Nonprofit Home Research Articles

Home care workers' views of employment conditions: private for-profit vs public and non-profit providers in Ireland

PurposeThe purpose of this paper is to compare home care workers' views of their employment conditions by provider type – private for-profit vs public and non-profit – using the case study of Ireland.Design/methodology/approachAn online survey was distributed to care workers (n = 350) employed by private for-profit, public and non-profit home care providers in Ireland. Returned questionnaires were analysed statistically in R using chi-squared tests to systematically compare key aspects of employment conditions.FindingsAnalysis shows that conditions are perceived to be significantly worse for those employed by private for-profit providers (and to a lesser extent non-profit organisations) compared to the public provider. There are wide disparities between public and private sector conditions in terms of contracts, pensions, unsocial hours pay and travel time allowances. The main area of convergence is in relation to employer support, where although the public sector performed better, the difference between the three provider types is smaller.Originality/valueRelatively little research compares working conditions in private for-profit providers vs public and non-profit providers in Ireland and other countries. The findings can be understood in the context of marketisation reforms and may partly be explained by a lack of regulation in Ireland's home care sector and low unionisation rates amongst care workers employed by private for-profit providers.

2053. The Need to Expand the Infection Prevention Workforce in Home Infusion Therapy

Abstract Background Infection preventionists who perform surveillance for central line-associated bloodstream infections (CLABSIs) in hospitals receive training in application of rigorous surveillance definitions. However, in the home infusion setting where CLABSIs also occur, the approach for training and methods to perform surveillance has not been well defined. Objective In this qualitative study, we sought to characterize how home infusion surveillance staff are trained in CLABSI surveillance and to identify barriers to CLABSI surveillance in the home infusion setting. Methods We interviewed 21 surveillance staff members of five non-profit home infusion agencies covering portions of thirteen states and Washington, DC across the Mid-Atlantic, Northeast, and Midwest. Interview questions were developed using the Systems Engineering in Patient Safety (SEIPS) 2.0 framework. Data were analyzed both inductively and deductively by two team members. These interviews are part of a larger study, some of whose findings have been previously discussed in prior publications. Data specific to training home infusion surveillance staff in CLABSI surveillance are presented (Table 1). Results Many of the CLABSI surveillance staff had received no formal training in CLABSI surveillance. Instead, many either learned on the job (often from predecessors who also had not been formally trained), drew from previous clinical experience, perused online resources, or attended conferences. A lack of (1) resources for learning, (2) formal training offered by their agencies, and (3) awareness of professional development resources were identified as barriers to CLABSI surveillance training in the home infusion setting. Conclusion Our findings indicate a current lack of formal training in CLABSI surveillance for staff performing CLABSI surveillance in home infusion therapy. The home infusion surveillance workforce can be strengthened by providing home infusion-specific standardized training, perhaps through adaptations of resources used for training surveillance staff in other settings. Disclosures Sara E. Cosgrove, MD, Basilea: Member of Infection Adjudication Committee.

Institutional Business Power: The Case of Ireland’s Private Home Care Providers

AbstractThe marketisation of European home care has given rise to significant private for-profit providers growth. However, little research has focused directly on commercial companies to examine the mechanisms through which they emerge, grow and shape long-term care policy – this is this paper’s task. Drawing on the literature on business power, the recent concept of “institutional business power” is introduced, defined as the power flowing from the entrenched position of business actors in the provision of public social services. The paper identifies the mechanisms through which private providers have grown and assesses the extent of their institutional power by examining their influence on policy and the support they obtain from relevant home care stakeholders. The limits of providers’ institutional power are also discussed. The paper relies on semi-structured interviews with representatives of public, private and non-profit home care providers.

Home with Hope: Green Infrastructure EEE 495: Urban Water Projects

Urban landscapes have serious impacts on water quality through the disruption of the hydrologic cycle. The Purdue University course, Environmental and Ecological Engineering 49500: Urban Water Projects, seeks to use student-led service-learning projects to improve both water quality and quantity in the Wabash River water-shed. This year, students investigated and implemented strategies to guarantee that previous implementations succeed well into the future. Two students, Victoria Chillscyzn and Madeline McIntosh, were part of a team working with the local nonprofit Home with Hope. Through interviews, a survey, and site visits, the team determined action items to improve the form and function of the installations. A grant was submitted and accepted through Purdue Student Service-Learning Grant Program for Community Service/Service-Learning Projects to fund an additional rain barrel and an edible garden at the nonprofit. Additionally, educational materials and a maintenance schedule were created to bolster care of the site. This course gave the authors the ability to give back to the local community in a meaningful and relevant way.

Does the Profit Motive Matter? COVID-19 Prevention and Management in Ontario Long-Term-Care Homes.

We introduce evidence that for-profit long-term-care providers are associated with less successful outcomes in coronavirus disease 2019 outbreak management. We introduce two sets of theoretical arguments that predict variation in service quality by provider type: those that deal with the institution of contracting (innovative competition vs. erosive competition) and those that address organizational features of for-profit, non-profit, and government actors (profit seeking, cross-subsidization, and future investment). We contextualize these arguments through a discussion of how contracting operates in Ontario long-term care. That discussion leads us to exclude the institutional arguments while retaining the arguments about organizational features as our three hypotheses. Using outbreak data as of February 2021, we find that government-run long-term-care homes surpassed for-profit and non-profit homes in outbreak management, consistent with an earlier finding from Stall et al. (2020). Non-profit homes outperform for-profit homes but are outperformed by government-run homes. These results are consistent with the expectations derived from two theoretical arguments—profit seeking and cross-subsidization—and inconsistent with a third—capacity for future investment.

Identifying Urinary Tract Infection-Related Information in Home Care Nursing Notes

ObjectivesUrinary tract infection (UTI) is common in home care but not easily captured with standard assessment. This study aimed to examine the value of nursing notes in detecting UTI signs and symptoms in home care. DesignThe study developed a natural language processing (NLP) algorithm to automatically identify UTI-related information in nursing notes. Setting and ParticipantsHome care visit notes (n = 1,149,586) and care coordination notes (n = 1,461,171) for 89,459 patients treated in the largest nonprofit home care agency in the United States during 2014. MeasuresWe generated 6 categories of UTI-related information from literature and used the Unified Medical Language System (UMLS) to identify a preliminary list of terms. The NLP algorithm was tested on a gold standard set of 300 clinical notes annotated by clinical experts. We used structured Outcome and Assessment Information Set data to extract the frequency of UTI-related emergency department (ED) visits or hospitalizations and explored time-patterns in documentation of UTI-related information. ResultsThe NLP system achieved very good overall performance (F measure = 0.9, 95% CI: 0.87-0.93) based on the test results obtained by using the notes for patients admitted to the ED or hospital due to UTI. UTI-related information was significantly more prevalent (P < .01 for all the tests) in home care episodes with UTI-related ED admission or hospitalization vs the general patient population; 81% of home care episodes with UTI-related hospitalization or ED admission had at least 1 category of UTI-related information vs 21.6% among episodes without UTI-related hospitalization or ED admission. Frequency of UTI-related information documentation increased in advance of UTI-related hospitalization or ED admission, peaking within a few days before the event. Conclusions and ImplicationsInformation in nursing notes is often overlooked by stakeholders and not integrated into predictive modeling for decision-making support, but our findings highlight their value in early risk identification and care guidance. Health care administrators should consider using NLP to extract clinical data from nursing notes to improve early detection and treatment, which may lead to quality improvement and cost reduction.

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths.

Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes. We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19. The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7%) were for profit, 162 (26.0%) were nonprofit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.19-3.05), the number of residents (adjusted OR 1.38, 95% CI 1.18-1.61), and older design standards of the home (adjusted OR 1.55, 95% CI 1.01-2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95% CI 1.26-3.05) and the number of resident deaths (adjusted RR 1.78, 95% CI 1.03-3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership. For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.

Understanding Reporting of Type II Workplace Violence Among Home Health Care Nurses.

Background: Home health care nurses (HHNs) work alone in patients' homes. They experience high rates of Type II (client/patient-on-worker) workplace violence (WPV); however, little is known about the extent and factors of their reporting. Methods: A convenience sample of employees aged 18 years and older and working as an HHN or management staff were recruited from a U.S. nonprofit home health care agency. To describe the extent of reporting of WPV events, an HHN survey was conducted. To identify the barriers and facilitators to reporting, two HHN focus groups were conducted, and management key informant interviews were employed. Findings: We recruited 18 HHNs and five management staff into the study. Almost all HHNs reported to management the most serious forms of violence they experienced, and that HHNs reported WPV when they perceived that reporting was beneficial (alerting other nurses and management) and supported by management staff. However, they were unwilling to report when it was perceived as disadvantageous (reliving the trauma), discouraged (by a norm that experiencing violence is a part of the job), unachievable (unstandardized reporting process), and ambiguous (uncertain of what is reportable). Management staff perceived a lack of standardized reporting processes as a barrier when responding to HHNs' reporting. Conclusion/Application to Practice: High reporting was related to strong support from management. Policies and procedures should clearly define WPV, the threshold for reporting, how to report, and how management will respond to the reports.

Employee Inclusion During Change: The Stories of Middle Managers in Non-Profit Home Care Organizations

Although extensive studies have provided valuable information to establish a strong relationship between the success of change and variables like communication, employee commitment, and leadership, it is important to understand the experiences of workers during a change process. The research problem exists because there is a minimal exploration of the experiences of middle management in the process of corporate decision-making during organizational change adoption in the home care industry. The purpose of this study was to explore the experience of middle managers related to employee inclusion during an organizational restructuring in non-profit home care organizations. The researcher interviewed six middle managers from two non-profit home healthcare organizations in New York City using purposive sampling. The results reflected the experiences of middle managers in non-profit home care organizations and may be transferable to other organizations. The findings were categorized under the following themes: Stress and Fear, Task-Oriented Leadership Behavior, Employee Exclusion, and Job Dissatisfaction. Employers should recognize and engage middle managers in corporate decision-making that target middle managers. As change is inevitable, understanding the experience of middle managers is crucial for leaders in home care organizations undergoing organizational restructuring because of the top-down management structure in these organizations. The information may be relevant for leaders to incorporate attitudes and steps that promote a good relationship and engage middle managers in the processes of organizational change.

Does Ownership Matter in the Selection of Service Providers? Evidence From Nursing Home Consumer Surveys

This study considers the role of ownership in consumer choice of service providers in mixed-ownership industries. First, it analyzes theoretically consumer search in the face of severe asymmetric information about important service attributes in a market where nonprofit, for-profit, and local government providers coexist. Second, the article distinguishes between two consumer decision strategies, traditional search for information, and using ownership as a signal of quality. Third, the article analyzes an original data set about nursing homes and their customers (residents and their families). We found that (a) despite empirical evidence showing that nonprofit nursing homes are of higher quality, consumers who use ownership status in their search were more likely to choose for-profit organizations; (b) better educated consumers are more likely to choose nonprofit over for-profit organizations; (c) consumers who search more in-depth and who find information about nursing home lobbies less important for selection are more likely to choose homes that are nonprofit. The choice of local government–owned homes is based on a process that resembles weakly the process used to choose nonprofit homes more than for-profit homes.

Community REACH: An Implementation of an Evidence-Based Caregiver Program.

Family caregivers (CGs) are critical to the provision of long-term services and support for older adults. Numerous intervention programs to alleviate CG distress have been developed and evaluated yet few have been implemented in community settings. This paper describes and presents outcomes from Community REACH, a community implementation of the evidence-based Resources for Enhancing Alzheimer's Caregiver Health (REACH) II program. Community REACH involved a partnership between REACH II investigators and United HomeCare Services (UHCS), a nonprofit home health organization that provides home health, personal care, companion, and respite services. The intervention program, an adapted version of an evidence-based program, was a 6-month multicomponent psychosocial intervention, which involved six individual face-to-face and six individual telephone sessions, and telephone support groups. One hundred and forty-six CGs who were primarily female (76%) and Latino, and providing care for an individual with Alzheimer's disease (AD) were enrolled. Program effectiveness was assessed by examining changes in perceived social support, burden, and depression, and CG self-efficacy. At 6 months, CGs reported significant decreases in depression, burden, being and bothered by the care recipient's memory problems. There was also a significant decline in the number of CGs at risk for clinical depression. These improvements were maintained at 12 months and there was an increase in feelings of social support. The findings indicate that evidence-based CG programs can be successfully implemented in community settings and benefit CGs of AD patients. A continued partnership between the program developers and community partners is key to implementation success.

Wolves in sheep’s clothing: Is non-profit status used to signal quality?

Why do many firms in the healthcare sector adopt non-profit status? One argument is that non-profit status serves as a signal of quality when consumers are not well informed. A testable implication is that an increase in consumer information may lead to a reduction in the number of non-profits in a market. We test this idea empirically by exploiting an exogenous increase in consumer information in the US nursing home industry. We find that the information shock led to a reduction in the share of non-profit homes, driven by a combination of home closure and sector switching. The lowest quality non-profits were the most likely to exit. Our results have important implications for the effects of reforms to increase consumer provision in a number of public services.

Managers' Compensation in a Mixed Ownership Industry: Evidence from Nursing Homes.

An extensive literature is devoted to differences between for-profit and non-profit health-care providers’ prices, utilization, and quality. Less is known about for-profit and non-profit managers’ compensation and its relationship with financial and quality performance. The aim of this study is to examine whether for-profit and non-profit nursing homes place differential weights on financial and quality performance in determining managers’ compensation. Using a unique 8-year dataset on Ohio nursing homes, fixed-effect regression models of managers’ compensation include financial and quality performance as well as other explanatory variables concerning firm and market characteristics and manager qualifications. Among for-profit nursing homes, compensation of owner-managers and non-owner managers are compared. Compensation of for-profit managers is significantly positively associated with profit margin and return-on-assets, while compensation of non-profit managers does not exhibit any consistent relationship with financial measures. Compensation of neither for-profit nor non-profit managers is significantly related to quality measures. Nursing home size and managers’ years of experience are the only consistent determinants of compensation. Owner-managers earn significantly higher compensation than non-owner managers and their compensation is less related to nursing home performance. Finding that home size and experience are strong determinants of compensation, and the association with ownership and financial performance for for-profit nursing homes are as expected. The insignificant relationship between compensation and quality performance is potentially troublesome.

Managing in the Regulatory Thicket: Regulation Legitimacy and Expertise

AbstractAlthough the influence of government regulation on organizations is undeniable, empirical research in this field is scarce. This article investigates how the understanding of and attitudes toward government regulation among public, nonprofit, and for‐profit managers affect organizational performance, using U.S. nursing homes as the empirical setting. Findings suggest that managers’ perceptions of regulation legitimacy—views of regulation fairness, inspectors’ effectiveness, and internal utility of the mandates—positively affect service quality. Subgroup analysis suggests that managers’ views of regulation matter in nonprofit and for‐profit organizations but not in public organizations. In nonprofit homes, performance declines when managers report higher regulatory expertise—better knowledge of the regulatory standards. In for‐profit facilities, frequent communication with regulators lowers quality. These findings suggest that the regulated entities’ views of government regulation are central to their success, which necessitates improvements in the regulatory process.

The Global Information Accountability Project at Five Years

The Accountability Project marked its five-year anniversary in April 2014. During each of its five years, the Project provided shape and definition to the data protection practices that make up accountability. The result has influenced lawmakers, regulators and policy makers to adopt elements of accountability.The Project’s first year established that, to be accountable, an organisation should design and implement comprehensive data and privacy protection programmes based on analysis of the risks data use raises for individuals and on responsible decisions about how those risks can be appropriately mitigated. Through its Galway Paper, the Project articulated essential elements of how an accountable organisation demonstrates commitment to accountability, implements data privacy policies linked to recognise outside criteria and establishes performance mechanisms to ensure responsible decision making about the management of data consistent with organisation policies. It is against these elements that an organisation’s accountability is measured.In its second year, the Project issued the Paris Paper that proposed the fundamental conditions of accountability that an organisation put in place and be able to demonstrate to regulators. It further considered how, and under what circumstances, regulators, data protection authorities and their designated agents would measure accountability. The Project anticipated that organisations and regulators must be able to implement and measure the fundamentals in a manner suitable for the organisation, its business model, and the way it collects, uses, and stores data. In year three, the Project considered accountability as an approach to privacy and data protection required and implemented across the marketplace, and articulated the benefits that would accrue to individuals, the market and organisations as a result. While all organisations would adopt accountability in this model, the Project presented the Madrid Paper that identified instances in which an organisation might seek recognition of its accountability. It also described under what circumstances organisations would be required to demonstrate their accountability and what exactly that demonstration would entail.By the Project’s fourth year in 2012, accountability had emerged as a recognised approach to privacy and data protection. The European Commission had proposed a data protection regulation that would apply across European Union (“EU”) member countries and in which accountability played a critical role. The Federal Privacy Commissioner of Canada and Information Commissioners of Alberta and British Columbia in Canada released a document articulating what data protection authorities would expect of organisations under an accountability approach. The Asia-Pacific Economic Cooperation (“APEC”) forum finalised its Cross Border Privacy Rules system, an accountability-based code of conduct for businesses in the APEC region.In its fifth year, the Project focused on the application of accountability under specific conditions such as distributed environments, public clouds and scalability. That year, the Project introduced risk as another element of consideration. The influence of the Project could be seen in the work of the regulators with the Hong Kong Privacy Commissioner’s guidance, “A Best Practice Guide.” In addition, the influence of the Project included the Article 29 Working Party and the APEC Data Privacy Subgroup release of their review of the EU’s Binding Corporate Rules (“BCRs”) and APEC’s CBPR system. Both explicitly acknowledged the common elements of the two accountability-certifying systems that used very different assessment processes. While the work of the Project continued at the Centre, a new organisation, the Foundation was formed to provide a non-profit home for work to implement accountability into governance structures. The Foundation focused its efforts on international dialogue on specific infrastructure issues related to accountability with a presentation before the Organisation for Economic Co-operation and Development (“OECD”).

For-profit medicare home health agencies' costs appear higher and quality appears lower compared to nonprofit agencies.

For-profit, or proprietary, home health agencies were banned from Medicare until 1980 but now account for a majority of the agencies that provide such services. Medicare home health costs have grown rapidly since the implementation of a risk-based prospective payment system in 2000. We analyzed recent national cost and case-mix-adjusted quality outcomes to assess the performance of for-profit and nonprofit home health agencies. For-profit agencies scored slightly but significantly worse on overall quality indicators compared to nonprofits (77.18 percent and 78.71 percent, respectively). Notably, for-profit agencies scored lower than nonprofits on the clinically important outcome "avoidance of hospitalization" (71.64 percent versus 73.53 percent). Scores on quality measures were lowest in the South, where for-profits predominate. Compared to nonprofits, proprietary agencies also had higher costs per patient ($4,827 versus $4,075), were more profitable, and had higher administrative costs. Our findings raise concerns about whether for-profit agencies should continue to be eligible for Medicare payments and about the efficiency of Medicare's market-oriented, risk-based home care payment system.

Effect of nursing home ownership on the quality of post-acute care: An instrumental variables approach

Given the preferential tax treatment afforded nonprofit firms, policymakers and researchers have been interested in whether the nonprofit sector provides higher nursing home quality relative to its for-profit counterpart. However, differential selection into for-profits and nonprofits can lead to biased estimates of the effect of ownership form. By using “differential distance” to the nearest nonprofit nursing home relative to the nearest for-profit nursing home, we mimic randomization of residents into more or less “exposure” to nonprofit homes when estimating the effects of ownership on quality of care. Using national Minimum Data Set assessments linked with Medicare claims, we use a national cohort of post-acute patients who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for ownership status, we found that post-acute patients in nonprofit facilities had fewer 30-day hospitalizations and greater improvement in mobility, pain, and functioning.

Attitudes of long-term care staff toward dementia and their related factors

Attitudes of residential care staff toward residents with dementia affect the quality of care. We examined the attitude of frontline residential care staff toward residents with dementia, and how the presence of specialized care units or programs may affect staff attitude. Staff working in nursing homes participated in a survey which covered demographic data, current state of dementia care in workplace, opinion regarding dementia care, and perceived importance of dementia behaviors. 1,047 nurses and personal care workers participated. 78.8% respondents reported difficulties in managing dementia residents. Those who ranked positive symptoms as more important were 4.5 times more likely to report difficulties, independent of experience. Independent factors associated with positive attitudes toward further training were working in a non-profit home (OR 2.4, 95% CI 1.1, 5.0; p = 0.024) and having a dementia program or unit in the current workplace (OR 1.8, 95% CI 0.985, 3.302; p = 0.056). Only having a dementia program or unit in the current workplace was associated with a positive attitude toward commitment to stay in dementia care (OR 1.9, 95% CI 1.1, 3.2; p = 0.021), adjusted for gender, type of home, post, dementia prevalence in workplace, and work experience. The majority of long-term care staff felt dementia care difficult yet hold positive attitude toward further training and were committed to stay in dementia care. Having a specialized dementia care unit or program in the current workplace was associated with commitment to stay in dementia care and was marginally associated with positive attitude toward further training.

Under-recognition of dementia in long-term care homes in Hong Kong

Objective: To examine the extent to which dementia in nursing homes is recognized by staff. Methods: About 189 residents with very mild to moderate dementia (Clinical Dementia Rating, CDR ≥ 0.5) and Mini-Mental State Examination (MMSE) = 10–24 were recruited from 12 nursing homes in Hong Kong. A senior staff in each home provided information on whether the participant was known to have dementia, and if so, the exact diagnosis. Logistic regression was conducted to predict identification by age, gender, whether for-profit or non-profit home, length of stay, MMSE, CDR, activities of daily living, and use of cholinesterase inhibitors and antipsychotic medications. Results: It was observed that 42.3% of the sample had mild dementia and 14.8% had moderate dementia. Although identification rates increased with increasing severity of cognitive impairment, only 30.0% of those with mild dementia and 64.3% of those with moderate dementia were known to have dementia by the homes. Identification rates did not differ between for-profit homes and non-profit homes which had regular MMSE screening. Logistic regression analysis showed that only MMSE (OR = 0.85, 95% CI = 0.76–0.95, p = 0.005) and CDR = 2 (as compared with CDR = 0.5; OR = 4.78, 95% CI = 1.23–18.65, p = 0.024) were significantly associated with dementia recognition. No other factors were related to dementia recognition. Conclusions: Despite a high prevalence of dementia in long-term care facilities, recognition of dementia as a medical condition in residents by staff was suboptimal, and MMSE screening in some homes did not seem to increase awareness significantly.

Experiencing the Benefits of Nonprofit Home Healthcare and Hospice Employment

Experiencing the Benefits of Nonprofit Home Healthcare and Hospice Employment