Helping Older Residents Remain in Subsidized Housing: Predictive Validity of the Live Well at Home-Rapid Screen (LWAH-RS) in a Real-World Application.

Common Bond Communities (CBC) is a nonprofit organization that provides housing for low-income individuals and families. CBC utilized the Live Well at Home-Rapid Screen (LWAH-RS) to identify the risks for nursing home admission or assisted living entry among housing residents aged 60 or above. Drawing data from 842 assessments, we studied how well the LWAH-RS predicted moves to nursing homes or assisted living settings. Cox regression models showed that the LWAH-RS did predict which residents would move to a care setting. Every 1-point higher in the LWAH-RS assessment score was associated with a 38% higher risk of moving to a higher-level care facility due to health issues. Given this demonstrated predictive validity in a real-world setting, we suggest more systematic approaches for housing practitioners to combat low assessment completion rates and unclear protocols for actions based on the scores.

A Statewide Model for Assisting Nursing Home Residents to Transition Successfully to the Community.

Minnesota's Return to Community Initiative (RTCI) is a novel, statewide initiative to assist private paying nursing home residents to return to the community and to remain in that setting without converting to Medicaid. The objective of this manuscript is to describe in detail RTCI's development and design, its key operational components, and characteristics of its clients and their care outcomes. Data on client characteristics and outcomes come from the Minimum Data Set, staff assessments of clients and caregivers, and Medicaid eligibility files. Most clients transitioned by the RTCI had entered the nursing facility from a hospital. Clients overwhelmingly wanted to return to the community and fit a health and functional profile making them good candidates for community discharge. Most clients went to a private residence, living alone or with a spouse; yet, adult children were the most frequent caregivers. At one year of follow-up 76% of individuals were alive and living in the community and only a small percentage (8.2%) had converted to Medicaid. The RTCI holds promise as a successful model for states to adopt in assisting individuals who are at risk to become long stay nursing home residents instead to return to the community.

What we learned through asking about evidence: A model for interdisciplinary student engagement.

Traditional university learning modalities of lectures and examinations do not prepare students fully for the evolving and complex world of gerontology and geriatrics. Students involved in more active, self-directed learning can develop a wider breadth of knowledge and perform better on practical examinations. This article describes the Evidence in Aging (EIA) study as a model of active learning with the aim of preparing students to be effective interdisciplinary researchers, educators, and leaders in aging. We focus particularly on the experiences and reflections of graduate students who collaborated with faculty mentors on study design, data collection, and analysis. Students acquired new methodological skills, gained exposure to diverse disciplines, built interdisciplinary understanding, and cultivated professional development. The EIA study is a model for innovative student engagement and collaboration, interactive learning, and critical scholarly development. Lessons learned can be applied to a range of collaborative research projects in gerontology and geriatrics education.

Impact of serious mental illness online training for certified nursing assistants in long term care.

Certified nurse assistants (CNAs) spend the most staff time with nursing home residents, yet they receive little training in addressing the mental health needs of residents with serious mental illness (SMI). Forty CNAs from four long-term-care facilities took the online interactive CARES-® Serious Mental Illness™ training consisting of two modules guided by the Recovery Movement philosophy of care. Responses from pre-post testing, Likert-type items, and open-ended questions indicated that CNAs gained information, changed their perspectives, and had more confidence in dealing with SMI. Although there were minor concerns regarding length, clarity of content, and technical issues, CNAs found the online format acceptable and easy to use, and many said they would recommend the training. CARES Serious Mental Illness online training appears to be a viable way of helping CNAs address the mental health needs of long term care residents. Additional testing on CARES Serious Mental Illness is planned.

Prevention of Functional Decline by Reframing the Role of Nursing Homes?

Institutionalization is generally a consequence of functional decline driven by physical limitations, cognitive impairments, and/or loss of social supports. At this stage, intervention to reverse functional losses is often too late. To be more effective, geriatric medicine must evolve to intervene at an earlier stage of the disability process. Could nursing homes (NHs) transform from settings in which many residents dwell to settings in which the NH residents and those living in neighboring communities benefit from staff expertise to enhance quality of life and maintain or slow functional decline? A task force of clinical researchers met in Toulouse on December 2, 2015, to address some of these challenges: how to prevent or slow functional decline and disabilities for NH residents and how NHs may promote the prevention of functional decline in community-dwelling frail elderly. The present article reports the main results of the Task Force discussions to generate a new paradigm.

Care-Delivery Interventions to Manage Agitation and Aggression in Dementia Nursing Home and Assisted Living Residents: A Systematic Review and Meta-analysis.

OBJECTIVES: To evaluate the efficacy of nonpharmacological care-delivery interventions (staff training, care-delivery models, changes to the environment) to reduce and manage agitation and aggression in nursing home and assisted living residents. DESIGN: Three bibliographic databases, references of systematic reviews, ClincalTrials.gov, and the International Controlled Trials Registry Platform were systematically searched for randomized controlled trials reporting behavioral outcomes for nonpharmacological care-delivery interventions in nursing homes and assisted living facilities. Five investigators independently assessed study eligibility, extracted data, rated risk of bias, and graded strength of evidence. Inclusion was limited to studies with low to moderate risk of bias. SETTING: Nursing homes and assisted living facilities. PARTICIPANTS: Facility caregiving staff. MEASUREMENTS: Agitation, aggression, antipsychotic and other psychotropic use, general behavior. RESULTS: Nineteen unique studies met entry criteria, addressing several categories of facility caregiver training interventions: dementia care mapping (DCM; n = 3), person-centered care (PCC; n = 3), clinical protocols to reduce the use of antipsychotic and other psychotropic drugs (n = 3), and emotion-oriented care (n = 2). Eleven additional studies evaluated other unique interventions. Results were pooled for the effect of each type of intervention on agitation and aggression: DCM (standardized mean difference -0.12, 95% confidence interval (CI) = -0.66 to 0.42), PCC (standardized mean difference -0.15, 95% CI = -0.67 to 0.38), and protocols to reduce antipsychotic and other psychotropic use (Cohen-Mansfield Agitation Inventory mean difference -4.5, 95% C = -38.84 to 29.93). Strength of evidence was generally insufficient to draw conclusions regarding efficacy or comparative effectiveness. CONCLUSION: Evidence was insufficient regarding the efficacy of nonpharmacological care-delivery interventions to reduce agitation or aggression in nursing home and assisted living facility residents with dementia.

Responding to the 2015 CMS Proposed Rule Changes for LTC Facilities: A Call to Redouble Efforts to Prepare Students and Practitioners for Nursing Homes.

In July of 2015, the Federal Register published for public comment proposed rule changes for nursing homes certified to receive Medicare and/or Medicaid. If the final rules are similar to the proposed rules, they will represent the largest change in federal rules governing nursing homes since the Nursing Home Reform Act which was part of OBRA 1987. The proposed changes have the potential to enhance the quality of care and quality of life of nursing home residents. Many of the proposed changes would directly affect the practice of social work and would likely expand the role for nursing home social workers. This article discusses the role that members of the National Nursing Home Social Work Network (NNHSW Network) played in developing and submitting a response to CMS. The article provides the context for the publication of the proposed rules, describes the process used by the NNHSW Network to develop and build support for comments on these rules, and also includes the actual comments submitted to CMS. Social work education programs and continuing education programs throughout the country will continue to have an important role to play in helping to prepare social work students and practitioners for a career in long-term care.

Re-imagining long-term services and supports: towards livable environments, service capacity, and enhanced community integration, choice, and quality of life for seniors.

In the half century since enactment of the 1965 Great Society programs, accomplishments were gradually made to improve access to and quality of long-term services and supports (LTSS), including: mitigation of financial and care abuses in nursing facilities (NFs); substantial rebalancing of LTSS towards consumer-preferred home-and-community-based services (HCBS); increasing flexible consumer-centered HCBS including payment to family caregivers; and more assisted-living and housing options for seniors with heavy care needs. A unified planning and advocacy agenda across age and disability type and greater consumer transparency fueled progress. Nonetheless, LTSS is a broken system; persistent problems interfere with substantial and necessary change. These include; over-emphasis on safety for LTSS consumers; inattention to physical environments in all settings; regulatory and professional rigidity; and poor communication and information. Our recommendations are aimed at builders and designers, LTSS professionals, regulators, and educators/trainers; the last may be crucial in forging new consensus and over-coming entrenched beliefs. Policy recommendations include relatively narrow steps-for example, requiring single occupancy in all NFs and assisted living settings financed with public dollars-to broad reworking of the prerequisites for livable age-friendly (and dementia-friendly) communities and for a capable, flexible LTSS workforce.

Long-Term Services and Supports for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care.

Despite a shift from institutional services toward more home and community-based services (HCBS) for older adults who need long-term services and supports (LTSS), the effects of HCBS have yet to be adequately synthesized in the literature. This review of literature from 1995 to 2012 compares the outcome trajectories of older adults served through HCBS (including assisted living [AL]) and in nursing homes (NHs) for physical function, cognition, mental health, mortality, use of acute care, and associated harms (e.g., accidents, abuse, and neglect) and costs. NH and AL residents did not differ in physical function, cognition, mental health, and mortality outcomes. The differences in harms between HCBS recipients and NH residents were mixed. Evidence was insufficient for cost comparisons. More and better research is needed to draw robust conclusions about how the service setting influences the outcomes and costs of LTSS for older adults. Future research should address the numerous methodological challenges present in this field of research and should emphasize studies evaluating the effectiveness of HCBS.

Does home- and community-based care affect nursing home use?

A study was conducted to assess change in numbers, expenditures, and case mix of nursing home residents as Medicaid investment in home- and community-based services (HCBS) 1915(c) waivers increased in seven states. The seven states provided Medicaid expenditure and utilization data from 2001 to 2005, including waiver and state plan utilization. The Minimum Data Set was used for nursing home residents. For three states, community assessment data were also used. In six states, the number of nursing home clients decreased as the numbers of HCBS clients grew. However, in most states, the number of additional waiver clients often greatly exceeded reductions in nursing home residents. Nursing home payments decreased moderately, but this decrease was offset by increases in HCBS waiver and state plan expenditures, leading to a net increase in long-term support services (LTSS) expenditures from 2001 to 2005. Increases in waiver expenditures outpaced increases in waiver clients, indicating expansion of services on top of expansion in clients. States that showed substantial increases in HCBS showed only modest increases in nursing home case mix. The case mix for nursing home residents was more acute than that for HCBS users. The expectation that greater HCBS use would siphon off less severe LTSS users and hence lead to a higher case mix in nursing homes was partially met. The more acute case mix in nursing homes suggests that HCBS serves some individuals who were previously cared for in nursing homes but many who were not. Efforts to promote substitution of HCBS for institutional care will require more proactive strategies such as diversion.

Use of mental health care by community-dwelling older adults.

OBJECTIVES: To examine relationships between perceived need for care, illness characteristics, attitudes toward care, and probability that older adults will use mental health care (MHC). DESIGN: Secondary data analysis. SETTING: The Collaborative Psychiatric Epidemiology Surveys (2001-2003). PARTICIPANTS: One thousand six hundred eighty-one community-dwelling adults aged 65 and older. MEASUREMENTS: Self-reported MHC use and perceived need for care in the previous 12 months, previous year and history of mental illness, history of physical illness, attitudes toward care, and sociodemographic characteristics. RESULTS: Of the entire sample, 6.5% had received some type of MHC in the previous year, although 65.9% of those with major depressive disorder (MDD) and 72.5% with anxiety did not receive MHC. In respondents with previous-year depression or anxiety, use was less likely for those with low World Health Organization Disability Assessment Scale (WHO-DAS) self-care ability. Use was more likely for those with more chronic physical conditions and worse WHO-DAS cognitive capacity. Seventeen percent of those with perceived need for MHC did not receive it. In respondents with perceived need, subthreshold generalized anxiety disorder was associated with lower likelihood of use. Use was more likely for older respondents and those with more household members, at least a high school education, and better self-care ability. Forty-one percent of those who perceived a need for care but did not use it met previous-year diagnostic criteria for anxiety, and 17% met criteria for MDD. CONCLUSION: Understanding the perceptions that underlie individuals' health care-seeking behavior is an important step toward reducing underuse of MHC by older adults.

Perceived need for mental health care among community-dwelling older adults.

Only half of older adults with a mental disorder use mental health services, and little is known about the causes of perceived need for mental health care (MHC). We used logistic regression to examine relationships among depression, anxiety, chronic physical illness, alcohol abuse and/or dependence, sociodemographics, and perceived need among a national sample of community-dwelling individuals 65 years of age and older (the Collaborative Psychiatric Epidemiology Surveys data set). Less than half of respondents with depression or anxiety perceived a need for care. Perceived need was greater for respondents with more symptoms of depression regardless of whether they met diagnostic criteria for a mental illness. History of chronic physical conditions, history of depression or anxiety, and more severe mental illness were associated with greater perceived need for MHC. Future studies of perceived need should account for individual perceptions of mental illness and treatment and the influence of social networks.

We've looked at care from both sides now: the effects of alternative evaluation strategies on study conclusions.

This study uses two studies about the role of managed-care programs in serving Medicaid long-term care clients in Florida to illustrate how different research designs can reach divergent conclusions. Two reports from different groups using essentially the same database to assess the impact of managed care on a group of older Medicaid clients served by a Nursing Home Diversion Program reached different conclusions. The report from Florida's Office of Program Policy Analysis and Government Accountability concluded that the Diversion program saved money, whereas the report from the Florida Policy Exchange Center on Aging at the University of South Florida reached basically the opposite conclusion. Both agreed that the capitation rate was too high. How the policy questions are framed and analyzed can affect the conclusions reached. A variety of factors can influence the apparent effects of programmatic interventions. Evaluations must take relevant confounding variables into account.

Characteristics of nursing home social services directors: how common is a degree in social work?

PURPOSE: To report the percentage of nursing homes whose social services director has a degree in social work, to report the characteristics of social service directors, and to describe the characteristics of nursing homes most likely to employ a degreed social worker. These questions are important because social workers are core members of the interdisciplinary team in nursing homes and have responsibilities for the psychosocial well-being of residents. DESIGN AND METHODS: Cross-sectional nationally representative survey of 1071 social service directors employed in US nursing homes certified to receive Medicare and/or Medicaid. RESULTS: Most nursing homes do employ at least one (and typically only one) social service staff person. Most are employed full-time and half have a degree in social work. About 20% do not have a college degree. The vast majority of social service directors are white and are women. Close to 40% are licensed social workers. Full-time salaries varies enormously from less than $15,000 to over $60,000 per year. Most do not belong to an organization that helps them keep apprised of developments in nursing home social services. Using logistic regression and controlling for the effects of other independent variables, for-profit nursing homes with fewer than 121 beds, in sparsely populated counties in the West are the least likely to hire a degreed social worker as social service director. IMPLICATIONS: The wide range in educational preparedness and salary indicates 2 roles: a social work role and a social services role. The different roles have implications for initial role preparation and continuing education. Clear communication about the role expectations associated with social services and social work would benefit residents, family, staff, and physicians, who would then be better prepared to draw on their skills in helping to meet the psychosocial needs of residents.

Identifying the barriers and challenges to voting by residents in nursing homes and assisted living settings.

To ascertain the need for and to inform development of guidelines for voting in long-term care settings, we conducted a telephone survey of Philadelphia nursing (n = 31) and assisted living (n = 20) settings following the 2003 election. Substantial variability existed in procedures used for registration and voting, in staff attitudes, and in the estimated proportion of residents who voted (29%+/-28, range 0-100%). Residents who wanted to vote were unable to do so at nearly one-third of sites, largely due to procedural problems. Nearly two-thirds of facilities indicated they assessed residents' voting capacity before the election. However, methods differed and may have disenfranchised residents who were actually competent to vote. Current procedures in many facilities fail to protect voting rights. These data suggest that rights might be better protected if election officials took charge of registration, filing absentee ballot requests, ballot completion, and trained LTC facility staff on voters' rights and reasonable accommodations.

Effects of Green House nursing homes on residents' families.

A longitudinal quasi-experimental study with two comparison groups was conducted to test the effects of a Green House (GH) nursing home program on residents' family members. The GHs are individual residences, each serving 10 elders, where certified nursing assistant (CNA)-level resident assistants form primary relationships with residents and family, family is encouraged to visits, and professionals adapted their roles to support the model. GH family were somewhat less involved in providing assistance to their residents although family contact did not differ among the settings at any time period. GH family were more satisfied with their resident's care and with their own experience as family members, and had no greater family burden. Issues in studying family outcomes are discussed as well as implications for roles of various personnel, including social service and activities staff in a GH model.

Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial green house program.

OBJECTIVES: To determine the effects of a small-house nursing home model, THE GREEN HOUSE (GH), on residents' reported outcomes and quality of care. DESIGN: Two-year longitudinal quasi-experimental study comparing GH residents with residents at two comparison sites using data collected at baseline and three follow-up intervals. SETTING: Four 10-person GHs, the sponsoring nursing home for those GHs, and a traditional nursing home with the same owner. PARTICIPANTS: All residents in the GHs (40 at any time) at baseline and three 6-month follow-up intervals, and 40 randomly selected residents in each of the two comparison groups. INTERVENTION: The GH alters the physical scale environment (small-scale, private rooms and bathrooms, residential kitchen, dining room, and hearth), the staffing model for professional and certified nursing assistants, and the philosophy of care. MEASUREMENTS: Scales for 11 domains of resident quality of life, emotional well-being, satisfaction, self-reported health, and functional status were derived from interviews at four points in time. Quality of care was measured using indicators derived from Minimum Data Set assessments. RESULTS: Controlling for baseline characteristics (age, sex, activities of daily living, date of admission, and proxy interview status), statistically significant differences in self-reported dimensions of quality of life favored the GHs over one or both comparison groups. The quality of care in the GHs at least equaled, and for change in functional status exceeded, the comparison nursing homes. CONCLUSION: The GH is a promising model to improve quality of life for nursing home residents, with implications for staff development and medical director roles.