Interactions between group homes and neighbors: Neighbor preferences

Group homes often are in conflict with their neighbors. Consequently, group home administrators tend to minimize contact between group homes and neighbors to reduce conflict. This study examined whether information about group homes and contact between homes and neighbors are related to neighbor problems as well as the preferences of potential neighbors about ways in which to become informed and involved with a group home if one were built in their neighborhood. Neighbors who interacted with residents and staff identified problems with group homes but showed fewer concerns about and had positive attitudes toward group homes generally. Potential neighbors wanted information about group homes entering their neighborhood, and preferred types of contact were associated with positive attitudes toward group homes. Group home administrators should consider neighbors as potential allies to help residents integrate into the community rather than as sources of conflict that must be avoided.     

End-of-life preferences of the general public: Results from a Japanese national survey

PurposeTo determine under different End-of-Life (EoL) scenarios the preferences of the general public for EoL care setting and Life-sustaining-Treatments (LST), and to develop a new framework to assess these preferences.MethodUsing a 2-stage, geographical cluster sampling method, we conducted a postal survey across Japan of 2000 adults, aged 20+. Four EoL scenarios were used: cancer, cardiac failure, dementia and persistent vegetative state (PVS).ResultsWe received 969 valid responses (response rate 48.5%). Preference for EoL care setting varied by illness with those wishing to spend EoL at home only 39% for cancer, 22% for cardiac failure, and 10–11% for dementia and PVS. Preference for LST differed by scenario and treatment type. In cancer, cardiac failure and dementia, about half to two thirds expressed a preference for antibiotics and fluid drip infusion but few for nasogastric (NG) tube feeding, percutaneous endoscopic gastrostomy (PEG), ventilation or cardiopulmonary resuscitation (CPR). Although our models accounted for only 3–9% of the variance, preferences to receive LST were associated with preference to spend EoL in hospital for cancer and cardiac failure but not dementia.ConclusionsFew people preferred to die at home, while a preference for hospital was largely determined by factors other than preference for LST.     

Strategies and innovative models for delivering palliative care in nursing homes

The goals of palliative care address critical issues for individuals with complex and serious illness residing in nursing homes, including pain and symptom management, communication, preparation for death, decisions about treatment preferences, and caregiver support. Because of the uncertain prognosis associated with chronic nonmalignant diseases such as dementia, many nursing home residents are either not referred to hospice or have very short or very long hospice stays. The integration of palliative care into nursing homes offers a potential solution to the challenges relating to hospice eligibility, staffing, training, and obtaining adequate reimbursement for care that aligns with resident and surrogate's preferences and needs. However, the delivery of palliative care in nursing homes is hindered by both regulatory and staffing barriers and, as a result, is rare. In this article, we draw on interviews with nursing home executives, practitioners, and researchers to describe the barriers to nursing home palliative care. We then describe 3 existing and successful models for providing nonhospice palliative care to nursing home residents and discuss their ongoing strengths and challenges. We conclude with specific policy proposals to expedite the integration of palliative care into the nursing home setting.     

There's no place like home: evaluating family medicine residents' training in home care

This study examined residents' experiences in a physician home visit program and their attitudes toward working with older patients in a home setting. In-depth personal interviews were conducted with all second and third year residents in a family medicine residency program (n = 17). Most residents expressed positive attitudes about caring for patients in their homes. Residents said home visits allowed them to provide better care, and enhanced their assessment skills and understanding of community services. We identified a lack of coordination and consistency in several areas, including home visit assessments and the role of physician preceptors. The need for formal training to identify and treat elder abuse was also identified. Participation in a home visit program appears to be an effective learning experience for residents, and helps residents to understand the needs of older people living in the community.     

Economic aspects of dementia special care units in Veterans Affairs nursing homes

Given the intermittent use of special care units (SCUs), we consider economic aspects associated with dementia SCUs by reviewing the literature and surveying 2 nursing homes in the VA healthcare network. In addition to reporting the features in different types of facilities in the Veterans Affairs (VA), we present an economic characterization useful for hospital and nursing home administrators whose decision-making processes incorporate clinical, management, and financial factors. We conclude that, theoretically, benefits likely outweigh the costs of instituting dementia SCUs in VA nursing homes with a large number of cognitively impaired residents.     

Nutrition and involuntary weight loss: a pilot study of an educational intervention for nursing home surveyors

OBJECTIVE: To describe the knowledge and attitudes of nursing home (NH) surveyors before and after a brief educational intervention related to nutrition and involuntary weight loss in nursing home residents. DESIGN: A questionnaire covering knowledge and attitudes about nutrition was given 1 month before and 6 months after a targeted educational intervention. PARTICIPANTS AND SETTING: State of Maryland nursing home surveyors. MEASUREMENTS: A 24-item questionnaire of NH surveyor knowledge (11 items) and attitudes (13 items) regarding issues related to nutrition and involuntary weight loss in NH residents. RESULTS: Overall surveyors' knowledge scores increased from 68% (SD, 17%) pre-intervention to 76% (SD, 18%) post-intervention (P = .11). Knowledge related to the lack of the effect of tube feeding on survival in NH residents with end-stage dementia was the only knowledge item that improved significantly with the intervention (39% correct pre-intervention and 68% correct post-intervention, P = .04). There were no changes in attitudes toward the diagnosis or treatment of nutrition after the intervention. CONCLUSION: Overall, NH surveyor knowledge related to nutrition and involuntary weight loss varied widely across topic areas. Neither knowledge nor attitudes were substantially affected by a brief educational intervention. Development of effective educational interventions for NH surveyors should be a priority for stakeholders in NH care.     

Social network transactions of psychiatric patients.

In this research we examine self-reported social network transactions of former psychiatric inpatients residing in different types of housing in the community. Unlike earlier research, we found considerable reciprocity in network transactions with family and friends. Only professionals provided more support than they received from patients. Providing emotional support to others was positively correlated with positive affect, community integration, and mastery. Respondents reported more supportive than unsupportive transactions with network members and more supportive transactions with friends than with family or professionals. Finally, residents of supportive apartments and group homes provided and received support more frequently than residents of board-and-care homes. We discuss the results in terms of their implications for policy and future research.     

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.     

Knowledge of and Perceived Need for Evidence-Based Education About Antipsychotic Medications Among Nursing Home Leadership and Staff

Background/Objectives

Antipsychotic use is common in US nursing homes, despite evidence of increased risk of morbidity and mortality, and limited efficacy in older adults with dementia. Knowledge, attitudes, and beliefs regarding antipsychotic use among nursing home staff are unclear. The study aim was to describe nursing home leadership and direct care staff members’ knowledge of antipsychotic risks, beliefs and attitudes about the effectiveness of antipsychotics and nonpharmacologic management of dementia-related behaviors, and perceived need for evidence-based training about antipsychotic medication safety.

Design, Setting, Participants, and Measurements

Survey of leadership and direct care staff of nursing homes in Connecticut was conducted in June 2011. Questionnaire domains included knowledge of antipsychotic risks, attitudes about caring for residents with dementia, satisfaction with current behavior management training, beliefs about antipsychotic effectiveness, and need for staff training about antipsychotics and behavior management.

Results

A total of 138 nursing home leaders and 779 direct care staff provided useable questionnaires. Only 24% of nursing home leaders identified at least 1 severe adverse effect of antipsychotics; 13% of LPNs and 12% of RNs listed at least 1 severe adverse effect. Fifty-six percent of direct care staff believed that medications worked well to manage resident behavior. Leaders were satisfied with the training that staff received to manage residents with challenging behaviors (62%). Fifty-five percent of direct care staff felt that they had enough training on how to handle difficult residents; only 37% felt they could do so without using medications.

Conclusions

Findings suggest that a comprehensive multifaceted intervention designed for nursing homes should aim to improve knowledge of antipsychotic medication risks, change beliefs about appropriateness and effectiveness of antipsychotics for behavior management, and impart strategies and approaches for nonpharmacologic behavior management.     

Sexuality, dementia and residential care: managers report and response

There is a growing literature on the subject of sexuality and an increased knowledge of sexuality and older people, but there is a dearth of information about sexuality and people with dementia, particularly those in residential care. The concern of this paper is with people with dementia; it also considers the impact of gender on their sexual expression. The expression of sexuality by people with dementia is an area which has been largely neglected by research, yet in practice appears to be of concern. The types and prevalence of sexual expression by people with dementia in residential care and staff's responses to such expression are examined. A postal questionnaire sent to managers of social work residential homes in one region in Scotland explored a number of different issues, including: the public versus private expression of sexuality by people with dementia, the public response versus the private feelings of managers to such expression, the influence of carer involvement on staff's responses, exploitation of one resident by another and sexual expression directed at staff by residents. Permeating all these was the issue of gender. The majority of homes were staffed predominantly by female managers and female care staff. Most residents were female yet the majority of incidents involving sexual expression, reported by managers, involved male residents directing their attention towards female staff or other residents. Female residents with dementia do express sexuality but numbers reported are considerably less with staff actions tending towards the protective. Some types of sexual expression appear to be of more concern than others, and some are reported to occur more frequently.     

Client-centred,community-based care for frail seniors

Compared with nursing home care, community care, which is often viewed in Canada as care at home, is assumed to be best for older adults with chronic disease or disabilities since it is seen as client-focused and less costly. As the number of frail seniors living in the community increases, governments in Canada seek to provide alternate models of nursing home care. As part of a larger initiative meant to increase the scope of community programmes, a demonstration project was conducted in western Canada to evaluate the implementation of client-centred, community-based residential care with individuals requiring nursing-home-level care. The present authors explore two main implementation challenges: whether care that is responsive to individual preferences can be provided to people who cannot assume active decision-making roles; and whether care can be centred in the community if people are living in residential care settings rather than in their own homes. Focus groups were conducted with two key stakeholder groups with varying informal (family members) and formal (programme staff) relationships with residents living in three new programmes. From content analysis, the programmes appeared successful in conveying the importance of recognising residents as individuals and of keeping them connected to the community, but fell short of implementation expectations. Three themes illustrate the challenges: (1) engaging with others in a care partnership; (2) responding to residents' preferences and care needs with limited resources; and (3) maintaining residents' connections with the community. To improve the feasibility of these programmes, some changes could be pursued within existing financial resources. However moderating the funding to bring it somewhat closer to nursing home levels could support the sustainability of community-situated programmes for frail seniors.     

Health Care and Personal Care Needs Among Residents in Nursing Homes,Group Homes,and Congregate Housing in Japan: Why Does Transition Occur,and Where Can the Frail Elderly Establish a Permanent Residence?

ObjectivesJapan has had high rates of transition to nursing homes from other long term care facilities. It has been hypothesized that care transitions occur because a resident's condition deteriorates. The aim of the present study was to compare the health care and personal care needs of residents in nursing homes, group homes, and congregate housing in Japan.DesignThe present study was conducted using a cross-sectional study design.Setting/SubjectsThe present study included 70,519 elderly individuals from 5 types of residential facilities: care medical facilities (heavy medical care; n = 17,358), geriatric intermediate care facilities (rehabilitation aimed toward a discharge to home; n = 26,136), special nursing homes (permanent residence; n = 20,564), group homes (group living, n = 1454), and fee-based homes for the elderly (congregate housing; n = 5007).MeasurementsThe managing director at each facility provided information on the residents' health care and personal care needs, including activities of daily living (ADLs), level of required care, level of cognitive impairment, current disease treatment, and medical procedures.ResultsA multinomial logistic regression analysis demonstrated a significantly lower rate of medical procedures among the residents in special nursing homes compared with those in care medical facilities, geriatric intermediate care facilities, group homes, and fee-based homes for the elderly. The residents of special nursing homes also indicated a significantly lower level of required care than those in care medical facilities.ConclusionThe results of our study suggest that care transitions occur because of unavailable permanent residence option for people who suffer with medical deterioration. The national government should modify residential facilities by reorganizing several types of residential facilities into nursing homes that provide a place of permanent residence.     

Change in Advance Care Plans of Nursing Home Residents With Dementia and Pneumonia: Secondary Analysis of Randomized Controlled Trial Data

ObjectivesTo explore changes in advance care plans of nursing home residents with dementia following pneumonia, and factors associated with changes. Second, to explore factors associated with the person perceived by elderly care physicians as most influential in advance treatment decision making.DesignSecondary analysis of physician-reported PneuMonitor trial data.Setting and ParticipantsThe PneuMonitor trial took place between January 2012 and May 2015 in 32 nursing homes across the Netherlands; it involved 429 residents with dementia who developed pneumonia.MethodsWe compared advance care plans before and after the first pneumonia episode. Generalized logistic linear mixed models were used to explore associations of advance care plan changes with the person most influential in decision making, with demographics and indicators of disease progression. Exploratory analyses assessed associations with the person most influential in decision making.ResultsFor >90% of the residents, advance care plans had been established before the pneumonia. After pneumonia, treatment goals were revised in 15.9% of residents; 72% of all changes entailed refinements of goals. Significant associations with treatment goal changes were not found. Treatment plans changed in 20.0% of residents. Changes in treatment decisions were more likely for residents who were more severely ill (odds ratio 1.5, 95% CI 1.2-1.9) and those estimated to live <3 months (odds ratio 3.3, 95% CI 1.9-5.8). Physicians reported that a family member was often (47.4%) most influential in decision making. Who is most influential was associated with the resident’s dementia severity.Conclusions and ImplicationsOverall, changes in advance care plans after pneumonia diagnosis were small, suggesting stability of most preferences or limited dynamics in the advance care planning process. Advance care planning involving family is common for nursing home residents with dementia, but advance care planning with persons with dementia themselves is rare and requires more attention.     

People with AIDS as residents: preparedness and acceptance by Connecticut long-term care facilities

The management of AIDS has become an issue of chronic care as well as acute treatment. As the number of people with AIDS increases, the demand for ongoing care and support, both informal and formal, is expected to increase. The present study is based on a survey of all licensed nursing homes in the state of Connecticut with respect to prevailing attitudes toward the admission of residents with AIDS, and the level of staff, resident and procedural preparedness that exists. Both positive attitudes among the various LTC constituent groups as well as the level of preparation in a number of areas are correlated with the admission of residents with AIDS. Implications are discussed and recommendations are offered for policy development.     

Family Decision-Making for Nursing Home Residents With Dementia: Rural-Urban Differences

CONTEXT: Research has demonstrated substantial differences between end-of-life care in rural and urban settings. As the end of life approaches, rural elders are less likely to be hospitalized, to be placed in an intensive care unit, or to have a feeding tube, compared to their urban counterparts. These differences cannot be fully explained by rural-urban differences in access to medical services. PURPOSE: To describe and understand rural-urban differences in attitudes toward death and in end-of-life decision making. METHODS: Eight focus groups were convened in rural and urban Minnesota nursing homes. The 38 focus group participants were family members of nursing home residents with severe cognitive impairment. FINDINGS: Most rural focus group participants voiced unqualified acceptance of death and placed few conditions on death, beyond their hope that it would be quick and peaceful. Urban respondents presented a wider range of attitudes toward death, from unambiguous acceptance of immediate death to evident discomfort with welcoming death under any circumstances. These rural-urban differences had practical implications. Rural respondents were much less likely to endorse interventions that would impede death, compared to their urban counterparts. CONCLUSIONS: Rural respondents tended to express confidence in natural forces; death was seen as neutral or beneficent. Resistance to the approach of death was more characteristic of urban respondents, some of whom insisted upon aggressive medical care in advanced dementia.     

Advance Directive and End-of-Life Care Preferences Among Nursing Home Residents in Wuhan,China: A Cross-Sectional Study

Objectives

To describe Chinese nursing home residents' knowledge of advance directive (AD) and end-of-life care preferences and to explore the predictors of their preference for AD.

Design

Population-based cross-sectional survey.

Settings

Nursing homes (n = 31) in Wuhan, Mainland Southern China.

Participants

Cognitively intact nursing home residents (n = 467) older than 60 years.

Measures

Face-to-face questionnaire interviews were used to collect information on demographics, chronic diseases, life-sustaining treatment, AD, and other end-of-life care preferences.

Results

Most (95.3%) had never heard of AD, and fewer than one-third (31.5%) preferred to make an AD. More than half (52.5%) would receive life-sustaining treatment if they sustained a life-threatening condition. Fewer than one-half (43.3%) chose doctors as the surrogate decision maker about life-sustaining treatment, whereas most (78.8%) nominated their eldest son or daughter as their proxy. More than half (58.2%) wanted to live and die in their present nursing homes. The significant independent predictors of AD preference included having heard of AD before (odds ratio [OR] 9.323), having definite answers of receiving (OR 3.433) or rejecting (OR 2.530) life-sustaining treatment, and higher Cumulative Illness Rating Scale score (OR 1.098).

Conclusions

Most nursing home residents did not know about AD, and nearly one-third showed positive attitudes toward it. AD should be promoted in mainland China. Education of residents, the proxy decision maker, and nursing home staff on AD is very important. Necessary policy support, legislation, or practice guidelines about AD should be made with flexibility to respect nursing home residents' rights in mainland China.     

Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison

OBJECTIVE: To compare the costs associated with caring for severely demented residents nursing homes with and without feeding tubes. DESIGN: Retrospective cohort study. SETTING: A 700-bed long-term care facility in Boston Participants: Nursing home residents aged 65 years and over with advanced dementia and eating problems for whom long-term feeding tube had been discussed as a treatment option. Measurements: Costs were compared over the 6 months that followed the tube-feeding decision for those residents who did and did not undergo feeding tube placement for the following items: nursing time, physician assessments, food, hospitalizations, emergency room visits, diagnostic tests, treatment with antibiotics and parenteral hydration, and feeding tube insertion. RESULTS: Twenty-two subjects were included, 11 were tube-fed (mean age 84.3 years +/- 6.0) and 11 were hand-fed (mean age 90.2 years +/- 9.1). The daily costs of nursing home care were higher for the residents without feeding tubes compared with residents with tubes ($4219 +/- 1546 vs $2379 +/- 1032, P = 0.006). Nonetheless, Medicaid reimbursement to nursing homes in at least 26 states is higher for demented residents who are tube-fed than for residents with similar deficits who are not tube-fed. Costs typically billed to Medicare were greater for the tube-fed patients ($6994 +/- 5790 vs. $959 +/- 591, P < 0.001), primarily because of the high costs associated with initial feeding tube placement and hospitalizations or emergency rooms visits for the management of complications of tube-feeding. CONCLUSIONS: Nursing homes are faced with a potential fiscal incentive to tube-feed residents with advanced dementia: tube-fed residents generate a higher daily reimbursement rate from Medicaid, yet require less expensive nursing home care. From a Medicare perspective, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications. Further work is needed to determine whether these potential financial incentives influence tube-feeding decisions in practice.