New Toolkit to Measure Quality of Person-Centered Care: Development and Pilot Evaluation With Nursing Home Communities

BackgroundIncreasingly, nursing home (NH) providers are adopting a person-centered care (PCC) philosophy; yet, they currently lack methods to measure their progress toward this goal. Few PCC tools meet criteria for ease of use and feasibility in NHs. The purpose of this article is to report on the development of the concept and measurement of preference congruence among NH residents (phase 1), its refinement into a set of quality indicators by Advancing Excellence in America's Nursing Homes (phase 2), and its pilot evaluation in a sample of 12 early adopting NHs prior to national rollout (phase 3). The recommended toolkit for providers to use to measure PCC consists of (1) interview materials for 16 personal care and activity preferences from Minimum Data Set 3.0, plus follow-up questions that ask residents how satisfied they are with fulfillment of important preferences; and (2) an easy to use Excel spreadsheet that calculates graphic displays of quality measures of preference congruence and care conference attendance for an individual, household or NH. Twelve NHs interviewed residents (N = 146) using the toolkit; 10 also completed a follow-up survey and 9 took part in an interview evaluating their experience.ResultsNH staff gave strong positive ratings to the toolkit. All would recommend it to other NHs. Staff reported that the toolkit helped them identify opportunities to improve PCC (100%), and found that the Excel tool was comprehensive (100%), easy to use (90%), and provided high quality information (100%). Providers anticipated using the toolkit to strengthen staff training as well as to enhance care planning, programming and quality improvement.ConclusionsThe no-cost PCC toolkit provides a new means to measure the quality of PCC delivery. As of February 2014, over 700 nursing homes have selected the Advancing Excellence in America's Nursing Homes PCC goal as a focus for quality improvement. The toolkit enables providers to incorporate quality improvement by moving beyond anecdote, and advancing more systematically toward honoring resident preferences.     

Fottler-Smith: theory of evaluating the effectiveness of nursing home administrators: an empirical analysis of determining dominant factors.

In a recent issue of EVALUATION AND THE HEALTH PROFESSIONS, Fottler and Smith (1982) developed a theory for determining the influence of Budgetary Evaluating the Effectiveness of Nursing Home Administration (EENA). The present study offers an extension to their multivariable theory, which is otherwise viewed as an excellent attempt at presenting a realistic model of EENA. Further analysis of the data included in the present paper ranks the dominant variables and factors as (1) Profit Per Patient Day (PPP) and Nursing Hours Per Patient Day (NH), (2) Other Hours Per Patient Day (OH) and Patient Mix (PM), (3) Occupancy Rate (OR) and Staffing Ratio (SR), (4) Administrator Years in Nursing Home Administration (AY) and Administrator Years at the Home (AYH), (5) External Comparisons (EC) and Cost Per Patient Day (CPP) and (6) Administrative Intensity (AI) and Report Use (RU). In addition, this analysis reduces the multicolinearity and data redundancy of the original 14 variables by creating 6 less redundant factors from them. These new factors yield a EENA model of measurement with a fewer number of terms, a lower multicolinearity, and a multivariate normal distribution. The variable entitled Internal Comparisons (IC) is ranked as the most subordinant, and most dependent, while PPP is ranked as the most dominant variable.     

COVID-19 Cases and Death in Nursing Homes: The Role of Racial and Ethnic Composition of Facilities and Their Communities

ObjectivesTo examine the extent to which the racial and ethnic composition of nursing homes (NHs) and their communities affects the likelihood of COVID-19 cases and death in NHs, and whether and how the relationship between NH characteristics and COVID-19 cases and death varies with the racial and ethnic composition of the community in which an NH is located.Methods and DesignCenters for Medicare & Medicare Services Nursing Home COVID-19 data were linked with other NH- or community-level data (eg, Certification and Survey Provider Enhanced Reporting, Minimum Data Set, Nursing Home Compare, and the American Community Survey). Setting and Participants: NHs with more than 30 occupied beds (N=13,123) with weekly reported NH COVID-19 records between the weeks of June 7, 2020, and August 23, 2020. Measurements and model: Weekly indicators of any new COVID-19 cases and any new deaths (outcome variables) were regressed on the percentage of black and Hispanic residents in an NH, stratified by the percentage of blacks and Hispanics in the community in which the NH was located. A set of linear probability models with NH random effects and robust standard errors were estimated, accounting for other covariates.ResultsThe racial and ethnic composition of NHs and their communities were both associated with the likelihood of having COVID-19 cases and death in NHs. The racial and ethnic composition of the community played an independent role in the likelihood of COVID-19 cases and death in NHs, even after accounting for the COVID-19 infection rate in the community (ie, daily cases per 1000 people in the county). Moreover, the racial and ethnic composition of a community modified the relationship between NH characteristics (eg, staffing) and the likelihoods of COVID-19 cases and death.Conclusions and ImplicationsTo curb the COVID-19 outbreaks in NHs and protect vulnerable populations, efforts may be especially needed in communities with a higher concentration of racial and ethnic minorities. Efforts may also be needed to reduce structural racism and address social risk factors to improve quality of care and population health in communities of color.     

The significance of autonomy in the nursing home administrator profession: a qualitative study

Nursing home administration is seeing high turnover and low entrance into the profession. Face-to-face interviews were conducted with thirty NH administrators and coded using qualitative analytical techniques. It was found that constrained autonomy contributes to job dissatisfaction in the nursing home administrator profession, and that autonomy contributes to increased satisfaction and may lower administrator turnover.     

The Change in Nursing Home Residents' Preferences Over Time

Objectives

Nursing home (NH) residents' preferences for everyday living are the foundation for delivering individualized person-centered care. Yet, work has not examined what the most and least important preferences of nursing home residents are and if those preferences change over time.

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.     

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.     

Nursing Home Compare Star Rating and Daily Direct-Care Nurse Staffing During Hurricane Irma

ObjectivesNursing homes (NHs) are affected by major hurricanes and other natural disasters. To mitigate adverse effects of a major hurricane, NHs often increase their direct-care nurse staffing levels to meet the needs of their residents. However, the quality rating of the NH may affect the resources available to obtain and retain staff. This data brief provides estimates of direct-care nurse staffing levels by quality star rating during Hurricane Irma.DesignRetrospective cohort study from September 3, 2017, to September 10, 2017.Setting and Participants570 Florida NHs that sheltered in place during Hurricane Irma.MethodsWe stratified NHs by their NH Compare overall quality star rating and then measured change in direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants.ResultsWe found that the NH Compare overall star rating was positively associated with a greater staffing level response during Hurricane Irma among registered nurses, licensed practical nurses, and certified nursing assistants. This change was largest for 5-star facilities and smallest for 1-star facilities.Conclusions and ImplicationsHigher-quality NHs may be more responsive and have the resources to be more responsive, to increased needs during a natural disaster. Our findings may serve as a platform for ongoing discussion on the role of the federal, state, and local governments in ensuring minimum staffing standards during natural disasters.     

Profiling the multidimensional needs of new nursing home residents: evidence to support planning

IntroductionNursing home (NH) residents have various needs that affect the care they require. This article describes the diverse needs that new NH residents have, emphasizing the proportion of people with milder needs in multiple areas.MethodsResearch was conducted on all older adults newly admitted to not-for-profit NHs in the Winnipeg Health Region, between April 1, 2005, and March 31, 2007, provided that they were assessed using the Resident Assessment Instrument Minimum Data Set (RAI/MDS 2.0) within 30 days of admission (n = 1061). Using the Activities of Daily Living (ADL) Hierarchy scale, residents were first defined as low, intermediate, or high ADL dependent. Residents' needs were also defined using the RAI/MDS 2.0 cognitive performance (CPS) and pain scales, by their degree of behavioral problems and visual challenges, and by their frequency of bladder and bowel incontinence. Cluster analysis was used to create subgroups of residents by their severity of clinical challenges.ResultsOf our cohort, 26.8% were low ADL dependent. Although some of these residents had moderate to severe needs in another area, many (46.8% of low ADL-dependent residents; 12.5% of our entire cohort) had milder needs across all clinical domains. Conversely, about one-third of our cohort was high ADL dependent; 31.7% of these residents had moderate to severe challenges in one clinical domain, and 35.5% had moderate to severe comorbid challenges.ConclusionsOverall, 12.5% of our cohort had lower needs, demonstrating the capacity for community-based programs to offset NH demands. Also, the diversity of residents' needs highlights the importance of having both the appropriate resources and strategies available to provide quality NH care. Future research is discussed for both low- and higher-need NH residents.     

Applying Agile Methodology to Reengineer the Delivery of Person-Centered Care in a Nursing Home: A Case Study

Nursing home (NH) providers would benefit from adopting evidence-based measures for gathering and utilizing resident preference information in their daily care activities. However, providers face barriers when implementing assessment tools used to promote person-centered care (PCC). Although Agile methodology is not commonly used in NH settings, this case study shows how it can be used to achieve the goal of delivering preference-based, PCC, within a large NH. We present a road map for breaking down care processes, prioritizing, and implementing iterative plan, do, study, act cycles using Agile methodology to enhance group collaboration on quality improvement cycles, to achieve our goal of providing preference-based PCC. We first determined if care plans reflected each resident’s important preferences, developed a method for tracking whether residents attended activities that matched their preferences, and determined if residents were satisfied that their preferences were being met. These efforts had positive effects throughout the NH particularly when COVID-19 limited visitors and significantly modified staff workflow. Specifically, Agile processes helped staff to know how to honor preferences during quarantines which necessitated a shift to individualized (and not group) approaches for meeting preferences for social contact, comfort, and belonging. The ready availability of preference-based reporting was critical to quickly informing new staff on how to meet residents’ most important preferences. Based on lessons learned, we describe a developmental approach that other providers can consider for adoption. Implications of this work are discussed in terms of the need for provider training in Agile methodologies to support iterative improvements, the need for policies that reimburse providers for their efforts, and additional research around workflow processes.     

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.     

Quality of Nursing Homes and Admission of Residents With Alzheimer's Disease and Related Dementias: The Potential Influence of Market Factors and State Policies

ObjectivesThis study aimed to examine the associations between nursing home (NH) quality and prevalence of newly admitted NH residents with Alzheimer's disease and related dementias (ADRD), and to assess the extent to which market-level wages for certified nursing assistants (CNAs) and state Medicaid behavioral and mental health add-on policy may influence such associations.DesignRetrospective cohort study.Setting and ParticipantsThe analytical sample included 2777 NHs with either high or low quality, located in urban areas of 41 states from 2011 to 2014.MethodsThe outcome variable was the prevalence of ADRD among newly admitted NH residents. NH quality was defined as dichotomous, based on the Nursing Home Compare (NHC) star rating system. We considered an NH with 5-star rating as having high quality and with 1-star rating as having low quality. Information on county-level CNA wages and state Medicaid behavioral and mental health add-on policies was included. Linear regression models with NH random effects and robust standard errors were estimated. A set of sensitivity analyses were performed.ResultsAfter accounting for NH-level aggregated resident characteristics and market/state-level factors, the prevalence of ADRD among newly admitted residents was 3% lower in high-quality NHs compared with low-quality NHs (P < .01). A 1-dollar increase in CNA hourly wage was associated with a 0.9–percentage point decrease in the prevalence of ADRD among newly admitted residents (P < .01). State Medicaid behavioral and mental health add-on policy was associated with a 2.5–percentage point increase in the prevalence of ADRD in high-quality NHs (P < .05), but not in low-quality NHs.Conclusions and ImplicationsOur findings suggest that high-quality NHs are less likely to admit residents with ADRD. The effect size of this relationship is modest and may be influenced by state Medicaid behavioral and mental health add-on policies. Future studies are needed to better understand reasons leading to these associations so that effective interventions can be developed to incentivize high-quality NHs to more readily serve residents with ADRD.     

Background rates of all-cause mortality,hospitalizations, and emergency department visits among nursing home residents in Ontario,Canada to inform COVID-19 vaccine safety assessments

BackgroundNursing home (NH) residents are prioritized for COVID-19 vaccination. We report monthly mortality, hospitalizations, and emergency department (ED) visit incidence rates (IRs) during 2010–2020 to provide context for COVID-19 vaccine safety assessments.MethodsWe observed outcomes among all NH residents in Ontario using administrative databases. IRs were calculated by month, sex, and age group. Comparisons between months were assessed using one-sample t-tests; comparisons by age and sex were assessed using chi-squared tests.ResultsFrom 2010 to 2019, there were 83,453 (SD: 652.4) NH residents per month, with an average of 2.3 (SD: 0.28) deaths, 3.1 (SD: 0.16) hospitalizations, and 3.6 (SD: 0.17) ED visits per 100 residents per month. From March to December 2020, mortality IRs were increased, but hospitalization and ED visit IRs were reduced (p < 0.05).ConclusionWe identified consistent monthly mortality, hospitalization, and ED visit IRs during 2010–2019. Marked differences in these rates were observed during 2020, coinciding with the COVID-19 pandemic.     

Center of Studies and Research in Nursing (CEPEn): a trajectory of 36 years

The study presents some trajectory highlights of the Center of Studies and Research in Nursing of the Brazilian Nursing Association, considering the period from 1971 to 2007. This is a historical study based on the Information Catalog of Research and Researchers in Nursing and the reports of the National Seminars of Nursing Research. The objectives were to rescue the contribution of CEPEn and to present one of the most important events for Brazilian Nursing. The concern with the future and the need for empowerment and enrichment, of professors as well as for assistance professionals, is one of the marks in nowadays and it is a challenge to be faced in present time.     

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.

The Prevalence and Course of Neuropsychiatric Symptoms in Nursing Home Patients With Dementia: A Systematic Review

BackgroundPersons with dementia frequently exhibit neuropsychiatric symptoms (NPSs). Previous studies have indicated that the prevalence is particularly high in nursing home (NH) patients. However, differences in methodology in studies of the prevalence and course of NPSs have made it difficult to compare their results.MethodsWe searched the electronic databases MEDLINE, EMBASE, PsycINFO, Ovid Nursing, and AgeLine from their inception until July 2012 using medical subject headings to identify studies that reported figures on the prevalence and course of NPSs in NH patients with dementia.ResultsA total of 28 studies met the inclusion criteria. In total, 8468 and 1458 persons participated in the prevalence and longitudinal studies, respectively. The weighted mean prevalence of having at least one NPS was 82%. Although the prevalence of individual symptoms varied, the highest prevalence figures were found for agitation and apathy. The persistence of individual NPSs varied substantially, but in these studies, having at least one NPS was highly persistent across the studies.ConclusionThis review confirms that clinically significant NPSs are common in NH patients with dementia. Even though great variability exists across studies, recent studies applying similar methodology have made comparisons between studies feasible, revealing relatively consistent prevalence patterns for individual symptoms. The natural course of symptoms deserves closer attention. This is vital in planning prevention and treatment of NPSs in NH patients with dementia.     

Knowledge and truths about nursing: discourse of new students

It is a study with a qualitative approach that proposes to analyze truths regimes that pass by and along Nursing as a profession, as manifested by students entering in the Graduate Course 2004/2, 2005/1 and 2005/2. The Discourse Analysis has been used as a methodological option for analyzing the data, under Michel Foucault's approaches. Three great themes have come out of such context of analysis and discussion: the traversing of gender knowledges in Nursing practice; Nursing as a knowledge made hierarchical; making as a might in Nursing's academic and professional day-by-day. Social conceptions became self evident, going through invisible knowledges that legitimate health and nursing practices, making them unquestionable.     

Nursing Home Design and COVID-19: Implications for Guidelines and Regulation

ObjectivesNursing homes (NHs) are important health care and residential environments for the growing number of frail older adults. The COVID-19 pandemic highlighted the vulnerability of NHs as they became COVID-19 hotspots. This study examines the associations of NH design with COVID-19 cases, deaths, and transmissibility and provides relevant design recommendations.DesignA cross-sectional, nationwide study was conducted after combining multiple national data sets about NHs.Setting and ParticipantsA total of 7785 NHs were included in the study, which represent 50.8% of all Medicare and/or Medicaid NH providers in the United States.MethodsZero-inflated negative binomial models were used to predict the total number of COVID-19 resident cases and deaths, separately. The basic reproduction number (R₀) was calculated for each NH to reflect the transmissibility of COVID-19 among residents within the facility, and a linear regression model was estimated to predict log(R₀ – 1). Predictors of these models included community factors and NHs’ resident characteristics, management and rating factors, and physical environmental features.ResultsIncreased percentage of private rooms, larger living area per bed, and presence of a ventilator-dependent unit are significantly associated with reductions in COVID-19 cases, deaths, and transmissibility among residents. After setting the number of actual residents as the exposure variable and controlling for staff cases and other variables, increased number of certified beds in the NH is associated with reduced resident cases and deaths. It also correlates with reduced transmissibility among residents when other risk factors, including staff cases, are controlled.Conclusions and ImplicationsArchitectural design attributes have significant impacts on COVID-19 transmissions in NHs. Considering the vulnerability of NH residents in congregated living environments, NHs will continue to be high-risk settings for infection outbreaks. To improve safety and resilience of NHs against future health disasters, facility guidelines and regulations should consider the need to increase private rooms and living areas.