Hospice enrollment and evaluation of its causal effect on hospitalization of dying nursing home patients

OBJECTIVE: To examine the patient, nursing home (NH), hospice provider, and local market factors associated with the selection of the Medicare hospice benefit by eligible NH residents, and evaluate the causal effect of hospice on end-of-life hospitalization rates. DATA SOURCES/STUDY SETTING: Secondary data for 1995-1997 for NH residents. STUDY DESIGN: This retrospective cohort study includes NH residents in five states (Kansa, Maine, New York, Ohio, South Dakota) who died in the years 1995-1997. Medicare claims identified hospice enrollment and hospitalizations. Geocoding of NHs, hospice providers, and hospitals was used to identify local markets. The two outcome measures are hospice enrollment and hospitalization of NH residents in their last 30 days of life. DATA COLLECTION/EXTRACTION METHOD: A file was constructed linking MDS assessments to Medicare claims and denominator files, NH provider files (OSCAR), hospice provider of service files, and the area resource file. PRINCIPAL FINDINGS: Twenty-six percent of hospice and 44 percent of nonhospice residents were hospitalized in their last 30 days of life (odds ratio [OR] 0.45; 95 percent confidence interval [CI]: 0.42-0.48). Adjusting for confounders, hospice patients were less likely than nonhospice residents to be hospitalized (OR 0.47; 95 percent CI: 0.45-0.50). Adding inverse propensity score weighting, hospice patients were still less likely than nonhospice residents to be hospitalized (OR 0.56; 95 percent CI: 0.53-0.61). CONCLUSIONS: Hospice selection introduces some bias in the evaluation of the causal effect of hospice on end-of-life hospitalization rates. However, even after adjusting for selection bias, hospice does have a powerful effect in reducing end-of-life hospitalization rates.     

Racial/Ethnic Disparities in Nursing Home End-of-Life Care: A Systematic Review

ObjectiveHealth disparities are pervasive in nursing homes (NHs), but disparities in NH end-of-life (EOL) care (ie, hospital transfers, place of death, hospice use, palliative care, advance care planning) have not been comprehensively synthesized. We aim to identify differences in NH EOL care for racial/ethnic minority residents.DesignA systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered in PROSPERO (CRD42020181792).Setting and ParticipantsOlder NH residents who were terminally ill or approaching the EOL, including racial/ethnic minority NH residents.MethodsThree electronic databases were searched from 2010 to May 2020. Quality was assessed using the Newcastle-Ottawa Scale.ResultsEighteen articles were included, most (n = 16) were good quality and most (n = 15) used data through 2010. Studies varied in definitions and grouping of racial/ethnic minority residents. Four outcomes were identified: advance care planning (n = 10), hospice (n = 8), EOL hospitalizations (n = 6), and pain management (n = 1). Differences in EOL care were most apparent among NHs with higher proportions of Black residents. Racial/ethnic minority residents were less likely to complete advance directives. Although hospice use was mixed, Black residents were consistently less likely to use hospice before death. Hispanic and Black residents were more likely to experience an EOL hospitalization compared with non-Hispanic White residents. Racial/ethnic minority residents experienced worse pain and symptom management at the EOL; however, no articles studied specifics of palliative care (eg, spiritual care).Conclusions and ImplicationsThis review identified NH health disparities in advance care planning, EOL hospitalizations, and pain management for racial/ethnic minority residents. Research is needed that uses recent data, reflective of current NH demographic trends. To help reduce EOL disparities, language services and cultural competency training for staff should be available in NHs with higher proportions of racial/ethnic minorities.     

Nursing Home–Hospice Collaboration and End-of-Life Hospitalizations Among Dying Nursing Home Residents

Objectives

Nursing homes (NHs) collaboration with hospices appears to improve end-of-life (EOL) care among dying NH residents. However, the potential benefits of NH-hospice collaboration may vary with the patterns of this collaboration. This study examines the relationship between the attributes of NH-hospice collaboration, especially the exclusivity of NH-hospice collaboration (ie, the number of hospice providers in a NH), and EOL hospitalizations among dying NH residents.

Thirty-Year Trends in Nursing Home Composition and Quality Since the Passage of the Omnibus Reconciliation Act

ObjectiveIn 1987, the Omnibus Reconciliation Act (OBRA) called for a dramatic overhaul of the nursing home (NH) quality assurance system. This study examines trends in facility, resident, and quality characteristics since passage of that legislation.MethodsWe conducted univariate analyses of national data on US NHs from 3 sources: (1) the 1985 National Nursing Home Survey (NNHS), (2) the 1992-2015 Online Survey Certification and Reporting (OSCAR) Data, and (3) LTCfocUS data for 2000-2015. We examined changes in NH characteristics, resident composition, and quality.Setting and participantsUS NH facilities and residents between 1985 and 2015.ResultsThe proportion of NHs that are Medicare and Medicaid certified, members of chains, and operating not-for-profit has increased over the past 30 years. There have also been reductions in occupancy and increases in the share of residents who are racial or ethnic minorities, admitted for post-acute care, in need of physical assistance with daily activities, primarily supported by Medicare, and diagnosed with a psychiatric condition such as schizophrenia. With regard to NH quality, direct care staffing levels have increased. The proportion of residents physically restrained has decreased dramatically, coupled with changes in inappropriate antipsychotic (chemical restraint) use.Conclusions and implicationsTogether with changes in the long-term care market, the NHs of today look very different from NHs 30 years ago. The 30th anniversary of OBRA provides a unique opportunity to reflect, consider what we have learned, and think about the future of this and other sectors of long-term care.     

Making the Investment Count: Revision of the Minimum Data Set for Nursing Homes, MDS 3.0

BackgroundThe Minimum Data Set (MDS) is a potentially powerful tool for implementing standardized assessment in nursing homes (NHs). Its content has implications for residents, families, providers, researchers, and policymakers, all of whom have expressed concerns about the reliability, validity, and relevance of MDS 2.0. Some argue that because MDS 2.0 fails to include items that rely on direct resident interview, it fails to obtain critical information and effectively disenfranchises many residents from the assessment process.PurposeDesign a major revision of the MDS, MDS 3.0, and evaluate whether the revision improves reliability, validity, resident input, clinical utility, and decreases collection burden.Design and MethodsIn the form design phase, we gathered information from a wide range of experts, synthesized existing literature, worked with a national consortium of VA researchers to revise and test eight sections, pilot tested a draft MDS 3.0 and revised the draft based on results from the pilot. In the national validation and evaluation phase, we tested MDS 3.0 in 71 community NHs and 19 VHA NHs, regionally distributed throughout the United States. The sample was selected based on scheduled MDS 2.0 assessments. Comatose residents were excluded. A total 3822 residents of community NHs in eight states were included. The evaluation was designed to test and analyze inter-rater agreement (reliability) between research nurses and between facility staff and research nurses, validity of key sections, response rates for interview items, anonymous feedback on changes from participating nurses, and time to complete the MDS assessment.ResultsThe reliability for research nurse to research nurse and for research nurse to facility staff was good or excellent for most items. Response rates for the resident interview sections were high: 90% for cognitive, 86% for mood, 85% for preferences, and 87% for pain. Staff survey responses showed increased satisfaction with clinical relevance, validity and clarity compared with MDS 2.0. The test version of the MDS 3.0 took 45% less time for facilities to complete.ImplicationsImproving the reliability, accuracy, and usefulness of the MDS has profound implications for NH care and public policy. Enhanced accuracy supports the primary legislative intent that MDS be a tool to improve clinical assessment and supports the credibility of programs that rely on MDS.     

Facility Characteristics Associated With Intensity of Care of Nursing Homes and Hospital Referral Regions

ObjectivesIntensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs).DesignCross-sectional analysis.Setting and Participants1449 NHs.MethodsNationwide 2016–2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR.ResultsIn high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH.Conclusions and ImplicationsThese findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care.     

The accuracy of monthly weight assessments in nursing homes: Implications for the identification of weight loss

Background  The prevalence of weight loss is a quality indicator for nursing homes (NH), and monthly weight assessments are conducted by NH staff to determine weight loss. Methods  A longitudinal study was conducted with 90 long-stay residents in four NHs for 12 study months. Monthly weight values documented in the medical record by NH staff were compared to independent weight values collected by research staff using a standardized protocol. Weight loss was defined according to the Minimum Data Set (MDS) criterion: ≥ 5% in 30 days or ≥ 10% in 180 days. Results  The total frequency of weight loss episodes per person was comparable between NH and research staff weight assessments across the 12 study months. However, monthly weight values recorded by NH staff were consistently higher than values recorded by research staff, which resulted in a higher prevalence of weight loss and earlier identification of weight loss according to research staff weight values using a standardized weighing protocol. Conclusions  A standardized weighing protocol improved the detection of weight loss among NH residents and should allow for earlier nutrition intervention.     

The Benefits of Culture Change in Nursing Homes—Obtaining Nationally Representative Evidence

ObjectiveDespite face validity and regulatory support, empirical evidence of the benefit of culture change practices in nursing homes (NHs) has been inconclusive. We used rigorous methods and large resident-level cohorts to determine whether NH increases in culture change practice adoption in the domains of environment, staff empowerment, and resident-centered care are associated with improved resident-level quality outcomes.DesignWe linked national panel 2009-2011 and 2016-2017 survey data to Minimum Data Set assessment data to test the impact of increases in each of the culture change domains on resident quality outcomes.Setting and ParticipantsThe sample included 1584 nationally representative US NHs that responded to both surveys, and more than 188,000 long-stay residents cared for in the pre- and/or postsurvey periods.MethodsWe used multivariable logistic regression with robust standard errors and a difference-in-differences methodology. Controlling for the endogeneity between increases in culture change adoption and NH characteristics that are also related to quality outcomes, we tested whether pre-post quality outcome differences (ie, improvements in outcomes) were greater for residents in NHs with culture change increases vs in those without such increases.ResultsNH performance on most quality indicators improved, but improvement was not significantly different by whether NHs increased or did not increase their culture change domain practices.Conclusions and ImplicationsThis study found that increases in an NH’s culture change domain practices were not significantly associated with improved resident-level quality. It describes a number of potential limitations that may have contributed to the null findings.     

Characteristics of Nursing Homes by COVID-19 Cases Among Staff: March to August 2020

ObjectiveTo measure the association between nursing home (NH) characteristics and Coronavirus Disease 2019 (COVID-19) prevalence among NH staff.DesignRetrospective cross-sectional study.Setting and ParticipantsCenters for Disease Control and Prevention COVID-19 database for US NHs between March and August 2020, linked to NH facility characteristics (LTCFocus database) and local COVID-19 prevalence (USA Facts).MethodsWe estimated the associations between NH characteristics, local infection rates, and other regional characteristics and COVID-19 cases among NH staff (nursing staff, clinical staff, aides, and other facility personnel) measured per 100 beds, controlling for the hospital referral regions in which NHs were located to account for local infection control practices and other unobserved characteristics.ResultsOf the 11,858 NHs in our sample, 78.6% reported at least 1 staff case of COVID-19. After accounting for local COVID-19 prevalence, NHs in the highest quartile of confirmed resident cases (413.5 to 920.0 cases per 1000 residents) reported 18.9 more staff cases per 100 beds compared with NHs that had no resident cases. Large NHs (150 or more beds) reported 2.6 fewer staff cases per 100 beds compared with small NHs (<50 beds) and for-profit NHs reported 0.8 fewer staff cases per 100 beds compared with nonprofit NHs. Higher occupancy and more direct-care hours per day were associated with more staff cases (0.4 more cases per 100 beds for a 10% increase in occupancy, and 0.7 more cases per 100 beds for an increase in direct-care staffing of 1 hour per resident day, respectively). Estimates associated with resident demographics, payer mix, or regional socioeconomic characteristics were not statistically significant.Conclusions and ImplicationsThese findings highlight the urgent need to support facilities with emergency resources such as back-up staff and protocols to reduce resident density within the facility, which may help stem outbreaks.     

Implementation of Goals of Care Communication Innovation Among Nursing Homes: A Multiple Case Study Design

ObjectiveNursing homes (NHs) provide care to residents with serious illness and related complex health care needs. As such, discussions about end-of-life care between NH staff and residents and families are necessary to ensure residents receive care consistent with their goals. Interventions such as video decision aids have been developed to promote discussions and improve advance care planning, but few studies have examined how NH characteristics may relate to the implementation of these interventions; such information might lead toward more use of successful interventions. The purpose of this study is to understand NH characteristics that are associated with the implementation of the Goals of Care (GOC) intervention, which combined a video decision aid with a structured discussion to guide decision-making in advanced dementia.DesignA multiple case study.Setting and ParticipantsStaff surveys were conducted to examine factors related to implementation effectiveness in 11 NHs in North Carolina that participated in the GOC trial.MethodsQuestions measured the dependent variable of implementation effectiveness: the consistency and quality of use of the GOC intervention. NH organizational characteristics were measured using publicly available data and an administrator survey. The analysis consisted of pattern matching logic.ResultsHigh management support aligned with implementation effectiveness within NHs. In addition, the within case pattern analysis indicated additional characteristics related to implementation effectiveness. Facility size, Medicare beds, residents’ racial composition, and star rating were related to implementation effectiveness across 6 of the 11 NHs. NH financial resources, such as size and number of Medicare beds, may be important factors for successful implementation.Conclusion and ImplicationsNHs seeking to implement advance care planning interventions should focus on within and across NH differences, such as adequate management and financial support prior to implementation to increase the likelihood of implementation effectiveness.     

Implementation and Use of Point-of-Care C-Reactive Protein Testing in Nursing Homes

ObjectivesThis study evaluated logistics, process data, and barriers/facilitators for the implementation and use of C-reactive protein point-of-care testing (CRP POCT) for suspected lower respiratory tract infections (LRTIs) in nursing home (NH) residents.DesignThis process evaluation was performed alongside a cluster randomized, controlled trial (UPCARE study) to evaluate the effect of CRP POCT on antibiotic prescribing for suspected LRTIs in NH residents.Setting and ParticipantsEleven NHs in the Netherlands.MethodsData sources for process data regarding intervention quality included a questionnaire among NH staff, logs, reports, and CRP POCT-analyzer records. Barriers and facilitators for implementation were assessed in focus group interviews with physicians and nurses from 3 NHs.ResultsCorrect patient selection for CRP POCT and generally continued CRP POCT use indicated good fidelity. The initial training and training of new employees seemed to fit the need, but some POCT-user group sizes had increased over time, which could have impeded frequent use. Users were generally satisfied with CRP POCT and perceived its use feasible and relevant. Facilitators for implementation were initial commitment and active initiation, followed by continued attention and enthusiasm for building routine practice and trust. Short lines of communication between staff, short distance to the POCT-analyzer, 24/7 coverage of staff, and a clear task division facilitated continued attention and routine practice.Conclusions and ImplicationsThis process evaluation showed sufficient quality of providing CRP POCT in Dutch NHs. We processed findings of intervention quality and implementation knowledge into key recommendations for CRP POCT implementation in this setting. Future research could focus on CRP POCT use in countries with different organization of care in NHs.     

Hospice quality improvement programs: an initial examination

Recognizing that little is known about use of quality improvement (QI) processes to enhance care of the dying, 11 large hospices exchanged information about their QI programs. These hospices reported monitoring from 3 to 50 outcomes measured by various indicators and methods. Agencies that related QI to their organization's mission, goals, and strategic plan were more likely to have dedicated QI staff; a more intense, comprehensive, and participatory QI program; and more QI projects resulting in performance enhancement. Both accomplishments and difficulties were identified in several areas, including establishing benchmarks, involving staff, and using computer technology to manage and analyze QI data.     

Quality improvement implementation and hospital performance on quality indicators

OBJECTIVE: To examine the association between the scope of quality improvement (QI) implementation in hospitals and hospital performance on selected indicators of clinical quality. DATA SOURCES: Secondary data from 1997 mailed survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets compiled by Solucient Inc. containing data on managed care penetration and hospital financial performance. STUDY DESIGN: Cross-sectional study of 1,784 community hospitals to assess relationship between QI implementation approach and six hospital-level quality indicators. DATA COLLECTION/ABSTRACTION METHODS: Two-stage instrumental variables estimation in which predicted values (instruments) of four QI scope variables and control (exogenous) variables used to estimate hospital-level quality indicators. PRINCIPAL FINDINGS: Involvement by multiple hospital units in QI effort is associated with worse values on hospital-level quality indicators. Percentage of hospital staff and percentage of senior managers participating in formally organized QI teams are associated with better values on quality indicators. Percentage of physicians participating in QI teams is not associated with better values on the hospital-level quality indicators studied. CONCLUSIONS: Results supported the proposition that the scope of QI implementation in hospitals is significantly associated with hospital-level quality indicators. However, the direction of the association varied across different measures of QI implementation scope.     

Nursing Home Characteristics Associated With Implementation of an Advance Care Planning Video Intervention

ObjectivesAdvance care planning (ACP) is important to ensure that nursing home (NH) residents receive care concordant with their goals. Video interventions have been developed to improve the process of ACP. Yet, little is known about which NH characteristics are associated with implementation of ACP video interventions in clinical practice. Our objective was to examine NH-level characteristics associated with the implementation of an ACP video intervention as part of the Pragmatic trial of Video Education in Nursing Homes (PROVEN) trial.DesignCross-sectional study of NHs in PROVEN.Setting and participants119 NHs randomized to receive the ACP video intervention.MeasurementsThe outcomes were the proportion of short- (<100 days) and long-stay (≥100 days) NH residents who were (1) offered to watch a video and (2) shown a video, aggregated to the NH-level, and measured using electronic forms of video offers. The association between outcomes and NH facility characteristics (eg, staffing, resident acuity) and participation in other aspects of the PROVEN trial (eg, monthly check-in calls) were estimated using multivariate linear regression models. NH characteristics were measured using data from Online Survey Certification and Reporting data, Long-term Care: Facts on Care in the US and NH Compare.ResultsOffer rates were 69% [standard deviation (SD): 28] for short-stay and 56% (SD: 20) for long-stay residents. Show rates were 19% (SD: 21) for short-stay and 17% (SD: 17) for long-stay residents. After adjusting for NH characteristics, compared to 1-star NHs, higher star-rated NHs had higher offer rates. Champions' participation in check-in calls was positively associated with both outcomes for long-stay residents.Conclusions/implicationsLower-quality NHs seem unable to integrate a novel ACP video education program into routine care processes. Ongoing support for and engagement with NH staff to champion the intervention throughout implementation is important for the success of a pragmatic trial within NHs.