least half of RC/AL residents have dementia, and 22% of settings provide or specialize in dementia care. Residents with dementia might benefit from regulations that account for specific behaviors and needs associated with dementia, making states' RC/AL regulations address dementia care an important policy topic. Design and Methods This study examined RC/AL regulations in all 50 states and the District of Columbia for regulatory requirements on five topics important to the quality of life of RC/AL residents with dementia: pre-admission assessment, consumer disclosure, staffing types and levels, administrator training, and physical environment. Results Sixteen states license or certify dementia care units within RC/AL settings. All states had at least one dementia care requirement, though only four states had requirements for all five of the topics reviewed. Most states addressed administrator training, consumer disclosure, and physical environment, 17 addressed staffing types and levels, and 14 addressed pre-admission assessment for dementia. Thus, most states rely on general RC/AL regulations to cover dementia care policies and practices. Implications This policy study provides a resource for researchers who do cross-state studies of dementia care in RC/AL settings and state policymakers who are updating RC/AL regulations, including those responding to a 2014 Centers for Medicare and Medicaid Services rule change.
Collapse
Affiliation(s)
- Paula C Carder
- Oregon Health & Science University-Portland State University School of Public Health and Institute on Aging, Portland State University, Oregon
| |
Collapse
|
7
|
Kollerup MG, Curtis T, Schantz Laursen B. Visiting nurses’ posthospital medication management in home health care: an ethnographic study. Scand J Caring Sci 2017; 32:222-232. [DOI: 10.1111/scs.12451] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 01/22/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Mette Geil Kollerup
- Aalborg Municipality; Clinical Nursing Research Unit; Aalborg Universityhospital; Aalborg University; Aalborg Denmark
| | - Tine Curtis
- Aalborg Municipality; Aalborg University; University of Southern Denmark; Aalborg Denmark
| | - Birgitte Schantz Laursen
- Aalborg University; Department of Clinical Medicine; Clinical Nursing Research Unit; Aalborg Universityhospital; Aalborg Denmark
| |
Collapse
|
8
|
Carder PC, O'Keeffe J. State Regulation of Medication Administration by Unlicensed Assistive Personnel in Residential Care and Adult Day Services Settings. Res Gerontol Nurs 2016; 9:209-22. [PMID: 27054368 DOI: 10.3928/19404921-20160404-03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 02/15/2016] [Indexed: 11/20/2022]
Abstract
Residential care settings and adult day services are two community-based care options used by older adults with chronic health conditions. Most states have regulatory provisions that allow unlicensed assistive personnel (UAP) to administer medications. The current national policy study examined state regulations to identify which states permit UAP to administer medications, as well as staffing and training requirements. Key findings include states lack clear and adequate provisions for nurse oversight of UAP who administer medications, although adult day service regulations provide a greater level of nurse oversight than residential care settings. Specifically, 32 states require residential care to hire a nurse, but only six include provisions regarding nurse availability (e.g., on-call, on-site, number of hours). In contrast, 10 of 20 states that require adult day service programs to hire a nurse provide availability provisions. Nurse oversight of UAP is an important means of assuring quality care and reducing errors; thus, state regulatory agencies might need to strengthen nurse oversight provisions. [Res Gerontol Nurs. 2016; 9(5):209-222.].
Collapse
|
9
|
Sikma SK, Young HM, Reinhard SC, Munroe DJ, Cartwright J, McKenzie G. Medication Management Roles in Assisted Living. J Gerontol Nurs 2014; 40:42-53. [DOI: 10.3928/00989134-20140211-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 12/18/2013] [Indexed: 11/20/2022]
|