Category Archives: Nursing Homes & Long Term Care

The Quality Measures Domain in Nursing Home Compare: Is High Performance Meaningful or Misleading?

Source: R Tamara Konetzka, Heather Davila, Daniel J Brauner, John F Cursio, Hari Sharma, Rachel M Werner, Young Shin Park, Tetyana P Shippee, The Gerontologist, Accepted Manuscript, April 27, 2021
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From the abstract:
Background and Objectives
The reported percent of nursing home residents suffering adverse outcomes decreased dramatically since Nursing Home Compare began reporting them, but the validity of scores is questionable for nursing homes that score well on measures using facility-reported data but poorly on inspections. Our objective is to assess whether nursing homes with these “discordant” scores are meaningfully better than nursing homes that score poorly across domains.

Research Design and Methods
We used a convergent mixed-methods design, starting with quantitative analyses of 2012-2016 national data. We conducted in-depth interviews and observations in 12 nursing homes in 2017-2018, focusing on how facilities achieved their Nursing Home Compare ratings. Additional quantitative analyses were conducted in parallel to study performance trajectories over time. Quantitative and qualitative results were interpreted together.

Discordant facilities engage in more quality improvement strategies than poor performers, but do not seem to invest in quality improvement in resource-intensive, broad-based ways that would spill over into other domains of quality and change their trajectory of improvement. Instead, they focus on lower-resource improvements related to data quality, staff training, leadership, and communication. In contrast, poor-performing facilities seemed to lack the leadership and continuity of staff required for even these low-resource interventions.

Discussion and Implications
High performance on the quality measures using facility-reported data is mostly meaningful rather than misleading to consumers who care about those outcomes, although discordant facilities still have quality deficits. The quality measures domain should continue to have a role in Nursing Home Compare.

Workers’ compensation costs for healthcare caregivers: Home healthcare, long‐term care, and hospital nurses and nursing aides

Source: Kermit G. Davis, Andrew M. Freeman, Jun Ying, Jeffrey R. Huth, American Journal of Industrial Medicine, Volume 64 Issue 5, May 2021
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From the abstract:
Background: Healthcare workers (nurses and nursing aides) often have different exposures and injury risk factors depending on their occupational subsector and location (hospital, long‐term care, or home health care).

Methods: A total of 5234 compensation claims for nurses and nursing aides who suffered injuries to their lower back, knee, and/or shoulder over a 5‐year period were obtained from the Ohio Bureau of Workers’ Compensation and analyzed. Injury causation data was also collected for each claim. The outcome variables included indemnity costs, medical costs, total costs, and the number of lost work days. The highest prescribed morphine equivalent dose for opioid medications was also calculated for each claim.

Results: Home healthcare nurses and nursing aides had the highest average total costs per claim. Hospital nurses and nursing aides had the highest total claim costs, of $5 million/year. Shoulder injuries for home healthcare nursing aides (HHNAs) had the highest average total claim costs ($20,600/injury) for all occupation, setting, and body area combinations. Opioids were most frequently prescribed for home healthcare nurses (HHNs) and nursing aides (18.9% and 17.7% having been prescribed opioids, respectively). Overexertion was the most common cause for HHN and nursing aide claims.

Conclusions: With the rapidly expanding workforce in the home healthcare sector, there is a potential health crisis from the continued expansion of home healthcare worker injuries and their associated costs. In addition, the potential for opioid drug usage places these workers at risk for future dependence, overdose, and prolonged disability. Future research is needed to investigate the specific and ideally reversible causes of injury in claims categorized as caused by overexertion.

High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information

Source: Ashvin Gandhi, Huizi Yu, and David C. Grabowski, Health Affairs, Vol. 40, No. 3, March 2021
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From the abstract:
Nursing staff turnover has long been considered an important indicator of nursing home quality. However, turnover has never been reported on the Nursing Home Compare website, likely because of the lack of adequate data. On July 1, 2016, the Centers for Medicare and Medicaid Services began collecting auditable payroll-based daily staffing data for US nursing homes. We used 492 million nurse shifts from these data to calculate a novel turnover metric representing the percentage of hours of nursing staff care that turned over annually at each of 15,645 facilities. Mean and median annual turnover rates for total nursing staff were roughly 128 percent and 94 percent, respectively. Turnover rates were correlated with facility location, for-profit status, chain ownership, Medicaid patient census, and star ratings. Disseminating facilities’ nursing staff turnover rates on Nursing Home Compare could provide important quality information for policy makers, payers, and consumers, and it may incentivize efforts to reduce turnover.

New York’s Nursing Homes Were on the Brink. Then Covid Hit. Covid was a nightmare — but it was a nightmare years in the making, workers say.

Source: Bridget Read, The Cut, April 2021

….But the blame for what happened in New York’s nursing homes extends far beyond the Cuomo administration. It is a huge crisis of neglect, decades in the making. Care workers who survived the pandemic say that the virus exposed preexisting gaps in funding and attention, compounding deficiencies that created the conditions for absolute disaster. Horrifying images of nurses dressed in black trash bags begging for PPE were shocking, but they were not a surprise to workers.

Though nursing homes are funded by billions of government dollars from Medicare and Medicaid, a majority in the United States are now owned by for-profit companies — in New York, it’s 60 percent of facilities. They’ve become cash cows for executives and owners, snapped up at alarming rates by huge conglomerates or private-equity firms. For staff and residents, the consequences have been dire. For-profit homes statistically have leaner staffing, bad food, substandard conditions, and higher chances of abuse, though they are intended to service residents that need intensive levels of care. Some patients are in relatively good health, but others require help with almost every aspect of life. Many have little or no family visiting them, which can lead to behavioral issues. Residents with dementia can be a danger to themselves. These are the people living in New York’s for-profit facilities, one in four of which have the state’s lowest-star-quality ratings….

Opinion: A Shift in Nursing Home Residents to Younger Psychiatric Patients

Source: Don Martin, Undark, March 9, 2021

The pandemic’s toll on nursing homes has opened up beds that younger people, often with mental illnesses, are filling.

One year ago, a nursing home in Kirkland, Washington, became an early battleground for the U.S. coronavirus outbreak. The disease has since decimated nursing home populations — more than one-third of the Covid-19-related deaths in the U.S. have been nursing home residents and staff. Virtually unnoticed is what has followed: In some nursing homes, a shift has occurred in the type of residents who live there, and Covid-19 is one of the reasons.

As older residents die from the pandemic and as more families choose to keep elderly relatives at home, some of these facilities are accepting more younger patients, including some with drug addictions and mental illness. Some patients have schizophrenia. Some have psychosis. This change in clientele can have a dramatic impact on the daily functioning of nursing homes, a change that administrators and staff may be unprepared to handle.

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:
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.

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.

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).

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.]