Online Survey Certification Research Articles

Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment.

Empiric data and expert opinion suggest that use of feeding tubes is not beneficial for older persons with advanced dementia. Previous research has shown a 10-fold variation in this practice across the United States. To identify the facility and resident characteristics associated with feeding tube use among US nursing homes residents with severe cognitive impairment. Cross-sectional study of all residents with advanced cognitive impairment who had Minimum Data Set assessments within 60 days of April 1, 1999, (N = 186,835) and who resided in Medicare- or Medicaid-certified US nursing homes. Main Outcomes Measures Facility and resident characteristics described in the 1999 On-line Survey Certification of Automated Records and the 1999 Minimum Data Set. Multivariate analysis using generalized estimating equations determined the facility and resident factors independently associated with feeding tube use. Thirty-four percent of residents with advanced cognitive impairment had feeding tubes (N = 63,101). Resident characteristics associated with a greater likelihood of feeding tube use included younger age, nonwhite race, male sex, divorced marital status, lack of advance directives, a recent decline in functional status, and no diagnosis of Alzheimer disease. Controlling for these patient factors, residents living in facilities that were for profit (adjusted odds ratio [OR], 1.09; 95% confidence interval [CI], 1.06-1.12); located in an urban area (OR, 1.14; 95% CI, 1.11-1.16); having more than 100 beds (OR, 1.04; 95% CI, 1.01-1.07); and lacking a special dementia care unit (OR, 1.11; 95% CI, 1.07-1.15) had a higher likelihood of having a feeding tube. Additionally, feeding tube use was more likely among residents living in facilities that had a smaller proportion of residents with do-not-resuscitate orders, had a higher prevalence of nonwhite residents, and lacked a nurse practitioner or physician assistant on staff. More than one third of severely cognitively impaired residents in US nursing homes have feeding tubes. Feeding tube use is independently associated with both the residents' clinical characteristics and the nursing homes' fiscal, organizational, and demographic features.

Clinical and Organizational Factors Associated With Feeding Tube Use Among Nursing Home Residents With Advanced Cognitive Impairment

<h3>Context</h3> Empiric data and expert opinion suggest that use of feeding tubes is not beneficial for older persons with advanced dementia. Previous research has shown a 10-fold variation in this practice across the United States. <h3>Objective</h3> To identify the facility and resident characteristics associated with feeding tube use among US nursing homes residents with severe cognitive impairment. <h3>Design, Setting, and Participants</h3> Cross-sectional study of all residents with advanced cognitive impairment who had Minimum Data Set assessments within 60 days of April 1, 1999, (N = 186 835) and who resided in Medicare- or Medicaid-certified US nursing homes. <h3>Main Outcomes Measures</h3> Facility and resident characteristics described in the 1999 On-line Survey Certification of Automated Records and the 1999 Minimum Data Set. Multivariate analysis using generalized estimating equations determined the facility and resident factors independently associated with feeding tube use. <h3>Results</h3> Thirty-four percent of residents with advanced cognitive impairment had feeding tubes (N = 63 101). Resident characteristics associated with a greater likelihood of feeding tube use included younger age, nonwhite race, male sex, divorced marital status, lack of advance directives, a recent decline in functional status, and no diagnosis of Alzheimer disease. Controlling for these patient factors, residents living in facilities that were for profit (adjusted odds ratio [OR], 1.09; 95% confidence interval [CI], 1.06-1.12); located in an urban area (OR, 1.14; 95% CI, 1.11-1.16); having more than 100 beds (OR, 1.04; 95% CI, 1.01-1.07); and lacking a special dementia care unit (OR, 1.11; 95% CI, 1.07-1.15) had a higher likelihood of having a feeding tube. Additionally, feeding tube use was more likely among residents living in facilities that had a smaller proportion of residents with do-not-resuscitate orders, had a higher prevalence of nonwhite residents, and lacked a nurse practitioner or physician assistant on staff. <h3>Conclusions</h3> More than one third of severely cognitively impaired residents in US nursing homes have feeding tubes. Feeding tube use is independently associated with both the residents' clinical characteristics and the nursing homes' fiscal, organizational, and demographic features.

Avoiding Physical Restraints in Long-Term Care Facilities

Despite evidence that physical restraints and full-length bed rails do not prevent falls and injuries in nursing home residents, their use is still widespread in many facilities. Although physical restraints use in nursing homes has significantly decreased since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) in 1990, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) Online Survey Certification and Reporting (OSCAR) data show that as of March 1999, 12.7% of nursing home residents were physically restrained (physical restraints as defined by CMS) ranging as high as 23.1% in Louisiana and as low as 2.5% in Iowa. Prevention of falls and related injuries in nursing homes remains a significant clinical challenge to the nursing home care team. There is evidence that alternatives to physical restraints and full-length bed rails can be applied safely, without increasing, and probably decreasing, negative outcomes such as falls and injuries. To consistently apply care principles rooted in evidence, the care team must adhere to a care process, which includes symptom identification, assessment and cause finding, care planning (with ethical considerations, considerations of risks and benefits, principles of risk prevention and evidence-based interventions), application of interventions, monitoring (for efficacy and complications), and revisions of the care plan based on the monitoring. This must be done while maintaining regulatory compliance but without compromising the appropriate individualized care for each resident. Because federal regulations define physical restraints and essentially require adherence to the care process in a detailed fashion, regulatory requirements can be integrated into the care process without compromising appropriate care. The wide geographical variation in the rate of restraint use suggests the presence of a pervasive system problem in the care process related to the use or avoidance of restraints. This problem is in part related to societal attitudes toward the care of the elderly, in which protection and safety receive undue emphasis at the expense of individual choices, freedom, control, and individuality. Confusion as to the definition of physical restraints adds to the problem. But to achieve and enhance the quality of care, standards defining the performance expectations, structures, or processes must be substantially in place in the facility. Organizing the process of care efficiently is an important determinant of quality of care. When processes of care and teamwork related to restraints are efficient and well organized, the use of physical restraints can be avoided. To successfully avoid the use of physical restraints, a facility must educate caregivers to consider resident preferences first in any care planning process and must have in place a care process that would assure the avoidance of unnecessary restraints. However, in some instances, the continuous recording of use or physical restraints in a facility is related not to outdated or inappropriate practice, but to the way the CMS defines physical restraints (as discussed below). Many interventions (which were first used as alternatives to physical restraints) must be considered as physical restraints based on CMS functional definition. Many of these interventions are indeed appropriate and necessary as part of the individualized care planning of specific residents. These treatments may include certain special seating devices, orthotic devices, devices such as Velcro belts or lap trays on chairs, and even the use of constraint therapy for poststroke rehabilitation. Frequently, such treatments or interventions are not intended to be used as restraints but rather as functional enablers for various purposes such as positioning or comfort. But because they have the effect of restricting movement, they must be defined as restraints. This is not necessarily negative because defining such devices as restraints assures that the team provides risk assessment and preventive interventions for potentially negative outcomes related to restricting mobility. The desire to create a “restraint free” environment, or remain in regulatory compliance, should not prevent the care team from providing appropriate interventions for specific residents who need them The purpose of this article is to describe the principles of a process of care that would help providers avoid use of restraints and institute other appropriate treatments and intervention to address resident risks or symptoms. It is likely that following the appropriate process of care in assessment, care planning, intervention, and monitoring of patients’ symptoms would cause the care team to plan for appropriate treatments Lutheran Augustana Center for Extended Care and Rehabilitation and Lutheran Medical Center, Brooklyn, New York.

Avoiding physical restraints in long-term care facilities.

Despite evidence that physical restraints and full-length bed rails do not prevent falls and injuries in nursing home residents, their use is still widespread in many facilities. Although physical restraints use in nursing homes has significantly decreased since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) in 1990, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) Online Survey Certification and Reporting (OSCAR) data show that as of March 1999, 12.7% of nursing home residents were physically restrained (physical restraints as defined by CMS) ranging as high as 23.1% in Louisiana and as low as 2.5% in Iowa. Prevention of falls and related injuries in nursing homes remains a significant clinical challenge to the nursing home care team. There is evidence that alternatives to physical restraints and full-length bed rails can be applied safely, without increasing, and probably decreasing, negative outcomes such as falls and injuries. To consistently apply care principles rooted in evidence, the care team must adhere to a care process, which includes symptom identification, assessment and cause finding, care planning (with ethical considerations, considerations of risks and benefits, principles of risk prevention and evidence-based interventions), application of interventions, monitoring (for efficacy and complications), and revisions of the care plan based on the monitoring. This must be done while maintaining regulatory compliance but without compromising the appropriate individualized care for each resident. Because federal regulations define physical restraints and essentially require adherence to the care process in a detailed fashion, regulatory requirements can be integrated into the care process without compromising appropriate care. The wide geographical variation in the rate of restraint use suggests the presence of a pervasive system problem in the care process related to the use or avoidance of restraints. This problem is in part related to societal attitudes toward the care of the elderly, in which protection and safety receive undue emphasis at the expense of individual choices, freedom, control, and individuality. Confusion as to the definition of physical restraints adds to the problem. But to achieve and enhance the quality of care, standards defining the performance expectations, structures, or processes must be substantially in place in the facility. Organizing the process of care efficiently is an important determinant of quality of care. When processes of care and teamwork related to restraints are efficient and well organized, the use of physical restraints can be avoided. To successfully avoid the use of physical restraints, a facility must educate caregivers to consider resident preferences first in any care planning process and must have in place a care process that would assure the avoidance of unnecessary restraints. However, in some instances, the continuous recording of use or physical restraints in a facility is related not to outdated or inappropriate practice, but to the way the CMS defines physical restraints (as discussed below). Many interventions (which were first used as alternatives to physical restraints) must be considered as physical restraints based on CMS functional definition. Many of these interventions are indeed appropriate and necessary as part of the individualized care planning of specific residents. These treatments may include certain special seating devices, orthotic devices, devices such as Velcro belts or lap trays on chairs, and even the use of constraint therapy for poststroke rehabilitation. Frequently, such treatments or interventions are not intended to be used as restraints but rather as functional enablers for various purposes such as positioning or comfort. But because they have the effect of restricting movement, they must be defined as restraints. This is not necessarily negative because defining such devices as restraints assures that the team provides risk assessment and preventive interventions for potentially negative outcomes related to restricting mobility. The desire to create a “restraint free” environment, or remain in regulatory compliance, should not prevent the care team from providing appropriate interventions for specific residents who need them The purpose of this article is to describe the principles of a process of care that would help providers avoid use of restraints and institute other appropriate treatments and intervention to address resident risks or symptoms. It is likely that following the appropriate process of care in assessment, care planning, intervention, and monitoring of patients’ symptoms would cause the care team to plan for appropriate treatments Lutheran Augustana Center for Extended Care and Rehabilitation and Lutheran Medical Center, Brooklyn, New York.

Reinventing long-term care: the effect of policy changes on trends in nursing home reimbursement and resident characteristics--Florida, 1989-1997.

This study investigated how changes in Medicare and Medicaid policies affected skilled nursing facility (SNF) revenue streams and resident characteristics in Florida during the 1990s. We used a series of ordinary least squares (OLS) regression models to analyze state-provided administrative data and Online Survey Certification and Reporting (OSCAR) data for all Florida SNFs. We found that Florida SNFs responded differently to the growing gap in reimbursement between Medicaid and other payers, depending on their profit status. As the reimbursement gap grew, for-profit SNFs maximized their revenues by admitting fewer Medicaid paying residents, whereas nonprofit facilities increased their percentage of Medicaid admissions. Changes in patterns of reimbursement altered the composition of Florida SNF residents in terms of age, physical status, length of stay, and place of discharge.

Oversight of nursing homes: pruning the tree or just spotting bad apples?

This study investigated whether higher rates of nursing home quality citations are associated with increased risk of voluntary and involuntary facility terminations from the Medicare/Medicaid certification process. We examined nationwide Online Survey Certification and Reporting (OSCAR) data from 1992 through 2000 and used a multinomial logistic regression model with time-varying covariates to estimate the relationship between nursing home deficiencies and terminations. In the study period, 8.7% of nursing homes voluntarily terminated and 2.4% of facilities were involuntarily terminated. Deficiencies significantly predicted both types of termination, controlling for state and market characteristics. Low occupancy and very high Medicaid mix were strongly related to voluntary and involuntary terminations (p <.05). Nursing homes that receive a high number of deficiencies exit the Medicare/Medicaid market and have lower occupancy rates before termination, although the relationship varies considerably across states. If competition on the basis of quality is increased because of public reporting efforts, our analyses suggest that terminations, both voluntary and involuntary, will likely increase.

Nursing Home Characteristics Associated with Tube Feeding in Advanced Cognitive Impairment

To identify nursing homes factors associated with the use of tube feeding in advanced cognitive impairment. Descriptive study. The On-line Survey Certification of Automated Records (OSCAR) was used to obtain facility characteristics from 1,057 licensed nursing homes in six states from 1995 to 1996. Residents aged 65 and older with advanced cognitive impairment who had a feeding tube placed over a 1-year period were identified using the Minimum Data Set. Nursing home characteristics independently associated with feeding tube placement were determined. Having a full-time speech therapist on staff, more licensed nurses and fewer nursing assistants were independently associated with greater use of tube feeding in severely cognitively impaired residents. Other features associated with tube feeding included larger facility size, higher proportion of Medicaid beds, absence of an Alzheimer's disease unit, pressure ulcers in 10% or more of residents, and a higher proportion of residents lacking advance directives and with total functional dependency. Assessment by a speech therapist, staffing ratios, advance directives, fiscal considerations, and specialized dementia units are potentially modifiable factors in nursing homes that may influence the practice of tube feeding in advanced cognitive impairment.

An exploration of job, organizational, and environmental factors associated with high and low nursing assistant turnover.

This article examines factors that distinguish nursing facilities with very high and very low nursing assistant turnover rates from a middle referent group, exploring the possibility that high and low turnover are discrete phenomena with different antecedents. Data from a stratified sample of facilities in eight states, with directors of nursing as respondents (N = 288), were merged with facility-level indicators from the On-Line Survey Certification of Automated Records and county-level data from the Area Resource File. Multinominal logistic regression was used to identify factors associated with low (less than 6.6% in 6 months) and high (more than 64% in 6 months) turnover rates. With the exception of registered nurse turnover rate, low turnover and high turnover were not associated with the same factors. Future studies of facility turnover should avoid modeling turnover as a linear function of a single set of predictors in order to provide clearer recommendations for practice.

Nursing Home Deficiencies in the United States

This is a confirmatory factor analysis (CFA) of deficiencies in nursing homes obtained from the On-line Survey Certification and Reporting system (OSCAR), a national database on nursing home quality maintained by the U.S. Health Care Financing Administration (HCFA). A major goal was to identify a core set of items that would reliably reflect a meaningful set of dimensions of problems in quality of care. The analysis suggests that it is reasonable to posit a model of eight underlying factors to which state surveyors are responding as they assign deficiencies to nursing homes. Forty items are robust indicators of the eight dimensions of problems in quality of care. The data contain considerable random and probably systematic error worth understanding. Establishing that the data contain systematic variability is crucial because OSCAR data are a potentially valuable source of quality of care information for researchers, policymakers, and consumers.

Legislative Imposition of Minimum Staffing

Legislative Imposition of Minimum Staffing

Deficiency citations for physical restraint use in nursing homes.

The average percentage of residents restrained in nursing homes is approximately 20%. Facilities that do not meet Health Care Financing Administration standards for restraint use may be issued a deficiency citation. This article investigates which structure and process factors of nursing homes are associated with a deficiency citation for restraint use. Nationally representative data from the 1997 On-line Survey Certification of Automated Records are used, first, to provide descriptive analyses, and second, for logistic regression analyses of structure and process factors associated with a deficiency citation for restraint use. A total of 2,321 facilities were found to have at least one restraint deficiency citation, and 14,703 had none. After controlling for seven other key variables, five structural factors and six process factors are significant. The structural factors--larger bed size, for-profit ownership, and hospital based--were significantly associated with a higher likelihood of a deficiency citation for restraint use; whereas higher numbers of full-time equivalent specialists per resident and nurse aide training were significantly associated with a lower likelihood. The process factors--suctioning therapy, pain management, and bladder training--were significantly associated with a lower likelihood of a deficiency citation for restraint use; whereas intravenous therapy, higher use of catheters, and physical restraints were significantly associated with a higher likelihood of a deficiency citation. This analysis establishes linkages between structures and processes and the outcome of a deficiency citation for restraint use. The structural results may have some utility for regulators. They could be used to develop a specific program to target facilities most commonly found to have inappropriate restraint use. The process results may have some utility for providers who could use the information to target residents for review of inappropriate restraint use.

Facility characteristics associated with hospitalization of nursing home residents: results of a national study.

To test the effect of facility characteristics on the probability of hospitalization of nursing home residents, controlling for resident characteristics and the competing risk of death. Study data were derived from the evaluation of the implementation of the Resident Assessment Instrument, the Minimum Data Set (MDS) in 1993. The data consisted of 2080 residents in 253 NHs as well as the annual On-Line Survey Certification of Automated Records (OSCAR). Multinomial logistic regression was used to determine the effects of selected resident and facility characteristics on hospitalization or death within 6 months of baseline, adjusting for the complex sampling design (using SUDAAN). By controlling for resident demographics, advance directives, diagnoses, selected clinical signs, and type of payer, we found that homes with special care units, more physicians (above the median 0.08 FTE physicians on staff or contract), and any physician extenders (nurse practitioners or physician assistants) were less likely to hospitalize their residents. Homes in which over 3.6% of the residents received respiratory treatment were more likely to hospitalize their residents. Findings suggest that Medicare HMOs should consider the capacity of nursing facilities, especially in terms of medical care capacity and clinical resources, to limit hospital admissions.

Nursing facility staffing in the states: the 1991 to 1995 period.

Trends in the average nurse staffing levels are reported for certified nursing facilities in the United States from 1991 through 1995. Data from the federal On-Line Survey Certification and Reporting system show a small overall increase in the staffing levels for registered nurses (RNs), licensed vocational and licensed practical nurses (LVNs/LPNs), and nursing assistants over the 5 years, but there are substantial variations across states and regions. A two-stage least squares panel analysis examined predictors of nurse staff levels in states. States with higher resident case mix levels had higher RN and LVN/LPN hours. States with higher percentages of large facilities had lower RN and LVN/LPN levels and states with higher percentages of for-profit facilities had lower RN staff levels. States with a higher percentage of Medicaid residents had higher LVN/LPN staff levels. These findings indicate the need for more studies of staff variations and public policies that affect staffing.