Kali S. Thomas

The Relationship between Older Americans Act Title III State Expenditures and Prevalence of Low‐Care Nursing Home Residents

OBJECTIVE To test the relationship between older Americans Act (OAA) program expenditures and the prevalence of low-care residents in nursing homes (NHs). DATA SOURCES AND COLLECTION: Two secondary data sources: State Program Reports (state expenditure data) and NH facility-level data downloaded from LTCfocUS.org for 16,030 US NHs (2000-2009). STUDY DESIGN Using a two-way fixed effects model, we examined the relationship between state spending on OAA services and the percentage of low-care residents in NHs, controlling for facility characteristics, market characteristics, and secular trends. PRINCIPAL FINDINGS Results indicate that increased spending on home-delivered meals was associated with fewer residents in NHs with low-care needs. CONCLUSIONS States that have invested in their community-based service networks, particularly home-delivered meal programs, have proportionally fewer low-care NH residents.

The Minimum Data Set 3.0 Cognitive Function Scale.

Background: The Minimum Data Set (MDS) 3.0 introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents. Not all residents are able to complete the BIMS and are consequently assessed by staff. We designed a Cognitive Function Scale (CFS) integrating self-report and staff-report data and present evidence of the scale’s construct validity. Design: A retrospective cohort study. Subjects: The subjects consisted of 3 cohorts: (1) long-stay NH residents (N=941,077) and (2) new admissions (N=2,066,580) during 2011–2012, and (3) residents with the older MDS 2.0 assessment in 2010 and the newer MDS 3.0 assessment (n=688,511). Measures: MDS 3.0 items were used to create a single, integrated 4-category hierarchical CFS that was compared with residents’ prior MDS 2.0 Cognitive Performance Scale scores and other concurrent MDS 3.0 measures of construct validity. Results: The new CFS suggests that 28% of the long-stay cohort in 2011–2012 were cognitively intact, 22% were mildly impaired, 33% were moderately impaired, and 17% were severely impaired. For the admission cohort, the CFS noted 56% as cognitively intact, 23% as mildly impaired, 17% as moderately impaired, and 4% as severely impaired. The CFS corresponded closely with residents’ prior MDS 2.0 Cognitive Performance Scale scores and with performance of Activities of Daily Living, and nurses’ judgments of function and behavior in both the admission and long-stay cohorts. Conclusions: The new CFS is valuable to researchers as it provides a single, integrated measure of NH residents’ cognitive function, regardless of the mode of assessment.

To Evacuate or Shelter in Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents

OBJECTIVE To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf hurricanes. METHODS Observational study using Medicare claims and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 nonhurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days. RESULTS Among 36,389 NH residents exposed to a storm, the 30- and 90-day mortality/hospitalization rates increased compared with nonhurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7% to 5.3% and hospitalization by 1.8% to 8.3%, independent of other factors. CONCLUSION Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.

Patient Safety Culture and the Association with Safe Resident Care in Nursing Homes

PURPOSE OF THE STUDY Studies have shown that patient safety culture (PSC) is poorly developed in nursing homes (NHs), and, therefore, residents of NHs may be at risk of harm. Using Donabedians Structure-Process-Outcome (SPO) model, we examined the relationships among top managements ratings of NH PSC, a process of care, and safety outcomes. DESIGN AND METHODS Using top managements responses from a nationally representative sample of 3,557 NHs on the 2008 Nursing Home Survey on PSC, the Online Survey, Certification, and Reporting Database, and the Minimum Data Set, we examined the relationships among the three components of Donabedians SPO model: structure (PSC), a process of care (physical restraints), and patient safety outcomes (residents who fell). RESULTS Results from generalized estimating equations indicated that higher ratings of PSC were significantly related to lower prevalence of physical restraints (odds ratio [OR] = 0.997, 95% confidence interval [CI] = 0.995-0.999) and residents who fell (OR = 0.999, 95% CI = 0.998-0.999). Physical restraint use was related to falls after controlling for structural characteristics and PSC (OR = 1.698, 95% CI = 1.619-1.781). IMPLICATIONS These findings can contribute to the development of PSC in NHs and promote improvements in health care that can be measured by process of care and resident outcomes.

Weathering the storm: challenges to nurses providing care to nursing home residents during hurricanes

This article documents the experience of 291 Florida nursing homes during the 2004 hurricane season. Using quantitative and qualitative methods, the authors described and compared the challenges nurses encountered when evacuating residents with their experiences assisting residents of facilities that sheltered in place. The primary concerns for evacuating facilities were accessing appropriate evacuation sites for residents and having ambulance transportation contracts honored. The main issue for facilities that sheltered in place was the length of time it took for power to be restored. Barriers to maintaining resident health during disasters for those who evacuated or sheltered in place are identified.

Predictors of Low-Care Prevalence in Florida Nursing Homes: The Role of Medicaid Waiver Programs

PURPOSE OF THE STUDY To examine the relationship between county-level Medicaid home- and community-based service (HCBS) waiver expenditures and the prevalence of low-care residents in Florida nursing homes (NHs). DESIGN AND METHODS The present study used a cross-sectional design. We combined two data sources: NH facility-level data (including characteristics of the facility and its residents) and county-level market characteristics (including HCBS waiver expenditures) for 653 Florida NHs in 2007. Low-care was defined as residents who require no physical assistance in any of the 4 late-loss activities of daily living (bed mobility, toileting, transferring, and eating). We estimated a 2-level hierarchical linear model (HLM) to examine the relationship between Medicaid HCBS waiver expenditures and the prevalence of low-care residents while accounting for resident assessment, facility-, and county-level covariates. RESULTS All Florida counties offered 2 statewide waivers, and 33 counties offered one or more of the 4 regional Medicaid HCBS waivers in 2007. Per-month beneficiary expenditures ranged from

Functional Improvement Among Short-Stay Nursing Home Residents in the MDS 3.0

755 to

Effects of Hurricane Katrina on nursing facility resident mortality, hospitalization, and functional decline.

1,778. The average Florida NH had 120 beds, and 8.0% of its residents were classified as low-care. Results from the HLM model showed that a

Are Dual Eligibles Admitted to Poorer Quality Skilled Nursing Facilities

10,000 increase in per-enrollee HCBS waiver expenditures was associated with a 3.5 percentage point reduction in low-care resident prevalence (p = .03). IMPLICATIONS The findings suggest that Medicaid HCBS waiver programs may reduce the prevalence of low-care residents in NHs. Future studies should evaluate whether Medicaid HCBS waiver programs are effective in promoting community-living among low-care residents and mitigating the growth in long-term care expenditures.

Effect of Forced Transitions on the Most Functionally Impaired Nursing Home Residents

OBJECTIVES To examine the completeness of the activities of daily living (ADL) items on admission and discharge assessments and the improvement in ADL performance among short-stay residents in the newly adopted Minimum Data Set (MDS) 3.0. DESIGN Retrospective analysis of MDS admission and discharge assessments. SETTING Nursing homes from July 1, 2011, to June 30, 2012. PARTICIPANTS New nursing home residents admitted from acute hospitals with corresponding admission and discharge assessments between July 1, 2011, and June 30, 2012, who had a length of stay of 100 days or less. MEASUREMENTS ADL self-performance items, including bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, at admission and discharge. RESULTS The ADL self-performance items are complete at both admission and discharge, with less than 1% missing for any item. More than 60% of residents improved over the course of their post-acute stay. New short-stay nursing home residents with conditions such as cognitive impairment, delirium, dementia, heart failure, and stroke showed less improvement in ADL performance during their stay. CONCLUSION The discharge assessment data in the MDS 3.0 provide new information to researchers and providers to examine and track ADL performance. Nursing homes can identify and track patients who require more intensive therapies or targeted interventions to achieve functional improvement during their stay. Future research can examine facility-level measures to better understand how ADL improvement varies across facilities.