Why Do(n't) they leave?: Motherhood and women's job mobility

Although the relationship between motherhood and women's labor market exits has received a great deal of popular and empirical attention in recent years, far less is known about the relationship between motherhood and women's job changes. In this paper, I use panel data from the National Longitudinal Survey of Youth (1979) (NLSY79) and Cox regression models to examine how motherhood influences the types of job changes and employment exits women make and how this varies by racial-ethnic group. I find preschool-age children are largely immobilizing for white women, as they discourage these women from making the types of voluntary job changes that are often associated with wage growth. No such effects were found for Black or Hispanic women.

Medicare and Medicaid Reimbursement Rates for Nursing Homes Motivate Select Culture Change Practices But Not Comprehensive Culture Change

Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and "culture change" NHs. We use mixed methods to examine the presence of culture change practices in the context of an NH's payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices, and quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices.

"Would You Do That in Your Home?" Making Nursing Homes Home-like in Culture Change Implementation

Qualitative interviews with nursing home administrators reveal innovative and cost-conscious ways to physically modify facilities that help institute culture change practices. Telephone interviews were conducted following a national survey of nursing home nursing directors and administrators. In this cross-sectional snapshot of administrator experiences, motivations for making facilities more home-like and less institutional and creative responses to challenges are described. State and corporate support and regulator encouragement are noted that help their reform efforts. Administrators note that small steps to create a more home-like environment can result in a positive impact that minimizes disruption to existing care processes. They describe how they respond to challenges, such as the physical plant and high costs, and note how comparative shopping, cost-conscious physical improvements, and continuous involvement of staff and residents contribute to successful efforts. Their examples illustrate novel ways to humanize long-term care facilities that other nursing homes can emulate.

Why and how do nursing homes implement culture change practices? Insights from qualitative interviews in a mixed methods study

To understand the process of instituting culture change (CC) practices in nursing homes (NHs). NH Directors of Nursing (DONs) and Administrators (NHAs) at 4,149 United States NHs were surveyed about CC practices. Follow-up interviews with 64 NHAs were conducted and analyzed by a multidisciplinary team which reconciled interpretations recorded in an audit trail.

RESULTS

The themes include: (a) Reasons for implementing CC practices vary; (b) NH approaches to implementing CC practices are diverse; (c) NHs consider resident mix in deciding to implement practices; (d) NHAs note benefits and few costs to implementing CC practices; (e) Implementation of changes is challenging and strategies for change are tailored to the challenges encountered; (f) Education and communication efforts are vital ways to institute change; and (g) NHA and other staff leadership is key to implementing changes. Diverse strategies and leadership skills appear to help NHs implement reform practices, including CC innovations.

Overcoming resistance to culture change: nursing home administrators' use of education, training, and communication

Nursing home culture change is becoming more prevalent, and research has demonstrated its benefits for nursing home residents and staff-but little is known about the role of nursing home administrators in culture change implementation. The purpose of this study was to determine what barriers nursing home administrators face in implementing culture change practices, and to identify the strategies used to overcome them. The authors conducted in-depth individual interviews with 64 administrators identified through a nationally representative survey. Results showed that a key barrier to culture change implementation reported by administrators was staff, resident, and family member resistance to change. Most nursing home administrators stressed the importance of using communication, education and training to overcome this resistance. Themes emerging around the concepts of communication and education indicate that these efforts should be ongoing, communication should be reciprocal, and that all stakeholders should be included.

Culture change practice in U.S. Nursing homes: prevalence and variation by state medicaid reimbursement policies

PURPOSE OF THE STUDY

To estimate the prevalence of culture change practice in U.S. nursing homes (NHs) and examine how state Medicaid policies may be associated with this prevalence.

DESIGN AND METHODS

In 2009/2010, we conducted a survey of a stratified proportionate random sample of NH directors of nursing (DONs) and administrators (NHAs) at 4,149 U.S. NHs; contact was achieved with 3,695. Cooperation rates were 62.6% for NHAs and 61.5% for DONs. Questions focused on NH (physical) environment, resident-centered care, and staff empowerment domains. Domain scores were created and validated, in part, using qualitative interviews from 64 NHAs. Other NH covariate data were from Medicare/Medicaid surveys (Online Survey, Certification and Reporting), aggregated resident assessments (Minimum Data Set), and Medicare claims. Medicaid policies studied were a state's average NH reimbursement rate and pay-for-performance (P4P) reimbursement (including and not including culture change performance measures). Multivariate generalized ordered logit regressions were used.

RESULTS

Eighty-five percent of DONs reported some culture change implementation. Controlling for NH attributes, a $10 higher Medicaid rate was associated with higher NH environment scores. Compared with NHs in non-P4P states, NHs in states with P4P including culture change performance measures had twice the likelihood of superior culture change scores across all domains, and NHs in other P4P states had superior physical environment and staff empowerment scores. Qualitative interviews supported the validity of survey results.

IMPLICATIONS

Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended.

Dying in U.S. nursing homes with advanced dementia: how does health care use differ for residents with, versus without, end-of-life Medicare skilled nursing facility care?

BACKGROUND

Because Medicare policy restricts simultaneous Medicare hospice and skilled nursing facility (SNF) care, we compared hospice use and sites of death for SNF/non-SNF residents with advanced dementia; and, for those with SNF, we evaluated how subsequent hospice use was associated with dying in a hospital.

METHODS

This study includes (non-health maintenance organization [HMO]) residents of U.S. nursing homes (NHs) who died in 2006 with advanced dementia (n=99,370). Sites of death, Medicare SNF, and hospice use were identified using linked resident assessment and Medicare enrollment and claims data. Advanced dementia was identified by a diagnosis of Alzheimer's disease or dementia on the Minimum Data Set (MDS) or a Medicare claim in the last year of life and severe to very severe cognitive impairment (5 or 6 on the MDS cognitive performance scale). For residents with SNF, we used multivariate logistic regression with generalized estimating equations to estimate the effect of subsequent hospice enrollment on dying in a hospital.

RESULTS

Forty percent of U.S. NH residents dying with advanced dementia in 2006 had SNF care in the last 90 days of life. Those with versus without SNF less frequently used hospice (30% versus 46%), more frequently had short (≤7 days) hospice stays (40% versus 19%), and more frequently died in hospitals (14% versus 9%). Among residents with SNF, those with subsequent hospice use had a 98% lower likelihood of a hospital death (95% confidence interval [CI]: 0.014, 0.025).

CONCLUSIONS

Dual hospice/SNF access may result in fewer hospital deaths and higher quality of life for dying NH residents.