Implementation of the Resident Assessment Instrument: A Canadian Experience

As the population ages, the increasing number and complexity of needs of individuals requiring institutionalization will increase the demands for chronic care services. In this article, the authors describe the implementation process used to introduce interdisciplinary staff to the use of the Minimum Data Set (MDS) for assessment of both nursing home and chronic care residents. This screening tool assesses resident characteristics over a wide spectrum of dimensions. The assessment findings are then integrated into the clinical plan of care.     

High-performing and low-performing nursing homes: a view from complexity science

BACKGROUND: There continues to be concern for the quality of care and quality of life for nursing home residents. Some scientists have turned their attention to viewing nursing homes as complex adaptive systems to inform our understanding of organizational performance. PURPOSE: The purpose of this study was to describe the working conditions in four nursing homes-two high performing and two low performing-through the lens of complexity science theory. METHODS: A qualitative case study approach was used to examine four nursing homes. Extreme case examples-high- and low-performing nursing homes-were purposefully selected. More than 100 hr of observation, 70 formal interviews, numerous informal interviews, and document review were the primary data collection methods. FINDINGS: Using select complexity science principles added richness to the analysis, highlighting the stark contrast between the high- and low-performing nursing homes. Leaders in the high-performing homes behaved congruently with the nursing home's stated and lived mission by fostering connectivity among staff, ample information flow, and the use of cognitive diversity. In contrast, leadership in low-performing homes behaved disharmoniously with the stated mission, which confused and eroded trust and relationships among staff members, contributed to poor communication, and fostered role isolation and discontinuity in resident care. PRACTICE IMPLICATIONS: The study offers insights into the importance of mission- and values-based leadership behaviors, suggesting that an overuse of mechanistic, linear command-and-control approaches to improving care, such as punitive measures to insist on regulatory compliance, will do little to ultimately improve care. Rather, relationship-centered leadership that embraces co-management and mutual shaping of resident care complements doing the right thing for residents from a values-based shared experience. Examples of practice implications include developing a strong, coherent organizational mission; having fewer, more flexible rules to foster creativity; and allowing lateral decision making.     

Relationship of nursing home staffing to quality of care

OBJECTIVE: To compare nursing homes (NHs) that report different staffing statistics on quality of care. DATA SOURCES: Staffing information generated by California NHs on state cost reports and during onsite interviews. Data independently collected by research staff describing quality of care related to 27 care processes. STUDY DESIGN: Two groups of NHs (n=21) that reported significantly different and stable staffing data from all data sources were compared on quality of care measures. DATA COLLECTION: Direct observation, resident and staff interview, and chart abstraction methods. PRINCIPAL FINDINGS: Staff in the highest staffed homes (n=6), according to state cost reports, reported significantly lower resident care loads during onsite interviews across day and evening shifts (7.6 residents per nurse aide [NA]) compared to the remaining homes that reported between 9 to 10 residents per NA (n=15). The highest-staffed homes performed significantly better on 13 of 16 care processes implemented by NAs compared to lower-staffed homes. CONCLUSION: The highest-staffed NHs reported significantly lower resident care loads on all staffing reports and provided better care than all other homes.     

Challenges of Using Quality Improvement Methods in Nursing Homes that “Need Improvement”

ObjectivesQualitatively describe the adoption of strategies and challenges experienced by intervention facilities participating in a study targeted to improve quality of care in nursing homes “in need of improvement”. To describe how staff use federal quality indicator/quality measure (QI/QM) scores and reports, quality improvement methods and activities, and how staff supported and sustained the changes recommended by their quality improvement teams.Design/setting/participantsA randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes in facilities in “need of improvement”. Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality-improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making.ResultsA qualitative analysis revealed a subgroup of homes likely to continue quality improvement activities and readiness indicators of homes likely to improve: (1) a leadership team (nursing home administrator, director of nurses) interested in learning how to use their federal QI/QM reports as a foundation for improving resident care and outcomes; (2) one of the leaders to be a “change champion” and make sure that current QI/QM reports are consistently printed and shared monthly with each nursing unit; (3) leaders willing to involve all staff in the facility in educational activities to learn about the QI/QM process and the reports that show how their facility compares with others in the state and nation; (4) leaders willing to plan and continuously educate new staff about the MDS and federal QI/QM reports and how to do quality improvement activities; (5) leaders willing to continuously involve all staff in quality improvement committee and team activities so they “own” the process and are responsible for change.ConclusionsResults of this qualitative analysis can help allocate expert nurse time to facilities that are actually ready to improve. Wide-spread adoption of this intervention is feasible and could be enabled by nursing home medical directors in collaborative practice with advanced practice nurses.     

Conceptualization of a Toolkit to Evaluate Everyday Competence in Planning Transitions From Nursing Homes to the Community

Living independently in the community is a primary goal for older adults, particularly for the estimated 10% to 20% of long-stay nursing home residents who have low care requirements. According to the model of person-environment fit, individuals with high levels of everyday competence have the ability to solve problems associated with everyday life. Nursing home residents with high levels of everyday competence and low care needs have poor person-environment fit, placing them at risk for declines in function, maladaptive behavior, and affective disorders. The goal of this article is to present a framework for the integration of everyday competence with standardized goal-setting and care-planning processes to enable the transition of appropriate nursing home residents back to the community. Barriers to community transitions exist across several Key Domains: rehabilitation, personal assistance and services, caregiver support, finances, housing, and transportation. We propose a research agenda to develop and implement a toolkit based on this framework that nursing home staff can use to overcome barriers to transition by (1) assessing residents' everyday competence, (2) developing personally meaningful goals that facilitate transition, and (3) conducting structured care planning to support resident goals around returning to the community. If successful, this toolkit has the potential to reduce costs associated with nursing home care and to improve functional health, psychological well-being, and quality of life for older adults. The proposed framework and toolkit complement national efforts focused on transitioning nursing home residents back into the community.     

The Influence of Teams to Sustain Quality Improvement in Nursing Homes that “Need Improvement”

ObjectivesQualitatively describe the use of team and group processes in intervention facilities participating in a study targeted to improve quality of care in nursing homes “in need of improvement.”Design/setting/participantsA randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes. Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making.ResultsThe qualitative analysis revealed a subgroup of homes (“Full Adopters”) likely to continue quality improvement activities that were able to effectively use teams. “Full Adopters” had either the nursing home administrator or director of nursing who supported and were actively involved in the quality improvement work of the team. “Full Adopters” also selected care topics for the focus of their quality improvement team, instead of “communication” topics of the “Partial Adopters” or “Non-Adopters” in the study who were identified as unlikely to continue to continue quality improvement activities after the intervention. “Full Adopters” had evidence of the key elements of complexity science: information flow, cognitive diversity, and positive relationships among staff; this evidence was lacking in other subgroups. All subgroups were able to recruit interdisciplinary teams, but only those that involved leaders were likely to be effective and sustain team efforts at quality improvement of care delivery systems.ConclusionsResults of this qualitative analysis can help leaders and medical directors use the key elements and promote information flow among staff, residents, and families; be inclusive as discussions about care delivery, making sure diverse points of view are included; and help build positive relationships among all those living and working in the nursing home. Wide-spread adoption of the intervention in the randomized study is feasible and could be enabled by nursing home Medical Directors in collaborative practice with Advanced Practice Nurses.     

Implementation of best practice in advance care planning in an 'ageing in place' aged care facility

Background For many older people, a residential aged care facility is home, a place where they should have the choice to die comfortably with a sense of control of care and treatment. An advance care plan describes the process of planning end-of-life care while a person is still able to make decisions with the aim of using this information should a person become unable to communicate their wishes. In the residential aged care setting, an advance care plan should be based on discussions involving the resident, family members and caregivers regarding the beliefs, values and goals of the resident and their family. It is not limited to the final days and weeks before dying, it can encompass a positive and open attitude towards death and dying. Aim The aim of this project was to examine the process of how residents' end-of-life care wishes is recorded and to ensure that the implementation of an advance care plan is performed according to the best available evidence. Method There were four stages to the project. The first stage involved interpretation of the five audit criteria. The criteria related to involving residents and their families in an advance care plan, providing them with appropriate information about end-of-life issues, and ensuring that staff are appropriately trained about an advance care plan. Next, the records of staff and resident were audited using JBI-PACES, the Joanna Briggs Institute's Practical Application of Clinical Evidence System. The next stage (Getting Research into Practice, GRIP) involved a process of situational analysis, action planning and action taking to improve compliance with best practice, followed by a post-implementation audit. Results Initially, compliance with an advance care plan best practice was fairly poor - less than 50% for each audit criterion. The GRIP phase highlighted seven barriers which were addressed during the implementation part of the project. These barriers included deficits related to the knowledge and education of residents, families and staff members, and issues related to administration and documentation, and concerns that any implementation process would not be sustainable. The post-implementation compliance was greater than 75% for each criterion. Conclusion The project highlights the ongoing challenges of educating residents and families, as well as staff on the importance of discussing/completing an advance care plan. Several improvements were made to the facility's documentation and records keeping processes, including the identification of resident's wishes regarding end-of-life treatment. Residents and their families expressed a high level of satisfaction with these changes. Indeed, an increase in completed advance care plans at the facility had a clear benefit in improving care for residents towards the end of their life.     

Randomized multilevel intervention to improve outcomes of residents in nursing homes in need of improvement

ObjectivesA comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement.Design/Setting/ParticipantsIntervention facilities (N = 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N = 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders.InterventionThe authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs.ResultsThe intervention did improve quality of care (P = .02); there were improvements in pressure ulcers (P = .05) and weight loss (P = .05). Organizational working conditions, staff retention, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups.Conclusion and ImplicationsSome facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed. Medical directors in collaborative practice with advanced practice nurses are ideally positioned to implement this low-cost, effective intervention nationwide.     

Nurses' attitudes of a web patient portal prior to its implementation in home health care nursing

ObjectivesEffective communication is essential in home health care nursing in order to meet the needs of both the patients and the caregivers. Given the key role of nursing staff inpatient training through the patient portal; nursing staffs' attitudes toward the use of this technology thus need to be further evaluated. The present study evaluated Iranian nurses' attitudes before the web-based patient portal implementation in home health care nursing.MethodsThis study was conducted on 600 nursing staff working in health care organizations affiliated to Semnan University of Medical Sciences in Iran. A questionnaire was used to evaluate the nurses’ attitudes.ResultsThe study subjects' attitudes scores were 3.06±0.71 on "patient education", 3.02±0.78 on "health care plan" and 2.95±0.82 on the cost of nursing services, based on the 5-point Likert scale (1-5: completely disagree to completely agree). There was a statistically significant relationship between nurses' attitudes and computer skill (B=0.07, SE=0.03, P=0.021) and nurses' acceptance of IT (B=0.085, SE=0.039, P=0.030), and sex (B=0.176, SE=0.058, P=0.003).ConclusionThe nurses agreed that the use of this self-management tool can ease patient education, easily implement a health care plan for patients and reduce the cost of nursing services. The nurses also agreed that changes are required at the minor and major levels of in-home health care institutions to support the implementation and meaningful use of this portal for home health care nursing.Public interest (lay) summaryHome health care is one of the alternative solutions to continue hospital care that is performed by nursing staff. The nursing staff in-home care should effectually cooperate to render secure and high-quality patient care. The web-based patient portals have confirmed effectiveness to improve patient gratification, engagement, and health outcomes, improve the quality and efficacy of the healthcare settings, decrease emergency unit appointments and ease patient-centered care. Nurses agree the implementation of the patient portal in home health care nursing depends on organizational and individual preparation in healthcare organizations and this technology should be also adopted by the nursing staff to meaningful use of the patient portal to attain significant improvements in home health care nursing.     

Nursing home medical staff organization and 30-day rehospitalizations

ObjectivesTo examine the relationship between features of nursing home (NH) medical staff organization and residents' 30-day rehospitalizations.DesignCross-sectional study combining primary data collected from a survey of medical directors, NH resident assessment data (minimum data set), Medicare claims, and the Online Survey Certification and Reporting (OSCAR) database.SettingA total of 202 freestanding US nursing homes.ParticipantsMedicare fee-for-service beneficiaries who were hospitalized and subsequently admitted to a study nursing home.MeasurementsMedical staff organization dimensions derived from the survey, NH residents' characteristics derived from minimum data set data, hospitalizations obtained from Part A Medicare claims, and NH characteristics from the OSCAR database and from www.ltcfocus.org. Study outcome defined within a 30-day window following an index hospitalization: rehospitalized, otherwise died, otherwise survived and not rehospitalized.ResultsThirty-day rehospitalizations occurred for 3788 (20.3%) of the 18,680 initial hospitalizations. Death was observed for 884 (4.7%) of residents who were not rehospitalized. Adjusted by hospitalization, resident, and NH characteristics, nursing homes having a more formal appointment process for physicians were less likely to have 30-day rehospitalization (b = –0.43, SE = 0.17), whereas NHs in which a higher proportion of residents were cared for by a single physician were more likely to have rehospitalizations (b = 0.18, SE = 0.08).ConclusionThis is the first study to show a direct relationship between features of NH medical staff organization and resident-level process of care. The relationship of a more strict appointment process and rehospitalizations might be a consequence of more formalized and dedicated medical practice with a sense of ownership and accountability. A higher volume of patients per physician does not appear to improve quality of care.     

Nurses' and nursing assistants' perceptions of patient safety culture in nursing homes.

OBJECTIVE: To evaluate whether perceptions of patient safety in nursing homes vary by length of employment, type of employee, and shift worked. DESIGN: Cross-sectional study. SETTING: Twenty-six nursing homes in Ohio participating in a randomized trial to test the effectiveness of a clinical informatics tool to improve patient safety during the medication monitoring. PARTICIPANTS: Nurses (n = 367) and nursing assistants (n = 636) employed at the time of the survey in the summer and fall of 2003. MAIN OUTCOME MEASUREMENTS: Resident safety questions included 34 items on different aspects of resident safety (overall safety perception, teamwork within and between departments, communication openness, feedback and communication about error, non-punitive response to error, organizational learning, management expectations, and actions promoting safety, staffing, and management support for patient safety). RESULTS: Overall perceptions of resident safety by employees were acceptable, with clear management communication of safety goals. Approximately 40% of nursing staff found it difficult to make changes to improve things most or all of the time; similar proportions indicated that management seriously considered staff suggestions to improve resident safety; only half reported management discussions with staff to prevent recurrence of mistakes. Regardless of staff type, one in five reported feeling punished and two in five reported that reporting of errors was seen as a 'personal attack'. CONCLUSIONS: Interventions to change the safety culture in nursing homes are warranted. Nursing homes need guidance on how to use information to implement safety improvement projects in the context of a strict regulatory environment which may prohibit innovative system change.     

Facility charter and quality of care for board and care residents

In this investigation structure, process, and outcome measures of quality in for-profit and not-for-profit board and care homes are compared. We find one structural measure (providing nursing care), three process measures (food quality, staff treat residents with respect, and staff verbally abuse residents), and two outcomes measures (cleanliness of the facility and complaints to Ombudsman) to be significant. Moreover, the directions of these effects are all consistent, with for-profit facilities rated more poorly that not-for-profit facilities. These results are discussed emphasizing their implications for efficient and effective resident care.     

Modeling efficiency at the process level: an examination of the care planning process in nursing homes

Objective. To examine the efficiency of the care planning process in nursing homes.
Methods: We collected detailed primary data about the care planning process for a stratified random sample of 107 nursing homes from Kansas and Missouri. We used these data to calculate the average direct cost per care plan and used data on selected deficiencies from the Online Survey Certification and Reporting System to measure the quality of care planning. We then analyzed the efficiency of the assessment process using corrected ordinary least squares (COLS) and data envelopment analysis (DEA).
Results: Both approaches suggested that there was considerable inefficiency in the care planning process. The average COLS score was 0.43; the average DEA score was 0.48. The correlation between the two sets of scores was quite high, and there was no indication that lower costs resulted in lower quality. For-profit facilities were significantly more efficient than not-for-profit facilities.
Conclusions. Multiple studies of nursing homes have found evidence of inefficiency, but virtually all have had measurement problems that raise questions about the results. This analysis, which focuses on a process with much simpler measurement issues, finds evidence of inefficiency that is largely consistent with earlier studies. Making nursing homes more efficient merits closer attention as a strategy for improving care. Increasing efficiency by adopting well-designed, reliable processes can simultaneously reduce costs and improve quality.     

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.     

The Relationship Between Quality of Care,Physical Therapy,and Occupational Therapy Staffing Levels in Nursing Homes in 4 Years' Follow-up

Objectives

To understand physical therapy (PT) and occupational therapy (OT) staffing levels in nursing homes and to examine their relationship with quality of care.

Intended and Unintended Consequences of Minimum Staffing Standards for Nursing Homes

Staffing is the dominant input in the production of nursing home services. Because of concerns about understaffing in many US nursing homes, a number of states have adopted minimum staffing standards. Focusing on policy changes in California and Ohio, this paper examined the effects of minimum nursing hours per resident day regulations on nursing home staffing levels and care quality. Panel data analyses of facility‐level nursing inputs and quality revealed that minimum staffing standards increased total nursing hours per resident day by 5% on average. However, because the minimum staffing standards treated all direct care staff uniformly and ignored indirect care staff, the regulation had the unintended consequences of both lowering the direct care nursing skill mix (i.e., fewer professional nurses relative to nurse aides) and reducing the absolute level of indirect care staff. Overall, the staffing regulations led to a reduction in severe deficiency citations and improvement in certain health conditions that required intensive nursing care. Copyright © 2014 John Wiley & Sons, Ltd.     

Nursing home resident barriers to effective pain management: why nursing home residents may not seek pain medication

OBJECTIVES: Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior. DESIGN: Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication. SETTING: The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings. PARTICIPANTS: A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices. MEASUREMENTS: A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication. RESULTS: More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01). CONCLUSION: Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.     

Living and dying: responsibility for end‐of‐life care in care homes without on‐site nursing provision ‐ a prospective study

The aim of the study was to describe the expectations and experiences of end‐of‐life care of older people resident in care homes, and how care home staff and the healthcare practitioners who visited the care home interpreted their role. A mixed‐method design was used. The everyday experience of 121 residents from six care homes in the East of England were tracked; 63 residents, 30 care home staff with assorted roles and 19 National Health Service staff from different disciplines were interviewed. The review of care home notes demonstrated that residents had a wide range of healthcare problems. Length of time in the care homes, functional ability or episodes of ill‐health were not necessarily meaningful indicators to staff that a resident was about to die. General Practitioner and district nursing services provided a frequent but episodic service to individual residents. There were two recurring themes that affected how staff engaged with the process of advance care planning with residents; ‘talking about dying’ and ‘integrating living and dying’. All participants stated that they were committed to providing end‐of‐life care and supporting residents to die in the care home, if wanted. However, the process was complicated by an ongoing lack of clarity about roles and responsibilities in providing end‐of‐life care, doubts from care home and primary healthcare staff about their capacity to work together when residents’ trajectories to death were unclear. The findings suggest that to support this population, there is a need for a pattern of working between health and care staff that can encourage review and discussion between multiple participants over sustained periods of time.