Nursing Home Care Providers Research Articles

The optimal intervention for preventing physical restraints among older adults living in the nursing home: A systematic review.

This study aimed to evaluate the effectiveness of restraint reduction programs for nursing home care providers in enforcing physical restraint on residents and identify the best strategies for such programs. Systematic Review. We searched for randomized controlled trials published until February 2021 for systematic review. The systematic review captured multifactorial interventions, education and consultation measures, including nursing home residents' and care providers' results. Study quality was assessed using the Cochrane Collaboration criteria. In all seven trials, the interventions were led by a nurse specialist or unit leader and targeted at care providers. Five of the restraint reduction programs effectively reduced the rate of physical restraint use; two increased knowledge of restraint reduction for care providers; and one each promoted positive attitudes and behaviours. Duration of at least 6 weeks significantly improved the knowledge of care providers.

THE INFLUENCE OF NURSING HOME CONTEXT ON IMPLEMENTATION: EARLY FINDINGS

Abstract Evidence suggests that organizational context, including context of care in nursing homes (NHs) is associated with implementation and improvement success and that optimized context contributes to improved resident and staff outcomes. However, evidence on mechanisms of these influences is scarce. The longitudinal Translating Research in Elder Care program (2007 to present) is our data source. This symposium reports findings of a secondary analysis of longitudinal organizational structural and contextual, staff worklife, and resident care quality data collected in nursing homes from 2007-2021, in a cohort of 94 Canadian nursing homes. Our data include continuously collected administrative data (RAI-MDS 2.0), 5 waves of primary surveys from multiple care providers in NHs (15,000 cases to date), extensive qualitative case study data, and data from two large scale pragmatic trials. The TREC program was framed originally and continues to be, using the Promoting Action on Research Implementation in Health Services (PARiHS) framework. Each of our 5 papers will report on a critical aspect of the findings. The symposium will conclude with a discussion of implications of these findings of phase one and a description of phase two and how it is shaped by our interactions with expert panels (context and implementation experts, policymakers, NH managers, paid care providers, and residents and families). Early implications of this work for future research in nursing homes and for practice and policy will be mentioned.

Medical Decision-Making Practices for Unrepresented Residents in Nursing Homes.

Unrepresented adults are individuals who lack decision-making capacity and have neither an available surrogate decision maker nor an applicable advance directive. Currently, the prevalence of unrepresented nursing home (NH) residents and how medical decisions are made is unknown. We examined (1) the prevalence of unrepresented NH residents, (2) NH policies and procedures to address medical decision making for those residents, and (3) NH staff's perceptions of medical decision making for unrepresented residents. We reviewed resident medical records and NH policy and procedure documents. We also conducted a survey of NH staff using an investigator-developed questionnaire. Sixty-six staff members recruited from 3 NHs (433 residents total) in 1 metropolitan area of Georgia, USA. Medical records and policy and procedure documents were reviewed using preset criteria. The survey included 31 structured and open-ended questions regarding medical decision-making practices for unrepresented residents (eg, awareness of medical decision-making processes, experiences in medical decision making, and suggestions to improve practice). We used descriptive statistics and conventional content analysis. Four residents (1%) met the criteria of being unrepresented. We found no written statements that specifically addressed medical decision making for unrepresented residents in the participating NHs. Of 66 survey participants, 11 had been involved in medical decision making for unrepresented residents. The most common decisions involved do-not-resuscitate orders, major medical and surgical treatments, and life-sustaining treatments. These decisions were made primarily by relying on the resident's physician or through discussions within the facility's interdisciplinary team. Suggestions included adopting explicit mechanisms or protocols related to decision making for unrepresented residents, education/training, and resources for group-based decision making. Although prevalence in the 3 NHs was low, NH care providers, ethical and legal professionals, and other key stakeholders should discuss practical approaches and policies to systematically identify unrepresented residents and to improve NHs' medical decision-making practices for them.

Do public nursing home care providers deliver higher quality than private providers? Evidence from Sweden

BackgroundSwedish nursing home care has undergone a transformation, where the previous virtual public monopoly on providing such services has been replaced by a system of mixed provision. This has led to a rapidly growing share of private actors, the majority of which are large, for-profit firms. In the wake of this development, concerns have been voiced regarding the implications for care quality. In this article, we investigate the relationship between ownership and care quality in nursing homes for the elderly by comparing quality levels between public, for-profit, and non-profit nursing home care providers. We also look at a special category of for-profit providers; private equity companies.MethodsThe source of data is a national survey conducted by the Swedish National Board of Health and Welfare in 2011 at 2710 nursing homes. Data from 14 quality indicators are analyzed, including structure and process measures such as staff levels, staff competence, resident participation, and screening for pressure ulcers, nutrition status, and risk of falling. The main statistical method employed is multiple OLS regression analysis. We differentiate in the analysis between structural and processual quality measures.ResultsThe results indicate that public nursing homes have higher quality than privately operated homes with regard to two structural quality measures: staffing levels and individual accommodation. Privately operated nursing homes, on the other hand, tend to score higher on process-based quality indicators such as medication review and screening for falls and malnutrition. No significant differences were found between different ownership categories of privately operated nursing homes.ConclusionsOwnership does appear to be related to quality outcomes in Swedish nursing home care, but the results are mixed and inconclusive. That staffing levels, which has been regarded as a key quality indicator in previous research, are higher in publicly operated homes than private is consistent with earlier findings. The fact that privately operated homes, including those operated by for-profit companies, had higher processual quality is more unexpected, given previous research. Finally, no significant quality differences were found between private ownership types, i.e. for-profit, non-profit, and private equity companies, which indicates that profit motives are less important for determining quality in Swedish nursing home care than in other countries where similar studies have been carried out.

Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review.

BackgroundPoor oral health has been a persistent problem in nursing home residents for decades, with severe consequences for residents and the health care system. Two major barriers to providing appropriate oral care are residents’ responsive behaviors to oral care and residents’ lack of ability or motivation to perform oral care on their own.ObjectivesTo evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents’ responsive behaviors to oral care, or enable/motivate residents to perform their own oral care.Materials and methodsWe searched the databases Medline, EMBASE, Evidence Based Reviews–Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science for intervention studies assessing the effectiveness of eligible strategies. Two reviewers independently (a) screened titles, abstracts and retrieved full-texts; (b) searched key journal contents, key author publications, and reference lists of all included studies; and (c) assessed methodological quality of included studies. Discrepancies at any stage were resolved by consensus. We conducted a narrative synthesis of study results.ResultsWe included three one-group pre-test, post-test studies, and one cross-sectional study. Methodological quality was low (n = 3) and low moderate (n = 1). Two studies assessed strategies to enable/motivate nursing home residents to perform their own oral care, and to studies assessed strategies to prevent or overcome responsive behaviors to oral care. All studies reported improvements of at least some of the outcomes measured, but interpretation is limited due to methodological problems.ConclusionsPotentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents’ responsive behaviors to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies.

Impact of Symptoms and Care Practices on Nursing Home Residents at the End of Life: A Rating by Front-line Care Providers

ObjectivesBurdensome symptoms and potentially inappropriate care practices are common at the end of life for nursing home residents. Appropriately managing symptoms and limiting aggressive care practices is key to high-quality end-of-life care. Little research is available, however, on the opinions of nursing home care providers about the impact of symptoms and practices for both residents and care facilities. Our objectives were to (1) identify common burdensome symptoms and potentially inappropriate practices at the end of life for nursing home residents, (2) develop and assess the feasibility of a procedure to have various groups of nursing home care providers rate impact of symptoms and practices, and (3) generate recommendations for action and further research, with key policy and decision makers. DesignProof-of-concept study. Partnered research by researchers, health professionals, and decision makers to identify and explore the impact of burdensome symptoms and potentially inappropriate care practices for nursing home residents at the end of life. SettingThirty-six nursing homes from Alberta, Manitoba, and Saskatchewan. ParticipantsA total of 6007 residents (prevalence rating); 4 medical directors, 5 directors of care, 4 nurse practitioners, 4 registered nurses, 5 licensed practical nurses, 5 care aides (impact rating); and 13 key policy or decision makers from Alberta, British Columbia, and Manitoba (expert panel). MethodsBased on a literature search and data in the Resident Assessment Instrument–Minimum Data Set (RAI-MDS) 2.0, we generated lists of burdensome symptoms and potentially inappropriate care practices for nursing home residents at the end of life. We rated prevalence of those symptoms and practices in the last quarter before death as high, medium, or low. Care providers rated the burden of symptoms and inappropriateness of practices as high, medium, or low. Directors of care rated the unnecessary cost of those symptoms and practices to a nursing home as high, medium, or low. We ranked symptoms and practices based on those ratings. We discussed our findings in an interactive expert panel and generated recommendations for action and further research. MeasurementsRAI-MDS 2.0 (symptom prevalence rating); online survey to rate symptoms and practices (impact rating). ResultsThe 3 most prevalent symptoms were urinary incontinence (79.7%), fecal incontinence (66.7%), and responsive behaviors (63%). The 3 most prevalent practices were polypharmacy (9+ medications; 55.2%), antipsychotic use with no diagnosis of psychosis (29.2%), and physical restraint use (18.7%). The symptoms rated as having highest overall impact were pain, responsive behaviors, and urinary incontinence. Practices rated as having the most impact were polypharmacy, hospital and emergency department transitions, and antipsychotic use with no diagnosis of psychosis. ConclusionBurdensome symptoms and inappropriate care practices near the end of life for residents in nursing homes are highly prevalent. Attending to those symptoms and practices is necessary to improve the quality of dying for nursing home residents. Our study provides preliminary demonstration of the feasibility and importance of engaging the spectrum of care providers in assessing the impact of symptoms and care practices on resident experience. Experiences of this proof-of-concept study will be the basis for the development of an indicator profile to monitor and improve quality of end-of-life care in nursing homes in the future.

ECHO-AGE: An Innovative Model of Geriatric Care for Long-Term Care Residents With Dementia and Behavioral Issues

ObjectivesTo design, implement, and assess the pilot phase of an innovative, remote case-based video-consultation program called ECHO-AGE that links experts in the management of behavior disorders in patients with dementia to nursing home care providers. DesignPilot study involving surveying of participating long-term care sites regarding utility of recommendations and resident outcomes. SettingEleven long-term care sites in Massachusetts and Maine. ParticipantsAn interprofessional specialty team at a tertiary care center and staff from 11 long-term care sites. InterventionLong-term care sites presented challenging cases regarding residents with dementia and/or delirium related behavioral issues to specialists via video-conferencing. MethodsBaseline resident characteristics and follow-up data regarding compliance with ECHO-AGE recommendations, resident improvement, hospitalization, and mortality were collected from the long-term care sites. ResultsForty-seven residents, with a mean age of 82 years, were presented during the ECHO-AGE pilot period. Eighty-three percent of residents had a history of dementia and 44% were taking antipsychotic medications. The most common reasons for presentation were agitation, intrusiveness, and paranoia. Behavioral plans were recommended in 72.3% of patients. Suggestions for medication adjustments were also frequent. ECHO-AGE recommendations were completely or partially followed in 88.6% of residents. When recommendations were followed, sites were much more likely to report clinical improvement (74% vs 20%, P < .03). Hospitalization was also less common among residents for whom recommendations were followed. ConclusionsThe results suggest that a case-based video-consultation program can be successful in improving the care of elders with dementia and/or delirium related behavioral issues by linking specialists with long-term care providers.

Music in the nursing home: hitting the right note! The provision of music to dementia patients with verbal and vocal agitation in Dutch nursing homes

The study aims to provide insight into the type of music being offered in Dutch nursing homes to patients with both dementia and verbal and vocal agitation. It also investigates the degree to which the music offered corresponds to the musical preferences of the nursing home residents. Using random sampling, 20 nursing homes were selected to participate in this study. Within these homes, semi-structured interviews were conducted with nursing home physicians (n = 17) and other nursing home care providers (n = 20). Each interview focused on up to three psychogeriatric residents with verbal and vocal agitation. In total, 51 residents were discussed in the interviews. For each resident, the frequency of music, the type of music being offered, and the degree of correspondence between the music being offered and the resident's preferences varied. In almost all cases, music was being offered in the communal living room during the mid-morning coffee and the afternoon tea, while music was only infrequently offered to residents during meals. However, this music was not tailored to the preferences of the residents. During patient-centered care activities in the early morning and before sleep, when offered, the music was generally tailored to the preferences of the resident(s). Music is frequently played in nursing homes to patients with dementia who have verbal and vocal agitation. When offered to a group of residents, the music tends not to be tailored to the preferences of the residents. However, when offered individually, musical preferences are generally taken into account.

DO NONPROFIT AND GOVERNMENT NURSING HOMES ENTER UNPROFITABLE MARKETS?

Using data from markets in the rural United States, this study addresses whether nonprofit and government nursing facilities locate in markets that for‐profit firms cannot profitably enter, thereby expanding access to nursing care to populations that would not otherwise be served. The results indicate that while nonprofit and for‐profit nursing homes typically enter similar markets, government nursing homes are more likely to enter markets that have small populations generally and too few elderly residents to be profitable for for‐profits. The results have implications for the efficient provision of access to long‐term care for isolated populations and other underserved groups. (JEL L10, L20, I11)

Using the Minimum Data Set to Determine Predictors of Terminal Restlessness Among Nursing Home Residents

The aim of this study was to determine predictive variables of terminal restlessness that were selected from the Minimum Data Set (MDS) among nursing home residents. A descriptive, cross-sectional design was used to retrospectively review decedents' Minimum Data Set records. Four independent variables from the MDS (distressed mood, problem conditions, pain, and medications) were examined as to whether they were predictive variables of terminal restlessness by utilizing path analysis statistical method. Residents from a nursing home located in the northwestern United States who died during 2000 and 2001, had at least one MDS record and no comatose in their MDS cognitive patterns were selected. A total of 84 decedents' records were consequently recruited for use in this study. A path analysis result showed (a) 44.6% of the variance in distressed mood is predicted by two variables: problem conditions (beta = .557) and pain (beta = .193) and (b) 34% of the variance in terminal restlessness is predicted by two variables: pain (beta = .370) and distressed mood (beta = .313). Results indicate that residents who (a) had more problem conditions and more pain are more likely to have distressed moods and (b) experienced more pain and had more distressed moods have a higher incidence of terminal restlessness. These findings provide important and valuable clinical implications. A careful evaluation of pain is necessary, especially as many elders are not able to communicate well during the terminal phase of their lives. How to access residents' moods and provide appropriate and immediate interventions, comfort, and even just being there for them are imperative for nursing home care providers.

The importance of intimacy to men living in a nursing home

Intimacy and its contribution to life satisfaction have not been explored among institutionalized elders. We studied residents of a Veterans Affairs nursing home and assessed cognitive and physical function, life satisfaction, and importance of intimacy. The Folstein Mini-Mental State, Barthel Index, Life Satisfaction Index-Z, and a series of vignettes were used to assess each domain. Vignettes depicted various scenarios (e.g., recent admission to a nursing home, notification of diagnosis of a terminal disease), and asked the subject to rate the importance of intimate social, intellectual, emotional, or physical interactions. Social intimacy was rated as most important, followed by nonsexual physical, intellectual, emotional, and finally, sexual-physical intimacy (social vs. sexual-physical, p = 0.0013). In addition, social (rs = .299, p = 0.023), nonsexual physical (rs = .312, p = 0.019), and intellectual (rs = .382, p = 0.005) intimacy were associated with life satisfaction. Nursing home care providers can enhance resident quality of life through social, intellectual, and nonsexual physical interactions even when the underlying medical, physical, or cognitive deficit cannot be ameliorated.