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.     

Serious Mental Illness and Nursing Home Quality of Care

Objective

To estimate the effect of a nursing home''s share of residents with a serious mental illness (SMI) on the quality of care.

Data Sources

Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims.

Study Design

We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects.

Principal Findings

An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents.

Conclusions

Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.     

FRED: an innovative approach to nursing home level-of-care assignments.

A clear need currently exists to consider new approaches for classifying nursing home residents. The traditional intermediate care facility/skilled nursing facility (ICF/SNF) dichotomy cannot provide adequate information on the type of care required by any one individual, and it provides only the most limited information required to address the care and quality-of-life needs of the total patient population within a facility, as well as the level of reimbursement appropriate for their care. This article describes an alternative procedure for allocating nursing home residents according to a more comprehensive array of internally homogeneous categories. This system is based on an operational perspective focused on the total nursing and staffing requirements for types of nursing home residents. The tool is titled "Functionally Ranked Explanatory Designations," or FRED.     

Hospice Family Members' Perceptions of and Experiences With End-of-Life Care in the Nursing Home

Objective

Even though more than 25% of Americans die in nursing homes, end-of-life care has consistently been found to be less than adequate in this setting. Even for those residents on hospice, end-of-life care has been found to be problematic. This study had 2 research questions; (1) How do family members of hospice nursing home residents differ in their anxiety, depression, quality of life, social networks, perceptions of pain medication, and health compared with family members of community dwelling hospice patients? (2) What are family members’ perceptions of and experiences with end-of-life care in the nursing home setting?

Methods

This study is a secondary mixed methods analysis of interviews with family members of hospice nursing home residents and a comparative statistical analysis of standard outcome measures between family members of hospice patients in the nursing home and family members of hospice patients residing in the community.

Results

Outcome measures for family members of nursing home residents were compared (n = 176) with family members of community-dwelling hospice patients (n = 267). The family members of nursing home residents reported higher quality of life; however, levels of anxiety, depression, perceptions of pain medicine, and health were similar for hospice family members in the nursing home and in the community. Lending an understanding to the stress for hospice family members of nursing home residents, concerns were found with collaboration between the nursing home and the hospice, nursing home care that did not meet family expectations, communication problems, and resident care concerns including pain management. Some family members reported positive end-of-life care experiences in the nursing home setting.

Conclusion

These interviews identify a multitude of barriers to quality end-of-life care in the nursing home setting, and demonstrate that support for family members is an essential part of quality end-of-life care for residents. This study suggests that nursing homes should embrace the opportunity to demonstrate the value of family participation in the care-planning process.     

Implementing swing-bed services in small rural hospitals.

Since 1983, twenty-six small rural hospitals in five states have been developing models of the "swing-bed" concept as part of a coordinated national demonstration project. Based on the experiences of these hospitals, swing-bed programs use excess hospital capacity to provide short-term, post-acute care in rural communities where there are nursing home shortages, and, thus, help avoid the need for new nursing home construction. The availability of swing-bed services in rural hospitals has allowed the elderly patient to receive a full-range of long-term care services within the community to avoid transfer to a nursing home outside the community. Introduction of services also has improved patient care for all hospitalized elderly. Finally, the revenue from the swing-bed services has helped to stabilize small, rural hospitals faced with declining utilization. The demonstration has provided evidence that the swing-bed program has the potential to deliver a needed service to the rural elderly while contributing to the preservation of the small, rural hospital as a valuable community resource.     

An imperfect refuge: life in an 'old folk's home' for younger residents with psychiatric disorders

Residents under age 65 comprise a small, but not insignificant, segment of the US nursing home population--a segment about which very little is known. This article explores the meaningful constitution of nursing home experience among younger, psychiatrically disabled residents of an urban nursing home. Residents' "behavior problems", the difficulties imposed by institutional life, and American age norms emerged as key dynamics in residents' understandings of nursing home life. In addition to these factors, the nursing home was evaluated in relation to previous life experiences, perceived alternatives, and expectations of personal freedom. Ultimately, most younger residents found the nursing home to be a refuge, albeit an imperfect one.     

Estimating patient-level nursing home costs.

This article presents a methodology developed to estimate patient-level nursing home costs. Such estimates are difficult to obtain because most cost data for nursing homes are available from Medicare or Medicaid cost reports, which provide only average values per patient-day across all patients (or all of a particular payer's patients). The methodology presented in this article yields "resource consumption" (RC) measures of the variable cost of nursing staff care incurred in treating individual nursing home patients. Results from the application of the methodology are presented, using data collected in 1980 on a sample of 961 nursing home patients in 74 Colorado nursing homes. This type of approach could be used to link nursing home payments to the care needs of individual patients, thus improving the overall equity of the payment system and possibly reducing the access barriers facing especially Medicaid patients with high-cost care needs.     

Resident smoking in long-term care facilities--policies and ethics.

Objective: To characterize smoking behavior, facility policies related smoking, and administrators'' views of smoking-related problems in Veterans Affairs nursing home care units nationwide. Methods: An anonymous mail survey of long-term care facilities was administered to 106 nursing home supervisors at VA Medical Centers with nursing home care units. The response rate was 82%. Results: Administrators from 106 VA nursing home units reported smoking rates ranging from 5% to 80% of long-term care residents, with an average of 22%. Half of the nursing homes had indoor smoking areas. Frequent complaints from nonsmokers about passive smoke exposure were reported in 23% of the nursing homes. The nursing administrators reported that patient safety was their greatest concern. Seventy- eight percent ranked health effects to the smokers themselves a "major concern," while 70% put health effects to exposed nonsmokers in that category. Smoking in the nursing home was described as a "right" by 59% of respondents and a ¿privilege¿ by 67%. Some individuals reported that smoking was both a right and a privilege. Conclusion: Smoking is relatively common among VA long-term care patients. The promotion of personal autonomy and individual resident rights stressed in the Omnibus Budget Reconciliation Act of 1987 may conflict with administrative concerns about the safety of nursing home smokers and those around them.     

Measuring health related quality of life (HRQoL) in community and facility-based care settings with the interRAI assessment instruments: development of a crosswalk to HUI3

Background

Health-related quality of life (HRQoL) measures are of interest because they can be used to describe health of populations and represent a broader health outcome for population health analyses than mortality rates or life expectancy. The most widely used measure of HRQoL for deriving estimates of health-adjusted life expectancy is the Health Utilities Index Mark 3 (HUI3). The HUI3 is available in most national surveys administered by Statistics Canada, and has been used as part of a microsimulation model to examine the impact of neurological conditions over the life course. Persons receiving home care and nursing home services are often not well-represented in these surveys; however, interRAI assessment instruments are now used as part of normal clinical practice in these settings for nine Canadian provinces/territories. Building on previous research that developed a HUI2 crosswalk for the interRAI assessments, the present study examined a new interRAI HRQoL index crosswalked to the HUI3.

Methods

interRAI and survey data were used to examine the distributional properties of global and domain-specific interRAI HRQoL and HUI3 index scores, respectively. Three populations were considered: well-elderly persons not receiving home care, home care clients and nursing home residents.

Results

The mean HUI3 and interRAI HRQoL index global scores declined from independent healthy older persons to home care clients, followed by nursing home residents. For the home care and nursing home populations, the interRAI HRQoL global estimates tended to be lower than HUI3 global scores obtained from survey respondents. While there were some statistically significant age, sex and diagnostic group differences in global scores and within attributes, the most notable differences were between populations from different care settings.

Discussion

The present study provides strong evidence for the validity of the interRAI HRQoL based on comparisons of distributional properties with those obtained with survey data based on the HUI3. The results demonstrate the importance of admission criteria for home care and nursing home settings, where function plays a more important role than demographic or diagnostic criteria. The interRAI HRQoL has a distinct advantage because it is gathered as part of normal clinical practice in care settings where interRAI instruments are mandatory and are used to assess all eligible persons in those sectors. In particular, those with severe cognitive and functional impairments (who tend to be under-represented in survey data) will be evaluated using the interRAI tools. Future research should build on this work by providing direct, person-level comparisons of interRAI HRQoL index and HUI3 scores, as well as longitudinal analyses to examine responsiveness to change.

     

论“互联网+护理服务”中患方的法律风险与防控对策

互联网的快速发展给传统的护理行业带来了巨大的影响。作为新生事物,“互联网+护理服务”在新时期具有重要的现实意义,满足了特殊人群的护理需求。但是“互联网+护理服务”在发展的过程中给患者带来了一定的法律风险,应该以患者利益为基础,厘清“互联网+护理服务”中利益各方的责权利;健全相关法律法规,严格规定“互联网+护理服务”的行业标准;构建风险防范体系,完善风险处理应急机制;完善知情同意制度,保护患者隐私安全;完善相关配套制度,合理规范“互联网+护理服务”价格,促进“互联网+护理服务”健康发展,真正提供高质量的居家护理服务。     

Associations Between Psychiatric Inpatient Bed Supply and the Prevalence of Serious Mental Illness in Veterans Affairs Nursing Homes

Objectives. We assessed whether reductions in inpatient psychiatric beds resulted in transinstitutionalization to nursing home care of patients with serious mental illness (SMI) within the Veterans Health Administration (VHA).Methods. We assessed trends in national and site-level inpatient psychiatric beds and nursing home patient demographics, service use, and functioning from the VHA National Patient Care Database, VHA Service Support Center Bed Control, and VHA Minimum Data Set. We estimated nursing home admission appropriateness using propensity score analyses based on Michigan Medicaid Nursing Facility Level of Care Determinations ratings.Results. From 1999 to 2007, the number of VHA inpatient psychiatric beds declined (43 894–40 928), the average inpatient length of stay decreased (33.1–19.0 days), and the prevalence of SMI in nursing homes rose (29.4%–43.8%). At site level, psychiatric inpatient bed availability was unrelated to SMI prevalence in nursing home admissions. However, nursing home residents with SMI were more likely to be inappropriately admitted than were residents without SMI (4.0% vs 3.2%).Conclusions. These results suggest the need for increased attention to the long-term care needs of individuals with SMI. Additional steps need to be taken to ensure that patients with SMI are offered appropriate alternatives to nursing home care and receive adequate screening before admission to nursing home treatment.Over the past half century, the locus of psychiatric care has shifted from long-term inpatient psychiatric hospitals to community-based outpatient care settings,1 with this “deinstitutionalization” movement resulting in a sharp decline in state psychiatric hospital beds.2 This movement is regarded as a “disaster of the past,”3 in part because of the inadequacy of outpatient services to meet the needs of symptomatic psychiatric patients.3,4 In the absence of adequate community-based services, deinstitutionalization in name often resulted in transinstitutionalization in practice, as symptomatic patients were shifted to other institutional settings, such as general hospitals and nursing homes.1Research investigating transinstitutionalization has mixed results. A 3-year follow-up of patients discharged from a state psychiatric hospital found rates of more than 20% admission to community inpatient psychiatric units, with an average of more than 75 yearly inpatient days per patient.5 Similarly, a large-scale longitudinal evaluation of the Canadian mental health system found that reductions in inpatient psychiatric beds were associated with increased utilization of general hospital psychiatric beds, a pattern that continued for more than 2 decades until community mental health services expanded to meet the needs of psychiatric patients.6 However, another evaluation of discharged state psychiatric patients found decreased rates of postdischarge jail and general hospital psychiatric unit utilization relative to the use of these services during the time that patients received state psychiatric care.7There has been limited investigation into transinstitutionalization to community nursing home settings. The only large-scale study of transinstitutionalization to nursing home care was conducted in Norway, in which the effects of downsizing psychiatric hospitals were evaluated for more than 50 years. During the first 2 decades, there was evidence for transinstitutionalization because patients previously treated in state-run psychiatric facilities were enrolled in increasing numbers in nursing homes. Similar to the Canadian evaluation, this pattern continued until community-based mental health services evolved to meet the needs of these psychiatric patients, with transinstitutionalization to nursing home care ending by the early 1970s.8Many nursing homes are unable to offer the specialized treatment required by patients discharged from state mental hospitals.9 Concerns about such shortcomings led to the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). This legislation set guidelines for standardized mental health screening and treatment within nursing homes, with the goal of reducing inappropriate admissions and improving the care of patients with psychiatric conditions already enrolled in nursing home care. Although OBRA-87 had positive effects,10,11 it also has its shortcomings.12Despite OBRA-87, available data suggest that nursing homes continue to have sizeable proportions of residents with serious psychiatric disorders. In a study of more than 9000 Veterans Health Administration (VHA) nursing home residents, nearly one fifth of residents (17.9%) met criteria for serious mental illness (SMI).13 Similar levels of SMI prevalence were found in nursing home populations outside of the VHA.14,15 It is unclear at this time whether these patients were placed appropriately into nursing home care or inappropriately admitted in the absence of adequate inpatient psychiatric services.Reductions in psychiatric inpatient bed availability have continued in recent years. There has been a national reduction from 99 223 psychiatric beds in 1990 to 55 576 beds in 2009 within hospitals.16 Meanwhile, nursing home bed availability has increased. The number of available beds within skilled nursing homes increased from 512 107 in 1990 to more than 1.5 million in 2009.16Transinstitutionalization demonstrates the interconnectedness of institutional settings.17 To date, however, few studies assessed relationships between psychiatric inpatient and long-term care services in a single health system. Although transinstitutionalization to nursing homes was observed in previous decades, it is unclear whether these patterns continued in recent years. This study examined trends in psychiatric inpatient resources in the VHA health system, in association with VHA-funded nursing home care, which includes both VHA-owned nursing homes (which are today known as Community Living Centers) and VHA-contracted community nursing homes. To further evaluate the potential for transinstitutionalization between these settings, changes in the process of inpatient psychiatric care were tracked to evaluate evidence for unmet psychiatric needs. This study had 3 primary objectives: (1) to assess trends in VHA inpatient psychiatric beds from fiscal year 1999 (FY99) to FY07, (2) to assess relationships between changes in VHA inpatient psychiatric bed supply and the prevalence of SMI in VHA nursing home residents, and (3) to assess potential relationships between VHA psychiatric inpatient bed availability and the appropriateness of VHA nursing home admissions for patients with SMI.     

Caring for the infirm: a task for the individual or for a social insurance programme?

In West Germany, seventy per cent of all nursing home patients receive only a pocket-money, for social health insurances are responsible only for the care of "sick" people, but not of those needing only "care". The infirm individual, however, rarely can pay for the costs of nursing homes out of his own revenue. Despite general agreement that guarding against the financial risks of becoming dependent on nursing is insufficient there is little consensus on what a new concept should look like. Some proposals are more concerned with avoiding cost-expansion than with effective health care. On the one hand, the implementation of a new branch in the social insurance system, called "nursing insurance", is demanded, which would pay for the stay in nursing homes. On the other hand, it is emphasized that the capacity for voluntary individual provision should be strengthened as well as the families' means to care for their bedridden members. This paper presents the discussion and outlines implications for health care of the various proposals.     

Measuring the quality of care in nursing homes: a pilot study in Wisconsin

The traditional method of evaluating nursing homes, which relies on State and Federal regulations, does not ensure quality care for nursing home residents. This fact led the Wisconsin State Department of Health and Social Services to fund a project for the development of a system that would permit rapid and reliable assessment of the quality of care given by nursing homes, permit the identification of specific problem areas, and suggest whether more in-depth investigation was needed. A corner-stone in that system was to be a screening instrument that would quickly determine where the care delivery system in a nursing home was breaking down so that resources could be focused on these problem areas.Eleven quality of care criteria to be used in the screening instrument were drawn up by a panel of experts. The instrument itself was then tested in nine Wisconsin nursing homes. Five teams of people with nursing home expertise (two persons per team) used the screening instrument to evaluate each of the homes. Another team, visiting the same homes, used a second screening instrument based on State and Federal regulations to evaluate the homes. Finally, without relying on any survey instrument, all of the teams did a general assessment of the homes. The purpose of this general assessment was to ascertain if a "common wisdom" exists among experts in the field. The results of the teams' evaluations using both instruments were compared with each other, as well as with the results of the general assessments and the results of the most recent standard survey. This analysis showed that there was a significant amount of inter-team reliability among the teams using the new screening model and, also, that the new screening model correlated well with the general assessments.The model is being tested further in a 2-year study of 170 nursing homes in urban and rural parts of Wisconsin.     

Private Investment Purchase and Nursing Home Financial Health

Objective

To explore the impact of nursing home acquisition by private investment firms on nursing home costs, revenue, and overall financial health.

Data Sources

Merged data from the Medicare Cost Reports and the Online Survey, Certification, and Reporting system for the period 1998–2010.

Study Design

Regression specification incorporating facility and time fixed effects.

Principal Findings

We found little impact on the financial health of nursing homes following purchase by private investment companies. However, our findings did suggest that private investment firms acquired nursing home chains in good financial health, possibly to derive profit from the company’s real estate holdings.

Conclusions

Private investment acquired facilities are an important feature of today’s nursing home sector. Although we did not observe a negative impact on the financial health of nursing homes, this development raises important issues about ownership oversight and transparency for the entire nursing home sector.     

Cost and care models for acutely ill nursing home residents in Germany: the example of pneumonia

Background

Hospitalisation of acutely ill nursing home residents is associated with health risks such as infections, complications, or falls, and results in high costs for the health care system. Taking the case of pneumonia, nursing homes generally can ensure care according to guidelines.

Aim

Extrapolation of overall expenditures for the German statutory health insurance system from the hospitalisation of nursing home residents with respiratory infection/pneumonia; developing alternative cost scenarios to compare nursing home care with hospital care in consideration of patients’ condition.

Methods

Data provided by health insurance funds were extrapolated to the German statutory health insurance system and weighted via German-DRG case values. Care processes (hospital vs. nursing home) were modelled, and treatment steps were divided into cost categories. The patient’s condition was standardised via the Barthel Index.

Results

Total expenditures of € 163.3 million were incurred for inpatient care of nursing home residents transferred to hospitals for respiratory infection/pneumonia in 2013 in Germany. Process modelling reveals lower direct costs for nursing home care as well as better development of patients’ condition. Looking at operators of nursing homes, both care scenarios necessitate additional services without reimbursement.

Conclusion

Expenditure projections for the hospital care of nursing home residents with pneumonia reveal high saving potential. Avoidance of hospital admission serves to considerably reduce the insurers’ expenditures but also the duration and severity of illness. The study illustrates economic incentive structures for health care providers and indicates courses of action for health policy and nursing homes operators.

     

提高气管造瘘口患者家庭护理合格率

成立畅通圈,选定“提高气管造瘘口患者家庭护理合格率”为活动主题,制作查检表。调查得知气管造瘘口患者家庭护理合格率仅63.85%。确定目标值,解析影响气管造瘘口患者家庭护理合格率的原因,从制定护理指导清单、制作护理包、制作专用滴药器、建立微信公众平台等方面实施改进,使气管造瘘口患者家庭护理合格率提高至87.69%,减少了并发症发生率,提高了患者满意度。     

Medicaid Bed‐Hold Policies and Hospitalization of Long‐Stay Nursing Home Residents

Objective

To evaluate the effect of Medicaid bed-hold policies on hospitalization of long-stay nursing home residents.

Data Sources

A nationwide random sample of long-stay nursing home residents with data elements from Medicare claims and enrollment files, the Minimum Data Set, the Online Survey Certification and Reporting System, and Area Resource File. The sample consisted of 22,200,089 person-quarters from 754,592 individuals who became long-stay residents in 17,149 nursing homes over the period beginning January 1, 2000 through December 31, 2005.

Study Design

Linear regression models using a pre/post design adjusted for resident, nursing home, market, and state characteristics. Nursing home and year-quarter fixed effects were included to control for time-invariant facility influences and temporal trends associated with hospitalization of long-stay residents.

Principal Findings

Adoption of a Medicaid bed-hold policy was associated with an absolute increase of 0.493 percentage points (95% CI: 0.039–0.946) in hospitalizations of long-stay nursing home residents, representing a 3.883 percent relative increase over the baseline mean.

Conclusions

Medicaid bed-hold policies may increase the likelihood of hospitalization of long-stay nursing home residents and increase costs for the federal Medicare program.     

State-by-State Variation in the Number of Children and Young Adults in Nursing Homes, 2005–2012

Objectives One goal of Healthy People 2020 is to reduce the number of children and young adults living in nursing homes. However, little is known about the prevalence of nursing home use among children and young adults on a state-by-state basis. The objective of this study was to determine the prevalence of nursing home use among children and young adults in each state from 2005 to 2012. The study also looked for prevalence trends between 2005 and 2012. Methods The Centers for Medicare and Medicaid Services Minimum Data Set and US Census data were used to calculate the prevalence of nursing home residents among children and young adults aged 0–30 in each US state in 2012 and assess trends in each state from 2005 to 2012. Results In 2012, the prevalence of nursing home residents among children and young adults aged 0–30 varied across states, ranging from 14 in 100,000 (New Jersey) to 0.8 in 100,000 (Alaska). Testing for trends from 2005 to 2012 also revealed significant trends (p?<?0.05), with Florida trending upward with borderline statistical significance (p?=?0.05) and six states trending downward. Conclusion There is wide variation in the prevalence of nursing home residents among children and young adults aged 0–30 across states. There is also variation in the nursing home prevalence trends across states. Observed variations may represent potential opportunities for some states to reduce their population of children and young adults in nursing homes.     

Making the best of it: adapting to the ambivalence of a nursing home environment

This article is based on a 9-month ethnographic study of a nursing home for older Jewish people. In this article, the process that 21 key informants went through in adapting to the dual nature of the nursing home as institution and as home is examined. A widely used phrase, "making the best of it," was used by informants and other residents of the nursing home to describe this process. Interpretive analysis of this emic phrase revealed four dimensions: (a) recognizing the ambivalence of their living environment and situation, (b) downplaying negative aspects of it, (c) having no other options, and (d) using their will to transcend and create a home.