Physical and Occupational Therapy Staffing Patterns in Nursing Homes and Their Association with Long-stay Resident Outcomes and Quality of Care.

The purpose of this study is to examine Physical Therapy (PT) and Occupational Therapy (OT) staffing patterns in nursing homes and understand their relationship with quality performance. Bivariate analyses between PT/OT staffing and facility characteristics were performed to understand staffing patterns and random effects regressions were run to explore the link between therapy staff and quality. Findings suggest PT/OT staff have a positive influence on resident outcomes and therapy staffing patterns significantly differ across provider attributes, including size, profit status, and occupancy rate, among others. The findings can be used to inform policymakers about potential unintended consequences resulting from changes to Medicare reimbursement policies.

First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance.

BACKGROUND: The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions. OBJECTIVE: The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP. RESEARCH DESIGN: We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis. RESULTS: The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312. CONCLUSIONS: SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.

Characteristics of Nursing Home Providers With Distinct Patterns of Physical and Occupational Therapy Staffing.

Previous work found a substantial growth in therapy staffing among nursing home providers following the introduction of Medicare's Prospective Payment System (PPS). Since the PPS, however, several new Medicare policies have been implemented that may impact the provision of rehabilitative care in nursing homes. In view of the rising focus on patient outcomes and provider performance, it is worthwhile to explore more recent therapy staffing patterns following the introduction of these Medicare programs. While our results show stable staffing levels through prior policy changes, upcoming Medicare payment changes will likely have a stronger impact that may result in reduced therapy staffing. In addition, given that our findings show that staffing patterns vary across provider type, we may see greater variation as a result of the upcoming changes. Thus, therapy staffing should continue to be monitored and deeper explorations into the impact of staffing changes on patient outcomes should be undertaken.

A Rising Tide Lifts "Related" Boats-Post-Acute Care Quality Improvement is Associated with Improvement in Long-Term Care Quality in Nursing Homes.

OBJECTIVES: To examine the relationship between post-acute care (PAC) quality improvement and long-term care (LTC) quality changes. DESIGN: Observational study using national nursing home data from Nursing Home Compare linked to Brown University's LTCFocus data. SETTING AND PARTICIPANTS: Free-standing nursing homes serving PAC and LTC residents in the United States. METHODS: This study used pooled cross-sectional analysis with nursing home-level data from 2005 to 2010 (12,150 unique nursing homes). We used fixed effects models to examine the association between a 1-year change in PAC quality and a 1-year change in LTC quality, with a specific focus on related care domains. RESULTS: Strong and positive associations were found between related PAC and LTC care domains, particularly between the PAC and LTC influenza vaccination care domains (ß = 0.30, P < .001) and the PAC and LTC pneumococcal vaccination care domains (ß = 0.55, P < .001). Meanwhile, model results showed PAC quality changes essentially had no associations with unrelated LTC care domains. CONCLUSIONS AND IMPLICATIONS: This is the first study that examines the association of changes in quality between 2 overlapping but different care domains (ie, PAC and LTC) using multiple quality measures. Our findings indicate that nursing homes can manage concurrent quality improvement in PAC and LTC, particularly on care domains that are related. More research is needed to examine the mechanism that enables such concurrent quality improvement.

Inpatient rehabilitation facilities' hospital readmission rates for medicare beneficiaries treated following a stroke.

BACKGROUND: Stroke is the leading cause for admission to the nearly 1,200 Inpatient Rehabilitation Facilities (IRFs) nationally in the US. For many patients, post-acute care is an important component of their rehabilitation. Several quality measures have been publicly reported for post-acute care providers, including hospital readmissions. However, to date none have focused on specific medical conditions, limiting the usability for patients and quality improvement. OBJECTIVE: To assess hospital readmission rates for Medicare patients receiving inpatient rehabilitation following stroke and to identify risk factors in order to evaluate the feasibility of a stroke-specific hospital readmission measure. METHODS: Observational study analyzing national Medicare inpatient claims and administrative data to assess hospital readmissions. Using logistic regression, we calculated unadjusted and risk-standardized readmission rates, which adjusted for patient characteristics, including type of stroke and admission function, to capture stroke severity. RESULTS: Our national study included 116,073 fee-for-service Medicare beneficiary discharged from IRFs in 2013-2014 following stroke from 1,162 IRFs nationally. The observed hospital readmission rate among IRF patients following stroke was 11.6% and varied by patients' admission motor function. Patients with greater functional dependence had higher readmission rates on average. Lower admission function, hemorrhagic and other stroke types (relative to ischemic) were significantly associated with higher odds of hospital readmission. CONCLUSION: Results suggest it is feasible to assess hospital readmission rates among a stroke-cohort treated in IRFs. Stroke-focused quality measures would be useful to patients in selecting a provider and for providers in evaluating their stroke rehabilitation program outcomes. Secondary results suggest that admission function (FIM) capture stroke severity, a limitation with other claims-based stroke measures.

Fewer Bonuses, More Penalties At Skilled Nursing Facilities Serving Vulnerable Populations.

The first round of incentives and penalties under the Medicare Skilled Nursing Facility Value-Based Purchasing Program were distributed October 1, 2018. Our results show that facilities serving vulnerable groups were less likely to receive bonus payments and more likely to be penalized.

The Relationship Between Quality of Care, Physical Therapy, and Occupational Therapy Staffing Levels in Nursing Homes in 4 Years' Follow-up.

OBJECTIVES: To understand physical therapy (PT) and occupational therapy (OT) staffing levels in nursing homes and to examine their relationship with quality of care. DESIGN: Observational study that used 4 secondary data sources to perform facility-level panel data analyses. SETTING AND PARTICIPANTS: For-profit and nonprofit US nursing homes participating in Medicare and/or Medicaid. The final analytic sample includes 42,374 observations from 12,352 nursing homes, 2013-2016. METHODS: Three Centers for Medicare & Medicaid Services quality measures, including activities of daily living (ADL), falls, and 5-star quality, were used to examine the association between PT/OT staffing and quality. Bivariate analyses between PT/OT staffing and facility-level characteristics were run to describe the staffing disciplines in this setting. F tests and t tests were used to test for significance of each relationship. The sample was stratified into quintiles to determine if nursing homes with higher PT/OT staffing levels were linked to higher quality. Significance was determined using F tests and chi-squared tests. Finally, multilevel random effects regressions were performed to examine the relationship between PT/OT staffing and quality. RESULTS: Bivariate analyses indicate that PT/OT staffing levels vary across several nursing home characteristics. After stratifying the sample based on staffing levels, this study found that nursing homes that differ in staffing levels also differ in their quality performance. The random effects regression models also estimated a significant, positive relationship between higher staffing levels and quality, evidenced by each quality domain. CONCLUSIONS/IMPLICATIONS: The findings demonstrate that PT/OT staffing may be important components in improving long-stay resident outcomes and overall quality. Evidence was found in support of utilizing a combination of both PT/OT staff and nursing staff to improve resident outcomes, and expanding coverage of these staff/services under Medicaid. Further research should evaluate effective multidisciplinary approaches to care to lend further support to policy makers and progress quality improvement strategies.

Multitasking in Nursing Homes: Differences Between For-Profit and Nonprofit Quality Outcomes.

BACKGROUND AND OBJECTIVES: Nursing homes (NHs) in the United States face increasing pressures to admit Medicare postacute patients, given higher payments relative to Medicaid. Changes in the proportion of residents who are postacute may initiate shifts in care practices, resource allocations, and priorities. Our study sought to determine whether increases in Medicare short-stay census have an impact on quality of care for long-stay residents. RESEARCH DESIGN AND METHODS: This study used panel data (2005-2010) from publicly-available sources (Nursing Home Compare, Area Health Resource File, LTCFocus.org) to examine the relationship between a 1-year change in NH Medicare census and 14 measures of long-stay quality among NHs that experienced a meaningful increase in Medicare census during the study period (N = 7,932). We conducted analyses on the overall sample and stratified by for- and nonprofit ownership. RESULTS: Of the 14 long-stay quality measures examined, only one was shown to have a significant association with Medicare census: increased Medicare census was associated with improved performance on the proportion of residents with pressure ulcers. Stratified analyses showed increased Medicare census was associated with a significant decline in performance on 3 of 14 long-stay quality measures among nonprofit, but not for-profit, facilities. DISCUSSION AND IMPLICATIONS: Our findings suggest that most NHs that experience an increase in Medicare census maintain long-stay quality. However, this may be more difficult to do for some, particularly nonprofits. As pressure to focus on postacute care mount in the current payment innovation environment, our findings suggest that most NHs will be able to maintain stable quality.

A National-Level Analysis of the Relationship Between Nursing Home Satisfaction and Quality.

Little research has explored the relationship between consumer satisfaction and quality in nursing homes (NHs) beyond the few states mandating satisfaction surveys. We examine this relationship through data from 1,765 NHs in the 50 states and District of Columbia using My InnerView resident or family satisfaction instruments in 2013 and 2014, merged with Certification and Survey Provider Enhanced Reporting, LTCfocus, and NH Compare (NHC) data. Family and resident satisfaction correlated modestly; both correlated weakly and negatively with any quality-of-care (QoC) and any quality-of-life deficiencies and positively with NHC five-star ratings; this latter positive association persisted after covariate adjustment; the negative relationship between QoC deficiencies and family satisfaction also remained. Overall, models explained relatively small proportions of satisfaction variance; correlates of satisfaction varied between residents and families. Findings suggest that satisfaction is a unique dimension of quality and that resident and family satisfaction represent different constructs.

Risk Factors for Shoulder Dystocia: the Impact of Mother's Race and Ethnicity.

Shoulder dystocia is a rare but severe birth trauma where the neonate's shoulders fail to deliver after delivery of the head. Failure to deliver the shoulders quickly can lead to severe, long-term injury to the infant, including nerve injury, skeletal fractures, and potentially death. This observational study examined shoulder dystocia risk factors by race and ethnicity using a sample of 19,236 pregnant women who presented for labor and delivery from July 1, 2010 until June 30, 2013 at five locations. Multivariate analyses were used to identify risk factors associated with shoulder dystocia occurrence in racial/ethnic groups with high incidence rates. For White non-Hispanic mothers, the strongest risk factors were delivering past 40 weeks' gestation (odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5, 3.9; p < .01) and use of epidural anesthesia during delivery (OR = 4.4; 95% CI = 3.0, 6.4; p < .01). Among Black non-Hispanic mothers, the risk factors with the greatest impact were use of epidural (OR = 5.3; 95% CI = 3.2, 8.7; p < .01) and having gestational diabetes and controlling the condition with insulin (OR = 4.6; 95% CI = 1.5, 13.8; p < .01). Additionally, among Hispanic mothers, having Spanish as primary language increased shoulder dystocia likelihood compared to those who did not cite it as their primary language (OR = 2.3; 95% CI = 1.1, 4.6; p < .05). This study provides evidence that risk factors for a labor and delivery condition can vary significantly across racial and ethnic subgroups. These differences emphasize the importance of evaluating risk by population subgroups and might provide a basis for labor and delivery clinicians to enhance personalized medicine to reduce adverse events.

Nursing home Facebook reviews: who has them, and how do they relate to other measures of quality and experience?

BACKGROUND: The growing use of social media creates opportunities for patients and families to provide feedback and rate individual healthcare providers. Whereas previous studies have examined this emerging trend in hospital and physician settings, little is known about user ratings of nursing homes (NHs) and how these ratings relate to other measures of quality. OBJECTIVE: To examine the relationship between Facebook user-generated NH ratings and other measures of NH satisfaction/experience and quality. METHODS: This study compared Facebook user ratings of NHs in Maryland (n=225) and Minnesota (n=335) to resident/family satisfaction/experience survey ratings and the Centers for Medicare and Medicaid (CMS) 5-star NH report card ratings. RESULTS: Overall, 55 NHs in Maryland had an official Facebook page, of which 35 provided the opportunity for users to rate care in the facility. In Minnesota, 126 NHs had a Facebook page, of which 78 allowed for user ratings. NHs with higher aid staffing levels, not affiliated with a chain and located in higher income counties were more likely to have a Facebook page. Facebook ratings were not significantly correlated with the CMS 5-star rating or survey-based resident/family satisfaction ratings. CONCLUSIONS: Given the disconnect between Facebook ratings and other, more scientifically grounded measures of quality, concerns about the validity and use of social media ratings are warranted. However, it is likely consumers will increasingly turn to social media ratings of NHs, given the lack of consumer perspective on most state and federal report card sites. Thus, social media ratings may present a unique opportunity for healthcare report cards to capture real-time consumer voice.

Geographic Region and Profit Status Drive Variation in Hospital Readmission Outcomes Among Inpatient Rehabilitation Facilities in the United States.

OBJECTIVE: To examine whether there are differences in inpatient rehabilitation facilities' (IRFs') all-cause 30-day postdischarge hospital readmission rates vary by organizational characteristics and geographic regions. DESIGN: Observational study. SETTING: IRFs. PARTICIPANTS: Medicare fee-for-service beneficiaries discharged from all IRFs nationally in 2013 and 2014 (N = 1166 IRFs). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We applied specifications for an existing quality measure adopted by Centers for Medicare & Medicaid Services for public reporting that assesses all-cause unplanned hospital readmission measure for 30 days postdischarge from inpatient rehabilitation. We estimated facility-level observed and risk-standardized readmission rates and then examined variation by several organizational characteristics (facility type, profit status, teaching status, proportion of low-income patients, size) and geographic factors (rural/urban, census division, state). RESULTS: IRFs' mean risk-standardized hospital readmission rate was 13.00%±0.77%. After controlling for organizational characteristics and practice patterns, we found substantial variation in IRFs' readmission rates: for-profit IRFs had significantly higher readmission rates than did not-for-profit IRFs (P<.001). We also found geographic variation: IRFs in the South Atlantic and South Central census regions had the highest hospital readmission rates than did IRFs in New England that had the lowest rates. CONCLUSIONS: Our findings point to variation in quality of care as measured by risk-standardized hospital readmission rates after IRF discharge. Thus, monitoring of readmission outcomes is important to encourage quality improvement in discharge care planning, care transitions, and follow-up.

Population-Based Risk Factors for Shoulder Dystocia.

OBJECTIVE: To re-examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women. DESIGN: Retrospective observational study. SETTING: Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama. PARTICIPANTS: We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013. METHODS: Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site. RESULTS: When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors. CONCLUSION: With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.

Examining Racial and Ethnic Differences in Nursing Home Quality.

BACKGROUND: Identifying racial/ethnic differences in quality is central to identifying, monitoring, and reducing disparities. Although disparities across all individual nursing home residents and disparities associated with between-nursing home differences have been established, little is known about the degree to which quality of care varies by race//ethnicity within nursing homes. A study was conducted to measure within-facility differences for a range of publicly reported nursing home quality measures. METHODS: Resident assessment data on approximately 15,000 nursing homes and approximately 3 million residents (2009) were used to assess eight commonly used and publicly reported long-stay quality measures: the proportion of residents with weight loss, with high-risk and low-risk pressure ulcers, with incontinence, with depressive symptoms, in restraints daily, and who experienced a urinary tract infection or functional decline. Each measure was stratified by resident race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic), and within-facility differences were examined. RESULTS: Small but significant differences in care on average were found, often in an unexpected direction; in many cases, white residents were experiencing poorer outcomes than black and Hispanic residents in the same facility. However, a broad range of differences in care by race/ethnicity within nursing homes was also found. CONCLUSION: The results suggest that care is delivered equally across all racial/ethnic groups in the same nursing home, on average. The results support the call for publicly reporting stratified nursing home quality measures and suggest that nursing home providers should attempt to identify racial/ethnic within-facility differences in care.

Choosing a Nursing Home: What Do Consumers Want to Know, and Do Preferences Vary across Race/Ethnicity?

OBJECTIVE: To identify what consumers want to know about nursing homes (NHs) before choosing one and to determine whether information preferences vary across race/ethnicity. DATA SOURCES/STUDY SETTING: Primary data were collected in Greater Boston (January 2013-February 2014) from community-dwelling, white, black, and Latino adults aged 65+ and 40-64 years, who had personal/familial experience with a NH admission or concerns about one. STUDY DESIGN: Eleven focus groups and 30 interviews were conducted separately by race/ethnicity and age group. PRINCIPAL FINDINGS: Participants wanted detailed information on the facility, policies, staff, and residents, such as location, staff treatment of residents, and resident conditions. They wanted a sense of the NH gestalt and were interested in feedback/reviews from residents/families. Black and Latino participants were especially interested in resident and staff racial/ethnic concordance and facility cultural sensitivity. Latino participants wanted information on staff and resident language concordance. CONCLUSIONS: Consumers want more information about NHs than what is currently available from resources like Nursing Home Compare. Report card makers can use these results to enhance their websites, and they should consider the distinct needs of different racial/ethnic groups. Future research should test methods for collecting and reporting resident and family feedback/reviews.

Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events.

Medical malpractice expenditures are mainly due to the occurrence of preventable harm with some of the highest liability rates in obstetrics. Establishing delivery system models which decrease preventable harm and malpractice risk have had varied results over the last decade. We conducted a case study of a risk reduction labor and delivery model at 5 demonstration sites. The model included standardized protocols for the most injurious events, training teams in labor and delivery emergencies, rapid reporting with cause analysis for all unplanned events, and disclosing unexpected occurrences to patients using coordinated communication and documentation. Each of the model's components required buy in from the hospital's clinical and administrative leadership, and it also required collaboration, training, and continual feedback to labor and delivery nurses, doctors, midwives, and risk managers. The case study examined the key elements in the development of the model based on interviews of all team members and document review. We also completed data analysis pre and post implementation of the new model to assess the impact on event reporting and high liability occurrence rates. After 27 months post implementation, reporting of unintended events increased significantly (43 vs 84 per 1000 births, p < .01) while high-risk malpractice events decreased significantly (14 vs 7 per 1000 births, p < .01). This decrease enabled money allotted for malpractice claims to be reallocated for the implementation of the new model at 42 additional labor and delivery sites. Due to these results, this multilevel integrated model showed promise.