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The supply of personal care aides (PCAs), who assist people receiving home care, is a growing concern. PCA shortages result, in part, from the low wages earned by these workers. State policies have had some effect on wages. Self-direction (SD) may be associated with wages because SD allows home care recipients to hire and manage workers, including setting wages in most states. We used wage data from the Bureau of Labor Statistics to examine the association between SD and the wages of PCAs. We found implementation of SD did not have a consistent association with PCA wages, with wages improving in some states and worsening in others. We also found little difference in PCA wages between states that allow participants to set worker wages and those that do not. SD does not seem to improve PCA wages in states, so other policy strategies will be needed. [ABSTRACT FROM AUTHOR]

Introduction: Previous research in acute care settings has shown that collaborative capacity, defined as the way providers collaborate as equal team members, can be improved by the ways in which an organization supports its staff and teams. This observational cross-sectional study examines the association between collaborative capacity and supportive organizational context, supervisory support, and person-centered care in nursing homes to determine if similar relationships exist. Methods: We adapted the Care Coordination Survey for nursing homes and administered it to clinical staff in 20 VA Community Living Centers. We used random effects models to examine the associations between supportive organizational context, supervisory support, and person-centered care with collaborative capacity outcomes including quality of staff interactions, task independence, and collaborative influence. Results: A total of 723 Community Living Center clinical staff participated in the Care Coordination Survey resulting in a response rate of 29%. We found that teamwork and collaboration—measured as task interdependence, quality of interactions and collaborative influence—did not differ significantly between Community Living Centers but did differ significantly across occupational groups. Moreover, staff members' experiences of teamwork and collaboration were positively associated with supportive organizational context and person-centered care. Discussion: Our findings suggest that elements of organizational context are important to facilitating collaborative capacity. Additionally, investing in staffing, rewards, and person-centered care may improve teamwork. [ABSTRACT FROM AUTHOR]

Objective: We explored post–Affordable Care Act hospital and skilled nursing facility (SNF) perspectives in discharge and admission practices. Method: Interviews were conducted with 138 administrative personnel in 16 hospitals and 25 SNFs in eight U.S. markets and qualitatively analyzed. Results: Hospitals may use prior referral rates and patients' geographic proximity to SNFs to guide discharges. SNFs with higher hospital referral rates often use licensed nurses to screen patients to admit more preferred patients. While SNFs with lower hospital referral rates use marketing strategies to increase admissions, these patients are often less preferred due to lower reimbursement or complex care needs. Conclusion: An unintended consequence of increased hospital-SNF integration may be greater disparity. SNFs with high hospital referral rates may admit well-reimbursed or less medically complex patients than SNFs with lower referral rates. Without policy remediation, SNFs with lower referral rates may thus care for more medically complex long-term care patients. [ABSTRACT FROM AUTHOR]

This article examines whether staff empowerment practices common to nursing home culture change are associated with certified nursing assistant (CNA) retention. Data from 2,034 nursing home administrators from a 2009/2010 national nursing home survey and ordered logistic regression were used. After adjustment for covariates, a greater staff empowerment practice score was positively associated with greater retention. Compared with the low empowerment category, nursing homes with scores in the medium category had a 44% greater likelihood of having higher CNA retention (odds ratio [OR] = 1.44; 95% confidence interval [CI] = [1.15, 1.81], p = .001) and those with high empowerment scores had a 64% greater likelihood of having higher CNA retention (OR = 1.64; 95% CI = [1.34, 2.00], p < 001). Greater opportunities for CNA empowerment are associated with longer CNA retention. This research suggests that staffing empowerment practices on the whole are worthwhile from the CNA staffing stability perspective. [ABSTRACT FROM AUTHOR]

Policies to “rebalance” funding away from nursing homes and toward home and community-based services (HCBS) have encouraged national trends of nursing home closure and an expansion of the HCBS industry. These changes are unfolding without a clear understanding of what services are available at the local level. The purpose of this study was: (1) to describe the current distribution of community-based services (CBS) in areas where nursing homes have closed and (2) to examine differences in availability of CBS using local market and population characteristics as regressors in a multinomial logistic model. We collected data on and geocoded CBS facilities and then used ArcGIS to define a 5-mile radius around all nursing homes that closed between 2006 and 2010 and compared these local market areas. In rural areas, availability of CBS does not appear to compensate for nursing home closures. Policies encouraging HCBS may be outpacing availability of CBS, especially in rural areas. [ABSTRACT FROM AUTHOR]

Nurse practitioners and physician assistants can alleviate some of the primary care shortage facing the United States, but their scope-of-practice is limited by state regulation. This study reports both cross-sectional and longitudinal trends in state scope-of-practice regulations for nurse practitioners and physician assistants over a 10-year period. Regulations from 2001 to 2010 were compiled and described with respect to entry-to-practice standards, physician involvement in treatment/diagnosis, prescriptive authority, and controlled substances. Findings indicate that most states loosened regulations, granting greater autonomy to nurse practitioners and physician assistants, particularly with respect to prescriptive authority and physician involvement in treatment and diagnosis. Many states also increased barriers to entry, requiring high levels of education before entering practice. Knowledge of state trends in nurse practitioner and physician assistant regulation should inform current efforts to standardize scope-of-practice nationally. [ABSTRACT FROM AUTHOR]

Quality improvement and cost containment initiatives in health care increasingly involve interdisciplinary teams of providers. To understand organizational functioning, information is often needed from multiple members of a leadership team since no one person may have sufficient knowledge of all aspects of the organization. To minimize survey burden, it is ideal to ask unique questions of each member of the leadership team in areas of their expertise. However, this risks substantial missing data if all eligible members of the organization do not respond to the survey. Nursing home administrators (NHA) and directors of nursing (DoN) play important roles in the leadership of long-term care facilities. Surveys were administered to NHAs and DoNs from a random, nationally representative sample of U.S. nursing homes about the impact of state policies, market forces, and organizational factors that impact provider performance and residents' outcomes. Responses were obtained from a total of 2,686 facilities (response rate [RR] = 66.6%) in which at least one individual completed the questionnaire and 1,693 facilities (RR = 42.0%) in which both providers participated. No evidence of nonresponse bias was detected. A high-quality representative sample of two providers in a long-term care facility can be obtained. It is possible to optimize data collection by obtaining unique information about the organization from each provider while minimizing the number of items asked of each individual. However, sufficient resources must be available for follow-up to nonresponders with particular attention paid to lower resourced, lower quality facilities caring for higher acuity residents in highly competitive nursing home markets. [ABSTRACT FROM AUTHOR]

To understand the process of instituting culture change (CC) practices in nursing homes (NHs). NH Directors of Nursing (DONs) and Administrators (NHAs) at 4,149 United States NHs were surveyed about CC practices. Follow-up interviews with 64 NHAs were conducted and analyzed by a multidisciplinary team which reconciled interpretations recorded in an audit trail. Results: The themes include: (a) Reasons for implementing CC practices vary; (b) NH approaches to implementing CC practices are diverse; (c) NHs consider resident mix in deciding to implement practices; (d) NHAs note benefits and few costs to implementing CC practices; (e) Implementation of changes is challenging and strategies for change are tailored to the challenges encountered; (f) Education and communication efforts are vital ways to institute change; and (g) NHA and other staff leadership is key to implementing changes. Diverse strategies and leadership skills appear to help NHs implement reform practices, including CC innovations. [ABSTRACT FROM PUBLISHER]

Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients’ SNF length of stay. Using a set of fee-for-service beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid. [ABSTRACT FROM AUTHOR]

Medical staff (physicians, nurse practitioners, physicians’ assistants) involvement in nursing homes (NH) is limited by professional guidelines, government policies, regulations, and reimbursements, creating bureaucratic burden. The conceptual NH Medical Staff Involvement Model, based on our mixed-methods research, applies the Donabedian “structure–process–outcomes” framework to the NH, identifying measures for a coordinated research agenda. Quantitative surveys and qualitative interviews conducted with medical directors, administrators and directors of nursing, other experts, residents and family members and Minimum Data Set, the Online Certification and Reporting System and Medicare Part B claims data related to NH structure, process, and outcomes were analyzed. NH control of medical staff, or structure, affects medical staff involvement in care processes and is associated with better outcomes (e.g., symptom management, appropriate transitions, satisfaction). The model identifies measures clarifying the impact of NH medical staff involvement on care processes and resident outcomes and has strong potential to inform regulatory policies. [ABSTRACT FROM PUBLISHER]

Aims: Most developed countries are taking steps to move away from institutional models of care for the aged, in an attempt to both improve quality of life for those receiving care and improve the work of those providing care. In the USA, the concept of ‘culture change’ (CC) encompasses a variety of philosophical and practice models being employed to de-institutionalise skilled nursing facilities, also known as long-term care (LTC) facilities. Teamwork among direct-care workers is often promoted as an important aspect of culture change. However, a recent study found that, among facilities attempting CC, teamwork was the least commonly implemented CC component. This suggests that facilities may be having difficulty implementing teamwork and also raises questions about the link between teamwork and facility organisational culture. This study examined the relationship between teamwork and organisational culture in the LTC setting. Methods: Observations in 20 LTC facilities were used to identify facilities with high and low amounts of teamwork. Interviews with nursing staff from four high-teamwork and five low-teamwork facilities were compared to determine the aspects of organisational culture associated with teamwork, and explore how teamwork might be sustained in LTC facilities. Findings: Aspects of culture, including positive staff attitudes toward co-workers, were associated with high-teamwork facilities. Managerial modelling of these attitudes may be one factor that helps sustain teamwork. Conclusions: LTC facility managers may need to adjust their own attitudes and behaviour to support teamwork in their facilities. This has implications for facilities attempting to de-institutionalise. [ABSTRACT FROM PUBLISHER]