Category Archives: Nursing Homes & Long Term Care

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
(subscription required)

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.

1,400 Nursing Homes Get Lower Medicare Ratings Because Of Staffing Concerns

Source: Jordan Rau and Elizabeth Lucas, Kaiser Health News, July 30, 2018

Medicare has lowered its star ratings for staffing levels in 1 in 11 of the nation’s nursing homes — almost 1,400 of them — because they either had inadequate numbers of registered nurses or failed to provide payroll data that proved they had the required nursing coverage, federal records released last week show.

Medicare only recently began collecting and publishing payroll data on the staffing of nursing homes as required by the Affordable Care Act of 2010, rather than relying as it had before on the nursing homes’ own unverified reports.

The payroll records revealed lower overall staffing levels than homes had disclosed, particularly among registered nurses. Those are the highest-trained caregivers required to be in a nursing home, and they supervise other nurses and aides. Medicare mandates that every facility have a registered nurse working at least eight hours every day…..

….The new payroll data, analyzed by Kaiser Health News, showed that for-profit nursing homes averaged 16 percent fewer staff than did nonprofits, even after accounting for differences in the needs of residents. The biggest difference was in the number of registered nurses: At the average nonprofit, there was one RN for every 28 residents, but at the average for-profit, there was only one RN for every 43 residents. Researchers have repeatedly found lower staffing in for-profit facilities, which make up 70 percent of the industry….

Related:
Mining A New Data Set To Pinpoint Critical Staffing Issues In Skilled Nursing Facilities
Source: Jordan Rau, Kaiser Health News, July 30, 2018

The Centers for Medicare & Medicaid Services is not known for linguistic playfulness. Nonetheless, at least one person there must have been chuckling when it named its rich new data source for nursing home staffing levels the Payroll-Based Journal, or PBJ.

Like that classic sandwich, the PBJ data set is irresistible. CMS created it to fulfill a requirement of the Affordable Care Act to improve the accuracy of its five-star staffing ratings on Medicare’s Nursing Home Compare website. The data set contains payroll records that nursing homes are required to submit to the government.

In April, Medicare began using them to rate staffing for more than 14,000 skilled nursing facilities (SNFs). The PBJ data gives a much better look at the how staffing relates to quality of care than the less precise — and too easy to inflate — staffing data Medicare had been using since 2008, which were based on two-week snapshots of staffing homes provided to inspectors. The data show staffing and occupancy on every day — an unprecedented degree of granularity that allows for new levels of inquiry.

What Consumers Say About Nursing Homes in Online Reviews

Source: Caitlyn Kellogg, Yujun Zhu, Valeria Cardenas, Katalina Vazquez, Kayla Johari, Anna Rahman, Susan Enguidanos, The Gerontologist, Advance Access, published April 20, 2018
(subscription required)

From the abstract:
Background:
Although patient-centered care is an expressed value of our healthcare system, no studies have examined what consumers say in online reviews about nursing homes (NHs). Insight into themes addressed in these reviews could inform improvement efforts that promote patient-centered NH care.

Research Design and Methods:
We analyzed nursing home (NH) Yelp reviews. From a list of all NHs in California, we drew a purposeful sample of 51 NHs, selecting facilities representing a range of geographical areas and occupancy rates. Two research teams analyzed the reviews using grounded theory to identify codes and tracked how frequently each code was mentioned.

Results:
We evaluated 264 reviews, identifying 24 codes, grouped under five categories: quality of staff care and staffing; physical facility and setting; resident safety and security; clinical care quality; and financial issues. More than half (53.41%) of Yelp reviewers posted comments related to staff attitude and caring and nearly a third (29.2%) posted comments related to staff responsiveness. Yelp reviewers also often posted about NHs’ physical environment. Infrequently mentioned were the quality of health care provided and concerns about resident safety and security.

Discussion and Implications:
Our results are consistent with those from related studies. Yelp reviewers focus on NH aspects that are not evaluated in most other NH rating systems. The federal Nursing Home Compare website, for instance, does not report measures of staff attitudes or the NH’s physical setting. Rather, it reports measures of staffing levels and clinical processes and outcomes. We recommend that NH consumers consult both types of rating systems because they provide complementary information.

Distributional Effects of Alternative Strategies for Financing Long-Term Services and Supports and Assisting Family Caregivers

Source: Melissa M. Favreault and Richard W. Johnson, Center for Retirement Research at Boston College, WP#2018-1, March 2018

From the abstract:
We use two historical data sources – the Health and Retirement Study and the Medicare Current Beneficiary Study – to consider the patterns in older Americans’ severe disability and their use of long-term services and supports (LTSS) by age and socioeconomic status.  We then use a dynamic microsimulation model to project how the effects of various interventions to support those with severe disabilities and their caregivers would be distributed across the income distribution.  The interventions that we examine fall into three broad classes: tax credits for caregiving expenses, respite care for people in the community with family caregivers, and new social insurance programs.  Within each broad class of policies, we examine how sensitive outcomes are to changes in policy details (such as, in the case of tax credits, deductible levels, refundability, and income phase-outs).

This paper found that:
– Older adults with less education and less wealth are more likely to report disabilities and service use than their more educated and wealthier counterparts.
– This pattern persists when we look at people at a point in time but also, more robustly, when we look at their disabilities prospectively. In a sample of older adults who do not report disabilities at baseline, we find that those with fewer economic resources earlier in life are generally more likely to develop disabilities and use paid LTSS over the next two decades, but the differences narrow when we restrict the sample to people who do not develop disabilities until their late 70s.  

The policy implications of this paper are:
– The uneven distribution of disability risks across the population poses challenges for developing effective LTSS policies. Those most likely to need LTSS often lack enough resources to contribute to LTSS programs, and programs that try to contain costs by using underwriting or imposing work requirements often disqualify those who most need coverage.
– Certain classes of policies, such as respite care benefits, tend to direct much of their benefits to those in lower income quintiles, according to our projections. Caregiver tax credits and social insurance programs generally distribute benefits more proportionally, although impacts vary depending on how the policies are specified.
– Policy design details can significantly affect distributional outcomes. Provisions’ effects can be sensitive to the stacking order in which they are implemented.
– It can be useful to examine trends and proposals not only cross-sectionally but also over longer time periods. For example, the distributional effects of social insurance programs depend on the relatively high early-life mortality of those with less education and lower earnings and wealth.

Unpaid Caregiving Roles and Sleep Among Women Working in Nursing Homes: A Longitudinal Study

Source: Nicole DePasquale, Martin J Sliwinski, Steven H Zarit, Orfeu M Buxton, David M Almeida, The Gerontologist, Advance Access, Published: January 19, 2018
(subscription required)

From the abstract:
Background and Objectives:
Although sleep is a critical health outcome providing insight into overall health, well-being, and role functioning, little is known about the sleep consequences of simultaneously occupying paid and unpaid caregiving roles. This study investigated the frequency with which women employed in U.S.-based nursing homes entered and exited unpaid caregiving roles for children (double-duty-child caregivers), adults (double-duty-elder caregivers), or both (triple-duty caregivers), as well as examined how combinations of and changes in these caregiving roles related to cross-sectional and longitudinal sleep patterns.

Research Design and Methods:
The sample comprised 1,135 women long-term care employees who participated in the baseline wave of the Work, Family, and Health Study and were assessed at three follow-up time points (6-, 12-, and 18-months). Sleep was assessed with items primarily adapted from the Pittsburgh Sleep Quality Index and wrist actigraphic recordings. Multilevel models with data nested within persons were applied.

Results:
Women long-term care employees entered and exited the unpaid elder caregiving role most frequently. At baseline, double-duty-child and triple-duty caregivers reported shorter sleep quantity and poorer sleep quality than their counterparts without unpaid caregiving roles, or workplace-only caregivers. Double-duty-elder caregivers also reported shorter sleep duration compared to workplace-only caregivers. Over time, double-duty-elder caregiving role entry was associated with negative changes in subjective sleep quantity and quality.

Discussion and Implications:
Simultaneously occupying paid and unpaid caregiving roles has negative implications for subjective sleep characteristics. These results call for further research to advance understanding of double-and-triple-duty caregivers’ sleep health and facilitate targeted intervention development.

Does Paid Family Leave Reduce Nursing Home Use? The California Experience

Source: Kanika Arora, Douglas A. Wolf, Journal of Policy Analysis and Management, Volume 37, Issue 1, Winter 2018
(subscription required)

From the abstract:
The intent of Paid Family Leave (PFL) is to make it financially easier for individuals to take time off from paid work to care for children and seriously ill family members. Given the linkages between care provided by family members and the usage of paid services, we examine whether California’s PFL program influenced nursing home utilization in California during the 1999 to 2008 period. This is the first empirical study to examine the effects of PFL on long-term care patterns. Multivariate difference-in-difference estimates across alternative comparison groups provide consistent evidence that the implementation of PFL reduced the proportion of the elderly population in nursing homes by 0.5 to 0.7 percentage points. Our preferred estimate, employing an empirically-matched group of control states, finds that PFL reduced nursing home usage by about 0.65 percentage points. For California, this represents an 11 percent relative decline in elderly nursing home utilization.