Resident- and Institutional-Level Factors, Frailty, and Nursing Homes Residents.

BACKGROUND: Frailty is a major cause of adverse health outcomes, such as hospitalization, falls, disability, and morbidity, among older adults; the elucidation of factors affecting frailty trends over time may facilitate the development of effective interventions. OBJECTIVES: This study aimed to examine the trend of frailty over time (at baseline, 6-month follow-up, and 12-month follow-up) among Chinese nursing home residents and identify associated resident- and institutional-level factors. METHODS: This longitudinal study included 353 residents who were admitted into 27 nursing homes in Jinan, China. Frailty was defined based on the seven self-reported components of the FRAIL-NH scale, which was designed for nursing home residents. Information was gathered using scales that assessed resident-level (sociodemographic characteristics and physical, psychological, and social factors) and institutional-level characteristics (hospital affiliation, fitness sites, green space, occupancy percentage, staff-resident ratio, and staff turnover rate). These data were subjected to a multilevel linear analysis. RESULTS: Frailty was identified in 49.7% of residents at baseline and exhibited a progressively worsening trend over 1 year. Among institutional-level characteristics, the provision of fitness sites in nursing homes was a protective factor for frailty. Among resident-level characteristics, undernutrition was a significant independent risk factor and played a key role in increasing frailty over time. Other risk factors for frailty included younger age, poorer self-rated health, lower physical function, chewing difficulty, loneliness, anxiety, and being less active in leisure activities. DISCUSSION: Frailty was highly prevalent among Chinese nursing home residents and gradually increased over time. The results of this study could be used to inform the development of interventions targeted at modifiable risk factors and shape public health policies aimed at promoting healthy aging and delaying frailty and its adverse outcomes.

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.

[Liaison geriatrics with nursing homes in COVID time. A new coordination model arrived to stay]. / La Geriatría de Enlace con residencias en la época de la COVID-19. Un nuevo modelo de coordinación que ha llegado para quedarse.

Older people living in nursing homes fulfil the criteria to be considered as geriatric patients, but they often do not have met their health care needs. Current deficits appeared as a result of COVID-19 pandemic. The need to improve the coordination between hospitals and nursing homes emerged, and in Madrid it materialized with the implantation of Liaison Geriatrics teams or units at public hospitals. The Sociedad Española de Geriatría y Gerontología has defined the role of the geriatricians in the COVID-19 pandemic and they have given guidelines about prevention, early detection, isolation and sectorization, training, care homes classification, patient referral coordination, and the role of the different care settings, among others. These units and teams also must undertake other care activities that have a shortfall currently, like nursing homes-hospital coordination, geriatricians visits to the homes, telemedicine sessions, geriatric assessment in emergency rooms, and primary care and public health services coordination. This paper describes the concept of Liaison Geriatrics and its implementation at the Autonomous Community of Madrid hospitals as a result of COVID-19 pandemic. Activity data from a unit at a hospital with a huge number of nursing homes in its catchment area are reported. The objective is to understand the need of this activity in order to avoid the current fragmentation of care between hospitals and nursing homes. This activity should be consolidated in the future.

Psychotropic drug use in residents with dementia living in small-scaled special care facilities; a longitudinal study.

Objectives: Over the past decade, a trend has been noticed in the Netherlands to replace large-scaled special care units (SCUs) caring for 20-30 residents with dementia by small-scaled SCUs caring for up to 8 residents. Systematic evaluations, however, have yielded a differentiated picture of the effects. As the impact on psychotropic drug use has hardly been addressed thus far, we examined the (potential) impact of psychotropic drug use when moving residents with dementia from large-scaled to small-scaled SCUs.Methods: We conducted a non-randomized, controlled study with a six-month follow-up. Among 145 residents with dementia living a large-scaled SCUs for dementia caring for 20-30 residents per unit, a total of 77 residents were moved to small-scaled SCUs caring for up to 8 residents per unit. Psychotropic drug use, classified according to the Anatomical Therapeutic Chemical Classification (ATC) system was monitored at 2 months before replacement, as well as at 3 and 6 months thereafter. Repeated measures ANOVAs were conducted for the mean Defined Daily Doses (DDDs) of both groups.Results: No significant differences between both groups in psychotropic medication use were found over a period of 8 months.Conclusion: Prescription of psychotropic drugs does not change after a transfer from a large-scaled SCU to a small-scaled SCU of patients with moderate to severe dementia.Current Controlled Trials: ISRCTN11151241.

Managerial Ownership in Nursing Homes: Staffing, Quality, and Financial Performance.

Purpose of the Study: Ownership of nursing homes (NHs) has primarily focused broadly on differences between for-profit (FP), nonprofit (NFP), and government-operated facilities. Yet, among FPs, the understanding of detailed ownership structures at individual NHs is rather limited. Particularly, NH administrators may hold significant equity interests in their facilities, leading to heterogeneous financial incentives and NH outcomes. Through the principal-agent theory, this article studies how managerial ownership of individual facilities affects NH outcomes. Design and Methods: We use a unique panel dataset of Ohio NHs (2005-2010) to empirically examine the relationship between managerial equity ownership and NH staffing, quality, and financial performance. We identify facility administrators as owner-managers if they have more than 5% of the equity stakes or are relatives of the owners. The statistical analysis is based on the pooled ordinary least squares and NH-fixed effect models. Results: We find that owner-managed NHs are associated with higher nursing staff levels compared to other FP NHs. Surprisingly, despite higher staffing levels, owner-managed NHs are not associated with better quality and we find no statistically significant difference in financial performance between owner-managed and nonowner-managed FP NHs. Our results do not support the principal-agent model and we offer alternative explanations for future research. Implications: Our findings provide empirical evidence that NH ownership structures are more nuanced than simply broadly categorizing facilities as FP or NFP, and our results do not fully align with the standard principal-agent model. The role of managerial ownership should be considered in future NH research and policy discussions.

Dementia care worker stress associations with unit type, resident, and work environment characteristics: a cross-sectional secondary data analysis of the Swiss Nursing Homes Human Resources Project (SHURP).

BACKGROUND: Although caring for residents with dementia in nursing homes is associated with various stressors for care workers, the role of the unit type, and particularly the proportion of residents with dementia, remains unclear. This study aimed to explore associations between unit type and care worker stress, taking into account additional potential stressors. METHODS: This cross-sectional study was a secondary data analysis in the Swiss Nursing Homes Human Resources Project, which included data from 3,922 care workers from 156 Swiss nursing homes. Care workers' stress was measured with a shortened version of the Health Professions Stress Inventory. Generalized estimating equation models were used to assess care worker stress and its relationships with three unit types (special care units and others with high or low proportions of residents with dementia), work environment factors, and aggressive resident behavior. RESULTS: After including all potential stressors in the models, no significant differences between the three unit types regarding care worker stress were found. However, increased care worker stress levels were significantly related to lower ratings of staffing and resources adequacy, the experience of verbal aggression, and the observation of verbal or physical aggression among residents. CONCLUSIONS: Although the unit type plays only a minor role regarding care worker stress, this study confirms that work environment and aggressive behavior of residents are important factors associated with work-related stress. To prevent increases of care worker stress, interventions to improve the work environment and strengthen care workers' ability to cope with aggressive behavior are suggested.

Impact of the nursing home scale on residents' social engagement in South Korea.

BACKGROUND: This study aimed to describe the levels of social engagement and to examine the relationship between the nursing home scale groups and social engagement in nursing homes in South Korea. METHODS: A total of 314 residents were randomly selected from rosters provided by 10 nursing homes located in three metropolitan areas in South Korea. The outcome variable was social engagement measured by the Revised Index of Social Engagement (RISE), and the key independent variable was the nursing home scale (small, medium, and large). Individual factors (age, gender, activities of daily living and cognitive function, and depressive symptoms) and organizational factors (location, ownership, and staffing levels) were controlled in the model as covariates. Multilevel logistic regression was used in this study. RESULTS: About half of the residents (46%) in this study were not socially engaged in the nursing home (RISE=0) where they resided. Controlling for individual- and organizational-level factors, the nursing home facility size was a significant factor to predict the likelihood of residents' social engagement, with that the residents in large-scale nursing homes being less likely to be socially engaged than those in medium-scale nursing homes (odds ratio = 0.457; p-value = 0.005). CONCLUSION: This study supports evidence from previous studies that smaller-scale nursing homes are likely to provide more person-centered care compared to larger-scale nursing homes. Subsequent quality studies are needed to examine how the mechanisms for how smaller-scale nursing homes can enhance residents' social engagement in terms of care delivery processes.

Are Obese Residents More Likely to Be Admitted to Nursing Homes That Have More Deficiencies in Care?

OBJECTIVES: To determine whether obese older adults who qualify for nursing home (NH) placement are as likely as nonobese adults to be admitted to NHs that provide adequate quality of care. DESIGN: Retrospective study. SETTING: NHs in New York State. PARTICIPANTS: Individuals aged 65 and older newly admitted to a NH in New York State in 2006-07. MEASUREMENTS: Total and healthcare-related deficiency citations for each facility were obtained from the Online Survey, Certification, and Reporting file. Bivariate and multivariate regression analyses were used to assess the association between obesity (body mass index (BMI) 30.0-39.9 kg/m(2) ) and morbid obesity (BMI ≥ 40.0 kg/m(2) ) separately and admission to facilities with more deficiencies. RESULTS: NHs that admitted a higher proportion of morbidly obese residents were more likely to have more deficiencies, whether total or healthcare related. These NHs also had greater odds of having severe deficiencies, or falling in the top quartile ranking of total deficiencies. After sequentially controlling for the choice of facilities within the inspection region, resident characteristics, and facility covariates, the association between morbid obesity and admission to higher-deficiency NHs persisted. CONCLUSION: Residents with morbid obesity were more likely to be admitted to NHs of poorer quality based on deficiency citations. The factors driving these disparities and their impact on the care of obese NH residents require further elucidation.

[Do nursing homes with higher quality ratings provide a better quality of care? : Empirical study based on administrative data]. / Bieten Pflegeheime mit besseren Pflegenoten auch eine bessere Qualität? : Empirische Analyse auf Basis von GKV-Routinedaten.

BACKGROUND: In 2009 a new system for the objective evaluation of nursing homes was introduced in Germany. The so-called nursing transparency agreement (Pflege-Transparenzvereinbarungen) was introduced to provide a reliable tool for an objective comparison of inpatient (PTVS) and outpatient (PTVA) care; however, the new regulations have been the subject of a broad discussion regarding reliability, efficiency and objectivity. AIMS: To overcome the lack of objective health outcomes, this study used administrative data from Germany's largest health insurance fund, the Techniker Krankenkasse, in order to analyze the association between the quality ratings and objective quality measures on an individual level. This is the first study that provides empirical evidence on this topic using administrative data. MATERIAL AND METHODS: The administrative dataset contained information on several individual characteristics as well as data on injuries, poisoning and other extrinsic effects on care-dependent individuals over the age of 64 years who were living in a nursing home in 2009. Based on these data an objective measure was constructed to test whether higher quality ratings of nursing homes led to a better quality of care of the respective patients using non-linear regression models. RESULTS: The results of the estimated models showed no significant evidence of such a relationship, neither considering the probability nor the number of injuries, poisoning and other extrinsic effects. Significant effects were only observed for gender and specific diseases. CONCLUSION: The results of this study support the argument that the current rating procedure for nursing homes has to be refined. Using quality indicators in combination with the administrative data could possibly contribute to such an enhancement.

An international definition for "nursing home".

There is much ambiguity regarding the term "nursing home" in the international literature. The definition of a nursing home and the type of assistance provided in a nursing home is quite varied by country. The International Association of Gerontology and Geriatrics and AMDA foundation developed a survey to assist with an international consensus on the definition of "nursing home."

[Age-Wohnmatrix. Using basic needs rather than defined terms]. / Age-Wohnmatrix. Bedürfnisse statt Begriffe ins Zentrum stellen.

BACKGROUND: The variety of living possibilities for ageing people has increased in the past few years. This vast range of housing arrangements does not make orientation any easier for individuals. The definition of housing and caring arrangements not only differs from one country to another but also within countries. MATERIAL AND METHOD: To develop a framework describing different housing offers, we started to work with a positioning matrix, which is known in economic sciences. The matrix turned into the Age-Wohnmatrix which is defined by two basic needs of elderly people: the importance of being autonomous and the desire to be integrated and secure. RESULTS: On the autonomy axis, there are three different types of housing arrangements: private living arrangements, special housing offers for elderly people, and institutional living. The security axis starts by offering apartments, followed by social integration, assistance, and care. CONCLUSION: The Age-Wohnmatrix should be a helpful tool to analyze and define the character of housing options for elderly people.

Does the Aged Care Funding Instrument provide increased funding in residential care? Comparisons with the Residential Classification Scale.

AIM: To determine whether the Aged Care Funding Instrument (ACFI) provides more funding than the Residential Classification Scale (RCS) for residents in the Hellenic Residential Care Facility. METHODS: All residents within the care facility were assessed over a six 6-month period using ACFI, RCS and Clifton Assessment Procedures for the Elderly (CAPE) scores. Differences in funding levels were calculated using ACFI and RCS instruments against a standardised CAPE score. RESULTS: CAPE dependency RCS funding per resident per day varied from $32.20 for grade A to $116.20 for grade E4 residents. CAPE ACFI funding varied from $20.20 for grade A to $127.50 for grade E4. There was no significant difference in mean overall funding between the two scales (ACFI $92.50 vs RCS $90.35, P = 0.76). CONCLUSIONS: The ACFI does provide a small but not significant increase in funding to residents in residential care. It redirects funding to higher dependency residents.

[Development and validation of a Quebec classification of private residences with services welcoming of older persons]. / Développement et validation d'une classification québécoise des résidences privées avec services accueillant des personnes âgées.

Private Residential Care Facilities (RCFs) fill the gap between independent community living and institutional settings for seniors. There are marked differences between RCFs which make them difficult to compare. To address this issue, the objective of this study was to develop and validate a classification of RCFs based on their physical and organizational environments. RCF owners across Quebec were invited to complete a questionnaire that described the setting's physical and organizational environment. Different combinations of cluster analysis methods and statistical parameters were used to identify plausible classifications. The final choice was made by an expert committee. Overall, 552 owners returned the questionnaire. Three plausible classifications were submitted to the committee. The selected classification included five clusters that differed with regard to admission criteria, services offered and recreational activities. This classification could help health professionals select the RCF that best responds to older adults' needs.

[Prices and quality in nursing homes - first empirical results for Germany]. / Preise und Qualität in Pflegeheimen - Erste empirische Ergebnisse für Deutschland.

OBJECTIVES: This paper analyses on the basis of data from over 2 400 nursing homes the relationship between remuneration rates and quality for Germany. Other factors influencing this relationship are taken into account.Data about nursing homes are taken from the nursing home data base PAULA, which includes about 11 500 nursing homes. DATA AND METHODS: Data about quality of care in nursing homes are derived from the so-called transparency reports for residential long-term care (PVTS). In a linear regression framework the different quality measures are regressed on the average nursing home price. Control variables are inter alia ownership, size and location of the nursing homes. RESULTS: The analyses show a statistically significant positive correlation between remuneration rates and quality. Better quality is reflected in higher remuneration rates. CONCLUSIONS: The results show a significant, but in actual size low relationship between quality and remunerations rates. The results cannot be interpreted as a causal relationship. Additionally, it is not possible to explain differences in nursing home prices over federal states with differences in quality.

Using the RUG-III classification system for understanding the resource intensity of persons with intellectual disability residing in nursing homes.

Since 1991, the Minimum Data Set 2.0 (MDS 2.0) has been the mandated assessment in US nursing homes. The Resource Utilization Groups III (RUG-III) case-mix system provides person-specific means of allocating resources based on the variable costs of caring for persons with different needs. Retrospective analyses of data collected on a sample of 9707 nursing home residents (2.4% had an intellectual disability) were used to examine the fit of the RUG-III case-mix system for determining the cost of supporting persons with intellectual disability (intellectual disability). The RUG-III system explained 33.3% of the variance in age-weighted nursing time among persons with intellectual disability compared to 29.6% among other residents, making it a good fit among persons with intellectual disability in nursing homes. The RUG-III may also serve as the basis for the development of a classification system that describes the resource intensity of persons with intellectual disability in other settings that provide similar types of support.

The care unit in nursing home research: evidence in support of a definition.

BACKGROUND: Defining what constitutes a resident care unit in nursing home research is both a conceptual and practical challenge. The aim of this paper is to provide evidence in support of a definition of care unit in nursing homes by demonstrating: (1) its feasibility for use in data collection, (2) the acceptability of aggregating individual responses to the unit level, and (3) the benefit of including unit level data in explanatory models. METHODS: An observational study design was used. Research (project) managers, healthcare aides, care managers, nursing home administrators and directors of care from thirty-six nursing homes in the Canadian prairie provinces of Alberta, Saskatchewan and Manitoba provided data for the study. A definition of care unit was developed and applied in data collection and analyses. A debriefing session was held with research managers to investigate their experiences with using the care unit definition. In addition, survey responses from 1258 healthcare aides in 25 of the 36 nursing homes in the study, that had more than one care unit, were analyzed using a multi-level modeling approach. Trained field workers administered the Alberta Context Tool (ACT), a 58-item self-report survey reflecting 10 organizational context concepts, to healthcare aides using computer assisted personal interviews. To assess the appropriateness of obtaining unit level scores, we assessed aggregation statistics (ICC(1), ICC(2), η², and ω²), and to assess the value of using the definition of unit in explanatory models, we performed multi-level modeling. RESULTS: In 10 of the 36 nursing homes, the care unit definition developed was used to align the survey data (for analytic purposes) to specific care units as designated by our definition, from that reported by the facility administrator. The aggregation statistics supported aggregating the healthcare aide responses on the ACT to the realigned unit level. Findings from the multi-level modeling further supported unit level aggregation. A significantly higher percentage of variance was explained in the ACT concepts at the unit level compared to the individual and/or nursing home levels. CONCLUSIONS: The statistical results support the use of our definition of care unit in nursing home research in the Canadian prairie provinces. Beyond research convenience however, the results also support the resident unit as an important Clinical Microsystem to which future interventions designed to improve resident quality of care and staff (healthcare aide) worklife should be targeted.

Interaction effect of Medicaid census and nursing home characteristics on quality of psychosocial care for residents.

BACKGROUND: Numerous studies have identified disparities in nursing home quality of care. Although previous studies have found the overlap among Medicaid census, nursing home characteristics, and negative quality of care outcomes, few studies have examined how the psychosocial well-being of nursing home residents is associated with Medicaid census and other nursing home characteristics. PURPOSE: The purpose of this study was to elucidate the intertwined relationships between Medicaid census and other important nursing home factors and its impact on psychosocial care for residents. This study examined the interactive effects of (1) nursing home ownership status and Medicaid census, (2) staffing level and Medicaid census, and (3) resident ethnic mix and Medicaid census on psychosocial well-being outcomes. METHODOLOGY: The sample, derived from a combined data set of New York State nursing homes' Online Survey Certification and Reporting System and Minimum Data Set, included 565 nursing homes in rural and urban areas of the state. FINDINGS: Medicaid census had no main effect on psychosocial well-being outcomes of nursing home care but had a significant interactive effect with other nursing home characteristics. High Medicaid census was associated with lower level of psychosocial symptom detection in nonprofit nursing homes and nursing homes with a higher proportion of ethnic minority residents. PRACTICE IMPLICATIONS: Nursing staff training on better psychosocial well-being care, in particular, better psychosocial assessment, is important. To obtain the training resources, nursing homes with high Medicaid census can collaborate with other nursing homes or social service agencies. Considering that nursing homes with a high proportion of ethnic minority residents have lower level of detection rate for psychosocial well-being issues, culturally competent care should be a component of quality improvement plans.