The minimum data set depression quality indicator: does it reflect differences in care processes?

PURPOSE: The objective of this work was to determine if nursing homes that score differently on prevalence of depression, according to the Minimum Data Set (MDS) quality indicator, also provide different processes of care related to depression. DESIGN AND METHODS: A cross-sectional study with 396 long-term residents in 14 skilled nursing facilities was conducted: 10 homes in the lower (25th percentile: low prevalence 0-2%) quartile and 4 homes in the upper (75th percentile: high prevalence 12-14%) quartile on the MDS depression quality indicator. Ten care processes related to depression were defined and operationalized into clinical indicators. Measurement of nursing home staff implementation of each care process and the assessment of depressive symptoms were conducted by trained research staff during 3 consecutive 12-hr days (7 a.m. to 7 p.m.), which included resident interviews (Geriatric Depression Scale), direct observations, and medical record review using standardized protocols. RESULTS: The prevalence of depressive symptoms according to independent assessments was significantly higher than prevalence based on the MDS quality indicator and comparable between homes reporting low versus high rates of depression (46% and 41%, respectively). Documentation of depressive symptoms was significantly more common in homes reporting a high prevalence rate; however, documentation of symptoms on the MDS did not result in better treatment or management of depression according to any care-process measure. Psychosocial prevention and intervention efforts, such as resident participation in organized social group activities, were not widely used within either group of homes. IMPLICATIONS: The MDS depression quality indicator underestimates the prevalence of depressive symptoms in all homes but, in particular, among those reporting low or nonexistent rates. The indicator may be more reflective of measurement processes related to detection of symptoms than of prevention, intervention, or management of depression outcomes. A depression quality indicator should not be eliminated from MDS reports because of the importance and prevalence of the condition. However, efforts to improve nursing home staff detection of depressive symptoms should be initiated prior to the use of any MDS-based depression indicator for improvement purposes. Homes that report a low prevalence of depression according to the nationally publicized MDS quality indicator should not be regarded as providing better care.

Improving food intake in nursing home residents with feeding assistance: a staffing analysis.

BACKGROUND: Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during mealtime. There are, however, no specific data related to two critical variables necessary to estimate mealtime staffing needs: (1) How many residents are responsive to feeding assistance? (2) How much staff time is required to provide feeding assistance to these residents? The purpose of this study was to collect preliminary data relevant to these two issues. METHODS: Seventy-four residents in three NHs received a 2-day, or six-meal, trial of one-on-one feeding assistance. Total percentage (0% to 100%) of food and fluid consumed during mealtime was estimated across 3 days during usual NH care and 2 days during the intervention. The amount of time that staff spent providing assistance and type of assistance (i.e., frequency of verbal and physical prompts) was measured under each condition. RESULTS: One half (50%) of the participants significantly increased their oral food and fluid intake during mealtime. The intervention required significantly more staff time to implement (average of 38 minutes per resident/meal vs 9 minutes rendered by NH staff). CONCLUSIONS: The time required to implement the feeding assistance intervention greatly exceeded the time the nursing staff spent assisting residents in usual mealtime care conditions. These data suggest that it will almost certainly be necessary to both increase staffing levels and to organize staff better to produce higher quality feeding assistance during mealtimes.

Health care utilization by old-old long-term care facility residents: how do Medicare fee-for-service and capitation rates compare?

OBJECTIVE: To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services. SETTING: A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds. PARTICIPANTS: Residents (n = 700) living in the community between September 1995 and February 1996. METHODS: Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time. RESULTS: Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls. CONCLUSIONS: Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.

Barriers to effective communication in skilled nursing facilities: differences in perception between nurses and physicians.

BACKGROUND: Effective communication between nurses and physicians is central to the clinical care of nursing home residents. Anecdotal evidence suggests that communication between the groups is unsatisfactory, but no empirical data exist with which to validate assumptions. The purpose of this pilot study was to compare perceptions of potential communication barriers among nurses and physicians in four California nursing homes. METHODS: Registered nurses (n = 59), and physicians (n = 47) involved in the direct clinical care of nursing home residents completed a 12-item questionnaire designed to elicit perceptions about potential communication barriers. Five specific categories of barriers were identified. These included nurse competence, time burden of calls, necessity of calls, professional respect, and language comprehension. Responses were compared using t test analysis. RESULTS: Significant differences in perceived communication barriers were identified. Physicians, but not nurses, perceive nursing competence to be a significant barrier. Nurses perceive physicians to be unpleasant. Both physicians and nurses perceive that physicians do not value nurses' opinions. Neither group perceived language expression, language comprehension, or time burden of phone calls to be barriers to communication. CONCLUSIONS: Issues related to the perceived competency of nurses by physicians is consistent with existing data from other clinical settings. Differences in awareness about scope of practice and regulatory requirements between the groups may offer a partial explanation for the discordant perceptions. Perceptions by nurses (but not physicians) of unpleasantness and/or disrespect during telephone encounters may reflect the broader ongoing differences in professional culture, social status, and gender inequality between the two groups. Further clarification of the causes of barriers to effective communication is essential in order to plan appropriate interventions.

Development and validation of a geriatrics attitudes scale for primary care residents.

OBJECTIVE: To develop and validate an instrument measuring attitudes toward older persons and caring for older patients. DESIGN: Cross-sectional and longitudinal studies. SETTING: An academic medical center. PARTICIPANTS: Initial Study: 121 primary care residents (n = 96), fellows (n = 14), and faculty (n = 11) participated in instrument development in 1995. Longitudinal Study: 95 residents (n = 87) and fellows (n = 8) of the initial cohort participated in the 1996 follow-up study, and 61 of the initial cohort (57 residents and 4 fellows) participated in the 1997 follow-up study. Cross Validation Study: 96 first-year residents (n = 78) and fellows (n = 18) participated in this study. MEASUREMENTS: A 14-item geriatrics attitudes scale was developed. The items were selected from a pool of 37 items administered to the 121 participants in the initial study. RESULTS: The instrument demonstrated high reliability (Cronbach's alpha = .76) and known-groups and construct validity. Attitudes were progressively more positive with more medical training (P < .001), and residents with greater career interest in geriatrics scored higher than those less interested (P = .007). Cross validation results supported the reliability and validity of the instrument. Longitudinal data showed significantly different trends of attitude changes among groups of residents and fellows over a 2-year period. CONCLUSIONS: The 14-item geriatrics attitudes scale developed in this study shows sound reliability, validity, and sensitivity to change among primary care residents. The performance of other groups of medical trainees and the relationship of attitude changes to specific medical training warrant further investigation.

Development and validation of a geriatrics knowledge test for primary care residents.

This study reports the development and preliminary validation of an instrument to measure geriatrics knowledge of primary care residents. A 23-item test was developed using questions selected from the American Geriatrics Society's Geriatrics Review Syllabus. Ninety-six internal medicine and family practice residents, 14 geriatrics fellows, and 11 geriatrics faculty members participated in the study. Findings support the reliability (Cronbach's alpha = 0.66) and validity (content and "known groups") of this short test. Predictive validity and sensitivity of the test to changes in knowledge will have to be further explored as residents progress through their training.

Falls and fall prevention in the nursing home.

The mean incidence of falls in nursing homes is 1.5 falls per bed per year (range 0.2-3.6). The most common precipitating causes include gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, and postural hypotension. The most important underlying risk factors for falls and injuries include some of these same items as well as others: leg weakness, gait and balance instability, poor vision, cognitive and functional impairment, and sedating and psychoactive medications. A focused history and physical examination after a fall can usually determine the immediate underlying cause(s) of the fall and contributory risk factors. Many strategies for fall prevention have been tried with mixed success. The most successful take into account the multifactorial causes of falls, and include interventions to improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Regular evaluations in the nursing home can help identify patients at high risk who can then be targeted for specific treatment and prevention strategies. Strategies that reduce mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided. A number of promising fall prevention strategies, involving both specific quality assurance programs and technologic devices, are being evaluated currently.

Perioperative care in the elderly urologic patient.

This article summarizes the preoperative evaluation and postoperative care recommended for elderly patients undergoing urologic procedures. Most of the common issues faced during the perioperative period are discussed, but many other topics require reference to other sources or consultation with specialists. A thorough preoperative evaluation is needed, and meticulous attention to postoperative care is mandatory. The most important common problem is assessment of cardiovascular risk in patients and a general approach is suggested by the authors. Surgical risk in elderly patients is increased, but most of this excess risk is because of associated comorbid conditions. Effective pre- and postoperative assessment and care can minimize this risk and maximize the chances of a successful outcome.

The medical director in hospital-based transitional care units.

This article begins with a brief overview of what subacute care is and why it is growing exponentially. It then discusses the characteristics of patients appropriate for treatment in a transitional care unit (TCU) and the evolving role of physicians in their care. The process of care in a typical hospital-based TCU from admission to discharge is discussed with an emphasis on documentation and an interdisciplinary approach. The role of the medical director is emphasized. The article closes with strategies the authors feel are useful for improving care in hospital-based TCUs.

Cost-effectiveness of low-air-loss beds for treatment of pressure ulcers.

BACKGROUND: Cost-effectiveness of low-air-loss beds for the healing of pressure ulcers was analyzed in the nursing home setting. A statistical model of pressure ulcer healing was used to estimate cost-effectiveness based on patient and ulcer characteristics. METHODS: Results of a previous randomized trial (84 patients from three nursing homes in Los Angeles) were reanalyzed and combined with estimates of costs to calculate the cost-effectiveness in dollars per added day free of pressure ulcers achieved by the use of low-air-loss beds compared to conventional foam mattresses. RESULTS: The cost-effectiveness of the low-air-loss bed was $26 per added day free of ulcers for our standard patient. Results were sensitive to low-air-loss bed lease costs and patient and wound healing characteristics. Results were less sensitive to expected mortality, daily wound care costs, and time-frame of consideration. Low-air-loss beds were more cost-effective for patients with good healing characteristics and mild ulcers. CONCLUSIONS: Findings support the expanded use of this technology for patients with mild pressure ulcers and good healing characteristics. For these patients, the cost-effectiveness of low-air-loss beds is comparable to other accepted health treatments. For patients with severe ulcers and poor healing characteristics, low-air-loss bed cost-effectiveness compares poorly with other accepted health treatments unless the lease cost can be substantially reduced, or unless life with a pressure ulcer is valued close to death.

Predictors of skilled nursing placement in a multilevel long-term-care facility.

OBJECTIVE: To determine if cognitive and functional data gathered before admission to residential care (i.e., board and care) placement can predict nursing home placement. DESIGN: Retrospective study using Cox proportional hazards analysis and pairwise assessment of adjusted relative risk factors to determine which independent variables predicted skilled nursing placement. Subjects were followed for an average of 23.7 months (SD = 18.6 months). SETTING: Multilevel 1,735-bed long-term care facility, Jewish Home for the Aging, Reseda, California. PARTICIPANTS: Of the 248 consecutive residential care admissions studied, 80% were women. Subject's mean age was 84.8 years (SD = 5.0); 67% had no significant cognitive impairment. INDEPENDENT VARIABLES: Categorical variables were classifications with respect to dementia status, incontinence, hearing, and ambulation. Interval variables were number of medications, Katz ADL, and five neuropsychological tests. Demographic variables were gender, age, language of origin, and education. OUTCOME VARIABLE: Time between preadmission testing and the move up to skilled nursing placement. RESULTS: Pairwise assessment of adjusted potential risk factors indicated that cognitive dysfunction, less than perfect Katz ADL performance, and hearing loss were the most important independent risk factors for nursing placement. CONCLUSIONS: The findings remind us to pay careful attention to residents exhibiting even relatively mild cognitive deficits upon admission because these residents are likely to need increased environmental support.

Cognitive function in old and very old residents of a residential facility: relationship to age, education, and dementia.

OBJECTIVE: To determine if age, education, and dementia status affect neuropsychological performance in old and very old frail residential care subjects. DESIGN: Descriptive study of performance at the time of preadmission assessment. SETTING: Jewish Home for the Aging, Reseda, California. PARTICIPANTS: 201 applicants to the Jewish Home for the Aging residential care setting. Mean age was 84.7 years; SD was 5.6. Ninety-five subjects were 84 years of age or younger, while 106 were age 85 and older. There were 141 nondemented, 21 demented, and 39 were possibly demented applicants. Levels of education were as follows: 0-4 years: n = 25; 5-8: n = 69; 9-12: n = 77; and, 13-20: n = 23. MEASUREMENTS: Independent variables were age, education, and dementia status. Outcome measures were Folstein MMSE, Inglis P-A Learning Test, Digit Span, Cube Copying, selected Boston Diagnostic Aphasia Exam subtests. RESULTS: Subjects with 0 to 4 years of education scored more poorly on cognitive tests than other subjects. The very old tended to score more poorly than the old. Neuropsychological tests discriminated between those with normal cognitive function, possible dementia, and established dementia. About one-third of nondemented elderly scored below the traditional impairment cut-off of 24 points on the Mini-Mental State Exam. CONCLUSIONS: Questions are raised about how to interpret the poorer cognitive performance of very old and often frail subjects, especially in long-term-care settings where there are fewer demands upon residents whose impairments might otherwise cause them more functional difficulty.

Physician evaluation and management of nursing home residents.

The diverse goals of nursing home care, the heterogeneity of nursing home residents, and the varied circumstances under which physicians care for them make their evaluation and care complex and challenging. When evaluating and caring for nursing home residents, physicians must address many issues besides treatment of multiple chronic diseases (including impairments in cognitive and physical functioning, sensory deficits, depression, and behavioral disorders associated with dementia) and concerns of family members. The physician should be integrated with an interdisciplinary team composed of nurses, rehabilitation therapists, social workers, and others. Recently implemented federal rules for nursing home care, which include the Minimum Data Set and Resident Assessment Protocols, provide a useful framework for interdisciplinary assessment and care planning and should improve the care nursing home residents receive. Better data are needed on the most cost-effective strategies for evaluating and caring for nursing home residents. Reimbursement for physician services, availability of nurse practitioners and physician assistants, and overall quality of nursing home care must be improved so physicians can better achieve the recommendations outlined.

Total quality management: administrative and clinical applications in nursing homes.

OBJECTIVE: Describe the application of the Total Quality Management (TQM) model to the unique work force, resident population, and regulatory issues that characterize long term care settings. DESIGN: The key differences between TQM and current management and training practices in nursing homes are described. A specific data-based example is provided of a successful TQM application to health care involving clinical work processes related to incontinence care. CONCLUSION: Significant organizational and clinical obstacles must be overcome if TQM is to improve the quality of life and satisfaction of nursing home residents and their families as it has improved the efficiency and product quality in hospital and non-health-care settings.

Change in self-reported functioning in older persons entering a residential care facility.

We evaluated the responsiveness of measures of function in admissions to a long-term care facility. Between baseline and follow-up assessment, one-fifth or more of the subjects either worsened or improved in most aspects of reported function. We compared two measures of self-reported function (COOP charts and a short-form survey). Convergent validity was observed for changes in pain, social health, and mental health (r = 0.39-0.74), but not for physical functioning. Although the short-form physical function measure discriminated worsening on several performance-based external criteria of physical functioning (area under ROC curves up to 0.82), the COOP and other measures of physical functioning were less likely to do so. All physical function measures were less responsive for detecting improvement. Clinicians and investigators intending to monitor change in function must consider the responsiveness of their measures.

Using multidimensional health measures in older persons to identify risk of hospitalization and skilled nursing placement.

We examine the relationship between multidimensional measures of function and outcomes in a cohort of older persons admitted to the residential care level of a multi-level long-term care facility. We collected self-reported measures of various aspects of health using the Medical Outcome Study Short-form Health Survey (SF-20) and the Dartmouth COOP charts, as well as performance-based measures of physical and cognitive function. Subjects (mean age 84.3 years) were followed for a median of 557 days. In multivariate analyses, emotional function (measured by either the SF-20 or COOP method) was a predictor of placement in skilled care. Self-reported overall health (measured by either the SF-20 or COOP method) and timed manual performance were predictive of hospitalization. Change on the functional status measures between 2 points in time was not associated with later placement in skilled care except in the case of timed manual performance. In an older population at risk for frequent and numerous health events, this study shows that two popularized self-report methods for assessing function yield results that predict future outcomes of great importance to older persons. However, measures that predict use of long-term care may not predict use of the hospital and vice versa.

A randomized trial of low-air-loss beds for treatment of pressure ulcers.

OBJECTIVE: To assess the effectiveness of low-air-loss beds for the treatment of pressure ulcers in nursing homes. DESIGN: Prospective, randomized, clinical trial. SETTING: Three teaching nursing homes in Los Angeles, Calif. SUBJECTS: Eighty-four nursing home residents with trunk or trochanter pressure ulcers (Shea stage > or = 2). INTERVENTIONS: Subjects were randomly assigned to use either a low-air-loss bed (n = 43) or a 10-cm corrugated foam mattress (n = 41) throughout the healing of their ulcers. OUTCOME MEASURES: Ulcers were assessed twice weekly using surface area and two observational scales (median follow-up, 37.5 days; range, 4 to 571 days). RESULTS: Groups were similar with respect to demographics, medical variables, wound care, and early dropouts. Results indicate more than a threefold improvement in median rate of healing for low-air-loss beds compared with foam mattresses (9.0 vs 2.5 mm2/d; P = .0002). This finding was true for deep as well as superficial ulcers (deep ulcers, 9.9 vs 0.7 mm2/d; P = .02; superficial ulcers, 9.0 vs 3.2 mm2/d; P = .004). Cox regression models revealed that the bed, ulcer depth, and fecal continence had independent effects on healing. After controlling for fecal continence, the deep and superficial subgroups using low-air-loss beds remained 2.5 times more likely to heal in a given length of time compared with those using foam mattresses (combined cure probability ratio, 2.66; 95% confidence interval, 1.34 to 5.17; P < .004). CONCLUSION: Low-air-loss beds provide substantial improvement compared with foam mattresses despite other factors in pressure ulcer healing.