Community Long-term Care Research Articles

Denosumab for osteoporosis in older adults in long-term care: A randomized trial.

In long-term care (LTC), the incidence of hip or vertebral fractures are eight times that in the community. Despite the wide availability of osteoporosis therapy, LTC residents are omitted from pivotal trials and not treated. Denosumab is a relatively new, monoclonal antibody therapy for osteoporosis treatment. Via a randomized trial, we sought to determine the safety and efficacy of denosumab in LTC residents. We conducted a 2-year, double-blind, placebo-controlled, randomized clinical trial in 201 osteoporotic men and women aged ≥ 65 years, living in LTC communities. Participants with multimorbidity, dysmobility, and cognitive impairment were not excluded. The intervention was denosumab 60 mg subcutaneous every 6 months or placebo. Our primary outcome measures were hip and spine bone mineral density (BMD) improvement at 24 months. Secondary outcomes included BMD at other skeletal sites, function, and safety. We included 123 women and 78 men with a mean ± standard error age of 81.5 ± 0.6. Overall, 83% and 71% completed 12 and 24 months, respectively. Compared with placebo, the women receiving denosumab had a greater 24-month percent increase in spine (7.41 ± 0.93 vs. 2.15 + 0.56; p = 0.014), and total hip BMD (4.62 ± 0.62 vs. -0.19 ± 0.79; p = 0.007); and men in spine (7.91 ± 0.96 vs. 1.12 ± 1.13; p = 0.002) and total hip (3.74 ± 0.55 vs. 0.48 ± 0.74; p = 0.018). There were no significant differences in safety metrics. Denosumab was a safe and effective therapy for improving BMD in osteoporotic older men and women with multiple comorbidities in LTC.

A Novel Primary Care-Based, Practice Nurse-Led Bone Health Service for People in Long Term Care

Abstract Background 11% of all Irish hip fractures originate in the long-term care (LTC) setting and LTC residents are at the highest risk of reduced bone density. Risk is poorly managed as no primary care framework exists. A novel practice nurse-prescriber-led service is described in which risk estimation directs stratification, investigation, and treatment of fragility fracture risk. Methods Baseline assessment uses FRAX (fracture risk assessment tool) to risk-stratify using NOGG (National Osteoporosis Guideline Group) risk charts and inform the need for bone mineral density (BMD) measurement. A bone health drug optimisation process ensured patients were offered treatment at appropriate intensity. Results 107 residents of mean age 86.2 were newly admitted to long-term care in 2023. 92 were included and 15 were excluded due to poor prognosis. 10 of the 92 residents included died in 2023. 91 patients were risk-stratified into NOGG categories as follows: Low 22%, n=20; intermediate, below intervention threshold 23%, n=21; intermediate, above intervention threshold 16%, n=15; high 19%, n=17; very high 20% n=18. 84% (n=77) of those in risk categories indicating anti-resorptive treatment were not prescribed a bisphosphonate at baseline and none were prescribed Denosumab. 84% (n=42) were prescribed Vitamin D either with or without supplemental calcium and 16% were prescribed nothing to improve bone health. Post-intervention, 100% (n=43) of patients at a risk level of NOGG ‘intervention threshold’ or above were prescribed either Vitamin D with or without supplemental calcium and 58% (n=25) were prescribed anti-resorptive therapy (denosumab =47%, n=20 or bisphosphonate = 9%, n=5). Discussion of treatment with the primary care and LTC team is periodic. At the time of data capture, 88% of residents were discussed and 12% were planned for discussion. Conclusion A practice nurse-prescriber led service targeting LTC residents is effective in optimising screening and prescribing. Future work could include replication in the national LTC community.

Comparative Clinical Characteristics of Frail Older Adults in the Emergency Department: Long-Term Care Hospital versus Community Residence.

Older patients from long-term care hospitals (LTCHs) presenting to emergency departments (EDs) exhibit a higher prevalence of frailty than those from the community. However, no study has examined frailty in patients from LTCHs in the ED. This study compared frailty in older patients from LTCHs and the community. We retrospectively analyzed data from the EDs of three university hospitals between 1 August and 31 October 2023, involving 5908 patients (515 from LTCHs and 5393 from the community). The Korean version of the Clinical Frailty Scale (CFS-K) was used to assess individuals aged 65 and older. We compared clinical characteristics, frailty, length of stay (LOS), and diagnosis between patients from LTCHs (LTCH group) and the community (community group). Among ED patients, 55.0% and 35.2% in the LTCH and the community groups, respectively, were frail (p < 0.001). Of these, 71.7% in the LTCH group were hospitalized compared with 53.1% in the community group (p = 0.001). The odds ratio for in-hospital mortality was 4.910 (95% CI 1.458-16.534, p = 0.010) for frail LTCH patients and 3.748 (95% CI 2.599-5.405, p < 0.001) for frail community patients, compared to non-frail patients. Patients from LTCHs with frailty had higher hospital admission rates and increased in-hospital mortality compared to those in the community at the same frailty level. This study offers essential insights into the characteristics of older patients in LTCHs for healthcare administrators and medical staff worldwide.

The gap between expectations and reality in advance care planning in long-term care settings

Background: Advance care planning (ACP) is an integral part of good quality end-of-life care. This study aimed to explore the role and practice of ACP among health and social care professionals (HSCPs) in a community long-term care facility. Methods: This was a mixed-methods study. The study purposefully sampled 12 HSCPs from one community long-term care facility in Macao, China. All data were collected in November 2022. Results: Some participants had discussed with terminally ill residents or with families in terms of end-of-life care preferences, the average correct rate of ACP knowledge was 67.4%. Interview data showed that HSCPs were primarily concerned with information-giving. The responsibility of decision-making was found to have been placed predominantly on family members of the residents. Conclusion: Study findings raised awareness in that the execution of ACP has remained in discord with the expectations in practicing ACP. The study illuminated that the perceived sense of responsibility among HSCPs was influenced by the potential legal risks involved and consequentially impacted on the adherence to individual's decisions.

A reflection on nurturing spirituality and creativity in those living with dementia

ABSTRACT This opinion piece focuses on an award-winning, evidence-based, intergenerational art program Opening Minds through Art, which pairs volunteers with people living with dementia in long-term care communities. Research on this program shows the benefit for both individuals living with dementia and those who volunteer. For both the artist and volunteer, spiritual connections are created and nurtured through the process of creating art and conversation. The goal of this piece is to showcase the creative and spiritual capacity of persons living with dementia and provide a new perspective on engaging art activities appropriate for this population.

Health care workers’ self-perceived meaning of residential care work

BackgroundAttracting and supporting a sustainable long-term care (LTC) workforce has been a persistent social policy challenge across the globe. To better attract and retain a sustainable LTC workforce, it is necessary to adopt a unified concept of worker well-being. Meaning of work is an important psychological resource that buffers the negative impacts of adverse working conditions on workers’ motivation, satisfaction, and turnover intention. The aim of this study was to explore the positive meaning of care work with older people and its implications for health care workers’ job satisfaction and motivation to work in the LTC sector.MethodsThis study adopted a qualitative descriptive design that pays particular attention to health care workers; such as nurses, personal care workers; as active agents of the meaning making and reframing of care work in LTC communities in a East Asia city. In-depth semi-structured interviews were conducted with thirty health care workers in LTC communities in Hong Kong. Thematic analysis was employed for data analysis.ResultsThe research findings indicate that while health care workers perform demanding care work and experience external constraints, they actively construct positive meanings of care work with older people as a helping career that enables them to facilitate the comfortable aging of older people, build affectional relationships, achieve professional identity, and gain job security.ConclusionsThis qualitative study explores how health care workers negotiate the positive meaning of older people care work and the implications of meaningful work for workers’ job satisfaction and motivation to work in the LTC sector. The importance of a culturally sensitive perspective in researching and developing social policy intervention are suggested.

Evolution of Telehealth Program to Meet Current Needs of Post-Acute and Long-Term Care Communities

This article describes a telehealth program initially created to reduce transfers to acute care from the nursing home and its evolution into a robust program that includes Behavioral Health, a Medical Director program, and telenursing.

An Iterative Participatory Design Approach to Develop Collaborative Augmented Reality Activities for Older Adults in Long-Term Care Facilities.

Over four million older adults living in long-term care (LTC) communities experience loneliness, adversely impacting their health. Increased contact with friends and family is an evidence-based intervention to reduce loneliness, but in-person visits are not always possible. Augmented Reality (AR)-based telepresence activities can offer viable alternatives with increased immersion and presence compared to video calls. However, its feasibility as an interaction technology for older adults is not known. In this paper, we detail the design of two dyadic collaborative AR activities that accommodate diminished physical and cognitive abilities of older adults. The findings include a general design framework based on an iterative participatory design focusing on preferred activities, modes of interaction, and overall AR experience of eight older adults, two family members, and five LTC staff. Results demonstrate the potential of collaborative AR as an effective means of interaction for older adults with their family, if designed to cater to their needs.

Bridging Educational Grant in Nursing (BEGIN) students’ intentions for retention in long-term, home and community care: A survey protocol

IntroductionRetention of nurses in long-term care (LTC) and home and community care (HCC) settings is a growing concern. Previous evidence underscores factors which contribute to nurses’ intentions for retention in...

Eating at Risk within Long-Term Care: A Case for the Relational Ethics Lens.

Within long-term care homes (LTCHs), conflicts occur between residents' desires, LTCH constraints, and healthcare providers' concerns about risks of harm. Due to the high prevalence of dysphagia and malnutrition in these settings, decisions regarding food choices are a common source of such tensions. Existing biomedical ethical models fail to capture the complexity of the interprofessional chronic care environment. This article proposes an alternative ethical lens, the relational ethics model. We describe a case illustrating the application of a decision-making framework with a relational ethics lens for a resident with severe dysphagia and malnutrition. We highlight how the bioethics model excludes important actors from ethical decision making. We encourage registered dietitians working in LTCH to incorporate a relational ethics model into their practice to help identify resident's values and bring attention to the interconnectedness of caring relationships and contextual factors. This approach can inform difficult decisions regarding the food and nutrition choices of residents and may facilitate meaningful outcomes for both individuals and the long-term care community.

RECRUITMENT OF PERSONS WITH COGNITIVE IMPAIRMENT FROM LONG-TERM CARE SETTINGS

Abstract Research that includes persons with cognitive impairment is important to develop evidence-based care to improve outcomes. Long -term care settings have a large proportion of residents with cognitive impairment; but recruitment is known to be difficult. The purpose of this study was to compare the effectiveness of recruitment methods for a randomized controlled clinical trial of persons with cognitive impairment in 15 long-term care communities. This study utilized a retrospective, descriptive design. Sites were recruited and site characteristics recorded. Residents were recruited to participate in the study based on combinations of 12 recruitment strategies. Recruitment data was analyzed at the level of site, research staff member, and participant level. Over the study period, 279 older adults were screened and 172 enrolled. The participants were cognitively impaired. Research staff spent 39-89 hours recruiting at each site and utilized an average of four different recruitment methods per site. The most common and efficacious method was introductions of participants by site contacts. Cost of recruiting averaged $1490 per site and was correlated to the number of resident rooms (r=.60, p=0.17). Those sites with a recruiter enrolled more participants (M=14.67, S.D. 4.55) than those without a recruiter (M=9.3, S.D. 2.55), t(13) = -2.92, p=.012. Recruitment of older adults with cognitive impairment from long term care communities requires multiple methods of recruitment; skilled recruitment staff, and trust with the LTC community staff and potential participants.

BUILDING BRIDGES AND CATALYZING RESEARCH FOR EVIDENCE-BASED INFECTION CONTROL: PROJECT ECHO FOR NURSING HOMES

Abstract Nursing homes were ill-equipped for the pandemic; though facilities are required to have infection control staff, only 3% have taken a basic infection control course. Significant research has focused on infection control in the acute care setting; however, little is known about the implementation of infection control practices in long-term care communities. In this symposium, we will describe findings from the Project ECHO for Nursing Homes- a national, Patient-Centered Outcomes Research Institute (PCORI) funded study. First, Dr. Kraschnewski will present over all study findings from the stratified, cluster randomized controlled trial of 136 nursing homes that participated in up to 33 weeks of best-practice training to improve COVID-19 infection control practices. Next, Dr. Calo will present on implementation outcomes at 6-months including readiness for change and the implementation climate in the NH. Next, Ms. Heilbrunn will discuss the impacts of implementing evidence-based infection control practices through COVID-19 on NH residents’ well-being. Finally, Dr. Behrens will describe NH leadership perspectives (n=14) on preparing and maintaining care quality during times of diminishing resources. Data presented in this symposium can guide NHs in strategies to implement evidence-based infection control in their homes and informs researchers who are looking to implement similar implementation studies in the NH setting.

INITIAL FINDINGS ON THE BENEFITS OF THE TOVERTAFEL: REDUCING BEHAVIORS IN PERSONS WITH DEMENTIA

Abstract Technologies have been developed to reduce behaviors in persons with dementia by addressing unmet needs through activities that stimulate multiple senses. The Tovertafel (“magic table”) is a novel device from the Netherlands that enables purposeful play using interactive games designed to promote social, physical, and cognitive engagement in people with dementia. This study is investigating whether an intervention using the Tovertafel improves quality of life for residents with moderate to severe dementia living in long-term care communities in the Midwest. Twelve white women with an average BIM score of 6 completed the study at the initial facility. The 4-week intervention consisted of 30-minute game sessions with 2 to 6 individuals each weekday. Participants attended 2.5 sessions per week on average and displayed increased engagement during the games per facilitator reports. Direct care staff completed the Revised Memory and Behavior Problems Checklist–Nursing Home and the Apathy Evaluation Scale–10 for all participants. Data collected eight times over six consecutive weeks during the control (2 weeks) and intervention (4 weeks) periods were analyzed. After checking assumptions, paired-sample t-tests were conducted that indicated significantly fewer memory-related behaviors (p=.047) (e.g., repetitive behaviors and questions) and instances of apathy (p=.027), during the intervention period than the control. Despite reductions in depressive and disruptive behaviors, no statistically significant differences were found. Initial findings suggest that the Tovertafel could offer innovative ways to provide activities to people with moderate to severe dementia in long-term care settings, increase their quality of life, and improve interactions with staff.

POLICIES TO OUTCOMES: MULTILEVEL CONSIDERATIONS FOR THE ASSISTED LIVING WORKFORCE

Abstract Assisted living (AL) staff mix, levels, training requirements, regulatory enforcement, and career opportunities vary widely across license types, companies, and states. ALs represent the largest care providers for people living with dementia across the U.S. In most states, ALs must have enough qualified, trained staff to sufficiently meet the needs of their resident populations. While the use of interventions to address appropriate staffing levels and workforce retention is increasing, little is known about how the variation in the AL workforce relates to resident and staff experiences or manifests from policies governing these settings. This symposium uses a socioecological framework to examine AL-specific workforce variation. Presentations focus on national variation in staff training requirements, workforce recruitment and retention, trends in staffing levels, how staffing levels can relate to resident outcomes, and direct care staff experiences with stress and coping in long-term care communities. Findings emphasize similarities and differences in workforce composition and experience between states and across different types of facilities. From national comparison of state regulations to facility contexts to individual resident and staff experiences, this panel embraces multilevel contextual understanding of how policies, practices, and outcomes can intersect across AL and residential care environments. This is an Assisted Living Interest Group Sponsored Symposium.

Recruitment of older adults from long-term care settings for a longitudinal clinical trial.

Recruitment of residents for research from long-term care settings is known to be difficult. The purpose of this study was to summarize the effectiveness and cost in terms of time and dollars of recruitment methods for a cluster-randomized controlled clinical trial conducted in long-term care settings. This study was a retrospective, exploratory, descriptive analysis of recruitment data. After recruitment of 15 independent and assisted living communities, residents at each site were recruited to participate in the study using combinations of 12 different recruitment methods. Recruitment methods, time spent screening, and enrollment data were collected. Recruitment data were analyzed at the levels of site, research staff member, and participant. Over the study period, 279 older adults were screened and 172 enrolled from the 15 sites. Many participants were cognitively impaired. Research staff spent 39-89 h recruiting at each site and utilized an average of four different recruitment methods per site. Introductions of participants by site contacts yielded the most consented participants compared to other recruitment methods. Sites that had a dedicated recruiter utilized more recruiting methods and enrolled more participants than those without a dedicated recruiter. The cost of recruiting averaged $1490 per site and $93-$258 per enrollee (mean $144, standard deviation $58), but was more costly in larger facilities. Recruitment of older adults from long-term care communities requires multiple methods of recruitment, skilled recruitment staff, and trust with the staff and potential participants.

What do outlet’s and provider’s characteristics mean for family planning consumers? A comparative study of Kenya, Nigeria and Uganda

BackgroundThis research investigated the determinants of the number of family planning consumers in Kenya, Nigeria and Uganda, with a focus on outlet’s and provider’s characteristics which are important factors influencing the choice of using contraceptive methods but largely unexplored in previous literature.MethodsWe utilized a unique panel survey on outlet’s in Kenya (n = 1,321), Nigeria (n = 1,255) and Uganda (n = 842), which is part of the Consumer Market for Family Planning conducted in between 2019 and 2020, for the analysis of the pooled data (n = 3,418) and individual country. Random effects Poisson regressions were performed.ResultsThe pooled data results showed that the expected number of consumers were significantly lower in Nigeria and Uganda than in Kenya, and that working experience (provider’s characteristics), types of stores, duration of providing family planning services, participations in community outreach and host community events, and sign of family planning services (outlet’s characteristics) were significant determinants of the number of customers. The results for each country revealed interesting similarities and differences in the determinants across the three countries.ConclusionsThis study sheds light on the relationship between the number of family planning customers and outlet’s and provider’s characteristics, thus providing informative evidence-based to on-going debates on the coverage of family planning services, which is still insufficient in developing countries. As a result, the government’s family planning expenditures should instead prioritize small, private enterprises such as pharmacies or drug stores. Furthermore, it is critical to focus on several critical tasks to improve the qualities of outlets and providers to attract customers, such as ensuring that they are eye-catching, advertising FP services, have professional credentials, fulfil providers’ obligations to counsel contraceptive users, provide long-term services and community care, and have female providers.

Relationship between physical activity and perceptions of ageing from the perspective of healthy ageing among older people with frailty with chronic disease: a cross-sectional study

BackgroundIn Taiwan, the 2019 Elderly Frailty Assessment found that 11.2% of older people have frailty problems. Some researchers have found that older persons’ negative perspectives on ageing aggravate the progression of frailty, thereby increasing their risk of disability. This study aimed to investigate associations of physical activity and perceptions of ageing on perspectives of healthy ageing in older people with frailty and chronic diseases and to compare the differences in their frailty status.MethodsThis study used a descriptive cross-sectional design. Participants were recruited from community long-term care stations. The inclusion criteria were (1) no severe cognitive impairment and ability to communicate in Mandarin and Taiwanese; (2) over 65 years old; (3) at least one chronic disease; and (4) at least one debilitating item in the Study of Osteoporotic Fracture index. A total of 312 participants were recruited. The Brief Ageing Perceptions Questionnaire Chinese version, Healthy Ageing Perspectives Questionnaire, and Physical Activity Scale for the Elderly Chinese Version were used for measurement.ResultsThe study results found that demographic variables, perceptions of ageing, and physical activity were significantly correlated with perspectives on healthy ageing, including age, Activities of Daily Living, education, all domains of perceptions of ageing, and household- and work-related physical activity. With regard to the frailty status level, prefrailty was better than frailty from the perspective of healthy ageing in older people with chronic disease (t = 5.35, p < 0.05). Hierarchical regression analysis was used to predict the healthy ageing perspectives of older persons with chronic disease involving a chronic time-line, positive control, health-related changes, and work-related activities. Those domains could predict 21% of the variance in healthy ageing perspectives.ConclusionIt is suggested that in community long-term care stations, health care providers can arrange activities to improve the perception of ageing that are acceptable for older people with frailty and chronic diseases and encourage older people to participate in service activities to achieve a sense of social participation.

189 Incidence of hospital admission among Long-Term Care Facility residents versus Community Dwelling older adults: a population based observational study

Abstract Background Long-Term Care Facility (LTCF) residents are prone to acute illness and hospital admission due to underlying factors including advanced age, chronic comorbidity and increased frailty. This study aims to determine the incidence of hospital admission among LTCF residents in comparison to their Community Dwelling (CD) counterparts, and to describe reasons for hospitalisation, and admission-related adverse outcomes. Methods Hospital In-Patient Enquiry (HIPE) data was obtained for all LTCF residents and CD adults over the age of 75 residing in Waterford County, Ireland, who were acutely admitted in 2022. This included demographic data, International Classification of Diseases (ICD-10) diagnosis, Length of Stay (LoS), and discharge outcome. Incidence was calculated by dividing the number of persons admitted to hospital by the total population at risk over a one-year period. Chi-squared test was used to determine significant difference between the two groups. Results Admission incidence was 0.40 for LTCF residents and 0.28 for CD (p &amp;lt; 0.001). Average age was 83 years, and median LOS was seven days in both groups. The most common causes for admission among LTCF residents were infection (56%, n = 147) and falls (12%, n = 31). CD were mostly admitted with infection (31%, n = 805), cardiac issues (16%, n = 414), and falls (12%, n = 303). LTCF residents were more likely than CD to be admitted with Covid-19 infection (9% vs 4%, p = 0.003). There was no difference in mortality rates (8% LTCF vs 6% CD, p = 0.33). LTCF residents were more likely to have a diagnosis of dementia (43% vs 11%, p &amp;lt; 0.001) and develop delirium during admission (30% vs 16%, p &amp;lt; 0.0001). Conclusion LTCF residents are significantly more likely to be hospitalised than CD, and to experience delirium during admission. Proper advanced care planning and provision for treatment with intravenous antibiotics in the LTCF may reduce admissions to hospital, but more importantly will provide person-centred care and potentially improve clinical outcomes.

Experiences of Families, Staff, Volunteers, and Administrators With Namaste Care for Persons With Advanced Dementia in Canadian Long-Term Care Homes

ObjectiveTo explore the experiences of the Namaste Care intervention for persons with advanced dementia (ie, moderate and late-stage) in long-term care (LTC). DesignA qualitative descriptive design was used. Staff Carers (eg, personal support worker, nurse, or activity aide) delivered Namaste Care with the support of volunteers in a small group. Activities provided during the Namaste Care sessions to enhance quality of life included massages, aromatherapy, music, and snacks/beverages. Setting and ParticipantsFamily carers of residents with advanced dementia, LTC staff, administrators, and volunteers from 2 Canadian LTC homes, located in a midsize metropolitan area, were included. MethodsExperiences and acceptability of Namaste Care was assessed through semistructured interviews ranging from 30 to 60 minutes following the 6-month study duration period with family carers, LTC staff, administrators, and volunteers. Thematic analysis was used for interview transcripts. ResultsA total of 16 family carers and 21 LTC staff, administrators, and volunteers participated in the study. Namaste Care was found to be acceptable and successful in enhancing the quality of life of residents due to collaborative efforts of all group of participants. Families, volunteers, and staff noted positive responses in residents, such as smiling and laughing. The program environment supported the development of relationships within the LTC community, which included families, residents, staff, and volunteers. Conclusions and ImplicationsNamaste Care was perceived by the LTC community as an acceptable intervention for persons with advanced dementia. It was perceived as offering multiple benefits for residents with advanced dementia such as improved communication and mood.

Autumn in New York: The Case of Long-Term Care Facilities in the "Safe Staffing" Lawsuit With Less Staffing But Similar COVID-19 Outcomes.

In 2022, 239 New York state long-term care facilities (LTCFs) challenged a "Safe Staffing" law in court. Our study compares LTCFs involved and not involved in the lawsuit, testing for differences in staffing measures and resident outcomes during the first year of the coronavirus disease 2019 (COVID-19) pandemic. New York LTCF-level data were obtained from the Centers for Medicare and Medicaid Services 2019 organization and 2020 COVID-19 data files. These data were then linked to data from the Long-Term Care Community Coalition, which identified the LTCFs involved in the "Safe Staffing" lawsuit. We first tested for differences in reported 2019 staffing levels by lawsuit involvement. Second, we specified "Doubly Robust" regression models to test if lawsuit involvement was associated with differences in resident COVID-19 infections, COVID-19 deaths, and overall mortality. LTCFs involved in the lawsuit reported lower staff ratings and fewer staffing hours compared to LTCFs not involved in the lawsuit. Despite finding higher rates of admissions with COVID-19 in LTCFs involved in the lawsuit, we did not find that COVID-19 infections, COVID-19 deaths, or overall mortality differed by lawsuit involvement. LTCFs involved in the lawsuit were deemed by policymakers as reducing staff, earning excess profits, and placing residents at risk. While these LTCFs reported lower staffing levels, we observed no differences in resident outcomes during the first year of the COVID-19 pandemic. Researchers and policymakers should develop more nuanced perspectives concerning the relationship among LTCF staffing, outcomes, and organizational profitability.