Changes in the relationship between nursing home financial performance and quality of care under public reporting

The relationship between financial performance and quality of care in nursing homes is not well defined and prior work has been mixed. The recent focus on improving the quality of nursing homes through market‐based incentives such as public reporting may have changed this relationship, as public reporting provides nursing homes with increased incentives to engage in quality‐based competition. If quality improvement activities require substantial production costs, nursing home profitability may become a more important predictor of quality under public reporting. This study explores the relationship between financial performance and quality of care and test whether this relationship changes under public reporting. Using a 10‐year (fiscal years 1997–2006) panel data set of 9444 skilled nursing facilities in the US, this study employs a facility fixed‐effects with and without instrumental variables approach to test the effect of finances on quality improvement and correct for potential endogeneity. The results show that better financial performance, as reflected by the 1‐year lagged total profit margin, is modestly associated with higher quality but only after public reporting is initiated. These findings have important policy implications as federal and state governments use market‐based incentives to increase demand for high‐quality care and induce providers to compete based on quality. Copyright © 2010 John Wiley & Sons, Ltd.     

Medicare payment changes and nursing home quality: effects on long-stay residents

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities, providing a natural experiment in nursing home behavior. Medicare payment policy (directed at short-stay residents) may have affected outcomes for long-stay, chronic-care residents if services for these residents were subsidized through cost-shifting prior to implementation of Medicare prospective payment for nursing homes. We link changes in both the form and level of Medicare payment at the facility level with changes in resident-level quality, as represented by pressure sores and urinary tract infections in Minimum Data Set (MDS) assessments. Results show that long-stay residents experienced increased adverse outcomes with the elimination of Medicare cost reimbursement.     

The influence of staffing characteristics on quality of care in nursing homes

OBJECTIVE: The influence staffing levels, turnover, worker stability, and agency staff had on quality of care in nursing homes was examined. DATA SOURCES/STUDY SETTING: Staffing characteristics came from a survey of nursing homes (N=1,071) conducted in 2003. The staffing characteristics were collected for Nurse Aides, Licensed Practical Nurses, and Registered Nurses. Fourteen quality indicators came from the Nursing Home Compare website report card and nursing home organizational characteristics came from the Online Survey, Certification, and Recording system. STUDY DESIGN: One index of quality (the outcome) was created by combining the 14 quality indicators using exploratory factor analysis. We used regression analyses to assess the effect of the four staffing characteristics for each of the three types of nursing staff on this quality index in addition to individual analyses for each of the 14 quality indicators. The effect of organizational characteristics as well as the markets in which they operated on outcomes was examined. We examined a number of different model specifications. PRINCIPAL FINDINGS: Quality of care was influenced, to some degree, by all of these staffing characteristics. However, the estimated interaction effects indicated that achieving higher quality was dependent on having more than one favorable staffing characteristic--the effect of quality was larger than the sum of the independent effects of each favorable staffing characteristic. CONCLUSIONS: Our results indicate that staff characteristics such as turnover, staffing levels, worker stability, and agency staff should be addressed simultaneously to improve the quality of nursing homes.     

Nursing home spending patterns in the 1990s: the role of nursing home competition and excess demand

OBJECTIVE: To examine nursing home expenditures on clinical, hotel, and administrative activities during the 1990s and to determine the association between nursing home competition and excess demand on expenditures. DATA SOURCES/STUDY SETTING: Secondary data sources for 1991, 1996, and 1999 for 500 free-standing nursing homes in New York State. STUDY DESIGN: A retrospective statistical analysis of nursing homes' expenditures. The dependent variables were clinical, hotel, and administrative costs in each year. Independent variables included outputs (inpatient and outpatient), wages, ownership, New York City location, and measures of competition and excess demand. DATA COLLECTION/EXTRACTION METHOD: Variables were constructed from annual financial reports submitted by the nursing homes, the Patient Review Instrument and Medicare enrollment data. PRINCIPAL FINDINGS: Clinical and administrative costs have increased over the decade, while hotel expenditures have declined. Increased competition was associated with higher clinical and administrative costs while excess demand was associated with lower clinical and hotel expenditures. CONCLUSIONS: Nursing home expenditures are sensitive to competition and excess demand conditions. Policies that influence competition in nursing home markets are therefore likely to have an impact on expenditures as well.     

Finding a useful conceptual basis for enhancing the quality of life of nursing home residents

In this article it is depicted that before nursing home staff can effectively contribute to optimising the quality of life (QOL) of nursing home residents, it has to be clear what exactly QOL is and how it can be enhanced. The aim is to identify a QOL framework that provides tools for optimising QOL and can form the basis for the development of guidelines for QOL enhancement. For that purpose, a framework should meet three basic criteria: (1) it should be based on assumptions about comprehensive QOL of human beings in general; (2) it should clearly describe the contribution of each dimension to QOL and identify relationships between the dimensions; (3) it should take individual preferences into account. After the criteria are defined, frameworks identified from a literature search are discussed and evaluated according to these criteria. The most suitable framework appears to be the QOL framework of the theory of Social Production Functions. The implications of this framework in understanding the QOL of nursing home residents are described and recommendations for further research are discussed.     

Effects of state minimum staffing standards on nursing home staffing and quality of care

Objective. To investigate the impact of state minimum staffing standards on the level of staffing and quality of nursing home care.
Data Sources. Online Survey and Certification Reporting System (OSCAR) merged with the Area Resource File from 1998 through 2001.
Study Design. Between 1998 and 2001, 16 states implemented or expanded staffing standards in excess of federal requirements, creating a natural experiment in comparison with facilities in states without new standards. Difference-in-differences models using facility fixed effects were estimated to determine the effect of state standards.
Data Collection/Extraction Methods. OSCAR data were linked to the data on market conditions and state policies. A total of 55,248 facility-year observations from 15,217 freestanding facilities were analyzed.
Principal Findings. Increased standards resulted in small staffing increases for facilities with staffing initially below or close to new standards. Yet the standards were associated with reductions in restraint use and the number of total deficiencies at all types of facilities.
Conclusions. Mandated staffing standards affect only low-staff facilities facing potential for penalties, and effects are small. Selected facility-level outcomes may show improvement at all facilities due to a general response to increased standards or to other quality initiatives implemented at the same time as staffing standards.     

Testing the effect of specific orders to provide oral liquid nutritional supplements to nursing home residents: A quality improvement project

Objectives: To improve nursing home (NH) staff delivery of oral liquid nutritional supplements between meals to residents with a history of weight loss.Design: Pre-Post intervention study.Setting: Two skilled nursing homes.Participants: Eighteen long term care residents.Intervention: At baseline all participants had a non-specific physician’s order to receive a nutritional supplement. The intervention consisted of specifying the physician’s order as follows: “Give 4 oz high protein supplement at 10am, 2pm, and 7pm”.Measurements: Research staff conducted direct observations for two days during and between meals for a total of 4 days, or 12 possible observation periods per participant before and one week following the intervention. Research staff documented NH staff delivery of snacks (including high protein supplements) and amount consumed (fluid ounces) for the high protein supplements using a standardized protocol during each observation period.Results: Before the specific order was written participants were offered any type of snack an average of 1.82 times per day and a high protein supplement 0.59 times per day. After the specific order was written participants were offered any type of snack an average of 1.59 times per day and a high protein supplement 0.91 times per day. There were no statistically significant differences in the average number of times snacks or supplements were offered before and after the specific order was written. The proportion of snacks offered that were high protein supplements did increase after the specific order was written (p<0.001). When a high protein supplement was provided, most residents consumed 100% of it.Conclusions: Oral liquid nutritional supplements were not provided consistent with orders in NH practice. The specificity of the order related to type of supplement and time of delivery did not influence when and how often supplements are provided to residents but it did influence the type of nutritional supplement offered.     

Vision-specific health-related quality of life: Content areas for nursing home residents

Nursing home residents have a high prevalence of remediable visual impairment and blindness. Future research on the effectiveness of providing eye care to nursing home residents will need to include a vision-targeted health-related quality of life (HRQOL) instrument appropriate for this population. The purpose of this study was to identify the core content areas for such an instrument. In-depth interviews on vision-related issues were conducted with 40 residents. Interviews were audio-taped, transcribed, and coded using a standardized protocol. Binocular distance and near visual acuity were assessed using the resident's walking around correction to examine whether one vision-specific HRQOL measure could address the needs of residents with good and poor vision. Overall 1070 vision-related comments were identified. Residents mentioned 315 problem comments that were grouped into 13 categories, including ocular symptoms (18% of comments), reading (15%), general vision (13%), psychological distress (12%), and activities of daily living (ADLs) (7%). Compared to published data on vision-specific content areas most relevant to community based persons, nursing home residents focused more on ocular symptoms and basic ADLs, with no mention of issues related to driving, home care, and finances. The majority of categories mentioned did not differ on the proportion of comments made by those with good and poor visual acuity, suggesting that one vision-specific HRQOL instrument would be appropriate for residents with varying levels of visual acuity. Future work will focus on developing a vision-specific HRQOL instrument for nursing home residents.     

急诊院内转运护理质量监测指标及其临床应用

目的建立急诊院内转运护理质量监测指标,通过对护理质量的量化监控和管理,提升急诊院内转运的护理质量。 方法根据文献检索和专家小组讨论结果选定"急诊院内转运不良事件发生率"和"急诊院内转运护理合格率"为急诊院内转运护理质量监测指标,并制定具体评定细则。对全科护士进行针对性培训考核,并应用于临床。回顾性分析2016年7月至2017年6月经江苏大学附属武进医院急诊科抢救后转运的5 958例患者的病历资料。其中男性2 850例,女性3 108例;年龄14～99岁,平均(51.97±10.15)岁。以2016年7至12月实施的2 650例次院内转运患者为对照组(未采用任何护理质量监测指标);2017年1至6月实施的3 308例次院内转运患者为观察组(采用了上述急诊院内转运护理质量监测指标)。对比两组在急诊院内转运过程中的护理不良事件发生率及具体不良事件发生情况、转运护理合格率差异;再分别以随机数字表法对两组患者资料进行抽样调查,对比其患者及相关科室满意度、措施执行规范性的差异,以评价急诊院内转运护理质量监测指标的临床应用效果。 结果观察组在转运过程中的护理不良事件发生率为3.2%(105/3 308),低于对照组15.5%(412/2 650),且仪器设备故障、氧气及药物维持不足、管路异常及患者生命体征急剧变化等转运不良事件的发生率均低于对照组,差异均有统计学意义(P均<0.05)。抽查结果显示,观察组的院内转运护理合格率[90.13%(137/152)比75.17%(112/149)]、患者(家属)及[93.42%(142/152)比84.56%(126/149)]相关转运科室[90.79%(138/152)比71.17%(106/149)]对转运护理的满意度均得到提高;但转运护理措施的执行规范性中,仅在"物品准备不完备"[1.32%(2/152)比9.39%(14/149)]以及"终末处理不到位"[1.97%(3/152)比4.03%(6/149)]的发生率有所降低,其余4项(未通知目的科室、未做好医患沟通、管道护理不到位、护理交接不清楚)的差异无统计学意义。 结论建立急诊转运护理质量监测指标,能体现急诊专科特色,可有效评价和提升急诊院内转运的护理质量。     

Participation and knowledge related to a nursing home admission decision among a working age population

The number of nursing home admissions for working age people (age 18-64) in the USA has increased. Minimal attention has been given to examining their participation in the admission decision. We use a conceptual framework proposed by Ong and colleagues to examine patient and provider predictors of perceived involvement in the admission decision and their relationship to both knowledge and preferences for continued care. In-person interviews were conducted with an admissions cohort of 205 working age individuals in 17 Maryland, USA nursing homes. Similar to previous profiles, participants were predominately male, of minority ethnic status, and of lower socioeconomic status. Common clinical conditions included cardiac disease (49.8%) and diabetes (27.3%). Slightly over half reported a lot (42.1%) or a moderate (15.2%) level of involvement in the admission decision, while 27.9% reported no involvement. Patient race, insurance source and knowledge of the health care decision maker were related to perceived involvement. Minority ethnic group patients were less likely to be aware of alternate settings for care, while patients who knew the medical decision maker were more aware of alternate settings, as well as their expected length of stay. Participants who perceived greater involvement in the decision more often preferred continued care in the nursing home, relative to their own home or other settings. Ethical, practical and legal concerns support involving individuals in this health care decision. Ways to foster improved communication and interpersonal relationships between patients and their health care provider(s) are thus required.     

Staffing ratios and quality: an analysis of minimum direct care staffing requirements for nursing homes

Objective. To study the impact of minimum direct care staffing (MDCS) requirements on nurse staffing levels, nurse skill mix, and quality. Data Sources. U.S. nursing home facility data from the Online Survey Certification and Reporting (OSCAR) System merged with MDCS requirements. Study Design. Facility‐level outcomes of nurse staffing levels, nurse skill mix, and quality measures are regressed on the level of nurse staffing required by MDCS requirements in the prior year and other controls using fixed effect panel regression. Quality measures are care practices, resident outcomes, and regulatory deficiencies. Data Extraction Method. Analysis used all OSCAR surveys from 1999 to 2004, resulting in 17,552 unique facilities with a total of 94,371 survey observations. Principle Findings. The effect of MDCS requirements varied with reliance of the nursing home on Medicaid. Higher MDCS requirements increase nurse staffing levels, while their effect on nurse skill mix depends on the reliance of the nursing home on Medicaid. MDCS have mixed effects on care practices but are generally associated with improved resident outcomes and meeting regulatory standards. Conclusions. MDCS requirements change staffing levels and skill mix, improve certain aspects of quality, but can also lead to use of care practices associated with lower quality.     

OBRA 1987 and the quality of nursing home care

Because minimum government standards for quality regulate only part of the market failure, they may have unintended effects. We present a general theory of how government regulation of quality of care may affect different market segments, and test the hypotheses for the nursing home market. OBRA 1987 was a sweeping government reform to improve the quality of nursing home care. We study how the effect of OBRA on the quality of nursing home care, measured by resident outcomes, varied with nursing home profitability. Using a semi-parametric method to control for the endogenous effects of regulation, we found that this landmark legislation had a negative effect on the quality of care in less profitable nursing homes, but improved the quality in more profitable nursing homes during the initial period after OBRA. But, this legislation had no statistically significant effect in the later period when the regulation was weakly enforced. JEL Classification I18 . I11     

A club of friends: enrolling nursing home residents in an adult day program

OBJECTIVE: To evaluate an innovative approach to maintaining physical, cognitive, and social functioning in frail, elderly nursing home residents at risk for transfer from a minimal care unit. SUBJECTS/SETTING: Nineteen Russian-speaking residents of the Jewish Home in San Francisco who were newly enrolled in an on-site adult day care program. METHODS: A formal evaluation of the program employed a repeated measures design with assessments at baseline and at Months 2, 3, 4, 6, and 9. Outcomes included stability of living situation, functional status, physical and mental health, cognitive functioning, sense of well-being and quality of life, and satisfaction with the program. RESULTS: During this period, the cohort was medically stable and, although some evidenced cognitive decline, there was little change in their functional status. Nearly all of the residents reported improvement from baseline in some aspects of their lives, with the greatest proportions reporting positive changes in social support and quality of life. CONCLUSIONS: Findings from this evaluation suggest that activities programming using the model described here may enhance the quality of life for some nursing home residents and enable them to remain in the least restrictive, as well as the least costly, living situation possible.     

Perceptual measures of quality: a tool to improve nursing home systems

Improvements in nursing home efficiency and quality typically have not addressed the needs of the entire customer base. The focus of most quality measures used in a health care setting is "technical," and perceptual or patient and family perspectives have been neglected. Data obtained from a survey of customers using services from a chain of nursing homes measured perceptual quality; the data are presented here in a variety of formats that may aid management in organizing and understanding better such information. The goal is to provide management with a tool to identify current strengths, as well as those areas needing attention. If nursing homes are operated without knowledge of perceptual quality data, their improvement efforts are unlikely to adequately address the needs of all their customers.