Michael Lepore

Culture Change Practice in U.S. Nursing Homes: Prevalence and Variation by State Medicaid Reimbursement Policies

PURPOSE OF THE STUDY To estimate the prevalence of culture change practice in U.S. nursing homes (NHs) and examine how state Medicaid policies may be associated with this prevalence. DESIGN AND METHODS In 2009/2010, we conducted a survey of a stratified proportionate random sample of NH directors of nursing (DONs) and administrators (NHAs) at 4,149 U.S. NHs; contact was achieved with 3,695. Cooperation rates were 62.6% for NHAs and 61.5% for DONs. Questions focused on NH (physical) environment, resident-centered care, and staff empowerment domains. Domain scores were created and validated, in part, using qualitative interviews from 64 NHAs. Other NH covariate data were from Medicare/Medicaid surveys (Online Survey, Certification and Reporting), aggregated resident assessments (Minimum Data Set), and Medicare claims. Medicaid policies studied were a states average NH reimbursement rate and pay-for-performance (P4P) reimbursement (including and not including culture change performance measures). Multivariate generalized ordered logit regressions were used. RESULTS Eighty-five percent of DONs reported some culture change implementation. Controlling for NH attributes, a

Hospice Use Among Urban Black and White U.S. Nursing Home Decedents in 2006

10 higher Medicaid rate was associated with higher NH environment scores. Compared with NHs in non-P4P states, NHs in states with P4P including culture change performance measures had twice the likelihood of superior culture change scores across all domains, and NHs in other P4P states had superior physical environment and staff empowerment scores. Qualitative interviews supported the validity of survey results. IMPLICATIONS Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended.

Geographic Concentration and Correlates of Nursing Home Closures: 1999–2008

PURPOSE Medicare hospice is a valuable source of quality care at the end of life, but its lower use by racial minority groups is of concern. This study identifies factors associated with hospice use among urban Black and White nursing home (NH) decedents in the United States. DESIGN AND METHODS Multiple data sources are combined and multilevel logistic regression is utilized to examine hospice use among urban Black and White NH residents who had access to hospice and died in 2006 (N = 288,202). RESULTS In NHs, Blacks are less likely to use hospice than Whites (35.4% vs. 39.3%), even when controlling for covariates, interactions, and clustering of decedents in NHs and counties (adjusted odds ratio = 0.81, 95% confidence interval = 0.77-0.86). Variation in hospice use is greater among subgroups of Blacks than between Blacks and Whites, and these variations are predominantly due to individual-level factors, with some influence of NH-level factors. Hospice use is higher for Blacks versus Whites with do-not-resuscitate orders and lower for Blacks versus Whites with congestive heart failure (CHF). Additionally, hospice use is greater among Blacks with versus without do-not-resuscitate or do-not-hospitalize orders or cancer and those in low-tier versus other NHs. There was also lower hospice use among Blacks with versus without CHF. IMPLICATIONS Efforts to reduce racial differences in hospice use should attend to individual-level factors. Heightening use of advance directives and targeting Blacks with CHF for hospice could be particularly helpful.

Does the introduction of nursing home culture change practices improve quality

BACKGROUND While demographic shifts project an increased need for long-term care for an aging population, hundreds of nursing homes close each year. We examine whether nursing home closures are geographically concentrated and related to local community characteristics such as the racial and ethnic population mix and poverty. METHODS National Online Survey Certification and Reporting data were used to document cumulative nursing facility closures over a decade, 1999 through 2008. Census 2000 zip code level demographics and poverty rates were matched to study facilities. The weighted Gini coefficient was used to measure geographic concentration of closures, and geographic information system maps to illustrate spatial clustering patterns of closures. Changes in bed supply due to closures were examined at various geographic levels. RESULTS Between 1999 and 2008, a national total of 1776 freestanding nursing homes closed (11%), compared with 1126 closures of hospital-based facilities (nearly 50%). Combined, there was a net loss of over 5% of beds. The relative risk of closure was significantly higher in zip code areas with a higher proportion of blacks or Hispanics or a higher poverty rate. The weighted Gini coefficient for closures was 0.55 across all metropolitan statistical areas and 0.71 across zip codes. Closures tended to be spatially clustered in minority-concentrated zip codes around the urban core, often in pockets of concentrated poverty. CONCLUSIONS Nursing home closures are geographically concentrated in minority and poor communities. Since nursing home use among the minority elderly population is growing while it is declining among whites, these findings suggest that disparities in access will increase.

Why and how do nursing homes implement culture change practices? Insights from qualitative interviews in a mixed methods study.

To understand whether nursing home (NH) introduction of culture change practices is associated with improved quality.

Kinship Care in Rural Georgia Communities: Responding to Needs and Challenges of Grandparent Caregivers

To understand the process of instituting culture change (CC) practices in nursing homes (NHs). NH Directors of Nursing (DONs) and Administrators (NHAs) at 4,149 United States NHs were surveyed about CC practices. Follow-up interviews with 64 NHAs were conducted and analyzed by a multidisciplinary team which reconciled interpretations recorded in an audit trail. Results: The themes include: (a) Reasons for implementing CC practices vary; (b) NH approaches to implementing CC practices are diverse; (c) NHs consider resident mix in deciding to implement practices; (d) NHAs note benefits and few costs to implementing CC practices; (e) Implementation of changes is challenging and strategies for change are tailored to the challenges encountered; (f) Education and communication efforts are vital ways to institute change; and (g) NHA and other staff leadership is key to implementing changes. Diverse strategies and leadership skills appear to help NHs implement reform practices, including CC innovations.

Patient-centered, Person-centered, and Person-directed Care They are Not the Same

In 2005, the Georgia Division of Aging Services initiated the Kinship Care Program to provide services to grandparents raising grandchildren throughout Georgias 12 regional Area Agencies on Aging. Many of the grandparents who receive Division of Aging Services services reside in rural communities. To assess the impact of the program among rural grandparents and learn more about their needs, an evaluation study was conducted with 30 grandparents in four rural Kinship Care Program sites around Georgia. Analysis of focus group and questionnaire data indicated that grandparents had concerns about their own health and the health of their grandchildren and faced many challenges related to child rearing. Challenges included limited services for children with disabilities, lack of assistance with permanency planning and other legal issues related to adoption, and insensitive service providers. The data showed that grandparents also were plagued with feelings of isolation and marginalization within the community. Many grandparents reported that the most beneficial service they received from the Kinship Care program was the psychological support and information exchange provided by support groups. Barriers to support group participation, such as lack of transportation and child care services and lack of options for intergenerational activities were identified as service gaps. This paper presents findings from this evaluation. Included are implications for service programs targeting rural grandparents raising grandchildren and recommendations for improving service delivery to this group of older adults.

Overcoming Resistance to Culture Change: Nursing Home Administrators’ Use of Education, Training, and Communication

The traditional “medical model” of health care consists of evaluating symptoms and complaints, prescribing treatments, and assessing outcomes—typically with a doctor or some other highly trained professional making the decisions. The role of the professional is to decide; the role of the patient is to comply with the decisions of the professional. As the health care and long-term services and supports systems move away from this paternalistic, doctor-knows-best approach, consumers are playing more active roles in their care. The Institute of Medicine has declared that patient-centered care—care that is “respectful of and responsive to the preferences, needs, and values” of the individual, “ensuring that the care recipient’s values guide all clinical decisions”—is a hallmark of high-quality care. 1 Patient-centered care promotes access to personal health information by computers or mobile phones, making patients better informed and more active participants in their care. Patient-centered care also gives priority to outcomes that are important to the patient—such as quality of life—over technical and process measures. 2 The IOM’s definition of patient-centered care could be expanded with terminology that denotes greater holism and empowerment. In place of the medical model, and expanding the patient-centered concept, are the models of person-centered and person-directed care, terms that are poorly understood and inconsistently applied. These other approaches to care vary according to who is the decision maker and the role of coordination and nonmedical services and concerns. Table 1 summarizes the similarities and differences across these terms. A health care system providing person-centered care would focus on the whole person (not just his or her medical conditions), and—perhaps even more radically—a health system providing person-directed care puts individuals in control of decisions about their care. 3,4 Person-centered and person-directed care approaches represent a paradigmatic shift in focus away from the biomedical approach; they emphasize social, mental, emotional, and spiritual needs, as well as individuals’ strengths, weaknesses, preferences, and values. Future research is needed in order to test the validity of our assignments of low/moderate/high/very high in Table 1, and—more importantly—the relative effectiveness of the different models. Research is also needed to better understand the preferences that care recipients have about different approaches to their care. Some individuals and families may, in fact, prefer the medical model because they are reassured by a paternalistic approach and do not wish to be decision makers. Not everyone wants to be in the director’s chair, and these preferences are also valid, but not unless some element of choice is involved. The holistic and empowering approach exemplified by person-centered and persondirected care is not a traditional part of the training for physicians and other health care providers, although there have been movements in that direction. 5 Nonetheless, recognizing each individual as a whole person with distinct goals, needs, and preferences is

Medicare and Medicaid Reimbursement Rates for Nursing Homes Motivate Select Culture Change Practices But Not Comprehensive Culture Change

Nursing home culture change is becoming more prevalent, and research has demonstrated its benefits for nursing home residents and staff—but little is known about the role of nursing home administrators in culture change implementation. The purpose of this study was to determine what barriers nursing home administrators face in implementing culture change practices, and to identify the strategies used to overcome them. The authors conducted in-depth individual interviews with 64 administrators identified through a nationally representative survey. Results showed that a key barrier to culture change implementation reported by administrators was staff, resident, and family member resistance to change. Most nursing home administrators stressed the importance of using communication, education and training to overcome this resistance. Themes emerging around the concepts of communication and education indicate that these efforts should be ongoing, communication should be reciprocal, and that all stakeholders should be included.

A Measure of Person-Centered Practices in Assisted Living: The PC-PAL

Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and “culture change” NHs. We use mixed methods to examine the presence of culture change practices in the context of an NH’s payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices, and quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices.