Category Archives: Nursing Homes & Long Term Care

Citizen Participation and Its Impact on Performance in U.S. Nursing Homes

Source: Anna A. Amirkhanyan, Ohbet Cheon, Jourdan A. Davis, Kenneth J. Meier, Fei Wang, The American Review of Public Administration, Volume 49 Issue 7, October 2019
(subscription required)

From the abstract:
Fundamental to democratic societies, citizen participation is an important tool for promoting active, informed, and empowered citizenry as well as responsive and accountable administration. Past literature on citizen participation has focused on its determinants, forms, and prevalence. This study examines the relationship between a specific form of citizen participation—client participation—and organizational performance. We use hybrid data on U.S. nursing homes that combine a survey of nursing home administrators’ managerial practices with federal performance appraisal data. Our empirical findings suggest that more intense levels of client participation, such as the use of clients’ feedback in decision-making, are positively associated with performance: They increase the overall five-star ratings and lower health deficiencies. In contrast, less intense client participation efforts, such as merely communicating with client/family groups, are not significantly related to performance. This study highlights the role of participation intensity, suggesting that public administrators should not only go beyond informing and listening to their stakeholders, but also take steps to use the obtained feedback in organizational decision-making.

U.S. Nursing Assistants Employed in Nursing Homes: Key Facts (2019)

Source: PHI, September 3, 2019

From the abstract:
This research brief provides the latest annual snapshot of U.S. nursing assistants employed in nursing homes, including key demographics and a variety of wage and employment trends. This year’s research found that 581,000 nursing assistants support older people and people with disabilities in nursing homes. Nursing assistants are injured more than three times more frequently than the typical American worker, and earn a median hourly wage of $13.38 and a median annual income of $22,200.

Key Takeaways:
– The number of nursing assistants employed in nursing homes in the U.S. declined from just over 599,000 in 2008 to 581,000 in 2018.
– Nursing assistants earn a median hourly wage of $13.38 and a median annual income of $22,200.
– Nursing homes will need to fill nearly 680,000 nursing assistant job openings between 2016 and 2026.

Daily Nursing Home Staffing Levels Highly Variable, Often Below CMS Expectations

Source: Fangli Geng, David G. Stevenson, and David C. Grabowski, Health Affairs, Vol. 38 No. 7, July 2019
(subscription required)

From the abstract:
Staffing is an important quality measure that is included on the federal Nursing Home Compare website. New payroll-based data reveal large daily staffing fluctuations, low weekend staffing, and daily staffing levels often below the expectations of the Centers for Medicare and Medicaid Services (CMS). These data provide a more accurate and complete staffing picture for CMS and consumers.

Evading the Catastrophic Costs of Nursing Home Care: A Theoretical Inquiry

Source: Gideon Yaniv, Public Finance Review, Volume: 47 issue: 4, July 2019
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From the abstract:
While many countries operate publicly funded programs to help care-needing elderly people finance the catastrophic costs of nursing home care, eligibility to public assistance may be means tested. To qualify for a means-tested program, applicants must first exhaust (spend down) their financial assets on privately paying for nursing home care, thereby wiping out their lifetime savings and children’s inheritance. They may naturally consider the possibility of hiding assets from the health agency, consequently shifting the financial burden to taxpayers. The present article adjusts two classical tax evasion models to capture the decision to evade the costs of nursing home care, focusing on the implications on the evaded costs and the program’s deficit of attempting to cope with the escalating costs of nursing home care by imposing a cost-sharing premium on the applicants’ adult children. Some insights on the socially optimal level of the cost-sharing premium are finally discussed.

Improving Job Quality for Direct Care Workers

Source: Paul Osterman, Economic Development Quarterly, Volume 33 Issue 2, May 2019
(subscription required)

From the abstract:
The prevalence of low wage work is a major challenge for American labor markets and health care is an industry in which many of these low wage workers are found. This paper provides data documenting these facts and then discusses strategies for upgrading job quality for long-term care workers who constitute the majority of low wage employees in health care occupations. In addition the paper briefly discusses approaches for upgrading the employment opportunities of low wage employees who are in the health industry but in jobs that are not health care specific.

Neglect Unchecked

Source: Kaiser Health News, 2018-2019

This Kaiser Health News series examines the reasons that long-term care facilities, their owners and the government fail to protect residents.

Though nursing homes are among the most heavily regulated types of medical providers, they remain dangerous places for frail residents. Four of 10 were cited for harming a patient or putting them in jeopardy over a three-year period.

Assisted living facilities have notably less oversight than nursing homes, even though they increasingly care for elderly people who are so frail that they might otherwise be in a nursing home.

This Kaiser Health News series examines the reasons that nursing homes, their owners and the government fail to protect residents.

Articles include:
Nursing Home Fines Drop As Trump Administration Heeds Industry Complaints
By Jordan Rau, Kaiser Health News, March 15, 2019
Inspectors are citing nursing facilities for violating health and safety more often than during the Obama administration. But the average fine is nearly a third lower than it was before President Donald Trump took office.

Assisted Living’s Breakneck Growth Leaves Safety Of Dementia Patients Behind
By Jordan Rau, Kaiser Health News, December 17, 2018
An analysis of inspection records in California, Florida and Texas shows significant numbers of violations related to assisted living residents with dementia.

1,400 Nursing Homes Get Lower Medicare Ratings Because Of Staffing Concerns
By Jordan Rau and Elizabeth Lucas, Kaiser Health News, July 30, 2018
Medicare said those homes either lacked a registered nurse for “a high number of days” over three months, provided data the government couldn’t verify or didn’t supply their payroll data at all.

‘Like A Ghost Town’: Erratic Nursing Home Staffing Revealed Through New Records
By Jordan Rau, Kaiser Health News, July 13, 2018
Daily nursing home payroll records just released by the federal government show the number of nurses and aides dips far below average on some days and consistently plummets on weekends.

Is the Quality of Nursing Homes Countercyclical? Evidence From 2001 Through 2015

Source: Sean Shenghsiu Huang, John R Bowblis, The Gerontologist, Advance Articles, Published: December 7, 2018
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From the abstract:
Background and Objectives:
To examine whether nursing homes (NHs) provide better quality when unemployment rates rise (countercyclical) and explore mechanisms contributing to the relationship between quality and unemployment rates.

Research Design and Methods:
The study uses the data on privately owned, freestanding NHs in the continental United States that span a period from 2001 through 2015. The empirical analysis relies on panel fixed-effect regressions with the key independent variable being the county-level unemployment rate. NH quality is measured using deficiencies, outcomes, and care process measures. We also examine nursing staff levels, as well as employee turnover and retention.

Results:
NHs have better quality when unemployment rates increase. Higher unemployment rates are associated with fewer deficiencies and lower deficiency scores. This countercyclical relationship is also found among other quality measures. In terms of mechanisms, we find higher nursing staff levels, lower employee turnover, and better workforce retention when unemployment rates rise. Improvement in staffing is likely contributing to better quality during recessions. Interestingly, these effects predominately occur in for-profit NHs for deficiencies and staffing levels.

Discussions and Implications:
NH quality is countercyclical. With near record-low unemployment rates in 2018, regulatory agencies should pay close attention to NH quality when and where the local economy registers strong growth. On the other hand, the finding of the unemployment rate–staffing/turnover relationship also suggests that policies increasing staffing and reducing employee turnover may not only improve NH quality but also have the potential to smooth quality fluctuations between business cycles.

CMS Strengthens Nursing Home Oversight and Safety to Ensure Adequate Staffing

Source: Centers for Medicare & Medicaid Services (CMS), Press Release, November 30, 2018

Agency works with states, facilities to identify and address potential cases of inadequate staffing
Today, the Centers for Medicare & Medicaid Services (CMS) announced actions that will bolster nursing home oversight and improve transparency in order to ensure that facilities are staffed adequately to provide high-quality care. These actions include sharing data with states when potential issues arise regarding staffing levels and the availability of onsite registered nurses; clarifying how facilities should report hours and deduct time for staff meal breaks; and providing facilities with new tools to help ensure their resident census is accurate. ….

…. Research shows the ratio of nurses to residents impacts quality of care and health outcomes. For example, facilities with higher nurse staffing levels tend to have fewer resident hospitalizations. In general, the new payroll-based staffing data shows most facilities have somewhat fewer staff on weekends, but some facilities have significantly lower weekend staffing. Additionally, some facilities have reported days with no registered nurse onsite, although nursing homes are generally required by law to have a registered nurse onsite eight hours a day, seven days a week.

To help address these risks, CMS will use frequently-updated payroll-based data to identify and provide state survey agencies with a list of nursing homes that have a significant drop in staffing levels on weekends, or that have several days in a quarter without a registered nurse onsite. State survey agencies will then be required to conduct surveys on some weekends based on this list. If surveyors identify insufficient nurse staffing levels, the facility will be cited for noncompliance and required to implement a plan of correction. ….

Multitasking in Nursing Homes: Differences Between For-Profit and Nonprofit Quality Outcomes

Source: Jennifer Gaudet Hefele, Xiao (Joyce) Wang, Christine E Bishop, Adrita Barooah, The Gerontologist, Advance Access, November 14, 2018
(subscription required)

From the abstract:
Background and Objectives:
Nursing homes (NHs) in the United States face increasing pressures to admit Medicare postacute patients, given higher payments relative to Medicaid. Changes in the proportion of residents who are postacute may initiate shifts in care practices, resource allocations, and priorities. Our study sought to determine whether increases in Medicare short-stay census have an impact on quality of care for long-stay residents.

Research Design and Methods:
This study used panel data (2005–2010) from publicly-available sources (Nursing Home Compare, Area Health Resource File, LTCFocus.org) to examine the relationship between a 1-year change in NH Medicare census and 14 measures of long-stay quality among NHs that experienced a meaningful increase in Medicare census during the study period (N = 7,932). We conducted analyses on the overall sample and stratified by for- and nonprofit ownership.

Results:
Of the 14 long-stay quality measures examined, only one was shown to have a significant association with Medicare census: increased Medicare census was associated with improved performance on the proportion of residents with pressure ulcers. Stratified analyses showed increased Medicare census was associated with a significant decline in performance on 3 of 14 long-stay quality measures among nonprofit, but not for-profit, facilities.

Discussion and Implications:
Our findings suggest that most NHs that experience an increase in Medicare census maintain long-stay quality. However, this may be more difficult to do for some, particularly nonprofits. As pressure to focus on postacute care mount in the current payment innovation environment, our findings suggest that most NHs will be able to maintain stable quality.

Knee pain in nursing home workers after implementation of a safe resident handling program

Source: Judith E. Gold, Alicia Kurowski, Rebecca J. Gore, Laura Punnett, American Journal of Industrial Medicine, Volume 61 Issue 10, October 2018
(subscription required)

From the abstract:
Purpose:
Approximately 25‐30% of nursing personnel experience knee pain (KP). We sought to identify physical and psychosocial work exposures, and personal factors related to prevalent, incident, and persistent KP 5‐8 years after safe resident handing program (SRHP) implementation in nursing homes.

Methods:
Health and exposure information was obtained from worker surveys 5‐6 years (“F5”) and 7‐8 years (“F6”) post‐SRHP implementation. Prevalent KP correlates were examined at F5; persistent and incident KP predictors were analyzed at F6, utilizing robust Poisson multivariable regression.

Results:
F5 KP prevalence (19.7%) was associated with combined physical exposures, and with either high job strain or low social support, in separate models. Two‐year persistent KP was similarly associated with these psychosocial exposures. Being overweight was associated with KP in all analyses.

Conclusions:
The SRHP program did not eliminate knee physical loading, which should be reduced to prevent nursing home worker KP. Workplace psychosocial exposures (high job strain, low social support) also appeared germane.