What determines the life satisfaction of the elderly? Comparative study of residential care home and community in Japan

Background:   Increasing lifespan has forced elderly persons and researchers alike to look at life and aging in a new way: at adding life to years rather than years to life. With increasing lifestyle choices for the elderly, the present study was undertaken to determine and compare the factors associated with life satisfaction in elderly living in a residential care home and in the community in Japan.
Methods:   This was a cross-sectional, self-reported, questionnaire-based study. Elderly persons from the residential care home in Kyoto City ( n  = 261, mean age ± SD = 79.6 ± 6.6 years, male : female = 1 : 3.1) and from the town of Urausu, Hokkaido ( n  = 733, mean age ± SD = 74.8 ± 6.8 years, male : female = 1 : 1.3), participated in the study. This represented 95.3% and 89.5% of all eligible elderly ≥ 65 years in the home and town, respectively. Activities of daily living, higher functions, medical and social history, geriatric depression scale and quality of life were studied. Using multiple logistic regression models, factors associated with high satisfaction of life were identified.
Results:   In community-dwelling elderly, relationship with friends, as opposed to relationship with family for elderly in residential care home, were factors related to life satisfaction.
Conclusions:   This study demonstrates the relative importance of social factors versus medical and functional factors as determinants of life of elderly. We have also shown how these factors differ for elderly living in different environments. Understanding these different as well as common determinants of life satisfaction from a whole array of diverse ones allows us to make effective strategy to improve the quality of life of elderly living in different conditions.     

Factors enabling home death of the elderly in an institution specializing in home medical care: Analysis of apprehension of the bereaved family

Aim:   To determine the factors enabling home death despite caregiver apprehension about home medical care.
Methods:   This study was an anonymous mailed survey of bereaved family members (the caregiver) of patients who died in a home medical care setting provided by an institution specializing in home medical care in Japan (home death rate, ∼80%). We analyzed the relationships between caregiver apprehension about home medical care, overall satisfaction with home medical care and the place of death.
Results:   Higher caregiver apprehension about home medical care and lower overall satisfaction with home medical care were significantly associated with dying in a hospital. In addition, the home death group with apprehension about home medical care significantly rated higher overall satisfaction with home medical care than the hospital death group. Meanwhile, there was no difference in the overall satisfaction with home medical care between those with or without apprehension about home medical care in the home death group. Factors influencing overall satisfaction with home medical care in the home death group with apprehension about home medical care were: (i) being free from pain or symptoms (partial regression coefficient: 0.83); and (ii) fulfilled medical care service system (partial regression coefficient: 0.40).
Conclusion:   These results suggest that caregiver satisfaction with home medical care is an essential factor to enable home death of the patient despite the caregiver apprehension about home medical care.     

Factors associated with ADL dependence: A comparative study of residential care home and community-dwelling elderly in Japan

Background:   Since the start of Long Term Nursing Insurance in Japan in April 2000, there has been much discussion about and emphasis on leading healthy and active twilight years, without ever being bedridden if possible. In an attempt to address some of these concerns, this comparative study examines the factors associated with dependence in the activities of daily living (ADL) in two samples of elderly people living in two different environments.
Methods:   In this cross-sectional, self-reported study, 262 and 968 elderly people from a residential care home and Yogo town completed a 65-item questionnaire. Questions pertaining to ADL, medical and social history, quality of life (QOL) and the 15-item Geriatric Depression Scale were included in the questionnaire. Using logistic regression model, factors associated with ADL dependence were determined.
Results:   In the residential care home group, age, female gender, instrumental ADL, communication-related ability, history of falls, stroke, and osteoarthropathy, depressive tendency and low satisfaction with life emerged as the factors associated with ADL dependence, after multivariate logistic regression. The corresponding factors in the community-dwelling elderly group were age, depressive tendency, history of osteoarthropathy, and low sense of health.
Conclusion:   Age and female gender were the two non-modifiable risk factors associated with ADL dependence. Stroke, followed by osteoarthropathy and falls were the main medical conditions predisposing to functional dependence. Dependence in instrumental ADL, independence in communication-related ADL, depressive tendency and components of QOL were factors associated with ADL dependence. Awareness of these factors not only helps to identify at-risk patients, to initiate preventive measures and to promote disability-delaying activities, but also helps in the holistic management of geriatric patients.     

Pain, dyspnea, and the quality of dying in long-term care

OBJECTIVES: To evaluate the relationship between pain, dyspnea, and family perceptions of the quality of dying in long-term care.
DESIGN: After-death interviews.
SETTING: Stratified random sample of 111 nursing homes and residential care and assisted living facilities in four states.
PARTICIPANTS: Paired interviews from facility staff and family caregivers for 325 deceased residents.
MEASUREMENTS: The outcome variable was the Quality of Dying in Long-Term Care (QOD-LTC), a psychometrically sound, retrospective scale representing psychosocial aspects of the quality of dying, obtained from interviews with family caregivers. Facility staff reported the presence, frequency, and severity of pain and dyspnea.
RESULTS: During the last month of life, nearly half of residents experienced pain or dyspnea. QOD-LTC scores did not differ for residents with and without pain (4.15 vs 4.02, P =.16). Overall, residents with dyspnea had better QOD-LTC scores than those without dyspnea (4.20 vs 3.99, P =.006). The association between dyspnea and a better QOD-LTC score was strongest in cognitively impaired residents and for those dying in residential care and assisted living facilities.
CONCLUSION: For residents dying in long-term care, pain and dyspnea were not associated with a poorer quality of dying as perceived by families of deceased residents. Instead, dyspnea may alert staff to the need for care. Initiatives to improve the quality of dying in long-term care should focus not only on physical symptoms, but also on the alleviation of nonphysical sources of suffering at the end of life.     

The Effect of a High-Intensity Functional Exercise Program on Activities of Daily Living: A Randomized Controlled Trial in Residential Care Facilities

OBJECTIVES: To evaluate whether a high-intensity functional weight-bearing exercise program reduces dependency in activities of daily living (ADLs) in older people living in residential care facilities, focusing on people with dementia.
DESIGN: Randomized, controlled trial.
SETTING: Nine residential care facilities.
PARTICIPANTS: One hundred ninety-one older people dependent in ADLs and with a Mini-Mental State Examination score of 10 or greater. One hundred (52.4%) of the participants had dementia.
INTERVENTION: A high-intensity functional weight-bearing exercise program or a control activity consisting of 29 sessions over 3 months.
MEASUREMENTS: The Barthel ADL Index; follow-up at 3 months (directly after the intervention) and 6 months with intention-to-treat analyses.
RESULTS: There were no statistically significant differences between the groups regarding overall ADL performance. Analyses for each item revealed that a smaller proportion of participants in the exercise group had deteriorated in indoor mobility at 3 months (exercise 3.5% vs control 16.0%, P =.01) and 6 months (7.7% vs 19.8%, P =.03). For people with dementia, there was a significant difference in overall ADL performance in favor of the exercise group at 3 months (mean difference 1.1, P =.03) but not at 6 months.
CONCLUSION: A high-intensity functional weight-bearing exercise program seems to reduce ADL decline related to indoor mobility for older people living in residential care facilities. The program does not appear to have an overall effect on ADLs. In people with dementia, the exercise program may prevent decline in overall ADL performance, but continuous training may be needed to maintain that effect.     

Hospital care of people living in residential care facilities: Profile, utilization patterns and factors impacting on quality and safety of care

Background:   Residents in residential care facilities (RCF) are frequent users of acute hospital services. However, the interface between the two sectors remains relatively unexplored. Our objective was to determine the patterns of utilization, characteristics and experiences of RCF residents accessing a tertiary referral center (TRC).
Methods:   An observational study of RCF residents presenting to the TRC emergency department (ED). The experiences of acute care services were explored for more than one-quarter of this group 2–3 days postdischarge. The carer within the RCF acted as the proxy respondent.
Results:   During the study period, RCF residents accounted for 2.3% of all ED presentations. These presentations involved 526 residents. The dimension "continuity of care" for the Picker Patient Experience questionnaire had the highest proportion (53.1%) reporting a problem. The likelihood of reporting a problem for "continuity of care" (odds ratio [OR], 3.58; confidence interval [CI], 1.72–7.45) and "information and education" (OR, 2.62; CI, 1.14–3.01) were higher if the resident was admitted to a ward compared to ED only. If the resident had a low level care status the likelihood of reporting a problem for "continuity of care" (OR, 2.8; CI, 1.02–7.72) also increased. The odds of RCF staff reporting a problem for "ambulance service" were significantly higher if the resident's presentation was related to a fall. (OR, 3.35; CI, 1.28–8.8).
Conclusion:   The utilization rates for acute hospital care in our study were similar to the two previous Australian studies. Factors at the patient and organizational level impacted significantly on problems relating to the quality and safety of care being reported.     

Daily living functions of the elderly requiring home visits: A study at a comprehensive assessment clinic for the elderly

Background:   To elucidate the characteristics of daily living functions of the elderly requiring home visits.
Methods:   Fifty-two elderly individuals (17 men and 35 women; age range, 72–95 years; average age, 82.2 ± 5.4 years) who visited a clinic for the elderly underwent comprehensive geriatric assessment. Activities of daily living were assessed using the Barthel Index and Lawton Scale. Cognitive function was assessed using the clock-drawing test (modified Shulman method), Mini-Mental State Examination, and the revised version of Hasegawa's Dementia Scale. Depression was assessed using the 15-item Geriatric Depression Scale. Volition was assessed using the Vitality Index. The 52 participants were divided into two groups: 41 who continued clinic visits after assessment (clinic group: 15 men and 26 women; age range, 72–95 years; average age, 81.5 ± 5.4 years), and 11 who required home visits (visit group: two men and nine women; age range, 75–91 years; average age, 84.7 ± 4.5 years). Various daily living functions were compared between the two groups.
Results:   Barthel Index, Lawton Scale, Mini-Mental State Examination, and Vitality Index scores were significantly lower in the home group. Moreover, Vitality Index score was low at the start of home visits.
Conclusions:   It is difficult for the elderly with cognitive and physical disorders to make periodical visits to medical institutions and they eventually require home visits. For effective prevention of dependence on nursing care, fragile elderly persons themselves must understand and actively participate in interventions, emphasizing the underlying difficulties associated with such interventions.     

Two new potent and convenient predictors of mortality in older nursing home residents in Japan

Background:   Malnourishment is closely connected with poor health outcomes in frail elderly. However, the relative importance of specific nutritional predictors of mortality remains unclear in the Japanese population. We investigated the potent nutritional factors associated with mortality from nutritional assessments of three parameters in Japanese frail elderly.
Methods:   Ninety residents in a nursing home in Japan, aged 65 and over (18 men, 72 women; mean age 82.2 ± 8.0 years) were enrolled in a 38-month follow-up study. The eligibility condition for analysis was having lived at the nursing home for more than 30 days, so three participants were excluded. Three nutritional parameters, which included: anthropometric measurements (body mass index, mid-arm circumference, triceps skinfold thickness and calf circumference); serum markers (albumin, total protein, prealbumin, retinol binding protein and total cholesterol); and food intake, were assessed. After categorizing each putative factor according to tertile distribution, risk of mortality was analyzed using Cox proportional hazard models.
Results:   At the end of the 38-month follow-up period, 29 participants had died. After adjustment for gender, age, clinical status, and functional status, three indicators (i.e. mid-arm circumference, triceps skinfold thickness and lipid intake) showed a significant relationship with mortality. When all of the putative factors were included in a stepwise procedure, mid-arm circumference and lipid intake were significantly associated with adjusted mortality.
Conclusion:   Among institutionalized Japanese frail elderly, lower levels of mid-arm circumference and lipid intake could potently predict an increased risk of mortality. These two indicators may be useful for many kinds of assessments and intervention for the improvement of health conditions in Japanese frail elderly.     

Comparison of hematologic or biochemical parameters among elderly hospital patients, institution-dwelling residents, and health check-up examinees

Background:   The purpose of the present paper was to examine the differences in the levels of hematological or biochemical parameters among elderly hospital patients, nursing home residents, and mass health check-up recipients.
Methods:   One hundred and 44 geriatric inpatients (aged ≥ 65 years), 237 outpatients, 146 nursing home residents, 120 aged examinees from mass health check-ups, and 512 younger health check-up examinees (controls) were included in the present study. They were divided into five male and five female subgroups, respectively. The levels of hemoglobin (Hb), white blood cells (WBC), serum albumin (Alb), Ca, albumin-corrected Ca, Na, creatinine (Cr), and total cholesterol (TC) were determined and compared.
Results:   There were significantly lower levels of Hb, Alb, Ca, Na, and TC in inpatients than in other groups in both sexes. In contrast, higher levels of WBC and Cr were found in inpatients. Among women there was no difference in the level of any parameter between nursing home residents, health check-up examinees, and controls.
Conclusion:   The data indicate that the levels of these parameters are affected to a greater extent in inpatients, and that female nursing home residents and health check-up examinees show values similar to those of controls.     

A national census of care home residents

BACKGROUND: the medical and dependency characteristics of UK care home residents have not been well described. This undermines care commissioning, development and regulation. Data to inform policy and practice are needed. OBJECTIVE: to survey the dependency and clinical diagnoses of 16,043 people resident in the 244 care homes distributed across the UK managed by the largest provider of care in the UK. RESULTS: (i) Return rate of 97% (15,483 returns suitable for analysis). (ii) 25% were 'residential' and 75% in 'nursing' care. (iii) Medical morbidity and associated disability rather than non-specific frailty and social needs had driven admission in over 90% of residents. (iv) More than 50% of residents had dementia, stroke or other neurodegenerative disease. (v) Overall, 76% of residents required assistance with their mobility or were immobile. 78% had at least one form of mental impairment and 71% were incontinent. 27% of the population were immobile, confused and incontinent. (vi) Considerable overlap in dependency between residential and nursing care observed: only 40% of those in residential care were ambulant without assistance and 46% were incontinent. CONCLUSIONS: the practicality of acquiring information on care home residents has been demonstrated. The care needs of people in care homes are largely determined by progressive chronic diseases. A single assessment and commissioning at the point of entry to care services is unlikely to address changing needs. Alternatives to institutional long-term care should only be considered in the context of current resident profiles, the practicality of providing alternative models and likely projected population needs.     

Family relationships for self-care-dependent older people at home

Background:   Although the government recommends self-care-dependent older people be cared for at home, family relationships between caregivers and self-care-dependent older people surely would be one of the key factors for care at home. Good memories of family caregivers for self-care-dependent older people before self-care-dependence would overcome negative psychological symptoms to care at home.
Methods:   We investigated family relationships before and after having self-care-dependent older people at home in a rural town of Oodate, Akita Prefecture, and an urban district of Katsushika, Tokyo. Among 12 261 dependent elderly (2668 in Oodate and 9593 in Katsushika), 9606 stayed at home (2009 in Oodate and 7597 in Katsushika) and 1036 family caregivers (381 in Oodate and 655 in Katsushika) completed the questionnaires and entered the present study.
Results:   Good and medium relationships were dominant and bad family relationships were limited in number after self-care-dependence. Family relationships after self-care significantly correlated with family relationships before self-care for all main caregivers. There was no significant difference in family relationships between Oodate and Katsushika.
Conclusion:   Keeping a good relationship with main caregivers before self-care would be one of the important factors in caring for self-care-dependent older people at home.     

Residual urine as a risk factor for lower urinary tract infection: a 1-year follow-up study in nursing homes

OBJECTIVES: To determine whether postvoid urine is a risk factor for the development of lower urinary tract infections (UTIs) in nursing home residents.
DESIGN: Prospective surveillance with a follow-up period of 1 year.
SETTING: Six Norwegian nursing homes.
PARTICIPANTS: One hundred fifty nursing home residents.
METHODS: Postvoid residual (PVR) urine volumes were measured using a portable ultrasound. UTIs were registered prospectively for 1 year.
RESULTS: Ninety-eight residents (65.3%) had a PVR less than 100 mL, and 52 (34.7%) had a PVR of 100 mL or greater. During the follow-up period, 51 residents (34.0%) developed one or more UTIs. The prevalence of UTI in women was higher than in men (40.4% vs 19.6%; P =.02). There was no significant difference in mean PVR between residents who did and did not develop a UTI (79 vs 97 mL, P =.26). PVR of 100 mL or greater was not associated with greater risk of developing a UTI ( P =.59).
CONCLUSION: High PVR is common in nursing home residents. No association between PVR and UTI was found.     

Nursing effort and quality of care for nursing home residents

PURPOSE: The purpose of this study was to determine the relationship between nursing home staffing level, care received by individual residents, and resident quality-related care processes and functional outcomes. DESIGN AND METHODS: Nurses recorded resident care time for 5,314 residents on 156 units in 105 facilities in four states (Colorado, Indiana, Minnesota, and Mississippi). We linked residents' care times to their measures of health and functioning from Minimum Data Set assessments. Major variables were unit- and resident-specific minutes of care per day, process measures (physical restraints, range of motion, toileting program, and training in activities of daily living [ADLs]), outcome measures (ADL decline, mobility decline, and worsening behavior between the time study and 90-day follow-up), and covariates such as unit type and resident health status. We used multilevel analysis to examine staffing and quality relationships. RESULTS: Residents with toileting programs, range of motion or ADL training, and restraints received significantly more care from unlicensed but not from licensed staff. However, functional outcomes were not significantly related to care received from licensed or unlicensed staff, except for ADL decline, which was greatest for residents receiving more unlicensed minutes of care. Unit staffing level (licensed and unlicensed) was unrelated to any of the care processes or outcome measures, although higher overall staffing was associated with more time devoted to direct resident care. IMPLICATIONS: Future research into nursing home quality should focus on organization and delivery rather than simply the amount of care available.     

The effect of a social work intervention to enhance advance care planning documentation in the nursing home

OBJECTIVES: To assess the effect of a multicomponent advance care planning intervention directed at nursing home social workers on identification and documentation of preferences for medical treatments and on patient outcomes. DESIGN: Controlled clinical trial. SETTING: New York City nursing home. PARTICIPANTS: One hundred thirty-nine newly admitted long-term care residents. INTERVENTION: Nursing home social workers were randomized to the intervention or control groups. The intervention consisted of baseline education in advance care planning that incorporated small-group workshops and role play/practice sessions for intervention social workers; structured advance care planning discussions with residents and their proxies at admission, after any change in clinical status, and at yearly intervals; formal structured review of residents' goals of care at preexisting regular team meetings; "flagging" of advance directives on nursing home charts; and feedback to individual healthcare providers of the congruence of care they provided and the preferences specified in the advance care planning process. Control social workers received an educational training session on New York State law regarding advance directives but no additional training or interventions. Subjects were enrolled from January 9, 2001 through May 25, 2003 and followed for 6 months after enrollment. MEASUREMENTS: Nursing home chart documentation of advance directives (healthcare proxies, living wills) and do-not-resuscitate orders; preferences for artificial nutrition and hydration, intravenous antibiotics, and hospitalization; and concordance of treatments received with documented preferences were compared for residents assigned to intervention and control social workers. RESULTS: Intervention residents were significantly more likely than residents in the control group to have their preferences regarding cardiopulmonary resuscitation (40% vs 20%, P=.005), artificial nutrition and hydration (47% vs 9%, P<.01), intravenous antibiotics (44% vs 9%, P<.01), and hospitalization (49% vs 16%, P<.01) documented in the nursing home chart. Control residents were significantly more likely than intervention residents to receive treatments discordant with their prior stated wishes. Two of 49 (5%) intervention residents received a treatment in conflict with their prior stated wishes (one hospitalization, one episode of intravenous antibiotics), compared with 17 of 96 (18%) control patients (P=.04). CONCLUSION: This generalizable intervention directed at nursing home social workers significantly improved the documentation and identification of patients' wishes regarding common life-sustaining treatments and resulted in a higher concordance between patients' prior stated wishes and treatments received.     

Bowel incontinence is related to improvement in basic activities of daily living in residents of long-term health care facilities for the elderly in Japan

Background:   The purpose of the present study is to clarify the target criteria for care in long-term health care facilities for the elderly in Japan and to investigate the relationship between changes in basic activities of daily living (BADL) over 1 year and the comprehensive geriatric assessment (CGA) scale.
Methods:   An observational study was conducted in a facility in Nagoya, Japan. The participants consisted of 54 residents. The following four scales of comprehensive geriatric assessment were administered to the residents in both 2000 and 2001: Barthel index (BI), Lawton scale, mini-mental state examination and geriatric depression scale 15.
Results:   The Barthel index was significantly improved in 2001 compared with 2000 ( P = 0.007). The Lawton scale was significantly lower in 2001 ( P = 0.029). Neither the mini-mental state examination nor geriatric depression scale 15 scores changed significantly. To determine the factors that influenced the change in BADL, logistic regression analyses were performed using the above four scales as independent variables and the BI change as a dependent variable. In multivariate analysis, a BI score of less than 75 approached significance for improvement in BADL ( P  = 0.094, odds ratio = 2.79). Other logistic regression analyses were also performed using each ADL task in BI as an independent variable and the change in BI as a dependent variable. In multivariate analysis, bowel incontinence was a significant independent variable ( P  = 0.006, odds ratio = 10.9).
Conclusion:   As bridging facilities between acute-care hospitals and home, long-term health care facilities are a reasonable choice for the elderly with bowel incontinence.     

The relationship between low vision and performance of activities of daily living in nursing home residents.

OBJECTIVE: To explore the link between low vision and Activities of Daily Living (ADL) performance in cognitively intact nursing home residents. DESIGN: Survey. SETTING: A non-profit geriatric long-term care facility. SUBJECTS: 21 males, 82 females, aged 66-98. MEASURES: Survey of 103 nursing home residents. ADL functioning assessed via Maryland Appraisal of Patient Progress (MAPP); medical data collected through chart review; ophthalmological data obtained through dilated eye examination by an ophthalmologist. RESULTS: In comparison with residents having good vision (n = 52), a significantly greater proportion of residents with low vision (n = 51) were dependent on caregivers for performing ADLs (eg, toileting, transferring, washing). Residents with low vision had significantly more eye pathology (eg, cataracts, age-related macular degeneration) than did residents with good vision. There were no significant differences between groups with regard to presence of musculoskeletal problems (eg, arthritis) or number of medical conditions (eg, cardiovascular disorder, cerebrovascular accident). CONCLUSIONS: There is a strong link between low vision and ADL disability in nursing home residents. Moreover, ADL dependency is significantly related to the presence of eye disorders.     

Factors influencing the proportion of food consumed by nursing home residents with dementia.

BACKGROUND: Assessment of and interventions for promoting eating in persons with late-stage dementia have primarily focused on facilitation of safe feeding and methods to promote ingestion of nutrients via several routes. Using Social Exchange Theory, this study examined how the quality of the interaction between care giver and care receiver influenced the proportion of food consumed by persons with late-stage dementia. METHODS: Fifty-three dyads composed of nursing home residents with late-stage dementia and Certified Nursing Assistants (CNAs) were observed during the breakfast meal. The proportion of food consumed by the residents was measured by weight. The study included measures of the quality of interaction between the resident and the CNA (Interaction Behavior Measure-Modified (IBM-M) and the IBM), CNA empathy (Interpersonal Reactivity Index), and CNA power (Control subscale of the FIRO-B). RESULTS: Specific resident behaviors and the CNA's ability to allow another person to control a relationship were most predictive of the variance in the proportion of food consumed (R2 = .41; F(3,49) = 12.54; P < .001). The quality of the resident-CNA interaction accounted for 32% of the variance in the proportion of food consumed. One aspect of power was correlated significantly to the proportion of food consumed whereas CNA empathy was not. CONCLUSIONS: Because eating is the most social of all ADLs and is culturally bound, clinicians need to examine the interactional components of meals within the caregiving dyad when a person with late-stage dementia fails to ingest adequate nutrients.     

Indicators of the quality of nursing home residential care

OBJECTIVES: To identify quality indicators (QIs) that can be used to measure nursing home (NH) residential care processes. DESIGN: Modified-delphi panel process to rate potential QIs that were identified through reported interviews with residents and families and through a review of the scientific literature. SETTING: Meetings of panel of experts. PARTICIPANTS: A national panel of nine experts in NH care rated potential QIs. A content expert and a clinical oversight committee performed external reviews. MEASUREMENTS: Panelists' median validity and importance ratings for each QI choice. RESULTS: The panel considered 64 choices for QI content and rated 28 of these as valid and important for measuring residential care quality. These 28 choices translated into 18 QIs. The external review process resulted in the addition of one QI that was not considered by the NH panel. The 19 indicators address areas identified as important by residents and proxies. Ten of these QIs were rated feasible to implement with current resources in average community NHs, and nine were rated feasible only in better NHs. The panelists identified nine as being measured most reliably by direct observations of care. CONCLUSION: Experts identified 19 specific care processes as valid and important measures of the quality of NH residential care. Nine of these QIs may be measured best by direct observation of NH care, rather than by interviews or review of existing NH records. Almost half of the QIs were viewed as discriminating between better and average NHs. The panel deemed that only well-staffed nursing homes could consistently implement nine of the QIs.