The Association Between Quality of Care and Quality of Life in Long-Stay Nursing Home Residents With Preserved Cognition

ObjectivesTo assess the overall quality of life of long-stay nursing home residents with preserved cognition, to examine whether the Centers for Medicare and Medicaid Service's Nursing Home Compare 5-star quality rating system reflects the overall quality of life of such residents, and to examine whether residents' demographics and clinical characteristics affect their quality of life.Design/measurementsQuality of life was measured using the Participant Outcomes and Status Measures—Nursing Facility survey, which has 10 sections and 63 items. Total scores range from 20 (lowest possible quality of life) to 100 (highest).Setting/participantsLong-stay nursing home residents with preserved cognition (n = 316) were interviewed.ResultsThe average quality- of-life score was 71.4 (SD: 7.6; range: 45.1–93.0). Multilevel regression models revealed that quality of life was associated with physical impairment (parameter estimate = −0.728; P = .04) and depression (parameter estimate = −3.015; P = .01) but not Nursing Home Compare's overall star rating (parameter estimate = 0.683; P = .12) and not pain (parameter estimate = −0.705; P = .47).ConclusionThe 5-star quality rating system did not reflect the quality of life of long-stay nursing home residents with preserved cognition. Notably, pain was not associated with quality of life, but physical impairment and depression were.     

Quality Clinical Care in Nursing Facilities

Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, and care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.     

The Association of Nursing Home Characteristics and Quality with Adverse Events After a Hospitalization

Background/ObjectivesWe previously found high rates of adverse events (AEs) for long-stay nursing home residents who return to the facility after a hospitalization. Further evidence about the association of AEs with aspects of the facilities and their quality may support quality improvement efforts directed at reducing risk.DesignProspective cohort analysis.Setting and Participants32 nursing homes in the New England states. A total of 555 long-stay residents contributed 762 returns from hospitalizations.MethodsWe measured the association between AEs developing in the 45 days following discharge back to long-term care and characteristics of the nursing homes including bed size, ownership, 5-star quality ratings, registered nurse and nursing assistant hours, and the individual Centers for Medicare & Medicaid Services (CMS) quality indicators. We constructed Cox proportional hazards models controlling for individual resident characteristics that were previously found associated with AEs.ResultsWe found no association of AEs with most nursing home characteristics, including 5-star quality ratings and the composite quality score. Associations with individual quality indicators were inconsistent and frequently not monotonic. Several individual quality indicators were associated with AEs; the highest tertile of percentage of residents with depression (4%-25%) had a hazard ratio (HR) of 1.65 [95% confidence interval (CI) 1.16, 2.35] and the highest tertile of the percentage taking antipsychotic medications (18%-35%) had an HR of 1.58 (CI 1.13, 2.21). The percentage of residents needing increased assistance with activities of daily living was statistically significant but not monotonic; the middle tertile (13% to <20%) had an HR of 1.69 (CI 1.16, 2.47).Conclusions and ImplicationsAEs occurring during transitions between nursing homes and hospitals are not explained by the characteristics of the facilities or summary quality scores. Development of risk reduction approaches requires assessment of processes and quality beyond the current quality measures.     

Quality Indicators of Primary Care Provider Engagement in Nursing Home Care

The initiative described here aims to identify quality indicators (QIs) germane to the international practice of primary care providers (PCP) in post-acute and long-term care in order to demonstrate the added value of medical providers in nursing homes (NHs). A 7-member international team identified and adapted existing QIs to the AMDA competencies for medical providers. QI sources included the ACOVE 3 Quality Indicators (2007), NH Quality Indicators (2004), NH Residential Care Quality Indicators (2002), and AGS Choosing Wisely (2014). We recruited a technical expert panel (TEP) consisting of 11 panelists from the US, Canada, and the European Union, selected for their knowledge and leadership in post-acute and long-term care. The TEP, using a RAND Modified Delphi approach, provided pre-meeting ratings, discussed items in-person for clarification, and re-rated items following discussion. When panelists rated more than 1 option for a particular QI as valid and feasible, the most stringent option was selected for inclusion in the final candidate set of QIs. Panelists confidentially rated an initial 103 items on validity and feasibility of implementation. During the meeting, panelists added 18 QIs and modified 18. In post-meeting analysis, we eliminated 7 QIs rated not valid and 11 QIs for which a more stringent QI was rated valid and feasible. This resulted in a final set of 95 QIs rated valid and feasible and 8 rated valid but not feasible. This set of QIs for PCPs in the NH identified practices in which provider engagement adds value through expertise in geriatric syndromes, employing evidence-based practice, advocating for residents, delivering person-centered care, facilitating advance care planning, and communicating effectively to coordinate care. Next steps include pilot testing and evaluating the association between adherence to QIs, PCP staffing models, and better outcomes.     

Frailty and Time at Home After Post-Acute Care in Skilled Nursing Facilities

ObjectivesTo examine the association of a claims-based frailty index with time at home, defined as the number of days alive and spent out of hospital or skilled nursing facility (SNF).DesignCohort Study.Setting and ParticipantsA 5% Medicare random sample of fee-for-service beneficiaries, who had continuous part A and B enrollment in the prior 6 months, that were discharged from a short SNF admission in 2014‒2016.MethodsFrailty was measured with a validated claims-based frailty index (CFI) (range: 0‒1, higher scores indicating worse frailty) and categorized into nonfrail (CFI <0.25), mild frailty (CFI 0.25‒0.34), and moderate-to-severe frailty (CFI ≥0.35). We measured home time in the 6 months following SNF discharge (range: 0‒182 days with higher values representing more days at home and thus a better outcome). We used logistic regression to assess the association between frailty and short home time, defined as <173 days, adjusting for age, sex, race, region, a comorbidity index, clinical SNF admission characteristics in the Minimum Data Set, and SNF characteristics.ResultsIn our sample of 144,708 beneficiaries (mean age, 80.8 years, 64.9% female, 85.9% white) who were discharged to community after SNF stay, the mean CFI was 0.26 (standard deviation, 0.07). The mean home time was 165.6 (38.1) days in nonfrail, 154.4 (47.4) days in mild frailty, 145.0 (52.0) days in moderate-to-severe frailty group. After full model adjustments, moderate to severe frailty was associated with a 1.71 (95% CI 1.65‒1.78) higher odds of having short time at home in the 6 months following SNF discharge.Conclusion and ImplicationsHigher CFI is associated with short time at home in Medicare beneficiaries who are discharged to the community after post-acute SNF stay. Our results support the utility of CFI in identifying SNF patients who need additional resources and interventions to prevent health decline and poor quality of life.     

One-Year Medical Utilization and Mortality in Home Health and Nursing Home Care Recipients from Northern Taiwan

ObjectivesHome health care (HHC) and nursing home care (NHC) are mainstays of long-term service in the aged population. Therefore, we aimed to investigate the factors associated with 1-year medical utilization and mortality in HHC and NHC recipients in Northern Taiwan.DesignThis study employed a prospective cohort design.Setting and ParticipantsWe enrolled 815 HHC and NHC participants who started receiving medical care services from the National Taiwan University Hospital, Beihu Branch between January 2015 and December 2017.MethodsMultivariate Poisson regression modeling was used to quantify the relationship between care model (HHC vs NHC) and medical utilization. Cox proportional-hazards modeling was used to estimate hazard ratios and factors associated with mortality.ResultsCompared with NHC recipients, HHC recipients had higher 1-year utilization of emergency department services [incidence rate ratio (IRR) 2.04, 95% CI 1.16-3.59] and hospital admissions (IRR 1.49, 95% CI 1.14-1.93), as well as longer total hospital length of stay (LOS) (IRR 1.61, 95% CI 1.52-1.71) and LOS per hospital admission (IRR 1.31, 95% CI 1.22-1.41). Living at home or in a nursing home did not affect the 1-year mortality.Conclusions and ImplicationsCompared with NHC recipients, HHC recipients had a higher number of emergency department services and hospital admissions, as well as longer hospital LOS. Policies should be developed to reduce emergency department and hospitalization utilization in HHC recipients.     

护理人员服务质量调查的实践与成效

介绍了按照《军队护理质量评价指标》中《护理人员服务质量民意调查表》拟定了各项服务项目对护士进行了评价,并在实践中不断总结经验,找出薄弱环节及缺陷,两次重新修订了标准,减少了评价的误差。同时还建立起了：重复反馈机制、全面泊励机制、良好的导向朵制,起到了强化护理人员的服务意识、提高护理质量、体现以病人为中心、促进医疗工作发展的作用。     

Identifying Urinary Tract Infection-Related Information in Home Care Nursing Notes

ObjectivesUrinary tract infection (UTI) is common in home care but not easily captured with standard assessment. This study aimed to examine the value of nursing notes in detecting UTI signs and symptoms in home care.DesignThe study developed a natural language processing (NLP) algorithm to automatically identify UTI-related information in nursing notes.Setting and ParticipantsHome care visit notes (n = 1,149,586) and care coordination notes (n = 1,461,171) for 89,459 patients treated in the largest nonprofit home care agency in the United States during 2014.MeasuresWe generated 6 categories of UTI-related information from literature and used the Unified Medical Language System (UMLS) to identify a preliminary list of terms. The NLP algorithm was tested on a gold standard set of 300 clinical notes annotated by clinical experts. We used structured Outcome and Assessment Information Set data to extract the frequency of UTI-related emergency department (ED) visits or hospitalizations and explored time-patterns in documentation of UTI-related information.ResultsThe NLP system achieved very good overall performance (F measure = 0.9, 95% CI: 0.87-0.93) based on the test results obtained by using the notes for patients admitted to the ED or hospital due to UTI. UTI-related information was significantly more prevalent (P < .01 for all the tests) in home care episodes with UTI-related ED admission or hospitalization vs the general patient population; 81% of home care episodes with UTI-related hospitalization or ED admission had at least 1 category of UTI-related information vs 21.6% among episodes without UTI-related hospitalization or ED admission. Frequency of UTI-related information documentation increased in advance of UTI-related hospitalization or ED admission, peaking within a few days before the event.Conclusions and ImplicationsInformation in nursing notes is often overlooked by stakeholders and not integrated into predictive modeling for decision-making support, but our findings highlight their value in early risk identification and care guidance. Health care administrators should consider using NLP to extract clinical data from nursing notes to improve early detection and treatment, which may lead to quality improvement and cost reduction.     

巩固医院评审成果 确保医院护理质量

介绍了天津市护理质控中心的组织结构职能及质控措施,并将两年来对66所二、三级以上医院两个周期的护理质量抽查的结果进行了分析并提出了目前影响护理质量的若干因素。 检查结果表明,已通过分级管理评审的医疗组织健全,护理管理均已逐步向标准化、科学化和系统化迈进。大部分医院保持了评审时的质量标准要求。第二周期质量抽查结果较第一周期有明显的提高,充分说明质控中心的建立对巩固分级管理医院评审成果,加强医院护理管理能起到积极的促进作用。     

Serious Mental Illness and Nursing Home Quality of Care

Objective

To estimate the effect of a nursing home''s share of residents with a serious mental illness (SMI) on the quality of care.

Data Sources

Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims.

Study Design

We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects.

Principal Findings

An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents.

Conclusions

Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.     

The Effect of Advance Care Planning Intervention on Hospitalization Among Nursing Home Residents: A Systematic Review and Meta-Analysis

ObjectiveTo evaluate the effect of advance care planning (ACP) interventions on the hospitalization of nursing home residents.DesignSystematic review and meta-analysis.Setting and ParticipantsNursing homes and nursing home residents.MethodsA literature search was systematically conducted in 6 electronic databases (Embase, Ovid MEDLINE, Cochrane Library, CINAHL, AgeLine, and the Psychology & Behavioral Sciences Collection), in addition to hand searches and reference list checking; the articles retrieved were those published from 1990 to November 2021. The eligible studies were randomized controlled trials, controlled trials, and pre-post intervention studies describing original data on the effect of ACP on hospitalization of nursing home residents; these studies had to be written in English. Two independent reviewers appraised the quality of the studies and extracted the relevant data using the Joanna Briggs Institute abstraction form and critical appraisal tools. A study protocol was registered in PROSPERO (CRD42022301648).ResultsThe initial search yielded 744 studies. Nine studies involving a total of 57,180 residents were included in the review. The findings showed that the ACP reduced the likelihood of hospitalization [relative risk (RR) 0.54, 95% CI 0.47-0.63; I² = 0%)], it had no effect on emergency department (ED) visits (RR 0.60, 95% CI 0.31-1.42; I² = 99), hospice enrollment (RR 0.98, 95% CI 0.88-1.10; I² = 0%), mortality (RR 0.83, 95% CI 0.68-1.00; I² = 4%), and satisfaction with care (standardized mean difference: ?0.04, 95% CI ?0.14 to ?0.06; I² = 0%).Conclusion and ImplicationsACP reduced hospitalizations but did not affect the secondary outcomes, namely, ED visits, hospice enrollment, mortality, and satisfaction with care. These findings suggest that policy makers should support the implementation of ACP programs in nursing homes. More robust studies are needed to determine the effects of ACP on ED visits, hospice enrollment, mortality, and satisfaction with care.     

Defining the Role and Value of Physicians Who Primarily Practice in Nursing Homes: Perspectives of Nursing Home Physicians

ObjectiveTo identify the perceptions of physicians with expertise in nursing home care on the value of physicians who primarily practice in nursing homes, often referred to as “SNFists,” with the goal of enriching our understanding of specialization in nursing home care.DesignQualitative analysis of semistructured interviews.Setting and ParticipantsVirtual interviews conducted January 18-29, 2021. Participants included 35 physicians across the United States, who currently or previously served as medical directors or attending physicians in nursing homes.MethodsInterviews were conducted virtually on Zoom and professionally transcribed. Outcomes were themes resulting from thematic analysis.ResultsParticipants had a mean 19.5 (SD = 11.3) years of experience working in nursing homes; 17 (48.6%) were female; the most common medical specializations were geriatrics (18; 51.4%), family medicine (8; 22.9%), internal medicine (7; 20.0%), physiatry (1; 2.9%), and pulmonology (1; 2.9%). Ten (28.6%) participants were SNFists. We identified 6 themes emphasized by participants: (1) An unclear definition and loose qualifications for SNFists may affect the quality of care; (2) Specific competencies are needed to be a “good SNFist”; (3) SNFists are distinguished by their unique practice approach and often provide services that are unbillable or underreimbursed; (4) SNFists achieve better outcomes, but opinions varied on performance measures; (5) SNFists may contribute to discontinuity of care; (6) SNFists remained in nursing homes during the COVID-19 pandemic.Conclusions and ImplicationsThere is a strong consensus among physicians with expertise in nursing home care that SNFists provide higher quality care for residents than other physicians. However, a uniform definition of a SNFist based on competencies in addition to standardized performance measures are needed. Unbillable and underreimbursed services create disincentives to physicians becoming SNFists. Policy makers may consider modifying Medicare reimbursements to incentivize more physicians to specialize in nursing home care.     

Dysphagia in Nursing Home Residents: Management and Outcomes

Objectives

To define the prevalence of dysphagia and its associated factors and to investigate the influence of dysphagia and nutritional therapies performed in dysphagic subjects on clinical outcomes, including nutritional status, pressure ulcers, hospitalization, and mortality.

Older Widows' Expectations of Home Care Nurses

ABSTRACT

The concept of expectations has been integral to research on home care satisfaction, but little is known about expectations of home care. The aim of this longitudinal phenomenological study was to describe part of the personal-social context of older widows' experience of home care-that of holding expectations of home care nurses. Data were drawn from interviews over three years with the 11 women who had home care nurses. The context of the home care experience was featured by leaning on helpers more at this stage and by expecting the nurse to do what the nurse is supposed to do, with its five parts including expecting the nurse to know how to do what needs to be done. Findings exemplified conceptual overlap among standard realms of expectations, such as behaviors and outcomes, and revealed the relevance of such data in appraisals of home care quality.     

Incidence and Outcomes of SARS-CoV-2 in Post-Acute Skilled Nursing Facility Care

ObjectivesTo examine the risk of contracting SARS-CoV-2 during a post-acute skilled nursing facility (SNF) stay and the associated risk of death.DesignCohort study using Minimum Data Set and electronic health record data from a large multistate long-term care provider. Primary outcomes included testing positive for SARS-CoV-2 during the post-acute SNF stay, and death among those who tested positive.Setting and ParticipantsThe sample included all new admissions to the provider's 286 SNFs between January 1 and December 31, 2020. Patients known to be infected with SARS-CoV-2 at the time of admission were excluded.MethodsSARS-CoV-2 infection and mortality rates were measured in time intervals by month of admission. A parametric survival model with SNF random effects was used to measure the association of patient demographic factors, clinical characteristics, and month of admission, with testing positive for SARS-CoV-2.ResultsThe sample included 45,094 post-acute SNF admissions. Overall, 5.7% of patients tested positive for SARS-CoV-2 within 100 days of admission, with 1.0% testing positive within 1-14 days, 1.4% within 15-30 days, and 3.4% within 31-100 days. Of all newly admitted patients, 0.8% contracted SARS-CoV-2 and died, whereas 6.7% died without known infection. Infection rates and subsequent risk of death were highest for patients admitted during the first and third US pandemic waves. Patients with greater cognitive and functional impairment had a 1.45 to 1.92 times higher risk of contracting SARS-CoV-2 than patients with less impairment.Conclusions and ImplicationsThe absolute risk of SARS-CoV-2 infection and death during a post-acute SNF admission was 0.8%. Those who did contract SARS-CoV-2 during their SNF stay had nearly double the rate of death as those who were not infected. Findings from this study provide context for people requiring post-acute care, and their support systems, in navigating decisions around SNF admission during the SARS-CoV-2 pandemic.     

A Research and Policy Agenda for Transitions from Nursing Homes to Home

SUMMARY

More than 1 million adults make the transition from nursing homes to the community every year, often using formal health services including Medicare Part A skilled home health care. Although the need for discharge planning is well described, and the risks associated with care transitions are increasingly recognized, there is very limited information about the process and outcomes as patients move from nursing home to home. This paper reviews pertinent published data and health services research as background information and outlines a research agenda for studying these important transitions.