Quality Of Care In Nursing Homes Research Articles

How do professionals working in the field of dementia care define quality of nursing home care and how do they believe warm technology contributes to this?

AbstractBackgroundWarm technology (WT) aims to improve quality of life of people living with dementia by supporting and enhancing human potential, social connectedness, dignity and self‐reliance. However, how care researchers and dementia care professionals think about the relationship between WT and quality of care (QOC) in nursing homes (NHs) is unknown. Also, there is a lack of international consensus on the definition of QOC in NHs. The goal of this project was to explore how care researchers and dementia care professionals define the concept QOC in NHs and how they believe WT contributes to this. The Tovertafel, a research based technology that activates nursing home residents with dementia by projecting interactive games on a surface, served as an example for WT in this study.MethodSemi‐structured (online) interviews were held in England, Ireland, Canada, United States of America and the Netherlands with 9 researchers and 11 care managers, 6 activity coordinators and 3 specialized nurses working in dementia care units of NHs. All care professionals had access to a Tovertafel. The interview guide was based on three existing multidimensional quality of nursing home care frameworks. To analyze the interviews, a thematic analysis was employed by means of open, axial, and selective coding using ATLAS.Ti.ResultsMost research and care professionals made a clear distinction between the clinical domains of QOC (e.g. providing effective and safe care) and the social domains of QOC (e.g. building relationships, trust, and providing person centered care) in NHs. According to the interviewees, the Tovertafel contributes to several social domains of QOC by: 1. supporting care professionals in the provision of person centered care and gaining trust from residents, 2. improving work pleasure of dementia care professionals, 3. creating a safe, pleasant and homelike environment, 4. increasing family involvement, and 5. increasing (non‐verbal) communication. The interviewees reported fewer and more indirect effects on the clinical domains of QOC in NHs. The results were comparable between countries.ConclusionWarm technology, such as the Tovertafel, seems to have a positive effect on QOC in NHs, primarily by having a positive impact on several social QOC domains.

247 Private equity acquisition of nursing homes and the impact on long stay residents and racial disparities in care outcomes

OBJECTIVES/GOALS: To investigate nursing homes (NHs) acquired by private equity (PE) firms and estimate the effect of PE NH acquisitions on NH care quality for NH residents and whether PE NH acquisitions exacerbate racial inequities in quality of care. METHODS/STUDY POPULATION: My research estimates the causal effect of NH PE acquisitions on NH access and quality of care for NH residents and whether acquisitions exacerbate racial disparities in NH care for about 115 PE-owned NHs in the US, measuring the quality of care at the facility survey year level, and using an array of NH-level data sources. I identified 115 PE-owned NHs (treatment group) and 665 non-PE-owned NHs between 2003 and 2010, using the Online Survey Certification and Reporting database to obtain facility characteristics. I compare facility characteristics (e.g., payer mix, staffing levels, and quality measures such as pressure ulcers, unexpected weight loss, acuity, and health deficiencies). I will then test whether effects differ by race, with hypotheses informed by Public Health Critical Race Praxis approach. RESULTS/ANTICIPATED RESULTS: Preliminary results show that staffing levels differ between PE and non-PE-owned NHs in a way that aligns with a shift in focus toward the Medicare population i.e. short stays. We also find that deficiencies increased in PE-owned NHs compared to non-PE-owned NHs. We expect that PE acquisitions may lead to slightly widening racial disparities in NH care quality. Results may show that PE-owned NHs have a higher share of low-rated, high-BIPOC facilities. In weak markets, PE-owned NHs may have a higher share of BIPOC residents compared to highly competitive markets. This is because PE managers may prioritize cost over quality by cutting services. However, since quality measures are self-reported, except for measures related to deficiencies, this predicted lower quality of care may not be evident in observed data. DISCUSSION/SIGNIFICANCE: Understanding how PE ownership impacts nursing home care quality for long-stay residents, especially those funded by Medicaid, can help develop intervention strategies to effectively mitigate racial inequities in NH care, as Medicaid funded NH residents are more likely to be Black, Indigenous, and people of color.

FACTORS ASSOCIATED WITH NURSING HOME DIRECT CARE PROFESSIONALS’ TURNOVER INTENT DURING COVID-19

Abstract The negative effects of the COVID-19 pandemic on the well-being of direct care professionals (DCPs; nursing assistants and aides) in nursing homes (NHs) has led to high rates of DCPs’ turnover and staff shortages - both issues that were already prevalent before the pandemic. More optimal staffing levels and less turnover are essential for optimal NH quality of care, but little is known about factors associated with turnover in DCPs in NHs during the pandemic. Hence, the purpose of this study was to examine the mediating roles of 1) quality of employer communication related to COVID-19; 2) DCPs’ perceived preparedness to care for residents with COVID-19; and 3) DCPs’ job satisfaction in the relationship between overall COVID-19-related work stress and intent to remain in one’s job (an indicator of turnover). Path analyses (N=809) demonstrate a significant, indirect effect between COVID-19-related stress and intent to remain in one’s position through the variables of communication, preparedness, and job satisfaction. Higher levels of COVID-19 related stress were associated with poorer communication quality, lower levels of preparedness, and lower job satisfaction, which was subsequently associated with a reduced likelihood of intent to remain in one’s job. However, direct effects show that better communication quality was associated with better preparedness correlating with higher job satisfaction which increased the likelihood of intent to remain in one’s job. Findings underscore the importance of employer supports in DCPs’ job satisfaction and turnover in NHs and, thus have implications for how to improve quality of care in NHs.

Registered Nurses' perspective of systemic factors affecting nursing home care quality decline: A qualitative descriptive study.

A growing number of older people are living in nursing homes worldwide, but their safety and quality of care are not guaranteed. This study explores registered nurses' (RNs) perspectives on systemic factors affecting the quality of care and safety decline of nursing home. Qualitative descriptive study. In this study, semi-structured interviews were conducted with 10 RNs working in six nursing homes, who were chosen through purposive sampling. Data were collected from 1 August-19 September 2019, and analysed using thematic analysis. The following five themes were derived: lack of sufficient number of RNs, poor work conditions, unclear job descriptions for RNs, no official position of nursing director and absence of transition care system. All reports of RNs affecting resident safety and quality of care decline were related to systemic factors. Therefore, improving quality of care in nursing homes should be supported by changes in systemic factors, such as maintaining an appropriate number of RNs and improving their working conditions.

Increasing implicit rationing of care in nursing homes: A time-series cross-sectional analysis

BackgroundImplicit rationing of nursing care is a socio-ecological problem where care workers, due to lack of resources, have to leave necessary nursing care activities undone. Cross-sectional studies on implicit rationing of nursing home care revealed associations with organizational and work environment characteristics. However, little is known on how implicit rationing of nursing care varies over time in nursing homes. ObjectiveThis study's purpose was to describe changes in levels and patterns of implicit rationing of nursing care in Swiss nursing homes over time, while accounting for key explanatory factors related to organizational, work environment, and individual characteristics. DesignTime-series cross-sectional analysis. SettingNursing homes in Switzerland. ParticipantsA convenience sample of 47 nursing homes and 3269 care workers from all educational levels participating in two multicenter cross-sectional studies (the Swiss Nursing Home Human Resources Project) conducted in 2013 and 2018. MethodsTo quantify implicit rationing of nursing care, care workers' data were collected via the nursing home version of the Basel Extent of Rationing of Nursing Care instrument. To control for leadership ability, staffing and resource adequacy, we used the Nursing Work Index–Practice Environment Scale. Objective measures including turnover, staffing and skill mix levels were aggregated at the nursing home level. Our analyses included multiple linear mixed models, using time as a fixed effect and nursing home as a random effect. ResultsWe found overall increases of rationing of care activities over the five-year period studied, with documentation and social activities most rationed at both measurement points (overall coefficients varied between 0.11 and 0.23, as well as the 95%-confidence intervals between 0.05 and 0.30). Moreover, a considerable increase in rationing of activities of daily living (coefficient of 0.47 in 2013 and 0.63 in 2018) was observed. ConclusionsAlongside long-term deterioration of staff resources, increases in rationing of nursing care are a worrying development, particularly given their potential negative impacts both on residents and on care workers. To assess nursing home care quality and to determine adequate staffing levels and skill mixes, policy makers and nursing home managers should consider regular monitoring of rationing of nursing care. Tweetable abstractTime-series cross-sectional analysis reveals increasing rationing of nursing care activities in Swiss nursing homes from 2013 to 2018.

Explaining spatial accessibility to high-quality nursing home care in the US using machine learning

In this study we measure and map the system-wide spatial accessibility to good quality nursing home care for all counties in the contiguous United States, and use an ‘imputed post-lasso’ machine learning technique to systematically examine this accessibility measure's associations with a broad range of county-level socio-demographic variables. Both steps were carried out using publicly available datasets. Analyses found clear evidence of spatial patterning in accessibility, particularly by population density, state and the populations of specific racial minorities. This has implications for outcomes that extend beyond the care homes and we highlight a number of policy measures that may help to address these shortcomings. The ‘out-of-sample’ predictive performance of the machine learning approach highlights the method's usefulness in identifying systematic differences in accessibility to services.

Appropriate leadership in nursing home care: a narrative review.

The purpose of this paper is to synthesize the existing evidence on leadership that best matches nursing home care, with a focus on behaviors, effects and influencing factors. A narrative review was performed in three steps: the establishment of scope, systematic search in five databases and assessment and analysis of the literature identified. A total of 44 articles were included in the review. The results of the study imply that a stronger focus on leadership behaviors related to the specific context rather than leadership styles could be of added value in nursing home care. Only articles applicable to nursing home care were included. The definition of "nursing home care" may differ between countries. This study only focused on the academic literature. Future research should focus on strategies and methods for the translation of leadership into behavior in practice. A broader and more conceptual perspective on leadership in nursing homes - in which leadership is seen as an attribute of all employees and enacted in multiple layers of the organization - could support leadership practice. Leadership is considered an important element in the delivery of good quality nursing home care. This study provides insight into leadership behaviors and influencing contextual factors specifically in nursing homes.

Purchasing Quality Nursing Home Care in the Veterans Health Administration

Abstract Background and Objectives U.S. Department of Veterans Affairs Medical Centers (VAMCs) contract with nursing homes (NHs) in their community to serve Veterans. This study compares the characteristics and performance of Veterans Affairs (VA)-paid and non-VA-paid NHs both nationally and within local VAMC markets. Research Design and Methods VA-paid NHs were identified, characterized, and linked to VAMC markets using data drawn from VA administrative files. NHs in the United States in December 2015 were eligible for the analysis, including. 1,307 VA-paid NHs and 14,253 non-VA-paid NHs with NH Compare measures in 128 VAMC markets with any VA-paid NHs. Measurements were derived from the Centers for Medicare and Medicaid Services (CMS) five-star rating system, NH Compare. Results VA-paid NHs had more beds, residents per day, and were more likely to be for-profit relative to non-VA-paid NHs. Nationally, the average CMS NH Compare star rating was slightly lower among VA-paid NHs than non-VA-paid NHs (3.05 vs. 3.21, p = .04). This difference was seen in all 3 domains: inspection (3.11 vs. 3.23, p < .001), quality (2.68 vs. 2.83, p < .001), and total nurse staffing (3.36 vs. 3.42, p < .10). There was wide variability across VAMC markets in the ratio of average star rating of VA-paid and non-VA-paid NHs (mean ratio = 0.93, interquartile range = 0.78–1.08). Discussion and Implications With increased community NH use expected following the implementation of the MISSION Act, comparison of the quality of purchased services to other available services becomes critical for ensuring quality, including for NH care. Methods presented in this article can be used to examine the quality of purchased care following the MISSION Act implementation. In particular, dashboards such as that for VA-paid NHs that compare to similar non-VA-paid NHs can provide useful information to quality improvement efforts.

The Effects of Medicare Payment Changes on Nursing Home Staffing

In light of persistent shortcomings in nursing home care quality and evidence that lower nurse staffing levels could be harmful to residents, we examine whether staffing levels are affected by changes in Medicare reimbursement rates. We exploit a 2006 change in Medicare’s methodology for adjusting provider payments for geographic differences in costs, a change that generated plausibly exogenous variation in nursing facility reimbursement rates. Our method compares facilities with higher and lower shares of Medicare resident days, which were differentially exposed to the payment changes we examine. Using panel data on US nursing homes from 2003 through 2009, we find that higher Medicare payments increased nurse staffing hours per resident day. Additional results suggest that changes in Medicare payments did not affect other measures of quality.

Towards personalized care: Factors associated with the quality of life of residents with dementia in Australian rural aged care homes.

Quality of dementia care improves with a personalized approach to aged care, and knowledge of the disease process and unique care needs of residents with dementia. A personalized model of care can have a significant impact on the overall organizational culture in aged care homes. However, the dimensions of personalized aged care relating to dementia often remain under-managed. We aim to explore the factors that shape the dimensions of personalized dementia care in rural nursing homes using qualitative data of a mixed-method 'Harmony in the Bush' dementia study. The study participants included clinical managers, registered nurses, enrolled nurses and care workers from five rural aged care homes in Queensland and South Australia. One hundred and four staff participated in 65 semi-structured interviews and 20 focus groups at three phases: post-intervention, one-month follow-up and three-months follow-up. A multidimensional model of nursing home care quality developed by Rantz et al. (1998) was used in data coding and analysis of the factors. Three key themes including seven dimensions emerged from the findings: resident and family [resident and family centeredness, and assessment and care planning]; staff [staff education and training, staff-resident interaction and work-life balance]; and organization [leadership and organizational culture, and physical environment and safety]. A lack of consideration of family members views by management and staff, together with poorly integrated, holistic care plan, limited resources and absence of ongoing education for staff, resulted in an ineffective implementation of personalized dementia care. Understanding the dimensions and associated factors may assist in interpreting the multidimensional aspects of personalized approach in dementia care. Staff training on person-centered approach, assessment and plan, and building relationships among and between staff and residents are essential to improve the quality of care residents receive.

VALIDATING THE CARE PREFERENCE ASSESSMENT OF SATISFACTION TOOL TO MEASURE QUALITY OF CARE IN NURSING HOMES

The Institute for Healthcare Improvement’s Triple Aim calls for measures of the ‘patient care experience’ to understand and improve the quality of care delivery. But, quality measures in the nursing home (NH) historically lack the resident perspective. Measuring whether residents are satisfied with the fulfillment of their care preferences using the Care Preference Assessment of Satisfaction Tool (ComPASS) has been encouraged nationally by the Centers for Medicare and Medicaid (CMS); however, the ComPASS has not been validated as a measure of the resident care experience. The purpose of this study was to compare ComPASS to the Ohio NH Resident Satisfaction Survey (a widely accepted quality measure for reimbursement). We examined 196 resident responses from 28 NHs in Pennsylvania using multilevel modeling to account for dependencies in the data (residents in the same NH may respond similarly compared to residents from different NHs). Residents were 81.2 years old (SD= 11.1), female (70.4%), and white (80.1%). Residents with higher scores on the ComPASS reported significantly higher levels of satisfaction with care (B=2.94, SE B=0.59, p<0.000). Results from this study support the potential use of ComPASS to measure, track, and improve the quality of NH care. Using ComPASS aligns with CMS’s Section F of the Minimum Dataset, an assessment of residents’ preferences which promotes the delivery of more person-centered care. Ultimately, ComPASS can help benchmark the quality of the resident care experience across facilities which aids staff, facilities, policy-makers, and NH-shoppers in improving decision-making and care delivery.

DISCOVERING STAFFING ISSUES AND EXPERIMENTING WITH STAFFING LEVELS IN DUTCH NURSING HOMES

Background: In 2017, the Dutch National Health Care Institute developed a quality framework describing what high quality nursing home care entails, aimed to improve nursing home care. The current study focuses on evaluating whether Dutch nursing homes comply to the framework, specifically regarding norms about staffing and formation of care teams (skill mix and educational level). Care teams that were experimenting with new staffing levels were monitored to evaluate what changes in staffing occurred and which obstructing or promoting factors they experienced. Methods: Quantitative data about staffing and team characteristics were gathered. Further, qualitative data about motives for wanting to change, the change approach, obstructing and promoting factors and evaluation of changes was collected. Telephone interviews were held at baseline, after 3 months and after 6 months. Thirty-two teams participated in the study. Results: Challenges for making changes in staffing consisted of attracting new care staff, dealing with sickness leave, communication within and between teams, communication with informal carers and combining care for and having attention for well-being of residents in the daily work routine. Additionally, teams wanted to better adjust the skill mix of staff to the needs of residents. Conclusion: For the formation of care teams, there seems to be no ‘one-size fits all’ approach. A quantitative norm that applies to all nursing homes in the Netherlands as described in the quality framework (e.g. a minimum of two care professionals for eight residents during intensive moments of care) is therefore not always the route to high quality care.

Development and Validation of the Nursing Home Care-related Quality of Life Scale

ObjectivesWe developed an instrument to assess nursing home residents' quality of life (QOL), with a focus on QOL-related factors modifiable through nursing home care, within the South Korean context; then, we tested its validity and reliability. DesignThe scale was constructed through a literature review, qualitative interviews, expert panel review, and a focus group interview; then, it was validated through survey research. Setting and participantsResidents (N = 667) from 42 nursing homes in South Korea participated in scale validation. MethodsNinety-nine items across 5 dimensions were initially drafted through a literature review and qualitative interview data. The expert panel review and a focus group interview yielded a scale with 31 items across 3 dimensions. Next, using survey data from nursing home residents, we examined the construct and concurrent validity and reliability (using Kuder-Richardson 20) of the 31-item QOL scale. ResultsThrough a series of factor analyses, the 31 items were reduced to 17 items across 2 dimensions: Environment and Services (13 items) and Social Interaction (4 items). This 17-item scale was further examined for model fitness and reliability. The scale had acceptable to good fit (root mean square error of approximation = 0.07 and 0.07; comparative fit index = 0.83 and 0.98 for Environment and Services and Social Interaction, respectively), and good concurrent validity and internal consistency (Kuder-Richardson 20 = 0.72). Conclusions and implicationsThis 17-item scale is a valid and reliable tool to assess nursing home residents' QOL in South Korea, with a focus on factors modifiable through nursing home care. Through more research to test its usefulness, validity, and reliability, the scale can be used as an index of nursing home care quality and contribute to the development of strategies to improve nursing home residents' QOL.

Medicaid Long-term Care Policies and Rates of Nursing Home Successful Discharge to Community

ObjectivesSuccessful discharge of nursing home (NH) residents to community has been reported in Nursing Home Compare (NHCompare) as a quality indicator, yet it is likely influenced by the availability of home- and community-based services (HCBS). Medicaid NH reimbursement rates and bed-hold policies have been shown to be related to quality of care, which may also affect successful discharge. This study explores the relationship of state Medicaid long-term care policies and successful discharge. DesignLongitudinal study of Medicaid policies and NHCompare successful discharge rates over 3 time periods, 2014-2015, 2015-2016, and 2016-2017, using generalized estimating equation models. Setting and participants11,694 unique NHs. MeasuresRisk-adjusted rates of successful discharge were downloaded from NHCompare. Truven's “Medicaid Expenditures for Long-term Services and Supports” reports provided states' expenditures on HCBS and NHs. Details of bed-hold policies in 2014 were obtained from the Medicaid and CHIP Payment and Access Commission. Data on NH and market characteristics were extracted from LTCFocUs.org and Area Health Resources File. ResultsThe national average-adjusted successful discharge rates were 49.7%, 56.8%, and 56.2% in 2014-2015, 2015-2016, and 2016-2017, respectively. In 2015, states spent between 30.6% (Mississippi) and 82.2% (Oregon) on HCBS, with an overall average of 53.1%. States reimbursed NHs, on average, $185.7 per resident day. Five percent increase in Medicaid spending for HCBS was statistically significantly associated with 0.47% higher successful discharge rates. Compared to NHs in states with reimbursement rates in the first quartile (≤$152), NHs in the second ($153-$178), third ($179-$212), and fourth (≥$213) quartiles were associated with 2.33%, 1.86%, and 1.15% higher successful discharge rates (all P < .01). Results were stronger in states without bed-hold policies. Conclusions/ImplicationsThis study provides promising evidence to state governments that shifting expenditures from institutions to communities as well as more generous reimbursements to NHs may improve quality of care in NHs.

Association Between Clinician Specialization in Nursing Home Care and Nursing Home Clinical Quality Scores

ImportanceWhile the number of prescribing clinicians (physicians and nurse practitioners) who provide any nursing home care remained stable over the past decade, the number of clinicians who focus their practice exclusively on nursing home care has increased by over 30%. ObjectivesTo measure the association between regional trends in clinician specialization in nursing home care and nursing home quality. DesignRetrospective cross-sectional study. Setting and ParticipantsPatients treated in 15,636 nursing homes in 305 US hospital referral regions between 2013 and 2016. MeasuresClinician specialization in nursing home care for 2012–2015 was measured using Medicare fee-for-service billings. Nursing home specialists were defined as generalist physicians (internal medicine, family medicine, geriatrics, and general practice) or advanced practitioners (nurse practitioners and physician assistants) with at least 90% of their billings for care in nursing homes. The number of clinicians was aggregated at the hospital referral region level and divided by the number of occupied Medicare-certified nursing home beds. Nursing Home Compare quality measure scores for 2013–2016 were aggregated at the HHR level, weighted by occupied beds in each nursing home in the hospital referral region. We measured the association between the number of nursing home specialists per 1000 beds and the clinical quality measure scores in the subsequent year using linear regression. ResultsAn increase in nursing home specialists per 1000 occupied beds in a region was associated with lower use of long-stay antipsychotic medications and indwelling bladder catheters, higher prevalence of depressive symptoms, and was not associated with urinary tract infections, use of restraints, or short-stay antipsychotic use. Conclusions and ImplicationsHigher prevalence of nursing home specialists was associated with regional improvements in 2 of 6 quality measures. Future studies should evaluate whether concentrating patient care among clinicians who specialize in nursing home practice improves outcomes for individual patients. The current findings suggest that prescribing clinicians play an important role in nursing home care quality.

Effect of an Educational and Organizational Intervention on Pain in Nursing Home Residents: A Nonrandomized Controlled Trial

ObjectivesTo determine whether an intervention based on education and professional support to nursing home (NH) staff would decrease the number of residents with a pain complaint, and to determine whether the intervention would improve pain management. DesignNonrandomized controlled trial. NHs were nonrandomly allocated either to a strong intervention group consisting in audit, feedback, and collaborative work on quality indicators with a hospital geriatrician, or to a light intervention group (LIG) consisting in audit and feedback only. SettingOne hundred fifty-nine NHs located in France. ParticipantsA subgroup of 3722 residents. MeasuresInformation on pain complaint and pain-related covariates at the resident-related and at the NH level were recorded by NH staff at baseline and 18 months later. These covariates were included in a mixed-effects logistic regression on resident's pain complaint. Pain management was compared between intervention groups by chi-square tests. ResultsA greater reduction of residents with a pain complaint after the strong intervention (odds ratio 0.69, 95% confidence interval 0.53, 0.90) and a better pain management (47.6% gold standard, vs 30.6% in the LIG, P < .001) than controls. Conclusion/ImplicationsCombining educational and organizational measures, evaluating pain as a patient-reported outcome and as a process endpoint, and implementing a broad-spectrum intervention were original approaches to improve quality of care in NHs. Our results support nonspecific, collaborative, educational, and organizational interventions in NHs to decrease residents' pain complaint and improve pain management.

A Study Examining the Influence of Proximity to Nurse Education Resources on Quality of Care Outcomes in Nursing Homes.

This examination seeks to determine the influence of proximal density to nurse education resources (nursing schools) on nursing home care quality outcomes in Alabama. Motivated by the social network theory, which highlights the influence of relational closeness on shared resources and values, we hypothesize that nursing homes that have higher levels of nursing education resources within a close proximity will exhibit significantly higher nursing home quality outcomes. As proximal density to nurse education resources increases, the opportunity for nursing homes to build closer, stronger ties increase, leading to higher quality outcomes. We examine this hypothesis via ordered logistic regressions of proximal density measures developed through geographic information systems (GIS) software, nurse education resource data from Johnson & Johnson’s Campaign for Nursing’s Future (n = 37), and nursing home quality outcome data from Centers for Medicare and Medicaid Services’s (CMS) Nursing Home Compare from 2016 (n = 226). The results find that increases in proximal density to nurse education resources have a negative and significant association with nursing home quality outcomes in Alabama. Additional sensitivity analysis, which examines the degree to which the nature of this relationship is sensitive to health care facilities’ location in high-density areas, is offered and confirms principal findings. Because nursing programs generally have stronger ties with hospitals, the findings suggest that the nursing homes in areas with higher nurse education resources may actually face greater competition for nurses.

Quality of Care In Nursing Homes In Brazil

BackgroundThere is an increased demand for nursing homes (NHs) in middle-income countries such as Brazil. To monitor the quality of NHs, there is a need for reliable instruments to assess the extent to which the care provided meets the expectations and rights of residents and their families. PurposeTo evaluate the reliability, applicability, and measurement results of an instrument for assessing the quality of NH care assessment. MethodsWe conducted a cross-sectional study in 31 NHs, applying the Observable Indicators of Nursing Home Care Quality Instrument (OINHQ) adapted to the Brazilian context. The instrument includes 30 infrastructure and process indicators measured by direct observation grouped into seven domains: Communication; Care Delivery; Grooming; Odors; Environment–Basic; Environment–Access; and Environment–Homelike. To assess feasibility and reliability, 3 pairs of raters with different profiles (health professionals, health inspectors, and potential residents) were independently involved in data collection. We calculated Cronbach α for internal consistency of the instrument, Overall Agreement Index (OAI), and Prevalence-Adjusted Bias-Adjusted Kappa (PABAκ) for interrater reliability and analyzed the baseline NH quality through individual indicators, dimensions, and facilities. ResultsThe OINHQ was in general reliable, with good internal consistency (Cronbach α = 0.93) and interrater agreement (mean OAI = 75%; PABAκ = 0.49). NH quality is not homogeneous (overall mean = 2.9, ranging by facility between 1.9 and 3.7, on a scale of 1-5). Process-related indicators (mean = 2.7) are generally worse than structure-related indicators (mean = 3.5). The best domains were associated with Odors (mean = 4.1) and Grooming (mean = 3.9), whereas the priority domains for receiving improvement interventions were Care Delivery (mean = 2.0) and Environment-Homelike (mean = 2.5). ConclusionsBaseline evaluation of NH quality shows remarkable variability among facilities and ample room for improvement.

Nursing home care quality: a cluster analysis

PurposeThe purpose of this paper is to explore potential differences in how nursing home residents rate care quality and to explore cluster characteristics.Design/methodology/approachA cross-sectional design was used, with one questionnaire including questions from quality from patients’ perspective and Big Five personality traits, together with questions related to socio-demographic aspects and health condition. Residents (n=103) from four Norwegian nursing homes participated (74.1 per cent response rate). Hierarchical cluster analysis identified clusters with respect to care quality perceptions. χ2 tests and one-way between-groups ANOVA were performed to characterise the clusters (p<0.05).FindingsTwo clusters were identified; Cluster 1 residents (28.2 per cent) had the best care quality perceptions and Cluster 2 (67.0 per cent) had the worst perceptions. The clusters were statistically significant and characterised by personal-related conditions: gender, psychological well-being, preferences, admission, satisfaction with staying in the nursing home, emotional stability and agreeableness, and by external objective care conditions: healthcare personnel and registered nurses.Research limitations/implicationsResidents assessed as having no cognitive impairments were included, thus excluding the largest group. By choosing questionnaire design and structured interviews, the number able to participate may increase.Practical implicationsFindings may provide healthcare personnel and managers with increased knowledge on which to develop strategies to improve specific care quality perceptions.Originality/valueCluster analysis can be an effective tool for differentiating between nursing homes residents’ care quality perceptions.

Differences in Nursing Home Quality Between Medicare Advantage and Traditional Medicare Patients

BackgroundMedicare Advantage (MA) enrollment is steadily growing, but little is known about the quality of nursing home (NH) care provided to MA enrollees compared to enrollees in traditional fee-for-service (FFS) Medicare. ObjectivesTo compare MA and FFS enrollees' quality of NH care. DesignCross-sectional. SettingUS nursing homes. Participants2.17 million Medicare enrollees receiving care at an NH during 2011. MeasurementsCMS methodology was used to calculate the 18 Nursing Home Compare quality measures as applicable for each enrollee. ResultsAmong Medicare enrollees using NH in 2011, 17% were in MA plans. Most quality scores were similar between MA and FFS. After adjusting for facility, beneficiary age and gender, CMS Hierarchical Condition Category score, and geographic region, short-stay MA enrollees had statistically significantly lower rates of new or worsening pressure ulcers [relative risk (RR) = 0.76, 95% confidence interval (CI) = 0.71–0.82] and new antipsychotic use (RR = 0.82, 95% CI = 0.80–0.83) but higher rates of moderate to severe pain (RR = 1.09, 95% CI = 1.07–1.12), compared with short-stay FFS enrollees. MA long-stay enrollees had lower rates of antipsychotic use (RR = 0.94, 95% CI = 0.93–0.96) but had higher rates of incontinence (RR = 1.08, 95% CI = 1.06–1.09) and urinary catheterization (RR = 1.10, 95% CI = 1.06–1.13), compared with long-stay FFS enrollees. ConclusionOverall, we found few differences in NH quality scores between MA and FFS Medicare enrollees. MA enrollment was associated with better scores for pressure ulcers and antipsychotic use but worse scores for pain control, incontinence, and urinary catheterization. Results may be limited by residual case-mix differences between MA and FFS patients or by the small number of short-stay measures reported.