On nursing home quality: a review and analysis

Do nursing homes with a higher proportion of residents with dementia have greater or fewer complaints?

Objectives: Nursing home (NH) residents' capacity to communicate deteriorates with dementia. Consequently, NHs with high proportions of people living with dementia (PLWD) may receive fewer resident complaints, and/or investigating complaints may be challenging. We assessed NHs' proportion of PLWD in relation to total and substantiated complaints. Methods: Data were from the ASPEN Complaints/Incident Tracking System and the Certification and Survey Provider Enhanced Reports (2017). NHs (N = 15,499) were categorized based on high (top-10%), medium (middle-80%), and low (bottom-10%) dementia prevalence. Negative binomial Poisson regression assessed complaint patterns in relation to NHs' high/low (vs. medium) proportions of PLWD and other facility/resident characteristics. Results: Compared to NHs with medium-dementia prevalence, NHs with low proportions of PLWD had higher total (average marginal effect [AME] = 0.16, p < 0.001) and substantiated (AME = 0.30, p < 0.001) complaints, whereas NHs with high proportions of PLWD had fewer total (AME= -0.07; p < 0.05) and substantiated (AME= -0.11, p < 0.05) complaints. Also, NHs' profit status, chain-affiliation, size, staffing, and resident ethnicity were associated with total and substantiated complaints. Conclusion: The association between high proportions of PLWD and lower NH complaints suggests either that these NHs have higher overall quality or that complaints are underreported. Regardless, surveyors and families may need more involvement in monitoring higher dementia prevalence facilities.

Intermediate Care Facilities for Individuals With Intellectual Disabilities: Does Ownership Type Affect Quality of Care?

Because many large, state-owned Intermediate Care Facilities for Individuals With Intellectual Disabilities (ICF/IIDs) have closed or downsized, their average size has fallen markedly, as has the number that are publicly owned. We probe the relationship between ownership type and four measures of care quality in ICF/IIDs. Data on deficiency citations suggest that for-profits underperform other ownership types, although data on complaints show no clear pattern. Meanwhile, data on staffing ratios and restrictive behavior management practices, based mostly on facility self-reports, generally tell the opposite story. Our results lend some credence to concerns regarding inadequate care in for-profit ICF/IIDs, while underscoring the importance of requiring ICF/IID operators to report more comprehensive, longitudinal data that are less prone to error and reporting bias.

Public/private ownership and quality of care: Evidence from Danish nursing homes

The involvement of private for-profit (FP) and not-for-profit (NFP) providers in the otherwise public delivery of welfare services is gradually changing the Nordic welfare state towards a more market-oriented mode of service delivery. This article examines the relationship between ownership and quality of care in public and private FP and NFP nursing homes in Denmark. The analysis draws on original survey data and administrative registry data (quality inspection reports) for the full population of almost 1000 nursing homes in Denmark. Quality is measured in terms of structural quality, process quality and outcome quality. We find that public nursing homes have a higher structural quality (in terms of, for instance, staffing), while FP providers perform better in terms of process quality (e.g. in the form of individualised care). NFP providers perform well in terms of structural criteria such as employment of full-time staff and receive fewer critical comments in the inspection reports. However, the results depend to some extent upon the method of data collection, which underlines the benefits of using multiple data sources to examine the relationship between ownership and the quality of care.

Nursing Home Closures and Quality of Care

The purpose of this research is to examine the relationship between quality of care in nursing homes and their likelihood of closure. We hypothesize that lower-quality facilities will be more likely to close than higher-quality facilities. Using the rates of physical restraint use, urethral catheterization, contractures, pressure ulcers, and psychotropic medication use as quality measures from approximately 12,000 facilities from 1992 to 1998, the author examine cross-sectional and change score relationships between these measures and a nursing home’s likelihood of closure. The descriptive analysis shows that 621 nursing homes closed in this time period, and the results for physical restraint use were robust in their positive association with closures in most analyses lending some support for this study’s hypothesis. However, overall, the author concludes that nursing facility closures are relatively rare events. And the likelihood of closure, even for poor-quality facilities, is low.

Nursing Homes with Persistent High and Low Quality

This article examines the concentration of low- and high-quality care within particular nursing facilities over time. The authors explore three different explanations for persistent low and high quality over time including the level of public reimbursement, the presence of bed constraint policies such as certificate-of-need and construction moratoria, and the role of consumer information. Using 1991 through 1999 data from the On-Line Survey, Certification, and Reporting system, the authors show that both low- and high-quality nursing home care is concentrated in certain facilities over time. Their results further show that public reimbursement and asymmetric information are both important factors in explaining why low quality persists over time in certain facilities.

The Effects of For-Profit and Not-for-Profit Facility Status on the Quality of Care for Nursing Home Residents with Mental Illnesses

This article examines whether a relationship exists between ownership status (for-profit and not-for-profit) of nursing homes and the quality of care for residents who are mentally ill. Rather than looking for an overall indicator of differences in quality between these ownership types, as other studies have done, three quality indicators are examined: structure, process, and outcome. Also, different types of nursing homes are examined by size and certification level. The authors fail to find consistent evidence that for-profit nursing homes provide poorer quality care to mentally ill residents using measures of structure, process, and outcome; they did find, however, that nursing homes may modify their approach to caring for these residents. That is, the size of the facility and the certification level could be important factors in the quality of the mental health care of nursing home residents.

Nursing Home Profit Status and Quality of Care: Is There Any Evidence of an Association?

This article critically reviews the association between the profit status of North American nursing homes and the quality of care. Studies were identified by searching MEDLINE (January 1990-October 2002), reference lists, letters, commentaries, and editorials. The quality indicator(s) used to measure quality of care, and its relationship to profit status, was extracted from each publication. The study design and risk-adjustment methodologies used were also extracted. The interrater reliability for the extraction of these three items was determined to be 1.0, 0.6, and 0.8, respectively. Aqualitative systematic review was performed using Donabedian’s framework of structure, process, and outcome for analyzing medical quality of care. Empirical research in the past 12 years has found that systematic differences exist between for-profit and not-for-profit nursing homes. Forprofit nursing homes appear to provide lower quality of care in many important areas of process and outcome.

Family Members' Perceptions of the Quality of Long-Term Care

The aim of the study is to assess family members' perceptions of the quality of nursing care of older people and its relationships between demographic factors and family involvement. Data were gathered from family members of four residential homes ( N= 474) using structured questionnaires. Data were analyzed using descriptive statistics, correlation, and predictive analyses. The results imply that family members' perceptions of quality were fairly positive. Age, educational background, and the frequency of visits on the ward were related with the quality perception. The association between quality perceptions and family involvement in care proved to be strong. The information and support from the staff and possibilities to participate in decision making were associated with high-quality ratings. The results demonstrate the need for formulating ward policies and training the nursing staff to allow increased family involvement and to support it in an appropriate way.

Family Satisfaction With Residential Care Provision: A Multilevel Analysis

The goal of this study was to assess the impact of staff commitment on outcomes of quality of care in residential care facilities in a sample of 260 family members of residents and 206 direct care staff from 24 residential care/assisted living (RC/AL) homes in Kansas. Quality of care was measured as family satisfaction, and individual- and facility-level predictors were used in the model. The significant predictors of family satisfaction were the family member’s age and relationship to elder. The findings suggest that both of these variables are tied to beliefs that family members have about their own responsibility for care, which may in turn influence their satisfaction with care. This hypothesis deserves further attention in future research. Also, the failure of this study to affirm an expected relationship between staff commitment and family satisfaction should prompt further research related to staff commitment and family satisfaction.

Staff Ratios and Resident Outcomes in Special Care Units: Do Activity Aides Make a Difference?

This study examines the effect of activity aide—to-resident ratios on outcomes of special-care-unit residents over a 1-year period following admission. Existing studies focusing on the effects of staff ratios on resident outcomes tend not to separate activity aides from other types of staff, if they study them at all. However, research on best care practices in special care units for persons with dementia has established the importance of activities for optimal resident outcomes. Employing multiple regression analyses, this study finds evidence that increased activity aide— to-resident ratios have positive effects on three resident outcomes—expressive language skills, social skills, and cognitive function—when controlling for resident characteristics, facility characteristics, and environmental design. It is concluded that because activity aide—to-resident ratios tend to be very low yet appear to have a significant positive effect on resident outcomes, a modest increase in activity aide—to-resident ratios would be beneficial for residents with dementia in special care units.

Resident and Staff Ratings of Foodservices in Long-Term Care: Implications for Autonomy and Quality of Life

Foodservices contribute to the health status, quality of life, and autonomy of long-term care (LTC) residents, yet malnutrition is prevalent. To improve nutritional status, LTC facilities should determine which aspects of foodservices are important to residents and which provoke the most dissatisfaction. Because staff control foodservices, it is equally important to examine their beliefs. Data were collected from nine LTC facilities in Quebec. Means and t tests of differences between residents' (n = 69) and staff 's (n = 52) mean importance and satisfaction rankings of 29 foodservice items are presented. Although residents rated foodservice choice and autonomy items lower in importance, these items were generally less satisfied. Staff consistently overrated both importance and satisfaction among residents. Specific recommendations for foodservice quality improvements are discussed in relation to residents' quality of life, autonomy, and nutritional status.

Nursing Home Ownership and Quality of Care

This article examines the relationship between nursing home ownership and the quality of care. It was hypothesized that not-for-profit homes provide less inappropriate care than for-profit homes, and that not-for-profit residents make more functional improvement than for-profit residents. A multiple regression analysis of 3,149 Virginia nursing home residents in 174 homes found that not-for-profit homes provided less inappropriate care than for-profit homes. However, not-for-profit residents did not achieve more functional improvement than for-profit residents. It is unclear why ownership was related to inappropriate care and not related to functional improvement. Research is needed that examines the interaction between ownership and poten tially related factors, such as organizational culture, that could influence the quality of care.

Changes in Resident and Facility Risk Factors for Psychotropic Drug Use in Nursing Homes Since the Nursing Home Reform Act

The purposes of this article are to identify resident and facility risk factors for the use of psychotropic drugs since the implementation of the Nursing Home Reform Act (NHRA) and to compare these results with resident and facility risk factors prior to the implementation of the NHRA. The results update our knowledge of resident risk factors for psychotropic drug use and identify important but previously unexplored facility risk factors for their use. No evidence was found that particular types of nursing homes, such as for-profits, were systematically more likely to use psychotropic drugs. There was some evidence to suggest that operating characteristics of nursing homes, such as Medicaid census, are more influential in changing psychotropic drug use. In addition, both resident and facility risk factors for psychotropic drug use differed pre and post-implementation of the NHRA. Antipsychotic drug use increased slightly during this study period.

Variations in Outcomes of Care in Urban and Rural Nursing Facilities in Maine

Federal and state regulators and the nursing home industry have accelerated efforts to improve care practices in response to the Institute of Medicine's 1986 report on the quality of nursing home care and the federal Nursing Home Reform Act of 1987 (OBRA 1987). Very little is known about the quality of care in rural nursing facilities compared to their urban counterparts. This study describes variations in facility and resident characteristics of urban and rural nursing facilities in Maine and examines differences in outcomes of care. The study estimates rural-urban differences in 11 quality indicators (measured at the facility level) controlling for resident, facility, and market characteristics and other factors that may affect quality. Results reveal few significant differences between rural and urban nursing facilities. Further research is needed to understand whether differences in the characteristics of rural and urban facilities not measured in this study may affect nursing facility quality.

Inter-SMSA Variation in Nursing Home Staffing and Resident Care Management Practices

In this study, data from the 1987 Medicare and Medicaid Automated Certification Survey (MMACS) is analyzed to determine the extent to which nursing home staffing and resident care management practices, such as urethral catheterization and physical restraint use, vary across a sample of 10 standard metropolitan statistical areas (SMSAs). After controlling for influential differences in case mix related to facility characteristics and the functional severity of the nursing home population at risk, significant SMSA effects associated with staffing and practice outcome measures were found by weighted least squares regression. Potential sources of variation related to local market conditions and state nursing home policy are considered.

Dancing the Two-Step in Ontario's Long-term Care Sector: More Deterrence-oriented Regulation = Ownership and Management Consolidation

This paper explores shifts in public and private delivery over time through an analysis of Ontario's approach to LTC funding and regulation in relation to other jurisdictions in Canada and abroad. The case of Ontario's long-term care (LTC) policy evolution - from the 1940s until early 2013 -- shows how moving from compliance to deterrence oriented regulation can support consolidation of commercial providers' ownership and increase the likelihood of non-profit and public providers outsourcing their management.

Change and predictors of change in social skills of nursing home residents with dementia

BACKGROUND

Social skills are of primary importance for those with dementia and their care providers, yet we know little about the extent to which basic social skills can be maintained over time and the predictors of change.

METHODS

A total of 18 nursing homes with 149 newly admitted residents with moderate to severe dementia, 195 direct care staff, and 135 family members, in British Columbia, Canada, contributed data on change in social skills from admission to 6 months and 1 year later.

RESULTS

Three-quarters of residents maintained or improved their basic social skills during both the time periods. Decline was explained primarily by cognitive status at the time of admission, notably present orientation. However, staff-to-resident communication becomes more important over time.

CONCLUSIONS

Social skills appear to present an opportunity to maintain interaction with these residents. The findings also suggest that a focus on the present orientation before and following admission and on staff-to-resident communication may be beneficial.

Do Medicaid incentive payments boost quality? Florida's direct care staffing adjustment program

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents--the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.

The Norwegian teaching home program: developing a model for systematic practice development in the nursing home sector

Background.  In the mid-1990s, there was persistent critique of the quality of care provided in residential aged care facilities in Norway, in line with similar concerns expressed in many other countries. Difficulties recruiting qualified staff and high turnover led to difficult working conditions. Little prestige was associated with providing geriatric care. Collaboration between educational institutions, universities and elderly care institutions with the purpose of strengthening education, competence development, practice development and research within elderly care was poorly developed. The Norwegian teaching nursing home (NTNH) program was launched to address these issues. Aim.  The purpose of the NTNH was to contribute to the quality of care of frail older persons by improving the competence of staff, improving the prestige of working with older people, stimulating development of services, facilitating research into the care of older persons, and developing good learning environments for students. Methods.  The NTNH-program was developed over a period of seven years, applying a participatory action research design. Progressing through four phases, it involved a number of people and institutions across Norway. Results.  Formal and informal competence of staff was increased. A large number of practice development projects contributed to increased quality of care in selected problem areas. Models of competence development were disseminated to other institutions, thereby improving the level of competence beyond the NTNHs. Learning conditions for students were improved. Following a formal evaluation of the program, teaching nursing homes (TNHs) were established on a permanent basis in 2004, with financial support from the Department of Health and Social Services. In 2008, a total of 20 TNHs are part of the NTNH program. Conclusions.  The NTNH program led to permanent establishment of a series of TNHs responsible for contributing to competence development, practice development and research on a continuous basis in order to secure high levels of care to the Norwegian nursing home population. The program has created substantial enthusiasm within the nursing home sector and has increased the prestige of these institutions.

Can hospital cultural competency reduce disparities in patient experiences with care?

BACKGROUND

Cultural competency has been espoused as an organizational strategy to reduce health disparities in care.

OBJECTIVE

To examine the relationship between hospital cultural competency and inpatient experiences with care.

RESEARCH DESIGN

The first model predicted Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores from hospital random effects, plus fixed effects for hospital cultural competency, individual race/ethnicity/language, and case-mix variables. The second model tested if the association between a hospital's cultural competency and HCAHPS scores differed for minority and non-Hispanic white patients.

SUBJECTS

The National CAHPS Benchmarking Database's (NCBD) HCAHPS Surveys and the Cultural Competency Assessment Tool of Hospitals Surveys for California hospitals were merged, resulting in 66 hospitals and 19,583 HCAHPS respondents in 2006.

MEASURES

Dependent variables include 10 HCAHPS measures: 6 composites (communication with doctors, communication with nurses, staff responsiveness, pain control, communication about medications, and discharge information), 2 individual items (cleanliness and quietness of patient rooms), and 2 global items (overall hospital rating, and whether patient would recommend hospital).

RESULTS

Hospitals with greater cultural competency have better HCAHPS scores for doctor communication, hospital rating, and hospital recommendation. Furthermore, HCAHPS scores for minorities were higher at hospitals with greater cultural competency on 4 other dimensions: nurse communication, staff responsiveness, quiet room, and pain control.

CONCLUSIONS

Greater hospital cultural competency may improve overall patient experiences, but may particularly benefit minorities in their interactions with nurses and hospital staff. Such effort may not only serve longstanding goals of reducing racial/ethnic disparities in inpatient experience, but may also contribute to general quality improvement.

Strategic groups and outcomes in the US hospice care industry

PURPOSE

As a result of a drastic increase in new patients, two major shifts are occurring in the US hospice care industry: an increase in the number of for-profit providers, and hospices are increasing in size through acquisitions and mergers. Hospices are trying to both increase the number of innovative programs they offer and decrease their operating expenses to improve their margins and attract more patients. This study seeks to investigate if strategic groups exist within the industry as hospices try to become more innovative and efficient, which grouping factors are most significant, and to determine whether there is a relationship between group membership and performance.

DESIGN/METHODOLOGY/APPROACH

Cluster analysis and ANOVA are used to analyze data from 93 California hospices.

FINDINGS

Three strategic groups exist within the market, innovative practices significantly affect group membership, and innovation-oriented groups outperform others in terms of quality of care.

PRACTICAL IMPLICATIONS

Many hospices focus on innovation, and evidence suggests that continued pursuit of innovative practices is critical, whereas efficiency does not appear to have a significant impact on quality of care. Focus on such evidence-based practices is important for long-term success.

ORIGINALITY/VALUE

This is the first study to investigate strategic group formation in the hospice care industry.

Predictors of emergency commitment for nursing home residents: the role of resident and facility characteristics

OBJECTIVES

The ability of nursing homes to manage the mental health needs of their residents is crucial to providing high quality care. An important element is preventing exacerbations of psychiatric conditions that trigger discharge from the nursing home (NH) because of an emergency commitment (EC) for an involuntary psychiatric examination. The objective of this study was to examine the relationship between resident and facility characteristics and the risk of EC for involuntary psychiatric examination among Medicaid-enrolled NH residents in Florida.

DESIGN

This retrospective cohort study employed 2.5 years (31 December 2002 through 30 June 2005) of Medicaid enrollment and fee-for-service, pharmacy, and involuntary commitment data to examine resident characteristics. NH characteristics were obtained from the Online Survey Certification and Reporting database.

SETTING

Medicaid-certified NHs in Florida (N= 584).

PARTICIPANTS

Medicaid-enrolled NH residents (N= 32,604).

RESULTS

Younger age, male gender, having dementia, having a serious mental illness (SMI), and residing in a for-profit facility were all independently associated with the greater risk of EC. Although most residents with EC were prescribed psychotropic medication, less than half received non-pharmacological behavioral health outpatient services before or after their involuntary psychiatric examination.

CONCLUSION

Our findings highlight the salience of resident and facility characteristics to prevalence rates of EC for involuntary psychiatric examinations among NH residents and underscore a need for increased education, communication, and future research on the predictive factors as well as the consequences of these adverse events.

Nursing home work environment and the risk of pressure ulcers and incontinence

OBJECTIVE

To examine the association between nursing home (NH) work environment attributes such as teams, consistent assignment and staff cohesion, and the risk of pressure ulcers and incontinence.

DATA SOURCES/SETTING

Minimum dataset for 46,044 residents in 162 facilities in New York State, for June 2006-July 2007, and survey responses from 7,418 workers in the same facilities.

STUDY DESIGN

For each individual and facility, primary and secondary data were linked. Random effects logistic models were used to develop/validate outcome measures. Generalized estimating equation models with robust standard errors and probability weights were employed to examine the association between outcomes and work environment attributes. Key independent variables were staff cohesion, percent staff in daily care teams, and percent staff with consistent assignment. Other facility factors were also included.

PRINCIPAL FINDINGS

Residents in facilities with worse staff cohesion had significantly greater odds of pressure ulcers and incontinence, compared with residents in facilities with better cohesion scores. Residents in facilities with greater penetration of self-managed teams had lower risk of pressure ulcers, but not of incontinence. Prevalence of consistent assignment was not significantly associated with the outcome measures.

CONCLUSIONS

NH environments and management practices influence residents' health outcomes. These findings provide important lessons for administrators and regulators interested in promoting NH quality improvement.

Which Residential Care Facilities Are Delivering Inadequate Care? A Simple Case-Finding Questionnaire

L'objectif de cette étude était de développer un outil de repérage des ressources d'hébergement qui dispensent des soins inadéquate à leur clientèle âgée en perte d'autonomie et d'en évaluer la validité. Elle a été réalisée à partir des données d'une étude récente menée auprès de 88 résidences pour personnes âgées en Estrie (province de Québec). Les caractéristiques générales des milieux étaient recueülies via une entrevue avec les responsables et la qualité des soins offerts aux résidants (n = 301) était évaluée à l'aide de l'échelle QUALCAEE. Des analyses de régression multivariées ont permis l'élaboration d'un court questionnaire pouvant être complété lors d'un entretien téléphonique avec le responsable. Ce questionnaire constitue un outil de repérage simple et peu dispendieux pour identifier les milieux dispensant des soins inadéquate. De plus, sa sensibilité de 85 pour cent et sa spécificité de 65 pour cent suggèrent une bonne validité.

Quality of mental health care for nursing home residents: a literature review

Because of the high proportion of nursing home residents with a mental illness other than dementia, the quality of mental health care in nursing homes is a major clinical and policy issue. The authors apply Donabedian's framework for assessing quality of care based on the triad of structure, process, and outcome-based measures in reviewing the literature on the quality of mental health care in nursing homes. Quality measures used within the literature include mental health consultations and hospitalizations, inappropriate use of medications, and mental health survey deficiencies. Factors related to the resident's welfare (nurse staffing), provider norms (locality), and financial factors (payer mix) were associated with the quality of mental health care. Although future research is necessary, the extant literature suggests that persons with mental illness are frequently admitted to nursing homes and their care is often of poor quality and related to a series of resident and facility factors.

Staffing characteristics, turnover rates, and quality of resident care in nursing facilities

Despite substantial spending and considerable regulatory oversight, the quality of care provided to residents in the nation's nursing facilities is inadequate, and strategies to address this problem are needed. Staffing characteristics are important predictors of quality in nursing facilities, and the relationship between staffing and various quality measures fluctuates across studies and in analyses that account for the effects of market, resident, and organizational characteristics. However and even with such variations, it is has generally been concluded that higher staffing levels, less turnover, and higher retention rates are associated with an array of improved resident and facility outcomes. This article synthesizes literature, including published reports, expert opinion, and peer reviewed studies, on staffing levels, turnover, and quality of care in nursing homes. The findings were used to develop three staffing interventions that need to be further evaluated in an effort to improve the quality of care in nursing facilities.

Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis

OBJECTIVE

To compare quality of care in for-profit and not-for-profit nursing homes.

DESIGN

Systematic review and meta-analysis of observational studies and randomised controlled trials investigating quality of care in for-profit versus not-for-profit nursing homes.

RESULTS

A comprehensive search yielded 8827 citations, of which 956 were judged appropriate for full text review. Study characteristics and results of 82 articles that met inclusion criteria were summarised, and results for the four most frequently reported quality measures were pooled. Included studies reported results dating from 1965 to 2003. In 40 studies, all statistically significant comparisons (P<0.05) favoured not-for-profit facilities; in three studies, all statistically significant comparisons favoured for-profit facilities, and the remaining studies had less consistent findings. Meta-analyses suggested that not-for-profit facilities delivered higher quality care than did for-profit facilities for two of the four most frequently reported quality measures: more or higher quality staffing (ratio of effect 1.11, 95% confidence interval 1.07 to 1.14, P<0.001) and lower pressure ulcer prevalence (odds ratio 0.91, 95% confidence interval 0.83 to 0.98, P=0.02). Non-significant results favouring not-for-profit homes were found for the two other most frequently used measures: physical restraint use (odds ratio 0.93, 0.82 to 1.05, P=0.25) and fewer deficiencies in governmental regulatory assessments (ratio of effect 0.90, 0.78 to 1.04, P=0.17).

CONCLUSIONS

This systematic review and meta-analysis of the evidence suggests that, on average, not-for-profit nursing homes deliver higher quality care than do for-profit nursing homes. Many factors may, however, influence this relation in the case of individual institutions.

The association of individual and facility characteristics with psychiatric hospitalization among nursing home residents

OBJECTIVE

To examine resident and facility characteristics associated with psychiatric hospitalizations (PH) for Medicaid enrolled nursing home (NH) residents.

METHODS

Participants were all Medicaid enrolled NH residents (n = 32,604) from all Medicaid certified nursing homes in Florida (n = 584) with complete data. We used individual demographic and diagnostic characteristics, as well as facility characteristics, to explore risk of psychiatric hospitalization in this dataset.

RESULTS

Using generalized estimating equations, we found that younger age, male gender, poor physical health, serious mental illness, dementia, and drug use disorder were associated with risk of psychiatric hospitalization. Most notably, residents under 65 were more than three times more likely to undergo psychiatric hospitalization and dementia was associated with a three-fold increase in the risk of psychiatric hospitalization. Predictors of PH differed somewhat for younger and older residents. Among facility characteristics, greater facility size, low proportion of those paying via Medicare and high proportion of residents with serious mental illness were associated with increased risk of psychiatric hospitalization, whereas, low proportion of residents paying via Medicaid, high proportion of residents paying via Medicare, and low proportion of resident with serious mental illness were associated with reduced risk.

CONCLUSIONS

Both resident and facility characteristics impact risk for psychiatric hospitalization. Attention to identified predictors may reduce risk and improve outcomes for nursing home residents.

A national view of workplace injuries in nursing homes

OBJECTIVES

Data from a large sample of nursing homes were used to examine the cross-sectional association between workplace injuries and organizational factors, caregiver staffing levels, and quality.

METHODS

Three sources of data were used, the Occupational Safety and Health Administration data initiative for 2004, the Online Survey Certification and Recording system representing 2004, and the 2004 Area Resource File.

RESULTS

For the organizational characteristics of interest, the results show that for-profit facilities were less likely to report high injury rates and that facilities with a higher average occupancy and belonging to a chain were more likely to report high injury rates. For the staffing characteristics of interest, facilities with high staffing levels of registered nurses were more likely to report high injury rates, whereas those with high staffing levels of nurse aides were less likely to report high injury rates. For the quality characteristic of interest, facilities of low quality (as measured by quality-of-care deficiency citations) were more likely to report high injury rates.

CONCLUSIONS

Workplace injuries are associated with organizational, caregiver, and quality characteristics of nursing homes. This may present an opportunity to reduce high injury rates.

The Percentage of Beds Designated for Medicaid in American Nursing Homes and Nurse Staffing Ratios

Previous analyses of the inverse relationship between a nursing home's Medicaid census and its quality of care have been based on samples limited to specific geographic regions, for-profit entities, or only skilled care facilities. The present study uses national-level data from the 1999 National Nursing Home Survey to examine the association between the proportion of beds designated for Medicaid residents and nurse staffing ratios. The results indicate that homes which designate a higher proportion of their beds for Medicaid recipients maintain lower ratios of registered nurses and nurse's aides to residents, even when key facility characteristics are controlled. It was also found that nursing homes with a higher proportion of Medicaid beds offer lower nursing ratios regardless of their profit status or the difference between private pay rates and Medicaid reimbursement rates. Since lower nursing ratios have been previously linked to negative outcomes, these findings suggest that homes which rely more heavily upon Medicaid recipients may be using cost-cutting strategies which have negative implications for quality.

Does Quality Pay for Nursing Homes?

Using physical restraints, urethral catheterization, pressure ulcers, psychotropic medication use, and contractures as quality indicators, this research examines whether the quality of nursing homes is associated with private-pay census. The primary data source was the 2000, 2001, and 2002 Online Survey Certification And Recording (OSCAR) data, which is nationally representative data containing information for approximately 17,000 nursing homes. The results of this study suggest that physical restraint use and psychotropic medication use have both a correlative and predictive relationship with private-pay census. Catheterization, pressure ulcers, and contractures are less important. The results of this study are important in two ways. First, the cross-sectional results show that the higher quality nursing homes are likely to have a higher private-pay census. Second, the change score analyses show that nursing homes can increase their private-pay census by increasing quality.

Nursing home performance in resident care in the United States: is it only a matter of for-profit versus not-for-profit?

Poorer resident care in US for-profit relative to not-for-profit nursing homes is usually blamed on the profit motive. But US nursing home performance may relate to Medicaid public financing in a manner qualifying the relationship between ownership and quality. We investigated effects of Medicaid resident census, Medicaid payment, and occupancy on performance. Resource dependence theory implies these predictors may affect discretion in resources invested in resident care across for-profit and not-for-profit facilities. Models on physical restraint use and registered nurse (RN) staffing were studied using generalized estimating equations with panel data derived from certification inspections of nursing homes. Restraint use increased and RN staffing levels decreased among for-profit and not-for-profit facilities when the Medicaid census increased and Medicaid payment decreased. Interaction effects supported a theory that performance relates to available discretion in resource allocation. Effects of occupancy appear contingent on the dependence on Medicaid. Poorer performance among US for-profit nursing homes may relate to for-profit homes having lower occupancy, higher Medicaid census, and operating in US states with lower Medicaid payments compared to not-for-profit homes. Understanding the complexity of factors affecting resources expended on resident care may further our understanding of the production of quality in nursing homes, whether in the US or elsewhere.

The relationship between agency characteristics and quality of home care

BACKGROUND

This project assessed the relationship between home care quality indicators (HCQIs) and agency characteristics.

METHODS

Twelve agencies completed a mailed survey on a variety of characteristics, including size of their caseload and for-profit (FP) status of contracted service providers. The HCQIs were derived from standardized assessments completed voluntarily for home care clients in Ontario and in Manitoba, Canada.

RESULTS

The average caseload was 121.3 clients per case manager, and over 40% of nursing, personal support and therapy providers were considered FP. For individual HCQIs, few correlations were statistically significant. An overall summary measure of quality was correlated with the size of the population served (r = -0.80; p < 0.05) and the number of clients per case manager (r = -0.56; p < 0.1).

CONCLUSION

These data represent unique information on home care quality and organizational characteristics in Canada. The question remains as to how best to use HCQI data to inform practice in an era of limited resources and increasing caseloads.

Characteristics of Community Nursing Homes Serving Per Diem Veterans, 1999 to 2002

This study compared the characteristics of community nursing homes where veterans received their care with those of facilities that did not treat veterans from 1999 to 2002 using the Centers for Medicare and Medicaid Services (CMS) Online Survey Certification and Reporting system data merged with the CMS Minimum Data Set. A structure, process, and outcome model was used to examine whether the presence of per diem veterans had any impact on multidimensional quality measures. Facilities with any veterans were less likely to meet recommended nurse staffing standards; more likely to have patients with tube feeding, new catheterizations, and mobility restraints; and more likely to have actual harm citations and new pressure sores, plus quality-of-care, quality-of-life, and total deficiencies, than facilities without veterans. The implications of this study are that the U.S. Department of Veterans Affairs may need to examine its contracting policies with community facilities to understand both quality and selection effects that may be occurring.

Nursing working conditions in relation to restraint practices in long-term care units

OBJECTIVES

This study examined the effects of nursing working conditions on the use of physical restraints and antipsychotics as restraints in long-term care units for elderly residents.

DESIGN

Cross-sectional data were obtained in Finland in 2002 from long-term care units that used the Resident Assessment Instrument (RAI) system and participated in a survey on working conditions.

SETTING

A sample of 91 inpatient units in 31 facilities (23 residential homes and 8 health centers).

PARTICIPANTS

Data included 2430 resident assessments and 977 nursing staff survey responses.

MEASUREMENTS

We measured unit-level mean scores of physical restraint and antipsychotics use as restraints and resident characteristics (activities of daily living, cognitive impairment, and daily behavioral problems) based on the RAI system as measured by the Minimum Data Set 2.0. Head nurses reported the structural factors (nurse staffing levels and unit size). Nursing working conditions were measured by the Job-Demands and Job-Control Scales in the staff survey questionnaire.

RESULTS

Controlling for resident characteristics, nurses' job demands and control had a combined effect on restraint practices. Job demands strongly increased the risk of physical restraint use in units where nurses reported low job control (odds ratio [OR] = 13.31, 95% confidence interval [CI] 1.55-114.30, P = 0.019), but not among high-control units (OR = 0.23, 95% CI 0.04-1.29, P = 0.090). Although the use of antipsychotics was not related to job demands in units with low control (OR = 1.11, 95% CI 0.26-4.99, P = 0.891), the antipsychotics use in particular decreased when high job demands were coupled with high job control (OR = 0.17, 95% CI 0.03-0.91, P = 0.038).

CONCLUSION

The results suggest that restraint use can be reduced by enhancing working conditions so that the nursing staff has possibilities for skill usage and decision-making.

Medicare payment changes and nursing home quality: effects on long-stay residents

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities, providing a natural experiment in nursing home behavior. Medicare payment policy (directed at short-stay residents) may have affected outcomes for long-stay, chronic-care residents if services for these residents were subsidized through cost-shifting prior to implementation of Medicare prospective payment for nursing homes. We link changes in both the form and level of Medicare payment at the facility level with changes in resident-level quality, as represented by pressure sores and urinary tract infections in Minimum Data Set (MDS) assessments. Results show that long-stay residents experienced increased adverse outcomes with the elimination of Medicare cost reimbursement.

An empirical typology of residential care/assisted living based on a four-state study

PURPOSE

Residential care/assisted living describes diverse facilities providing non-nursing home care to a heterogeneous group of primarily elderly residents. This article derives typologies of assisted living based on theoretically and practically grounded evidence.

DESIGN AND METHODS

We obtained data from the Collaborative Studies of Long-Term Care, which examined 193 assisted living facilities in four states: Florida, Maryland, New Jersey, and North Carolina. By using mixture modeling, we derived typologies in five different ways, based on: structure; process; resident case-mix; structure and process; and structure, process, and resident case-mix.

RESULTS

Although configurations of typologies varied as a function of criterion variables used, common themes emerged from different cluster solutions. A typology based on resident case-mix yielded a five-cluster solution, whereas a typology based on structure, process, and resident case-mix resulted in six distinct clusters. Medicaid case-mix/psychiatric illness and high resident impairment were two clusters identified by both strategies.

IMPLICATIONS

Because of the wide variation in structure, residents, and services within assisted living facilities, typologies such as those described here may be useful in clinical practice, research, and policy. To the extent that public payment defines its own cluster, the potential for inequities in care merits careful attention.

Systematic Review of Studies of Staffing and Quality in Nursing Homes

PURPOSE

To evaluate a range of staffing measures and data sources for long-term use in public reporting of staffing as a quality measure in nursing homes.

METHOD

Eighty-seven research articles and government documents published from 1975 to 2003 were reviewed and summarized. Relevant content was extracted and organized around 3 themes: staffing measures, quality measures, and risk adjustment variables. Data sources for staffing information were also identified.

RESULTS

There is a proven association between higher total staffing levels (especially licensed staff) and improved quality of care. Studies also indicate a significant relationship between high turnover and poor resident outcomes. Functional ability, pressure ulcers, and weight loss are the most sensitive quality indicators linked to staffing. The best national data sources for staffing and quality include the Minimum Data Set (MDS) and On-line Survey and Certification Automated Records (OSCAR). However, the accuracy of this self-reported information requires further reliability and validity testing.

CONCLUSIONS

A nationwide instrument needs to be developed to accurately measure staff turnover. Large-scale studies using payroll data to measure staff retention and its impact on resident outcomes are recommended. Future research should use the most nurse-sensitive quality indicators such as pressure ulcers, functional status, and weight loss.