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Despite important advances in the linkage of residents' Medicare claims and Minimum Data Set (MDS) information, the data infrastructure for long-term care remains inadequate for public health surveillance and clinical research. It is widely known that the evidence base supporting treatment decisions for older nursing home residents is scant as residents are systematically excluded from clinical trials. Electronic health records (EHRs) hold the promise to improve this population's representation in clinical research, especially with the more timely and detailed clinical information available in EHRs that are lacking in claims and MDS. The COVID-19 pandemic shined a spotlight on the data gap in nursing homes. To address this need, the National Institute on Aging funded the Long-Term Care (LTC) Data Cooperative, a collaboration among providers and stakeholders in academia, government, and the private sector. The LTC Data Cooperative assembles residents' EHRs from major specialty vendors and facilitates linkage of these data with Medicare claims to create a comprehensive, longitudinal patient record. These data serve 4 key purposes: (1) health care operations and population health analytics; (2) public health surveillance; (3) observational, comparative effectiveness research; and (4) clinical research studies, including provider and patient recruitment into Phase 3 and Phase 4 randomized trials. Federally funded researchers wanting to conduct pragmatic trials can now enroll their partnering sites in this Cooperative to more easily access the clinical data needed to close the evidence gaps in LTC. Linkage to Medicare data facilitates tracking patients' long-term outcomes after being discharged back to the community. As of August 2022, nearly 1000 nursing homes have joined, feedback reports to facilities are being piloted, algorithms for identifying infections are being tested, and proposals for use of the data have been reviewed and approved. This emerging EHR system is a substantial innovation in the richness and timeliness of the data infrastructure of the nursing home population., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest.

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce findings that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants identified 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) stakeholder engagement, (2) diversity and inclusion, (3) organizational strain and readiness, and (4) learn from adaptations. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions., (Copyright © 2021. Published by Elsevier Inc.)

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce data that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants recommended 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) engage stakeholders, (2) ensure diversity and inclusion, (3) assess organizational strain and readiness, and (4) learn from adaptations. Specifically related to implementation, participants provided 2 recommendations: (1) integrate interventions into existing workflows and (2) maintain agility and responsiveness. Finally, participants had 3 recommendations specific to dissemination: (1) package the message for the audience, (2) engage diverse audiences, and (3) apply dissemination and diffusion tools. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2022. Published by Elsevier Inc.)

Background/objectives: The coronavirus disease 2019 (COVID-19) pandemic has taken a disproportionate toll on long-term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID-19 cases and deaths., Design: Systematic review., Setting: Long-term care facilities (nursing homes and assisted living communities)., Participants: Thirty-six empirical studies of factors associated with COVID-19 cases and deaths in long-term care facilities published between January 1, 2020 and June 15, 2021., Measurements: Outcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably., Results: Larger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID-19 outcomes in long-term care facilities. Larger bed size and location in an area with high COVID-19 prevalence were the strongest and most consistent predictors of facilities having more COVID-19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID-19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5-star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID-19 outcomes., Conclusion: Given the importance of community COVID-19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID-19 spread would have been critical for mitigating much of the morbidity and mortality long-term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5-Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID-19 presented a novel problem requiring extensive adaptation by both long-term care providers and policymakers., (© 2021 The American Geriatrics Society.)

Background: Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment., Methods: We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment., Results: Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44)., Conclusion: In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used., (© 2021. The Author(s).)

Residents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Suboptimal antibiotic treatment of urinary tract infection (UTI) is high in long-term care facilities (LTCFs) and likely varies between facilities. Large-scale evaluations have not been conducted., Aim: To identify facility-level predictors of potentially suboptimal treatment of UTI in Veterans Affairs (VA) LTCFs and to quantify variation across facilities., Methods: This was a retrospective cohort study of 21,938 residents in 120 VA LTCFs (2013-2018) known as Community Living Centers (CLCs). Potentially suboptimal treatment was assessed from drug choice, dose frequency, and/or treatment duration. To identify facility characteristics predictive of suboptimal UTI treatment, LTCFs with higher and lower rates of suboptimal treatment (≥median, < median) were compared using unconditional logistic regression models. Joinpoint regression models were used to quantify average percentage difference across facilities. Multilevel logistic regression models were used to quantify variation across facilities., Findings: The rate of potentially suboptimal antibiotic treatment varied from 1.7 to 34.2 per 10,000 bed-days across LTCFs. The average percentage difference in rates across facilities was 2.5% (95% confidence interval (CI): 2.4-2.7). The only facility characteristic predictive of suboptimal treatment was the incident rate of UTI per 10,000 bed-days (odds ratio: 4.9; 95% CI: 2.3-10.3). Multilevel models demonstrated that 94% of the variation between facilities was unexplained after controlling for resident and CLC characteristics. The median odds ratio for the full multilevel model was 1.37., Conclusion: Potentially suboptimal UTI treatment was variable across VA LTCFs. However, most of the variation across LTCFs was unexplained. Future research should continue to investigate factors that are driving suboptimal antibiotic treatment in LTCFs., (Published by Elsevier Ltd.)

Background: Multidrug-resistant organisms (MDROs) spread between hospitals, nursing homes (NHs), and long-term acute care facilities (LTACs) via patient transfers. The Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County is a regional public health collaborative involving decolonization at 38 healthcare facilities selected based on their high degree of patient sharing. We report baseline MDRO prevalence in 21 NHs/LTACs., Methods: A random sample of 50 adults for 21 NHs/LTACs (18 NHs, 3 LTACs) were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum β-lactamase-producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, skin (axilla/groin), and peri-rectal swabs. Facility and resident characteristics associated with MDRO carriage were assessed using multivariable models clustering by person and facility., Results: Prevalence of MDROs was 65% in NHs and 80% in LTACs. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). CRE prevalence was higher in facilities that manage ventilated LTAC patients and NH residents (8% vs <1%, P < .001). MDRO status was known for 18% of NH residents and 49% of LTAC patients. MDRO-colonized adults commonly harbored additional MDROs (54% MDRO+ NH residents and 62% MDRO+ LTACs patients). History of MRSA (odds ratio [OR] = 1.7; confidence interval [CI]: 1.2, 2.4; P = .004), VRE (OR = 2.1; CI: 1.2, 3.8; P = .01), ESBL (OR = 1.6; CI: 1.1, 2.3; P = .03), and diabetes (OR = 1.3; CI: 1.0, 1.7; P = .03) were associated with any MDRO carriage., Conclusions: The majority of NH residents and LTAC patients harbor MDROs. MDRO status is frequently unknown to the facility. The high MDRO prevalence highlights the need for prevention efforts in NHs/LTACs as part of regional efforts to control MDRO spread., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature., Methods: We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged ≥60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively., Results: A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%., Conclusions: The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts.

Objectives: Fecal incontinence (FI) is a problem in growing older populations. Validating a suspected association between FI and mortality in community dwelling older adults could lead to improved planning for and management of the increasing complex older population. In a large cohort of New Zealand older adults, we assessed the prevalence of FI, urinary incontinence (UI), combined FI and UI, and their associations with mortality., Methods: This study consisted of a retrospective analysis of international standardized geriatric assessment-home care (InterRAI-HC) data from community-dwelling adults aged 65 years or older, who met the criteria required for the InterRAI-HC, having complex needs and being under consideration for residential care. The prevalence of UI and FI was analyzed. Data were adjusted for demography and 25 confounding factors. Mortality was the primary outcome measure., Results: The total cohort consisted of 41,932 older adults. Both UI and FI were associated with mortality (P<0.001), and risk of mortality increased with increased frequency of incontinence. In the adjusted model, FI remained significantly related to survival (P<0.001), whereas UI did not (P=0.31). Increased frequency of FI was associated with an increased likelihood of death (hazard ratio 1.28)., Conclusions: This large national study is the first study to prove a statistically significant relationship between FI and mortality in a large, old and functionally impaired community. These findings will help improve the management of increasingly complex older populations.

Background: While clinical trial data support decompressive hemicraniectomy (DHC) as improving survival among patients with severe ischemic stroke, quality of life outcomes among older persons remain controversial., Aims: To aid decision-making and understand practice variation, we measured long-term outcomes and patterns of regional variation for a nationwide cohort of ischemic stroke patients after DHC., Methods: Medicare fee-for-service ischemic stroke cases over age 65 during the year 2008 were used to create a cohort followed for 2 years (2009-2010) after stroke and DHC procedure. Rates of mortality, acute hospital readmission, and long-term care (LTC) utilization were calculated. Multiple logistic regression was used to identify individual predictors of institutional LTC. Regional variation in DHC was calculated through aggregation and merging with the state-level data., Results: Among 397,503 acute ischemic stroke patients, 130 (0.03 %) underwent DHC. Mean age was 72 years, and 75 % were between the ages of 65 and 74. Mortality was highest (38 %) within the first 30 days. At 2 years, 59 % of the original cohort had died. The 30-day rate of acute hospital readmission was 25 %. Among survivors, 75 % returned home 1 year after index stroke admission. States with higher per capita health expenditures were associated with wider variation in utilization of DHC., Conclusions: There is a high rate of mortality among older stroke patients undergoing DHC. Although most survivors of DHC are not permanently institutionalized, there is wide variation in utilization of DHC across the USA.

Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objective: To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states' Medicaid long-term care policies., Data Sources/collection: We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009., Study Design: We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending., Principal Findings: Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps., Conclusions: Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid., (© Health Research and Educational Trust.)

Purpose of the Study: To examine how Medicaid capital reimbursement policy is associated with nursing homes (NHs) having high proportions of private rooms and small households., Design and Methods: Through a 2009/2010 NH national survey, we identified NHs having small households and high proportions of private rooms (≥76%). A survey of state Medicaid officials and policy document review provided 2009 policy data. Facility- and county-level covariates were from Online Survey, Certification and Reporting, the Area Resource File, and aggregated resident assessment data (minimum data set). The policy of interest was the presence of traditional versus fair rental capital reimbursement policy. Average Medicaid per diem rates and the presence of NH pay-for-performance (p4p) reimbursement were also examined. A total of 1,665 NHs in 40 states were included. Multivariate logistic regression analyses (with clustering on states) were used., Results: In multivariate models, Medicaid capital reimbursement policy was not significantly associated with either outcome. However, there was a significantly greater likelihood of NHs having many private rooms when states had higher Medicaid rates (per $10 increment; adjusted odds ratio [AOR] 1.13; 95% CI 1.049, 1.228), and in states with versus without p4p (AOR 1.78; 95% CI 1.045, 3.036). Also, in states with p4p NHs had a greater likelihood of having small households (AOR 1.78; 95% CI 1.045, 3.0636)., Implications: Higher NH Medicaid rates and reimbursement incentives may contribute to a higher presence of 2 important environmental artifacts of culture change-an abundance of private rooms and small households. However, longitudinal research examining policy change is needed to establish the cause and effect of the associations observed.

In China, formal long-term care services for the large aging population have increased to meet escalating demands as demographic shifts and socioeconomic changes have eroded traditional elder care. We analyze China's evolving long-term care landscape and trace major government policies and private-sector initiatives shaping it. Although home and community-based services remain spotty, institutional care is booming with little regulatory oversight. Chinese policy makers face mounting challenges overseeing the rapidly growing residential care sector, given the tension arising from policy inducements to further institutional growth, a weak regulatory framework, and the lack of enforcement capacity. We recommend addressing the following pressing policy issues: building a balanced system of services and avoiding an "institutional bias" that promotes rapid growth of elder care institutions over home or community-based care; strengthening regulatory oversight and quality assurance with information systems; and prioritizing education and training initiatives to grow a professionalized long-term care workforce.

Deficiencies in current long-term care (LTC) financing models are substantial and must be addressed if the nation is going to meet the needs of the growing population of frail and disabled elders. Because debate over reforming LTC financing has traditionally focused on the relative roles of the public and private sectors, this article examines what characteristics predispose LTC specialists to weigh one approach--public or private--more than the other. Data are derived from a Web-based survey of 1,147 individuals with known or demonstrable experience with LTC, including consumer advocates, provider representatives, policy experts, and public officials. Results suggest that support for spurring private sector mechanisms, bolstering the government's role, and reforming Medicare and Medicaid vary with key characteristics of the respondents, including experiential, attitudinal, and background variables. Findings also suggest consensus that reform of LTC financing should improve on the current public-private partnership in this area.

Concerns about the quality of long-term care have resulted in an extensive array of regulations governing provider behavior. This article reports the results of a survey of 1,147 long-term care specialists on issues related to the government's performance in assuring quality and improving care. With the exception of providers, more than half of specialists ranked the quality of the average nursing home as fair or poor; home health agencies and even assisted-living facilities fared only somewhat better. Yet despite the perceived ineffectiveness of the current regime, the majority of specialists expressed a general willingness to continue pursuing more stringent and enhanced enforcement and to proceed down the same path with assisted-living facilities. Furthermore, while most were not sanguine about public reporting, the majority favored pay-for-performance, even though both rely on the same information. In addition to constituency group affiliation, differences in views derived largely from respondents' ideological predispositions.

A significant rebalancing of the long-term care system away from nursing homes toward home- and community-based services (HCBS) has occurred over the past two decades. This article reports the results of the Commonwealth Fund Long-Term Care Opinion Leader Survey (N = 1,147) on issues related to supporting HCBS. Respondents expressed strong enthusiasm for rebalancing of the long-term care system toward HCBS. In particular, respondents supported system-based approaches for this expansion, with the majority indicating that greater care coordination was the single most preferred approach for rebalancing the system, helping consumers make informed long-term care choices, and supporting caregivers. Building on the long-term care specialists' enthusiasm for system-based reforms, we encourage state policy makers to pursue HCBS models that are linked to Medicare, engage primary care physicians, and are based on rigorous evaluations.

A decade-long grassroots movement aims to deinstitutionalize nursing home (NH) environments and individualize care. Coined "NH Culture Change" the movement is often described by its resident-centered/directed care focus. While empirical data of "culture change's" costs and benefits are limited, it is broadly viewed as beneficial and widely promoted. Still, debate abounds regarding barriers to its adoption. We used data from a Web-based survey of 1,147 long-term care specialists (including NH and other providers, consumers/advocates, state and federal government officials, university/academic, researchers/consultants, and others) to better understand factors associated with perceived barriers. Long-term care specialists view the number-one barrier to adoption differently depending on their employment, familiarity with culture change, and their underlying policy views. To promote adoption, research and broad-based educational efforts are needed to influence views and perceptions. Fundamental changes in the regulatory process together with targeted regulatory changes and payment incentives may also be needed.

A challenge in the adoption of long-term care (LTC) policy reform is the number of constituency groups active in LTC and historical antagonism among these groups regarding critical issues such as LTC financing and regulation. As part of a national survey of LTC specialists, the authors asked previously identified specialists to nominate other "experts" with known or demonstrable experience in LTC. As a proxy for potential information exchange, data about nominations were used to construct and describe the networks of LTC specialists representing consumer advocates, provider representatives, public officials, policy experts, and others. Associations between network characteristics and attitudes about LTC policy reform were also examined. Individuals tended to nominate other people within their same constituency group as experts. Academic and research-based policy experts were most likely to be classified as prominent network members. Network structure was associated with attitudes toward LTC financing but not the regulation of nursing homes.

Purpose: Theories of the policy process recognize that policy proposals are typically generated, debated, redrafted, and accepted for consideration through the gradual accumulation of knowledge within communities of specialists. Thus, to inform long-term care (LTC) reform efforts, we conducted a Web-based survey of 1,147 LTC specialists nationwide., Design and Methods: Survey respondents included consumer advocates, provider representatives, public officials, policy experts, and others with experience in LTC. Administration took place between September 2007 and March 2008 and addressed prevailing challenges and options for reform., Results: Although differences could be discerned, constituency group views converged in several areas. There was general agreement that LTC financing needed to be socialized more and that impediments to organizational change needed to be overcome. Respondents also felt that LTC needed to be rebalanced toward home- and community-based settings, though few supported doing so by limiting nursing home (NH) bed supply. Although virtually all felt that the federal government was doing a poor job regulating LTC providers, most believed that the approaches used to oversee NHs should also be applied to assisted living. Payment incentives were highlighted as the most effective strategy for improving quality even though it suffers from the same informational deficits compromising consumer reporting., Implications: By giving voice to those who know LTC very well, and identifying areas of agreement and disagreement, this study should prove useful in promoting LTC reform where it might otherwise remain politically intransigent.

The proportion of Hispanics age sixty-five and older who are living in nursing homes rose from 5 percent in 2000 to 6.4 percent in 2005. Although segregation in nursing homes seems to have declined slightly, elderly Hispanics are more likely than their non-Hispanic white peers to reside in nursing homes that are characterized by severe deficiencies in performance, understaffing, and poor care.

Marginalization of physicians in the nursing home threatens the overall care of increasingly frail nursing home residents who have medically complex illnesses. The authors propose that creating a nursing home medicine specialty, which recognizes the nursing home as a unique practice site, would go a long way toward remedying existing problems with care in skilled nursing facilities and would best serve the needs of the 1.6 million nursing home residents in the United States. Reviewing what is known about physician practice in nursing homes and hospitals, and taking a lead from the hospitalist movement, the specialty would be characterized in 3 dimensions: the degree of physicians' commitment, physicians' practice competencies, and the structure of the medical staff organization in which they practice. Challenges to the adoption of a nursing home specialist model include mainstream medicine's failure to recognize the nursing home as a legitimate medical practice, the need for the nursing home industry and policymakers to appreciate the links between physician practice and quality, and assurance of financial viability. Implications for quality of care, health policy, and research needs are discussed in this article.

Informal caregivers face difficulties navigating the services and funding sources that constitute long-term care. Indeed, barriers to identifying and accessing even the most basic resources compound the sense of isolation felt by millions of unpaid individuals who provide the bulk of long-term care. Though expansion of home- and community-based options is welcomed, it may also shift additional caregiving burden onto an already overburdened informal care system, especially when the intention is to delay or substitute for institutional care. This essay argues that growing government emphasis on rebalancing long-term care away from nursing homes will founder unless public officials recognize increased burdens on the informal care system.

Aims: This study reports findings from the first national survey of long-term care opinion leaders in New Zealand., Methods: Potential respondents were chosen purposively based on their knowledge and experience in long-term care policy and planning. Questions focused on assessing views regarding long-term care quality, financing, services, workforce, organisation, and regulation. The survey was administered via Web-based format during May-June 2007. Seventy-three individuals responded for an overall response rate of 47.7%., Results: Experts support cost-sharing, insurance, and individual savings/preparation as supplements to predominately government-based financing. They view increased compensation and improved work environments as the key to recruiting/retaining paraprofessionals and educational assistance and curriculum reform as the key to attracting professionals. Most would expand access to home-based support through adoption of comprehensive service packages and various navigational aides (e.g. care coordination, counselling). Consumer-direction and public payment of family members were also deemed desirable. There was a lack of knowledge regarding emerging models of culture change/client-centred care in long-term care. Promoting quality by advising providers about how to improve quality and increasing public availability of comparative provider information was highlighted., Conclusions: There are varying degrees of consensus regarding the kinds of solutions to long-term care problems that are viable from a policy perspective. Results should help determine how best to improve the current system to meet the needs of the growing elderly population.

While nursing homes were insulated from civil-rights enforcement at the time of the implementation of the Medicare program and lagged behind other parts of the health sector in providing comparable access to minorities, they are the only providers for which current reporting requirements make it possible to fully assess racial disparities in use and quality of care. We find that African Americans' use of nursing homes in 2000 in the United States was 14 percent higher than Caucasians' use. The largest relative African American use of nursing homes in 2000 took place in the South and West. Average nursing-home case-mix acuity for African Americans and Caucasians were essentially identical, suggesting that shifts in payment incentives have eliminated the selective admission of easy-care private-pay (predominantly Caucasian) patients and helped fuel the growth of private pay home care and assisted living for this segment of the population. While these shifts in incentives helped increase the use of nursing homes by African Americans, a high degree of segregation and disparity in the quality of the nursing homes used by African Americans persists. Parity in use is an illusive benchmark for measuring progress in assuring equity in treatment.

Government oversight of long-term care involves inspections of patients' records, limited observations of patients and care practices, reviews of policies and procedures, and distribution of publicly available information. Although many providers bemoan the stifling consequences of excessive regulation, oversight in this area remains a highly legitimate endeavor for the public, though the public has limited trust in the existing regulatory regime. This distrust stems from many sources, not least of which includes considerable variation, both within and across states, in the way government oversight occurs. Reforming the current regulatory structure requires that we regulate "smarter" and more consistently. This means improving and maximizing use of the data already being collected, but it also means explicitly rationalizing the regulator's responsibility to review performance and apply sanctions when necessary. Oversight should more closely resemble consultancy, with regulators sharing information with providers about how to improve quality. Ideally, there needs to be an iterative process in which state inspectors identify performance problems and the nation's quality improvement organizations then help providers design quality improvement interventions to ameliorate the problems identified. The benefits of a revised regulatory approach are especially apparent in the aftermath of Hurricane Katrina, where more effective oversight would have identified nursing home residents at risk for low-quality care before the disaster occurred while better identifying those in need of evacuation or assistance afterward.

Background: The proliferation of noninstitutional long-term care (LTC) alternatives, particularly assisted living (AL), raises questions about how the nursing home (NH) industry is affected. Dementia special care units (SCUs), which provided NHs a competitive edge in the past, are of interest because they have traditionally served residents who now have other options., Objectives: To quantify the effect of LTC competition on the odds of SCU presence in a NH; among those NHs with an SCU, to quantify the effect of competition on overall acuity., Research Design: Cross-sectional with LTC market defined as the NH's county., Subjects: Nine hundred forty-two NHs, 88 with an SCU, in 122 Texas counties during 2004., Measures: LTC competition was measured by a NH's share of beds, the presence of another NH SCU, the presence of AL, the presence of dementia care in AL, and the presence of home health in the market. The outcomes were the presence of an SCU in a NH and the average level of resident acuity on those SCUs., Results: Competition from another NH-based SCU was associated with the presence of an SCU in a NH [adjusted odds ratio, 3.3; 95% confidence interval (CI), 1.6-6.6] but there were no associations with other measures. Within NH-based SCUs, mean acuity was higher when there was AL in the market (beta, 1.6; 95% CI, 0.4-2.7), but there was no additional effect of AL dementia beds (beta, 1.6; 95% CI, 0.2-3.0)., Conclusions: A NH's investment in specialized dementia care is influenced by the behavior of nearby NHs but not yet by other forms of LTC; however, the profile of residents served by SCUs is affected by AL competition.

The US health care industry increasingly agrees that sharing information about quality of care is necessary to stimulate providers' efforts to improve the quality of health care. The availability of mandated, uniform clinical data in all nursing homes and home health agencies has facilitated the rapid adoption of public reporting of comparative quality data. This paper examines the conceptual and technical challenges underlying the application of information about long-term care provider quality to judge and compare the quality of care provided by nursing homes and home health agencies. In general, the impetus to apply the emerging set of quality "tools" based on mandated clinical assessments may have outstripped the evidence for their valid application in selecting top providers or for rewarding their superior performance.

Objectives: To examine the association between having a nurse practitioner/physician assistant (NP/PA) on staff, other nursing home (NH) characteristics, and the rate of potentially preventable/avoidable hospitalizations of long-stay residents, as defined using a list of ambulatory care-sensitive (ACS) diagnoses., Design: Cross-sectional prospective study using Minimum Data Set (MDS) assessments, Centers for Medicare and Medicaid Services inpatient claims and eligibility records, On-line Survey Certification Automated Records, (OSCAR) and Area Resource File (ARP)., Setting: Freestanding urban NHs in Maine, Kansas, New York, and South Dakota., Participants: Residents of 663 facilities with a quarterly or annual MDS assessment in the 2nd quarter of 1997, who had a prior MDS assessment at least 160 days before, and who were not health maintenance organization members throughout 1997 (N=54,631)., Measurements: A 180-day multinomial outcome was defined as having any hospitalization with primary ACS diagnosis, otherwise having been hospitalized, otherwise died, and otherwise remained in the facility., Results: Multilevel models show that facilities with NP/PAs were associated with lower hospitalization rates for ACS conditions (adjusted odds ratio (AOR)=0.83), but not with other hospitalizations. Facilities with more physicians were associated with higher ACS hospitalizations (ACS, AOR=1.14, and non-ACS, AOR=1.10). Facilities providing intravenous therapy, and those that operate a nurses' aide training program were associated with fewer hospitalizations of both types., Conclusion: Employment of NP/PAs in NHs, the provision of intravenous therapy, and the operation of certified nurse assistant training programs appear to reduce ACS hospitalizations, and may be feasible cost-saving policy interventions.

We summarize work done to identify and evaluate existing quality indicators (QIs) for long-term care (LTC) settings. Indicators operationally defined using routinely collected and computerized patient assessments were identified and then aggregated to characterize the performance of the nursing facility over a specific period of time. Of 143 indicators reviewed, only 22 were recommended for use in comparing performance across facilities. Conceptual and technical issues influence the appropriateness of QIs for different audiences.

In the 1990s, acute care hospitals in the United States encountered an unstable operating environment created by a series of transformations in the health care delivery system and long-term-care market. Confronted with an array of economic pressures and demographic changes, hospitals were motivated to engage in long-term-care diversification, such as establishing a long-term-care unit or providing home health services, as a means of entering new markets and ensuring financial stability. This article examines the organizational, market, and community factors associated with this strategic activity among a national sample of urban and rural hospitals.

The majority of patients with diabetes are elderly, but little is known about their disease management. This study evaluates the prevalence and correlates of treatment of elderly diabetics residing in long-term care. We performed a retrospective, cross-sectional study of 75,829 elderly diabetics residing in nursing homes from 1992 to 1996. Nearly half (47%) of the residents received no antidiabetic medications. Independent predictors not receiving antidiabetic medications included age, race, impaired physical ability, and impaired cognitive function. Although the absence of resident's blood glucose or glycosylated hemoglobin (HbA1c) values prevents us from passing judgment about the adequacy of diabetic care, further research is needed to understand why some residents do not receive antidiabetic medications in the long-term care setting.

Background: Increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail., Methods: Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model., Results: The mean age of the population was 84.9 +/- 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the facilities., Conclusions: Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors varies significantly across facilities and depends on organizational characteristics.

Background: Because there is a lack of databases specific to long-term care, standardized assessments of nursing home residents are seen as a potential new resource for studying an important but neglected population. We describe the design and principal population characteristics of the first integrated database combining detailed clinical information and administrative claims data., Methods: We studied nearly 300,000 residents admitted between 1992 and 1994 to all Medicare/Medicaid certified nursing homes of five U.S. states (Kansas, Maine, Mississippi, New York, and South Dakota). The database crosslinks: (a) Resident Data: over 350 items (demographic, diagnostic, clinical, and treatments) collected with the Minimum Data Set; (b) Drug Data: brand name, dosage route, and frequency of administration for all drugs consumed by each resident; (c) Medicare Data: eligibility and inpatient hospital claims; (d) Facilities Data: structural and staffing information on nursing homes; and (e) Country Data: information on population, health professions and facility data, and economic parameters., Results: Ninety-two percent of the residents were aged 65 years and older. Residents were predominantly white (85%) and female (72%). The average number of medical diagnoses was above three, and residents were receiving an average of six medications. Sixty-five percent of residents had at least one hospital claim following the initial assessment, most commonly related to cardiovascular diseases and metabolic disorders. Fifty-five percent of the facilities were for-profit and 33% were of small size. Quality indicators and staffing level varied significantly by state., Conclusions: The SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) database provides a unique resource to study the relation between treatments received and outcomes experienced, particularly functional and health services outcomes, that have not been possible before in very old, frail people.

Cognitive impairment is associated with an increased mortality in older people. The prevalence and impact of comorbidity on functional status and mortality of demented patients has not been fully elucidated. Using a population-based data set, we describe the prevalence of cognitive impairment, functional status, principal comorbid conditions and 1-year survival for over 300,000 patients admitted to the nursing homes in five US states. Sixty-one percent of patients have some level of cognitive impairment, and this correlates with the degree of physical frailty. Severer cognitive impairment is associated with a higher mortality rate. Yet, patients with cognitive impairment appear to have fewer comorbid conditions and are less likely to receive medications and special treatments than residents with normal cognitive status. Additional studies are needed to understand whether demented patients may paradoxically be considered healthier or, instead, are only neglected.

Recent increases in the types of services offered by nursing facilities and in the formation of specialized care units have resulted in the emergence of two distinct but broadly defined types of services: subacute and long-term care. The authors examine the market, regulatory, and structural incentives behind diversification and specialization and speculate how these trends will affect the future of the nursing home industry.