Examining the Nursing Home Physical Environment Through Policy-Driven Culture Change

A critical need exists to challenge approaches to nursing home care due to rigid organizational factors and hospital-like culture. It has been argued that resident care needs to move toward a person-centered approach by addressing the organizational, social, and physical environments in nursing home facilities, a process often known as culture change. In response to this need, the Centers for Medicare & Medicaid Services (CMS) has created funding for pay for performance (P4P) nursing home incentive programs to allow nursing home providers to receive CMS reimbursements for culture change in the facilities. Through care staff interviews, site observations, and a document review, this qualitative study assesses the impact of a Midwestern state P4P incentive program in three participating nursing homes. Using an environment and behavior (E-B) policy orientation framework, this study examines culture change through a focus on policy, the physical environment, place attachment, and social and psychological processes in the study settings.     

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.     

Family members’ experiences and management of resident-to-resident abuse in long-term residential care

ABSTRACT

Objectives: Resident-to-resident (RRA) abuse is increasingly recognized as a significant problem in long-term residential care.Families have a constant presence in this setting, yet their inclusion in research about RRA is minimal. The purpose of this study was to examine family members’ experiences and management of RRA. Methods: The methodology was critical ethnography.Twelve family members participated in in-depth interviews and 56 hours of participant observation were conducted. Data were analyzed thematically. Results: The main themes illuminate families’ experiences of RRA in a context that largely normalizes it.In the absence of formal supports, families developed a range of management strategies, ranging from passive to active intervention.Organizational factors, such as staffing levels and mix, and the physical environment also contributed to RRA. Discussion: Families are actively managing RRA in long-term residential care. Policies and programs, including educational supports, should be developed to validate and support families.     

Developing a Research Agenda on Resident-to-Resident Aggression: Recommendations From a Consensus Conference

This article provides an overview of the development of a research agenda on resident-to-resident aggression (RRA) in long-term care facilities by an expert panel of researchers and practitioners. A 1-day consensus-building workshop using a modified Delphi approach was held to gain consensus on nomenclature and an operational definition for RRA, to identify RRA research priorities, and to develop a roadmap for future research on these priorities. Among the six identified terms in the literature, RRA was selected. The top five priorities were: (a) developing/assessing RRA environmental interventions; (b) identification of the environmental factors triggering RRA; (c) incidence/prevalence of RRA; (d) developing/assessing staff RRA education interventions; and (e) identification of RRA perpetrator and victim characteristics. Given the significant harm RRA poses for long-term care residents, this meeting is an important milestone, as it is the first organized effort to mobilize knowledge on this under-studied topic at the research, clinical, and policy levels.     

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.     

Family Members' Reports of Abuse in Michigan Nursing Homes

The objective of this article is to describe abuse and neglect of adults age 65 and older in Michigan nursing homes, as reported by members of their families. Using list-assisted random-digit dialing, data on abuse and neglect for a 12-month period were collected from individuals who had a relative age 65 or older in a Michigan nursing home. Of the nursing home residents represented in this analysis, the majority were female, Caucasian, and widowed. Neglect and caretaking mistreatment were the most frequent types of abuse reported. Comparison of these data with data from the National Ombudsman Reporting System suggests that family members constitute a sensitive source of data on abuse in nursing homes.     

Job demands,emotional dissonance and elderly abuse: The moderating role of organizational resources

ABSTRACT

The present study focuses on elderly abuse committed by caregivers in nursing homes. It aimed at a better understanding of neglect and abusive behaviors by considering the working context and the emotional dissonance of these professionals. To achieve this goal, direct effects of emotional dissonance, job demands (workload and emotional demands) and organizational resources (high-quality relationships with the colleagues and the supervisor) on neglect and abusive behaviors were analyzed. Moreover, the moderating role of organizational resources was explored. The study was conducted among 481 nurses and healthcare assistants from different French nursing homes. Overall, results contributed to the literature by pointing out the impact of emotional dissonance and caregivers’ working context on neglect and abusive behaviors. Moreover, results highlighted the moderating effect of high-quality relationships with the colleagues and the supervisor and give rise to potential implications in preventing elderly abuse in nursing homes.     

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.     

Neglect of older adults in Michigan nursing homes

Although research on domestic elder abuse and neglect has grown over the past 20 years, there is limited research on elder neglect in nursing homes. The purpose of this study is to estimate the incidence of elder neglect in nursing homes and identify the individual and contextual risks associated with elder neglect. Data came from a 2005 random digit dial survey of individuals in Michigan who had relatives in long term care. Our analytic sample included 414 family members who had a relative aged 65 or older in nursing homes. Results showed that about 21% of nursing home residents were neglected on one or more occasion in the last 12 months. Two nursing home residents' characteristics reported by family members appear to significantly increase the odds of neglect: functional impairments in activities of daily living and previous resident-to-resident victimization. Behavior problems also are associated with higher odds of neglect (p = 0.078). Policy implications of these results are discussed.     

The Centers for Medicare and Medicaid Services' Nursing Home Case-Mix and Quality Demonstration: a descriptive overview

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 NHCMQDemonstration 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.     

The Long-Term Care Ombudsman Program and Complaints of Abuse and Neglect:

This historical summary demonstrates that concern about elder abuse and neglect in long-term care facilities has played a vital role in the development and expansion of the Long-Term Care Ombudsman Program (LTCOP). Some 15 years after the Older Americans Act mandated ombudsman services in all nursing homes, the 1989-1990 state LTCOP reports were analyzed for information about abuse and neglect of elders in nursing homes nationwide. Following a brief review of the nursing home abuse literature, this paper reports on the findings from the 1989-90 reports about complaints of abuse and neglect and their implications for future research.     

Effects of a multimodal activation program (SimA-P) in residents of nursing homes

Is it possible to maintain or even enhance functional and cognitive independence in residents of nursing homes? Little is known about the potentials and limits of therapeutic methods designed to maintain independence in elderly people already in need of residential nursing care. The aim of the “Rehabilitation in Nursing Homes” research project was to determine the practicability and effectiveness of a rehabilitative approach targeting residents of nursing homes. The main objectives of the activation program were to maintain and enhance residents’ cognitive and functional autonomy. Data on psychological, functional, and medical variables were obtained from a sample of 294 nursing home residents (age range?=?70–99 years) at three points of measurement over a 12-month period. The intervention approach draws on the theoretical and practical findings of the SimA Study (“Bedingungen der Erhaltung und Förderung von Selbstständigkeit im höheren Lebensalter,” “conditions on maintaining and supporting independent living in old age”; Oswald et al., Z. Gerontopsychol. Psychiatr., 15:61–84, 2002, Z. Gerontopsychol. Psychiatr., 15:13–31, 2002) and incorporates the results of recent therapeutic and rehabilitative studies in the fields of geriatrics and gerontopsychiatry. The intervention involves a combined program of cognitive and physical activation. An alternative program based on biographical information was designed specifically for residents with dementia. Results show that the intervention had significant effects on cognitive and functional parameters. Moreover, transfer effects were observed with respect to activities of daily living and frequency of falls.     

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.     

Family Support in Nursing Homes Serving Residents with a Mental Health History

Using 2003 nursing home data from the Minimum Data Set (MDS) database, this study investigated the role of family support among nursing homes serving residents with a mental health history. Exploratory factor analysis was used to create and test a conceptual model of family support using indicators located within the MDS database. Families were found to be in regular contact with their relatives and supportive of their care. In nursing homes, daily contact, an ongoing relationship, involvement in assessment, and being responsible for the resident constitute the model family support. This study advances the understanding of family support in nursing homes and conveys information to guide practice through proposing ways to enhance family support and involvement in nursing homes.     

The “Our Homes,Not Nursing Homes” Project

ABSTRACT

The voices of non-elderly adults with disabilities who currently-or used to-reside in nursing homes are rarely heard. A grassroots disability advocacy organization conducts participatory action research in the form of a writing workshop in collaboration with a local community-college. Participants with disabilities describe their lives and their experiences in nursing homes with the help of volunteer scribes. The information provided in their accounts will help strengthen community-organizing efforts of the disability advocacy organization. And participants have been empowered by the realization that their life stories are helping others to leave nursing homes and join community settings.     

A troubling triangle. An exploration of loneliness, helplessness, and boredom of residents of a veterans home

1. Lack of companionship, no opportunity to care for others, and little variety result in the problems of loneliness, helplessness, and boredom for many nursing home residents. 2. Loneliness, helplessness, and boredom may be even greater challenges than physical and functional problems for individuals in nursing homes. 3. Through clinical research and practice innovations, nursing has an opportunity to take a leading role in increasing information about emotional and functional issues that affect the quality of life for nursing home residents.