Paying A Heavy Price: Costs of Care for People with Severe Obesity in Nursing Homes.

BACKGROUND AND OBJECTIVES: The prevalence of resident obesity in nursing homes has increased dramatically from 22% to 28% between 2005 and 2015. To provide care for people with obesity, nursing homes have changed their admissions, staffing, and equipment, but underlying these changes are increased resources and financial costs of care. The purpose of this study is to describe nursing home organizational aspects of caring for older adults with obesity, with a focus on economic factors, from the perspective of nursing home staff and leadership. RESEARCH DESIGN AND METHODS: This qualitative study used descriptive approaches; data were collected through semi-structured telephone interviews. Of 77 nursing home staff and leaders identified as potential study participants, 6 were ineligible, and 71 participated in the study through interviews conducted from 2019 to 2022. RESULTS: Four primary themes described the issues surrounding cost of care for obesity in nursing homes: inefficient and risky use of staff time in a setting of persistent staff shortage, expensive and unique equipment needs, inadequate general reimbursement with an absence of obesity-specific reimbursement supplements, and competing short and long-term management solutions. DISCUSSION AND IMPLICATIONS: This qualitative study of nursing home staff and leadership underscores a need for improved approaches to funding obesity care within existing nursing payment models. The increasing prevalence of obesity and the burden of the costs of obesity care for nursing homes will escalate this need over the coming decade.

Exploring social-based discrimination among nursing home certified nursing assistants.

Certified nursing assistants (CNAs) provide the majority of direct care to nursing home residents in the United States and, therefore, are keys to ensuring optimal health outcomes for this frail older adult population. These diverse direct care workers, however, are often not recognized for their important contributions to older adult care and are subjected to poor working conditions. It is probable that social-based discrimination lies at the core of poor treatment toward CNAs. This review uses perspectives from critical social theory to explore the phenomenon of social-based discrimination toward CNAs that may originate from social order, power, and culture. Understanding manifestations of social-based discrimination in nursing homes is critical to creating solutions for severe disparity problems among perceived lower-class workers and subsequently improving resident care delivery.

Organizational and Geographic Nursing Home Characteristics Associated With Increasing Prevalence of Resident Obesity in the United States.

Nursing home resident obesity increases the complexity of nursing care, and nursing homes report avoiding residents with obesity when choosing which prospective residents to accept. The objective of this study was to examine the associations between nursing home obesity prevalence rate and nursing home organizational, staffing, resident, and geographic factors within a profit maximization framework. The study cohort included U.S. Centers for Medicare and Medicaid Services data from U.S. nursing homes in 2013. Study findings supported hypothesized associations between obesity prevalence rate and higher occupancy, higher bed capacity, and multi-facility affiliation, but findings did not support a relationship between obesity prevalence rate and for-profit status.

Obesity and intensive staffing needs of nursing home residents.

The objective of this study is to examine how increasing body mass index (BMI) among nursing home residents affects the amount of staffing assistance needed for activities of daily living (ADL). We analyzed 1,627,141 US nursing home residents reported in the 2013 Minimum Data Set in seven BMI categories, from underweight (BMI < 18.5 kg/m2) to obesity Class IIIB (≥50 kg/m2). Logistic regression models estimated the odds of nursing home-reported need for extensive (≥2 staff member) assistance needed for ADLs. The adjusted odds increased from 1.07 (95% Confidence Interval (95%CI) 1.06-1.08) for Class I, 1.16 (95%CI 1.14-1.17) for Class II, 1.33 (95%CI 1.31-1.35) for Class IIIA, and 1.90 (95%CI 1.86-1.95) for Class IIIB obesity residents compared to residents of normal weight. As a nursing home resident's BMI increases, especially for BMI ≥40 kg/m2, the need for extensive staffing assistance with ADLs also increases substantially.

Is Mental Illness a Risk Factor for Hospital Readmission?

People with mental illnesses (MI) receive suboptimal care for medical comorbidities and their high risk for readmission may be addressed by adequate medication management and follow-up care. We examined the association between MI, medication changes, and post-discharge outpatient visits with 30-day readmission in 40,048 Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure or pneumonia. Beneficiaries with MI were more likely to be readmitted than those without MI (14 vs. 11%). Probability of readmission was 13 and 12% when medications were dropped or added, respectively, versus 11% when no change was made. Probability of readmission also increased with outpatient visits.

Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set.

OBJECTIVE: This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. METHOD: Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI ( n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. RESULT: The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. DISCUSSION: Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.

Physician Perceptions of Consultant Pharmacist Services Associated with an Intervention for Adverse Drug Events in the Nursing Facility.

OBJECTIVE: To assess the importance and performance of consultant pharmacist services delivered before and after an intervention to detect and manage adverse drug events among nursing facility residents. DESIGN: Before and after intervention survey of physicians participating in a randomized, controlled trial. SETTING: Four nonprofit, academically affiliated nursing facilities. PARTICIPANTS: Attending physicians providing nursing facility care who were randomized to intervention or control groups. INTERVENTIONS: Within the intervention arm, consultant pharmacists provided academic detailing in which trained health care professionals visit practicing physicians in their offices and present the most up-to-date clinical information. Physicians responded to alerts from a medication monitoring system, adjudicated system alerts for adverse drug events (ADEs), and provided structured recommendations about ADE management. MAIN OUTCOME MEASURES: We compared physicians' assessments of the importance and performance of consultant pharmacist services before and after the trial intervention in the intervention and control groups. RESULTS: In the intervention group, ratings of importance increased for all 24 survey questions, and 5 of the changes were statistically significant (P < 0.05). In the control group, ratings of importance increased for 16 questions, and none of the changes were statistically significant. In the intervention group, ratings of performance increased for all 24 questions, and 20 of the changes were statistically significant. In the control group, ratings of performance increased for 16 questions, and none of the changes was statistically significant. CONCLUSION: A multifaceted, consultant pharmacist-led intervention comprising academic detailing, computerized decision support, and structured communication framework can improve physicians' assessment of importance and performance of consultant pharmacist services. ABBREVIATIONS: ADE = Adverse drug event, M = Statistically significant mean, RCT = Randomized controlled trial, SBAR = Situation, Background, Discussion, Recommendation, SD = Standard deviation.

Service-Enriched Housing: The Staying at Home Program.

INTRODUCTION: The purpose of this research was to determine whether service-enriched housing (i.e., the Staying at Home [SAH] program) in publicly subsidized buildings for low-income older adults influenced resident outcomes. METHOD: Eleven elderly high-rise buildings were used. Seven buildings had the SAH program and four did not. Information was collected from resident questionnaires, housing managers data, and medical information. A total of 10 desired outcomes were proposed as part of SAH (e.g., health improvements, receive more non-institutional services, receive more preventive services, and be less likely to be institutionalized). Information was collected over the course of the SAH program every 6 months from December 2008 through June 2011. RESULTS: Overall, 736 surveys were completed by SAH program participants and 399 were completed by control group participants. Seven of the ten desired outcomes were achieved, and in 3 of the ten cases, no differences between the SAH group and control group were identified. The program was also beneficial with respect to cost savings. CONCLUSION: On the basis of these findings, the SAH program should be viewed as a success. In this case, service-enriched housing for elders in high-rise buildings would appear to be beneficial.

Nursing home administrators' opinions of pay for performance.

The research presented here provides some descriptive information of nursing home pay for performance (P4P) initiatives and an examination of the opinions of nursing home administrators (NHAs) about P4P. Opinions on three common elements of P4P were examined: the incentive format, program format, and quality format. Information came from a mail survey of 2,426 NHAs. Most of the summary scores show that few NHAs gave positive responses to P4P. Very few NHAs believed that P4P would increase their revenues. NHAs were skeptical that P4P systems were for quality improvement and instead believed they were developed for purposes of cost reduction. Relatively few NHAs believed that P4P would improve quality of care. Given that we have limited experience with setting performance goals and incentive formats for NHAs, the findings presented may prove useful in modeling future P4P systems.

Impact of infection preventionists on Centers for Medicare and Medicaid quality measures in Maryland nursing homes.

BACKGROUND: Health care-associated infections are the leading cause of morbidity and mortality in US nursing homes (NHs). The objective of the research is to assess the impact of Maryland NH infection preventionists (IPs) on NH quality measures. METHODS: Two hundred thirty-four NHs were queried through mailed survey. These survey data were then linked with 2008 quality data from Nursing Home Compare and the On-line Survey Certification of Automated Records. RESULTS: Three of the 8 quality measures examined-influenza vaccination for both short- and long-stay residents and pressure ulcer prevention in high-risk residents-were significantly associated with the number of IPs. None of the quality measures were shown to be significant with IPs who received specialized training on infection prevention and management compared with those who did not receive specialized training. CONCLUSION: IPs play a critical role in preventing and managing health care-associated infections in nursing homes, especially in the areas of influenza vaccination and pressure ulcer prevention among high-risk nursing home residents. Quality measures that reflect the effects of IP training may not have been elucidated yet. Further research is needed to support the IP role in order for policy to advocate for increased IP funding.

Nursing home deficiency citations for physical restraints and restrictive side rails.

This article examines whether nursing home facility-level characteristics are associated with the likelihood of receiving deficiency citations for physical restraints, including restrictive side rails. Data from the on-line survey certification of automated records were used to calculate odds ratios for facility-level characteristics associated with these deficiency citations. Repeat records from 2000 to 2007 were combined to produce longitudinal data. The results of this study show that restraint/side rail deficiency citations were negatively associated with higher staffing levels of registered nurses and licensed practical nurses (p ≤ .001) and higher Medicaid reimbursement rates (p ≤ .01). Citations were positively associated with greater nurse aide staffing (p ≤ .01) and higher quality-of-care deficiency citation percentiles (p ≤ .001). The extent of physical restraint and restrictive side rail misuse within nursing homes appears to vary according to various facility characteristics. It is less clear how internal processes within a facility bring about these observed patterns of variation.

An assessment of cultural values and resident-centered culture change in U.S. nursing facilities.

BACKGROUND: Culture change initiatives propose to improve care by addressing the lack of managerial supports and prevalent stressful work environments in the industry; however, little is known about how culture change facilities differ from facilities in the industry that have not chosen to affiliate with the resident-centered care movements. PURPOSE: The aim of this study was to evaluate representation of organizational culture values within a random sample of U.S. nursing home facilities using the competing values framework and to determine whether organizational values are related to membership in resident-centered culture change initiatives. DESIGN AND METHODS: We collected reports of cultural values using a well-established competing values framework instrument in a random survey of facility administrators and directors of nursing within all states. We received responses from 57% of the facilities that were mailed the survey. Directors of nursing and administrators did not differ significantly in their reports of culture and facility measures combined their responses. FINDINGS: Nursing facilities favored market-focused cultural values on average, and developmental values, key to innovation, were the least common across all nursing homes. Approximately 17% of the facilities reported that all cultural values were strong within their facilities. Only high developmental cultural values were linked to participation in culture change initiatives. Culture change facilities were not different from non-culture change facilities in the promotion of employee focus as organizational culture, as emphasized in group culture values. Likewise, culture change facilities were also not more likely to have hierarchical or market foci than non-culture change facilities. PRACTICE IMPLICATIONS: Our results counter the argument that culture change facilities have a stronger internal employee focus than facilities more generally but do show that culture change facilities report stronger developmental cultures than non-culture change facilities, which indicates a potential to be innovative in their strategies. Facilities are culturally ready to become resident centered and may face other barriers to adopting these practices.

U.S. Department of Health adverse event reporting policies for nursing homes.

The objectives of this study were to describe state policies for the frequency of adverse event reporting and follow-up that occurs in U.S. nursing homes, and to identify the health information technology used to facilitate these processes. The study was conducted using a mailed survey to the Departments of Health (DOH) in all 50 states, specifically the department that is responsible for the oversight and regulation of nursing home care. Thirty-two state DOH representatives participated. The primary variables examined were (1) which incidents were most commonly reported to state DOH and (2) whether or not they were followed up with a surveyor visit to the nursing home. There was wide variation in incident reporting processes across all states and lack of a standardized process. Abuse is the only adverse event that almost always is required to be reported to the state DOH and has the highest incidence of follow-up with a surveyor visit. Improving and standardizing adverse event reporting systems is a necessary strategy to enhance patient safety in nursing homes. This study provides an important step by increasing our knowledge base of the current state of adverse event reporting policies and processes at the state level.

Implementation of quality assurance and performance improvement programs in nursing homes: a brief report.

The purpose of this article was to investigate nursing homes' (NHs') readiness to implement a quality assurance and performance improvement (QAPI) program as required by Section 6102 of the Affordable Care Act. Nursing home administrators (NHAs) in 3000 NHs (response rate, 67%) were surveyed using a 70-item questionnaire to assess: (1) current facility approaches to quality, (2) NHA's self-assessed knowledge of QAPI techniques; and (3) the use of QAPI techniques. The Online Survey, System for Certification and Administrative Reporting data and the Area Resource File were also used to examine and compare facility and market characteristics. As rated on a scale of 1 to 10, NHs are more likely to use quality assurance (rating, 7.2) and least likely to use total quality management (rating, 4.1). Few NHAs use tools for QAPI such as flow charts (23%), Plan-Do-Check-Act cycles (13%), or run charts (9%). A gap in knowledge of quality improvement tools has been identified signifying that the new QAPI regulations may pose an issue for NHAs who possibly lack the knowledge and technical expertise to implement a comprehensive QAPI program.

Consistent assignment of nurse aides: association with turnover and absenteeism.

Consistent assignment refers to the same caregivers consistently caring for the same residents almost every time caregivers are on duty. This article examines the association of consistent assignment of nurse aides with turnover and absenteeism. Data came from a survey of nursing home administrators, the Online Survey Certification and Reporting data, and the Area Resource File. The measures were from 2007 and came from 3,941 nursing homes. Multivariate logistic regression models were used to examine turnover and absenteeism. An average of 68% of nursing homes reported using consistent assignment, with 28% of nursing homes using nurse aides consistent assignment at the often recommended level of 85% (or more). Nursing homes using recommended levels of consistent assignment had significantly lower rates of turnover and of absenteeism. In the multivariate analyses, consistent assignment was significantly associated with both lower turnover and lower absenteeism (p < .01). Consistent assignment is a practice recommended by many policy makers, government agencies, and industry advocates. The findings presented here provide some evidence that the use of this staffing practice can be beneficial.

Staffing-related deficiency citations in nursing homes.

There is evidence that staffing characteristics influence quality of care in nursing homes. Federal and state surveyors conduct inspections of homes to assess their compliance with regulatory standards, including requirements related to staffing. Deficiency citations are issued when these standards are not met. This article examines the relationship between operational, facility, and market characteristics and organizational performance measured as staffing-related deficiency citations. Online Survey Certification of Automated Records (OSCAR) data from 2000 through 2007 were used with multinomial logistic regression analyses to identify factors associated with deficiency citations for staffing. Chain members and facilities with poor quality of care were more likely to receive deficiency citations for staffing. Greater bed count and competition between nursing homes were associated with a decreased likelihood of deficiency citations for staffing. Staffing-related deficiencies within nursing homes vary according to various operational, facility, and market characteristics.

Use of antipsychotics among older residents in VA nursing homes.

BACKGROUND: Antipsychotic medications are commonly prescribed to nursing home residents despite their well-established adverse event profiles. Because little is known about their use in Veterans Affairs (VA) nursing homes [ie, Community Living Centers (CLCs)], we assessed the prevalence and risk factors for antipsychotic use in older residents of VA CLCs. METHODS: This cross-sectional study included 3692 Veterans age 65 or older who were admitted between January 2004 and June 2005 to one of 133 VA CLCs and had a stay of ≥90 days. We used VA Pharmacy Benefits Management data to examine antipsychotic use and VA Medical SAS datasets and the Minimum Data Set to identify evidence-based indications for antipsychotic use (eg, schizophrenia, dementia with psychosis). We used multivariable logistic regression and generalized estimating equations to identify factors independently associated with antipsychotic receipt. RESULTS: Overall, 948/3692(25.7%) residents received an antipsychotic, of which 59.3% had an evidence-based indication for use. Residents with aggressive behavior [odds ratio (OR)=2.74, 95% confidence interval (CI), 2.04-3.67] and polypharmacy (9+ drugs; OR=1.84, 95% CI, 1.41-2.40) were more likely to receive antipsychotics, as were users of antidepressants (OR=1.37, 95% CI, 1.14-1.66), anxiolytic/hypnotics (OR=2.30, 95% CI, 1.64-3.23), or drugs for dementia (OR=1.52, 95% CI, 1.21-1.92). Those residing in Alzheimer/dementia special care units were also more likely to receive an antipsychotic (OR=1.66, 95% CI, 1.26-2.21). Veterans with dementia but no documented psychosis were as likely as those with an evidence-based indication to receive an antipsychotic (OR=1.10, 95% CI, 0.82-1.47). CONCLUSIONS: Antipsychotic use is common among VA nursing home residents aged 65 and older, including those without a documented evidence-based indication for use. Further quality improvement efforts are needed to reduce potentially inappropriate antipsychotic prescribing.

Why do nursing homes close? An analysis of newspaper articles.

Using Non-numerical Unstructured Data Indexing Searching and Theorizing (NUD'IST) software to extract and examine keywords from text, the authors explored the phenomenon of nursing home closure through an analysis of 30 major-market newspapers over a period of 66 months (January 1, 1999 to June 1, 2005). Newspaper articles typically represent a careful analysis of staff impressions via interviews, managerial perspectives, and financial records review. There is a current reliance on the synthesis of information from large regulatory databases such as the Online Survey Certification And Reporting database, the California Office of Statewide Healthcare Planning and Development database, and Area Resource Files. Although such databases permit the construction of studies capable of revealing some reasons for nursing home closure, they are hampered by the confines of the data entered. Using our analysis of newspaper articles, the authors are able to add further to their understanding of nursing home closures.