Barriers to vision care for nursing home residents

OBJECTIVE: To describe the prevalence of periodic eye examinations by eye professionals and to examine nursing facility resident characteristics associated with lack of periodic screening. DESIGN: Retrospective chart review. SETTING: Two Midwestern nursing facilities. Participants: Between 1995 and 1997, 134 subjects aged 60 and older were recruited from two metropolitan nursing facilities. Measurements: Nursing home charts were reviewed for: demographics, length of stay, date of eye examination, eye diagnosis,visual acuity. Nursing assessments were used to obtain information about cognition, function, behavior, and the presence of Do Not Resuscitate or Do Not Hospitalize orders. The chart was reviewed for visual acuity, intraocular pressures, and the presence of eye pathology. Individuals who had not had eye examinations in the previous 2 years were screened by an ophthalmologist. This examination included external examination of the eye, fundoscopic examination, tonometry,visual acuity with correction. RESULTS: Only 62 (46%) of the subjects had been seen by an eye care professional in the previous 2 years. Visual acuity information was available for 37/64 previously examined subjects. Of those with no eye examination in the previous 2 years (n = 72), visual acuity was obtained in 32 (44%) of subjects. New eye diagnoses were made in 64% (41/64). Logistic regression models with "eye examination within the past 2 years" as the dependent variable show that residents who do not desire hospital transfer are 80% less likely to have had an eye examination than those without this designation. Sex, age, length of stay, functional status, presence of severe dementia, behavior problems, or DNR orders do not change the likelihood that a resident would have been examined. Logistic regression models with "visual acuity measured" as the dependent variable show that residents with severe dementia are 12.6 times less likely to have acuity measured than those without dementia. Those with a length of stay in the facility less than 6 months are 10% less likely to have visual acuity measured. CONCLUSIONS: This study does not confirm that barriers still exist in the provision of eye care to all nursing home residents, but the prevalence of such assessments remains low. Additional screening results in a substantial increase in the identification of treatable eye diseases. Contrary to the original hypotheses that patient characteristics that make testing difficult would provide a barrier or disincentive to vision testing, this study did not show statistical differences in the rates of vision screening for those with dementia, behavior problems, or severe functional impairment. Severe dementia does seem to affect the ability of the eye care specialist to gather subjective data such as visual acuity. It also demonstrates that vision screening does take place on nursing home residents with a broad range of cognitive and functional abilities, and this screening results in the diagnosis of many treatable eye conditions. Future efforts should be made to increase vision screening and treatment in the nursing home.     

Nurse assistant mental models, sensemaking, care actions, and consequences for nursing home residents

In a nursing home case study using observation and interview data, the authors described two mental models that guided certified nurse assistants (CNAs) in resident care. The Golden Rule guided CNAs to respond to residents as they would want someone to do for them. Mother wit guided CNAs to treat residents as they would treat their own children. These mental models engendered self-control and affection but also led to actions such as infantilization and misinterpretations about potentially undiagnosed conditions such as depression or pain. Furthermore, the authors found that CNAs were isolated from clinicians; little resident information was exchanged. They suggest ways to alter CNA mental models to give them a better basis for action and strategies for connecting CNAs and clinical professionals to improve information flow about residents. Study results highlight a critical need for registered nurses (RNs) to be involved in frontline care.     

Improving nutrition care for nursing home residents using the INRx process

The purpose of this article is to describe the Individual Nutrition Rx (INRx) assessment process and report findings on elder nutritional status, common nutrition problems identified by the INRx process, resolution outcomes from each problem, and the most efficacious approaches used to address the identified nutrition problems. The study used a two-group prospective quasi-experimental design with measures taken at baseline and at 6 months. Participants in the treatment group (n = 41) received the 6-month INRx assessment process, while residents in the comparison group (n = 40) received routine care specific to their nursing home. The most frequent nutritional problems identified were appetite change, poor positioning while eating, and problems with oral status. A total of 39 approaches were recommended by the interdisciplinary research team. Serum albumin and prealbumin, and depression scores were all significantly improved post intervention. The problems, approaches, and outcomes identified during the INRx process support the premise that interdisciplinary teams following the INRx process can assess complex nutritional problems and influence outcomes for older adults living in nursing homes.     

Clinical findings associated with radiographic pneumonia in nursing home residents.

OBJECTIVE: Subtle presentation and the frequent lack of on-site physicians complicate the diagnosis of pneumonia in nursing home residents. We sought to identify clinical findings (signs, symptoms, and simple laboratory studies) associated with radiographic pneumonia in sick nursing home residents. STUDY DESIGN: This was a prospective cohort study. POPULATION: The residents of 36 nursing homes in central Missouri and the St. Louis area with signs or symptoms suggesting a lower respiratory infection were included. OUTCOME MEASURED: We compared evaluation findings by project nurses with findings reported from chest radiographs. RESULTS: Among 2334 episodes of illness in 1474 nursing home residents, 45% of the radiograph reports suggested pneumonia (possible=12%; probable or definite = 33%). In 80% of pneumonia episodes, subjects had 3 or fewer respiratory or general symptoms. Eight variables were significant independent predictors of pneumonia (increased pulse, respiratory rate =30, temperature =38 degrees C, somnolence or decreased alertness, presence of acute confusion, lung crackles on auscultation, absence of wheezes, and increased white blood count). A simple score (range = -1 to 8) on the basis of these variables identified 33% of subjects (score > or =3) with more than 50% probability of pneumonia and an additional 24% (score of 2) with 44% probability of pneumonia. CONCLUSIONS: Pneumonia in nursing home residents is usually associated with few symptoms. Nonetheless, a simple clinical prediction rule can identify residents at very high risk of pneumonia. If validated in other studies, physicians could consider treating such residents without obtaining a chest radiograph.     

Effect of Medicaid payment on rehabilitation care for nursing home residents

There is considerable interest in examining how Medicaid payment affects nursing home care. This study examines the effect of Medicaid payment methods and reimbursement rates on the delivery of rehabilitation therapy to Medicaid nursing home residents in six States from 1992-1995. In States that changed payment from prospective facility-specific to prospective case-mix adjusted payment methods, Medicaid residents received more rehabilitation therapy after the change. While residents in States using case-mix adjusted payment rates for Medicaid payment were more likely to receive rehabilitation than residents in States using prospective facility-specific Medicaid payment, the differences were general and not specific to Medicaid residents. Retrospective payment for Medicaid resident care was associated with greater use of therapy for Medicaid residents.     

Prevalence and molecular epidemiology of meticillin-resistant Staphylococcus aureus in nursing home residents in northern Germany

Nursing home residents are a population at risk for carrying meticillin-resistant Staphylococcus aureus (MRSA). To better guide infection control and healthcare network initiatives, we investigated the point prevalence and molecular epidemiology of MRSA colonisation among nursing home residents in Brunswick, northern Germany. Among the 32 participating nursing homes of the available 34 in the region, 68% of residents (1827 of 2688) were screened for nasal and/or wound colonisation. A total of 139 residents (7.6%; 95% confidence interval: 6.4-8.8%) were identified as MRSA positive, almost six-fold more than the 24 MRSA carriers (0.9%) expected according to the nursing homes' pre-test information. Although known risk factors including urinary tract catheters, wounds, preceding hospital admission, and high grade resident care were confirmed, none was sensitive enough to be considered as the sole determinant of MRSA carriage. spa typing revealed that more than 70% of isolates belonged to the Barnim strain (ST-22, EMRSA-15, CC22) typical for hospital-acquired MRSA in northern Germany. There was no evidence for the presence of community-acquired or livestock-associated S.?aureus strains. These data show that in northern Germany MRSA has spread from the hospital environment to other healthcare institutions, which must now be regarded as important reservoirs for MRSA transmission.     

The nursing home versus the hospital as the place of dying for nursing home residents in Japan

OBJECTIVES: To determine the characteristics of nursing home residents that are associated with dying in a nursing home versus a hospital in Japan. DESIGN: Retrospective case-control study. SETTING: A nonprofit nursing home with 110 beds in Tokyo, Japan. PARTICIPANTS: Eighty-six nursing home residents who died in the nursing home (n=43) or in a hospital (n=43) between 1 April 1999 and 30 September 2004. MEASUREMENTS: Nursing home records were reviewed to gain information regarding the following domains: demography, the family decision-maker, health status, resident and family preference for nursing home end-of-life care, and presence of a full-time physician. RESULTS: The variables older age [adjusted odds ratio (adjusted OR)=1.08, 95% confidence interval (95% CI)=1.01-1.17], the family decision-maker's preference for nursing home end-of-life care (adjusted OR=3.95, 95% CI=1.21-12.84), and presence of a full-time physician (adjusted OR=3.74, 95% CI=1.03-13.63) were associated with dying in the nursing home. CONCLUSION: Older age, the family's preference for nursing home end-of-life care, and the presence of a full-time physician were significantly related to dying in the nursing home versus in a hospital.     

Prospects for transferring nursing home residents to the community

The Deficit Reduction Act (DRA) of 2005 calls for states to develop strategies to "deinstitutionalize" nursing home residents. Using Minimum Data Set assessment data from 2005, we calculated the number of nursing home residents classified as "low-care" in each state using both a "narrow" and a "broad" definition. Between 5 percent (narrow) and 12 percent (broad) of the 1.4 million long-stay residents and similar proportions of new admissions remaining in a nursing home meet definitions for low care. States with lower investment in community alternatives had higher proportions of low-care nursing home residents.     

Notes on the care of mentally ill residents in nursing homes in the Uelzen county district

From 1999 to 2001 the "Centre of Applied Health Sciences" (University of Luneburg) carried out a research project in cooperation with the Psychiatric Hospital Hacklingen in Luneburg and the department of social psychiatry and psychotherapy of the Hanover College of Medicine. The project covered the prevalence of mental disorders among the residents of nursing and geriatric homes in the district of Uelzen including different aspects of medical, psychiatric and nursing care. The research was based on a survey including all residents of these institutions. The response rate was 925 of a total of 1,100 residents. Results showed that three-quarters of the residents had considerable and different psychiatric symptoms and that almost half of the residents suffered from symptoms of dementia. The provision of health care as well as nursing care for these residents are considerably deficient. Care facilities are hardly of therapeutical standard and guidelines. This refers in particular to treatment with psychoactive drugs. The (few) comparable studies show that -- with the exception of some pilot projects -- the situation in the district of Uelzen may be similar to that in other regions of Germany.     

Hospitalizations during the last months of life of nursing home residents: a retrospective cohort study from Germany

Background  

To describe hospitalisations of nursing home (NH) residents in Germany during their last months of life.     

Predictors of mortality in nursing home residents

A prospective cohort study was conducted to examine predictors of mortality in the nursing home. Participants were 399 long-term nursing home residents, who were followed up for 11 years at the end of which 380 had died, 16 were still alive, 2 were discharged with unknown status, and 1 was alive when discharged. The median duration from baseline to death was 2.75 years. For cognitively intact residents, male gender, larger number of medical diagnoses, and manifestations of physically nonaggressive agitated behaviors (e.g., restlessness, pacing) were significant predictors. For cognitively impaired residents, the significant predictors were older age, impaired activities of daily living, and screaming behavior at a high frequency. Cognitive impairment is important both in predicting death in this population and in understanding the impact of other predictors. The impact of agitated behaviors, quality of social relations, and appetite on mortality highlights issues of quality of life at the end of life.     

Maintaining continuity of care for nursing home residents: effect of states' Medicaid bed-hold policies and reimbursement rates

Objective. Recent public concern in response to states' intended repeal of Medicaid bed-hold policies and report of their association with higher hospitalization rates prompts examination of these policies in ensuring continuity of care within the broader context of Medicaid policies.
Data Sources/Study Design. Minimum Data Set assessments of long-stay nursing home residents in April–June 2000 linked to Medicare claims enabled tracking residents' hospitalizations during the ensuing 5 months and determining hospital discharge destination. Multinomial multilevel models estimated the effect of state policies on discharge destination controlling for resident, hospitalization, nursing home, and market characteristics.
Results. Among 77,955 hospitalizations, 5,797 (7.4 percent) were not discharged back to the baseline nursing home. Bed-hold policies were associated with lower odds of transfer to another nursing home (AOR=0.55, 95 percent CI 0.52–0.58) and higher odds of hospitalization (AOR=1.36), translating to 9.5 fewer nursing home transfers and 77.9 more hospitalizations per 1,000 residents annually, and costing Medicaid programs about $201,311. Higher Medicaid reimbursement rates were associated with lower odds of transfer.
Conclusions. Bed-hold policies were associated with greater continuity of NH care; however, their high cost compared with their small impact on transfer but large impact on increased hospitalizations suggests that they may not be effective.