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Purpose: Individual-randomized trials are the gold standard for testing the efficacy and effectiveness of drugs, devices, and behavioral interventions. Health care delivery, educational, and programmatic interventions are often complex, involving multiple levels of change and measurement precluding individual randomization for testing. Cluster-randomized trials and cluster-randomized stepped-wedge trials are alternatives where the intervention is allocated at the group level, such as a clinic or a school, and the outcomes are measured at the person level. These designs are introduced along with the statistical implications of similarities among individuals within the same cluster. We also illustrate the parameters that have the most impact on the likelihood of detecting intervention effects, which must be considered when planning these trials. Conclusion: Cluster-randomized and stepped-wedge designs should be considered by researchers as experimental alternatives to individual-randomized trials when testing speech, language, and hearing care interventions in real-world settings.

Non-pharmacological strategies are prioritized to manage dementia-related symptoms in nursing homes (NHs). A multiple-case study design, embedded within a pragmatic trial, examined NH staff perspectives of applying a team-based (TB) or problem-based dementia training program to resident care. A purposive sample of staff was recruited from 23 NHs to participate in one-on-one interviews, which were analyzed using a rapid qualitative approach. Both approaches yielded staff who were able to apply their training to resident care. Staff described similarities in communication strategies, family interactions, recognizing sources of behaviors, providing comfort, and ensuring resident safety. In addition, staff demonstrated increased self-efficacy when caring for residents. Differences emerged for team collaboration, engaging residents, and managing behaviors. Among TB staff, training impacted how staff cared for residents and increased teamwork. Leaders may want to consider the benefits of each approach as they deliberate on which dementia care training to provide to their staff. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Shortly after Medicare implemented post‐acute care payment reforms, the COVID‐19 pandemic began, but little is known about how these reforms and the pandemic impacted admissions to the most common post‐acute settings—skilled nursing facilities (SNF) and home health agencies (HHAs)—for the full Medicare fee‐for‐service population.Using 100% of Medicare fee‐for‐service data, we conducted adjusted interrupted time series analyses of 31,730,994 hospital stays of all adult beneficiaries discharged alive from the hospital between 2018 and 2021 to examine whether payment reforms and the pandemic were associated with differences in admissions to SNFs and HHAs compared to pre‐reform and pre‐COVID (baseline) trends.At baseline, an average 18.0% of hospitalized beneficiaries were admitted to SNFs and 14.8% to HHAs. While SNF payment reform in October 2019 was associated with an immediate reduction in SNF admissions, a positive temporal trend reversed this decrease in admissions. HHA payment reform implemented in January 2020 was associated with increased HHA admissions compared to baseline. Post‐COVID, admissions to SNF declined to 15.5% of patients being discharged from hospitals and HHA admissions increased to 19.2%.SNF and HHA payment reforms were associated with small increases in admissions to their respective settings, suggesting that Medicare reforms did not negatively impact access. However, the baseline trends of decreasing admissions to SNF and increasing HHA admissions were greatly accelerated by the COVID‐19 pandemic. Results highlight changes in the demand for these settings, which must be recognized in policy efforts and research examining impacts on specific patient populations. [ABSTRACT FROM AUTHOR]

Objective: To examine skilled nursing facility (SNF) staffing shortages across job roles during the COVID‐19 pandemic. We aimed to capture the perspectives of leaders on the breadth of staffing shortages and their implications on staff that stayed throughout the pandemic in order to provide recommendations for policies and practices used to strengthen the SNF workforce moving forward. Study Setting and Design: For this qualitative study, we engaged a purposive national sample of SNF leaders (n = 94) in one‐on‐one interviews between January 2021 and December 2022. Data Source and Analytic Sample: Using purposive sampling (i.e., Centers for Medicare & Medicaid quality rating, region, ownership) to capture variation in SNF organizations, we conducted in‐depth, semi‐structured qualitative interviews, guided a priori by the Institute of Medicine's Model of Healthcare System Framework. Interviews were conducted via phone, audio‐recorded, and transcribed. Rigorous rapid qualitative analysis was used to identify emergent themes, patterns, and relationships. Principal Findings: SNF leaders consistently described staffing shortages spanning all job roles, including direct care (e.g., activities, nursing, social services), support services (e.g., laundry, food, environmental services), administrative staff, and leadership. Ascribed sources of shortages were multidimensional (e.g., competing salaries, family caregiving needs, burnout). The impact of shortages was felt by all staff that stayed. In addition to existing job duties, those remaining staff experienced re‐distribution of essential day‐to‐day operational tasks (e.g., laundry) and allocation of new COVID‐19 pandemic‐related activities (e.g., screening). Cross‐training was used to cover a wide range of job duties, including patient care. Conclusions: Policies are needed to support SNF staff across roles beyond direct care staff. These policies must address the system‐wide drivers perpetuating staffing shortages (i.e., pay differentials, burnout) and leverage strategies (i.e., cross‐training, job role flexibility) that emerged from the pandemic to ensure a sustainable SNF workforce that can meet patient needs. [ABSTRACT FROM AUTHOR]

Background and Objectives Alzheimer's disease and related dementias progress over time and result in cognitive decline, loss of independence, and behavioral and psychiatric symptoms of dementia that can lead to nursing home placement. Research has focused on examining the effects of nursing home placement on the family caregiver; however, their experiences are less understood. We sought to investigate the experiences and perceptions of family caregivers of nursing home residents with dementia. The objective was to create a conceptual model that explains the complex nature of the family caregiver experience. Research Design and Methods This study is part of a larger randomized controlled trial. Following a grounded theory approach, we completed 30 in-depth, one-on-one interviews with family caregivers of nursing home residents with dementia. Data analysis followed an iterative process that employed open, axial, and selective coding. Results Our conceptual model depicts the interrelationship between contributing factors that interrelate and impact family caregiver satisfaction with nursing home care. Six factors contribute to family caregiver satisfaction: family caregiver interactions with nursing home staff; staff management of resident behavioral symptoms; nursing home context; family caregiver knowledge of dementia; family caregiver strain; and the resident experience. Discussion and Implications Our findings revealed family caregiver experiences that are unique to the institutional nursing home setting and not reflected in prior work focusing on experiences within community-based settings. Understanding family caregiver experiences and the contributors to how satisfaction in care is perceived, may foster collaboration and teamwork among families and staff. [ABSTRACT FROM AUTHOR]

Understanding therapy providers' experiences with cognitive screening, assessment, and documentation can provide guidance on improving care quality. Semi-structured interviews (n = 18) were conducted with therapy providers across disciplines and post-acute settings. Thematic analysis was used to identify themes. Six over-arching themes emerged pertaining to cognitive screening and assessment. (1) Therapists routinely conducted screening through task performance and informal observation. (2) Documentation habits varied due to multiple conflicting goals and lack of guidelines. (3) Therapists' approach was honed on the job through clinical experience and trial and error. (4) Patient diagnosis, emerging medical conditions, and goals most strongly influenced therapists' approach. (5) Roles and responsibilities were implicit. (6) The end goal was determining patient safety. All therapy providers frequently screened for cognition, yet documentation varied widely. To increase consistent delivery and documentation of cognitive screening and assessment, future studies can examine strategies to streamline electronic health record platforms. [ABSTRACT FROM AUTHOR]

Background: Implementation of new skilled nursing facility (SNF) Medicare payment policy, the Patient Driven Payment Model (PDPM), resulted in immediate declines in physical and occupational therapy staffing. This study characterizes continuing impacts of PDPM in conjunction with COVID‐19 on SNF therapy staffing and examines variability in staffing changes based on SNF organizational characteristics. Methods: We analyzed Medicare administrative data from a national cohort of SNFs between January 2019 and March 2022. Interrupted time series mixed effects regression examined changes in level and trend of total therapy staffing minutes/patient‐day during PDPM and COVID‐19 and by type of staff (therapists, assistants, contractors, and in‐house staff). Secondary analyses examined the variability in staffing by organizational characteristics. Results: PDPM resulted in a −6.54% level change in total therapy staffing, with larger declines for assistants and contractors. Per‐patient staffing fluctuated during COVID‐19 as the census changed. PDPM‐related staffing declines were larger in SNFs that were: Rural, for‐profit, chain‐affiliated, provided more intensive therapy, employed more therapy assistants, and admitted more Medicare patients before PDPM. COVID‐19 resulted in larger staffing declines in rural SNFs but smaller early declines in SNFs that were hospital‐based, for‐profit, or received more relief funding. Conclusions: SNFs that historically engaged in profit‐maximizing behaviors (e.g., providing more therapy via lower‐paid assistants) had larger staffing declines during PDPM compared to other SNFs. Therapy staffing fluctuated during COVID‐19, but PDPM‐related reductions persisted 2 years into the pandemic, especially in rural SNFs. Results suggest specific organizational characteristics that should be targeted for staffing and quality improvement initiatives. [ABSTRACT FROM AUTHOR]