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PubMed1991

Effects of sheltered care environments and resident characteristics on the development of social networks.

Two hundred and thirty-four members of a 1973 sample of sheltered care residents, three-fourths of whom had schizophrenic disorders, were followed up between 1983 and 1985 to examine the role of supportive and of transitional, high-expectation sheltered care environments in the development of residents' social networks. The influences of revolving-door treatment experiences, psychopathology, and institutionalization were taken into account. The results showed that supportive rather than transitional, high-expectation environments contributed to the development of emotionally and instrumentally supportive social networks. Higher levels of psychopathology and a history of institutionalization resulted in the absence of certain support relationships. Surprisingly, revolving-door treatment experiences were related to positive support and social network outcomes.

Adult↗
PubMed2005

Urinary incontinence in the nursing home: resident characteristics and prevalence of drug treatment.

OBJECTIVES: To provide a descriptive overview of the elderly, nursing home patient population with urinary incontinence (UI). METHODS: This study was a descriptive, cross-sectional database analysis (2002-2003) examining UI prevalence, demographic and clinical characteristics of UI patients, and UI pharmacotherapy prevalence in the nursing home setting. RESULTS: Of the 29 645 eligible subjects, 8995 experienced some level of UI at the time the minimum data set (MDS) was completed (30%). Compared with continent residents, a greater percentage of incontinent residents were older, white women and had a longer length of stay. Incontinent residents also had more indicators of frailty than those who were continent; they were more impaired on activities of daily living and cognitive performance scale scores, were hospitalized more frequently, and had more urinary tract infections, pressure ulcers, and depression. More incontinent residents were using pads/briefs and had bladder retraining and scheduled toileting. Only 8.7% of those residents rated as having the most severe level of incontinence (MDS level 4) were being treated with pharmacotherapy. Of the 8995 residents with a UI rating of 1 to 4, only 8% (n = 731) had pharmacotherapy. CONCLUSION: There is a high prevalence of UI among nursing home residents and having this condition is negatively correlated with measures of resident health status and healthcare utilization. A variety of interventions are used in this setting to treat UI, and use of pharmacologic therapy appears to be quite low. Appropriate use of interventional strategies that may include drug treatment for UI in the nursing home may reduce the substantial personal and cost burdens associated with this condition. However, clinicians may need population-specific scientific evidence in determining which nursing home patients will benefit most from pharmacotherapy.

Aged↗
PubMed2006

Which clinical indicators and resident characteristics are associated with health care practitioner nursing home visits or hospital transfer for urinary tract infections?

OBJECTIVES: (1) To determine factors associated with practitioner visitation and/or hospital transfer for skilled nursing facility (SNF) patients who develop a urinary tract infection (UTI) and (2) to determine if SNF patients with a Do Not Resuscitate (DNR) directive are less likely to be personally assessed and/or transferred to the hospital in the event of a UTI when compared to patients without a DNR directive. DESIGN: Retrospective cohort study using nursing home medical record review. PARTICIPANTS: Participants were 564 residents from 35 nursing homes in 3 states who became acutely ill with UTI during the first 90 days of their nursing home admission. They were identified from 2832 random nursing home Medicare admissions and divided into 2 groups, those with DNR directives (n = 334) and those without (n = 230). MEASUREMENTS: Logistic regression was used to determine factors associated with practitioner in-person assessment and/or hospitalization, and to determine differences in the likelihood of practitioner in-person assessment and/or hospitalization among those with DNR directives versus those without DNR directives. RESULTS: Only one third (29%) of patients with unstable vital signs were seen by a practitioner or transferred to a hospital. Factors associated with practitioner assessment or hospital transfer were elevated temperature (OR 1.7, CI 1.04-2.64), pulse more than 100 beats per minute (OR 1.7, CI 1.01-2.99), and delirium (OR 2.1, CI 1.267-3.44). White residents were less likely to be assessed by a practitioner or transferred to a hospital (OR 0.45, CI 0.22-0.95). DNR directives were not significantly associated with fewer in-person assessments (P = .067). CONCLUSION: Only one third of SNF patients who developed a UTI with unstable vital signs were personally assessed by a practitioner and/or hospitalized. Patients with delirium were twice as likely to be assessed or transferred to a hospital, suggesting that practitioners use delirium as an indicator of illness severity. However, practitioner visit or transfer was also associated with ethnic background. In the absence of good evidence regarding which nursing home residents are likely to benefit from hospitalization or an urgent practitioner visit, these care decisions will continue to be associated with factors that are unknown.

Aged↗
PubMed1993

Who cares for Missouri's Medicaid nursing home residents? Characteristics of attending physicians.

OBJECTIVE: To describe the characteristics of physicians attending Medicaid recipients in Missouri's certified nursing homes (NH). DESIGN: Retrospective survey of multiple data sources. SETTING: Missouri's certified nursing homes. PARTICIPANTS: 1,339 physicians attending 22,452 Medicaid recipients. MEASUREMENTS: Physician characteristics were determined by reviewing a roster of medical directors of NHs compiled by the Missouri Department of Social Services' Division of Aging and physician directories compiled by the Missouri State Board of Registration for the Healing Arts, the AMA, the AOA, the ABFP, and the ABIM. Physician clinical activity was determined by examining NH inspection of care reports compiled by the Missouri Department of Social Services' Division of Aging. RESULTS: Each physician attended a mean of 16.8 and a median of six Medicaid recipients in the nursing home. The skewed distribution is reflected by 426 (31.8%) of the physicians attending only one or two residents, and 28 (2.1%) of the physicians attending 100 or more residents. Twenty-seven percent of the state's licensed osteopaths (DOs, 362) attended nursing home patients, compared with 11% of allopathic physicians (MDs, 977). Significantly more DOs than MDs attended more than the median number of patients (57% vs 45%, P < 0.001). Half were attended by the 605 (45%) physicians without board certification. Of those who were board certified, family physicians were more likely to include Medicaid nursing home patients in their practices than internists (43% vs 18%, P < 0.001). Physicians licensed for 11 to 20 years and rural physicians had the heaviest patient loads. CONCLUSIONS: Many doctors are caring for very few nursing home residents while a few doctors may be caring for too many patients. In addition, half the Medicaid recipients residing in Missouri's nursing homes in 1988 were attended by physicians without board certification, and almost one-third were attended by physicians who may be retiring between 2000 and 2010.

Aged↗
PubMed1977

Resident characteristics and staff behavior in two hospitals for mentally retarded adults.

Results of part of a study aimed at evaluating the implications of different nurse staffing levels were reported. Two samples of 30 patients were observed in the two hospitals and measures were obtained of the proportion of time they were involved in adaptive and maladaptive activities, the frequency with which they interacted in particular ways with the nursing staff, and their Adaptive Behavior Scale scores. When these various measures were examined, we found that those patients who needed more attention received it but not necessarily of the appropriate type. While such results are understandable and even perhaps predictable, they do serve to reveal a situation deserving remedial attention. We in fact suggested that one possible means of countering this tendency to ignore the less attractive patients is for the nursing staff to be assigned much smaller groups of patients than is customary.

Adult↗
PubMed2006

Dermatology residency program characteristics that correlate with graduates selecting an academic dermatology career.

OBJECTIVE: To examine the characteristics of 107 dermatology residency programs to determine which factors are correlated with producing academic dermatologists to help reverse the trend of a growing shortage of academic dermatologists. DESIGN: We collected data ranging from total publications to grant funding. Extensive Internet searches were completed to obtain most of the data. Individual programs were contacted as needed to obtain any missing data that were not found on the program's Web site. SETTING: Dermatology residency programs (departments and divisions) in the United States. MAIN OUTCOME MEASURES: Factors that correlated with producing full-time academic dermatologists. RESULTS: We tabulated and analyzed characteristics of 107 dermatology residency programs. Total full-time faculty members in 2004, total publications in 2004, and total publications from January 1, 2001, to December 31, 2004, were the 3 factors most strongly correlated with producing full-time faculty. National Institutes of Health and Dermatology Foundation grants and American Skin Association grant recipients were the 3 characteristics most strongly inversely correlated with producing full-time faculty. Those who entered academic dermatology tended to stay at the same program where they completed a dermatology residency, especially if this program was considered a "smaller" program. CONCLUSIONS: The programs' characteristics of total publications in 2004 and from 2001 to 2004 were 2 of the 3 factors most strongly positively correlated with dermatology residents entering academic dermatology. Encouraging residents to publish may be a window to motivate them toward a career in academic dermatology.

Career Choice↗
PubMed1986

Field-based generation and social validation managers and staff competencies for small community residences.

Characteristics and competencies for four staff positions in community residences for individuals with mental retardation were identified utilizing multiple empirical and deductive methods with field-based practitioners and field-based experts. The more commonly used competency generation methods of expert opinion and job performance analysis generated a high degree of knowledge and skill-based competencies similar to course curricula. Competencies generated by incumbent practitioners through open-ended methods of personal structured interview and critical incident analysis were ones which related to personal style, interpersonal interaction, and humanistic orientation. Although seldom included in staff, paraprofessional, or professional training curricula, these latter competencies include those identified by Carl Rogers as essential for developing an effective helping relationship in a therapeutic situation (i.e., showing liking, interest, and respect for the clients; being able to communicate positive regard to the client). Of 21 core competency statements selected as prerequisites to employment for all four staff positions, the majority (17 of 21) represented interpersonal skills important to working with others, including responsiveness to resident needs, personal valuation of persons with mental retardation, and normalization principles.

Employee Performance Appraisal↗
PubMed2000

Influence of facility characteristics on use of antipsychotic medications in nursing homes.

OBJECTIVES: This study investigated the effect of facility and resident characteristics on the use of antipsychotic medications in the long-term care setting. RESEARCH DESIGN: This research used data available from the On-Line Survey and Certification of Automated Records (OSCAR) for all Medicare/Medicaid-certified nursing homes in the contiguous United States in 1997. The data consisted of 14,631 facilities. MEASURES: A multiple linear regression model was used to determine the effects of selected facility and resident characteristics on antipsychotic drug use while simultaneously controlling for the effects of resident characteristics and stratifying by ownership type. beta-Coefficients provided measures of effect and represented the per-unit change in the prevalence of antipsychotic use corresponding to the per-unit change in each independent variable. RESULTS: In for-profit facilities, both the presence of special care units and mental health professionals were associated with increased antipsychotic use (beta = 1.70, SE = 0.23; beta = 0.24, SE = 0.17, respectively), while other facility factors such as increasing size, being part of a chain, and higher occupancy rate were associated with decreased antipsychotic drug use. In the nonprofit environment, facility characteristics (eg, increasing occupancy rate, certified nurses' aides per 100 beds) were associated with decreasing antipsychotic use. Increasing percentages of residents covered by Medicare, those with dementia, and residents with mental retardation (beta = 0.05, SE = 0.01; beta = 0.03, SE = 0.01; beta = 0.08, SE = 0.08, respectively) were predictive of increased drug use. CONCLUSIONS: Facility and resident characteristics are associated with use of antipsychotic medications, although the extent to which these factors explain variability in use of anti-psychotics may vary on the basis of the underlying financial incentives of the institution.

Antipsychotic Agents↗
PubMed2003

Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment.

CONTEXT: Empiric data and expert opinion suggest that use of feeding tubes is not beneficial for older persons with advanced dementia. Previous research has shown a 10-fold variation in this practice across the United States. OBJECTIVE: To identify the facility and resident characteristics associated with feeding tube use among US nursing homes residents with severe cognitive impairment. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of all residents with advanced cognitive impairment who had Minimum Data Set assessments within 60 days of April 1, 1999, (N = 186,835) and who resided in Medicare- or Medicaid-certified US nursing homes. Main Outcomes Measures Facility and resident characteristics described in the 1999 On-line Survey Certification of Automated Records and the 1999 Minimum Data Set. Multivariate analysis using generalized estimating equations determined the facility and resident factors independently associated with feeding tube use. RESULTS: Thirty-four percent of residents with advanced cognitive impairment had feeding tubes (N = 63,101). Resident characteristics associated with a greater likelihood of feeding tube use included younger age, nonwhite race, male sex, divorced marital status, lack of advance directives, a recent decline in functional status, and no diagnosis of Alzheimer disease. Controlling for these patient factors, residents living in facilities that were for profit (adjusted odds ratio [OR], 1.09; 95% confidence interval [CI], 1.06-1.12); located in an urban area (OR, 1.14; 95% CI, 1.11-1.16); having more than 100 beds (OR, 1.04; 95% CI, 1.01-1.07); and lacking a special dementia care unit (OR, 1.11; 95% CI, 1.07-1.15) had a higher likelihood of having a feeding tube. Additionally, feeding tube use was more likely among residents living in facilities that had a smaller proportion of residents with do-not-resuscitate orders, had a higher prevalence of nonwhite residents, and lacked a nurse practitioner or physician assistant on staff. CONCLUSIONS: More than one third of severely cognitively impaired residents in US nursing homes have feeding tubes. Feeding tube use is independently associated with both the residents' clinical characteristics and the nursing homes' fiscal, organizational, and demographic features.

Advance Directives↗
PubMed1999

Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees, and immigrants.

Path analysis was used to examine the antecedents of posttraumatic stress (PTS) symptoms in Tamil asylum-seekers, refugees, and immigrants in Australia. The Harvard Trauma Questionnaire and a postmigration living difficulties questionnaire were completed by 62 asylum-seekers, 30 refugees, and 104 immigrants who responded to a mail-out. Demographic characteristics, residency status, and measures of trauma and postmigration stress were fitted to a structural model in PTS symptoms. Premigration trauma exposure accounted for 20% of the variance of PTS symptoms. Postmigration stress contributed 14% of the variance. Although limited by sampling constraints and retrospective measurement, the study supports the notion that both traumatic and posttraumatic events contribute to the expression of PTS symptoms.

Adult↗
PubMed1985

The impact of quality on cost in the provision of long-term care.

Regulatory and reimbursement policies in the health care industry have generally been developed on the assumption that a trade-off exists between quality enhancement and cost control. In this study of 494 proprietary, nonprofit, and government nursing home facilities in New York State, I examined the relationship between quality and costs while controlling for facility characteristics and resident characteristics. I found that although the capital-intensive aspects of patient care quality make a significant impact on costs, the labor-intensive aspects of patient care quality do not. I discuss the policy implications of these findings.

Costs and Cost Analysis↗
PubMed2004

Examining differences in death rates for medicaid and non-medicaid nursing home residents.

OBJECTIVES: The purpose of this work was to examine differences in the probability of death for Medicaid and privately funded nursing home residents, controlling for differences in facility, market, and resident characteristics. METHODS: Given that Medicaid residents are more likely to die in nursing facilities, the probability of dying within 1 or 2 years is estimated using a series of probit models, controlling for whether a resident is Medicaid-funded or privately-funded. As resident characteristics, market attributes, facility characteristics, and facility fixed effects are sequentially added to the specifications, the gap in the probability of death between Medicaid and private-pay residents is considered. RESULTS: The overall mortality rate for Medicaid residents was 14.8% points higher than the death rate for privately funded residents. When considering death within 1 year and 2 years, Medicaid resident death rates were 4.2% and 7.8% higher, respectively. The apparent difference in mortality declines as one controls for resident, market, and facility characteristics. Both facility characteristics and facility fixed effects are relatively important in explaining differences in death rates between Medicaid and private-pay residents. CONCLUSIONS: Differences in death rates between Medicaid and private-pay residents are relatively small, suggesting that residents with different payment sources are not treated differently in nursing homes in ways that impact the probability of death. However, policymakers may want to look more closely at whether Medicaid residents are segregated into lower-quality facilities.

Age Factors↗
PubMed2002

Why are hospital-based nursing homes so costly? Relative importance of acuity and treatment setting.

OBJECTIVES: To determine the extent to which higher costs in hospital-based skilled nursing facilities (HBSNF) can be explained by observable resident characteristics and unobservable selection effects, implying a design shortcoming of the skilled nursing facility prospective payment system (SNF PPS) implemented for Medicare-covered stays by the Balanced Budget Act of 1997 (BBA 1997). RESEARCH DESIGN: Data on resident characteristics from the Minimum Data Set (MDS) are combined with staff time costs from the Centers for Medicare and Medicaid Services' (CMS, formerly HCFA) 1995 and 1997 SNF Staff Time Measurement (STM) studies and nontherapy ancillary claim costs extracted from CMS SNF claim records. An endogenous switching model was estimated to measure the effect on costs of the relatively high acuity of HBSNF residents, net of differences purely attributable to the treatment setting. RESULTS: It was found that virtually the entire HBSNF differential is attributable to setting effects with resident characteristics and selection effects playing a negligible role. In addition, it was found that marginal costs associated with particular services and conditions are often lower in hospital-based than in freestanding facilities. CONCLUSIONS: HBSNFs incur high costs regardless of the characteristics of their residents. Their high fixed costs accompany relatively low marginal costs associated with admitting high-acuity residents. Consequently, a PPS casemix system that depends on resident characteristics and excludes consideration of facility characteristics (as mandated by BBA 1997) need not unfairly penalize HBSNFs, provided a powerful casemix system is used and HBSNFs specialize in the care of high-acuity residents.

Diagnosis-Related Groups↗
PubMed1999

Organizational determinants of resident satisfaction with assisted living.

This article examines the relationship of organizational factors to resident satisfaction with assisted living, while controlling for resident characteristics. Data were collected in interviews with 156 residents in 13 assisted living facilities. Results indicate that more satisfied residents are also happier, more functionally independent, more involved in their housing decision, and less educated. When controlling for resident characteristics, higher levels of resident satisfaction are associated with smaller facility size, a moderate level of physical amenities, greater availability of personal space, fewer sociorecreational activities, and nonprofit ownership. These findings might be helpful in structuring a resident-centered regulatory approach to assisted living.

Aged↗
PubMed1991

Suicides among older United States residents: epidemiologic characteristics and trends.

Suicide rates for elderly US residents decreased between 1950 and 1980, but have increased recently. We analyzed suicide mortality trends using national mortality data for the period 1980 through 1986. Suicide rates during this period increased for each 5-year age group over age 65. Elderly White males have the highest suicide rates and experienced a rate increase of 23%. The rate for Black males rose by 42%. Divorced males have the highest age-adjusted sex- and martial status-specific rates, and experienced a rate increase of 38% over the 7-year period. Suicide rates among older US residents vary by region of the country and are highest in the West. Rates increased in all regions except the Northeast. Fire-arms are the most common method of suicide in the elderly, and firearm use increased during this period from 60% to 66% of all suicides. Given the recent increase in suicide rates for the elderly and the magnitude of the problem in this age group, it is again important to direct our attention to the problem of suicide in the elderly and recognize the need for effective prevention strategies.

Aged↗
PubMed1991

Characteristics of nursing homes that affect resident outcomes.

Although there has been increased interest in using outcomes as measures of quality, few studies have shown a link between structure or process and outcomes. In this analysis, based on approximately 2,500 residents in 80 nursing homes in Rhode Island, multivariate models estimate which aspects of care are associated with resident outcomes after controlling for resident characteristics. Outcomes, measured over a 6-month period included death, functional decline, and functional improvement. Results suggest that higher staff levels and lower RN turnover were related to functional improvement. Facilities with high catheter use, low rates of skin care, and low participation in organized activities were associated with negative outcomes. Facilities with few private-pay residents were also associated with negative outcomes. Receipt of a serious federal citation was associated with improved outcomes. For-profit facilities appeared to be more efficient in use of resources.

Activities of Daily Living↗
PubMed1977

Discharge patterns of residents from halfway houses for male alcoholics.

Length of stay (LOS) data for male alcoholics discharged from eitht halfway houses were examined in the light of the hypothesis that the rate of discharge would be a linear function of time. In general, the hypothesis was confirmed, although the rate of discharge for four houses was significantly accelerated during the first two weeks of residence. Further analysis showed that both resident characteristics and house structure (defined in terms of the number of hours of formal activities each week) contributed significantly to LOS. Resident characteristics accounted for 5.3% of the variance in LOS when house structure was controlled, and structure accounted for 1.6% of variance when resident characteristics were controlled. No significant interaction effects were detected. Implications of these results are discussed.

Adult↗