High-Quality Nursing Home and Palliative Care—One and the Same

Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches’ effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.     

Creating “Well-Functioning” Residential Care and Defining Its Place in a System of Care

This article presents a model for understanding the elements and dynamics of a well-functioning residential group care resource based upon the study of 10 group care residences over a 14-month period. In addition, seven characteristics related to the differential use of foster care and residential care are presented. Finally, five key processes suggested as necessary for the creation of a system of care for young people are offered for consideration.     

Long-Term Care Preferences and Sexual Orientation–A Systematic Review and Meta-Analysis

ObjectivesThe number of sexual and gender minority older adults who require long-term care is steadily increasing. The purpose of this systematic review and meta-analysis was to synthesize the evidence related to preference for long-term care with regard to sexual orientation and gender identity.DesignSystematic review and meta-analysis.Setting and ParticipantsWe searched PubMed/MEDLINE, Ovid/PsycINFO, and Web of Science from inception to July 2020 (updated in July 2021). Search terms embraced 3 themes (1) sexual and gender minorities, (2) long-term care, and (3) preferences. Quantitative studies of the adult population were included.MethodsScreening, data extraction, and quality assessment followed the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The proportions were pooled using meta-analysis and random effects models.ResultsA total of 17 articles were included out of 5944 studies of potential relevance. The perception of nursing homes (NHs) that emerges from these studies is predominantly negative for heterosexuals and lesbian, gay, bisexual and trans (LGBT) individuals (n = 11). Across 6 studies (10 outcomes), the pooled estimate for the proportion of individuals with a preference to move into a NH was 10.6% [95% confidence interval (CI) 7.88%?13.22%, I² = 97.4%]; 13.7% (95% CI 8.6%?18.7%) for LGBT individuals and 7.3% (95% CI 3.14%?11.50%) for heterosexuals. LGBT-friendly NHs were preferred by between 55% and 98% of LGBT respondents. Informal care provided by partner or family was one of the preferred options (n = 6). It was preferred by 33% to 70% of various groups of LGBT respondents.Conclusions and ImplicationsThe preference to move into a NH is relatively low among both heterosexuals and sexual and gender minority adults. Findings showed negligible differences in preferences to move into a NH between heterosexuals and sexual and gender minorities. LGBT-friendly long-term care facilities where every member feels welcomed and not discriminated against seem to be one of the favorable long-term care choices among LGBT individuals. This knowledge is important to inform nursing services and policy makers about the preferred long-term care options. Providing LGBT-friendly facilities is usually less expensive than providing care in newly created LGBT-only facilities.     

Whom Should We Profile? Examining Diabetes Care Practice Variation among Primary Care Providers,Provider Groups,and Health Care Facilities

OBJECTIVE: To evaluate the amount of variation in diabetes practice patterns at the primary care provider (PCP), provider group, and facility level, and to examine the reliability of diabetes care profiles constructed using electronic databases. DATA SOURCES/STUDY SETTING: Clinical and administrative data obtained from the electronic information systems at all facilities in a Department of Veterans Affairs' (VA) integrated service network for a study period of October 1997 through September 1998. STUDY DESIGN: This is a cohort study. The key variables of interest are different types of diabetes quality indicators, including measures of technical process, intermediate outcomes, and resource use. DATA COLLECTION/EXTRACTION METHODS: A coordinated registry of patients with diabetes was constructed by integrating laboratory, pharmacy, utilization, and primary care provider data extracted from the local clinical information system used at all VA medical centers. The study sample consisted of 12,110 patients with diabetes, 258 PCPs, 42 provider groups, and 13 facilities. PRINCIPAL FINDINGS: There were large differences in the amount of practice variation across levels of care and for different types of diabetes care indicators. The greatest amount of variance tended to be attributable to the facility level. For process measures, such as whether a hemoglobin A1c was measured, the facility and PCP effects were generally comparable. However, for three resource use measures the facility effect was at least six times the size of the PCP effect, and for inter-mediate outcome indicators, such as hyperlipidemia, facility effects ranged from two to sixty times the size of the PCP level effect. A somewhat larger PCP effect was found (5 percent of the variation) when we examined a "linked" process-outcome measure linking hyperlipidemia and treatment with statins). When the PCP effect is small (i.e., 2 percent), a panel of two hundred diabetes patients is needed to construct profiles with 80 percent reliability. CONCLUSIONS: little of the variation in many currently measured diabetes care practices is attributable to PCPs and, unless panel sizes are large, PCP profiling will be inaccurate. If profiling is to improve quality, it may be best to focus on examining facility-level performance variations and on developing indicators that promote specific, high-priority clinical actions.     

Oregon’s Coordinated Care Organizations and Their Effect on Prenatal Care Utilization Among Medicaid Enrollees

Introduction Previous studies indicate that inadequate prenatal care is more common among women covered by Medicaid compared with private insurance. Increasing the proportion of pregnant women who receive early and adequate prenatal care is a Healthy People 2020 goal. We examined the impact of the implementation of Oregon’s accountable care organizations, Coordinated Care Organizations (CCOs), for Medicaid enrollees, on prenatal care utilization among Oregon women of reproductive age enrolled in Medicaid. Methods Using Medicaid eligibility data linked to unique birth records for 2011–2013, we used a pre-posttest treatment–control design that compared prenatal care utilization for women on Medicaid before and after CCO implementation to women never enrolled in Medicaid. Additional stratified analyses were conducted to explore differences in the effect of CCO implementation based on rurality, race, and ethnicity. Results After CCO implementation, mothers on Medicaid had a 13% increase in the odds of receiving first trimester care (OR 1.13, CI 1.04, 1.23). Non-Hispanic (OR 1.20, CI 1.09, 1.32), White (OR 1.20, CI 1.08, 1.33) and Asian (OR 2.03, CI 1.26, 3.27) women on Medicaid were more likely to receive initial prenatal care in the first trimester after CCO implementation and only Medicaid women in urban areas were more likely (OR 1.14, CI 1.05, 1.25) to initiate prenatal care in the first trimester. Conclusion Following Oregon’s implementation of an innovative Medicaid coordinated care model, we found that women on Medicaid experienced a significant increase in receiving timely prenatal care.     

Financial “Rules” for Child and Youth Care Managers

Contemporary realities demand that child and youth care managers cast off their traditional avoidance of all things financial. This article offers a jargon-free list of twelve financial rules for thriving in turbulent times. Grounded in a concept of client-centered, results-based agency performance, rules include promoting an entrepreneurial spirit throughout the organization, destroying the taboo on open discussion of financial matters, slashing program development time, and spending lavishly on recruitment and universal staff training.     

Influences on Parents’ Child Care Choices: A Comparative Analysis of Preschool and Long Day Care Users

Background

This paper investigates Australian parents’ child care decision-making, including the motivational and influential factors that they attribute to their choice. Research demonstrates that child care decision making is multifaceted, involving a combination of child-related, personal, familial and contextual considerations. Existing research has tended to compare centre-based child care users with those using family-based options, and has not examined differences in the decision-making of parents who using different centre-based options.

Objective

This study compared the characteristics and child care choices of parents using long day care (LDC) with those using preschool services to determine (1) whether they differ demographically and (2) if their reported child care decision-making motivations and influences diverge.

Method

Participants were 1418 parents who completed a nationally-distributed survey in which they provided demographic information, specified their reasons for choosing to use child care, and rated the importance of factors that influenced their child care choice.

Results

LDC parents had, on average, younger children, worked longer hours and resided in areas with lower socioeconomic resources than preschool parents. When compared with preschool parents, those using LDC were more likely to nominate pragmatic factors as influencing their child care decision making. External pressures, mainly related to educational outcomes, were more salient for preschool than LDC parents. However, both groups of parents similarly rated child-centred factors as the most important overall influence.

Conclusion

Our findings add complexity to current understandings of parents’ child care decision making by showing that parents should not be treated as a homogenous group by policy makers, providers, and researchers.

     

Care for Nurses Only? Medicine and the Perceiving Eye

In this paper I introduce a theoretical framework on care developed by the Norwegian nurse and philosopher Kari Martinsen, and I argue that this approach has relevance not only within nursing, but also within clinical medicine. I try to substantiate this claim by analysing some of the key concepts in this approach, and I illustrate the potential clinical relevance of this approach by applying it in relation to two care scenarios. Finally, I discuss some of the concerns that have been raised in relation to the aim of highlighting care in medicine.     

Post-Acute Care and ACOs — Who Will Be Accountable?

Objective

To determine how the inclusion of post-acute evaluation and management (E&M) services as primary care affects assignment of Medicare beneficiaries to accountable care organizations (ACOs).

Data Sources

Medicare claims for a random 5 percent sample of 2009 Medicare beneficiaries linked to American Medical Association Group Practice data identifying provider groups sufficiently large to be eligible for ACO program participation.

Study Design

We calculated the fraction of community-dwelling beneficiaries whose assignment shifted, as a consequence of including post-acute E&M services, from the group providing their outpatient primary care to a different group providing their inpatient post-acute care.

Principal Findings

Assignment shifts occurred for 27.6 percent of 25,992 community-dwelling beneficiaries with at least one post-acute skilled nursing facility stay, and they were more common for those incurring higher Medicare spending. Those whose assignment shifted constituted only 1.3 percent of all community-dwelling beneficiaries cared for by large ACO-eligible organizations (n = 535,138), but they accounted for 8.4 percent of total Medicare spending for this population.

Conclusions

Under current Medicare assignment rules, ACOs may not be accountable for an influential group of post-acute patients, suggesting missed opportunities to improve care coordination and reduce inappropriate readmissions.     

Convergence or Divergence? Reforming Primary Care in Norway and Britain

Many countries are currently reorganizing their health services in response to cultural, economic, and technological changes. Because the changes are global, different countries are drawn toward similar reform programs. But countries' cultural, economic, and political differences also may lead to divergent responses. This article examines the convergence thesis by comparing recent changes in primary care in Norway and Britain. There seems to be a convergence in objectives, a divergence in remuneration systems, and both divergence and convergence in organizational structures. To understand the dynamics of change, divergence is discussed in relation to the social context of the political initiatives. Divergences are explained by economic, political, and cultural differences, as well as differences in physicians' political power and density.     

Parental Nativity Affects Children’s Health and Access to Care

Objective To examine the effect of parental nativity on child health and access to health care. Data Source The 2002 National Survey of America’s Families. Results Among US children, 14% have foreign-born parents; 5% have one foreign- and one native-born parent (“mixed-nativity”). In multivariate logistic regression analyses, children with foreign-born parents were less likely than children with US-born parents to be perceived in “very good” or “excellent health” [OR = 0.68; 95% CI (0.56–0.82)] and to have a usual health care site [OR = 0.52 (0.38–0.69)]; having mixed-nativity parents is associated with better perceived child health. These effects persisted for minority, but not white, children. Regardless of race and ethnicity, non-citizen children have worse access to care. Conclusion Efforts to improve children of immigrants’ health and access to care should focus on families in which both parents are immigrants, particularly those who are ethnic or racial minorities. Efforts to increase use of health services should focus on non-citizen children.     

Spirituality in Child and Youth Care: Considering Spiritual Development and “Relational Consciousness”

In response to the identification of spiritual development as part of children's lives in both the United Nations Convention on the Rights of the Child (1991) and the Association for Child and Youth Care Practice's document: Competencies for Professional Child and Youth Work Practitioners (Mattingly & Stuart, 2001), this paper considers a theoretical model of children's spirituality, relational consciousness, as proposed by Hay and Nye (1998). The paper encourages the introduction of a framework for understanding and exploring spiritual development in child and youth care research and practice that respects the cultural and social diversity of both religious and nonreligious settings and the lifespan developmental processes of children.     

Creativity as Openness: Improvising Health and Care ‘Situations’

Creativity has become an oft-used word in UK public policy, but perhaps it is also under-imagined. This paper contends that there is an instrumental tendency to narrowly frame creativity as innovation, implying a reproducible product, instead of more openly as improvisation, a situational, embodied and temporal process. This is not a simple dichotomy (innovation and improvisation, product and process, can be mutually informing concepts), nor is it specifically a question of definition; rather, it relates to an ontological orientation, and related to that are issues of epistemological implications. In particular the paper is concerned with the value of the arts in public policy, as situated in the social, and therefore human, spaces of health and care; and more generally the arts in society. The paper brings together a broad discussion from across disciplines, not in an interdisciplinary attempt to solve a problem, or to be reductive in the analysis, but to begin to approach a reorienting of understandings of creativity and the human value and foundation of the arts in society.     

Hearing Loss and Older Adults’ Perceptions of Access to Care

We investigated whether hard-of-hearing older adults were more likely to report difficulties and delays in accessing care and decreased satisfaction with healthcare access than those without hearing loss. The Wisconsin Longitudinal Study (2003–2006 wave, N = 6,524) surveyed respondents regarding hearing, difficulties/delays in accessing care, satisfaction with healthcare access, socio-demographics, chronic conditions, self-rated health, depression, and length of relationship with provider/site. We used multivariate regression to compare access difficulties/delays and satisfaction by respondents’ hearing status (hard-of-hearing or not). Hard-of-hearing individuals comprised 18% of the sample. Compared to those not hard-of-hearing, hard-of-hearing individuals were significantly more likely to be older, male and separated/divorced. They had a higher mean number of chronic conditions, including atherosclerotic vascular disease, diabetes and depression. After adjustment for potential confounders, hard-of-hearing individuals were more likely to report difficulties in accessing healthcare (Odds Ratio 1.85; 95% Confidence Interval 1.19–2.88). Satisfaction with healthcare access was similar in both groups. Our findings suggest healthcare access difficulties will be heightened for more of the population because of the increasing prevalence of hearing loss. The prevalence of hearing loss in this data is low and our findings from a telephone survey likely underestimate the magnitude of access difficulties experienced by hard-of-hearing older adults. Further research which incorporates accessible surveys is needed. In the meantime, clinicians should pay particular attention to assessing barriers in healthcare access for hard-of-hearing individuals. Resources should be made available to proactively address these issues for those who are hard-of-hearing and to educate providers about the specific needs of this population.     

Cost,Utilization, and Quality of Care: An Evaluation of Illinois’ Medicaid Primary Care Case Management Program

PURPOSE

In 2006, Illinois established Illinois Health Connect (IHC), a primary care case management program for Medicaid that offered enhanced fee-for-service, capitation payments, performance incentives, and practice support. Illinois also implemented a complementary disease management program, Your Healthcare Plus (YHP). This external evaluation explored outcomes associated with these programs.

METHODS

We analyzed Medicaid claims and enrollment data from 2004 to 2010, covering both pre- and post-implementation. The base year was 2006, and 2006–2010 eligibility criteria were applied to 2004–2005 data to allow comparison. We studied costs and utilization trends, overall and by service and setting. We studied quality by incorporating Healthcare Effectiveness Data and Information Set (HEDIS) measures and IHC performance payment criteria.

RESULTS

Illinois Medicaid expanded considerably between 2006 (2,095,699 full-year equivalents) and 2010 (2,692,123). Annual savings were 6.5% for IHC and 8.6% for YHP by the fourth year, with cumulative Medicaid savings of $1.46 billion. Per-beneficiary annual costs fell in Illinois over this period compared to those in states with similar Medicaid programs. Quality improved for nearly all metrics under IHC, and most prevention measures more than doubled in frequency. Medicaid inpatient costs fell by 30.3%, and outpatient costs rose by 24.9% to 45.7% across programs. Avoidable hospitalizations fell by 16.8% for YHP, and bed-days fell by 15.6% for IHC. Emergency department visits declined by 5% by 2010.

CONCLUSIONS

The Illinois Medicaid IHC and YHP programs were associated with substantial savings, reductions in inpatient and emergency care, and improvements in quality measures. This experience is not typical of other states implementing some, but not all, of these same policies. Although specific features of the Illinois reforms may have accounted for its better outcomes, the limited evaluation design calls for caution in making causal inferences.