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Despite elders' overwhelming preference for home-based care, rural elders use nursing homes at higher rates than their urban counterparts. Little is known about how rural and urban home care users differ. We used administrative data to compare the characteristics of urban and rural elders (age 60+) admitted to Michigan's Home and Community Based Services (HCBS) Waiver Program (N=6,655). Rural elders were more likely to have an acute illness immediately preceding HCBS admission (31.7% vs. 19.6%, p

Recent studies have highlighted an inverse relationship between proprietary status and quality of care in US nursing homes. One interpretation of this is that proprietary homes direct resources to profit at the expense of quality. Using data from OSCAR and the California Department of Health Services on 1098 free-standing Californian nursing homes, we investigated the relationship between quality and profit, controlling for a range of other explanatory variables. Quality was measured both in terms of total deficiencies issued by CMS surveyors and total serious deficiencies issued. Multivariate analyses revealed that profit levels were significantly related to the number of serious deficiencies issued (controlling for other variables) but not total deficiencies. Other variables found to significantly predict quality were ethnic mix of patients, percentage of patients funded under Medicaid, facility size, occupancy level and location. When these factors were controlled for, proprietary status did not significantly predict quality.

OBJECTIVES: To test the predictive properties of the Vulnerable Elders-13 Survey (VES-13) a short tool that predicts functional decline and mortality over a 1- to 2-year followup interval over a 5-year interval. DESIGN: Longitudinal evaluation with mean follow-up of 4.5 years. SETTING: Two managed-care organizations. PARTICIPANTS: Six hundred forty-nine communitydwelling older adults (>/=75) enrolled in the Assessing Care of Vulnerable Elders observational study who screened positive for symptoms of falls or fear of falling, bothersome urinary incontinence, or memory problems. MEASUREMENTS: VES-13 score (range 1--10, higher score indicates worse prognosis), functional decline (decline in count of 5 activities of daily living or nursing home entry), and deaths. RESULTS: Higher VES-13 scores were associated with greater predicted probability of death and decline in older patients over a mean observation period of 4.5 years. For each additional VES-13 point, the odds of the combined outcome of functional decline or death was 1.37 (95% confidence interval (CI)=1.25--1.50), and the area under the receiver operating curve was 0.75 (95% CI=0.71-- 0.80). In the Cox proportional hazards model predicting time to death, the hazard ratio was 1.23 (95% CI=1.19-- 1.27) per additional VES-13 point. CONCLUSION: This study extends the utility of the VES-13 to clinical decisions that require longer-term prognostic estimates of functional status and survival. [ABSTRACT FROM AUTHOR]

Background: 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.Methods: 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.Results: 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% (P < 0.05 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.Conclusions: 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. [ABSTRACT FROM AUTHOR]

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 Statewide 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. [ABSTRACT FROM AUTHOR]

The article presents an abstract of the article "Quality of Care Is Associated with Survival in Vulnerable Older Patients," published in the August 16, 2005 issue of the journal "Annals of Internal Medicine," vol. 143. In response to the question related to the problem, the author replied that evaluations of the quality of medical care often focus on processes of care, such as how often patients receive certain tests or treatments. Some people believe that a better way to measure quality of care would be to look at patient outcomes, such as how often they become sick enough to need hospitalization or how long they live. The author says that researchers found that the fewer quality-of-care measures that a patient's care met, the more likely a person was to die during the 3 years of follow-up.

Background: The availability of patient assessment data collected by all Medicare- and Medicaid-certified nursing homes (NHs) (the Minimum Data Set [MDS]) and home health agencies (HHAs) (the Outcome and Assessment Information Set [OASIS]) provides an opportunity to measure quality of care in these settings.Objective: The objective of this study was to examine methodologic issues encountered as these datasets are used to report the nation's health care in the National Healthcare Quality Report (NHQR) at national and state levels.Findings: Although the reliability of most data elements from MDS and OASIS are considered acceptable in research studies, mixed evidence exists for the reliability and validity of the quality measures themselves. Detection bias can affect the quality measures, particularly for pain and pressure ulcers. Although risk adjustment is used for all measures, effectiveness varies among measures and methods. Additional quality measures such as patient satisfaction, quality of life, and structural measures would be desirable but will require additional data collection efforts. Although the NH measures represent most NH residents, the HHA measures only apply to Medicare and Medicaid patients served by Medicare-certified agencies. Finally, the absence of clinical benchmarks limits the interpretation of the NHQR HHA and NH measures.Conclusions: Further developmental work is needed to address many of these issues to improve the usefulness of these quality measures in future NHQR reports. [ABSTRACT FROM AUTHOR]

This article cites a study conducted by researcher N.S. Wenger and colleagues, published in the November 4, 2003 issue of the medical journal "Annals of Internal Medicine," which evaluated the quality of care provided to older patients who are at risk for functional decline. Quality of care varied substantially by condition, being worst for end-of-life care and best for stroke. Care aimed at treating an illness was more likely to meet quality indicator standards than care aimed at follow-up, diagnosis, or prevention. Quality of care was better for general medical conditions than for common geriatric conditions.

Background: While a number of tools exist to predict mortality among older adults, less research has described the characteristics of Medicare Advantage (MA) enrollees at higher risk for 1 year mortality., Objectives: To describe the characteristics of MA enrollees at higher mortality risk using patient survey data., Research Design: Retrospective cohort., Subjects: MA enrollees completing the 2019 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey., Measures: Linked demographic, health, and mortality data from a sample of MA enrollees were used to predict 1-year mortality risk and describe enrollee characteristics across levels of predicted mortality risk., Results: The mortality model had a 0.80 c-statistic. Mortality risks were skewed: 6 % of enrollees had a ≥ 10 % 1-year mortality risk, while 45 % of enrollees had 1 % to < 5 % 1-year mortality risk. Among the high-risk (≥10 %) group, 47 % were age 85+ versus 12 % among those with mortality risk <5 %. 79 % were in fair or poor self-rated health versus 29 % among those with mortality risk of <5 %. 71 % reported needing urgent care in the prior 6 months versus 40 % among those with a mortality risk of 1 to<5 %., Conclusions: Relatively few older adults enrolled in MA are at high 1-year mortality risk. Nonetheless, MA enrollees over age 85, in fair or poor health, or with recent urgent care needs are far more likely to be in a high mortality risk group., Competing Interests: Declaration of competing interest The authors confirm that they have no conflicts of interest., (Copyright © 2024. Published by Elsevier B.V.)

Recent decades have seen state successes in rebalancing Medicaid long-term care from institutional care (e.g., nursing homes) into home and community settings. However, significant barriers can prevent access to home and community-based services (HCBS) among older adults and persons with dementia. Qualitative research on potential innovations and solutions in the contemporary context with attention to a wider range of state-level policy contexts is limited. Drawing on interviews with 49 key informants including state Medicaid officials, HCBS providers, and advocates for persons with dementia across 11 states, we examined perceived solutions to barriers. Key informants articulated a range of potential solutions and innovations, ranging from tangible or realized policy changes to 'magic wand' solutions. Policy research has typically focused on the former; excluding the latter may miss opportunities to envision and design a more effective long-term care system for persons living with dementia and older adults., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Limitations in the quality of race-and-ethnicity information in Medicare's data systems constrain efforts to assess disparities in care among older Americans. Using demographic information from standardized patient assessments may be an efficient way to enhance the accuracy and completeness of race-and-ethnicity information in Medicare's data systems, but it is critical to first establish the accuracy of these data as they may be prone to inaccurate observer-reported or third-party-based information. This study evaluates the accuracy of patient-level race-and-ethnicity information included in the Outcome and Assessment Information Set (OASIS) submitted by home health agencies., Methods: We compared 2017-2022 OASIS-D race-and-ethnicity data to gold-standard self-reported information from the Medicare Consumer Assessment of Healthcare Providers and Systems® survey in a matched sample of 304,804 people with Medicare coverage. We also compared OASIS data to indirect estimates of race-and-ethnicity generated using the Medicare Bayesian Improved Surname and Geocoding (MBISG) 2.1.1 method and to existing Centers for Medicare & Medicaid Services (CMS) administrative records., Results: Compared with existing CMS administrative data, OASIS data are far more accurate for Hispanic, Asian American and Native Hawaiian or other Pacific Islander, and White race-and-ethnicity; slightly less accurate for American Indian or Alaska Native race-and-ethnicity; and similarly accurate for Black race-and-ethnicity. However, MBISG 2.1.1 accuracy exceeds that of both OASIS and CMS administrative data for every racial-and-ethnic category. Patterns of inconsistent reporting of racial-and-ethnic information among people for whom there were multiple observations in the OASIS and Consumer Assessment of Healthcare Providers and Systems (CAHPS) datasets suggest that some of the inaccuracies in OASIS data may result from observation-based reporting that lessens correspondence with self-reported data., Conclusions: When health record data on race-and-ethnicity includes observer-reported information, it can be less accurate than both true self-report and a high-performing imputation approach. Efforts are needed to encourage collection of true self-reported data and explicit record-level data on the source of race-and-ethnicity information., (© 2024 The American Geriatrics Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Objective: To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality., Data Sources and Study Setting: A national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus., Study Design: Retrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics., Data Collection/extraction Methods: Hospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded., Principal Findings: We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome., Conclusions: These findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities., (© 2023 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: Nursing homes make staffing decisions in conjunction with choosing quality goals, potentially leading to endogeneity bias between staffing and quality. We use instrumental variables (IVs) to explore it., Design: Retrospective statistical analysis of 2017-2019 Payroll-Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term Care Focus., Settings and Participants: A total of 11,261 nursing homes nationally., Methods: We estimated separate models for each of 6 quality measures as dependent variables, and registered nurses (RNs), certified nurse assistants (CNAs), and licensed practical nurses (LPNs) as independent variables, including other control variables associated with quality. The models were estimated using both ordinary least squares (OLS) and 2-stage least squares (2SLS) methods, the latter accounting for endogeneity. The IVs were defined as the average staffing of competing nursing homes in the same market as the index facility., Results: Estimated coefficients for the quality measures in the 2SLS models were up to 5 times larger than in the OLS models. The 2SLS estimates for antipsychotic medications use increased with higher RN staffing [0.279 (0.004 to 0.553)] and decreased with higher CNAs [-0.125 (-0.198 to -0.052)]. Hospitalizations decreased with more RNs [-1.328 (-1.673 to -0.983)] and LPN staffing [-0.483 (-0.755 to -0.211])] and increased with CNA [0.201 (0.109 to 0.293)] staffing. Emergency room visits decreased with higher RNs [-1.098 (-1.500 to -0.696)] and increased with CNAs [0.191 (0.084 to 0.298)]. Long-stay activities of daily living [-0.313 (-0.416 to -0.209)] and short-stay functioning [-0.481 (-0.598 to -0.364)] improved only with higher CNA staffing and pressure sores improved only with increased RN staffing [-0.436 (-0.836 to -0.035)]., Conclusions and Implications: Our findings demonstrate the importance of accounting for endogeneity in studies of staffing and quality. Endogeneity changes conclusions about significance, direction, and magnitude of the relationship between staffing and specific quality measures. These findings highlight the need to further study and understand the nuanced relationship between different staffing types and different health outcomes such as the difference between the relationship of RN and CNA hours per resident day to antipsychotic quality measures., Competing Interests: Disclosures The authors declare no conflicts of interest. Debra Saliba is an employee of the Veterans Administration. The views presented here do not represent those of the Department of Veterans Affairs. The sponsor had no role except for funding. This work was supported by National Institutes of Health Grant R01AG066742., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: The sustained stress and trauma experienced by frontline nursing home (NH) staff throughout the COVID-19 pandemic has been described in health care literature and popular press. Yet, limited attention has been given to attempts to support NH staff. The objective of this study was to examine efforts to support the mental health and well-being of NH staff during the COVID-19 pandemic., Design: Qualitative, multiple-case-study design that purposively sampled NHs from 3 groups based on the Centers for Medicare & Medicaid Services NH 5-star quality performance ratings [ie, high (4-5-star), medium (3-star), and low (1-2-star)]., Settings and Participants: Ninety-four US NH leaders participated in semistructured interviews via phone, between January 2021 and December 2022., Methods: A 3-step rapid qualitative analysis process was used to conduct a thematic analysis., Results: Five themes emerged as NH leaders described strategies used to address the mental health and well-being of their staff, including (1) efforts to address stressors in staff's personal lives (eg, risk of COVID-19 transmission to families, finances), (2) providing mental health services (eg, counseling, Employee Assistance Program) and resources (eg, staff self-care, mindfulness), (3) appreciation initiatives to combat negative media portrayals of NHs, (4) fostering an environment that supports mental health and well-being (eg, leadership initiatives to prioritize mental health, embedding training on burnout into standing meetings), and (4) modifying staff benefits (eg, expanding mental health coverage within staff insurance plan, paid time off)., Conclusions: In light of concerns about NH staffing levels and the recently proposed minimum staffing levels, there is a need to design and evaluate initiatives to recruit and retain qualified NH staff. Insights into efforts implemented by NH leaders to improve mental health and well-being can inform the design of future efforts to improve staff retention., Competing Interests: Disclosure Natalie Leland, Cait Brown, Amanda Shore, Kathyrn Reed, and Debra Saliba have no conflicts to disclose. Michael Cary discloses that he is a contributor to UpToDate., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

DNA nanotechnology has revolutionized the ability to position matter at the nanoscale, but the preparation of DNA-based architectures remains laborious. To facilitate the formation of custom structures, a fully automated method is reported to produce sequence- and size-defined DNA nanotubes. By programming the sequential addition of desired building blocks, rigid DX-tile-based DNA nanotubes and flexible wireframe DNA structures are attained, where the total number of possible constructs increases as a power function of the number of different units available. Using single-molecule fluorescence imaging, the kinetics and yield of each synthetic step can be quantitatively determined, revealing differences in self-assembly dynamics as the nanotube is built up from the solid support and providing new insights into DNA self-assembly. The exploitation of automation for both assembly and analysis (through an ad-hoc developed K-means clustering algorithm) facilitates a workflow wherein the synthesis parameters may be iteratively improved upon, demonstrating how a single-molecule "assembly-analysis-optimization" sequence can be used to generate complex, noncovalent materials in good yield. The presented synthetic strategy is generalizable, making use of equipment already available in most standard laboratories and represents the first fully automated supramolecular assembly on a solid support., (© 2024 The Author(s). Advanced Materials published by Wiley‐VCH GmbH.)

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., (© 2024 The Author(s). Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)