Category Archives: Nursing Homes & Long Term Care

Does Private Equity Investment in Healthcare Benefit Patients? Evidence from Nursing Homes

Source: Atul Gupta, Sabrina T. Howell, Constantine Yannelis & Abhinav Gupta, NBER Working Paper 28474, February 2021
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The past two decades have seen a rapid increase in Private Equity (PE) investment in healthcare, a sector in which intensive government subsidy and market frictions could lead high-powered for-profit incentives to be misaligned with the social goal of affordable, quality care. This paper studies the effects of PE ownership on patient welfare at nursing homes. With administrative patient-level data, we use a within-facility differences-in-differences design to address non-random targeting of facilities. We use an instrumental variables strategy to control for the selection of patients into nursing homes. Our estimates show that PE ownership increases the short-term mortality of Medicare patients by 10%, implying 20,150 lives lost due to PE ownership over our twelve-year sample period. This is accompanied by declines in other measures of patient well-being, such as lower mobility, while taxpayer spending per patient episode increases by 11%. We observe operational changes that help to explain these effects, including declines in nursing staff and compliance with standards. Finally, we document a systematic shift in operating costs post-acquisition toward non-patient care items such as monitoring fees, interest, and lease payments.

Occupational Licensing of Social Services and Nursing Home Quality: A Regression Discontinuity Approach

Source: John R. Bowblis, Austin C. Smith, ILR Review, Volume 74 Issue 1, January 2021
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From the abstract:
Occupational licensing has grown dramatically in recent years, with more than 25% of the US workforce having a license as of 2008, up from 5% in 1950. Has licensing improved quality or is it simply rent-seeking behavior by incumbent workers? To estimate the impact of increased licensure of social workers in skilled nursing facilities (SNFs) on service quality, the authors exploit a federal staffing provision that requires SNFs of a certain size to employ licensed social workers. Using a regression discontinuity design, the authors find that qualified social worker staffing increases by approximately 10%. However, the overall increase in social services staffing is negligible because SNFs primarily meet this requirement in the lowest cost way—substituting qualified social workers for unlicensed social services staff. The authors find no evidence that the increase in licensure improves patient care quality, patient quality of life, or quality of social services provided.

Always Essential: Valuing Direct Care Workers in Long-Term Care

Source: Kezia Scales, Michael J Lepore, Public Policy & Aging Report, Volume 30, Issue 4, 2020
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From the abstract:
In the United States and worldwide, the coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted the long-term services and supports (LTSS) sector, which serves those individuals who are most at risk of morbidity and mortality from the disease. Although devastating, the crisis also, importantly, heightened the visibility of the direct care workforce—thanks to increased attention on the LTSS sector and extensive news coverage of the responsibilities and risks shouldered by these workers (Almendrala, 2020; Lyons, 2020; Quinton, 2020; Woods, 2020)—and catalyzed action to improve direct care job quality. This new momentum to improve direct care jobs builds on decades of efforts to reinvent the financing mechanisms, laws and policies, and regulatory processes that have historically marginalized this workforce. However, with the largest payer for LTSS in the United States being Medicaid, a means-tested public assistance program, past efforts to improve LTSS and elevate direct care jobs have tended to achieve incremental progress at best, and more often have ended in political gridlock or inertia (Lepore, 2019). Drawing on empirical data and historical and theoretical analyses of direct care work in the United States, this article examines how efforts to improve direct care jobs have historically been stymied by the incongruence between the moral value and material value attributed to this work (Lepore, 2008). We argue that this incongruity of values has not been sufficiently emphasized in past LTSS reform efforts, and recommend an approach for aligning these values in the post–COVID-19 era.

Workers’ compensation claims among private skilled nursing facilities, Ohio, 2001–2012

Source: Ashley M. Bush, Audrey A. Reichard, Steven J. Wurzelbacher, Chih‐Yu Tseng, Michael P. Lampl, American Journal of Industrial Medicine, Vol. 63, No. 12, December 2020
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From the abstract:
Introduction:
Skilled nursing facilities have one of the highest rates of occupational injury and illness among all industries. This study quantifies the burden of occupational injury and illness in this industry using data from a single state‐based workers’ compensation (WC) system.

Methods:
Ohio Bureau of Workers’ Compensation claims from 2001 to 2012 were analyzed among privately owned, state‐insured skilled nursing facilities and are presented as claim counts and rates per 100 full‐time equivalents (FTE). Worker, employer, incident, and injury characteristics were examined among all claims and by medical‐only (medical care expenses and/or less than eight days away from work) and lost‐time (eight days or more away from work) claim types.

Results:
There were 56,442 claims in this population of Ohio skilled nursing facilities from 2001 to 2012. Overexertion and bodily reaction, slips, trips, and falls, and contact with objects and equipment accounted for the majority of all WC claims (89%). Overexertion and bodily reaction, and slips, trips, and falls comprised 85% of the 10,793 lost‐time claims. The highest injury event/exposure rates for all claims were for overexertion and bodily reaction (3.7 per 100 FTE for all claims), followed by slip, trips, and falls (2.1), and contact with objects and equipment (1.9).

Conclusion:
Understanding the details surrounding injury events and exposures resulting in WC claims can help better align prevention efforts, such as incorporation of safe patient handling policies and lifting aids, improvement in housekeeping practices, and employee training within skilled nursing facilities to prevent worker injury and mitigate related expenses.

Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes

Source: Adam Dean, Atheendar Venkataramani, and Simeon Kimmel, Health Affairs, Ahead of Print, September 10, 2020
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From the abstract:
More than 40% of all reported coronavirus disease 2019 (COVID-19) deaths in the United States have occurred in nursing homes. As a result, health care worker access to personal protective equipment (PPE) and infection control policies in nursing homes have received increased attention. However, it is not known if the presence of health care worker unions in nursing homes is associated with COVID-19 mortality rates. Therefore, we used cross-sectional regression analysis to examine the association between the presence of health care worker unions and COVID-19 mortality rates in 355 nursing homes in New York State. Health care worker unions were associated with a 1.29 percentage point mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions. Unions were also associated with greater access to PPE, one mechanism that may link unions to lower COVID-19 mortality rates. [Editor’s Note: This Fast Track Ahead Of Print article is the accepted version of the peer-reviewed manuscript. The final edited version will appear in an upcoming issue of Health Affairs.]

Facility-level Factors Associated with CNA Turnover and Retention: Lessons for the Long-Term Services Industry

Source: Katherine A Kennedy, Robert Applebaum, John R Bowblis, The Gerontologist, Published: July 29, 2020
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From the abstract:
Background and Objectives:
Certified nursing assistant (CNA) turnover and retention are critical aspects of facilities’ ability to provide cost-effective, high quality person-centered care. Previous studies and industry practice often treat turnover and retention as similar concepts, assuming that low turnover and high retention are synonymous. The study addressed the question of whether turnover and retention rates differ and if so, what do those differences mean for nursing home practice, policy, and research.

Research Design and Methods:
This study examines facility-level factors associated with CNA retention and turnover rates using 2015 data from the Ohio Biennial Survey of Long-Term Care Facilities, Ohio Medicaid Cost Reports, Certification and Survey Provider Enhanced Report, and the Area Health Resource File. Using bivariate tests and regression analysis, we compare rates and the factors associated with retention and turnover.

Results:
The mean facility annual retention rate was 64% and the mean annual turnover rate was 55%. As expected, there was a statistically significant and negative correlation between the rates (r = -0.26). However, some facilities had both high retention and high turnover and some had low rates for both measures. Not all the variables that are associated with turnover are also associated with retention.

Discussion and Implications:
CNA retention is not simply the absence of CNA turnover. Given the differences, nursing homes may need to use strategies and policies designed to target a particular stability measure.

Nurse Aide Retention in Nursing Homes

Source: Nicholas G Castle, PhD, Kathryn Hyer, PhD, MPP, John A Harris, MD, MSc, John Engberg, PhD, The Gerontologist, Advance Access, March 6, 2020
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From the abstract:
Background and Objectives: The association of nurse aide retention with three quality indicators is examined. Retention is defined as the proportion of staff continuously employed in the same facility for a defined period of time.

Research Design and Methods: Data used in this investigation came from survey responses from 3,550 nursing facilities, Certification and Survey Provider Enhanced Reporting data, and the Area Resource File. Staffing characteristics, quality indicators, facility, and market information from these data sources were all measured in 2016. Nurse aide retention was measured at 1, 2, and 3 years of employment. The quality indicators examined were a count of all deficiency citations, quality of care deficiency citations, and J, K, L deficiency citations. Negative binomial regression analyses were used to study the associations between the three different retention measures and these three quality indicators.

Results: The 1-, 2-, and 3-year nurse aide retention measures were 53.2%, 41.4%, and 36.1%, respectively. The regression analyses show low levels of retention to be generally associated with poor performance on the three deficiency citation quality indicators examined.

Discussion and Implications: The research presented starts to provide information on nurse aide retention as an important workforce challenge and its potential impact on quality. Retention may be an additional staffing characteristic of nursing facilities with substantial policy and practice relevance.

Service Professionals’ Response to Volunteer Involvement in Service Production

Source: Mette Kjærgaard Thomsen, Ulrich Thy Jensen, Journal of Public Administration Research and Theory, Advance Access, Published: October 15, 2019
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From the abstract:
Involving volunteers in the production and delivery of public services is a core policy objective of governments around the world. While existing research on volunteer involvement in service production, for example, has focused on advantages and disadvantages of such involvement and different dimensions of volunteer involvement, little is known about service professionals’ response to volunteer involvement in public service production. Integrating perspectives from multiple theories, we build a theoretical framework for understanding how and when service professionals come to see volunteers as a threat to the quality of service, the profession’s privileged position and monopoly, and professionals’ own work tasks and job security. Based on a central distinction between production of core and complementary tasks, we propose that volunteers come to be seen as a threat in the eyes of service professionals when volunteers solve core rather than complementary tasks. Using a survey experiment among health assistants at nursing homes, we find partial support for our argument. Health assistants are more likely to perceive volunteers as a threat to the quality of care when volunteers solve core rather than complementary tasks. The study guides research toward a more nuanced understanding of volunteer involvement in service production in public organizations.

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
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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.