Physician Availability in Long-Term Care and Resident Hospital Transfer: A Retrospective Cohort Study

ObjectivesTo investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations.DesignRetrospective cohort study.Setting and participants161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes.MethodsWe administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death.We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access.ResultsFifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED.The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P = .02) and 14% lower (rate ratio = 0.86, P = .07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access.Conclusions and implicationsResidents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates.     

Surveillance of lower respiratory tract infections outbreaks in nursing homes in France

Lower respiratory tract infections (LRTI) are the leading cause of infectious deaths in nursing homes. An early reporting procedure of LRTI outbreaks to local public health authorities was set up in France in 2006 in order to reduce the morbidity and the mortality related to these events. Local public health authorities reported these outbreaks to the French institute for Public Health Surveillance through a web application allowing a real-time exchange of information. Between August 2006 and July 2007, 64 outbreaks were reported. In more than 30% of the episodes, influenza virus was detected. On average, attacks rates were 22% for the residents and 7% for the staff. Staff members were affected in at least 56% of outbreaks. Average influenza vaccine uptake was 91% for the residents and 38% for the staff. The time for control measures implementation was 6.7 days on average and control measures were implemented after reporting in 36% of outbreaks. When control measures were implemented more than 2 days after the onset of the first case, the duration of outbreaks was longer (16.4 days vs. 8.3 days, P < 0.005) and residents had an increased rate of LRTI (P < 0.001) than when these measures were implemented earlier. These data show that the influenza immunization coverage for staff working in nursing homes is limited. The implementation of control measures is often delayed, although recommendations stress that they should start upon diagnosis of the first case. Reporting creates a dialog between nursing homes and public health professionals which facilitates outbreak management.     

Copper for the Prevention of Outbreaks of Health Care–Associated Infections in a Long-term Care Facility for Older Adults

ObjectiveWe aimed to study the efficacy of copper as an antimicrobial agent by comparing incidence rates during outbreaks in areas equipped vs not equipped with copper surfaces in a long-term facility for dependent older adults (nursing home).DesignProspective observational pilot study in a nursing home.Setting and participantAll persons resident in the nursing home belonging to Reims University Hospital, from February 1, 2015 to June 30, 2016, were included.MethodsIncidence rates for health care–related infections during outbreaks occurring during the study period were compared between the wing that was equipped and the wing that was not equipped with copper surfaces. Results are expressed as relative risks (RRs) and 95% confidence intervals (95% CIs).ResultsDuring the study period, 556 residents were included; average age was 85.4 ± 9.2 years, and 76% were women. Four outbreaks occurred during the study period: 1 influenza, 1 keratoconjunctivitis, and 2 gastroenteritis outbreaks. The risk of hand-transmitted health care–associated infection was significantly lower in the area equipped with copper surfaces (RR 0.3, 95% CI 0.1-0.5).Conclusions and implicationsIn our study, copper was shown to reduce the incidence of hand-transmitted health care–associated infections and could represent a relatively simple measure to help prevent HAIs in nursing homes.     

Cost Benefit of High-Dose vs Standard-Dose Influenza Vaccine in a Long-Term Care Population During an A/H1N1-Predominant Influenza Season

ObjectivesInfluenza is a leading cause of avoidable admissions for nursing home (NH) residents. We previously evaluated the effectiveness of a high-dose trivalent influenza vaccine (HD) compared to a standard-dose influenza vaccine (SD) through a cluster-randomized trial of NH residents. Fewer residents from facilities randomized to HD were hospitalized. In this article, we extend our analyses to consider direct medical care costs relative to vaccine costs for HD ($31.82/dose) as compared to SD ($12.04/dose).DesignPost hoc, cost-benefit analysis.Setting and participantsFrom the participating NH facilities (n = 817), we identified Medicare fee-for-service enrollees who were long-stay residents (>100 days) at the start of the 2013-2014 influenza season (November 1–May 31). The intervention was residence in a facility randomized to HD or SD influenza vaccine.MethodsWe summed expenditures from long-stay NH residents' Medicare Part A, B, and D fee-for-service claims and compared person-level expenditures between residents of facilities offering HD vs SD. Expenditures were adjusted for clustering of residents within NHs, person-time, and prespecified covariates using 2-part, generalized linear models with bootstrapped standard errors. We examined the incremental cost-benefit of HD vs SD vaccines from a payer perspective.ResultsThere were 18,605 and 18,658 Medicare fee-for-service long-stay residents in facilities offering HD and SD, respectively. Person- and facility-adjusted total expenditures differed by $546 (P = .006). The $20 incremental cost of HD to SD offset adjusted expenditures for a net benefit of $526 per NH resident and a financial return on investment of 546/20 = 27:1.Conclusions/implicationsThe use of HD influenza vaccine in long-stay NH residents reduced total health care expenditures for a net benefit despite HD being more expensive per dose. These cost offsets applied to Medicare beneficiaries residing in NHs could result in important savings to the Medicare program.     

Racial inequities in receipt of influenza vaccination among nursing home residents in the United States, 2008-2009: a pattern of low overall coverage in facilities in which most residents are black

ObjectivesNationwide among nursing home residents, receipt of the influenza vaccine is 8 to 9 percentage points lower among blacks than among whites. The objective of this study was to determine if the national inequity in vaccination is because of the characteristics of facilities and/or residents.DesignCross-sectional study with multilevel modeling.Setting and ParticipantsStates in which 1% or more of nursing home residents were black and the difference in influenza vaccination coverage between white and black nursing home residents was 1 percentage point or higher (n = 39 states and the District of Columbia). Data on residents (n = 2,359,321) were obtained from the Centers for Medicare &; Medicaid Service’s Minimum Data Set for October 1, 2008, through March 31, 2009.MeasurementsResidents’ influenza vaccination status (vaccinated, refused vaccine, or not offered vaccination).ResultsStates with higher overall influenza vaccination coverage among nursing home residents had smaller racial inequities. In nursing homes with higher proportions of black residents, vaccination coverage was lower for both blacks and whites. The most dramatic inequities existed between whites in nursing homes with 0% blacks (L1) and blacks in nursing homes with 50% or more blacks (L5) in states with overall racial inequities of 10 percentage points or more. In these states, more black nursing home residents lived in nursing homes with 50% or more blacks (L5); in general, the same homes with low overall coverage.ConclusionInequities in influenza vaccination coverage among nursing home residents are largely because of low vaccination coverage in nursing homes with a high proportion of black residents. Findings indicate that implementation of culturally appropriate interventions to increase vaccination in facilities with larger proportions of black residents may reduce the racial gap in influenza vaccination as well as increase overall state-level vaccination.     

The Adverse Effects of the COVID-19 Pandemic on Nursing Home Resident Well-Being

ObjectiveQuantify the effects of the COVID-19 pandemic on nursing home resident well-being.DesignQuantitative analysis of resident-level assessment data.Setting and participantsLong-stay residents living in Connecticut nursing homes.MethodsWe used Minimum Data Set assessments to measure nursing home resident outcomes observed in each week between March and July 2020 for long-stay residents (eg, those in the nursing home for at least 100 days) who lived in a nursing home at the beginning of the pandemic. We compared outcomes to those observed at the beginning of the pandemic, controlling for both resident characteristics and patterns for outcomes observed in 2017-2019.ResultsWe found that nursing home resident outcomes worsened on a broad array of measures. The prevalence of depressive symptoms increased by 6 percentage points relative to before the pandemic in the beginning of March—representing a 15% increase. The share of residents with unplanned substantial weight loss also increased by 6 percentage points relative to the beginning of March—representing a 150% increase. We also found significant increases in episodes of incontinence (4 percentage points) and significant reductions in cognitive functioning. Our findings suggest that loneliness and isolation play an important role. Though unplanned substantial weight loss was greatest for those who contracted COVID-19 (about 10% of residents observed in each week), residents who did not contract COVID-19 also physically deteriorated (about 7.5% of residents in each week).Conclusions and ImplicationsThese analyses show that the pandemic had substantial impacts on nursing home residents beyond what can be quantified by cases and deaths, adversely affecting the physical and emotional well-being of residents. Future policy changes to limit the spread of COVID-19 or other infectious disease outbreaks should consider any additional costs beyond the direct effects of morbidity and mortality due to COVID-19.     

Staffing and Protective Equipment Access Mitigated COVID-19 Penetration and Spread in US Nursing Homes During the Third Surge

ObjectivesDuring the last quarter of 2020—despite improved distribution of personal protective equipment (PPE) and knowledge of COVID-19 management—nursing homes experienced the greatest increases in cases and deaths since the pandemic's beginning. We sought to update COVID-19 estimates of cases, hospitalization, and mortality and to evaluate the association of potentially modifiable facility-level infection control factors on odds and magnitude of COVID-19 cases, hospitalizations, and deaths in nursing homes during the third surge of the pandemic.DesignCross-sectional analysis.Setting and ParticipantsFacility-level data from 13,156 US nursing home facilities.MethodsTwo series of multivariable logistic regression and generalized linear models to examine the association of infection control factors (personal protective equipment and staffing) on incidence and magnitude, respectively, of confirmed COVID-19 cases, hospitalizations, and deaths in nursing home residents reported in the last quarter of 2020.ResultsNursing homes experienced steep increases in COVID-19 cases, hospitalizations, and deaths during the final quarter of 2020. Four-fifths (80.51%; n = 10,592) of facilities reported at least 1 COVID-19 case, 49.44% (n = 6504) reported at least 1 hospitalization, and 49.76% (n = 6546) reported at least 1 death during this third surge. N95 mask shortages were associated with increased odds of at least 1 COVID-19 case [odds ratio (OR) 1.21, 95% confidence interval (CI) 1.05-1.40] and hospitalization (1.26, 95% CI 1.13-1.40), as well as larger numbers of hospitalizations (1.11, 95% CI 1.02-1.20). Nursing aide shortages were associated with lower odds of at least 1 COVID-19 death (1.23, 95% CI 1.12-1.34) and higher hospitalizations (1.09, 95% CI 1.01-1.17). The number of nursing hours per resident per day was largely insignificant across all outcomes. Of note, smaller (<50-bed) and midsized (50- to 150-bed) facilities had lower odds yet higher magnitude of all COVID outcomes. Bed occupancy rates >75% increased odds of experiencing a COVID-19 case (1.48, 95% CI 1.35-1.62) or death (1.25, 95% CI 1.17-1.34).Conclusions and ImplicationsAdequate staffing and PPE—along with reduced occupancy and smaller facilities—mitigate incidence and magnitude of COVID-19 cases and sequelae. Addressing shortcomings in these factors is critical to the prevention of infections and adverse health consequences of a next surge among vulnerable nursing home residents.     

Changes in Long-Term Care Markets: Assisted Living Supply and the Prevalence of Low-Care Residents in Nursing Homes

ObjectivesTo assess the effect of changes in assisted living (AL) capacity within a market on prevalence of residents with low care needs in nursing homes.DesignRetrospective, longitudinal analysis of nursing home markets.Setting and participantsTwelve thousand two hundred fifity-one nursing homes in operation during 2007 and 2014.MeasurementsWe analyzed the percentage of residents in a nursing home who qualified as low-care. For each nursing home, we constructed a market consisting of AL communities, Medicare beneficiaries, and competing nursing homes within a 15-mile radius. We estimated the effect of change in AL beds on prevalence of low-care residents using multivariate linear models with year and nursing home fixed effects.ResultsThe supply of AL beds increased by an average 258 beds per nursing home market (standard deviation = 591) during the study period. The prevalence of low-care residents decreased from an average of 13.0% (median 10.5%) to 12.2% (median 9.5%). In adjusted models, a 100-bed increase in AL supply was associated with a decrease in low-care residents of 0.041 percentage points (P = .026), controlling for changes in market and nursing home characteristics, county demographics, and year and nursing home fixed effects. In markets with a high percentage of its Medicare beneficiaries (≥14%) dual eligible for Medicaid, the effect of AL is stronger, with a 0.066–percentage point decrease per 100 AL beds (P = .026) vs a 0.016–percentage point decrease in low-duals markets (P = .48).Conclusions and implicationsOur analysis suggests that some of the growth in AL capacity serves as a substitute for nursing homes for patients with low care needs. Furthermore, the effects are concentrated in markets with an above-average proportion of beneficiaries with dual Medicaid eligibility.     

Institutional Factors Associated with Residents’ Malnutrition in Nursing Homes: A Cross-Sectional Study

ObjectivesMalnutrition is frequent in older adults, associated with increased morbidity, mortality, and higher costs. Nursing home residents are especially affected, and evidence on institutional factors associated with malnutrition is limited. We calculated the prevalence of malnutrition in Swiss nursing home residents and investigated which structure and process indicators of nursing homes are associated with residents’ malnutrition.DesignSubanalysis of the Swiss Nursing Homes Human Resources Project 2018, a multicenter, cross-sectional study conducted from 2018 to 2019 in Switzerland.Setting and ParticipantsThis study included 76 nursing homes with a total of 5047 residents.MethodsMalnutrition was defined as a loss of bodyweight of ≥5% in the last 30 days or ≥10% in the last 180 days. Binomial generalized estimating equations (GEE) were applied to examine the association between malnutrition and structural (staffing ratio, grade mix, presence of a dietician, malnutrition guideline, support during mealtimes) and process indicators (awareness of malnutrition, food administration process). GEE models were adjusted for institutional (profit status, facility size) and specific resident characteristics.ResultsThe prevalence of residents with malnutrition was 5%. A higher percentage of units per nursing home having a guideline on prevention and treatment of malnutrition was significantly associated with more residents with weight loss (OR 2.47, 95% CI 1.31-4.66, P = .005). Not having a dietician in a nursing home was significantly associated with a higher rate of residents with weight loss (OR 1.60, 95% CI 1.09-2.35, P = .016).Conclusions and ImplicationsHaving a dietician as part of a multidisciplinary team in a nursing home is an important step to address the problem of residents’ malnutrition. Further research is needed to clarify the role of a guideline on prevention and treatment of malnutrition to improve the quality of care in nursing homes.     

Effectiveness of post-exposition prophylaxis with oseltamivir in nursing homes: a randomised controlled trial over four seasons

Background

Oseltamivir has been registered for use as post-exposition prophylaxis (PEP) following exposure to influenza, based on studies among healthy adults. Effectiveness among frail elderly nursing home populations still needs to be properly assessed.

Methods

We conducted a randomised double-blind placebo-controlled trial of PEP with either oseltamivir (75 mg once daily) or placebo among nursing home units where influenza virus was detected; analysis was unblinded. The primary outcome was laboratory-confirmed influenza among residents in units on PEP; the secondary outcome was clinical diagnosis of influenza-like illness (ILI).

Results

42 nursing homes were recruited, in which 17 outbreaks occurred from 2009 through 2013, two caused by influenza virus B, the others caused by influenza virus A(H3N2). Randomisation was successful in 15 outbreaks, with a few chance differences in baseline indicators. Six outbreaks were assigned to oseltamivir and nine to placebo. Influenza virus positive secondary ILI cases were detected in 2/6 and 2/9 units respectively (ns); secondary ILI cases occurred in 2/6 units on oseltamivir, and 5/9 units on placebo (ns). Logistical challenges in ensuring timely administration were considerable.

Conclusion

We did not find statistical evidence that PEP with oseltamivir given to nursing home residents in routine operational settings exposed to influenza reduced the risk of new influenza infections within a unit nor that of developing ILI. Power however was limited due to far fewer outbreaks in nursing homes than expected since the 2009 pandemic. (RCT nr NL92738)

     

Influenza vaccine effectiveness among elderly nursing home residents: a cohort study.

Outbreaks of influenza in nursing homes still occur, even when a large portion of residents have been inoculated with inactivated vaccine. Data were collected in 1991--1992 from 83 eligible skilled nursing homes located in southern Lower Michigan to determine the effectiveness of inactivated influenza vaccine in preventing influenza-like illness and influenza-associated pneumonia. Surveillance was conducted to identify the occurrence of influenza in the homes and, at the end of the season, specific data were gathered on all residents of homes with influenza activity. Age- and sex-adjusted estimates of vaccine effectiveness were calculated using Cox proportional hazards models for each nursing home. Estimates were pooled using precision-based weights calculated from data for each home. Vaccine was found to be 33% effective in preventing total respiratory illness (influenza-like illness and clinically diagnosed pneumonia). In prevention of pneumonia alone, vaccine was 43% effective. The estimate for prevention of pneumonia rose to 55% if the period under consideration was limited to the time of peak influenza activity. Given the number of eligible homes and the cohort methodology used, the results support continuation of current policy, encouraging use of vaccine in all nursing home residents.     

Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations

ObjectivesNursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use.DesignObservational propensity-matched study.Setting and ParticipantsMedicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration.MethodsACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending.ResultsNearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents’ attribution status switched (14.6%), either into or out of an ACO.Conclusions and ImplicationsACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.     

State Variation in Chronic Opioid Use in Long-Term Care Nursing Home Residents

ObjectivePolicies and regulations on opioid use have evolved from being primarily state-to federally based. We examined the trends and variation in chronic opioid use among states and nursing homes.DesignRetrospective cohort study.Setting and ParticipantsWe used the nursing home Minimum Data Set and Medicare claims from 2014 to 2018 and included long-term care nursing home residents from each year who had at least 120 days of consecutive stay.MeasurementsChronic opioid use was defined as use for ≥90 days. Three-level hierarchical logistic regression models (resident, nursing home, state) were constructed to estimate intraclass correlation coefficient (ICC) at the state level and at the nursing home level. The ICC shows the proportion of variation in chronic opioid use that is attributable to states or nursing homes. All models were constructed separately for each calendar year and controlled for resident, nursing home, and state characteristics.ResultsWe included 3,245,714 nursing home stays from 2014 to 2018, representing 1,502,131 unique residents. The stays ranged from 676,413 in 2014 to 594,874 in 2018, with residents contributing a maximum of 1 stay per year. Chronic opioid use among nursing home residents declined from 14.1% in 2014 to 11.4% in 2018. The variation (ICC) in chronic opioid use among states declined from 2.5% in 2014 to 1.7% in 2018. In contrast, the variation (ICC) among nursing homes increased from 5.6% in 2014 to 6.5% in 2018.Conclusions and ImplicationsVariation in chronic opioid use declined by one-third at the state level but not at the nursing home level. National guidelines on opioid use and federal policies on opioid use may have contributed to reducing state-level variation in chronic opioid use.     

Prevention of Mortality and Pneumonia Among Nursing Home Older Adults by Dual Pneumococcal and Seasonal Influenza Vaccination During a Pandemic Caused by Novel Pandemic Influenza A (H1N1)

ObjectiveTo evaluate the efficacy of dual vaccination of seasonal influenza and pneumococcus in nursing home older adults during a novel pandemic of influenza A (H1N1).SettingNine nursing homes in Hong Kong.ParticipantsA total of 532 nursing home older adults were included in the study.MeasurementsEfficacy of dual vaccination of seasonal influenza and pneumococcus in nursing home older adults during a novel pandemic influenza A (H1N1).DesignA prospective 12-month cohort study was conducted on older residents from December 2009 to November 2010. Participants were divided into 3 groups according to their choice of vaccination: received both seasonal influenza and 23-valent pneumococcal polysaccharide vaccine (PPV-TIV group), received seasonal influenza vaccine alone (TIV group), and those who refused both vaccinations (unvaccinated group). Those who had received vaccination for influenza A (H1N1) were excluded. Outcome measures included mortality from all causes, pneumonia, and vascular causes.ResultsThere were 246 in the PPV-TIV group, 211 in the TIV group, and 75 in the unvaccinated group. Baseline characteristics were similar among the groups. The 12-month mortality rates of the PPV-TIV, TIV alone group, and unvaccinated group were 17.1%, 27.0%, and 37.3% respectively (P < .001). Multivariate analysis demonstrated that, compared with vaccination of seasonal influenza alone, dual vaccination significantly reduced all-cause mortality (hazard ratio [HR] 0.54; 95% confidence interval [CI]: 0.35–0.84; P < .01), mortality from pneumonia (HR 0.60; 95% CI: 0.35–0.99; P < .05), and mortality from vascular causes (HR 0.24; 95% CI: 0.09–0.64; P < .01).ConclusionsDuring an influenza pandemic or when the circulating influenza strain was not matched by the trivalent seasonal influenza vaccine, dual vaccination of influenza and pneumococcus provided additional protection to nursing home older adults in reducing mortality.     

A Randomized Controlled Trial of a Digital Adaptation of the WHELD Person-Centered Nursing Home Training Program

ObjectiveDigital approaches to delivering person-centered care training to nursing home staff have the potential to enable widespread affordable implementation, but there is very limited evidence and no randomized controlled trials (RCTs) evaluating digital training in the nursing home setting. The objective was to evaluate a digital person-centered care training intervention in a robust RCT.DesignWe conducted a 2-month cluster RCT in 16 nursing homes in the United Kingdom, randomized equally to receive a digitally adapted version of the WHELD person-centered care home training program with virtual coaching compared to the digital training program alone.Setting and ParticipantsThe study was conducted in UK nursing homes. There were 175 participants (45 nursing home staff and 130 residents with dementia).MethodsThe key outcomes were the well-being and quality of life (QoL) of residents with dementia and the attitudes and knowledge of nursing home staff.ResultsThere were significant benefits in well-being (t = 2.76, P = .007) and engagement in positive activities (t = 2.34, P = .02) for residents with dementia and in attitudes (t = 3.49, P = .001), including hope (t = 2.62, P = .013) and personhood (t = 2.26, P = .029), for staff in the group receiving digital eWHELD with virtual coaching compared to the group receiving digital learning alone. There was no improvement in staff knowledge about dementia.Conclusion and ImplicationsThe study provides encouraging initial clinical trial evidence that a digital version of the WHELD program supported by virtual coaching confers significant benefits for care staff and residents with dementia. Evidence-based digital interventions with remote coaching may also have particular utility in supporting institutional recovery of nursing homes from the COVID-19 pandemic.     

Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia

ObjectivesPneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the COVID-19 pandemic. Risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. Little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. We sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia.DesignRetrospective cohort study.Setting and ParticipantsParticipants included Medicare enrollees aged ≥65 years, hospitalized from a nursing home in the United States between 2013 and 2014 for pneumonia.MethodsActivities of daily living (ADL), patient sociodemographics, and comorbidities were obtained from the Minimum Data Set (MDS), an assessment tool completed for all nursing home residents. MDS assessments from prior to and following hospitalization were compared to assess for functional decline. Following hospital discharge, all patients were evaluated for a composite outcome of severe disability (≥4 ADL limitations) following hospitalization or death prior to completion of a postdischarge MDS.ResultsIn 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. Although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization ADL limitation, and 82% with no cognitive limitation experienced the outcome.Conclusions and ImplicationsHospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. Nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts.     

Nursing home medical staff organization and 30-day rehospitalizations

ObjectivesTo examine the relationship between features of nursing home (NH) medical staff organization and residents' 30-day rehospitalizations.DesignCross-sectional study combining primary data collected from a survey of medical directors, NH resident assessment data (minimum data set), Medicare claims, and the Online Survey Certification and Reporting (OSCAR) database.SettingA total of 202 freestanding US nursing homes.ParticipantsMedicare fee-for-service beneficiaries who were hospitalized and subsequently admitted to a study nursing home.MeasurementsMedical staff organization dimensions derived from the survey, NH residents' characteristics derived from minimum data set data, hospitalizations obtained from Part A Medicare claims, and NH characteristics from the OSCAR database and from www.ltcfocus.org. Study outcome defined within a 30-day window following an index hospitalization: rehospitalized, otherwise died, otherwise survived and not rehospitalized.ResultsThirty-day rehospitalizations occurred for 3788 (20.3%) of the 18,680 initial hospitalizations. Death was observed for 884 (4.7%) of residents who were not rehospitalized. Adjusted by hospitalization, resident, and NH characteristics, nursing homes having a more formal appointment process for physicians were less likely to have 30-day rehospitalization (b = –0.43, SE = 0.17), whereas NHs in which a higher proportion of residents were cared for by a single physician were more likely to have rehospitalizations (b = 0.18, SE = 0.08).ConclusionThis is the first study to show a direct relationship between features of NH medical staff organization and resident-level process of care. The relationship of a more strict appointment process and rehospitalizations might be a consequence of more formalized and dedicated medical practice with a sense of ownership and accountability. A higher volume of patients per physician does not appear to improve quality of care.     

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

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