Refining a case-mix measure for nursing homes: Resource Utilization Groups (RUG-III)

Case-Mix Classification for Mental Health Care in Community Settings: A Scoping Review

As mental health care transitions from facility-based care to community-based services, methods to classify patients in terms of their expected health care resource use are an essential tool to balance the health care needs and equitable allocation of health care resources. This study performed a scoping review to summarize the nature, extent, and range of research on case-mix classifications used to predict mental health care resource use in community settings. This study identified 17 eligible studies with 32 case-mix classification systems published since the 1980s. Most of these studies came from the USA Veterans Affairs and Medicare systems, and the most recent studies came from Australia. There were a wide variety of choices of input variables and measures of resource use. However, much of the variance in observed resource use was not accounted for by these case-mix systems. The research activity specific to case-mix classification for community mental health care was modest. More consideration should be given to the appropriateness of the input variables, resource use measure, and evaluation of predictive performance. Future research should take advantage of testing case-mix systems developed in other settings for community mental health care settings, if possible.

A Case-Mix System for Adults with Developmental Disabilities

Effective management of publicly funded services matches the provision of needed services with cost-efficient payment methods. Payment systems that recognize differences in care needs (eg, case-mix systems) allow for greater proportions of available funds to be directed to providers supporting individuals with more needs. We describe a new way to allocate funds spent on adults with intellectual disabilities (ID) as part of a system-wide Medicaid payment reform initiative in Arkansas. Analyses were based on population-level data for persons living at home, collected using the interRAI ID assessment system, which were linked to paid service claims. We used automatic interactions detection to sort individuals into unique groups and provide a standardized relative measure of the cost of the services provided to each group. The final case-mix system has 33 distinct final groups and explains 26% of the variance in costs, which is similar to other systems in health and social services sectors. The results indicate that this system could be the foundation for a future case-mix approach to reimbursement and stand the test of “fairness” when examined by stakeholders, including parents, advocates, providers, and political entities.

Indigenous compared with non-Indigenous Australian patients at entry to specialist palliative care: Cross-sectional findings from a multi-jurisdictional dataset

BACKGROUND

There are few quantitative studies on palliative care provision to Indigenous Australians, a population known to experience distinctive barriers to quality healthcare and to have poorer health outcomes than other Australians.

OBJECTIVES

To investigate equity of specialist palliative care service provision through characterising and comparing Indigenous and non-Indigenous patients at entry to care.

METHODS

Using data (01/01/2010-30/06/2015) from all services participating in the multi-jurisdictional Palliative Care Outcomes Collaboration, Indigenous and non-Indigenous patients entering palliative care were compared on proportions vis-à-vis those expected from national statutory datasets, demographic characteristics, and entry-to-care status across fourteen 'problem' domains (e.g., pain, functional impairment) after matching by age, sex, and specific diagnosis.

RESULTS

Of 140,267 patients, 1,465 (1.0%, much lower than expected from statutory data) were Indigenous, 133,987 (95.5%) non-Indigenous, and 4,905 (3.5%) had a missing identifier. The proportion of patients with a missing identifier diminished markedly over the study period, without a corresponding increase in the proportion identified as Indigenous. Indigenous compared with non-Indigenous patients were younger (mean 62.8 versus 73.0 years, p<0.001), a higher proportion were female (51.5% versus 46.3%; p<0.001) or resided outside major cities (44.2% versus 21.5%, p<0.001). Across all domains, Indigenous compared with matched non-Indigenous patients had lower or equal risk of status requiring prompt intervention.

CONCLUSIONS

Indigenous patients (especially those residing outside major cities) are substantially under-represented in care by services participating in the nationwide specialist palliative care Collaboration, likely reflecting widespread access barriers. However, the similarity of status indicators among Indigenous and non-Indigenous patients at entry to care suggests that Indigenous patients who are able to access these services do not disproportionately experience clinically important impediments to care initiation.

Do-Not-Resuscitate and Do-Not-Hospitalize Orders in Nursing Homes: Who Gets Them and Do They Make a Difference?

OBJECTIVES

To describe the rate of do-not-resuscitate (DNR) and do-not-hospitalize (DNH) orders among residents newly admitted into long-term care homes. We also assessed the association between DNR and DNH orders with hospital admissions, deaths in hospital, and survival.

DESIGN

A retrospective cohort study.

SETTING AND PARTICIPANTS

Admissions in all 640 publicly funded long-term care homes in Ontario, Canada, between January 1, 2010 and March 1, 2012 (n = 49,390).

MEASURES

We examined if a DNR and/or DNH was recorded on resident's admission assessment. All residents were followed until death, discharge, or end of study to ascertain rates of several outcomes, including death and hospitalization, controlling for resident characteristics.

RESULTS

Upon admission, 60.7% of residents were recorded to have a DNR and 14.8% a DNH order. Those who were older, female, widowed, lived in rural facilities, lived in higher income neighborhoods prior to entry, had higher health instability or cognitive impairment, and spoke English or French were more likely to receive a DNR or DNH. Survival time was only slightly shorter for those with a DNR and DNH with a mean of 145 and 133 days, respectively, vs 160 and 153 days for those without a DNR and DNH. After controlling for age, sex, rurality, neighborhood income, marital status, health instability, cognitive performance score, and multimorbidity, DNR and DNH were associated with an odds ratio of 0.57 [95% confidence interval (CI) 0.53-0.62] and 0.41 (95% CI 0.37-0.46) for dying in hospital, respectively. Those with a DNR and DNH, after adjustment, had an incidence rate ratio of 0.87 (95% CI 0.83-0.90) and 0.70 (95% CI 0.67-0.73), respectively, days spent in hospital.

CONCLUSIONS AND IMPLICATIONS

This study outlines identifiable factors influencing whether residents have a DNR and/or DNH order upon admission. Both orders led to lower rates, but not absolute avoidance, of hospitalizations near and at death.

Resource Intensity for Children and Youth: The Development of an Algorithm to Identify High Service Users in Children's Mental Health

Children’s mental health care plays a vital role in many social, health care, and education systems, but there is evidence that appropriate targeting strategies are needed to allocate limited mental health care resources effectively. The aim of this study was to develop and validate a methodology for identifying children who require access to more intense facility-based or community resources. Ontario data based on the interRAI Child and Youth Mental Health instruments were analysed to identify predictors of service complexity in children’s mental health. The Resource Intensity for Children and Youth (RIChY) algorithm was a good predictor of service complexity in the derivation sample. The algorithm was validated with additional data from 61 agencies. The RIChY algorithm provides a psychometrically sound decision-support tool that may be used to inform the choices related to allocation of children’s mental health resources and prioritisation of clients needing community- and facility-based resources.

An Overview of International Staff Time Measurement Validation Studies of the RUG-III Case-mix System

The RUG-III case-mix system is a method of grouping patients in long-term and post-acute care settings. RUG-III groups patients by relative per diem resource consumption and may be used as the basis for prospective payment systems to ensure that facility reimbursement is commensurate with patient acuity. Since RUG-III's development in 1994, more than a dozen international staff time measurement studies have been published to evaluate the utility of the case-mix system in a variety of diverse health care environments around the world. This overview of the literature summarizes the results of these RUG-III validation studies and compares the performance of the algorithm across countries, patient populations, and health care environments. Limitations of the RUG-III validation literature are discussed for the benefit of health system administrators who are considering implementing RUG-III and next-generation resource utilization group case-mix systems.

Multicomponent non-pharmacological intervention to prevent delirium for hospitalised people with advanced cancer: study protocol for a phase II cluster randomised controlled trial

INTRODUCTION

Delirium is a significant medical complication for hospitalised patients. Up to one-third of delirium episodes are preventable in older inpatients through non-pharmacological strategies that support essential human needs, such as physical and cognitive activity, sleep, hydration, vision and hearing. We hypothesised that a multicomponent intervention similarly may decrease delirium incidence, and/or its duration and severity, in inpatients with advanced cancer. Prior to a phase III trial, we aimed to determine if a multicomponent non-pharmacological delirium prevention intervention is feasible and acceptable for this specific inpatient group.

METHODS AND ANALYSIS

The study is a phase II cluster randomised wait-listed controlled trial involving inpatients with advanced cancer at four Australian palliative care inpatient units. Intervention sites will introduce delirium screening, diagnostic assessment and a multicomponent delirium prevention intervention with six domains of care: preserving natural sleep; maintaining optimal vision and hearing; optimising hydration; promoting communication, orientation and cognition; optimising mobility; and promoting family partnership. Interdisciplinary teams will tailor intervention delivery to each site and to patient need. Control sites will first introduce only delirium screening and diagnosis, later implementing the intervention, modified according to initial results. The primary outcome is adherence to the intervention during the first seven days of admission, measured for 40 consecutively admitted eligible patients. Secondary outcomes relate to fidelity and feasibility, acceptability and sustainability of the study intervention, processes and measures in this patient population, using quantitative and qualitative measures. Delirium incidence and severity will be measured to inform power calculations for a future phase III trial.

ETHICS AND DISSEMINATION

Ethical approval was obtained for all four sites. Trial results, qualitative substudy findings and implementation of the intervention will be submitted for publication in peer-reviewed journals, and reported at conferences, to study sites and key peak bodies.

TRIAL REGISTRATION NUMBER

ACTRN12617001070325; Pre-results.

Potential quality indicators for seriously ill home care clients: a cross-sectional analysis using Resident Assessment Instrument for Home Care (RAI-HC) data for Ontario

Background

Currently, there are no formalized measures for the quality of home based palliative care in Ontario. This study developed a set of potential quality indicators for seriously ill home care clients using a standardized assessment.

Methods

Secondary analysis of Resident Assessment Instrument for Home Care data for Ontario completed between 2006 and 2013 was used to develop quality indicators (QIs) thought to be relevant to the needs of older (65+) seriously ill clients. QIs were developed through a review of the literature and consultation with subject matter experts in palliative care. Serious illness was defined as a prognosis of less than 6 months to live or the presence of severe health instability. The rates of the QIs were stratified across Ontario’s geographic regions, and across four common life-limiting illnesses to observe variation.

Results

Within the sample, 14,312 clients were considered to be seriously ill and were more likely to experience negative health outcomes such as cognitive performance (OR = 2.77; 95% CI: 2.66–2.89) and pain (OR = 1.59; 95% CI: 1.53–1.64). Twenty subject matter experts were consulted and a list of seven QIs was developed. Indicators with the highest overall rates were prevalence of falls (50%) prevalence of daily pain (47%), and prevalence of caregiver distress (42%). The range in QI rates was largest across regions for prevalence of caregiver distress (21.5%), the prevalence of falls (16.6%), and the prevalence of social isolation (13.7%). Those with some form of dementia were most likely to have a caregiver that was distressed (52.6%) or to experience a fall (53.3%).

Conclusion

Home care clients in Ontario who are seriously ill are experiencing high rates of negative health outcomes, many of which are amenable to change. The RAI-HC can be a useful tool in identifying these clients in order to better understand their needs and abilities. These results contribute significantly to the process of creating and validating a standardized set of QIs that can be generated by organizations using the RAI-HC as part of normal clinical practice.

Which client characteristics predict home-care needs? Results of a survey study among Dutch home-care nurses

Fee-for-service, funding care on an hourly rate basis, creates an incentive for home-care providers to deliver high amounts of care. Under casemix funding, in contrast, clients are allocated-based on their characteristics-to homogenous, hierarchical groups, which are subsequently funded to promote more effective and efficient care. The first step in developing a casemix model is to understand which client characteristics are potential predictors of home-care needs. Nurses working in home care (i.e. home-care nurses) have a good insight into clients' home-care needs. This study was conducted in co-operation with the Dutch Nurses' Association and the Dutch Healthcare Authority. Based on international literature, 35 client characteristics were identified as potential predictors of home-care needs. In an online survey (May, 2017), Dutch home-care nurses were asked to score these characteristics on relevance, using a 9-point Likert scale. They were subsequently asked to identify the top five client characteristics. Data were analysed using descriptive statistics. The survey was completed by 1,007 home-care nurses. Consensus on relevance was achieved for 15 client characteristics, with "terminal phase" being scored most relevant, and "sex" being scored as the least relevant. Relevance of the remaining 20 characteristics was uncertain. Additionally, based on the ranking, "ADL functioning" was ranked as most relevant. According to home-care nurses, both biomedical and psychosocial client characteristics need to be taken into account when predicting home-care needs. Collaboration between clinical practice, policy development, and science is necessary to realise a funding model, to work towards the Triple Aim (improved health, better care experience, and lower costs).

Delay in commencement of palliative care service episodes provided to Indigenous and non-Indigenous patients: cross-sectional analysis of an Australian multi-jurisdictional dataset

BACKGROUND

Rapid effective responsiveness to patient needs is pivotal to high quality palliative care. Aboriginal and Torres Strait Islander (Indigenous) people are susceptible to life-limiting illnesses at younger ages than other Australians and experience inequity of health service provision. The Palliative Care Outcomes Collaboration collects Australia-wide health service data on patient care, and has established performance benchmarks for specialist palliative care services. We investigated whether the benchmark for timely commencement of palliative care episodes (occurrence of delay >1 day after being designated 'ready for care' in <10% instances) is being met for Indigenous Australians in participating services. Additionally, we investigated the association between identification as Indigenous and delay.

METHODS

Using multi-jurisdictional Palliative Care Outcomes Collaboration data, this cross-sectional analytical study investigated all episodes of care (n = 84,238) provided to patients ≥18 years (n = 61,073: Indigenous n = 645) in hospital and community settings commenced and completed during the period 01/07/2013-30/06/2015. Proportions of episodes resulting in delay were determined. Crude and adjusted odds of delay among Indigenous compared with non-Indigenous patients were investigated using multiple logistic regression, with missing data handled by multiple imputation.

RESULTS

The benchmark was met for both Indigenous and non-Indigenous patients (delay in 8.3 and 8.4% episodes respectively). However, the likelihood of delay was modestly higher in episodes provided to Indigenous than non-Indigenous patients (adjusted odds ratio [aOR], 1.41; 95% confidence interval [CI] 1.07-1.86). Excess delay among Indigenous patients was accentuated in first episodes (aOR, 1.53; 95% CI 1.14-2.06), in patients aged < 65 years (aOR, 1.66; 95% CI 1.14-2.41), and among those residing in Inner Regional areas (aOR, 1.97; 95% CI 1.19-3.28), and also approached significance among those in outer regional, remote and very remote areas collectively (aOR, 1.72; CI 0.97-3.05).

CONCLUSIONS

Although the timeliness benchmark is being met for Indigenous Australians in palliative care, they may experience delayed initiation of care episodes, particularly if younger, and especially at first encounter with a service. Qualitative research is required to explore determinants of delay in initiating palliative care episodes. The timeliness of initial referral for specialist palliative care in this population remains to be determined.

Factors Associated with Medical Cost among Patients with Terminal Cancer in Hospice Units

This study identified factors associated with higher medical costs for patients with terminal cancer in hospice units in order to develop a daily payment system for hospice services within Korea's National Health Insurance (NHI) program. Through chart reviews conducted by staff nurses, medical information and costs were obtained for 274 patients with terminal cancer in 20 hospice units in October 2007. The daily medical cost per patient was calculated based on the fee-for-service scheme. The characteristics of the hospice units were examined by means of a semi-structured questionnaire administered to hospice unit coordinators. Higher daily costs were associated with general hospital-based hospice units (as compared with free-standing units: p<0.01), low Palliative Performance Scale scores (PPS<50, p<0.05), and the presence of fever (p<0.01). In multivariate analysis, hospice unit type was found to be the factor most strongly associated with medical cost. A hospice payment system based on patient characteristics should be thoroughly considered.

The associations between staffing hours and quality of care indicators in long-term care

BACKGROUND

Long-term care (LTC) staffing practices are poorly understood as is their influence on quality of care. We examined the relationship between staffing characteristics and residents' quality of care indicators at the unit level in LTC homes.

METHODS

This cross-sectional study collected data from administrative records and resident assessments from July 2014 to June 2015 at 11 LTC homes in Ontario, Canada comprising of 55 units and 32 residents in each unit. The sample included 69 registered nurses, 183 licensed/registered practical nurses, 858 nursing assistants, and 2173 residents. Practice sensitive, risk-adjusted quality indicators were described individually, then combined to create a quality of care composite ranking per unit. A multilevel regression model was used to estimate the association between staffing characteristics and quality of care composite ranking scores.

RESULTS

Nursing assistants provided the majority of direct care hours in LTC homes (76.5%). The delivery of nursing assistant care hours per resident per day was significantly associated with higher quality of resident care (p = < 0.01). There were small but significant associations with quality of care for nursing assistants with seven or more years of experience (p = 0.02), nursing assistants late to shift (p = < 0.01) and licensed/registered practical nurses late to shift (p = 0.02).

CONCLUSIONS

The number of care hours per resident per day delivered by NAs is an important contributor to residents' quality of care in LTC homes. These findings can inform hiring and retention strategies for NAs in LTC, as well as examine opportunities to optimize the NA role in these settings.

Psychometric Properties of the Needs Assessment Tool-Progressive Disease Cancer in U.K. Primary Care

BACKGROUND

The assessment of patients' needs for care is a critical step in achieving patient-centered cancer care. Tools can be used to assess needs and inform care planning. The Needs Assessment Tool:Progressive Disease-Cancer (NAT:PD-C) is an Australian oncology clinic tool for assessment by clinicians of patients' and carers' palliative care needs. This has not been validated in the U.K. primary care setting.

AIM

The aim of this study was to test the psychometric properties and acceptability of a U.K. primary care adapted NAT:PD-C.

DESIGN

Reliability: NAT:PD-C-guided video-recorded consultations were viewed, rated, and rerated by clinicians. Weighted Fleiss' kappa and prevalence- and bias-adjusted kappa statistics were used. Construct: During a consultation, general medical practitioners (GPs) used NAT:PD-C, patient measures (Edmonton Symptom Assessment Scale; Research Utilisation Group Activities of Daily Living; Palliative care Outcome Score; Australian Karnofsky Performance Scale), and carer measures (Carer Strain Index; Carer Support Needs Assessment Tool). Kendall's Tau-b was used.

SETTING/PARTICIPANTS

GPs, nurses, patients, and carers were recruited from primary care practices.

RESULTS

Reliability: All patients' well-being items and four of five items in the carer/family ability to care section showed adequate interrater reliability. There was moderate test-retest reliability for five of six in the patients' well-being section and five of five in the carer/family ability to care section. Construct: There was at least fair agreement for five of six of patients' well-being items; high for daily living (Kendall's Tau-b = 0.57, P < 0.001). The NAT:PD-C has adequate carer construct validity (five of eight) with strong agreement for two of eight patients. Over three-quarters of GPs considered the NAT:PD-C to have high acceptability.

CONCLUSION

The NAT PD-C is reliable, valid, and acceptable in the UK primary care setting. Effectiveness in reducing patient and carer unmet needs and issues regarding implementation are yet to be evaluated.

The Pediatric Personal Care Allocation Model for Home Care (PCAM): A Personal Care Case-Mix Model for Children Facing Special Health Care Challenges

Background:

State Medicaid programs in the United States provide services to children with special health care challenges through the Early Prevention, Screening, Diagnostic, and Treatment program. One element of the services provided is Medicaid Personal Care Services (PCS), which are intended to correct or ameliorate any functional impairments faced by a child or youth (C/Y) in the community. Previous research indicates that considerable variation in the allocation of PCS depends on the assessor. A case-mix model is developed that might make the distribution of such services more uniform and equitable.

Data:

The sample in this research includes 2708 C/Y aged 4 to 20 who were receiving PCS in Texas in 2008.

Results:

A case-mix model was developed that groups sample members into 33 categories based on the number of hours of PCS authorized by an assessor. The Pediatric Personal Care Allocation Model (PCAM) explains 27% of the variance in the allocation of PCS hours.

Discussion:

The implementation of the PCAM should provide guidance to assist in ensuring that C/Y facing similar functional challenges receive similar levels of PCS. However, implementation of any case-mix model is only a first step in moving to a prospective payment system for PCS.

Quality Changes after Implementation of an Episode of Care Model with Strict Criteria for Physical Therapy in Ontario's Long-Term Care Homes

OBJECTIVES

To describe the proportion of residents receiving rehabilitation in long-term care (LTC) homes, and scores on activities of daily living (ADL) and falls quality indicators (QIs) before and after change from fee-for-service to an episode of care model; and to evaluate the effect of the change on the QIs.

DATA SOURCES

Secondary data were collected from all LTC homes in Ontario, Canada, between January 1, 2011 and March 31, 2015. Variables of interest were the proportion of residents per home receiving physical therapy (PT), and the scores on seven ADL and one falls QI.

STUDY DESIGN

Retrospective, longitudinal study.

DATA EXTRACTION

All data were extracted from the Resident Assessment Instrument Minimum Data Set.

PRINCIPAL FINDINGS

Fewer residents received PT after the policy change (84.6 percent, 2011; 56.6 percent, 2015). The policy change was associated with improved performance on several ADL QIs. However, having a large proportion of residents receive no PT or little PT was associated with poorer performance on two of the QIs measuring improvement in ADLs [No PT: -0.029 (-0.043 to -0.014); -0.048 (-0.068 to -0.027). PT <45 minutes per week: -0.012 (-0.026 to -0.002); -0.026 (-0.045 to -0.007); p < .01].

CONCLUSIONS

While controversial, the policy and subsequent PT service delivery change appears to be associated with improved performance on several ADL QIs, except in homes where a large proportion of residents receive no PT and low time-intensive PT.

Racial and Ethnic Differences in the Prevalence of Depressive Symptoms Among U.S. Nursing Home Residents

This study aimed to examine racial and ethnic differences in significant depressive symptoms among long-term nursing home residents. We analyzed the 2014 national Minimum Data Set linked to a nursing home file and estimated multivariable logistic regressions to determine the associations of race and ethnicities with significant depressive symptoms (score ≥ 10 on the 9-item Patient Health Questionnaire [PHQ-9] scale) and whether associations were explained by resident and nursing home covariates. Stratified analyses further determined independent associations in subgroups of residents. We found that the prevalence rate of PHQ-9 scores ≥ 10 was 8.8% among non-Hispanic White residents (n = 653,031) and 7.4%, 6.9%, and 6.6% among Black (n = 97,629), Hispanic (n = 39,752), and Asian (n = 16,636) residents, respectively. The reduced likelihoods of significant depressive symptoms for minority residents compared to non-Hispanic Whites persisted after sequential adjustments for resident and nursing home covariates, as well as in stratified analyses. The persistently lower rate of significant depressive symptoms among racial and ethnic minority residents suggests that training of nursing home caregivers for culturally sensitive depression screening is needed for improved symptom recognition among minority residents.

The Relationship between Costs and Quality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data

OBJECTIVE

To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data.

DATA SOURCES/STUDY SETTING

One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool.

STUDY DESIGN

We used a generalized estimating equation model with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days.

PRINCIPAL FINDINGS

With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs.

CONCLUSIONS

The relationship between cost and quality depends on facility size and current level of performance.

The Impact of Dementia Special Care Units on Quality of Care: An Instrumental Variables Analysis

OBJECTIVE

To compare the quality of care following admission to a nursing home (NH) with and without a dementia special care unit (SCU) for residents with dementia.

DATA SOURCES/STUDY SETTING

National resident-level minimum dataset assessments (MDS) 2005-2010 merged with Medicare claims and provider-level data from the Online Survey, Certification, and Reporting database.

STUDY DESIGN

We employ an instrumental variable approach to address the endogeneity of selection into an SCU facility controlling for a range of individual-level covariates. We use "differential distance" to a nursing home with and without an SCU as our instrument.

DATA COLLECTION/EXTRACTION METHODS

Minimum dataset assessments performed at NH admission and every quarter thereafter.

PRINCIPAL FINDINGS

Admission to a facility with an SCU led to a reduction in inappropriate antipsychotics (-9.7 percent), physical restraints (-9.6 percent), pressure ulcers (-3.3 percent), feeding tubes (-8.3 percent), and hospitalizations (-14.7 percent). We found no impact on the use of indwelling urinary catheters. Results held in sensitivity analyses that accounted for the share of SCU beds and the facilities' overall quality.

CONCLUSIONS

Facilities with an SCU provide better quality of care as measured by several validated quality indicators. Given the aging population, policies to promote the expansion and use of dementia SCUs may be warranted.

Developing and utilising a new funding model for home-care services in New Zealand

Worldwide increases in the numbers of older people alongside an accompanying international policy incentive to support ageing-in-place have focussed the importance of home-care services as an alternative to institutionalisation. Despite this, funding models that facilitate a responsive, flexible approach are lacking. Casemix provides one solution, but the transition from the well-established hospital system to community has been problematic. This research seeks to develop a Casemix funding solution for home-care services through meaningful client profile groups and supporting pathways. Unique assessments from 3,135 older people were collected from two health board regions in 2012. Of these, 1,009 arose from older people with non-complex needs using the interRAI-Contact Assessment (CA) and 2,126 from the interRAI-Home-Care (HC) from older people with complex needs. Home-care service hours were collected for 3 months following each assessment and the mean weekly hours were calculated. Data were analysed using a decision tree analysis, whereby mean hours of weekly home-care was the dependent variable with responses from the assessment tools, the independent variables. A total of three main groups were developed from the interRAI-CA, each one further classified into "stable" or "flexible." The classification explained 16% of formal home-care service hour variability. Analysis of the interRAI-HC generated 33 clusters, organised through eight disability "sub" groups and five "lead" groups. The groupings explained 24% of formal home-care services hour variance. Adopting a Casemix system within home-care services can facilitate a more appropriate response to the changing needs of older people.

Implementation of a Standardized Comprehensive Assessment Tool in France: A Case Using the InterRAI Instruments

BACKGROUND

The improvement of quality of care requires a standardized and comprehensive assessment tool but implementation is challenging.

PURPOSE

We have reported on the development of the interRAI instruments in France from the onset to the mandatory use at the national level. We also have identified in the literature and in practices, incentives and barriers for the implementation of this integrated clinical information system in long term care.

RESULTS

Three periods in the interRAI instruments development were identified over the last twenty years. The first one was a research approach about improving quality of long term care. The second one was an experimental clinical use into an integrated care model with case management. The third one was a call for tenders issued by a French national agency, and the choice to use the interRAI-HC (Home Care) for all case managers. The main incentives and barriers that were identified include the national context, the target population, the providers involved and the impact on their practice, the interRAI instrument characteristics, training and leadership.

CONCLUSION

This historical overview of the development of interRAI instruments in France gives health care organizations pertinent information to guide the implementation of a standardized and comprehensive assessment tool.

Can specially trained community care workers effectively support patients and their families in the home setting at the end of life?

Surveys indicate that many Australians would prefer to die at home, but relatively few do. Recognising that patients and their families may not have the support they need to enable end-of-life care at home, a consortium of care providers developed, and received funding to trial, the Palliative Care Home Support Program (PCHSP) across seven health districts in New South Wales, Australia. The programme aimed to supplement end-of-life care in the home provided by existing multidisciplinary community palliative care teams, with specialist supportive community care workers (CCWs). An evaluation of the service was undertaken, focussing on the self-reported impact of the service on family carers (FCs), with triangulation of findings from community palliative care teams and CCWs. Service evaluation data were obtained through postal surveys and/or qualitative interviews with FCs, community palliative care teams and CCWs. FCs also reported the experience of their loved one based on 10 items drawn from the Quality of Death and Dying Questionnaire (QODD). Thematic analysis of surveys and interviews found that the support provided by CCWs was valued by FCs for: enabling choice (i.e. to realise end-of-life care in the home); providing practical assistance ("hands-on"); and for emotional support and reassurance. This was corroborated by community palliative care teams and CCWs. Responses by FCs on the QODD items indicated that in the last week of life, effective control of symptoms was occurring and quality of life was being maintained. This study suggests that satisfactory outcomes for patients and their families who wish to have end-of-life care in the home can be enabled with the additional support of specially trained CCWs. A notable benefit of the PCHSP model, which provided specific palliative care vocational training to an existing community care workforce, was a relatively rapid increase in the palliative care workforce across the state.

Variation of Care Time Between Nursing Units in Classification-Based Nurse-to-Resident Ratios: A Multilevel Analysis

A validity test was conducted to determine how care level-based nurse-to-resident ratios compare with actual daily care times per resident in Germany. Stability across different long-term care facilities was tested. Care level-based nurse-to-resident ratios were compared with the standard minimum nurse-to-resident ratios. Levels of care are determined by classification authorities in long-term care insurance programs and are used to distribute resources. Care levels are a powerful tool for classifying authorities in long-term care insurance. We used observer-based measurement of assignable direct and indirect care time in 68 nursing units for 2028 residents across 2 working days. Organizational data were collected at the end of the quarter in which the observation was made. Data were collected from January to March, 2012. We used a null multilevel model with random intercepts and multilevel models with fixed and random slopes to analyze data at both the organization and resident levels. A total of 14% of the variance in total care time per day was explained by membership in nursing units. The impact of care levels on care time differed significantly between nursing units. Forty percent of residents at the lowest care level received less than the standard minimum registered nursing time per day. For facilities that have been significantly disadvantaged in the current staffing system, a higher minimum standard will function more effectively than a complex classification system without scientific controls.

A pilot-feasibility study of measuring emotional expression during oral care

This study explored the feasibility of measuring emotional responses to oral care among individuals with dementia living in residential long-term care (LTC). Eleven residents with dementia were recruited from a U.S. Department of Veterans Affairs LTC unit and were observed eight times before, during, and after oral care episodes. Study participants showed a trend toward more positive emotional expressions during and after oral care (mean ± SD: 6.49 ± 1.57 and 6.27 ± 1.20 respectively) than before oral care (6.15 ± 0.86) at the margin of statistical significance (p = .08). Negative emotional expression increased among participants during oral care, from 0.22 ± .35 expressions per minute to 0.60 ± .65 expressions per minute, but returned to baseline after oral care (p < .01). Future studies with more representative samples are needed to more fully examine emotional responses to different types of care, adjusting for potential confounders, and to determine whether residents' emotional responses influence staff members' provision of care.

Association Between Therapy Intensity and Discharge Outcomes in Aged Medicare Skilled Nursing Facilities Admissions

OBJECTIVES

To determine the association between therapy intensity and discharge outcomes for aged Medicare skilled nursing facilities (SNFs) fee-for-service beneficiaries and to determine the association between therapy intensity and time to community discharge.

DESIGN

Retrospective observational design.

SETTING

SNFs.

PARTICIPANTS

Aged Medicare fee-for-service beneficiaries (N=311,338) in 3605 SNFs.

INTERVENTIONS

The total minutes of physical therapy, occupational therapy, and speech therapy per day were divided into intensity groups: high (≥60min); medium-high (45-<60min); medium-low (30-<45min); and low (<30min).

MAIN OUTCOME MEASURES

Four discharge outcomes-community, hospitalization, permanent placement, and death-were examined using a multivariate competing hazards model. For those associated with community discharge, a Poisson multivariate model was used to determine whether length of stay differed by intensity.

RESULTS

High intensity therapy was associated with more community discharges in comparison to the remaining intensity groups (hazard ratio, .84, .68, and .433 for medium-high, medium-low, and low intensity groups, respectively). More hospitalizations and deaths were found as therapy intensity decreased. Only high intensity therapy was associated with a 2-day shorter length of stay (incident rate ratio, .95).

CONCLUSIONS

High intensity therapy was associated with desirable discharge outcomes and may shorten SNF length of stay. Despite growing reimbursements to SNFs for rehabilitation services, there may be desirable benefits to beneficiaries who receive high intensity therapy.

Carer Appraisal Scale: A Pilot Study of a Novel Carer-Based Assessment of Patient Functioning

Measurement of patient outcomes is an integral part of mental health service evaluation, as well as guiding clinical practice to ensure best outcomes for patients. Moreover, carers have long held a need for a voice in care outcomes. Despite there existing numerous tools for quantifying patient functioning based on clinician assessments or self-reports, there is a serious paucity of tools available for the carers of patients to appraise their functioning. This tool, developed for use in a community aged care psychiatric service, involves 4 sections—a global impression of patient progress, a scorable checklist of patient functioning in multiple domains, a qualitative section for identifying the most pressing concerns from the carer’s perspective, and an open-ended feedback on treatment to date. In this pilot study, the Carer Appraisal Scale was found to have a fair correlation with the Health of Nation Outcomes Scale for over 65. This tool has potential for use in community aged care psychiatric services, as it provides a framework for communication of concerns, assists in prioritizing care, and adds value to clinician treatment plans, as well as providing another dimension to assessment of the patient while empowering carers in care participation. Practical implications of its use, limitations, and potential for modifications are also discussed.

Activities of daily living trajectories among institutionalised older adults: A prospective study

AIMS AND OBJECTIVES

To examine activities of daily living trajectory groups among older residents in Taiwan, and to determine the relative risks of demographic characteristics and health status in explaining the trajectory group of activities of daily living.

BACKGROUND

Activity of daily living is a crucial indicator of health status for institutionalised older adults. activities of daily living is a dynamic process and has differences in trajectory groups.

DESIGN

This study was a 3-year longitudinal analysis of long-term care facility residents in Taiwan.

METHODS

A total of 364 older residents completed the entire research process. We used group-based trajectory modelling and multinomial logistic models for statistical analysis.

RESULTS

The result of this study revealed that three activities of daily living trajectory groups among older residents exhibited high dependency with gradually declining function (Group 1, 22.53%), low dependency with gradually declining function (Group 2, 43.13%) and persistent independent function (Group 3, 34.34%). Compared with Group 3, Group 1 was related to the following potential risk factors: older age, female, nonmainland China born and a married status. After considering resident health status in the analysis, three significant factors emerged for Group 1: the number of chronic diseases (odds ratio = 2.45), depressive symptoms (odds ratio = 1.71) and cognitive status (odds ratio = 83.11). Compared with Group 3, Group 2 was related to older age. After adding resident health status to the analysis, two significant factors of Group 2 emerged: the number of chronic diseases (odds ratio = 1.68) and depressive symptoms (odds ratio = 1.74).

CONCLUSION

The findings of this study indicated that health factors, including the number of chronic diseases, cognitive status and depressive symptoms, were more likely to contribute to the development of a decline pattern of activities of daily living.

RELEVANCE TO CLINICAL PRACTICE

Appropriate exercise programmes and physical activities, according to residents' personal characteristics and activities of daily living status, is crucial for improving physical functioning, alleviating depression and cognitive defects in institutionalised older adults.

A Longitudinal Assessment of the Effect of Resident-Centered Care on Quality in Veterans Health Administration Community Living Centers

OBJECTIVE

To examine whether changes in resident-centered care (RCC) over time were associated with changes in quality.

DATA SOURCES/STUDY SETTING

Data sources were the Minimum Dataset quality indicators (which consist of measures of both prevalence and incidence of adverse events) and the Artifacts of Culture Change Tool (which measures RCC; FYs 2009-2012) from 130 Veterans Health Administration community living centers.

STUDY DESIGN

A retrospective longitudinal study.

DATA COLLECTION/EXTRACTION METHODS

Data were from VA secondary data sources.

PRINCIPAL FINDINGS

The overall relationship between RCC and quality was not statistically significant (p = .22), although there was a weakly significant negative relationship (i.e., increased RCC was associated with poorer quality) in the seven quarters after implementation of an automated version of the Artifacts Tool (p = .08). In facility-specific analyses, there were 15 facilities with a weakly significant (p < .10) positive relationship between RCC and quality and 21 with a weakly significant negative relationship. Adjusted cost per patient day was over 50 percent higher in the 21 facilities with a negative relationship than in the 15 facilities with a positive relationship (p < .05).

CONCLUSIONS

The Artifacts score is a formal performance metric in the VA, and thus, facilities were explicitly incentivized to increase RCC. Using qualitative methods to identify characteristics that distinguished those facilities able to increase both RCC and quality from those that suffered declines in quality as RCC was improved is an important follow-up to this study.

A study to reduce readmissions after surgery in the Veterans Health Administration: design and methodology

BACKGROUND

Hospital readmissions are associated with higher resource utilization and worse patient outcomes. Causes of unplanned readmission to the hospital are multiple with some being better targets for intervention than others. To understand risk factors for surgical readmission and their incremental contribution to current Veterans Health Administration (VA) surgical quality assessment, the study, Improving Surgical Quality: Readmission (ISQ-R), is being conducted to develop a readmission risk prediction tool, explore predisposing and enabling factors, and identify and rank reasons for readmission in terms of salience and mutability.

METHODS

Harnessing the rich VA enterprise data, predictive readmission models are being developed in data from patients who underwent surgical procedures within the VA 2007-2012. Prospective assessment of psychosocial determinants of readmission including patient self-efficacy, cognitive, affective and caregiver status are being obtained from a cohort having colorectal, thoracic or vascular procedures at four VA hospitals in 2015-2017. Using these two data sources, ISQ-R will develop readmission categories and validate the readmission risk prediction model. A modified Delphi process will convene surgeons, non-surgeon clinicians and quality improvement nurses to rank proposed readmission categories vis-à-vis potential preventability.

DISCUSSION

ISQ-R will identify promising avenues for interventions to facilitate improvements in surgical quality, informing specifications for surgical workflow managers seeking to improve care and reduce cost. ISQ-R will work with Veterans Affairs Surgical Quality Improvement Program (VASQIP) to recommend potential new elements VASQIP might collect to monitor surgical complications and readmissions which might be preventable and ultimately improve surgical care.

The Alice Springs Hospital Readmission Prevention Project (ASHRAPP): a randomised control trial

Background

Hospitals are frequently faced with high levels of emergency department presentations and demand for inpatient care. An important contributing factor is the subset of patients with complex chronic diseases who have frequent and preventable exacerbations of their chronic diseases. Evidence suggests that some of these hospital readmissions can be prevented with appropriate transitional care. Whilst there is a growing body of evidence for transitional care processes in urban, non-indigenous settings, there is a paucity of information regarding rural and remote settings and, specifically, the indigenous context.

Methods

This randomised control trial compares a tailored, multidimensional transitional care package to usual care. The objective is to evaluate the efficacy of the transitional care package for Indigenous and non-Indigenous Australian patients with chronic diseases at risk of recurrent readmission with the aim of reducing readmission rates and improving transition to primary care in a remote setting. Patients will be recruited from medical and surgical admissions to Alice Springs Hospital and will be followed for 12 months. The primary outcome measure will be number of admissions to hospital with secondary outcomes including number of emergency department presentations, number of ICU admissions, days alive and out of hospital, time to primary care review post discharge and cost-effectiveness.

Discussion

Successful transition from hospital to home is important for patients with complex chronic diseases. Evidence suggests that a coordinated transitional care plan can result in a reduction in length of hospital stay and readmission rates for adults with complex medical needs. This will be the first study to evaluate a tailored multidimensional transitional care intervention to prevent readmission in Indigenous and non-Indigenous Australian residents of remote Australia who are frequently admitted to hospital. If demonstrated to be effective it will have implications for the care and management of Indigenous Australians throughout regional and remote Australia and in other remote, culturally and linguistically diverse populations and settings.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12615000808549- Retrospectively registered on 4/8/15.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2077-7) contains supplementary material, which is available to authorized users.

Nurse Staffing Hours At Nursing Homes With High Concentrations Of Minority Residents, 2001-11

Recent increases in state Medicaid payments to nursing homes have the potential to reduce disparities in nurse staffing between facilities with high and low concentrations of racial/ethnic minority residents. Analyses of nursing home and state policy survey data for the period 2001-11 suggest that registered nurse and licensed practical nurse staffing levels increased slightly during this period, regardless of racial/ethnic minority resident concentration. Adjusted disparities in registered nurse hours per resident day between nursing homes with high and low concentrations of minority residents persisted, although they were reduced. Certified nursing assistant hours per patient day increased in nursing homes with low concentrations of minorities but decreased in homes with high concentrations, creating a new disparity. Overall, increases in state Medicaid payment rates to nursing homes were associated with improvements in staffing and reduced staffing disparities across facilities, but the adoption of case-mix payments had the opposite effect. Further reforms in health care delivery and payment are needed to address persistent disparities in care between nursing homes serving higher proportions of minority residents and those serving lower proportions, and to prevent unintended exacerbations of such disparities.

Deficiencies In Care At Nursing Homes And Racial/Ethnic Disparities Across Homes Fell, 2006-11

Despite the increased use of nursing homes by minority residents, nursing home care remains highly segregated. Compared to whites, racial/ethnic minorities tend to be cared for in facilities with limited clinical and financial resources, low nurse staffing levels, and a relatively high number of care deficiency citations. We assessed the trends from 2006 to 2011 in those citations and in disparities across facilities with four different concentrations of racial/ethnic minority residents. We found that the number of health care-related deficiencies and the percentage of facilities with serious deficiencies decreased over time for all four facility groups. From 2006 to 2011 the average annual number of health care-related deficiencies declined from 7.4 to 6.8 for facilities with low minority concentrations (<5 percent) and from 10.6 to 9.4 for facilities with high minority concentrations (≥35 percent). In multivariable analyses, across-site disparities in health care-related deficiencies and in life-safety deficiencies narrowed over time. We also found that increasing the Medicaid payment rate might help improve both overall quality and disparities, but state case-mix payment approaches might worsen both. These results suggest the need to reevaluate quality improvement and cost containment efforts to better foster the quality and equity of nursing home care.

Do hospital-owned skilled nursing facilities provide better post-acute care quality?

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.

The Effect of Medicare's Prospective Payment System on Discharge Outcomes of Skilled Nursing Facility Residents

In July 1998, the Centers for Medicare and Medicaid Services (CMS) changed the payment method for Medicare (Part A) skilled nursing facility (SNF) care from a cost-based system to a prospective payment system (PPS). Unlike the previous cost-based payment system, PPS restricts skilled nursing facility payment to pre-determined levels. CMS also reduced the total payments to SNFs coincident with PPS implementation. These changes might reduce quality of care at skilled nursing facilities and could be reflected in resident discharge patterns. The present study examines the effect of the 1998 policy change on resident discharge outcomes. The results indicate that PPS reduced the relative risk of discharge to home and to death for Medicare residents (compared to non-Medicare residents) and had no significant effect on hospitalizations or transfers.

Smoke without Fire: Nursing Facility Closures in California, 1997–2001

This paper draws from a rich longitudinal California data set to analyze the scope and nature of nursing home closures between 1997 and 2001, and to present a Cox proportionate hazards model of the risks of closure that arise from a range of facility and market characteristics. When compared with the sample total of 1,482 facilities operating in the baseline year of 1997, only 56 facilities closed through 2001, involving the loss of 3.8% of facilities and 2,915 beds (2.3%). The multivariate Cox model of factors associated with closure reports that: 1) hospital-based facilities are 600% more likely to close than are free-standing homes; 2) reducing bed size by one standard deviation (52 beds) increases the risk of closure by 460%; 3) facilities with losses of 5% or worse are more than twice as likely to close; and 4) a one-standard deviation increase in the spare bed capacity measure of county competition raises the risk of facility closure by 140%.

Medicare's Prospective Payment System for Skilled Nursing Facilities: Effects on Staffing and Quality of Care

In 1998, Medicare began phasing in a new prospective payment system (PPS) for skilled nursing facilities (SNFs). This paper measures facility-level changes in nurse staffing and quality at freestanding SNFs from 1997 (pre-PPS) to 2001 (post-PPS). Findings show a positive but small association between changes in payment levels and changes in nurse staffing. Among for-profits, the elimination of cost reimbursement is associated with a large drop in nurse staffing. Additionally, the elimination of cost reimbursement is associated with worsening in one of four measures of quality of care; however, the quality results are not statistically robust.

Case-mix adjustment and efficiency measurement

Aims: The importance of using valid case-mix systems in long-term care is addressed by comparing the predictive power of different case-mix models, and by applying them in the calculation of technical efficiency scores of care units. Methods: To construct different case-mix models a statistical clustering technique (Automatic Interaction Detection) was used. Technical efficiency score were calculated using data envelopment analysis (DEA). Results: The Resource Utilization Groups (RUG-III/22) classification explained 39% of resident specific cost, compared with 16% for a functional dependency scale in the Finnish patient information system HILMO. Conclusion: When assessing the economic performance of long-term care units it is important to pay attention to the predictive validity of the case-mix measure to be used. The choice of case-mix measure significantly affected how units were rated in efficiency.

Delivery of Care to Nursing Home Residents With Diabetes: Results From the SHELTER Study

OBJECTIVES

To describe health care and preventive service provision to nursing home (NH) residents with diabetes mellitus (DM) and to analyze factors determining use of selected services.

DESIGN

In the period between 2009 and 2011, the Services and Health for Elderly in Long TERm care (SHELTER) project, a 12-month prospective cohort study, was conducted to assess 4037 NH residents aged 60 years and older residing in 59 NHs in 7 European countries and Israel.

METHODS

The InterRAI tool for long-term care facilities was used to assess care needs and provided health care services. Descriptive statistics and multivariate logistic regression were applied to describe differences between NH residents with (DR) and without DM (non-DR), and to find factors determining use of services and care provided to both groups.

RESULTS

DR more often than non-DR were hospitalized (18.2% vs 14.3%) and required rehabilitation (23.8% vs 18.2%) or clinically complex care (15.9% vs 13.7%). They also more frequently received a repositioning program (26.8% vs 22.7%), a wound care (15.1% vs 9.8%), and some preventive services as yearly eye examination (41.0% vs 35.9%), pneumococcal vaccination (33.5% vs 26.6%), mammography in women (12.1% vs 7.4%), and colonoscopy (5.6% vs 3.6%). Yet, rates of some of them (mammography, colonoscopy, hearing and dental examinations) were very low in both study cohorts with exception of annual influenza vaccination (82.1%) and yearly blood pressure checkup (95.0%). Interestingly, DM enhanced odds only for mammography [odds ratio (OR) 1.55, 95% confidence interval [CI] 1.15-2.09, P = .004) and eye examination (OR 1.21, 95% CI 1.03-1.42; P = .018).

CONCLUSIONS

DR more frequently receive care related to DM clinical complexity; nevertheless, the recommended frequency of preventive procedures is not met both in DR and non-DR.

Medicaid Nursing Facility Utilization

This study uses a longitudinal California data set (1995 to 2000) to address two concerns about Medicaid nursing facility (NF) utilization. First, to consider the impact of national cost-control policies, the authors analyze data trends in Medicaid NF participants, days of care, and expenditures. Second, the authors investigate the percentage of Medicaid days of care (%MDOC) using a panel regression model to consider resident, facility, and county market predictors. The findings show that although statewide Medicaid NF participants, expenditures, and%MDOC remain stable, Medicaid market segmentation persistes, with program participants distributed unevenly among facilities. Factors associated positively with facility%MDOC are the proportion of minority residents, a larger facility size, for-profit status, the percentage of aged Black persons in the county, and market concentration. The factors associated negatively with%MDOC are the percentages of resident men, residents aged 85 or older, residents with Alzheimer’s disease, Medicaid reimbursement rates, and county wealth.

New Initiation of Long-Acting Opioids in Long-Stay Nursing Home Residents

OBJECTIVES

To estimate the prevalence of new initiation of long-acting opioids since introduction of national efforts to increase prescriber and public awareness on safe use of transdermal fentanyl patches.

DESIGN

Cross-sectional.

SETTING

U.S. nursing homes (NHs).

PARTICIPANTS

Medicare-enrolled long-stay NH residents (N = 22,253).

MEASUREMENTS

Minimum Data Set 3.0 was linked with Medicare enrollment, hospital claims, and prescription drug transaction data (January-December 2011) and used to determine the prevalence of new initiation of a long-acting opioid prescribed to residents in NHs.

RESULTS

Of NH residents prescribed a long-acting opioid within 30 days of NH admission (n = 12,278), 9.4% (95% confidence interval = 8.9-9.9%) lacked a prescription drug claim for a short-acting opioid in the previous 60 days. The most common initial prescriptions of long-acting opioids were fentanyl patch (51.9% of opioid-naïve NH residents), morphine sulfate (28.1%), and oxycodone (17.2%).

CONCLUSION

New initiation of long-acting opioids-especially fentanyl patches, which have been the subject of safety communications-persists in NHs.

Usefulness, feasibility and face validity of the interRAI Palliative Care instrument according to care professionals in nursing homes: A qualitative study

BACKGROUND

Nursing homes are important locations for palliative care. High quality palliative care requires an evaluation of the different care needs of the nursing home residents. The interRAI Palliative Care instrument is a comprehensive assessment that evaluates the needs and preferences of adults receiving palliative care.

OBJECTIVES

This study aims to evaluate the usefulness, feasibility and face validity of the interRAI Palliative Care instrument.

DESIGN

A qualitative study was conducted, based on the abductive reasoning approach.

SETTING

Fifteen nursing homes in Flanders (Belgium).

PARTICIPANTS

Calls for participation were sent out by four umbrella organizations of Flemish nursing homes (Belgium) and at a national conference for nursing home staff. Nineteen care professionals (nurses, certified nursing assistants, psychologists, physiotherapists, quality coordinators and directors) of 15 nursing homes voluntarily agreed to participate in the study.

METHODS

During one year, care professionals evaluated the needs and preferences of all nursing home residents receiving palliative care by means of the interRAI Palliative Care instrument. Data on the usefulness, feasibility and face validity of the interRAI Palliative Care instrument were derived from notes, semi-structured interviews and focus groups with participating care professionals and were thematically analyzed and synthesized. Data were gathered between December 2013 and March 2015.

RESULTS

In general, the interRAI Palliative Care (interRAI PC instrument) is a useful instrument according to care professionals in nursing homes. However, care professionals made a series of recommendations in order to optimize the usefulness of the instrument. The interRAI PC instrument is not always feasible to complete because of organizational reasons. Furthermore, the face validity of the instrument could be improved since certain items are incomplete, lacking, redundant or too complex.

CONCLUSIONS

Findings highlight the importance of adapting the content of the interRAI Palliative Care instrument for use in nursing homes. Furthermore, the use of the instrument should be integrated in the organization of daily care routines in the nursing homes. Tackling the critical remarks of care professionals will help to optimize the interRAI Palliative Care instrument and hence support palliative care of high quality in nursing homes.

Care Provision in Housing With Supportive Services: The Importance of Care Type, Individual Characteristics, and Care Site

Housing with supportive services is an important long-term sector, but information about care provision to residents in these settings is largely unavailable. The role of individual characteristics versus facility identity in determining how care is provided is completely unexplored. Data from 60 facilities in a single state were used to investigate the degree to which individual characteristics and facility identity determined how much care was provided to residents. Individual characteristics had the greatest impact on the amount of direct care time received by individuals. Care that was dementia oriented (i.e., cueing), however, was more strongly affected by the identity of the facility than by individual characteristics. These results have important implications for how consumers should think about seeking, and policy makers should think about supporting, care for those with impaired cognitive status who utilize housing with supportive services.

Variations in Outcomes of Care in Urban and Rural Nursing Facilities in Maine

Federal and state regulators and the nursing home industry have accelerated efforts to improve care practices in response to the Institute of Medicine's 1986 report on the quality of nursing home care and the federal Nursing Home Reform Act of 1987 (OBRA 1987). Very little is known about the quality of care in rural nursing facilities compared to their urban counterparts. This study describes variations in facility and resident characteristics of urban and rural nursing facilities in Maine and examines differences in outcomes of care. The study estimates rural-urban differences in 11 quality indicators (measured at the facility level) controlling for resident, facility, and market characteristics and other factors that may affect quality. Results reveal few significant differences between rural and urban nursing facilities. Further research is needed to understand whether differences in the characteristics of rural and urban facilities not measured in this study may affect nursing facility quality.

Routine outcome measurement in Australia

Australia has been implementing routine outcome measurement in its specialized public sector mental health services for over a decade. It uses a range of clinician-rated and consumer-rated measures that are administered at set times during episodes of inpatient, ambulatory and community residential episodes of care. Routine outcome measurement is now embedded in service delivery, and data are made available in a variety of ways to different audiences. These data are used by policy-makers and planners to inform decisions about system-wide reforms, by service managers to monitor quality and effectiveness, and by clinicians to guide clinical decision-making and to promote dialogue with consumers. Consumers, carers and the general community can use these data to ensure that services are accountable for the care they deliver. This paper describes the status quo in Australia with respect to routine outcome measurement, discusses the factors that led to its successful implementation, and considers the steps that are necessary for its continued development.

Palliative Care Problem Severity Score: Reliability and acceptability in a national study

BACKGROUND

The Palliative Care Problem Severity Score is a clinician-rated tool to assess problem severity in four palliative care domains (pain, other symptoms, psychological/spiritual, family/carer problems) using a 4-point categorical scale (absent, mild, moderate, severe).

AIM

To test the reliability and acceptability of the Palliative Care Problem Severity Score.

DESIGN

Multi-centre, cross-sectional study involving pairs of clinicians independently rating problem severity using the tool.

SETTING/PARTICIPANTS

Clinicians from 10 Australian palliative care services: 9 inpatient units and 1 mixed inpatient/community-based service.

RESULTS

A total of 102 clinicians participated, with almost 600 paired assessments completed for each domain, involving 420 patients. A total of 91% of paired assessments were undertaken within 2 h. Strength of agreement for three of the four domains was moderate: pain (Kappa = 0.42, 95% confidence interval = 0.36 to 0.49); psychological/spiritual (Kappa = 0.48, 95% confidence interval = 0.42 to 0.54); family/carer (Kappa = 0.45, 95% confidence interval = 0.40 to 0.52). Strength of agreement for the remaining domain (other symptoms) was fair (Kappa = 0.38, 95% confidence interval = 0.32 to 0.45).

CONCLUSION

The Palliative Care Problem Severity Score is an acceptable measure, with moderate reliability across three domains. Variability in inter-rater reliability across sites and participant feedback indicate that ongoing education is required to ensure that clinicians understand the purpose of the tool and each of its domains. Raters familiar with the patient they were assessing found it easier to assign problem severity, but this did not improve inter-rater reliability.

The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes

Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.

The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes

Many U.S. nursing homes have serious quality problems, in part, because of inadequate levels of nurse staffing. This commentary focuses on two issues. First, there is a need for higher minimum nurse staffing standards for U.S. nursing homes based on multiple research studies showing a positive relationship between nursing home quality and staffing and the benefits of implementing higher minimum staffing standards. Studies have identified the minimum staffing levels necessary to provide care consistent with the federal regulations, but many U.S. facilities have dangerously low staffing. Second, the barriers to staffing reform are discussed. These include economic concerns about costs and a focus on financial incentives. The enforcement of existing staffing standards has been weak, and strong nursing home industry political opposition has limited efforts to establish higher standards. Researchers should study the ways to improve staffing standards and new payment, regulatory, and political strategies to improve nursing home staffing and quality.