Racial Differences in Nursing Home Quality of Life Among Residents Living With Alzheimer's Disease and Related Dementias.

ObjectivesAmong nursing home (NH) residents with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD), racial/ethnic disparities in quality of care exist. However, little is known about quality of life (QoL). This study examines racial/ethnic differences in self-reported QoL among NH residents with AD/ADRD. Methods: Validated, in-person QoL surveys from 12,562 long-stay NH residents with AD/ADRD in Minnesota (2012-2015) were linked to Minimum Data Set assessments and facility characteristics. Hierarchical linear models assessed disparities in resident-reported mean QoL score (range, 0-100 points), adjusting for case-mix and facility factors. Results: Compared to White residents, racially/ethnically minoritized residents reported significantly lower total mean QoL scores (75.53 points vs. 80.34 points, p < .001). After adjustment for resident- and facility-level characteristics, significant racial/ethnic differences remained, with large disparities in food enjoyment, attention from staff, and engagement domains. Discussion: Policy changes and practice guidelines are needed to address racial/ethnic disparities in QoL of NH residents with AD/ADRD.

Measuring Nursing Home Quality of Life: Validated Measures Are Poorly Correlated With Proxies From MDS and Quality of Life Deficiency Citationsl.

OBJECTIVES: Ensuring quality of life (QoL) is an important goal of person-centered nursing home care. The provision of person-centered care relies on information captured in the Minimum Data Set 3.0 (MDS). It is unclear to what extent MDS items or QoL-related facility deficiency citations correlate with validated measures of nursing home residents' QoL. This study evaluated correlation among MDS items, facility deficiency citations, and residents' QoL from 2 states that currently collect these measures. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: A total of 11,487 long-stay residents in 356 facilities in Minnesota and 13,835 long-stay residents in 851 facilities in Ohio in 2015. METHODS: The outcome, QoL, was measured using validated instruments (Minnesota QoL survey and Ohio Resident Satisfaction Survey). Predictor variables included scores for Preference Assessment Tool (Section F), Patient Health Questionnaire-9 (Section D) for depressive symptoms from MDS, and count of QoL-related facility deficiency citations from the Certification and Survey Provider Enhanced Reporting database. Spearman's ranked test assessed correlation between predictor and outcome variables. Mixed effects models evaluated associations of QoL summary scores with predictor variables, adjusting for resident- and facility-level characteristics, accounting for clustering at the facility level. RESULTS: In Minnesota and Ohio, predictor variables (Section F and D items, and facility deficiency citations) correlated significantly but poorly with QoL (coefficients ranging from 0.003 to 0.3, P < .001). In the fully adjusted mixed effects model, all predictor variables, demographics, and functional status explained <21% of the total variance in QoL among residents. These findings were consistent in sensitivity analyses stratified by 1-year length of stay and by diagnosis of dementia. CONCLUSIONS AND IMPLICATIONS: MDS items and facility deficiency citations encapsulate a significant but very small proportion of variance in residents' QoL. This indicates the need to measure QoL directly among residents, to plan person-centered care, and to evaluate its performance in nursing home facilities.

Evidence to Inform Policy and Practice: Mechanisms to Address Racial/Ethnic Disparities in Nursing Home Quality of Life.

Background and Objectives: Abundant evidence documents racial/ethnic disparities in access, quality of care, and quality of life (QoL) among nursing home (NH) residents who are Black, Indigenous, and people of color (BIPOC) compared with White residents. BIPOC residents are more likely to be admitted to lower quality NHs and to experience worse outcomes. Yet, little is known about processes for differences in QoL among residents receiving care in high-proportion BIPOC NHs. This study presents an examination of the processes for racial/ethnic disparities in QoL in high-proportion BIPOC facilities while highlighting variability in QoL between these facilities. Research Design and Methods: Guided by the Minority Health and Health Disparities Research Framework and the Zubritsky framework for QoL in NHs, we employ a concurrent mixed-methods approach involving in-depth case studies of 6 high-proportion BIPOC NHs in Minnesota (96 resident interviews; 61 staff interviews; 614 hours of observation), coupled with statewide survey data on residents' QoL linked to resident clinical Minimum Data Set assessments. Results: Quantitative findings show that BIPOC residents experience lower QoL than White residents across various domains. Qualitative findings reveal variability in BIPOC residents' QoL between high-proportion BIPOC facilities. In some facilities, BIPOC residents experienced worse QoL based on their race/ethnicity, whereas in others BIPOC residents QoL was not directly affected by their race/ethnicity or they had mixed experiences. Discussion and Implications: The findings highlight variability in racial/ethnic disparities in QoL across NHs with a high proportion of BIPOC residents. We identify health equity initiatives, including engaging with community BIPOC organizations and volunteers, and providing more resources to high-proportion BIPOC facilities to support staff training, additional staffing, and culturally specific programming. Given the increasing racial/ethnic diversity of NHs, ensuring equity in QoL for BIPOC residents is an urgent priority for NHs to remain relevant in the future.

Longitudinal Comparison of Stability and Sensitivity in Quality of Life Scores Among Nursing Home Residents With and Without Diagnoses of Alzheimer's Disease and Related Dementias.

BACKGROUND AND OBJECTIVES: Prevalence of nursing home residents with Alzheimer's disease and related dementias (ADRD) has increased along with a growing consensus that person-centered ADRD care in nursing homes should maximize quality of life (QoL). However, concerns about whether residents with ADRD can make appropriate QoL judgments persist. This study assesses the stability and sensitivity of a self-reported, multidomain well-being QoL measure for nursing home residents with and without ADRD. RESEARCH DESIGN AND METHODS: This study linked the 2012-2015 Minnesota Nursing Home Resident QoL and Satisfaction with Care Survey, Minimum Data Set 3.0 (nursing home assessments), and Minnesota Department of Human Services Cost Reports. The QoL survey included cohort-resident pairs who participated for 2 consecutive years (N = 12 949; 8 803 unique residents from 2012-2013, 2013-2014, and 2014-2015 cohorts). Change in QoL between 2 years was conceptualized as stable when within 1.5 SD of the sample average. We used linear probability models to estimate associations of ADRD/Cognitive Function Scale status with the stability of QoL summary and domain scores (eg, social engagement) and the absolute change in QoL summary score, controlling for resident and facility characteristics. RESULTS: Most (86.82%) residents had stable QoL summary scores. Residents with moderate to severe cognitive impairment, irrespective of ADRD, were less likely to have stable summary scores than cognitively capable residents without ADRD (p < .001), but associations varied by QoL domains. Among those with stable summary QoL scores, changes in health/functional status were associated with absolute changes in summary QoL score (p < .001), suggesting sensitivity of the QoL measure. DISCUSSION AND IMPLICATIONS: QoL scores were similarly stable over time for most residents with and without ADRD diagnoses and were sensitive to changes in health/functional status. This self-reported QoL measure may be appropriate for nursing home residents, regardless of ADRD diagnosis, and can efficaciously be recommended to other states.

Using a Semi-Markov Model to Estimate Medicaid Cost Savings due to Minnesota's Return to Community Initiative.

OBJECTIVES: To provide an estimate and level of uncertainty for Medicaid cost savings due to Minnesota's Return to Community Initiative (RTCI). DESIGN: Medicaid cost savings are estimated using a semi-Markov model and simulation approach. SETTING AND PARTICIPANTS: RTCI is a statewide program that assists private paying nursing home residents with discharge to the community. When originally proposed, it was expected that the program would reduce state Medicaid expenditures, primarily through the shifting of residents from nursing homes to a less costly community setting. In prior analysis, we estimated that approximately 1 in 9 residents targeted for transition by the program would not have returned to the community without the RTCI. Accurate cost savings estimates require consideration of complex resident care trajectories, that is, nursing home readmissions, use of assisted living and community-based services, and mortality. MEASURES: Data were from 30,234 private pay nursing home residents admitted during 2011, primarily for post-acute stays, to 378 facilities in Minnesota, and followed for 4 years postadmission for outcomes and time to event. Resident characteristics were taken from the Minimum Data Set (MDS) admission assessment. We modeled variability in care trajectories with a semi-Markov formulation. Transition probabilities were estimated using Multinomial regression. Time to event was modeled using the best-fitting, positive, right-skewed distribution for each path. The simulation was run (1000 times) with and without the RTCI impact to estimate change in Medicaid days in various settings. RESULTS: Program savings was estimated at $4.1 million per year of effort over a 4-year accumulation period. CONCLUSIONS AND IMPLICATIONS: The RTCI produced a modest Medicaid cost savings in excess of the annual program budget of $3.5 million. Findings from the semi-Markov model and simulation increase our understanding of care transitions between nursing home, community, Medicaid status, and mortality.

Unmet and Unimportant Preferences Among Nursing Home Residents: What Are Key Resident and Facility Factors?

OBJECTIVES: The Preferences Assessment Tool (PAT) in the Minimum Data Set (MDS) 3.0 assesses 16 resident preferences for daily routines and activities. Although integrating important preferences into care planning is essential to provide person-centered care in nursing homes (NHs), preferences rated as important but unmet or unimportant may not receive much attention. This study aims to (1) identify the prevalence of unmet preferences and unimportant preferences, and (2) examine their associations with resident and facility-level characteristics. DESIGN: This is a longitudinal study of residents in NHs. SETTINGS AND PARTICIPANTS: We used data from 2012-2017 MDS assessments of long-stay residents aged 65 or older in 295 Minnesota NHs. In total, 51,859 assessments from 25,668 residents were included. METHODS: Generalized linear mixed models were used to analyze resident and facility-level characteristics associated with having any unmet preferences, and with the number of unimportant preferences. RESULTS: Across all years for both daily routine preferences and activity preferences, 3.3% to 5.1% of residents reported that at least 1 or more preference was important but unmet, and 10.0% to 16.6% reported that 4 or more out of the 8 preferences were unimportant. Residents with higher depressive symptoms, and poorer physical and sensory function were more likely to report unmet preferences. Residents with poorer physical and sensory function, and living in rural facilities and facilities having fewer activity staff hours per resident day were more likely to report unimportant preferences. CONCLUSIONS AND IMPLICATIONS: Residents with functional and sensory limitations and living in underresourced NHs are more likely to report that preferences are unimportant, or that they are important but unmet. It is important for staff to elicit preferences that truly matter for residents, and to enable residents to meet their preferences.

Changes over Time in Racial/Ethnic Differences in Quality of Life for Nursing Home Residents: Patterns within and between Facilities.

Objectives: To investigate trends in racial/ethnic differences in nursing home (NH) residents' quality of life (QoL) and assess these patterns within and between facilities. Method: Data include resident-reported QoL surveys (n = 60,093), the Minimum Data Set, and facility-level characteristics (n = 376 facilities) for Minnesota. Hierarchical linear models were estimated to identify differences in QoL by resident race/ethnicity and facility racial/ethnic minority composition for 2011-2015. Results: White residents in low-proportion racial/ethnic minority facilities reported higher QoL than both minority and white residents in high-proportion minority facilities. While the year-to-year differences were not statistically significant, the point estimates for white-minority disparity widened over time. Discussion: Racial/ethnic differences in QoL are persistent and may be widening over time. The QoL disparity reported by minority residents and all residents in high-proportion minority facilities underscores the importance of examining NH structural characteristics and practices to ultimately achieve the goal of optimal, person-centered care in NHs.

COVID-19 Pandemic: Exacerbating Racial/Ethnic Disparities in Long-Term Services and Supports.

What services are available and where racial and ethnic minorities receive long-term services and supports (LTSS) have resulted in a lower quality of care and life for racial/ethnic minority users. These disparities are only likely to worsen during the COVID-19 pandemic, as the pandemic has disproportionately affected racial and ethnic minority communities both in the rate of infection and virus-related mortality. By examining these disparities in the context of the pandemic, we bring to light the challenges and issues faced in LTSS by minority communities with regard to this virus as well as the disparities in LTSS that have always existed.

Do Residents Participating in Minnesota's Return to Community Initiative Experience Similar Postdischarge Outcomes to Their Peers?

OBJECTIVE: The objective of this study was to evaluate the impact of Minnesota's Return to Community Initiative (RTCI) on postdischarge outcomes for nursing home residents transitioned through the program. DATA SOURCES: Secondary data were from the Minimum Data Set and RTCI staff (January 2015 to December 2016), state Medicaid eligibility files and death records. The sample consisted of 29,201 nursing home discharges in Minnesota occurring in 2015. RESEARCH DESIGN: Cox proportional hazard models were used to compare 1-year postdischarge outcomes of nursing home readmission, mortality, and Medicaid conversion for RTCI assisted community discharges and a propensity-matched sample of unassisted community discharges. RESULTS: The majority (60%) of RTCI assisted discharges remained alive, in the community and not having converted at Medicaid at 1 year after discharge. Time to mortality was significantly lower for the assisted group than the unassisted group, but time to readmission and Medicaid conversion were similar. CONCLUSION: The RTCI assisted residents fared well postdischarge in their time to mortality, nursing home readmission, and Medicaid conversion; they lived longer than a propensity-matched sample of their peers.

Assessing the impact of Minnesota's return to community initiative for newly admitted nursing home residents.

OBJECTIVE: To evaluate Minnesota's Return to Community Initiative's (RTCI) impact on community discharges from nursing homes. DATA SOURCES: Secondary data were from the Minimum Data Set and RTCI staff (April 2014 - December 2016). The sample consisted of 18 444 non-Medicaid nursing home admissions in Minnesota remaining for at least 45 days, with high predicted probability of community discharge. STUDY DESIGN: The RTCI facilitates community discharge for non-Medicaid nursing home residents by assisting with discharge planning, transitioning to the community, and postdischarge follow-up. A key evaluation question is how many of those transitions were directly attributable to the program. Return to Community Initiative was implemented statewide without a control group. Program impact was measured using regression discontinuity, a quasi-experimental design approach that leverages the programs targeting model. PRINCIPAL FINDINGS: Return to Community Initiative increased community discharge rates by an estimated 11 percent (P < 0.05) for the targeted population. The program effect was robust to time and increased with level of facility participation in RTCI. CONCLUSIONS: The RTCI had a modest yet significant impact on the community discharge rates for its targeted population. Findings have been applied in strengthening the RTCI's targeting approach and transitioning process.

Modeling Community Discharge of Medicaid Nursing Home Residents: Implications for Money Follows the Person.

OBJECTIVE: To build and test a model that predicts community discharge probabilities for Medicaid-eligible nursing home (NH) residents who remain in the nursing home at 90 days after admission and, thus, would be candidates for the Money Follows the Person (MFP) program. DATA SOURCE: The Minimum Data Set, Medicaid Management Information Systems, and Minnesota Vital Statistics file. DATA: Cohort of 33, 590 nursing home stays that qualified for Medicaid by the 90th day of their stay from 383 Minnesota nursing homes from July 2011 to June 2013. STUDY DESIGN: Mixed effects logistic regression model to predict community discharge. PRINCIPAL FINDINGS: The scoring system had a high level of accuracy in predicting community discharge for both the fitting and validation cohorts. Subpopulations with severe mental illness or intellectual disability were well represented across the entire score range. CONCLUSIONS: Findings are being applied in the Minnesota's MFP initiative (Moving Home Minnesota) to target Medicaid-eligible NH residents for transitioning to the community. This approach could be applied to MFP in other states.

Uncertainty analysis of a model of wind-blown volcanic plumes.

Mathematical models of natural processes can be used as inversion tools to predict unobserved properties from measured quantities. Uncertainty in observations and model formulation impact on the efficacy of inverse modelling. We present a general methodology, history matching, that can be used to investigate the effect of observational and model uncertainty on inverse modelling studies. We demonstrate history matching on an integral model of volcanic plumes that is used to estimate source conditions from observations of the rise height of plumes during the eruptions of Eyjafjallajökull, Iceland, in 2010 and Grímsvötn, Iceland, in 2011. Sources of uncertainty are identified and quantified, and propagated through the integral plume model. A preliminary sensitivity analysis is performed to identify the uncertain model parameters that strongly influence model predictions. Model predictions are assessed against observations through an implausibility measure that rules out model inputs that are considered implausible given the quantified uncertainty. We demonstrate that the source mass flux at the volcano can be estimated from plume height observations, but the magmatic temperature, exit velocity and exsolved gas mass fraction cannot be accurately determined. Uncertainty in plume height observations and entrainment coefficients results in a large range of plausible values of the source mass flux. Our analysis shows that better constraints on entrainment coefficients for volcanic plumes and more precise observations of plume height are required to obtain tightly constrained estimates of the source mass flux.

Charge structure in volcanic plumes: a comparison of plume properties predicted by an integral plume model to observations of volcanic lightning during the 2010 eruption of Eyjafjallajökull, Iceland.

Observations of volcanic lightning made using a lightning mapping array during the 2010 eruption of Eyjafjallajökull allow the trajectory and growth of the volcanic plume to be determined. The lightning observations are compared with predictions of an integral model of volcanic plumes that includes descriptions of the interaction with wind and the effects of moisture. We show that the trajectory predicted by the integral model closely matches the observational data and the model well describes the growth of the plume downwind of the vent. Analysis of the lightning signals reveals information on the dominant charge structure within the volcanic plume. During the Eyjafjallajökull eruption both monopole and dipole charge structures were observed in the plume. By using the integral plume model, we propose the varying charge structure is connected to the availability of condensed water and low temperatures at high altitudes in the plume, suggesting ice formation may have contributed to the generation of a dipole charge structure via thunderstorm-style ice-based charging mechanisms, though overall this charging mechanism is believed to have had only a weak influence on the production of lightning.