Addressing the nutritional needs of older people in residential care homes

In the UK and Europe, malnutrition in older people is a significant and continuing problem. Malnutrition predisposes to disease, impedes recovery from illness, increases mortality and is costly to society. Despite the high number of older people potentially at risk, malnutrition in care homes has been under explored. There is concern that national guidelines regarding the nutritional care of older people in residential care homes are not always implemented. This qualitative study explored the factors that influence the nutritional care provided to residents in two different types of local authority residential care homes (providing personal care) in Wales. One home had communal dining rooms; the other had eight bedded units with their own kitchen and dining facilities. The sample of 45 participants, comprised 19 staff (managers, care and catering staff), 16 residents and 10 residents' relatives. Data were collected using semi-structured interviews, focus groups, observation and documentary review between August 2009 and January 2010. This paper focuses on how staff assessed and addressed residents' nutritional needs. In both care homes, staff strove to be responsive to residents' dietary preferences, provided person-centred care and worked in partnership with residents and their families to provide nutritious food in a homely environment. Neither home conducted nutritional screening to identify those at risk of malnutrition, contrary to national guidelines, but relied on ad hoc observation and monitoring. The staff's knowledge of special dietary needs was limited. A need for further training for care home staff regarding the importance of nutrition in maintaining health in older people, use of nutritional screening and special dietary needs was identified. Shared nutrition training between health and social care staff needs expansion and policy implications in terms of an enhanced regulatory focus on maintaining nutritional needs in care homes are proposed.     

HIV/AIDS and long-term care: A state perspective

Long-term care services for people with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) were fostered in New York State by passage of HIV-specific regulations that set program standards and authorized reimbursement rates sufficient to support these standards. A rapid expansion of HIV-specific capacity has occurred. Demographic and selected clinical characteristics of the populations in AIDS residential health care facilities and AIDS adult day health care programs in New York State are presented. Aspects of the service models for these two program types that have changed to meet new needs are discussed. Ms. Chorost is from the Chronic Care Section, Division of HIV Health Care, AIDS Institute; Dr. Chesnut is from the Information Systems Office of the AIDS Institute.     

The experiences of non-medical health professionals undertaking community-based health assessments for people aged 75 years and over

Our objective was to explore the perceptions of allied health professionals who conducted over 3000 home-based health assessments within the general-practice-dominated Australian primary healthcare system. A series of semistructured qualitative interviews were carried out within the Department of Veterans' Affairs 'Preventive Care Trial', where health assessments are undertaken by health professionals in the homes of participating veterans and war widows. Health professionals were employed within the Preventive Care Trial to conduct assessments in 10 areas of New South Wales and Queensland. Subjects were mainly registered nurses, but also included a social worker, an occupational therapist, a physiotherapist and a psychologist. The health professionals described positive attitudes towards the health assessments, and showed that they have the broad range of necessary personal and professional skills to undertake them. Home visits were seen as an essential component and the most useful aspects included direct observation of home safety and medications. This study demonstrates that health assessments for older people can be acceptably and competently undertaken by suitably qualified allied health professionals, and that an effective collaborative approach to patient care can be achieved through such a system.     

Examining day centre provision for older people in the UK using the Equality Act 2010: findings of a scoping review

This article reports the findings from a literature review of day care services undertaken during March–June 2012 and repeated in May 2013. The databases searched included AgeInfo, Embase, Medline, PsycINFO, Social Care Online, Web of Science and the publication platform Ingenta Connect as well as specialist older people's sites. It discusses these findings in the context of services for older people in the UK, defined as those aged 65 years and over. The aim of the scoping review was to identify what is known about how day services (here confined to congregate day care or day centres) will meet the challenges posed by the Equality Act 2010 in supporting different user groups, such as lesbian, gay, bisexual and transgender older people or older people from minority ethnic groups. The review found that research on all aspects of day services was limited and that information about older people using such services was often provided context‐free. It concludes that those funding or evaluating day services' support to diverse groups of older people need to urgently address matters such as differential access and differential views about specific services.     

Organizational Leadership For Building Effective Health Care Teams

The movement toward accountable care organizations and patient-centered medical homes will increase with implementation of the Affordable Care Act (ACA). The ACA will therefore give further impetus to the growing importance of teams in health care. Teams typically involve 2 or more people embedded in a larger social system who differentiate their roles, share common goals, interact with each other, and perform tasks affecting others. Multiple team types fit within this definition, and they all need support from leadership to succeed. Teams have been invoked as a necessary tool to address the needs of patients with multiple chronic conditions and to address medical workforce shortages. Invoking teams, however, is much easier than making them function effectively, so we need to consider the implications of the growing emphasis on teams. Although the ACA will spur team development, organizational leadership must use what we know now to train, support, and incentivize team function. Meanwhile, we must also advance research regarding teams in health care to give those leaders more evidence to guide their work.     

In 2011 nearly one-third of physicians said they would not accept new medicaid patients, but rising fees may help

When fully implemented, the Affordable Care Act will expand the number of people with health insurance. This raises questions about the capacity of the health care workforce to meet increased demand. I used data on office-based physicians from the 2011 National Ambulatory Medical Care Survey Electronic Medical Records Supplement to summarize the percentage of physicians currently accepting any new patients. Although 96?percent of physicians accepted new patients in 2011, rates varied by payment source: 31?percent of physicians were unwilling to accept any new Medicaid patients; 17?percent would not accept new Medicare patients; and 18?percent of physicians would not accept new privately insured patients. Physicians in smaller practices and those in metropolitan areas were less likely than others to accept new Medicaid patients. Higher state Medicaid-to-Medicare fee ratios were correlated with greater acceptance of new Medicaid patients. The findings serve as a useful baseline from which to measure the anticipated impact of Affordable Care Act provisions that could boost Medicaid payment rates to primary care physicians in some states while increasing the number of people with health care coverage.     

How the Affordable Care Act can help move States toward a high-performing system of long-term services and supports

The United States may advance toward a high-performing health care system that offers long-term services and supports for people with disabilities and chronic conditions, or it may retreat from gains achieved in recent years. Since the 1980s, policy makers and advocates for the disabled have sought to move from a system that emphasizes nursing homes and institutional care to one that includes a broader range of care options. The Affordable Care Act of 2010 gives this movement a considerable boost by offering states timely new options and enhanced federal funding to create a care system that meets the diverse needs and preferences of people with disabilities and that also recognizes the role of family caregivers. In this paper we outline the five key characteristics of a high-performing system of long-term services and supports. We describe an emerging "scorecard" that could help measure states' progress toward this goal. And we itemize aspects of the Affordable Care Act intended to support the creation of such a high-performing system for the disabled and those with chronic conditions.     

Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system

The Affordable Care Act, along with Medicaid expansions, offers the opportunity to redesign the nation's highly flawed mental health system. It promotes new programs and tools, such as health homes, interdisciplinary care teams, the broadening of the Medicaid Home and Community-Based Services option, co-location of physical health and behavioral services, and collaborative care. Provisions of the act offer extraordinary opportunities, for instance, to insure many more people, reimburse previously unreimbursed services, integrate care using new information technology tools and treatment teams, confront complex chronic comorbidities, and adopt underused evidence-based interventions. The Centers for Medicare and Medicaid Services and its Center for Medicare and Medicaid Innovation should work intensively with the states to implement these new programs and other arrangements and begin to fulfill the many unmet promises of community mental health care.     

What types of home are closing? The characteristics of homes which closed between 1996 and 2001

Closures of care homes have received considerable public attention. Fee levels and the cost of upgrading homes to meet the national minimum standards have been identified as the main factors influencing closures. The present paper compares private residential homes, dual‐registered homes and nursing homes for older people which have closed between 1996 and 2001 with homes which have remained open. Homes which closed tended to be: smaller; to have had lower occupancy levels in 1996; to be the only home run by the organisation; to occupy converted buildings; to occupy multi‐storey buildings, and if so, to have no lift; to have more shared bedrooms; and to have en suite facilities in none or only some of the bedrooms. These factors were interrelated and the effect of these variables in combination was examined using multivariate (logistic regression) analysis. Among the homes which remained open, only 34% provided at least 80% of places in single rooms, which was to have become the national minimum standard for existing homes until the standards were amended in March 2003. A separate analysis of data on social climate found that the homes with a more positive social environment were those most likely to have closed. The findings support the view that there is likely to be an increase in the importance of homes run by corporate providers relative to homes run as single, owner‐managed homes, with a consequent reduction in choice for potential residents. At the same time, projections of future demand in a range of countries indicate that a considerable increase in provision will be required to meet the expected growth in the population of dependent older people, while developments in alternative forms of accommodation are unlikely to meet the growth in demand in the foreseeable future.     

The Care Span: Medicaid savings resulted when community health workers matched those with needs to home and community care

The Affordable Care Act of 2010 builds on earlier efforts to expand home and community-based alternatives to institutional long-term care. Identifying people living in the community who have unmet long-term care needs and who may be at risk for entering nursing homes may be crucial to these efforts. The Arkansas Community Connector Program used specially trained community health workers to identify such people in three disadvantaged counties and connect them to Medicaid home and community-based services. The result was a 23.8?percent average reduction in annual Medicaid spending per participant during the period 2005-08. Net three-year savings to the Arkansas Medicaid program equaled $2.619?million. Similar interventions may help other localities achieve cost-saving and equitable access to publicly funded long-term care options other than institutional care.     

Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician,Registered

The Academy of Nutrition and Dietetics (Academy) is the world’s largest organization of food and nutrition professionals and the association that represents credentialed nutrition and dietetics practitioners—nutrition and dietetics technicians, registered (NDTRs) and registered dietitian nutritionists (RDNs). An NDTR’s scope of practice in nutrition and dietetics has flexible boundaries to capture the depth and breadth of the individual's practice. The NDTR’s practice expands with advances in many areas, including nutrition, food production, food safety, food systems management, health care, public health, community health, and information and communication technology. The Revised 2017 Scope of Practice for the NDTR reflects the position of the Academy on the essential role of the NDTR in the management and delivery of food and nutrition services. The scope of practice for the NDTR is composed of education and credentialing, practice resources, Academy Standards of Practice and Standards of Professional Performance, codes of ethics, accreditation standards, state and federal regulations, national guidelines, and organizational policy and procedures. The Revised 2017 Scope of Practice for the NDTR is used in conjunction with the Revised 2017 Standards of Practice in Nutrition Care and the Standards of Professional Performance for NDTRs. The Standards of Practice address activities related to direct patient and client care. The Standards of Professional Performance address behaviors related to the technical role of NDTRs. These standards reflect the minimum competent level of nutrition and dietetics practice and professional performance for NDTRs. A companion document addresses the scope of practice for the RDN.     

Risks to home care workers: Professional perspectives

Care at home is fundamental to community care policy, but the simultaneous growth of health and safety regulation has implications for home care services because of the duty of employers towards home care workers. This grounded theory study set in Northern Ireland used data from 19 focus groups and nine semi-structured interviews with a range of health and social services professionals and managers to explore perspectives on planning long term care for older people. Home care workers faced a wide range of hazards in the homes of clients, who themselves were faced with adapting their living habits due to their changing health and care needs and ‘risks.’ Creative approaches were used to ensure the health and safety of home care workers and simultaneously to meet the choices of clients. Staff experienced feelings of conflict when they judged it necessary to impose their way of providing home care and thus impose their values on clients to create a safe working environment. There was variation between and within organizations in terms of the staff focus on client needs or on their employer responsibility towards home care workers. The planning of home care services must take account of both the choices of clients and the hazards facing home care staff.     

Despite obstacles, considerable potential exists for more robust federal policy on community development and health

The implementation of the Affordable Care Act of 2010 and the Obama administration's urban policy create an opportunity to link community development with health in new and powerful ways. The administration's policy emphasizes improved access to and quality of care through coordinated local and regional approaches, expansion of access to healthy food, and the support of environmental health-including clean air, water, and soil-and healthy homes. New federal programs, such as the Affordable Care Act's Community Transformation Grants, seek to prevent death and disability through policy, environmental, programmatic, and infrastructure changes. But fragmented congressional jurisdiction and budget "scoring" rules pose challenges to needed reform. We argue that government agencies need to adopt so-called systems of innovation, or organizational practices and support mechanisms that seek continuously to test new models, refine promising ones, bring to scale those that work best, and restructure or terminate what does not. We also argue that a strong and well-focused policy advocacy coalition is needed to help drive reform focused on the social determinants of health.     

Older adults living in social housing in Canada: the next COVID-19 hotspot?

Older adults in social housing have high rates of chronic diseases and live in clustered housing, creating the ideal situation for a tragic outbreak in this vulnerable population, which has been largely unrecognized in the public health discourse. It is estimated that two thirds of this population have cardiometabolic conditions that put them at higher risk of poor outcomes from COVID-19. In addition, their social isolation, low mobility, low health literacy, and limited internet access are barriers to accessing basic needs, health information, and health care in a Canadian context where many services have moved to virtual platforms. Since older adults in social housing tend to be clustered in apartment buildings with shared facilities, there is an increased risk of exposure through common spaces (e.g., elevator, laundry room) and high-touch surfaces. Compared to long-term care homes, there is substantial movement in and out of social housing buildings as residents are required to go out to meet their basic needs and individuals providing support enter the buildings without screening (e.g., personal support workers, volunteers delivering groceries). Without a targeted public health strategy to support this vulnerable population, we surmise that social housing will be the next COVID-19 hotspot.     

Bed-blocking. Discharge of the late brigade

Delayed discharges are seen as a litmus test for how the whole health and social care system is working. The problem has been exacerbated by delays in developing intermediate care schemes. There has been less use of the private nursing homes for intermediate care than envisaged a year ago, possibly because of NHS concerns about standards. More support should be given to people with chronic conditions to keep them out of hospital.     

Choosing and paying for care

This paper presents data from before and after implementation of the 1990 NHS and Community Care Act in 1993. It shows the low proportions of the population who are covered by private health insurance and draws attention to the fact that, although some older people have considered private health insurance, few are covered. Comparing data for people aged <65 with those aged >65, the paper explores the preferred sources of help in a range of situations. The findings show that in most instances, statutory services are preferred. Data for older people aged >80 are presented comparing findings from 1990/91 and 1995, which show that use of services for which charges have been introduced appear to have fallen. Low take-up of dental and optician services are identified. The implications of the findings for social policy are considered and it is suggested: that insurance cover for long-term care should be organized at a national level; that greater attention should be given to service preferences of users and potential users; and, that the effectiveness of various health and social care services should be evaluated.     

Why are some care homes better than others? An empirical study of the factors associated with quality of care for older people in residential homes in Surrey,England

This paper reports an empirical study that investigated associations between the quality of care received by older people in residential settings and features of the care homes in which they live. Data were gathered from the first announced inspection reports (2002–2003) of all 258 care homes for older people in one county of England (Surrey). The number of inspected standards failed in each home was used as the main indicator of quality of care. Independent variables (for each home) were: size, type, specialist registration, on‐site nursing, ownership, year registered, location, maximum fee, vacancies, resident dependency, whether the home took publicly funded residents, care staff qualifications and managerial quality. Quality of care was modelled using a Poisson count maximum likelihood method based on 245 (91%) of the inspected homes for which relevant data were available. The results showed that quality of care (as defined by failures on national standards) was statistically associated with features of care homes and their residents. A higher probability of failing a standard was significantly associated with being a home that: was a for‐profit small business (adjusted risk ratio (RR) = 1.17); was registered before 2000 (adj. RR = 1.22), accommodated publicly funded residents (adj. RR = 1.12); was registered to provide nursing care (adj. RR = 1.12). Fewer failures were associated with homes that were corporate for‐profit (adj. RR = 0.82); held a specialist registration (adj. RR = 0.91); charged higher maximum fees (adj. RR = 0.98 per 100 pound sterling unit). A secondary analysis revealed a stronger model: higher scores on managerial standards correlated with fewer failures on other standards (r = 0.65, P < 0.001). The results of this study may help inform future policy. They are discussed in the context of alternative approaches to measuring quality of residential care, and in terms of their generalisability.     

Management of pain in older people within the nursing home: a preliminary study

The provision of continuing care for older people has largely shifted from the hospital setting to the community, and nursing homes increasingly provide support for older people, many of whom exhibit multiple pathology and complex health and social care needs. However, the quality of pain management within this setting has been identified as an issue of concern. It has been estimated that approximately two-thirds of people aged 65 years and over experience chronic pain, and that the prevalence of chronic pain in nursing home residents is between 45% and 80%. However, there exist a number of barriers to the identification and management of chronic pain among older people resident in nursing homes, including sensory impairments in older people themselves and educational deficits among professionals. Such barriers need to be overcome if pain management is to be improved. The present study involved administering a pre-piloted postal questionnaire to the managers of 121 nursing homes within a geographically defined area. Sixty-eight (56%) were completed and returned. The questionnaire broadly covered the following: prevalence of chronic pain and use of interventions; assessment and management strategies; education and training; and communication barriers. Overall, 37% of nursing home residents were identified as experiencing chronic non-malignant pain (pain lasting longer than 3 months not caused by cancer) and 2% were reported as experiencing chronic malignant pain (pain lasting for more than 3 months caused by cancer). Paracetamol was identified as the most 'often' used analgesia for both pain modalities. Sixty-nine per cent of nursing homes did not have a written policy regarding pain management and 75% did not use a standardised pain assessment tool. Forty-four per cent of nursing homes provided education or training sessions for qualified staff and 34% provided this for care assistants. Forty per cent of qualified staff and 85% of care assistants had no specialist knowledge regarding the management of pain in older people. The present study confirms the need for the development of effective pain management strategies underpinned by appropriate training and education in order to meet the particular needs of older people.     

Defining a minimum income for healthy living (MIHL): older age, England

BACKGROUND: Worldwide biomedical and social research is providing evidence on the personal requirements for health and well-being. Assessment of the minimum personal costs entailed in meeting these requirements is important for the definition of 'poverty'. Barriers to health must arise if income is below this level. We demonstrate the principle of such assessment for people aged 65 years plus without significant disability living independently in England. METHODS: Current best evidence on the needs for healthy living was derived for nutrition, physical activity, housing, psychosocial relations/social inclusion, getting about, medical care and hygiene. We used conclusions of expert reviews, published research and where necessary, our judgement. This knowledge was translated into presumptively acceptable ways of living for the specified population. Current corresponding minimal personal costs were assessed from familiar low cost retailers/suppliers or, where unavoidable, from national data on the expenditure of low-income older people. RESULTS: Minimum income requirements for healthy living, MIHL, for this population in England is 50% greater than the state pension. It is also appreciably greater than the official minimum income safety floor (after means testing), the Pension Credit Guarantee; that will also have to meet any extra costs of disability. CONCLUSION: Objective evidence-based assessment of MIHL now is practicable but not presently as a basis of health and social policy in the UK or elsewhere apparently. Such assessment could also be an operational criterion of poverty and society's minimum income standards. The results suggest that inadequate income currently could be a barrier to healthy living for older people in England.