Gerontological nursing leadership in the Advancing Excellence Campaign: moving interdisciplinary collaboration forward.

Nursing was not a part of the coalition of multiple nursing home stakeholders at the roll out of the Advancing Excellence Campaign (AEC). In January 2007, several nurse organizations proactively approached the AEC leadership, were welcomed and immediately began to volunteer for leadership positions such as committee chairs and conference coordinators. This paper presents an exemplar of how a proactive stance, even when not initially included, allowed nurses to secure chairs at the decision making table of this quality campaign and contribute to improved resident outcomes.

Estimated prevalence of people with cognitive impairment: results from nationally representative community and institutional surveys.

PURPOSE: We address how the national prevalence of cognitive impairment can be estimated from two nationally representative surveys. DESIGN AND METHODS: Data are from the 1999-2001 National Health Interview Survey (NHIS) and the 1999 National Nursing Home Survey (NNHS). The NHIS represents all community-dwelling people living in the United States, and the NNHS is representative of all nursing home residents. RESULTS: NHIS data show that there are approximately 800,000 community-based elders aged 65 and older with reported confusion or memory loss, and 2.3 million elders with reported limitation of activity caused by senility or dementia. There are an estimated 632,000 nursing home residents aged 65 and older with a reported diagnosis of dementia. IMPLICATIONS: Estimates of the prevalence of cognitive impairment that are based on nationally representative data are rare, because comprehensively evaluating a national sample by using standard, validated cognitive-impairment assessment methods is difficult and expensive, and because most national surveys are broad based and designed to cover a wide variety of topics. Crude measures of cognitive impairment, such as the presence of confusion or memory loss or limitations caused by senility or dementia, that are included in these multipurpose surveys may be only rough proxies for clinically evaluated cognitive impairment, but they do appear to produce prevalence estimates that are similar to estimates found with the use of more precise case-ascertainment methods. These nationally representative data sets may be used to generate hypotheses related to the prevalence, epidemiology, and health care utilization patterns of people with cognitive impairment that can be tested in studies using more specific case-ascertainment criteria.

Agency ownership, patient payment source, and length of service in home care, 1992 2000.

PURPOSE: Little is known about whether an association exists between agency ownership and length of service among home care patients with different payment sources. This study investigated how for-profit and not-for-profit agencies responded to policy changes in the 1990s with respect to length of service. DESIGN AND METHODS: We examined length of service among 37,364 home care patients using the 1992, 1994, 1996, 1998, and 2000 National Home and Hospice Care Surveys. We used Kaplan-Meier methods and Cox regression models. RESULTS: After we adjusted for patient and agency characteristics, our results revealed that agency ownership was not associated with length of service for patients with private insurance, Medicare, Medicaid, Medicare plus Medicaid, or Medicare plus private insurance. This finding was consistent from 1992 through 2000. Length of service among patients with Medicare decreased significantly from 1998 through 2000, but length of service among patients with Medicaid did not change significantly from 1992 through 2000. IMPLICATIONS: Agency ownership is not associated with patient length of service in home care. Regardless of the policy changes in the home care arena in the 1990s, for-profit and not-for-profit home health agencies behaved similarly with regard to length of service among patients within differently structured payment systems.

Length of hospice care among U.S. adults: 1992-2000.

This study examined length of service use among U.S. adult hospice patients based on data from the 1992-2000 National Home and Hospice Care Surveys. With the Kaplan-Meier method, we estimated length of service use of current and discharged hospice patients simultaneously. Using a multivariate Cox proportional hazards model, we examined trends in patients' service use during the 1990s. Findings show that length of service use decreased significantly among adult patients who had Medicare as their only payment source. Although overall length of service use declined significantly in 1996, 1998, and 2000 compared to 1992, it was similar between 1996 and 2000.

Characteristics of patients receiving hospice care at home versus in nursing homes: results from the National Home and Hospice Care Survey and the National Nursing Home Survey.

This study examined 1170 deceased home hospice patients from the 1998 National Home and Hospice Care Survey and 617 deceased nursing home hospice patients from the 1997 and 1999 National Nursing Home Surveys. T tests and Bonferroni adjustments for multiple comparisons were performed to assess differences in characteristics of patients receiving hospice care at home versus in nursing homes. We found that the nursing home hospice population differs significantly from the home hospice population in the United States. Nursing home hospice patients were more likely to be older, have Medicaid as their primary payment source, have dementia and other noncancer primary diagnosis, and receive dietary/nutrition service, medication management, and physician services than home hospice patients.

Influenza immunization in nursing homes: who does not get immunized and whose status is unknown?

OBJECTIVE: To identify nursing home resident and facility characteristics associated with patients not receiving influenza immunization and having unknown immunization status. DESIGN: Secondary data analysis using multinomial logistic regression of data from the National Nursing Home Survey, a nationally representative establishment-based survey. SETTING: A total of 1,423 nursing facilities of all ownerships and certifications systematically sampled with probability proportional to number of beds. PATIENTS: A total of 7,350 randomly sampled people aged 65 years or older residing in nursing homes between July and December 1999 (approximately 6 per facility). MAIN OUTCOME MEASURE: Immunization status of residents. RESULTS: Fifteen percent of residents were not immunized and 19% had unknown immunization status. In multivariate analysis, lack of immunization and unknown immunization status were each separately associated with being newly admitted, with no or unknown pneumococcal immunization, and with facility failures to screen for immunization and to record inoculation in the medical record. High-risk status and staff immunization requirements had no effect. Separate analyses showed that residents with unknown immunization status are statistically significantly different from both those vaccinated and those not vaccinated. CONCLUSION: This study indicates that both resident and facility characteristics are associated with failure to be immunized for influenza. Facilities should consider targeting younger, newly admitted, and residential care residents for influenza immunization, since they are more likely to be missed. Further research into the barriers to immunization specific to nursing home resident choice or opportunity may be warranted.

Changes in use of voluntary workers in nursing homes: United States, 1985 and 1999.

OBJECTIVE: This report describes changes in the use of voluntary workers in nursing homes between 1985 and 1999. Statistics are presented on selected characteristics of nursing homes using voluntary workers and the services they perform. Factors that may contribute to the increased use of voluntary workers are also discussed. METHODS: The data presented in this report were collected from the 1985 and 1999 National Nursing Home Surveys (NNHS). NNHS is a part of the National Health Care Survey, which measures health care utilization across various types of providers. Conducted periodically since 1973, NNHS obtains information from a nationally representative sample of nursing home facilities based on interviews with administrators and staff. Sample data are weighted to produce annual national estimates. RESULTS: In 1999, 87 percent of all nursing homes reported using voluntary workers, up from 78 percent in 1985. In 1985, unpaid workers were most likely found in large nursing homes (100 beds or more). By 1999, about the same proportion of nursing homes, large and small, reported their use. In 1999, the Northeast region had the greatest proportion of nursing homes that used volunteers--93 percent. Chain-affiliated and independent facilities used volunteers with about the same frequency, and about the same percentage of nursing homes not certified by either Medicaid or Medicare used voluntary workers as did dually-certified facilities. However, in 1999, proportionately fewer proprietary (for-profit) nursing homes reported having volunteers (85 percent) than did nonproprietary facilities (93 percent).

Nursing home resident and facility characteristics associated with pneumococcal vaccination: national nursing home survey, 1995-1999.

OBJECTIVES: To assess Advisory Committee for Immunization Practices recommendations for the pneumococcal vaccine in nursing home residents using national surveys to examine factors associated with vaccination. DESIGN: Cross-sectional national sample surveys of nursing homes and nursing home residents with a two-stage probability design, stratified on size and Medicare and Medicaid certification status. SETTING: U.S. nursing homes during 1995, 1997, and 1999. PARTICIPANTS: Six current residents were randomly selected from each facility (n=approximately 8,000 each year). MEASUREMENTS: Residents' pneumococcal vaccination status was obtained by asking the facility respondent for each resident: "Has [the resident] EVER had a pneumococcal vaccine, that is a pneumonia vaccination?" Vaccination status was coded as yes, no, and unknown. RESULTS: The proportion of residents aged 65 and older that received pneumococcal vaccination increased significantly, from 23.6% in 1995 to 28.2% in 1997 to 37.4% in 1999 (P<.001). The proportion of residents in homes with pneumococcal immunization programs increased significantly, from 65.2% in 1995 to 88.9% in 1999. CONCLUSION: The proportion of nursing home residents aged 65 and older receiving the pneumococcal vaccine increased significantly from 1995 to 1999. Residents living in nursing homes with programs for pneumococcal immunizations were significantly more likely to be vaccinated.

Demographic and health characteristics of residents choosing to use on-site medical care in a newly opened continuing care retirement community (CCRC).

OBJECTIVE: To determine demographic and health characteristics of older adults choosing to use on-site medical care in a continuing care retirement community (CCRC). DESIGN: A descriptive study of residents moving into a newly opened CCRC. Residents responded to a self-report mail survey composed of questions related to reasons for moving to a CCRC, health and functional status,health care use during the previous 5 years. RESULTS: Of 942 residents, 642 (68%) completed the survey. Medical center users and nonusers were similar demographically and reported similar reasons for moving to the CCRC including desire for a low maintenance apartment (49% vs. 48%; P = 0.806), concern about health or spouse's health (67% vs. 63%; P = 0.345), and desire for social activities (63% vs. 58%; P = 0.151). However, on-site medical center users versus nonusers reported increased rates of fair/poor health (31% vs. 18%; P = 0.0001), fair/poor vision (27% vs. 15%; P = 0.0003),difficulty walking in the home (13% vs. 8%; P = 0.53), using the toilet (6% vs. 2%; P = 0.044), shopping (29% vs. 20%; P = 0.007), using transportation (19% vs. 10%; P = 0.005), doing laundry (13% vs. 7%; P = 0.016), using the telephone (8% vs. 3%; P = 0.002), and taking medication (5% vs. 1%; P = 0.022). CONCLUSION: For both users and nonusers of the medical center, the most frequently cited reason for moving to the CCRC was concern about health. On-site medical center users had lower perceived health, were functionally more disabled, and had health characteristics that made them at higher risk for high health care utilization. The challenges to provide high quality medical care and enhance quality of life for CCRC residents will continue to increase. Physicians should play an active role not only in providing medical care to CCRC residents, but also in providing medical leadership for these institutions.

Lifestyle behaviors, chronic diseases, and ratings of health between black and white adults with pre-diabetes.

PURPOSES: The purposes of this study were to assess differences in lifestyle behaviors and other health-related factors between black and white adults with pre-diabetes and to identify predictors for lifestyle behaviors. METHODS: Using the 2007 and 2009 data from the Behavioral Risk Factor Surveillance System (BRFSS), an annual cross-sectional survey of randomly selected samples from each state, black (n = 1156) and white (n = 9539) adults with pre-diabetes were compared on lifestyle behaviors, general health practices, perceptions of health, chronic diseases, and access to care. Predictors for participating in regular physical activity and adequate intake of fruits and vegetables were identified for each racial and gender group using multiple regression procedures. RESULTS: Less than 40% of the adults with pre-diabetes participated in regular physical activity, and less than a quarter had adequate intake of fruits and vegetables; only 20% met the body weight recommendations. Compared to whites, blacks were more likely to be overweight/obese (86% vs 79%) and less likely to engage in regular physical activity (29% vs 40%). Except for adequate intake of fruits and vegetables, each racial and gender group had different predictors for regular physical activity. For black males, the predictors included impaired physical health and coronary heart disease/stroke. For black females, the predictors were younger age and routine checkup. CONCLUSIONS: Significant disparities exist between blacks and whites in lifestyle behaviors and other health-related factors. Targeted intervention strategies are needed to motivate blacks to modify behaviors to prevent or delay the development of diabetes.

Do vaccination strategies implemented by nursing homes narrow the racial gap in receipt of influenza vaccination in the United States?

OBJECTIVES: To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility-wide vaccination strategies than in residents of facilities without vaccination strategies. DESIGN: Secondary data analysis using the National Nursing Home Survey 2004, a nationally representative survey. SETTING: One thousand one hundred seventy-four participating nursing homes sampled systematically with probability proportional to bed size. PARTICIPANTS: Thirteen thousand five hundred seven randomly sampled residents of nursing homes between August and December 2004. MEASUREMENTS: Receipt of influenza vaccine within the last year. Logistic regression was used to examine the relationship between facility-level influenza immunization strategy and racial inequity in receipt of vaccination, adjusted for characteristics at the resident, facility, state, and regional levels. RESULTS: Overall in the United States, vaccination coverage was higher for Caucasian and African-American residents; the racial vaccination gaps were smaller (<6 percentage points) and nonsignificant in residents of homes with standing orders for influenza vaccinations (P=.14), verbal consent allowed for vaccinations(P=.39), and routine review of facility-wide vaccination rates (P=.61) than for residents of homes without these strategies. The racial vaccination gap in residents of homes without these strategies were two to three times as high (P=.009, P=.002, and P=.002, respectively). CONCLUSION: The presence of several immunization strategies in nursing homes is associated with higher vaccination coverage for Caucasian and African-American residents, narrowing the national vaccination racial gap.

Are standing order programs associated with influenza vaccination? - NNHS, 2004.

BACKGROUND: Influenza vaccination coverage among nursing home residents has consistently been reported well below the Healthy People goals. We sought to determine if standing order programs (SOPs) in long-term care facilities are associated with greater influenza vaccination coverage among residents. METHODS: The National Nursing Home Survey (2004) is cross-sectional. A total of 1152 US long-term care facilities were systematically sampled with probability proportional to number of beds. A total of 11,939 people aged 65 years or older residing in sampled long-term care facilities between August and December 2004 were randomly sampled. Influenza vaccination coverage of residents was obtained from facility records. Facility's immunization program included standing orders versus other (preprinted admission order, advance physician order, personal physician order, and no program). Multinomial logistic regression was used to examine the relationship between type of influenza immunization program and receipt of vaccination, adjusted for resident and facility confounders. RESULTS: The proportion of residents aged 65 years or older who received influenza vaccination was 64%; 41% of residents lived in a facility with an SOP. Influenza vaccination coverage among residents residing in facilities with standing orders was 68% compared with 59% to 63% of residents in facilities with other program types. Logistic regression showed that standing order programs were independently associated with greater influenza vaccination coverage (66.7% versus 62.0%, P < .01). CONCLUSION: This study indicates that residents in long-term care facilities having standing order programs for influenza were more likely to be immunized. More research needs to be done to understand how to facilitate adoption of these programs.

The National Nursing Assistant Survey: improving the evidence base for policy initiatives to strengthen the certified nursing assistant workforce.

PURPOSE: This study introduces the first National Nursing Assistant Survey (NNAS), a major advance in the data available about certified nursing assistants (CNAs) and a rich resource for evidence-based policy, practice, and applied research initiatives. We highlight potential uses of this new survey using select population estimates as examples of how the NNAS can be used to inform new policy directions. DESIGN AND METHODS: The NNAS is a nationally representative survey of 3,017 CNAs working in nursing homes, who were interviewed by phone in 2004-2005. Key survey components are recruitment; education; training and licensure; job history; family life; management and supervision; client relations; organizational commitment and job satisfaction; workplace environment; work-related injuries; and demographics. RESULTS: One in three CNAs received some kind of means-tested public assistance. More than half of CNAs incurred at least 1 work-related injury within the past year and almost one quarter were unable to work for at least 1 day due to the injury. Forty-two percent of uninsured CNAs cite not participating in their employer-sponsored insurance plan because they could not afford the plan. Years of experience do not translate into higher wages; CNAs with 10 or more years of experience averaged just $2/hr more than aides who started working in the field less than 1 year ago. IMPLICATIONS: This survey can be used to understand CNA workforce issues and challenges and to plan for sustainable solutions to stabilize this workforce. The NNAS can be linked to other existing data sets to examine more comprehensive and complex relationships among CNA, facility, resident, and community characteristics, thereby expanding its usefulness.

End-of-life care in nursing homes: 2004 National Nursing Home Survey.

OBJECTIVES: This report presents information on nursing home residents receiving end-of-life (EOL) care in nursing homes. Residents receiving EOL care are compared with those not receiving EOL care on demographics, functional and cognitive status, reported pain, medications, and diagnoses. Residents receiving EOL care are further categorized by whether they started EOL care on or prior to admission to the nursing home or after admission to the nursing home. These two groups receiving EOL care are compared with each other on demographics, functional and cognitive status, medications, diagnoses, length of time receiving EOL care, and treatments received. METHODS: Data are from the resident component of the 2004 National Nursing Home Survey (NNHS). The 2004 NNHS is a nationally representative, cross-sectional probability sample survey of all current residents in nursing homes in the United States with three or more beds and either certified by Medicare or Medicaid or licensed by the state. All information is derived from interviews with nursing home staff. RESULTS: Nursing home residents receiving EOL care were older, more functionally and cognitively impaired, and more likely to have reported pain in the previous 7 days compared with nursing home residents not receiving EOL care. They were also more likely to have at least one advance directive. Three-fourths of residents who received EOL care in the nursing home started EOL care after admission to the nursing home. Differences in age, functional impairment, and cognitive impairment were observed among residents receiving EOL care depending on when they started EOL care. However, no differences in services and treatments received were observed depending on whether EOL care started on or prior to admission or after admission to the nursing home. The mean length of time on EOL care was approximately 5 months and did not differ by whether the care started on or prior to admission or after admission to the nursing home.

Pneumococcal vaccination in nursing homes: does race make a difference?

OBJECTIVES: Known disparities in pneumococcal vaccination in the community raise the question of whether disparities also exist in the nursing home setting, which is better controlled. This study used nationally representative nursing home data to compare black and white nursing home residents with respect to receiving, not receiving, or having an unknown PPV vaccination status, and to examine the interaction of race with various facility characteristics. DESIGN: Multinomial logistic regression was used to analyze a 2-year merged file (1997 and 1999) of the National Nursing Home Survey, a cross-sectional national probability sample of nursing homes and residents. SETTING AND PARTICIPANTS: Residents 65 years or older (n = 14,782) residing in nursing homes between July and December of 1997 or 1999. MEASUREMENTS: Record-based staff report of whether residents ever had a pneumococcal immunization (yes/no/unknown); race measured as black or white. RESULTS: Pneumococcal vaccination rates are lower for black nursing home residents than for white residents, as shown using a merged file of the 1997 and 1999 National Nursing Home Surveys. Participants include 14,303 randomly sampled residents 65 years or older. In this sample, 31% of black residents compared with 24% of white residents 65 years or older had never received pneumococcal vaccination (P < .01). Multivariate logistic regression confirmed that blacks were more likely to be unimmunized than whites (95% CIs), specifically in Medicaid-only facilities and dually certified Medicare and Medicaid facilities. Blacks also had higher odds of unknown vaccination status than whites in Medicaid-only facilities and lower odds of unknown status in government-owned facilities. CONCLUSIONS: Results suggest that the racial difference in pneumococcal vaccination exists predominantly in certain facility types. In addition, facility-based interventions such as having an organized PPV immunization program or improving documentation of vaccination status can be effective in increasing vaccination rates for all races.