Variation in Residential Care Community Nurse and Aide Staffing Levels: United States, 2014.

OBJECTIVES: This report presents national and state estimates of staffing levels in residential care communities for registered nurses, licensed practical or vocational nurses, and aides in the United States for 2014. METHODS: Data were drawn from the residential care community component of the 2014 wave of the biennial National Study of Long-Term Care Providers, conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. For each staff type, the "staffing level" measure is presented as average hours per resident per day, defined as the total number of hours worked divided by the total number of residents, which does not necessarily reflect the amount of care given to a specific resident. Analyses examined the extent to which residential care community nurse and aide staffing levels varied by selected organizational characteristics and selected resident composition characteristics of the communities. Differences among subgroups were evaluated using two-sided t tests at the 0.05 level. RESULTS: In 2014, the total registered nurse, licensed practical or vocational nurse, and aide staffing level among all residential care communities was about 2 hours and 50 minutes. Registered nurse staffing levels differed for two of the three organizational characteristics (size and metropolitan statistical area [MSA]) and for only one of the four resident composition characteristics (primarily serving residents needing any assistance with activities of daily living). Licensed practical or vocational nurse staffing levels differed for all three organizational characteristics (size, MSA, and ownership) and for only one of the four resident composition characteristics (primarily serving residents diagnosed with Alzheimer's disease or other dementias). In contrast, differences in aide staffing levels were common when examining both community organizational and resident composition characteristics. Registered nursing, licensed practical and vocational nursing, and aide staffing levels varied geographically by state.

Variation in Operating Characteristics of Adult Day Services Centers, by Center Ownership: United States, 2014.

More than one-quarter of a million participants were enrolled in 4,800 adult day services centers in the United States in 2014. Unlike other long-term care providers, such as nursing homes, home health agencies, hospices, and residential care communities, the majority of adult day services centers are nonprofit. However, for-profit ownership of adult day services centers has increased, from 27% in 2010 to 40% in 2012, and more recently to 44% in 2014. This report presents the most current national estimates of selected adult day services center operating characteristics, and compares these characteristics by center ownership. State estimates for the characteristics presented in this data brief are available online at: http://www.cdc.gov/nchs/ nsltcp/nsltcp_products.htm.

Variation in Adult Day Services Center Participant Characteristics, by Center Ownership: United States, 2014.

More than one-quarter million participants were enrolled in adult day services centers in the United States on the day of data collection in 2014. The number of for-profit adult day services centers has grown in recent years. In 2012, 40% of adult day services centers were for-profit, serving more than one-half of all participants. This report presents the most current national estimates of selected characteristics of participants in adult day services centers and compares these characteristics by center ownership type. State-level estimates for the characteristics presented in this report are available online at http://www.cdc.gov/nchs/nsltcp/nsltcp_products.htm.

Differences in adult day services center participant characteristics by center ownership: United States, 2012.

KEY FINDINGS: Data from the National Study of Long-Term Care Providers. In 2012, more than one-third of participants in adult day services centers were younger than 65. A higher percentage of participants in nonprofit centers than in for-profit centers were younger than 65. About one-half of participants in adult day services centers were non-Hispanic white persons. A higher percentage of participants in for-profit centers than in nonprofit centers were Hispanic or were non-Hispanic and of a race other than black or white. Almost one-third of adult day services center participants had Alzheimer's disease or other dementias, and about one-quarter had a developmental disability. A lower percentage of participants in for-profit than in nonprofit centers had Alzheimer's disease or other dementias or a developmental disability. The 4,800 adult day services centers nationwide provide a variety of services to their 273,200 participants, the majority of whom are older adults and women (1). The number of for-profit adult day services centers has grown in recent years (2). The 1,900 for-profit centers, representing 40% of centers nationally, served nearly one-half (47%) of center participants in 2012 (3). Using data from the National Study of Long-Term Care Providers, this report presents selected characteristics of adult day services center participants in 2012 and compares the characteristics of participants in for-profit centers with those in nonprofit centers.

Differences in adult day services center characteristics by center ownership: United States, 2012.

KEY FINDINGS: Data from the National Study of Long-Term Care Providers. In 2012, 40% of the 4,800 adult day services centers were for-profit entities, serving nearly one-half of the 272,300 center participants. About 60% of adult day services centers used a standardized tool to screen for cognitive impairment, and about 20% used a standardized tool for depression screening. A greater percentage of for-profit than nonprofit centers used these tools. More than one-half of adult day services centers provided skilled nursing, therapeutic, and social work services, while less than one-half of centers provided mental health, pharmacy, and dental services. With the exception of social work services, a greater percentage of for-profit than nonprofit centers provided these services. Almost all adult day services centers provided daily transportation to and from the center. The most recent data estimate that 4,800 adult day services centers nationwide serve nearly a quarter million participants daily (1). Unlike other long-term care providers, such as nursing homes, home health agencies, hospices, and residential care communities, the majority of adult day services centers are nonprofit (1). However, for-profit ownership of adult day services centers appears to be increasing, from 27% in 2010 to 40% in 2012 (2). Using data from the National Study of Long-Term Care Providers, this report presents national estimates for characteristics of adult day services centers in 2012 and compares them by type of center ownership.

Dementia special care units in residential care communities: United States, 2010.

In 2010, 17% of residential care communities had dementia special care units. Beds in dementia special care units accounted for 13% of all residential care beds. Residential care communities with dementia special care units were more likely than those without to have more beds, be chain-affiliated, and be purposely built as a residential care community, and less likely to be certified or registered to participate in Medicaid. Residential care communities with dementia special care units were more likely than those without to be located in the Northeast and in a metropolitan statistical area, and less likely to be in the West. Assisted living and similar residential care communities provide an alternative to nursing homes for individuals with dementia who can no longer live independently. In 2010, about 42% of individuals living in residential care communities had Alzheimer's disease or other dementia. Individuals with dementia can live in residential care communities that have dementia special care units, or in a more traditional setting where these residents are integrated with residents without dementia. Many states require residential care communities with dementia special care units to have certain physical features (e.g., locked door) and specially trained staff to care for residents with dementia. This report compares residential care communities with and without dementia special care units.

Infections in long-term care populations in the United States.

OBJECTIVES: To estimate infection prevalence and explore associated risk factors in nursing home (NH) residents, individuals receiving home health care (HHC), and individuals receiving hospice care. DESIGN: Cross-sectional. SETTING: Nationally representative samples of 1,174 U.S. NHs in the 2004 National Nursing Home Survey (NNHS) and 1,036 U.S. HHC and hospice agencies in the 2007 National Home and Hospice Care Survey (NHHCS). PARTICIPANTS: A nationally representative sample of 12,270 NH residents, 4,394 individuals receiving HHC, and 4,410 individuals receiving hospice care. MEASUREMENTS: International Classification of Diseases, Ninth Revision, Clinical Modification, codes were used to identify the presence of infection, including community-acquired infection and those acquired during earlier healthcare exposures. RESULTS: Unweighted response rates were 78% for the 2004 NHHS and 67% for the 2007 NHHCS. Approximately 12% of NH residents and 12% of individuals receiving HHC had an infection at the time of the survey interview, and more than 10% of individuals receiving hospice care had an infection when discharged from hospice care. The most common infections were urinary tract infection (3.0­5.2%), pneumonia (2.2­4.4%), and cellulitis (1.6­2.0%). Short length of care and recent inpatient stay in a healthcare facility were associated with infections in all three populations. Taking 10 or more medications and urinary catheter exposure were significant in two of these three long-term care populations. CONCLUSION: Infection prevalence in HHC, hospice, and NH populations is similar. Although these infections may be community acquired or acquired during earlier healthcare exposures, these findings fill an important gap in understanding the national infection burden and may help inform future research on infection epidemiology and prevention strategies in long-term care populations.

Training of home health aides and nurse aides: findings from national data.

Training and satisfaction with training were examined using data from nationally representative samples of 2,897 certified nursing assistants (CNAs) from the National Nursing Assistant Survey and 3,377 home health aides (HHAs) from the National Home Health Aide Survey conducted in 2004 and 2007, respectively. This article focuses on the commonalities and differences in the perceptions of CNAs and HHAs regarding the initial and continuing education they received to prepare them for their job. More than 80% of HHAs and all CNAs received some initial training. Of these, significantly more HHAs compared to CNAs felt that training had prepared them "very well" for their jobs. The two groups also differed in their assessments of the content of the initial training; for example, more CNAs believed that their training was "excellent" in helping them address patients' limitations in activities of daily living compared to HHAs. The vast majority of HHAs and CNAs received continuing education, and about three fourths in each group assessed this training as being "very useful." In light of the increasing demands for HHAs and CNAs with the aging of America, findings from these national studies could be used to inform educational and training initiatives for this critical workforce.

An overview of home health aides: United States, 2007.

OBJECTIVES: This report presents national estimates of home health aides providing assistance in activities of daily living (ADLs) and employed by agencies providing home health and hospice care in 2007. Data are presented on demographics, training, work environment, pay and benefits, use of public benefits, and injuries. METHODS: Estimates are based on data collected in the 2007 National Home Health Aide Survey. Estimates are derived from data collected during telephone interviews with home health aides providing assistance with ADLs and employed by agencies providing home health and hospice care. RESULTS: In the United States in 2007, 160,700 home health and hospice aides provided ADL assistance and were employed by agencies providing home health and hospice care. Most home health aides were female; approximately one-half were white and one-third black. Approximately one-half of aides were at least 35 years old. Two-thirds had an annual family income of less than $40,000. More than 80% received initial training to become a home health aide and more than 90% received continuing education classes in the previous 2 years. Almost three-quarters of aides would definitely become a home health aide again, and slightly more than one-half of aides would definitely take their current job again. The average hourly pay was $10.88 per hour. Almost three-quarters of aides reported that they were offered health insurance by their employers, but almost 19% of aides had no health insurance coverage from any source. More than 1 in 10 aides had had at least one work-related injury in the previous 12 months. CONCLUSIONS: The picture that emerges from this analysis is of a financially vulnerable workforce, but one in which the majority of aides are satisfied with their jobs. The findings may be useful in informing initiatives to train, recruit, and retain these direct care workers.

Use of advance directives in long-term care populations.

An advance directive (AD) allows a patient to communicate health care preferences in the event that he or she is no longer able to make these decisions. Many view advance care planning (ACP)­a process that includes discussing values and goals of care among the patient, family, and physician, and determining or executing treatment directives­as a way to help ensure that wishes about end-of-life care are honored. Ideally, ADs are part of the ACP process. Twenty years ago, Congress passed the Patient Self-Determination Act (PSDA) requiring most health care facilities to inform adult patients about their rights to execute an AD. Research indicates that the preference for having an AD can be influenced by individual attitudes, cultural beliefs, health conditions, and trust in health care professionals. This report presents the latest national data on ADs in three long-term care populations­those receiving home health care or hospice care and those residing in nursing homes.

Complementary and alternative therapies in hospice: The national home and hospice care survey: United States, 2007.

Objective-This report presents national estimates on the provision and use of complementary and alternative therapies (CAT) in hospice. Comparisons of organizational characteristics of hospice care providers are presented by whether the provider offered CAT. Comparisons of selected characteristics of patients discharged from hospice are presented by whether they received care from a provider that offered CAT, and whether they received a CAT service. Methods-Estimates are based on data from the 2007 National Home and Hospice Care Survey (NHHCS), conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. Results-In 2007, 41.8% of hospice care providers offered CAT services, had a CAT provider on staff or under contract, or both. Among hospice care providers offering CAT, over one-half offered massage (71.7%), supportive group therapy (69.0%), music therapy (62.2%), pet therapy (58.6%), or guided imagery or relaxation (52.7%). Of the hospice care providers that offered CAT, 21.5% had at least one discharged hospice patient who received CAT during hospice care. Overall, 4.9% of all discharged hospice patients received at least one CAT from the hospice care provider. Over one-half of discharged patients (56.5%) received care from a provider that offered CAT, and of those, 8.6% received at least one CAT from the hospice care provider during their stays. There were no differences in demographics, health, functional status, or admission diagnoses between patients discharged from hospice either by whether they received care from a provider that offered CAT or whether they received CAT.

Residential care facilities: a key sector in the spectrum of long-term care providers in the United States.

RCFs in the United States totaled 31,100 in 2010, with 971,900 state-licensed, certified, or registered residential care beds. About one-half of RCFs were small facilities which served one-tenth of all RCF residents. The remaining RCFs were medium-sized facilities (16%) which served about one-tenth of all RCF residents, large facilities (28%) which served about one-half of all RCF residents, and extra large facilities (7%) which housed about three-tenths of all RCF residents. RCFs were predominantly for profit (82%), not part of a chain (62%), and located in an MSA (81%). Small RCFs were more likely to be for profit than larger RCFs. The proportion of chain-affiliated RCFs grew with increasing facility size. Small and extra large RCFs were most likely to be located in an MSA, while medium RCFs were least likely to be in an MSA. RCFs were most commonly located in the West. The mix of facility sizes varied by region. The West had almost twice as many residential care beds per 1,000 persons aged 85 and over as the Northeast (245 to 131). Comparing the supply of RCF beds with nursing home beds (data compiled by Centers for Medicare & Medicaid Services) shows that the supply of RCF beds (245) and nursing home beds (203) per 1,000 persons aged 85 and over was relatively comparable in the West, but nursing home beds far outnumbered RCF beds in all other regions. There were about twice as many nursing home beds as RCF beds per 1,000 persons aged 85 and over in the South (325 to 164), Midwest (390 to 177), and Northeast (303 to 131). More research is needed to identify and examine factors that may explain these regional differences in both the supply of residential care beds, including variations in state regulation and financing of different types of LTC providers, and in consumer preferences for different kinds of long-term services and support. RCFs serve primarily a private-pay adult population (6). However, the use of Medicaid financing for services in residential care settings has gradually increased in recent years (7). About 4 out of 10 RCFs had at least one resident who had some or all of their LTC services paid by Medicaid. The percentage of facilities having residents who received LTC services paid by Medicaid varied by facility size. Although nearly all RCFs provided basic health monitoring (96%) and incontinence care (93%), larger RCFs were more likely than smaller RCFs to offer occupational and physical therapy. Larger RCFs were also more likely than small RCFs to provide social services counseling and case management. The provision of skilled nursing services did not vary by facility size. This report presents national estimates of RCFs using data from the first-ever national probability sample survey of RCFs with four or more beds. Findings on differences in selected characteristics and services offered by facility size and on regional variations in the supply of beds provide useful information to policymakers, LTC providers, and consumer advocates as they plan to meet the needs of an aging population. Moreover, these findings establish baseline national estimates as researchers continue to track growth and changes in the residential care industry.

Design and operation of the 2010 National Survey of Residential Care Facilities.

OBJECTIVES: This methods report provides an overview of the National Survey of Residential Care Facilities (NSRCF) conducted in 2010. NSRCF is a first-ever national probability sample survey that collects data on U.S. residential care providers, their staffs and services, and their residents. Included are residential care facilities consisting of assisted living residences; board and care homes; congregate care; enriched housing programs; homes for the aged; personal care homes; and shared housing establishments that are licensed, registered, listed, certified, or otherwise regulated by a state. A survey-specific definition was used to select residential care facilities into the study. This report discusses the need for and objectives of the survey, design process, survey methods, and data availability. METHODS: In 2008, a small pilot study and a pretest were conducted to test and refine the survey protocol, data collection procedures, and questionnaires. NSRCF was conducted between March and November 2010. The survey used a two-stage probability sampling design in which residential care facilities were sampled. Then, depending on facility size, three to six current residents were sampled. In-person interviews were conducted with facility directors and designated staffs; no interviews were conducted with residents. The survey instrument contained a facility screening module, facility- and resident-level modules, a resident sampling module, and a pre-interview worksheet. RESULTS: National data were collected on 2,302 facilities, and 8,094 current residents. The first-stage facility weighted response rate (for differential probabilities of selection) was 81%. The second-stage resident weighted response rate was 99%. Two public-use files will be released. The facility and resident files include sampling weights to generate national estimates, and design variables to calculate accurate standard errors.

A national overview of the training received by certified nursing assistants working in U.S. nursing homes.

A few geographically limited studies have indicated that training of direct care workers may be insufficient. Using the first-ever nationally representative sample of certified nursing assistants (CNAs) from the 2004 National Nursing Assistant Survey (NNAS), this descriptive article provides an overview of the type of initial training and continuing education received by CNAs working in nursing homes, reports CNAs' assessments of the adequacy of their training, and identifies perceived training needs from the points of view of CNAs. Findings could be used to inform changes to the initial training and continuing education curriculum for this essential labor workforce.

Redesign and operation of the National Home And Hospice Care Survey, 2007.

OBJECTIVES: This methods report provides an overview of the redesigned National Home and Hospice Care Survey (NHHCS) conducted in 2007. NHHCS is a national probability sample survey that collects data on U.S. home health and hospice care agencies, their staffs and services, and the people they serve. The redesigned survey included computerized data collection, greater survey content, increased sample sizes for current home health care patients and hospice care discharges, and a first-ever supplemental survey called the National Home Health Aide Survey. METHODS: The 2007 NHHCS was conducted between August 2007 and February 2008. NHHCS used a two-stage probability sampling design in which agencies providing home health and/or hospice care were sampled. Then, up to 10 current patients were sampled from each home health care agency, up to 10 discharges from each hospice care agency, and a combination of up to 10 patients/discharges from each agency that provided both home health and hospice care services. In-person interviews were conducted with agency directors and their designated staff; no interviews were conducted directly with patients. The survey instrument contained agency- and person-level modules, sampling modules, and a self-administered staffing questionnaire. RESULTS: Data were collected on 1036 agencies, 4683 current home health care patients, and 4733 hospice care discharges. The first-stage agency weighted response rate (for differential probabilities of selection) was 59%. The second-stage patient/discharge weighted response rate was 96%. Three public-use files were released: an agency-level file, a patient/discharge-level file, and a medication file. The files include sampling weights, which are necessary to generate national estimates, and design variables to enable users to calculate accurate standard errors.

Design and operation of the national home health aide survey: 2007-2008.

OBJECTIVES: This report provides an overview of the National Home Health Aide Survey (NHHAS), the first national probability survey of home health aides. NHHAS was designed to provide national estimates of home health aides who provided assistance in activities of daily living (ADLs) and were directly employed by agencies that provide home health and/or hospice care. This report discusses the need for and objectives of the survey, the design process, the survey methods, and data availability. METHODS NHHAS, a multistage probability sample survey, was conducted as a supplement to the 2007 National Home and Hospice Care Survey (NHHCS). Agencies providing home health and/or hospice care were sampled, and then aides employed by these agencies were sampled and interviewed by telephone. Survey topics included recruitment, training, job history, family life, client relations, work-related injuries, and demographics. NHHAS was virtually identical to the 2004 National Nursing Assistant Survey of certified nursing assistants employed in sampled nursing homes with minor changes to account for differences in workplace environment and responsibilities. RESULTS From September 2007 to April 2008, interviews were completed with 3,416 aides. A public-use data file that contains the interview responses, sampling weights, and design variables is available. The NHHAS overall response rate weighted by the inverse of the probability of selection was 41 percent. This rate is the product of the weighted first-stage agency response rate of 57 percent (i.e., weighted response rate of 59 percent for agency participation in NHHCS times the weighted response rate of 97 percent for agencies participating in NHHCS that also participated in NHHAS) and the weighted second-stage aide response rate of 72 percent to NHHAS.

Prevalence and management of pain, by race and dementia among nursing home residents: United States, 2004.

KEY FINDINGS: Data from the National Nursing Home Survey, 2004. About one-quarter of all nursing home residents reported or showed signs of pain. Nonwhite residents and residents with dementia were less likely to report or show signs of pain compared with white residents and residents without dementia. Nonwhite residents with dementia were least likely, and white residents without dementia were most likely to report or show signs of pain. Forty-four percent of nursing home residents with pain received neither standing orders for pain medication nor special services for pain management (i.e., appropriate pain management). Among residents with dementia and pain, nonwhite residents were more likely than white residents to lack appropriate pain management.

Racial differences in functioning among elderly nursing home residents, 2004.

Reducing racial disparities in health care is an important national policy goal. Previous research on racial disparities has focused on nursing home placement rates. Recent research suggests that black nursing home residents may be more likely than residents of other races to reside in facilities that have serious deficiencies, such as low staffing ratios and greater financial vulnerability. In 2004, 11% of the 1.3 million nursing home residents aged 65 and over in the United States were black. National descriptions of black nursing home residents are limited. Using data from the most recent National Nursing Home Survey, this report highlights differences observed between elderly black nursing home residents and residents of other races in functioning and resident-centered care. The specific measures highlighted are functional status, incontinence, and management of incontinence.

Intrinsic job satisfaction, overall satisfaction, and intention to leave the job among nursing assistants in nursing homes.

PURPOSE: We examined predictors of intrinsic job satisfaction, overall satisfaction, and intention to leave the job among nursing assistants (NAs). DESIGN AND METHODS: The study focused on NAs who worked 30 or more hours per week in a nursing home. Data on 2,146 NAs meeting this criterion came from the 2004 National Nursing Assistant Survey, the first telephone interview survey of NAs nationwide. Regression equations were calculated in which intrinsic satisfaction, overall satisfaction, and intention to leave were dependent variables. NA attributes (e.g., job tenure and education) and extrinsic job factors (e.g., assessment of supervisor behavior, pay satisfaction, and benefits) were exogenous variables. RESULTS: A positive assessment of the supervisor's behavior had the strongest association with intrinsic satisfaction. Pay satisfaction had the second strongest association with intrinsic satisfaction. Predictors with the strongest associations with intention to leave were overall and intrinsic satisfaction. Assessment of the supervisor was not associated directly with intention to leave. Assessments of the supervisor and pay may affect overall satisfaction and intention to leave in part through their direct effects on intrinsic satisfaction. Some facility and NA attributes were related to intrinsic satisfaction but not to overall satisfaction, suggesting that intrinsic satisfaction may be an intervening variable in the impact of these attributes on overall satisfaction. IMPLICATIONS: Intrinsic satisfaction and extrinsic job factors amenable to change appear central to NAs' overall satisfaction and intention to leave. A facility may be able to improve extrinsic job factors that improve NAs' job-related affects, including intrinsic satisfaction.

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.