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Purpose: Nursing facilities with nurse practitioners or physician assistants (NPs or PAs) have been reported to provide better care to residents. Assuming that freestanding nursing homes in urban areas that employ these professionals are making an investment in medical infrastructure, we test the hypotheses that facilities in states with higher Medicaid rates, and those in more competitive markets and markets with higher managed care penetration, are more likely to employ NPs or PAs. Design and Methods: The Online Survey Certification and Reporting System (OSCAR) database, Area Resource File, and information from surveys of state policies from 1993 to 2002 are used to study the employment of NPs or PAs, using a cross-sectional time-series generalized estimating equation model with surveys nested within facilities, testing several market and state-policy effects while controlling for facility and market characteristics. Results: Throughout the 1990s the proportion of nursing facilities with NPs or PAs doubled, from less than 10% to over 20%. Facilities in states in the upper quartile of Medicaid reimbursement rates were 10% more likely to employ NPs or PAs. Facilities in more competitive markets, and in markets with higher managed care penetration, were more likely to employ NPs or PAs (adjusted odds ratio = 1.27, 1.20 respectively). Implications: More generous state Medicaid nursing home reimbursement and higher competition may advance the investment in medical infrastructure, which in turn may positively affect the quality of care provided to nursing home residents.

Background Influenza leads in preventable infection-related hospitalization in nursing home (NH) residents. The adjuvanted trivalent influenza vaccine (aTIV) is more immunogenic than similarly dosed nonadjuvanted trivalent influenza vaccine (TIV), and observational studies suggest aTIV better prevents hospitalizations in older adults. We prospectively tested this in an NH setting. Methods NHs with ≥50 long-stay residents aged ≥65 years were randomized to offer aTIV or TIV for residents for the 2016–2017 influenza season. Using intent-to-treat resident-level analysis with Cox proportional hazards regression models adjusted for clustering by facility and a priori baseline covariates (eg, age, heart failure, and facility-level characteristics), we assessed relative aTIV:TIV effectiveness for hospitalization (ie, all-cause, respiratory, and pneumonia and influenza [P&I]). Results We randomized 823 NHs, housing 50 012 eligible residents, to aTIV or TIV. Residents were similar between groups by age (mean, ~79 years), heart failure, lung disease, and influenza and pneumococcal vaccine uptake, except aTIV homes housed fewer Black residents (14.5 vs 18.9%). Staff vaccine uptake was similar (~55%). P&I and all-cause resident hospitalization rates were lower (adjusted HR [aHR],.80 [95% CI,.66–.98; P =.03] and.94 [.89–.99; P =.02], respectively) for aTIV versus TIV, while the respiratory hospitalization rate was similar, in a season where vaccine effectiveness was considered poor. Conclusions aTIV was more effective than TIV in preventing all-cause and P&I hospitalization from NHs during an A/H3N2-predominant season when TIV was relatively ineffective. Clinical Trials Registration NCT02882100. [ABSTRACT FROM AUTHOR]

The last days of life for a substantial proportion of dying older adults are spent in nursing homes. Considering this, the provision of Medicare hospice care in nursing homes would appear to be an equitable use of Medicare expenditures as well as a valid investment in improving the quality of life for dying nursing home residents. However, government concerns regarding possible abuse of the hospice benefit in nursing homes, as well as suggestion that the payment for the benefit in nursing homes may be excessive, has perhaps slowed the adoption of hospice services into the nursing home setting. Currently, access to hospice care in nursing homes is inequitable across facilities, and across geographic areas. In nursing homes where hospice is available and present, however, recent research documents superior outcomes for residents enrolled in hospice, and perhaps for nonhospice residents. Still, more research is needed, particularly research focusing on the government costs associated with the provision of hospice care in nursing homes. If subsequent research continues to support the "added value" of hospice care in nursing homes and at the same or less total costs, the issue of foremost concern becomes how equitable access to Medicare hospice care in nursing homes can be achieved. Access may be increased to some extent by changing government policies, and conflicting regulations and interpretive guidelines, so they support and encourage the nursing home/hospice collaboration. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Study Participants Key Measures Analytic Plan Results Conclusions With the growing number of Medicare beneficiaries attributed to Accountable Care Organizations (ACO) or enrolled in Medicare Advantage (MA) and their financial incentives to lower the cost of the cared patients, it is essential to understand how these alternative payment models affect post‐acute outcomes among beneficiaries, with or without dementia diagnoses. In this study, we examined the quality of skilled nursing facilities (SNFs) that beneficiaries entered after hospital discharge under different payment models.Medicare beneficiaries who were discharged from hospitals and admitted to SNFs between 2013 and 2018.The exposure variable was a payment indicator, including ACO, MA, or non‐ACO traditional Medicare (TM) fee‐for‐service. The dependent variable was high overall quality SNF, defined as with at least 4‐star rating in the CMS Nursing Home Care Compare.We examined the payer distribution by dementia diagnosis using ZIP Code Tabulation Areas (ZCTAs) fixed effects and adjusted for age, gender, and race. We also estimated the probabilities of entering high‐quality SNF as a function of payer status and dementia diagnosis each year using hospital and ZCTA fixed effects and accounting for beneficiary‐level covariates.Among SNF admissions from 2013 to 2018, the share of ACO‐attributed beneficiaries increased from 7.6% to 20.2%, MA enrollees increased from 25.2% to 32.8%, and non‐ACO‐attributed TM enrollees decreased from 67.2% to 47.3%. Consistently, ACO‐attributed beneficiaries were the most likely, while MA enrollees were the least likely to enter high‐quality SNFs, regardless of dementia diagnosis.Our findings highlight significant differences in access to high‐quality SNFs across Medicare payment models, with ACO‐attributed beneficiaries consistently experiencing better access than their MA or traditional Medicare counterparts, regardless of dementia diagnosis. These results underscore the need for further investigation into how payment models influence care quality and access, particularly for vulnerable populations. [ABSTRACT FROM AUTHOR]