Objectives: We hypothesised that among nursing home decedents, nursing home for-profit status and poor quality-of-care ratings, as well as patient characteristics, would lower the likelihood of transfer to hospital prior to heart disease death.Methods: Using death certificates from a large metropolitan area (Tampa Florida Metropolitan Statistical Area) for 1998-2002, we geocoded residential street addresses of heart disease decedents to identify 2172 persons who resided in nursing homes (n=131) at the time of death. We analysed decedent place of death as an indicator of transfer prior to death. Multilevel logistic regression modelling was used for analysis. Cause of death and decedent characteristics were obtained from death certificates. Nursing home characteristics, including state inspector ratings for multiple time points, were obtained from Florida's Agency for Healthcare Administration.Results: Nursing home for-profit status, level of nursing care and quality-of-care ratings were not associated with the likelihood of transfer to hospital prior to heart disease death. Nursing homes > 5 miles from a hospital were more likely to transfer decedents, compared with facilities located close to a hospital. Significant predictors of no transfer for nursing home residents were being white, female, older, less educated and widowed/unmarried.Conclusions: In this study population, contrary to our hypotheses, sociodemographic characteristics of nursing home decedents were more important predictors of no transfer prior to cardiac death than quality rankings or for-profit status of nursing homes.

Objectives To evaluate an intervention to improve care transitions at the time of skilled nursing facility (SNF) discharge. Design Natural experiment using a prepost design. Setting Veterans Affairs hospital, community SNF, and outpatient clinic. Participants The pre-intervention group comprised 134 individuals discharged to the community from posthospitalization SNF care, and the intervention group was 217 individuals who received a postdischarge clinic (PDC) intervention at SNF discharge after receiving posthospitalization care at the SNF. Intervention This study is a natural experiment using a prepost design. The intervention was a one-time visit to a PDC before SNF discharge, where an advanced nurse practitioner conducted medication reconciliation, ordered medical supplies and equipment and home health services if needed, provided individual and caregiver education, and communicated the information to the individual's primary outpatient care provider through electronic medical records. Measurements The pre-PDC and PDC intervention groups were compared on various measures of hospital utilization within 30 days of the SNF discharge (number of rehospitalizations, acute care inpatient days, and emergency department (ED) visits). Results Although there was a 23% rehospitalization rate in the pre-PDC group, participants in the PDC intervention group had a 14% rehospitalization rate within 30 days of SNF discharge (P = .02). Those who received the PDC intervention had significantly fewer acute care inpatient days during the 30-day follow-up (P < .001). Although the difference in the number of ED visits between the two groups was not statistically significant, the number of ED visits per 1,000 patient follow-up days during the 30-day interval was significantly lower in the PDC intervention group (P = .03). Conclusion Comprehensive care coordination at the time of SNF discharge can reduce postdischarge hospital use in settings with shared electronic records.

This article presents preliminary evidence for a novel way of promoting use of non-psychopharmacological interventions for mental health problems among nursing home (NH) residents. Mental health assessments addressing cognitive status, mood, behavior problems, typical activities, and quality of life were conducted on newly admitted NH residents, with recommendations supporting non-psychopharmacological alternatives conveyed to the NH staff. The purpose was to determine whether non-psychopharmacological recommendations based on the assessments would have a significant influence on psychoactive prescribing patterns, use of psychological interventions, number of falls, and the number of hospitalizations among NH residents. Chart reviews were conducted 1 month post-NH assessment in a non-randomized design comparing the 23 residents in four for-profit NHs who received a mental health assessment with 25 residents in one of the for-profit NHs who did not receive an assessment. A mental health assessment administered to all incoming NH residents is feasible and takes a brief amount of time to implement. One month post-assessment, those residents who received the mental health assessment were less likely to begin to be prescribed psychoactive medication and insomnia medication, and there was a trend for them to be more likely to receive mental health consultations. Findings of this pilot study suggest that the systematic provision of such an assessment/intervention may promote good quality mental health care by reducing prescriptions of psychoactive medications and by increasing broadly defined psychological interventions. This evidence-based approach could lead to reduced medical costs that more than offset the expense of the assessments, but more controlled long-term studies with better comparison groups are needed.

PURPOSE OF THE STUDY Studies have shown that patient safety culture (PSC) is poorly developed in nursing homes (NHs), and, therefore, residents of NHs may be at risk of harm. Using Donabedian's Structure-Process-Outcome (SPO) model, we examined the relationships among top management's ratings of NH PSC, a process of care, and safety outcomes. DESIGN AND METHODS Using top management's responses from a nationally representative sample of 3,557 NHs on the 2008 Nursing Home Survey on PSC, the Online Survey, Certification, and Reporting Database, and the Minimum Data Set, we examined the relationships among the three components of Donabedian's SPO model: structure (PSC), a process of care (physical restraints), and patient safety outcomes (residents who fell). RESULTS Results from generalized estimating equations indicated that higher ratings of PSC were significantly related to lower prevalence of physical restraints (odds ratio [OR] = 0.997, 95% confidence interval [CI] = 0.995-0.999) and residents who fell (OR = 0.999, 95% CI = 0.998-0.999). Physical restraint use was related to falls after controlling for structural characteristics and PSC (OR = 1.698, 95% CI = 1.619-1.781). IMPLICATIONS These findings can contribute to the development of PSC in NHs and promote improvements in health care that can be measured by process of care and resident outcomes.

Objective: This study examines the relationship between increasing certified nursing assistants (CNAs) and licensed nurse staffing ratios and deficiencies in Florida nursing homes over a 4-year period. Methods: Data from Florida staffing reports and the Online Survey Certification and Reporting database examine the relationship among staffing levels and deficiency citations for 663 Florida nursing homes between 2002 and 2005. Using a generalized estimating equation approach in SAS Proc Genmod, we estimate the relationship between CNA and licensed nursing staff, and facilities’ total deficiency score and quality of care deficiency scores—calculated using the Centers for Medicare and Medicaid Services’ Nursing Home Compare Five-Star Quality Rating System, which accounts for the complexity of the scope and severity of the cittions. Results: Our results confirmed that higher CNA staffing levels were predictors of lower total deficiency scores and quality of care deficiency scores after controlling for facility characteristics. Conclusion: With a large sample size, repeated measure design, and advanced methods, we have found a relationship between CNA staffing and nursing home quality.

Objectives: This article focuses on justification of psychoactive medication prescription for NH residents during their first three months post-admission.Method: We extracted data from 73 charts drawn from a convenience sample of individuals who were residents of seven nursing homes (NHs) for at least three months during 2009. Six focus groups with NH staff were conducted to explore rationales for psychoactive medication usage.Results: Eighty-nine percent of the residents who received psychoactive medications during the first three months of residence had a psychiatric diagnosis, and all residents who received psychoactive medications had a written physician's order. Mental status was monitored by staff, and psychoactive medications were titrated based on changes in mental status. One concern was that no Level II Preadmission Screening and Annual Resident Review (PASRR) evaluations were completed during the admissions process. Further, while 73% had mental health diagnoses at admission, 85% of the NH residents were on a psychoactive medication three months after admission, and 19% were on four or more psychoactive medications. Although over half of the residents had notes in their charts regarding non-psychopharmacological strategies to address problem behaviors, their number was eclipsed by the number receiving psychopharmacological treatment.Conclusions: While the results suggest that NHs may be providing more mental health care than in the past, psychopharmacological treatment remains the dominant approach, perhaps because of limited mental health training of staff, and lack of diagnostic precision due to few trained geriatric mental health professionals. A critical review of the role of the PASRR process is suggested.

We examined the psychopharmacological services provided within 3 months of nursing home (NH) admission to a whole population of newly admitted Florida NH residents 65 years and older (N = 947) for a 1-year period via secondary analyses of selected variables from Medicaid and the Online Survey and Certification and Reporting System. Within 3 months of admission, 12% received nonpsychopharmacological mental health care. However, 71% of new residents received at least one psychoactive medication, and more than 15% were taking four or more psychoactive medications. Most of those being treated with psychoactive medication had not received psychopharmacological treatment 6 months prior to admission (64%) and had not received a psychiatric diagnosis 6 months preceding admission (71%). Blacks were less likely to receive medications than non-Hispanic Whites. Results expand on past research by identifying an increase in the amount of psychoactive medications prescribed to NH residents, a lack of prior psychiatric treatment and diagnoses for those currently receiving psychoactive medications, only limited provision of nonpsychopharmacological mental health care, and racial or ethnic differences in the use of medications by NHs.

This study examined the prevalence of self-reported 'poor health' among Cuban elders in Havana (n = 1,183) and Miami (n = 288) and explored the roles of chronic conditions and functional disability in their self-reports. A logistic regression model of reported poor health was estimated for each group, testing both independent and interactive effects of chronic conditions and functional disability. Despite differences in sociodemographic characteristics and disease/disability profiles between Cuban elders in the two cities, an equal proportion of each group (13%) reported poor health. Financial strain and functional disability were common predictors of self-reported poor health across the groups. Gender and chronic conditions were significant only in the Havana sample, among whom the likelihood of reporting poor health increased with female gender and the presence of chronic conditions. In the Havana sample, not only did chronic conditions have an independent effect, but also its interaction with functional disability was significant. The overall results suggest a particular role of chronic conditions in determining subjective health among elders in Havana. Findings are discussed in a sociocultural context.

Background. A myocardial infarction (MI) results typically in abrupt functional deterioration immediately postevent, followed by recovery. The post-MI health disparities experienced by black older adults may be attributable to the social and health correlates of race. We explored patterns of change in functional status in a community-based sample of 243 older white and black persons hospitalized for an incident MI.Methods. The study sample was drawn from the Established Populations for Epidemiologic Studies of the Elderly (EPESE). All older adults hospitalized for an incident MI between the first two waves of data collection were followed up yearly for two additional years. Nonlinear quadratic trajectories of functional status, as measured by disability in activities of daily living (ADL) and functional limitation (FL), were fit using mixed-effects models.Results. Although there were no nonlinear differences in ADL trajectories, there was a faster nonlinear rate of change in FL in older blacks compared to whites, independent of other social and health factors. The baseline white-black gap in FL widened after the MI by the first follow-up, continued to widen at a less accelerated pace until the second follow-up, and narrowed by the third follow-up.Conclusions. Disparities in relevant social and health factors did not account for the more abrupt deterioration in FL postevent or for the more substantial recovery in older blacks compared to older whites. Disparities in therapeutic strategies and the "survival of the fittest" may underlie the pattern of this white-black gap in FL after an incident MI.

Objective: To investigate the effects of providing a motorized scooter on physical performance and mobility.Design: Randomized clinical trial comparing scooter users with usual care. Setting: One academic and 1 Veterans Affairs medical center.Participants: Ambulatory, community-dwelling outpatients with rheumatoid arthritis or osteoarthritis of the knee.Intervention: Provision of a motorized scooter for 3 months.Main Outcome Measures: Six-minute walk distance (6MWD) and mobility methods in diverse locations at baseline, 1 month, and 3 months, and accidents while using the scooter.Results: The majority of scooter subjects (n=16/22 [72.7%]) used the scooter 4 or more days per week. The difference +/- standard deviation between the 2 groups in change in 6MWD over the study period was not statistically significant (scooter users, 16.9 +/- 73.0m [55.5 +/- 239.6ft]; usual care, 17.2 +/- 72.5m [56.5 +/- 238.0ft], P=.55). Four (18.1%) scooter users reported 9 accidents. Over the study period, the proportion of persons reporting use of a scooter (provided by the study or otherwise available) increased in the scooter-users group (eg, food stores, 16.7% to 52.6%; doctor's office, 0% to 35.7%) but not the usual-care group (food stores, 9.1% to 9.5%; doctor's office, 0% to 0%).Conclusions: Motorized scooters provided to ambulatory persons with arthritis were used intermittently. The greatest short-term risk from scooter usage appeared to be minor collisions.

AIMS:The primary objective of this retrospective case-control study in an elderly veteran population was to assess the impact of specific medications with recognized side-effects that increase the risk of a fall and were prescribed prior to fractures treated in the outpatient setting compared with patients treated for nonspecific chest pain. METHODS:Two national Veterans Health Administration (VHA) databases were used to identify 17 273 unique patients, aged > or =65 years, treated in outpatient settings with a fracture in fiscal year 2005, and for whom we could link to all of their outpatient prescriptions (809 536). For comparison, we identified other elderly patients with outpatient clinic visits for nonspecific chest pain (N = 62 331) for whom we could link with their 2 987 394 outpatient prescriptions. We categorized the fall-related medications as drugs that primarily affect the cardiovascular (CVS), the central nervous (CNS) or the muscular skeletal system (MSS). RESULTS:Significant differences in the two patient groups occurred in the CNS category. Approximately 41% of the patients with fracture-coded encounters were prescribed CNS drugs compared with 31% of the patients in the comparison group (P < 0.0003). Finally, the use of muscle relaxants in the MSS category was significantly higher in the fracture group than in the nonspecific chest pain group. CONCLUSIONS:Studies using administrative data can foster the development of more proactive pharmacovigilance systems and assist in formulary refinement, particularly in countries with national healthcare systems that have integrated patient data. Particular attention and monitoring of elderly patients taking CNS medications may be important for injury prevention.