Redesign in the long-term care industry: a restraint reduction or restraint elimination program in the nursing home

The Nursing Home Reform Act of 1987 required nursing homes in the United States to modify their use of physical and chemical restraints in the provision of care to the residents. Nursing home staff members can restrain only if a medical professional determines that they must temporarily restrain residents in order to provide care for them. The author employs the Kast and Rosenzweig model of systems theory to describe the approaches that nursing homes have taken to implement a restraint-free or restraint-elimination program. He then describes the benefits that residents and staff members receive when they participate in a restraint-reduction of restraint-elimination program.     

The cost of chronic constipation

OBJECTIVES: This study investigates the cost of chronic constipation care. DESIGN AND PARTICIPANTS: A consecutive sample of 31 chronically constipated elderly patients. SETTING: A not-for-profit long-term care facility in New Hyde Park, New York. MEASUREMENTS: Patient demographics and functional status, including activity of daily living scores, diagnosis, and medications were recorded. All constipation medication costs were obtained using the average wholesale price obtained from the Redbook (November 1999). All subjects were closely monitored for constipation care during two shifts a day (from 7:00 AM to 11:00 PM), over a 6-week period resulting in the collection of 1,860 shift reports. Each component of constipation treatment cost, namely drugs and staff time for drug administration, was identified and analyzed. RESULTS: The average number of nursing interactions for constipation treatment was 23.3 per month. The average cost per day for care specifically for the treatment of constipation was 2.11 US dollars. Fleet Enema trade mark and milk of magnesia accounted for 49% of all treatments. Administration (staffing) costs accounted for 70% of total drug costs. CONCLUSIONS: Although laxatives are the most frequently prescribed drugs used in long-term care settings, drug utilization patterns and associated costs in the treatment of chronic constipation have not been systematically reported. Our study identified staffing as the major cost factor in constipation care.     

Health status,staffing, and medicaid reimbursement in nursing homes: 1985 to 1995

CONTEXT: Policy changes implemented by Medicaid and Medicare in the early 1980s resulted in a functionally more dependent nursing home population. OBJECTIVES: This paper contends that (1) staffing in nursing homes has become more efficient; (2) nursing home residents are functionally more dependent;(3) Medicaid per diem reimbursement is inadequate. DATA SOURCES: Staffing data came from the National Nursing Home Facility Survey conducted by the National Center for Health Statistics (NCHS) in 1985 and 1995. Functional dependency data, defined as assistance with any of six Activities of Daily Living (ADLs), came from the NCHS National Nursing Home Current Resident Surveys in 1985 and 1995. Reimbursement rates came from the State Medicaid Reimbursement Surveys conducted by the University of California at San Francisco to which the Consumer Price Index, Hospital and Related Services Item was applied. DATA SYNTHESIS: Administration decreased by 4.4 full-time equivalents (FTEs) (80.0%) per 100 beds, whereas patient care increased by 8.2 FTEs (18.9%). Residents requiring assistance with four or more ADLs increased by 9.9%, and the mean number of ADLs per patient increased from 3.9 to 4.3. Applying the Consumer Price Index to the 1984 reimbursement rate indicated an annual deficit of 5526.00 dollars for each Medicaid patient by 1995. CONCLUSIONS: This research strongly supports its contentions but fails to demonstrate them conclusively. The data indicate that long-term care facilities have reallocated staffing to accommodate the requirements of more functionally dependent residents and that Medicaid reimbursement has failed to maintain its initial purchasing power.     

The Seniors Quality Leap Initiative (SQLI): An International Collaborative to Improve Quality in Long-Term Care

ObjectivesTo describe an innovative Canadian and US community of practice that employs empirical evidence based on risk-adjusted indicators to guide collaborative initiatives to improve the quality of care in nursing homes.DesignOngoing study of quality of care related to pain management in nursing home residents using clinical assessment records.Settingand Participants: Nursing home residents in 14 organizations in Canada and the United States between 2014 and 2017. The most recent analytic samples for quality indicator calculation involve 11,123 unique residents in 68 homes associated with 12 different long-term care organizations.MeasuresAssessment data on pain and associated risk adjusters were obtained from the RAI/MDS 2.0 and MDS 3.0 assessments in Canadian and US nursing homes, respectively.ResultsThe Seniors Quality Leap Initiative has been functioning as an active community of practice for almost a decade with the aim of demonstrating leadership in the use of collaborative approaches to drive evidence-informed improvements in the quality of long-term care. Initiatives with a specific emphasis on improving care related to pain resulted in notable improvements in quality of clinical care in specific homes as well as within the network as a whole.Conclusions and ImplicationsThe Seniors Quality Leap Initiative demonstrates that a partnership between organizations in 2 countries can foment quality transitions through a shared commitment to identifying needs; employing flexible, but practical initiatives; and evaluating the impact of those initiatives through a transparent reporting mechanism.     

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.     

Nursing home cost and ownership type: evidence of interaction effects.

Due to steadily increasing public expenditures for nursing home care, much research has focused on factors that influence nursing home costs, especially for Medicaid patients. Nursing home cost function studies have typically used a number of predictor variables in a multiple regression analysis to determine the effect of these variables on operating cost. Although several authors have suggested that nursing home ownership types have different goal orientations, not necessarily based on economic factors, little attention has been paid to this issue in empirical research. In this study, data from 150 Virginia nursing homes were used in multiple regression analysis to examine factors accounting for nursing home operating costs. The context of the study was the Virginia Medicaid reimbursement system, which has intermediate care and skilled nursing facility (ICF and SNF) facility-specific per diem rates, set according to facility cost histories. The analysis revealed interaction effects between ownership and other predictor variables (e.g., percentage Medicaid residents, case mix, and region), with predictor variables having different effects on cost depending on ownership type. Conclusions are drawn about the goal orientations and behavior of chain-operated, individual for-profit, and public and nonprofit facilities. The implications of these findings for long-term care reimbursement policies are discussed.     

Prevalence of urinary catheterization in UK nursing homes

A postal questionnaire survey was undertaken in registered nursing homes in three different health districts in England: Gloucestershire, North Staffordshire and Leeds. Nursing homes may be registered as general nursing or mental health homes. If homes also have provision for residential beds these are defined as dual registered homes. Overall, 9% (438/4900) of residents, with an equal male:female split, had urinary catheters. There was no significant difference in the overall urinary catheterization rate in the three districts (P=0.9). There was a wide range of urinary catheterization prevalence between homes, with some homes of all three categories having no catheterized residents and several with a prevalence of over 40%. The wide range of prevalence may be due to differences in residents' underlying medical conditions or to differences in attitudes towards urinary catheterization by nursing home staff. Almost all homes (114/124, 92%) stated they had an infection control policy, but 31% (38/124) did not have a written policy on urinary catheter care. In view of the potential for morbidity, infection control policies should include a section on the care of urinary catheters and this should form part of the continuing training of nursing home staff.     

Concentrated poverty and nursing home bed supply in Chicago

This study explores whether poverty areas of Chicago have fewer nursing home beds and unique staffing patterns. Using 1990 census data and Illinois's 1994 Long-Term Care Facility Survey, census tracts were compared by need for long-term care, bed supply, and nursing home characteristics. While facilities cluster on the north side, and the number of beds follow the elderly, the supply of beds per elderly is actually greater in tracts with high proportions of poverty, disability, and African American residents due, in part, to the predominance of larger facilities. Ironically, economic segregation may work together with Medicaid's policy of serving the poorest to increase the supply of beds to those who might otherwise remain unserved. Nursing homes in the poorest communities have high percentages of Medicaid residents, are larger, and employ fewer staff per resident; homes with a high Medicaid population are more likely to employ LPNs, which may reflect labor supply differences.     

Falls in the nursing home: are they preventable?

INTRODUCTION: Falls are prevalent in elderly patients residing in nursing homes, with approximately 1.5 falls occurring per nursing home bed-years. Although most are benign and injury-free, 10% to 25% result in hospital admission and/or fractures. Primary care providers for nursing home residents must therefore aim to reduce both the fall rate as well as the rate of fall-related morbidity in the long-term care setting. Interventions have been demonstrated to be successful in reducing falls in community-dwelling elderly patients. However, less evidence supports the efficacy of fall prevention in nursing home residents. METHODS: The authors conducted a Medline search using the key words Falls and Nursing Homes. RESULTS: Several studies examined the efficacy of multifaceted intervention programs on reducing falls in nursing homes with varied results. Components of these intervention programs include: environmental assessment, assistive device evaluation and modification, medication changes, gait assessment and training, staff education, exercise programs, hip protector use, and blood pressure evaluation. Current literature supports the use of environmental assessment and intervention in reducing falls in nursing homes, and demonstrates an association between certain medications and falls. However, there are no studies that examine the effect of medication adjustments on fall rates. Also, the literature does not strongly suggest that exercise programs are effective in fall reduction. Although not effective in reducing fall rates, the use of hip protectors appears to result in less fall-related morbidity. CONCLUSION: More studies must be done to clarify the effects of high-risk medication reduction, the optimal nature and intensity of exercise programs, and patient targeting criteria to maximize the effectiveness of nursing home fall prevention programs. Based on the current literature, an effective multifaceted fall prevention program for nursing home residents should include risk factor assessment and modification, staff education, gait assessment and intervention, assistive device assessment and optimization, as well as environmental assessment and modification. Although there is no association between the use of hip protectors and fall rates, their use should be encouraged because the ultimate goal of any fall prevention program is to prevent fall-related morbidity.     

The cost of treating pneumonia in the nursing home setting

OBJECTIVE: To determine the costs of treating pneumonia in the nursing home setting and explore what factors are most responsible for that cost with a view to reducing cost. DESIGN: Prospective cohort study. SETTING: Thirty-six Missouri nursing homes participating in the study from April 1997 through September 1998. PARTICIPANTS: Nursing home residents with pneumonia who were not hospitalized (n = 502). We included residents evaluated in the emergency department (ED) and returned to the nursing home without admission. MEASUREMENTS: Residents were evaluated by project nurses. Examination findings, diagnostic testing, and treatment information for 30 days following evaluation were abstracted from medical records. Bills were obtained for individuals evaluated in the ED. RESULTS: There was significant variation in the cost of treating pneumonia in nursing homes. Episode costs were higher for residents seen in the ED of a hospital, residents with decubitus ulcers, black residents, and residents in larger facilities. Although total episode costs were related to illness severity, most of the variation in cost is not explained by resident or illness characteristics. The average cost for treating an episode of pneumonia in the nursing home, over and above usual care, was $458. CONCLUSIONS: There is wide variation in treatment for residents with similar clinical presentations. For residents at low risk of mortality, using less expensive antibiotics and reducing ED evaluation could result in cost reductions, although the effect on outcomes is unknown.     

Diagnosed Mental and Physical Health Conditions in the united States Nursing Home Population: Differences Between Urban and Rural Facilities

CONTEXT: There has been limited examination of the differences in health characteristics of the rural long-term care population. Recognizing these differences will allow policymakers to improve access to long-term care services in rural communities. PURPOSE: To determine whether differences in likelihood of diagnosis exist between urban and rural nursing home residents for 8 common medical conditions: 4 mental health conditions (depression, anxiety, Alzheimer's, and non-Alzheimer's dementia) and 4 physical health conditions (cancer, emphysema/chronic obstructive pulmonary disease, heart disease, and stroke/transient ischemic attack). METHODS: We used multivariate logistic regression to examine data derived from the 1996 Nursing Home Component of the Medical Expenditure Panel Survey, a multistage stratified probability sample of 815 nursing homes and 5899 residents, representing 3.1 million individuals in the United States who spent 1 or more nights in nursing homes during 1996. FINDINGS: Residents in rural homes were less likely to be diagnosed with depression compared to those in homes in large metropolitan areas, and residents in homes in small metropolitan areas were less likely to have cancer than those in large metropolitan areas. Diagnostic status between urban and rural residents was comparable for the other 6 conditions. CONCLUSIONS: Further research is necessary to determine whether and why depression is inadequately diagnosed in rural nursing homes and to ascertain which types of cancer are responsible for the observed differential. Such research is particularly important for elderly nursing home residents who are more likely to suffer from chronic conditions that require significant medical supervision.     

Management of constipation in residents with dementia: sorbitol effectiveness and cost

OBJECTIVE: The objective of this report is to describe a cost-effective strategy for management of constipation in nursing home residents with dementia. DESIGN: We conducted a prospective observational quality improvement study of 41 residents with chronic constipation and receiving an osmotic laxative. Sorbitol was substituted for lactulose. SETTING: The study was conducted at a dementia special care unit at a Veterans Administration hospital. MEASUREMENT: We measured the number and amount of laxative use over a period of 4 weeks that were required to maintain regular bowel function. RESULTS: There was no difference in efficacy of lactulose and sorbitol. Use of additional laxatives was infrequent: Milk of Magnesia on approximately 10% of days/patient, bisacodyl suppository on 2% to 4% of days/patient, and Fleet enema only on 3 occasions. The cost of constipation management using routine administration of sorbitol and as-needed use of other laxatives was 27% to 55% lower than the cost of other constipation management strategies reported in the literature. CONCLUSION: Substitution of sorbitol for lactulose does not change efficacy of the treatment and decreases cost. Regular use of an osmotic laxative avoids the costs and discomforts of rectal laxatives.     

Front-line Nursing Home Staff Experiences During the COVID-19 Pandemic

ObjectiveThe Coronavirus disease 2019 (COVID-19) pandemic is an unprecedented challenge for nursing homes, where staff have faced rapidly evolving circumstances to care for a vulnerable resident population. Our objective was to document the experiences of these front-line health care professionals during the pandemic.DesignElectronic survey of long-term care staff. This report summarizes qualitative data from open-ended questions for the subset of respondents working in nursing homes.Setting and ParticipantsA total of 152 nursing home staff from 32 states, including direct-care staff and administrators.MethodsFrom May 11 through June 4, 2020, we used social media and professional networks to disseminate an electronic survey with closed- and open-ended questions to a convenience sample of long-term care staff. Four investigators identified themes from qualitative responses for staff working in nursing homes.ResultsRespondents described ongoing constraints on testing and continued reliance on crisis standards for extended use and reuse of personal protective equipment. Administrators discussed the burden of tracking and implementing sometimes confusing or contradictory guidance from numerous agencies. Direct-care staff expressed fears of infecting themselves and their families, and expressed sincere empathy and concern for their residents. They described experiencing burnout due to increased workloads, staffing shortages, and the emotional burden of caring for residents facing significant isolation, illness, and death. Respondents cited the presence or lack of organizational communication and teamwork as important factors influencing their ability to work under challenging circumstances. They also described the demoralizing impact of negative media coverage of nursing homes, contrasting this with the heroic public recognition given to hospital staff.Conclusions and ImplicationsNursing home staff described working under complex and stressful circumstances during the COVID-19 pandemic. These challenges have added significant burden to an already strained and vulnerable workforce and are likely to contribute to increased burnout, turnover, and staff shortages in the long term.     

An overview of nursing home facilities: data from the 1997 National Nursing Home Survey

OBJECTIVE: This report presents estimates on the number and distribution of nursing home facilities, their services, current residents, and discharges in the United States during 1997. METHODS: Data presented in this report are estimates based on a sample of nursing home facilities, residents, and discharges from the 1997 National Nursing Home Survey (NHHS). The survey collects information about providers and recipients of care from nursing home facilities. NHHS has been periodically conducted by the National Center for Health Statistics since 1973. RESULTS: In 1997 there were an estimated 1.6 million current residents and 2.4 million discharges from 17,000 nursing homes nationwide. These facilities were predominantly proprietary and certified by both Medicare and Medicaid. There was an average of 107 beds per nursing home with an occupancy rate of 88 percent and a discharge rate of 130 patients per 100 beds. The majority of nursing home residents and discharges were elderly, white, and female.     

Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison

OBJECTIVE: To compare the costs associated with caring for severely demented residents nursing homes with and without feeding tubes. DESIGN: Retrospective cohort study. SETTING: A 700-bed long-term care facility in Boston Participants: Nursing home residents aged 65 years and over with advanced dementia and eating problems for whom long-term feeding tube had been discussed as a treatment option. Measurements: Costs were compared over the 6 months that followed the tube-feeding decision for those residents who did and did not undergo feeding tube placement for the following items: nursing time, physician assessments, food, hospitalizations, emergency room visits, diagnostic tests, treatment with antibiotics and parenteral hydration, and feeding tube insertion. RESULTS: Twenty-two subjects were included, 11 were tube-fed (mean age 84.3 years +/- 6.0) and 11 were hand-fed (mean age 90.2 years +/- 9.1). The daily costs of nursing home care were higher for the residents without feeding tubes compared with residents with tubes ($4219 +/- 1546 vs $2379 +/- 1032, P = 0.006). Nonetheless, Medicaid reimbursement to nursing homes in at least 26 states is higher for demented residents who are tube-fed than for residents with similar deficits who are not tube-fed. Costs typically billed to Medicare were greater for the tube-fed patients ($6994 +/- 5790 vs. $959 +/- 591, P < 0.001), primarily because of the high costs associated with initial feeding tube placement and hospitalizations or emergency rooms visits for the management of complications of tube-feeding. CONCLUSIONS: Nursing homes are faced with a potential fiscal incentive to tube-feed residents with advanced dementia: tube-fed residents generate a higher daily reimbursement rate from Medicaid, yet require less expensive nursing home care. From a Medicare perspective, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications. Further work is needed to determine whether these potential financial incentives influence tube-feeding decisions in practice.     

SARS-CoV-2 in Nursing Homes after 3 Months of Serial,Facilitywide Point Prevalence Testing,Connecticut, USA

Nursing homes house populations that are highly vulnerable to coronavirus disease. Point prevalence surveys (PPSs) provide information on the severe acute respiratory syndrome coronavirus 2 infection status of staff and residents in nursing homes and enable isolation of infectious persons to halt disease spread. We collected 16 weeks of public health surveillance data on a subset of nursing homes (34/212) in Connecticut, USA. We fit a Poisson regression model to evaluate the association between incidence and time since serial PPS onset, adjusting for decreasing community incidence and other factors. Nursing homes conducted a combined total of 205 PPSs in staff and 232 PPSs in residents. PPS was associated with 41%–80% reduction in incidence rate in nursing homes. Our findings provide support for the use of repeated PPSs in nursing home staff and residents, combined with strong infection prevention measures such as cohorting, in contributing to outbreak control.     

Economic impact of a specialist outreach team in residential and nursing home settings

BACKGROUND: The results of a randomized controlled trial have indicated that a training and educational programme for staff in nursing or residential homes may result in reductions in levels of depression and levels of cognitive impairment for residents presenting with an active management problem. The training and educational intervention consisted of members of a hospital outreach team who presented a series of 1 hour seminars on topics which staff had indicated would improve their knowledge and skills. AIMS OF THE STUDY: The aim of this study was to present an exploratory analysis of the impact on costs associated with providing an old age psychiatry outreach team giving training and education for staff in nursing and residential homes. METHOD: For the economic study, a societal perspective was employed. Measures of resource use and costs to the health service, social and community services and the nursing and residential homes were analysed for 120 residents from 12 nursing or residential homes, as part of a randomized controlled trial to assess a training package provided in residential and nursing homes. Cost estimates were based on estimates from generalized estimated equations. To allow for clustering effects within homes, the unit of randomization was the home as opposed to the individual. To ensure models were correctly specified, several tests including the Ramsey RESET test were employed. RESULTS: There were no significant differences in the total cost per person in the homes that received the intervention and the control homes. This study has shown that the additional cost of providing the specialist outreach team was likely to be covered by reductions in the use of other resources such as GP visits to nursing and residential homes. Therefore, though the study had limitations, it appeared that improved care could be provided at little or no extra cost. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The evidence presented suggests that the specialist outreach team was unlikely to add to the total cost of caring for residents in nursing and residential homes. This finding combined with the benefits in terms of lower levels of depression and cognitive impairment suggested that the intervention was good value for money. The intervention should be considered for use in other nursing and residential homes.     

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.