Getting the Basics Right: Care Delivery in Nursing Homes

Longitudinal Evaluation of a Statewide Quality Improvement Program for Nursing Homes

OBJECTIVES

The National Academies of Sciences, Engineering, and Medicine (NASEM) Nursing Home Quality report recommends that states "develop and operate state-based…technical assistance programs…to help nursing homes…improve care and…operations." The Quality Improvement Program for Missouri (QIPMO) is one such program. This longitudinal evaluation examined and compared differences in quality measures (QMs) and nursing home (NH) characteristics based on intensity of QIPMO services used.

DESIGN

A descriptive study compared key QMs of clinical care, facility-level characteristics, and differing QIPMO service intensity use. QIPMO services include on-site clinical consultation by expert nurses; evidence-based practice information; teaching NHs use of quality improvement (QI) methods; and guiding their use of Centers for Medicare and Medicaid Services (CMS)-prepared QM comparative feedback reports to improve care.

SETTING AND PARTICIPANTS

All Missouri NHs (n = 510) have access to QIPMO services at no charge. All used some level of service during the study, 2020-2022.

METHODS

QM data were drawn from CMS's publicly available website (Refresh April 2023) and NH characteristics data from other public websites. Service intensity was calculated using data from facility contacts (on-site visits, phone calls, texts, emails, webinars). NHs were divided into quartiles based on service intensity.

RESULTS

All groups had different beginning QM scores and improved ending scores. Group 2, moderate resource intensity use, started with "worse" overall score and improved to best performing by the end. Group 4, most resource intensity use, improved least but required highest service intensity.

CONCLUSIONS AND IMPLICATIONS

This longitudinal evaluation of QIPMO, a statewide QI technical assistance and support program, provides evidence of programmatic stimulation of statewide NH quality improvements. It provides insight into intensity of services needed to help facilities improve. Other states should consider QIPMO success and develop their own programs, as recommended by the NASEM report so their NHs can embrace QI and "initiate fundamental change" for better care for our nation's older adults.

Understanding organizational and cultural premises for quality of care in nursing homes: an ethnographic study

BACKGROUND

Internationally, there are concerns about the quality of care in nursing homes. The concept of 'corporate culture' as an internal variable could be seen as the means to improve quality of care and quality of life for the residents. The aim of this article was to describe the nursing home culture from the staff's perspective and to include how the residents describe quality of care.

METHODS

An ethnographic design was employed. A purposive sample of four municipal public nursing homes in Norway with long-term care residents was included in the study. Data were collected by participant observation including informal conversation with the staff, and in-depth interviews with 15 residents using a narrative approach.

RESULTS

The main findings were that organizational cultures could be seen as relatively stable corporate cultures described as 'personalities' with characteristics that were common for all nursing homes (conformity) and typical traits that were present in some nursing homes, but that they were also like no other nursing home (distinctiveness). Conformity ('Every nursing home is like all other nursing homes') meant that nursing home organizations formed their services according to a perception of what residents in general need and expect. Trait ('Every nursing home is like some other nursing homes') expressed typologies of nursing homes: residency, medical, safeguard or family orientation. The distinctness of each nursing home ('Every nursing home is like no other nursing home') was expressed in unique features of the nursing home; the characteristics of the nursing home involved certain patterns of structure, cultural assumptions and interactions that were unique in each nursing home. Nursing home residents experienced quality of care as 'The nursing home as my home' and 'Interpersonal care quality'. The resident group in the different types of nursing homes were unique, and the experience of quality of care seemed to depend on whether their unique needs and expectations were met or not.

CONCLUSION

In order to create a sustainable nursing home service the service needs to be characterized by learning and openness to change and must actually implement practices that respond to the resident and his or her family's values.

The match between institutional elderly care management research and management challenges - a systematic literature review

BACKGROUND

Elderly care practice and its management together with policy and research play a crucial role in responding to increasing challenges in institutional care for elderly people. Successful dialogue between these is necessary. The purpose of this systematic literature review is to compare how institutional elderly care management research meets the care challenges currently emphasized in international long-term care policy documents.

METHODS

This paper was based on a systematic literature review. After screening 1971 abstracts using inclusion/exclusion criteria, 58 refereed articles published between 2000 and 2010 remained for analysis. The articles were analyzed using theory-based content analysis by comparing the results to the framework based on analysis of international long-term care management policy documents.

RESULTS

The current challenges of long-term care management identified from policy documents were Integrated Care Management, Productivity Management, Quality Management, Workforce Management and ICT Management. The research on institutional elderly care management responded somewhat to the challenges mentioned in policy documents. However, some of the challenges were studied broadly and some were paid only minor attention. Further, only few studies focused on the core items of challenges addressed in policy documents.

CONCLUSIONS

Institutional care management research needs to focus more on challenges in integrated care, productivity, ICT and division of labor. Managers, researchers and policy-makers should assume more active collaborative roles in processes of research, policymaking and policy implementation. In addition managers' and policymakers' scientific literacy needs to be enhanced.

The influence of teams to sustain quality improvement in nursing homes that "need improvement"

OBJECTIVES

Qualitatively describe the use of team and group processes in intervention facilities participating in a study targeted to improve quality of care in nursing homes "in need of improvement."

DESIGN/SETTING/PARTICIPANTS

A randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes. Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making.

RESULTS

The qualitative analysis revealed a subgroup of homes ("Full Adopters") likely to continue quality improvement activities that were able to effectively use teams. "Full Adopters" had either the nursing home administrator or director of nursing who supported and were actively involved in the quality improvement work of the team. "Full Adopters" also selected care topics for the focus of their quality improvement team, instead of "communication" topics of the "Partial Adopters" or "Non-Adopters" in the study who were identified as unlikely to continue to continue quality improvement activities after the intervention. "Full Adopters" had evidence of the key elements of complexity science: information flow, cognitive diversity, and positive relationships among staff; this evidence was lacking in other subgroups. All subgroups were able to recruit interdisciplinary teams, but only those that involved leaders were likely to be effective and sustain team efforts at quality improvement of care delivery systems.

CONCLUSIONS

Results of this qualitative analysis can help leaders and medical directors use the key elements and promote information flow among staff, residents, and families; be inclusive as discussions about care delivery, making sure diverse points of view are included; and help build positive relationships among all those living and working in the nursing home. Wide-spread adoption of the intervention in the randomized study is feasible and could be enabled by nursing home Medical Directors in collaborative practice with Advanced Practice Nurses.

Challenges of using quality improvement methods in nursing homes that "need improvement"

OBJECTIVES

Qualitatively describe the adoption of strategies and challenges experienced by intervention facilities participating in a study targeted to improve quality of care in nursing homes "in need of improvement". To describe how staff use federal quality indicator/quality measure (QI/QM) scores and reports, quality improvement methods and activities, and how staff supported and sustained the changes recommended by their quality improvement teams.

DESIGN/SETTING/PARTICIPANTS

A randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes in facilities in "need of improvement". Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality-improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making.

RESULTS

A qualitative analysis revealed a subgroup of homes likely to continue quality improvement activities and readiness indicators of homes likely to improve: (1) a leadership team (nursing home administrator, director of nurses) interested in learning how to use their federal QI/QM reports as a foundation for improving resident care and outcomes; (2) one of the leaders to be a "change champion" and make sure that current QI/QM reports are consistently printed and shared monthly with each nursing unit; (3) leaders willing to involve all staff in the facility in educational activities to learn about the QI/QM process and the reports that show how their facility compares with others in the state and nation; (4) leaders willing to plan and continuously educate new staff about the MDS and federal QI/QM reports and how to do quality improvement activities; (5) leaders willing to continuously involve all staff in quality improvement committee and team activities so they "own" the process and are responsible for change.

CONCLUSIONS

Results of this qualitative analysis can help allocate expert nurse time to facilities that are actually ready to improve. Wide-spread adoption of this intervention is feasible and could be enabled by nursing home medical directors in collaborative practice with advanced practice nurses.

Director of nursing current job tenure and past experience and quality of care in nursing homes

BACKGROUND

Directors of nursing (DONs) are central to quality of care in nursing homes (NHs) because of their role in coordinating and overseeing nursing care. Research is needed to test the association between DON characteristics and quality using large, representative samples of NHs and global measures of quality. One such measure is the quality measure (QM) rating from the Centers for Medicare & Medicaid Services' Five-Star Quality Rating, which aggregates 10 individual QMs into a single rating.

PURPOSE

This study examined whether DON current job tenure or past experience (a) differed across levels of the QM rating, (b) was associated with QM ratings, and (c) was associated with any of the individual 10 QM scores that comprise QM ratings.

METHODOLOGY

Data for a nationally representative sample of 1,174 NHs were obtained from the 2004 National Nursing Home Survey, publicly reported QMs, and an Area Resource File. Wald tests were used to test differences in mean DON current job tenure and past experience across levels of the QM rating. Multinomial logistic and Poisson regression analyses were used to examine the association between DON current job tenure and past experience and QM ratings and QM scores, respectively, controlling for selected market and organizational characteristics.

FINDINGS

Nursing homes with longer DON current job tenure tended to have higher QM ratings. Longer DON current job tenure was associated with higher QM ratings and lower QM scores for several individual QMs, suggesting higher quality. The past experience of the DON did not differ across levels of the QM rating and was not associated with QM ratings or QM scores.

PRACTICE IMPLICATIONS

This study highlights the need for owners and administrators to support DONs as they either the transition into the role of the DON for the first time or learn to effectively fulfill their role in a new NH.

Randomized multilevel intervention to improve outcomes of residents in nursing homes in need of improvement

OBJECTIVES

A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement.

DESIGN/SETTING/PARTICIPANTS

Intervention facilities (N = 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N = 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders.

INTERVENTION

The authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs.

RESULTS

The intervention did improve quality of care (P = .02); there were improvements in pressure ulcers (P = .05) and weight loss (P = .05). Organizational working conditions, staff retention, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups.

CONCLUSION AND IMPLICATIONS

Some facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed. Medical directors in collaborative practice with advanced practice nurses are ideally positioned to implement this low-cost, effective intervention nationwide.

Evaluation of a leadership development academy for RNs in long-term care

While evidence strongly suggests that nursing leadership impacts nursing home care, most nursing home (NH) RN leaders have not had the benefit of a structured educational program that emphasizes the skills necessary to effectively lead in today's complex NH environment. The University of Missouri Leadership Development Academy for RNs in Long-Term Care was developed as an innovative educational program to prepare NH RNs to become effective leaders. Early data evaluating the leadership academy suggest that participation in a structured leadership program over an extended period of time may enhance the leadership behaviors of NH RNs.

Cost implications of organizing nursing home workforce in teams

OBJECTIVE

To estimate the costs associated with formal and self-managed daily practice teams in nursing homes.

DATA SOURCES/STUDY SETTING

Medicaid cost reports for 135 nursing homes in New York State in 2006 and survey data for 6,137 direct care workers.

STUDY DESIGN

A retrospective statistical analysis: We estimated hybrid cost functions that include team penetration variables. Inference was based on robust standard errors.

DATA COLLECTION

Formal and self-managed team penetration (i.e., percent of staff working in a team) were calculated from survey responses. Annual variable costs, beds, case mix-adjusted days, admissions, home care visits, outpatient clinic visits, day care days, wages, and ownership were calculated from the cost reports.

PRINCIPAL FINDINGS

Formal team penetration was significantly associated with costs, while self-managed teams penetration was not. Costs declined with increasing penetration up to 13 percent of formal teams, and increased above this level. Formal teams in nursing homes in the upward sloping range of the curve were more diverse, with a larger number of participating disciplines and more likely to include physicians.

CONCLUSIONS

Organization of workforce in formal teams may offer nursing homes a cost-saving strategy. More research is required to understand the relationship between team composition and costs.

Helping nursing homes "at risk" for quality problems: a statewide evaluation

The Quality Improvement Program for Missouri (QIPMO), a state school of nursing project to improve quality of care and resident outcomes in nursing homes, has a special focus to help nursing homes identified as "at risk" for quality concerns. In fiscal year 2006, 92 of 492 Medicaid-certified facilities were identified as "at risk" using quality indicators (QIs) derived from Minimum Data Set (MDS) data. Sixty of the 92 facilities accepted offered on-site clinical consultations by gerontological expert nurses with graduate nursing education. Content of consultations include quality improvement, MDS, care planning, evidence-based practice, and effective teamwork. The 60 "at-risk" facilities improved scores 4%-41% for 5 QIs: pressure ulcers (overall and high risk), weight loss, bedfast residents, and falls; other facilities in the state did not. Estimated cost savings (based on prior cost research) for 444 residents who avoided developing these clinical problems in participating "at-risk" facilities was more than $1.5 million for fiscal year 2006. These are similar to estimated savings of $1.6 million for fiscal year 2005 when 439 residents in "at-risk" facilities avoided clinical problems. Estimated savings exceed the total program cost by more than $1 million annually. QI improvements demonstrate the clinical effectiveness of on-site clinical consultation by gerontological expert nurses with graduate nursing education.

Daily practice teams in nursing homes: evidence from New York state

PURPOSE

Most health care organizations, including nursing homes, report having teams. However, little is known about everyday practice teams among staff providing direct resident care. We assess the prevalence of such teams in nursing homes as reported by direct care staff and administrators, and examine characteristics of facilities that foster these teams.

DESIGN AND METHODS

The analytical model is based on 149 nursing homes. Data sources include surveys of administrators (n = 292) and direct care staff (n = 6,867), and Online Survey Certification and Reporting System. Linear regression with robust standard errors and sampling probability weights is used to examine the relationship between daily practice teams and facility characteristics.

RESULTS

On average, 16% of workers per facility report practicing in formal multidisciplinary teams providing daily resident care. Team prevalence is 3.3% higher when managers view teams as very important for clinical care quality, 2.6% higher when the directors of nursing report formally organized teams, 2.5% higher for each 10% increase in workers' involvement in teams other than the daily practice teams, and 1.95% higher for each 1-hr increase in nursing hours.

IMPLICATIONS

Our study shows that multidisciplinary daily practice teams can be found in most facilities in our large sample, but their penetration within nursing homes is far from pervasive; in 72% of facilities, staff report team prevalence of less than 25%. Given that the majority of managers report teamwork as very important to their facilities' operations, we discuss why only a relatively small proportion of daily care is provided in this fashion.

Modeling efficiency at the process level: an examination of the care planning process in nursing homes

OBJECTIVE

To examine the efficiency of the care planning process in nursing homes.

METHODS

We collected detailed primary data about the care planning process for a stratified random sample of 107 nursing homes from Kansas and Missouri. We used these data to calculate the average direct cost per care plan and used data on selected deficiencies from the Online Survey Certification and Reporting System to measure the quality of care planning. We then analyzed the efficiency of the assessment process using corrected ordinary least squares (COLS) and data envelopment analysis (DEA).

RESULTS

Both approaches suggested that there was considerable inefficiency in the care planning process. The average COLS score was 0.43; the average DEA score was 0.48. The correlation between the two sets of scores was quite high, and there was no indication that lower costs resulted in lower quality. For-profit facilities were significantly more efficient than not-for-profit facilities.

CONCLUSIONS

Multiple studies of nursing homes have found evidence of inefficiency, but virtually all have had measurement problems that raise questions about the results. This analysis, which focuses on a process with much simpler measurement issues, finds evidence of inefficiency that is largely consistent with earlier studies. Making nursing homes more efficient merits closer attention as a strategy for improving care. Increasing efficiency by adopting well-designed, reliable processes can simultaneously reduce costs and improve quality.

Entrepreneurial program of research and service to improve nursing home care

This is a methodological article intended to demonstrate the integration of multiple goals, multiple projects with diverse foci, and multiple funding sources to develop an entrepreneurial program of research and service to directly affect and improve the quality of care of older adults, particularly nursing home residents. Examples that illustrate how clinical ideas build on one another and how the research ideas and results build on one another are provided. Results from one study are applied to the next and are also applied to the development of service delivery initiatives to test results in the real world. Descriptions of the Quality Improvement Program for Missouri and the Aging in Place Project are detailed to illustrate real-world application of research to practice.

Managements' perception of community nurses' decision-making processes when referring older adults to an emergency department

In Sweden, older adults are living and being cared for under the responsibility of their respective community. Extensive reorganizations in the community led to management having different backgrounds, which may have caused uncertainty among community nurses, especially in decision-making processes. The aim was to understand how 10 nurses, 10 doctors and 10 home care assistants as leaders for the nurses conceptualized the decision-making processes of community nurses, when referring older persons to Emergency Departments, and whether perceptual differences and/or similarities exist. Narrative interviews and content analysis were performed. The managers had differing views, but all felt there was a need to feel secure in order to trust professional decisions as being correct, thus avoiding inappropriate referrals. Management could see nurses' exposed position, but had varying solutions. This might lead to different messages being given regarding what is important and might explain why the nurses reported that the managers did not understand them.