Nursing Home Research Articles

Private Enterprises and Innovative Interventions in Long-Term Care for Older People: Insights into Residual Stereotypes of Greek Rural Areas

In many areas of rural Greece there exist remnants of traditional stereotypes that were socially constructed in closed societies where the institution of the patriarchal family previously reigned and are regenerated by the dominant culture. These stereotypes have shaped over time the perception that long-term care for older adults should be provided within the family structure and exclusively by family members. Notably, it was previously considered a disgrace in Greek rural society if children moved their parents to a residential or nursing home. Public or other care facilities for older people emerged just two decades ago, except a few led by the church. However, these attitudes have been softened in recent years. European and National funded programmes have shaped different notions towards long-term care in these areas. This was facilitated by the structural changes that occurred in the Greek countryside in combination with the existing low birth rate in these areas and the presence of concrete migratory flows. The present study explores the business environment that is being formed and its potential to unleash the productive forces that have pinned down the relevant residual stereotypes. It also examines the socio-economic impact of the above enterprises on rural areas. Qualitative interviews were conducted with eight entrepreneurs who have invested in rural long-term care settings for older persons and eight elected chairpersons of local councils. Our findings indicate that regardless of financial support towards private care entities for older people, in order for the services offered to take a more prominent social role, the development of local consensus and innovative interventions is required in tandem. If achieved, such care providers can contribute to the socio-economic development of rural areas. This study provides international literature with further evidence on the crucial role of such enterprises on supportiveness towards inhabitants’ quality of life improvement while results can be useful for Greek and European decision-making centers as well as potential rural entrepreneurs.

Prescribing Trends and Associated Outcomes of Antiepileptic Drugs and Other Psychotropic Medications in US Nursing Homes: Proposal for a Mixed Methods Investigation.

Pilot data suggest that off-label, unmonitored antiepileptic drug prescribing for behavioral and psychological symptoms of dementia is increasing, replacing other psychotropic medications targeted by purposeful reduction efforts. This trend accelerated during the COVID-19 pandemic. Although adverse outcomes related to this trend remain unknown, preliminary results hint that harms may be increasing and concentrated in vulnerable populations. Using a mixed methods approach including both a retrospective secondary data analysis and a national clinician survey, this study aims to describe appropriate and potentially inappropriate antiepileptic and other psychoactive drug prescribing in US nursing homes (NHs), characteristics and patient-oriented outcomes associated with this prescribing, and how these phenomena may be changing under the combined stressors of the COVID-19 pandemic and the pressure of reduction initiatives. To accomplish the objective, resident-level, mixed-effects regression models and interrupted time-series analyses will draw on cohort elements linked at an individual level from the Centers for Medicare and Medicaid Services' (CMS) Minimum Data Set, Medicare Part D, Medicare Provider Analysis and Review, and Outpatient and Public Use Files. Quarterly cohorts of NH residents (2009-2021) will incorporate individual-level data, including demographics; health status; disease variables; psychotropic medication claims; comprehensive NH health outcomes; hospital and emergency department adverse events; and NH details, including staffing resources and COVID-19 statistics. To help explain and validate findings, we will conduct a national qualitative survey of NH prescribers regarding their knowledge and beliefs surrounding changing approaches to dementia care and associated outcomes. Funding was obtained in September 2022. Institutional review board exemption approval was obtained in January 2023. The CMS Data Use Agreement was submitted in May 2023 and signed in March 2024. Data access was obtained in June 2024. Cohort creation is anticipated by January 2025, with crosswalks finalized by July 2025. The first survey was fielded in October 2023 and published in July 2024. The second survey was fielded in March 2024. The results are in review as of July 2024. Iterative survey cycles will continue biannually until December 2026. Multidisciplinary dissemination of survey analysis results began in July 2023, and dissemination of secondary data findings is anticipated to begin January 2025. These processes are ongoing, with investigation to wrap up by June 2027. This study will detail appropriate and inappropriate antiepileptic drug use and related outcomes in NHs and describe disparities in long-stay subpopulations treated or not treated with psychotropics. It will delineate the impact of the pandemic in combination with national policies on dementia management and outcomes. We believe this mixed methods approach, including processes that link multiple CMS data sets at an individual level and survey-relevant stakeholders, can be replicated and applied to evaluate a variety of patient-oriented questions in diverse clinical populations. DERR1-10.2196/64446.

Clinical profiles of older adults in French Caribbean nursing homes: a descriptive cross-sectional study.

Nursing homes in the Caribbean are scarce and the characteristics of their residents have not been previously documented. This study aimed to describe the clinical profiles of residents living in nursing homes in Guadeloupe and Martinique (French West Indies). This is a cross-sectional study of the baseline screening data from the KASEHPAD (Karukera Study of Ageing in nursing homes) study. Clinical characteristics and geriatric scale scores, including the Activities of Daily Living (ADL), Mini-Mental State Examination (MMSE), Mini Nutritional Assessment Short-Form (MNA-SF) and Short Physical Performance Battery (SPPB) were collected and analysed. A total of 332 older adults were recruited between September 2020 and November 2022. The mean age of the residents was 81.3 ± 10.1, with a male-female ratio of 1:1. Diabetes was reported in 28.3% of the residents, hypertension in 66.6% and heart disease in 18.4%. Dementia was diagnosed in 52.3% of the residents and 74.9% had a MMSE score ≤18. The prevalence of Parkinson's disease was 9.0%. Additionally, 18.4% were unable to perform any basic activities of daily living (ADL score of 0). The prevalence of physical impairment (SPPB < 8) was 90.0%. One-quarter of the residents were classified as undernourished (MNA-SF score ≤ 7). Residents in Caribbean nursing homes are younger than in metropolitan France, whereas they present quite similar clinical profiles. Notably, a high prevalence of diabetes, cardiovascular diseases and neurodegenerative diseases was observed. This study represents a preliminary effort to address the knowledge gap regarding the aging trajectories of older adults in the Caribbean and could guide the development of future nursing homes in these countries.

Delirium in nursing home residents: is there a role of antidepressants? A cross sectional study

BackgroundDelirium is strongly associated with poor health outcomes, yet it is frequently underdiagnosed. Limited research on delirium has been conducted in Nursing Homes (NHs). Our aim is to assess delirium prevalence and its associated factors, in particular pharmacological prescription, in this care setting.MethodsData from the Italian “Delirium Day” 2016 Edition, a national multicenter point-prevalence study on patients aged 65 and older were analyzed to examine the associations between the prevalence of delirium and its subtypes with demographics and information about medical history and pharmacological treatment. Delirium was assessed using the Assessment test for delirium and cognitive impairment (4AT). Motor subtype was evaluated using the Delirium Motor Subtype Scale (DMSS).Results955 residents, from 32 Italian NHs with a mean age of 84.72 ± 7.78 years were included. According to the 4AT, delirium was present in 260 (27.2%) NHs residents, mainly hyperactive (35.4%) or mixed subtypes (20.7%). Antidepressant treatment with selective serotonin reuptake inhibitors (SSRIs) was associated with lower delirium prevalence in univariate and multivariate analyses.ConclusionsThe high prevalence of delirium in NHs highlights the need to systematically assess its occurrence in this care settings. The inverse association between SSRIs and delirium might imply a possible preventive role of this class of therapeutic agents against delirium in NHs, yet further studies are warranted to ascertain any causal relationship between SSRIs intake and reduced delirium incidence.

“You close the door, wipe your sadness and put on a smiling face”: a qualitative study of the emotional labour of healthcare professionals providing palliative care in nursing homes in France

BackgroundPalliative care provided to frail and dying older persons in nursing homes results in intense emotions for residents and their relatives as well as for healthcare professionals. In France, scant attention has been given to how nursing home professionals manage their emotions when providing palliative care. This study analysed the emotional demands of providing palliative care in the nursing home context, the emotional strategies used by healthcare professionals to navigate such demands, and how these demands affect their emotional wellbeing.MethodsThis qualitative study used a multiple case study approach. We purposively selected nine nursing homes from three geographical provinces in France with diverse ownership statuses (public, private, associative). Individual interviews and focus group discussions were held with 93 healthcare professionals from various occupational groups employed in the participating nursing homes. Data was collected from April 2021 to September 2022 and was analysed using thematic content analysis.ResultsData revealed that providing palliative care to dying residents within the nursing home context results in intertwined rewarding and exhausting emotional experiences for healthcare professionals. Professionals have to utilize multifaceted emotional strategies to navigate these experiences, including suppressing and modifying emotions and distancing themselves emotionally from residents to protect themselves from emotional suffering. Participants noted a lack of formal space to express emotions. Unrecognized emotional labour undermines the wellbeing of healthcare professionals in nursing homes, whereas acknowledging emotions enhances satisfaction and gives enhanced meaning to their crucial role in resident care.ConclusionAcknowledging emotional labour as an inevitable component of providing palliative care in nursing homes is critical to supporting healthcare professional wellbeing, resilience, and retention, which may ultimately improve the quality of care for dying residents. Ensuring quality care and supporting the emotional wellbeing of nursing home professionals requires an organisational culture that considers emotional expression a collective strength-building resource rather than an individual responsibility, in hopes of shaping a new culture that fully acknowledges their humanity alongside their professional skills.Trial registrationClinicalTrials.gov ID: NCT04708002; National registration: ID-RCB number: 2020-A01832-37, Registration date: 2020-12-03.

Watching care behind closed doors: upward and downward accountability mechanisms in nursing home services

ABSTRACT Nursing homes (NHs) play a critical role in caring for vulnerable people, yet their operations often remain hidden from public scrutiny, potentially causing a negative impact on service quality. We investigate upward and downward accountability mechanisms in NH services, examining how relatives of NH residents assess these mechanisms and what influences their assessments. We conducted an original survey in Spain (n = 1009), targeting direct relatives of NH residents. Our findings show important insights about the influence of private ownership, performance during COVID-19, and knowledge on the two types of accountability. The study demonstrates that downward and upward mechanisms are closely intertwined.

Cognitive assessment of nursing home residents: Survey data on tools used and perceptions of use among social service professionals in one U.S. state.

Background: Social service professionals routinely use screening tools to assess for cognitive decline or identify suspected dementia in nursing home residents. Published literature lacks details about the specific tools used and how professionals use and perceive them in practice. The aim of this study is to better understand cognitive screening roles performed by nursing home social service professionals and how they view their use and efficacy.Methods: An online survey was administered to all 230 nursing homes in the US state of Alabama between October 2021 and March 2022. Fifty-three social service professionals who conduct resident cognitive screenings responded to the survey.Results: In addition to completing the US-mandated Brief Interview of Mental Status (BIMS) quarterly, 75% of participants reported using additional tools, most notably the Mini Mental Status Examination (MMSE). Participants reported using different tools for varied purposes. Those who used both the BIMS and MMSE rated the BIMS significantly higher on ease and time to administer while rating the MMSE higher on reliability and validity. Although most participants reported high levels of confidence using the tools, over half of participants indicated interest in further training in cognitive assessment tools.Discussion: Findings provide evidence regarding who administers nursing home cognitive screenings, which tools are used, and their experiences using those tools. Participant responses reveal the value of using multiple screening tools for improved detection of cognitive status and decline for residents as well as a need for additional training in cognitive assessment. Findings also suggest that the primary tool used for cognitive screening may be quick and easy to use at the expense of perceived reliability and validity. Further evaluation of nursing home cognitive assessment is needed.

The in- and outpatient health care use of patients with COPD before and after initiation of home care: a registry study from Norway

Objective Chronic obstructive pulmonary disease (COPD) is a common condition associated with age, multimorbidity and frequently involves the use of health care across levels. Understanding the factors associated with the initiation of long-term care is important when planning the future need for services. We describe healthcare use before and after the reception of any home care. We further studied the associations between healthcare use and first registered home care service and from first registered home care service to nursing home admission or death. Design and subjects Patients residing in Oslo or Trondheim at the time of first contact with a COPD primary diagnosis, 2009–2018. Patient data were linked across national and municipal registries, covering healthcare and sociodemographics. The sample consisted of 16,738 individuals. Results There was a marked increase in inpatient and outpatient hospital contacts in the years prior to and after the reception of any home care. Adjusted for comorbidities and sociodemographics, high numbers of GP consultations, and inpatient and outpatient hospital contacts for respiratory diagnoses were associated with a significantly higher likelihood of receiving home care the next year (hazard odds ratios > 1.3). Following the reception of home care, the type of home care service received (e.g. home nursing or short-term rehabilitation/treatment) was more important than outpatient services in predicting next-year nursing home admission or death. Conclusion Including data on prior outpatient care when predicting future need for home care is beneficial. A high frequency (top 10%) of yearly GP, in- or outpatient hospital contacts can imply that the patient may be in need of home care in the near future.

Predicting the risk of nursing home placement of elderly persons using a population-based stratification score

ObjectiveTo develop and validate a novel score predictive of nursing home placement in elderly. Study designPopulation-based case-control study based on healthcare utilization databases of Lombardy, a region of Northern Italy. MethodsThe 2.4 million citizens aged ≥65 years who on January 1, 2018 lived outside nursing home formed the target population. Cases were citizens who experienced nursing home admission (the outcome of interest) until December 31, 2019. Cases were matched 1:1 by gender, age, and municipality of residence to one control. Conditional logistic regression was fitted to select candidate predictors (the exposure to 69 clinical conditions and 11 social and healthcare services) independently associated with the outcome. The model was built from the 26,156 cases, and as many controls (training set), and applied to a validation set (15,807 case-control couples). Predictive performance was assessed by discrimination and calibration. ResultsTwenty-one factors were identified as predictive of nursing home admission and were included in the “Elderly Nursing Home Placement” (ENHP) score. Mental health disorders and chronic neurological illnesses contributed most to prediction of nursing home admission. ENHP performance showed an area under the receiver operating characteristic curve of 0.77 and a remarkable calibration of observed and predicted outcome risk. ConclusionsA simple score derived from data used for public health management may reliably predict the risk of nursing home placement in elderly. Its use by healthcare decision makers allows to accurately identify high-risk individuals who need home services, thereby avoiding admission to nursing homes.

Differentiating Between Home Care Types to Identify Older Adults at Risk of Adverse Health Outcomes in the Community

ObjectivesAcute hospitalization, recurrent admissions, institutionalization, and death are important adverse health outcomes. Older adults receiving home care are especially at risk of these outcomes, yet it remains unclear if this risk differs between older adults receiving different types of home care and older adults not receiving home care. DesignRetrospective cohort study using national claims data from 2019. Setting and ParticipantsCommunity-dwelling Dutch individuals aged ≥ 65 years (N = 3,174,953). MethodsParticipants were categorized: no home care, household help, personal care, household help combined with personal care, or nursing home care at home. The primary outcomes were the number of people experiencing acute hospitalization, recurrent admissions, institutionalization, or death. Logistic regression models were applied. ResultsIn total, 2,758,093 adults were included in the no home care group, 131,260 in the household help group, 154,462 in the personal care group, 96,526 in the household help combined with personal care group, and 34,612 in the nursing home care at home group. The risk of adverse outcomes differed between home care groups, with all showing higher odds compared with the no home care group. Individuals receiving household help combined with personal care had the highest odds for acute hospitalization [odds ratio (OR), 2.60; 95% CI, 2.55–2.64] and recurrent admissions (OR, 2.60; 95% CI, 2.55–2.65), while those receiving nursing home care at home had the highest odds for death (OR, 7.59; 95% CI, 7.35–7.85) and institutionalization (OR, 63.22; 95% CI, 60.94–65.58). Conclusions and ImplicationsDifferentiating between the type of home care older adults receive identifies subpopulations with different risks for adverse health outcomes compared with older adults not receiving home care. Older adults receiving personal care (nurse based) are at high risk for these outcomes and represent a substantial population with prevention potential. Future research should focus on developing effective interventions for this group.

Expecting Relocation to a Nursing Home: Longitudinal Links with Functional Limitations, Self-Rated Health, and Life Satisfaction

Introduction: Developing realistic expectations of future old age constitutes an adaptational process which facilitates the anticipation of and adjustment to challenges, such as relocation to a nursing home. Developing such expectations might minimize the negative impacts of relocation. This pre-registered study examined (1) to which extent lower levels and declines in health (i.e., functional limitations and self-rated health) and life satisfaction before relocation were associated with higher levels and increases in expectations to relocate and (2) to which extent higher expectations to relocate were associated with more positive changes in health and life satisfaction after relocation. Methods: Using data from the Health and Retirement Study (HRS; 2006–2018), we selected older adults (aged 65 years and older) who relocated to a nursing home. We used latent growth curve models to assess the longitudinal links between self-reported measures of health, life satisfaction, and expectations to relocate to a nursing home from up to 7 years before (n = 1,048) until up to 5 years after relocation (n = 307). Results: As hypothesized, more functional limitations and lower self-rated health were related to higher expectations of relocation. Surprisingly, changes in expectations to relocate were not related to changes in health and life satisfaction before relocation. Moreover, expectations to relocate were not associated with changes in health and life satisfaction after relocation. Conclusion: The absence of a link between expectations to relocate to a nursing home with changes in health and well-being suggests that these expectations did not constitute adaptational processes before or after this transition.

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

ObjectivesTo assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs). DesignObservational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021. Setting and ParticipantsNHs (n = 678) and ALCs (n = 542) that reported staffing by shift in Ohio. MethodsResident-to-staff ratios in Ohio were calculated from staffing data. The proportion of daily nursing staff assigned to each shift was based on staffing data from the Biennial Survey for NHs and ALCs. Outcomes were calculated for aides and licensed nursing staff. ResultsOhio's NHs and ALCs had lower resident-to-staff ratios on the day shift. Lower resident-to-staff ratios mean there were more staff per resident (ie, better staffed). For both types of staff and all shifts, overall resident-to-staff ratios were lower in NHs than ALCs. However, resident-to-staff ratios for ALC MCUs were on par with NH MCUs. This was consistent with ALC and NH MCUs staffing in a more similar manner. Across all settings, the day shift had the most staff members present, while a number of ALCs had no licensed nurses on duty during the overnight shift. Conclusions and ImplicationsNHs and ALCs have different staffing patterns due to differences in resident needs. However, as ALCs provide for more residents that need NH level of care, ALCs may require additional staffing, especially on the overnight shift where some ALCs have no licensed nurses on duty. The evidence here can be used for decision making about future staffing policies, whether facility-wide policies that encompass MCUs or state-wide policies, so that care delivery aligns with care needs.

“I think we just saw happier residents”: nursing home provider reported readiness assessment of the individualized positive psychosocial interaction (IPPI) program

Objectives This study assessed the readiness of The Individualized Positive Psychosocial Interaction (IPPI) program in the nursing home (NH) setting from the perspective of NH providers implementing the IPPI. The evidence-based IPPI program is designed to help remediate distress and improve mood for residents living with dementia. NH staff are trained to engage residents in brief (i.e. 10-min) one-to-one, preference-based activities to alleviate emotional distress and enhance quality of life. Method NH providers (n = 15) who championed the IPPI implementation completed an exit interview based on the nine domains of the Readiness Assessment for Pragmatic Trials (RAPT). Interviews were audio-recorded, transcribed, and coded by RAPT domains, then scored by the research team to reflect an average for each domain. Results Providers rated the IPPI program’s readiness high on the domains of alignment, impact, risk, implementation protocol, evidence, cost, and acceptability. The domains of measurement and feasibility scored lower, likely due to broader contextual issues and require particular attention. Conclusion Results illustrate that the IPPI program successfully aligns with stakeholder priorities, is a safe intervention with minimal risk, and has beneficial outcomes. The IPPI’s low cost, design, and alignment with organizational goals also facilitated implementation while measuring outcomes and staffing considerations impacted organizational capacity for implementation.

Oral health, treatment burden and demographics of elders with care-resistant behavior: A cross-sectional study.

To assess oral health, treatment burden, mortality risk, and demographics in elders with care-resistant behaviors (CRB) in nursing homes (NH) and compare them with those without CRB. 503 participants from eight NH who received dental treatment through a mobile dental clinic were included. Their medical and dental records were screened regarding oral/dental health, treatment history, general health, demographics, and CRB. Statistical analysis was performed to show correlations between CRB and the measured parameters. Data were verified for normal distribution; a point-biserial correlation model was used (95% CI: α=0.05). No correlation was found between CRB and Decayed Missing Filled Teeth (DMF-T) (rpb=-0.061, p=.177), as well as periodontal status (rpb=0.004, p=.946). A negative correlation was observed between CRB and the required number of treatment procedures (rpb=-0.181, p<.0001), time (rpb=-0.118, p=.010), and costs (rpb=-0.100, p=.028). Sex predilection for men regarding CRB was evident (rpb=-0.155, p=.01). No correlation appeared between CRB and vital status (rpb=-0.41, p=.355). Oral health seems to be similar in institutionalized elders with or without CRB. Treatment burden was not elevated, but even reduced in elders with CRB, evincing that few/no treatment procedures were performed in those elders. CRB demonstrated a sex predilection for men. An association between CRB and increased mortality was not evident.

Adrien Rist (1841–1923), membre de la Société Médico-Psychologique (1881) et fondateur d’une maison de santé privée à Versailles « La Châtaigneraie » (1889) (Partie I)

Professor Edouard Rist (1871–1956), a former president of the Academy of Medicine (1948), wrote an unpublished text entitled “His Memories”. This text allows us to sketch the portrait of his father: Adrien Rist (1841–1923) and to review the professional career of this alienist doctor who always had a deep sense of loyalty and attachment to France and its culture. Coming from a family of surgeons, his grandfather Jean-Louis Rist (1769–1839) was a surgeon of the Grande-Armée like his uncle Côme Damien Rist (1760–1826) and their father Jean Népomucène Sébastien Rist (1725–1798) was too a surgeon in Wissembourg. It was under the July Monarchy that A. Rist (1841–1923) was born in Strasbourg. Raised in a Protestant family, he enrolled at the Military Health Service School in Strasbourg. He left the school after one year to enroll in the medical school of the same city. However, he finished his medical study in Paris. After his externship, he was accepted as an intern on December 26, 1864. Five years later (1869), he was a doctor of medicine and became the first one to make known in France the psychophysical law of Gustav Théodor Fechner (1801–1887), which bridges the gap between psychology and the exact sciences. Then, he returned to Strasbourg where he opened a medical practice and started to prepare for the aggregation in physics at the University of Göttingen (Germany). He stayed there long enough to fall in love with Emma Cornelia Gess (1848–1928), a native of Württemberg, to whom he married on April 5, 1870. Three months after his marriage, the war with Prussia broke out. During the conflict, his wife gave birth in Strasbourg to a boy named Edouard (1871–1956). Thus, his new family life and the Franco-Prussian war and its outcome deterred him from passing the aggregation. But also, A. Rist chooses to leave Alsace so as not to renounce his French nationality. After a brief stay in Le Havre (Normandy), he decided to expatriate to Switzerland. In order to be able to practice in this country, A. Rist passed the examinations in the canton of Vaud where he provided an important memorandum on the legislation of insane persons. In 1867, the Champ de l’Air Hospital for the insane was transferred to the Bois-de-Cery located near Lausanne where six years later (1873) a new hospital called “Asile de Cery” was inaugurated. Authorized to practice in Switzerland, A. Rist became in 1873 the first doctor-director of the Bois-de-Cery. A few years earlier, the first private psychiatric clinic in Romanisch Switzerland opened: La Métairie. In 1877, he became the director of this establishment located not far from the previous one at about forty kilometers away still on the banks of Lake Geneva. Board of Directors of this private establishment composed of a majority of Geneva bankers was able to receive about forty patients of well-to-do condition who came from all over the world. A. Rist lived there with his family and the organization at La Métairie was based on the participation of the insane in the family life of the doctor. A. Rist's children (Edouard, Charles, Elisabeth and Eve) founded the “Children's Society” which aimed to give concerts and theatrical performances to the patients of La Métairie. Also, they contributed when patients ran away. At the Métairie, A. Rist received the visit of Alexandrovitch Herzen (1839–1906) who was a professor of physiology at the medical faculty of Lausanne (1881) and whose father, Alexander Ivanovich Herzen (1812–1870) was the father of Russian populist socialism. However, the separation from his children who were studying in France and the tragic death of his daughter Elisabeth at the age of 17 were two factors that led to his return to France. In 1889, A. Rist and his wife decided to leave La Métairie. Rudolf Friedreich Fetscherin (1829–1892), a former assistant physician at the Waldau (Bern; 1859) succeeded him. A. Rist moved to Versailles near Paris where he opened a nursing home at 11 rue des Deux-Moulins: La Châtaigneraie.

Medical director presence and time in U.S. nursing homes, 2017-2023.

Federal regulations require all nursing homes to have a medical director, where medical directors oversee resident medical care and develop, implement, and evaluate resident care policies and procedures that reflect current standards of practice. This descriptive study examined medical director: (1) presence or absence and the amount of time spent from 2017 to 2023; (2) presence and time by ownership type; (3) variations in presence and time across states; and (4) overall CMS deficiencies for violations of medical director regulations. This study used federal Payroll-Based Journal (PBJ) data on staffing positions for the period of 2017-2023, along with federal nursing home ownership data and deficiencies data for 2023. More than a third of U.S. nursing homes (36.1%) reported zero medical director presence in Quarter 1, 2023. Medical director presence fluctuated between 2017 and 2023 with a decline over the past 4 years. Among nursing homes reporting a medical director, the medical director was on payroll for an average 36 min per day or 4.2 h per week per facility, and less than 1 min per resident day. Medical director presence and time varied significantly by ownership type and state. For-profit nursing homes reported a lower rate of medical director presence (61.4%) compared to non-profit (71.3%) and government (66.5%) nursing homes and reported that medical directors spent less time in the facilities. Facilities seldom (0.2%) receive regulatory deficiencies for medical director requirements. Though medical directors have a critical role in overseeing clinical care, some nursing homes report no medical director time and those that do report about 4 h per week. Together, these findings may indicate the need for improvement. More research is needed to understand these variations and the extent to which medical director regulations are being followed by nursing homes and enforced by regulators.

Registry study of cardiovascular death in Sweden 2013–2019: Home as place of death and specialized palliative care are the preserve of a minority

BackgroundPalliative care needs in patients with cardiovascular diseases (CVD) are expected to increase. For the planning of equitable palliative care, it is important to understand where people with CVD die. The aim was to examine trends in place of death, associated factors including utilization of specialized palliative services, and to what extent longitudinal development is influenced by national policy. MethodsA population-level registry study of place of death for adults deceased due to CVD (n = 209 671) in Sweden 2013–2019. Linear regression analysis was applied. ResultsThe predominant place of death was nursing home (39.1 %) and hospital (37.6 %), followed by home (22.0 %). From 2013 to 2019 home deaths increased by 2.8 % and hospital deaths decreased by 3.0 %. An overall downward trend was found for dying in hospital compared to dying at home. With variations, this trend was seen in all healthcare regions and for all CVD types, except Stockholm and cerebrovascular disease, with no significant trend. Overall, but with cross-regional variations, 2.1 % utilized specialized palliative services, while 94.2 % had potential palliative care needs. Other variables significantly influencing the trend were age and having had an unplanned healthcare visit. ConclusionDespite a slight positive trend, only a minority of people with CVD die in their own home. Regional variations in place of death and the low and varied utilization of specialized palliative services indicate inequity in access to palliative care. Hence, the impact of current national policies is questionable and calls for strengthening through inclusion of early palliative care in specific CVD policies.

Attitudes of Nursing Home Managers Regarding Cognitively Stimulating Activities in People With Dementia: A Multicentre Cross-Sectional Study.

Group-based cognitive stimulation has shown short-term benefits for the cognitive outcomes of people with dementia living in nursing homes (NH). However, group participation can be a barrier for people with advanced dementia, bedridden people or isolated people. The CogStim24 project seeks to develop and implement a new psychosocial intervention based on cognitively stimulating (CS) activities integrated into daily nursing care. As part of the intervention development process, this study aimed to survey NH managers' attitudes and describe currently used approaches to CS activities in German NH. We performed a multicentre cross-sectional study between September and December 2021 in randomly recruited NH in the German federal state of North Rhine-Westphalia. NH representatives were asked to fill in a self-developed online questionnaire. We analysed data descriptively, presenting means and standard deviations. For case scenario questions, we used a summative content analysis. We contacted 354 NH and 106 agreed to participate. Representatives of 64 facilities completed the survey. Almost all stated to have implemented CS activities. Cognitive exercises (98%), physical and relaxation exercises (98%) and reminiscence therapy (95%) were most often used. The majority (96%) thought that CS activities could support people with dementia in maintaining their cognitive functions and that nurses should have a key role in the implementation of CS activities. More than half believed that regular CS activities were easy to implement alongside routine nursing care. Results indicate that CS activities are frequently applied in German NH. The positive attitude of NH managers regarding the implementation and effects of CS activities is an important implementation resource. Nursing staff should be more involved in providing CS activities for people with dementia. Training, information, and implementation material must be made available for nursing staff who wish to have an active role in providing CS activities.

Dual-Eligible Nursing Home Residents: Enrollment Growth In Managed Care Plans That Coordinate Care, 2013-20.

Dual-eligible beneficiaries have insurance through two distinct and uncoordinated programs: Medicaid, which pays for long-term care; and Medicare, which pays for medical care, including hospital stays. Concern that this system leads to poor quality and inefficient care, particularly for dual-eligible nursing home residents, has led policy makers to test managed care plans that provide incentives for coordinating care across Medicare and Medicaid. We examined enrollment in three such plans among dual-eligible beneficiaries receiving long-term nursing home care. Two of those plans, Medicare-Medicaid plans and Fully Integrated Dual Eligible Special Needs Plans, are integrated care plans that establish a global budget including Medicare and Medicaid spending. The third, Institutional Special Needs Plans, puts insurers and nursing homes at risk for Medicare spending but not Medicaid spending. Among dual-eligible nursing home residents, enrollment in these plans increased from 6.5percent of residents per month in 2013 to 16.9percent in 2020. Enrollment varied across counties but did not vary appreciably with respect to nursing home characteristics, including the share of residents with Medicaid. As policy makers pursue strategies to coordinate medical and long-term care for dual-eligible beneficiaries, it remains critical to evaluate how these plans influence the care of dual-eligible nursing home residents.

Trends in Hyperpolypharmacy Before and After Nursing Home Admission Among Older Adults in Ontario, Canada

To examine trends in the prevalence of hyperpolypharmacy prior to and following nursing home admission in Ontario, Canada. We conducted a cohort study of adults aged 75+ years admitted to nursing homes between 2017 and 2020 using health administrative data (n = 61,470). The prevalence of hyperpolypharmacy (≥10 dispensed drugs) was assessed quarterly from ten years prior to 1.5 years following admission. Over ten years, the prevalence of hyperpolypharmacy increased from 4.4% to 12.0% (+0.2% per quarter, [p <0.001]) and further increased after admission (13.8%). Antidepressants (three-fold), antipsychotics (seven-fold) and cholinesterase inhibitors (14-fold) increased significantly over ten years prior to admission, while cardiovascular medications peaked 4 to 5 years prior to admission. While hyperpolypharmacy increased nearly three-fold in the ten years prior to nursing home admission, patterns varied by drug class. Increasing hyperpolypharmacy throughout the life course suggests opportunities exist for medication reconciliation in community and nursing home settings.