Private investment purchase and nursing home financial health.

OBJECTIVE: To explore the impact of nursing home acquisition by private investment firms on nursing home costs, revenue, and overall financial health. DATA SOURCES: Merged data from the Medicare Cost Reports and the Online Survey, Certification, and Reporting system for the period 1998-2010. STUDY DESIGN: Regression specification incorporating facility and time fixed effects. PRINCIPAL FINDINGS: We found little impact on the financial health of nursing homes following purchase by private investment companies. However, our findings did suggest that private investment firms acquired nursing home chains in good financial health, possibly to derive profit from the company's real estate holdings. CONCLUSIONS: Private investment acquired facilities are an important feature of today's nursing home sector. Although we did not observe a negative impact on the financial health of nursing homes, this development raises important issues about ownership oversight and transparency for the entire nursing home sector.

The quality of advanced dementia care in the nursing home: the role of special care units.

BACKGROUND: The quality of nursing home care for residents with advanced dementia has been described as suboptimal. One relatively understudied factor is the impact of special care units (SCUs) for dementia for residents at the end stage of this disease. OBJECTIVE: To examine the association between residence in an SCU and the quality of end-of-life care for nursing home residents with advanced dementia. RESEARCH DESIGN: This study used longitudinal data on 323 nursing home residents with advanced dementia living in 22 Boston-area facilities. Using multivariate methods, we analyzed the association between residence in an SCU and measures of quality of end-of-life care including: treatment of pain and dyspnea, prevalence of pressure ulcers, hospitalization, tube feeding, antipsychotic drug use, advance care planning, and health care proxy (HCP) satisfaction with care. RESULTS: A total of 43.7% residents were cared for in an SCU. After multivariate adjustment, residents in SCUs were more likely to receive treatment for dyspnea, had fewer hospitalizations, were less likely to be tube fed, and more likely to have a do-not-hospitalize order, compared with non-SCU residents. However, non-SCU residents were more likely to be treated for pain, had fewer pressure ulcers, and less frequent use of antipsychotic drugs than SCU residents. HCPs of SCU residents reported greater satisfaction with care than HCPs of non-SCU residents. CONCLUSIONS: Residence in an SCU is associated with some, but not all, markers of better quality end-of-life care among nursing home residents with advanced dementia.

The evidence base for effectiveness of preparedness training: a retrospective analysis.

OBJECTIVES: In 2007, the Centers for Disease Control and Prevention (CDC) commissioned an Evidence-Based Gaps Collaboration Group to consider whether past experience could help guide future efforts to educate and train public health workers in responding to emergencies and disasters. METHODS: The Group searched the peer-reviewed literature for preparedness training articles meeting three criteria: publication during the period when CDC's Centers for Public Health Preparedness were fully operational, content relevant to emergency response operations, and content particular to the emergency response roles of public health professionals. Articles underwent both quantitative and qualitative analyses. RESULTS: The search identified 163 articles covering the topics of leadership and command structure (18.4%), information and communications (14.1%), organizational systems (78.5%), and others (23.9%). The number of reports was substantial, but their usefulness for trainers and educators was rated only "fair" to "good." Thematic analysis of 137 articles found that organizational topics far outnumbered leadership, command structure, and communications topics. Disconnects among critical participants--including trainers, policy makers, and public health agencies--were noted. Generalizable evaluations were rare. CONCLUSIONS: Reviews of progress in preparedness training for the public health workforce should be repeated in the future. Governmental investment in training for preparedness should continue. Future training programs should be grounded in policy and practice needs, and evaluations should be based on performance improvement.

Supporting home- and community-based care: views of long-term care specialists.

A significant rebalancing of the long-term care system away from nursing homes toward home- and community-based services (HCBS) has occurred over the past two decades. This article reports the results of the Commonwealth Fund Long-Term Care Opinion Leader Survey (N = 1,147) on issues related to supporting HCBS. Respondents expressed strong enthusiasm for rebalancing of the long-term care system toward HCBS. In particular, respondents supported system-based approaches for this expansion, with the majority indicating that greater care coordination was the single most preferred approach for rebalancing the system, helping consumers make informed long-term care choices, and supporting caregivers. Building on the long-term care specialists' enthusiasm for system-based reforms, we encourage state policy makers to pursue HCBS models that are linked to Medicare, engage primary care physicians, and are based on rigorous evaluations.

"Operation Helping Hands": Massachusetts health and medical response to Hurricane Katrina.

INTRODUCTION: As Hurricane Katrina bore down on New Orleans in August 2005, the city's mandatory evacuation prompted the exodus of an estimated 80% of its 485,000 residents. According to estimates from the US Centers for Disease Control and Prevention (CDC), at least 18 states subsequently hosted more than 200,000 evacuees. HYPOTHESIS/PROBLEM: In this case study, "Operation Helping Hands" (OHH), the Massachusetts health and medical response in assisting Hurricane Katrina evacuees is described. Operation Helping Hands represents the largest medical response to evacuees in recent Massachusetts history. METHODS: The data describing OHH were derived from a series of structured interviews conducted with two leading public health officials directing planning efforts, and a sample of first responders with oversight of operations at the evacuation site. Also, a literature review was conducted to identify similar experiences, common challenges, and lessons learned. RESULTS: Activities and services were provided in the following areas: (1) administration and management; (2) medical and mental health; (3) public health; and (4) social support. This study adds to the knowledge base for future evacuation and shelter planning, and presents a conceptual framework that could be used by other researchers and practitioners to describe the process and outcomes of similar operations. CONCLUSIONS: This study provides a description of the planning and implementation efforts of the largest medical evacuee experience in recent Massachusetts history, an effort that involved multiple agencies and partners. The conceptual framework can inform future evacuation and shelter initiatives at the state and national levels, and promotes the overarching public health goal of the highest attainable standard of health for all.

Altered standards of care during an influenza pandemic: identifying ethical, legal, and practical principles to guide decision making.

Although widespread support favors prospective planning for altered standards of care during mass casualty events, the literature includes few, if any, accounts of groups that have formally addressed the overarching policy considerations at the state level. We describe the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. Community stakeholders were also engaged in the process through facilitated discussion of case scenarios focused on these and other issues. The objective of this initiative was to establish a framework and some fundamental principles that would subsequently guide the process of establishing specific altered standards of care protocols. The group collectively identified 4 goals and 7 principles to guide the equitable allocation of limited resources and establishment of altered standards of care protocols. Reviewing and analyzing this process to date may serve as a resource for other states.

Assessing public health capabilities during emergency preparedness tabletop exercises: reliability and validity of a measurement tool.

OBJECTIVES: Improving the ability of local public health agencies to respond to large-scale emergencies is an ongoing challenge. Tabletop exercises can provide an opportunity for individuals and groups to practice coordination of emergency response and evaluate performance. The purpose of this study was to develop a valid and reliable self-assessment performance measurement tool for tabletop exercise participants. METHODS: The study population comprised 179 public officials who attended three tabletop exercises in Massachusetts and Maine between September 2005 and November 2006. A 42-item questionnaire was developed to assess five public health functional capabilities: (1) leadership and management, (2) mass casualty care, (3) communication, (4) disease control and prevention, and (5) surveillance and epidemiology. Analyses were undertaken to examine internal consistency, associations among scales, the empirical structure of the items, and inter-rater agreement. RESULTS: Thirty-seven questions were retained in the final questionnaire and grouped according to the original five domains. Alpha coefficients were 0.81 or higher for all scales. The five-factor solution from the principal components analysis accounted for 60% of the total variance, and the factor structure was consistent with the five domains of the original conceptual model. Inter-rater agreement ranged from good to excellent. CONCLUSIONS: The resulting 37-item performance measurement tool was found to reliably measure public health functional capabilities in a tabletop exercise setting, with preliminary evidence of a factor structure consistent with the original conceptualization and of criterion-related validity.

Evaluation of brain biopsy in the diagnosis of severe neurologic disease of unknown etiology.

OBJECTIVE: To determine the value of non-stereotactic brain biopsies in patients with severe neurologic disease of unknown etiology and indeterminate brain imaging. METHODS: We reviewed 42 consecutive patients who underwent non-stereotactic brain biopsy at a single institution for evaluation of severe neurologic disease of unknown etiology. All patients had indeterminate or normal imaging results. Seventy-nine percent had been symptomatic for less than a year. Exclusion criteria were immunocompromise or a preoperative diagnosis of intracranial neoplasm. Diagnostic yield and surgical complication rate were calculated. We performed exploratory univariate analysis aimed at identifying clinical features possibly predictive of diagnostic biopsies. RESULTS: A histologic diagnosis was achieved in 12 of 42 biopsies (29%). Three patients experienced minor transient complications from the procedure (7%). There were no permanent deficits or deaths. Treatment was altered based on biopsy result in five patients (12%). A more precise prognosis was obtained in eight patients (19%). In total, 11 different patients (26%) benefited from biopsy. Exploratory univariate analysis showed a possible inverse relationship between age and the likelihood of a diagnostic biopsy (OR=0.929; 95% CI=0.864-0.998). CONCLUSIONS: Our data suggest that the value of non-stereotactic brain biopsy is sufficiently high and the morbidity sufficiently low to justify its use in carefully selected patients with severe neurologic disease that remains undiagnosed despite thorough less invasive evaluation.

Teaching population health as a basic science at Harvard Medical School.

In 2006-2007, Harvard Medical School implemented a new, required course for first-year medical and dental students entitled Clinical Epidemiology and Population Health. Conceived of as a "basic science" course, its primary goal is to allow students to develop an understanding of caring for individuals and promoting the health of populations as a continuum of strategies, all requiring the engagement of physicians. In the course's first iteration, topical content accessible to first-year students was selected to exemplify physicians' roles in addressing current threats to population health. Methodological areas included domains of clinical epidemiology, decision sciences, population-level prevention and health promotion, physicians' roles in the public health system, and population-level surveillance and intervention strategies. Large-group settings were selectively used to frame the relevance of each topic, and conceptual learning of statistical and epidemiologic methods occurred in conference groups of 24 students. Finally, tutorials of eight students and one or two faculty were used for critical reading of published studies, review of problem sets, and group discussion of population health issues. To help students appreciate the structure and function of the public health system and physicians' role in public health emergencies, the course included a role-playing exercise simulating response to an influenza pandemic. The first iteration of the course was well received, and assessment of students suggested mastery of basic skills. Preclinical courses represent a progressive step in developing a workforce of physicians who embrace their responsibility to improve the health of the population as a whole, as well as the health of the patient in front of them.