Nursing Home Ownership Trends and Their Impacts on Quality of Care: A Study Using Detailed Ownership Data From Texas

The role of ownership in the provision of nursing home care has long been a challenging issue for policy makers and researchers. Although much of the focus historically has been on differences between for-profit and not-for-profit facilities, this simple distinction has become less useful in recent years as companies have employed more complicated ownership and management structures. Using detailed ownership data from the state of Texas, we describe the evolution of nursing home corporate structures from 2000 to 2007, analyze the effect of these structures on quality of care and staffing in nursing homes, and discuss the policy implications of these changes.     

Quality of Life in Nursing Homes

Abstract

The Nursing Home Reform Act (NHRA) of 1987 established nursing home requirements and dually emphasized quality of care and quality of life outcomes. We researched elders' perceptions of quality of life in nursing homes using focus groups. Analysis revealed four major themes important to residents: generativity, spiritual well-being, homelike environment, and privacy. Themes were used to analyze the disparity between NHRA's goal of dual emphasis and the dominance of quality of care in the treatment of frail elders living in nursing homes. Policies and procedures must be developed that promote decisional control in everyday matters of an older person's life.     

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.     

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.     

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.     

Efficiency and the Fix Revisited: Informal Relations and Mock Routinization in a Nonprofit Nursing Home

Participant observation in a nonprofit nursing home reveals that informal patterns of work routinization depart markedly from official procedures designed to protect the health and safety of workers and residents. Six aspects of the informal organization of work are found to correspond closely to patterns observed by Roy (1954): the mismatch between time and tasks, the development of new (informal) skills, the institutionalization of rule-breaking, negative effects on quality, the collaboration of shop-level supervision, and workers’ experience of managerial irrationality. However, whereas classic manufacturing studies emphasized upper management's periodic attempts to force compliance to official rules and routines, here upper management engages only in symbolic interventions, collaborating with workers and nursing home residents in the “mock routinization” of work. The article concludes by showing how, in the context of contradictory external workplace regulation, all three parties to the labor process of the contemporary nursing home experience mock routinization as compatible with their own interests.

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 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.     

The Centers for Medicare and Medicaid Services' Nursing Home Case-Mix and Quality Demonstration

Abstract

This paper presents the first comprehensive account of a major national demonstration designed to integrate skilled nursing facilities (SNF) prospective case-mix payment and quality of care. It describes the Centers for Medicare and Medicaid Services' Nursing Home Case-Mix and Quality (NHCMQ) Demonstration—the template for Medicare's SNF Prospective Payment System (PPS) implemented July 1998. The NHCMQ Demonstration provided the basis for one of the most significant changes in SNF reimbursement and quality monitoring policies to date. Prospective reimbursement policies created positive incentive for providers to admit Medicare residents under more equitable payment rates. However, controversy regarding unanticipated perverse provider incentives remains. The quality management system designed under the NHCMQ Demonstration is currently used in over 17,000 nursing homes. Furthermore, under the NHCMQ Demonstration, one standardized assessment tool—the MDS—was used to assess a resident's clinical condition, to monitor quality, and to calculate provider reimbursement. Experiences from the NHCMQ Demonstration and continued evaluation of the current national PPS, along with state systems, provide a rich information source regarding prospective, case-mix reimbursement, and provider incentives.     

Documenting Inadequate Care in the Nursing Home:

An undercover agent describes his experiences as a nurse's aide gathering evidence that was ultimately used in the prosecution of a corporate entity responsible for the deaths of two Philadelphia nursing home residents.     

The Use of Chemical Restraints for Older Long-Term Hospital Patients: A Case Report from Finland

The purpose of this study was to describe the use and concomitant use of psychotropics and other drugs as chemical restraints in the aged in long-term hospital care. The study consisted of 154 patients (42 men, 112 women) hospitalized in five long-term care wards in Pori City Hospital, Finland. Three or more psychotropics were regularly given to 33% of the patients and regularly or irregularly to 53% of the patients. Two or more benzodiazepine derivatives or related drugs were regularly given to 24% of the patients and regularly or irregularly to 46% of the patients. The very poor cognitive and functional abilities of the patients, the common concomitant use of psychotropic drugs, the use of psychotropics to control the behavior of the patients, and the lack of documentation of the effects and side effects of the drugs give rise to the conclusion that psychotropics were used as chemical restraints in these long-term care wards.     

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.     

Quality indicator survey versus traditional survey in New York State: a comparison of results from annual nursing home surveys

Despite the passage of OBRA’87 for nursing home reform, concerns about care in facilities continue. The Centers for Medicare and Medicaid developed new regulations and the Traditional Survey (TS) process for annual nursing home survey. The survey is conducted by state regional offices to determine facility compliance with federal regulations. Despite the regulations and new survey process, the TS inconsistently identified problems. A computerized process called the Quality Indicator Survey (QIS) was subsequently developed. This study was designed to compare results from TS and QIS on overall deficiencies, select quality indicators, high-severity deficiencies, and severity differences of seven quality indicators in New York State over a 6-year period from 2010 through 2015. Results of t-tests determined a significant difference in the overall mean number of deficiencies (p < .001), and on four indicators: choices (p < .001), nursing staff (p < .001), dental (p < .001), and dignity (p < .05). Facilities using the TS showed a higher mean number of harm level or higher deficiencies (p < .001). Chi-square tests for severity levels showed significantly more higher severity deficiencies on two quality indicators: nutrition (p < 0.001) and hydration (p < 0.05). Thus, the QIS produced a greater mean number of deficiencies, while TS produced more higher severity deficiencies in New York State.     

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.     

“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.     

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.     

Monitoring Quality of Care in Residential Care for the Elderly: The Information Challenge

This study assesses the administrative data compiled on residential care facilities for the elderly (RCFEs) by the state of California and considers the feasibility of their adaptation into a comprehensive information system. Required state RCFE reporting forms were reviewed for potential data elements. Recording and reporting variation was evaluated using a stratified probability sample of 340 facilities licensed in Northern and Central California. Stratification was by facility size and state district office. Data collection included a 5-year retrospective review of forms and documents in each facility's public file. Little of the information required from RCFEs is computerized. Most of it is maintained at the individual facility and not included in public files. Basic information, while included in the public file, is commonly either not available or not current. Resident characteristics and outcomes are not compiled, except indirectly in citations. The information required from RCFEs, if appropriately compiled and maintained, would produce a comprehensive quality assurance system and more effectively support consumer information and policy needs.     

The Presence of Memory-Enriched Environments for Cognitively Impaired Nursing Home Residents

Abstract

Enriched living environments that contain a wide array of personal memorabilia and memory-stimulating cues have the potential to support cognitive functioning. The purpose of this ethnographic research was to describe the care environments of older adults with cognitive impairment living in nursing homes (n?=?42), to evaluate the degree to which these environments contained memory-stimulating cues, and to understand the extent to which these environments were cognitively stimulating for older adults with dementia. Results indicated varying levels of enrichment both within and between homes, with nearly a quarter of the residents living in environments that contained no memory-enhancing stimuli.     

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.     

Predictors of Nursing Home Admission: A Social Work Perspective

Abstract

Institutionalisation of geriatric patients is a growing trend in ageing societies, such as Singapore. Earlier studies focused on the sociodemographic profile and attributes of nursing home residents and applications, but neglected to address the predictors of nursing home admission from a social work perspective. The present retrospective study identifies independent risk factors that predispose a patient to a nursing home discharge from a general rehabilitation ward in a community hospital in Singapore, with a multidisciplinary emphasis on clinical intervention. Factor analysis results reinforced findings that functional impairment and dementia are consistent predictors of nursing home admission. Multivariate logistic regression analysis showed that positive predictors of nursing home admission include older age, length of hospital stay, low socioeconomic status, dementia, and functional disability. Social work interventions include early referrals to the medical social worker, so that options for social and family support can be explored prior to deciding to place patients in a nursing home. Other interventions include suitable family therapy and counselling for patients and their families.