For-profit Nursing Homes Research Articles

Nursing practice environment and registered nurses' job satisfaction in nursing homes.

Recruiting and retaining registered nurses (RNs) in nursing homes is problematic, and little research is available to guide efforts to make nursing homes a more attractive practice environment for RNs. The purpose of this study was to examine relationships between aspects of the nursing practice environment and job satisfaction among RNs in nursing homes. The sample included 863 RNs working as staff RNs in 282 skilled nursing facilities in New Jersey. Two-level hierarchical linear modeling was used to account for the RNs nested by nursing homes. Controlling for individual and nursing home characteristics, staff RNs' participation in facility affairs, supportive manager, and resource adequacy were positively associated with RNs' job satisfaction. Ownership status was significantly related to job satisfaction; RNs working in for-profit nursing homes were less satisfied. A supportive practice environment is significantly associated with higher job satisfaction among RNs working in nursing homes. Unlike other nursing home characteristics, specific dimensions of the nursing practice environment can be modified through administrative actions to enhance RN job satisfaction.

Nurse Staffing and Deficiencies in the Largest For‐Profit Nursing Home Chains and Chains Owned by Private Equity Companies

To compare staffing levels and deficiencies of the 10 largest U.S. for-profit nursing home chains with five other ownership groups and chain staffing and deficiencies before and after purchase by four private equity (PE) companies. Facilities for the largest for-profit chains were identified through Internet searches and company reports and matched with federal secondary data for 2003-2008 for each ownership group. Descriptive statistics and generalized estimation equation panel regression models examined staffing and deficiencies by ownership groups in the 2003-2008 period, controlling for facility characteristics, resident acuity, and market factors with state fixed effects. The top 10 for-profit chains had lower registered nurse and total nurse staffing hours than government facilities, controlling for other factors. The top 10 chains received 36 percent higher deficiencies and 41 percent higher serious deficiencies than government facilities. Other for-profit facilities also had lower staffing and higher deficiencies than government facilities. The chains purchased by PE companies showed little change in staffing levels, but the number of deficiencies and serious deficiencies increased in some postpurchase years compared with the prepurchase period. There is a need for greater study of large for-profit chains as well as those chains purchased by PE companies.

Ethical Climates in For-Profit, Nonprofit, and Government Skilled Nursing Facilities

This study investigates ethical climates in government, nonprofit, and for-profit nursing homes and determines their similarities and differences. Surveys were collected from 656 (21.4%) licensed nurses who worked in 100 skilled nursing facilities in one Midwestern state. Shared law and code and caring ethical climates were identified across the 3 sector nursing homes. Those climates were also polarized. Important implications were drawn for consideration of ethical perceptions of each sector during negotiations and contract management.

Off-Label Use of Second-Generation Antipsychotic Agents Among Elderly Nursing Home Residents

This study examined off-label and evidence-based use of second-generation antipsychotic agents among elderly nursing home residents and factors associated with off-label use. This study involved a retrospective, cross-sectional analysis of data from the 2004 National Nursing Home Survey (NNHS). The sample included nursing home residents 65 years and older who received second-generation antipsychotic agents. This study used an indication-based definition of off-label use established by the U.S. Food and Drug Administration (FDA). Evidence-based use included FDA-approved indications and indications for which the Agency of Healthcare Research and Quality found at least moderate strength of evidence of effectiveness. Descriptive statistics were used to examine the prevalence of off-label and evidence-based use. Multiple logistic regression was used to examine the patient and facility factors associated with off-label use of second-generation antipsychotics. According to the 2004 NNHS, 308,990 (23.5%) elderly nursing home residents received at least one second-generation antipsychotic agent. Of those using second-generation antipsychotics, 86.3% received them for off-label indications and 56.9% received them for an evidence-based use. Multivariate analysis found that age (> or =75 years), self-pay for nursing home care, diagnosis of dementia, and residing in a nonprofit nursing home were positively associated with off-label use, whereas receiving Medicaid benefits was negatively associated with such use. Although second-generation antipsychotics were frequently used for off-label indications, most of the usage was evidence based among elderly nursing home residents. However, the high level of non-evidence-based use combined with recent safety and efficacy data suggests an urgent need to address the evidence base for this vulnerable population.

An Examination of Entrepreneurial Orientation, Environmental Scanning, and Market Strategies of Nonprofit and For-Profit Nursing Home Administrators

This study explores differences in entrepreneurial orientation (EO) by profit status. In addition to EO, other survey questions sought to determine how firms scanned the external market for information and the firm’s view of external market volatility. The sample, collected in 2004, consisted of 134 nursing home administrators located in the state of Florida. The data were analyzed using generalized linear model. The results show that there was no significant difference in the EO between nonprofits and for-profits but that nonprofits were significantly more likely to engage in environmental scanning activities such as gathering information from trade magazines and suppliers and that they remained abreast of economic and technological trends more than their for-profit counterparts. Given the demands of the external market, nonprofits may find that developing strategies to better compete with for-profit firms is vital.

Characteristics of Nursing Home Social Services Directors: How Common is a Degree in Social Work?

To report the percentage of nursing homes whose social services director has a degree in social work, to report the characteristics of social service directors, and to describe the characteristics of nursing homes most likely to employ a degreed social worker. These questions are important because social workers are core members of the interdisciplinary team in nursing homes and have responsibilities for the psychosocial well-being of residents. Cross-sectional nationally representative survey of 1071 social service directors employed in US nursing homes certified to receive Medicare and/or Medicaid. Most nursing homes do employ at least one (and typically only one) social service staff person. Most are employed full-time and half have a degree in social work. About 20% do not have a college degree. The vast majority of social service directors are white and are women. Close to 40% are licensed social workers. Full-time salaries varies enormously from less than $15,000 to over $60,000 per year. Most do not belong to an organization that helps them keep apprised of developments in nursing home social services. Using logistic regression and controlling for the effects of other independent variables, for-profit nursing homes with fewer than 121 beds, in sparsely populated counties in the West are the least likely to hire a degreed social worker as social service director. The wide range in educational preparedness and salary indicates 2 roles: a social work role and a social services role. The different roles have implications for initial role preparation and continuing education. Clear communication about the role expectations associated with social services and social work would benefit residents, family, staff, and physicians, who would then be better prepared to draw on their skills in helping to meet the psychosocial needs of residents.

PACE: Has It Changed the Chronic Care Paradigm?

SUMMARY The Program of All-inclusive Care for the Elderly (PACE) grew out of a small community organization in San Francisco and has been replicated by non-profit organizations in a number of other communities across the country. The authors review the successes of PACE as reported in the literature and discuss reasons for its limited growth as well as its significant influence on state and federal long term care policy. They argue that PACE has significantly changed how we think of long term care through its pioneering work fully integrating medical and long term care. PACE has also provided an influential model for breaking down the funding silos that characterize the medical and long term care services arena. State Medicaid agencies and Medicare have learned from PACE. Health plans and private long term insurers may also still learn from PACE. However, the fact that only a little more than 10,000 elders have enrolled in PACE nationwide prevents the authors from finding that PACE has brought about significant structural change in a long term care industry dominated by for-profit nursing homes.

Nursing home performance in resident care in the United States: is it only a matter of for-profit versus not-for-profit?

Poorer resident care in US for-profit relative to not-for-profit nursing homes is usually blamed on the profit motive. But US nursing home performance may relate to Medicaid public financing in a manner qualifying the relationship between ownership and quality. We investigated effects of Medicaid resident census, Medicaid payment, and occupancy on performance. Resource dependence theory implies these predictors may affect discretion in resources invested in resident care across for-profit and not-for-profit facilities. Models on physical restraint use and registered nurse (RN) staffing were studied using generalized estimating equations with panel data derived from certification inspections of nursing homes. Restraint use increased and RN staffing levels decreased among for-profit and not-for-profit facilities when the Medicaid census increased and Medicaid payment decreased. Interaction effects supported a theory that performance relates to available discretion in resource allocation. Effects of occupancy appear contingent on the dependence on Medicaid. Poorer performance among US for-profit nursing homes may relate to for-profit homes having lower occupancy, higher Medicaid census, and operating in US states with lower Medicaid payments compared to not-for-profit homes. Understanding the complexity of factors affecting resources expended on resident care may further our understanding of the production of quality in nursing homes, whether in the US or elsewhere.

Does the public sector outperform the nonprofit and for‐profit sectors? Evidence from a national panel study on nursing home quality and access

Are public and private organizations fundamentally different? This question has been among the most enduring inquiries in public administration. Our study explores the impact of organizational ownership on two complementary aspects of performance: service quality and access to services for impoverished clients. Derived from public management research on performance determinants and nursing home care literature, our hypotheses stipulate that public, nonprofit, and for-profit nursing homes use different approaches to balance the strategic tradeoff between two aspects of performance. Panel data on 14,423 facilities were analyzed to compare measures of quality and access across three sectors using different estimation methods. Findings indicate that ownership status is associated with critical differences in both quality and access. Public and nonprofit organizations are similar in terms of quality, and both perform significantly better than their for-profit counterparts. When compared to nonprofit and, in some cases, for-profit facilities, public nursing homes have a significantly higher share of Medicaid recipients. The paper proposes strategies to address the identified long-term care divide.

Ownership Issue Can Compromise Patient Care

ARNOLD S. RELMAN is professor emeritus of medicine and of social medicine at Harvard Medical School, Boston, and a former editor-in-chief of the New England Journal of Medicine. The views in this column are those of the writer. If you would like to express another viewpoint on this issue, please contact us at www.caringfortheages.com. About two-thirds of U.S. nursing homes are investor owned, mostly by large chains. Most nursing home income is derived from Medicaid and a smaller fraction from Medicare and out-of-pocket private payments. Payments are based on standard per diem charges, although they may vary according to the level of nursing care provided to residents, and, in the case of self-paying residents, by the amenities offered. With payment fixed, facilities generate net income only if they operate with economic efficiency. Everything else being equal, the less they spend on staffing and on service to residents, the more profit they make. A careful study published about 6 years ago in the American Journal of Public Health reported that serious deficiencies in care, found by government inspection, were 40% more frequent in private investor-owned nursing homes than in nonprofit private homes (Am. J. Pub. Health 2001;91:1452–55). Nurse staffing at the investor-owned facilities was 32% lower than in nonprofit facilities. Similar, but less rigorous, earlier studies had drawn the same general conclusions. A recent report in The New York Times has added to this evidence. The front-page story in the Sept. 23, 2007, issue reported that after investment companies acquired ownership of for-profit nursing home chains, deficiencies in care found by government regulators increased above the national average. The for-profit chains were selling out to the investment companies as a means of avoiding litigation over their many bad outcomes. Whenever corporate imperatives to generate profit for investors conflict with the requirements for optimum care, as they clearly do in investor-owned nursing homes, there is always the danger that management will cut corners to keep its costs down and maximize net income, thereby jeopardizing the safety of residents. Investor ownership, not just of nursing homes, but of almost any health care facility that is paid on a fixed per diem or per treatment basis, carries this same kind of risk. Their overhead expenses are almost always higher, and to meet investors' expectations, corporate managers must reduce the money spent on staff and services. They do not possess unique skills in cutting corners without compromising patient care, so fixed payment to investor-owned facilities is likely to affect the quality of care. The nursing home story is just one example of the mischief created by investor ownership of health care facilities. Health care should be regarded as a social service, not as a business or industry. Investors invaded the U.S. health care field a few decades ago, in search of profits—not to lower costs to payers, or to improve the quality or accessibility of services. There can be no comprehensive solution to the problems of health care in our country until we restore facilities to nonprofit ownership and replace current market forces with socially responsive regulation.

Facility and county effects on racial differences in nursing home quality indicators

This study's goal was to examine the effects of nursing home (NH) and county racial mix on quality of care in NHs. We examined quality indicator (QI) outcomes for residents in 408 urban New York NHs in July through September, 1995. The QI outcomes studied were restraint and antipsychotic drug use (for low and high-risk residents), and at study commencement, these QIs were being used by the Centers for Medicare and Medicaid Services to monitor the quality of care in USA Medicare and/or Medicaid-certified NHs. A hierarchical modeling approach was used to properly reflect the nesting of both residents within NHs and NHs within counties. Separate regression models were fit to the two strata of interest (Urban Non-Hispanic Whites and Urban African Americans) to test, for each race group, the effect on quality of residing in NHs and counties with higher proportions of African Americans (than state medians). Descriptive analyses found that, compared to Whites, the unadjusted restraint rate was lower for African Americans while the antipsychotic drug rate was higher. For both race groups, multi-level analyses showed residence in for-profit NHs was associated with higher likelihoods of being restrained, and of receiving antipsychotic drugs. Also, for both race groups, residence in NHs with higher proportions of African-Americans was associated with lower likelihoods of being restrained and with higher, statistically nonsignificant, likelihoods of receiving antipsychotic drugs. Higher NH nurse staffing ratios were associated with higher likelihoods of being restrained and with lower likelihoods of antipsychotic drug use (statistically significant for low-risk African-Americans). Findings support the notion that differential care is provided in USA NHs caring for higher proportions of African-American residents and thereby suggest intervention at the organizational level is warranted to improve QI outcomes for both race groups.

Characteristics Associated With Depression in Long-Term Care Residents With Dementia

We describe the prevalence, assessment, and treatment of, as well as characteristics associated with, depression in residential care/assisted living and nursing home residents with dementia. Overall, 25% of the participants were depressed. Depression was related to severe cognitive impairment, behavioral symptoms, pain, and for-profit nursing home residence.

Staffing levels in not-for-profit and for-profit long-term care facilities: Does type of ownership matter?

Currently there is a lot of debate about the advantages and disadvantages of for-profit health care delivery. We examined staffing ratios for direct-care and support staff in publicly funded not-for-profit and for-profit nursing homes in British Columbia. We obtained staffing data for 167 long-term care facilities and linked these to the type of facility and ownership of the facility. All staff were members of the same bargaining association and received identical wages in both not-for-profit and for-profit facilities. Similar public funding is provided to both types of facilities, although the amounts vary by the level of functional dependence of the residents. We compared the mean number of hours per resident-day provided by direct-care staff (registered nurses, licensed practical nurses and resident care aides) and support staff (housekeeping, dietary and laundry staff) in not-for-profit versus for-profit facilities, after adjusting for facility size (number of beds) and level of care. The nursing homes included in our study comprised 76% of all such facilities in the province. Of the 167 nursing homes examined, 109 (65%) were not-for-profit and 58 (35%) were for-profit; 24% of the for-profit homes were part of a chain, and the remaining homes were owned by a single operator. The mean number of hours per resident-day was higher in the not-for-profit facilities than in the for-profit facilities for both direct-care and support staff and for all facility levels of care. Compared with for-profit ownership, not-for-profit status was associated with an estimated 0.34 more hours per resident-day (95% confidence interval [CI] 0.18-0.49, p < 0.001) provided by direct-care staff and 0.23 more hours per resident-day (95% CI 0.15-0.30, p < 0.001) provided by support staff. Not-for-profit facility ownership is associated with higher staffing levels. This finding suggests that public money used to provide care to frail eldery people purchases significantly fewer direct-care and support staff hours per resident-day in for-profit long-term care facilities than in not-for-profit facilities.

Predicting Lawsuits against Nursing Homes in the United States, 1997–2001

To examine how nursing home characteristics impacted the number of lawsuits filed against the facilities in the United States during 1997-2001. A stratified random sample of 2,378 nursing home in 45 states from 1997-2001. Data were obtained from Westlaw's Adverse Filings: Lawsuits database, the Centers for Medicare and Medicaid Services' (CMS) Online Survey, Certification, and Reporting (OSCAR) database, state complaint surveys, and through primary data. Negative binomial regression was used to explain total lawsuit variance by year. Explanatory variables included (a) facility characteristics-including staffing, number of beds, multistate system membership, for-profit ownership, (b) quality indicators-including total number and type of quality survey deficiencies, pressure sore development, and (c) market area-state has resident rights statutes, state complaint information. Resident acuity levels and year effects were controlled for. Nursing homes were identified and linked to Westlaw data that was searched for the number of lawsuits filed against the home, and then linked to OSCAR data and a primary data analysis of multistate chain membership. Staffing levels for certified nursing assistants (CNAs) and registered nurses (RNs) and multistate chain membership were negatively related with higher numbers of lawsuits. More deficiencies on the licensing survey, larger, for-profit nursing homes, and being located in resident rights states were positively related with higher numbers of lawsuits. This study suggests that nursing homes that meet long-stay staffing standards and minimum quality indicators, are nonprofit, smaller, and not located in resident rights states will experience fewer lawsuits.

Comparing quality of care in non-profit and for-profit nursing homes: a process perspective

Using data from a sample of nursing homes, this paper uses an operations centric approach to test the economic hypothesis asserting that quality in non-profit healthcare entities will exceed quality in for-profit counterparts [Arrow, K., 1963. Uncertainty and welfare economics of medical care. The American Economic Review, 5, 941–973]. For-profit healthcare entities face an inherent conflict between providing profits to investors and health welfare to patients. Thus, non-profit entities exist as a signal and evidence of higher quality services. To date, research examining differences in quality between for-profit and non-profit nursing homes has focused on a direct link between outcome quality and non-profit status. These studies have produced inconclusive or mixed results. We argue that non-profit or for-profit status and outcome quality are linked via two intermediate factors, namely process quality and input quality. Consistent with many prior studies, we report no direct link between non-profit status and outcome quality. However, we report that process quality is indeed higher at non-profit nursing homes than for-profit nursing homes, but that input quality is lower. We also examine the association between outcome quality with process and input quality. We report that different aspects of process quality are tied to better outcome quality, but report several notable exceptions. This research provides support for Arrow's hypothesis at the process level and gives insights into the link between process quality, input quality and outcome quality in the nursing home environment.

Jane Dent Home: The Rise and Fall of Homes for the Aged in Low-Income Communities

The Jane Dent Home was established in 1898 (as the Home for Aged and Infirm Colored People) to serve African American elderly barred from admission to most homes for the aged. Sustained by community leadership through difficult times, the Home finally closed in 1975 after growing and persistent racial and economic segregation of Chicago's low-income neighborhoods combined with pressure from state government to ensure fire safety. This history illustrates the decline of not-for-profit homes for the aged while for-profit nursing homes were capturing market share. In Chicago this trend is strongest in low-income communities of color, which may lead to lower quality of care for such communities. Support for indigenous not-for-profit long-term care may promote the goals of health care equity articulated by Healthy People 2010.

Factors predicting lawsuits against nursing homes in Florida 1997-2001.

We explore how nursing home characteristics affect the number of lawsuits filed against the facilities in Florida during the period from 1997 to 2001. We examined data from 478 nursing homes in 30 Florida counties from 1997 to 2001. We obtained the data from Westlaw's Adverse Filings: Lawsuits database, the Online Survey, Certification, and Reporting system database from the Centers for Medicare and Medicaid Services, and state complaint surveys, and we also used primary data. We used negative binomial regression to explain total lawsuit variance by year. We controlled for acuity and year effects, and our explanatory variables included (a) facility characteristics--including staffing, number of beds, multistate system membership, and for-profit ownership--and (b) quality measures--including total number and type of state licensing survey deficiencies, pressure-sore development, and medication errors per resident. Higher registered nurse and certified nursing assistant staffing levels were associated with fewer lawsuits. More deficiencies on the licensing survey and larger and for-profit nursing homes were positively related with higher numbers of lawsuits. This study suggests that nursing homes that meet long-stay staffing standards, meet minimum quality measures, are not for profit, and are smaller will experience fewer lawsuits.

Competitive spillovers across non-profit and for-profit nursing homes

The importance of non-profit institutions in the health care sector has generated a vast empirical literature examining quality differences between non-profit and for-profit nursing homes. Recent theoretical work has emphasized that much of this empirical literature is flawed in that previous studies rely solely on dummy variables to capture the effects of ownership rather than accounting for the share of non-profit nursing homes in the market. This analysis considers whether competitive spillovers from non-profits lead to higher quality in for-profit nursing homes. Using instrumental variables to account for the potential endogeneity of non-profit market share, this study finds that an increase in non-profit market share improves for-profit and overall nursing home quality. These findings are consistent with the hypothesis that non-profits serve as a quality signal for uninformed nursing home consumers.

Enacting litigious environments: litigation and Florida's nursing homes.

This article examines how different for-profit nursing home facilities with varying levels of lawsuit risk responded to the litigious environment existing in Florida during 1999. Specifically, this article considers the question: How do nursing home staffs differ in their views of litigation risks and their reactions to those perceived risks? To answer this question, this study examined selected Florida facilities from a large, multinational, for-profit long-term-care chain.

Consumer information and competition between nonprofit and for-profit nursing homes

This paper develops implications of Arrow's hypothesis that nonprofit organizations are prevalent in health care because of quality uncertainty. The model analyzes the ability of nonprofits to mitigate market failures created by asymmetric information in an environment characterized by potential competition from both explicitly for-profit firms and for-profits in disguise (profit-motivated firms who obtain nonprofit status in order to exploit the perceived trustworthiness of the nonprofit sector). Under certain conditions, it is shown that nonprofit status can serve as a credible signal of quality and that nonprofits can decrease the underprovision of quality both by providing high quality services and indirectly via a spillover effect on quality in the for-profit sector. Applicability to long-term care and implications for empirical research and policy towards nonprofits in health care are discussed.