Medicare hospice care in US nursing homes: a 2006 update.

INTRODUCTION: This research examines 2006 population-based data on persons who died in US nursing homes (NHs) and received hospice in the NH. METHODS: We compared dying persons characteristics and lengths of hospice stay in five US states between 1992 and 1996 and in 2006. We also compared characteristics of dying persons in 2006 by whether they first entered hospice in the community (i.e. 'community-NH', N=12,950) or the NH (i.e. 'NH-only', N=159,065). RESULTS: In five US states, dying persons who received NH hospice in 2006, compared to 1992-1996, were older, had more short hospice stays (≤7 days), and were less frequently diagnosed with cancer. Also, in 2006, dying persons receiving 'NH-only' versus 'community-NH' hospice were older, had more short stays, and were less frequently diagnosed with cancer. DISCUSSION: Persons in 2006 who received hospice in the community and in the NH (vs. 'NH-only') were strikingly similar to hospice participants in 1992-1996. 2006 'NH-only' vs. 'community-NH' dying persons, more closely resemble U.S. NH residents.

The health of older-adult, long-term cancer survivors.

Research indicates that cancer-related health problems persist for decades among survivors. The combination of late effects of cancer or its treatment and age-related health problems may add to the vulnerability of older survivors. This research reports on the health and functioning of a sample of long-term (5+ years), older-adult (>60 years) survivors of breast, prostate, and colorectal cancer. Data were derived from 321 in-person interviews with a sample randomly selected from a tumor registry at a comprehensive cancer center. Descriptive data analyzed comorbid health conditions and continued cancer symptoms reported by survivors. Correlational analysis examined the association among demographic cancer-related factors and a range of health quality-of-life outcomes, including functioning and illness impact. Nearly 40% of respondents have at least 1 symptom attributed to cancer/treatment. Pain was the most commonly reported symptom, with 21% attributing it to cancer. More than 40% of breast cancer survivors and nearly 20% of prostate cancer survivors reported pain. Being African American or female was significantly associated with more current symptoms and greater functional difficulty. Survivors who had chemotherapy and survivors with more types of treatment reported significantly more symptoms both during treatment and currently. Many older-adult survivors are more vulnerable due to both cancer-related symptoms and comorbid health conditions. Women and African Americans are at special risk. This combined vulnerability is an important factor for clinicians treating long-term survivors.

Culture change practice in U.S. Nursing homes: prevalence and variation by state medicaid reimbursement policies.

PURPOSE OF THE STUDY: To estimate the prevalence of culture change practice in U.S. nursing homes (NHs) and examine how state Medicaid policies may be associated with this prevalence. DESIGN AND METHODS: In 2009/2010, we conducted a survey of a stratified proportionate random sample of NH directors of nursing (DONs) and administrators (NHAs) at 4,149 U.S. NHs; contact was achieved with 3,695. Cooperation rates were 62.6% for NHAs and 61.5% for DONs. Questions focused on NH (physical) environment, resident-centered care, and staff empowerment domains. Domain scores were created and validated, in part, using qualitative interviews from 64 NHAs. Other NH covariate data were from Medicare/Medicaid surveys (Online Survey, Certification and Reporting), aggregated resident assessments (Minimum Data Set), and Medicare claims. Medicaid policies studied were a state's average NH reimbursement rate and pay-for-performance (P4P) reimbursement (including and not including culture change performance measures). Multivariate generalized ordered logit regressions were used. RESULTS: Eighty-five percent of DONs reported some culture change implementation. Controlling for NH attributes, a $10 higher Medicaid rate was associated with higher NH environment scores. Compared with NHs in non-P4P states, NHs in states with P4P including culture change performance measures had twice the likelihood of superior culture change scores across all domains, and NHs in other P4P states had superior physical environment and staff empowerment scores. Qualitative interviews supported the validity of survey results. IMPLICATIONS: Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended.

Determinants of altered life perspectives among older-adult long-term cancer survivors.

BACKGROUND: In the recent literature on cancer survivorship, positive changes are emphasized in the aftermath of trauma. However, there is insufficient research on older-adult survivors and more complex transformations. OBJECTIVE: Consistent with nursing researchers' views about the duality of cancer survivor experiences, this research examined both positive and negative posttraumatic transformations (PTTs) among long-term survivors. Demographic, stress, and appraisal-related predictors of transformations were considered. METHODS: Using cross-sectional survey design, interviews were conducted with 288 survivors of breast, colorectal, and prostate cancer. The sample, obtained from a hospital tumor registry, was 58% female, 33% African American, and 67% white (mean age, 72.5 [SD, 7.6] years). Demographic characteristics, cumulative stress exposure, appraisals of stress, and self-reported PTTs were measured. RESULTS: Most respondents reported diverse transformations attributed to their illness experience. Demographic characteristics and stress appraisals were more strongly associated with PTT outcomes than was cumulative stress exposure. Appraisals of the cancer experience as stressful, as generating worry, and as stigmatizing were significantly associated with diverse PTT outcomes. CONCLUSION: Many long-term older cancer survivors report PTT reflecting altered perspectives on life. Posttraumatic transformations are related to the view that cancer is a continuing worrisome and stigmatizing experience. IMPLICATIONS FOR PRACTICE: Nurses have a unique opportunity to discuss with patients the potentially life-changing nature of the cancer experience in a manner that allows for understanding and acceptance of complex changes, incorporating benefit finding along with acknowledgement of loss and suffering. This type of discussion can enhance cancer survivors' mental health.

The complexity of implementing culture change practices in nursing homes.

PURPOSE: The culture change (CC) movement aims to transform the traditional nursing home (NH) that is institutional in design with hierarchical management structure into a homelike environment that empowers residents and frontline staff. This study examines differences in adoption of CC practices according to a NH's self-reported extent of CC implementation and its duration of CC adoption. Furthermore, it examines differences in adoption by whether a CC practice is considered less versus more complex, using complexity theory as the theoretical framework for this classification. DESIGN AND METHODS: Using data from a 2007 Commonwealth-funded study, we analyzed a national sample of 291 US nursing homes that identified as being "for the most part" or "completely" CC facilities for "1 to 3 years" or "3+ years." Also, using a complexity theory framework, we ranked 16 practices commonly associated with CC as low, moderately, or highly complex based on level of agreement needed to actuate the process (number of parties involved) and the certainty of intended outcomes. We then examined the prevalence of CC-associated practices in relation to their complexity and the extent and duration of a NH's CC adoption. RESULTS: We found practices ranked as less complex were implemented more frequently in NHs with both shorter and longer durations of CC adoption. However, more complex CC practices were more prevalent among NHs reporting "complete" adoption for 3+ years versus 1 to 3 years. This was not observed in NHs reporting having CC "for the most part." CONCLUSIONS/IMPLICATIONS: Less complex practices may be more economical and easier to implement. These early successes may result in sufficient momentum so that more complex change can follow. A nursing home that more completely embraces the culture change movement may be more likely to attempt these complex changes.

Nursing home organizational change: the "Culture Change" movement as viewed by long-term care specialists.

A decade-long grassroots movement aims to deinstitutionalize nursing home (NH) environments and individualize care. Coined "NH Culture Change" the movement is often described by its resident-centered/directed care focus. While empirical data of "culture change's" costs and benefits are limited, it is broadly viewed as beneficial and widely promoted. Still, debate abounds regarding barriers to its adoption. We used data from a Web-based survey of 1,147 long-term care specialists (including NH and other providers, consumers/advocates, state and federal government officials, university/academic, researchers/consultants, and others) to better understand factors associated with perceived barriers. Long-term care specialists view the number-one barrier to adoption differently depending on their employment, familiarity with culture change, and their underlying policy views. To promote adoption, research and broad-based educational efforts are needed to influence views and perceptions. Fundamental changes in the regulatory process together with targeted regulatory changes and payment incentives may also be needed.

Functioning and activity participation restrictions among older adult, long-term cancer survivors.

This research examines how cancer and treatment sequelae combine with comorbidities to influence the physical functioning and activity participation restrictions reported by older adult (> or =60), long-term survivors (5+ years) of breast, prostate, and colorectal cancer. The number of current comorbidities was the best predictor of functional difficulties and also a significant predictor of participation restrictions. Cancer stage at diagnosis and continuing cancer symptoms had direct effects on functional difficulties, and indirect effects through functional difficulties on participation restrictions. Clinicians working with older adult survivors need to be aware of the interplay between cancer and other health problems as they affect quality of life after cancer.

Coping among older-adult, long-term cancer survivors.

This research focuses on the coping behavior of older adult, long-term cancer survivors. Specifically, it identifies the personal (including race and gender) and illness/treatment characteristics of survivors that are significantly associated with the use of specific coping styles: planning, acceptance, venting, denial and seeking social support. It also examines the mediating role that these forms of coping play in terms of psychological distress: anxiety, depression and cancer-related worries. Multivariate analysis of data from a random sample of 321 long-term survivors in a major cancer center tumor registry is used to address the above issues. The most prominent forms of coping used by long-term survivors were planning and acceptance; least used were venting and denial. Increased age was associated with lower use of all forms of coping, but cancer type was not. Denial as a form of coping was associated with higher anxiety, depression and cancer-related worries. While race was not found to be a significant predictor of coping style, it was a significant predictor of three dimensions of psychological distress, anxiety, depression and cancer-related worries, with African Americans exhibiting lower levels of distress than Whites. The relevance of these findings for health and social service practitioners is discussed.

Cancer-related health worries and psychological distress among older adult, long-term cancer survivors.

While long-term survivors (5 years+) do not face the stressors of diagnosis and treatment, they continue to face the uncertainties that survivorship brings: recurrence, other cancers, late effects of treatment, and the potential of a shortened life expectancy. This research focuses on the cancer-related health worries of older adult, long-term cancer survivors, the factors that predict these worries, and their link to traditional measures of psychological distress. Specifically, a model is proposed that identifies the personal (including race and gender) and illness/treatment characteristics of survivors that are significantly associated with cancer-related health worries and their effects on anxiety and depression. Descriptive and multivariate analyses of a random sample of 321 long-term survivors in a major cancer center tumor registry are used to address these issues. About one-third of survivors continue to report worries about recurrence, worries about a second cancer, and worries that symptoms they experience may be from cancer. The regression analyses show that cancer-related health worries is a significant predictor of both depression (beta=0.36) and anxiety (beta=0.21). Race is a significant predictor; being African American is related to fewer cancer-related health worries (beta=-0.22). Having more symptoms during treatment is also a predictor of having more cancer-related health worries (beta=0.20). The most consistent predictor of psychosocial distress is dispositional optimism/pessimism, with more optimistic individuals reporting fewer cancer-related health worries (beta=-0.27), lower levels of both anxiety (beta=-0.16) and depression (beta=-0.23). Overall, for many older adult, long-term survivors, the legacy of cancer continues in terms of cancer-related health worries. In spite of these, for most survivors, their quality of life is not dramatically compromised either physically or psychologically.