Victoria T. Grando

Nursing home care quality: a multidimensional theoretical model integrating the views of consumers and providers.

This exploratory study was undertaken to discover the defining dimensions of nursing home care quality from the viewpoint of consumers of nursing home care. Eleven focus groups were conducted in five Missouri communities. The seven dimensions of the consumer multidimensional model of nursing home care quality are: staff, care, family involvement, communication, environment, home, and cost. The views of consumers and families are compared with the results of a previous study of providers of nursing home services. An integrated, multidimensional theoretical model is presented for testing and evaluation. An instrument based on the model is being tested to observe and score the dimensions of nursing home care quality.

Nursing Home Care Quality: A Multidimensional Theoretical Model

This exploratory study was undertaken to discover the defining dimensions of nursing home care quality and to propose a conceptual model to guide nursing home quality research and the development of instruments to measure nursing home care quality. Three focus groups were conducted in three central Missouri communities. A naturalistic inductive analysis of the transcribed content was completed. Two core variables (interaction and odor) and several related concepts emerged from the data. Using the core variables, related concepts, and detailed descriptions from participants, three models of nursing home care quality emerged from the analysis: (1) a model of a nursing home with good quality care; (2) a model of a nursing home with poor quality care; and (3) a multidimensional model of nursing home care quality. The seven dimensions of the multidimensional model of nursing home care quality are: central focus, interaction, milieu, environment, individualized care, staff, and safety. To pursue quality, the many dimensions must be of primary concern to nursing homes. We are testing an instrument based on the model to observe and score the dimensions of nursing home care quality.

Verifying Nursing Home Care Quality Using Minimum Data Set Quality Indicators and Other Quality Measures

Researchers, providers and government agencies have devoted time and resources to the development of a set of Quality Indicators derived from Minimum Data Set (MDS) data. Little effort has been directed toward verifying that Quality Indicators derived from MDS data accurately measure nursing home quality. Researchers at the University of Missouri-Columbia have independently verified the accuracy of QI derived from MDS data using four different methods; 1) structured participative observation, 2) QI Observation Scoring Instrument, 3) Independent Observable Indicators of Quality Instrument, and 4) survey citations. Our team was able to determine that QIs derived from MDS data did differentiate nursing homes of good quality from those of poorer quality.

Setting thresholds for quality indicators derived from MDS data for nursing home quality improvement reports: an update.

BACKGROUND Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas in nursing home care is critical for preparing reports for nursing homes to use in their quality improvement programs. This article builds on the work of an earlier panel of experts that set thresholds for quality indicators (QIs) derived from Minimum Data Set (MDS) assessment data. Thresholds were now set for the revised MDS 2.0 two-page quarterly form and Resource Utilization Groups III (RUGS III) quarterly instrument. SETTING THRESHOLDS In a day-long session in October 1998, panel members individually determined lower (good) and upper (poor) threshold scores for each QI, reviewed statewide distributions of MDS QIs, and completed a follow-up Delphi of the final results. REPORTING MDS QIS FOR QUALITY IMPROVEMENT The QI reports compiled longitudinal data for all residents in the nursing home during each quarter and cumulatively displayed data for five quarters for each QI. A resident roster was provided to the nursing home so that the quality improvement team could identify the specific residents who developed the problems defined by each QI during the last quarter. Quality improvement teams found the reports helpful and easy to interpret. SUMMARY AND CONCLUSIONS As promised in an earlier report, to ensure that thresholds reflect current practice, research using experts in a panel to set thresholds was repeated as needed. As the MDS instrument or recommended calculations for the MDS QIs change, thresholds will be reestablished to ensure a fit with the instrument and data.

Minimum Data Set and Resident Assessment Instrument. Can using standardized assessment improve clinical practice and outcomes of care

Regulating and standardizing the assessment of residents was envisioned by the 1986 Committee on Nursing Home Reform to have many advantages for facility management, government regulatory agencies, and clinical staff to evaluate changes in resident status and adjust the care plans accordingly. Standardized assessment data was viewed as a source of management information to be used to track case mix (i.e., acuity) of residents, allocate resources such as staff, and evaluate care quality. The Resident Assessment Instrument is a clinically relevant assessment process that can facilitate effective care planning, interventions, and quality improvement. It is a clinically complex process requiring care delivery systems developed by RNs to support the implementation of individualized care.

Challenges in conducting qualitative research with individuals with dementia.

Qualitative research can capture the meaningful experiences and life values of individuals with dementia not reported in quantitative studies. This article shares a personal experience of the challenges faced and the lessons learned while conducting a qualitative study of 15 people with early-stage Alzheimers disease. The purpose of this article is to discuss the issues concerning determination of capacity to consent to research, consent/assent, communication challenges, and trustworthiness of data when conducting a qualitative study of people with dementia. Understanding communication challenges related to dementia is important to develop effective communication strategies, such as simplifying the structure of questions, allowing ample time for the participants response, using reminiscence, and redirecting the dialogue. This information will be valuable to researchers conducting qualitative studies and the resulting contributions to the body of knowledge about Alzheimers disease.

Getting the Basics Right: Care Delivery in Nursing Homes

In this study, the key exemplar processes of care in facilities with good resident outcomes were described. It follows that with description of these processes, it is feasible to teach facilities about the basics of care and the ways to systematically approach care so they can adopt these care processes and improve resident outcomes. However, for this to happen key organizational commitments must be in place for staff to consistently provide the basics of care. Nursing leadership must have a consistent presence over time, they must be champions of using team and group processes involving staff throughout the facility, and they must actively guide quality improvement processes. Administrative leadership must be present and express the expectation that high quality care is expected for residents, and that workers are expected to contribute to the quality improvement effort. If facilities are struggling with achieving average or poor resident outcomes, they must first make an effort to find nursing and administrative leaders who are willing to stay with the organization. These leaders must be skilled with team and group processes for decision-making and how to implement and use a quality improvement program to improve care. These leaders must be skilled at building employee relations and at retention strategies so residents are cared for by consistent staff who know them. The results of this study illustrate the simplicity of the basics of care that residents in nursing facilities need. The results also illustrate the complexity of the care processes and the organizational systems that must be in place to achieve good outcomes. Achieving these outcomes is the challenge facing those currently working in and leading nursing facilities.

Using Spirituality to Cope With Early-Stage Alzheimer's Disease:

Alzheimers disease (AD) robs persons living with the disease of their independence and self-esteem, which can lead to depression, anxiety, and loneliness. Understanding how people with early-stage AD cope is a critical step in enhancing their adaptive abilities and ultimately improving their quality of life. This qualitative study describes how individuals with early-stage AD use spirituality to cope with the losses of self-esteem, independence, and social interaction that they face. The purposive sample for this focused ethnographic study consisted of 15 participants living at home in central Arkansas. Holding onto faith, seeking reassurance and hope, and staying connected were the global themes. Personal faith, prayer, connection to church, and family support enhanced the ability of people with early-stage AD to keep a positive attitude as they face living with AD.

Improving quality of care in nursing facilities. Gerontological clinical nurse specialist as research nurse consultant.

It is becoming increasingly common for nursing facilities to use Quality Indicators (QI) derived from Minimum Data Set (MDS) data for quality improvement initiatives within their facilities. It is not known how much support facilities need to effectively review QI reports, investigate problems areas, and implement practice changes to improve care. In Missouri, the University of Missouri-Columbia MDS and Nursing Home Quality Research Team has undertaken a Quality Improvement Intervention Study using a gerontological clinical nurse specialist (GCNS) to support quality improvement activities in nursing homes. Nursing facilities have responded positively to the availability of a GCNS to assist them in improving nursing facility care quality.

Why Older Adults with Light Care Needs: Enter and Remain in Nursing Homes

Many patients in nursing homes receive limited services. In 1996, approximately 17% of the 1.6 million nursing home residents received assistance with two or less activities of daily living (ADL). This descriptive study addressed this issue by investigating why residents with light care needs enter and remain in nursing homes. Residents with light care needs (N = 20) identified by directors of nursing were interviewed to elicit why they entered and remain in nursing homes. Their care level was estimated using the Minimum Data Set (MDS) and Resource Utilization Groups, Version III (RUG-III). In this study, older adults with light care needs who decide to enter and remain in nursing homes were found to be influenced by a prior hospitalization or a health event; the perceived inability to manage instrumental ADLs (IADLs), ADLs, or health monitoring at home; and lack of knowledge about alternatives to nursing home care. This study demonstrates the vital role nurse case managers can play in both acute care settings and nursing homes. They can help older adults with light care needs to make informed decisions about long-term care, seek out community options, and set in place assistive care systems that can help them age in the community.