Factors Associated With Pain Assessment for Nursing Home Residents: A Systematic Review and Meta-Synthesis

ObjectivesThe burden of pain in nursing home residents is substantial; unfortunately, many times it goes undiagnosed and is inadequately treated. To improve identification of pain in this population, we aimed to review and synthesize findings from qualitative studies that report primary barriers and facilitators to pain assessment in nursing home residents.DesignThis is a Cochrane-style systematic review and narrative synthesis of qualitative evidence adhering to PRISMA guidelines. Databases were searched from inception to June 2018, supplemented by hand searching of references. We assessed the quality of included studies using the Critical Appraisal Skills Program Quality Appraisal Checklist.Setting and participantsWe included studies conducted in nursing homes. Studies focused on nursing home residents, nursing home staff, or both.MeasuresExtracted data were subject to thematic analyses and were collated and summarized into 3 groups: resident, health care provider, and health care system factors.ResultsThirty-one studies met our inclusion criteria. Resident factors had 3 subthemes: physical or cognitive impairments, attitudes and beliefs, and social/cultural/demographic characteristics. Health care provider factors had 3 subthemes: knowledge and skills, attitudes and beliefs, and social/cultural/demographic characteristics. Health care system-level factors had 3 subthemes: interpersonal factors, resources, and policy. Key barriers to pain assessment included the presence of resident cognitive impairment, health care providers' lack of knowledge, and the breakdown of communication across organizational hierarchies. Key facilitators to pain assessment included the identification of pain-related behaviors in residents, the experience and skills of health care providers, and establishing facility-level pain assessment protocols and guidelines.Conclusion and implicationsFindings from this review identify primary barriers and facilitators to pain assessment in nursing home residents, highlighting key considerations for stakeholders, including health care providers, and health care policy decision makers. These efforts have the potential to improve the identification of pain in residents, and may ultimately improve pain management and residents' quality of life.     

State Variation in Chronic Opioid Use in Long-Term Care Nursing Home Residents

ObjectivePolicies and regulations on opioid use have evolved from being primarily state-to federally based. We examined the trends and variation in chronic opioid use among states and nursing homes.DesignRetrospective cohort study.Setting and ParticipantsWe used the nursing home Minimum Data Set and Medicare claims from 2014 to 2018 and included long-term care nursing home residents from each year who had at least 120 days of consecutive stay.MeasurementsChronic opioid use was defined as use for ≥90 days. Three-level hierarchical logistic regression models (resident, nursing home, state) were constructed to estimate intraclass correlation coefficient (ICC) at the state level and at the nursing home level. The ICC shows the proportion of variation in chronic opioid use that is attributable to states or nursing homes. All models were constructed separately for each calendar year and controlled for resident, nursing home, and state characteristics.ResultsWe included 3,245,714 nursing home stays from 2014 to 2018, representing 1,502,131 unique residents. The stays ranged from 676,413 in 2014 to 594,874 in 2018, with residents contributing a maximum of 1 stay per year. Chronic opioid use among nursing home residents declined from 14.1% in 2014 to 11.4% in 2018. The variation (ICC) in chronic opioid use among states declined from 2.5% in 2014 to 1.7% in 2018. In contrast, the variation (ICC) among nursing homes increased from 5.6% in 2014 to 6.5% in 2018.Conclusions and ImplicationsVariation in chronic opioid use declined by one-third at the state level but not at the nursing home level. National guidelines on opioid use and federal policies on opioid use may have contributed to reducing state-level variation in chronic opioid use.     

Do Patients in Dutch Nursing Homes Have More Pressure Ulcers Than Patients in German Nursing Homes? A Prospective Multicenter Cohort Study

ObjectivesTo investigate whether the incidence of pressure ulcers in nursing homes in the Netherlands and Germany differs and, if so, to identify resident-related risk factors, nursing-related interventions, and structural factors associated with pressure ulcer development in nursing home residents.DesignA prospective multicenter cohort study.SettingTen nursing homes in the Netherlands and 11 nursing homes in Germany (around Berlin and Brandenburg).ParticipantsA total of 547 newly admitted nursing home residents, of which 240 were Dutch and 307 were German. Residents had an expected length of stay of 12 weeks or longer.MeasurementsData were collected for each resident over a 12-week period and included resident characteristics (eg, demographics, medical history, Braden scale scores, nutritional factors), pressure ulcer prevention and treatment characteristics, staffing ratios and other structural nursing home characteristics, and outcome (pressure ulcer development during the study). Data were obtained by trained research assistants.ResultsA significantly higher pressure ulcer incidence rate was found for the Dutch nursing homes (33.3%) compared with the German nursing homes (14.3%). Six factors that explain the difference in pressure ulcer incidence rates were identified: dementia, analgesics use, the use of transfer aids, repositioning the residents, the availability of a tissue viability nurse on the ward, and regular internal quality controls in the nursing home.ConclusionThe pressure ulcer incidence was significantly higher in Dutch nursing homes than in German nursing homes. Factors related to residents, nursing care and structure explain this difference in incidence rates. Continuous attention to pressure ulcer care is important for all health care settings and countries, but Dutch nursing homes especially should pay more attention to repositioning residents, the necessity and correct use of transfer aids, the necessity of analgesics use, the tasks of the tissue viability nurse, and the performance of regular internal quality controls.     

Predictors of hospitalization in Italian nursing home residents: the U.L.I.S.S.E. project

ObjectiveTo examine resident and facility characteristics associated with hospitalization in a cohort of Italian older nursing home residents.DesignA longitudinal observational study.SettingThe nursing homes participating in the U.L.I.S.S.E. study, a project evaluating the quality of care for older persons in Italy.Setting ParticipantsNursing home residents in 31 Italian nursing homes.MeasurementEach resident underwent a comprehensive geriatric assessment at baseline, and after 6 months and 1 year by means of the RAI MDS 2.0. Facility characteristics were collected using an ad hoc designed questionnaire. Hospitalizations were self-reported by facilities.ResultsA total of 170 (11.6%) of 1466 nursing home residents were admitted to the hospital at least once during the study period. Female gender and higher physician, nurse, and nursing assistant hours per resident were predictive of a lower probability to be admitted to the hospital, whereas a diagnosis of arrhythmia, a previous urinary tract infection, and polypharmacy were associated with a higher probability of being hospitalized.ConclusionThese findings suggest that a reduction of hospitalization of nursing home residents could be achieved by providing an adequate amount of care and optimizing the management of chronic diseases and polypharmacy. This hypothesis should be tested in future clinical trials.     

Geographic Variation in Anticoagulant Use and Resident,Nursing Home,and County Characteristics Associated With Treatment Among US Nursing Home Residents

ObjectivesTo quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population.DesignA repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016.Setting and ParticipantsSecondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded.MethodsMultilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated.ResultsAmong 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation.Conclusions and ImplicationsIn this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.     

The Development and Test of an Intervention to Improve ADR Screening in Nursing Homes

ObjectivesThe aim of this study was to develop and test the effect of an instrument, Pharmanurse, to facilitate nurse-driven adverse drug reaction (ADR) screening as an input for interdisciplinary medication review in nursing homes.DesignIntervention study with a pre-posttest designParticipantsAll residents of a convenience sample of 8 nursing homes of more than 80 beds were eligible if they resided at least 1 month in the nursing home and took 4 or more different medications. Residents receiving palliative care were excluded.InterventionThe intervention consisted of interdisciplinary medication review, prepared by nurse observations of potential ADRs using personalized screening lists generated by the Pharmanurse software. Pharmanurse is specifically adapted to use by nurses and to use in nursing homes.MeasurementsOutcome parameters were the number of ADRs detected by nurses, ADRs confirmed by general practitioners, and medication changes. After the intervention, health care professionals involved completed a questionnaire to evaluate the value and the feasibility of the intervention.ResultsNurses observed 1527 potential ADRs in 81% of the 418 residents (mean per resident 3.7). Physicians confirmed 821 ADRs in 60% of the residents (mean per resident 2.0). As a result, 214 medication changes were planned in 21% of the residents (mean per resident 0.5) because of ADRs. Health care professionals gave the Pharmanurse intervention a score of 7 of 10 for the potential to improve pharmacotherapy and 83% of the physicians were satisfied about nurses' screening for ADRs.ConclusionsThe Pharmanurse intervention supports nurses in ADR screening and may have the potential to improve pharmacotherapy.     

Physician Availability in Long-Term Care and Resident Hospital Transfer: A Retrospective Cohort Study

ObjectivesTo investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations.DesignRetrospective cohort study.Setting and participants161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes.MethodsWe administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death.We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access.ResultsFifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED.The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P = .02) and 14% lower (rate ratio = 0.86, P = .07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access.Conclusions and implicationsResidents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates.     

Continuous Palliative Sedation Until Death: The Development of a Practice Protocol for Nursing Homes

ObjectivesChallenges inherent in the practice of continuous palliative sedation until death appear to be particularly pervasive in nursing homes. We aimed to develop a protocol to improve the quality of the practice in Belgian nursing homes.MethodsThe development of the protocol was based on the Medical Research Council Framework and made use of the findings of a systematic review of existing improvement initiatives and focus groups with 71 health care professionals [palliative care physicians, general practitioners (GPs), and nursing home staff] identifying perceived barriers to the use of continuous palliative sedation until death in nursing homes. The protocol was then reviewed and refined by another 70 health care professionals (palliative care physicians, geriatricians, GPs, and nursing home staff) through 10 expert panels.ResultsThe final protocol was signed off by expert panels after 2 consultation rounds in which the remaining issues were ironed out. The protocol encompassed 7 sequential steps and is primarily focused on clarification of the medical and social situation, communication with all care providers involved and with the resident and/or relatives, the organization of care, the actual performance of continuous sedation, and the supporting of relatives and care providers during and after the procedure. Although consistent with existing guidelines, our protocol describes more comprehensively recommendations about coordination and collaboration practices in nursing homes as well as specific matters such as how to communicate with fellow residents and give them the opportunity to say goodbye in some way to the person who is dying.Conclusions and ImplicationsThis study succeeded in developing a practice protocol for continuous palliative sedation until death adapted to the specific context of nursing homes. Before implementing it, future research should focus on developing profound implementation strategies and on thoroughly evaluating its effectiveness.     

Staffing Shortages,Staffing Hours,and Resident Deaths in US Nursing Homes During the COVID-19 Pandemic

ObjectivesStaffing shortages at nursing homes during the COVID-19 pandemic may have impacted care providers' staffing hours and affected residents’ care and outcomes. This study examines the association of staffing shortages with staffing hours and resident deaths in nursing homes during the COVID-19 pandemic.DesignThis study measured staffing hours per resident using payroll data and measured weekly resident deaths and staffing shortages using the Centers for Disease Control and Prevention's National Healthcare Safety Network data. Multivariate linear regressions with facility and county-week fixed effects were used to investigate the association of staffing shortages with staffing hours and resident deaths.Setting and Participants15,212 nursing homes.MeasuresThe primary outcomes included staffing hours per resident of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) and weekly total deaths per 100 residents.ResultsBetween May 31, 2020, and May 15, 2022, 18.4% to 33.3% of nursing homes reported staffing shortages during any week. Staffing shortages were associated with lower staffing hours per resident with a 0.009 decrease in RN hours per resident (95% CI 0.005-0.014), a 0.014 decrease in LPN hours per resident (95% CI 0.010-0.018), and a 0.050 decrease in CNA hours per resident (95% CI 0.043-0.057). These are equivalent to a 1.8%, 1.7%, and 2.4% decline, respectively. There was a positive association between staffing shortages and resident deaths with 0.068 (95% CI 0.048-0.088) total deaths per 100 residents. This was equivalent to an increase of 10.5%.Conclusion and ImplicationsOur results showed that self-reported staffing shortages were associated with a statistically significant decrease in staffing hours and with a statistically significant increase in resident deaths. These results suggest that addressing staffing shortages in nursing homes can save lives.     

Autonomy Support of Nursing Home Residents With Dementia in Staff-Resident Interactions: Observations of Care

ObjectivesPeople with dementia living in nursing homes benefit from a social environment that fully supports their autonomy. Yet, it is unknown to what extent this is supported in daily practice. This study aimed to explore to which extent autonomy is supported within staff–resident interactions.DesignAn exploratory, cross-sectional study.Setting and ParticipantsIn total, interactions between 57 nursing home residents with dementia and staff from 9 different psychogeriatric wards in the Netherlands were observed.MethodsStructured observations were carried out to assess the support of resident autonomy within staff–resident interactions. Observations were performed during morning care and consisted of 4 main categories: getting up, physical care, physical appearance, and breakfast. For each morning care activity, the observers consecutively scored who initiated the care activity, how staff facilitated autonomy, how residents responded to staff, and how staff reacted to residents’ responses. Each resident was observed during 3 different mornings. In addition, qualitative field notes were taken to include environment and ambience.ResultsIn total, 1770 care interactions were observed. Results show that autonomy seemed to be supported by staff in 60% of the interactions. However, missed opportunities to engage residents in choice were frequently observed. These mainly seem to occur during interactions in which staff members took over tasks and seemed insensitive to residents’ needs and wishes. Differences between staff approach, working procedures, and physical environment were observed across nursing home locations.Conclusions and ImplicationsThe findings of this study indicate that staff members support resident autonomy in more than one-half of the cases during care interactions. Nonetheless, improvements are needed to support resident autonomy. Staff should be encouraged to share and increase knowledge in dementia care to better address residents’ individual needs. Especially for residents with severe dementia, it seems important that staff develop skills to support their autonomy.     

Structural and process indicators of nutritional care: a comparison between Austrian hospitals and nursing homes

ObjectiveThe aim of this study was to describe and compare structural and process indicators of nutritional care in Austrian hospitals and nursing homes.MethodsA multicenter, cross-sectional study was performed using a standardized and tested questionnaire. Data were collected on patient and institutional levels of hospitals and nursing homes.ResultsData from 18 Austrian hospitals (n = 2326 patients) and 18 Austrian nursing homes (n = 1487 residents) were collected. The prevalence of malnutrition was 23.2% in hospitals and 26.2% in nursing homes. All hospitals and 83.3% of the nursing homes employed dietitians. Guidelines for the prevention and treatment of malnutrition were used infrequently. Nutritional screening at admission was performed in 62.6% of the hospitalized patients and 93.4% of the nursing home residents. Nutritional screening tools were used in 28.9% of the nursing home residents and 14.5% of the hospitalized patients. Oral nutritional support was preferred to enteral and parenteral nutrition in the two settings. Dietitians were consulted in 27.5% of the malnourished hospitalized patients and 74.7% of the malnourished nursing home residents.ConclusionThe study demonstrated that nursing homes fulfilled more structural indicators and performed nutritional screening at admission more often than hospitals. Nevertheless, the prevalence of malnutrition was high in the two settings and a substantial number of malnourished patients/residents received no nutritional intervention at all. These results show the necessity for improvements in the nutritional care in Austria, for instance, through the routine use of nutritional screening tools followed by tailored nutritional interventions in patients/residents in need.     

Racial inequities in receipt of influenza vaccination among nursing home residents in the United States, 2008-2009: a pattern of low overall coverage in facilities in which most residents are black

ObjectivesNationwide among nursing home residents, receipt of the influenza vaccine is 8 to 9 percentage points lower among blacks than among whites. The objective of this study was to determine if the national inequity in vaccination is because of the characteristics of facilities and/or residents.DesignCross-sectional study with multilevel modeling.Setting and ParticipantsStates in which 1% or more of nursing home residents were black and the difference in influenza vaccination coverage between white and black nursing home residents was 1 percentage point or higher (n = 39 states and the District of Columbia). Data on residents (n = 2,359,321) were obtained from the Centers for Medicare &; Medicaid Service’s Minimum Data Set for October 1, 2008, through March 31, 2009.MeasurementsResidents’ influenza vaccination status (vaccinated, refused vaccine, or not offered vaccination).ResultsStates with higher overall influenza vaccination coverage among nursing home residents had smaller racial inequities. In nursing homes with higher proportions of black residents, vaccination coverage was lower for both blacks and whites. The most dramatic inequities existed between whites in nursing homes with 0% blacks (L1) and blacks in nursing homes with 50% or more blacks (L5) in states with overall racial inequities of 10 percentage points or more. In these states, more black nursing home residents lived in nursing homes with 50% or more blacks (L5); in general, the same homes with low overall coverage.ConclusionInequities in influenza vaccination coverage among nursing home residents are largely because of low vaccination coverage in nursing homes with a high proportion of black residents. Findings indicate that implementation of culturally appropriate interventions to increase vaccination in facilities with larger proportions of black residents may reduce the racial gap in influenza vaccination as well as increase overall state-level vaccination.     

Institutional Factors Associated with Residents’ Malnutrition in Nursing Homes: A Cross-Sectional Study

ObjectivesMalnutrition is frequent in older adults, associated with increased morbidity, mortality, and higher costs. Nursing home residents are especially affected, and evidence on institutional factors associated with malnutrition is limited. We calculated the prevalence of malnutrition in Swiss nursing home residents and investigated which structure and process indicators of nursing homes are associated with residents’ malnutrition.DesignSubanalysis of the Swiss Nursing Homes Human Resources Project 2018, a multicenter, cross-sectional study conducted from 2018 to 2019 in Switzerland.Setting and ParticipantsThis study included 76 nursing homes with a total of 5047 residents.MethodsMalnutrition was defined as a loss of bodyweight of ≥5% in the last 30 days or ≥10% in the last 180 days. Binomial generalized estimating equations (GEE) were applied to examine the association between malnutrition and structural (staffing ratio, grade mix, presence of a dietician, malnutrition guideline, support during mealtimes) and process indicators (awareness of malnutrition, food administration process). GEE models were adjusted for institutional (profit status, facility size) and specific resident characteristics.ResultsThe prevalence of residents with malnutrition was 5%. A higher percentage of units per nursing home having a guideline on prevention and treatment of malnutrition was significantly associated with more residents with weight loss (OR 2.47, 95% CI 1.31-4.66, P = .005). Not having a dietician in a nursing home was significantly associated with a higher rate of residents with weight loss (OR 1.60, 95% CI 1.09-2.35, P = .016).Conclusions and ImplicationsHaving a dietician as part of a multidisciplinary team in a nursing home is an important step to address the problem of residents’ malnutrition. Further research is needed to clarify the role of a guideline on prevention and treatment of malnutrition to improve the quality of care in nursing homes.     

A Longitudinal,Clinical, and Spatial Epidemiologic Analysis of a Large COVID-19 Long-Term Care Home Outbreak

ObjectivesCOVID-19 has had devastating effects on long-term care homes across much of the world, and especially within Canada, with more than 50% of the mortality from COVID-19 in 2020 in these homes. Understanding the way in which the virus spreads within these homes is critical to preventing further outbreaks.DesignRetrospective chart review.Settings and ParticipantsLong-term care home residents and staff in Ontario, Canada.MethodsWe conducted a longitudinal study of a large long-term care home COVID-19 outbreak in Ontario, Canada, using electronic medical records, public health records, staff assignments, and resident room locations to spatially map the outbreak through the facility.ResultsBy analyzing the outbreak longitudinally, we were able to draw 3 important conclusions: (1) 84.5% had typical COVID-19 symptoms and only 15.5% of residents had asymptomatic infection; (2) there was a high attack rate of 85.8%, which appeared to be explained by a high degree of interconnectedness within the home exacerbated by staffing shortages; and (3) clustering of infections within multibedded rooms was common.Conclusion and ImplicationsLow rates of asymptomatic infection suggest that symptom-based screening in residents remains very important for detecting outbreaks, a high degree of interconnectedness explains the high attack rate, and there is a need for improved guidance for homes with multibedded rooms on optimizing resident room movement to mitigate spread of COVID-19 in long-term care homes.     

The Adverse Effects of the COVID-19 Pandemic on Nursing Home Resident Well-Being

ObjectiveQuantify the effects of the COVID-19 pandemic on nursing home resident well-being.DesignQuantitative analysis of resident-level assessment data.Setting and participantsLong-stay residents living in Connecticut nursing homes.MethodsWe used Minimum Data Set assessments to measure nursing home resident outcomes observed in each week between March and July 2020 for long-stay residents (eg, those in the nursing home for at least 100 days) who lived in a nursing home at the beginning of the pandemic. We compared outcomes to those observed at the beginning of the pandemic, controlling for both resident characteristics and patterns for outcomes observed in 2017-2019.ResultsWe found that nursing home resident outcomes worsened on a broad array of measures. The prevalence of depressive symptoms increased by 6 percentage points relative to before the pandemic in the beginning of March—representing a 15% increase. The share of residents with unplanned substantial weight loss also increased by 6 percentage points relative to the beginning of March—representing a 150% increase. We also found significant increases in episodes of incontinence (4 percentage points) and significant reductions in cognitive functioning. Our findings suggest that loneliness and isolation play an important role. Though unplanned substantial weight loss was greatest for those who contracted COVID-19 (about 10% of residents observed in each week), residents who did not contract COVID-19 also physically deteriorated (about 7.5% of residents in each week).Conclusions and ImplicationsThese analyses show that the pandemic had substantial impacts on nursing home residents beyond what can be quantified by cases and deaths, adversely affecting the physical and emotional well-being of residents. Future policy changes to limit the spread of COVID-19 or other infectious disease outbreaks should consider any additional costs beyond the direct effects of morbidity and mortality due to COVID-19.     

Hospice in the Nursing Home: Perspectives of Front Line Nursing Home Staff

ObjectiveUse of hospice has been associated with improved outcomes for nursing home residents and attitudes of nursing home staff toward hospice influences hospice referral. The objective of this study is to describe attitudes of certified nursing assistants (CNAs), nurses, and social workers toward hospice care in nursing homes.Design, setting, and participantsWe conducted a survey of 1859 staff from 52 Indiana nursing homes.MeasurementsStudy data include responses to 6 scaled questions and 3 open-ended qualitative prompts. In addition, respondents who cared for a resident on hospice in the nursing home were asked how often hospice: (1) makes their job easier; (2) is responsive when a patient has symptoms or is actively dying; (3) makes care coordination smooth; (4) is needed; (5) taught them something; and (6) is appreciated by patients/families. Responses were dichotomized as always/often or sometimes/never.ResultsA total of 1229 surveys met criteria for inclusion. Of the respondents, 48% were CNAs, 49% were nurses, and 3% were social workers; 83% reported caring for a nursing home patient on hospice. The statement with the highest proportion of always/often rating was ‘patient/family appreciate added care’ (84%); the lowest was ‘hospice makes my job easier’ (54%). More social workers responded favorably regarding hospice responsiveness and coordination of care compared with CNAs (P = .03 and P = .05, respectively).ConclusionsA majority of staff responded favorably regarding hospice care in nursing homes. About one-third of nursing home staff rated coordination of care lower than other aspects, and many qualitative comments highlighted examples of when hospice was not responsive to patient needs, representing important opportunities for improvement.     

Hospital Influenza Admissions as a Harbinger for Nursing Home Influenza Cases

ObjectivesTo determine temporal associations of local measures of influenza morbidity and mortality by the Centers for Disease Control and Prevention (CDC) with influenza hospitalizations in nursing home residents.DesignRetrospective, longitudinal panel study.Setting and participantsLong-stay nursing home residents, aged 65 years or older in 823 nursing homes from 2011 to 2015.MeasuresCDC-reported rates of influenza and pneumonia mortality and laboratory-confirmed influenza hospitalizations. We compared the CDC measures to nursing home resident hospitalizations due to (1) all-cause, (2) a primary diagnosis of respiratory or circulatory illness, and (3) a primary diagnosis of pneumonia or influenza based on Medicare Part A Claims data.ResultsOur final sample included 273,743 unique residents in 819 nursing homes in 108 cities. National laboratory-confirmed influenza-associated hospitalizations for the group aged 65 and older occurred 0 to 1 week prior to nursing home resident influenza-related hospitalizations (Spearman ρ = 0.54). CDC-reported influenza hospitalizations occurred 3 weeks prior to CDC-reported influenza deaths (ρ = 0.59). Nursing home resident influenza hospitalizations occurred 2 weeks before local CDC-reported pneumonia and influenza deaths occurred (ρ = 0.44).Conclusions/implicationsPublicly reported CDC measures correlate well with nursing home hospitalizations for pneumonia and influenza. Rates of laboratory-confirmed influenza hospitalizations (as reported by the CDC) may be a useful surrogate for nursing home influenza outbreaks but should be considered along with local indicators of disease outbreaks. Early community signals could be clinically leveraged as a trigger for increased infection control measures in nursing homes.     

Reducing potentially preventable hospital transfers: results from a thirty nursing home collaborative

BackgroundNursing home (NH) residents experience frequent hospital transfers, some potentially avoidable. The objective of this report is to describe a replication of the Interventions to Reduce Acute Care Transfers program among member facilities of a New York City area NH provider association (INTERACT NY) and estimate its effect on hospital transfers.MethodsINTERACT is a program that provides tools and strategies to assist NH staff in early identification, communication, and documentation of changes in resident status. Funding was obtained from a New York State health workforce training grant to conduct 13 INTERACT education and training sessions in 2010–2011. INTERACT NY session topics included the implementation process; use of its simple standardized communication tools, advance care planning tools, care paths, and change in condition support tools; quality review of hospital transfers; exercises for refining clinical skills; teamwork; and lessons learned. Sessions engaged NH executives, department heads, front-line nursing staff and their labor union, and staff from NHs’ partner hospitals. Pre-/post- INTERACT NY hospitalization rates per 1000-resident days were compared using paired t-tests, stratified by level of facility engagement with the program and by baseline hospitalization rates.ResultsAll 100% of participating NHs were non-profit or public. Those with complete evaluation data had 377 beds on average. There were a total of 333 attendees of the program (mean 25.6 per session; mean 11.1 per facility over the course of the program; range 1–44 per facility). The most common attendees in order of frequency were (1) nurse administrators, (2) unit-based nurses, (3) medical directors and attending physicians, (4) nursing home administrators, (5) certified nursing assistants, and (6) case managers and social workers. Sixteen nursing homes implemented at least one INTERACT tool. Overall, there was a nonsignificant 10.6% reduction in hospital admissions from 4.07 to 3.64 per 1000 resident-days from pre- to post-INTERACT NY (P = .332). Among nursing homes with high engagement there was a nonsignificant 14.3% reduction in hospital admissions from 4.19 to 3.59 per 1000 resident-days (P = 0.213). Finally, among nursing homes in the highest tertile of baseline (pre-INTERACT NY) hospital admission rate, there was a nonsignificant 27.2% reduction in hospital admissions from 7.32 to 5.33 per 1000 resident-days (P = .102). Planning and implementation lessons from INTERACT NY leaders and participants are reported.ConclusionsINTERACT NY, a novel collaborative training program, resulted in good uptake of the INTERACT tools and processes among its member nursing homes. Changes in hospitalization rates associated with INTERACT NY were similar to those observed in previous implementations of INTERACT. The program addresses a growing interest in reducing potentially preventable hospital admissions among nursing home residents and providing alternatives to hospital care through standardized approaches to communication, early identification of clinical issues, decision-support, and support for partnerships between acute and post-acute care providers.     

Successfully Reducing Hospitalizations of Nursing Home Residents: Results of the Missouri Quality Initiative

Purpose

The goals of the Missouri Quality Initiative (MOQI) for long-stay nursing home residents were to reduce the frequency of avoidable hospital admissions and readmissions, improve resident health outcomes, improve the process of transitioning between inpatient hospitals and nursing facilities, and reduce overall healthcare spending without restricting access to care or choice of providers. The MOQI was one of 7 program sites in the United States, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services (CMS) Innovations Center.