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.     

Bringing Assisted Living Services into Congregate Housing

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents—the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.     

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.     

Nursing Home Ownership

Abstract

Following the Second World War, the idea of the life course with distinct periods of education, work, and retirement became popular as a result of the alliance of interests of unions and management, with politicians seizing the opportunity to accommodate them. These “social partners” implemented benefit rules and created practices for using old age and disability to ease the exit of older workers. Although justifiable at the time, now those rules and practices hinder individual and employer incentives to invest in human capital and work environments that enable older workers to remain in the workforce. The article argues that the workforce environment of the coming half-century, which is relevant for persons born around 2000, is much different from that a hundred years earlier, which determined the opportunities for people born around 1900. People are healthier and live much longer and work environments are friendlier. The article argues that it is no longer justifiable to subsidize exit from the workforce around the age of 60 for healthy workers, especially in view of the coming labor shortage in Europe. It also argues that the introduction of the principles of the Swedish NDC pension reform in Europe would provide possibilities for flexible exit from the workforce and remove impediments to labor mobility in Europe, which are embedded in many of Europe's present pension arrangements.     

Perceptions of Institutional Elder Neglect in Civil Court

Perception of institutional elder neglect (IEN) in civil court was investigated. Experiment 1 participants (N = 162) read an IEN trial summary in which alleged victim testimony was presented or not. Victim testimony increased the likelihood of ruling for the plaintiff, partially mediated by credibility of witnesses for each side. Experiment 2 (N = 68) included a condition with testimony from the victim's floor-mate. Likelihood of ruling for the victim: victim = floor-mate > no testimony, was mediated by perceived credibility of the plaintiff's case. Results are discussed in terms of the importance of alleged victim testimony in IEN cases.     

Ethical challenges in researching in group homes for people with severe learning difficulties: shifting the balance of power

Our aim in this paper is to open up debate about informed consent. We do this by presenting stories from group homes where staff have frustrated our research efforts and marginalised the interests of people with severe learning difficulties. We problematise normative ethics and argue that in some circumstances the basic principle of informed consent should be waived for employees of human service organisations. We maintain that, in such circumstances, researchers and an organisation’s senior managers can still act in a manner that is consistent with the broad aims of ethical regulation. We consider the role of Research Ethics Committees and suggest that in order to fully consider the conflicting interests of multiple stakeholders, the application of different ethical theories is required. A requirement for making balanced ethical judgements is to see outside the extant dominant view of ethical research standards and behaviour.     

Social Work Student Interest in Nursing Home Employment: A North American Study

Nursing homes (NHs) are a primary setting for gerontological social work; yet, little is known about social workers' career interest relative to this setting. This article reports the findings of an online survey of social work students (177 US and 91 Canadian) that sought to identify personal characteristics and beliefs that influence NH employment intentions. Students who were enrolled in bachelors programs, lacked previous practice experience, and had already had a NH field placement or wanted this experience were more likely to express employment intent. The implications of these findings for social work education and research are discussed.     

福建省农村敬老院发展现状及对策研究

通过对福建省农村敬老院现状的调查,分析目前我省农村敬老院存在的入住率较低、运营资金困难等问题及其原因,以适度普惠为视角,从转变政府观念、加快立法、建立公共财政投入制度以及提升敬老院管理服务水平等方面入手,对福建省农村敬老院的发展提出建议。     

Multi-system factors impacting youth justice involvement of children in residential out-of-home care

Children placed in residential care are significantly over-represented in youth justice systems. Drawing on interviews and focus groups with service providers, this exploratory study examines practice factors that impact on the criminalization of this group of children across multiple services and systems, including in the residential care environment, police, lawyers, courts and youth justice systems, as well as multi-systems practice with this group in one Australian state. Positive outcomes were observed for children in residential care where well-functioning care teams existed, as well as for children in therapeutic residential care settings. However, clear limitations were identified across all phases of children's youth justice system involvement, including placement with offending peers, the criminalization of behaviours of concern, greater use of remand and detention, limited support to navigate legal and youth justice processes, challenges to service collaboration, and limited applicability of sentencing considerations. The findings indicate a pervasive level of systemic disadvantage for this group of children, and imply that a holistic strategy underpinned by affirmative action across several systems will be necessary to address the ongoing criminalization of children in residential care.