Nursing Home Involuntary Relocation: Clinical Outcomes and Perceptions of Residents and Families

Transfer Trauma Among Nursing Home Residents: Development of a Composite Measure

BACKGROUND AND OBJECTIVES

Nursing home (NH)-to-NH transfers place NH residents at risk for developing transfer trauma. We aimed to develop a composite measure of transfer trauma and apply it among those transferring before and during the pandemic.

RESEARCH DESIGN AND METHODS

Cross-sectional cohort analysis of long-stay NH residents with a NH-to-NH transfer. Minimum Data Set data (2018-2020) were used to create the cohorts. A composite measure of transfer trauma was developed (2018 cohort) and applied to the 2019 and 2020 cohorts. We analyzed resident characteristics and conducted logistic regression analyses to compare rates of transfer trauma between periods.

RESULTS

In 2018, 794 residents were transferred; 242 (30.5%) met the criteria for transfer trauma. In the 2019 and 2020, 750 residents (2019) and 795 (2020) were transferred. In 2019 cohort, 30.7% met the criteria for transfer trauma, and 21.9% in 2020 cohort. During the pandemic, a higher proportion of transferred residents left the facility before the first quarterly assessment. Among residents who stayed in NH for their quarterly assessment, after adjusting for demographic characteristics, residents in the 2020 cohort were less likely to experience transfer trauma than those in the 2019 cohort (adjusted odds ratio [AOR] = 0.64, 95% confidence interval [CI]: 0.51, 0.81). However, residents in 2020 cohort were two times more likely to die (AOR = 1.94, 95% CI: 1.15, 3.26) and 3 times more likely to discharge within 90 days after transfer (AOR = 2.86, 95% CI: 2.30, 3.56) compared with those in 2019 cohort.

DISCUSSION AND IMPLICATIONS

These findings highlight how common transfer trauma is after NH-to-NH transfer and the need for further research to mitigate negative outcomes associated with the transfer in this vulnerable population.

Residential Environments for Older Persons: A Comprehensive Literature Review (2005-2022)

BACKGROUND

Independent noninstitutional and institutional residential long-term care environments for older persons have been the subject of significant empirical and qualitative research in the 2005-2022 period. A comprehensive review of this literature is reported, summarizing recent advancements in this rapidly expanding body of knowledge.

PURPOSE AND AIM

This comprehensive review conceptually structures the recent literature on environment and aging to provide conceptual clarity and identify current and future trends.

METHOD AND RESULT

Each source reviewed was classified as one of the five types-opinion piece/essay, cross-sectional empirical investigation, nonrandomized comparative investigation, randomized study, and policy review essay-within eight content categories: community-based aging in place; residentialism; nature, landscape, and biophilia; dementia special care units; voluntary/involuntary relocation; infection control/COVID-19, safety/environmental stress; ecological and cost-effective best practices; and recent design trends and prognostications.

CONCLUSIONS

Among the findings embodied in the 204 literature sources reviewed, all-private room long-term care residential units are generally safer and provide greater privacy and personal autonomy to residents, the deleterious impacts of involuntary relocation continue, family engagement in policy making and daily routines has increased, multigenerational independent living alternatives are increasing, the therapeutic role of nature and landscape is increasingly well-documented, ecological sustainability has increased in priority, and infection control measures are of high priority in the wake of the coronavirus pandemic. Discussion of the results of this comprehensive review sets the stage for further research and design advancements on this subject in light of the rapid aging of societies around the globe.

Nursing Home to Nursing Home Transfers during the Early COVID-19 Pandemic

OBJECTIVES

To examine the nursing home to nursing home transfer rates before and during the early COVID-19 pandemic and to identify risk factors associated with those transfers in a state with a policy to create COVID-19-care nursing homes.

DESIGN

Cross-sectional cohorts of nursing home residents in prepandemic (2019) and COVID-19 (2020) periods.

SETTING AND PARTICIPANTS

Michigan long-term nursing home residents were identified from the Minimum Data Set.

METHODS

Each year, we identified transfer events as a resident's first nursing home to nursing home transfer between March and December. We included residents' characteristics, health status, and nursing home characteristics to identify risk factors for transfer. Logistic regression models were conducted to determine risk factors for each period and changes in transfer rates between the 2 periods.

RESULTS

Compared to the prepandemic period, the COVID-19 period had a higher transfer rate per 100 (7.7 vs 5.3, P < .05). Age ≥80 years, female sex, and Medicaid enrollment were associated with a lower likelihood of transfer for both periods. During the COVID-19 period, residents who were Black, with severe cognitive impairment, or had COVID-19 infection were associated with a higher risk of transfer [adjusted odds ratio (AOR) (95% CI): 1.46 (1.01-2.11), 1.88 (1.11-3.16), and 4.70 (3.30-6.68), respectively]. After adjusting for resident characteristics, health status, and nursing home characteristics, residents had 46% higher odds [AOR (95% CI): 1.46 (1.14-1.88)] of being transferred to another nursing home during the COVID-19 period compared to the prepandemic period.

CONCLUSIONS AND IMPLICATIONS

In the early COVID-19 pandemic, Michigan designated 38 nursing homes to care for residents with COVID-19. We found a higher transfer rate during the pandemic than during the prepandemic period, especially among Black residents, residents with COVID-19 infection, or residents with severe cognitive impairment. Further investigation is warranted to understand the transfer practice better and if any policies would mitigate the transfer risk for these subgroups.

Moving our care home: A qualitative study of the views and experiences of residents, relatives and staff

INTRODUCTION

Involuntary relocation when care homes close can be detrimental to residents' health and well-being and is associated with increased mortality. There is little formal evidence to support whether planning can mitigate the impact of such moves. This study aimed to understand the experiences of a whole care home relocation where staff and residents relocated together using existing published guidance.

METHODS

A longitudinal qualitative research study using individual face-to-face semi-structured interviews was conducted between August 2018 and August 2019. Baseline interviews were conducted 6-8 weeks after relocation with follow-up interviews 10-12 months later. Interviews were recorded, transcribed and analysed using framework analysis.

RESULTS

27 interviews were conducted; 19 baseline interviews (4 residents, 7 family members, 8 staff) and 8 follow-up interviews (2 residents, 2 family members, 4 staff). Participants' feelings about the relocation were mixed: some reported apprehension before the move but others excitement. Residents and families felt variably involved in planning the move, whereas staff expressed lack of involvement. Time, family support and continuity of care helped participants settle in. The new environment shaped participants' experiences and abilities to adjust, especially the lack of a homely feeling with the new home, the larger size and changes in staff organisation and management.

CONCLUSIONS

Despite implementation of existing guidance, relocation was still challenging for residents, staff and family members. Future relocations should increase involvement of staff in the planning and design of the home; offer continuous support to those involved; and ensure continuity of care and management style.

Nursing Home Residents' Relocation to Another Facility: an Exploratory Study of Family Caregiver Experiences

Over time, family caregivers for older adults may face care transitions for their loved ones. The move from home to residential care facility is a much-studied transition. Yet we know little of family caregiver experiences when their loved ones move from one facility to another. We interviewed family caregivers of nursing home residents and inquired about caregiver experiences in prior facilities and factors that prompted moving to another facility. Our analysis identified three themes: 1) A precursor of moving to another facility was caregivers' assessment of poor fit between their family member and the facility; 2) Executing a move was demanding for the caregiver in instrumental and emotional ways; 3) Once in the new facility, caregivers adapted their caregiving to the capacity of the new facility and fostered resident-facility fit (not interfering with good care and supplementing facility care). Findings suggest that family caregivers continually assess and respond to emerging problems with resident-facility fit, which sometimes escalate and necessitate a move to another facility. Nursing home social workers are well-positioned to help families address emerging care problems, so they do not escalate. Doing so can promote care continuity, which benefits both the resident and the family caregiver.

Municipal healthcare professionals' interprofessional collaboration during older patients' transitions in the municipal health and care services: a qualitative study

Background

Interprofessional collaboration is vital to assist patients towards a healthy transition in the municipal health and care services. However, no study has so far investigated municipal health care providers’ inter-professional collaboration during older patients’ transition in the municipal health and care services. The aim of this study is therefore to describe and explore what influence health care providers’ inter-professional collaboration within and across municipal facilities during older patients’ transitions in the municipal health and care services.

Method

The study has a descriptive, interpretive design. Focus group interviews and individual interviews with municipal health care providers different professions were performed.

Results

Municipal health care providers’ inter-professional collaboration during older patients transitions in the municipal health and care services was challenging. Two main themes were identified: The patient situation itself and Professional. Personal, and Practical circumstances. The results show that the municipal priority of patients staying at home as long as possible facilitated inter-professional collaboration across the short-term care facility and the home care services. Inter-professional collaboration across facilities with the long-term care facility was downgraded and health care providers in this facility had to cope as best they could.

Conclusion

Prioritising and facilitating inter-professional collaboration between the short-term care facility and the home care services, contributed to health care providers experiencing doing a proper and safe patient assistance. Yet, this priority was at a cost: Health care providers in the long-term care facility, and in particular registered nurses felt squeezed and of less worth in the municipal health and care services. It was a strain on them to experiencing unplanned and often rushed patient transition into long-term care facility. To focus on municipal inter-professional and inter-facility collaboration during patients in transition to long-term care placement is vital to maintain the patients, and the health care providers working in these facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08226-5.

A critique of the marketisation of long-term residential and nursing home care

Long-term care systems across countries within the Organisation for Economic Co-operation and Development have undergone a progressive marketisation and financialisation in recent decades, characterised by the embedding of neoliberal market values such as competition, consumer choice, and the profit motive. In this Personal View, we argue that these make poor guiding principles for the care sector, identifying the dysfunctional dynamics that arise as a result, and reflecting on the clinical implications of each, with a focus on facility-based care. We outline why providers can scarcely respond to competitive forces without compromising care quality. We explain why the promotion of consumer choice cannot effectively motivate improvements to quality of care. And we explore how privatisation opens the door to predatory financial practices. We conclude by considering how far proposals for reform can take us, ultimately arguing for a rejection of neoliberal market ideology, and calling for sector-wide discussions about what principles would be more fitting for a caring economy.

Perceived barriers and contributors to sense of purpose in life in retirement community residents

Despite the growing use of retirement communities and ageing care facilities, little is known about how residing in retirement residences may impact aspects of older adult wellbeing. Living in these communities may hold particular influence on residents’ sense of purpose, if they feel limited in their opportunities for individual action, or could serve to promote purposefulness depending on the social connections available. The current study sought to explore contributing factors as well as barriers to purpose in older adults living in three continuing care retirement communities. Using brief semi-structured interviews, 18 older adults were asked to describe their purpose in life, community-related activities and any perceived challenges limiting their ability to pursue this purpose. Thematic analysis was used to examine themes common across interviews. Interviews presented a mixed picture of the nature of purposefulness in retirement facilities. Residents espoused several benefits of community living such as social and leisure opportunities, while also noting several obstacles to their purpose, including health concerns and the belief that purpose in life was not relevant for older adults. These findings provide insight into how older adults can derive a sense of purpose from activities within their retirement community and how facilities can better tailor programmes to promote purposefulness and support personally valued roles for residents.

A Scoping Review: Characteristics and Outcomes of Residents Who Experience Involuntary Relocation

BACKGROUND AND OBJECTIVES

Relocation to a residential care facility has been described as the most significant relocation affecting older adults, yet subsequent relocations, like in the case of a facility closure, have received minimal attention in the scholarly research literature. This paper reviews the published literature on involuntary relocation, focusing on the experiences of residents, families, and staff and the effects of involuntary relocation on nursing home residents' health.

RESEARCH DESIGN AND METHODS

We conducted a scoping review to identify peer-reviewed studies reporting on involuntary relocation of nursing home residents. A total of 28 quantitative, qualitative, and mixed-method articles met inclusion criteria.

RESULTS

Researchers mostly relied on longitudinal designs and quantitative indicators of functional health, cognitive status, psychological and emotional well-being, environment, and relocation context to examine residents' mortality risk and health outcomes associated with involuntary relocation. Inclusion of qualitative and mixed-method approaches was infrequent, as were indicators of social engagement and perceptions of relocation. Residents' awareness of and preparation for involuntary relocation positively influenced their health and well-being. Family involvement was frequently hindered by communication challenges with facilities. Staff expressed concern about residents, experienced increased workload demands, and acknowledged challenges with planning and communication.

DISCUSSION AND IMPLICATIONS

Based on the collective findings, we propose a conceptual model of critical factors at play during relocation for consideration for guiding future research and developing provisions to current policies guiding relocation processes. Facilities and policymakers need to consider procedures that enhance planning efforts and decision-making among this vulnerable population and their families.

Nursing Home Facility-Initiated Involuntary Discharge

Involuntary discharge of nursing home (NH) residents is a prominent reason for NH complaints in the United States, but little is known about facility-initiated involuntary discharge (FID). A literature review was conducted to improve understanding of FID. The findings distinguish between six types of FID, identify populations at risk of FID, and differentiate between legal and unlawful FID practices and processes. The findings also characterize common FID destinations; show how policy, regulatory, and financial factors impact FID; and indicate that FID outcomes are commonly detrimental to the health and well-being of NH residents. Findings highlight challenges with understanding FID, including differentiating legal from unlawful FID. Although more research about NH FID is needed, the current study indicates that FID outcomes are regularly adverse, protections against unlawful FID are needed for Medicaid beneficiaries and NH residents with dementia, and stronger enforcement of existing policies and regulations regarding NH FID-including NH bed-hold requirements-are needed. [Journal of Gerontological Nursing, 45(8), 23-31.].

A national survey of aged care facility managers' views of preparedness for natural disasters relevant to residents with dementia

OBJECTIVE

The aim was to explore the natural disaster preparedness strategies of Australian residential aged care facilities (RACFs), focussing on aspects relevant to people with dementia.

METHODS

An online survey was sent to 2617 RACF managers, with 416 responding. Questions included the following: (a) demographics; (b) presence and detail level of disaster/evacuation plans; and (c) references to people with dementia.

RESULTS

One in four facilities had experienced a natural disaster in the previous five years. The majority had plans for natural disaster and evacuation. Two-thirds recognised the unique needs of people with dementia. Managers anticipated that residents with dementia would require more staff time and resources and might become disoriented.

CONCLUSIONS

Gaps identified in existing RACF evacuation plans highlighted challenges in ensuring the ongoing safety and care of residents, especially those with dementia. Facilities need to have adequate plans and processes that minimise the potential risks of natural disasters.

Measures of emergency preparedness contributing to nursing home resilience

Resilience approaches have been successfully applied in crisis management, disaster response, and high reliability organizations and have the potential to enhance existing systems of nursing home disaster preparedness. This study's purpose was to determine how the Center for Medicare and Medicaid Services (CMS) "Emergency Preparedness Checklist Recommended Tool for Effective Health Care Facility Planning" contributes to organizational resilience by identifying the benchmark resilience items addressed by the CMS Emergency Preparedness Checklist and items not addressed by the CMS Emergency Preparedness Checklist, and to recommend tools and processes to improve resilience for nursing homes. The CMS Emergency Preparedness Checklist items were compared to the Resilience Benchmark Tool items; similar items were considered matches. Resilience Benchmark Tool items with no CMS Emergency Preparedness Checklist item matches were considered breaches in nursing home resilience. The findings suggest that the CMS Emergency Preparedness Checklist can be used to measure some aspects of resilience, however, there were many resilience factors not addressed. For nursing homes to prepare and respond to crisis situations, organizations need to embrace a culture that promotes individual resilience-related competencies that when aggregated enable the organization to improve its resiliency. Social workers have the skills and experience to facilitate this change.

Nursing home Facebook reviews: who has them, and how do they relate to other measures of quality and experience?

BACKGROUND

The growing use of social media creates opportunities for patients and families to provide feedback and rate individual healthcare providers. Whereas previous studies have examined this emerging trend in hospital and physician settings, little is known about user ratings of nursing homes (NHs) and how these ratings relate to other measures of quality.

OBJECTIVE

To examine the relationship between Facebook user-generated NH ratings and other measures of NH satisfaction/experience and quality.

METHODS

This study compared Facebook user ratings of NHs in Maryland (n=225) and Minnesota (n=335) to resident/family satisfaction/experience survey ratings and the Centers for Medicare and Medicaid (CMS) 5-star NH report card ratings.

RESULTS

Overall, 55 NHs in Maryland had an official Facebook page, of which 35 provided the opportunity for users to rate care in the facility. In Minnesota, 126 NHs had a Facebook page, of which 78 allowed for user ratings. NHs with higher aid staffing levels, not affiliated with a chain and located in higher income counties were more likely to have a Facebook page. Facebook ratings were not significantly correlated with the CMS 5-star rating or survey-based resident/family satisfaction ratings.

CONCLUSIONS

Given the disconnect between Facebook ratings and other, more scientifically grounded measures of quality, concerns about the validity and use of social media ratings are warranted. However, it is likely consumers will increasingly turn to social media ratings of NHs, given the lack of consumer perspective on most state and federal report card sites. Thus, social media ratings may present a unique opportunity for healthcare report cards to capture real-time consumer voice.

Relocation experiences with unplanned admission to a nursing home: a qualitative study

BACKGROUND

In many countries, people over 85 years of age are relocated involuntarily or unplanned to a nursing home. In Switzerland, 43% of elderly over 85 years are admitted to nursing homes after hospital discharge. This percentage is higher than in the USA with 32.5% or in Germany with only 19%. Despite those more frequent Swiss admissions, no research has been conducted exploring how unplanned admissions to nursing homes affect the adaptation. Therefore, the aim of this study was to gain an in-depth understanding into unplanned admissions to nursing homes and to explore its impact on adaptation.

METHODS

The study used a qualitative interview design based on Meleis' transition model. Secondary data analysis was guided by Mayring's qualitative content analysis. Face-to-face interviews with elderly over 77 years (n = 31) were conducted from a convenience sample in Switzerland between January and March 2013.

RESULTS

The following four patterns of adaptation emerged from the analysis: "being cut-off," "being restricted," "being cared for," and "moving on." The patterns evaluate the relocation into nursing homes and provide an opportunity to appraise the stages of adaption.

CONCLUSIONS

This study presents a model of analysis to evaluate patterns of adaptation following an unplanned admission to a nursing home after hospital discharge.

Death Following Recent Admission Into Nursing Home From Community Living: A Systematic Review Into the Transition Process

Objective: This study examines the impact of the transition process on the mortality of elderly individuals following their first admission to nursing home from the community at 1, 3, and 6 months postadmission, and causes and risk factors for death. Method: A systematic review of relevant studies published between 2000 and 2015 was conducted using key search terms: first admission, death, and nursing homes. Results: Eleven cohort studies met the inclusion criteria. Mortality within the first 6 month postadmission varied from 0% to 34% (median = 20.2). Causes of deaths were not reported. Heightened mortality was not wholly explained by intrinsic resident factors. Only two studies investigated the influence of facility factors, and found an increased risk in facilities with high antipsychotics use. Discussion: Mortality in the immediate period following admission may not simply be due to an individual’s health status. Transition processes and facility characteristics are potentially independent and modifiable risk factors.

Moving as a gift: relocation in older adulthood

While discussions of accessibility, mobility and activities of daily living frame relocation studies, in older adulthood, the paper explores the emotional motivation of gift giving as a rationale for moving. This ethnographic study investigates the processes of household disbandment and decision-making of older adults in the Midwestern United States relocating in post-Global Financial Crisis contexts. In this study, relationships are created and sustained through the process of moving, linking older adults (n=81), their kin (n=49), and professionals (n=46) in the Midwestern United States. Using Marcel Mauss' The Gift (1925/1990) as a theoretical lens, relocation in older adulthood is conceptualized as a gift in two ways: to one's partner, and one's kin. Partners may consider gift-giving in terms of the act of moving to appease and honor their partner. Kin who were not moving themselves were also recipients of the gift of moving. These gifts enchain others in relationships of reciprocity. However these gifts, like all gifts, are not without costs or danger, so this paper examines some of the challenges that emerge along with gift-giving.

Psychometric properties of the index of relocation adjustment

More and more American older adults are relocating to retirement communities, and they experience challenges in adjusting to new surroundings that may increase their depression and mortality. An instrument not previously tested in the United States, the Index of Relocation Adjustment (IRA), may help in early identification of poor relocation adjustment. This study examined the psychometric properties of the IRA using secondary data from a convenience sample of 104 older adults who relocated to 6 retirement communities in Northeast Ohio. Cronbach's alpha was .86. The IRA was correlated with measures of positive cognitions (r = .48, p < .01) and relocation controllability (r = -.62, p < .01), suggesting construct validity. Results indicated a single factor reflecting relocation adjustment with loadings for all items ranging from .62 to .83. The IRA is potentially useful as a screening measure for early detection of poor adjustment among relocated older adults.

Forced relocation between nursing homes: residents' health outcomes and potential moderators

That transfer of older people from one institution to another is detrimental to well-being, health and survival has been reported for 50 years. This has led to fear, anger and legal challenges when closures occur. Previous reviews identified accounts of relocation followed by adverse outcomes and others where problems were avoided or benefits claimed. This paper reviews the last twelve years of literature on health outcomes following involuntary relocation between nursing homes. Reports of post-move mortality, physical or psychological health suggest and confirm that relocation without preparation carries higher risk of poor outcomes than moves that are orderly and include preparation. The literature on the care home closure process, admissions and individual transfers offers insights into practices that might help minimize adverse outcomes. A number of agencies have produced helpful guidelines. How these are implemented needs to be monitored and linked to in-depth studies of sample closures.

Effect of forced transitions on the most functionally impaired nursing home residents

OBJECTIVES

To examine the hospitalization rate and mortality associated with forced mass transfer of nursing home (NH) residents with the highest levels of functional impairment.

DESIGN

Retrospective cohort study.

SETTING

One hundred nineteen Texas and Louisiana NHs identified as being at risk for evacuation for Hurricane Gustav.

PARTICIPANTS

Six thousand four hundred sixty-four long-stay residents residing in at-risk NHs for at least three consecutive months before landfall of Hurricane Gustav.

MEASUREMENTS

Using Medicare claims and instrumental variable analysis, the mortality (death at 30 and 90 days) and hospitalization rates (at 30 and 90 days) of the most functionally impaired long-stay residents who were evacuated for Hurricane Gustav were compared with those of the most functionally impaired residents who did not evacuate.

RESULTS

The effect of evacuation was associated with 8% more hospitalizations by 30 and 90 days for the most functionally impaired residents. Evacuation was not significantly related to mortality.

CONCLUSION

The most functionally impaired NH residents experience more hospitalizations but not mortality as a consequence of forced mass transfer. With the inevitability of NH evacuations for many different reasons, harm mitigation strategies focused on the most impaired residents are needed.

Resourcefulness, positive cognitions, relocation controllability and relocation adjustment among older people: a cross-sectional study of cultural differences

BACKGROUND

The population of older people in both the United States and Egypt is expected to double by the year 2030. With ageing, chronic illnesses increase and many older people need to relocate to retirement communities. Research has shown that positive cognitions and resourcefulness are positively correlated with adaptive functioning and better adjustment.

AIMS AND OBJECTIVES

The purpose of this study was to examine and compare relocation controllability, positive cognitions, resourcefulness and relocation adjustment between American and Egyptian older people living in retirement communities. The purpose of this cultural comparison is to gain insight into influencing factors in each culture that might lead to interventions to help relocated older adults in both cultures adjust to their new surroundings.

DESIGN AND METHOD

A cross-sectional, descriptive design was used to compare relocation controllability, positive cognitions, resourcefulness and relocation adjustment of a convenience sample of American older people (n = 104) and a convenience sample of Egyptian older people (n = 94). The study was a secondary analysis of two studies of older people residing in six retirement communities in Northeast Ohio and in five retirement communities in Alexandria, Egypt.

RESULTS

Examination of mean scores and standard deviations on the measure of positive cognitions using independent sample t-tests indicated that on average, the American older people reported more positive cognitions (t (131.16) = 11.29, P < 0.001), more relocation controllability (t (196) = -6.78, P < 0.001) and more relocation adjustment (t (196) = 9.42, P < 0.001) than the Egyptian older people. However, there was no significant difference between Egyptians and Americans in resourcefulness (t (174.16) = -0.97, P > 0.05).

CONCLUSION

The results provide direction for the development of positive cognition interventions and engaging older people in the decision-making process to help them to adjust to relocation. Implications for practice.  Positive thinking and resourcefulness training interventions can be used by nurses to help relocated older people to adjust to the stress of relocation to retirement communities. These interventions can be used on primary, secondary, and tertiary levels. Primary interventions can help to prevent the stress of relocation before happening by helping older people to use their positive thinking and their resources and work with them before relocating to retirement communities. Secondary prevention can be used by nurses to help older people who have already relocated to retirement communities and have already experienced stress of relocation to help them out by decreasing the stress that they are suffering. Tertiary prevention can be used to prevent further stress and deterioration for those who have suffered physical and psychological symptoms as a result of relocation.

Nutritional status and eating habits of older Manitobans after relocating to a personal care home

We explored the effect of relocating to a personal care home (PCH) on older adults' nutritional status and eating habits. Fourteen Caucasian older adults (F=57%) with a mean age of 83 years (standard deviation = 9.79) consented to participate. Anthropometric information (height, weight, bioelectrical impedance analysis), biochemical and clinical information (diagnoses, data from scales measuring risk or function), and dietary information (three-day plate waste analysis) were collected at time points A (two to three months after relocation) and B (six to seven months after relocation) through face-to-face interviews and medical chart reviews, and from nursing staff. At time B, cognitive function declined (z = -2.185, p<0.05) and the number of medications prescribed increased (z = -2.00, p<0.05). Levels of 25-hydroxyvitamin D were insufficient among 83% of participants at both time points. Mean serum albumin was 34.4 ± 7.2 g/L at time B, and the prevalence of potential nutritional risk increased from 57% to 77%. Dietary intake was inadequate at both time points. Nutritional risk became more prevalent at time B. Protein-energy malnutrition and other nutritional inadequacies may result if dietary intakes do not improve. Strategies to improve dietary intakes should be implemented within PCHs to reduce potential malnutrition.

To evacuate or shelter in place: implications of universal hurricane evacuation policies on nursing home residents

OBJECTIVE

To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf hurricanes.

METHODS

Observational study using Medicare claims and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 nonhurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days.

RESULTS

Among 36,389 NH residents exposed to a storm, the 30- and 90-day mortality/hospitalization rates increased compared with nonhurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7% to 5.3% and hospitalization by 1.8% to 8.3%, independent of other factors.

CONCLUSION

Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.

The Health Consequences of Relocation for Nursing Home Residents Following Hurricane Katrina

In this research, the authors examine whether the relocation of nursing home residents following Hurricane Katrina is associated with subsequent lower physical or mental health. All nursing homes in Louisiana that were closed following Hurricane Katrina ( N = 12) were used, with 439 residents who could be followed to a new location. The authors compare the subsequent health outcomes of these residents to that of a matched sample of other nursing home residents in Southern states, with the match based on prior health status as well as other resident and facility characteristics. Relocated residents were more likely to die than non-relocated residents. In addition, relocated residents were more likely to have pressure ulcers; they were, however, less likely to be physically restrained. Relocated residents were also less likely to have behavioral health issues. These results would appear to have both practical and policy relevance.

Disaster strikes! Long-term care resident outcomes following a natural disaster

This report describes the outcomes of 17 long-term care residents who were participating in a nursing intervention study. The residents were evacuated for 5 days due to a severe summer storm that caused widespread power outages. These residents were seen the day of the storm and three times per week for 2 weeks following their return to the nursing home. More than half of the participants had significant changes in their NEECHAM Confusion Scale scores (n = 11) and modified Confusion Assessment Method scores (n = 9) scores, suggesting the onset of delirium. Two participants were hospitalized within the 2 weeks of the evacuation. One participant died unexpectedly. This report provides a rare look into the negative effects of a short-term evacuation due to a natural disaster.

Creating a therapeutic milieu in retirement communities

Elderly persons' relocation to retirement communities is a stressful event that requires person-milieu adjustment. Research has shown differences in relocation adjustment for elders residing in different retirement communities. A secondary analysis used findings from a study of relocated elders in order to determine whether certain therapeutic factors were lacking in retirement communities where elders had difficulty in adjusting. Study participants were 104 elders who relocated to six retirement communities in Northeast Ohio. This study analyzed qualitative data from the researchers' observations and field notes and narratives obtained from the elders who participated in the original study. The analysis focused on data that described the environmental characteristics of retirement communities where elders reported less successful adjustment. These environmental characteristics were evaluated for consistency with the characteristics of Shives' therapeutic milieu. Most retirement communities in the study did not fulfill all eight dimensions of a therapeutic milieu as defined by Shives. For example, individualized treatment programs were lacking in most of the retirement communities and the activities offered were not based on individual assessment and did not contribute to personal growth. The findings point to the need to create a more therapeutic milieu in retirement communities in order to facilitate successful readjustment for relocated elders.

Psychometric properties of the pressure to move scale in relocated american older adults: further evaluation

The number of elders who relocate to retirement communities is increasing exponentially, and their ability to exercise free choice, personal control, and autonomy has been associated with relocation adjustment and positive outcomes in regard to physical, emotional, and social well-being. Although a measure of relocation controllability (the degree of personal control associated with the move) exists, there is limited evidence of its psychometric adequacy. This study tested the reliability and validity of the Pressure to Move Scale (PTMS). A convenience sample of 104 American elders who relocated to six Northeast Ohio retirement communities was recruited. Study participants completed the nine-item PTMS and two validation measures during structured interviews. Cronbach's alpha was .71. Homogeneity was supported by item-to-total correlations between .30 and .70, except for two items. Deletion of the item asking about the elder's first impression of relocation improved the alpha to .74. The PTMS was correlated in the expected direction with positive cognitions (r = -.37, p < .01) and relocation adjustment (r = -.62, p < .01), indicating convergent validity. Factor extraction generated three factors, the first reflecting "internal" control factors and the second reflecting "external" control factors; a third factor, containing two items with low item-to-total correlations, reflected another level of "external" control. With preliminary evidence of its reliability and validity, this scale can be a useful tool for screening for pressure to move or involuntary relocation among older adults so that negative outcomes associated with relocation can be prevented through tailored interventions.

The Role of Positive Cognitions in Egyptian Elders’ Relocation Adjustment

Relocation is a major life event for elders and it has been found to adversely affect their adjustment. Resilience theory suggests that adverse effects can be minimized if elders have positive cognitions. In addition, research has shown that positive cognitions are related to independence and healthy, productive lifestyles in older adults. Yet no studies have determined whether the relationship between relocation and adjustment is mediated or moderated by positive cognitions. This study examined these relationships in a sample of 94 cognitively intact elders (aged 60+ years) who had relocated to retirement communities in Alexandria, Egypt. Results showed that relocation controllability had direct effects on positive cognitions and on relocation adjustment. Positive cognitions had a moderating and a partial mediating effect on the relationship between relocation controllability and relocation adjustment. These findings suggest that it is imperative to develop interventions to enhance positive thinking for elders facing the need to relocate.

State regulatory enforcement and nursing home termination from the medicare and medicaid programs

OBJECTIVES

Nursing homes certified by the Medicare and/or Medicaid program are subject to federally mandated and state-enforced quality and safety standards. We examined the relationship between state quality enforcement and nursing home terminations from the two programs.

STUDY DESIGN

Using data from a survey of state licensure and certification agencies and other secondary databases, we performed bivariate and multivariate analyses on the strength of state quality regulation in 2005, and nursing home voluntary terminations (decisions made by the facility) or involuntary terminations (imposed by the state) in 2006-2007.

PRINCIPAL FINDINGS

Involuntary terminations were rarely imposed by state regulators, while voluntary terminations were relatively more common (2.16 percent in 2006-2007) and varied considerably across states. After controlling for facility, market, and state covariates, nursing homes in states implementing stronger quality enforcement were more likely to voluntarily terminate from the Medicare and Medicaid programs (odds ratio = 1.53, p = .018).

CONCLUSIONS

Although involuntary nursing home terminations occurred rarely in most states, nursing homes in states with stronger quality regulations tend to voluntarily exit the publicly financed market. Because of the consequences of voluntary terminations on patient care and access, state regulators need to consider the effects of increased enforcement on both enhanced quality and the costs of termination.

Reasons for Relocation to Retirement Communities

The purpose of this qualitative study is to understand the reasons why elders move to retirement communities and what living in retirement communities is like from the perspective of relocated elders. Several themes emerged following qualitative analysis. The themes reflect three categories, labeled as “pushing” factors, “pulling” factors, and “overlapping” factors. Pushing factors included own or spouse's failing health, getting rid of responsibilities, not helped, facility closed out, and loneliness. Pulling factors were location, familiarity and reputation of the facility, security, and joining friends. The third category reflected both pushing and pulling factors, which overlapped and constituted their reason for moving. The findings help to inform the planning of tailored interventions to address elders' special needs or concerns associated with relocation.

Maintaining continuity of care for nursing home residents: effect of states' Medicaid bed-hold policies and reimbursement rates

OBJECTIVE

Recent public concern in response to states' intended repeal of Medicaid bed-hold policies and report of their association with higher hospitalization rates prompts examination of these policies in ensuring continuity of care within the broader context of Medicaid policies.

DATA SOURCES/STUDY DESIGN

Minimum Data Set assessments of long-stay nursing home residents in April-June 2000 linked to Medicare claims enabled tracking residents' hospitalizations during the ensuing 5 months and determining hospital discharge destination. Multinomial multilevel models estimated the effect of state policies on discharge destination controlling for resident, hospitalization, nursing home, and market characteristics.

RESULTS

Among 77,955 hospitalizations, 5,797 (7.4 percent) were not discharged back to the baseline nursing home. Bed-hold policies were associated with lower odds of transfer to another nursing home (AOR=0.55, 95 percent CI 0.52-0.58) and higher odds of hospitalization (AOR=1.36), translating to 9.5 fewer nursing home transfers and 77.9 more hospitalizations per 1,000 residents annually, and costing Medicaid programs about $201,311. Higher Medicaid reimbursement rates were associated with lower odds of transfer.

CONCLUSIONS

Bed-hold policies were associated with greater continuity of NH care; however, their high cost compared with their small impact on transfer but large impact on increased hospitalizations suggests that they may not be effective.

Maintaining continuity of care for nursing home residents: effect of states' Medicaid bed-hold policies and reimbursement rates

OBJECTIVE

Recent public concern in response to states' intended repeal of Medicaid bed-hold policies and report of their association with higher hospitalization rates prompts examination of these policies in ensuring continuity of care within the broader context of Medicaid policies.

DATA SOURCES/STUDY DESIGN

Minimum Data Set assessments of long-stay nursing home residents in April-June 2000 linked to Medicare claims enabled tracking residents' hospitalizations during the ensuing 5 months and determining hospital discharge destination. Multinomial multilevel models estimated the effect of state policies on discharge destination controlling for resident, hospitalization, nursing home, and market characteristics.

RESULTS

Among 77,955 hospitalizations, 5,797 (7.4 percent) were not discharged back to the baseline nursing home. Bed-hold policies were associated with lower odds of transfer to another nursing home (AOR=0.55, 95 percent CI 0.52-0.58) and higher odds of hospitalization (AOR=1.36), translating to 9.5 fewer nursing home transfers and 77.9 more hospitalizations per 1,000 residents annually, and costing Medicaid programs about $201,311. Higher Medicaid reimbursement rates were associated with lower odds of transfer.

CONCLUSIONS

Bed-hold policies were associated with greater continuity of NH care; however, their high cost compared with their small impact on transfer but large impact on increased hospitalizations suggests that they may not be effective.

Predictors of Mortality Following Involuntary Interinstitutional Relocation

Relocation is traumatic for older adults. There is a paucity of literature about the characteristics of individuals who are most susceptible to negative effects of relocation. Residents of a nursing home that closed were compared with residents of a control institution to determine whether relocation had a significant effect on mortality and to identify risk factors for death. The difference in mortality was significant. A Cox regression model demonstrated that the only variable to achieve significance in predicting mortality was the relocation itself. Research must evaluate strategies that will reduce the negative effects of involuntary relocation.