Health Care Administration and Organization

Collection of articles on Health Care Administration and Organization is available here.

Nurses’ knowledge about malnutrition in older people: A multicenter cross-sectional study.
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B. Bassola, V. Tommasi, L. Bonetti, S. Bauer and M. Lusignani.
Nutrition 2020 Jul 18;78:110947
Malnutrition, among older people, has a prevalence of 22% in hospitals, 17.5% in nursing homes, and 8.7% in home care. Adequate knowledge among health care staff is necessary for risk identification and adequate intervention. The aim of this study was to translate and validate the Knowledge of Malnutrition-Geriatric (KoM-G) questionnaire in Italian and to investigate the malnutrition knowledge of registered nurses working in hospitals, nursing homes, home care, and palliative care in Italy. METHOD: The KoM-G questionnaire was translated and validated in terms of content validity, internal consistency, and interrater reliability. Subsequently, a multicenter cross-sectional study in different settings was performed. RESULTS: The KoM-G ITA questionnaire showed excellent content validity, internal consistency, and good intrarater reliability. There were 511 nurses who completed the questionnaire. On average, 61.9% of the respondents answered the questions correctly. CONCLUSION: The level of knowledge about malnutrition in nurses is adequate. Training courses and management protocols should be implemented to improve nursing care for malnourished older people.

Nurse Decision-making for Suspected Urinary Tract Infections in Nursing Homes: Potential Targets to Reduce Antibiotic Overuse.
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A. S. Beeber, C. E. Kistler, S. Zimmerman, et al.
J Am Med Dir Assoc 2020 Aug 21
To determine what information is most important to registered nurses’ (RNs) decisions to call clinicians about suspected urinary tract infections (UTIs) in nursing home residents. DESIGN: Web-based discrete choice experiment with 19 clinical scenarios. SETTING AND PARTICIPANTS: Online survey with a convenience sample of RNs (N = 881) recruited from a health care research panel. METHODS: Clinical scenarios used information from 10 categories of resident characteristics: UTI risk, resident type, functional status, mental status, lower urinary tract status, body temperature, physical examination, urinalysis, antibiotic request, and goals of care. Participants were randomized into 2 deliberation conditions (self-paced, n = 437 and forced deliberation, n = 444). The degree to which evidence- and non-evidence-based information was important to decision-making was estimated using unconditional multinomial logistic regression. RESULTS: For all nurses (22.8%) and the self-paced group (24.1%), lower urinary tract status had the highest importance scores for the decision to call a clinician about a suspected UTI. For the forced-deliberation group, body temperature was most important (23.7%), and lower urinary tract status was less important (21%, P = .001). The information associated with the highest odds of an RN calling about a suspected UTI was painful or difficult urination [odds ratio (OR) 4.85, 95% confidence interval (CI) 4.16-5.65], obvious blood in urine (OR 4.66, 95% CI 3.99-5.44), and temperature at 101.5° (OR 3.80, 95% CI 3.28-4.42). For the self-paced group, painful or difficult urination (OR 5.65, 95% CI 4.53-7.04) had the highest odds, whereas obvious blood in urine (OR 4.39, 95% CI 3.53-5.47) had highest odds for the forced-deliberation group. CONCLUSIONS AND IMPLICATIONS: This study highlighted the importance of specific resident characteristics in nurse decision-making about suspected UTIs. Future antimicrobial stewardship efforts should aim to not only improve the previously studied overprescribing practices of clinicians, but to improve nurses’ assessment of signs and symptoms of potential infections and how they weigh resident information.

A new model of care and in-house general practitioners for residential aged care facilities: a stepped wedge, cluster randomised trial.
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T. P. Haines, A. J. Palmer, P. Tierney, L. Si and A. L. Robinson.
Med J Aust 2020 May;212(9):409-415
To evaluate whether an alternative model of care in aged care facilities, including in-house general practitioners, influenced health outcomes for residents. DESIGN: Stepped wedge, cluster randomised controlled trial over 90 weeks (31 December 2012 – 21 September 2014), with a 54-week pre-trial retrospective data period (start: 19 December 2011) and a 54-week post-trial prospective data collection period (to 4 October 2015). PARTICIPANTS, SETTING: Fifteen residential aged care facilities operated by Bupa Aged Care in metropolitan and regional cities in four Australian states. INTERVENTION: Residential aged care facilities sought to recruit general practitioners as staff members; care staff roles were redefined to allow registered nurses greater involvement in care plan development. MAIN (PRIMARY) OUTCOME MEASURES: Numbers of falls; numbers of unplanned transfers to hospital; polypharmacy. RESULTS: The new model of care could be implemented in all facilities, but four could not recruit in-house GPs at any time during the trial period. Intention-to-treat analyses found no statistically significant effect of the intervention on the primary outcome measures. Contamination-adjusted intention-to-treat analyses identified that the presence of an in-house GP was associated with reductions in the numbers of unplanned hospital transfers (incidence rate ratio [IRR], 0.53; 95% CI, 0.43-0.66) and admissions (IRR, 0.52; 95% CI, 0.41-0.64) and of out-of-hours GP call-outs (IRR, 0.54; 95% CI, 0.36-0.80), but also with an increase in the number of reported falls (IRR, 1.37; 95% CI, 1.20-1.58). CONCLUSIONS: Recruiting GPs to work directly in residential aged care facilities is difficult, but may reduce the burden of unplanned presentations to hospitals and increase the reporting of adverse events. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry, ACTRN12613000218796 (25 February 2013).

Factors Associated With Antimicrobial Use in Nursing Home Residents With Advanced Dementia.
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M. Hendricksen, D. Habtemariam, E. M. C. D’Agata and S. L. Mitchell.
J Am Med Dir Assoc 2020 Aug 21
Widespread antimicrobial misuse among nursing home (NH) residents with advanced dementia raises concerns regarding the emergence of multidrug-resistant organisms and avoidable treatment burden in this vulnerable population. The objective of this report was to identify facility and resident level characteristics associated with receipt of antimicrobials in this population. DESIGN: Cross-sectional analysis of baseline data from the Trial to Reduce Antimicrobial use in Nursing home residents with Alzheimer’s disease and other Dementias (TRAIN-AD). SETTING AND PARTICIPANTS: Twenty-eight Boston area NHs, 430 long stay NH residents with advanced dementia. MEASURES: The outcome was the proportion of residents who received any antimicrobials during the 2 months prior to the start of TRAIN-AD determined by chart review. Multivariable logistic regression was used to identify resident and facility characteristics associated with this outcome. RESULTS: A total of 13.7% of NH residents with advanced dementia received antimicrobials in the 2 months prior to the start of TRAIN-AD. Residents in facilities with the following characteristics were significantly more likely to receive antimicrobials: having a full time nurse practitioner/physician assistant on staff [adjusted odds ratio (aOR) 3.02; 95% confidence interval (CI), 1.54, 5.94], fewer existing infectious disease practices (eg, antimicrobial stewardship programs, established algorithms for infection management) (aOR, 2.35; 95% CI 1.14, 4.84), and having fewer residents with severely cognitively impaired residents (aOR 1.96; 95% CI 1.12, 3.40). No resident characteristics were independently associated with receipt of antimicrobials. CONCLUSIONS AND IMPLICATIONS: Facility-level characteristics are associated with the receipt of antimicrobials among residents with advanced dementia. Implementation of more intense infectious disease practices and targeting the prescribing practices of nurse practitioners/physician assistants may be critical targets for interventions aimed at reducing antimicrobial use in this population.

Function-Focused Person-Environment Fit for Long-Term Care Residents with Dementia: Impact on Apathy.
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Y. L. Jao, W. Liu, H. Chaudhury, J. Parajuli, S. Holmes and E. Galik.
Gerontologist 2020 Aug 24
Apathy is a common symptom in dementia and is associated with rapid cognitive decline, poor quality of life, and higher mortality. Lawton’s Competence and Environmental Press model suggests that an individual’s behavior and affect are influenced by the fit of their functional abilities with the environmental demands. Yet, empirical evidence on association between person-environment (P-E) fit and apathy is lacking. Thus, this study examined the relationship between P-E fit and apathy in dementia. Specifically, this study focused on the extent the physical environment fits individual functional limitations. RESEARCH DESIGN AND METHODS: This is a cross-sectional study using the baseline data from long-term care residents with dementia. The sample included 199 residents with moderate to severe cognitive impairment from four assisted living and four nursing homes. Function-focused P-E fit was measured using the Housing Enabler scale. Apathy was measured using the Apathy Evaluation Scale. Multilevel linear models were used to analyze the relationship between P-E fit and apathy. RESULTS: Findings revealed that greater P-E fit, specifically indoor environment, was significantly associated with lower apathy after controlling for age, gender, and years living in the facility. Yet, the association became not significant after controlling for individual physical function. DISCUSSION AND IMPLICATIONS: Findings support the association between function focused P-E fit and apathy, but the association is no longer significant after physical function is adjusted. Future research may explore other aspects of P-E fit and the impact of social and organizational environment on apathy in dementia.

The burden of gastroenteritis outbreaks in long-term care settings in Philadelphia, 2009-2018.
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H. Kang, Y. Khachadourian, D. Perella, T. M. Peritz, K. A. Feemster and S. E. Coffin.
Infect Control Hosp Epidemiol 2020 Aug 17:1-5
Gastroenteritis causes significant morbidity and mortality in long-term care facility (LTCF) residents, a growing population within the United States. We set out to better understand gastroenteritis outbreaks in LTCF by identifying outbreak and facility characteristics associated with outbreak incidence as well as outbreak duration and size. DESIGN: We conducted a retrospective cross-sectional study on LTCFs in Philadelphia County from 2009 to 2018. Outbreak characteristics and interventions were extracted from Philadelphia Department of Public Health (PDPH) database and quality data on all LTCFs was extracted from Centers for Medicare and Medicaid Services Nursing Home Compare database. RESULTS: We identified 121 gastroenteritis outbreaks in 49 facilities. Numbers of affected patients ranged from 2 to 211 patients (median patient illness rate, 17%). Staff were reported ill in 94 outbreaks (median staff illness rate, 5%). Outbreak facilities were associated with higher occupancy rates (91% vs 88%; P = .033) and total bed numbers (176 vs 122; P = .071) compared to nonoutbreak facilities. Higher rates of staff illness were associated with prolonged outbreaks (13% vs 4%; P < .001) and higher patient illness rates (9% vs 4%; P = .012). Prolonged outbreaks were associated with lower frequency of cohorting for outbreak management (13% vs 41%; P = .046). CONCLUSION: This study is the largest published analysis of gastroenteritis outbreaks in LTCFs. Facility characteristics and staff disease activity were associated with more severe outbreaks. Heightened surveillance for gastrointestinal symptoms among staff and increased use of cohorting might reduce the risk of prolonged gastroenteritis outbreaks in LTCF.

Certified Nursing Assistants’ Barriers and Facilitators to Accessing and Using Worksite Health Promotion Programs.
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M. Kim, Y. C. Lin, G. Luna, J. Ma and E. Stiehl.
J Occup Environ Med 2020 Aug 26
Certified nursing assistants (CNAs) are low-wage healthcare workers who provide direct care to nursing home residents, yet who experience significant health disparities. However, limited research has been conducted on CNAs’ perceived barriers and facilitators to workplace health promotion (WHP) participation. METHOD: Informed by the Consolidated Framework for Implementation Research (CFIR), 24 CNA semi-structured, in-depth interview were conducted in two Chicagoland nursing homes. RESULTS: Key barriers were time-constraints and lack of staffing, lack of access to WHP programs, and limited organizational and employer support. Facilitators included the availability of WHP programs, breaks, and other workplace benefits, and enhanced leadership and familial support CONCLUSION:: An effective WHP program must attempt to minimize the work-related, organizational, and environmental barriers while supporting high motivation of CNAs in health promotion. We offer some suggestions for enhancing CNAs’ WHP access and utilization.

Impact of a Safe Resident Handling Program in Nursing Homes on Return-to-Work and Re-injury Outcomes Following Work Injury.
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A. Kurowski, G. Pransky and L. Punnett.
J Occup Rehabil 2019 Jun;29(2):286-294
This study examined the impact of a Safe Resident Handling Program (SRHP) on length of disability and re-injury, following work-related injuries of nursing home workers. Resident handling-related injuries and back injuries were of particular interest. Methods A large national nursing home corporation introduced a SRHP followed by three years of training for 136 centers. Lost-time workers’ compensation claims (3 years pre-SRHP and 6 years post-SRHP) were evaluated. For each claim, length of first episode of disability and recurrence of disabling injury were evaluated over time. Differences were assessed using Chi square analyses and a generalized linear model, and “avoided” costs were projected. Results The SRHP had no impact on length of disability, but did appear to significantly reduce the rate of recurrence among resident handling-related injuries. As indemnity and medical costs were three times higher for claimants with recurrent disabling injuries, the SRHP resulted in significant “avoided” costs due to “avoided” recurrence. Conclusions In addition to reducing overall injury rates, SRHPs appear to improve long-term return-to-work success by reducing the rate of recurrent disabling injuries resulting in work disability. In this study, the impact was sustained over years, even after a formal training and implementation program ended. Since back pain is inherently a recurrent condition, results suggest that SRHPs help workers remain at work and return-to-work.

Qualitative Validation of the Nursing Home IT Maturity Staging Model.
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K. R. Powell and G. L. Alexander.
J Gerontol Nurs 2020 Jul 1;46(7):47-54
The goal of the current study was to qualitatively explore issues of validity, specificity, and sensitivity regarding the nursing home (NH) information technology (IT) maturity survey and staging model. Participants who completed the NH IT maturity survey were recruited during pilot testing of the survey and staging model. Cognitive interviewing was used to collect qualitative data. Findings indicate the NH IT maturity survey and staging model is a straightforward and acceptable instrument. Every participant in our study agreed with the IT maturity stage assigned to their facility, based on their total score on the IT maturity survey. However, some participants were not sure how to answer some questions on the survey because they did not have in-depth knowledge of IT processes that took place outside of their NH facility and others experienced difficulty interpreting items because their NH facility was in a time of transition. The next step in development is quantitative psychometric testing and use of the instrument in a 3-year national study

Towards specialised and differentiated long-term care services: a cross-sectional study.
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H. M. Rostad, M. S. Skinner, R. Hellesø and M. K. R. Sogstad.
BMC Health Serv Res 2020 Aug 26;20(1):793-020-05647-y
Numerous forces drive the evolution and need for transformation of long-term care services. During the previous decade, primary health care has assumed increased responsibility for developing and providing care services, but there is still limited knowledge about how European care service systems are evolving to address new tasks and patients. Based on data from Norwegian municipalities, this study aims to (1) describe the availability of specialised services in Norwegian nursing homes and home care services and (2) analyse whether structural factors, like population size and/or centrality, are associated with the availability of specialised services in nursing homes and home care. METHODS: This is a cross-sectional study of survey data. An online survey was designed specifically for this study. Its questions were developed from a comprehensive review of the literature and in partnership with a user panel. One representative from all of Norway’s 422 municipalities were invited to answer the survey from February to April 2019. In total, 277 municipalities completed the survey (response rate 66%). Chi-square analysis and Fisher’s exact test were used to test the associations between different categorical variables. RESULTS: Specialised care services were highly prevalent. For example, there were nursing home units specialising in dementia care (89%) and rehabilitation (81%) and home care teams for dementia care (79%) and reablement (76%). Approximately two-thirds of our sample were categorised as having high availability of specialisation in nursing home and home care services. The larger, more central municipalities had higher availability of specialisation compared to medium-sized and small, less central municipalities. CONCLUSIONS: Our study indicates that a majority of nursing homes and home care services provide specialised and differentiated services that serve patient groups of different ages and diagnoses. Municipalities’ population size and centrality are associated with availability of specialised services in nursing homes and home care services.

It’s Time to Resolve the Direct Care Workforce Crisis in Long-Term Care.
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K. Scales.
Gerontologist 2020 Aug 27
Nearly 4.5 million direct care workers-including personal care aides, home health aides, and nursing assistants-provide daily support to older adults and people with disabilities across a range of settings in the United States, predominantly in long-term care (LTC). Even as the population grows older and drives up demand for LTC, the sector continues its decades-long struggle to fill direct care positions and stabilize this essential workforce. Recent events and emerging trends have converged, however, to produce new opportunities to address this longstanding workforce crisis, including the unprecedented attention generated by the coronavirus disease 2019 (COVID-19) pandemic and the systemic shifts to managed care and value-based payment in LTC. This Forum article outlines the pressing direct care workforce challenges in LTC before describing these potential levers of change, emphasizing the importance of not just expanding the workforce but also maximizing direct care workers’ contributions to the delivery of high-quality services for a growing and evolving population of LTC consumers.

Adequacy of care provision in long-term home nursing arrangements: A triangulation of three perspectives.
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A. H. Seidlein, M. Buchholz, S. Salloch and I. Buchholz.
Nurs Open 2020 Jul 2;7(5):1634-1642
A growing proportion of older people in Germany receive long-term care from informal and professional caregivers at home. Their personal assessment of the individual care situation is scarcely considered. AIM: This study aimed to explore the subjective views of care recipients, informal and professional caregivers on the adequacy of care provision in long-term home care arrangements. DESIGN AND METHODS: Qualitative semi-structured face-to-face interviews were conducted with ten care recipients, ten professional caregivers and eight informal caregivers to capture their perspectives on the adequacy of the care received and delivered. Qualitative content analysis was applied using MAXQDA software. RESULTS: All groups highlighted that they perceive an underprovision of care, even though their explanations differed. The underprovision was mainly described regarding the quality rather than quantity of services. It occurs especially in interpersonal relationships and social inclusion, where the gap between the self-perceived current situation and the desires of those affected is most prominent. The ambivalent impact of home care on social participation becomes apparent. Perceptions of an overprovision of care range from the view that it appears mainly with respect to informal care to the statement that it is currently non-existent or generally impossible. Misprovision of care is experienced as serious whenever the interviewees face the challenge of preserving existing abilities or regaining certain skills.

The role of transformational leadership, job demands and job resources for patient safety culture in Norwegian nursing homes: a cross-sectional study.
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C. Seljemo, P. Viksveen and E. Ree.
BMC Health Serv Res 2020 Aug 26;20(1):799-020-05671-y
Transformational leadership style is considered to be of importance to increase patient safety, to facilitate a balance between job resources and job demands, and to create a sound patient safety culture within health care services. However, there is limited research assessing these associations within the context of nursing homes. The aim of this study was to assess the association between transformational leadership, job demands and job resources; and patient safety culture and employees’ overall perception of patient safety in nursing homes. METHOD: A cross-sectional survey of employees in four Norwegian nursing homes was conducted (N = 165). Multiple hierarchical regression analysis was used to assess the explained variance of transformational leadership, job demands and job resources on patient safety culture and overall perception of patient safety. RESULTS: Transformational leadership explained 47.2% of the variance in patient safety culture and 25.4% of overall perception of patient safety, controlling for age and gender (p < 0.001). Additionally, job demands and job resources explained 7.8% of patient safety culture and 4.7% of overall perception of patient safety (p < 0.001). CONCLUSION: Implementing transformational leadership style may be important in creating and sustaining sound patient safety culture in nursing homes. Furthermore, leaders should make an effort to facilitate a good work environment with an optimal balance between job demands and job resources, as this in turn might have a positive influence on patient safety culture.

Mental Health Care for LGBT Older Adults in Long-Term Care Settings: Competency, Training, and Barriers for Mental Health Providers.
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R. W. Smith, J. K. Altman, S. Meeks and K. L. Hinrichs.
Clin Gerontol 2019 Mar-Apr;42(2):198-203
To assess mental health providers’ experience with LGBT older adults in long-term care (LTC) settings and perceived barriers to quality care. METHODS: Providers (N = 57) completed an online survey on demographics and practice characteristics. They were also asked about: number of LGBT residents they’ve worked with, relevance of LGBT issues to their practice, preparedness, willingness to learn, hours of formal/informal training, and barriers to providing care to LGBT patients. RESULTS: Respondents were 63% psychologists, 16% social workers, 14% psychiatrists, and 5% nurses, most of whom practiced in LTC consulting roles. Most providers felt working with LGBT issues was relevant to their practice and felt well-prepared and willing to learn, though they were unaware of evidence based practices (EBTs), especially for LTC settings. They had little coursework on LGBT issues, and identified lack of training, stigma, and residents concealing their identity as the greatest barriers to quality care. CONCLUSIONS: Mental health providers in LTC facilities would benefit from more training in LGBT-specific mental health problems and evidence-based treatments, and efforts to destigmatize LGBT identities in these settings might improve access to mental health care. CLINICAL IMPLICATIONS: LGBT-specific training and EBTs are needed. Facilities need to address stigma with residents and providers.

Ophthalmic Care in Nursing Homes for the Blind: A Growing Challenge.
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H. Wagner, J. Stifter, D. Engesser, et al.
Klin Monbl Augenheilkd 2020 Aug 31
The demographic change in Germany will lead to an increase in irreversible age-related eye diseases. This will increase the need for specialised care facilities for visually impaired people. Due to reduced mobility, residents in such facilities often do not receive adequate ophthalmological care. New concepts must therefore be considered for this group of patients. One approach is to set up an ophthalmological examination unit within the facility combined with regular visits by an ophthalmologist. We now present the experience with such a model in a home for the blind. PATIENTS AND METHODS: The project was initiated in 2009. Since then there have been visits by medical staff of the Eye Center at Medical Center, University of Freiburg, every two weeks. All patient records (2010 - 2017) were reviewed systematically. The following data were extracted in a structured and anonymous way: Age at first presentation, gender, ophthalmological diagnoses and if a therapy was initiated. This data set was finally analysed descriptively. RESULTS: Out of 130 residents aged between 48 and 100 years, half were between 78 and 90 years old. The youngest resident was 48, the oldest 100 years old. The median visual acuity was 0.2. Sixty percent of the residents had at least mild visual impairment according to the WHO (visual acuity < 0.5; category 1 - 6). In one of 6 - 7 residents, visual acuity could not be determined using Snellen charts. The most frequent ophthalmological diagnoses included cataract (44%), age-related macular degeneration (36%) and glaucoma (29%). In 67 residents (52%), the ophthalmological examination lead to treatment, such as application of local therapy or planning an operation. CONCLUSION: In every second resident, the ophthalmologist’s visit lead to treatment during the observation period. This underlines the difficulty of providing ophthalmological care even in specialised institutions for the blind and visually impaired, which is possibly due to the residents’ mobility problems. The concept presented here has established a low-threshold, sustainable and high-quality ophthalmological service on site. These positive experiences indicate that corresponding measures may also be useful for other locations. However, in order to implement such a project on a larger scale, suitable financing and accounting modalities for the construction measures, the nursing staff and the ophthalmological procedure still need to be developed.