Medical practice with nursing home residents: results from the National Physician Professional Activities Census

State scope of practice restrictions and nurse practitioner practice in nursing homes: 2012-2019

Increased engagement of nurse practitioners (NPs) has been recommended as a way to address care delivery challenges in settings that struggle to attract physicians, such as primary care and rural areas. Nursing homes also face such physician shortages. We evaluated the role of state scope of practice regulations on NP practice in nursing homes in 2012-2019. Using linear probability models, we estimated the proportion of NP-delivered visits to patients in nursing homes as a function of state scope of practice regulations. Control variables included county demographic, socioeconomic, and health care workforce characteristics; state fixed effects; and year indicators. The proportion of nursing home visits conducted by NPs increased from 24% in 2012 to 42% in 2019. Expanded scope of practice regulation was associated with a greater proportion and total volume of nursing home visits conducted by NPs in counties with at least 1 NP visit. These relationships were concentrated among short-stay patients in urban counties. Removing scope of practice restrictions on NPs may address clinician shortages in nursing homes in urban areas where NPs already practice in nursing homes. However, improving access to advanced clinician care for long-term care residents and for patients in rural locations may require additional interventions and resources.

Physician Practice in Ontario Nursing Homes: Defining Physician Commitment

OBJECTIVES

To characterize the practice profile of nursing home (NH) physicians in Ontario, Canada.

DESIGN

Population-based cross-sectional study.

SETTING AND PARTICIPANTS

A total of 1527 most responsible physicians (MRPs) across 626 NHs in Ontario, Canada, for the calendar year, 2017.

METHODS

We examined physician services within all publicly regulated and funded NH facilities. Descriptive summaries were generated to characterize MRPs and their practice patterns by the physician's primary practice location, the NH facility size, and the proportion of physician billings that occurred within NHs. Community sizes were classified into quintiles based on population size and assigned as urban or rural. The number of ministry-designated NH beds were assessed by quintiles to examine physician services by facility size. We also assessed the proportion of physician billings within NHs by quintiles.

RESULTS

MRPs tended to be older, male, and practice family medicine. The majority of MRPs practiced in communities with populations exceeding 100,000 residents, although physicians with greater NH billings tended to practice in rural locations. The mean number of NH residents that a physician was MRP for was positively associated with the community size. Physicians provided care for more NH residents than they were assigned most responsible. Fifty-one percent of physicians were MRP for 90% of all NH residents.

CONCLUSIONS AND IMPLICATIONS

Our work provides an exemplar for characterizing physician commitment in NHs, using 2 approaches, according to the NH specialist model. We demonstrated the medical practice characteristics, locations, and billing patterns of physicians within Ontario NHs. Future work can investigate the association between physician commitment and the quality of care provided to NH residents. A greater understanding of physician commitment may lead to the development of quality metrics based on physician practice patterns.

Medical Care Delivery in U.S. Nursing Homes: Current and Future Practice

The delivery of medical care services in U.S. nursing homes (NHs) is dependent on a workforce that comprises physicians, nurse practitioners, and physician assistants. Each of these disciplines operates under a unique regulatory framework while adhering to common standards of care. NH provider characteristics and their roles in NH care can illuminate potential links to clinical outcomes and overall quality of care with important policy and cost implications. This perspective provides an overview of what is currently known about medical provider practice in NH and organizational models of practice. Links to quality, both conceptual and established, are presented as is a research and policy agenda that addresses the gaps in the evidence base within the context of our ever-changing health care landscape.

Assessing First Visits By Physicians To Medicare Patients Discharged To Skilled Nursing Facilities

Although approximately one in five Medicare beneficiaries are discharged from hospital acute care to postacute care at skilled nursing facilities (SNFs), little is known about access to timely medical care for these patients after they are admitted to a SNF. Our analysis of 2,392,753 such discharges from hospitals under fee-for-service Medicare in the period January 2012-October 2014 indicated that first visits by a physician or advanced practitioner (a nurse practitioner or physician assistant) for initial medical assessment occurred within four days of SNF admission in 71.5 percent of the stays. However, there was considerable variation in days to first visit at the regional, facility, and patient levels. We estimated that in 10.4 percent of stays there was no physician or advanced practitioner visit. Understanding the underlying reasons for, and consequences of, variability in timing and receipt of initial medical assessment after admission to a SNF for postacute care may prove important for improving patient outcomes and particularly relevant to current efforts to promote value-based purchasing in postacute care.

Trends In Hospitals And Skilled Nursing Facilities Sharing Medical Providers, 2008-16

Hospitals and skilled nursing facilities (SNFs) face increasing pressure to improve care coordination and reduce unnecessary readmissions. One strategy to accomplish this is to share physicians and advanced practice clinicians, so that the same providers see patients in both settings. Using 2008-16 Medicare claims, we found that as SNFs moved increasingly toward using SNF specialists, there was a steady decline in the number of facilities sharing medical providers and in the proportion of SNF primary care delivered by provider practices with both hospital and SNF clinicians (hospital-SNF practices). In SNF fixed effects analyses, we found that SNFs that increased primary care visits by hospital-SNF practices had slightly fewer readmissions, shorter lengths-of-stay, and increased successful community discharges. These findings suggest that SNFs that share medical providers with hospitals may see some benefit from that linkage, although the magnitude of the benefit may be small.

Implementing a Warm Handoff Between Hospital and Skilled Nursing Facility Clinicians

OBJECTIVES

Care transitions between hospitals and skilled nursing facilities (SNFs) are associated with disruptions in patient care and high risk for adverse events. Communication between hospital-based and SNF-based clinicians is often suboptimal; there have been calls to foster direct, real-time communication between sending and receiving clinicians to enhance patient safety. This article described the implementation of a warm handoff between hospital and SNF physicians and advanced practice providers at the time of hospital discharge.

METHODS

Before patient transfer, hospital clinicians called SNF clinicians to provide information relevant to the continuation of safe patient care and offer SNF clinicians the opportunity to ask clarifying questions. The calls were documented in the hospital discharge summary.

RESULTS

A total of 2417 patient discharges were eligible for inclusion. Warm handoffs were documented at an increasing rate throughout implementation of the intervention, beginning with 15.78% (n = 3) in stage 1, then 20.27% (n = 75) in stage 2, and finally 46.89% (n = 951) in stage 3. The overall average rate of documentation was 42.57%. Participant feedback indicated that clinicians were most concerned about understanding the purpose of the warm handoff, managing their workload, and improving the efficiency of the process.

CONCLUSIONS

Use of a warm handoff showed promise in improving communication during hospital-SNF patient transfers. However, the implementation also highlighted specific barriers to the handoff related to organizational structures and clinician workload. Addressing these underlying issues will be critical in ensuring continued participation and support for efforts that foster direct communication among clinicians from different healthcare institutions.

Postacute care outcomes and medicare payments for patients treated by physicians and advanced practitioners who specialize in nursing home practice

OBJECTIVE

To measure the association between clinician specialization in nursing home (NH) practice and outcomes of patients who received postacute care in skilled nursing facilities (SNFs).

DATA SOURCES

Medicare claims and NH assessments for 2 118 941 hospital discharges to 14 526 SNFs in January 2012-October 2014 and MD-PPAS data for 52 379 clinicians.

STUDY DESIGN

Generalist physicians and advanced practitioners with ≥ 90 percent of claims for NH-based care were considered NH specialists. The primary clinician during each SNF stay was determined based on plurality of claims during that stay. We estimated the effect of being treated by a NH specialist on 30-day rehospitalizations, successful discharge to community, and 60-day episode-of-care Medicare payments (Parts A and B). All models included patient demographics, clinical variables, and SNF fixed effects.

PRINCIPAL FINDINGS

Nursing home specialists' patients were less likely to be rehospitalized (14.71 percent vs 16.23 percent; adjusted difference, -1.51 percent, 95% CI -1.78 to -1.24), more likely to be successfully discharged to community (56.33 percent vs 55.49 percent; adjusted difference, 0.84 percent, 95% CI 0.54 to 1.14), but had higher 60-day Medicare payments ($31 628 vs $31 292; adjusted difference, $335; 95% CI $242 to $429).

CONCLUSIONS

Clinicians who specialize in NH practice may achieve better postacute care outcomes at slightly higher costs.

Nursing Home Physicians Discuss Caring for Elderly Residents: An Exploratory Study

Malgré la complexité croissante des soins en foyers de soins de longue durée, le rôle des médecins dans la prestation des soins aux résidents a été peu étudié. Cette étude exploratoire internationale visait à mieux comprendre les rôles des médecins, leurs responsabilités et leurs tâches, ainsi qu’à explorer les caractéristiques uniques de la pratique médicale dans les foyers de soins de longue durée. Des entrevues ont été menées avec 18 médecins. Ces médecins ont mentionné qu’ils contribuaient fortement à la qualité des soins pour les résidents, en clarifiant les objectifs des soins, en prenant des mesures pour réduire les hospitalisations et les prescriptions de médicaments non nécessaires, et en contribuant à la formation du personnel. Les pratiques en foyers de soins de longue durée impliquaient les médecins au centre de réseaux de relations qui assuraient non seulement une meilleure qualité des soins médicaux, mais aussi une satisfaction professionnelle chez les médecins. L’importance de ces relations est telle qu’elle permettait d’aller au-delà des démarcations traditionnelles entre le domaine médical et le domaine social, et mettait en évidence qu’une bonne pratique médicale implique de bonnes pratiques sociales. Considérant la nature exploratoire de l’étude, les auteurs recommandent que de futures recherches soient menées pour mieux comprendre les dimensions relationnelles associées à la pratique de la médecine en foyers de soins de longue durée.

Contemporary health care for Huntington disease

Providing medical care for people and families affected by Huntington disease (HD) can be a rewarding effort when realistic goals of improved quality of life and optimized functional status are set. Multiple disease symptoms can remit or improve with currently available pharmacologic and behavioral interventions, even though barriers exist that interfere with access to treatment. Connecting expert multidisciplinary teams with community-based care, developing treatment guidelines, and involving the HD family community in quality improvements can achieve an integrated system of health care delivery. Engaging people with HD in high-quality compassionate care will not only improve lives, it will also encourage participation in clinical trials that search for disease-modifying treatments that will reduce or bring the suffering of HD to an end.

Nursing Home Stakeholder Views of Resident Involvement in Medical Care Decisions

Demand by nursing home residents for involvement in their medical care, or, patient-centered care, is expected to increase as baby boomers begin seeking long-term care for their chronic illnesses. To explore the needs in meeting this proposed demand, we used a qualitative descriptive method with content analysis to obtain the joint perspective of key stakeholders on the current state of person-centered medical care in the nursing home. We interviewed 31 nursing home stakeholders: 5 residents, 7 family members, 8 advanced practice registered nurses, 5 physicians, and 6 administrators. Our findings revealed constraints placed by the long-term care system limited medical involvement opportunities and created conflicting goals for patient-centered medical care. Resident participation in medical care was perceived as low, but important. The creation of supportive educational programs for all stakeholders to facilitate a common goal for nursing home admission and to provide assistance through the long-term care system was encouraged.

Physicians in nursing homes: effectiveness of physician accountability and communication

OBJECTIVES

The objective of this study was to develop a measure of the perceptions of nursing home (NH) directors of nursing (DONs) on the adequacy of physician care and to examine its variation as well as its construct validity.

DESIGN

A nationwide cross-sectional study with primary data collection.

SETTING

A total of 2043 NHs surveyed between August 2009 and April 2011.

PARTICIPANTS

DONs and NH administrators responded to questions pertaining to their perceptions of the care provided by physicians in their NH.

MEASUREMENTS

Ten items were used to create 3 domains: medical staff attentiveness, physician communication, and staff concerns about physician practice. These were combined into an overall summary score measure called "Effectiveness of Physician Accountability and Communication" (EPAC). EPAC construct validity was ascertained from other DON questions and from a complementary survey of NH administrators.

RESULTS

The established EPAC score is the first measure to capture specific components of the adequacy of physician care in NHs. EPAC exhibited good construct validity: more effective practices were correlated with greater physician involvement in discussions of do-not-resuscitate orders, the frequency with which the medical director checked on the medical care delivered by the attending physician, the tightness of the NH's control of its physician resources, and the DON's perception of whether or not avoidable hospitalizations and emergency room visits could be reduced with greater physician attention to resident needs.

CONCLUSION

As increased attention is given to the quality of care provided to vulnerable elders, effective measures of processes of care are essential. The EPAC measure provides an important new metric that can be used in these efforts. The goal is that future studies could use EPAC and its individual domains to shed light on the manner through which physician presence is related to resident outcomes in the NH setting.

Nursing home control of physician resources

OBJECTIVE

Physician services are increasingly recognized as important contributors to quality care provision in nursing homes (NH)s, but knowledge of ways in which NHs manage/control physician resources is lacking.

DATA

Primary data from surveys of NH administrators and directors of nursing from a nationally representative sample of 1938 freestanding United States NHs in 2009-2010 matched to Online Survey Certification and Reporting, aggregated NH Minimum Data Set assessments, Medicare claims, and county information from the Area Resource File.

METHODS

The concept of NH Control of Physician Resources (NHCOPR) was measured using NH administrators' reports of management implementation of rules, policies, and procedures aimed at coordinating work activities. The NHCOPR scale was based on measures of formal relationships, physician oversight and credentialing. Scale values ranged from weakest (0) to tightest (3) control. Several hypotheses of expected associations between NHCOPR and other measures of NH and market characteristics were tested.

RESULTS

The full NHCOPR score averaged 1.58 (standard deviation = 0.77) on the 0-3 scale. Nearly 30% of NHs had weak control (NHCOPR ≤1), 47.5% had average control (NHCOPR between 1 and 2), and the remaining 24.8% had tight control (NHCOPR >2). NHCOPR exhibited good face- and predictive-validity as exhibited by positive associations with more beds, more Medicare services, cross coverage, and number of physicians in the market.

CONCLUSIONS

The NHCOPR scale capturing NH's formal structure of control of physician resources can be useful in studying the impact of NH's physician resources on residents' outcomes with potential for targeted interventions by education and promotion of NH administration regarding physician staff.

Medical staff involvement in nursing homes: development of a conceptual model and research agenda

Medical staff (physicians, nurse practitioners, physicians' assistants) involvement in nursing homes (NH) is limited by professional guidelines, government policies, regulations, and reimbursements, creating bureaucratic burden. The conceptual NH Medical Staff Involvement Model, based on our mixed-methods research, applies the Donabedian "structure-process-outcomes" framework to the NH, identifying measures for a coordinated research agenda. Quantitative surveys and qualitative interviews conducted with medical directors, administrators and directors of nursing, other experts, residents and family members and Minimum Data Set, the Online Certification and Reporting System and Medicare Part B claims data related to NH structure, process, and outcomes were analyzed. NH control of medical staff, or structure, affects medical staff involvement in care processes and is associated with better outcomes (e.g., symptom management, appropriate transitions, satisfaction). The model identifies measures clarifying the impact of NH medical staff involvement on care processes and resident outcomes and has strong potential to inform regulatory policies.

Association between proportion of provider clinical effort in nursing homes and potentially avoidable hospitalizations and medical costs of nursing home residents

OBJECTIVES

To assess potential avoidable hospitalizations of nursing home (NH) residents as a function of the percentage of clinical effort their primary care provider (PCP) devotes to NH practice.

DESIGN

Retrospective cohort study.

SETTING

NHs in Texas.

PARTICIPANTS

Residents newly admitted to long-term NHs in 2006 to 2008 were identified by linking the Minimum Data Set to 100% Texas Medicare claims data (N = 12,249).

MEASUREMENTS

The care that residents received over successive 6-month periods was measured as a time-dependent covariate. Potentially avoidable hospitalizations and Medicare costs were assessed over 6 to 48 months.

RESULTS

Seventy percent of NH residents had a physician as their major PCP, 25% had an advance practice nurse (APN), and 5% had a physician assistant (PA). Physician PCPs who derived less than 20% of their Medicare billings from NH residents cared for 36% of all NH residents. Most NH residents with APN or PA PCPs had providers with 85% or more of Medicare billings generated in NHs. Residents with PCPs who devoted less than 5% of their clinical effort to NH care were at 52% higher risk of potentially avoidable hospitalization than those whose PCPs devoted 85% or more of their clinical effort to NHs (hazard ratio = 1.52, 95% confidence interval = 1.25-1.83) and had $2,179 higher annual Medicare spending, controlling for PCP discipline.

CONCLUSION

The percentage of clinical effort that providers devote to NHs is associated with risk of avoidable hospitalization.

Factors associated with the use of advanced practice nurses/physician assistants in a fee-for-service nursing home practice: a comparison with primary care physicians

The purpose of this research was to examine factors associated with the use of advanced practice nurse and physician assistant (APN/PA) visits to nursing home (NH) patients compared with those by primary care physicians (PCPs). This was a secondary analysis using Medicare claims data. General estimation equations were used to determine the odds of NH residents receiving APN/PA visits. Ordinary least squares analyses were used to examine factors associated with these visits. A total of 5,436 APN/PAs provided care to 27% of 129,812 residents and were responsible for 16% of the 1.1 million Medicare NH fee-for-service visits in 2004. APN/PAs made an average of 33 visits annually compared with PCPs (21 visits). Neuropsychiatric and acute diagnoses and patients with a long-stay status were associated with more APN/PA visits. APN/PAs provide a substantial amount of care, but regional variations occur, and Medicare regulations constrain the ability of APN/PAs to substitute for physician visits.

Assessment and treatment of behavior problems in dementia in nursing home residents: a comparison of the approaches of physicians, psychologists, and nurse practitioners

OBJECTIVE

To compare physicians (MDs), psychologists (PhDs), and nurse practitioners (NPs) regarding their approach to dementia-associated behavior problems in nursing home residents.

METHODS

A web-based questionnaire solicited information about symptoms, assessment methods, suspected etiologies, and interventions with respect to the last resident treated for dementia-associated behavior problems.

RESULTS

Responses were obtained from 108 MDs, 38 PhDs, and 100 NPs. All groups relied similarly on information from the nursing staff, speaking with nursing assistants, and care team meetings in assessment; NPs were more likely to consult with family members. A standard assessment instrument was used most frequently by PhDs (50%), but this generally assessed cognitive status rather than problem behaviors. PhDs most frequently noted depression in residents. Groups were similar in attributing the behavioral symptoms to dementia and to underlying medical conditions, but PhDs were more likely to indicate depression, loneliness/boredom, staff-resident communication, and insufficient activities as etiologies. Use of pharmacological and nonpharmacological interventions of MDs and NPs were similar. PhDs reported least satisfaction with treatment.

CONCLUSION

Awareness of similarities and differences in the approaches of different health professionals can facilitate interdisciplinary interaction in providing care for dementia-associated behavior problems in nursing home residents.

Knowledge of and attitudes toward nonpharmacological interventions for treatment of behavior symptoms associated with dementia: a comparison of physicians, psychologists, and nurse practitioners

PURPOSE OF THE STUDY

Behavior problems are common in nursing homes. Current guidelines recommend nonpharmacological interventions (NPHIs) as first-line treatment, but pharmacological regimens (PIs) continue to be used. Given differences in background and training of those who treat behavior problems in residents, we compared attitudes of physicians (MDs), psychologists (PhDs), and nurse practitioners (NPs) concerning PI and NPHI usage as well as knowledge of NPHIs.

DESIGN AND METHODS

One hundred and eight MDs, 36 PhDs, and 89 NPs responded to a web-based questionnaire that captured level of agreement with statements concerning treatment of behavior symptoms and familiarity with NPHIs.

RESULTS

NPs were the most favorable toward NPHIs. MDs were significantly more favorable to the use of PIs than were PhDs, with attitudes of NPs falling in between. All felt that NPHI usage should increase and that NPHIs should be implemented before using PIs but also believed that PIs work well for behavior problems. MDs had significantly lower knowledge of NPHIs than PhDs or NPs. Overall, NPHI knowledge was similar for PhDs and NPs, although they differed on their use of specific interventions.

IMPLICATIONS

As levels of knowledge and familiarity with NPHIs differed among providers, it is conceivable that all might benefit from training and experience with a wider range of NPHIs. Future studies might evaluate the impact of a uniform understanding of NPHI on communication and teamwork in nursing homes and examine ways to enhance a multidisciplinary approach that would allow for the tailoring and individualization that is required of successful interventions.

Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety

OBJECTIVES

To examine the overall responses of nursing home staff to a newly developed nursing home specific survey instrument to assess patient safety culture (PSC) and to examine whether nursing home staff (including administrator/manager, licensed nurse, nurse aide, direct care staff, and support staff) differ in their PSC ratings.

METHODS

Data were collected in late 2007 through early 2008 using a survey administered to staff in each of 40 nursing homes. In 4 of these nursing homes, the responses of different staff were identified. The Nursing Home Survey on Patient Safety Culture was used to assess the 12 domains of the PSC and identify differences in PSC perceptions between staff.

RESULTS

For the 40 nursing homes in the sample, the overall facility response rate was 72%. For the 4 nursing homes of interest, the overall facility response rate was 68.9%. The aggregate Nursing Home Survey on Patient Safety Culture scores, using all staff types for all survey items, show that most respondents report a poor PSC. However, administrators/managers had more positive scores than the other staff types (P < 0.05) across most domains.

CONCLUSIONS

Staff in nursing homes generally agree that PSC is poor. This may have a significant impact on quality of care and quality of life for residents.

Discussion as a factor in racial disparity in advance directive completion at nursing home admission

Studies have consistently shown racial disparities in advance directive completion for nursing home residents but have not examined whether this disparity is due to differences in interactions with healthcare providers. This study had two aims: to determine whether the racial disparity in advance directive completion by nursing home residents is related to differences in discussion of treatment restrictions with healthcare providers and to examine whether there is a racial disparity in perceptions of residents' significant others that additional discussions would be helpful. Participants were 2,171 white or black (16% of sample) residents newly admitted to 59 nursing homes. Data were collected from structured interviews with residents' significant others and review of nursing home charts. Questions included whether advance directives were completed, whether treatment restrictions were discussed with the resident or family, and whether more discussion would have been helpful. Frequencies according to race were determined for each question; P-values and logistic regression models were obtained. Black residents were less likely to have completed any advance directives (P<.001), and they (P<.001) and their family members (P<.001) were less likely than whites to have discussed treatment restrictions with healthcare providers. Logistic regression models indicated that disparity in treatment restrictions narrowed when these discussions occurred. Significant others of black residents were more likely than those of white residents to consider further discussion helpful (P<.001), especially with physicians. Racial disparity in treatment restrictions may be due in part to a difference in discussion with healthcare providers; increasing discussion may narrow this disparity.

Profile of physicians in the nursing home: time perception and barriers to optimal medical practice

OBJECTIVES

To describe physician medical practice in nursing homes, including actual time spent for routine encounters with nursing home residents and demographic characteristics of the physicians who serve as medical directors; to determine the congruence between actual time spent for routine encounters with nursing home residents and the physician's view of the optimal time; and to identify barriers to providing optimal visits.

DESIGN

A mail survey of a national random sample of 200 medical directors of all Medicare-certified nursing facilities using the Dillman Total Design mail survey methodology.

PARTICIPANTS

100 medical directors (50% response rate).

MEASUREMENTS

The survey consisted of open- and closed-ended items on the following: the demographic characteristics of the medical director; demographic characteristics of the nursing home; the extent of the medical director's nursing home practice, including the ideal and actual time spent in nursing home visits for 4 common types of visits; and perception of barriers to providing optimum visits in the nursing home.

RESULTS

Medical directors were most likely to be primary care physicians, the majority of whom were male; had practiced in long-term care for more than 18 years; were medical directors in 2 facilities; provided, on average, primary care in 4 facilities; spent 31 hours per month in the nursing home with nursing staff; and devoted 44% of their practice to nursing homes. Most, (74%) were members of the American Medical Directors Association (AMDA), 41% were certified medical directors (CMD), 42% had a certificate of added qualification (CAQ) in geriatrics, and only 15% had fellowship training. Reports of actual time spent on 4 common types of nursing home visits were significantly less than optimal visit times, but fellowship-trained physicians reported significantly greater discrepancies between the optimal and actual time spent for the 30- to 60-day reviews and readmissions compared with physicians who were not. A parallel pattern was seen comparing physicians with and without CAQs. Nursing support and accurate/accessible information were recorded as most problematic and reimbursement the least problematic barrier to providing optimal nursing home visits.

CONCLUSION

The present study provides a snapshot of current physician practice in US nursing homes. Such information is needed as the debate over the physician's role in the nursing home continues and new policy is framed that will ultimately define the future of medical practice in the nursing home. That 74% of the national survey respondents were members of AMDA suggests that the AMDA membership is representative of the national medical director population.

Mobility and other predictors of hospitalization for urinary tract infection: a retrospective cohort study

BACKGROUND

Many hospitalizations for residents of skilled nursing facilities are potentially avoidable. Factors that could prevent hospitalization for urinary tract infection (UTI) were investigated, with focus on patient mobility.

METHODS

A retrospective cohort study was conducted using 2003-2004 data from the Centers for Medicare and Medicaid Services. The study included 408,192 residents of 4267 skilled nursing facilities in California, Florida, Michigan, New York, and Texas. The patients were followed over time, from admission to the skilled nursing facility to discharge or, for those who were not discharged, for 1 year. Cox proportional hazards regression was conducted with hospitalization for UTI as the outcome.

RESULTS

The ability to walk was associated with a 69% lower rate of hospitalization for UTI. Maintaining or improving walking ability over time reduced the risk of hospitalization for UTI by 39% to 76% for patients with various conditions. For residents with severe mobility problems, such as being in a wheelchair or having a missing limb, maintaining or improving mobility (in bed or when transferring) reduced the risk of hospitalization for UTI by 38% to 80%. Other potentially modifiable predictors included a physician visit at the time of admission to the skilled nursing facility (Hazard Ratio (HR), 0.68), use of an indwelling urinary catheter (HR, 2.78), infection with Clostridium difficile or an antibiotic-resistant microorganism (HR, 1.20), and use of 10 or more medications (HR, 1.31). Patient characteristics associated with hospitalization for UTI were advancing age, being Hispanic or African-American, and having diabetes mellitus, renal failure, Parkinson's disease, dementia, or stroke.

CONCLUSION

Maintaining or improving mobility (walking, transferring between positions, or moving in bed) was associated with a lower risk of hospitalization for UTI. A physician visit at the time of admission to the skilled nursing facility also reduced the risk of hospitalization for UTI.

Assessment and treatment approaches for behavioral disturbances associated with dementia in the nursing home: self-reports of physicians' practices

OBJECTIVES

Behavior problems are common in dementia, yet little is known about how physicians deal with these problems in practice. This article reports on a survey asking physicians to describe, with respect to the last nursing home resident with dementia they treated for behavior problems, the behaviors observed, assessment methods used, suspected etiology of the problem, types of intervention, and their reaction to the intervention process.

DESIGN

This is a descriptive study presenting responses to a Web-based questionnaire.

PARTICIPANTS

Participants were 110 physicians providing services to nursing home residents.

MEASUREMENTS

Physicians answered a close-ended questionnaire with open-ended "other" options concerning symptoms, methods of assessment, suspected etiological factors, and interventions to describe the last nursing home resident they treated for behavior problems associated with dementia.

RESULTS

Resisting care was the most frequently reported symptom (71%). Physicians were most likely to attribute the behavior problems to the indirect effects of dementia on the ability to remember, communicate, and comprehend (67%). Most (87%) reported using more than one method for treating these problems. Rate of reported use of psychotropic drugs (80%) was slightly higher than that for nonpharmacological methods (75%), with the majority (61%) reporting use of both of these methods. Standardized instruments were not used in assessment. Forty percent of the participants reported feeling satisfied or very satisfied with the intervention they provided, and close to a third (32%) reported feeling frustrated with the intervention process.

CONCLUSION

The data underscore the complexity in the treatment of behavior problems. Despite federal regulations limiting their use, the potential for side effects, and ambivalence toward such treatment, psychotropic drugs are still used for the majority of nursing home residents with behavior problems associated with dementia. On the other hand, physicians report employing nonpharmacological methods to a closely similar extent, although their role in the implementation of these treatments is less clear. Further work is needed to clarify physicians' involvement in and decision to use nonpharmacological interventions.

Short-stay nursing home rehabilitation patients: transitional care problems pose research challenges

A clinical intervention pilot study to improve depression care for short-stay nursing home Medicare-reimbursed rehabilitation patients funded by the National Institute on Aging was conducted. Despite solid theoretical and clinical grounding and the support of a large nursing home company, several roadblocks to implementation were encountered, including involving patients and families, communication between providers, involving community primary care physicians, staff time constraints, and conducting research with short-stay patients. Although frustrating from a research standpoint, these roadblocks closely reflect problems identified by the American Geriatrics Society as impeding the delivery of high-quality transitional care in geriatrics. These research roadblocks are described as they were encountered in the clinical setting, and each is placed within the larger context of challenges associated with care transitions, especially for older persons with complex health needs receiving nursing home rehabilitation. Finally, recommendations are offered for researchers conducting much-needed research within geriatric transitional care settings, including starting early in the care transition chain and assisting patients and families with providing continuity across care settings.

The impact of integrated care on direct nursing home care

BACKGROUND/AIM

The introduction of integrated nursing home care is an important policy goal in many countries and is expected to affect the type, frequency and duration of activities delivered to nursing home residents. The exact impact however is unknown. The aim of this paper is to reduce this information gap in order to provide decision supporting information to policy makers and managers. DESIGN/METHODS/ETHICAL ISSUES: At three measurement points between 1999 and 2003, caregivers belonging to 18 functions registered activities delivered to somatic and psycho-geriatric nursing home residents in The Netherlands. Residents either received traditional care, integrated care or care that contained elements of traditional and integrated care (hybrid care). Thirty-six thousand and seventy-one registration lists were used for data analysis. Data analysis included determining, comparing and linking the (total) average frequency and duration of each activity per care type, measurement point and type of resident.

RESULTS

The (total) average frequency and total duration of most activities were higher for integrated care than for traditional and hybrid care. The average duration per activity was generally higher for traditional care. The (total) average frequency of most direct care activities at most measurement points and the total average duration per resident per day were higher for somatic care than for psycho-geriatric care.

CONCLUSIONS

The introduction of integrated nursing home care affects the total average duration and frequency of direct care activities. However, there is no noticeable impact on individual activities or on differences in activities received by somatic and psycho-geriatric residents and the degree to which the occurrence of an activity is related to the duration of that activity. This is because a large proportion of care delivery represents patterned behaviour (routines). Because existing routines are difficult to get rid of, we should not have too high expectations about the effect of integrated care on service delivery.

Rural Physiciansʼ Attitudes Toward the Elderly

Rural elderly patients receive health services primarily in the outpatient setting, with their primary care provider often serving as their only point of contact with the health care system. Little is known however about the attitudes of physicians, and more specifically attitudes of those practicing in rural locations, toward differing age groups of the elderly. The current study was undertaken to examine the perceptions and attitudes of rural Florida physicians who routinely provide care for the elderly. We utilized an existing and validated survey instrument designed to measure the perceptions and attitudes of health professionals toward 3 different cohorts of elderly people: the elderly population in general, the elderly population older than 85 years, and the nursing home population. The study provides evidence that physicians who routinely provide care for the elderly in rural Florida demonstrate ageist perceptions, especially against those older than 85 years and the nursing home population. The trends identified are important because they may directly influence the quality of care that this population receives.

Function and response of nursing facilities during community disaster

OBJECTIVES

We sought to describe the role and function of nursing facilities after disaster.

METHODS

We surveyed administrators at 144 widely dispersed nursing facilities after the Los Angeles Northridge earthquake.

RESULTS

Of the 113 (78%) nursing facilities that responded (11 365 beds), 23 sustained severe damage, 5 closed (625 beds), and 72 lost vital services. Of 87 nursing facilities implementing disaster plans, 56 cited problems that plans did not adequately address, including absent staff, communication problems, and insufficient water and generator fuel. Fifty-nine (52%) reported disaster-related admissions from hospitals, nursing facilities, and community residences. Nursing facilities received limited postdisaster assistance. Five months after the earthquake, only half of inadequate nursing facility disaster plans had been revised.

CONCLUSIONS

Despite considerable disaster-related stresses, nursing facilities met important community needs. To optimize disaster response, community-wide disaster plans should incorporate nursing facilities.

Challenges and strategies for initiating a nursing facility practice

PURPOSE

To provide a summary analysis of five case reports describing the challenges and strategies of nurse practitioners' (NPs') first-year experiences on initiating an effective role in a nursing facility practice.

DATA SOURCES

Original qualitative research analyzing written journals of five NPs and written notes from two loosely structured group discussions among project participants.

CONCLUSIONS

Two broad themes emerged: Figuring it Out and Responding/Getting a Handle on Things. Common sense and good resources were identified as critical.

IMPLICATIONS FOR PRACTICE

Strategies to promote ease of role transition are essential for NPs in the nursing facility. Further, in addition to a focus on care of frail older adults, emphasis on the culture of and strategies for nursing facility visits, ethical issues, and ethical decision making are important components of NP educational programs.