Search

Background and Objectives Abundant evidence documents racial/ethnic disparities in access, quality of care, and quality of life (QoL) among nursing home (NH) residents who are Black, Indigenous, and people of color (BIPOC) compared with White residents. BIPOC residents are more likely to be admitted to lower quality NHs and to experience worse outcomes. Yet, little is known about processes for differences in QoL among residents receiving care in high-proportion BIPOC NHs. This study presents an examination of the processes for racial/ethnic disparities in QoL in high-proportion BIPOC facilities while highlighting variability in QoL between these facilities. Research Design and Methods Guided by the Minority Health and Health Disparities Research Framework and the Zubritsky framework for QoL in NHs, we employ a concurrent mixed-methods approach involving in-depth case studies of 6 high-proportion BIPOC NHs in Minnesota (96 resident interviews; 61 staff interviews; 614 hours of observation), coupled with statewide survey data on residents’ QoL linked to resident clinical Minimum Data Set assessments. Results Quantitative findings show that BIPOC residents experience lower QoL than White residents across various domains. Qualitative findings reveal variability in BIPOC residents’ QoL between high-proportion BIPOC facilities. In some facilities, BIPOC residents experienced worse QoL based on their race/ethnicity, whereas in others BIPOC residents QoL was not directly affected by their race/ethnicity or they had mixed experiences. Discussion and Implications The findings highlight variability in racial/ethnic disparities in QoL across NHs with a high proportion of BIPOC residents. We identify health equity initiatives, including engaging with community BIPOC organizations and volunteers, and providing more resources to high-proportion BIPOC facilities to support staff training, additional staffing, and culturally specific programming. Given the increasing racial/ethnic diversity of NHs, ensuring equity in QoL for BIPOC residents is an urgent priority for NHs to remain relevant in the future.

Objectives: To investigate trends in racial/ethnic differences in nursing home (NH) residents’ quality of life (QoL) and assess these patterns within and between facilities. Method: Data include resident-reported QoL surveys ( n = 60,093), the Minimum Data Set, and facility-level characteristics ( n = 376 facilities) for Minnesota. Hierarchical linear models were estimated to identify differences in QoL by resident race/ethnicity and facility racial/ethnic minority composition for 2011–2015. Results: White residents in low-proportion racial/ethnic minority facilities reported higher QoL than both minority and white residents in high-proportion minority facilities. While the year-to-year differences were not statistically significant, the point estimates for white–minority disparity widened over time. Discussion: Racial/ethnic differences in QoL are persistent and may be widening over time. The QoL disparity reported by minority residents and all residents in high-proportion minority facilities underscores the importance of examining NH structural characteristics and practices to ultimately achieve the goal of optimal, person-centered care in NHs.

The number of adults with serious mental illness (SMI) who receive care in nursing homes (NHs) continues to rise. The Preadmission Screening and Resident Review (PASRR) program requires screening for SMI prior to NH placement, in order to avoid inappropriate admission and unnecessary institutional care. We interviewed staff responsible for the processing of PASRR documentation at four NHs in Minnesota (n=15), and obtained and analyzed all completed PASRR-II assessments in Minnesota from 2019 (N=532). PASRR assessments overwhelmingly recommended 24-hour NH care (94.7%) with 94% of assessments indicating a need for mental health services while at the NH. Most NH staff interviewed noted that PASRR is not used in the care planning process and described PASRR as a regulatory hoop. Staff shared that PASRR assessments could provide insight into an individual’s mental health history, current and future needs, and can be helpful in assessing NH capacity to provide such services. Although mental health services provided while at the NH are supposed to be facilitated in partnership with the county, there is a lack of follow-up and NH staff are largely left to deal with SMI in isolation. PASRR assessments are supposed to be a tool for care coordination, but leave the NH as the sole responsible point of contact for residents with SMI. A more integrated PASRR program that better focuses on incorporating PASRR into care planning and mental health service delivery in NHs and the broader community is necessary to improve the lives of individuals with SMI.

Multiple studies have shown an increasing prevalence of adults with serious mental illness (SMI) in nursing homes. As adults with SMI age, the reality of care needs that span physical, medical, and psychosocial services necessitates further consideration of the role of comprehensive, ancillary mental health services in nursing homes (NH). Yet, little work examines characteristics of those with SMI, their care needs & the role of facility structural factors. Using the 2011-2017 Minimum Dataset (MDS) assessment data for Minnesota, we examined resident-level demographic characteristics of NH residents with and without SMI, and facility-level characteristics including quality of life (QoL), quality of care (QoC), and state recertification survey scores. We defined SMI as a diagnosis of bipolar disorder, schizophrenia or schizoaffective disorder, or psychotic conditions other than schizophrenia present on the reference assessment. Individuals admitted with SMI were younger, had better physical health, were more likely to be racial/ethnic minorities, and more likely to be admitted to a facility with a higher proportion of racial/ethnic minority residents. SMI-only admissions were concentrated in larger, for-profit facilities with a high-reliance on Medicaid. Lastly, SMI-only admissions were more likely to occur in facilities with lower QoL, QoC, and inspection scores. There is a growing need for behavioral health services in NHs, yet access to services is inadequate and lacks equity based on geography, race/ethnicity and other system-level disparities.

Background and Objectives Prevalence of nursing home residents with Alzheimer’s disease and related dementias (ADRD) has increased along with a growing consensus that person-centered ADRD care in nursing homes should maximize quality of life (QoL). However, concerns about whether residents with ADRD can make appropriate QoL judgments persist. This study assesses the stability and sensitivity of a self-reported, multidomain well-being QoL measure for nursing home residents with and without ADRD. Research Design and Methods This study linked the 2012–2015 Minnesota Nursing Home Resident QoL and Satisfaction with Care Survey, Minimum Data Set 3.0 (nursing home assessments), and Minnesota Department of Human Services Cost Reports. The QoL survey included cohort–resident pairs who participated for 2 consecutive years (N = 12 949; 8 803 unique residents from 2012–2013, 2013–2014, and 2014–2015 cohorts). Change in QoL between 2 years was conceptualized as stable when within 1.5 SD of the sample average. We used linear probability models to estimate associations of ADRD/Cognitive Function Scale status with the stability of QoL summary and domain scores (eg, social engagement) and the absolute change in QoL summary score, controlling for resident and facility characteristics. Results Most (86.82%) residents had stable QoL summary scores. Residents with moderate to severe cognitive impairment, irrespective of ADRD, were less likely to have stable summary scores than cognitively capable residents without ADRD (p < .001), but associations varied by QoL domains. Among those with stable summary QoL scores, changes in health/functional status were associated with absolute changes in summary QoL score (p < .001), suggesting sensitivity of the QoL measure. Discussion and Implications QoL scores were similarly stable over time for most residents with and without ADRD diagnoses and were sensitive to changes in health/functional status. This self-reported QoL measure may be appropriate for nursing home residents, regardless of ADRD diagnosis, and can efficaciously be recommended to other states.

What services are available and where racial and ethnic minorities receive long-term services and supports (LTSS) have resulted in a lower quality of care and life for racial/ethnic minority users. These disparities are only likely to worsen during the COVID-19 pandemic, as the pandemic has disproportionately affected racial and ethnic minority communities both in the rate of infection and virus-related mortality. By examining these disparities in the context of the pandemic, we bring to light the challenges and issues faced in LTSS by minority communities with regard to this virus as well as the disparities in LTSS that have always existed.

Eruptive column models are crucial for managing volcanic crises, forecasting future events, and reconstructing past eruptions. Given their central role in volcanology and the large uncertainties weakening their predictions, the evaluation and improvement of these models is critical. Such evaluation is challenging as it requires independent estimates of the main model inputs (e.g. mass eruption rate) and outputs (e.g. column height). Despite recent efforts to extend datasets of independently estimated eruption source parameters (ESP) (e.g. Mastin 2014, Aubry et al. 2017), there is no standardized, maintained, and community-based ESP database devoted to the evaluation of eruptive column models.Here we present a new ESP database designed to respond to the needs of the plume modelling community, and which will also be valuable to observatories, field volcanologists, and volcanic ash advisory centers. We compiled data for over 130 eruptive events with independent estimates of: i) the mass eruption rate; ii) the height reached by the column; and iii) atmospheric conditions during the eruption. In contrast with previous ESP datasets, we distinguish estimates of column height that relate to different phases (ash and SO2) and parts of the column (plume top or umbrella). We additionally provide the total grain size distribution, uncertainties in eruption parameters, and multiple sources for atmospheric profiles for events where these parameters are available. The database also includes a wealth of additional information which will enable modelers to distinguish between different eruptions when evaluating or calibrating models. This includes the type of eruption, the morphology of the plume (weak/transitional/strong), and the occurrence and mass entrained within pyroclastic density currents.We will apply the new database to revisit empirical scaling relationships between the mass eruption rate and “plume height”. In particular, we will show how such relationships depend on the type of height (e.g. SO2 height vs. ash top height) and eruption (e.g. magmatic vs. phreatomagmatic) considered. We will also discuss the difficulties and limitations of compiling ESP estimates from the literature as well as characterizing fundamentally unsteady volcanic events by a single value for each ESP.

Objectives The Preferences Assessment Tool (PAT) in the Minimum Data Set (MDS) 3.0 assesses 16 resident preferences for daily routines and activities. Although integrating important preferences into care planning is essential to provide person-centered care in nursing homes (NHs), preferences rated as important but unmet or unimportant may not receive much attention. This study aims to (1) identify the prevalence of unmet preferences and unimportant preferences, and (2) examine their associations with resident and facility-level characteristics. Design This is a longitudinal study of residents in NHs. Settings and Participants We used data from 2012–2017 MDS assessments of long-stay residents aged 65 or older in 295 Minnesota NHs. In total, 51,859 assessments from 25,668 residents were included. Methods Generalized linear mixed models were used to analyze resident and facility-level characteristics associated with having any unmet preferences, and with the number of unimportant preferences. Results Across all years for both daily routine preferences and activity preferences, 3.3% to 5.1% of residents reported that at least 1 or more preference was important but unmet, and 10.0% to 16.6% reported that 4 or more out of the 8 preferences were unimportant. Residents with higher depressive symptoms, and poorer physical and sensory function were more likely to report unmet preferences. Residents with poorer physical and sensory function, and living in rural facilities and facilities having fewer activity staff hours per resident day were more likely to report unimportant preferences. Conclusions and Implications Residents with functional and sensory limitations and living in underresourced NHs are more likely to report that preferences are unimportant, or that they are important but unmet. It is important for staff to elicit preferences that truly matter for residents, and to enable residents to meet their preferences.

Objectives To provide an estimate and level of uncertainty for Medicaid cost savings due to Minnesota's Return to Community Initiative (RTCI). Design Medicaid cost savings are estimated using a semi-Markov model and simulation approach. Setting and Participants RTCI is a statewide program that assists private paying nursing home residents with discharge to the community. When originally proposed, it was expected that the program would reduce state Medicaid expenditures, primarily through the shifting of residents from nursing homes to a less costly community setting. In prior analysis, we estimated that approximately 1 in 9 residents targeted for transition by the program would not have returned to the community without the RTCI. Accurate cost savings estimates require consideration of complex resident care trajectories, that is, nursing home readmissions, use of assisted living and community-based services, and mortality. Measures Data were from 30,234 private pay nursing home residents admitted during 2011, primarily for post-acute stays, to 378 facilities in Minnesota, and followed for 4 years postadmission for outcomes and time to event. Resident characteristics were taken from the Minimum Data Set (MDS) admission assessment. We modeled variability in care trajectories with a semi-Markov formulation. Transition probabilities were estimated using Multinomial regression. Time to event was modeled using the best-fitting, positive, right-skewed distribution for each path. The simulation was run (1000 times) with and without the RTCI impact to estimate change in Medicaid days in various settings. Results Program savings was estimated at $4.1 million per year of effort over a 4-year accumulation period. Conclusions and Implications The RTCI produced a modest Medicaid cost savings in excess of the annual program budget of $3.5 million. Findings from the semi-Markov model and simulation increase our understanding of care transitions between nursing home, community, Medicaid status, and mortality.

OBJECTIVE The objective of this study was to evaluate the impact of Minnesota's Return to Community Initiative (RTCI) on postdischarge outcomes for nursing home residents transitioned through the program. DATA SOURCES Secondary data were from the Minimum Data Set and RTCI staff (January 2015 to December 2016), state Medicaid eligibility files and death records. The sample consisted of 29,201 nursing home discharges in Minnesota occurring in 2015. RESEARCH DESIGN Cox proportional hazard models were used to compare 1-year postdischarge outcomes of nursing home readmission, mortality, and Medicaid conversion for RTCI assisted community discharges and a propensity-matched sample of unassisted community discharges. RESULTS The majority (60%) of RTCI assisted discharges remained alive, in the community and not having converted at Medicaid at 1 year after discharge. Time to mortality was significantly lower for the assisted group than the unassisted group, but time to readmission and Medicaid conversion were similar. CONCLUSION The RTCI assisted residents fared well postdischarge in their time to mortality, nursing home readmission, and Medicaid conversion; they lived longer than a propensity-matched sample of their peers.

Objective: Quality of life (QoL) is a multidimensional construct that assesses the quality of lived experience in nursing homes (NHs). QoL is directly important to NH residents. However, QoL is only publicly reported in a few states, partly because of concerns regarding measure stability. To address these concerns, we tested the stability of Minnesota’s NH QoL measure over one year. Study Design: A pair of two-year cohorts of Minnesota NH residents who responded to the 2012-2013 (N = 4,448) or 2014-2015 (N = 4,644) QoL survey in consecutive years. Stability was measured using the intra-class correlation (ICC) from hierarchical linear models. Models were fit without any covariates, then individual and facility-level characteristics were added. Principal Findings: Overall QoL had ICCs of 0.602 and 0.614 in the earlier and later cohort respectively. Domain-level ICCs were lower, ranging from 0.374 (positive mood) to 0.571 (lack of negative mood) in the 2012-2013 cohort, with similar trends for the later cohort. Adjusting for important covariates reduces the ICCs slightly, but they remained at 0.565 or higher for the summary score. Conclusions: Person-reported summary QoL has adequate stability over a period of one year. Our results provide impetus to assess and report NH QoL on a national level. Consumers can be confident that if an NH’s QoL scores improve from year to year, that represents a real improvement, and not just the scores varying due to which residents were sampled. Some caution, however, is warranted when presenting facility-level domain scores, as these are less stable.

OBJECTIVE: To evaluate Minnesota's Return to Community Initiative's (RTCI) impact on community discharges from nursing homes. DATA SOURCES: Secondary data were from the Minimum Data Set and RTCI staff (April 2014 – December 2016). The sample consisted of 18 444 non‐Medicaid nursing home admissions in Minnesota remaining for at least 45 days, with high predicted probability of community discharge. STUDY DESIGN: The RTCI facilitates community discharge for non‐Medicaid nursing home residents by assisting with discharge planning, transitioning to the community, and postdischarge follow‐up. A key evaluation question is how many of those transitions were directly attributable to the program. Return to Community Initiative was implemented statewide without a control group. Program impact was measured using regression discontinuity, a quasi‐experimental design approach that leverages the programs targeting model. PRINCIPAL FINDINGS: Return to Community Initiative increased community discharge rates by an estimated 11 percent (P

Objective To build and test a model that predicts community discharge probabilities for Medicaid-eligible nursing home (NH) residents who remain in the nursing home at 90 days after admission and, thus, would be candidates for the Money Follows the Person (MFP) program. Data Source The Minimum Data Set, Medicaid Management Information Systems, and Minnesota Vital Statistics file. Data Cohort of 33, 590 nursing home stays that qualified for Medicaid by the 90th day of their stay from 383 Minnesota nursing homes from July 2011 to June 2013. Study Design Mixed effects logistic regression model to predict community discharge. Principal Findings The scoring system had a high level of accuracy in predicting community discharge for both the fitting and validation cohorts. Subpopulations with severe mental illness or intellectual disability were well represented across the entire score range. Conclusions Findings are being applied in the Minnesota's MFP initiative (Moving Home Minnesota) to target Medicaid-eligible NH residents for transitioning to the community. This approach could be applied to MFP in other states.

The proportion of racial/ethnic minorities in nursing homes (NHs) has increased steadily in recent years. This study longitudinally examines minority NH residents’ quality of life (QoL); a key measure of overall well-being. We used unique data from Minnesota annual QoL interviews (2011-2015), merged with resident and facility characteristics to model QoL. Mixed models with various resident and facility level controls, facility random effects, and both fixed and random effects for year were fit to estimate the effect of being a minority and living in a high-proportion minority facility on QoL. While white residents’ unadjusted QoL scores remained stable over time, scores for minority residents declined. In full models, white residents in low-minority facilities consistently had the highest QoL scores while minority residents in high-minority facilities had the lowest scores. More policy attention is needed to address these persistent and possibly widening racial disparities, with targeted attention needed for high-minority facilities.

Nursing homes (NHs) are often racially segregated, and minority residents admitted to NHs usually have more advanced stages of dementia at the time of admission than their white counterparts, with different care needs. Previous work has shown that racial disparities in NH quality of life (QoL) were partially due to different case mix of white and minority residents; it is unclear if disparities persist when comparing residents with similar ADRD diagnoses. The 2011-2015 Minnesota Resident Quality of Life and Satisfaction with Care Survey data contain in-person resident responses from a random sample of residents of all Medicare/Medicaid certified NHs in the state, about 40% of whom have AD/ADRD. These data were linked to the Minimum Data Set (MDS) and facility characteristics data. The population consists of 25,039 White, 580 Black, 94 Hispanic, 229 Native Americans, and 99 Asian/Pacific Islander NH residents with ADRD residing in 376 NHs. Racial/ethnic minority residents reported significantly lower QoL scores compared to their white counterparts, with the largest disparities in the food and relationships domains. We adjusted for resident (age, marital status, education, sex, length of stay, anxiety/mood disorder, activities of daily living scores) and facility characteristics (proportion of minority residents, ownership, urban vs rural, size, and occupancy ratio) using a multivariate random intercept model. After adjustment, significant differences remained in total QoL score and several QoL domains for Black, Asian and Hispanic residents (no significant differences for Native American residents). Practice guidelines should consider different care needs of racial/ethnic minority NH residents with ADRD.

Dictionary of Literary Biography. Vol. 343. New York: Gale Cengage Learning, 2009. 424 pp. $267.00 cloth.

This paper will present a form of mobility control for a 6x6 Hybrid Electric Vehicle (HEV). The vehicle concerned is a series configured HEV utilising Hub Mounted Electric Drives (HMED) at each of the six wheel stations to provide Individual Wheel Control (IWC). Whereas a conventional vehicle needs individual brake actuators or bulky differentials to vary individual wheel torques, IWC can be realised in this hybrid configuration through software control of each HMED, making it potentially more accurate, responsive and flexible than a mechanically implemented version. Direct Yaw-moment Control (DYC) is a method of regulating individual wheel torque to control vehicle yaw motion, providing greater stability in cornering. By varying the torque applied to the left and right wheels, tyre forces can be controlled to produce a desired yaw moment. Not only can this be used to aid cornering, but also to reject disturbances, such as side winds, in straight line running. When combined with a Traction Control System (TCS), optimisation of these tyre forces are considered, ensuring that the vehicle handling characteristics remain stable while acceleration performance is improved. When integrating these two systems, consideration is given to the torque demands of each controller. This co-ordinated control ensures that the vehicle takes full advantage of the torque capabilities associated with the electric motor to provide improved vehicle handling, acceleration and stability. The proposed control algorithms are implemented in MATLAB/SIMULINK on a basic non-linear vehicle handling model utilising a Dugoff tyre model to determine longitudinal and lateral tyre forces. The torque of each individual wheel is controlled to maintain a desired yaw rate and/or wheel slip. The model is then simulated on a number of road surfaces, undertaking a variety of test manoeuvres to assess the potential improvements that the combined controller can offer over a vehicle with fixed-torque distribution. The paper shows how the resultant controller offers a robust method of improving vehicle mobility, providing good stability under varying conditions.