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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

This study uses a longitudinal California data set (1995 to 2000) to address two concerns about Medicaid nursing facility (NF) utilization. First, to consider the impact of national cost-control policies, the authors analyze data trends in Medicaid NF participants, days of care, and expenditures. Second, the authors investigate the percentage of Medicaid days of care (%MDOC) using a panel regression model to consider resident, facility, and county market predictors. The findings show that although statewide Medicaid NF participants, expenditures, and %MDOC remain stable, Medicaid market segmentation persistes, with program participants distributed unevenly among facilities. Factors associated positively with facility %MDOC are the proportion of minority residents, a larger facility size, for-profit status, the percentage of aged Black persons in the county, and market concentration. The factors associated negatively with %MDOC are the percentages of resident men, residents aged 85 or older, residents with Alzheimer's disease, Medicaid reimbursement rates, and county wealth. Keywords: nursing homes; access; Medicaid: policy

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

Long Term Care Ombudsman Complaint data from one state's 261 nursing homes are examined in the study. We assessed differences between male and female groups, including chiefly residents, but also ombudsmen, the residents' relatives or friends, administrators, legal representatives, and others regarding types and rates of complaints as reported in the Administration on Aging (AoA) major categories of: Resident Care, Resident Rights, Administration, Quality of Life, and Complaints Not Against Facility. Proportionately, male residents lodged more complaints than females. Further, males complained more than females about Resident Rights violations and filed more Complaints Not Against Facility. Females lodged significantly more complaints about Care, Quality of Life and Administration. Thus, males were more likely to report technical, impersonal, and legalistic issues, than females, who were more likely to express concerns about personal care and socioemotional-environmental issues. Results yielded further evidence of gender differences in the patterns of resident complaints. Nursing home social workers are highlighted as agents in changing embedded stereotypes about residents and complaints. KEYWORDS. Nursing home complaints, gender, long term care ombudsman program

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.

This purpose of this exploratory study is to describe the education, responsibilities, and knowledge of social service workers in skilled nursing facilities. The study used a stratified random sample for structured telephone interviews of 108 social service workers in Missouri. The data indicate that 16% of respondents have a graduate degree, 46% a bachelor's degree, and the remaining 38% have no college degree. Results show that 11% of facilities with more than 120 beds were out of compliance with OBRA requirements for a 'qualified' social service staff person, while the credentials of 35% of facilities with less than 120 beds exceeded the credential requirements. Social service staff report their responsibilities include facilitating the social and psychological well being of residents, discharge planning, the admission process, and care planning, The findings have implications for policy makers as consideration is given to the mental health needs of nursing home residents and for social work educators preparing students for gerontological practice. KEYWORDS. Nursing homes, social services, social workers, policy, practice, survey research, gerontology

While much of the gerontological literature emphasizes the institutionalization of an older adult as an endpoint of family care, research has emerged illustrating the continued involvement of family members in the lives of residents. The purpose of the present study was to determine how resident setting, family context, resident background, staff background, and resident function influence the provision of family involvement in three long-term care environments: nursing homes, assisted living facilities, and family care homes. Five nursing homes, five assisted living facilities, and 16 family care homes and residents (N = 112) in the state of Kentucky were randomly selected. Results showed that type of facility was less important in accounting for different dimensions of family involvement than family context, family orientation of facilities, or resident need. The findings demonstrate the complex process of family involvement across the long-term care landscape, and have several research and practice implications for the facilitation of family integration in residential long-term care. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: [C] 2003 by The Haworth Press, Inc. All rights reserved] KEYWORDS. Assisted living, nursing homes, adult foster care, family caregiving, family involvement, long-term care, family orientation, visits, informal care, long-term care continuum

Since the Patient Self-Determination Act became law in 1991, nursing homes routinely address advance directives with all residents. This study investigated the implementation of end-of-life care wishes of residents in one nursing home in Florida. Data were collected from the medical records of residents who died in the facility (n = 75) in one year. Two-thirds of the residents had either completed a living will, or designated a health care decision-maker, and 90.7% of the residents had do-not-resuscitate orders. Findings suggest that in 94% of the cases advance directives were followed, and that professional social work activities contributed to the high rate of compliance. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: [C] 2003 by The Haworth Press, Inc. All rights reserved.] KEYWORDS. Advance directives, nursing home, autonomous decision-making

Factors influencing the willingness to enter a nursing home were examined among Holocaust survivors (N = 94) and elderly persons who did not experience the Holocaust (N = 74). No differences were found between the groups regarding their willingness to enter a nursing home. Attitudes toward nursing homes were the main factor influencing the decision-making process for both groups. Income was an additional factor for Holocaust survivors, while living situation and education were additional factors for the other group. Holocaust survivors who tried to avoid memories of the Holocaust, were less willing to enter a nursing home, than survivors who made less of an effort to avoid such memories. KEYWORDS. Holocaust survivors, nursing homes, attitudes

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.