Electronic health record implementation in community nursing homes

INTRODUCTION: The Electronic Health Record (EHR) is being advocated as a tool to improve patient care. Nationwide initiatives are under way to determine how to implement EHR. To date, community nursing homes have not been involved in that effort. Many reasons, including multiple providers in a home, physical structure of a facility, multiple facilities, high costs of implementation, and maintenance of an EHR, hinder efforts to establish such a record in a nursing home. Convinced that an EHR would improve resident care, we undertook a project to establish an EHR in 11 community nursing homes. METHODS: Boston University Geriatric Services and Boston Medical Center partnered with 11 community nursing homes in the Boston, MA, area to introduce GE Centricity as the medical provider's medical record for the residents under the care of this medical practice. This effort included allowing the software to be used at various sites, providing hardware, and establishing Internet connectivity. RESULTS: All 11 of the nursing homes served by Boston University Geriatric Services have been connected to the system. DISCUSSION: It is possible to establish an EHR in a diverse, unrelated group of nursing homes. This has allowed for improved communication between providers, consultants, hospital, and nursing home staff.     

Nursing home case-mix reimbursement in Mississippi and South Dakota

OBJECTIVE: To evaluate the effects of nursing home case-mix reimbursement on facility case mix and costs in Mississippi and South Dakota. DATA SOURCES: Secondary data from resident assessments and Medicaid cost reports from 154 Mississippi and 107 South Dakota nursing facilities in 1992 and 1994, before and after implementation of new case-mix reimbursement systems. STUDY DESIGN: The study relied on a two-wave panel design to examine case mix (resident acuity) and direct care costs in 1-year periods before and after implementation of a nursing home case-mix reimbursement system. Cross-lagged regression models were used to assess change in case mix and costs between periods while taking into account facility characteristics. DATA COLLECTION: Facility-level measures were constructed from Medicaid cost reports and Minimum Data Set-Plus assessment records supplied by each state. Resident case mix was based on the RUG-III classification system. PRINCIPAL FINDINGS: Facility case-mix scores and direct care costs increased significantly between periods in both states. Changes in facility costs and case mix were significantly related in a positive direction. Medicare utilization and the rate of hospitalizations from the nursing facility also increased significantly between periods, particularly in Mississippi. CONCLUSIONS: The case-mix reimbursement systems appeared to achieve their intended goals: improved access for heavy-care residents and increased direct care expenditures in facilities with higher acuity residents. However, increases in Medicare utilization may have influenced facility case mix or costs, and some facilities may have been unprepared to care for higher acuity residents, as indicated by increased rates of hospitalization.     

Supply and segregation of nursing home beds in Chicago communities

Objective. Previous research suggests that a shortage of nursing home beds in Latino communities and segregation within facilities in urban settings may contribute to low utilization patterns that both Latino and African American elders exhibit. In order to explore structural barriers to nursing home care for African American and Latino families, this study examines the supply and ethnoracial composition of nursing homes in Chicago communities. Design. With data from the 1990 US Census of Population and Illinois' 1994 Long-Term Care Facility Survey, regression was used to determine if Latino nursing home residents in Chicago follow neighborhood residential patterns in the same way that African American nursing home residents do. Next the availability of nursing home beds by ethnoracial community is examined using analysis of variance. Finally, we present correlations between the racial/ethnic composition of Chicago's facilities, community demographics and facility characteristics that have been associated with quality outcomes. Results. Both African American and Latino nursing home residents follow residential housing patterns, tending to reside in facilities located in their own communities. Latino communities have the fewest beds. However, Latinos appear to be more mobile in their utilization of nursing facilities in other communities than either African Americans or whites and tend to reside in smaller homes with fewer Medicaid recipients. Conclusion. Health policy makers must actively address racial and ethnic differences in access to long-term care or risk reinforcing the effects of poverty and segregation. In order to ensure that Latino elders living alone are not going without needed care city leaders must promote a range of culturally sensitive alternatives to nursing home care within Latino communities while promoting geographic mobility for African Americans.     

Ethics Committees in the Rural Midwest: Exploring the Impact of HIPAA

ABSTRACT:  Context: Confidentiality of personal health information is an ethical principle and a legislated mandate; however, the impact of the Health Insurance Portability and Accountability Act (HIPAA) on ethics committees ethics committees is limited. Purpose: This study investigates the prevalence, activity, and composition of ethics committees located in rural central and southern Illinois. Additionally, the impact of the HIPAA Officer serving on the committee is reported. Methods: Surveys were mailed to the "Administrator or Ethics Committee Chairperson" at rural Illinois hospitals and skilled care facilities. Survey items included committee composition and perception of HIPAA-related involvement. Findings: Over one third (36.7%) of the facilities reported having formal ethics committees. Hospitals were more likely (79.3%) to have ethics committees than skilled nursing facilities (20.7%). Ethics committee members usually include an administrator, nurse, and physician. The smaller the facility (based on number of beds), the more likely it was to have a HIPAA Officer on the committee. Committees with a HIPAA Officer were more likely to be involved in monitoring and/or remediation of HIPAA privacy and security violations. Most respondents, however, did not feel the committee should be involved in these issues. Conclusions: Although the sample size is too small to generalize, HIPAA does seem to have an effect on the issues discussed by ethics committees. Furthermore, ethics committees that include a HIPAA Officer in the membership report increased committee involvement in HIPAA related issues .     

Long-Term Care Facility Ownership and Acute Hospital Service Use in British Columbia,Canada: A Retrospective Cohort Study

ObjectivePrevious studies report higher hospitalization rates in for-profit compared with nonprofit long-term care facilities (LTCFs), but have not included staffing data, a major potential confounder. Our objective was to examine the effect of ownership on hospital admission rates, after adjusting for facility staffing levels and other facility and resident characteristics, in a large Canadian province (British Columbia).DesignRetrospective cohort study.Setting and ParticipantsOur cohort included individuals resident in a publicly funded LTCF in British Columbia at any time between April 1, 2012 and March 31, 2016.MeasuresHealth administrative data were extracted from multiple databases, including continuing care, hospital discharge, and Minimum Data Set (MDS 2.0) assessment records. Cox extended hazards regression was used to estimate hospitalization risk associated with facility- and resident-level factors.ResultsThe cohort included 49,799 residents in 304 LTCF facilities (116 publicly owned and operated, 99 for-profit, and 89 nonprofit) over the study period. Hospitalization risk was higher for residents in for-profit (adjusted hazard ratio [adjHR] 1.34; 95% confidence interval [CI] 1.29–1.38) and nonprofit (adjHR 1.37; 95% CI 1.32–1.41) facilities compared with publicly owned and operated facilities, after adjustment for staffing, facility size, urban location, resident demographics, and case mix. Within subtypes, risk was highest in single-site facilities: for-profit (adjHR 1.42; 95% CI 1.36–1.48) and nonprofit (adjHR 1.38, 95% CI 1.33–1.44).Conclusions and ImplicationsThis is the first Canadian study using linked health data from hospital discharge records, MDS 2.0, facility staffing, and ownership records to examine the adjusted effect of facility ownership characteristics on hospital use of LTCF residents. We found significantly lower adjHRs for hospital admission in publicly owned facilities compared with both for-profit and nonprofit facilities. Our finding that publicly owned facilities have lower hospital admission rates compared with for-profit and nonprofit facilities can help inform decision-makers faced with the challenge of optimizing care models in both nursing homes and hospitals as they build capacity to care for aging populations.     

Utilization of nurse practitioners in long-term care: findings and implications of a national survey

OBJECTIVES: The objective of this study was to determine the national practice patterns of nurse practitioners (NPs) providing care in long-term care (LTC) facilities, including the number and characteristics of LTC facilities that use NPs for any portion of care to residents, NP activities, and employment arrangements between NPs, physicians, and facilities. DESIGN: Mailed survey. PARTICIPANTS: Participants included all physicians who are members of the American Medical Directors Association (AMDA). MEASUREMENT: The survey instrument was constructed to obtain information in the following six domains: (1) the number of LTC facilities that have NPs involved in providing care; (2) the number of NPs engaged in care at these facilities; (3) the types of employment/financial arrangements between NPs and LTC facilities; (4) the types of services provided by the NPs; (5) the effectiveness of the NPs as perceived by the medical directors; and (6) the perceived future demand for NPs in LTC. RESULTS: Of a total of 870 respondents (response rate 19%), 546 respondents (63%) reported the involvement of NPs in the care of residents in their facilities. In total, respondents identified 1160 NPs involved in care, with a median of two NPs per responding facility (range, 1-10). Respondents reported that NPs make sick/urgent resident visits (96%), provide preventive care to long-stay residents (88%), and perform alternating required regulatory 30/60 (88%), hospice care (80%), and wound care (78%). Significant variations in practice patterns were found between NPs employed by a LTC facility (19% of respondents) as compared with those NPs employed in other arrangements. Large majorities of medical directors stated that NPs are particularly effective in maintaining physician satisfaction (90%), resident satisfaction (87%), and family satisfaction (85%). An additional 34% of the respondents projected an increased need for NPs in nursing homes in the future. CONCLUSION: NPs involved in LTC are more likely to be involved in the care of residents in the nation's larger (>100-bed) LTC facilities. The substantial number and types of services provided by these NPs, coupled with the high resident, family, and physician satisfaction with their services, suggests the need for educational, policy, and reimbursement strategies to encourage the further involvement of NPs in the care of residents in nursing homes.     

Predictors of do not resuscitate orders in the nursing home

BACKGROUND: The outcome of cardiopulmonary resuscitation of residents of long-term care facilities is poor. However, only about one half of residents of long term care facilities have a do not resuscitate (DNR) order. The remainder usually have resuscitation by order or by default policy. Understanding predictors of DNR may help clinicians address end-of-life issues with the older long-term care population. OBJECTIVES: To determine (1) the prevalence of DNR orders, and (2) predictors of DNR orders in older institutionalized individuals in a large community teaching nursing home. METHODS: A cross-sectional chart review study of 177 consecutively located older patients from an 899-bed academic long-term care facility. RESULTS: The prevalence of a DNR order was 40%. The frequency of ordering DNR was greater in subjects who were 85 years or older compared with subjects who were younger than 85 years (57% vs. 30%, P < .05). Ordering DNR was associated significantly with race (49% of whites compared with 13% African Americans, P < .05) but not with sex. Subjects with a DNR order were more likely to have been diagnosed with depression (52% vs. 35%, P < .05) but not dementia, and overall had greater number of medical conditions (5.9 +/- 2 vs. 5.1 +/- 2, P < .05) compared with subjects without DNR orders. The frequency of DNR orders did not significantly differ between subjects who were able to ambulate (with or without assistance) compared with subjects who were wheelchair or bed bound. Using logistic regression analysis, only age (with a B of -1.04 and P of .017) and race (with a B of 1.4 and a P of .01) were independent predictors of DNR status. CONCLUSION: Fewer than half of this sample of long-term care residents had a DNR order. Among seven factors studied, only age and race were independent predictors of DNR status in the nursing home.     

Cardiac Resuscitation Procedures in US Nursing Facilities: Time to Reevaluate the Standard of Care?

Although the use of automated external defibrillators (AEDs) in out-of-hospital cardiac arrest (OHCA) response has become the standard of care in many community settings over the past 20+ years, the adoption of AEDs in US nursing facilities is variable and the current number of facilities with AEDs is unknown. Recent research into the use of AEDs as part of cardiopulmonary resuscitation (CPR) procedures for nursing facility residents with sudden cardiac arrest demonstrates improved outcomes in the limited cohort with witnessed arrests, early bystander CPR, and an initial amenable rhythm, shocked with an AED before the arrival of Emergency Medical Services (EMS) personnel. This article reviews data about outcomes of CPR in older adults and nursing facility settings and proposes that standard procedures for CPR attempts in US nursing facilities should be reevaluated and continue to evolve, commensurate with the evidence and community standards.     

Detecting systematic discrepancies in nursing home assessments of residents

Medicare and Medicaid reimbursement received by nursing homes are linked to the care needs of residents in a facility. Thus, a facility may have an incentive to overestimate the care needs of residents. To evaluate this, a sample of nursing homes in Ohio was selected, and independent assessors were sent to sampled facilities, and the rating of residents by the independent assessor was compared to a similar rating by the staff at nursing homes. We first evaluated whether the independent assessors were homogeneous with respect to agreement with nursing facility assessors using a permutation test procedure. Since there was evidence of heterogeneity among the independent assessors, we evaluated agreement between the independent nurse and facility assessors separately for each independent nurse. Responses were collapsed into three categories: independent assessor was lower, equal or greater than the facility assessor. Under a null hypothesis that lower and greater categories were equally probable, the maximum likelihood estimate of the vector of probabilities corresponding to these categories was constructed for each independent assessor. The P-value for detecting a difference between independent and facility assessors was calculated for each facility by summing the multinomial probabilities of obtaining a result at least as extreme as observed in the direction of the “lower” category being more probable. Five of the 39 facilities had P-value < 0.10 with three of the low P-value facilities occurring in reviews by one of the independent assessors. We believe that there is not evidence of systematic differences between the facility assessors and independent assessors although a caveat associated with this statement is the power of this assessment procedure is strongly linked to number of cases reviewed per facility along with the size of the effect expected. We believe this provides a screening mechanism to identify facilities where additional samples are warranted.     

Low-care residents in nursing homes: the impact of market characteristics

Approximately 30% of nursing home residents were recently identified as low-care cases; that is, residents with low levels of acuity. Other institutional venues, board and care homes and assisted living facilities, for example, are often recommended as alternative domiciliaries providing more appropriate and less expensive care for these residents. In this investigation the effect of nine market factors on the prevalence of low-care residents in 14,646 nursing homes are studied. Government regulations, competition from other providers, and the overall munificence of the market are found to influence their prevalence. These results are discussed along with several issues inherent to channeling low-care residents to other care setting.     

Safe Interorganizational Health Information Exchange During the COVID-19 Pandemic

Accurate and timely transmission of medical records between skilled nursing facilities and acute care settings has been logistically problematic. Often people are sent to the hospital with a packet of paper records, which is easily misplaced. The COVID-19 pandemic has further magnified this problem by the possibility of viral transmission via fomites. To protect themselves, staff and providers were donning personal protective equipment to review paper records, which was time-consuming and wasteful.We describe an innovative process developed by a team of hospital leadership, members of a local collaborative of skilled nursing facilities, and leadership of this collaborative group, to address this problem. Many possible solutions were suggested and reviewed. We describe the reasons for selecting our final document transfer process and how it was implemented. The critical success factors are also delineated. Other health systems and collaborative groups of skilled nursing facilities may benefit from implementing similar processes.     

Long-term care survey reveals challenges. Facilities grapple with five broad issues, including changes in leadership and AIDS

The Catholic Health Association's 1992 survey of Catholic long-term care (LTC) facilities identified five broad issues LTC facilities face in the 1990s: leadership, system affiliation, community programs, resident issues, and care of persons with AIDS. The transition to lay leadership presents new challenges to the relationship between LTC facilities and their sponsors. Despite the dominance of religious sponsors, an increasing number of laypersons are serving as healthcare administrators both in long-term and acute care. Thirty percent of respondents reported being affiliated with a multi-institutional system. This percentage has changed little in the past few years, although the number of facilities that are system members continues to increase at the fastest rate of any type of LTC facility. Only 27 percent of survey respondents said they provide educational or informational programs for persons in their communities. Thirty-nine percent of system-affiliated LTC facilities reported offering such programs. One encouraging finding shows that 80 percent of facilities have written policies for living wills, 64 percent for designated proxy, and 86 percent for durable power of attorney for healthcare. LTC providers are struggling to determine their role in caring for persons with HIV and AIDS. Only 3.6 percent of respondents care for residents with AIDS. A major problem LTC administrators face is a fear of potential infection of staff or residents.     

Experience and expectation: Conflict and change in traditional family health care among the Quichua of Saraguro

Quichua Indian mothers have traditionally served as primary health caretakers for the families of Saraguro in highland Ecuador. A hospital has recently opened, providing biomedical health care and programs in preventive medicine for local indigenous communities. Opposition to the new facility has arisen, however, as families express dissatisfaction with hospital policies. Surveys and in-depth interviews, conducted with Saraguro families and hospital staff between 1977 and 1982 have outlined problems encountered in the introduction and administration of biomedical care. The hospital is seen by some residents as a threat to Quichua women's authority as herbalists and family curers. More importantly, however, Sarguro families view the facility as a disappointment, as it provided services inconsistent with traditional health values, practices and felt needs, and it fails residents' expectations of hospital care. Conflicts between traditional and hospital health care experiences and between expectations and reality, have bred hostility between the health facility and the community it serves. Inability to negotiate with hospital staff for greater flexibility in policies has intensified community frustration. The impact of cultural health values, expectations, and program flexibility are discussed with potential implications for planning and administration of biomedical delivery services.     

Opportunities for advance practice nurses in the nursing facility

Advance practice nurses (APNs) have emerged as valuable members of the nursing facility interdisciplinary team. They function in a variety of roles, including clinical care, administration, nursing consultation, and education. Positive outcomes in key indicators of care and reduction in costs to the healthcare systems have been attributed to their practice. Barriers to implementation of the role include regulatory issues, facility resistance, and difficulty adapting to the environment. Facilitation of the role is enhanced by collegial relationships and role negotiation. There is strength in the APN-physician collaborative model. The APN is likely to concentrate on prevention, restoration, maintenance, and palliative care, allowing the physician to concentrate on complex medical problems. There is a need for APN practices to identify APN-sensitive outcomes, collect and analyze data, and disseminate findings.     

Nutritional issues in long-term care

Because long-term care residents often have chronic illnesses and complex care regimens, nutritional issues are common in these populations. Furthermore, management is complicated because some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings. Quality nutritional practice in long-term care involves careful assessment of barriers to adequate nutrition; reduction of risk factors; attention to specialized diets, food presentation, and supplements, when appropriate; awareness of the importance of psychosocial and environmental issues; and consideration of the role of medication both as a cause and a therapeutic adjunct. Optimal practice at a facility level would involve a systematic approach to applying the best evidence-based approaches, with a focus on individualizing each resident's nutritional management.     

Body, mind, and soul. The parish nurse offers physical, emotional, and spiritual care

Many hospitals see the parish nurse program as a way to bring their mission to the community and collaborate with area parishes. Because people are finding it increasingly difficult to access our nation's complex healthcare system, the parish nurse program is becoming more popular with hospitals, parishes, and the communities they serve. The parish nurse is a resource person--a health educator, a personal health counselor, a volunteer coordinator and support group organizer, a community liaison, and a role model for the relationship between one's faith and health. Parish nurses do not provide invasive treatments. Parish nurse programs that have been most successful have been developed through the hospital's pastoral care department in conjunction with the nursing department. The hospital establishes a steering committee to guide the program's formation. Daily, the faculty, a group made up of a physician and representatives from nursing and from pastoral care, supervise and monitor the parish nurse program.     

The percentage of beds designated for medicaid in american nursing homes and nurse staffing ratios

Previous analyses of the inverse relationship between a nursing home's Medicaid census and its quality of care have been based on samples limited to specific geographic regions, for-profit entities, or only skilled care facilities. The present study uses national-level data from the 1999 National Nursing Home Survey to examine the association between the proportion of beds designated for Medicaid residents and nurse staffing ratios. The results indicate that homes which designate a higher proportion of their beds for Medicaid recipients maintain lower ratios of registered nurses and nurse's aides to residents, even when key facility characteristics are controlled. It was also found that nursing homes with a higher proportion of Medicaid beds offer lower nursing ratios regardless of their profit status or the difference between private pay rates and Medicaid reimbursement rates. Since lower nursing ratios have been previously linked to negative outcomes, these findings suggest that homes which rely more heavily upon Medicaid recipients may be using cost-cutting strategies which have negative implications for quality.     

Identifying types of nursing facility stays using medicare claims data: an algorithm and validation

Nursing facilities provide skilled nursing and rehabilitative care to patients for short stays and custodial care to patients for long stays. The type of nursing facility stay (short- or long-term) is a potentially important risk factor and health outcome in health services research and is informative from both medical and fiscal perspectives. The purpose of this study was to develop and validate an algorithm to identify the use of nursing facility services and differentiate short- from long-term care using Medicare claims data. We used claims data for a 5% sample of Medicare beneficiaries to develop an algorithm to detect the use of nursing facility services and to distinguish between short- and long-term stays. We tested this algorithm using residency status from Medicaid long-term care claims for dually eligible beneficiaries and using residency status from the Medicare Current Beneficiary Survey (MCBS). Among 1,694,051 beneficiaries included in the baseline cohort, 25.6% had some indication of nursing facility residency. Using our algorithm, 59.8% of beneficiaries using any nursing facility care were classified as long-term residents. Validation of the algorithm against Medicaid long-term care claims and MCBS yielded high sensitivity and specificity. To our knowledge, this is the first paper to present a validated algorithm for identification of use of nursing facility services among Medicare beneficiaries that differentiates between short- and long-term care residency status.