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This article describes a pay-for-performance system developed for Minnesota nursing homes. In effect, nursing homes can retain a greater proportion of the difference between their costs and the average costs on the basis of their quality scores. The quality score is a derived and weighted composite measure currently composed of five elements: staff retention (25 points), staff turnover (15 points), use of pool staff (10 points), nursing home quality indicators (40 points), and survey deficiencies (10 points). Information on residents' quality of life and satisfaction, derived from interviews with a random sample of residents in each Minnesota nursing home, is now available for inclusion in the quality measure. The new payment system was designed to create a business case for quality when used in addition to a nursing home report card that uses the same quality elements to inform potential consumers about the quality of nursing homes. Although the nursing home industry has announced general support for the new approach, it has lobbied the legislature to delay its implementation, claiming concerns about operational details. Key Words: Nursing homes, Pay for performance, Quality, Payment, Accountability

Purpose: The purpose of this report is to evaluate the reliability and validity of the five-item Evaluation to Sign Consent (ESC), a measure that can guide determination of an older adult's capacity to consent for research. Design and Methods: Information was obtained from 346 nursing home residents from six facilities who were being enrolled into a randomized controlled trial testing a restorative care intervention. In addition to the ESC, the resident's cognitive status and demographic information was obtained. Results: The average age of the participants was 86.1 [+ or -] 7.3 years; most of the participants were female (84%) and Caucasian (95%). The mean Mini-Mental State Exam score was 18.0 [+ or -] 7.4. A total of 218 residents (63%) did not pass the ESC. According to a Rasch analysis and the inter-rater reliability (r = .81), there was some evidence of reliability and validity with this measure. Logistic regression showed that Items 1 (describing two risks to participation in the study) and 2 (knowing what is associated with participation) had the greatest overall percentage of agreement with the full ESC, and the Mini-Mental State Exam was the only resident-tested variable to predict the results of the ESC. Implications: This study provides useful information about the ESC. It indicates a reason and a method to move beyond cognitive testing that can more appropriately evaluate the capacity to consent to participate in research. Key Words: Recruitment, Consent, Nursing homes, Research participants

Purpose: The Providing Assistance to Caregivers in Transition (PACT) program offers nursing home discharge planning and case management for individuals in the transitional period following a return to the community. The PACT program targeted individuals newly admitted to nursing homes and worked with a family caregiver to develop and implement a nursing home discharge plan. Design and Method: Reported are the results of a randomized control design evaluating the program's effectiveness. Those individuals randomly assigned to the intervention group (n = 33) received PACT case management in addition to their usual medical and nursing home care. The individuals in the control group (n = 29) continued their usual care. Result: There were no statistical differences in the discharge rate (84% treatment vs 76% controls) or in the median length of stay (42 days vs 55 days) between the two groups of individuals. Implications: Replications or extensions of a PACT-type intervention might consider a broader mix of nursing homes, working directly with the nursing home's admission Minimum Data Set coordinator in patient selection, or working with Medicare or Medicaid HMO plans. Key Words: Nursing home, Case management, Postacute care, Geriatrics

Purpose: Advance directives are important planning and decision-making tools for individuals in nursing homes. Design and Methods: By using the nursing facility Minimum Data Set, we examined the prevalence of advance directives at admission and 12 months post-admission. Results: The prevalence of having any advance directive at admission declined slightly from 2000 to 2004, whereas the prevalence of having any advanced directive at 12 months after admission increased slightly during the same period. Compared with admissions, residents at 12 months post-admission were more likely to have their decisions made by family members and to have advance directives of any type. Implications: The results suggest that greater use of advance directives in nursing homes may depend on additional information and support from nursing facility personnel and the health and social services professionals who are in contact with individuals moving toward nursing home admission, as well as those who remain in facilities over time. Key Words: Long-term care, Health care decisions, End of life, Late-life long-term care

Purpose: The purpose of this study was to investigate pain management among 42 hospice and 65 non-hospice residents in two proprietary nursing homes. Design and Methods: In this prospective, anthropological, quantitative, and qualitative study, we used participant observation, event analysis, and chart review to obtain data. The Medication Quantification Scale was used in order to account for the prescription and administration of all analgesic medications. Results: Although 72% of residents experienced pain, we found no statistically significant differences in the proportion of hospice versus nonhospice residents (a) who had been prescribed opioids and co-analgesics, and (b) whose medication was administered around the clock or as needed. Limited physician availability, lack of pharmacologic knowledge, and limitations of nursing staff hindered pain management of both groups of residents. Implications: Although hospice care is of some benefit, pain management and high-quality end-of-life care is dependent upon the context in which it is provided. Given that between 1991 and 2001 Medicare expenditures for nursing home-based hospice care increased from $8.6 million to $21.8 million, the effectiveness of hospice-care programs in nursing homes warrants further study. Key Words: Hospice, Nursing home, Pain management

Background. The objective of this research was to profile and compare state-level physical restraint use, urethral catheterization, contractures, pressure ulcers, and psychoactive medication use as indicators of quality of care in nursing facilities. Methods. Using nationally representative data from the Online Survey, Certification, and Reporting system for 2000 (N = 17,072), we calculated predicted quality scores using risk-adjusted models based on aggregate resident variables generated by hierarchical linear regression models for each of the five quality indicators. Results. We observed significant variation in both the actual and risk-adjusted quality measures. The average risk- adjusted physical restraint quality score ranged from 8.4% to 12.8%; the average risk-adjusted catheterization quality score ranged from 3.6% to 7.7%; the average risk-adjusted contractures quality score ranged from 19.0% to 31.6%; the average risk-adjusted pressure ulcer quality score ranged from 3.8% to 7.6%; and the average risk-adjusted psychoactive medication quality score ranged from 47.8% to 56.9%. Eleven states had quality measures better than the risk-adjusted expectation for at least four of the five measures, and eight states were worse than expected in at least four of the rive. Conclusions. This study provides evidence that there is variation in quality indicators across states. These differences exist even after risk adjustment. Our results may be important for state regulators trying to understand and improve quality.

Purpose: The aim of this study was to estimate the longitudinal relationship between transitions in the use of long-term care and older adults' depressive symptoms and to investigate whether this relationship could be explained by markers of older adults' underlying health, or other variables including demographics, personality, and partner status. Design and Methods: Data were from the Longitudinal Aging Study Amsterdam, which consists of a random, community-based sample of 3,107 older Dutch people (55-85 years of age) stratified by age and gender. The use of informal care, professional home care, and institutional care was recorded, and respondents were screened on depressive symptoms. Follow-up measurements took place at 3 and 6 years. Results: Longitudinal analyses showed significant associations between the enduring use of professional long-term care and an increase in depressive symptoms. Transitions to professional home care or institutional care were also associated with considerably more depressive symptoms after 3 years, whereas transitions from professional home care or institutional care to no care or informal care only were not associated with a change in depressive symptoms. Most of the associations remained significant after indicators of underlying health and other covariates were adjusted for, and also after the data were reanalyzed for respondents with and without functional limitations. Implications: This study does not involve a controlled experiment of professional long-term care among older adults. However, the findings suggest the possibility that receiving professional long-term care could introduce new stressors and increase the risk of depressive symptoms. Our analyses illuminate the concerns of elders regarding their use of professional long-term care and may help in planning for more effective delivery of this type of care. Key Words: Health services, Nursing homes, Home care, Aged, Community

Purpose: This study examined the association between turnover of caregivers and turnover of nursing home top management. The top managers examined were administrators and directors of nursing, and the caregivers examined were registered nurses, licensed practical nurses, and nurse aides. Design and Methods: The data carne from a survey of 419 nursing facilities and the Online Survey, Certification, and Reporting system. Multinomial logistic regression analyses were used to examine the association between turnover of nursing home top management and turnover of caregivers. Results: A 10% increase in top management turnover is associated (p < .05) with a 21% increase in the odds that a facility will have a high turnover rate of nurse aides and is associated (p < .05) with ah 8% decrease in the odds that a facility will have a low turnover rate of nurse aides. A 10% increase in top management turnover is associated (p < . 1) with a 30% increase in the odds that a facility will have a high turnover rate for registered and licensed practical nurses. Implications: This study provides preliminary evidence that the turnover of top managers may have ah important influence on caregiver turnover in nursing homes. Key Words: Turnover, Top management, Nursing home staff

Department of Sociology, Case Western Reserve University, Cleveland, Ohio. Objectives. We examine anticipated preferences for nursing home placement as a strategy for meeting possible future long-term care needs among a sample of community-dwelling elderly European Americans who migrated to Florida after retirement. We synthesize prior research on ethnicity in late life, retirement migration patterns, and informal networks of retired migrants. Methods. We gathered data through structured personal interviews with 578 retired migrants identified through screening from telephone listings, supplemented with snowball sampling techniques. Results. Lifetime migration patterns and current ethnic involvement are significant predictors of mentioning nursing home placement as a strategy for possible long-term care needs. Discussion. We interpret these results within the framework of Rowles's emphasis on the permeability of community-nursing home boundaries.

Purpose: This study investigated whether higher rates of nursing home quality citations are associated with increased risk of voluntary and involuntary facility terminations from the Medicare/Medicaid certification process. Design and Methods: We examined nationwide Online Survey Certification and Reporting (OSCAR) data from 1992 through 2000 and used a multinomial logistic regression model with time-varying covariates to estimate the relationship between nursing home deficiencies and terminations. Results: In the study period, 8.7% of nursing homes voluntarily terminated and 2.4% of facilities were involuntarily terminated. Deficiencies significantly predicted both types of termination, controlling for state and market characteristics. Low occupancy and very high Medicaid mix were strongly related to voluntary and involuntary terminations (p < .05). Implications: Nursing homes that receive a high number of deficiencies exit the Medicare/Medicaid market and have lower occupancy rates before termination, although the relationship varies considerably across states. If competition on the basis of quality is increased because of public reporting efforts, our analyses suggest that terminations, both voluntary and involuntary, will likely increase. Key Words: Deficiencies, Termination, Quality, Regulation, Nursing home

Purpose: Despite substantial regulatory oversight, quality of care in nursing homes remains problematic. This article assesses strategies for improving quality of care in these facilities. Design and Methods: This article reviews the research literature on eight strategies: strengthening the regulatory process, improving information systems for quality monitoring, strengthening the caregiving workforce, providing consumers with more information, strengthening consumer advocacy, increasing Medicare and Medicaid reimbursement, developing and implementing practice guidelines, and changing the culture of nursing facilities. Results: Although individual approaches vary, several themes emerge. First, several strategies require substantially more resources and will increase costs. Second, the research literature does not provide much guidance as to the effectiveness of these options. Third, several strategies assume a degree of data sophistication on the part of nursing homes that may not exist. Fourth, regulation is likely to continue to be the main strategy of quality assurance. Finally, the political saliency of nursing home quality issues is uneven. Implications: Quality of care in nursing homes is a major issue for which there is no simple solution. Key Words: Long-term care, Nursing facilities, Regulation, Quality indicators.

Purpose: The premise of this article is that interventions should be based explicitly on theory and basic research findings. Although there appears to be general agreement with that assertion, the connections among theory, research, and intervention in the field of gerontology are often tenuous or nonexistent. In this article, we argue for better integration of these three domains, providing two case studies from the Cornell Roybal Center that illustrate the positive role theory and research can play in intervention designs and broader applicability of findings. Design and Methods: Study 1 involved a social support intervention for persons making the transition to becoming a family caregiver. Study 2 was an organizational intervention designed to improve interpersonal relationships and increase mutual support between family caregivers and staff in nursing homes. Results: Several benefits emerged as a result of creating theoretically grounded and research-based interventions, including guidance for innovative intervention design and the production of findings that inform both basic research and intervention. Implications: A much closer link between theory and basic research and intervention studies is indicated, suggesting that current federal support of translational research initiatives is justified and worthy of expansion. Key Words: Intervention studies, Research-practice relationship, Caregiving, Nursing homes

Purpose: The aim of this study was to identify health-related changes occurring between 1983 and 1990 that characterize and differentiate 1996 long-term care outcomes (no services, home care, nursing home) among people aged 85 years and older. Design and Methods: Variables capturing health-related changes between 1983 and 1990 in a cohort (N = 616) of Aging in Manitoba Longitudinal Study participants aged 85 years and older were used in a series of logistic regression models to identify factors that best predicted the use of long-term care services in 1996, controlling for age and sex. Results: Factors predicting home care use relative to no services included changes in self-rated health, income adequacy, and railings outside of the house. Factors predicting nursing home use relative to home care included age and changes in general life satisfaction. Factors predicting nursing home use relative to no services included age; previous service use; length of time in the community; and changes in income adequacy, type of housing, and state of mind. Implications: These findings challenge assumptions about the linearity of the continuum of long-term care services, because different factors were shown to predict home care use than were shown to predict nursing home use. Key Words: Longitudinal study, Home care predictors, Nursing home predictors

This article describes and evaluates the Buddy Program, which uses a natural helping network model to enhance the well-being of persons in nursing homes. Thirty-six nondemented patients ('buddies') and 33 persons with dementia completed the 6-month study that involved an educational program for the buddies and regular meetings between buddy-dementia patient pairs. Over the 6 months, compared to a matched control group, the dementia patients showed no advantage on any of the seven outcome measures and actually had significantly more depressive symptoms and greater nursing home dissatisfaction. The nondementia buddies showed no differences from the controls on any of the outcome measures. The results suggest that natural helping network models may not be easily imported into nursing home settings. Key Words: Social networks, Dementia, Nursing homes

A primary care nursing model was developed and implemented in 2 nursing homes for the demented, 1 rural and 1 urban to try and improve staff morale and the quality of care. Three types of intervention took place: nursing aide; team work and improved communication. Affective, behaviourial and social interaction were monitored. The results show that the nursing model benifitted the residents, resulting in behaviorial, affective and social changes.

There are currently 15 research institutes associated with long-term care facilities in the United States. With the recent growth in number of research departments affiliated with nursing homes, the process of establishing and operating research departments is currently being assessed. A survey of these research institutes identified strengths and developmental issues concerning the establishment of research departments in nursing homes. Some reasons for establishing a research institute in a long-term care setting are to further knowledge, particularly in the area of aging, and solve problems encountered in a health care facility; to increase staff development and morale; to enhance prestige by including scientific research as one of its functions in addition to care provider; and to utilize opportunities in studying a community-based operation responsible for a large elderly population. Other considerations and constraints, including topics of research, are discussed. Research institutes associated with long-term care facilities are committed both to health care service delivery and to academic environments. The presence of a research department in a nursing home provides excellent opportunities in aging research, but may also be associated with difficulties in performing research. Some nursing home-affiliated research institutes have successfully used such opportunities to advance gerontological research. (Consumer Summary produced by Reliance Medical Information, Inc.)

Despite widespread concern voiced by the public about the potential for abuse of elderly patients in nursing homes, virtually no research has been done to assess the nature and extent of this problem. A random telephone survey of 577 nurses and nurse's aides investigated abuse of patients by asking the staff to report on their own behavior and on incidents they had observed involving other staff members. The results showed that 36 percent of the nurses and aides interviewed had seen physical abuse occur at least once in the previous year. Restraining a patient excessively was most commonly reported; pushing, grabbing or pinching a patient were the next most frequent forms of physical abuse. A much greater proportion of those interviewed, 81 percent, had seen psychological abuse of a patient in the past year; yelling at the residents was the most common form of this abuse. Also, 50 percent of those interviewed reported incidents in which staff insulted or swore at patients, and 23 percent had witnessed an employee isolating a patient more than was needed to maintain control. When asked about their own behavior, 10 percent of the staff members interviewed admitted to a physically abusive act, while 40 percent said they had been psychologically abusive. The authors conclude that abuse of patients is occurring at a level that warrants public concern. Inhumane treatment may indeed be a frequent occurrence, rather than an isolated incident. In addition, there may have been a tendency for the staff to underreport such incidents, and patients might present a different picture of the care they receive. The author reviews related research and discusses possible approaches for reducing the incidence of abuse in nursing homes. (Consumer Summary produced by Reliance Medical Information, Inc.)