Commentary: The Physician's Role in Nursing Home Quality of Care: Focus on Restraints

The physician can play an important role in managing high-risk nursing home residents without restraints and working with interdisciplinary care teams in comprehensive fall evaluations. A reduction or elimination of physical restraints can be measured for a facility over time, and it represents a relevant quality indicator of physician and facility interactions during the process of care. We discuss how the physician's role fits into this quality of care equation for nursing homes and its implications for new clinical, research, and policy directions for long-term care.     

Enhancing the Quality of Care in Residential and Nursing Homes: More than Just a Professional Responsibility

ABSTRACT

This article highlights a range of issues considered essential to improving the quality of care received by older people in residential and nursing home settings. It is argued that improving such care represents a societal as well as a professional responsibility and that remedial action is needed at a number of levels. Five ‘routes’ to achieving quality are outlined, and it is suggested that these are not simply alternatives but that each requires attention if genuine progress is to be made.     

A Further Opinion on Reimagining Nursing Homes

A commentary of the article discussing the possible reimagining of long-term care (LTC) is provided. The reimagining article examines how to diminish the role of nursing homes in the LTC system. The text is provocative. It is also thought-provoking. In this commentary I provide a further opinion that we could do better within the current system using the current resources.     

Florida's Efforts to Improve Quality of Nursing Home Care Through Nurse Staffing Standards,Regulation, and Medicaid Reimbursement

Between 1999 and 2007, Florida implemented two initiatives combining legislative, regulatory, and reimbursement strategies to increase nurse staffing levels in nursing homes to improve quality of care. Despite a $40 million incentive package allocated for direct-care staffing, per-resident-day staffing increased only after legislative requirements mandated minimum nursing hours per resident day. Total Medicaid expenditures grew by $1.1 billion over the 8 years; per diem rates increased 65% to reimburse providers' costs. Registered nurses' hours decreased, while licensed nurses' and paraprofessionals' hours increased. This article describes the impact of staffing policy changes, includes stakeholders' views about approaches to achieve quality outcomes, and documents state policy implementation efforts. Seven lessons from the implementation of state nurse staffing standards to improve quality of care outcomes are also presented.     

The Nursing Home Compare Report Card: Consumers' Use and Understanding

The Nursing Home Compare report card provides information on the World Wide Web about quality measures for almost every nursing home in the United States. In this research, we first examined whether consumers were using Nursing Home Compare. Second, we examined whether consumers could accurately interpret the quality information given in Nursing Home Compare. Data were collected from 4754 family members of nursing home residents. A comprehension index was used to examine whether the information contained in Nursing Home Compare for each quality measure was understood by family members. We found that 31% of these consumers used the Internet in choosing a nursing home, and 12% recalled using Nursing Home Compare. We also found that, in general, the comprehension index scores were high, indicating good understanding. Simply having the Nursing Home Compare report card available does not mean that it will be used, nor does it mean that it can influence consumers in any meaningful way. The findings show that consumers understand Nursing Home Compare information, and approximately 12% currently access the Web site.     

Long-Term Services and Supports for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care

Despite a shift from institutional services toward more home and community-based services (HCBS) for older adults who need long-term services and supports (LTSS), the effects of HCBS have yet to be adequately synthesized in the literature. This review of literature from 1995 to 2012 compares the outcome trajectories of older adults served through HCBS (including assisted living [AL]) and in nursing homes (NHs) for physical function, cognition, mental health, mortality, use of acute care, and associated harms (e.g., accidents, abuse, and neglect) and costs. NH and AL residents did not differ in physical function, cognition, mental health, and mortality outcomes. The differences in harms between HCBS recipients and NH residents were mixed. Evidence was insufficient for cost comparisons. More and better research is needed to draw robust conclusions about how the service setting influences the outcomes and costs of LTSS for older adults. Future research should address the numerous methodological challenges present in this field of research and should emphasize studies evaluating the effectiveness of HCBS.     

Physical Abuse of Older Adults in Nursing Homes: A Random Sample Survey of Adults With an Elderly Family Member in a Nursing Home

Few empirical studies have focused on elder abuse in nursing home settings. The present study investigated the prevalence and risk factors of staff physical abuse among elderly individuals receiving nursing home care in Michigan. A random sample of 452 adults with elderly relatives, older than 65 years, and in nursing home care completed a telephone survey regarding elder abuse and neglect experienced by this elder family member in the care setting. Some 24.3% of respondents reported at least one incident of physical abuse by nursing home staff. A logistic regression model was used to estimate the importance of various risk factors in nursing home abuse. Limitations in activities of daily living (ADLs), older adult behavioral difficulties, and previous victimization by nonstaff perpetrators were associated with a greater likelihood of physical abuse. Interventions that address these risk factors may be effective in reducing older adult physical abuse in nursing homes. Attention to the contextual or ecological character of nursing home abuse is essential, particularly in light of the findings of this study.     

“It’s a Dignity Thing”: Nursing Home Care Workers’ Use of Emotions1

This article examines how nursing home care workers use emotions to construct dignity at work. Previous scholarship has shown how the financial and organizational characteristics of nursing homes shape and constrain emotion work among staff. Using evidence gathered during 18 months of participant observation in two nursing homes and 65 interviews with staff, this article analyzes how, despite obstacles, nursing home care workers generated authentic emotional attachments to residents. Surprisingly, some staff members said they particularly appreciated working with residents difficult to control. They felt accomplished when such residents successfully transitioned from life at home to life in institutional care. Emotions created dignity for staff and induced compliance among residents. Emotions are not only generated by organizations and imposed on workers; staff themselves produced emotions—sometimes in ways consistent with organizational demands, and sometimes not—and they consistently found in their emotions a resource to manage the strains of their work lives.     

A New Model for Long-Term Care: Balancing Palliative and Restorative Care Delivery

ABSTRACT

Nursing homes have been mandated to maintain or promote the physical and psychological functioning of residents since the enactment of the 1987 Omnibus Reconciliation Act. Although this restorative approach to care has improved outcomes for some residents (Institute of Medicine, 2001 Institute of Medicine. 2001. Improving the quality of long term care, Washington, DC: National Academy Press.  [Google Scholar]), it ignores the reality that all permanently placed residents will die. A new model for long-term care, one that includes a simultaneous restorative and palliative approach to care delivery, is proposed. Palliative care principles provide a guiding framework for changing care delivery. Basic tenets, such as resident and family viewed as a unit of care, interdisciplinary teamwork, and interdisciplinary plans of care, provide a basis for specific operational suggestions. Operational strategies, such as psychosocial and spiritual support for family, resident decision making and participation in goal setting, expertise in aggressive pain and symptom control, and bereavement services following resident death, are described.     

Nursing Home Deficiencies: An Exploratory Study of Interstate Variations in Regulatory Activity

This study examines nursing home regulatory activity by the states, assesses interstate variations in the volume and severity of nursing home deficiencies, and explores state-level factors that may account for these differences. Nursing home deficiency citation data over a 5-year period (2000–2004) were obtained from the Centers for Medicare and Medicaid Services. We examined interstate variations in regulatory activity and identified predictors of deficiency volume and severity at the state level (demographics, elected officials, industry characteristics, etc.) using the linear mixed model. Deficiency volume remained stable across the 50 states from 2000 to 2004, while deficiency severity decreased significantly. California had the highest volume of deficiencies per nursing home; Wisconsin had the lowest. New Hampshire had the highest percentage of severe deficiencies; California had the lowest. Higher deficiency volume was found in states with lower median household income, a lower proportion of residents aged 85 and older, and a Democratic legislature. Higher deficiency severity was associated with higher median household income and a higher proportion of Medicaid nursing home residents in a state. In contrast, greater state agency funding, higher state standards for nursing home administrators, and a Democratic and more professional legislature predicted lower deficiency severity. Nursing home residents in the United States receive unequal protection from abuse and neglect, and this is partly due to their state of residence. Interstate variations in deficiency volume and severity are due to a complex set of factors beyond nursing home quality.     

The Quality Indicator Survey: Background,Implementation, and Widespread Change

The Quality Indicator Survey (QIS) is the most comprehensive regulatory change to the nursing home survey process since the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). In this article we describe the policy evolution that led to the QIS, summarize the QIS method and implementation, and profile the QIS survey results. Following over a decade of development, in 2007 the Centers for Medicare and Medicaid Services (CMS) began the national rollout of QIS. The intent was to improve consistency in the nursing home survey and to render the survey process more resident-centered and aligned with the intent of OBRA-87. We reviewed policy reports and firsthand accounts from the lead developer of the QIS methodology and leader of the national training contract for QIS. Changes in survey findings are profiled based on analysis of the publicly available Nursing Home Compare database from 2004 to 2010. Nineteen states implemented the QIS between 2007 and 2010, with nearly 20% of U.S. nursing homes receiving QIS surveys in 2010. Nursing homes surveyed with the QIS received more survey deficiencies on average than in the traditional survey; however, average numbers of deficiencies across states became more similar over the early implementation of QIS, with lower-than-average geographic areas experiencing increases and higher-than-average geographic areas experiencing decreases in survey deficiencies. The explicit and structured questioning of residents in the QIS is associated with increases in deficiencies related to choice, dignity, dental care, and nurse staffing. We describe ways in which the QIS affected the regulatory agencies, providers, and resident communities, although these effects are difficult to quantify. CMS's implementation of QIS is a significant step toward a more resident-centered, comprehensive, and consistent survey process. Substantial changes, however, are required not only among regulators but also among nursing homes. We argue that these new expectations and norms surrounding quality assessment and quality assurance are an important component of achieving culture change in U.S. nursing homes.     

To Empower with Meaningful Data: Lessons Learned in Building an Alliance Between Researchers and Long-Term Care Ombudsmen

Abstract

This is the story of how a research team formed an alliance with state long-term care ombudsmen to develop a national database of resident complaints. Beginning with background information on problem identification and analysis, the article focuses on lessons learned in building alliances between practitioners and researchers, in recognizing individual site needs, in advocating for credible dissemination of findings, and in acknowledging philosophical and political differences. The article stresses the importance of tenacity in seeking funding for projects that empower practitioners to truly advocate for the needs of vulnerable populations.     

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.     

Improving Australian Residential Aged Care Facilities: A Review of Minor Refurbishment Elements

The objective of this study is to identify elements pertaining to minor refurbishments of residential aged care facilities. A narrative review of relevant publications was conducted. Inductive content analysis was used to categorize coded data into major or minor refurbishment or staff practices. Further analysis identified minor refurbishment domains. There were 14 major refurbishment, seven minor refurbishment and two staff practices domains established. The minor refurbishment elements (n?=?7) identified were lighting, furniture, color and contrast, wayfinding, noise, signage, and flooring. Assessing these elements would assist residential aged care providers to prioritize the provision of minor improvements to the environment for residents.     

Comparing States' Medicaid Nursing Facilities and Home and Community-Based Services Long-Term Care Programs: Quality and Fit with Inclination,Capacity, and Need

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality.     

Administrators and Quality of Care in Long-Term Care Facilities

This exploratory study investigated administrator and facility-related predictors of quality of care in long-term care facilities. Quality was measured using several unmet standards of care identified in the last inspection report of the Ontario Ministry of Health and Long-Term Care (2007). Supplemental data were gathered from surveys mailed to all 602 long-term care administrators in Ontario, Canada, 302 of whom completed the questionnaire. Multiple regression analyses were conducted to test sets of hypotheses linking characteristics of administrators and those of the long-term care facility to quality of care. Education and experience as an administrator in a participant's current position had a moderate positive influence on quality of care; however, negative associations were found between administrator salary and effort devoted to resident care problems and quality of care. In addition, smaller facilities, being located in less populated communities, and administrators with a nursing background significantly affected quality of care in a positive manner.     

The Influence of Agency Staffing on Quality of Care in Nursing Homes

ABSTRACT

Data from a large sample of nursing homes were used to examine the cross-sectional association between use of agency staff, regular staff, and quality. Agency use data came from a survey conducted in 2003 (N?=?1071 nursing homes). The agency and regular staff measures were for nurse aides, licensed practical nurses, and registered nurses. We used a single quality factor constructed from the 14 quality measures in Nursing Home Compare. More agency nurse aides resulted in a smaller increase in quality, compared to the use of an equivalent number of regular nurse aides. Agency registered nurse staff were associated with better quality factor scores, especially in the presence of high levels of regular licensed practical nurses. Our results have policy and practice implications, the most significant of which is that agency registered nurses may be beneficial in a wide variety of circumstances, whereas agency nurse aides and licensed practical nurses should be used with caution.     

Consultancy to a Care Home: The Influences of Family and Gender Roles,and of Race and Colonialism

This paper is an account and critical analysis of the psychodynamic and systemic consultancy that the author provided to a care home (and the voluntary organisation running it) over a period of about 16 months. In addition two emergent, linked themes are identified and discussed: family and gender roles in care homes, and racism and colonialism. Care homes are of course part of the society in which they exist and of which they are a product. This means that all the overt and covert psychological and social pressures, defences and trends that occur in the wider society, for individuals, families, groups and communities are also to be found in care homes and in the organisations that run them. They are not isolated from these forces, indeed, it is argued in this paper, the forces are intensified in the ‘hot house’ environment of a care home and, if ignored, avoided and denied, result in the exploitation, abuse and neglect of both staff and residents.     

Health Insurance for All Long-Term Care Workers: Estimated Costs and Coverage Impacts in Minnesota and Recommendations for States

A major barrier to building a strong workforce to meet the growing need for long-care is lack of affordable health benefits. This study projects impacts of funding health coverage for all long-term care workers in Minnesota. Under the most cost effective model plan design, enrollment in employer-sponsored coverage would increase 73% to 100% for individual coverage and 26% to 42% for family coverage. Total monthly costs would be $698/worker in the commercial market or $634/worker through a new dedicated risk pool. Based on our findings and past research, the authors present recommendations for structuring and implementing a long-term care worker health insurance initiative.     

Nursing-Home Resident Quality of Life: A Longitudinal Case Study Approach

Longitudinal quality-of-life (QOL) research incorporating multiple perspectives can add to knowledge about how nursing home residents experience QOL, but these methods are seldom used. This study employed interviews and participant observation to conduct multiple-perspective, longitudinal case studies of six residents. Close, reciprocal relationships with staff members, staff knowledge of residents, and autonomy were fundamental to QOL. Autonomy was experienced through choice and self-advocacy. Changes in QOL over time related to changes in resident health status, acclimation to the setting and family member availability. Study results may have implications for staffing and staff training.