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

OBJECTIVE: Thea aim of this study was to explore the relationship between Florida nursing home and assisted living facility characteristics and their ability to comply with a new emergency power rule in the aftermath of Hurricane Irma. METHODS: This study used characteristics data on Florida nursing homes (NHs) (N = 680) and assisted living facilities (ALFs) (N = 2940) in operation between September 2017 and January 2019. Logistic regressions were used to determine whether certain characteristics were associated with compliance with the emergency power rule by January 1, 2019. RESULTS: A total of 219 (32.9%) NHs and 2219 (75.5%) ALFs had an emergency power plan implemented by January 1, 2019. Results suggest having a dementia care unit increased the odds of compliance for NHs, while chain membership, for-profit status, and a higher reliance on Medicaid decreased the odds. Additionally, smaller size, mental health specialty license, and higher reliance on supplemental state funding increased the odds of compliance for ALFs, while nursing care specialty license and for-profit status decreased the odds of compliance. CONCLUSIONS: Policy implications from these results include informing policy-makers on the barriers faced by NHs and ALFs to implement a new regulation that may cause financial difficulties and compromise quality care.

Factors Associated With Assisted Living Facility Closure.

BACKGROUND AND OBJECTIVES: Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing home market for the ALF market to examine the organizational, internal, and external factors associated with closure. RESEARCH DESIGN AND METHODS: Data on 1,939 ALFs operating in 2013 from Florida were used to estimate a logistic regression to examine the organizational, internal, and external factors that were associated with closure between 2013 and 2015. RESULTS: During the 2-year study period, 141 ALFs (7.3%) closed. Significant factors associated with increased odds of closure included fewer beds, not accepting Medicaid, and more deficiencies. Two factors (market concentration and population density) were marginally significant. DISCUSSION AND IMPLICATIONS: The results of this study confirm the usefulness of a model that includes organizational, internal, and external factors to predict ALF closure. These outcomes highlight the concerns that closure can affect access to community-based long-term care, especially for rural older adults, and indicate an expansion of Medicaid acceptance in ALFs could be protective against closure.

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

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

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

OBJECTIVES: To examine the effect of Hurricane Irma on staff-related financial expenditures and daily direct-care nurse staffing levels. DESIGN: Retrospective cohort study. SETTING: September 3-24, 2017 in the state of Florida, United States. Hurricane Irma made landfall on September 10, 2017. PARTICIPANTS: Six hundred and fifty-three nursing homes (NHs), 81 evacuated facilities, and 572 facilities that sheltered-in-place. MEASUREMENTS: This study used data from Payroll-Based Journaling (PBJ), Certification and Survey Provider Enhanced Reports (CASPER), and Florida's health providers' emergency reporting system. PBJ provided estimates of daily direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants. CASPER reported facility-level characteristics such as profit status, chain membership, and special care unit availability. Florida's emergency reporting system identified evacuation status during Hurricane Irma. Linear mixed-effects models were used to estimate the unique contribution of evacuation status on daily staffing increases over time from September 3 to 10. RESULTS: Among all facilities, we found significant increases in staffing for licensed practical nurses (p = 0.02) and certified nursing assistants (p < 0.001), but not for registered nurses (p = 0.10) before Hurricane Irma made landfall. From 1 week before landfall to 2 weeks after landfall (September 3-24), an additional estimated $2.41 million was spent on direct-care nurse staffing. In comparison to facilities that sheltered-in-place, evacuated facilities increased staffing levels of all nurse types (all p < 0.001). At landfall, evacuated facilities spent an estimated $93.74 on nurse staffing per resident whereas facilities that sheltered-in-place spent $76.10 on nurse staffing per resident. CONCLUSION: NHs face unprecedented challenges during hurricanes, including maintaining adequate direct-care nurse staffing levels to meet the needs of their residents. NHs that evacuated residents had an increase in direct-care nurse staffing that was greater than that seen in NHs that sheltered-in-place.

Emergency Department Use Among Assisted Living Residents After Hurricane Irma.

OBJECTIVES: Nursing home residents are especially vulnerable to adverse outcomes after a hurricane. Prior research suggests that emergency department (ED) visits increase among community-residing older adults after natural disasters. However, little is known about the impact of hurricanes on the large population of older adults residing in assisted living (AL) settings, particularly the influence of storms on the rates and causes of ED visits. We examined whether rates of ED use for injuries and other medical reasons increased after Hurricane Irma in 2017 among AL residents in Florida. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Samples of 30,358 Medicare fee-for-service beneficiaries in 2016 and 28,922 beneficiaries in 2017 who resided in Florida AL communities. MEASURES: The number of injury-related and other medical visits per 1,000 person-days within 30 and 90 days of September 1 in 2016 and 2017. We adjusted for age, race, sex, and chronic conditions using linear regression with AL fixed effects. We compared the top 10 primary diagnoses resulting in an ED visit between 2016 and 2017. RESULTS: Adjusted rates of injury-related visits were 12.5% higher at 30 days but did not differ at 90 days. Other medical visits were 12% higher at 30 days in 2017 than in 2016 and 7.7% higher at 90 days. Heart failure was a leading cause of ED visits within 90 days of September 1 in 2017, unlike in 2016. CONCLUSIONS AND IMPLICATIONS: Increased attention should be paid to AL communities in disaster preparedness and response efforts given the increased likelihood of ED visits following a hurricane.

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

BACKGROUND AND OBJECTIVES: Nursing homes (NHs) are serving greater proportions of residents with serious mental illness (SMI), and it is unclear whether this affects NH quality. We analyze the highest and lowest quartiles of NHs based on the proportion of residents with SMI and compare these NHs on facility characteristics, staffing, and quality stars. RESEARCH DESIGN AND METHODS: National Certification and Survey Provider Enhanced Reports data were merged with NH Compare data for all freestanding certified NHs in the continental United States in 2016 (N = 14,460). NHs were categorized into "low-SMI" and "high-SMI" facilities using the lowest and highest quartiles, respectively, of the proportion of residents in the NH with SMI. Bivariate analyses and logistic models were used to examine differences in organizational structure, payer mix, resident characteristics, and staffing levels associated with high-SMI NHs. Linear models examined differences in quality stars. RESULTS: High-SMI facilities were found to report lower direct-care staffing hours, have a greater Medicaid-paying resident census, were more likely to be for-profit, and scored lower on all NH Compare star ratings in comparison to all other NHs. DISCUSSION AND IMPLICATIONS: As the SMI population in NHs continues to grow, a large number of residents have concentrated in a few NHs. These are uniquely different from typical NHs in terms of facility characteristics, staffing, and care practices. While further research is needed to understand the implications of these trends, public policymakers and NH providers need to be aware of this population's unique-and potentially unmet-needs.

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

BACKGROUND AND OBJECTIVES: Assisted living (AL) is a growing sector of the U.S. long-term care market, with its development driven largely by private market choices. However, consumers need information to choose the right AL community (ALC). This paper examined information available on U.S. state websites concerning ALC quality, costs, and services. RESEARCH DESIGN AND METHODS: Based on prior research and their analysis of a sample of state websites, researchers identified 39 key informational elements and grouped them into four categories, (a) ALC characteristics, (b) payment and services, (c) quality, and (d) website usability. Researchers then examined the presence of the 39 elements on 51 websites (U.S. states and the District of Columbia), meeting regularly to discuss findings and resolve differences. RESULTS: A majority of states provided basic information about individual ALCs (e.g., number of beds, ownership). Only 35% listed payment(s) accepted (e.g., Medicaid), and 31% indicated the availability of memory care. Nearly 70% posted inspection results, while only 43% provided information about complaints. Many met basic usability guidelines (e.g., type size), but locating content on many sites required multiple steps, and none met 5th-grade-or-below readability standards. DISCUSSION AND IMPLICATIONS: A majority of websites provided important information, such as inspection results. However, many were lacking key elements concerning payment accepted and services. Finding what was available was burdensome. More work is needed to help states provide information that enables consumers to find ALCs that meet their needs. The lack of such information puts older adults at risk of inappropriate placements.

The Role of Assisted Living Capacity on Nursing Home Financial Performance.

The rapid growth of the assisted living industry has coincided with decreased levels of nursing home occupancy and financial performance. The purpose of this article is to examine the relationships among assisted living capacity, nursing home occupancy, and nursing home financial performance. In addition, we explore whether the relationship between assisted living capacity and nursing home financial performance is mediated by nursing home occupancy. This research utilized publicly available secondary data, for the state of Florida from 2003 through 2015. General descriptive statistics were used to assess the relationships among financial performance, assisted living capacity, and occupancy. To explore the relationships among financial performance, assisted living capacity and occupancy, and test potential mediation of occupancy, we followed Baron and Kenny's approach and estimated 3 models examining the relationships between (1) assisted living capacity and nursing home financial performance, (2) assisted living capacity and nursing home occupancy, and (3) nursing home occupancy and financial performance after assisted living capacity is included in the model. We used generalized estimating equations, to adjust for repeated measures and to model the above relationships. Year fixed effects control for time trend. The independent variable, assisted living beds, was lagged for 1 year to account for the potential influence on financial performance. The final analytic sample consisted of 7688 nursing home-year observations from 657 unique nursing homes. Our findings suggest that assisted living capacity does have a negative impact on nursing homes' financial performance. Even though, assisted living capacity seems not to significantly decrease nursing home occupancy. The relationship between assisted living capacity and financial performance was not mediated through occupancy. These findings suggest that assisted living communities may not be able to significantly reduce nursing home occupancy; however, the presence of assisted living communities may create additional financial/competitive pressures that result in decreased nursing home financial performance.

Culture Change in Nursing Homes: What Is the Role of Nursing Home Resources?

Quality of care has been a long-standing issue in US nursing homes. The culture change movement attempts to transition nursing homes from health care institutions to person-centered homes. While the adoption of culture change has been spreading across nursing homes, barriers to adoption persist. Nursing homes that disproportionately serve minority residents may have additional challenges implementing culture change compared with other facilities due to limited financial and staffing resources. The objective of this study was to examine how nursing home characteristics are associated with culture change adoption in Central Florida nursing homes. This cross-sectional study included 81 directors of nursing (DONs) who completed the Artifacts of Culture Change survey. In addition, nursing home organizational data were obtained from the Certification and Survey Provider Enhanced Reports (CASPER). A logistic regression was conducted to examine the relationship between high culture change adoption and nursing home characteristics. The overall adoption of culture change scores in Central Florida nursing homes was low. Nevertheless, there was variability across nursing homes in the adoption of culture change. High culture change adoption was associated with nursing homes having lower proportions of Medicaid residents.

Medicaid Hearing Aid Coverage For Older Adult Beneficiaries: A State-By-State Comparison.

Age-related hearing loss affects nearly thirty million older adults in the United States and is associated with increased risk of several other adverse health outcomes. Although hearing aids are the most common efficacious treatment, Medicaid coverage of the aids is not federally mandated, and cost has been cited as a barrier to access. In this first (to our knowledge) comprehensive review of state-level Medicaid coverage of hearing aids and associated services for age-related hearing loss, we found that twenty-eight states offer some degree of coverage-which varies substantially with respect to extent and hearing loss eligibility requirements. Based on six criteria, we rated those states' coverage as fair, good, or excellent. The remaining twenty-two states have no coverage, which leaves few options for their residents with hearing loss who face financial constraints. Policy makers at the state and federal levels should consider how to make care for age-related hearing loss more accessible, affordable, and equitable nationwide.

Cross-sectional study of factors associated with community health centre use in a recently urbanised community in Chengdu, China.

OBJECTIVES: Public investment in community health centres (CHCs) has been increasing as a response to rapid urbanisation in China. The objectives of this study were: (1) to examine factors associated with CHC use among residents from a recently urbanised community in western China and (2) to describe satisfaction with CHC among users. DESIGN: Cross-sectional design. SETTING: A community recently converted to urban status with a newly constructed CHC in Southwest China. PARTICIPANTS: A random sample of 2259 adults in the Hezuo community in Chengdu, China, completed the survey in 2013. OUTCOME MEASURES: Trained staff interviewed study participants in their homes using structured questionnaires. The survey included questions regarding sociodemographics, health status, access to and usage of healthcare, health behaviours and CHC use. The Andersen's behavioural model of health service use was used to guide multivariable logistic regression modelling in identifying predisposing, enabling and need factors associated with the likelihood of using CHC. Descriptive statistics were used to describe residents' satisfaction with the CHC. RESULTS: A total of 71.8% of the respondents reported using the CHC during the past year. Factors influencing adults' CHC use included: gender, marital status, education level and knowledge of one's blood pressure (predisposing factors); annual household per capita income and walking time to the CHC (enabling factors) and self-rated health as well as physical activities (need factors). CHC users reported modest satisfaction across various aspects of the CHC. CONCLUSIONS: Neighbourhood CHC in urban areas provides important services to these residents living in a recently urbanised community. All three categories of factors in the Andersen model help explain the likelihood of CHC use. There is much room for improvement in CHC to enhance customer satisfaction. Future research is needed to improve access to CHCs and promote their use in urbanised populations with low to modest education.

Shifting to Medicaid-Managed Long-Term Care: Are Vulnerable Florida Beneficiaries Properly Informed?

PURPOSE: To examine and assess the adequacy of informational material provided to Florida long-term care beneficiaries being required to choose a managed care provider as part of a statewide, mandatory shift to Medicaid-managed long-term care (MMLTC). DESIGN AND METHOD: Informational materials provided by the state of Florida to 90,000 Medicaid long-term care beneficiaries via print mailings and a state website were examined using established content, usability, and readability criteria. RESULTS: Overall, the presentation minimized cognitive complexity, but the information was lacking in critical areas, such as providing clear explanations of the change taking place and the significance of beneficiaries' choices, and enabling beneficiaries to assess their own needs and preferences. IMPLICATIONS: A key feature of managed care is the users' choice of plans, but amid a significant policy shift toward MMLTC in Florida, vulnerable beneficiaries may not be receiving the information necessary to make choices that best meet their needs. Our analysis offers lessons to other states shifting to MMLTC.

Community Discharge of Nursing Home Residents: The Role of Facility Characteristics.

OBJECTIVE: Using a socio-ecological model, this study examines the influence of facility characteristics on the transition of nursing home residents to the community after a short stay (within 90 days of admission) or long stay (365 days of admission) across states with different long-term services and supports systems. DATA SOURCE: Data were drawn from the Minimum Data Set, the federal Online Survey, Certification, and Reporting (OSCAR) database, the Area Health Resource File, and the LTCFocUs.org database for all free-standing, certified nursing homes in California (n = 1,127) and Florida (n = 657) from July 2007 to June 2008. STUDY DESIGN: Hierarchical generalized linear models were used to examine the impact of facility characteristics on the probability of transitioning to the community. PRINCIPAL FINDINGS: Facility characteristics, including size, occupancy, ownership, average length of stay, proportion of Medicare and Medicaid residents, and the proportion of residents admitted from acute care facilities are associated with discharge but differed by state and whether the discharge occurred after a short or long stay. CONCLUSION: Short- and long-stay nursing home discharge to the community is affected by resident, facility, and sometimes market characteristics, with Medicaid consistently influencing discharge in both states.

Racial disparities in receipt of hospice services among nursing home residents.

This study examined the relationship between race and advance care planning, hospitalization, and death among nursing home residents receiving hospice care. Secondary data analysis using the 2007 Minimum Data Set (MDS) was used to identify documentation of these activities for White, Black, Hispanic, and Asian residents with linear regression models fitted to each dependent variable. Across different types of advance directives, compared to White nursing home residents, Black, Hispanic, and Asian residents who received hospice services were significantly less likely overall to have documented advance directives. All racial groups were also more likely to experience hospitalization while on hospice, regardless of whether they had a documented "do not hospitalize" order. As nursing homes become more diverse, recognizing differences in hospice use and end-of-life planning will continue to increase in importance.

Assessing approaches and barriers to reduce antipsychotic drug use in Florida nursing homes.

OBJECTIVES: Antipsychotic medications have been federally regulated since 1987, yet research suggests they continue to be used inappropriately to alleviate behavioral symptoms associated with dementia. In 2012, the Centers of Medicare and Medicaid launched a new initiative to reduce antipsychotic medication in nursing homes by 15% nationally. The aim of this study was to examine qualitative data to explore strategies that have been implemented, to assess which strategies are evidence-based, and to make recommendations to improve upon practices to reduce antipsychotic medication use. METHOD: A convenience sample of 276 nursing home professional staff members were surveyed about these topics using open-ended questions. RESULTS: Theme-based content analysis yielded three main themes. The themes related to changes in practice included the following: (1) increased review of resident behavior and antipsychotic medication regimens; (2) reduction in antipsychotic medications or dosage; and (3) increased use of nonpharmacological interventions. The main themes relevant to needed assistance included the following: (1) education; (2) clinical support; and (3) increased financial resources and reimbursement. DISCUSSION: Overall findings indicate that the majority of facilities are actively responding to the initiative, but challenges remain in education, finding mental health support, and in reimbursement.

Hospice use and public expenditures at the end of life in assisted living residents in a Florida Medicaid waiver program.

OBJECTIVES: To examine the association between hospice use and public expenditures in a sample of dually eligible assisted living (AL) residents at the end of life. DESIGN: A retrospective cohort study. SETTING: Florida AL facilities. PARTICIPANTS: Newly enrolled dually eligible older AL residents under Florida's Medicaid Assisted Living for the Elderly waiver program who died between January 2003 and December 2004 (N = 382). MEASUREMENTS: Individual sociodemographic characteristics were obtained from Florida's Medicaid comprehensive assessment data. Medicaid eligibility status, enrollment in the AL waiver programs, International Classification of Diseases, Ninth Revision, Clinical Modification, codes and Medicaid claims data were obtained from Florida's Medicaid payment agency. Individual characteristics and Medicare and Medicaid claims data were merged with vital statistics to determine diagnoses, date of death, hospice enrollment, and public expenditures. RESULTS: The mean age of the study sample was 84.8 (range 65-102); 71.5% were female, and 63.4% were white. During the average 9.6 months of follow-up, 35.6% of the sample enrolled in hospice, and the average hospice length of stay was 47.9 d; 73.3% of the sample had been admitted to a hospital, and 38.0% had been admitted to a nursing home. The generalized linear model showed that hospice use was not significantly associated with lower public expenditures (average marginal effect = -$1,127, 95% confidence interval = -$8,377, $6,122). CONCLUSION: Hospice use at the end of life may not be associated with lower public expenditures in older dually eligible AL residents. Future research should examine the association between hospice enrollment and the quality of end-of-life care.

Nursing home quality and financial performance: does the racial composition of residents matter?

OBJECTIVE: To examine the effects of the racial composition of residents on nursing homes' financial and quality performance. The study examined Medicare and Medicaid-certified nursing homes across the United States that submitted Medicare cost reports between the years 1999 and 2004 (11,472 average per year). DATA SOURCE: Data were obtained from the Minimum Data Set, the On-Line Survey Certification and Reporting, Medicare Cost Reports, and the Area Resource File. STUDY DESIGN: Panel data regression with random intercepts and negative binomial regression were conducted with state and year fixed effects. PRINCIPAL FINDINGS: Financial and quality performance differed between nursing homes with high proportions of black residents and nursing homes with no or medium proportions of black residents. Nursing homes with no black residents had higher revenues and higher operating margins and total profit margins and they exhibited better processes and outcomes than nursing homes with high proportions of black residents. CONCLUSION: Nursing homes' financial viability and quality of care are influenced by the racial composition of residents. Policy makers should consider initiatives to improve both the financial and quality performance of nursing homes serving predominantly black residents.

Facility characteristics associated with the use of electronic health records in residential care facilities.

The integration of electronic health records (EHRs) across care settings including residential care facilities (RCFs) promises to reduce medical errors and improve coordination of services. Using data from the 2010 National Survey of Residential Care Facilities (n=2302), this study examines the association between facility structural characteristics and the use of EHRs in RCFs. Findings indicate that in 2010, only 3% of RCFs nationwide were using an EHR. However, 55% of RCFs reported using a computerized system for one or more (but not all) of the functionalities defined by a basic EHR. Ownership, chain membership, staffing levels, and facility size were significantly associated with the use of one or more core EHR functionalities. These findings suggest that facility characteristics may play an important role in the adoption of EHRs in RCFs.

Do Medicaid incentive payments boost quality? Florida's direct care staffing adjustment program.

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents--the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.