The relationship between person-centered care in nursing homes and COVID-19 infection, hospitalization, and mortality rates.

OBJECTIVES: This cohort study compared rates of COVID-19 infections, admissions/readmissions, and mortality among a statewide person-centered model known as PEAK and non-PEAK NHs. METHODS: Rates per 1000 resident days were derived for COVID-19 cases and admissions/readmissions, and per 100 positive cases for mortality. A log-rank test compared rates between PEAK (n = 109) and non-PEAK NHs (n = 112). RESULTS: Rates of COVID-19 cases, admission, and mortality were higher in non-PEAK compared to PEAK NHs. The median rates for all indicators had a zero value for all NHs, but in NHs above 90th percentiles, the non-PEAK case rate was 3.9 times more and the admission/readmission rate was 2.5 times more. CONCLUSIONS AND IMPLICATIONS: COVID-19 case, and mortality rates were lower in PEAK than non-PEAK NHs. Although PEAK and non-PEAK NHs may differ in other ways as well, person-centered care may be advantageous to promote infection control and improve outcomes.

Initiating Aha moments when implementing person-centered care in nursing homes: a multi-arm, pre-post intervention.

BACKGROUND: Comprehensive adoption of culture change via person-centered care (PCC) practices in nursing homes has been slow. Change such as this, requires transformation of organizational culture, frequently generating resistance and slow moving change. This study examined how nursing homes perceive their adoption of PCC practices across seven domains and how these perceptions change in response to an educational intervention embedded in a statewide program, Promoting Excellent Alternatives in Kansas nursing homes (PEAK 2.0). Given perception is an important feature of the change process, it was hypothesized that pre-adopters engaging in PEAK 2.0's initial Foundation year (level 0) would have lower perceived PCC adoption following a year of education and exposure to PCC, whereas adopters (PEAK 2.0 level 1-5 homes) would have higher perceived PCC adoption following a year of participation in their respective level in the program. METHODS: A multi-arm, pre/post intervention study was conducted during the 2014 and 2015 years of the PEAK 2.0 program comparing pre-PCC adopters to adopters. Outcomes were self-ratings of perceived PCC implementation across seven domains of PCC at the beginning and end of the 2014-15 program year, after pre-adopters had received PCC education and adopters had implemented a year of PCC. Paired t-tests and mixed repeated-measures linear models, controlling for potential confounders, were employed to test the study hypotheses. RESULTS: Across all seven domains of PCC, pre-adopters rated their PCC implementation as significantly higher on pre-test (2014) than on post-test (2015). In contrast, adopters rated their PCC achievement as higher on post-test (2015) than on pre-test (2014). CONCLUSIONS: Pre-adopters' lower score following a year of education and exposure to PCC may reflect a shift in perceptions of PCC as a concept or a deeper conceptualization of PCC. Since perceptions or assumptions can serve as a source of resistance to change, redefinition or "unlearning" to make way for more accurate definitions of PCC could aid in reducing organizational resistance to implementation of PCC and thus improve the rate of adoption.

Engagement and Adoption of Person-Centered Care: Participant Experiences in the Kansas PEAK 2.0 Program.

The Promoting Excellent Alternatives in Kansas (PEAK) 2.0 program provides training, evaluation, and support in person-centered care (PCC) for nursing homes across Kansas. To represent the participant voice, nursing home employees (N = 141) provided feedback on their experiences and their home's level of engagement in PEAK 2.0 as well as achievement of PCC adoption. Analyses were conducted to capture the positive/negative valence and specificity of their comments and examine how engagement in PEAK 2.0 relates to the process and outcome of PEAK 2.0. Qualitatively, staff participants demonstrated that PEAK 2.0 is viewed positively overall, with approximately twice as many participants with more positive (e.g., community support, satisfaction with resources) than negative (e.g., over-regulation, too structured) comments. Employees reporting moderate engagement in PCC provided the majority of specific suggestions for improvement. In addition, higher levels of engagement were significantly associated with higher levels of PCC achievement. Based on these results, suggestions are offered to enhance nursing staff experiences and engagement that will help support PCC adoption. [Journal of Gerontological Nursing, 45(11), 5-10.].

Content analysis of public opinion on sexual expression and dementia: Implications for nursing home policy development.

PURPOSE: We examined public opinion of sexual expression and dementia to inform nursing home policy and practice. DESIGN AND METHODS: A content analysis was conducted on public comments (N=1194) posted in response to a New York Times article about a highly publicized legal case involving a husband engaging in sexual acts with his wife who had dementia, living in a nursing home. Researchers utilized constant comparative analysis to code the comments; reliability analysis showed moderately strong agreement at the subcategory level. Data were also coded to indicate whether the commenter thought the couple should or should not have been allowed to be sexual. RESULTS: One primary theme was identified: conditions necessary for someone to be sexual. Six categories were identified within this theme, with the public commentary considering factors such as marital relationships, intimacy needs and several sexual consent-related issues as key conditions necessary to be sexual in a nursing home setting. Overall, the majority of commenters were in support of sexual expression for an individual with dementia in the described situation. DISCUSSION: This study revealed sexual expression among individuals with dementia is a contentious issue with strong public opinions about how this should be managed in a nursing home setting. These opinions should be considered as policy related to sexual expression in nursing homes is developed.

Sexual Expression, Policies, and Practices in Skilled Nursing Settings Serving Older Adults: An Updated Assessment in the State of Kansas.

Doll assessed sexual expressions, policies, and practices in Skilled Nursing Facilities (SNFs) in the state of Kansas. This study provided an updated and expanded assessment. A mixed-methods survey was distributed to administrators of all SNFs in the state of Kansas. Among 60 administrations, 84% reported any sexual expression among residents in their community within the past year and 55% reported expressions involving an individual with cognitive impairment. In response to sexual expressions, 70% of administrators believe staff would treat residents with dignity and respect and about 40% anticipated staff discomfort. About 40% of administrators reported having a policy related to sexual expression. Attitudes and responses of staff and administrators appear to be shifting in a sex-positive direction. While policies related to sexuality are more common than a decade ago, there is room for additional uptake, standardization, and infusion of person-centered language and practices.

The Kansas PEAK 2.0 Program Facilitates the Diffusion of Culture-Change Innovation to Unlikely Adopters.

Purpose of the Study: Recent studies have shown that nursing homes adopting culture change are disproportionately not-for-profit and CCRC-affiliated, with greater quality of care. Through the lens of diffusion-of-innovation theory, we examined whether Kansas' Medicaid pay-for-performance program PEAK 2.0, which incents the adoption of person-centered care (PCC) and worker empowerment, succeeded in its goal of spreading adoption to atypical- as well as typical-adopting nursing homes. Design and Methods: We conducted a retrospective cohort study of 349 nursing homes in the state during PEAK 2.0's existence, 2012-2016. We constructed a data set combining state program data, provider characteristics from CMS data sets, and other demographic information from the 2010 Census. With a series of logistic regression models, we tested whether program joiners differed from nonjoiners by profit status and other demographic factors, as well as quality-related and case-mix factors. Results: We found that in PEAK 2.0's first year, 2012, adopters were more likely to be not-for-profit and part of a CCRC, with higher occupancy rates and greater quality. However, by 2013 these associations became marginal, and in 2014 and 2015, we found no differences between program joiners and nonjoiners. Implications: The results show that by PEAK 2.0's third year, the program-with its large financial incentive and other potentially important characteristics-succeeded in attracting a large set of nursing homes whose demographics were representative of those in the state. This is important because other studies have found that the adoption of PCC is associated with improved health and well-being for residents.

Person-Centered Care as Facilitated by Kansas' PEAK 2.0 Medicaid Pay-for-Performance Program and Nursing Home Resident Clinical Outcomes.

PURPOSE OF THE STUDY: Person-centered care (PCC) is intended to improve nursing home residents' quality of life, but the closer bonds it engenders between residents and staff may also facilitate improvements to residents' clinical health. Findings on whether adoption ameliorates resident clinical outcomes are conflicting, with some evidence of harm as well as benefit. To provide clearer evidence, the present study made use of Kansas' PEAK 2.0 Medicaid pay-for-performance (P4P) program, which incents the adoption of PCC. The program is distinctive in training facilities' staff on adopting PCC through a series of well-defined stages and providing regular feedback about their progress. DESIGN AND METHODS: A retrospective cohort study was performed with 349 Kansas facilities spread across several well-defined PCC adoption stages, ranging from nonadoption to comprehensive adoption. The outcomes were thirteen 2014-2016 Nursing Home Compare long-stay resident clinical measures and a composite measure incorporating only nonimputed data for those 13 outcomes. Observed facility demographic differences were controlled for with propensity score adjustment. Treatment effect analyses were run with each outcome, with the predictor variable of program stage. RESULTS: Seven of the 13 clinical measures plus the composite measure indicated better health for residents in homes at higher program stages, relative to those in nonparticipating homes, including a 49% lower prevalence of major depressive symptoms in strongly adopting facilities. IMPLICATIONS: The findings suggest that greater PCC adoption through PEAK participation is associated with better quality of care. Policymakers in other states may want to consider implementing a program modeled on PEAK 2.0.

Actualizing culture change: The Promoting Excellent Alternatives in Kansas Nursing Homes (PEAK 2.0) program.

Nursing homes have been challenged in their attempts to achieve deep, organizational change (i.e., culture change) aimed at providing quality of care and quality of life for nursing home residents through person-centered care. To attain deep change, 2 well-defined components must be in place: a shared understanding of (a) the what, or content goals, and (b) the how, or process of change. However, there are few examples of this at a macro or micro level in long-term care. In an effort to enact true culture change in nursing homes statewide, the Kansas Department for Aging and Disability Services implemented the Promoting Excellent Alternatives in Kansas Nursing Homes program. This program is a Medicaid, pay-for-performance program that formalizes the content and process of achieving culture change through person-centered care principles. This article aims to detail the content (what) and process (how) of a model macro-level program of culture change throughout the State of Kansas. Applications to the micro level (individual homes) are presented, and implications for psychologists' roles in facilitating culture change are discussed. (PsycINFO Database Record

Does Person-Centered Care Improve Residents' Satisfaction With Nursing Home Quality?

OBJECTIVE: Person-centered care (PCC) is meant to enhance nursing home residents' quality of life (QOL). Including residents' perspectives is critical to determining whether PCC is meeting residents' needs and desires. This study examines whether PCC practices promote satisfaction with QOL and quality of care and services (QOC and QOS) among nursing home residents. DESIGN: A longitudinal, retrospective cohort study using an in-person survey. SETTING: Three hundred twenty nursing homes in Kansas enrolled or not enrolled in a pay-for-performance program, Promoting Excellent Alternatives in Kansas (PEAK 2.0), to promote PCC in nursing homes. PARTICIPANTS: A total of 6214 nursing home residents in 2013-2014 and 5538 residents in 2014-2015, with a Brief Interview for Mental Status score ≥8, participated in face-to-face interviews. Results were aggregated to the nursing home level. MEASUREMENTS: My InnerView developed a Resident Satisfaction Survey for Kansas composed of 32 questions divided into QOL, QOC, QOS, and global satisfaction subdomains. RESULTS: After controlling for facility characteristics, satisfaction with overall QOL and QOC was higher in homes that had fully implemented PCC. Although some individual measures in the QOS domain (eg, food) showed greater satisfaction at earlier levels of implementation, high satisfaction was observed primarily in homes that had fully implemented PCC. CONCLUSION: These findings provide evidence for the effectiveness of PCC implementation on nursing home resident satisfaction. The PEAK 2.0 program may provide replicable methods for nursing homes and states to implement PCC systematically.

Management of sexual expression in long-term care: ombudsmen's perspectives.

PURPOSE: This study investigates sexual expression management in long-term care settings based on cases requiring intervention from ombudsmen. Although the literature frequently mentions a lack of policies governing sexual expression in these settings, there is little information available on management of situations when they occur. This study addresses these missing elements through the perspective of resident advocates. DESIGN AND METHODS: 31 in-depth interviews using a multiple case study approach were conducted with long-term care ombudsmen in 6 states. A thematic analysis was performed on the interview transcripts. RESULTS: Ombudsmen intervened in cases based on dilemma or conflict due to risk, risk associated with dementing illness, limited knowledge, privacy, and values. The theoretical framework of the total institution was utilized to interpret the results. IMPLICATIONS: The results underscored the importance of resident advocates to support residents' rights. This research also highlights the importance of workforce training and examination of the institutional impact on resident sexual expression. Formulation of standards of practice for ethically complex situations is also critically important.