Resident Outcomes Research Articles

CULTURALLY SENSITIVE STRATEGIES TO RECRUIT FOREIGN EDUCATED NURSES FOR US LONG-TERM CARE RESEARCH

Abstract Long-term care (LTC) facilities experience chronic nursing staff instability which negatively impacts resident health outcomes. Recruiting Foreign Educated Nurses (FENs) is one strategy to stabilize the nursing workforce but most studies on FENs, use secondary data from: American Community Survey and the National Sample Survey of Registered Nurses. Few empirical studies have examined FEN experiences, employment outcomes, and impact on US LTC facilities. Since LTC facilities are dependent on FENs to meet minimum staffing requirements, additional research is needed to better understand FEN workforce issues in LTC, how to improve its sustainability, and the links to resident outcomes. Mistrust of researchers, however, may make FENs hard to reach. Therefore, conducting primary research on FENs in LTC requires culturally sensitive and community-engaged recruitment strategies. Drawing from existing literature and lessons learned from primary research conducted with FENs working in LTC facilities in the southeastern US, we will review best practices for recruitment so researchers can understand the cultural and structural issues that may affect research conduct in facilities where FENs are employed and their recruitment as participants. Developing relationships with FEN leaders as well as the Nigerian, Jamaican, Filipino, and/or Asian nurses associations can facilitate access to the population. Key stakeholder relationships also include the American Nurses Association, State Boards of Nursing, and Commission on Graduates of Foreign Nursing Schools as they can facilitate entrée into data sources and networks for recruitment. Understanding recruitment strategies will strengthen research that deepens our understanding of workforce issues among FENs in LTC.

DYING WITH DEMENTIA IN NURSING HOMES: A POPULATION-BASED PERSPECTIVE OF DECEDENTS AND THEIR FAMILIES

Abstract Families play a critical role in person-centered end-of-life (EOL) care for nursing home (NH) residents with dementia. Many NH residents, however, do not have any family to advocate for care, which may contribute to poorer EOL outcomes. Little is known about the characteristics of families of persons with dementia who die in a NH despite the importance of family at EOL. This study aimed to describe the size and composition of first-degree families (FDF) of Utah NH residents with dementia who died 1998-2016 (n=18,842). Using the Utah Population Caregiving Database, we linked NH decedents with dementia to their FDF (n=54,174; spouses=11.3%; children=57.6%; siblings=30.7%) and compared characteristics of those with and without FDF. Compared to NH decedents with FDF (78.5%), those without (21.5%) were more likely to be older (median 87.3 vs 85.9), female (64.7% vs 57.1%), non-white/Hispanic (10.3% vs 3.4%), less educated (<9th grade; 42.2% vs 33.4%); die in a rural/frontier NH (24.8% vs. 23.2%); and less likely to have 2+ hospitalizations in the last 6 months of life (14.3% vs. 16.5%, all p<.001). Findings highlight social determinants of health that may increase the risk of poor EOL outcomes in an already vulnerable population. Understanding the nature of FDF relationship type on EOL outcomes for NH residents with dementia is an important next step in clarifying the role of families and understanding the supports they may need.

EXAMINING THE USE AND IMPACT OF CONTRACT CERTIFIED NURSING ASSISTANT STAFFING IN NURSING HOMES

Abstract Certified nursing assistants (CNAs) provide the majority of hands-on care in nursing homes, and adequate CNA staffing is associated with better resident and staff outcomes. However, low wages and overall poor job quality make adequate CNA staffing particularly challenging. There is evidence that nursing homes have increased reliance on contract staffing to fill staffing shortages, though the full scope of this trend for CNAs remains unclear and the impacts on care quality are still unknown. This study addresses this gap by examining staffing levels and patterns for fully employed versus contract CNAs in nursing homes over the past five years and assessing how these staffing trends are associated with quality outcomes for nursing home residents. Specifically, this session will present analysis of data from the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal daily nurse staffing files, CMS nursing homes data archive, LTCFocus data, community transmission of COVID-19 data, and unemployment data to demonstrate how staffing patterns among fully employed versus contract CNAs varied from 2017 to 2022 according to facility-level characteristics, local market conditions, and pandemic-related factors. We also examine how CNA staffing levels and patterns affected care quality for nursing home residents. These findings will be presented with policy and practice recommendations for strengthening and stabilizing CNA nursing home staffing.

MISSING IN ACTION: STRATEGIES FOR DEMONSTRATING ORGANIZATIONAL COMMUNICATION IN NURSING HOMES

Abstract A scoping review was conducted to learn more about strategic organizational communication within long-term care. Strategic organizational communication is a purposeful, system-wide, and system-level effort to transform the organization and delivery of care and services to make it easier to navigate, understand, and coordinate care. Care in nursing homes is complex and must consider residents’ goals, values, and preferences. Communication strategies enacted at the system-level may include direct care staff, human resources, nursing-to-resident and family interactions, and care planning. Strategies at the institutional or system-wide level also include corporate stakeholders, administration, and employee leadership. The aim of the literature search was to locate evidence of communication strategies that reflect corporate and organizational goals, and that exemplify the processes by which communication influences administrative policy. Key words in the search were entered in varying iterations and combinations with the guidance of a skillful research librarian. Key words were long-term care, communication, feedback, nursing homes, patient-centered care, quality improvement. Returns were greater than 2,000, yet seemingly relevant abstracts were fewer than 300, and selected articles were fewer than 30. The research reports reviewed were explanatory or explorative and just one article was found to explore the role of communication strategies and the impact on organizational outcomes. Further, no research reports were found to discuss strategic organizational communication and a combination of resident and organizational outcomes. Rather, most work described specific communication interventions among key groups, many of which lacked sustainable impact. Study results, limitations, and examples of communication strategies are presented herein.

ORGANIZATIONAL COMMUNICATION STRATEGIES IN NURSING HOMES: A SCOPING REVIEW

Abstract A scoping review was conducted to learn more about strategic organizational communication within long-term care. Strategic organizational communication is a purposeful, system-wide, and system-level effort to transform the organization and delivery of care and services to make it easier to navigate, understand, and coordinate care. Care in nursing homes is complex and must consider residents’ goals, values, and preferences. Communication strategies enacted at the system-level may include direct care staff, human resources, nursing-to-resident and family interactions, and care planning. Strategies at the institutional or system-wide level also include corporate stakeholders, administration, and employee leadership. The aim of the literature search was to locate evidence of communication strategies that reflect corporate and organizational goals, and that exemplify the processes by which communication influences administrative policy. Key words in the search were entered in varying iterations and combinations with the guidance of a skillful research librarian. Key words were long-term care, communication, feedback, nursing homes, patient-centered care, quality improvement. Returns were greater than 2,000, yet seemingly relevant abstracts were fewer than 300, and selected articles were fewer than 30. The research reports reviewed were explanatory or explorative and just one article was found to explore the role of communication strategies and the impact on organizational outcomes. Further, no research reports were found to discuss strategic organizational communication and a combination of resident and organizational outcomes. Rather, most work described specific communication interventions among key groups, many of which lacked sustainable impact. Study results, limitations, and examples of communication strategies are presented herein.

COVID-19 AND PSYCHOTROPIC DRUG USE IN ASSISTED LIVING RESIDENTS: VARIATION BY WAVE AND SETTING TYPE

Abstract The onset of COVID-19 was associated with significant, albeit modest, increases in the use of psychotropics and opioids in nursing home residents. Little research exists on whether similar trends occurred among older residents of publicly funded assisted living (AL) homes, a growing and poorly investigated setting. We examined the impact of pandemic wave (1 to 4) and setting type (dementia designated spaces [AL-D] vs other [AL-O]) on prevalent antipsychotic, antidepressant, benzodiazepine, opioid and anticonvulsant use in AL residents from Alberta, Canada. Using linked population-based clinical and health administrative databases, we conducted a repeated cross-sectional study of quarterly medication prevalence from January 2018 to December 2021. Log-binomial GEE models estimated prevalence ratios (PR) for 4 waves (vs 2018-19 historical months) and setting (AL-D vs AL-O) and period-setting interactions. On March 1, 2020, there were 2,874 AL-D and 6,611 AL-O residents in our cohorts (mean age 82.4 vs 79.9 years and 93.5% vs 42.6% with dementia, respectively). Antipsychotic prevalence increased during waves 2-4 for both settings but this increase was significantly greater for AL-D than AL-O in later waves (e.g., AL-D: PR 1.21, 95%CI 1.14-1.27; AL-O: 1.12 (1.07-1.17) for March-May 2021 vs 2018-19). For both settings, there was a significant but modest increase in antidepressants but a decrease in benzodiazepines during several waves. No pandemic effect was observed for opioids in either setting. The AL resident and home characteristics associated with these medication trends, concerns about medication risks (particularly for dementia care settings), and consequent health outcomes for residents require further study.

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.

VIVALDI Cohort Profile: Using linked, routinely collected data and longitudinal blood sampling to characterise COVID-19 infections, vaccinations, and related outcomes in care home staff and residents in England

VIVALDI (ISRCTN14447421) is a government-funded longitudinal open observational cohort study of staff and residents in care homes for older people in England. The study aimed to describe epidemiology (including seroprevalence) and immune responses to COVID-19 in a subset of care homes, in the context of extremely high mortality in this setting, in the first 12-18 months of the pandemic. Data linkage to routine health data was undertaken for all staff and residents and a subset of individuals who consented to sequential blood sampling to investigate SARS-CoV-2 immunity. This paper aims to describe the samples stored within the study biobank, available for use by researchers. Over 70,000 individuals from 346 care homes were included in the data linkage cohort (1st March 2020–31st March 2023). 4975 samples from 2268 individuals (1419 staff, 827 residents) collected between 29th October 2020 and 10th March 2023 are stored. Amongst these samples, there was a maximum of seven per participant however, 217 (26.2%) residents and 555 (39.1%) staff participated in one round only. Key study findings include high COVID-19 seroprevalence among surviving residents, exceeding rates in community-dwelling peers. COVID-19 vaccinations generated robust immune responses in staff and residents which waned, supporting the need for booster vaccination, particularly in response to new variants. Prior infection significantly improved vaccine-induced immune responses, however protection from infection declined following Omicron variant emergence. This is a unique cohort of pre- and post-infection samples linked to data on COVID-19 infections, vaccinations, and outcomes. The cohort spans host immune response evolution to infection and vaccination in this rarely sampled population of frail older care home residents who are especially vulnerable to infection and severe outcomes. These samples can be used to investigate biological mechanisms behind disparate infection responses in older people and make a valuable contribution to research into ageing.

The Care Home Independent Pharmacist Prescriber Study (CHIPPS): development and implementation of an RCT to estimate safety, effectiveness and cost-effectiveness

Background Medicine prescribing, monitoring and administration in care homes can be significantly enhanced. Effective interventions to improve pharmaceutical care and resident outcomes are required. The enablement of pharmacists to prescribe provides an opportunity for pharmacist independent prescribers to assume responsibility for improving pharmaceutical care, medication-related outcomes and resident safety whilst reducing general practitioner workload. Objective(s) To determine the effectiveness and cost-effectiveness of pharmacist independent prescribing in care homes. Design Development work was undertaken through five work packages before the delivery of the definitive trial. Triads of pharmacist independent prescribers, care home and general practice with responsibility over 20 care home residents were recruited and cluster randomised to intervention or usual care for 6 months. Researchers were blinded at recruitment stage only. Recruitment of 880 residents was required to provide 80% statistical power, to show a 21% reduction in falls over 6 months, assuming 20% attrition. Randomisation was undertaken electronically at triad level, stratified by geographical area. Intention-to-treat analysis undertaken using a negative binomial model. Parameters were estimated using a generalised estimating equation approach. Costs were captured from an NHS perspective. Quality of life (EuroQol; five domain; five level) was collected by proxy to enable cost/quality-adjusted life-year estimation. A concurrent process evaluation was performed. Safety was monitored through a review of pharmacist independent prescriber activities, independent concerns reporting and review of adverse events. Participants Forty-nine triads of general practitioners, pharmacist independent prescribers and care homes were recruited with 454 residents allocated to the intervention arm and 428 to the control arm. Intervention Medication review and care planning, medication reconciliation, staff training, support with care home medication-related procedures, deprescribing and authorisation of monthly prescriptions. Main outcome measure Fall rate per person over 6 months. Results Data for 449 intervention and 427 control residents available for final analysis. The 6-month fall rate ratio in favour of intervention was 0.91 (95% confidence interval 0.66 to 1.26; p=0.58). No significant difference in secondary outcomes was identified except Drug Burden Index (rate ratio 0.83, 95% confidence interval 0.75 to 0.92; p<0.001). No harms were identified. One quarter of medication-related interventions were associated with a reduced risk of falls. The intervention was positively received. Limitations Participant self-selection bias may have affected the generalisability of findings. Open-label cluster randomised controlled trial limited by 6-month follow-up. Potential ceiling effect due to concurrent pharmacist-led interventions. Falls potentially insufficiently proximal to the intervention. Conclusions To enhance effectiveness and acceptance of the proposed model, effective integration into care home and general practitioner teams was identified as a central requirement. A core outcome set and a training package were developed. The final model of care, whilst being safe and well received and resulting in a reduction in drug burden, demonstrated no improvement in the primary outcome of falls. With no improvement in quality-adjusted life-years identified, the pharmacist independent prescriber intervention was not estimated to be cost-effective. Future work To develop and evaluate better models of care for enhancing medication outcomes and safety in care homes or re-test with a longer intervention and follow-up period and a stronger primary outcome. Trial registration This trial is registered as ISRCTN10663852, definitive trial: ISRCTN17847169. Study registration This study is registered as PROSPERO CRD20150907. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-0613-20007) and is published in full in Programme Grants for Applied Research; Vol. 11, No. 10. See the NIHR Funding and Awards website for further award information.

Re-Examine: The Power of China’s New Rural Pension Scheme

Drawing upon data from the China Family Panel Studies (CFPS) and the China Health and Retirement Longitudinal Study (CHARLS), this paper employs a Difference in Differences (DID) approach to investigate the varying impacts of the New Rural Pension Scheme (NRPS) across different regions in China. The empirical results reveal that the NRPS has generally improved the health outcomes of residents. Notably, the benefits of the NRPS are more pronounced in rural and economically advanced areas, while its effects are not statistically significant in less developed and urban regions. This analysis elucidates the underlying reasons for these regional disparities, attesting to the pension policy’s efficacy and advancing the scholarly conversation on pension policy research.

1859. Median Income by Location of Residence and Clinical Outcomes of Hospitalized Persons with COVID-19 in an Urban Veterans Affairs Medical Center

Abstract Background The COVID-19 pandemic has disproportionately affected racial and ethnic minorities and those of low socioeconomic status, including higher rates of illness severity and death. This has been attributed in part to decreased healthcare access. We sought to determine whether place of residence as a marker of socioeconomic status, healthcare access, and median income were predictive of disease severity in a large integrated healthcare system. Methods We conducted a prospective observational cohort study of ­348 patients admitted to the hospital with a diagnosis of COVID-19 between March 1, 2020 through June 30, 2021. Using univariate and multivariable logistic regression, we evaluated associations of disease severity outcomes with demographic characteristics of veterans, age-adjusted Charlson Comorbidity Index (CCI), and median income by place of residence. Results < The mean age of our cohort was 68 and 90% were male. The racial and ethnic makeup was 83% black, 14% white, 5% Hispanic or Latino, and 3% other. In unadjusted models, only median income and the CCI predicted need for high-flow oxygen (p = 0.009 and p < 0.0001, respectfully) and death (p = 0.04 and p = 0.0005, respectively), while the CCI also predicted the need for intubation (p = 0.02). In multivariable models, CCI was strongly associated with the need for high-flow oxygen, intubation, and death (p = 0.0001, 0.01, and 0.02, respectively); age alone remained the most powerful predictor of death. Race and ethnicity were not associated with the need for high-flow oxygen, intubation, or death. Place of residence was not associated with worse outcomes. Conclusion This cohort study of hospitalized patients in an urban Veterans Affairs Medical Center found that race, ethnicity, and location of residence were not associated with COVID-19 disease severity and death, but median income and higher scores on the CCI predicted worse outcomes. Disclosures Pratish C. Patel, PharmD, BCIDP, AAHIVP, VBI Vaccines: Stocks/Bonds

Leveraging PDS teacher preparation grants: a majority–minority research university’s approach to increasing the diverse teacher pipeline

PurposeA primary goal of the Collaboration and Resources for Encouraging and Supporting Transformations in Education (CREST-Ed) program was to increase the number of highly qualified, minoritized teachers committed to teaching in minority-serving, high-need school districts. This study's purpose was to evaluate the CREST-Ed program's impact on teacher residency outcomes using multiple sources of program evaluation data collected during the five-year grant.Design/methodology/approachThis study of a federal Teacher Quality Partnership (TQP) grant at Georgia State University (GSU), a minority-serving institution (MSI) and research university, shows teacher residency programs can improve the diverse teacher pipeline. The grant, CREST-Ed, provided professional development schools (PDS) support for four urban and 23 rural school districts through partnerships with GSU, Albany State University (ASU) and Columbus State University (CSU).FindingsThe study findings suggest that teacher preparation grants can be leveraged to recruit traditionally minoritized teachers of color to increase the diverse teacher pipeline and strengthen PDS partnerships.Originality/valueBoth urban and rural PDSs could benefit from teacher residency programs like the CREST-Ed model that catered to the unique needs of each school and partnership district.

The Impact of State Dementia Training Requirements for Nursing Homes on Antipsychotic Medication Use

ObjectivesNursing home (NH) staff often report not having adequate dementia-specific knowledge to effectively care for these residents. Between 2011 and 2019, 9 states in the United States implemented dementia training requirements for NH staff. This study evaluated whether the state-mandated dementia training for NH staff was associated with improving resident outcomes. DesignCompared trends in antipsychotic medication before and after implementation of state training requirements to trends in states without requirements. Setting and ParticipantsNHs. MethodsData from Care Compare for NHs and LTCFocus were linked to state policy data. We excluded 14 states that had implemented training requirements before the start of the study period in 2011. We estimated difference-in-differences models that compared trends in antipsychotic medication use before and after implementation of training requirements in states that have newly implemented requirements to trends in states without requirements. We also investigated whether the impact of training was larger in states with more stringent training requirements (eg, specifying a minimum number of training hours) and in NHs with a special care unit for dementia and examined similar analyses for restraint use and falls. ResultsWe found that training requirements were associated with a 0.59–percentage point reduction (95% CI −0.91 to −0.27) in antipsychotics use. Effects were larger in NHs with a special care unit for dementia and in states that had stricter training requirements. We also found that training requirements were associated with a 0.17–percentage point reduction (95% CI −0.26 to −0.07) in restraint use measure and had no impact on falls. Conclusions and ImplicationsState requirements for NH staff dementia training were associated with a small, but significant, reduction in the use of antipsychotic medication and physical restraints.

The experience of Australian aged care workers during a trial implementation of a palliative care outcomes programme.

End of life care is an essential part of the role of Australian aged care homes (ACHs). However, there is no national framework to support aged care staff in systematically identifying residents with palliative care needs or to routinely assess, respond to, and measure end of life needs. The Palliative Care Outcomes Collaboration (PCOC) is a national outcomes and benchmarking programme which aims to systematically improve palliative care for people who are approaching the end of life, and for their families and carers. The PCOC Wicking Model for Residential Aged Care was developed and piloted in four Australian ACHs. This paper reports on the qualitative findings from semi-structured interviews and focus groups conducted with ACH staff (N=37) to examine feasibility. Thematic analysis identified three overarching themes about the pilot: (i) processes to successfully prepare and support ACHs; (ii) appropriateness of PCOC tools for the ACH setting; and (iii) realised and potential benefits of the model for ACHs. The lessons presented valuable insights to refine the PCOC Wicking Model and enrich understanding of the potential challenges and solutions for implementing similar programs within ACHs in future. The results suggest that key to successfully preparing ACHs for implementation of the PCOC Wicking Model is an authentic and well-paced collaborative approach with ACHs to ensure the resources, structures and systems are in place and appropriate for the setting. The PCOC Wicking Model for Residential Aged Care is a promising prototype to support ACHs in improving palliative and end of life care outcomes for residents and their carers.

Flanders Nursing Home (FLANH) project: Protocol of a multicenter longitudinal observational study on staffing, work environment, rationing of care, and resident and care worker outcomes.

While the demand for high quality of care in nursing homes is rising, it is becoming increasingly difficult to recruit and retain qualified care workers. To date, evidence regarding key organizational factors such as staffing, work environment, and rationing of care, and their relationship with resident and care worker outcomes in nursing homes is still scarce. Therefore, the Flanders Nursing Home (FLANH) project aims to comprehensively examine these relationships in order to contribute to the scientific knowledge base needed for optimal quality of care and workforce planning in nursing homes. FLANH is a multicenter longitudinal observational study in Flemish nursing homes based on survey and registry data that will be collected in 2023 and 2025. Nursing home characteristics and staffing variables will be collected through a management survey, while work environment variables, rationing of care, and care worker characteristics and outcomes will be collected through a care worker survey. Resident characteristics and outcomes will be retrieved from the Belgian Resident Assessment Instrument for long-Term Care Facilities (BelRAI LTCF) database. Multilevel regression analyses will be applied to examine the relationships between staffing variables, work environment variables, and rationing of care and resident and care worker outcomes. This study will contribute to a comprehensive understanding of the nursing home context and the interrelated factors influencing residents and care workers. The findings will inform the decision-making of nursing home managers and policymakers, and evidence-based strategies to optimize quality of care and workforce planning in nursing homes.

Randomized controlled trial of tailored audit with feedback in VHA long-term care settings

BackgroundThe Long-Term Care QUERI program supported implementation of the Life-Sustaining Treatment Decisions Initiative in US Veterans Health Administration long-term care settings. The program worked with eleven Community Living Centers (CLCs) and twelve Home-Based Primary Care (HBPC) programs to increase rates of completed templates, using audit with feedback. We distributed monthly feedback reports to site champions showing the number of Veterans with appropriate documentation. Although feedback reports are a common implementation tool, little is known about the most effective ways to design, distribute, and support them. We sought to test tailoring reports with tips using site-specific data, as well as national comparator data.MethodsWe conducted a cluster randomized controlled trial of monthly feedback reports utilizing site-tailored tips and national comparator data compared to our original feedback reports that included only graphical and numerical data. CLC and HBPC team members were invited to participate in brief surveys each quarter to determine if they had received and used the feedback reports. The outcome for CLC residents was the percent with a completed LST template any time prior to the 14th day of their stay. The outcome for HBPC residents was the percent of Veterans with a completed LST template by their second HBPC visit.ResultsThe response rate to the survey ranged between 6.8 and 19.3% of staff members across the CLC and HBPC sites with 12.8–25.5% of survey respondents reporting that they had seen the feedback reports. The linear regression models showed no significant association between receiving the enhanced feedback reports and having a higher documentation completion rate.ConclusionsReceiving feedback reports tailored to sites by including tips based on baseline context assessments and qualitative findings, and reports showing national comparator data, did not have an impact on the number of Veterans with a completed LST template. Having a higher proportion of CLC or HBPC team members view the reports was not associated with an increase in LST template completion. These findings suggest that tailored audit with feedback may not have been effective at the program level, although the proportion of respondents who reported seeing the reports was small.

Nursing home managers' descriptions of multi-level barriers to leading person-centred care: A content analysis.

Research suggests that person-centred care can be beneficially implemented and sustained, even though barriers remain that prevent uptake in clinical practice. Understanding barriers to person-centred care seems important, as this has an impact on care practices and resident outcomes. Moreover, there is limited knowledge about nursing home managers' descriptions of barriers when leading person-centred care. To explore barriers to leading person-centred care as narrated by nursing home managers. A descriptive qualitative design was used to collect data using individual interviews with 12 nursing home managers in highly person-centred nursing homes. Data were analysed using content analysis. Multi-level barriers to leading person-centred care were identified on the (1) person level, (2) team level and (3) organisational level. Placing professional and family considerations ahead of resident considerations was described as a barrier on the personal level (1). Also, staff's divergent care values, processes, and priorities together with turnover and low foundational knowledge were identified as barriers on the team level (2). On an organisational level (3), constrained finances, functional building design and group level rostering were identified as barriers. Multi-level barriers influence nursing home managers' ability to lead and promote person-centred care. Promoting the development of person-centred practices requires efforts to eliminate barriers on person, team and organisational level. Identifying and overcoming barriers at various levels in nursing home care has the potential to promote person-centred practices. This study can inform stakeholders and policymakers of challenges and complexities in person-centred practices. Multi-level strategies are needed to target challenges at person-, team- and organisational level when striving to develop person-centred care.

The effect of rural hospital closures on maternal and infant health.

To evaluate the effect of rural hospital closures on infant and maternal health outcomes. We used restricted National Vital Statistics System birth and linked birth and infant death data, merged with county-level hospital closures from the Sheps Center for the period 2005-2019. We used difference-in-difference and event study methods, employing new estimators that account for staggered treatment timing. Our key outcome variables were prenatal care initiation; birth outcomes (<2500 g; <1500 g; <37 weeks; <28 weeks; 5-min Apgar); delivery outcomes (cesarean, induction, hospital birth); and infant death (<1 year of birth; <=30 days of birth; <=7 days of birth; <= 1 day after birth). The analysis covered all births in the United States in rural counties (by rurality: all, most, moderately rural). We found evidence that fewer individuals delivered in their county of residence after a hospital closure, and this was most pronounced for residents of the most rural counties (29%-52% decline (p < 0.01) in the likelihood of delivering in their residence county). We found that hospital closures worsen prenatal, infant, and delivery outcomes for residents of moderately rural counties but improve those outcomes for those in the most rural counties. In moderately rural counties, low birth weight births increased by 10.4% (p < 0.01). We found suggestive evidence of decreased infant deaths in the most rural counties. This pattern of findings is consistent with closures leading residents of the most rural counties to seek care in a different county and residents of moderately rural counties to seek care at a different hospital in the same county. Loss of hospital care has meaningful effects on the rural populations; investigating rural counties in aggregate may miss nuanced differences in the effects on the margin of rurality.

Being Present and Meaningful Engagement for Aged Care Residents Living With Dementia: A Mixed-Methods Evaluation of Australian Care Worker's Experiences.

Meaningful engagement is essential for aged care residents living with dementia. Our knowledge pertaining to caring presence for residents living with dementia is limited. This study aims to understand care workers' experiences of providing care to residents, the challenges they face in being present with residents and support that enable them to be more present and provide person-centered care. A mixed-methods approach using surveys and semi-structured interviews with care workers from three Australian residential aged care homes was adopted. Surveys were analyzed using descriptive statistics. Open-ended survey responses and interviews were analyzed using thematic analysis. Twenty-six care workers completed surveys and a subset (n = 8) participated in interviews. Survey participants were largely positive about their role and reported that they loved caring for and making a difference in the lives of residents. Three themes emerged from interviews: (a) trust, connection, and the complexities of maintaining engagement; (b) time as gift and challenge; (c) organizational culture, structure and resources, and enabling carer presence. Care workers in our study expressed their desire to be present with residents and stated that enablers such as meaningfully engaging with residents was one of the most enjoyable aspects of their work. Barriers such as staff shortages, competing demands of the role, and time-related impediments to being present were reported. Addressing challenges to being present with residents living with dementia is key to help avoiding poor care practices and resident outcomes.

Family Ties at End-of-Life: Characteristics of Nursing Home Decedents With and Without Family.

Little is known about nursing home (NH) residents' family characteristics despite the important role families play at end-of-life (EOL). To describe the size and composition of first-degree families (FDFs) of Utah NH residents who died 1998-2016 (n = 43,405). Using the Utah Population Caregiving Database, we linked NH decedents to their FDF (n = 124,419; spouses = 10.8%; children = 55.3%; siblings = 32.3%) and compared sociodemographic and death characteristics of those with and without FDF members (n = 9424). Compared to NH decedents with FDF (78.3%), those without (21.7%) were more likely to be female (64.7% vs. 57.1%), non-White/Hispanic (11.2% vs. 4.2%), less educated (<9th grade; 41.1% vs. 32.4%), and die in a rural/frontier NH (25.3% vs. 24.0%, all p < 0.001). Despite similar levels of disease burden (Charlson Comorbidity score 3 + 37.7% vs. 38.0%), those without FDF were more likely to die from cancer (14.2% vs. 12.4%), Chronic Obstructive Pulmonary Disease (COPD) (6.0% vs. 4.0%), and dementia (17.1% vs. 16.6%, all p < 0.001), and were less likely to have 2+ hospitalizations at EOL (20.5% vs. 22.4%, p < 0.001). Among NH decedents, those with and without FDF have different sociodemographic and death characteristics-factors that may impact care at EOL. Understanding the nature of FDF relationship type on NH resident EOL care trajectories and outcomes is an important next step in clarifying the role of families of persons living and dying in NHs.