An Exploration of Safety Climate in Nursing Homes

OBJECTIVES: Although nursing homes provide complex care requiring attention to safety, research on safety climate in nursing homes is limited. Our study assessed differences in attitudes about safety among nursing home personnel and piloted a new survey, specifically designed for the nursing home context. METHODS: Drawing on previous safety climate surveys for hospitals and nursing homes, researchers developed the Survey on Resident Safety in Nursing Homes and administered it March to June 2008 to frontline caregivers and managers in 8 randomly selected Massachusetts nursing homes. Our sample consisted of 751 employees, including all full-time, direct-care staff and managers from participating facilities. First, we performed factor analysis and determined Cronbach alphas for the Survey on Resident Safety in Nursing Homes. Then, we described facilities' safety climate and variation by personnel category and among facilities by calculating the proportion of responses that were strongly positive by item, personnel category, and nursing home. RESULTS: Of 432 respondents (57% response), 29% gave their nursing home an excellent rating overall. Scores varied by personnel category and home: 51% of senior managers gave an excellent safety grade versus 26% of nursing assistants; the range in top safety grades among nursing homes was 30 percentage points. CONCLUSIONS: Safety climate varied substantially among this small sample of nursing homes and by personnel category; managers had more positive perceptions about safety than frontline workers. Efforts to measure safety climate in nursing homes should include the full range of staff at a facility and comparisons among staff categories to provide a full understanding for decision making and to promote targeted response to improve resident safety.     

Characteristics of patients receiving hospice care at home versus in nursing homes: results from the National Home and Hospice Care Survey and the National Nursing Home Survey

This study examined 1170 deceased home hospice patients from the 1998 National Home and Hospice Care Survey and 617 deceased nursing home hospice patients from the 1997 and 1999 National Nursing Home Surveys. T tests and Bonferroni adjustments for multiple comparisons were performed to assess differences in characteristics of patients receiving hospice care at home versus in nursing homes. We found that the nursing home hospice population differs significantly from the home hospice population in the United States. Nursing home hospice patients were more likely to be older, have Medicaid as their primary payment source, have dementia and other noncancer primary diagnosis, and receive dietary/nutrition service, medication management, and physician services than home hospice patients.     

Nursing home bed capacity in the States, 1978-86.

Trends in nursing home bed supply in the States show large variations in beds per population and a gradual decline in supply per aged population. A cross-sectional time-series regression analysis was used to examine some factors associated with nursing home bed supply. Variation was accounted for by economic factors, supply of alternative services, and climate. State Medicaid reimbursement rates had negative coefficients, with supply suggesting States may be increasing rates to improve access where supply is limited. Medicaid waiver policy was not found to be significant.     

Do elderly Medicaid patients experience reduced access to nursing home care?

This paper uses data from the National Long-Term Care Survey and the Area Resources File to analyze the problem of diminished access to nursing home care for elderly Medicaid patients. Using a proxy for the length of time on a waiting list before nursing home entry as my measure of access, I find evidence suggesting that nursing home operators in some areas preferentially admit private patients. Waitlisting of Medicaid patients appears to be a problem mainly in counties in which a high proportion of potential nursing home patients are private and counties in which bed supply is low.     

Depression as a risk factor for nursing home admission among older individuals

OBJECTIVES: Depression is common among those aged 65 and older and has been associated with increased morbidity and mortality. This study investigated whether individuals enrolled in Medicare+Choice with symptoms of depression as measured using the mental health scale from the SF-36 were at increased risk of using nursing home services. DESIGN: A Cox proportional hazards model was used. SETTING: The study investigated community-based adults aged 65 and older. PARTICIPANTS: Participants were individuals aged 65 years and older enrolled in Medicare+Choice who responded to the Health Outcomes Survey and were not institutionalized or incapable of responding for themselves at the time of survey administration. MEASUREMENTS: The purpose of the study was to predict the risk of admission to a nursing home over time, controlling for variables related to demographics, comorbidity, age, and functional status. RESULTS: The results indicated that, even after controlling for physical health, functional status, age, demographics, and socioeconomic status, Medicare+Choice enrollees over the age of 65 experiencing symptoms of depression as identified by the SF-36 are at increased risk of using nursing home services. CONCLUSIONS: These results have implications for payers of nursing home services such as Medicare and Medicaid as well as for providers and the families of older individuals. While the results do not prove that prevention is possible, they do suggest that better identification and treatment of depression reduce the risk of nursing home admission. Even if nursing home placement cannot be avoided, it is possible that the individual's quality of life could be significantly enhanced by better diagnosis and treatment of depression. These findings have implications beyond the Medicare+Choice population.     

Influenza immunization in nursing homes: who does not get immunized and whose status is unknown?

OBJECTIVE: To identify nursing home resident and facility characteristics associated with patients not receiving influenza immunization and having unknown immunization status. DESIGN: Secondary data analysis using multinomial logistic regression of data from the National Nursing Home Survey, a nationally representative establishment-based survey. SETTING: A total of 1,423 nursing facilities of all ownerships and certifications systematically sampled with probability proportional to number of beds. PATIENTS: A total of 7,350 randomly sampled people aged 65 years or older residing in nursing homes between July and December 1999 (approximately 6 per facility). MAIN OUTCOME MEASURE: Immunization status of residents. RESULTS: Fifteen percent of residents were not immunized and 19% had unknown immunization status. In multivariate analysis, lack of immunization and unknown immunization status were each separately associated with being newly admitted, with no or unknown pneumococcal immunization, and with facility failures to screen for immunization and to record inoculation in the medical record. High-risk status and staff immunization requirements had no effect. Separate analyses showed that residents with unknown immunization status are statistically significantly different from both those vaccinated and those not vaccinated. CONCLUSION: This study indicates that both resident and facility characteristics are associated with failure to be immunized for influenza. Facilities should consider targeting younger, newly admitted, and residential care residents for influenza immunization, since they are more likely to be missed. Further research into the barriers to immunization specific to nursing home resident choice or opportunity may be warranted.     

Moral hazard in nursing home use

Nursing home expenditures are a rapidly growing share of national health care spending with the government functioning as the dominant payer of services. Public insurance for nursing home care is tightly targeted on income and assets, which imposes a major tax on savings; moreover, low state reimbursement for Medicaid patients has been shown to lower treatment quality, and bed supply constraints may deny access to needy individuals. However, expanding eligibility, increasing Medicaid reimbursement, or allowing more nursing home bed slots has the potential to induce more nursing home use, increasing the social costs of long-term care. A problem in evaluating this tradeoff is that we know remarkably little about the effects of government policy on nursing home utilization. We attempt to address this shortcoming using multiple waves of the National Long-Term Care Survey, matched to changing state Medicaid rules for nursing home care. We find consistent evidence of no effect of Medicaid policies on nursing home utilization, suggesting that demand for nursing home care is relatively inelastic with respect to public program generosity. From a policy perspective, this finding indicates that changes in overall Medicaid generosity will not have large effects on utilization.     

Where are the missing elders? The decline in nursing home use, 1985 and 1995.

Findings from the 1995 National Nursing Home Survey suggest that elderly Americans are reducing their use of nursing home care. The numbers reflect a change in the role of the nursing home, as defined in this survey. By 1995 nursing facilities were increasingly focusing on patients with greater disability and postacute care needs. Preferred alternatives, most notably home-delivered care and assisted living, were likely filling the gap left by declining nursing home use. Better population-based studies are needed to track emerging trends and ascertain whether elders with disabilities are receiving the care they need. Such data could inform development of better public and private financing strategies for long-term care.     

An overview of nursing home facilities: data from the 1997 National Nursing Home Survey

OBJECTIVE: This report presents estimates on the number and distribution of nursing home facilities, their services, current residents, and discharges in the United States during 1997. METHODS: Data presented in this report are estimates based on a sample of nursing home facilities, residents, and discharges from the 1997 National Nursing Home Survey (NHHS). The survey collects information about providers and recipients of care from nursing home facilities. NHHS has been periodically conducted by the National Center for Health Statistics since 1973. RESULTS: In 1997 there were an estimated 1.6 million current residents and 2.4 million discharges from 17,000 nursing homes nationwide. These facilities were predominantly proprietary and certified by both Medicare and Medicaid. There was an average of 107 beds per nursing home with an occupancy rate of 88 percent and a discharge rate of 130 patients per 100 beds. The majority of nursing home residents and discharges were elderly, white, and female.     

How nursing homes behave: a multi-equation model of nursing home behavior

This paper estimates a multi-equation model of nursing home behavior using the 1973 NCHS National Nursing Home Survey for data. The paper investigates empirically the effects of public reimbursement and regulatory policies, as well as other exogenous factors, on the following dependent variables: (1) average operating cost; (2) nursing hours per patient-day; (3) an index of rehabilitation-type services; (4) the occupancy rate; (5) the mix of public and private patients; and (6) the rate charged to private patients. The results dramatize the importance of endogeneity concerns in nursing home behavior. Rate setting and many regulations are shown empirically to have unintended and often undesired consequences on cost and other policy criteria of interest. While there has been anecdotal evidence of such system-wide interdependencies, this study affirms that such possibilities must be taken seriously. Rational nursing home regulation cannot proceed apart from a comprehensive understanding of the nursing home behavioral environment.     

Mental health service use by the elderly in nursing homes.

OBJECTIVES. Because current Omnibus Budget Reconciliation Act regulations influence the disposition of US nursing home residents who have mental illness, National Nursing Home Survey (1985) data are analyzed for predictors of mental health service use. METHODS. Elderly residents' rates of mental health service use are presented. Logistic regression yielded odds ratios for treatment by both mental health specialists and general practitioners for client and service system variables. RESULTS. Among the two thirds of elderly residents with a mental disorder (including dementia), only 4.5% receive any mental health treatment in a 1-month period. The ratio of specialist to general practitioner care is approximately 1:1. Patients seen by a specialist are likely to be younger (aged 65 to 74); live in the Northeast; and have a diagnosis of schizophrenia (13:1), dementia (3:1), or other mental disorders (5:1). Prior residence in a psychiatric hospital predicts care by both health professional types. Rural location, nonproprietary ownership of the nursing home, and aggressive behavior point to general physician care. CONCLUSIONS. Our findings indicate significant neglect of the mental health needs of older nursing home residents and underscore the importance of monitoring the regulations for screening and treatment of mental disorders under the Omnibus Budget Reconciliation Act.     

The National Nursing Home Survey: 1997 summary

OBJECTIVES: This report presents estimates of nursing home facilities, their current residents and discharges in the United States. Data are presented on facility characteristics, demographic characteristics, utilization measures, health and functional status of current residents, and discharges. METHODS: Data used in this report are based on data collected from the 1997 National Nursing Home Survey. The survey collects information about providers and recipients of care from nursing home facilities.     

Mental health services for nursing home residents: What will it cost?

The Nursing Home Reform Act of 1987 requires nursing homes to provide basic mental health services for all residents and to give active mental health treatment, a set of specialized mental health services, to those residents who are admitted with a serious mental illness. This article examines the potential size of the nursing home population who will require mental health services, its demographic composition, and the facilities in which these individuals reside using the Institutional Population Component of the National Medical Expenditure Survey. Estimates of the potential costs of providing monthly psychotherapy and pharmacological management to this population in nursing homes indicate that the mandate will have significant financial effects on nursing facilities. Conclusions about how the requirements for maintaining the mental and psychosocial well-being of nursing home residents may affect the future of nursing home care and mental health care are considered.     

The provision and use of mental health services in nursing homes: results from the National Medical Expenditure Survey.

Data from the Institutional Population Component of the National Medical Expenditure Survey were used to provide national estimates of annual mental health service provision and use in nursing homes. In addition, the relationship between service provision and setting characteristics such as ownership, size, Medicaid certification, and chain status was examined. Although more than three quarters of residents with a mental disorder resided at a nursing home that provided counseling services, fewer than one fifth actually received any mental health services within the year.     

Obesity affects nursing-care facility admission among whites but not blacks

OBJECTIVE: This study examines whether obese individuals have a greater rate of nursing care facility admission than normal weight individuals. RESEARCH METHODS AND PROCEDURES: Data from the National Health and Nutrition Examination Survey Epidemiological Follow-up Survey were analyzed. Cox proportional hazards models were used to examine the relationship between baseline weight status and subsequent time to first nursing home admission while adjusting for sex, age, race, marital status, height, presence of children, smoking status, education, region, urban residence, income, and physical activity. RESULTS: Of 5960 adults 45 to 74 years old, 989 individuals were admitted to a nursing care facility over the subsequent 20 years. Body mass index (BMI) was studied using five categories: < 18.5, 18.5 to <25, 25.0 to <30, 30.0 to <35, > or =35 kg/m(2). The effects of BMI differed by race: compared with those with a BMI of 18.5 to < 25 kg/m(2), adults with a BMI > or =30 kg/m(2) or a BMI <18.5 kg/m(2) had a greater rate of nursing home admission in whites, whereas no relationship was found in blacks. The inclusion of time to death with nursing home admission as a joint outcome yielded similar results. DISCUSSION: The large increase in the prevalence of obesity coupled with the rapid expansion of the number of older Americans will likely increase the demand for nursing facility use. More research is needed to understand differences in factors related to nursing home admission among ethnic groups.     

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.     

Estimating the long-term care population: prevalence rates and selected characteristics.

To facilitate manpower and service need estimates, the long-term care population must be defined in terms of dependency on human assistance in daily functioning. Such a definition of dependency is applied to national population data bases, using the 1977 National Nursing Home Survey and the 1977, 1979, and 1980 National Health Interview Surveys. The four categories of dependency are personal care, mobility, household activities, and home-administered health care services. Although projections to the year 2000 show a doubling of the nursing home population, estimates of the overall prevalence of functional dependency remain smaller than is popularly believed.     

中国老年人口失能流行趋势的分析与建议

目的整理分析四次国家卫生服务调查中关于老年人失能的资料,揭示中国老年人口失能流行趋势、预测未来变化,为研究与制定未来老年人的照护政策提供参考。方法利用1993、1998、2003和2008年国家卫生服务调查相关失能资料进行时间序列分析、增长趋势预测与年龄组变化分析。结果老年人失能率随时间推移不断增加、各失能别老年人口数庞大,随着年龄组递增失能率成倍增长,至2050年中国将有1.4亿60岁以上老年人做家务中度以上困难,需要他人帮助。结论失能老年人口日益增加,社会经济负担越来越严重,长期护理照顾的制度性建设、失能康复的系统性建设已迫在眉睫。     

Institutional factors of nursing homes that predict the provision of mental health services

This article explores the likelihood of the provision of mental health services in a nursing home as a function of the home&#x2019;s institutional factors. Data from the Institutional Population Component of the National Medical Expenditure Survey were used, and a modified model of equilibrium quality and price in a multivariate logistic framework is employed. The results indicate that meeting the demands for active mental health treatment, as mandated by the Nursing Home Reform Act of 1987, may be more difficult in those institutions that are part of a chain, are small, or contain Medicaid skilled nursing facility beds.