Robyn I. Stone

Use of Electronic Information Systems in Nursing Homes: United States, 2004

OBJECTIVES This study sought to define the extent of utilization of 12 types of electronic information system (EIS) function in U.S. nursing homes (NH), to relate EIS utilization to selected facility characteristics and to contrast these findings to previous estimates of EIS use in NH. DESIGN This study used data from the National Nursing Home Survey (NNHS), a nationally representative, cross-sectional sample of U.S. NH. MEASUREMENTS Data on current use of EIS in 12 functional areas, including administrative and resident care activities, were collected. Information was also collected on facility characteristics including ownership, bed size, and whether the facility was a member of a chain. RESULTS Essentially all (99.6%) U.S. NH had >or=1 EIS, a figure that was driven by the nearly universal use of EIS for Minimum Data Set (MDS) reporting (96.4%) and for billing (95.4%). Nearly 43% of U.S. NH had EIS for medical records, including nurses notes, physician notes, and MDS forms. EIS use ranged from a high of 79.6% for admission, transfer, and discharge to a low of 17.6% for daily care by certified nursing assistants (CNAs). Ownership, membership in a chain, and bed size were associated with use of selected EIS. Larger facilities and those that were part of a chain used more EIS than smaller standalone facilities. CONCLUSION In 2004, NH use of EIS for functions other than MDS and billing was highly variable, but considerably higher than previous estimates.

The impact of health care reform on the workforce caring for older adults.

This article summarizes the Patient Protection and Affordable Care Act (ACA) provisions that have a direct or indirect impact on the workforce caring for the elder population, explores the challenges to developing the workforce, and critiques the adequacy of the ACA provisions in meeting those challenges. The ACA is the first comprehensive federal legislation to acknowledge gaps in the workforce caring for the elder population. However, its provisions are inadequate given insufficient supply in the number and types of workers necessary both to meet the caregiving demand of the growing elder population and to implement the delivery system reforms instituted by the ACA. One of the challenges is that the workforce is not prepared for the new service delivery models specified in the legislation. They are not trained, supported, or held accountable for effective care coordination and service integration, and they lack the requisite skills, knowledge, and competencies. Moreover, it is likely to remain difficult to recruit and retain competent direct care workers, who represent the largest component of the long-term care workforce, because of the negative industry image, noncompetitive wages and benefits, a challenging work environment, and inadequate education and training. Several of the ACA provisions for developing the workforce have not received appropriations. Most are also demonstration projects of limited scope and duration.

The Home Health Workforce: A Distinction Between Worker Categories

The demand for home health aides is expected to rise, despite concerns about the sustainability of this workforce. Home health workers receive low wages and little training and have high turnover. It is difficult to recruit and retain workers to improve clinical outcomes. This study presents national estimates to examine how home health workers and the subgroup of workers differ in terms of sociodemographic characteristics, compensation, benefits, satisfaction, and retention. Hospice aides fare better than other categories of workers and are less likely to leave their job. Policymakers should consider strategies to increase the quality and stability of this workforce.

Tenure, Certification, and Education of Nursing Home Administrators, Medical Directors, and Directors of Nursing in For-Profit and Not-for-Profit Nursing Homes: United States 2004

OBJECTIVES To understand key characteristics of the leadership team, and to examine if differences in these factors exist between for-profit (FP) and not-for-profit (NFP) nursing homes (NHs). DESIGN Cross sectional. SETTING US nursing homes. PARTICIPANTS A nationally representative sample of 1174 US NHs conducted in 2004. INTERVENTION N/A. MEASUREMENTS Reported data on tenure, education, and certification of NH administrators (NHAs), medical directors (MeDs), and directors of nursing (DoNs) at FP and NFP facilities. RESULTS NHAs, MeDs, and DoNs at NFP facilities all had significantly greater tenure at their current facilities compared with their FP counterparts. NHAs and MeDs at NFP facilities were also more likely to have more years of accumulated experience in those roles. MeD certifications differed substantially by specialty, with 23.3%, 37.6%, and 43.5% of MeDs having certification in geriatric, internal, and family medicine, respectively, and about 42% of MeDs were certified by AMDA. However, no differences in MeD certification were observed by facility ownership. Although 68% of all US nursing homes had a MeD who spent 4 or fewer days per month in the facility and only 14% spent 11 days or more per month in the facility, nearly twice as many NFP MeDs spent 11 days or more onsite in the facility compared with FP MeDs. Facility ownership was strongly associated with NHA educational attainment, with a significantly higher proportion of NFP NHAs having masters degrees or higher (41.4% versus 26.6%, P < .0001), and smaller proportions of NFP NHAs having a bachelors degree or less. CONCLUSION In 2004, members of the leadership teams of NFP NHs had more favorable profiles for several characteristics related to education and tenure compared with their FP counterparts. More research is needed to understand how variation in leadership skills and capacity affects quality of care and quality of work life outcomes, including the role of FP/NFP differences in explaining differential quality outcomes.

Predictors of Intent to Leave the Job Among Home Health Workers: Analysis of the National Home Health Aide Survey

Purpose To identify agency policies and workplace characteristics that are associated with intent to leave the job among home health workers employed by certified agencies. Design and Methods Data are from the 2007 National Home and Hospice Care Survey/National Home Health Aide Survey, a nationally representative, linked data set of home health and hospice agencies and their workers. Logistic regression with survey weights was conducted to identify agency and workplace factors associated with intent to leave the job, controlling for worker, agency, and labor market characteristics. Results Job satisfaction, consistent patient assignment, and provision of health insurance were associated with lower intent to leave the job. By contrast, being assigned insufficient work hours and on-the-job injuries were associated with greater intent to leave the job after controlling for fixed worker, agency, and labor market characteristics. African American workers and workers with a higher household income also expressed greater intent to leave the job. Implications This is the first analysis to use a weighted, nationally representative sample of home health workers linked with agency-level data. The findings suggest that intention to leave the job may be reduced through policies that prevent injuries, improve consistency of client assignment, improve experiences among African American workers, and offer sufficient hours to workers who want them.

Implications for Policy: The Nursing Home as Least Restrictive Setting

The culture change movement has emerged as an answer to a public policy challenge: How can a nursing home, as a facility providing services under one roof to unrelated individuals with disabilities, ensure that every resident “attains and maintains his or her highest practicable level of physical, mental and psycho-social wellbeing” (Omnibus Budget Reconciliation Act, 1987)? And can a nursing home simultaneously become “the most integrated setting appropriate to the needs of qualified individuals with disabilities” as required by the regulations carrying out the Supreme Court’s 1999 decision in Olmstead v. L.C. (U.S. Administration for Community Living, 2013)? Care for persons with disabilities in the least restrictive setting is so important that public policy has moved ahead to support resident-centered care in nursing homes even though the evidence base concerning culture change is still developing. As the Introduction to this supplement notes, “the train has left the station” (Zimmerman, Shier, & Saliba, 2014). Policy champions situated at state and federal levels are persuaded by the concept and have set in motion a number of policy initiatives to foster culture change. At the Federal level, the Centers for Medicare & Medicaid Services have pursued efforts to encourage culture change through changes in survey and certification requirements for Medicaid, inclusion of resident experience in the latest Minimum Data Set instrument, and dissemination of organizational transformation through the Eighth Statement of Work contract for state Quality Improvement Organizations. The Administration for Community Living Long-Term Care Ombudsman Program promotes personcentered practices for residents of long-term care facilities in a manner aligned with culture change efforts. States have pursued a variety of avenues to foster person-centered services in nursing homes (Stone & Bryant, 2013). They have used statutory or regulatory authority to flex rigid, traditional nursing home regulation that can impede culture change; enabled state officials’ participation in coalitions and working groups facilitating the diffusion of culture change models (Beck, Gately, Lubin, Moody, & Beverly, 2014); and supported technical assistance activities to spark and sustain implementation. Some states have developed payfor-performance payment systems for Medicaid nursing home care that encourage adoption of elements of resident-centered care (Miller et al., 2013). Although not funded or implemented, demonstrations of nursing home culture change were included in the Patient Protection and Affordable Care Act at §6114 (Hawes, Moudouni, Edwards, & Phillips, 2012; Wells & Harrington, 2013). Although policy supporting person-centered care has moved forward, scholars are simultaneously developing an evidence base to evaluate impact, understand adoption patterns, and guide implementation strategies for the culture change concept. The policy questions implicit in this research are first, whether culture change as currently defined and implemented provides outcomes better than the outcomes of standard practice, making it worthy of public policy support; and second, if so, how can public policy encourage adoption and implementation of residentcentered nursing home care. After examining how the diverse collection of studies and reviews in

Educating Direct Care Workers on Transitions of Care

This chapter explores the potential role direct care workers can play in ensuring appropriate and safe transitions across settings. Direct care workers are critical to the transitional care process and outcomes because they provide the majority of hands-on care to older adults across a range of settings where transitions occur. Their close relationship with residents, clients, and family members allows them to serve as a bridge between the health care system and the consumer. However, it is difficult to recruit and retain direct care workers and to develop a quality, competent workforce. Insufficient initial and ongoing training, without a specific focus on transitions of care, leaves these workers inadequately prepared and supported to address the complex health and functional needs of older adults and to have an active part of any transition team. Direct care workers are often forgotten partners in care coordination teams, even though they can be integral to successful transitions. This chapter concludes with a call to recognize direct care workers as a critical part of the transitional care team, the need for better training and organizational support to attain this goal, and the implications for public policy and practice. The passage of the

U.S. Department of Health Adverse Event Reporting Policies for Nursing Homes

&NA; The objectives of this study were to describe state policies for the frequency of adverse event reporting and follow‐up that occurs in U.S. nursing homes, and to identify the health information technology used to facilitate these processes. The study was conducted using a mailed survey to the Departments of Health (DOH) in all 50 states, specifically the department that is responsible for the oversight and regulation of nursing home care. Thirty‐two state DOH representatives participated. The primary variables examined were (1) which incidents were most commonly reported to state DOH and (2) whether or not they were followed up with a surveyor visit to the nursing home. There was wide variation in incident reporting processes across all states and lack of a standardized process. Abuse is the only adverse event that almost always is required to be reported to the state DOH and has the highest incidence of follow‐up with a surveyor visit. Improving and standardizing adverse event reporting systems is a necessary strategy to enhance patient safety in nursing homes. This study provides an important step by increasing our knowledge base of the current state of adverse event reporting policies and processes at the state level.