Charles D. Phillips

The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality.

OBJECTIVE: To characterize changes in key aspects of process quality received by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms.

A commitment to change: revision of HCFA's RAI.

OBJECTIVE: To describe the reliability of new assessment items and their clinical utility as judged by experienced nurse assessors, based on the results from the field test of Version 2.0 of the Resident Assessment Instrument (RAI).

Effect of the National Resident Assessment Instrument on Selected Health Conditions and Problems

OBJECTIVE: To evaluate the effect of the implementation of the National Resident Assessment Instrument (RAI) system on selected conditions representing outcomes for nursing home residents.

The Resident Assessment Instrument-Mental Health (RAI-MH): Inter-Rater Reliability and Convergent Validity

An important challenge facing behavioral health services is the lack of good quality, clinically relevant data at the individual level. The article describes a multinational research effort to develop a comprehensive, multidisciplinary mental health assessment system for use with adults in facilities providing acute, long-stay, forensic, and geriatric services. The Resident Assessment Instrument-Mental Health (RAI-MH) comprehensively assesses psychiatric, social, environmental, and medical issues at intake, emphasizing patient functioning. Data from the RAI-MH are intended to support care planning, quality improvement, outcome measurement, and case mix-based payment systems. The article provides the first set of evidence on the reliability and validity of the RAI-MH.

Changes in Hospitalization Associated with Introducing the Resident Assessment Instrument

OBJECTIVE: To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI).

Health in Rural America: Remembering the Importance of Place

Historically, public health has been viewed through a variety of lenses. One lens focuses on the contrast between the science and the practice of public health.1 Another focuses on individual versus social responsibility for health.2 A third lens visualizes the contrast between an emphasis on disease categories and an emphasis on functional communities.3 A fourth focuses attention on the distinction between market forces and social justice.4 Of particular importance for public health professionals interested in rural health is that lens through which one sees an important part of the history of public health’s development as oscillation between a focus on health issues facing populations defined by their demographic characteristics and health issues in populations defined by their geographic location. Many of the early public health efforts in the United States focused on specific populations, such as merchant seamen and the urban poor,5 or specific outbreaks of disease, such as cholera, smallpox, tuberculosis, yellow fever, malaria, and typhoid.6 With the challenges created by the burgeoning industrial machine that dominated the late 19th and early 20th centuries, the roots of public health became deeply intertwined with the muck and mire of specific places—the urban slums that fed the industrial machine.7,8 This emphasis on poor populations in urban slums may have sprung from the self-interest of industrial and urban elites fearful about epidemics and their own physical health. It may also be attributed to the need for an adequate urban workforce that could be exploited for economic benefit or to a philanthropic ethos that required the more fortunate to assist those less fortunate than themselves. If nothing else, the consistent focus on simplistic causal explanations for the ill health of the urban poor probably indicates that public health’s focus on urban slums originated from some admixture of all these factors.9

Effects of Cognitive Impairment on the Reliability of Geriatric Assessments in Nursing Homes

To explore the relationship between an elderly subjects cognitive status and the reliability of multidimensional assessment data.

Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes

BackgroundUrinary tract infections (UTIs) are the most commonly treated infection among nursing home residents. Even in the absence of specific (e.g., dysuria) or non-specific (e.g., fever) signs or symptoms, residents frequently receive an antibiotic for a suspected infection. This research investigates factors associated with the use of antibiotics to treat asymptomatic bacteriuria (ASB) among nursing home residents.MethodsThis was a cross-sectional study involving multi-level multivariate analyses of antibiotic prescription data for residents in four nursing homes in central Texas. Participants included all nursing home residents in these homes who, over a six-month period, received an antibiotic for a suspected UTI. We investigated what factors affected the likelihood that a resident receiving an antibiotic for a suspected UTI was asymptomatic.ResultsThe most powerful predictor of antibiotic treatment for ASB was the presence of an indwelling urinary catheter. Over 80 percent of antibiotic prescriptions written for catheterized individuals were written for individuals with ASB. For those without a catheter, record reviews identified 204 antibiotic prescriptions among 151 residents treated for a suspected UTI. Almost 50% of these prescriptions were for residents with no documented UTI symptoms. Almost three-quarters of these antibiotics were ordered after laboratory results were available to clinicians. Multivariate analyses indicated that resident characteristics did not affect the likelihood that an antibiotic was prescribed for ASB. The only statistically significant factor was the identity of the nursing home in which a resident resided.ConclusionsWe confirm the findings of earlier research indicating frequent use of antibiotics for ASB in nursing homes, especially for residents with urinary catheters. In this sample of nursing home residents, half of the antibiotic prescriptions for a suspected UTI in residents without catheters occurred with no documented signs or symptoms of a UTI. Urine studies were performed in almost all suspected UTI cases in which an antibiotic was prescribed. Efforts to improve antibiotic stewardship in nursing homes must address clinical decision-making solely on the basis of diagnostic testing in the absence of signs or symptoms of a UTI.

Rurality and Nursing Home Quality: Results from a National Sample of Nursing Home Admissions

OBJECTIVES We examined differences in quality of care among nursing homes in locales of varying degrees of rurality. METHODS We classified locales into 4 classes according to rurality. We analyzed a 10% sample of nursing home admissions in the United States in 2000 (n=198613) to estimate survival models for 9 quality indicators. RESULTS For postacute admissions, we observed significant differences in rates of decline for residents in facilities in large towns compared with urban areas, but differences in quality were both negative and positive. Among admissions for long-term or chronic care, rates of decline in 2 of 9 quality areas were lower for residents in isolated areas. CONCLUSIONS We observed significant differences in a number of quality indicators among different classes of nursing home locations, but differences varied dramatically according to type of admission. These differences did not exhibit the monotonicity that we would have expected had they derived solely from rurality. Also, quality indicators exhibited more similarities than differences across the 4 classes of locales. The results underscore the importance, in some instances, of emphasizing the effects of specific settings rather than some continuum of rurality and of moving beyond the assumption that nursing home residents constitute a homogeneous population.

Nursing home spending, staffing and turnover

Background: Recent work on nursing home staffing and turnover has stressed the importance of ownership and resources. However, few studies have examined spending behaviors, which might also influence staffing levels and staff turnover rates. Purpose: This study investigates whether spending behaviors measured by financial ratios are associated with staffing levels and staff turnover in nursing homes. Methodology: We analyzed cross-sectional data from 1,014 Texas homes. Data were from the 2002 Texas Nursing Facility Medicaid Cost Report and the 2003 Area Resource File. First, we examined differences in financial ratios by ownership type. Next, the effect of 10 financial ratios on staffing levels and turnover rates for registered nurses, licensed vocational nurses, and certified nursing assistants was examined using robust regression models. Findings: Descriptive data indicated that expense ratios related to resident care activities and staff development were significantly higher among not-for-profit than for-profit homes. Higher profits were associated with lower staffing levels, but not higher turnover rates. Administrative expenses (a measure of management capacity) had a negative impact both on staffing levels and staff turnover for licensed vocational nurses and certified nursing assistants, but they did not affect registered nurse staffing. Employee benefit expenses exhibited a positive impact on registered nurse and licensed vocational nurse staffing levels. The addition of information on financial ratios to models predicting staffing indicators reduced the effect of ownership on these indicators. Practice Implications: Solutions to the staffing and turnover problem should focus on more effective management practices. Certain levels of administrative and staff benefit expenses may be necessary to improve professional staff recruitment and reduce both staffing and turnover costs. Differences in these financial ratios may partially explain the role played by ownership in determining staffing levels and turnover.