Kathryn Hyer

Risk factors for nursing home placement in older adults with and without dementia.

Objective: The authors explored the effect of predisposing, enabling, and need characteristics on risk of nursing home placement (NHP) in participants with and without dementia. Method: Participants were 1,943 newly enrolled Medicare/Medicaid beneficiaries in Florida who were evaluated for health services by the Department of Elder Affairs. They were at least 65 years of age during fiscal year 1998-1999 and were followed for up to 4 years. Results: Cox proportional hazard regressions indicated that baseline characteristics including older age, White race, diabetes, incontinence, stroke, and difficulties with instrumental activities increased risk of NHP in those without dementia. Caregiver, widowed status, arthritis, and heart disease reduced the risk. Only age, race, and marital status were predictive among participants with dementia. Discussion: Dementia plays a central role in risk of NHP. Understanding risk factors for NHP in this relatively vulnerable population has important policy implications.

The Controversy Inherent in Managing Frail Nursing Home Residents During Complex Hurricane Emergencies

Emergency planning for vulnerable populations constitutes a major element of community disaster preparedness and is an area in which guidance is particularly sparse. As evidenced by the well-publicized deaths of nursing home residents following Hurricanes Katrina and Rita, the need to improve nursing home emergency preparedness is self-evident. Nevertheless, as efforts to improve preparedness develop, a central controversy remains. Aside from mandatory complete evacuations, is it better to evacuate or not to evacuate frail elderly nursing home residents in the setting of hurricane emergencies? This paper reviews the historical evidence on both sides of the argument and suggests a policy and research agenda.

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.

The geriatric interdisciplinary team training (GITT) program.

ABSTRACT Geriatric interdisciplinary team training (GITT) is an initiative funded by the John A. Hartford Foundation since 1995. Building from the substantial knowledge gained from the Veterans Administration project in interdisciplinary team training and lessons from the Pew Foundation initiative, GITT was reconceived by the Foundation to address the need for teams in the care of older adults in the new era of managed care and health care cost containment. This training program has served to help us understand attitudes toward teams, how teams function, and how teams should be trained in the changing health care environment, where length of stay is dramatically different from the earlier team training projects. This introductory paper provides an overview of GITT, and the companion papers give detail of the GITT curricula, measures and lessons learned.

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

Rating the Importance of Nursing Home Residents' Quality of Life

755 to

Nursing home financial performance: the role of ownership and chain affiliation.

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

Serious Mental Illness in Florida Nursing Homes: Need for Training

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.