Age-Friendly Nursing Homes

How Neighborhood Social Deprivation Is Associated With Nursing Home Quality: A Structure, Process, Outcome Model

Background and Objectives

Nursing home (NH) quality often varies across socioeconomic gradients. The purpose of this study was to explore the relationship between social deprivation and NH quality.

Research Design and Methods

Integrating resource dependence theory with Donabedian's structure-process-outcome model, this study utilized 2019 data from Payroll Based Journal, Care Compare: Five-Star Quality Rating System, and LTCFocus.org. The analytic file included 12,900 free-standing NH observations. The primary variable of interest was severe social deprivation index (SDI) defined as SDI ≥85/100. Structural equation modeling was used to explore the effects of severe deprivation on NH structural (nursing staff), processes (antipsychotic medications [APMs]), and outcomes (falls, pressure ulcers, activities of daily living [ADL] decline, and hospitalizations) quality indicators among long-stay NH residents.

Results

Nursing homes in communities with severe SDI showed a decrease of 0.02 registered nurse (RN) hours per resident day (PRD) (p < .001) and an increase of 0.03 certified nursing assistant (CNA) hours PRD (p = .01). Higher licensed practical nurse (LPN) hours PRD (β = -1.03; p = .003) and higher CNA hours PRD (β = -0.80; p < .001) were significantly associated with reduced APM use. Increased APM use was significantly associated with ADL decline (β = 0.03; p < .001) and hospitalizations (β = 0.001; p = .013). Severe SDI indirectly resulted in higher hospitalizations (β = 0.01; p = .01) and falls (β = 0.01; p = .001) through lower RN staffing but lower pressure ulcers (β = -0.07; p < .001) through higher CNA staffing. Directly, severe SDI increased pressure ulcers (β = 0.69; p < .001) and hospitalizations (β = 0.09; p < .001) and decreased falls (β = -0.53; p < .001).

Discussion and Implications

Severe social deprivation affected nursing staff patterns, affecting care quality. These findings highlight the importance of considering environmental factors in the NH quality policymaking process.

"What Does 'Age-Friendly' Mean to You?": The Role of Microaggressions in a Retirement and Assisted Living Community

BACKGROUND AND OBJECTIVES

In conversations about expanding age-friendly ecosystems, the concept of "age-friendliness" has not been explored in relation to residential settings.

RESEARCH DESIGN AND METHODS

This multiple-case study compared four residents' perspectives on the age-friendliness of a retirement and assisted living community, combining individual semi-structured interviews with observational data and organizational document analyses in a contextualist thematic examination.

RESULTS

Three themes depict (A) existing experiences of the setting as "age-friendly" and the tension of the built design vs. identity; (B) resident-to-resident microaggressions, delineated into 4 subthemes including identity-related, intergenerational, condition-related microaggressions, and their influence on social isolation; and (C) desired experiences of the setting as "age-friendly" reflecting the social design. In cases of visibly perceptible diversity (white cane, darker skin tone), residents fared worse in experiencing microaggressions stemming from ableism, racism, and age differences. Conversely, in cases of visibly imperceptible diversity, residents had more positive or entirely positive experiences. Although the setting met many environmental and healthcare needs, it lacked design factors prioritizing meaningful social relationships among residents, affecting social isolation.

DISCUSSION AND IMPLICATIONS

Resident-to-resident social relationships were key in the experience of a retirement and assisted living community as age-friendly. Resident-to-resident microaggressions undermined perceptions of the community as age-friendly, and influenced social isolation. We reflect on the organizational role in mitigating against negative social relationships and social isolation to maximize dignity.

Ownership Matters: Not-for-Profit Chain Nursing Homes Have Higher Utilization of Agency Nursing Staff

Nursing homes (NHs) have long struggled with nurse shortages, leading to a greater reliance on agency nurses. The purpose of this study was to examine the impact of NH ownership on agency nurse utilization. Data were derived from multiple sources, including the Payroll-Based Journal and NH Five-Star Facility Quality Reporting System (n: 38,550 years: 2020-2022). A 2-part logistic regression model with 2-way fixed effects (state and year) was used to assess the association of ownership and agency nurse utilization. Model 1 compared facilities with and without agency nurse use, while Model 2 focused on NHs using agency nurses, examining high utilization (top 10%). The dependent variables were agency nurse utilization ratios for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). The primary independent variable was ownership/chain affiliation: for-profit chain (FPC), for-profit independent (FPI), not-for-profit chain (NFPC), and not-for-profit independent (NFPI). Model 1 showed that NFPC facilities had higher odds of using agency RNs (OR = 1.65), LPNs (OR = 1.53), and CNAs (OR = 1.38) compared to NFPI facilities (all P < .001), while FPC facilities also had increased odds for RNs (OR = 1.43), LPNs (OR = 1.30), and CNAs (OR = 1.15) (all P < .001). Model 2 indicated that NFPC, FPC, and FPI facilities were more likely to be high utilizers (top 10%) of agency nurses, with NFPC facilities having the highest odds across all categories. Pairwise comparisons showed that NFPC had the highest utilization of agency RNs and LPNs compared to other ownership groups. These results highlight the significant impact of NH ownership on staffing practices, suggesting that ownership type influences agency nurse utilization.

Creating age-friendly nursing homes: The time is now

The current global age-friendly movement supports older adults by promoting different policies and services. However, there is a dearth of attention to nursing home (NH) residents as part of age-friendly movements. The pioneering idea of an age-friendly health system, i.e., the "4 Ms" model is significant for NHs and formative for further developments; however, it does not identify unique components of NH care. This article aims to identify specific aspects of person-centered care in the literature to advance the development of a standardized conceptual framework. Along with residents, NH staff and administrators are integral parts of NHs. Incorporating the central role of caregivers, this study proposes a new "8 Ms" framework to describe the age-friendly NH. The traditional 4 Ms model notes that everything related to care matters to residents, along with care related to medication, mobility, and mentation. The proposed age-friendly framework introduces five additional "M," i.e., meaningful care, motivation, moderation, modification, and monitoring. This framework is proposed to advance education, training, clinical practice, research, and advocacy to promote quality of care in NHs. Application of the 8 Ms framework may yield multiple benefits, assuring good quality of care to residents, caregivers' job satisfaction, and supporting NH management in providing residents optimal care.