Nursing home staffing and its relationship to deficiencies

Special Focus Facilities vs Special Focus Facility Candidates: What is the Difference?

OBJECTIVES

This study compares Special Focus Facilities (SFFs) and Special Focus Facility Candidate Facilities (SFFcs) on organizational traits and quality outcomes to evaluate the effectiveness of the SFF program as a quality improvement intervention and inform potential areas for program reform.

DESIGN

This is a retrospective analysis.

SETTINGS AND PARTICIPANTS

Using data from the Centers for Medicare and Medicaid Services archives for 2020, this retrospective study analyzed 247 nursing facilities (50 SFFs and 197 SFFcs).

METHODS

Variables of interest were staffing, profit status, facility size, certification status, number of residents, and complaint citations: t tests, χ2, Fisher's Exact test, and multivariate analysis of variance were used to compare the 2 groups.

RESULTS

From an organizational perspective, SFFs and SFFcs are minimally different. Both groups had similar facility size, profit status, hospital affiliation, continuing care retirement community status, and Medicare/Medicaid certification. Large and for-profit facilities were overrepresented in both groups. SFFs and SFFcs exhibited statistical differences in the number of complaint deficiencies. The groups had no significant difference in staffing levels, category, severity of complaints, or incident reports.

CONCLUSIONS AND IMPLICATION

The study's findings suggest that the SFF program, while resource-intensive, is minimally impactful. The similarities between SFFs and SFFcs raise questions about the program's effectiveness in improving nursing facility care. Previous adjustments to the program may not have successfully achieved the desired quality improvements. This research highlights the need to further evaluate the SFF program's effectiveness as a quality improvement intervention. It also underscores the importance of addressing biases and subjectivity in state survey agency processes, which affect the enrollment of nursing facilities. The study underscores the flaws within the nursing home monitoring system and the 5-star quality rating system, especially when comparing small samples between states.

Primary medical and health preparedness and people's life satisfaction in China: The mediating role of satisfaction with medical and health services

Objective

To examine the association between primary medical and health preparedness (PMHP), satisfaction with medical and health services (SMHS), and life satisfaction (LS).

Methods

Using the latest national representative data from the 2019 Chinese Social Survey and the 2018 Health Statistics Yearbook for each province in China, we conducted multi-level models to test the effect of three aspects of PMHP (the number of primary medical and health institutions (PMHIs), the number of beds in PMHIs, and the number of staff in PMHIs) on LS, and the mediation role of SMHS in this effect.

Results

The number of staff in PMHIs has a significant positive effect on people's LS. Besides, this effect is mediated completely by SMHS. However, the number of PMHIs and the number of beds in PMHIs do not affect LS significantly.

Conclusions

PMHP has a positive impact on LS, but this impact is associated only with the number of staff in PMHIs. Therefore, governments should focus on optimizing human resources in PMHIs to meet the LS needs of individuals.

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

OBJECTIVES

To examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations.

DESIGN

We conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary Files. Other data sources were the Area Health Resource Files, a previously compiled national AL directory, and the US census. Data on state AL regulations were available from a prior study.

SETTING AND PARTICIPANTS

Participants included administrators and DCWs working in assisted living communities serving Medicare beneficiary residents.

METHODS

We employed exploratory factor analysis, examined Pearson correlations, and obtained standardized Cronbach alphas to test the PSC instrument. We estimated linear regression models with the dependent variable being the proportion of positive PSC assessments, for each PSC domain, with SEs clustered at the AL level.

RESULTS

Surveys were completed by 714 administrators and DCWs in 257 ALs. The PSC instrument tested reliable and valid for AL communities. Administrators' and DCWs' perceptions of PSC differed significantly across almost all domains. A 1-unit increase in state regulatory specificity for DCW staffing was associated with a 4.13-percentage point (P < .05) increase in the PSC staffing domain. Associations with regulatory specificity in staff training were also found for other PSC domains.

CONCLUSIONS AND IMPLICATIONS

PSC is an important metric for assessing organizational performance. DCWs have significantly worse perceptions of PSC than do administrators, suggesting it is crucial to understand the source of these differing perceptions. Because state regulations relate to PSC, achieving a comprehensive focus on patient safety in AL may require regulatory action, particularly increasing specificity with regard to staffing and training.

Factors Influencing Admission Decisions in Skilled Nursing Facilities: A Retrospective Quantitative Study (Preprint)

BACKGROUND

Occupancy rates within skilled nursing facilities (SNFs) in the United States have reached a record low. Understanding drivers of occupancy, including admission decisions, is critical for assessing the recovery of the long-term care sector as a whole. We provide the first comprehensive analysis of financial, clinical, and operational factors that impact whether a patient referral to an SNF is accepted or denied, using a large health informatics database.

OBJECTIVE

Our key objectives were to describe the distribution of referrals sent to SNFs in terms of key referral- and facility-level features; analyze key financial, clinical, and operational variables and their relationship to admission decisions; and identify the key potential reasons behind referral decisions in the context of learning health systems.

METHODS

We extracted and cleaned referral data from 627 SNFs from January 2020 to March 2022, including information on SNF daily operations (occupancy and nursing hours), referral-level factors (insurance type and primary diagnosis), and facility-level factors (overall 5-star rating and urban versus rural status). We computed descriptive statistics and applied regression modeling to identify and describe the relationships between these factors and referral decisions, considering them individually and controlling for other factors to understand their impact on the decision-making process.

RESULTS

When analyzing daily operation values, no significant relationship between SNF occupancy or nursing hours and referral acceptance was observed (P>.05). By analyzing referral-level factors, we found that the primary diagnosis category and insurance type of the patient were significantly related to referral acceptance (P<.05). Referrals with primary diagnoses within the category "Diseases of the Musculoskeletal System" are least often denied whereas those with diagnoses within the "Mental Illness" category are most often denied (compared with other diagnosis categories). Furthermore, private insurance holders are least often denied whereas "medicaid" holders are most often denied (compared with other insurance types). When analyzing facility-level factors, we found that the overall 5-star rating and urban versus rural status of an SNF are significantly related to referral acceptance (P<.05). We found a positive but nonmonotonic relationship between the 5-star rating and referral acceptance rates, with the highest acceptance rates found among 5-star facilities. In addition, we found that SNFs in urban areas have lower acceptance rates than their rural counterparts.

CONCLUSIONS

While many factors may influence a referral acceptance, care challenges associated with individual diagnoses and financial challenges associated with different remuneration types were found to be the strongest drivers. Understanding these drivers is essential in being more intentional in the process of accepting or denying referrals. We have interpreted our results using an adaptive leadership framework and suggested how SNFs can be more purposeful with their decisions while striving to achieve appropriate occupancy levels in ways that meet their goals and patients' needs.

Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID-19 pandemic

Objective

To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID‐19.

Study setting

Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020.

Study design

Semi‐structured interviews and focus groups exploring staffing challenges during COVID‐19, strategies used to address them, and recommendations moving forward.

Data collection

We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles.

Principal findings

CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work–life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place.

Conclusions

Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy‐level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person‐centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID‐related innovations (self‐managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry‐wide structural practices that target CNA recruitment and retention.

Medicare Beneficiary Factors Associated with Skilled Nursing Facility Lengths of Stay

The objectives of this study are (1) to identify beneficiary-level characteristics associated with skilled nursing facility (SNF) length of stay (LOS), and (2) to determine if significant differences in LOS exist for vulnerable populations at the individual level or among nursing homes that serve a disproportionate share of vulnerable populations. This study employed 2014-2015 Medicare Long-Term Care Minimum Data Set (MDS v3.0) assessment, fee-for-service claims and enrollment, and 2014 Nursing Home Compare data to examine SNF LOS in Medicare beneficiaries. We used a hierarchical linear model to identify which beneficiary-level characteristics are associated with SNF LOS, while controlling for facility-level characteristics. After controlling for beneficiary-and facility-level characteristics, we found dual eligibility, racial or ethnic minority, depression, and Alzheimer's disease to be associated with longer Medicare covered SNF stays. We found that facilities that served higher proportions of dually eligible individuals tended to have higher average LOS compared to other facilities.

A Call to Address RN, Social Work, and Advanced Practice Registered Nurses in Nursing Homes: Solutions From the Missouri Quality Initiative

BACKGROUND

US nursing homes (NHs) have struggled to overcome a historic pandemic that laid bare limitations in the number and clinical expertise of NH staff.

PROBLEM

For nurse staffing, current regulations require only one registered nurse (RN) on duty 8 consecutive hours per day, 7 days per week, and one RN on call when a licensed practical/vocational nurse is on duty. There is no requirement for a degreed or licensed social worker, and advanced practice registered nurses (APRNs) in NHs cannot bill for services.

APPROACH

It is time to establish regulation that mandates a 24-hour, 7-day-a-week, on-site RN presence at a minimum requirement of 1 hour per resident-day that is adjusted upward for greater resident acuity and complexity. Skilled social workers are needed to improve the quality of care, and barriers for APRN billing for services in NHs need to be removed.

CONCLUSIONS

Coupling enhanced RN and social work requirements with access to APRNs can support staff and residents in NHs.

County-Level Social Determinants of Health and COVID-19 in Nursing Homes, United States, June 1, 2020-January 31, 2021

OBJECTIVES

Nursing homes are a primary setting of COVID-19 transmission and death, but research has primarily focused only on factors within nursing homes. We investigated the relationship between US nursing home-associated COVID-19 infection rates and county-level and nursing home attributes.

METHODS

We constructed panel data from the Centers for Medicare & Medicaid Services (CMS) minimum dataset, CMS nursing home data, 2010 US Census data, 5-year (2012-2016) American Community Survey estimates, and county COVID-19 infection rates. We analyzed COVID-19 data from June 1, 2020, through January 31, 2021, during 7 five-week periods. We used a maximum likelihood estimator, including an autoregressive term, to estimate effects and changes over time. We performed 3 model forms (basic, partial, and full) for analysis.

RESULTS

Nursing homes with nursing (0.005) and staff (0.002) shortages had high COVID-19 infection rates, and locally owned (-0.007) or state-owned (-0.025) and nonprofit (-0.011) agencies had lower COVID-19 infection rates than privately owned agencies. County-level COVID-19 infection rates corresponded with COVID-19 infection rates in nursing homes. Racial and ethnic minority groups had high nursing home-associated COVID-19 infection rates early in the study. High median annual personal income (-0.002) at the county level correlated with lower nursing home-associated COVID-19 infection rates.

CONCLUSIONS

Communities with low rates of nursing home infections had access to more resources (eg, financial resources, staffing) and likely had better mitigation efforts in place earlier in the pandemic than nursing homes that had access to few resources and poor mitigation efforts. Future research should address the social and structural determinants of health that are leaving racial and ethnic minority populations and institutions such as nursing homes vulnerable during times of crises.

The Impact of Nursing Staffs’ Working Conditions on the Quality of Care Received by Older Adults in Long-Term Residential Care Facilities: A Systematic Review of Interventional and Observational Studies

Background: Little documentation exists on relationships between long-term residential care facilities (LTRCFs), staff working conditions and residents’ quality of care (QoC). Supporting evidence is weak because most studies examining this employ cross-sectional designs. Methods: Systematic searches of twelve bibliographic databases sought experimental and longitudinal studies, published up to May 2021, focusing on LTRCF nursing staff’s working conditions and the QoC they provided to older adults. Results: Of the 3577 articles identified, 159 were read entirely, and 11 were retained for inclusion. Higher nursing staff hours worked per resident per day (HPRD) were associated with significant reductions in pressure sores and urinary tract infections. Overall staff qualification levels and numbers of RNs had significant positive influences on QoC. Conclusions: To the best of our knowledge, this systematic review is the first to combine cohort studies with a quasi-experimental study to explore associations between LTRCF nursing staff’s working conditions and older adult residents’ QoC. Human factors (including HPRD, staff turnover, skill mix, staff ratios) and the specific working contribution of RNs had overwhelmingly significant influences on QoC. It seems essential that LTRCF supervisory and decision-making bodies should promote optimal working conditions for nursing staff because these have such a direct impact on residents’ QoC.

First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance

BACKGROUND

The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions.

OBJECTIVE

The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP.

RESEARCH DESIGN

We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis.

RESULTS

The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312.

CONCLUSIONS

SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.

Changing landscape of nursing homes serving residents with dementia and mental illnesses

OBJECTIVE

Nursing homes (NHs) are serving an increasing proportion of residents with cognitive issues (e.g., dementia) and mental health conditions. This study aims to: (1) implement unsupervised machine learning to cluster NHs based on residents' dementia and mental health conditions; (2) examine NH staffing related to the clusters; and (3) investigate the association of staffing and NH quality (measured by the number of deficiencies and deficiency scores) in each cluster.

DATA SOURCES

2009-2017 Certification and Survey Provider Enhanced Reporting (CASPER) were merged with LTCFocUS.org data on NHs in the United States.

STUDY DESIGN

Unsupervised machine learning algorithm (K-means) clustered NHs based on percent residents with dementia, depression, and serious mental illness (SMI, e.g., schizophrenia, anxiety). Panel fixed-effects regressions on deficiency outcomes with staffing-cluster interactions were conducted to examine the effects of staffing on deficiency outcomes in each cluster.

DATA EXTRACTION METHODS

We identified 110,463 NH-year observations from 14,671 unique NHs using CASPER data.

PRINCIPAL FINDINGS

Three clusters were identified: low dementia and mental illnesses (Postacute Cluster); high dementia and depression, but low SMI (Long-stay Cluster); and high dementia and mental illnesses (Cognitive-mental Cluster). From 2009 to 2017, the number of Postacute Cluster NHs increased from 3074 to 5719, while the number of Long-stay Cluster NHs decreased from 6745 to 3058. NHs in Long-stay/Cognitive-mental Clusters reported slightly lower nursing staff hours in 2017. Regressions suggested the effect of increasing staffing on reducing deficiencies is statistically similar across NH clusters. For example, 1 hour increase in registered nurse hours per resident day was associated with -0.67 (standard error [SE] = 0.11), -0.88 (SE = 0.12), and -0.97 (SE = 0.15) deficiencies in Postacute Cluster, Long-stay Cluster, and Cognitive-mental Cluster, respectively.

CONCLUSIONS

Unsupervised machine learning detected a changing landscape of NH serving residents with dementia and mental illnesses, which requires assuring staffing levels and trainings are suited to residents' needs.

Working experience of certified nursing assistants in the greater New York City area during the COVID-19 pandemic: Results from a survey Study

This study aimed to examine the challenges and needs of certified nursing assistants (CNAs) working in nursing homes during the COVID-19 pandemic in the greater New York City area. Between September and November of 2020, a telephone survey was administered to and completed by 208 CNAs in the study area about various aspects of their working experience during COVID-19. CNAs reported significant exposure to COVID-19 and experienced additional emotional and financial strain due to the pandemic. CNAs also expressed the influence of COVID-19 on their work schedules and intent to continue working as CNAs, and strong interest in financial support and further training. This study offers empirical insights into the experiences of CNAs working in nursing homes during the pandemic, which are of unique value to inform future efforts to support CNAs and other long-term care providers in general and during public health emergencies in New York and beyond.

Social Services Involvement in Care Transitions and Admissions in Nursing Homes

Care transitions (CT) are critical junctures in the healthcare delivery process. Effective transitions reduce the need for subsequent transfers between healthcare settings, including nursing homes. Understanding social services (SS) involvement in these processes in nursing homes is important from a quality and holistic care perspective. Using logistic regression, this study examines structural and relational factors identified with higher involvement of SS in care transitions and admissions. SS directors from 924 nursing homes were evaluated in relation to SS involvement in care transitions and admissions processes. Results suggest the level of SS involvement in care transitions and admissions are associated with structural factors such as size of facility, geographical location, ratio of FTE's to beds, ownership status, and standalone SS departments, as well as relational factors, including perceptions and utilization of SS staff by facility leadership, coworkers, and family. Additionally, SS staff with higher levels of expertise and with social work degrees are less involved in admissions tasks.

The Relationship Between Staffing Levels and Consumer Complaints in Nursing Homes

While research tends to find an association of nurse staffing with quality in nursing homes, few studies examine complaints as a quality measure or account for ancillary staff. This study used federal nursing home complaint data to examine how key explanatory variables including nursing and ancillary staffing were associated with numbers of complaints and the likelihood of receiving a complaint. Results support that nursing home staffing is associated with quality. While direct care staffing was associated with fewer complaints, larger effects were found for social service and activities staffing. Increasing ancillary staffing may be a cost-effective way to reduce complaints.

Factors Associated with Assisted Living Facility Closure

BACKGROUND AND OBJECTIVES

Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing home market for the ALF market to examine the organizational, internal, and external factors associated with closure.

RESEARCH DESIGN AND METHODS

Data on 1,939 ALFs operating in 2013 from Florida were used to estimate a logistic regression to examine the organizational, internal, and external factors that were associated with closure between 2013 and 2015.

RESULTS

During the two-year study period, 141 ALFs (7.3%) closed. Significant factors associated with increased odds of closure included fewer beds, not accepting Medicaid, and more deficiencies. Two factors (market concentration and population density) were marginally significant.

DISCUSSION AND IMPLICATIONS

The results of this study confirm the usefulness of a model that includes organizational, internal, and external factors to predict ALF closure. These outcomes highlight the concerns that closure can affect access to community based long-term care, especially for rural older adults, and indicate an expansion of Medicaid acceptance in ALFs could be protective against closure.

COVID-19 Cases and Death in Nursing Homes: The Role of Racial and Ethnic Composition of Facilities and Their Communities

OBJECTIVES

To examine the extent to which the racial and ethnic composition of nursing homes (NHs) and their communities affects the likelihood of COVID-19 cases and death in NHs, and whether and how the relationship between NH characteristics and COVID-19 cases and death varies with the racial and ethnic composition of the community in which an NH is located.

METHODS AND DESIGN

Centers for Medicare & Medicare Services Nursing Home COVID-19 data were linked with other NH- or community-level data (eg, Certification and Survey Provider Enhanced Reporting, Minimum Data Set, Nursing Home Compare, and the American Community Survey).

SETTING AND PARTICIPANTS

NHs with more than 30 occupied beds (N=13,123) with weekly reported NH COVID-19 records between the weeks of June 7, 2020, and August 23, 2020. Measurements and model: Weekly indicators of any new COVID-19 cases and any new deaths (outcome variables) were regressed on the percentage of black and Hispanic residents in an NH, stratified by the percentage of blacks and Hispanics in the community in which the NH was located. A set of linear probability models with NH random effects and robust standard errors were estimated, accounting for other covariates.

RESULTS

The racial and ethnic composition of NHs and their communities were both associated with the likelihood of having COVID-19 cases and death in NHs. The racial and ethnic composition of the community played an independent role in the likelihood of COVID-19 cases and death in NHs, even after accounting for the COVID-19 infection rate in the community (ie, daily cases per 1000 people in the county). Moreover, the racial and ethnic composition of a community modified the relationship between NH characteristics (eg, staffing) and the likelihoods of COVID-19 cases and death.

CONCLUSIONS AND IMPLICATIONS

To curb the COVID-19 outbreaks in NHs and protect vulnerable populations, efforts may be especially needed in communities with a higher concentration of racial and ethnic minorities. Efforts may also be needed to reduce structural racism and address social risk factors to improve quality of care and population health in communities of color.

Determinants of regulatory compliance in health and social care services: a systematic review protocol

Background: The delivery of high quality health and social care services is a fundamental goal for health systems worldwide. Identifying the determinants of quality is a complex task as there are a myriad of variables to choose from. Researchers in this field have assessed a range of organisational and environmental factors (for example: staff composition, facility ownership, facility size) for an association with various quality metrics. Less attention has been paid to the determinants of compliance with quality regulation. Identifying the determinants of compliance has the potential to improve regulatory processes and can inform quality improvement initiatives undertaken by service providers and policy makers. This protocol describes a systematic review which will review literature from a wide range of study designs and sources to develop an overview of the determinants of regulatory compliance in health and social care services. Methods: A wide range of study designs and grey literature will be sought for this review. Searches will be conducted using PubMed, MEDLINE, PsycInfo, SocINDEX and CINAHL databases. The studies included in the review will be subject to quality appraisal with reference to the collection of tools available from the Joanna Briggs Institute. Data extraction will be informed by the Consolidated Framework for Implementation Research (CFIR). A narrative synthesis will be conducted on the barriers, facilitators and factors associated with compliance, with reference to the concepts mapped onto the CFIR. GRADE-CERQual will be used to grade the overall body of evidence. Conclusion: The findings of this review will be useful to regulators to inform regulatory policy and practice. Service providers and policy makers may also use the findings to inform quality improvement initiatives aimed at improving compliance and quality across a range of health and social care services.

Delivering, funding, and rating safe staffing levels and skills mix in aged care

BACKGROUND

Staffing levels and skill mix are critical issues within residential aged care. The positive impact of a sufficient number and skills mix of staff is upheld by abundant evidence within and beyond the sector. While being able to determine suitable staffing levels and skills mix to provide care to nursing home residents is vital, having an appropriate approach to funding the delivery of care is also critical. Beyond determining staffing levels and skills mix and funding care delivery, transparently rating the adequacy of staffing is also important to enable informed decision-making amongst consumers, policy makers, staff, and other stakeholders. There are existing tools for determining nursing home staffing levels and skills mix, funding care, and rating and reporting staffing, however there appears to be ongoing confusion regarding how these different tools might work together to achieve different things in order to ensure safe, quality care.

OBJECTIVES

In order to explain the importance of ensuring at least a minimum number (staffing level) of the right kind of staff (skills mix) to provide care to nursing home residents, in this paper we briefly explain key differences and interrelationships between three tools; one for determining staffing and skills mix, one for determining funding, and one for rating and reporting the level of staffing within a facility as a measure of quality.

RESULTS

Our explanation of the three existing tools has resulted in the development of a conceptual model for how minimum staffing levels and skills mix supports the delivery of safe, quality care and how this can be understood in relation to determining, funding, and rating staffing levels and skills mix.

CONCLUSIONS

Our conceptual model of how determining, funding, and rating staffing levels and skills mix relate to one another and fulfil different but related purposes can be used to demonstrate how minimum staffing levels and skills mix can be understood as foundational to ensuring respectful, safe, quality care.

Determinants of regulatory compliance in health and social care services: a systematic review protocol

Background: The delivery of high quality health and social care services is a fundamental goal for health systems worldwide. Identifying the determinants of quality is a complex task as there are a myriad of variables to choose from. Researchers in this field have assessed a range of organisational and environmental factors (for example: staff composition, facility ownership, facility size) for an association with various quality metrics. Less attention has been paid to the determinants of compliance with quality regulation. Identifying the determinants of compliance has the potential to improve regulatory processes and can inform quality improvement initiatives undertaken by service providers and policy makers. This protocol describes a systematic review which will review literature from a wide range of study designs and sources to develop an overview of the determinants of regulatory compliance in health and social care services. Methods: A wide range of study designs and grey literature will be sought for this review. Searches will be conducted using PubMed, MEDLINE, PsycInfo, SocINDEX and CINAHL databases. The studies included in the review will be subject to quality appraisal with reference to the collection of tools available from the Joanna Briggs Institute. Data extraction will be informed by the Consolidated Framework for Implementation Research (CFIR). A narrative synthesis will be conducted on the barriers, facilitators and factors associated with compliance, with reference to the concepts mapped onto the CFIR. GRADE-CERQual will be used to grade the overall body of evidence. Conclusion: The findings of this review will be useful to regulators to inform regulatory policy and practice. Service providers and policy makers may also use the findings to inform quality improvement initiatives aimed at improving compliance and quality across a range of health and social care services.

Determinants of regulatory compliance in health and social care services: a systematic review protocol

Background: The delivery of high quality health and social care services is a fundamental goal for health systems worldwide. The measurement of quality in health and social care services is a complex task as there are a myriad of determinants and outcome measures to choose from. Researchers in this field have assessed a range of organisational and environmental factors (for example: staff composition, facility ownership, facility size) for an association with various measurements for quality. Compliance with regulations is one such quality measure. Compliance with regulations is variable and the determinants of this variability are under-investigated. Identifying the determinants of compliance has the potential to improve regulatory processes and can inform quality improvement initiatives undertaken by service providers and policy makers. This protocol describes a systematic review which will review literature from a wide range of study designs and sources to develop an overview of the determinants of regulatory compliance in health and social care services. Methods: A wide range of study designs and grey literature will be sought for this review. Searches will be conducted using PubMed, MEDLINE, PsycInfo, SocINDEX and CINAHL databases. The studies included in the review will be subject to quality appraisal with reference to the collection of tools available from the Joanna Briggs Institute. Data extraction will be informed by the Consolidated Framework for Implementation Research (CFIR). A narrative synthesis will be conducted with reference to the CFIR and Normalisation Process Theory (NPT). GRADE-CERQual will be used to grade the overall body of evidence. Conclusion: The findings of this review will be useful to regulators to inform regulatory policy and practice. Service providers and policy makers may also use the findings to inform quality improvement initiatives aimed at improving compliance and quality across a range of health and social care services.

Care Deficiencies and Super-Organization of American Nursing Homes in Hospital Referral Region

Super-organization has been associated with worse care quality in nursing homes. Previous research on the chain ownership of American nursing homes excluded government facilities in public-private partnerships, and focused on corporate entities. This longitudinal study proposes a novel method of demarcating the latent ownership networks of for-profit, government and non-profit nursing homes in the United States through use of open data and social network analysis. Facility characteristics and care quality measures were analyzed from an ecological cohort of 9,001 American nursing homes that had a registered organization for owner, and were reimbursed through Medicare or Medicaid. Information was obtained from the Nursing Home Compare open datasets at five semi-annual processing dates from March 2016 to March 2018. Ownership networks of American nursing homes were constructed using the exact legal name of registered organizations. As hospital discharge is a routine admission source of nursing home residents, hospital referral region was actualized to demarcate focal area. Utilizing Bayesian hierarchical models, the association between nursing home super-organization in hospital referral region (inferred by degree-based centrality and Herfindahl-Hirschman Index) to scope of cited care deficiencies (denoted by Total Weighted Health Survey Score) was explored. The percentage of nursing homes having super-organization increased from 56.8 to 56.9% over the 2-year period. During this interval, the mean size of nursing home ownership group in hospital referral region increased from 3.11 to 3.23 facilities. Overall, super-organization in hospital referral region was not associated with care deficiencies in American nursing homes. However, being part of an ownership group with more facilities was beneficial for care quality among nursing homes with super-organization.

Determinants of Successful Nursing Home Accreditation

OBJECTIVES

This study examined the factors associated with better accreditation outcomes among nursing homes.

METHOD

A total of 538 nursing homes in Taiwan were included in this study. Measures included accreditation scores, external factors (household income, Herfindahl-Hirschman Index, old-age dependency ratio, population density, and number of older adult households), organizational factors (hospital-based status, chain-affiliated status, occupancy rate, the number of registered nurses or nurse aides per bed, and bed size), and internal factors (accountability, deficiencies, person-centered care, nursing skills, quality control, and integrated care).

RESULTS

Bed size, hospital-based status, accountability, deficiencies, person-centered care, nursing skills, quality control, and integrated care were found to predict accreditation.

CONCLUSION

Among all variables in this study, the quality indicators contributed to the most variation, followed by organizational factors. External environmental factors played a minor role in predicting accreditation. A focus on quality of care would benefit not only the residents of a nursing home but also facilitate its accreditation.

Nursing Home Culture Change Practices and Survey Deficiencies: A National Longitudinal Panel Study

BACKGROUND AND OBJECTIVES

Nursing home (NH) adoption of culture change practices has substantially increased in recent decades. We examined how increasing adoption of culture change practices affected the prevalence of health, severe health, and quality of life (QoL) deficiencies.

RESEARCH DESIGN AND METHODS

Novel data on culture change practice adoption from a nationally representative NH panel (N = 1,585) surveyed in 2009/2010 and 2016/2017 were used to calculate change in practice adoption scores in 3 culture change domains (resident-centered care, staff empowerment, physical environment). These data were linked to data on health, severe health, and QoL deficiencies and facility-level covariates. Multinomial logistic regression models, with survey weights and inverse probability of treatment weighting, examined how increased culture change practice adoption related to change in deficiencies.

RESULTS

We generally observed less increase in deficiencies when culture change practices increased. However, after weighting and controlling for baseline deficiencies and culture change scores, we found few statistically significant effects. Still, results show increased physical environment practices resulted in a higher likelihood of decreases or no change (vs increases) in QoL deficiencies; increased resident-centered care practices resulted in decreases or no change (vs increases) in health deficiencies; and increased staff empowerment practices resulted in a higher likelihood of no change (vs increases) in severe health deficiencies.

DISCUSSION AND IMPLICATIONS

This study provides some evidence that culture change practices can help reduce the risk of increasing some types of deficiencies, but the impact of increases in each culture change domain related differently to different types of deficiencies.

A Rising Tide Lifts "Related" Boats-Post-Acute Care Quality Improvement is Associated with Improvement in Long-Term Care Quality in Nursing Homes

OBJECTIVES

To examine the relationship between post-acute care (PAC) quality improvement and long-term care (LTC) quality changes.

DESIGN

Observational study using national nursing home data from Nursing Home Compare linked to Brown University's LTCFocus data.

SETTING AND PARTICIPANTS

Free-standing nursing homes serving PAC and LTC residents in the United States.

METHODS

This study used pooled cross-sectional analysis with nursing home-level data from 2005 to 2010 (12,150 unique nursing homes). We used fixed effects models to examine the association between a 1-year change in PAC quality and a 1-year change in LTC quality, with a specific focus on related care domains.

RESULTS

Strong and positive associations were found between related PAC and LTC care domains, particularly between the PAC and LTC influenza vaccination care domains (β = 0.30, P < .001) and the PAC and LTC pneumococcal vaccination care domains (β = 0.55, P < .001). Meanwhile, model results showed PAC quality changes essentially had no associations with unrelated LTC care domains.

CONCLUSIONS AND IMPLICATIONS

This is the first study that examines the association of changes in quality between 2 overlapping but different care domains (ie, PAC and LTC) using multiple quality measures. Our findings indicate that nursing homes can manage concurrent quality improvement in PAC and LTC, particularly on care domains that are related. More research is needed to examine the mechanism that enables such concurrent quality improvement.

Nursing Staff Time and Care Quality in Long-Term Care Facilities: A Systematic Review

BACKGROUND AND OBJECTIVES

In long-term care (LTC) facilities, nursing staff are important contributors to resident care and well-being. Despite this, the relationships between nursing staff coverage, care hours, and quality of resident care in LTC facilities are not well understood and have implications for policy-makers. This systematic review summarizes current evidence on the relationship between nursing staff coverage, care hours, and quality of resident care in LTC facilities.

RESEARCH DESIGN AND METHODS

A structured literature search was conducted using four bibliographic databases and gray literature sources. Abstracts were screened by two independent reviewers using Covidence software. Data from the included studies were summarized using a pretested extraction form. The studies were critically appraised, and their results were synthesized narratively.

RESULTS

The systematic searched yielded 15,842 citations, of which 54 studies (all observational) were included for synthesis. Most studies (n = 53, 98%) investigated the effect of nursing staff time on resident care. Eleven studies addressed minimum care hours and quality of care. One study examined the association between different nursing staff coverage models and resident outcomes. Overall, the quality of the included studies was poor.

DISCUSSION AND IMPLICATIONS

Because the evidence was inconsistent and of low quality, there is uncertainty about the direction and magnitude of the association between nursing staff time and type of coverage on quality of care. More rigorously designed studies are needed to test the effects of different cutoffs of care hours and different nursing coverage models on the quality of resident care in LTC facilities.

The burden of gastroenteritis outbreaks in long-term care settings in Philadelphia, 2009-2018

OBJECTIVE

Gastroenteritis causes significant morbidity and mortality in long-term care facility (LTCF) residents, a growing population within the United States. We set out to better understand gastroenteritis outbreaks in LTCF by identifying outbreak and facility characteristics associated with outbreak incidence as well as outbreak duration and size.

DESIGN

We conducted a retrospective cross-sectional study on LTCFs in Philadelphia County from 2009 to 2018. Outbreak characteristics and interventions were extracted from Philadelphia Department of Public Health (PDPH) database and quality data on all LTCFs was extracted from Centers for Medicare and Medicaid Services Nursing Home Compare database.

RESULTS

We identified 121 gastroenteritis outbreaks in 49 facilities. Numbers of affected patients ranged from 2 to 211 patients (median patient illness rate, 17%). Staff were reported ill in 94 outbreaks (median staff illness rate, 5%). Outbreak facilities were associated with higher occupancy rates (91% vs 88%; P = .033) and total bed numbers (176 vs 122; P = .071) compared to nonoutbreak facilities. Higher rates of staff illness were associated with prolonged outbreaks (13% vs 4%; P < .001) and higher patient illness rates (9% vs 4%; P = .012). Prolonged outbreaks were associated with lower frequency of cohorting for outbreak management (13% vs 41%; P = .046).

CONCLUSION

This study is the largest published analysis of gastroenteritis outbreaks in LTCFs. Facility characteristics and staff disease activity were associated with more severe outbreaks. Heightened surveillance for gastrointestinal symptoms among staff and increased use of cohorting might reduce the risk of prolonged gastroenteritis outbreaks in LTCF.

Shortages of Staff in Nursing Homes During the COVID-19 Pandemic: What are the Driving Factors?

Objectives

During the Coronavirus Disease 2019 (COVID-19) pandemic, US nursing homes (NHs) have been under pressure to maintain staff levels with limited access to personal protection equipment (PPE). This study examines the prevalence and factors associated with shortages of NH staff during the COVID-19 pandemic.

Design

We obtained self-reported information on staff shortages, resident and staff exposure to COVID-19, and PPE availability from a survey conducted by the Centers for Medicare and Medicaid Services in May 2020. Multivariate logistic regressions of staff shortages with state fixed-effects were conducted to examine the effect of COVID-19 factors in NHs.

Setting and Participants

11,920 free-standing NHs.

Measures

The dependent variables were self-reported shortages of licensed nurse staff, nurse aides, clinical staff, and other ancillary staff. We controlled for NH characteristics from the most recent Nursing Home Compare and Certification and Survey Provider Enhanced Reporting, market characteristics from Area Health Resources File, and state Medicaid reimbursement calculated from Truven data.

Results

Of the 11,920 NHs, 15.9%, 18.4%, 2.5%, and 9.8% reported shortages of licensed nurse staff, nurse aides, clinical staff, and other staff, respectively. Georgia and Minnesota reported the highest rates of shortages in licensed nurse and nurse aides (both >25%). Multivariate regressions suggest that shortages in licensed nurses and nurse aides were more likely in NHs having any resident with COVID-19 (adjusted odds ratio [AOR] = 1.44, 1.60, respectively) and any staff with COVID-19 (AOR = 1.37, 1.34, respectively). Having 1-week supply of PPE was associated with lower probability of staff shortages. NHs with a higher proportion of Medicare residents were less likely to experience shortages.

Conclusions/Implications

Abundant staff shortages were reported by NHs and were mainly driven by COVID-19 factors. In the absence of appropriate staff, NHs may be unable to fulfill the requirement of infection control even under the risk of increased monetary penalties.

Leadership Perceptions and Practices of Hospitality in Senior Care

Senior care providers are increasingly focused on hospitality to distinguish themselves from competitors. A mixed-methods approach was used to examine perceptions of hospitality from leadership (i.e., administrators of nursing homes and assisted living facilities) and use of hospitality practices across settings and lines of service. Results indicated that hospitality practices readily exist in senior care settings (i.e., nursing homes, assisted living facilities), but may be referred to by names other than hospitality. There also appear to be more similarities than differences in practices across long-term care service lines (i.e., short- and long-stay nursing home residents, assisted living), suggesting that, regardless of provider type, hospitality in senior care is becoming part of the expected culture and cadre of services for residents. Overall, findings suggest hospitality practices are related to providers' census, payer mix, and organizational performance.

Suicidal Ideation in US Nursing Homes: Association With Individual and Facility Factors

OBJECTIVE

To assess prevalence of suicidal ideation (SI) among new postacute and long-stay nursing home (NH) admissions and examine the associations with individual and NH-level factors.

SETTING/PARTICIPANTS

A total of 1,864,102 postacute and 304,106 long-stay admissions to just over 15,000 NHs between 7/1/2014 and 6/30/2015.

MEASUREMENT

Using 100% of the national Minimum Data Set 3.0, we identified SI and key covariates. SI was based on responses to one item on the PHQ-9 scale. For postacute residents, SI was measured at admission and discharge. For long-stay residents, SI was assessed at admission and assessments closest to 90, 180, and 365 days thereafter. Patient sociodemographics, functional and cognitive status, comorbid conditions, and other covariates were included as independent variables, as were several NH-level factors. Logistic regression models were fit to estimate SI risk at admission and at subsequent time intervals.

RESULTS

Observed 2-week prevalence rates of SI were highest at admission (1.24% for postacute and 1.84% for long stays) and declined thereafter at each subsequent time interval. The odds of SI were significantly increased for residents with severe depression at admission and all subsequent intervals. Residents in for-profits had significantly lower rates of SI, compared with those in not-for-profits.

CONCLUSIONS

Our findings demonstrate that SI risk in NHs is highest at admission and subsequently declines. We found several potentially modifiable individual-level risk factors for SI. The identification of SI may be seriously underreported in for-profit-facilities. Future research may be needed to explore how the PHQ-9 item on SI is understood by residents and recorded by staff.

Exploring social-based discrimination among nursing home certified nursing assistants

Certified nursing assistants (CNAs) provide the majority of direct care to nursing home residents in the United States and, therefore, are keys to ensuring optimal health outcomes for this frail older adult population. These diverse direct care workers, however, are often not recognized for their important contributions to older adult care and are subjected to poor working conditions. It is probable that social-based discrimination lies at the core of poor treatment toward CNAs. This review uses perspectives from critical social theory to explore the phenomenon of social-based discrimination toward CNAs that may originate from social order, power, and culture. Understanding manifestations of social-based discrimination in nursing homes is critical to creating solutions for severe disparity problems among perceived lower-class workers and subsequently improving resident care delivery.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Staff mix and nursing home quality by level of case mix in Korea

AIM

The purpose of the present study was to identify the relationship between staff mix in nursing homes and quality of care by level of case mix in Korea.

METHODS

Data used in the present study came from Long-Term Care Insurance claims data with basic information of nursing homes with >29 beds (n = 1137) and quality evaluation reports. Staff mix was calculated as the number of nursing staff, social workers and care workers per total staff number.

RESULTS

In multinomial logistic regression analyses, institutions with a higher ratio of social workers were classified as top-quality class institutes after controlling ownership, location, size and percentage of high level of care needs residents. In analyzing the higher case mix nursing homes, institutions with a high ratio of nursing staff and social workers were more likely to be classified as top-quality class than the lowest class institutions. However, there was no significant association between quality of care and ratio of staff mix in the lower case mix nursing homes.

CONCLUSIONS

A higher staff mix was positively related to nursing home quality of care, but the relationship was affected by case mix of residents' care demand. Therefore, the current minimum staffing standard for personnel in nursing homes should be modified considering the acuity of the residents. Geriatr Gerontol Int 2019; 19: 438-443.

Comparative effectiveness analysis of Medicare dialysis facility survey processes

BACKGROUND

To assure and improve the quality and safety of care provided by dialysis facilities, federal oversight has been conducted through periodic survey assessment. However, with the growing number of individuals living with ESRD and dialysis facilities, state survey agencies have faced challenges in time and resources to complete survey activities. Therefore, the survey process ('Basic Survey' used prior to 2013) was redesigned in order to develop a more efficient process ('Core Survey' newly implemented since 2013). The purpose of this analysis was to evaluate and compare dialysis facility survey outcomes between the Core and Basic Survey processes, using a causal inference technique. The survey outcomes included condition-level citations, total citations (condition- and standard-level), and citation rate per survey-hour.

METHODS

For comparisons of non-randomly assigned survey types, propensity score matching was used. Data were drawn from CMS' Quality Improvement Evaluation System (QIES) database from January 1, 2013 through July 31, 2014. Covariates available included survey type, facility characteristics (state, urban, practices catheter reuse, dialysis modalities offered, number of patients, mortality, hospitalization, infection) and survey-related characteristics (number of surveyors, time since last survey).

RESULTS

Compared to the Basic Survey, the Core Survey identified 10% more total citations (P = 0.001) and identified condition-level citations more frequently, although the latter finding did not reach statistical significance. These findings suggest an increase of 10% in citation rate (i.e. ratio between citations and survey time) with the Core survey process (P = 0.002).

CONCLUSIONS

Greater efficiency has implications for attenuating the time-intensive burden of the state survey process, and improving the safety and quality of care provided by dialysis facilities.

The Impact of Long-Term Care Ombudsman Presence on Nursing Home Survey Deficiencies

OBJECTIVES

Each year states are required to survey nursing homes (NHs), including issuing deficiency citations when regulatory standards are not met. These deficiency citations can have substantial consequences for NHs. Because it is imperative that the survey process is conducted consistently across facilities, this study aims to determine whether deficiency outcomes vary with the presence of a long-term care ombudsman at the survey.

DESIGN

A retrospective secondary data analysis of facility-level data using panel regression techniques was used to determine whether the presence of an ombudsman at a survey affected deficiency outcomes. Additional analysis assured the results were not due to ombudsmen being more likely to be present at poorer performing facilities.

SETTING AND PARTICIPANTS

The data include freestanding NHs in the United States with at least 2 surveys between 2009 and 2015, resulting in 95,237 surveys from 14,996 unique NHs.

MEASURES

The number and deficiency score were analyzed for 4 types of deficiencies: all deficiencies and the broad categories of quality of care, quality of life, and administration. The key explanatory variable is the presence of an ombudsman at survey. The regression model controlled for other important facility-level covariates.

RESULTS

The presence of an ombudsman varied across states (range: 0.8%-82.0%; mean: 29.9%). Regression analysis found ombudsman presence was associated with a 0.2 increase in the number of deficiencies and 2.2-point increase in deficiency score. These correspond to a 3.9% and 5.9% increase, respectively. On a percentage basis, the largest effects were found for quality of life and administration deficiencies.

CONCLUSIONS/IMPLICATIONS

By being present at surveys, ombudsmen may bring issues to the attention of state surveyors, resulting in worse deficiency outcomes during annual surveys. This can have consequences for NHs, and further work is needed to assure that ombudsmen are using their resources where they are most needed.

Assessing the Quality of Nursing Homes in Managed Care Organizations: Integrating LTSS for Dually Eligible Beneficiaries

Little is known about the quality of nursing homes in managed care organizations (MCOs) networks. This study (1) described decision-making criteria for selecting nursing home networks and (2) compared selected quality indicators of network and nonnetwork nursing homes. The sample was 17 MCOs participating in a California demonstration that provided integrated long-term services and supports to dually eligible enrollees in 2017. The findings showed that the MCOs established a broad network of nursing homes, with only limited attention to using quality criteria. Network nursing homes (602) scored significantly lower on 6 selected quality measures than nonnetwork (117) nursing homes. Low registered nurse and total nurse staffing were strong predictors of network nursing homes controlling for facility characteristics. Managed care organizations should consider greater transparency about the quality of their nursing homes and use specific quality criteria to improve the quality of their networks.

Pain perception of older adults in nursing home and home care settings: evidence from China

Background

In the past decade, the number of long-term care (LTC) services for older adults in China has grown annually by an average of 10%. Older adults, their family members, and policymakers in China are concerned about patient outcomes in different care settings because older adults who have a similar functional status and LTC needs may choose either nursing home care or home care. The aim of this study was to compare pain perception in nursing home care and home care settings for physically dependent older adults in China.

Methods

Multi-stage sampling method was used to recruit respondents aged 65 and older from Yichang City, China, in 2015. The researchers employed a two-step analytical strategy—zero-inflated ordered probit regression followed by propensity score matching method—to model the effect of contrasting residence types on pain perception.

Results

Zero-inflated ordered probit regression analysis with participants unmatched (n = 484) showed that compared with older adults who received home care, those who received nursing home care did not have more severe pain (β = 0.088, SE = 0.196, p = 0.655). After propensity-score matching, the research found that older adults in the home care group perceived less pain compared with the nursing home group (β = 0.489, SE = 0.169, p = 0.004).

Conclusions

The older adults who received home care perceived significantly less pain than the nursing home residents. The pain of older adults may differ based on the type of LTC services and therapy intensity they received, and home care might lead to less pain and better comfort than nursing home care.

Cost-Effective Adjustments to Nursing Home Staffing to Improve Quality

Health care providers face fixed reimbursement rates from government sources and need to carefully adjust staffing to achieve the highest quality within a given cost structure. With data from the Certification and Survey Provider Enhanced Reports (1999-2015), this study holistically examined how staffing levels affect two publicly reported measures of quality in the nursing home industry, the number of deficiency citations and the deficiency score. While higher staffing consistently yielded better quality, the largest quality improvements resulted from increasing administrative registered nurses and social service staffing. After adjusting for wages, the most cost-effective investment for improving overall deficiency outcomes was increasing social services. Deficiencies related to quality of care were improved most by increasing administrative nursing and social service staff. Quality of life deficiencies were improved most by increasing social service and activities staff. Approaches to improve quality through staffing adjustments should target specific types of staff to maximize return on investment.

How does availability of county-level healthcare services shape terminal decline in well-being?

Both lifespan psychology and life course sociology highlight that contextual factors influence individual functioning and development. In the current study, we operationalize context as county-level care services in inpatient and outpatient facilities (e.g., number of care facilities, privacy in facilities) and investigate how the care context shapes well-being in the last years of life. To do so, we combine 29 waves of individual-level longitudinal data on life satisfaction from now deceased participants in the nationwide German Socio-Economic Panel Study (N = 4557; age at death: M = 73.35, SD = 14.20; 47% women) with county-level data from the Federal Statistical Office. Results from three-level growth models revealed that having more inpatient care facilities, more employees per resident, and more staff in administration are each uniquely associated with higher late-life well-being, independent of key individual (age at death, gender, education, disability) and county (affluence, demographic composition) characteristics. Number of employees in physical care, residential comfort, and flexibility and care indicators in outpatient institutions were not found to be associated with levels or change in well-being. We take our results to provide empirical evidence that some contextual factors shape well-being in the last years of life and discuss possible routes how local care services might alleviate terminal decline.

Financial performance, employee well-being, and client well-being in for-profit and not-for-profit nursing homes: A systematic review

BACKGROUND

Expanding the opportunities for for-profit nursing home care is a central theme in the debate on the sustainable organization of the growing nursing home sector in Western countries.

PURPOSES

We conducted a systematic review of the literature over the last 10 years in order to determine the broad impact of nursing home ownership in the United States. Our review has two main goals: (a) to find out which topics have been studied with regard to financial performance, employee well-being, and client well-being in relation to nursing home ownership and (b) to assess the conclusions related to these topics. The review results in two propositions on the interactions between financial performance, employee well-being, and client well-being as they relate to nursing home ownership.

METHODOLOGY/APPROACH

Five search strategies plus inclusion and quality assessment criteria were applied to identify and select eligible studies. As a result, 50 studies were included in the review. Relevant findings were categorized as related to financial performance (profit margins, efficiency), employee well-being (staffing levels, turnover rates, job satisfaction, job benefits), or client well-being (care quality, hospitalization rates, lawsuits/complaints) and then analyzed based on common characteristics.

FINDINGS

For-profit nursing homes tend to have better financial performance, but worse results with regard to employee well-being and client well-being, compared to not-for-profit sector homes. We argue that the better financial performance of for-profit nursing homes seems to be associated with worse employee and client well-being.

PRACTICAL IMPLICATIONS

For policy makers considering the expansion of the for-profit sector in the nursing home industry, our findings suggest the need for a broad perspective, simultaneously weighing the potential benefits and drawbacks for the organization, its employees, and its clients.

Using a new interrater reliability method to test the modified Oulu Patient Classification instrument in home health care

Aim

To test the interrater reliability of the modified Oulu Patient Classification instrument, using a multiple parallel classification method based on oral case presentations in home health care in Norway.

Design

Reliability study.

Methods

Data were collected at two municipal home healthcare units during 2013-2014. The reliability of the modified OPCq instrument was tested using a new multiple parallel classification method. The data material consisted of 2 010 parallel classifications, analysed using consensus in per cent and Cohen's kappa. Cronbach's alpha was used to measure internal consistency.

Results

For parallel classifications, consensus varied between 64.78-77.61%. Interrater reliability varied between 0.49-0.69 (Cohen's kappa), the internal consistency between 0.81-0.94 (Cronbach's alpha). Analysis of the raw scores showed 27.2% classifications had the same points, 39.1% differed one point, 17.9% differed two points and 16.5% differed ≥3 points.

Nursing Home Chain Affiliation and Its Impact on Specialty Service Designation for Alzheimer Disease

Specialty care units (SCUs) in nursing homes (NHs) grew in popularity during the 1990s to attract residents while national policies and treatment paradigms changed. Alzheimer disease has consistently been the dominant form of SCU. This study explored the extent to which chain affiliation, which is common among NHs, affected SCU bed designation. Using data from the Online Survey Certification and Reporting (OSCAR) from 1996 through 2010 with 207 431 NH-year observations, we described trends and compared chain-affiliated NHs with independent NHs. Designation of beds for Alzheimer disease SCUs grew from 1996 to 2003 and then declined. At the peak, 19.6% of all NHs had at least one Alzheimer disease SCU bed. In general, chain affiliation promoted Alzheimer disease SCU bed designation across time, chain size, and NH profit status. During the period of largest growth from 1996 to 2003, the likelihood of designation of Alzheimer disease SCU beds was 1.55 percentage points higher among for-profit NHs affiliated with large chains than independent for-profit NHs ( P < .001) and remained 1.28 percentage points higher from 2004 to 2010. However, chain-affiliated NHs generally had a lower percentage of residents with dementia than independent NHs. For example, although for-profit NHs affiliated with large chains had more Alzheimer disease SCU beds, they had nearly 3% fewer residents with dementia than independent NHs ( P < .001). We conclude that organizational decisions to designate beds for Alzheimer disease SCUs may be related to marketing strategies to attract residents since adoption of Alzheimer disease SCUs has fluctuated over time, but did not appear driven by demand.

Analyses of Complaints, Investigations of Allegations, and Deficiency Citations in United States Nursing Homes

Quality of care in nursing homes has been evaluated from varying perspectives, but few studies analyze complaints made to surveyors. This study analyzed complaints, investigations, and citations for nursing homes nationwide. Using the complaint and survey data sets, analyses match nursing home complaints with findings of investigations conducted. Results showed the average complaint rate was 13.3 complaints per 100 residents and that 43.2% of complaint allegations were substantiated, with complaints about care and services provided being the most prevalent. Variability was noted among the Centers for Medicare and Medicaid Services regions and, on average, 47.5% of facilities had five or more complaints in a given year. While additional research could evaluate the effect of complaint investigations on nursing home quality, results indicated that complaints and subsequent investigations provide further information regarding quality for residents. Results also suggest improvements in the training for surveyors and more consistency across Centers for Medicare and Medicaid Services survey regions.

Readily Identifiable Risk Factors of Nursing Home Residents' Oral Hygiene: Dementia, Hospice, and Length of Stay

BACKGROUND/OBJECTIVES

The poor oral hygiene of nursing home (NH) residents is a matter of increasing concern, especially because of its relationship with pneumonia and other health events. Because details and related risk factors in this area are scant and providers need to be able to easily identify those residents at most risk, this study comprehensively examined the plaque, gingival, and denture status of NH residents, as well as readily available correlates of those indicators of oral hygiene, including items from the Minimum Data Set (MDS).

DESIGN

Oral hygiene assessment and chart abstract conducted on a cross-section of NH residents.

SETTING

NHs in North Carolina (N = 14).

PARTICIPANTS

NH residents (N = 506).

MEASUREMENTS

Descriptive data from the MDS and assessments using three standardized measures: the Plaque Index for Long-Term Care (PI-LTC), the Gingival Index for Long-Term Care (GI-LTC), and the Denture Plaque Index (DPI).

RESULTS

Oral hygiene scores averaged 1.7 (of 3) for the PI-LTC, 1.5 (of 4) for the GI-LTC, and 2.2 (of 4) for the DPI. Factors most strongly associated with poor oral hygiene scores included having dementia, being on hospice care, and longer stay. MDS ratings of gingivitis differed significantly from oral hygiene assessments.

CONCLUSIONS

The findings identify resident subgroups at especially high risk of poor oral health who can be targeted in quality improvement efforts related to oral hygiene; they also indicate need to improve the accuracy of how MDS items are completed.

Comparing the Contributions of Acute and Postacute Care Facility Characteristics to Outcomes After Hospitalization for Hip Fracture

OBJECTIVE

To quantify the contribution of acute versus postacute care factors to survival and functional outcomes after hip fracture.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using Medicare data; subjects included previously ambulatory nursing home residents hospitalized for hip fracture between 2005 and 2009.

METHODS

We used logistic regression to measure the associations of hospital and nursing home factors with functional and survival outcomes at 30 and 180 days among patients discharged to a nursing facility; we quantified the contribution of hospital versus nursing home factors to outcomes by the ω statistic.

RESULTS

Among 45,996 hospitalized patients, 1814 (3.9%) died during hospitalization. A total of 42,781 (93%) were discharged alive to a nursing home. Of these, 12,126 (28%) died within 180 days and 20,479 (48%) died or were newly unable to walk within 180 days. Hospital characteristics were not consistently associated with outcomes. Multiple nursing home characteristics predicted 30- and 180-day outcomes, including bed count, chain membership, and performance on selected quality measures. Nursing home factors explained 3 times more variation in the odds of 30-day mortality than did hospital factors [ω, hospital vs. nursing home: 0.32; 95% confidence interval (CI), 0.11, 0.96], 7 times more variation in the odds of 180-day mortality (ω: 0.15; 95% CI, 0.04, 0.61), and 8 times more variation in the odds of 180-day death or new dependence in locomotion (ω: 0.12; 95% CI, 0.05, 0.31).

CONCLUSIONS

Nursing home factors explain a larger proportion of the variation in clinical outcomes following hip fracture than do hospital factors.