Anna N. Rahman

Next Steps for Achieving Person-Centered Care in Nursing Homes

To what extent are nursing home residents’ preferences for daily care and recreational activities being met? In their article in this issue of the Journal, Van Haitsma and colleagues report on the development and pilot evaluation of an Excel-based toolkit designed to help nursing homes address this question.1 It is an important question for nursing homes to both ask and answer, especially in light of recent emphasis on person-centered care (PCC) and culture change in longterm care settings. PCC is considered by many to be the “true north” in health care quality as described by Berwick.2 Not only is such care consistent with promoting quality of life, it also is considered critical to achieving quality of care and improved clinical outcomes.2,3 For this reason, “the experiences of patients” are, as Berwick observed in an often-cited essay, “the fundamental source of the definition of quality.”2 This dictum seems especially applicable to nursing homes, which, as the term implies, serve not just as nursing facilities but also as home for the many older adults who reside there in what is often their final years of life. Only recently has the nursing home industry embraced PCC, both in policy and practice, generally operationalizing this multifaceted concept by emphasizing the fundamental importance of individual choice, particularly as it relates to daily care and recreational activities. Federal regulatory guidelines implemented in 2009, for instance, now identify choice over daily schedules as a resident right and explicitly instruct surveyors to ask and observe whether residents are offered choices about daily life activities, such as bedtimes and dining.4 Similarly, the Centers for Medicare and Medicaid Services have directed federally funded Quality Improvement Organizations to work with nursing homes in all states to enhance PCC.5 Among providers, a culture change movement to de-institutionalize and transform nursing homes intomore home-like environmentswith residents at the center has spread rapidly with broad support from multiple long-term care stakeholder groups.6 In 2007, one-third of nursinghomes reported that they had implemented some aspects of culture change and another one-third reported they were planning to follow suit.7 To promote faster uptake, the national collaborative Advancing Excellence

The Coach Is In: Improving Nutritional Care in Nursing Homes

PURPOSE  This article describes and evaluates a long distance coaching course aimed at improving nutritional care in nursing homes (NHs). The course was structured to provide more support than traditional training programs offer.  METHODS  In a series of 6 monthly teleconferences led by an expert in NH nutritional care, participating NH staff received step-by-step instructions for implementing an evidence-based nutritional management program. After each session, participants were asked to implement the care step they had just learned. Coaching calls helped facilitate implementation. Staff in 18 NHs in 12 states completed the course. Evaluation data were collected using a resident data form, pre- and post-training quizzes, a participant course evaluation survey, and a supervisors report.  RESULTS  NH staff attended an average of 4.8 teleconferences, with 5 staff members typically attending each teleconference. Average quiz scores increased 30% (p < .0001) from pre- to post-training. A majority of course participants (N = 35) said they would participate in a similar course (82.9%) and would recommend the course (80%). Just under half preferred the coaching course to a more traditional 1- to 2-day conference. Nine of 12 reporting supervisors said their facility planned to continue the new nutritional care program. The 10 NHs that submitted resident data assessed an average of 5 residents using the recommended protocols.  IMPLICATIONS  We recommend the coaching course format. Dissemination outcomes may improve if resources currently used for short-duration training activities are used instead on coaching activities that support NHs over extended periods.

Ethnic Differences in Advance Directive Completion and Care Preferences: What Has Changed in a Decade?

Studies have documented ethnic differences in advance directive (AD) completion, with lower rates in minority groups. Of those with ADs, blacks are more likely than whites to prefer aggressive care, but little is known about how these differences in preferences have changed over time in ethnic groups. This nationally representative study aimed to investigate whether these differences in AD development persisted after adjusting for important confounding variables. Year of death was analyzed to see how AD completion changed over time within ethnic groups, and for those with an AD, the association between these factors and opting for aggressive care was investigated. Data from the 2000 to 2012 Health and Retirement Study (HRS) exit interviews from 7,177 decedents were used. Analyses included logistic regression to determine the relationship between ethnicity and AD completion and preferences for aggressive care and how it changed over time in ethnic groups. Forty‐six percent of decedents had completed an AD (whites 51.7%, Hispanics 18.0%, blacks 15.0%). Of blacks completing an AD, 23.8% elected prolonged care, compared with 13.3% of Hispanics and 3.3% of whites. Logistic regression revealed that blacks 75% lower odds of completing an AD and Hispanics had 70% lower odds. Model covariates had a small influence on ethnic differences, although in examining the change in AD completion over time, the odds of having an AD increased with each subsequent death year for blacks and whites but not Hispanics. Additional research is needed to investigate the effect of cultural differences in AD completion rates of ethnic minority groups to ensure that preferences are honored in the clinical setting.

Implementing toileting trials in nursing homes: evaluation of a dissemination strategy.

OBJECTIVES This study sought to improve incontinence care in nursing homes (NHs) by administering and evaluating a webinar course that provided extended instruction to help NHs implement toileting trials in accordance with recommended procedures. Of particular interest was: 1) whether the course design would prompt NH staffs to implement the recommended protocol, and 2) whether participants preferred this course design to other models. DESIGN The study collected descriptive evaluation data. SETTING The setting was comprised of seven NHs. PARTICIPANTS Participants were staff members, typically nurses, from enrolled NHs who attended at least three of the six webinars that comprised the course. MEASURES Data was collected using a course evaluation and implementation survey. RESULTS Staff in the participating nursing homes attended an average of 4.85 webinars, with an average of nine staff members attending each webinar (range: 3-20). Twelve of 16 responding participants said they preferred the webinar course to other course designs. All respondents said they would recommend the course and take a similar course again. All facilities submitted some evidence that staff providers had completed implementation assignments. Most facilities reported plans to sustain use of the recommended protocol. CONCLUSION This study found limited evidence that the webinar course prompts NHs to implement a recommended toileting trial protocol and is preferred to other training program designs.

Ratings game: an analysis of Nursing Home Compare and Yelp ratings

Background Two strategies for rating the quality of nursing homes (NHs) in the USA are exemplified by the Nursing Home Compare (NHC) website, launched by the federal Centers for Medicare and Medicaid Services in 1998, and Yelp.com, an online consumer review site that has grown in popularity since its founding in 2004. Both sites feature a 5-star rating system. While much is known about NHC ratings, little is known about NH Yelp ratings. This study examines Yelp ratings for NHs in California and compares these ratings with NHC ratings. Understanding how these ratings relate can inform efforts to empower consumers and enhance NH decision-making. Methods We collected NHC and Yelp ratings for all California NHs between September and November 2016. For each NH with a Yelp review, we recorded the star rating and the total number of reviews. We also recorded the NHC 5-star rating and NHC ratings for inspections, staffing and quality measures (QMs). We conducted descriptive statistics and frequencies for these variables. We conducted correlations and tested means to compare the ratings. Results A total of 675 NHs (68.1% of the total sample of 991 NHs) had both Yelp ratings and NHC ratings. Correlations between the Yelp and NHC ratings were relatively weak. The Yelp rating was significantly lower than the 5-star NHC rating and the NHC ratings for staffing and QMs. It was significantly higher than the NHC inspection rating. Conclusions This study found that when consumers rate NHs on Yelp, their ratings differ considerably from NHC ratings, a finding in keeping with similar studies of NH quality measurement. Further research is needed to analyse the content of Yelp reviews and compare the themes and topics consumers identify with those reported on NHC.

Who Knew? Hospice Is a Business. What that Means for All of Us

A seasoned gerontologist whose work has explored end-of-life care, I thought I knew what I was getting into when I undertook care for my brother Jim. In April 2014, Jim, whose health was then declining rapidly due to liver cancer, moved from his apartment in Minneapolis to my house in Santa Monica. Jim had come for a liver transplant evaluation at the University of California, Los Angeles (UCLA). When the UCLA team declined to list him—his cancer was just too widespread—Jim elected to stay with my family and me, enrolling in hospice. I did my homework when shopping for a hospice provider. Colleagues in the field gave me referrals. I googled their recommendations and read the reviews. I interviewed admissions counselors. When Jim signed the admission papers, I was confident that we were in good hands with the agency we selected. For the most part, we were. Hospice is widely considered an effective program. Studies show that it prevents pain and suffering among dying patients and increases satisfaction with care. Although other health care programs are regularly pilloried in the press, hospice programs are often lauded. Indeed, they sometimes appear so mission driven that one might mistake them for charities. They are not. Whether for-profit or not-for-profit enterprises, they are businesses—and concerned about their bottom line. Through Jim’s story and mine, this article highlights the implications of this business orientation for patients and providers. Methods for evaluating hospice programs nationally are critiqued. Finally, recommendations for improving the business of hospice care are offered.