A GIS enhanced data analytics approach for predicting nursing home hurricane evacuation response

Nursing homes (NHs) are responsible for caring for frail, older adults, who are highly vulnerable to natural disasters, such as hurricanes. Due to the influence of highly uncertain environmental conditions and varied NH characteristics (e.g., geo-location, staffing, residents' health conditions), the NH evacuation response, namely evacuating or sheltering-in-place, is highly uncertain. Accurate prediction of NH evacuation response is important for emergency management agencies to accurately anticipate the NH evacuation demand surge with healthcare resources proactively planned. Existing hurricane evacuation research mainly focuses on the general population. For NH evacuation, existing studies mainly focus on conceptual studies and/or qualitative analysis using a single source of data, such as surveys or resident health data. There is a lack of research to develop analytics-based method by fusing rich environmental data with NH data to improve the prediction accuracy. In this paper, we propose a Geographic Information System (GIS) data enhanced predictive analytics approach for forecasting NH evacuation response by fusing multi-source data related to storm conditions, geographical information, NH organizational characteristics as well as staffing and residents characteristics of each NH. In particular, multiple GIS features, such as distance to storm trajectory, projected wind speed, potential storm surge and NH elevation, are extracted from rich GIS information and incorporated to improve the prediction performance. A real-world case study of NH evacuation during Hurricane Irma in 2017 is examined to demonstrate superior prediction performance of the proposed work over a large number of predictive analytics methods without GIS information.

Complexities of care: Common components of models of care in geriatrics

As people age, they are more likely to have an increasing number of medical diagnoses and medications, as well as healthcare providers who care for those conditions. Health professionals caring for older adults understand that medical issues are not the sole factors in the phenomenon of this “care complexity.” Socioeconomic, cognitive, functional, and organizational factors play a significant role. Care complexity also affects family caregivers, providers, and healthcare systems and therefore society at large. The American Geriatrics Society (AGS) created a work group to review care to identify the most common components of existing healthcare models that address care complexity in older adults. This article, a product of that work group, defines care complexity in older adults, reviews healthcare models and those most common components within them and identifies potential gaps that require attention to reduce the burden of care complexity in older adults.

Impact of establishing a Geriatrics Workforce Enhancement Program clinic on preventive health and Medicare Annual Wellness Visits

We established a Geriatrics Workforce Enhancement Program (GWEP) clinic to enhance resident training on comprehensive preventive care and chronic disease management, and to increase the number of older patients who received Medicare Annual Wellness Visit (AWV) preventive services. A total of 1,104 patients were tracked at baseline and during the intervention period. Patients were grouped into two categories: Adult (aged 55-64) and Senior (aged 65+). Clinical quality measures were monitored by electronic health record and tracked through monthly reports at baseline (May 2018) and during the intervention period (July 2018-June 2019). In the Senior group, the proportion of patients receiving the Medicare AWV increased after GWEP began (p <.001). Additionally, the Senior group showed significant improvements in the frequency of body mass index assessments (p = .04), colorectal cancer screenings (p < .001), advance directive documentation (p < .001), cognitive screenings (p < .001), and pneumococcal vaccinations (p < .001). In the Adult group, a trending increase was seen in influenza vaccinations (p = .06). Curricular innovations including the establishment of a GWEP clinic in our residency outpatient center, development of new educational materials, and use of a nurse coordinator resulted in significant improvements in the percentage of older adults who received the Medicare AWV benefit and preventive health performance metrics.

Implementation of an Emergency Power Rule: Compliance of Florida Nursing Homes and Assisted Living Facilities

OBJECTIVE

Thea aim of this study was to explore the relationship between Florida nursing home and assisted living facility characteristics and their ability to comply with a new emergency power rule in the aftermath of Hurricane Irma.

METHODS

This study used characteristics data on Florida nursing homes (NHs) (N = 680) and assisted living facilities (ALFs) (N = 2940) in operation between September 2017 and January 2019. Logistic regressions were used to determine whether certain characteristics were associated with compliance with the emergency power rule by January 1, 2019.

RESULTS

A total of 219 (32.9%) NHs and 2219 (75.5%) ALFs had an emergency power plan implemented by January 1, 2019. Results suggest having a dementia care unit increased the odds of compliance for NHs, while chain membership, for-profit status, and a higher reliance on Medicaid decreased the odds. Additionally, smaller size, mental health specialty license, and higher reliance on supplemental state funding increased the odds of compliance for ALFs, while nursing care specialty license and for-profit status decreased the odds of compliance.

CONCLUSIONS

Policy implications from these results include informing policy-makers on the barriers faced by NHs and ALFs to implement a new regulation that may cause financial difficulties and compromise quality care.

Resources and Relationships in Disasters: Differences Among Small and Large Assisted Living Communities

Disaster preparedness among assisted living communities (ALCs) has not been widely researched, despite the growth of ALCs and evidence of disability in this population. An additional issue of concern is the way in which ALCs vary, including variation by size. The purpose of this paper was to explore the experiences of ALCs in Florida that experienced Hurricane Irma in 2017 and how experiences varied by ALC size. Qualitative interviews and focus groups were conducted with representatives of small ALCs (<25 beds; n=32) and large ALCs (25+; n=38). Transcripts were analyzed using Atlas.ti version 8, and research team members collaborated to reach consensus on codes and further analyze differences based on ALC size. Results suggest there are differences among ALCs in their disaster preparedness and response, and these differences are related to size (e.g., access to resources, organizational characteristics). Implications for ALC resident wellbeing and future disaster planning will be discussed.

The Difference LTC Corporate Ownership Makes in Collaborations With Emergency Operation Centers During Disasters

Collaboration between nursing homes (NHs) and assisted living communities (ALCs) with state and local entities (e.g., emergency operation centers (EOCs)) is critical during a disaster. The corporate structure of NHs and ALCs can make a difference in their ability to collaborate with these entities during a disaster. This mixed-method study examines differences in satisfaction with collaboration with state and local entities during Hurricane Irma in Florida in 2017 between corporate-owned NHs (N=24), larger (25+ beds) ALCs (N=38) and smaller ALCs (N=30). We also explore collaboration in Florida NHs (N=35) and ALCs (N=123) specific to COVID19. Scaled 1-5 survey data results indicate that small ALCs are the least satisfied (M=2.90) with EOC collaboration, compared to NHs (M=3.04) and larger ALCs (M=3.33) during Irma. Smaller ALCs were more dissatisfied with COVID19 mandates compared to larger ALCs and NHs. Ways to improve collaboration during a disaster, especially for smaller ALCs, will be discussed.

Nurse Staffing in Nursing Homes During Hurricane Irma

Little is known about the effect of hurricanes on nurse staffing in nursing homes. Hurricane Irma made landfall on September 10th, 2017 in Florida. This study examined daily nurse staffing levels from September 3rd-24th, 2017 in 653 nursing homes; 81 facilities evacuated and 572 facilities sheltered-in-place. Data from Payroll-Based Journaling (PBJ), Certification and Survey Provider Enhanced Reports (CASPER), and Florida’s health providers’ emergency reporting system were used. Among all facilities, we found significant increases in staffing for licensed practical nurses (p=.02) and certified nursing assistants (p<.001), but not for registered nurses (p=.10) before Hurricane Irma made landfall. In comparison to facilities that sheltered-in-place, evacuating facilities increased staffing levels of all nurse types (all p<.001). From one week before landfall to two weeks after landfall, an additional estimated $2.41 million was spent on nurse staffing. Policymakers attempting to reduce the burden of natural disasters on nursing homes should reimburse staffing-related expenses.

Failing to Complain: Do Nursing Homes with more Residents with Dementia have Fewer Complaints?

The majority of nursing home (NH) residents have Alzheimer’s Disease or Related Dementias (ADRD). However, the association of ADRD prevalence and NH quality is unclear. The objective of the current study is to understand the association of NH characteristics, including the proportion of ADRD residents, with the prevalence of NH complaints as an indicator of quality of care and quality of life. We merged data from the ASPEN Complaints/Incident Tracking System with national NH data from the Certification and Survey Provider Enhanced Reports, the Minimum Data Set, the Area Health Resource File, and zip-code level rural-urban codes in 2017. Three groups of NHs were created, including those whose proportion of residents with ADRD was in the top decile (i.e., high-dementia NHs (N=1,473)) and those whose proportion of ADRD residents was in the lowest decile (i.e., low-dementia NHs (N=1,524)). Bivariate results revealed high-ADRD NHs had higher percentages of Medicaid-paying residents, were less likely to be for-profit and chain-affiliated, had lower staffing hours and lower percentages of Black, Hispanic, and Asian residents. Using NHs in the middle deciles as reference, negative binomial regression models showed that having a low proportion of ADRD residents was significantly associated with higher numbers of total complaints (p<.001) and substantiated complaints (p<.001), whereas having a high proportion of ADRD residents was significantly associated with lower numbers of substantiated complaints (p=.001). The findings suggest the proportion of residents with ADRD in NHs is associated with quality, as measured by complaints. Policy implications of these findings will be discussed.

Disaster Vulnerability in Long-Term Care: The Importance of Social and Organizational Connections

The risks to older adults in nursing homes (NHs) and assisted living communities (ALCs) exposed to disasters are evident in prior research. However, little research has been conducted to understand the factors related to facilities’ vulnerability. This research examined NH and ALC experiences during Hurricane Irma in 2017. Qualitative interviews were conducted with representatives of facilities (N=100), transcripts were analyzed using Atlas.ti version 8. Team members met to reach consensus on codes and major themes and subthemes, which they analyzed using a conceptual model designed to identify factors related to the disaster vulnerability in long-term care (LTC). We found physical factors (e.g. location, physical characteristics) are important, but physical strength is not enough. Multiple social/organizational factors are critical. Results indicate managing a major disaster and protecting LTC residents involve social and organizational connections across a range of groups from staff and family members to emergency mangers and neighborhood associations.

Alzheimer's Association Project VITAL: A Florida Statewide Initiative Using Technology to Impact Social Isolation and Well-Being

Lack of social engagement and the resulting social isolation can have negative impacts on health and well-being, especially in senior care communities and for those living with dementia. Project VITAL leverages technology and community resources to create a network for connection, engagement, education, and support of individuals with dementia and their caregivers, and explores the impact of these interventions in reducing feelings of social isolation and increasing mood among residents during the COVID-19 pandemic. Through two phases, 600 personalized Wi-Fi-enabled iN2L tablets were distributed to 300 senior care communities (55% assisted living communities, 37% skilled nursing communities, 6% memory care communities, and 2% adult family-care homes) to connect and engage residents and their families. Different phases also included Project ECHO, a video-based learning platform, Alzheimer's Association virtual and online education and support for family caregivers, evidence-based online professional dementia care staff training and certification, and Virtual Forums designed to explore ways to build sustainable, scalable models to ensure access to support and decrease social isolation in the future. Tablet usage was collected over an 11-month period and an interim survey was designed to assess the effectiveness of the tablets, in preventing social isolation and increasing mood among residents during the COVID-19 pandemic. A total of 105 care community staff (whose community used the tablets) completed the survey and overall, these staff showed a high level of agreement to statements indicating that residents struggled with loneliness and mood, and that the tablet was useful in improving loneliness and mood in residents and allowing them to stay in touch with family and friends. Additional positive results were seen through a variety of other responses around the tablets and Project ECHO. Overall, the tablets were shown to be an effective way to engage residents and connect them with friends and family, as well as being a useful tool for staff members. A third phase is currently underway in the homes of people with dementia and their family caregivers, which includes tablets and direct access to Alzheimer's Association virtual and online education and support programs.

Attitudes toward aging of health professions students: Implications for geriatrics education

We compared attitudes toward aging of students from several health professions (N = 1,156: 286 medical, 275 pharmacy, 213 undergraduate nursing, 160 graduate nursing, 139 Internal Medicine residents, 49 physical therapy, and 34 physician assistant), and assessed the construct validity of the Image of Aging Scale. Physical therapy and graduate nursing students reported more positive attitudes toward aging in comparison to all other health professions (all p <.001). Differences in attitudes were not strongly affected by demographic variables, clinical exposure, desire to pursue primary care, or interest in providing care to older adults. The Image of Aging Scale yielded good internal reliability and adequate construct validity for health professions students. Health professions students' attitudes toward aging largely reflect the students' professional training, rather than student characteristics or career goals. The Image of Aging Scale is a robust measure of attitudes toward aging in health professions students and in older adults.

"You Just Forge Ahead": The Continuing Challenges of Disaster Preparedness and Response in Long-Term Care

BACKGROUND AND OBJECTIVES

Protecting nursing home and assisted living community residents during disasters continues to be a challenge. The present study explores the experiences of long-term care facilities in Florida that were exposed to Hurricane Irma in 2017.

RESEARCH DESIGN AND METHODS

We used an abductive approach, combining induction and deduction. Interviews and focus groups beginning in May 2018 were conducted by telephone and in person with 89 administrative staff members representing 100 facilities (30 nursing homes and 70 assisted living communities). Analyses identified themes and subthemes. Findings were further analyzed using the social ecological model to better understand the preparedness and response of nursing homes and assisted living communities to Hurricane Irma.

RESULTS

3 main themes were identified including: (1) importance of collaborative relationships in anticipating needs and planning to shelter in place or evacuate; (2) efforts required to maintain safety and stability during an unprecedented event; and (3) effects, repercussions, and recommendations for change following the disaster.

DISCUSSION AND IMPLICATIONS

Preparing for and managing disasters in nursing homes and assisted living communities involves actions within multiple environments beyond the residents and facilities where they live. Among these, community-level relationships are critical.

The Relationship Between Staffing Levels and Consumer Complaints in Nursing Homes

While research tends to find an association of nurse staffing with quality in nursing homes, few studies examine complaints as a quality measure or account for ancillary staff. This study used federal nursing home complaint data to examine how key explanatory variables including nursing and ancillary staffing were associated with numbers of complaints and the likelihood of receiving a complaint. Results support that nursing home staffing is associated with quality. While direct care staffing was associated with fewer complaints, larger effects were found for social service and activities staffing. Increasing ancillary staffing may be a cost-effective way to reduce complaints.

Factors Associated with Assisted Living Facility Closure

BACKGROUND AND OBJECTIVES

Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing home market for the ALF market to examine the organizational, internal, and external factors associated with closure.

RESEARCH DESIGN AND METHODS

Data on 1,939 ALFs operating in 2013 from Florida were used to estimate a logistic regression to examine the organizational, internal, and external factors that were associated with closure between 2013 and 2015.

RESULTS

During the two-year study period, 141 ALFs (7.3%) closed. Significant factors associated with increased odds of closure included fewer beds, not accepting Medicaid, and more deficiencies. Two factors (market concentration and population density) were marginally significant.

DISCUSSION AND IMPLICATIONS

The results of this study confirm the usefulness of a model that includes organizational, internal, and external factors to predict ALF closure. These outcomes highlight the concerns that closure can affect access to community based long-term care, especially for rural older adults, and indicate an expansion of Medicaid acceptance in ALFs could be protective against closure.

Movement-based mind-body practices and cognitive function in middle-aged and older adults: Findings from the Midlife in the United States (MIDUS) study

OBJECTIVES

Cognitive function is a key component of healthy aging. While conventional physical activities (walking, jogging, etc.) have been shown to support physical and cognitive health in late-life, it remains unclear whether traditional Eastern movement-based mind-body practices (MBP) have long-term cognitive benefits above and beyond conventional leisure physical activities. This study examines the relationship between movement-based MBP and cognitive function in middle-aged and older adults during a 10-year follow-up period.

METHODS

We used data from Waves 2 (2004-05) and 3 (2013-14) of the Midlife in the United States (MIDUS) study. MIDUS initially surveyed a national probability sample of community-living adults aged 24-75 years in 1995 (Wave 1). Tests of cognitive functioning measuring executive function and episodic memory were added in Wave 2 and repeated in Wave 3. We estimated multivariable linear regression models to examine the effect of MBP (Wave 2) on the episodic memory and executive function (Wave 3) while controlling for covariates (sociodemographic factors, health, and cognitive function at Wave 2).

RESULTS

A total of 2097 individuals aged 42-92 years (M = 64 ± 11, 56 % women) were included. After controlling for sociodemographic factors, health and functional status, and prior levels of cognitive function, engaging in MBP was independently associated with a smaller decline in episodic memory (b = 0.11, p = .03), but not executive function (b=0.03, p = .34).

DISCUSSION

The findings provide the first large population-based evidence supporting the cognitive benefits of MBP over a 10-year period among middle-aged and older adults. Future research should examine whether MBP are effective non-pharmacological intervention to attenuate age-related cognitive decline.

Self-Reported Satisfaction of Older Adult Residents in Nursing Homes: Development of a Conceptual Framework

BACKGROUND AND OBJECTIVES

Resident satisfaction is an integral part of nursing home (NH) quality of care. However, there is no uniform categorization framework to classify self-reported satisfaction of older adult residents in NHs. This scoping review systematically investigated the studies reporting data on older residents' satisfaction to evaluate the quality of NH service and to create a conceptual model for older residents' satisfaction.

RESEARCH DESIGN AND METHODS

We used Donabedian's structure-process-outcome model as a theoretical framework. In three electronic databases (PubMed, Scopus, and CINAHL), potential studies were searched using specific inclusion criteria identifying original studies that investigated older adult residents' satisfaction in NHs.

RESULTS

Fifteen studies, including 264,133 residents and 15,577 NHs, were selected for this review. Although a wide variety of resident satisfaction measures were used in the included studies, all these indicators reflect five primary domains: Psychological, Clinical, Social, Environmental, and Spiritual, with the common focus of improving the quality of life of residents. Though technical competence is a fundamental aspect of healthcare service, we found autonomy, environment, meaningful activities, and interpersonal quality of professionals as the most important predictors for the resident's satisfaction.

DISCUSSION AND IMPLICATIONS

The current review has synthesized a broad range of satisfaction measures, which will help future researchers and policymakers provide guidance for further improvement of NH care services and as a heuristic device to spur research. Future research is needed to apply this conceptual framework for comparisons of self-reported resident satisfaction in other institutional settings across countries.

Effect of Hurricane Irma on daily direct-care nurse staffing in nursing homes

OBJECTIVES

To examine the effect of Hurricane Irma on staff-related financial expenditures and daily direct-care nurse staffing levels.

DESIGN

Retrospective cohort study.

SETTING

September 3-24, 2017 in the state of Florida, United States. Hurricane Irma made landfall on September 10, 2017.

PARTICIPANTS

Six hundred and fifty-three nursing homes (NHs), 81 evacuated facilities, and 572 facilities that sheltered-in-place.

MEASUREMENTS

This study used data from Payroll-Based Journaling (PBJ), Certification and Survey Provider Enhanced Reports (CASPER), and Florida's health providers' emergency reporting system. PBJ provided estimates of daily direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants. CASPER reported facility-level characteristics such as profit status, chain membership, and special care unit availability. Florida's emergency reporting system identified evacuation status during Hurricane Irma. Linear mixed-effects models were used to estimate the unique contribution of evacuation status on daily staffing increases over time from September 3 to 10.

RESULTS

Among all facilities, we found significant increases in staffing for licensed practical nurses (p = 0.02) and certified nursing assistants (p < 0.001), but not for registered nurses (p = 0.10) before Hurricane Irma made landfall. From 1 week before landfall to 2 weeks after landfall (September 3-24), an additional estimated $2.41 million was spent on direct-care nurse staffing. In comparison to facilities that sheltered-in-place, evacuated facilities increased staffing levels of all nurse types (all p < 0.001). At landfall, evacuated facilities spent an estimated $93.74 on nurse staffing per resident whereas facilities that sheltered-in-place spent $76.10 on nurse staffing per resident.

CONCLUSION

NHs face unprecedented challenges during hurricanes, including maintaining adequate direct-care nurse staffing levels to meet the needs of their residents. NHs that evacuated residents had an increase in direct-care nurse staffing that was greater than that seen in NHs that sheltered-in-place.

Emergency Department Use Among Assisted Living Residents After Hurricane Irma

OBJECTIVES

Nursing home residents are especially vulnerable to adverse outcomes after a hurricane. Prior research suggests that emergency department (ED) visits increase among community-residing older adults after natural disasters. However, little is known about the impact of hurricanes on the large population of older adults residing in assisted living (AL) settings, particularly the influence of storms on the rates and causes of ED visits. We examined whether rates of ED use for injuries and other medical reasons increased after Hurricane Irma in 2017 among AL residents in Florida.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Samples of 30,358 Medicare fee-for-service beneficiaries in 2016 and 28,922 beneficiaries in 2017 who resided in Florida AL communities.

MEASURES

The number of injury-related and other medical visits per 1,000 person-days within 30 and 90 days of September 1 in 2016 and 2017. We adjusted for age, race, sex, and chronic conditions using linear regression with AL fixed effects. We compared the top 10 primary diagnoses resulting in an ED visit between 2016 and 2017.

RESULTS

Adjusted rates of injury-related visits were 12.5% higher at 30 days but did not differ at 90 days. Other medical visits were 12% higher at 30 days in 2017 than in 2016 and 7.7% higher at 90 days. Heart failure was a leading cause of ED visits within 90 days of September 1 in 2017, unlike in 2016.

CONCLUSIONS AND IMPLICATIONS

Increased attention should be paid to AL communities in disaster preparedness and response efforts given the increased likelihood of ED visits following a hurricane.

Beliefs regarding geriatrics primary care topics among medical students and internal medicine residents

This study evaluated beliefs regarding 25 content areas essential to the primary care of older adults and attitudes toward aging held by first-yearmedical students and Internal Medicine residents. A survey of 136 medical students and 61 Internal Medicine residents was conducted at an academic health-center. Beliefs were assessed by the 25-item Geriatrics Clinician-Educator Survey. Gap scores reflecting the difference in ratings between self-rated importance and knowledge were calculated. Attitudes toward aging was assessed by the Images of Aging Scale. Students and residents expressed similar beliefs about the importance of content areas, but students provided lower ratings in knowledge. Students reported larger gap scores in areas that reflected general primary care (e.g., chronic conditions, medications), whereas residents reported larger gap scores in areas that reflected specialists' expertise (e.g., driving risk, cognition, psychiatric symptoms). Attitudes toward aging did not differ appreciably between students and residents. Our findings suggest that primary care topics applicable for any age demographic were rated as most important by first-year medical students and Internal Medicine residents. Topics relevant to older populations--particularly those requiring specialists' knowledge of or requiring sensitive discussion with older adults-were rated as less important and were less well-mastered.

Availability of Audiology Services in Assisted Living Communities in Florida

Florida has one of the largest populations of older adults in the U.S., and as a result the state also has a high prevalence of hearing loss. Given the growth of assisted living as a housing option for older adults, the purpose of this study was to determine the availability of audiology services in assisted living communities (ALCs) across Florida. Data on ALC location, characteristics and audiology service availability were collected from the Florida Agency for Health Care Administration (AHCA). County socioeconomic data were collected from the U.S. Department of Labor. Logistic regression and chi2 tests were used to examine the relationship between county socioeconomics and whether an ALC provided audiology services. We found that of the 3090 ALCs in Florida, audiology services were present in only 57 (3.2%). ALCs with audiology services were significantly more likely to be located in counties with a higher education level and a higher average income. This suggests a shortage of ALCs with audiology services in counties where residents have fewer resources. The results are concerning, given that individuals with fewer resources are less able to pay for audiology services on their own and evidence showing that poor hearing health late in life impacts individuals’ health and quality of life. Policy implications will be discussed, including the need for more ALCs to provide audiology services in counties with fewer resources. One possible solution is tele-audiology, which would enable a single audiologist to diagnose and prescribe hearing aids to patients in underserved areas.

Experiences of Assisted Living Communities Affected by Hurricane Irma: Leadership, Lessons Learned

Little is known about the effects of disasters on assisted living community (ALC) residents. This is a concern given the growth of the AL industry and the increasing numbers of AL residents with functional limitations and chronic health conditions. This research examined the experiences of AL administrative staff to better understand the impact of Hurricane Irma. Qualitative interviews were conducted with representatives of ALCs across Florida (N=70), and transcripts were analyzed using Atlas.ti version 8. Research team members met regularly to reach consensus on codes, identifying five major themes across the interviews, 1) planning and preparation, 2) leadership, including plan execution and managing the unexpected, 3) effects/consequences of the storm, including effect on residents and staff, 4) lessons learned, and 5) electrical power. Results provide a broad view of ALC preparedness, how it varies across different types of ALCs and implications for resident wellbeing and future emergency planning.

Prevalence of Insomnia Symptoms and Need for an Intervention Among Direct-Care Workers in Long-Term Care

This study examined the prevalence of insomnia symptoms among direct-care workers at an assisted-living community and their perceived need for a sleep intervention. Thirty-five participants reported their main sleep-related concerns, willingness to participate in a sleep intervention, and preferred delivery forms/content of the intervention. They also reported nightly sleep characteristics via ecological momentary assessment (EMA) for 2 weeks. 80% reported any sleep-related concern; insomnia-related concern was most prevalent (57%). This was also evident in their EMA reports of waking up in the middle of the night or early morning for 72% of the days. Most (66%) expressed interest in participating in a sleep intervention either online or in group sessions. Mindfulness strategies were most preferred, followed by cognitive-behavioral therapy, and sleep hygiene education. The high prevalence of insomnia symptoms in direct-care workers needs to be addressed by future interventions for their well-being as well as for the quality of care.

Evacuation or Shelter in Place in Assisted Living: Adherence to Emergency Evacuation Orders for Hurricane Dorian

Hurricane Dorian devastated parts of the Bahamas in 2019 with 185-mph winds. As it moved toward Florida, the state went on alert. This paper examines whether assisted living communities (ALCs) in affected counties evacuated or sheltered in place in the context of emergency management communications concerning evacuation. In 16 coastal counties, 66 ALCs were under mandatory evacuation orders, but 12 sheltered in place. Of 603 ALCs not under orders, 17 evacuated. Seven ALCs evacuated contrary to orders in one county, which issued a mandatory order Sept. 1, delayed it to Sept. 2 as Dorian weakened, and lifted it Sept. 4. Interviews with ALC administrators and emergency managers will be used to understand more about their decisions. Given prior findings that evacuation (versus sheltering in place) increases the mortality and morbidity risk of long-term care (LTC) residents, this research suggests a need for clearer LTC evacuation standards and communication. Part of a symposium sponsored by Disasters and Older Adults Interest Group.

Distinctions on the Importance of Age-Friendly Services by Old Age Groups: A Comparative Study Between the USA and the EU

Based on the initiative of the World Health Organization in 2007, when describing the global age-friendly cities by a guide to enhance active aging and the age-friendliness of communities, Black and Hyer (2019) presented generational distinctions on the importance of age-friendly community features by focusing efforts on the built, social, and service environment in USA. Their study aimed to examine the differential salience of community features by older generational age groups including Baby Boomers and younger persons 50 years and older, and older cohorts, born before and during WWII. They found that the Chi-square results indicate significant differences across the generational age groups in all domains. We wanted to compare the preference of the same age cohorts in Europe. The sizes of samples were half of the size of samples considered by Black and Hyer, therefore we used z+4 tests which also have shown the distinctions pertaining to preferences on housing and participation in social activities. The differences between ranking in importance of Age-Friendly Community Features by Older Age cohorts in USA and EU are presented and discussed.

Analyzing Nursing Home Complaints: From Substantiated Allegation to Deficiency Citations

Complaints provide important information to consumers about nursing homes (NHs). Complaints that are substantiated often lead to an investigation and potentially a deficiency citation. The purpose of this study is to understand the relationship between substantiated complaints and deficiency citations. Because a complaint may contain multiple allegations, and the data do not identify which allegation(s) lead to a complaint’s substantiation, we identified all substantiated single allegation complaints for NHs in 2017. Our data were drawn from federally collected NH complaint and inspection records. Among the 369 substantiated single-allegation complaints, we found most were categorized as quality of care (31.7%), resident abuse (17.3%), or resident neglect (14.1%). Of the deficiency citations resulting from complaints in our sample, 27.9% were categorized as quality of care and 19.5% were in the category of resident behavior and facility practices, which includes abuse and neglect. While two-thirds (N=239) of the substantiated complaints generated from 1 to 19 deficiency citations, nearly one third had no citations. Surprisingly, 28% of substantiated abuse and neglect allegations resulted in no deficiency citations. More surprisingly, a fifth of complaints that were categorized as “immediate jeopardy” at intake did not result in any deficiency citations. We also found a number of asymmetries in the allegation categories suggesting different processes by Centers for Medicare and Medicaid Services (CMS) region. These results suggest that the compliant investigation process warrants further investigation. Other policy and practice implications, including the need for better and more uniform investigation processes and staff training, will be discussed.

Challenges of Caring for an Acute Population in a Disaster

The U.S. Gulf Coast hurricanes of 2004-08 led to research and policy reports highlighting the need for more emergency preparation among nursing homes (NH). In 2016, the federal government issued final rules requiring Medicaid and Medicare providers to develop comprehensive preparedness plans. The state of Florida previously imposed its own long-term care (LTC) preparedness requirements. Hurricane Irma tested the readiness of LTC facilities that care for disabled and vulnerable residents. This research examined the experiences of NHs (N=30) affected by the hurricane through qualitative interviews with administrative staff. Research team members analyzed the transcripts, identified codes, and met to reach consensus on themes. Three major themes emerged, 1) managing the unexpected, including last-minute evacuation orders, 2) caring for vulnerable residents amid the crisis, and 3) the struggle of maintaining staff. Results suggest LTC preparation has increased but long-standing problems continue, including conflicts with emergency management priorities.

The Association of Nursing Home Staffing Levels With Consumer Complaints

Nursing homes (NH) are inspected annually, however, residents and others can file complaints any time. Complaints are critical to NH oversight. Another important quality factor is staffing. Our objective was to examine the association of complaints and staffing levels in a 2017 sample of 14,194 freestanding NHs. We used federal data on NH complaints, quality, staffing, and other characteristics. The outcomes were having received at least one complaint (or not) and numbers of complaints. Using logit and negative binomial regression, controlling for facility and resident characteristics, we found greater registered nurse, nursing assistant, and social services staffing were associated with fewer complaints. Interestingly, licensed practical nurse (LPN) staffing was associated with a higher likelihood of receiving a complaint. Results are consistent with literature on nurse staffing and quality. LPN results raise questions about substituting LPNs for RNs. The social services results show social services staffing may be important for quality.

Deficiency Citations in Nursing Homes That Predominantly Serve Residents With Serious Mental Illness

Studies suggest that nursing homes (NHs) that predominantly serve residents with serious mental illness (SMI) are of worse quality due to poor resources (i.e., high Medicaid-paying census) and lower staffing. We used national Certification and Survey Provider Enhanced Reports (CASPER) data to examine the deficiencies issued to NHs from 37,800 recertification inspections of 14,582 unique NHs from 2014 to 2017. NHs were categorized into “low-SMI” and “high-SMI” facilities using the lowest and highest quartiles, respectively, of the proportion of residents in the NH with SMI. Bivariate analyses were used to assess for differences between low-SMI and high-SMI NHs in the number of deficiencies, the deficiency score (a point-based metric developed by the Centers for Medicare & Medicaid Services), and the scope and severity of deficiencies. In total, there were 245,178 deficiencies issued. In comparison to low-SMI NHs, high-SMI NHs received a greater deficiency score and more deficiencies per survey (p<.001). Deficiencies given to high-SMI NHs were associated with greater risk of harm (p<.001) and were of wider scope (p<.001). High-SMI NHs were cited 215% more often for resident abuse or neglect and 61% more often for the policies that prohibit and monitor for risk of abuse and neglect in comparison to low-SMI NHs. In conclusion, high-SMI NHs were documented for providing worse care to residents, with one particular area of concern being the heightened risk of resident abuse and neglect. Implications for policy and practice will be discussed.

NH Compare’s Health Deficiency 5-Star Rating: Do We Learn Different Things From Survey and Complaint Deficiencies?

The Centers for Medicare and Medicaid Services (CMS) publishes a 5-star rating system for nursing homes (NH). Currently, the 5-star rating for health deficiencies weights deficiencies from annual recertification surveys and complaints equally. Complaint deficiencies may contain different information than survey deficiencies because complaint deficiencies originate with consumers and complaint inspections are less predictable than surveys. The objective of this study is to construct separate 5-star ratings for survey and complaint deficiencies, and to compare them to CMS’ 5-star rating for health deficiencies. Using CASPER and ASPEN Complaints/Incident Tracking System for all NHs in 2017 (N=15,373), we calculated the 5-star rating for health deficiencies as reported by CMS, and then decompose CMS’ rating into separate 5-star ratings for survey and complaint deficiencies. The overall distributions of the CMS’ deficiency rating and survey deficiency rating are similar. The distribution of the complaint deficiency rating is different from CMS’ deficiency rating. Using complaint deficiencies, more NHs have 5-stars (26.5% vs. 10.5%) and fewer facilities have 4-stars (11.2% vs. 23.3%). Comparing the ratings for each facility relative to CMS’ rating, 35.3% of NHs have a different survey deficiency rating while 54.4% have a different complaint deficiency rating. A 5-star rating based on survey and complaint deficiencies results in different ratings for NHs, indicating that complaint deficiency ratings contain different information from survey deficiency ratings. CMS should publish separate ratings based on survey and complaint deficiencies to provide different information.

Hurricane Irma’s Impact on Assisted Living Residents’ Rates of Hospitalization, Nursing Home Placement, and Mortality

Little is known about the impact of hurricanes on the large and increasingly vulnerable population residing in assisted living communities (ALs). The objective of this paper was to leverage a novel methodology to identify Medicare beneficiaries residing in Florida ALs and determine their outcomes associated with Hurricane Irma in 2017. With Medicare enrollment records, claims, and the nursing home Minimum Data Set, we identified a cohort of AL residents in 2015 (n=45,505) and 2017 (n=42,306) and compared their rates of 30-day hospitalization, nursing home placement, and mortality in the two years. AL residents in 2017 had a 10% increase in their 30-day hospitalization rates (3.96 in 2015, 4.34 in 2017), 16% increase in their 30-day nursing home placement rates (1.61 in 2015, 1.87 in 2017), and 22% increase in their 30-day mortality (0.54 in 2015, 0.66 in 2017). Findings suggest Florida AL residents experienced adverse outcomes following Hurricane Irma.

Evaluating Collective Impact for Healthy Aging at the Intersection of Public Health and Age-Friendly Communities

There is mounting interest in promoting - and evaluating efforts that improve healthy aging in age-friendly communities. Additionally, there is increasing recognition that multi-sectoral engagement beyond the aging network is needed to maximize impact and sustainability. Within the context of collective impact, this paper reviews a framework that explicates public health activities in collaboration across a range of stakeholders in age-friendly communities. Metrics demonstrating evidence of five categorical roles, processes and outcomes will be presented including: 1) Connecting and Convening; 2) Coordinating; 3) Collecting and Disseminating Data; 4) Communicating; and 5) Complementing and Supplementing. Examples that illustrate evidence vis-à-vis the components and phases of collective impact will be presented.

The Integral Role of Hospice Nurse Educators in a Palliative Care Education Program for Nurses in Assisted Living

Persons with dementia (PWD) are increasingly cared for in assisted living (AL) settings with an annual mortality rate of close to 20%. Palliative care (PC) for PWD in ALs can improve end-of-life care. From May, 2019 to February, 2020 a 4-week PC education in AL (PCEAL) program for nurses who provide care to PWD, facilitated by hospice nurses in Florida, was tested in a sample of nurses (N=20) in a cluster randomized trial (9 ALs, 4 treatment/5 control). We examined if PC knowledge increased from pre to post-intervention using a validated measure (Thompson, 2011). All intervention nurses (N=10) completed all four sessions of the PCEAL. While the baseline score was lower for the intervention group compared to the control group, the intervention group improved (M=2.20 to 2.37) compared to the control group (M=2.83 to 2.75) post-intervention. Two-month booster sessions indicate nurses have integrated PC care learned in the PCEAL program.

Mortality and Morbidity Among Nursing Home Residents Exposed to Hurricane Irma

We combined Medicare claims and nursing home (NH) administrative data to determine the mortality and morbidity effect of Hurricane Irma on nursing home residents. We utilized the Centers for Medicare and Medicaid Services (CMS) Standard Analytical Files (SAFs) combined with the Minimum Data Set (MDS) to create an exposure cohort of NH residents residing in Florida facilities immediately prior to Hurricane Irma’s landfall on September 10, 2017. We created a control group of residents who resided in the same NHs over the same dates in 2015, a year when there were no hurricanes. Outcome variables included 30/90-day mortality and first hospitalizations post storm. Compared to the control, an additional 260 more NH deaths were identified at 30 days and 429 more deaths at 90 days. Long stay residents (≥100 days) were at particular risk for mortality compared to short stay residents (<100 days). Hospitalization was also markedly increased.

Movement Therapy and Cognitive Function in Middle-Aged and Older Adults: A 10-Year Study

Cognitive function is an important component of healthy aging and physical activities have been shown to support late life cognitive function. However, it is unclear whether non-traditional physical activities provide additional benefits for cognitive function above and beyond traditional leisure physical activities. This study examines the associations between movement therapy and cognitive function in the US population. We used data from the waves 1, 2 and 3 (1995-2014) of the Midlife in the United States (MIDUS) study. MIDUS included a national probability sample of community-living adults aged 25-75 years old in 1995 (wave 1) and added the wave 2 cognitive functioning tests of executive function and episodic memory. We applied multivariate linear regression models to estimate the effect of movement therapy (wave 2) on the cognitive episodic memory and executive function (wave 3) while controlling the covariates (wave 2 sociodemographic factors, health, and cognitive function). A total of 2097 individuals aged 42-92 years (mean 64.4, sd 10.9, 55.6% women) were included in the analysis. Movement therapy was independently associated with better episodic memory (beta=0.117, p=0.02), but not with executive function (beta=0.039, p=0.14), after including control variables. The results suggest that movement therapy may be an effective non-pharmacological intervention to attenuate age-related cognitive decline in middle-aged and older adults. Future research should test whether these findings can be replicated in similar populations and if confirmed, interventions should incorporate a wider range of physical activities in community-living older adults with the goal of maintaining and improving physical and cognitive health.

Prevalent Insomnia Concerns and Perceived Need for Sleep Intervention Among Direct-Care Workers in Long-Term Care

This study examined sleep concerns among direct-care workers in long-term care and their perceived need for a sleep intervention. Thirty-five participants reported their sleep concerns and willingness to participate in a sleep intervention with preferred delivery forms/content. Multiple sleep characteristics were assessed via ecological momentary assessment and actigraphy for 2 weeks. Eighty percent reported at least one sleep concern with insomnia-related concerns being most prevalent. Those with insomnia-related concerns tended to have long sleep onset latency, frequent awakenings, suboptimal (long) sleep duration, and long naps. Most participants (66%) expressed interest in participating in a sleep intervention either online or in group sessions; interest was higher in those with insomnia-related concerns. Mindfulness strategies were most preferred, followed by cognitive-behavioral therapy and sleep hygiene education. The high prevalence of insomnia-related concerns in direct-care workers needs to be addressed for the well-being of these workers and for the quality of geriatric care delivery.

Infection Control Citations in Nursing Homes: Compliance and Geographic Variability

Objectives

To report the initial compliance with new infection control regulations and geographic disparities in nursing homes (NHs) in the United States.

Design

Retrospective cohort study from November 27, 2017 to November 27, 2019.

Setting and Participants

In total, 14,894 NHs in the continental United States comprising 26,201 inspections and 176,841 deficiencies.

Methods

We measured the cumulative incidence of receiving F880: Infection Prevention and Control deficiencies, geographic variability of F880 citations across the United States, and the scope and severity of the infection control deficiencies.

Results

A total of 6164 NHs (41%) in the continental United States received 1 deficiency for F880, and 2300 NHs (15%) were cited more than once during the 2-year period. Geographic variation was evident for F880 deficiencies, ranging from 20% of NHs in North Carolina to 79% of NHs in West Virginia. Between 0% (Vermont) and 33% (Michigan) of states’ NHs were cited multiple times over 2 years. Facilities receiving 2 or more F880 deficiencies were more reliant on Medicaid, for-profit, and served more acute residents. Infection Prevention and Control deficiencies were of similar severity but of greater scope in NHs that were cited multiple times.

Conclusions and Implications

As the coronavirus disease 2019 pandemic challenges hospitals with an increased surge of patients from the community, NHs will be asked to accept convalescing patients who were previously infected with the virus. NHs will need to rely on infection control practices to mitigate the effects of the virus in their facilities. Particular attention to NHs that have fared poorly with repeat infection control practices deficiencies might be a good first step to improving care overall and preventing downstream morbidity and mortality among the highest-risk patients.

The State of States' Assisted Living Websites: Information Available to Consumers

BACKGROUND AND OBJECTIVES

Assisted living (AL) is a growing sector of the U.S. long-term care market, with its development driven largely by private market choices. However, consumers need information to choose the right AL community (ALC). This paper examined information available on U.S. state websites concerning ALC quality, costs, and services.

RESEARCH DESIGN AND METHODS

Based on prior research and their analysis of a sample of state websites, researchers identified 39 key informational elements and grouped them into four categories, (a) ALC characteristics, (b) payment and services, (c) quality, and (d) website usability. Researchers then examined the presence of the 39 elements on 51 websites (U.S. states and the District of Columbia), meeting regularly to discuss findings and resolve differences.

RESULTS

A majority of states provided basic information about individual ALCs (e.g., number of beds, ownership). Only 35% listed payment(s) accepted (e.g., Medicaid), and 31% indicated the availability of memory care. Nearly 70% posted inspection results, while only 43% provided information about complaints. Many met basic usability guidelines (e.g., type size), but locating content on many sites required multiple steps, and none met 5th-grade-or-below readability standards.

DISCUSSION AND IMPLICATIONS

A majority of websites provided important information, such as inspection results. However, many were lacking key elements concerning payment accepted and services. Finding what was available was burdensome. More work is needed to help states provide information that enables consumers to find ALCs that meet their needs. The lack of such information puts older adults at risk of inappropriate placements.

Evaluation of a quality improvement initiative to increase rates of advance directive conversation documentation in primary care

As life expectancy increases, long periods of comorbidity and low quality of life commonly precede death. Advance care planning within primary care settings is necessary to increase patient agency and prioritize personal wishes. This article disseminates a quality improvement initiative within a federally qualified health center. New procedures were developed to systematically track advance directive conversations using current procedural terminology codes. The systems change resulted in a substantial and sustained increase in advance directive conversation documentation. The increase was presumably due to the implementation of small-scale changes, providers' commitment to geriatric primary care, increases in appointment times, allocation of tasks across disciplines, availability of Spanish speaking staff and translated forms, and the change to record keeping that enabled codes to be easily captured and tracked in the electronic medical record. This work may inform future quality improvement efforts to boost advance care planning among underserved populations in diverse settings.

Association Between Exposure to Hurricane Irma and Mortality and Hospitalization in Florida Nursing Home Residents

IMPORTANCE

Nursing home residents are at heightened risk for morbidity and mortality following an exposure to a disaster such as a hurricane or the COVID19 pandemic. Previous research has shown that nursing home resident mortality related to disasters is frequently underreported. There is a need to better understand the consequences of disasters on nursing home residents and to differentiate vulnerability based on patient characteristics.

OBJECTIVE

To evaluate mortality and morbidity associated with exposure to Hurricane Irma, a Category 4 storm that made landfall on September 10, 2017, in Cudjoe Key, Florida, among short-stay (<90-day residence) and long-stay (≥90-day residence) residents of nursing homes.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study of Florida nursing home residents comparing residents exposed to Hurricane Irma in September 2017 to a control group of residents residing at the same nursing homes over the same time period in calendar year 2015. Data were analyzed from August 28, 2019, to July 22, 2020.

EXPOSURE

Residents who experienced Hurricane Irma were considered exposed; those who did not were considered unexposed.

MAIN OUTCOME AND MEASURES

Outcome variables included 30-day and 90-day mortality and first hospitalizations after the storm in both the short term and the long term.

RESULTS

A total of 61 564 residents who were present in 640 Florida nursing home facilities on September 7, 2017, were identified. A comparison cohort of 61 813 residents was evaluated in 2015. Both cohorts were mostly female (2015, 68%; 2017, 67%), mostly White (2015, 79%; 2017, 78%), and approximately 40% of the residents in each group were over the age of 85 years. Compared with the control group in 2015, an additional 262 more nursing home deaths were identified at 30 days and 433 more deaths at 90 days. The odds of a first hospitalization for those exposed (vs nonexposed) were 1.09 (95% CI, 1.05-1.13) within the first 30 days after the storm and 1.05 (95% CI, 1.02-1.08) at 90 days; the odds of mortality were 1.12 (95% CI, 1.05-1.18) at 30 days and 1.07 (95% CI, 1.03-1.11) at 90 days. Among long-stay residents, the odds of mortality for those exposed to Hurricane Irma were 1.18 (95% CI, 1.08-1.29) times those unexposed and the odds of hospitalization were 1.11 (95% CI, 1.04-1.18) times those unexposed in the post 30-day period.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that nursing home residents are at considerable risk to the consequences of disasters. These risks may be underreported by state and federal agencies. Long-stay residents, those who have resided in a nursing home for 90 days or more, may be most vulnerable to the consequences of hurricane disasters.

U.S. State Variation in Frequency and Prevalence of Nursing Home Complaints

Consumers play a key role in the U.S. nursing home (NH) oversight through a federally established complaint process. However, past variation by state in complaint numbers and rates raised questions about the uniformity of the process. We examined state variation in numbers of complaints at intake and substantiated complaints, percentages of NHs with at least one complaint and one substantiated complaint, number of allegations per complaint, and complaint substantiation rates. We found state variation most prominently at the intake level, ranging from 0.4 to 30.4 complaints per NH. The investigation process appears to reduce this variation: however, variation remains among states in frequency and prevalence of substantiated complaints. Further work is needed to ensure federal standards concerning the handling of consumer complaints are applied equally across the states. This includes policies affecting how complaints are initially filed, in addition to how complaints are investigated.

Assisted Living Communities During Hurricane Irma: The Decision to Evacuate or Shelter in Place and Resident Acuity

OBJECTIVES

To investigate the factors associated with whether assisted living communities (ALCs) in Florida evacuated or sheltered in place for Hurricane Irma in 2017, focusing on license type as a proxy for acuity of care.

DESIGN

Cross-sectional study using data collected by the state through its emergency reporting system and a post-hurricane survey.

SETTING AND PARTICIPANTS

Analyses included all 3112 ALCs in the emergency reporting system. A subset of 1880 that completed the survey provided supplementary data.

METHODS

χ2 tests were used to examine differences between ALC characteristics (license type, size, payment, profit status, rural location, geographical region, and being under an evacuation order) and whether they evacuated. Logistic regression was used to test associations between characteristics and evacuation status.

RESULTS

Of 3112 ALCs, 560 evacuated and 2552 sheltered in place. Bivariate analysis found significant associations between evacuation status and evacuation order, license type (mental health care), payment, and region. In the adjusted analysis, medium and larger ALCs were 43% (P < .001) and 53% (P < .001) less likely to evacuate than ALCs with fewer than 25 beds. Compared with ALCs in the Southeast, nearly every region was more likely to evacuate, with the highest likelihood in the Central West (odds ratio 1.76, 95% confidence interval 1.35‒2.30). ALCs under an evacuation order were 8 times more likely to evacuate (P < .001). We found no relationship between evacuation status and having a license to provide higher care.

CONCLUSIONS AND IMPLICATIONS

Prior research highlighting harm associated with evacuation has led to recommendations that long-term care facilities carefully consider resident impairment in evacuation decision-making. Evidence that small ALCs are more likely to evacuate and that having a higher-care license is not associated with evacuation likelihood shows research is needed to understand how ALCs weigh resident risks in decisions to evacuate or shelter in place.

Effectiveness of online dementia caregivers training programs: A systematic review

Over the next thirty years, Alzheimer's disease rates will increase alongside global aging. With the anticipated increase in demand, knowledgeable and skilled dementia caregivers will be in need across the long-term care spectrum. This study is a systematic review of online dementia-based training programs for formal and informal caregivers conducted to analyze evidence for using online training programs. We used the Preferred Reporting Items for Systematic Reviews (PRISMA) method. Methodological quality was assessed by the Cochrane Collaboration Back Review Group criteria. No previously published systematic review has analyzed online dementia training programs among both formal and informal caregivers. A systematic search of Web of Science, PsychInfo, and PubMed resulted in a final sample of (N = 19) studies. Results suggest that online interventions improve the condition and preparedness of caregivers, but future evaluations should consider study designs with multiple time points, control groups, and content that is personalized and interactive.

The Unique Challenges Faced by Assisted Living Communities to Meet Federal Guidelines for COVID-19

This perspective addresses the challenges that assisted living (AL) providers face concerning federal guidelines to prevent increased spread of COVID-19. These challenges include restriction of family visitation, use of third-party providers as essential workers, staffing guidelines, transfer policies, and rural AL hospitalizations. To meet these challenges we recommend that AL providers incorporate digital technology to maintain family-resident communication. We also recommend that states adopt protocols that limit the number of AL communities visited by home health care workers in a 14-day period, appeal to the federal government for hazard pay for direct care workers, and to extend the personal care attendant program to AL. It is further recommended that states work with AL communities to implement COVID-19 comprehensive emergency management plans that are well-coordinated with local emergency operation centers to assist with transfers to COVID-19 specific locations and to assist in rural areas with hospital transfers. Together, these recommendations to AL providers and state and federal agencies address the unique structure and needs of AL and would enable AL communities to be better prepared to care for and reduce those infected with COVID-19.

Hearing Aid Prevalence and Factors Related to Use Among Older Adults From the Hispanic Community Health Study/Study of Latinos

Importance

Hearing loss is highly prevalent in the rapidly growing and aging Hispanic/Latino population in the United States. However, little is known or understood about hearing aid use among US adults from Hispanic/Latino backgrounds.

Objective

To describe hearing aid prevalence and factors associated with hearing aid use among US adults of Hispanic/Latino backgrounds.

Design, Setting, and Participants

Cross-sectional data were collected between 2008 and 2011 from 4 field centers (Bronx, New York; Chicago, Illinois; Miami, Florida; and San Diego, California) as part of the multisite Hispanic Community Health Study/Study of Latinos. Included individuals were adults aged 45 to 76 years with hearing loss (pure-tone average ≥25 dB HL) from randomly selected households in the 4 field centers and were from self-reported Hispanic/Latino backgrounds, including Central American, Cuban, Dominican, Mexican, Puerto Rican, South American, and mixed or other backgrounds. Analysis, including age- and background-weighted prevalence estimates and multivariate logistic regression using survey methodology, was conducted from 2017 to 2018.

Main Outcomes and Measures

The primary outcome of interest was self-reported hearing aid use. The a priori hypothesis was that hearing aid prevalence estimates among included Hispanic/Latino adults would be less than recently published estimates of the general US population, and that poorer hearing, higher perceived need, older age, and higher acculturation would be associated with hearing aid use.

Results

Of 1898 individuals with hearing loss, 1064 (56.1%) were men, and the mean (SE) age was 60.3 (0.3) years. A total of 87 (4.6%) included individuals reported hearing aid use. Increased odds of self-reported use was associated with poorer measured hearing (odds ratio [OR], 1.06; 95% CI, 1.03-1.09), higher Hearing Handicap Inventory-Screening scores (OR, 1.06; 95% CI, 1.03-1.08), access to health insurance coverage (OR, 2.30; 95% CI, 1.20-4.37), and place of residence (OR, 2.42; 95% CI, 1.17-5.02) in an adjusted logistic regression model.

Conclusions and Relevance

Findings revealed underuse of hearing aids among adults from Hispanic/Latino backgrounds. A primary factor related to use was lack of health insurance, which suggests that access influenced hearing aid use. Changes to policy and clinical service provision are needed to increase hearing aid use among aging Hispanic/Latino adults in the United States.

Quality Concerns in Nursing Homes That Serve Large Proportions of Residents With Serious Mental Illness

Background and Objectives

Nursing homes (NHs) are serving greater proportions of residents with serious mental illness (SMI), and it is unclear whether this affects NH quality. We analyze the highest and lowest quartiles of NHs based on the proportion of residents with SMI and compare these NHs on facility characteristics, staffing, and quality stars.

Research Design and Methods

National Certification and Survey Provider Enhanced Reports data were merged with NH Compare data for all freestanding certified NHs in the continental United States in 2016 (N = 14,460). NHs were categorized into “low-SMI” and “high-SMI” facilities using the lowest and highest quartiles, respectively, of the proportion of residents in the NH with SMI. Bivariate analyses and logistic models were used to examine differences in organizational structure, payer mix, resident characteristics, and staffing levels associated with high-SMI NHs. Linear models examined differences in quality stars.

Results

High-SMI facilities were found to report lower direct-care staffing hours, have a greater Medicaid-paying resident census, were more likely to be for-profit, and scored lower on all NH Compare star ratings in comparison to all other NHs.

Discussion and Implications

As the SMI population in NHs continues to grow, a large number of residents have concentrated in a few NHs. These are uniquely different from typical NHs in terms of facility characteristics, staffing, and care practices. While further research is needed to understand the implications of these trends, public policymakers and NH providers need to be aware of this population’s unique—and potentially unmet—needs.

Nurse Aide Retention in Nursing Homes

Background and Objectives

The association of nurse aide retention with three quality indicators is examined. Retention is defined as the proportion of staff continuously employed in the same facility for a defined period of time.

Research Design and Methods

Data used in this investigation came from survey responses from 3,550 nursing facilities, Certification and Survey Provider Enhanced Reporting data, and the Area Resource File. Staffing characteristics, quality indicators, facility, and market information from these data sources were all measured in 2016. Nurse aide retention was measured at 1, 2, and 3 years of employment. The quality indicators examined were a count of all deficiency citations, quality of care deficiency citations, and J, K, L deficiency citations. Negative binomial regression analyses were used to study the associations between the three different retention measures and these three quality indicators.

Results

The 1-, 2-, and 3-year nurse aide retention measures were 53.2%, 41.4%, and 36.1%, respectively. The regression analyses show low levels of retention to be generally associated with poor performance on the three deficiency citation quality indicators examined.

Discussion and Implications

The research presented starts to provide information on nurse aide retention as an important workforce challenge and its potential impact on quality. Retention may be an additional staffing characteristic of nursing facilities with substantial policy and practice relevance.

THE INFLUENCE OF STAFF RETENTION ON NURSING HOME QUALITY

The association of retention of Nurse Aides (NAs) with nursing home quality of care is examined. Retention is defined as staff continuously employed in the same facility for a defined period of time. Deficiency citations were used as quality indicators. Data used came from a survey of nursing home administrators, the Certification and Survey Provider Enhanced Reporting (CASPER) data, and the Area Resource File. All of the data was from 2015, and included 3,550 facilities. Analyses included negative binomial regression and multivariate logistic regression models (using GEE). The analytic modeling included staffing variables (turnover, agency use, staffing levels), facility factors (size, ownership, occupancy rate), and market characteristics (competition, Medicaid rates). The average number of deficiency citations was significantly lower (p<.01) in facilities with the higher levels of NAs consistently employed for one year or more. The same was found for facilities with the higher levels of NAs consistently employed for two years or more. While the average number of deficiency citations, the quality of care grouping of deficiency citations, and J, K, L deficiency citations were all significantly lower (p<.01) in facilities with the higher levels of NAs consistently employed for three years or more. Staff retention has been promoted as potentially influential based on little empirical evidence. The findings provide some justification for the importance of NA retention.

BELIEFS REGARDING GERIATRICS PRIMARY CARE TOPICS AMONG MEDICAL STUDENTS AND INTERNAL MEDICINE RESIDENTS

Our study evaluated and contrasted responses to 25 content areas essential to the primary care of older adults by medical students and residents, and identified attitudes toward aging amongst students and residents. One hundred and thirty-six medical students and 61 Internal Medicine residents completed a survey including the 25-item Geriatrics Clinician-Educator Survey and 18-item Images of Aging Scale. Students and residents rated importance and knowledge for content areas from 1 (low) to 10 (high). Gap scores reflecting the difference in ratings between importance and knowledge were calculated. The Images of Aging scale ranges between 0 (furthest from what you think) and 6 (closest to what you think). Results indicated that students and residents reflected similar beliefs about the importance of content areas, but students provided lower ratings in knowledge. Students revealed larger gap scores in areas that reflected general primary care (e.g., assess chronic conditions, medications), whereas residents revealed larger gap scores in areas that reflected specialists’ expertise (e.g., driving risk, cognition, psychiatric symptoms). Attitudes toward older adults did not differ appreciably between students and residents. In sum, primary care topics applicable for any age demographic were rated as most important by first-year medical students and Internal Medicine residents. Topics relevant to older populations – particularly those requiring specialists’ knowledge of or requiring sensitive discussion with older adults – were rated as less important and were less well mastered.

PRESIDENTIAL SYMPOSIUM: EDUCATION NETWORKS: STRENGTHENING GERONTOLOGY AND GERIATRICS THROUGH CONNECTIVITY

The AGHE Presidential Symposium, related to the theme of the annual scientific meeting, underscores the importance of networks, collaborations and partnerships in advancing education in gerontology and geriatrics. AGHE has been at the forefront of many innovative programs since it was founded in 1974, contributing to the growth of the field and the recognition of education as one pillar of the field of gerontology and geriatrics, along with research, policy and practice. This symposium highlights three ongoing initiatives that promote connections and collaborations. The first paper discusses the Age-Friendly University (AFU) network which is made of institutions around the globe who have committed themselves to becoming more age-friendly in their programs and policies. AGHE endorses the AFU principles and invites its members and affiliates to call upon their institutions become part of this pioneering initiative. The AFU initiative is one of several international activities that AGHE, global leaders in education on aging, has engaged in. The second paper describes international networking activities such as collaborations with international organizations including the World Health Organization and connecting international and US students. In the third paper, initiatives to connect disciplines and professions through competency-based education and curricula are discussed. For instance, the Gerontology Competencies for Undergraduate and Graduate Education and the Program of Merit promote competency-based gerontology education across disciplines and professions.