Inside the Green House "Black Box": Opportunities for High-Quality Clinical Decision Making

Transfer from long-term care to acute care and risk of new permanent cognitive or physical disability among long-term care residents in Canada: protocol for a retrospective cohort study

INTRODUCTION

Long-term care (LTC) residents are frequently transferred to acute care hospitals. Transfer decisions should align with residents' wishes and goals. Decision to transfer to hospital, when not aligned with the resident's wishes, can result in transfers that are harmful to residents, leaving residents in a state of disability that could be considered worse than death. We aim to examine whether transfer to an acute care hospital is associated with subsequent new onset of severe permanent physical and cognitive disability in LTC residents.

METHOD AND ANALYSIS

We will conduct a retrospective cohort study of all LTC residents ≥65 admitted to LTC homes between 1 April 2013 and 31 March 2018 in Ontario, Canada. We will use health administrative data from the Continuing Care Reporting System (CCRS), National Ambulatory Care Reporting System (NACRS) and Registered Persons Databases (RPDB), which include data on emergency department visits, hospitalisations, demographic information and mortality. All participants will be followed until 31 March 2023. The exposure is any transfer from LTC to an emergency department or acute care hospital. The outcomes are (1) subsequent new permanent physical disability, (2) subsequent new permanent cognitive disability and (3) all-cause mortality. Due to the time-varying nature of the exposure and confounders, we will use an extended cause-specific Cox regression model to explore this relationship. We will fit marginal structural models (MSMs) to account for the known shortcomings of traditional regression modelling, such as collider bias. Lastly, we will use a preference-based instrumental variable approach to address unmeasured confounders.

ETHICS AND DISSEMINATION

Ethics approval was obtained through Bruyère Research Institute Ethics Committee (REB#M16-23-030). Study findings will be submitted for publication in a peer-reviewed journal. Findings will be disseminated in conferences and seminars.

TRIAL REGISTRATION

Open Science Framework (https://doi.org/10.17605/OSF.IO/JCDEY).

The Greenhouse Model of Nursing Home Care: A Scoping Review

The study aimed to comprehensively review and assess evidence-based outcomes of the Greenhouse model. We systematically reviewed, assessed, and reported on relevant literature using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines for the scoping review. We identified qualitative or quantitative studies that met our inclusion criteria from PubMed, Medline, CINAHL, and EBSCOhost. The review yielded 41,515 articles published between January 2015 and December 2022; eleven articles met the inclusion criteria and were included in the analysis. The emerging themes were organizational culture, clinical outcomes, and business effects. The Greenhouse model offers a favorable organizational culture with opportunities to enhance clinical and business outcomes. The scoping review was registered in Prospero: CRD42023389048.

Revealing the divide: Contrasting COVID-19 outcomes in Green Houses and traditional nursing homes in the United States

INTRODUCTION

This study compares COVID-19 case and mortality rates in Green Houses (GHs) and traditional nursing homes (NHs) during the COVID-19 pandemic.

METHODS

CMS data from 10 states (June 2020 to September 2022) were analyzed for GHs (n = 19), small NHs (n = 266), and large NHs (n = 2,932). Multivariate Poisson regressions with GEE were used.

RESULTS

Participants (mean age 73.4) were predominantly female (57.8 %) and White (78.2 %). Small and large NHs had a significantly higher COVID-19 case risk (RR = 1.61; 95 % CI 1.25-2.08 and RR = 1.75; 95 % CI 1.36-2.24, respectively) compared to GHs. Large NHs also had an increased mortality risk (RR = 1.67; 95 % CI 1.01-2.77) compared to GHs, with no difference found between GHs and small NHs.

CONCLUSION

After adjusting for age, gender, and ADL disability, GHs demonstrated lower COVID-19 case and mortality rates than traditional NHs, likely due to their unique features, including person-centered care, size, and physical structure.

A Fresh Look at the Nursing Home Workforce Crisis: Transforming Nursing Care Delivery Models

The current State of the Science Commentary focuses on workforce challenges in the nursing home (NH) setting that lie within the purview of professional nursing-what professional nurses can do to promote high-quality person-centered care within a context of existing resources-individually and broadly across the collective profession. Historically, three models of care delivery have characterized the way in which nursing care is organized and delivered in different settings: primary nursing, functional nursing, and team nursing. Based on the existing evidence, we call for scientific leadership in the redesign, testing, and implementation of a nursing care delivery model that operationalizes relationship-centered team nursing. This integrative model incorporates successful evidence-based approaches that have the potential to improve quality of care, resident quality of life, and staff quality of work life: clear communication, staff empowerment, coaching styles of supervision, and family/care partner involvement in care processes. In addition to the needed evidence base for NH care delivery models, it is imperative that educational programs incorporate content and clinical experiences that will enable the future nursing workforce to fill the leadership gap in NH care delivery. [Research in Gerontological Nursing, 16(1), 5-13.].

Working at Green Care Farms and Other Innovative Small-Scale Long-Term Dementia Care Facilities Requires Different Competencies of Care Staff

The culture change movement within long-term care in which radical changes in the physical, social and organizational care environments are being implemented provides opportunities for the development of innovative long-term care facilities. The aim of this study was to investigate which competencies care staff working at green care farms and other innovative types of small-scale long-term dementia care facilities require, according to care staff themselves and managers, and how these competencies were different from those of care staff working in more traditional large-scale long-term dementia care facilities. A qualitative descriptive research design was used. Interviews were conducted with care staff (n = 19) and managers (n = 23) across a diverse range of long-term facilities. Thematic content analysis was used. Two competencies were mainly mentioned by participants working in green care farms: (1) being able to integrate activities for residents into daily practice, and (2) being able to undertake multiple responsibilities. Two other competencies for working in long-term dementia care in general were identified: (3) having good communication skills, and (4) being able to provide medical and direct care activities. This study found unique competencies at green care farms, showing that providing care in innovative long-term care facilities requires looking further than the physical environment and the design of a care facility; it is crucial to look at the role of care staff and the competencies they require.

Community Visioning for Innovation in Integrated Dementia Care: Stakeholder Focus Group Outcomes

It is estimated that 5.4 million Americans have some form of dementia and these numbers are expected to rise in the coming decades, leading to an unprecedented demand for memory care housing and services. In searching for innovative options to create more autonomy and better quality of life in dementia care settings, repurposing existing structures, in particular vacant urban malls, may be 1 option for the large sites needed for the European model of dementia villages. These settings may become sustainable Dementia Friendly City Centers (DFCC), because in the case of enclosed mall construction, the internal infrastructure is in place for lighting, HVAC, with varied spatial configuration of public spaces. This paper describes the community engagement research being conducted by a research team at a Midwestern university, laying groundwork for the DFCC model for centralized dementia programs, services, and attached housing. Using graphics and plans for the DFCC model using an 800 000 ft² closed mall site, focus groups were conducted with family caregivers of individuals with dementia and long-term care residents to gather their input and response to the model. The participants identified both opportunities and barriers in using an adaptive reuse of a large site for an innovative integrated dementia care model and through the cross-case analysis of the focus group findings, 5 themes were identified which include: community education and acceptance; amenities and activities; maintaining family connections; resident adaptation and staffing.

"From living in a hotel to living in a home": Stakeholders' views about living and working in a nursing home which is undergoing culture change

Culture change models are intended to improve the quality of life and care of nursing home residents. Using longitudinal qualitative methodology, this study evaluated the effectiveness of implementing culture change on the main stakeholders living and working in an Israeli nursing home. Eight focus groups with nursing home residents, family members and staff members (N = 57) were conducted at two-time points: one year after and two years after implementing a culture change model. Using thematic content analysis and comparing the experiences of each group and across time, the results revealed that implementing culture change in a nursing home is a complex process, which requires am adaptation in the values, expectations, and perceptions of care of all those involved. Particular attention should be paid to the unique needs of each stakeholder group, while ensuring their engagement and cooperation in the change process.

A complex intervention to reduce avoidable hospital admissions in nursing homes: a research programme including the BHiRCH-NH pilot cluster RCT

Background

An unplanned hospital admission of a nursing home resident distresses the person, their family and nursing home staff, and is costly to the NHS. Improving health care in care homes, including early detection of residents’ health changes, may reduce hospital admissions. Previously, we identified four conditions associated with avoidable hospital admissions. We noted promising ‘within-home’ complex interventions including care pathways, knowledge and skills enhancement, and implementation support.

Objectives

Develop a complex intervention with implementation support [the Better Health in Residents in Care Homes with Nursing (BHiRCH-NH)] to improve early detection, assessment and treatment for the four conditions. Determine its impact on hospital admissions, test study procedures and acceptability of the intervention and implementation support, and indicate if a definitive trial was warranted.

Design

A Carer Reference Panel advised on the intervention, implementation support and study documentation, and engaged in data analysis and interpretation. In workstream 1, we developed a complex intervention to reduce rates of hospitalisation from nursing homes using mixed methods, including a rapid research review, semistructured interviews and consensus workshops. The complex intervention comprised care pathways, approaches to enhance staff knowledge and skills, implementation support and clarity regarding the role of family carers. In workstream 2, we tested the complex intervention and implementation support via two work packages. In work package 1, we conducted a feasibility study of the intervention, implementation support and study procedures in two nursing homes and refined the complex intervention to comprise the Stop and Watch Early Warning Tool (S&W), condition-specific care pathways and a structured framework for nurses to communicate with primary care. The final implementation support included identifying two Practice Development Champions (PDCs) in each intervention home, and supporting them with a training workshop, practice development support group, monthly coaching calls, handbooks and web-based resources. In work package 2, we undertook a cluster randomised controlled trial to pilot test the complex intervention for acceptability and a preliminary estimate of effect.

Setting

Fourteen nursing homes allocated to intervention and implementation support (n = 7) or treatment as usual (n = 7).

Participants

We recruited sufficient numbers of nursing homes (n = 14), staff (n = 148), family carers (n = 95) and residents (n = 245). Two nursing homes withdrew prior to the intervention starting.

Intervention

This ran from February to July 2018.

Data sources

Individual-level data on nursing home residents, their family carers and staff; system-level data using nursing home records; and process-level data comprising how the intervention was implemented. Data were collected on recruitment rates, consent and the numbers of family carers who wished to be involved in the residents’ care. Completeness of outcome measures and data collection and the return rate of questionnaires were assessed.

Results

The pilot trial showed no effects on hospitalisations or secondary outcomes. No home implemented the intervention tools as expected. Most staff endorsed the importance of early detection, assessment and treatment. Many reported that they ‘were already doing it’, using an early-warning tool; a detailed nursing assessment; or the situation, background, assessment, recommendation communication protocol. Three homes never used the S&W and four never used care pathways. Only 16 S&W forms and eight care pathways were completed. Care records revealed little use of the intervention principles. PDCs from five of six intervention homes attended the training workshop, following which they had variable engagement with implementation support. Progression criteria regarding recruitment and data collection were met: 70% of homes were retained, the proportion of missing data was < 20% and 80% of individual-level data were collected. Necessary rates of data collection, documentation completion and return over the 6-month study period were achieved. However, intervention tools were not fully adopted, suggesting they would not be sustainable outside the trial. Few hospitalisations for the four conditions suggest it an unsuitable primary outcome measure. Key cost components were estimated.

Limitations

The study homes may already have had effective approaches to early detection, assessment and treatment for acute health changes; consistent with government policy emphasising the need for enhanced health care in homes. Alternatively, the implementation support may not have been sufficiently potent.

Conclusion

A definitive trial is feasible, but the intervention is unlikely to be effective. Participant recruitment, retention, data collection and engagement with family carers can guide subsequent studies, including service evaluation and quality improvement methodologies.

Future work

Intervention research should be conducted in homes which need to enhance early detection, assessment and treatment. Interventions to reduce avoidable hospital admissions may be beneficial in residential care homes, as they are not required to employ nurses.

Trial registration

Current Controlled Trials ISRCTN74109734 and ISRCTN86811077.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

"It's a lot!" the universal worker model and dementia care in assisted living

The culture change movement aims to create a more home-like environment in long-term care settings, promote person-centered care, and support the well-being of staff and residents. One feature of Culture Change is the Universal Worker (UW) model where direct care workers (DCWs) are responsible for housekeeping, laundry, and activities in addition to administering medication and personal support. The longitudinal approach in the ethnographic study on which this paper is based compares data collected from one assisted living across three NIA-supported research grants. This paper focuses on modifications to the UW model following the implementation of culture change over a period of ten years. As DCWs cared for residents with increasing levels of dementia, time constraints under the UW model led to sporadic attention to housekeeping chores and challenged person-centered care. Modifying the UW model, by using dedicated cleaning staff and other support workers, better preserves the intent of the culture change movement.

Dementia-Focused Person-Directed Care Training With Direct Care Workers in Nursing Homes: Effect on Symptom Reduction

The majority of older adult nursing home residents have dementia and are at risk of not having their care needs met, largely due to communication deficits. Promoting comfort and minimizing distress for these residents is important. Direct care workers (DCW) and clinical staff completed a 6-day training on a person-directed care (PDC) model-a model guided by the needs of the individual that focuses on empowering DCW to understand and support resident preferences and remaining abilities supported by relationship development and consistent staffing. A retrospective comparison was conducted of residents in two PDC communities with matched residents (n = 72) and three traditional communities (n = 72) on functional and clinical outcomes over a 6-month period. A two-way analysis of variance showed a significant interaction between group and time, where only those in the PDC group had a decreased number of clinical symptoms (e.g., pain, depression, agitation) over time. This study found support for the benefit of PDC on clinical outcomes of interest over time. PDC training for DCW and clinical staff promotes quality care and the reduction of clinical symptoms, leading to improved quality of life. [Journal of Gerontological Nursing, 46(8), 7-11.].

Making the Case for Centralized Dementia Care Through Adaptive Reuse in the Time of COVID-19

It is estimated that 5.4 million Americans have some form of dementia and these numbers are expected to rise in the coming decades, leading to an unprecedented demand for memory care housing and services. At the same time, infectious disease outbreaks like the COVID-19 pandemic have raised great concerns for the future of care settings for people living with dementia. In searching for innovative options to create more autonomy and better quality of life in dementia care settings, while at the same time improving infectious disease control, repurposing existing structures, in particular vacant urban malls, may be one option for the large sites needed for the European model of dementia villages. This editorial paper makes the case for the Dementia Friendly City Center model for centralized dementia programs, medical services and housing. By working across multiple disciplines, this research team has simultaneously addressed numerous issues, including community revitalization, building sustainability, and the strengthening of infectious disease control in care sites which are inclusive, progressive and convergent with the needs of an aging population.

Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship

Purpose of Study

To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions.

Design and Methods

In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification.

Results

The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review.

Implications

The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.

Family involvement in timely detection of changes in health of nursing homes residents: A qualitative exploratory study

Aims and objectives

To explore family perspectives on their involvement in the timely detection of changes in their relatives' health in UK nursing homes.

Background

Increasingly, policy attention is being paid to the need to reduce hospitalisations for conditions that, if detected and treated in time, could be managed in the community. We know that family continue to be involved in the care of their family members once they have moved into a nursing home. Little is known, however, about family involvement in the timely detection of changes in health in nursing home residents.

Design

Qualitative exploratory study with thematic analysis.

Methods

A purposive sampling strategy was applied. Fourteen semi‐structured one‐to‐one interviews with family members of people living in 13 different UK nursing homes. Data were collected from November 2015–March 2016.

Results

Families were involved in the timely detection of changes in health in three key ways: noticing signs of changes in health, informing care staff about what they noticed and educating care staff about their family members' changes in health. Families suggested they could be supported to detect timely changes in health by developing effective working practices with care staff.

Conclusion

Families can provide a special contribution to the process of timely detection in nursing homes. Their involvement needs to be negotiated, better supported, as well as given more legitimacy and structure within the nursing home.

Relevance to clinical practice

Families could provide much needed support to nursing home nurses, care assistants and managers in timely detection of changes in health. This may be achieved through communication about their preferred involvement on a case‐by‐case basis as well as providing appropriate support or services.

Staff Empowerment Practices and CNA Retention: Findings From a Nationally Representative Nursing Home Culture Change Survey

This article examines whether staff empowerment practices common to nursing home culture change are associated with certified nursing assistant (CNA) retention. Data from 2,034 nursing home administrators from a 2009/2010 national nursing home survey and ordered logistic regression were used. After adjustment for covariates, a greater staff empowerment practice score was positively associated with greater retention. Compared with the low empowerment category, nursing homes with scores in the medium category had a 44% greater likelihood of having higher CNA retention (odds ratio [OR] = 1.44; 95% confidence interval [CI] = [1.15, 1.81], p = .001) and those with high empowerment scores had a 64% greater likelihood of having higher CNA retention (OR = 1.64; 95% CI = [1.34, 2.00], p < 001). Greater opportunities for CNA empowerment are associated with longer CNA retention. This research suggests that staffing empowerment practices on the whole are worthwhile from the CNA staffing stability perspective.

Green House Adoption and Nursing Home Quality

OBJECTIVE

To evaluate the impact of the Green House (GH) model on nursing home resident-level quality of care measures.

DATA SOURCES/STUDY SETTING

Resident-level minimum data set (MDS) assessments merged with Medicare inpatient claims for the period 2005 through 2010.

STUDY DESIGN

Using a difference-in-differences framework, we compared changes in care quality and outcomes in 15 nursing homes that adopted the GH model relative to changes over the same time period in 223 matched nursing homes that had not adopted the GH model.

PRINCIPAL FINDINGS

For individuals residing in GH homes, adoption of the model lowered readmissions and several MDS measures of poor quality, including bedfast residents, catheter use, and pressure ulcers, but these results were not present across the entire GH organization, suggesting possible offsetting effects for residents of non-GH "legacy" units within the GH organization.

CONCLUSIONS

GH adoption led to improvement in rehospitalizations and certain nursing home quality measures for individuals residing in a GH home. The absence of evidence of a decline in other clinical quality measures in GH nursing homes should reassure anyone concerned that GH might have sacrificed clinical quality for improved quality of life.

The Impact of Green House Adoption on Medicare Spending and Utilization

OBJECTIVE

To evaluate the impact of the Green House (GH) model of nursing home care on Medicare acute hospital, other hospital, skilled nursing facility, and hospice spending and utilization.

DATA SOURCES/STUDY SETTING

Medicare claims and enrollment data from 2005 through 2010 merged with resident-level minimum data set (MDS) assessments.

STUDY DESIGN

Using a difference-in-differences framework, we compared Medicare Part A and hospice expenditures and utilization in 15 nursing homes that adopted the GH model relative to changes over the same time period in 223 matched nonadopting nursing homes. We applied the same method for residents of GH homes and for residents of "legacy" homes, the original nursing homes that stay open alongside the GH home(s).

PRINCIPAL FINDINGS

The adoption of GH had no detectable impact on Medicare Part A (plus hospice) spending and utilization across all residents living in the nursing home. When we analyzed residents living in GH homes and legacy units separately, however, we found that the adoption of the GH model reduced overall annual Medicare Part A spending by $7,746 per resident, although this appeared to be partially offset by an increase in spending in legacy homes.

CONCLUSIONS

To the extent that the GH model reduces Medicare spending, adopting nursing homes do not receive any of the related Medicare savings under traditional payment mechanisms. New approaches that are currently being developed and piloted, which better align financial incentives for providers and payers, could incentivize greater adoption of the GH model.

New Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy, Practice, and Research

OBJECTIVE

To synthesize new findings from the THRIVE Research Collaborative (The Research Initiative Valuing Eldercare) related to the Green House (GH) model of nursing home care and broadly consider their implications.

DATA SOURCES

Interviews and observations conducted in GH and comparison homes, Minimum Data Set (MDS) assessments, Medicare data, and Online Survey, Certification and Reporting data.

STUDY DESIGN

Critical integration and interpretation of findings based on primary data collected 2011-2014 in 28 GH homes (from 16 organizations), and 15 comparison nursing home units (from 8 organizations); and secondary data derived from 2005 to 2010 for 72 GH homes (from 15 organizations) and 223 comparison homes.

PRINCIPAL FINDINGS

Implementation of the GH model is inconsistent, sometimes differing from design. Among residents of GH homes, adoption lowers hospital readmissions, three MDS measures of poor quality, and Part A/hospice Medicare expenditures. Some evidence suggests the model is associated with lower direct care staff turnover.

CONCLUSIONS

Recommendations relate to assessing fidelity, monitoring quality, capitalizing opportunities to improve care, incorporating evidence-based practices, including primary care providers, supporting high-performance workforce practices, aligning Medicare financial incentives, promoting equity, informing broad culture change, and conducting future research.

Workforce Characteristics, Perceptions, Stress, and Satisfaction among Staff in Green House and Other Nursing Homes

OBJECTIVE

To compare workforce characteristics and staff perceptions of safety, satisfaction, and stress between Green House (GH) and comparison nursing homes (CNHs).

DATA SOURCES/STUDY SETTING

Primary data on staff perceptions of safety, stress, and satisfaction from 13 GHs and 8 comparison NHs in 11 states; secondary data from human resources records on workforce characteristics, turnover, and staffing from 01/01/2011-06/30/2012.

STUDY DESIGN

Observational study.

DATA COLLECTION METHODS

Workforce data were from human resources offices; staff perceptions were from surveys.

PRINCIPAL FINDINGS

Few significant differences were found between GH and CNHs. Exceptions were GH direct caregivers were older, provided twice the normalized hours per week budgeted per resident than CNAs in CNHs or Legacy NHs, and trended toward lower turnover.

CONCLUSIONS

GH environment may promote staff longevity and does not negatively affect worker's stress, safety perceptions, or satisfaction. Larger studies are needed to confirm findings.

The Green House Model of Nursing Home Care in Design and Implementation

OBJECTIVE

To describe the Green House (GH) model of nursing home (NH) care, and examine how GH homes vary from the model, one another, and their founding (or legacy) NH.

DATA SOURCES/STUDY SETTING

Data include primary quantitative and qualitative data and secondary quantitative data, derived from 12 GH/legacy NH organizations February 2012-September 2014.

STUDY DESIGN

This mixed methods, cross-sectional study used structured interviews to obtain information about presence of, and variation in, GH-relevant structures and processes of care. Qualitative questions explored reasons for variation in model implementation.

DATA COLLECTION/EXTRACTION METHODS

Interview data were analyzed using related-sample tests, and qualitative data were iteratively analyzed using a directed content approach.

PRINCIPAL FINDINGS

GH homes showed substantial variation in practices to support resident choice and decision making; neither GH nor legacy homes provided complete choice, and all GH homes excluded residents from some key decisions. GH homes were most consistent with the model and one another in elements to create a real home, such as private rooms and baths and open kitchens, and in staff-related elements, such as self-managed work teams and consistent, universal workers.

CONCLUSIONS

Although variation in model implementation complicates evaluation, if expansion is to continue, it is essential to examine GH elements and their outcomes.