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The Minimum Data Set (MDS) is a standardized assessment that is completed on all residents admitted to Medicare certified nursing homes in the US. It is also completed on all residents admitted to Veteran Health Administration Community Living Centers. Its content addresses multiple domains of resident health and function and is intended to facilitate better recognition of each resident's needs. A new version of the MDS, MDS 3.0, was implemented in October, 2010. This article highlights significant clinical changes found in the MDS 3.0, including new structured resident interviews to assess mood, preferences, pain and cognition; inclusion of the Confusion Assessment Method to screen for delirium; revised psychosis and behavior items; revised balance and falls sections; revised bladder and bowel assessment items; revised pressure ulcer assessment items; revisions to the nutrition items; items reporting on resident expectations for return to the community; and changes to race/ethnicity item and language report. These changes aim to improve the clinical utility of these assessment items.

Objectives: To examine the independent association between five stages of activities of daily living (ADLs) and mortality after accounting for known diagnostic and sociodemographic risk factors. Design: For five stages of ADLs (0 to IV), determined according to the severity and pattern of ADL limitations, unadjusted life expectancies and adjusted associations with mortality were estimated using a Cox proportional hazards regression model. Setting: Community. Participants: Nine thousand four hundred forty-seven participants aged 70 and older from the second Longitudinal Study of Aging. Measurements: One-, 5-, and 10-year survival and time to death. Results: Median life expectancy was 10.6 years for participants with no ADL limitations and 6.5, 5.1, 3.8, and 1.6 years for those at ADL stages I, II, III, and IV, respectively. The sociodemographic- and diagnostic-adjusted hazard of death at 1 year was five times as great at stage IV as at stage 0 (hazard ratio = 5.6, 95% confidence interval = 3.8�8.3). The associations between ADL stage and mortality declined over time but remained statistically significant at 5 and 10 years. Conclusion: ADL stage continued to explain mortality risk after adjusting for known risk factors including advanced age, stroke, and cancer. ADL stages might aid clinical care planning and policy as a powerful prognostic indicator particularly of short-term mortality, improving on current ADL measures by profiling activity limitations of relevance to determining community support needs.

To determine if the combined effects of patient-level (demographic and clinical characteristics) and organizational-level (structure and strategies to improve access) factors are uniformly associated with utilization of Indian Health Service (IHS) and/or Veterans Health Administration (VHA) by American Indian and Alaska Native (AIAN) Veterans to inform policy which promotes dual use.We estimated correlates and compared two separate multilevel logistic regression models of VHA-IHS dual versus IHS-only and VHA-IHS dual versus VHA-only in a sample of 18,892 AIAN Veterans receiving care at 201 VHA and IHS facilities during FY02 and FY03. Demographic, diagnostic, eligibility, and utilization data were drawn from administrative records. A survey of VHA and IHS facilities defined availability of services and strategies to enhance access to healthcare for AIAN Veterans.Facility level strategies that are generally associated with enhancing access to healthcare (e.g., population-based services and programs, transportation or co-location) were not significant factors associated with dual use. In both models the common variable of dual use was related to medical need, defined as the number of diagnoses per patient. Other significant demographic, medical need and organizational factors operated in opposing manners. For instance, age increased the likelihood of dual use versus IHS-only but decreased the likelihood of dual use versus VHA-only.Efforts to enhance access through population-based and consumer-driven strategies may add value but be less important to utilization than availability of healthcare resources needed by this population. Sharing health records and co-management strategies would improve quality of care while policies allow and promote dual use.

OBJECTIVES: To determine whether the VulnerableElders Survey (VES)-13, a survey based on functional statusthat has been validated in uninjured older populations, willpredict complications and mortality in injured older adults.DESIGN: Prospective observational pilot study.SETTING: Level 1 trauma center.PARTICIPANTS: Sixty-three older adults ( 65) with atraumatic injury who survived and required inpatient carefor at least 24 hours.MEASUREMENTS: Predictor: preinjury VES-13 score(0–10 points, higher5greater risk) obtained by interview-ing participants or proxies. Outcomes: composite outcomeof one or more medical complications (e.g., aspirationpneumonia, respiratory failure) or death, discharge desti-nation(home, nursing home, death), length ofstay, hospitalcharges. Covariates: Charlson Comorbidity Index (CCI),Injury Severity Score (ISS), and sex.RESULTS: Of the 63 participants, 30 (48%) were dis-charged to home and 28 (44%) to a nursing facility, 21(33%) developed one or more complications, and four (6%)died.InamodelthatalsocontrolledforISSandcomorbidity,each additional VES-13 point was associated with greaterrisk of complication or death (odds ratio51.53 per point,95% confidence interval 51.12–2.07).CONCLUSION: The VES-13, in combination with injuryseverity,maybeusefulearlyinthehospitalcoursetopredictcomplications and death in older adults with traumaticinjury, potentially identifying candidates who may benefitfrom additional inpatient geriatric services. J Am GeriatrSoc 59:1471–1476, 2011.Key words: trauma; acute surgical care; functional status

Purpose: The Medicare Consumer Assessments of Healthcare Providers and Systems (MCAHPS) survey, a primarily English-language mail survey with English and Spanish telephone follow-up, is the primary means of assessing the health care experiences of American seniors. We examine unit (whole survey) and item nonresponse for this survey to explore issues regarding surveying seniors about their health care. Design and Methods: We describe overall rates and analyze predictors of unit and item nonresponse for the 695,197 Medicare benefi ciaries selected for the 2007 MCAHPS survey (335,249 unit respondents, 49% overall response rate). Results: Asians, African Americans, and Hispanics responded at adjusted response rates 7–17 percentage points lower than non-Hispanic Whites (p < .001 for each). Among seniors, response rates dropped beyond age 75. Asians and older beneficiaries were especially likely to respond by mail, and African Americans and Hispanics by phone. Breakoff from telephone surveys was most common among African Americans and older respondents. Among respondents, older age was the strongest predictor of item missingness (e.g., those 85 years and older failed to answer items at twice the rate of those aged 65–74 years, p < .001). Non-Hispanic Whites had lower rates of item missingness than other racial/ ethnic groups (p < .001 for each; one-third lower than African Americans). Implications: Survey research on older adults, especially regarding racial/ethnic disparities in health care, could benefit from improved response rates. These results suggest that targeted prenotification materials and campaigns, tailored follow-up, targeted Spanish mailings, Chinese translations/calls, and adjustments to telephone protocols may improve representation and response.

OBJECTIVE: To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older. DESIGN: Cross-sectional. SETTING: Community. PARTICIPANTS: Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II). MEASUREMENTS: Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV). RESULTS: ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI)=2.4�4.4) to 41.9 (95% CI=19.6�89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR=17.8, 95% CI=13.0�24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race. CONCLUSIONS: ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features.

OBJECTIVES: To identify the potentially modifiable resident-level factors associated with rejection of care in nursing home (NH) residents. DESIGN: Secondary analysis of a 3.0 national field test to revise the Minimum Data Set (MDS). SETTING: Seventy-one NHs in eight states. PARTICIPANTS: Three thousand two hundred thirty NH residents scheduled for MDS assessments from September 2006 through February 2007. MEASUREMENTS: The potentially mutable characteristics assessed were mood (Patient Health Questionnaire-9), delirium (Confusion Assessment Method), delusions, hallucinations or illusions, hearing impairment, vision impairment, pain severity, and infection diagnoses. Characteristics considered as covariates were cognition, communication abilities, and impairment in activities of daily living. RESULTS: Of 3,230 residents assessed, 312 (9.7%) had demonstrated rejection of care in the preceding 5 days. In multiple regression analysis adjusted for covariates, rejection of care was associated with delusions (odds ratio (OR)=3.9; 95% confidence interval (CI)=2.5–6.0), delirium (OR=1.8, 95% CI=1.3–2.4), minor (OR=2.1, 95% CI=1.5–2.8) and major (OR=2.3, 95% CI=1.5–3.4) depression, and severe to horrible pain (OR=1.6, 95% CI=1.1–2.3). Infection diagnoses were not significant in bivariate analysis. Hallucinations or illusions, mild to moderate pain, and hearing and vision impairment were not significant in multiple regression analysis. CONCLUSION: In this population, delirium, delusions, depression, and severe pain were associated with rejection of care, suggesting that some care rejection behaviors may resolve with appropriate interventions for the identified target conditions if the associations observed are causal.

In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced 3 new quality measures (QMs) to its report card, Nursing Home Compare (NHC). These measures—rehospitalizations, emergency department visits, and successful discharges to the community—focus on short-stay residents. We offer a first analysis of nursing homes’ performance in terms of these new measures. We examined their properties and distribution across nursing homes using descriptive statistics and regression models. We found that, similar to other QMs, performance varies across the country, and that there is very minimal correlation between these 3 new QMs as well as between these QMs and other NHC QMs. Regression models reveal that better performance on these QMs tends to be associated with fewer deficiencies, higher staffing and more skilled staffing, nonprofit ownership, and lower proportion of Medicaid residents. Other characteristics are associated with better performance for some but not all 3 QMs. We also found improvement in all 3 QMs in the second year of publication. This study contributes to the validity of these measures by demonstrating their relationship to these structural QMs. It also suggests that these QMs are important by demonstrating their large variation across the country, suggesting substantial room for improvement, and finding that nursing homes are already responding to the incentives created by publication of these QMs.

Patients and families frequently turn to healthcare providers and health researchers for advice about insurance plans and healthcare related purchases. While these questions occur throughout the year, they are more frequent during the annual Medicare Open enrollment period which this year runs from October 15, 2017 to December 7, 2017. During this period, eligible individuals may enroll in or change their Medicare Part D plan and enroll in or change their Medicare Advantage plan (Medicare part C). This article is protected by copyright. All rights reserved.

The Veterans Health Administration (VHA) and Indian Health Service (IHS) have executed an agreement to share resources to improve access and health outcomes for American Indian and Alaska Native (AIAN) veterans.To describe the extent of dual use, health needs, and utilization patterns for IHS-enrollees served by VHA and IHS. Our objective is to fill those gaps in knowledge to inform strategic planning between these federal agencies.Secondary data analysis of linked and merged VHA and IHS centralized administrative data from FY02 and FY03.Of 64,746 IHS enrollees who used VHA and/or IHS, 25% accessed care at both healthcare organizations, whereas most used either the VHA (28%) or the IHS (46%). The proportion of dual users varied markedly by state. Like all other VHA users, these AIAN veterans have the same 3 most frequent diagnoses associated with healthcare encounters: posttraumatic stress disorder, hypertension, and diabetes. VHA-IHS dual users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VHA. Many dual users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping attention in VHA and IHS.Strategies to improve outcomes for AIAN veterans should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Strategies to improve access may differ regionally.

Assessing and improving the quality of care for chronically ill older individuals living in institutional settings is increasingly important in the United States. Members of a growing frail older population reliant on publicly funded healthcare, often unable to speak for themselves, must be ensured to receive the care they need. Although the assessment of quality of care uses 3 types of measures–structure, process, and outcome1– historically, the national measurement of the quality of care delivered to nursing home residents has focused on facility-level measures of structure (eg, facility size, ownership, and staffing) and outcomes (eg, risk-adjusted adverse events). The Centers for Medicare and Medicaid Services use the minimum data set (MDS) to estimate and report on complication rates (eg, falls, fractures, and pressure ulcers) and prevalence of worsening patient status (eg, increasing need for ADL assistance).2,3 Centers for Medicare and Medicaid Services also maintains the Online Survey, Certification, and Reporting database, which reports on nursing home characteristics and the health deficiencies issued by government inspectors during state surveys, broken out into 8 types of deficiencies in structure, process, and outcome occurring within the facility.3 In contrast, structured measurement of the delivery of specific processes of care is not generally performed at either the level of the individual or of the nursing home.4 Efforts to measure the processes of care provided to older adults have been challenged by the lack of measures aimed at this population and difficulty with measurement.4–6 The Assessing Care of Vulnerable Elders (ACOVE) set of quality indicators (QIs) was developed to measure processes of care delivered to vulnerable older patients.7,8 QIs developed for community-dwelling geriatric patients were validated for use with administrative data,9 and have been used to evaluate the care of a population of community-dwelling elders dually enrolled in Medicare and Medicaid.10 Because QIs developed for a community-dwelling population might not directly be applicable for a nursing home (NH) population, a structured process was used to create a separate set of NH specific QIs for care provided to NH residents.5,6,11 Experts in NH care identified these measures as valid for assessing quality. These NH QIs were developed to be measured by a combination of direct interview, chart review, and direct observation, but have not been adapted for use with secondary data sources. The goals of the current study were to adapt the ACOVE NH QIs for use with routinely collected data, evaluate which clinical conditions and types of care were inadequately measured using these data sources, and describe the quality of care received by a population of NH patients. QIs were modified for use with Medicare and Medicaid fee-for-service claims and the MDS. Characteristics of implemented and nonimplemented QIs were compared by condition and type of intervention. Care delivered to NH residents dually enrolled in Medicaid and Medicare in 19 California counties during a 2-year period, 1999 to 2000, was evaluated by individual quality indictor, by clinical condition, and by type of intervention.

Background Many American Indian and Alaska Native (AIAN) women serve in the military and are eligible for healthcare from both the Veterans Health Administration (VHA) and the Indian Health Service (IHS). Little was known about these women's patterns of health care utilization when VHA and IHS executed a resource-sharing agreement in 2003 to improve access and health outcomes. Objective We sought to describe women's healthcare utilization in VHA and IHS. Methods We conducted a descriptive secondary data analysis of linked IHS and VHA administrative records from fiscal years 2002 and 2003 for women among all IHS beneficiaries who were veterans or used VHA for health care (n = 64,746). Results Among these IHS beneficiaries, 4,338 (6.7%) were female veterans and 1,518 (2.8%) were female nonveterans. Comparing IHS services to VHA, the VHA provided the majority of outpatient specialty care to veterans, providing 89.9% of diagnostic and imaging services, 84.4% of mental health care, and 78.1% of physical medicine and rehabilitation. Conversely, the IHS provided the majority of ambulatory and inpatient care for obstetrics and gynecology to these veterans. Dual users received primary care from both organizations. Nonveterans generally accessed VHA under sharing agreements and their use of health care was generally limited to outpatient diagnostic and imaging. Conclusions The VHA seems to supplement healthcare provided by the IHS for female AIAN veterans, as well as for a small proportion of nonveterans. The VHA and the IHS have developed specialized and complementary expertise, which might be aligned to serve the needs of female AIAN veterans.

This research evaluated a draft preference assessment tool (draft-PAT) designed to replace the current Customary Routine section of the Minimum Data Set (MDS) for nursing homes. The draft-PAT was tested with a sample of nursing home residents to evaluate survey-level administration time and noncompletion rates, as well as item-level nonresponse rates, response distributions, and test-retest reliability. Modifications to the draft-PAT were then retested with a subsample of residents. Completion times were brief (generally less than 10 minutes), and only a small percentage of residents were unable to complete the interview. Item-level nonresponse rates were low for the draft-PAT (0% to 8%) and even lower during retesting for items advanced to the national field trial (0% to 4%). Item response distributions indicated reasonable use of all options across both testing occasions, and item-level test-retest reliability was high. This study found that nursing home residents can reliably report their preferences. Eighteen items from the modified draft-PAT were advanced to the national field trial of the MDS 3.0. Inclusion of the PAT in the MDS revision underscores increased emphasis on including residents’ voice in the assessment process.

OBJECTIVES: To test the accuracy of a brief cognitive assessment of nursing home (NH) residents and to determine whether facility nurses can reliably perform this assessment. DESIGN: Cross-sectional, independent cognitive screening tests with NH residents. SETTING: Six Department of Veteran Affairs nursing facilities. PARTICIPANTS: Three hundred seventy-four residents from six regionally distributed Veteran Affairs NHs. MEASUREMENTS: Three cognitive assessment instruments: the Brief Interview of Mental Status (BIMS), created for this study; the Minimum Data Set (MDS) 2.0 Cognitive Performance Scale (CPS), and the Modified Mini-Mental State Examination (3MS) as the criterion standard. The 15-point BIMS tests memory and orientation and includes free and cued recall items. Research assistants administered the 3MS and BIMS to all subjects. Facility nurses administered the same BIMS to a subsample. RESULTS: Three hundred seventy-four of 417 (89.7%) residents approached completed the 3MS and research assistant–administered BIMS (BIMS-R); 212 residents also received a facility nurse–administered BIMS (BIMS-N). The BIMS-R was more highly correlated with the 3MS than was the CPS (Pearson correlation coefficient (r)=0.79 vs 0.62; P

OBJECTIVES: To investigate whether an abbreviated five-item functional status survey consisting of five activities of daily living (ADLs) reflects changes measured over time in a full 12-item functional status survey. DESIGN: Longitudinal evaluation with mean follow-up of 11 months. SETTING: Two managed-care organizations in the United States. PARTICIPANTS: Four hundred twenty community-dwelling older people at moderate to high risk of death and functional decline enrolled in the Assessing Care of Vulnerable Elders (ACOVE) observational study. MEASURES: Number of ADL abilities according to the short (range 0–5) and full functional status surveys (range 0–12); change in function as defined according to a 1-point change in short score and 1- to 2-point change in full survey scores. RESULTS: Changes in short functional status survey scores were highly correlated to changes in long survey scores (correlation coefficient=0.88). On average, a 1-point change in the short survey score was associated with a 1.4-point change on the long survey score (P

OBJECTIVES: To examine nursing home (NH) residents' use of Medicare-paid skilled nursing facility (SNF) services and the outcomes of that care and to identify clinical and non-clinical factors associated with that care. DESIGN: Retrospective cohort. SETTING: United States. PARTICIPANTS: NH residents aged 65 and older with Medicare claims for a hospitalization for hip fracture or stroke during 2001 to 2003. MEASUREMENTS: Resident diagnoses and use of SNF postacute care were measured using Medicare hospital claims. Market and provider characteristics were drawn from the Provider of Services file. Baseline characteristics, institutionalization, and mortality outcomes were drawn from the Minimum Data Set and Medicare Denominator File. RESULTS: Of the NH population hospitalized for hip fracture (49,903) or stroke (23,084), 79.7% and 64.1%, respectively, used the SNF benefit. Residents not using the SNF benefit had poorer baseline health status; their mortality rates and rates of resuming long-term care were similar to the rates of residents who used the SNF benefit. CONCLUSION: NH residents used postacute SNF benefits at high rates yet had similar mortality and institutionalization outcomes as those without SNF care.

Home-based primary care (HBPC) is an effective model of noninstitutional long-term care developed in the Department of Veterans Affairs (VA) to provide ongoing care to homebound persons. Significant rural populations of American Indians have limited access to services designed for frail older adults. Fourteen Veterans Affairs Medical Centers (VAMCs) initiated efforts to expand access to HBPC in concert with local tribes and Indian Health Service (IHS) facilities. This study characterizes the resulting emerging models of HBPC and co-management. Using an observational design, key respondent telephone interviews (n = 37) were conducted with stakeholders representing the 14 VAMCs to describe these HBPC programs, and HBPC models were evaluated in relation to VAMC organizational culture as revealed on the annual VA All Employee Survey. Twelve VAMCs independently developed HBPC expansion programs for American Indian veterans, and six different program models were implemented. Two models were unique to collaborations between VAMCs and tribes; in these collaborations, the tribes retained primary care responsibilities. VAMC used the other four models for delivery of care in remote rural areas to all veteran populations, American Indians and non-Indians alike. Strategies to improve access by reducing geographic barriers occur in all models. Comparing mean VAMC organizational culture ratings, as defined in the Competing Values Framework, revealed significant group differences for one of these six models. Findings from this study illustrate the flexibility of the HBPC program and opportunities for co-management and expansion of healthcare access for American Indians and non-Indians, particularly in rural areas.

OBJECTIVES: To examine whether the Vulnerable Elders Survey (VES-13) score predicts risk of death and functional decline in vulnerable older adults. DESIGN: Longitudinal evaluation with mean follow-up of 11 months (range 8–14 months). SETTING: Two managed care organizations in the United States. PARTICIPANTS: Four hundred twenty community-dwelling older people identified as having moderate to high risk of death and functional decline based on a VES-13 score of 3 or higher. These older people were enrolled in the Assessing Care of Vulnerable Elders observational study. MEASUREMENTS: Baseline: VES-13 score, sex, income, cognitive score, and number of medical diagnoses. Outcome measures: functional decline and death. RESULTS: VES-13 scores strongly predicted death and functional decline (P

Administrative data are used to determine performance for publicly reported in health plan "report cards," accreditation status, and reimbursement. However, it is unclear how performance based on administrative data and medical records compare.We compared applicability, eligibility, and performance on 182 measures of health care quality using medical records and administrative data during a 13-month period for a random sample of 399 vulnerable older patients enrolled in managed care.Of 182 quality indicators (QIs) spanning 22 conditions, 145 (80%) were applicable only to medical records and 37 (20%) to either medical records or administrative data. Among 48 QIs specific to geriatric conditions, all were applicable to medical records; 2 of these also were applicable to administrative data. Eligibility for the 37 QIs that were applicable to both medical records and administrative data was similar for both data sources (94% agreement, kappa = 0.74). With the use of medical records, 152 of the 182 the QIs that were applicable to medical records were triggered and yielded an overall performance of 55%. Using administrative data, 30 of the 37 QIs that were applicable to administrative data were triggered and yielded overall performance of 83% (P0.05 vs. medical records). Restricting to QIs applicable to both data sources, overall performance was 84% and 83% (P = 0.21) for medical records and administrative data, respectively.The number and spectrum of QIs that can be measured for vulnerable elderly patients is far greater for medical records than for administrative data. Although summary estimates of health care quality derived from administrative data and medical records do not differ when using identical measures, summary scores from these data sources vary substantially when the totality of care that can be measured by each data source is measured.

OBJECTIVES: To assist facilities in identifying those evidence-based processes of poststroke care that enhance measurable patient outcomes. The guideline(s) should be used by facilities (hospitals, subacute-care units and providers of long-term care) to implement a structured approach to improve rehabilitative practices and by clinicians to determine best interventions to achieve improved patient outcomes. OPTIONS: The guideline considers five elements of poststroke rehabilitation care: interdisciplinary teams; use of standardized assessments; intensity, timing, and duration of therapy; involvement of patients' families and caregivers in decision-making; and educational interventions for patients, families, and caregivers. Evidence, benefits, harms, and recommendations for each of the five designated elements and specific annotated recommendations for poststroke managements are presented separately. OUTCOMES: The overall guideline considers improvement in functional status measures as the primary outcome. Achieving community-dwelling status and preventing complications, death, and rehospitalization are also important outcomes. Costs are not specifically addressed. PARTICIPANTS: The Department of Veterans Affairs/Department of Defense (VA/DoD) Stroke Rehabilitation Working Group consisted of 28, largely VA and military hospital, representatives of medical and allied professions concerned with stroke diagnosis, management, and rehabilitation. Nine additional members with similar credentials served as the editorial committee. Technical consultation was contracted from ACS Federal Health Care, Inc., and the Center for Evidence-Based Practice, State University of New York—Upstate Medical University, Department of Family Medicine conducted evidence appraisal. Consensus was achieved over several years of facilitated group discussion and iterative evaluation of draft documents and supporting evidence. SPONSOR: The guideline was prepared under the auspices of the VA/DoD. No other source of support was identified in the document, or supporting documents.

Objective To examine the relationships between various components of nursing home staffing (total staffing levels and staff mix, staff turnover, and changes in staffing patterns) to an important measure of quality, risk-adjusted rates of pressure ulcer development. Design, setting, and measurements Staffing records from 35 Department of Veterans Affairs (DVA) nursing homes were reviewed and nursing home administrators from each of the facilities were interviewed. Incidence rates for pressure ulcers were obtained from DVA’s national long-term care database and risk adjusted using patients’ baseline characteristics. The relationships of risk-adjusted pressure ulcer rates to staffing patterns were tested. Results Although there was no linear association between staffing levels and pressure ulcer rates, data analysis revealed a strong trend (P = .07) that among the nursing homes meeting staffing guidelines, 60% were among the best performing. Ten nursing homes reduced staffing levels from their baseline levels at the beginning of the study and/or changed their staffing mix by replacing licensed personnel with nursing assistants. This change was associated with a 2.1% higher rate of pressure ulcer development (P = .004) Conclusion Changes in nursing home staffing patterns (either a decrease in overall staffing levels or a change in staffing mix) are related to the quality of nursing home care. Staff stability is associated with better outcomes.

Objectives: To investigate quality of care for falls and instability provided to vulnerable elders. Design: Six process of care quality indicators (QIs) for falls and instability were developed and applied to community-living persons aged 65 and older who were at increased risk of death or decline. QIs were implemented using medical records and patient interviews. Setting: Northeastern and southwestern United States. Participants: Three hundred seventy-two vulnerable elders enrolled in two senior managed care plans. Measurements: Percentage of QIs satisfied concerning falls or mobility disorders. Results: Of the 372 consenting vulnerable elders with complete medical records, 57 had documentation of 69 episodes of two or more falls or fall with injury during the 13-month study period (14% of patients fell per year, 18% incidence). Double this frequency was reported at interview. An additional 22 patients had documented mobility problems. Clinical history of fall circumstances, comorbidity, medications, and mobility was documented from 47% of fallers and two or more of these four elements from 85%. Documented physical examination was less complete, with only 6% of fallers examined for orthostatic blood pressure, 7% for gait or balance, 25% for vision, and 28% for neurological findings. The evaluation led to specific recommendations in only 26% of cases, but when present they usually led to appropriate treatment modalities. Mobility problems without falls were evaluated with gait or balance examination in 23% of cases and neurological examination in 55%. Conclusion: Community physicians appear to underdetect falls and gait disorders. Detected falls often receive inadequate evaluation, leading to a paucity of recommendations and treatments. Adhering to guidelines may improve outcomes in community-dwelling older adults.

Purpose The purpose of this study was to develop a set of specific care processes associated with better outcomes for general medical conditions identified as quality improvement targets for institutionalized vulnerable elders. Methods A national panel of nursing home experts used a modified-Delphi process to rate the validity (process linked to improved outcomes) and feasibility (of implementation and measurement) of candidate measures for depression, diabetes, hearing impairment, heart failure, hypertension, ischemic heart disease, osteoarthritis, osteoporosis, pneumonia, stroke, and vision impairment. Each quality indicator was written as an "if" statement, describing persons to whom the quality indicator applied followed by a "then" statement identifying the care process to be provided. A separate clinical committee reviewed the resulting set of indicators. Results One hundred fourteen quality indicators were identified across the 11 medical conditions. The quality indicators capture a broad range of medical care addressing assessment, management, and follow up. Fifty-five indicators (48%) were identical to quality measures for community-dwelling vulnerable elders. A limited number were rated as questionably feasible to implement or measure (6 and 2, respectively). Thirty-eight (33%) would not be applied to measures of care quality for persons with advanced dementia or poor prognosis. Conclusions Explicit care processes linked to improved nursing home outcomes for general medical conditions can be identified. Most of these care processes can be measured by medical records or interview. Nursing home quality measures for medical conditions must account for exclusions related to poor prognosis and advanced dementia.

Purpose The assessment and management of dementia, falls and mobility disorders, malnutrition, end-of-life issues, pressure ulcers, and urinary incontinence have been identified as important quality improvement targets for vulnerable elders residing in nursing homes. This study aimed to identify valid and feasible measures of specific care processes associated with improved outcomes for these conditions. Methods Nine experts in nursing home (NH) care participated in a modified Delphi process to evaluate potential quality indicators (QIs) for care in NHs. Panelists met and discussed potential indicators before completing confidential ballots rating validity (process associated with improved outcomes), feasibility of measurement (with charts or interviews), feasibility of implementation (given staffing resources in average community NHs), and importance (expected benefit and prevalence in NHs). The NH panel's median votes were used to identify a final set of QIs that were subsequently reviewed by a clinical oversight committee. Results Sixty-eight geriatric syndrome QIs were identified as valid and important in NH populations. Panelists assessed 12 (18%) of these QIs as having questionable feasibility to implement in average community nursing homes trying to provide quality care. Nine (13%) would not be included in systems assessing quality of care for persons with advanced dementia or poor prognosis. Conclusions Steps of care critical to the assessment and management of geriatric syndromes in NHs were identified. Feasibility is an important issue for a significant number of these, indicating that much remains to be done to design systems that efficiently and reliably implement these care processes.

Objectives. We sought to describe the role and function of nursing facilities after disaster. Methods. We surveyed administrators at 144 widely dispersed nursing facilities after the Los Angeles Northridge earthquake. Results. Of the 113 (78%) nursing facilities that responded (11 365 beds), 23 sustained severe damage, 5 closed (625 beds), and 72 lost vital services. Of 87 nursing facilities implementing disaster plans, 56 cited problems that plans did not adequately address, including absent staff, communication problems, and insufficient water and generator fuel. Fifty-nine (52%) reported disaster-related admissions from hospitals, nursing facilities, and community residences. Nursing facilities received limited postdisaster assistance. Five months after the earthquake, only half of inadequate nursing facility disaster plans had been revised. Conclusions. Despite considerable disaster-related stresses, nursing facilities met important community needs. To optimize disaster response, communitywide disaster plans should incorporate nursing facilities.

Objective The objective of this study was to assess the qualityofcareprovidedtovulnerableoldercommunity-based patients with urinary incontinence (UI). Design We conducted an observational study using medical record review and patient (or proxy) interview. Participants We studied 372 randomly selected community-dwelling older patients enrolled in two senior managed care plans identified by interview to be at increased risk for functional decline or death. Measurements Percentage of quality indicators passed for patients with UI. Results Thirty-six percent of the patients reported having UI, and during a 13-month period, 32 (7%) presented to their physician with new or worsening UI. Analysis of medical records for these 32 patients revealed that characteristics of voiding were documented for 75% of the patients with new or worsening UI, but importance of the problem, toileting function, and prior treatment were rarely addressed. Pelvic examination was performed for 20% of female patients and a rectal examination for 42% of men. Only 38% had a urinalysis performed and 16% had a postvoid residual. Drug treatment was prescribed for 50% of the patients but behavioral intervention for only 13%. Compared with patients seen by primary care providers alone, patients seen in consultative care received more comprehensive evaluation and treatment of UI. Conclusion Quality of care for UI provided to vulnerable older patients, particularly by primary care providers alone, is inadequate. Despite the proven effectiveness of patient-dependent behavioral treatments, physicians rarely prescribe these interventions for UI.

Background. Recent work has highlighted a negative correlation between proprietary status and nursing home quality of care. This relationship might be explained by the context in which proprietary homes operate. However, another possible explanation is that some proprietary homes take excessive profit to the detriment of care quality. Objective. To examine the relationship between profit levels and quality in proprietary and nonproprietary nursing homes (NHs), accounting for resident and market characteristics. Methods. Data on 1098 free-standing NHs were taken from the California Office of State-wide Health Planning and Development, the On-line Survey Certification and Reporting System, and California licensing and statistical reports for 1998 and 1999. Tobit multivariate techniques were used to examine the relationship between deficiency citations and a range of explanatory variables, including profit. Results. Proprietary homes in California had significantly lower quality of care than nonproprietary homes. A stratified analysis revealed that, controlling for resident, facility, and market characteristics, profits located within the highest 14% of the proprietary sector's profit distribution were associated with significantly more total deficiencies and serious deficiencies. This relationship was not found in nonproprietary facilities. Other factors related to deficiencies included the ethnic mix of residents and facility size. Conclusions. Within the context in which proprietary homes operate, profit above a given threshold is associated with a higher number of deficiencies. Given this and the role of the proprietary sector in NH care, careful monitoring of profit levels in this sector appears warranted.

Diabetes mellitus (DM) is highly prevalent and increasing in persons aged 65 and older, particularly among racial and ethnic minorities. The purpose of this guideline is to improve the care of older persons with DM by providing a set of evidence-based recommendations that include DM-specific recommendations individualized to persons with DM who are aged 65 and older and recommendations for the screening and detection of geriatric syndromes.

Objectives To determine the incidence of acute medical conditions in incontinent nursing home residents, and associated costs of diagnostic testing and treatment Design Prospective, cohort study. Setting Three community nursing homes. Participants 161 long-stay residents with urinary incontinence in (mean age 86 years, 77% female, 92% white). Measurements Acute medical conditions were identified prospectively through medical record review based on standardized criteria. All diagnostic testing and treatment provided for these conditions were recorded, and related costs in the nursing home were assigned based on 1997–1998 Medicare and Medicaid reimbursement. Results The highest incidences of illness were for dermatological conditions (107 episodes per 1000 patient-weeks, involving 70% of subjects), respiratory illnesses (29 per 1000 patient-weeks, 47% of subjects) and gas-trointestinal illnesses (24 per 1000 patient-weeks, 36% of subjects). Among episodes with an incidence of at least 5 per 1000 patient-weeks, the illness events with the highest median diagnostic testing and treatment costs per episode were pneumonia, acute bronchitis, and depression. Only 42 out of the total 1071 episodes identified resulted in a hospitalization. Significant predictors of higher illness incidence included greater baseline comorbidity and higher number of routine medications (model adjusted R-square = 0.319, P = 0.021). Conclusion Acute illness is very common among incontinent nursing home residents, and is generally diagnosed and treated at the nursing home site, with variation among conditions in associated costs. Important policy implications include resource allocation (including appropriate staffing patterns), educational and quality improvement activities, and future research and guideline development for the optimal management of medical conditions in the nursing home setting.

Date Presented 3/31/2017 Falls are a quality measure under national value-based care initiatives. Thus, this session will present results from a mixed-methods study examining the alignment between best practices and rehabilitation patient documentation to inform future quality initiatives and documentation refinement. Primary Author and Speaker: Natalie Leland Contributing Authors: Carin Wong, Jenny Martinez, Brenda Fagan, Kate Wilber, Debra Saliba, Neeraj Sood

The nursing home culture change movement aims to improve resident quality of life and quality of care by emphasizing the deinstitutionalization of nursing home culture and focusing on person-centered care. This article briefly reviews the history of culture change, discusses some of the challenges related to culture change in nursing homes, and overviews the conceptualization and select models of culture change. Building from this background, it critiques current understanding, identifies critical research questions, and notes key issues arising during a workshop that addressed existing and emerging evidence in the field. This review and analysis provide a context for how 9 accompanying papers in this supplemental issue of The Gerontologist fill identified evidence gaps and provide evidence for future practice and policies that aim to transform nursing home culture.

Purpose of the Study: Although nursing home culture change efforts are becoming more widespread, there have been few efforts to systematically compile the evidence related to the efficacy of cul ture change. This study uses an analytic framework to evaluate the existing evidence for the impact of culture change on nursing home quality. We focus on the nature and scope of culture change interventions, measurement of culture change and adherence to interventions, measurement of culture change outcomes, and the relationship between culture change and its outcomes. Design and Methods: We conducted a comprehensive review of peer-reviewed and gray literature published between 2005 and 2012 to identify intervention evaluations that addressed at least one culture change domain. Of 4,982 identified publications, 625 underwent full review; 27 peer-reviewed and 9 gray literature studies met inclusion criteria. Results: Studies varied widely in scope and outcomes. Most addressed more than one culture change domain; resident direction, home environment, and close relationships were most common. Few studies measured culture change implementation, but most used validated tools to measure outcomes. Although few studies reported negative outcomes, there was little consistent evidence of positive effects. Implications: Nursing home culture change remains an evolving field. Although culture change has clear face validity, the current evidence does not give providers sufficient information for selecting interventions based on the expectation of improving outcomes. Rigorous research on implementation and outcomes of culture change is needed to determine the specific impact of culture change on quality and to provide guidance to providers and policy makers.

OBJECTIVE: To identify a set of geriatric conditions as optimal targets for quality improvement to be used in a quality measurement system for vulnerable older adults. DESIGN: Discussion and two rounds of ranking of conditions by a panel of geriatric clinical experts informed by literature reviews. METHODS: A list of 78 conditions common among vulnerable older people was reduced to 35 on the basis of their (1) prevalence, (2) impact on health and quality of life, (3) effectiveness of interventions in improving mortality and quality of life, (4) disparity in the quality of care across providers and geographic areas, and (5) feasibility of obtaining the data needed to test compliance with quality indicators. A panel of 12 experts in geriatric care discussed and then ranked the 35 conditions on the basis of the same five criteria. We then selected 21 conditions, based on panelists' iterative rankings. Using available national data, we compiled information about prevalence of the selected conditions for community-dwelling older people and older nursing home residents and estimated the proportion of inpatient and outpatient care attributable to the selected conditions. RESULTS: The 21 conditions selected as targets for quality improvement among vulnerable older adults include (in rank order): pharmacologic management; depression; dementia; heart failure; stroke (and atrial fibrillation); hospitalization and surgery; falls and mobility disorders; diabetes mellitus; end-of-life care; ischemic heart disease; hypertension; pressure ulcers; osteoporosis; urinary incontinence; pain management; preventive services; hearing impairment; pneumonia and influenza; vision impairment; malnutrition; and osteoarthritis. The selected conditions had mean rank scores from 1.2 to 3.8, and those excluded from 4.6 to 6.9, on a scale from 1 (highest ranking) to 7 (lowest ranking). Prevalence of the selected conditions ranges from 10 to 50% among community-dwelling older adults and from 25 to 80% in nursing home residents for the six most common selected conditions. The 21 target conditions account for at least 43% of all acute hospital discharges and 33% of physician office visits among persons 65 years of age and older. Actual figures must be higher because several of the selected conditions (e.g., end-of-life care) are not recorded as diagnoses. CONCLUSIONS: Twenty-one conditions were selected as targets for quality improvement in vulnerable older people for use in a quality measurement system. The 21 geriatric conditions selected are highly prevalent in this group and likely account for more than half of the care provided to this group in hospital and ambulatory settings. J Am Geriatr Soc 48: 363–369, 2000.

OBJECTIVES: To develop and test a standardized instrument, the purpose of which is to assess (1) whether skilled nursing facilities (SNFs) transfer residents to emergency departments (ED) inappropriately, (2) whether residents are admitted to hospitals inappropriately, (3) and factors associated with inappropriate transfers. DESIGN: A structured implicit review (SIR) of medical records. SETTING AND PARTICIPANTS: Using nested random sampling in eight community SNFs, we identified SNF and hospital records of 100 unscheduled transfers to one of 10 hospitals. MEASUREMENTS: Seven trained physician reviewers assessed appropriateness using a SIR form designed for this study (2 independent reviews per record, 200 total reviews). We measured interrater reliability with kappa statistics and used bivariate analysis to identify factors associated with assessment that transfer was inappropriate. RESULTS: In 36% of ED transfers and 40% of hospital admissions, both reviewers agreed that transfer/admit was inappropriate, meaning the resident could have been cared for safely at a lower level of care. Agreement was high for both ED (percent agreement 84%, kappa .678) and hospital (percent agreement 89%, kappa .779). When advance directives were considered, both reviewers rated 44% of ED transfers and 45% of admissions inappropriate. Factors associated with inappropriateness included the perceptions that: (1) poor quality of care contributed to transfer need, (2) needed services would typically be available in outpatient settings, and (3) the chief complaint did not warrant hospitalization. CONCLUSIONS: Inappropriate transfers are a potentially large problem. Some inappropriate transfers may be associated with poor quality of care in SNFs. This study demonstrates that structured implicit review meets criteria for reliable assessment of inappropriate transfer rates. Structured implicit review may be a valuable tool for identifying inappropriate transfers from SNFs to EDs and hospitals. J Am Geriatr Soc 48: 154–163, 2000.

Background Medicare Advantage (MA) enrollment is steadily growing, but little is known about the quality of nursing home (NH) care provided to MA enrollees compared to enrollees in traditional fee-for-service (FFS) Medicare. Objectives To compare MA and FFS enrollees' quality of NH care. Design Cross-sectional. Setting US nursing homes. Participants 2.17 million Medicare enrollees receiving care at an NH during 2011. Measurements CMS methodology was used to calculate the 18 Nursing Home Compare quality measures as applicable for each enrollee. Results Among Medicare enrollees using NH in 2011, 17% were in MA plans. Most quality scores were similar between MA and FFS. After adjusting for facility, beneficiary age and gender, CMS Hierarchical Condition Category score, and geographic region, short-stay MA enrollees had statistically significantly lower rates of new or worsening pressure ulcers [relative risk (RR) = 0.76, 95% confidence interval (CI) = 0.71–0.82] and new antipsychotic use (RR = 0.82, 95% CI = 0.80–0.83) but higher rates of moderate to severe pain (RR = 1.09, 95% CI = 1.07–1.12), compared with short-stay FFS enrollees. MA long-stay enrollees had lower rates of antipsychotic use (RR = 0.94, 95% CI = 0.93–0.96) but had higher rates of incontinence (RR = 1.08, 95% CI = 1.06–1.09) and urinary catheterization (RR = 1.10, 95% CI = 1.06–1.13), compared with long-stay FFS enrollees. Conclusion Overall, we found few differences in NH quality scores between MA and FFS Medicare enrollees. MA enrollment was associated with better scores for pressure ulcers and antipsychotic use but worse scores for pain control, incontinence, and urinary catheterization. Results may be limited by residual case-mix differences between MA and FFS patients or by the small number of short-stay measures reported.

Background The unique needs of homebound adults receiving home-based medical care (HBMC) (ie, home-based primary care and home-based palliative care services) are ideally provided by interdisciplinary care teams (IDTs) that provide coordinated care. The composition of team members from an array of organizations and the unique dimension of providing care in the home present specific challenges to timely access and communication of patient care information. The objective of this work was to develop a conceptual framework and corresponding quality indicators (QIs) that assess how IDT members for HBMC practices access and communicate key patient information with each other. Methods A systematic review of peer-reviewed and gray literature was performed to inform a framework for care coordination in the home and the development of candidate QIs to assess processes by which all IDT members optimally access and use patient information. A technical expert panel (TEP) participated in a modified Delphi process to assess the validity and feasibility of each QI and to identify which would be most suitable for testing in the field. Results Thematic analysis of literature revealed 4 process themes for how HBMC practices might engage in high-quality care coordination: using electronic medical records, conducting interdisciplinary team meetings, sharing standardized patient assessments, and communicating via secure e-messaging. Based on these themes, 9 candidate QIs were developed to reflect these processes. Three candidate QIs were assessed by the TEP as valid and feasible to measure in an HBMC practice setting. These indicators focused on use of IDT meetings, standardized patient assessments, and secure e-messaging. Conclusion Translating the complex issue of care coordination into QIs will improve care delivered to vulnerable home-limited adults who receive HBMC. Guided by the literature, we developed a framework to reflect optimal care coordination in the home setting and identified 3 candidate QIs to field-test in HBMC practices.

The International Classification of Functioning, Disability, and Health (ICF) is fast becoming the international standard for describing health and disabilities.1 The ICF defines activity limitations as difficulties encountered when people perform a task and participation restrictions as problems individuals encounter when engaging in life situations. Although many taxonomies express disability concepts, the Institute of Medicine2 recently recommended using the ICF as the conceptual framework for developing a comprehensive disability monitoring system. Moreover, the National Committee on Vital and Health Statistics (NCVHS) argued that it is essential to produce comparable functional status measures across care settings that are similar to International Classification of Diseases-9-Clinical Modification and International Classification of Diseases-10 for diagnoses.3 Therefore, we developed a staging system for activities of daily living (ADLs),4 applying terminology from the ICF and data from the second Longitudinal Study of Aging (LSOA II). The ADL questions are self- or proxy-reported, making it feasible to acquire information on large populations through telephone or in-person interview formats, where measurements based on clinician-observed performance would be too labor intensive. The ADL system includes five stages of increasing limitations defining discreet “patterns of retained function.” The tasks within the ADL stages express sets of activity limitations consistent with the ICF “self-care” chapter. Each stage reflects ICF qualifiers beginning with stage 0 (no limitation) and concluding with stage IV (total limitation; unable to do any ADLs).4 To be at a particular stage, individuals must be functioning at or better than specified levels across individual ADLs. In addition to severity, stages group people in ways that place a ceiling on the amount of dif-ficulty they can experience when performing each ADL. We demonstrated that people at higher stages of ADL limitation are more likely to have health conditions such as stroke known to be disabling.4 In addition, stages show predictive validity with regard to short- and long-term mortality, with median survivals ranging from 1.6–10.6 yrs.5

How to Obtain Contact Hours by Reading This Article Instructions 2.1 contact hours will be awarded for this activity. A contact hour is 60 minutes of instruction. This is a Learner-Paced Program. Vindico Medical Education does not require submission of quiz answers. A contact hour certificate will be awarded 4 to 6 weeks upon receipt of your completed Registration Form, including the Evaluation portion. To obtain contact hours: 1. Read the article “Patient Safety in the Nursing Home: How Nursing Staff Assess and Communicate about Change in Condition” by Karen G. Scandrett, MD, MPH; Mary Ann Anichini, GNP-BC; Celia Berdes, PhD, MSPH; Sherry Estabrook; Kenneth Boockvar, MD, MS; Debra Saliba, MD, MPH; Linda Emanuel, MD, PhD; and Stephanie L. Taylor, PhD on pages 28–37, carefully noting the tables and other illustrative materials that are provided to enhance your knowledge and understanding of the content. 2. Read each question and record your answers. After completing all questions, compare your answers to those provided at the end of the quiz. 3. Type or print your full name, address, and date of birth in the spaces provided on the registration form. 4. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity. 5. Forward the completed form with your check or money order for $20 made payable to JGN-CNE. All payments must be made in U.S. dollars and checks must be drawn on U.S. banks. CNE Registration Forms must be received no later than November 30, 2014. This activity is co-provided by Vindico Medical Education and the J ournal of G erontological N ursing . Vindico Medical Education, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Activity Objectives 1. Identify the conceptual framework upon which the study conducted by the authors was designed. 2. Identify the group positioned at the center of the model of nursing home care adapted by the authors for their study. 3. Discuss the goals of the study conducted by the authors. 4. Discuss the major themes and findings of the study. 5. Describe conclusions identified from the study. Author Disclosure Statement The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. Dr. Scandrett, Ms. Estabrook, and Dr. Taylor disclose related grant funding from the Agency for Healthcare Research and Quality. Commercial Support Statement All authors and planners have agreed that this activity will be free of commercial bias. There is no commercial support for this activity. There is no non-commercial support for this activity. Nursing homes must improve quality of care even as it becomes increasingly complex, and patient safety science may provide a helpful paradigm. Training materials are needed to build staff capacity for clinical assessment and communication, thereby improving care processes. Designed to develop curricular materials, this study used focus groups to determine how experienced nurses and aides assess and communicate about resident clinical changes. Four focus groups were conducted, and interviews were analyzed for themes in an iterative process by multidisciplinary team members. Staff reported that consistent caregiving enables detection of subtle clinical changes; aides further noted the importance of affective bonding. Aides and nurses alike regarded all clinical changes as potentially significant, while nursing staff lacked a consistent approach to assessment. Using a patient safety framework, structural changes and process elements were identified as important topics for further training to support clinical communication and improve resident and facility outcomes.

Stineman MG, Xie D, Streim JE, Pan Q, Kurichi JE, Henry-Sanchez JT, Zhang Z, Saliba D. Home accessibility, living circumstances, stage of activity limitation, and nursing home use. Objective To explore the influence of physical home and social environments and disability patterns on nursing home (NH) use. Design Longitudinal cohort study. Self- or proxy-reported perception of home environmental barriers accessibility, 5 stages expressing the severity and pattern of activities of daily living (ADLs) limitations, and other characteristics at baseline were applied to predict NH use within 2 years or prior to death through logistic regression. Setting General community. Participants Population-based, community-dwelling individuals (N=7836; ≥70y) from the Second Longitudinal Study of Aging interviewed in 1994 with 2-year follow-up that was prospectively collected. Interventions Not applicable. Main Outcome Measure NH use within 2 years. Results Perceptions of home environmental barriers and living alone were both associated with approximately 40% increased odds of NH use after adjustment for other factors. Compared with those with no limitations at ADL stage 0, the odds of NH use peaked for those with severe limitations at ADL stage III (odds ratio [OR]=3.12; 95% confidence interval [CI], 2.20–4.41), then declined sharply for those with total limitations at ADL stage IV (OR=.96; 95% CI, .33–2.81). Sensitivity analyses for missing NH use showed similar results. Conclusions Accessibility of home environment, living circumstance, and ADL stage represent potentially modifiable targets for rehabilitation interventions for decreasing NH use in the aging U.S. population.

To determine whether the Vulnerable Elders Survey (VES)-13, a survey based on functional status that has been validated in uninjured older populations, will predict complications and mortality in injured older adults.Prospective observational pilot study.Level 1 trauma center.Sixty-three older adults (≥65) with a traumatic injury who survived and required inpatient care for at least 24 hours.preinjury VES-13 score (0-10 points, higher=greater risk) obtained by interviewing participants or proxies.composite outcome of one or more medical complications (e.g., aspiration pneumonia, respiratory failure) or death, discharge destination (home, nursing home, death), length of stay, hospital charges. Covariates: Charlson Comorbidity Index (CCI), Injury Severity Score (ISS), and sex.Of the 63 participants, 30 (48%) were discharged to home and 28 (44%) to a nursing facility, 21 (33%) developed one or more complications, and four (6%) died. In a model that also controlled for ISS and comorbidity, each additional VES-13 point was associated with greater risk of complication or death (odds ratio=1.53 per point, 95% confidence interval=1.12-2.07).The VES-13, in combination with injury severity, may be useful early in the hospital course to predict complications and death in older adults with traumatic injury, potentially identifying candidates who may benefit from additional inpatient geriatric services.

To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older.Cross-sectional.Community.Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II).Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV).ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI)=2.4-4.4) to 41.9 (95% CI=19.6-89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR=17.8, 95% CI=13.0-24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race.ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features.

Quality indicators are standardized measures of health care quality. We designed a survey to assess how knowledge, attitude, and organizational practices might affect healthcare provider behaviors in meeting quality indicators for fall prevention to plan curricula for a continuing educational intervention. The survey was pilot tested in the Veterans Affairs (VA) in a small stratified sample. Some items that had been previously used in assessments for continuing education among community physicians were not well matched to the VA practice environment or to midlevel clinicians, suggesting that instruments need to be adapted for relevance to the health care setting as well as discipline.

To identify the potentially modifiable resident-level factors associated with rejection of care in nursing home (NH) residents.Secondary analysis of a 3.0 national field test to revise the Minimum Data Set (MDS).Seventy-one NHs in eight states.Three thousand two hundred thirty NH residents scheduled for MDS assessments from September 2006 through February 2007.The potentially mutable characteristics assessed were mood (Patient Health Questionnaire-9), delirium (Confusion Assessment Method), delusions, hallucinations or illusions, hearing impairment, vision impairment, pain severity, and infection diagnoses. Characteristics considered as covariates were cognition, communication abilities, and impairment in activities of daily living.Of 3,230 residents assessed, 312 (9.7%) had demonstrated rejection of care in the preceding 5 days. In multiple regression analysis adjusted for covariates, rejection of care was associated with delusions (odds ratio (OR)=3.9; 95% confidence interval (CI)=2.5-6.0), delirium (OR=1.8, 95% CI=1.3-2.4), minor (OR=2.1, 95% CI=1.5-2.8) and major (OR=2.3, 95% CI=1.5-3.4) depression, and severe to horrible pain (OR=1.6, 95% CI=1.1-2.3). Infection diagnoses were not significant in bivariate analysis. Hallucinations or illusions, mild to moderate pain, and hearing and vision impairment were not significant in multiple regression analysis.In this population, delirium, delusions, depression, and severe pain were associated with rejection of care, suggesting that some care rejection behaviors may resolve with appropriate interventions for the identified target conditions if the associations observed are causal.

Rejection of care behaviors is common in the geriatric population, especially among patients with dementia. Nonetheless, the concept of rejection of care is not well defined and existing psychosocial theoretical models fall short of capturing complex relationships between factors associated with rejection of care. We propose a definition of rejection of care and develop a conceptual framework of rejection of care incorporating 7 components: intrinsic factors, match between needs and environmental resources, behavior state, antecedents, individual preferences, rejection of care behaviors, and consequences. A literature search yielded 55 studies that examined the associations between rejection of care and factors of the conceptual framework. We quantitatively synthesized studies focused on dementia severity and rejection of care. The literature review demonstrated that rejection of care is more prevalent among patients with dementia or functional impairment, associated with some mutable factors, and is triggered by specific antecedents in the context of daily personal care provision and associated with various adverse outcomes. The meta-analysis provided evidence that severe dementia is associated with higher likelihood of developing rejection of care behaviors compared with mild to moderate dementia. We also found that research on unmet needs, antecedents, and individual preferences has been scarce. The direction of further research is discussed.