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Demographic and health characteristics of residents choosing to use on-site medical care in a newly opened continuing care retirement community (CCRC).

OBJECTIVE: To determine demographic and health characteristics of older adults choosing to use on-site medical care in a continuing care retirement community (CCRC). DESIGN: A descriptive study of residents moving into a newly opened CCRC. Residents responded to a self-report mail survey composed of questions related to reasons for moving to a CCRC, health and functional status,health care use during the previous 5 years. RESULTS: Of 942 residents, 642 (68%) completed the survey. Medical center users and nonusers were similar demographically and reported similar reasons for moving to the CCRC including desire for a low maintenance apartment (49% vs. 48%; P = 0.806), concern about health or spouse's health (67% vs. 63%; P = 0.345), and desire for social activities (63% vs. 58%; P = 0.151). However, on-site medical center users versus nonusers reported increased rates of fair/poor health (31% vs. 18%; P = 0.0001), fair/poor vision (27% vs. 15%; P = 0.0003),difficulty walking in the home (13% vs. 8%; P = 0.53), using the toilet (6% vs. 2%; P = 0.044), shopping (29% vs. 20%; P = 0.007), using transportation (19% vs. 10%; P = 0.005), doing laundry (13% vs. 7%; P = 0.016), using the telephone (8% vs. 3%; P = 0.002), and taking medication (5% vs. 1%; P = 0.022). CONCLUSION: For both users and nonusers of the medical center, the most frequently cited reason for moving to the CCRC was concern about health. On-site medical center users had lower perceived health, were functionally more disabled, and had health characteristics that made them at higher risk for high health care utilization. The challenges to provide high quality medical care and enhance quality of life for CCRC residents will continue to increase. Physicians should play an active role not only in providing medical care to CCRC residents, but also in providing medical leadership for these institutions.

Journal Article↗

[How pediatric residents involve children during medical decision-making?].

OBJECTIVE: To describe how pediatric residents involve children during medical decision-making and evaluate the relationship between practice patterns and residents characteristics. POPULATION AND METHODS: We conducted a prospective multicenter anonymous written survey. Self-reported involvement of children by 45 French pediatric residents in practice pattern was collected and analysed. RESULTS: Most residents reported they informed patients in more than 50% of the cases (82%). Only a minority of the residents asked for consent, respected children refusal or presented other choices to the treatment. The main reasons that explain the lack of partnership are children incompetence and the medical situation. No statistically significant relationship between practice patterns and residents characteristics was found. CONCLUSIONS: Partnership with children varies across residents and according to the level of involvement considered. No statistical differences were obtained to explain variations between residents' attitude toward involvement of children. Nevertheless medical education in ethics or decision-making could increase partnership with children.

Child↗

Nursing home-to-nursing home transfers: prevalence, time pattern, and resident correlates.

OBJECTIVES: To characterize the time pattern of nursing home-to-nursing home transfers and assess which resident characteristics are associated with transfers. METHODS: Minimum Data Set assessments of all Maine and New York nursing home residents were obtained for 1994-1996. The hazard rate for nursing home transfers was estimated by nonparametric statistical techniques, censored at loss to follow-up. Comparisons of resident characteristics were made between those who transferred and those who stayed at their initial facility. RESULTS: Residents of Maine nursing homes were considerably more likely to transfer than were New York residents. Transfer rates declined during the first 2 years after admission and remained stable thereafter. Correlates of transfers were similar across states. Residents who transferred were more likely to be male, to be married, to be younger, to have better cognitive and physical health, to have Medicare or private payment sources (vs. Medicaid), and to have pressure ulcers. Rural location did not affect the likelihood of transfer. CONCLUSIONS: This study provides the most detailed information to date on the prevalence, timing, and correlates of nursing home transfers. These transitions occur most frequently early in the stay but continue at a lower rate even among long stayers. This information is useful for understanding lifetime dynamics of long-term-care utilization. Several barriers to mobility appear to be present (eg, less generous payment source, health limitations, and absence of a spouse). The higher transfer rates observed in Maine might imply that institutional or other factors limit the mobility of New York residents.

Aged↗

Relationships between self-assessment skills, test performance, and demographic variables in psychiatry residents.

Some researchers have seen the capacity for self-assessment in trainees as a special skill, and some reports have concluded that this skill is positively and crucially correlated with academic competence. Thus, it is believed that those trainees who are most deficient in knowledge are least likely to be aware of their limitations. Other researchers have emphasized the impact of statistical regression and other technical considerations in the studies, which have led to these conclusions. Our study used a relative-ranking design to measure the accuracy of self-assessments of both strengths and weaknesses in psychiatry residents. We analyzed the relationships between indices of self-assessment accuracy and other resident characteristics, particularly current academic strength as measured by a standard test of psychiatric knowledge. A total of 56 residents in two general psychiatry programs evaluated their performance on the Psychiatry Resident in Training Examination by estimating the rank order of their scores in the 11 psychiatry subject areas. For each resident, actual examination results were then used to generate measures of the accuracy of the identification of strengths and weaknesses. Residents' identifications of their strengths and weaknesses were significantly more accurate than chance levels. Strengths and weaknesses were identified with roughly equal proficiency, and accuracy in these assessments was not correlated to any of the following variables: academic competence as measured by examination raw scores, postgraduate year, gender, international vs. American medical education, program membership, or age. Our results do not support the hypothesis that trainees who show the least academic mastery also make the most inaccurate self-assessments. In addition, we found no resident characteristics that accounted for variation in self-assessment accuracy.

Age Factors↗

Characteristics of staffed community housing services for people with learning disabilities: a stratified random sample of statutory, voluntary and private agency provision.

Within the staffed housing model relatively little is known about the characteristics of different types of provider agency. Data on size, homeliness and physical integration of settings, organisational culture, working methods, staffing levels and resident characteristics, were collected on a stratified random sample of provision in South-West England and Wales. Provider agencies did not differ significantly on three of the four variables relating to residents' characteristics. Nor did they differ in terms of the homeliness or physical integration of settings. However, there were significant differences between providers on the important variables of working methods and staffing levels. Resident ability correlated with staffing levels and organisational culture, but not with staff working methods. The results and their implications are discussed in the context of other research which has used the same measures.

Journal Article↗

Mental health correlates of aggression in nursing home residents with dementia.

PURPOSE: Aggression continues to challenge caregivers of persons with dementia, and identification of foci for effective interventions is needed. The purpose of this study was to examine the influence of (a) the resident characteristics of depression, communication, and cognition and (b) behavior management strategies on aggression in a group of older nursing home residents (N = 405) with evidence of dementia. DESIGN AND METHODS: This cross-sectional correlational study examined the association of resident characteristics and behavior management strategies with bivariate aggression, physical aggression, and verbal aggression, using hierarchical regression. RESULTS: Main findings are that impaired communication is associated with all forms of aggression, depression with physical aggression, and disorientation with verbal aggression. A 3-month prior pattern of antipsychotic drug use was consistently associated with all forms of aggression and physical restraint use with physical aggression. Most of the explained variance was attributable to antipsychotic drug use. IMPLICATIONS: The separate explanatory models for physical and verbal aggression indicate that these may be unique entities with different foci for treatment. These results provide evidence that aggression persists despite antipsychotic drug use and that further mental health interventions might be targeted at compensating for impaired communication and the treatment of depression to improve the mental health of nursing home residents with dementia.

Aggression↗

Comparing case-mix systems for nursing home payment.

Case-mix systems for nursing homes use resident characteristics to predict the relative use of resources. Seven systems are compared in structure, accuracy in explaining resource use, group homogeneity, and ability to identify residents receiving heavy care. Resource utilization groups, version II (RUG-II), was almost uniformly the best system, although management minutes and the Minnesota case-mix system were also highly effective. Relative weights for case-mix groups were sensitive to cost differences and should be recomputed for new applications. Multiple criteria should be used in choosing a case-mix system, including consideration of inherent incentives and how residents' characteristics are defined.

Diagnosis-Related Groups↗

Racial and state differences in the designation of advance directives in nursing home residents.

OBJECTIVES: To examine racial and state differences in the use of advance directives and surrogate decision-making in a nursing home population. DESIGN: A retrospective cohort study. SETTING: Nursing homes in the states of California (CA), Massachusetts (MA), New York (NY), and Ohio (OH). PARTICIPANTS: Nursing home residents: 130,308 in CA, 59,691 in MA, 112,080 in NY, and 98,954 in OH. MEASUREMENTS: Minimum Data Set information concerning resident race and whether or not residents have a living will (LW), a do not resuscitate (DNR) order, or a surrogate decision-maker (SDM). RESULTS: The proportion of LWs, DNR orders, and SDMs varied significantly (P < .0001) by racial categories in each state. In general, whites were distinctly different from other racial categories. Whites were significantly more likely to have a LW (odds ratio (OR) = 1.9 (CA), OR = 2.2 (NY), OR = 4.9 (OH)), a DNR order (OR = 2.4 (CA), OR = 2.4 (MA), OR = 3.3 (NY), OR = 3.2 (OH)), and a SDM (OR = 1.1 (CA), OR = 1.2 (NY), OR = 1.6 (OH)) than were nonwhites, after adjusting for potentially confounding factors. Significant state differences (P < .0001) were observed in LWs, DNR orders, and SDMs and were most pronounced in residents of Ohio, who were significantly more likely to have a LW than were residents in other states (OR = 9.3). CONCLUSIONS: Various resident characteristics explain some of the racial differences, although whites are still more likely to have a LW, a DNR order, or an SDM independent of various resident characteristics included in the adjusted analyses. This pattern is observed in all states, although the ORs varied by state. Some of these differences may be due to distinct cultural approaches to end-of-life care and lack of knowledge and understanding of advance directives. The distinctly higher rates of LWs among all racial groups in Ohio than in other states suggest that states can potentially increase the use of advance directives through intervention.

Advance Directives↗

Dually incontinent nursing home residents: clinical characteristics and treatment differences.

OBJECTIVE: Previous studies have described urinary and fecal incontinence in nursing homes and their separate effects on healthcare utilization. However, little is known about those who are incontinent of both. DESIGN: Retrospective chart review. SETTINGS: Twenty sites in three states PARTICIPANTS: A total of 413 nursing home residents were categorized as having neither fecal nor urinary incontinence (C, n = 114), urinary incontinence only (UI, n = 53), fecal incontinence only (FI, n = 9), or were dually incontinent (DI, n = 237). MEASUREMENTS: Charts were abstracted for sociodemographic information and health status information as well as utilization for the year before the date of abstraction. We then compared these characteristics across groups using ANOVA with pairwise comparisons and multiply adjusted regression. RESULTS: Almost all patients with DI were cognitively and mobility impaired. However, there were no significant differences between the groups with respect to age and number of diagnoses. A diagnosis of stroke was also more common among those with DI compared with C. When examining healthcare utilization in multiply adjusted regression, dually incontinent residents received significantly fewer days of hospital care than those with UI. CONCLUSIONS: Dual incontinence in NH residents is likely to have an important functional component. These residents seem to be treated less aggressively with respect to hospitalization compared with those with UI alone. The reasons for these differences need to be explored further.

Aged↗

Program characteristics and residents' length of stay in alcoholism halfway houses.

Data from 23 alcoholism halfway houses are analyzed to assess the relationship of organizational and programmatic variables to clients' average length of stay. Results indicate that programs which have more resources, a more complex administrative structure, better staffing, and stronger community ties report a shorter average length of stay than do those which lack these characteristics. The discussion focuses on differences in interpretation of a longer stay by an individual alcoholic versus a longer average stay by clients of a residential facility. Conclusions are that longitudinal research of a comparative nature is needed to identify the consequences of a longer versus shorter average stay for both long- and short-term residents of a given of facility.

Alcoholism↗

Provision of rehabilitation nursing in long-term care facilities.

AIM: This paper reports an investigation into rehabilitation nursing provided in long-term care settings in Finland, focusing on the amount of time spent with residents, types of rehabilitation nursing provided and resident characteristics associated with rehabilitation nursing. BACKGROUND: In long-term care, nurses have important roles as members of multidisciplinary care teams in the provision of rehabilitation care. Evidence suggests that rehabilitation nursing has a positive impact on maintaining residents' functional performance. However, there is little information on the patterns and scope of rehabilitation nursing in long-term care facilities. METHODS: A quantitative, retrospective and cross-sectional study was designed with the data collected between July and December 2002. Rehabilitation nursing was analysed using the Resident Assessment Instrument used in Finland (n = 5312). The frequency and focus of rehabilitation nursing were presented by mean scores and 95% confidence intervals. Univariate and multivariate logistic regression models were built to describe the factors associated with rehabilitation nursing. Odds ratios and confidence intervals were derived from these models. RESULTS: About 64% of residents received some rehabilitation nursing. Residents assessed as having rehabilitation potential received statistically significantly more rehabilitation nursing than others, such as skills practice in transfer, walking and dressing. Resident factors associated with rehabilitation nursing were cognition, activities of daily living, urinary incontinence, instability of health condition, falls, depression and greater social engagement. CONCLUSION: Specific resident characteristics and nurses' views of rehabilitation potential determine the provision of rehabilitation nursing. This information could be useful in both targeting and planning rehabilitation nursing in long-term care.

Activities of Daily Living↗

Nursing working conditions in relation to restraint practices in long-term care units.

OBJECTIVES: This study examined the effects of nursing working conditions on the use of physical restraints and antipsychotics as restraints in long-term care units for elderly residents. DESIGN: Cross-sectional data were obtained in Finland in 2002 from long-term care units that used the Resident Assessment Instrument (RAI) system and participated in a survey on working conditions. SETTING: A sample of 91 inpatient units in 31 facilities (23 residential homes and 8 health centers). PARTICIPANTS: Data included 2430 resident assessments and 977 nursing staff survey responses. MEASUREMENTS: We measured unit-level mean scores of physical restraint and antipsychotics use as restraints and resident characteristics (activities of daily living, cognitive impairment, and daily behavioral problems) based on the RAI system as measured by the Minimum Data Set 2.0. Head nurses reported the structural factors (nurse staffing levels and unit size). Nursing working conditions were measured by the Job-Demands and Job-Control Scales in the staff survey questionnaire. RESULTS: Controlling for resident characteristics, nurses' job demands and control had a combined effect on restraint practices. Job demands strongly increased the risk of physical restraint use in units where nurses reported low job control (odds ratio [OR] = 13.31, 95% confidence interval [CI] 1.55-114.30, P = 0.019), but not among high-control units (OR = 0.23, 95% CI 0.04-1.29, P = 0.090). Although the use of antipsychotics was not related to job demands in units with low control (OR = 1.11, 95% CI 0.26-4.99, P = 0.891), the antipsychotics use in particular decreased when high job demands were coupled with high job control (OR = 0.17, 95% CI 0.03-0.91, P = 0.038). CONCLUSION: The results suggest that restraint use can be reduced by enhancing working conditions so that the nursing staff has possibilities for skill usage and decision-making.

Aged↗

The use of standardized indicators as quality improvement tools: an application in Pennsylvania nursing homes.

The Institute of Medicine recommends the use of key quality indicators (resident outcomes that suggest the presence of good or bad care) as tools for interfacility comparison of the quality of care provided in nursing homes. In the spirit of this recommendation, the Health Care Financing Administration released selected results from its Medicare and Medicaid Annual Certification Survey to guide consumers in purchasing nursing home services. However, because this information is published without adjustment for resident characteristics that can influence the outcomes of nursing home care, its utility for policy-makers or consumers interested in variation in nursing home quality is limited. This research study utilizes federal and state survey data to evaluate variations in mortality, pressure ulcers, urethral catheterization, and physical restraint use in 438 Medicare-certified skilled nursing care facilities in Pennsylvania. A standardization function adjusting for resident characteristics known to influence outcomes is developed and estimated by ordinary least squares regression. Results suggest considerable variation in rates for these indicators across Pennsylvania nursing home facilities. Alternative uses for risk-adjusted key quality indicators as tools for improving nursing home quality and assisting potential consumers of nursing home care in making better informed choices are considered.

Aged↗

Predictors of continued physical restraint use in nursing home residents following restraint reduction efforts.

OBJECTIVES: To examine predictors of continued restraint use in nursing home residents following efforts aimed at restraint reduction. DESIGN: Secondary analysis of data from a clinical trial using a one-group, pre-test post-test design. SETTING: Three nonprofit, religion-affiliated nursing homes in a metropolitan area. PARTICIPANTS: The sample consisted of 201 physically restrained nursing home residents. Following restraint reduction efforts, 135 of the sample were still restrained. Mean age of participants was 83.9 years. MEASUREMENTS: Physical restraint use was measured by observation and included any chest/vest, wrist, mitt, belt, crotch, suit, or harness restraint plus any sheet used as restraint or a geriatric chair with fixed tray table. Nursing home residents were subjected to any one of three conditions aimed at restraint reduction, including adherence to the mandate of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), staff education, and education with consultation from a gerontological clinical nurse specialist. Resident characteristics including dependency, health status, mental status, depression, behavior, fall risk; presence of treatment devices and institutional factors were determined. RESULTS: Physical dependency, lower cognitive status, behavior, presence of treatment devices, presence of psychiatric disorders, fall risk, and fall risk as staff rationale for restraint were associated (P < .10) with continued restraint use. Nursing hours, staff mix, prevalence of restraint use by unit, and site were also associated (P < .10) with continued use of physical restraints. Following bivariate analysis, associated resident characteristics were subjected to logistic regression. Lower cognitive status (OR = 2.4 (for every 7-point decrease in MMSE), 95% CI, 1.7, 3.3) and fall risk as staff rationale for restraint (OR = 3.5, 95% CI., 1.5, 8.0) were predictive of continued restraint use. Adding nursing hours, staff mix, and prevalence of restraint use by unit to the logistic regression model was not statistically significant (partial chi-square = 2.79, df = 6, P = .834). Nursing home site was added to the model without changing the significance (P < .05) of cognitive status or fall risk as a staff rationale for restraint use. CONCLUSION: Continued restraint use in nursing home residents in this study most often occurred with severe cognitive impairment and/or when fall risk was considered by staff as a rationale for restraint. Efforts to reduce or eliminate physical restraint use with these groups will require greater efforts to educate staff in the assessment and analysis of fall risk, along with targeted interventions, particularly when cognition is also impaired.

Accidental Falls↗

Tumor-associated macrophages share in vitro growth characteristics with resident but not elicited macrophages.

Recent studies have shown that tissue macrophages are capable of proliferation and that this capability is enhanced by various cytokines, including macrophage colony-stimulating factor (M-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF). Tumor-associated macrophages (TAM) have been demonstrated to proliferate in vitro, but no information is currently available on the ability of M-CSF and GM-CSF to enhance this response. To address this problem, limiting dilution analysis was utilized to examine the proliferative ability of macrophages isolated from two murine tumors of distinct origin following growth in secondary hosts. As a means of comparison, resident peritoneal macrophages (RPM) and thioglycolate-elicited macrophages (TEM) were also analyzed. Results indicate that a rare subset of TAM and RPM is capable of proliferation and that M-CSF and GM-CSF enhance the frequency of TAM and RPM which proliferate, but do not enhance the growth of TEM.

Animals↗

Alteration of some functional and metabolic characteristics of resident mouse peritoneal macrophages by lymphocyte mediators.

Resident mouse peritoneal macrophages were incubated in Sephadex G-100 fractions of supernates from concanavalin A-stimulated lymphocytes. A significant effect of the lymphocyte supernatant fractions containing mediators on macrophage 5'-nucleotidase, glucose-1 14C oxidation, cell maintenance, and migration is reported. The 5'-nucleotidase was depressed to an extent similar to that seen in activated macrophages obtained from Listeria-infected mice. On the other hand, glucose-1-14C oxidation was enhanced, but not to the same degree as seen in the counterparts in vivo. Whereas migration inhibitory factor (MIF) and cell adherence-augmenting activity were found in a number of adjacent fractions, the metabolic effects were found predominantly in a single fraction. Resident peritoneal macrophages or those elicited by the injection of a lymphocyte-derived chemotactic factor were more responsive with respect to the biochemical changes than caseinate-elicited macrophages. On the other hand, caseinate-elicited macrophages appeared to be more sensitive with respect to the effects of mediator(s) on cell retention. A possible dissociation between MIF and cell-adherence augmenting activity, on the one hand, and the entities that stimulate glucose-1-14C oxidation is reported, based on fractionation studies, and loss of the latter activity upon storage of lymphocyte supernates.

Animals↗

Designing a report card for nursing facilities: what information is needed and why.

PURPOSE: This article presents a rationale and conceptual framework for making comprehensive consumer information about nursing facilities available. Such information can meet the needs of various stakeholder groups, including consumers, family/friends, health professionals, providers, advocates, ombudsman, payers, and policy makers. DESIGN AND METHODS: The rationale and framework are based on a research literature review of key quality indicators for nursing facilities. RESULTS: The findings show six key areas for information: (a) facility characteristics and ownership; (b) resident characteristics; (c) staffing indicators; (d) clinical quality indicators; (e) deficiencies, complaints, and enforcement actions; and (f) financial indicators. This information can assist in selecting, monitoring, and contracting with nursing facilities. IMPLICATIONS: Model information systems can be designed using existing public information, but the information needs to be enhanced with improved data.

Information Dissemination↗