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Background: Chronic ventilator use in Tennessee nursing homes surged following 2010 increases in respiratory care payment rates. Tennessee's Medicaid program implemented multiple policies between 2014 and 2017 to promote ventilator liberation in 11 nursing homes, including quality reporting, on-site monitoring, and pay-for-performance incentives., Methods: Using repeated cross-sectional analysis of Medicare and Medicaid nursing home claims (2011-2017), hospital discharge records (2010-2017), and nursing home quality reports (2015-2017), we examined how service use changed as Tennessee implemented policies designed to promote ventilator liberation in nursing homes. We measured the annual number of nursing home patients with ventilator-related service use; discharge destination of ventilated inpatients and percent of nursing home patients liberated from ventilators., Results: Between 2011 and 2014, the number of Medicare SNF and Medicaid nursing home patients with ventilator use increased more than sixfold. Among inpatients with prolonged mechanical ventilation, discharges to home decreased as discharges to nursing homes increased. As Tennessee implemented policy changes, ventilator-related service use moderately declined in nursing homes from a peak of 198 ventilated Medicare SNF patients in 2014 to 125 in 2017 and from 182 Medicaid patients with chronic ventilator use in 2014 to 145 patients in 2017. Nursing home weaning rates peaked at 49%-52% in 2015 and 2016, but declined to 26% by late 2017. Median number of days from admission to wean declined from 81 to 37 days., Conclusions: This value-based approach demonstrates the importance of designing payment models that target key patient outcomes like ventilator liberation., (© 2021 The American Geriatrics Society.)

Background/objectives: Regulatory oversight has been a central strategy to assure nursing home quality of care for decades. In response to COVID-19, traditional elements of oversight that relate to resident care have been curtailed in favor of implementing limited infection control surveys and targeted complaint investigations. We seek to describe the state of nursing home oversight during the pandemic to facilitate a discussion of whether and how these activities should be altered going forward., Design and Setting: In a retrospective study, we describe national oversight activities in January-June 2020 and compare these activities to the same time period from 2019. We also examine state-level oversight activities during the peak months of the pandemic., Participants: United States nursing homes., Data: Publicly available Quality, Certification, and Oversight Reports (QCOR) data from the Centers for Medicare and Medicaid Services (CMS)., Measurements: Number of standard, complaint, and onsite infection surveys, number of deficiencies from standard and complaint surveys, number of citations by deficiency tag, and number and amount of civil monetary penalties., Results: The number of standard and complaint surveys declined considerably in the second quarter of 2020 relative to the same time frame in 2019. Deficiency citations generally decreased to near zero by April 2020 with the exception of infection prevention and control deficiencies and citations for failure to report COVID-19 data to the national health safety network. Related enforcement actions were down considerably in 2020, relative to 2019., Conclusion: In the months since COVID-19 first impacted nursing homes, regulatory oversight efforts have fallen off considerably. While CMS implemented universal infection control surveys and targeted complaint investigations, other routine aspects of oversight dropped in light of justifiable limits on nursing home entry. Going forward, we must develop policies that allow regulators to balance the demands of the pandemic while fulfilling their responsibilities effectively., (© 2021 The American Geriatrics Society.)

Background/objectives: Relatively little is known regarding predictors of advance care planning (ACP) in former nurses. We aimed to evaluate potential predictors of ACP documentation and discussion., Design: Cross-sectional study, 2012-2014., Setting: Nurses' Health Study., Participants: A total of 60,917 community-dwelling female nurses aged 66 to 93 years living across the United States., Measurements: Based on self-reports, participants were categorized as having (1) only ACP documentation, (2) ACP documentation and a recent ACP discussion with a healthcare provider, or (3) neither. Multivariable log-binomial models were used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) of the two separate ACP categories vs those with neither. We evaluated various demographic, health, and social factors., Results: The large majority (84%) reported ACP documentation; 35% reported a recent ACP discussion. Demographic factors such as age and race were associated with both ACP categories. In multivariable analyses, race was most strongly associated: compared with whites, African Americans were 27% less likely (PR = 0.73; 95% CI = 0.69-0.78) to report ACP documentation alone and 41% (PR = 0.59; 95% CI = 0.54-0.66) less likely to report documentation with discussion. Additionally, health/healthcare-related characteristics were more strongly associated with ACP documentation plus discussion. Women with functional limitations (PR = 1.15; 95% CI = 1.10-1.20), women who were recently hospitalized (PR: 1.10; 95% CI = 1.08-1.12) or women who had seen a physician for health symptoms (PR = 1.43; 95% CI = 1.35-1.52) or screening (PR = 1.40; 95% CI = 1.32-1.49) were more likely to report having both ACP documentation and discussion. Social factors showed limited relationships with ACP documentation only; for documentation plus discussion, being widowed and living alone was associated with higher prevalence (PR = 1.21; 95% CI = 1.19-1.24) and having little emotional support was associated with lower prevalence (PR = 0.84; 95% CI = 0.81-0.86)., Conclusions: Among older nurses, most of whom reported having documented ACP, 35% reported recent patient-clinician ACP discussions, indicating a major participatory gap in an element critical to ACP effectiveness. Even in nurses, African Americans reported less ACP documentation or discussion. J Am Geriatr Soc 67:292-301, 2019., (© 2018, Copyright the AuthorJournal compilation © 2018, The American Geriatrics Society.)

Objectives: To assess differences in populations and service use according to hospice ownership, chain status, and agency size., Design: Retrospective cohort study., Setting: United States., Participants: Medicare beneficiaries aged 65 and older enrolled in hospice during 2005 to 2011 N = 5,405,526)., Measurements: Hospice use according to ownership category (for-profit nonchain and chain, not-for-profit nonchain and chain, government) and agency size (0-50, 51-200, 201-400, ≥401 individuals discharged each year). Mean length of use, stays of 3 days or fewer, stays ending with live discharge, and decedents receiving no general inpatient care (GIP)- or continuous home care (CHC)-level hospice in the last 7 days of life., Results: After adjusting for individual and geographic differences, for-profit nonchain and chain agencies had longer mean length of use (84.5 and 91.2 days, respectively) than other agency types (66.3-72.5 days), higher rates of live discharge (21.0% and 20.2% vs 14.6-15.9%), and lower proportions of stays of 3 days or fewer (13.9% and 14.7% vs 16.6-17.5%) (all P < .001). The proportion of decedents not receiving GIP- or CHC-level care before death was highest in for-profit chains (75.9%) and lowest in not-for-profit nonchains (63.2%). Smaller agencies had longer mean length of use, higher live discharge rates, lower rates of stays of 3 days or fewer, and higher rates of individuals receiving no GIP- or CHC-level care. There were considerable differences in patient traits and unadjusted service use between the nation's largest chains., Conclusion: In addition to for-profit and not-for-profit hospice agencies differing according to important dimensions, there is substantial heterogeneity within these ownership categories, highlighting the need to consider factors such as agency size and chain affiliation in understanding variations in Medicare beneficiaries' hospice care., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: In 2006, Medicare Part D transitioned prescription drug coverage for dual-eligible nursing home residents from Medicaid to Medicare and randomly assigned them to Part D prescription drug plans (PDPs). Because PDPs may differ in coverage, plans may be more or less generous for drugs that an individual is taking. Taking advantage of the fact that randomization mitigates potential selection bias common in observational studies, this study sought to assess the effect of PDP coverage on resident outcomes for three medication classes--antidepressants, antipsychotics, and cholinesterase inhibitors., Design: Retrospective cohort study to examine the effect of coverage restrictions--including noncoverage and coverage with restrictions--on depression, hallucinations and delusions, aggressive behaviors, cognitive performance, and activities of daily living for dual-eligible nursing home residents randomized to PDPs in 2006 to 2008. The analyses further adjusted for baseline health status to address any residual imbalances in the comparison groups., Setting: Linked data from Medicare claims, Minimum Data Set assessments, pharmacy claims, and PDP formulary information., Participants: Dual-eligible nursing home residents aged 65 and older living in facilities that contracted with a single pharmacy provider., Results: PDP coverage restrictions in three medication classes of interest were not significantly associated with the resident outcomes examined. Although cholinesterase inhibitor users facing coverage restrictions had a 0.04-point lower depression rating score than residents facing no restrictions, this difference was not statistically significant after adjusting for multiple comparisons., Conclusion: The findings suggest that exogenous changes in coverage for three commonly used medication classes had no detectable effect on nursing home resident outcomes in 2006 to 2008. There are several possible explanations for this lack of association, including the role of policy protections for dual-eligible nursing home residents and the possibility that suitable clinical alternatives were identified or that previously used medications offered little clinical benefit., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

In the Quality Improvement Organization (QIO) program's latest Statement of Work, the Centers for Medicare and Medicaid Services (CMS) is targeting its nursing home activities toward facilities that perform poorly on two quality measures-pressure ulcers and restraint use. The designation of target facilities is a shift in strategy for CMS and a direct response to criticism that QIO program resources were not being targeted effectively to facilities or clinical areas that most needed improvement. Using administrative data, this article analyzes implications of using narrowly defined criteria to identify facilities that need improvement, particularly in light of considerable evidence showing that nursing home quality is multidimensional and may change over time. The analyses show that one in four facilities is targeted for improvement nationally but that approximately half of some states' facilities are targeted while other states have almost none targeted. The analyses also convey deeper limitations to using threshold values on individual measures to identify poorly performing homes. Target facilities can be among the top performers on a range of other quality measures, and their performance on targeted measures themselves may change over time. The implication of these features is that a very different group of facilities would have been chosen had the QIO program targeted other measures or examined performance at a different point in time. Ultimately, CMS has chosen a blunt instrument to identify poorly performing nursing homes, and supplemental strategies-such as soliciting input from state survey agencies and more closely aligning quality improvement and quality assurance efforts-should be considered to address potential limitations.

The objective of this study was to analyze national Part D formulary data to assess adequacy of coverage across seven drug classes commonly used by nursing home residents and older people, focusing on individuals dually eligible for Medicare and Medicaid and plans in which they enroll. Focusing at the molecule level, reasonably broad coverage across drug classes and minimal prior authorization overall was found. Of nonprotected classes, 69% of plans cover at least four of five Alzheimer's medications, 76% cover at least three of four bisphosphonates, 86% cover at least three of five proton pump inhibitors, and 61% cover at least four of six 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins). Nevertheless, a minority of plans are less generous, and some drug formulations important to nursing home residents are covered less well. For example, 11% of plans cover only one or two of the six statins. Of protected drug classes, plans generally cover all molecules, as expected. The majority of plans require no prior authorization for covered medications in six of seven classes reviewed (excepting bisphosphonates). A minority of plans once again are more stringent. For example, 22% and 9% of Part D Plans nationally require prior authorization for all covered Alzheimer's drugs and proton pump inhibitors, respectively. Random assignment of dually eligible patients to below-benchmark plans means that some residents initially will be enrolled in these more-restrictive plans. Part D allows nursing home residents to switch plans at any time, but there are important barriers to residents' self-advocacy. Finally, it is unclear how well nursing homes and the pharmacies they work with will work across Part D plans, and vigilance will be required as the benefit proceeds.