Partnership working by default: district nurses and care home staff providing care for older people

Older people residents in care homes that only offer residential care rely on primary healthcare services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary healthcare team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on‐site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community‐based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community‐based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.     

Perspectives on Parkinson Disease Care in Dutch Nursing Homes

Introduction

Parkinson's disease (PD) is a complex and disabling disorder. Ultimately, 20% to 40% of patients are admitted to a nursing home, and neurologists often lose track of these patients. Care and treatment of these institutionalized patients have not been addressed comprehensively, but anecdotal reports suggest it is suboptimal. We conducted a qualitative study to analyze the quality of PD care in Dutch nursing homes from the perspective of residents, caregivers, and health care workers.

Methods

Experiences and (unmet) needs of 15 nursing home residents with PD and parkinsonism (90% Hoehn and Yahr stage 4 and 5) and 15 informal caregivers were assessed using semistructured interviews. Furthermore, 5 focus group discussions were organized with 13 nurses and 22 other health care professionals to explore the experiences and barriers of PD care.

Results

Three core unmet needs were identified: (1) unsatisfactory empathy and emotional support, according to residents and informal caregivers; (2) insufficient staff knowledge on PD-related issues, such as motor fluctuations, leading to poorly timed administration of levodopa; (3) suboptimal organization of care with limited access to neurologists and specialized PD nurses.

Conclusions

PD care in Dutch nursing homes is suboptimal according to residents, informal caregivers, and health care workers. Three core areas for improvement were identified, including greater attention for psychosocial problems, improved PD-specific knowledge among nursing home staff, and better collaboration with hospital staff trained in movement disorders.     

Investigating the educational needs of licensed nursing staff and certified nursing assistants in nursing homes regarding end-of-life care

Nursing homes care for people at the end of life (EOL). There is evidence to suggest, however, that nursing staff in these settings is often unprepared to provide a high level of EOL care. This article reports the findings from three preliminary studies that investigated the needs of licensed staff and certified nursing assistants in nursing homes regarding EOL care. The studies involved needs assessment surveys, focus group interviews with staff members, and telephone interviews with nursing home administrators. Data show that the major needs included a lack of knowledge and skills in symptom management; communication difficulties; conflicts with families and physicians; and emotional distress in dealing with time constraints and attachment to residents. Implications for nursing home staff education are described.     

"I get to spend time with my patients": nursing home physicians discuss their role

OBJECTIVES: The purpose of this study was to learn about the role of the nursing home physician, and to begin to identify and articulate key concepts related to the role. DESIGN: A qualitative exploratory methodology was selected. Two medical students interviewed nursing home physicians in person, using open-ended questions. SETTING: The data reflect the nursing home setting. PARTICIPANTS: Twelve physicians who practice full-time or part-time in a nursing home setting were interviewed. Six physicians were fellowship trained and seven were affiliated with an academic medical center. Eight physicians were from an urban area, and four were from a rural area in a Midwestern state. MEASUREMENT: Qualitative data were grouped and coded to develop conceptual categories. RESULTS: Physicians were categorized as "pursuers, inheritors, or practice builders," based on their path to coming to care for nursing home residents. The medical directors among the physicians reported that their role was heavily dependent upon the desires of the nursing home administrator. Students were encouraged to visit many nursing homes to learn about the different ways in which the medical director role can be played out. Physicians reported positive aspects of their role including relationships with residents, families,staff; interesting and meaningful patient care; and autonomy. Less desirable aspects included: staff turnover, difficult expectations, and administrative issues. Although physicians indicated that social and indeed professional stigma are troublesome to people who work in nursing homes, they assured the medical student interviewer that caring for nursing home residents was gratifying and meaningful work. CONCLUSION: The need for physicians to care for the growing number of nursing home residents will continue for decades. Learning more about how physicians come to care for nursing home residents can be used to develop better ways to recruit, train, and retain physicians. Information about what nursing home physicians value about their role can be used to structure more desirable roles.     

Physician Availability in Long-Term Care and Resident Hospital Transfer: A Retrospective Cohort Study

ObjectivesTo investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations.DesignRetrospective cohort study.Setting and participants161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes.MethodsWe administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death.We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access.ResultsFifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED.The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P = .02) and 14% lower (rate ratio = 0.86, P = .07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access.Conclusions and implicationsResidents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates.     

Continuous Palliative Sedation Until Death: The Development of a Practice Protocol for Nursing Homes

ObjectivesChallenges inherent in the practice of continuous palliative sedation until death appear to be particularly pervasive in nursing homes. We aimed to develop a protocol to improve the quality of the practice in Belgian nursing homes.MethodsThe development of the protocol was based on the Medical Research Council Framework and made use of the findings of a systematic review of existing improvement initiatives and focus groups with 71 health care professionals [palliative care physicians, general practitioners (GPs), and nursing home staff] identifying perceived barriers to the use of continuous palliative sedation until death in nursing homes. The protocol was then reviewed and refined by another 70 health care professionals (palliative care physicians, geriatricians, GPs, and nursing home staff) through 10 expert panels.ResultsThe final protocol was signed off by expert panels after 2 consultation rounds in which the remaining issues were ironed out. The protocol encompassed 7 sequential steps and is primarily focused on clarification of the medical and social situation, communication with all care providers involved and with the resident and/or relatives, the organization of care, the actual performance of continuous sedation, and the supporting of relatives and care providers during and after the procedure. Although consistent with existing guidelines, our protocol describes more comprehensively recommendations about coordination and collaboration practices in nursing homes as well as specific matters such as how to communicate with fellow residents and give them the opportunity to say goodbye in some way to the person who is dying.Conclusions and ImplicationsThis study succeeded in developing a practice protocol for continuous palliative sedation until death adapted to the specific context of nursing homes. Before implementing it, future research should focus on developing profound implementation strategies and on thoroughly evaluating its effectiveness.     

Growth of Physicians and Nurse Practitioners Practicing Full Time in Nursing Homes

ObjectivesThe objective was to describe the growth of physicians, nurse practitioners (NPs), and physician assistants (PAs) who practice full time in nursing homes, to assess resident and nursing home characteristics associated with receiving care from full-time providers, and describe variation among nursing homes in use of full-time providers.DesignRetrospective cohort study.Setting and ParticipantsA 20% national sample Medicare data on long-term care residents in 2008 to 2018 and the physicians, NPs, and PAs who submitted charges to Medicare for their care.MethodsWe measured the percentage of provider charges for services rendered in nursing homes, in addition to resident and facility characteristics.ResultsFull-time nursing home providers increased from 26.0% of all nursing home providers in 2008 to 44.6% in 2017. The largest increase was in NPs: from 1986 in 2008 to 4479 in 2017. Resident age, sex, Medicaid eligibility, and race/ethnicity had minimal association with the odds of having a full-time provider, whereas residents with an NP primary care provider were 23.0 times more likely (95% confidence interval = 21.6, 24.6) to have a full-time provider. Residents who received care from both a physician and an NP or PA increased from 33.6% in 2008 to 62.5% in 2018. There was large variation among facilities in the percentage of residents with full-time providers, from 5.72% of residents with full-time providers in the bottom quintile of facilities to 91.44% in the top quintile. Individual nursing homes accounted for 59% of the variation in whether a resident had a full-time provider.Conclusions and ImplicationsThe percentage of nursing home residents with full-time providers continues to grow, with very large variation among nursing homes.     

Nursing Homes and End-of-Life Care in Japan

Objectives

To describe end-of-life care in Japanese nursing homes by comparing facility and characteristics of residents dying in nursing homes with those who had been transferred and had died in hospitals, and by comparing the quality of end-of-life care with hospitals and with their respective counterparts in the United States.

Setting

National sample of 653 nursing homes with responses from 371 (57%) on their facility characteristics, 241 (37%) on their resident characteristics, and 92 (14%) on the residents’ quality of life. All 5 hospitals in a city 80 miles from Tokyo cooperated.

Participants

Nursing home staff answered questionnaires on facility and resident characteristics. Resident level data were obtained from 1158. The questionnaire on the quality of care was responded to by 256 (63%) of the decedents’ families in nursing homes and 205 (48%) in hospitals.

Measurements

Facility characteristics included items on physicians, nurse staffing, and the facility’s end-of-life care policy. Resident characteristics included basic demographics, level of dementia, and resident’s and family’s preference for the site of death. The Toolkit was used to measure the quality of end-of-life care.

Results

The proportion of those dying within the nursing home was related to the facility’s policy on end-of-life care and the family’s preference. The quality of end-of-life care in nursing homes was generally better than in hospitals, and than in their respective counterparts in the United States.

Conclusion

Financial incentives by the Japanese government to promote end-of-life care in nursing homes may have contributed to increasing the proportion of deaths within the facility. The quality of care in nursing homes was evaluated as being better than hospitals.     

Physician care in assisted living: a qualitative study

OBJECTIVES: To identify patterns and emerging concepts used by assisted living (AL) residents, their families, and the facility staff to describe the care provided by physicians to the AL residents. DESIGN: Qualitative research and analysis based on audio-taped and transcribed ethnographic interviews with residents, family members, and staff of AL facilities. SETTING: Three AL facilities representing small and traditional AL facilities. PARTICIPANTS: Forty-three in-depth interviews including 16 AL residents, 13 family members, three facility managers, and 11 staff members. MEASUREMENTS: Ethnographic, audio-taped interviews coded by consensus by a doctoral-level analysis team. Coding focused broadly on any references to physicians or doctors in the interviews. RESULTS: Emergent themes included four major physician-related themes in AL including: magnification of physician authority; disagreements with physician care; physician communication; and continuity/discontinuity of physician care. CONCLUSION: Physicians caring for residents of AL facilities should consider how residents, families, and staff stakeholders may influence their patient care for AL residents in terms of their authority, decision-making, communication, and continuity of care.     

Association Between Clinician Specialization in Nursing Home Care and Nursing Home Clinical Quality Scores

ImportanceWhile the number of prescribing clinicians (physicians and nurse practitioners) who provide any nursing home care remained stable over the past decade, the number of clinicians who focus their practice exclusively on nursing home care has increased by over 30%.ObjectivesTo measure the association between regional trends in clinician specialization in nursing home care and nursing home quality.DesignRetrospective cross-sectional study.Setting and ParticipantsPatients treated in 15,636 nursing homes in 305 US hospital referral regions between 2013 and 2016.MeasuresClinician specialization in nursing home care for 2012–2015 was measured using Medicare fee-for-service billings. Nursing home specialists were defined as generalist physicians (internal medicine, family medicine, geriatrics, and general practice) or advanced practitioners (nurse practitioners and physician assistants) with at least 90% of their billings for care in nursing homes. The number of clinicians was aggregated at the hospital referral region level and divided by the number of occupied Medicare-certified nursing home beds. Nursing Home Compare quality measure scores for 2013–2016 were aggregated at the HHR level, weighted by occupied beds in each nursing home in the hospital referral region. We measured the association between the number of nursing home specialists per 1000 beds and the clinical quality measure scores in the subsequent year using linear regression.ResultsAn increase in nursing home specialists per 1000 occupied beds in a region was associated with lower use of long-stay antipsychotic medications and indwelling bladder catheters, higher prevalence of depressive symptoms, and was not associated with urinary tract infections, use of restraints, or short-stay antipsychotic use.Conclusions and ImplicationsHigher prevalence of nursing home specialists was associated with regional improvements in 2 of 6 quality measures. Future studies should evaluate whether concentrating patient care among clinicians who specialize in nursing home practice improves outcomes for individual patients. The current findings suggest that prescribing clinicians play an important role in nursing home care quality.     

Clinical findings associated with radiographic pneumonia in nursing home residents.

OBJECTIVE: Subtle presentation and the frequent lack of on-site physicians complicate the diagnosis of pneumonia in nursing home residents. We sought to identify clinical findings (signs, symptoms, and simple laboratory studies) associated with radiographic pneumonia in sick nursing home residents. STUDY DESIGN: This was a prospective cohort study. POPULATION: The residents of 36 nursing homes in central Missouri and the St. Louis area with signs or symptoms suggesting a lower respiratory infection were included. OUTCOME MEASURED: We compared evaluation findings by project nurses with findings reported from chest radiographs. RESULTS: Among 2334 episodes of illness in 1474 nursing home residents, 45% of the radiograph reports suggested pneumonia (possible=12%; probable or definite = 33%). In 80% of pneumonia episodes, subjects had 3 or fewer respiratory or general symptoms. Eight variables were significant independent predictors of pneumonia (increased pulse, respiratory rate =30, temperature =38 degrees C, somnolence or decreased alertness, presence of acute confusion, lung crackles on auscultation, absence of wheezes, and increased white blood count). A simple score (range = -1 to 8) on the basis of these variables identified 33% of subjects (score > or =3) with more than 50% probability of pneumonia and an additional 24% (score of 2) with 44% probability of pneumonia. CONCLUSIONS: Pneumonia in nursing home residents is usually associated with few symptoms. Nonetheless, a simple clinical prediction rule can identify residents at very high risk of pneumonia. If validated in other studies, physicians could consider treating such residents without obtaining a chest radiograph.     

Living and dying: responsibility for end‐of‐life care in care homes without on‐site nursing provision ‐ a prospective study

The aim of the study was to describe the expectations and experiences of end‐of‐life care of older people resident in care homes, and how care home staff and the healthcare practitioners who visited the care home interpreted their role. A mixed‐method design was used. The everyday experience of 121 residents from six care homes in the East of England were tracked; 63 residents, 30 care home staff with assorted roles and 19 National Health Service staff from different disciplines were interviewed. The review of care home notes demonstrated that residents had a wide range of healthcare problems. Length of time in the care homes, functional ability or episodes of ill‐health were not necessarily meaningful indicators to staff that a resident was about to die. General Practitioner and district nursing services provided a frequent but episodic service to individual residents. There were two recurring themes that affected how staff engaged with the process of advance care planning with residents; ‘talking about dying’ and ‘integrating living and dying’. All participants stated that they were committed to providing end‐of‐life care and supporting residents to die in the care home, if wanted. However, the process was complicated by an ongoing lack of clarity about roles and responsibilities in providing end‐of‐life care, doubts from care home and primary healthcare staff about their capacity to work together when residents’ trajectories to death were unclear. The findings suggest that to support this population, there is a need for a pattern of working between health and care staff that can encourage review and discussion between multiple participants over sustained periods of time.     

Physician practice patterns in nursing homes

This review of the literature describes models of physician practice in nursing homes including the barriers to increasing physician workforce in nursing homes and the impact of various physician practice models on quality of care in nursing homes. Traditional nursing home practice is first described followed by a review of the literature pertaining to nurse practitioners and physician assistants in nursing home practices, closed staffing models, managed care, and nursing home specialist models. Literature describing barriers to increasing the physician workforce in nursing homes is then presented including training, reimbursement, and malpractice insurance for physicians who work in nursing homes. Finally, the impact of physician practice models on quality of care is reviewed with a focus on frequency of visits, hospitalizations, cost-effectiveness, communication, and patient satisfaction.     

Does Universal Testing for COVID-19 Work for Everyone?

The Coronavirus disease 2019 (COVID-19) pandemic has been especially devastating among nursing home residents, with both the health circumstances of individual residents as well as communal living settings contributing to increased morbidity and mortality. Preventing the spread of COVID-19 infection requires a multipronged approach that includes early identification of infected residents and health care personnel, compliance with infection prevention and control measures, cohorting infected residents, and furlough of infected staff. Strategies to address COVID-19 infections among nursing home residents vary based on the availability for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests, the incorporation of tests into broader surveillance efforts, and using results to help mitigate the spread of COVID-19 by identifying asymptomatic and presymptomatic infections. We review the tests available to diagnose COVID-19 infections, the implications of universal testing for nursing home staff and residents, interpretation of test results, issues around repeat testing, and incorporation of test results as part of a long-term response to the COVID-19 pandemic. We propose a structured approach for facility-wide testing of residents and staff and provide alternatives if testing capacity is limited, emphasizing contact tracing. Nursing homes with strong screening protocols for residents and staff, that engage in contact tracing for new cases, and that continue to remain vigilant about infection prevent and control practices, may better serve their residents and staff by thoughtful use of symptom- and risk-based testing strategies.     

Easing the strain. The physician and the long-term care facility should work together to improve patient care

Numerous regulations, inadequate reimbursement, and poor communication can strain the physician--long-term care facility relationship. Three major roles define the physician's responsibilities in the nursing home: care giver, communicator, and complier. Although the physician's roles in the nursing home may be similar to those in an office practice, they can be complicated by a number of factors. Many professionals, such as the nutritionist, social worker, and pharmacist, care for the nursing home resident. The physician thus loses some control over the patient's care. Communication barriers, such as the nursing home's misinterpretation of federal regulations, can frustrate both the physician and the facility's medical staff. This can lead to suboptimal patient care. Nursing homes must ensure that they keep physicians who treat residents abreast of facility regulations and federal and state guidelines. Although a physician may want to continue providing care to a patient who has entered a long-term care facility, he or she may find it necessary to transfer care to the medical director or house physician. Often the time and distance a physician must travel prohibit the physician from giving patients the high-quality care to which they are entitled.     

A clinical pathway for treating pneumonia in the nursing home: part I: the nursing perspective

OBJECTIVES: This paper examines nursing staff's perspectives on the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia. DESIGN: A qualitative (case study) design was used. SETTING: Data were collected from 6 nursing homes in Southern Ontario (5 from metro regions and 1 from a nonmetro region). Nursing homes were drawn from a larger randomized controlled trial of a clinical pathway for nursing home-acquired pneumonia conducted between 2001 and 2005. The clinical pathway was designed to assist in the identification, diagnosis, and management of pneumonia, including a decision tool for determining the appropriate location of treatment (hospital versus nursing home). PARTICIPANTS: A total of 7 focus groups and 1 one-on-one interview were conducted between February 2003 and May 2004. Interview data were analyzed using the template style, described by Miller and Crabtree, to identify key themes. FINDINGS: Nurses strongly supported the idea of the clinical pathway and believed that providing pneumonia care in the nursing home was better for the resident. As a result of using the clinical pathway, nurses felt that pneumonia was being identified, diagnosed, and treated earlier, resulting in fewer hospitalizations. In addition to the benefits to resident care, the nurses felt that their skills and knowledge also improved. Nurses generally supported the implementation of the pathway although some concern was expressed about the additional responsibility and resources that would entail. CONCLUSIONS: The implementation of a clinical pathway for treating pneumonia in nursing homes and quick access to a backup clinician are desired by nurses who also believe it will result in better care and fewer hospitalizations of residents.     

Challenges in transitional care between nursing homes and emergency departments

OBJECTIVE: To obtain opinions of knowledgeable professionals involved in the emergency care of nursing home (NH) residents. DESIGN: Structured focus group interviews. PARTICIPANTS: Five provider categories, including NH staff, NH physicians and nurse practitioners, emergency medical services (EMS) providers, emergency department (ED) nurses, and ED physicians. SETTING: Two NHs, 2 EDs, and a county-wide EMS system. ANALYSIS: Audiotaped discussions were transcribed and analyzed independently by 2 authors. RESULTS: Themes included barriers to providing high-quality care, data needed when residents are transported in both directions between EDs and NHs, and possible solutions to improve care. Communication problems were the most frequently cited barrier to providing care. Residents are often transported in both directions without any written documentation; however, even when communication does occur, it is often not in a mode that is useable by the receiving provider. ED personnel need a small amount of organized, written information. When residents are released from the ED, NH personnel need a verbal report from ED nurses as well as written documentation. All groups were optimistic that communication can be improved. Ideas included use of (1) fax machines or audiotape cassette recorders to exchange information, (2) an emergency form in residents' charts that contains predocumented information with an area to write in the reason for transfer, and (3) brief NH-to-ED and ED-to-NH transfer forms that are accepted and used by local NHs and EDs. CONCLUSION: The transitional care of NH residents is laden with problems but has solutions that deserve additional development and investigation.