Zhanlian Feng

Use of physical restraints and antipsychotic medications in nursing homes: a cross-national study.

This study compares inter‐ and intra‐country differences in the prevalence of physical restraints and antipsychotic medications in nursing homes, and examines aggregated resident conditions and organizational characteristics correlated with these treatments.

Decisions to forgo hospitalization in advanced dementia: a nationwide study.

OBJECTIVES: To examine the prevalence and factors associated with decisions to forgo hospitalization in nursing home (NH) residents with advanced dementia.

Medicaid Payment Rates, Case-Mix Reimbursement, and Nursing Home Staffing-1996-2004

Objective:We examined the impact of state Medicaid payment rates and case-mix reimbursement on direct care staffing levels in US nursing homes. Methods:We used a recent time series of national nursing home data from the Online Survey Certification and Reporting system for 1996–2004, merged with annual state Medicaid payment rates and case-mix reimbursement information. A 5-category response measure of total staffing levels was defined according to expert recommended thresholds, and examined in a multinomial logistic regression model. Facility fixed-effects models were estimated separately for Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nurse Aide (CNA) staffing levels measured as average hours per resident day. Results:Higher Medicaid payment rates were associated with increases in total staffing levels to meet a higher recommended threshold. However, these gains in overall staffing were accompanied by a reduction of RN staffing and an increase in both LPN and CNA staffing levels. Under case-mix reimbursement, the likelihood of nursing homes achieving higher recommended staffing thresholds decreased, as did levels of professional staffing. Independent of the effects of state, market, and facility characteristics, there was a significant downward trend in RN staffing and an upward trend in both LPN and CNA staffing. Conclusions:Although overall staffing may increase in response to more generous Medicaid reimbursement, it may not translate into improvements in the skill mix of staff. Adjusting for reimbursement levels and resident acuity, total staffing has not increased after the implementation of case-mix reimbursement.

The Effect of State Policies on Nursing Home Resident Outcomes

OBJECTIVES: To test the effect of changes in Medicaid reimbursement on clinical outcomes of long‐stay nursing home (NH) residents.

An Industry in the Making: The Emergence of Institutional Elder Care in Urban China

Demographic shifts in China pose unprecedented challenges in the care of a rapidly growing older population. Sporadic reports suggest the recent emergence of institutional elder care in China, but little is currently known about this phenomenon. This study documents the growth, ownership, financing, staffing, and resident characteristics of elder care institutions using survey data collected in 2009 from Nanjing, China, supplemented with government registry data from seven additional major Chinese cities. Between one‐half and two‐thirds of facilities operating in these cities were founded in the last decade, primarily in the non‐government sector. In Nanjing, government ownership dominated homes built before 1990 (96%) but was increasingly rare in the 1990s (60%) and in the 2000s (23%), a pattern observed in the other seven cities as well. In Nanjing, the average home now draws more than 80% of its daily operating revenues from private‐pay or other non‐government sources, and this share increases sharply with the recency of facility establishment. The majority (85%) of non‐government‐owned homes are receiving ongoing per‐bed subsidies from the government. The lack of clinical staff characterizes the majority of study facilities; most care staff are rural migratory workers. There is considerable variability across facilities in the case‐mix of residents in terms of functional dependence and acuity levels. These findings portray the emergence and rapid growth of a nascent industry of institutional long‐term care in urban China and a fundamental shift in institutional ownership, financing, and clientele.

Elderly hispanics more likely to reside in poor-quality nursing homes.

The proportion of Hispanics age sixty-five and older who are living in nursing homes rose from 5 percent in 2000 to 6.4 percent in 2005. Although segregation in nursing homes seems to have declined slightly, elderly Hispanics are more likely than their non-Hispanic white peers to reside in nursing homes that are characterized by severe deficiencies in performance, understaffing, and poor care.

The use of contract licensed nursing staff in U.S. nursing homes.

The extent to which nursing homes rely on the use of contracted licensed staff, factors associated with this staffing practice, and the resultant effect on the quality of resident care has received little public attention. Merging the On-line Survey Certification and Reporting System database with the Area Resource File from 1992 through 2002, the authors regressed organizational and market-level variables on the use of 5 percent or more contract full-time equivalent registered nurses and licensed practical nurses. Since 1997, the proportion of facilities using 5 percent or more contract licensed staff more than tripled. Use of contract nurses was associated with more deficiency citations, characteristics of poorer facilities, and tight labor markets. Nursing homes increasingly rely on contract nurses. The failure of nursing homes to attract and retain a competent, stable workforce creates a vicious cycle of staffing practices, which may lead to decline in quality of care.

Hospital And ED Use Among Medicare Beneficiaries With Dementia Varies By Setting And Proximity To Death

Hospitalizations and emergency department (ED) visits for people with Alzheimers disease and related disorders are of particular concern because many of these patients are physically and mentally frail, and the care delivered in these settings is costly. Using data from the Health and Retirement Study linked with Medicare claims from the period 2000-08, we found that among community-dwelling elderly fee-for-service Medicare beneficiaries, those who had dementia were significantly more likely than those who did not to have a hospitalization (26.7 percent versus 18.7 percent) and an ED visit (34.5 percent versus 25.4 percent) in each year. Comparing nursing home residents who had dementia with those who did not, we found only small differences in hospitalizations (45.8 percent versus 41.9 percent, respectively) and ED use (55.3 percent versus 52.7 percent). As death neared, however, utilization rose sharply across settings and by whether or not beneficiaries had dementia: Nearly 80 percent of community-dwelling decedents were hospitalized, and an equal proportion had at least one ED visit during the last year of life, regardless of dementia. Our research suggests that substantial portions of hospitalizations and ED visits both before and during the last year of life were potentially avoidable.

Determinants of performance failure in the nursing home industry

This study investigates the determinants of performance failure in U.S. nursing homes. The sample consisted of 91,168 surveys from 10,901 facilities included in the Online Survey Certification and Reporting system from 1996 to 2005. Failed performance was defined as termination from the Medicare and Medicaid programs. Determinants of performance failure were identified as core structural change (ownership change), peripheral change (related diversification), prior financial and quality of care performance, size and environmental shock (Medicaid case mix reimbursement and prospective payment system introduction). Additional control variables that could contribute to the likelihood of performance failure were included in a cross-sectional time series generalized estimating equation logistic regression model. Our results support the contention, derived from structural inertia theory, that where in an organizations structure change occurs determines whether it is adaptive or disruptive. In addition, while poor prior financial and quality performance and the introduction of case mix reimbursement increases the risk of failure, larger size is protective, decreasing the likelihood of performance failure.

The costs of turnover in nursing homes.

Background:Turnover rates in nursing homes have been persistently high for decades, ranging upwards of 100%. Objectives:To estimate the net costs associated with turnover of direct care staff in nursing homes. Data and Sample:Nine hundred two nursing homes in California in 2005. Data included Medicaid cost reports, the Minimum Data Set, Medicare enrollment files, Census, and Area Resource File. Research Design:We estimated total cost functions, which included in addition to exogenous outputs and wages, the facility turnover rate. Instrumental variable limited information maximum likelihood techniques were used for estimation to deal with the endogeneity of turnover and costs. Results:The cost functions exhibited the expected behavior, with initially increasing and then decreasing returns to scale. The ordinary least square estimate did not show a significant association between costs and turnover. The instrumental variable estimate of turnover costs was negative and significant (P = 0.039). The marginal cost savings associated with a 10% point increase in turnover for an average facility was