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Antipsychotic medication use for nursing home residents with dementia poses major patient safety challenges. This article investigates health professionals’ experiences with decision-making during changes under the National Partnership to Improve Dementia Care in Nursing Homes (National Partnership) and its companion state coalitions. These programs were introduced in 2012 to encourage reductions in antipsychotic use and increased use of nonpharmacological treatments for dementia. Interviews with 40 nursing home physicians and staff in seven states found that reducing antipsychotics is more time and resource-intensive than relying on medication, because it requires a person-centered approach. However, respondents supported reductions in antipsychotic use, and indicated that with sufficient staffing, effective communications, and training, they could create or implement individualized treatments. Their positive attitudes suggest that the National Partnership has been a catalyst in reducing antipsychotic medications, and their perspectives can inform further research, policy and practice in nursing homes toward achieving quality dementia care.

Background and Objectives Antipsychotic medications have been widely used in nursing homes to manage behavioral and psychological symptoms of dementia, despite significantly increased mortality risk. Use grew rapidly during the 2000s, reaching 23.9% of residents by 2011. A national campaign for safer dementia care in U.S. nursing homes was launched in 2012, with public reporting of quality measures, increased regulatory scrutiny, and accompanying state and facility initiatives. By the second quarter of 2019, use had declined by 40.1% to 14.3%. We assessed the impact of state and facility initiatives during the Campaign aimed at encouraging more-judicious prescribing of antipsychotic medications. Research Design and Methods Our mixed-methods strategy integrated administrative and clinical data analyses with state and facility case studies. Results Results suggest that substantial change in prescribing is achievable through sustained, data-informed quality improvement initiatives integrating educational and regulatory interventions, supported by public quality reporting. Adequate staffing, particularly of registered nurses, is key to support individualized management of symptoms through nonpharmacological strategies. Case study results suggest that state and facility initiatives during the campaign achieved considerable buy-in for the goal of more conservative prescribing, through a social process of normalization. Reporting and reduction of antipsychotic use was not followed by increases in sedative-hypnotic medication use. Rather, sedative-hypnotic use declined in tandem with antipsychotic reduction, suggesting that increased attention to prescribing patterns led to more cautious use of other risky psychotropic medications. Discussion and Implications Quality improvement initiatives to change entrenched but problematic clinical practices face many barriers to success, including provider-level inertia; perceptions that alternatives are not available; and family and staff resistance. Nevertheless, systemic change is possible through concerted, collaborative efforts that touch prescribing practices at multiple points; integrate educational and regulatory influences; activate local and state champions for improvement; foster reputational influences through public reporting and benchmarking; and support a social process of normalization of preferred care processes as a best practice that is in the interest of patients.

OBJECTIVE Improved treatments for juvenile idiopathic arthritis (JIA) have increased remission rates. We conducted this study to investigate how patients and caregivers make decisions about stopping medications when JIA is inactive. METHODS We performed a mixed-methods study of caregivers and patients affected by JIA, recruited through social media and flyers, and selected by purposive sampling. Participants discussed their experiences with JIA, medications, and decision-making through recorded telephone interviews. Of 44 interviewees, 20 were patients (50% ages

Safe management of behavioral and psychological symptoms of dementia, with reduced reliance on antipsychotics, has been the focus of national and state safer-use initiatives. This paper will examine factors associated with successful reduction in antipsychotic use, drawing on a mixed-methods study integrating nursing home data analysis with state and facility case studies examining state strategies for improvement and how these strategies were experienced by staff and prescribers. Overall, use rates have declined by 35%, from 23.9% to 15.4%, since the 2012 launch of the U.S. national campaign. Success has varied considerably across states and facilities, highlighting needs to better understand the levers for improvement. Several large states, notably California and Texas, made greater progress later in the campaign than earlier, highlighting the importance of sustained implementation in large systems. Results suggest that sustainable risk reduction is facilitated by effective integration of educational and regulatory elements and by adequate staff resources. The initiatives achieved considerable buy-in on the need to reduce antipsychotic use, but staffing shortages, overprescribing of antipsychotics at hospitals, and pressure from families were limiting factors. Substantial improvement is achievable, but sustaining improvement will require continuing collaborative effort. Nursing staffing and dependence on Medicaid emerged as key factors, highlighting economic challenges of assuring safe care for residents with dementia. Converging quantitative and qualitative finding demonstrate that improvement depends on a process of normalization of preferred practices and their incorporation into routine care processes, which will require continuing reinforcement and support to be sustained.

In conjunction with the National Partnership to Improve Dementia Care in Nursing Homes initiated in 2012, states implemented initiatives to reduce antipsychotic use. All achieved substantial reductions, but improvement varied across states. By 2018, several states had achieved reductions of more than 45%, including several of the largest states. These reductions are noteworthy given the challenging nature of behavioral symptoms of dementia, and difficulties encountered historically and internationally in changing strongly-rooted clinical practices. How were these successful interventions achieved in high-performing state initiatives? What were the barriers encountered and facilitators that helped overcome these barriers? What does this experience suggest for sustainability of change? To address these questions, we draw on a mixed-methods study of antipsychotic prescribing in nursing homes incorporating analyses of prescribing data, state policy case studies, and facility case studies. Successful states integrated large-scale educational initiatives with strong regulatory action, often focusing especially on laggard facilities. Texas’ initiative was particularly noteworthy, achieving a 56.5% reduction across its far-flung network of nearly 100,000 residents and 1,200 facilities. Texas used metrics to identify facilities that achieved notable reductions in antipsychotic prescribing, and encouraged them to share their strategies with “late adopters”. The state deployed a designated Quality Monitoring Program (QMP), distinct from the survey process, to provide on-site technical assistance to laggard facilities, and provided education for all levels of staff and assistance in implementing data-driven improvement strategies. Successful state initiatives achieved considerable buy-in on the need to reduce antipsychotic use, a key factor in achieving successful system change.

To describe pharmacy students' changes in self-perceptions during a program that introduces them to working as a "patient navigator" with patients who have diabetes. Pharmacy students were trained during their Advanced Pharmacy Practice Experience (APPE) as part of a continuing study of patients in an urban clinic. The interdisciplinary program combines hands-on experience in primary care with behavioral knowledge including cultural competency. Training by pharmacy and social science faculty included the use of lectures, video, and role-playing. These applied clinical education, motivational interviewing, and a well-tested behavioral model of health beliefs. The students then observed and held direct, supervised interactions with patients. To assess their experience, students completed surveys at the beginning and end of the five-week rotations. This article discusses responses from 34 students (2009–2012) and compares changes in students' perceptions after the experience. Students' self-perceptions of their knowledge or abilities in four areas of patient self-management were significantly more positive upon completion: providing diabetes education, setting self-management goals, identifying barriers to treatment, and understanding patients' health beliefs and attitudes. Students felt that the experience was useful for their professional development and future practice. Exposing students to skills as patient navigators can have a positive effect on their confidence about assisting with diabetes management. Hands-on application of behavioral techniques and cultural competence within a primary care-based APPE can provide a promising learning experience. This is meaningful for today's pharmacists, who will function in a multicultural environment, in which diabetes has a powerful effect on public health.

Although it is a well-recognized standard in high-quality survey development, cognitive-based testing of surveys has not been standard practice in long-term care research or has not been commonly reported in research publications. Although focus groups and pilot testing have been routinely utilized, few nursing home (NH) studies have reported including cognitive testing as part of survey development (e.g., see Frank, Flynn, & Rothman, 2001; Housen et al., 2008; Katz et al., 2009). Cognitive-based testing is the systematic testing of survey questions intended to determine how respondents understand the question and the thought process involved in providing an answer (Presser et al., 2004). This form of testing is used to establish how respondents understand and interpret questions, to determine how and why they choose specific responses, and to identify questions that are difficult for respondents for a variety of reasons. The main objectives of cognitive-based testing are to reduce measurement error, increase validity, and improve response rates (Jobe & Mingay, 1989) by identifying instances where researchers have different interpretations of terms or concepts from those of respondents. Unlike pilot testing, cognitive-based testing examines the assumptions researchers may make about how terms are defined and understood without realizing that these assumptions may not be shared. Cognitive-based testing is also useful for determining those instances where respondents may simply not possess the information the researcher is seeking to collect. Identifying differing interpretations of terms and concepts regarding philosophies and systems of care may be especially important when new trends emerge and then evolve within the field, such as NH “culture change” and “palliative care.” For example, the Consumer Assessment of Health Providers and Systems survey was originally designed to include measures of “coordination of care” and “shared decision making,” but these constructs ultimately were not included in the final survey because uniformly understood questions could not be developed (Levine, Fowler, & Brown, 2005). Furthermore, researchers, clinicians, administrators, and consumers may have different perspectives or understanding of such complex concepts. A recent study found that those in the long-term care field who were not directly involved in the provision or study of palliative care knew little about its philosophy or strategies (Lima, Miller, & Shield, 2009). Cognitive-based testing can play an important role in developing surveys that more accurately measure practitioners’ understanding of and response to emerging concepts. Determining where mismatches occur between the interpretation of terms and concepts by researchers and those of long-term care professionals may also have important implications for future research and policy and may explain discrepant findings in past research. For example, numerous studies have examined turnover among NH employees and found widely varying results (Barry, Kemper, & Brannon, 2008). A review of the turnover literature by Castle (2006) revealed a wide range of reported turnover rates for nurse aides (14% to 346%), licensed practical nurses (LPNs, 8% to 103%), and registered nurses (RNs, 19% to 64%). This may be related in part to discrepant interpretations of the concept of “turnover” between those designing surveys and those responding to surveys or may be related to other measurement issues not previously discovered. The purpose of this study was to cognitively test two instruments, one designed to be administered to Nursing Home Administrators (NHAs) and one to directors of nursing (DONs) in a national study. We sought to ensure that survey respondents understood questions as intended, to determine whether the NHA or the DON was best able to answer questions on certain topics, and to inform the answer choices provided for questions. In doing so, we also identified a number of issues that raise concerns about the validity of previous questionnaires and the assumptions implicit in some long-term care policy.

Since 2012, some states have reduced inappropriate prescription of APs in nursing homes (NHs) by 20–25%, while others show little change. To assist attendees in replicating quality improvement across facilities and states, case studies from the field will provide successful facility-level dementia care strategies. As part of an AHRQ-funded study, administrators and prescribers (medical directors, physicians, consulting pharmacists, and directors of nursing) are interviewed by phone at 14 NHs in 7 states. They describe the decision process for prescribing APs, and issues prescribers face including how they are affected by changes in regulations, barriers to change, and sources of improvement. Their descriptions cover a range of NHs by facility size, organizational status (for profit/not-for-profit), proportion of Medicaid-covered residents, and progress in reducing AP use. These case studies of high success vs. limited success will provide examples of points of intervention, and effective alternative strategies for addressing dementia in NHs.

Many believe that managed care creates pressure on physicians to increase productivity, see more patients, and spend less time with each patient.We used nationally representative data from the National Ambulatory Medical Care Survey (NAMCS) of the National Center for Health Statistics and the American Medical Association's Socioeconomic Monitoring System (SMS) to examine the length of office visits with physicians from 1989 through 1998. We assessed the trends for visits covered by a managed-care or other prepaid health plan (prepaid visits) and non-prepaid visits for primary and specialty care, for new and established patients, and for common and serious diagnoses.Between 1989 and 1998 the number of visits to physicians' offices increased significantly from 677 million to 797 million, although the rate of visits per 100 population did not change significantly. The average duration of office visits in 1989 was 16.3 minutes according to the NAMCS and 20.4 minutes according to the SMS survey. According to both sets of data, the average duration of visits increased by between one and two minutes between 1989 and 1998. The duration of the visits increased for both prepaid and nonprepaid visits. Nonprepaid visits were consistently longer than prepaid visits, although the gap declined from 1 minute in 1989 to 0.6 minute in 1998. There was an upward trend in the length of visits for both primary and specialty care and for both new and established patients. The average length of visits remained stable or increased for patients with the most common diagnoses and for those with the most serious diagnoses.Contrary to expectations, the growth of managed health care has not been associated with a reduction in the length of office visits. The observed trends cannot be explained by increases in physicians' availability, shifts in the distribution of physicians according to sex, or changes in the complexity of the case mix.

This is a practice-based essay, drawing upon current research and practice in long term care planning and finance. The main thesis is that women of all ages, including those who are well educated, and those who are in business occupations, resist thinking about their own long term care needs. As a result, women are at great risk for financial exposure and impoverishment when they reach old age. The authors explore the reasons for women's attitudes and make recommendations for steps that should be taken to change women's perceptions and assist them in planning for their needs. The article focuses on the different reasons for this resistance at three different stages of the life cycle: under age 40, ages 40-55, and over age 55. Four case studies, drawn from the authors' practice, are cited. The demographic and economic realities are defined, based on published research. Given the disparity between women's perceptions and the demographic and economic projections, the authors conclude with a series of steps t...

Starting roughly a quarter century ago, american medicine began a dramatic transformation from a system dominated by clinicians' decision making and professional norms to one in which medical care is expected to reflect the preferences and choices of individual consumers. This growing aspiration toward “medical consumerism” began during the 1970s with a set of popular social movements devoted to giving patients more control over their own treatment and a more informed choice of their physicians (Rodwin 1994). Although the seeds of consumerism were only haphazardly sown and incompletely germinated (Hibbard and Weeks 1987), by the end of the decade they had grown into a noticeable presence in the health care system (Haug and Lavin 1981). During the 1980s, these shifts in popular attitudes were reinforced by public policies and private practices intended to give consumers greater incentives to learn more about their medical choices and to exercise these choices in a cost-conscious manner (Arnould, Rich, and White 1993).

Managed care organizations (MCOs) are facing intense criticism at national, state, and local levels and battling initiatives that would impose stricter regulation. Medical directors of HMOs were surveyed regarding their organizations' strategies of communication, the programs they have instituted to build trust, and their commitment to sponsoring family and patient support groups. The responses obtained from 252 directors indicate that nonprofit and free-standing organizations are more likely than either for-profit HMOs or organizations that are part of a chain to sponsor community activities and programs and to offer family and patient support groups. Staff- and group-model HMOs are more likely than other organizational configurations to initiate many types of "trust programs." The results indicate that more dispersed and "virtual-type" organizations must explore ways to respond meaningfully to community concerns--and to public health, prevention, and health promotion needs as well--while continuing to improve their practice patterns.