Variation in Licensed Nurse Staffing Characteristics by State Requirements in Residential Care

Assisted living or nursing home: Who is moving in?

BACKGROUND

Despite the rapid growth of assisted living (AL) communities and the increasing similarity between AL and nursing home (NH) populations, little is known about the characteristics of older adults at the time of AL admission and how these characteristics compare to individuals newly admitted to NH from the community. This study examined the individual, facility, and geographic factors associated with new AL admission.

METHODS

This retrospective descriptive study used data from the national Medicare enrollment and claims datasets, the Minimum Data Set, and the Medicare Provider Analysis and Review. The study cohort included 158,124 Medicare beneficiaries newly admitted to ALs and 715,261 newly admitted to NHs during 10/2017-10/2019. Multinomial logistic regression analysis and logistic regression analysis were conducted to examine factors associated with new admissions.

RESULTS

Demographic, socioeconomic, and health service use characteristics were associated with new admission to long-term care. Specifically, Medicare fee-for-service beneficiaries, those age 75 years and older, male, having one skilled nursing facility (SNF) stay or any hospital stay in the past 6 months are more likely to be newly admitted to AL, whereas those who are dually eligible, racial/ethnic minorities, and having two or more SNF stays in the past 6 months are more likely to be admitted to an NH.

CONCLUSION

There are substantial differences between individuals who are newly admitted from the community to AL versus those to NH.

Implementation and Acceptance of Information and Communication Technology Incorporated into Long-Term Care

Every country in the world is facing serious demographic aging, since the average life expectancy is consistently increasing. Agencies involved in the implementation of caregiving through long-term care institutions can develop more convenient approaches using information and communication technology to enhance overall efficiency. Communication technology has enabled the strengthening of physiological instruments, improving the efficiency and quality of services, while integrating management systems for optimum efficiency. This work conducted empirical studies, collecting responses to questionnaires from residents and caregivers in five institutions located in the south of Taiwan. The PZB model, proposed by Parasuraman, Zeithaml, and Berry, was used to construct the questionnaire to analyze the service quality following the incorporation of information and communication technology. The results of the empirical study show that 34% and 63% of the relatives of the residents agreed and strongly agreed that the system was practical and convenient, respectively. As for the caregivers, 77% of them agreed or strongly agreed that the system was mobile, practical, and convenient, and they agreed that the system could significantly increase working efficiency, reduce waiting time, and improve administration for chronic diseases among care-home residents.

The Relationship Between States' Staffing Regulations And Hospitalizations Of Assisted Living Residents

Assisted living provides housing and long-term care services to more than 811,000 older adults in the United States daily and is regulated by the states. This article describes changes in the specificity of state regulations governing the staffing in assisted living settings (that is, requirements for sufficient staffing or staffing ratios or levels) between 2007 and 2018 and the association between these changes and rates of hospitalization among a national sample of assisted living residents, including a subgroup with dementia. We found that increased regulatory specificity for direct care workers (for example, a change from requiring "sufficient" direct care worker staffing to requiring a specific staffing ratio or level) was associated with a 4 percent reduction in the monthly risk for hospitalization among residents in our sample and a 6 percent reduction among the subgroup with dementia. However, an increase in regulatory specificity for licensed practical nurses was associated with a 2.5 percent increase in the monthly risk for hospitalization and a 5 percent increase among the subgroup with dementia. Given that no federal requirements exist for the number of staff members or composition of staff in assisted living, these findings can inform states' policy decisions about staffing requirements for assisted living settings.

Coronavirus Disease 2019 Regulatory Response in United States-Assisted Living Communities: Lessons Learned

Coronavirus disease 2019 (COVID-19) has disproportionately affected residents, their families, staff, and operators of congregate care settings. Assisted living (AL) is a type of long-term care setting for older adults who need supportive care but not ongoing nursing care and emphasizes a social model of care provision. Because AL is a type of long-term care, it has at times been referenced along with nursing homes in discussions related to COVID-19 but not recognized for its different care practices that pose unique challenges related to COVID-19; in that manner, it has largely been left out of the COVID-19 discourse, although ~812,000 older adults live in AL. To identify COVID-19 issues specific to AL, stakeholders with expertise in AL operations, policy, practice, and research (n = 42) were recruited to participate in remote interviews between July and September 2020. Using a thematic analysis, we derived the following overarching themes: (1) Policymakers are disconnected from and lack an understanding of the AL context; (2) AL administrators were left to coordinate, communicate, and implement constantly changing guidelines with little support; (3) AL organizations faced limited knowledge of and disparate access to funding and resources; (4) state-level regulatory requirements conflicted with COVID-19 guidelines resulting in uncertainty about which rules to follow; and (5) AL operators struggled to balance public health priorities with promoting their residents' quality of life and well-being. To develop evidence-informed policy and avoid unintended consequences, AL operators, direct care workers, residents, and clinicians practicing in these settings should have opportunities to provide feedback throughout the policy development process, both state and national.

Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care

BACKGROUND/OBJECTIVES

Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services.

DESIGN

Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File.

SETTING

AL facilities and Medicare HH agencies in the United States.

PARTICIPANTS

741,926 Medicare HH admissions of AL residents in 2017.

MEASUREMENTS

Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission.

RESULTS

Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)).

CONCLUSION

For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.

Cognition-Enhancing, Antipsychotic, and Opioid Medication Use Among Assisted Living and Residential Care Residents in Oregon

OBJECTIVES

Explore community- and resident-level characteristics associated with polypharmacy and use of cognition-enhancing, antipsychotic, and opioid medications among a statewide representative sample of assisted living and residential care (AL/RC) residents.

DESIGN

Cross-sectional, descriptive.

SETTING AND PARTICIPANTS

A total of 1135 AL/RC residents living in 387 licensed communities in Oregon were recruited. One-third of residents lived in communities certified to provide memory care to residents with dementia.

METHODS

All licensed AL/RC communities received a mail survey with questions about 3 randomly selected residents' demographic, health service use, health conditions, medication use, and payment information. We estimated bivariate and multiple logistic regression models, resulting in unadjusted and adjusted odds ratios of resident- and community-level characteristics associated with each medication use indicator.

RESULTS

One in 5 residents took a cognition-enhancing medication (20%) in the prior 7 days. Just more than one-fifth (22%) and one-quarter (25%) of residents took opioid or antipsychotic medications, on a scheduled or as-needed basis in the prior 7 days, respectively. Residents with Alzheimer's disease or related dementia (ADRD) living in rural communities were half as likely to take cognitive-enhancing medications compared with their urban counterparts. When controlling for all resident and community covariates, residents with ADRD were almost 3 times as likely to receive an antipsychotic and half as likely to receive an opioid compared to residents without an ADRD diagnosis.

CONCLUSIONS AND IMPLICATIONS

Understanding variation in the use of medications associated with behavioral expressions of ADRD in AL/RC residents is a crucial clinical and policy area.

Revisiting the Role of Physicians in Assisted Living and Residential Care Settings

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.