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Caspi E. Residents' Fear of Retaliation in America's Nursing Homes: An Exploratory Study. J Appl Gerontol 2024; 43:497-514. [PMID: 37991342 DOI: 10.1177/07334648231214413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Abstract
The phenomenon of residents' fear of staff retaliation when voicing care concern and making mistreatment complaints in nursing homes has been shown in research to be common. Despite longstanding concerns by care advocacy organizations about this phenomenon and its impact on residents (including emotional suffering, inadequate care, and mistreatment due to fear-driven lack of reporting, investigation, and resolution), little research examined it to date. Using 100 standard survey and complaint investigation reports from state survey agencies in nursing homes in 30 states, the researcher of this qualitative study aimed to improve understanding of residents' lived experience of four aspects of this phenomenon-fear of retaliation, allegations of threats of retaliation, perceived retaliation, and actual (confirmed) retaliation-and their emotional consequences. The findings could inform practice and policy changes necessary to realize residents' federal right to speak up without fear of retaliation when advocating for dignified and safe care.
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Harrington C, Mollot R, Braun RT, Williams D. United States' Nursing Home Finances: Spending, Profitability, and Capital Structure. INTERNATIONAL JOURNAL OF SOCIAL DETERMINANTS OF HEALTH AND HEALTH SERVICES 2024; 54:131-142. [PMID: 38115716 PMCID: PMC10955796 DOI: 10.1177/27551938231221509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/12/2023] [Accepted: 11/06/2023] [Indexed: 12/21/2023]
Abstract
Little is known about nursing home (NH) financial status in the United States even though most NH care is publicly funded. To address this gap, this descriptive study used 2019 Medicare cost reports to examine NH revenues, expenditures, net income, related-party expenses, expense categories, and capital structure. After a cleaning process for all free-standing NHs, a study population of 11,752 NHs was examined. NHs had total net revenues of US$126 billion and a profit of US$730 million (0.58%) in 2019. When US$6.4 billion in disallowed costs and US$3.9 billion in non-cash depreciation expenses were excluded, the profit margin was 8.84 percent. About 77 percent of NHs reported US$11 billion in payments to related-party organizations (9.54% of net revenues). Overall spending for direct care was 66 percent of net revenues, including 27 percent on nursing, in contrast to 34 percent spent on administration, capital, other, and profits. Finally, NHs had long-term debts that outweighed their total available financing. The study shows the value of analyzing cost reports. It indicates the need to ensure greater accuracy and completeness of cost reports, financial transparency, and accountability for government funding, with implications for policy changes to improve rate setting and spending limits.
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Affiliation(s)
- Charlene Harrington
- Department of Social & Behavioral Sciences, University of California, San Francisco, CA, USA
| | | | | | - Dunc Williams
- Department of Health Care Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
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Poulin LIL, Colibaba A, Skinner MW, Balfour G, Byrne D, Dieleman C. Lost in transition? Community residential facility staff and stakeholder perspectives on previously incarcerated older adults' transitions into long-term care. BMC Geriatr 2023; 23:180. [PMID: 36978019 PMCID: PMC10045254 DOI: 10.1186/s12877-023-03807-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 02/07/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Establishing an effective continuum of care is a pivotal part of providing support for older populations. In contemporary practice; however, a subset of older adults experience delayed entry and/or are denied access to appropriate care. While previously incarcerated older adults often face barriers to accessing health care services to support community reintegration, there has been limited research on their transitions into long-term care. Exploring these transitions, we aim to highlight the challenges of securing long-term care services for previously incarcerated older adults and shed light on the contextual landscape that reinforces the inequitable care of marginalized older populations across the care continuum. METHODS We performed a case study of a Community Residential Facility (CRF) for previously incarcerated older adults which leverages best practices in transitional care interventions. Semi-structured interviews were conducted with CRF staff and community stakeholders to determine the challenges and barriers of this population when reintegrating back into the community. A secondary thematic analysis was conducted to specifically examine the challenges of accessing long-term care. A code manual representing the project themes (e.g., access to care, long-term care, inequitable experiences) was tested and revised, following an iterative collaborative qualitative analysis (ICQA) process. RESULTS The findings indicate that previously incarcerated older adults experience delayed access and/or are denied entry into long-term care due to stigma and a culture of risk that overshadow the admissions process. These circumstances combined with few available long-term care options and the prominence of complex populations already in long-term care contribute to the inequitable access barriers of previously incarcerated older adults seeking entry into long-term care. CONCLUSIONS We emphasize the many strengths of utilizing transitional care interventions to support previously incarcerated older adults as they transition into long-term care including: 1) education & training, 2) advocacy, and 3) a shared responsibility of care. On the other hand, we underscore that more work is needed to redress the layered bureaucracy of long-term care admissions processes, the lack of long-term care options and the barriers imposed by restrictive long-term care eligibility criteria that sustain the inequitable care of marginalized older populations.
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Affiliation(s)
- Laura I L Poulin
- Trent Centre for Aging & Society, Trent University, 1600 West Bank Dr., Peterborough, ON, K9L 0G2, Canada.
| | - Amber Colibaba
- Trent Centre for Aging & Society, Trent University, 1600 West Bank Dr., Peterborough, ON, K9L 0G2, Canada
| | - Mark W Skinner
- Trent School of the Environment, Trent University, 1600 West Bank Dr., Peterborough, ON, K9L 0G2, Canada
| | - Gillian Balfour
- Office of the Provost and Vice-President Academic, Thompson River University, 805 TRU Way, Kamloops, BC, V2C 0C8, Canada
| | - David Byrne
- Community and Justice Services, Centennial College, 941 Progress, Ave, Scarborough, ON, M1G 3T8, Canada
| | - Crystal Dieleman
- School of Occupational Therapy, Dalhousie University, 5869 University Ave., Halifax, NS, B3H 4R2, Canada
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Garrett MD. Critical Age Theory: Institutional Abuse of Older People in Health Care. EUROPEAN JOURNAL OF MEDICAL AND HEALTH SCIENCES 2022; 4:24-37. [DOI: 10.24018/ejmed.2022.4.6.1540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Theories of elder abuse focus on the characteristics of the victim, the perpetrator, and the context of abuse. Although all three factors play a role, we are biased to notice individual misbehavior as the primary and sole cause of abuse. We see individuals as responsible for abuse. By examining abuses across a spectrum of healthcare services, abuse is more likely to be due to the institutional culture that includes the use of medications, Assisted Living, Skilled Nursing Facilities/nursing homes, hospices, hospitals, and Medicare Advantage programs. This study highlights multiple and consistent institutional abuses that result in harm and death of older adults on a consistent basis. The results show that when profit is increased, standards of care are diminished, and abuse ensues. Assigning responsibility to the management of healthcare becomes a priority in reducing this level of abuse. However, there are biases that stop us from assigning blame to institutions. Individual healthcare workers adhere to work protocol and rationalize the negative outcomes as inevitable or due to the vulnerability and frailness of older people. This culture is socialized for new employees that develop a culture of diminishing the needs of the individual patient in favor of the priorities dictated by the management protocol. In addition, the public is focused on assigning blame to individuals. Once an individual is assigned blame then they do not look beyond that to understand the context of abuse. A context that is generated by healthcare facilities maximizing profit and denigrating patient care. Regulatory agencies such as the U.S. DHHS, CDC, State Public Health Agencies, State/City Elder Abuse units, and Ombudsmen Programs all collude, for multiple reasons, in diminishing institutional responsibility.
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Bishop CE, Degenholtz HB. Evidence Base for the Future of Nursing Homes: Special Issue. Innov Aging 2022; 6:igac039. [PMID: 35832203 PMCID: PMC9273401 DOI: 10.1093/geroni/igac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Christine E Bishop
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Howard B Degenholtz
- Department of Health Policy and Management, Graduate School of Public Health, Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Kingsley DE, Harrington C. Financial and Quality Metrics of A Large, Publicly Traded U.S. Nursing Home Chain in the Age of Covid-19. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2022; 52:212-224. [PMID: 35118905 DOI: 10.1177/00207314221077649] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nursing homes faced serious challenges with large COVID-19 resident infection rates and deaths during the pandemic. This descriptive case study examined the structure, operations, strategies, care outcomes, and owners of The Ensign Group Inc. the second largest U.S. for-profit chain, between 2007 and 2021. Ensign, as a holding company, has a complex organizational structure that uses more than 430 corporate entities to manage its 228 nursing homes and senior living facilities. With mostly Medicare and Medicaid revenues and favorable government COVID-19 relief, Ensign grew rapidly, even during the pandemic, to $2.5 billion (all amounts in U.S. Dollars) in revenues with a market capitalization of $4.5 billion and strong profits and financial metrics in 2020 to 2021. The company used real estate purchasing, debt financing, and spin-off companies, and tax arbitrage to optimize shareholder value. Before and during the pandemic, its 198 nursing homes had low registered nurse and total nurse staffing levels and regulatory violations with below-average ratings, and they had high COVID-19 infection rates during the pandemic. Ensign's small board, executives, and institutional investors protected and enhanced shareholder interests rather than ensuring that its nursing homes met professional standards and regulatory requirements.
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Affiliation(s)
- David E Kingsley
- Department of Health Policy & Management, 12251University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Charlene Harrington
- Social & Behavioral Sciences, University of California, San Francisco, CA, USA
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Berridge C, Grigorovich A. Algorithmic harms and digital ageism in the use of surveillance technologies in nursing homes. FRONTIERS IN SOCIOLOGY 2022; 7:957246. [PMID: 36189442 PMCID: PMC9525107 DOI: 10.3389/fsoc.2022.957246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/26/2022] [Indexed: 05/10/2023]
Abstract
Ageism has not been centered in scholarship on AI or algorithmic harms despite the ways in which older adults are both digitally marginalized and positioned as targets for surveillance technology and risk mitigation. In this translation paper, we put gerontology into conversation with scholarship on information and data technologies within critical disability, race, and feminist studies and explore algorithmic harms of surveillance technologies on older adults and care workers within nursing homes in the United States and Canada. We start by identifying the limitations of emerging scholarship and public discourse on "digital ageism" that is occupied with the inclusion and representation of older adults in AI or machine learning at the expense of more pressing questions. Focusing on the investment in these technologies in the context of COVID-19 in nursing homes, we draw from critical scholarship on information and data technologies to deeply understand how ageism is implicated in the systemic harms experienced by residents and workers when surveillance technologies are positioned as solutions. We then suggest generative pathways and point to various possible research agendas that could illuminate emergent algorithmic harms and their animating force within nursing homes. In the tradition of critical gerontology, ours is a project of bringing insights from gerontology and age studies to bear on broader work on automation and algorithmic decision-making systems for marginalized groups, and to bring that work to bear on gerontology. This paper illustrates specific ways in which important insights from critical race, disability and feminist studies helps us draw out the power of ageism as a rhetorical and analytical tool. We demonstrate why such engagement is necessary to realize gerontology's capacity to contribute to timely discourse on algorithmic harms and to elevate the issue of ageism for serious engagement across fields concerned with social and economic justice. We begin with nursing homes because they are an understudied, yet socially significant and timely setting in which to understand algorithmic harms. We hope this will contribute to broader efforts to understand and redress harms across sectors and marginalized collectives.
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Affiliation(s)
- Clara Berridge
- School of Social Work, University of Washington, Seattle, WA, United States
- *Correspondence: Clara Berridge
| | - Alisa Grigorovich
- Recreation and Leisure Studies, Brock University, St. Catharines, ON, Canada
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Asante BL, Zúñiga F, Favez L. Quality of care is what we make of it: a qualitative study of managers' perspectives on quality of care in high-performing nursing homes. BMC Health Serv Res 2021; 21:1090. [PMID: 34645441 PMCID: PMC8515763 DOI: 10.1186/s12913-021-07113-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/01/2021] [Indexed: 11/24/2022] Open
Abstract
Background Leadership has a vital role regarding quality of care in nursing homes. However, few studies have explored upper-level managers’ views on how to assure that residents receive high quality of care. Therefore, this study’s aim was to examine how managers of top-quality nursing homes define, develop and maintain high-quality of care. Method We used interpretive description, an inductive, qualitative approach. Our research included 13 semi-structured interviews with 19 managers. We analyzed their input using reflexive thematic analysis, which is an iterative approach. Results Quality development and maintenance are cyclic processes. Managers in high-performing nursing homes lead with high commitment towards a person-centred quality of care, creating appropriate working conditions and continuously co-creating a vision and the realization of quality of care together with employees. Conclusions This study confirms that, in high-performing nursing homes, a person-centered approach—one where both residents and employees are at the center—is essential for quality development and maintenance. The most effective managers exemplify “person centeredness”: they lead by example and promote quality-focused working conditions. Such strategies motivate employees to provide person-centered care. As this means focusing on residents’ needs, it results in high care quality.
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Affiliation(s)
- Brigitte Lalude Asante
- Institute of Nursing Science, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Franziska Zúñiga
- Institute of Nursing Science, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
| | - Lauriane Favez
- Institute of Nursing Science, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
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Liu PJ, Caspi E, Cheng CW. Complaints Matter: Seriousness of Elder Mistreatment Citations in Nursing Homes Nationwide. J Appl Gerontol 2021; 41:908-917. [PMID: 34486438 DOI: 10.1177/07334648211043063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Mistreatment of nursing home residents is prevalent and leads to harmful consequences. The Centers for Medicare & Medicaid Services's (CMS) mission to protect residents' right to be free from mistreatment is implemented partially through state survey agencies' (SSAs) issuance of deficiency citations. The goal of this study was to compare SSA standard surveys and SSA complaint investigations with regard to the seriousness (scope and severity) of the mistreatment citations issued. A cumulative link mixed model was built to estimate the differences between standard surveys and complaint investigations in the seriousness of four core and two secondary mistreatment citations nationwide from 2014 to 2017. In all of the six mistreatment deficiency citations, complaint investigations were more likely to be determined as more serious compared with standard surveys. The findings reinforce the importance of strengthening nursing homes' and CMS/SSA response to consumers' concerns and grievances before they escalate into more harmful mistreatment.
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Affiliation(s)
- Pi-Ju Liu
- Purdue University, West Lafayette, IN, USA
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Siegel EO, Young HM. Assuring Quality in Nursing Homes: The Black Box of Administrative and Clinical Leadership—A Scoping Review. THE GERONTOLOGIST 2020; 61:e147-e162. [DOI: 10.1093/geront/gnaa175] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Indexed: 01/18/2023] Open
Abstract
Abstract
Background and Objectives
Licensed nursing home administrators (NHA) and directors of nursing (DON) are responsible for nursing home quality and assuring optimal performance and job satisfaction/retention of their nursing home workforce. NHA/DON-focused studies have generated important foundational knowledge over the last three decades; yet, targeted research is needed to understand and apply the complexities of the black box of this top management team. This scoping review identifies, reviews, synthesizes, and maps the topical areas of research in NHA/DON positions in U.S. nursing homes.
Research Design and Methods
We conducted searches of 5 databases, yielding 3,479 records; screening/review yielded 88 unique records. We used thematic analysis to code the primary foci of the studies and the variables associated with the concepts of interest.
Results
Most papers (n = 40) focused on role characteristics, 23 examined approaches to management and leadership, 24 focused on perceptions about the role, and the remaining 12 examined role structure. The role-related themes linked to outcomes (n = 42), processes (n = 27), and structures (n = 30).
Discussion and Implications
We highlight important gaps for future research and offer a call to action for research, policy, practice, and education collaborations to accelerate the rate of research and translate the findings into best practices for NHA/DON to lead and manage the nursing home workforce and build capacity to ensure person-centered, high-quality care. Based on foundational descriptive studies, it is time to use what is known to design and implement interventions that enhance the capacity of NHA/DON to improve the structures, processes, and outcomes of nursing homes.
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Affiliation(s)
- Elena O Siegel
- Betty Irene Moore School of Nursing, University California, Davis, Sacramento, USA
| | - Heather M Young
- Betty Irene Moore School of Nursing, University California, Davis, Sacramento, USA
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Harrington C, Ross L, Chapman S, Halifax E, Spurlock B, Bakerjian D. Nurse Staffing and Coronavirus Infections in California Nursing Homes. Policy Polit Nurs Pract 2020; 21:174-186. [PMID: 32635838 DOI: 10.1177/1527154420938707] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.
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Affiliation(s)
- Charlene Harrington
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Leslie Ross
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Susan Chapman
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Elizabeth Halifax
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Bruce Spurlock
- Department of Social & Behavioral Sciences, University of California, San Francisco
| | - Debra Bakerjian
- Department of Social & Behavioral Sciences, University of California, San Francisco
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