Using outcomes to make inferences about nursing home quality.

Recent concerns about containing the growth of public expenditures on nursing home care and the development of prospective and casemix reimbursement systems with incentives for cost containment have increased the importance of monitoring quality in nursing homes. The current view is that quality assurance systems should include more outcome measures to improve quality. This article discusses why it is difficult to develop facility-level outcome measures that can be used to evaluate and compare the quality of care of nursing homes. The article places the current interest in outcomes measures in its historical policy context and reviews important conceptual and methodological issues associated with outcome-based quality assessment. The authors discuss the difficulty in isolating the facility effect when studying nursing home outcomes and implications of using different estimation approaches. In conclusion, they discuss the need to integrate research with outcome-based quality assurance systems to allow ongoing evaluation and quality improvement.     

The Western Domiciliary Care Service

This article reports the development and first five years experience of the Western Domiciliary Care Service, Adelaide, South Australia. This service began accepting referrals in July 1971. Referrals are accepted without regard to age or degree of disability. Assessments are made in the patients' homes by social workers and therapists, who maintain close contact with the general practitioners. Liaison with The Queen Elizabeth Hospital has been a tremendous advantage. Of the 1,800 active patients, about 700 would be in nursing homes if this service did not exist, and many referrals to The Queen Elizabeth Hospital have been avoided. The scheme has proved very economical.     

The Western Domiciliary Care Service: a report on the development and activities of a home care scheme associated with a teaching hospital

This article reports the development and first five years experience of the Western Domiciliary Care Service, Adelaide, South Australia. This service began accepting referrals in July 1971. Referrals are accepted without regard to age or degree of disability. Assessments are made in the patients' homes by social workers and therapists, who maintain close contact with the general practitioners. Liaison with The Queen Elizabeth Hospital has been a tremendous advantage. Of the 1,800 active patients, about 700 would be in nursing homes if this service did not exist, and many referrals to The Queen Elizabeth Hospital have been avoided. The scheme has proved very economical.     

Infection control in British nursing homes.

Infection control in British nursing homes is different from that in U.S. nursing homes in seveal ways. Most British nursing homes, for example, do not have a designated on-site infection control nurse, and several agencies are responsible for regulatory oversight. This article discusses the state of infection control in British nursing homes.     

Special care units for Alzheimer's patients: their role in the nursing home market

The Special Care Unit (SCU) is a new, rapidly proliferating mode of caring for people with Alzheimer's disease (AD). Approximately 10% of nursing homes within the U.S. have SCUs with the number expected to grow substantially in coming years. SCUs are largely unregulated and not uncontroversial. This article discusses their emergence over time, their origins, growth, and the call for standardization. Subsequent sections review the range of potential benefits and costs associated with SCUs, optimally defined as well as research evidence available on this mode of care. Recent cost-setting and reform pressures in the nursing home industry are discussed in the final sections along with the likely future of AD SCUs in this environment.     

Assuring Professional Pastoral Care for Every Nursing Home Resident

SUMMARY

Ministry to persons in nursing homes is built on two mandates: “… He has sent me to bring good news to the oppressed, to bind up the brokenhearted, to proclaim liberty to the captives, and release to the prisoners; … to comfort all who mourn …” (Isaiah 61:1–3). The federal government provides the second: “Quality of Life. A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life” (OBRA '87, Guidance to Surveyors in Long Term Care Facilities, Code of Federal Regulations, Health Care Financing Administration, 1995, section 483.15, F240). This article discusses both the religious and the U.S. political history of caring for the old and frail. It concludes by describing political efforts in one state to increase the quality of that care and pastoral efforts to support the nursing assistants in long-term care facilities.     

Nursing home regulation. Shadowlands

The healthcare of 200,000 people living in nursing homes will not be regulated by the Commission for Health Improvement or by the proposed healthcare division of the National Care Standards Commission under current proposals. This is despite the fact that patients in nursing homes are highly dependent and many would previously have been cared for by the NHS. It is not acceptable that the current NHS quality initiatives should ignore this sector.     

Participatory ergonomic improvement in nursing home

The number of nursing home has increased largely in Japan since 1990. The Long-term Care Insurance in 2000 has accelerated the increase of nursing homes. The care giving and cooking in nursing homes have high risk factors of muscle-skeletal diseases (MSDs). However, the working conditions have not yet been improved. Thus, the incidence of low back pain and cervico-brachial disorder is very high among the care workers and cooks. Therefore, it is important to prevent the MSDs among the care workers and cooks. This study has been conducted to make a model of the participatory improvement focusing on low back pain in a nursing home for three years. As a result of the study, many improvements have been implemented and the incidence of low back pain has been reduced.     

Improving Evidence-Based Oral Health of Nursing Home Residents Through Coaching by Dental Hygienists

Good oral hygiene has an impact on the overall health of residents in long-term care; however, significant improvement is needed in nursing homes. A “boots on the ground” project was developed that incorporates Mouth Care without a Battle, an evidence-based approach to person-centered daily mouth care, into 22 New York State nursing homes using a coaching model with part-time dental hygienists. This report discusses implementation of the quality improvement project, which improved the quality of daily mouth care provided to nursing home residents, as well as changed the knowledge and attitudes of the staff providing their care, all supported by regional dental hygienist coaches.     

The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program: An Overview for Medical Directors and Primary Care Clinicians in Long Term Care

Interventions to Reduce Acute Care Transfers (INTERACT) is a publicly available quality improvement program that focuses on improving the identification, evaluation, and management of acute changes in condition of nursing home residents. Effective implementation has been associated with substantial reductions in hospitalization of nursing home residents. Familiarity with and support of program implementation by medical directors and primary care clinicians in the nursing home setting are essential to effectiveness and sustainability of the program over time. In addition to helping nursing homes prevent unnecessary hospitalizations and their related complications and costs, and thereby continuing to be or becoming attractive partners for hospitals, health care systems, managed care plans, and accountable care organizations, effective INTERACT implementation will assist nursing homes in meeting the new requirement for a robust quality assurance performance improvement program, which is being rolled out by the federal government over the next year.     

Public health nursing: in sickness or in health?

Public health nursing began in the United States as a small undertaking in which a few wealthy women hired one or two nurses to visit the sick poor in their homes. By 1910, the work of these nurses had expanded to include a variety of preventive programs. While most preventive programs originated with voluntary organizations, such as the visiting nurse societies, they were eventually taken over either by boards of education or health departments. As a consequence of the new division that resulted, sick nursing would increasingly become the sole domain of the voluntary organizations, while the teaching of prevention would become the responsibility of public agencies. By examining the history of public health nursing between 1900-30, this article considers why a movement that might have been significant in delivering comprehensive health care to the American public failed to reach its potential.     

美国老年医学与医疗模式的发展及启示

我国正面临严峻的人口老龄化问题,但老年医学与及医疗模式的研究相对薄弱,亟待发展。笔者分析了美国老年医学与医疗模式的发展,首先介绍美国老年医学在其基础研究、临床研究、预防医学研究的进展和美国老年医学的发展理念。随后分析了美国老年医疗模式,包括老年病房(acute care for the elderly,ACE)、老年护理院、PACE(The Program of All-inclusive Care of the Elderly)、老年社区。在此基础上指出我国可以结合国情,借鉴美国老年医学新理念与新的医疗模式,以便更好应对我国老年人口医疗问题。     

Dutch home care: towards a new organization?

As in all western countries the demand for home care in the Netherlands is rapidly growing. Reduced institutionalization in hospitals and nursing homes, combined with an increasing number of elderly people, have led to new groups of patients, with complex and diverse problems, to be cared for in their home settings. To meet this new demand, it is argued, comprehensive home care arrangements are needed. Development of such arrangements was the target of 12 demonstration projects that were part of the 'National Home Health Care Programme'. This article presents the results of an evaluation study of the Programme, with special attention to factors favouring the development of comprehensive home care arrangements and its effectiveness.     

Determinants of the use of specialist mental health services by nursing home residents.

OBJECTIVE. This study examines the effects of resident and facility characteristics on the probability of nursing home residents receiving treatment by mental health professionals. DATA SOURCES/STUDY SETTING. The study uses data from the Institutional Population Component of the 1987 National Medical Expenditure Survey, a secondary data source containing data on 3,350 nursing home residents living in 810 nursing homes as of January 1, 1987. STUDY DESIGN. Andersen's health services use model (1968) is used to estimate a multivariate logistic equation for the effects of independent variables on the probability that a resident has received services from mental health professionals. Important variables include resident race, sex, and age; presence of several behaviors and reported mental illnesses; and facility ownership, facility size, and facility certification. DATA COLLECTION/EXTRACTION METHODS. Data on 188 residents were excluded from the sample because information was missing on several important variables. For some additional variables residents who had missing information were coded as negative responses. This left 3,162 observations for analysis in the logistic regressions. PRINCIPAL FINDINGS. Older residents and residents with more ADL limitations are much less likely than other residents to have received treatment from a mental health professional. Residents with reported depression, schizophrenia, or psychoses, and residents who are agitated or hallucinating are more likely to have received treatment. Residents in government nursing homes, homes run by chains, and homes with low levels of certification are less likely to have received treatment. CONCLUSIONS. Few residents receive treatment from mental health professionals despite need. Older, physically disabled residents need special attention. Care in certain types of facilities requires further study. New regulations mandating treatment for mentally ill residents will demand increased attention from nursing home administrators and mental health professionals.     

Umsetzung der Influenzaimpfempfehlung in Alten- und Pflegeheimen

Residents and staff of nursing homes are important target groups for influenza vaccination in Germany. The aim of this study was to gain the first insights into whether nursing homes organize activities with respect to vaccination against influenza and whether there is a demand for further information. In the context of the national influenza immunization campaign—which is jointly carried out by the Robert Koch Institute (RKI) and the Federal Centre for Health Education (BZgA) on an annual basis—influenza information kits were sent to the management of 10,700 nursing homes in September 2013. Along with the information material, the institutions also received a questionnaire to which they were able to respond via mail, fax, or online. Data from 988 homes were included in the analysis. The majority of institutions informed both residents (88.9?%) and nursing staff (81.2?%) about influenza vaccination. However, only 64.7?% of nursing homes carried out specific immunization activities for their residents and only half (49.3?%) offered a flu shot to their staff. When asked why the institutions do not provide influenza-specific information and vaccination to their staff, the majority had the opinion that this is the responsibility of each individual’s general practitioner. Overall, only 4.9?% of nursing homes assessed influenza vaccination coverage among their staff annually. A third of all surveyed institutions (33.6?%) expressed a demand for additional influenza vaccine-related information. In conclusion, improved health education is needed to raise awareness about the importance of influenza vaccination among residents and employees of nursing homes in Germany so as to prevent influenza-associated morbidity and mortality in this risk group.     

Assessing the impact of enforcement and compliance with minimum staffing standards on the quality of care in nursing homes: Evidence from the Centers for Medicare and Medicaid Services' staff star rating downgrade policy

Policymakers have historically attempted to influence quality in nursing homes through the imposition of minimum staffing standards and through the public dissemination of quality on websites like Care Compare. One current Federal standard necessitates a registered nurse (RN) on duty for at least eight consecutive hours each day. In 2018, the Centers for Medicare and Medicaid Services announced that they would incentivize compliance with this requirement by downgrading nursing homes with 7+ days without an RN present during the quarter by one star on their Care Compare staffing domain quality rating. This study evaluates the impact of this new enforcement mechanism. Using an intent-to-treat sample of nursing homes at risk for downgrade with difference-in-differences and event study models, it finds that the policy increased compliance and staffing levels. Using the policy to instrument for full compliance, it finds that the daily presence of an RN causally improves several quality dimensions.     

The relationship between quality of care and financial performance in nursing homes

Changes in the reimbursement structure of the Medicaid and Medicare programs have caused nursing homes to face severe revenue restraints. In the hopes of alleviating the effect of payment cutbacks on their financial performance, nursing homes have been instituting quality improvement initiatives. The goal of this study was to examine the relationships of quality of care with revenues, private-pay market share, and costs in the nursing home industry, and how these dynamics interplay to affect financial performance. This goal was achieved by using secondary data consisting of: (1) the Minimum Data Set Plus (MDS+); (2) the Health Care Information Analyst (HCIA) nursing home data set; and (3) the On-line Survey Certification of Automated Records (OSCAR) data set. Structural equation modeling (SEM) using maximum likelihood estimation was used to examine the total, direct, and indirect effects of the variables. Findings indicate that nursing homes that produce high quality care are able to achieve lower resident costs and in the process, report better financial performance than those facilities producing lower quality care. On the other hand, quality of care provided was not significantly associated with the revenues or private-pay market share of the nursing home. Overall, the total effects of quality to financial performance were positive (.055).     

Foster home care for the frail elderly as an alternative to nursing home care: an experimental evaluation.

This paper describes a program (Community Care Program) in which some elderly hospital patients who were candidates for nursing home placement were placed in foster homes. Caregivers were carefully trained and supervised. A total of 112 elderly inpatients were randomly assigned to placement in a nursing home or a foster care home. Patients and caregivers were interviewed at 3, 6, 9, and 12 months after placement. Community Care Program patients were more likely to maintain or improve ADL (activities of daily living) and mental status scores. They also had better nursing outcomes and were more likely to get out of the house than were nursing home patients. Nursing home patients had higher life satisfaction, and participated in more social and recreational activities. The Community Care Program was 17 per cent less costly than nursing home care. The results suggest that foster care may be a viable alternative for a segment of the nursing home population.     

Medicare-the development of publicly financed health insurance: Medicare's impact on the nation's health care system

It is useful for health care managers to understand Medicare's history and the impact on providers of ever-changing Medicare payment methods. Initially, Medicare payments resembled those of commercial insurance plans and Blue Cross Blue Shield plans. When Congress became concerned about the increasing costs of Medicare, new payment methods were created to limit payments to providers. The prospective payment system, imposed on hospitals in 1987 and later on nursing homes, home health agencies, and other services, has been adapted by commercial plans, Blue Cross Blue Shield associations, and state Medicaid programs. Changes in payer reimbursements require health care managers to adjust the department's charge master and exert more control of departmental costs. The story of Medicare's beginnings and development can provide some insight into the possibility of national health insurance, given the historic and current politics that limit publicly financed social programs. This article discusses the development of Medicare and its administration and serves as an introduction to the complex realities of health care reimbursement policy.