Jasmine Travers Altizer

Abstract

Importance: Inappropriate use of antipsychotic medications in nursing homes is a growing public health concern. Residents exposed to higher levels of socioeconomic deprivation in the area around a nursing home may be currently exposed, or have a long history of exposure, to more noise pollution, higher crime rates, and have less opportunities to safely go outside the facility, which may contribute to psychological stress and increased risk of receiving antipsychotic medications inappropriately. However, it is unclear whether neighborhood deprivation is associated with use of inappropriate antipsychotic medications and whether this outcome is different by facility staffing levels. Objective: To evaluate whether reported inappropriate antipsychotic medication use differs in severely and less severely deprived neighborhoods, and whether these differences are modified by higher levels of total nurse staffing. Design, Setting, and Participants: This was a cross-sectional analysis of a national sample of nursing homes that linked across 3 national large-scale data sets for the year 2019. Analyses were conducted between April and June 2023. Exposure: Neighborhood deprivation status (severe vs less severe) and total staffing hours (registered nurse, licensed practical nurse, certified nursing assistant). Main Outcome and Measures: This study estimated the association between neighborhood deprivation and the percentage of long-stay residents who received an antipsychotic medication inappropriately in the nursing home at least once in the past week and how this varied by nursing home staffing through generalized estimating equations. Analyses were conducted on the facility level and adjusted for state fixed effects. Results: This study included 10966 nursing homes (1867 [17.0%] in severely deprived neighborhoods and 9099 [83.0%] in less deprived neighborhoods). Unadjusted inappropriate antipsychotic medication use was greater in nursing homes located in severely deprived neighborhoods (mean [SD], 15.9% [10.7%] of residents) than in those in less deprived neighborhoods (mean [SD], 14.2% [8.8%] of residents). In adjusted models, inappropriate antipsychotic medication use was higher in severely deprived neighborhoods vs less deprived neighborhoods (19.2% vs 17.1%; adjusted mean difference, 2.0 [95% CI, 0.35 to 3.71] percentage points) in nursing homes that fell below critical levels of staffing (less than 3 hours of nurse staffing per resident-day). Conclusions and Relevance: These findings suggest that levels of staffing modify disparities seen in inappropriate antipsychotic medication use among nursing homes located in severely deprived neighborhoods compared with nursing homes in less deprived neighborhoods. These findings may have important implications for improving staffing in more severely deprived neighborhoods..

Abstract

INTRODUCTION: Professional caregivers (nursing assistants and personal care aides) in nursing homes (NH) and assisted living (AL) provide the majority of long-term residential care for persons with Alzheimer's disease and related dementias. Their work is stressful, but until recently, no measures were available to assess stress in this workforce. Using the new Long-Term Care Cope (LTC COPE) scale, this study evaluates the relationship of coping with staff demographic characteristics and outcomes; the findings can be used to develop and evaluate interventions to improve staff well-being. METHODS: We used a cross-sectional online questionnaire completed by professional caregivers working in a purposive selection of 10 NHs and three AL communities in California, New York, and North Carolina. The sample included 391 professional caregivers and had a representative distribution by age; it was 87% female; 42% non-Hispanic/Latinx (NHL) Black, 25% NHL White, 20% Hispanic/Latinx, and 7% NHL Asian. Worker job satisfaction, mental health, and health-related quality of life were examined in relation to caregiver demographics and the following approaches to coping as measured by the LTC COPE: avoidance, adaptive psychological strategies, active engagement, maladaptive psychological strategies, minimizing emotional impact, and substance use. Statistical comparisons used non-parametric Spearman correlation coefficients. RESULTS: Little difference in coping strategies was noted by sex and education; older caregivers used adaptive psychological strategies more than younger caregivers; and traditionally minoritized adults (NHL Black, NHL Asian, and Hispanic/Latinx), compared to NHL White adults, more often used adaptive and less often used maladaptive psychological coping strategies. The use of maladaptive and avoidance strategies was strongly associated with depressive symptoms, anxiety, and burnout. DISCUSSION: Professional caregivers report using a wide variety of coping strategies, with multiple strategies being the norm, and both adaptive/engaged and maladaptive/disengaged approaches are common. Certain coping approaches are strongly linked to depression, anxiety, and burnout; attention to training and support of adaptive and positive coping may augment other efforts to improve job satisfaction and performance. The LTC COPE scale has the potential to guide and evaluate practices to improve workers’ well-being. Highlights: Professional caregivers in nursing homes and assisted living generally use multiple strategies to cope with work-related stress. Certain coping approaches are strongly linked to depression, anxiety, and burnout. The Long-Term Care Cope scale has potential to guide and evaluate practices to improve worker well-being.

Abstract

PURPOSE: To understand perceived facilitators and barriers older adults experienced in accessing coronavirus disease 2019 (COVID-19) vaccines. METHOD: An electronic survey was distributed to older adults and those familiar with experiences of older adults accessing COVID-19 vaccines. Analysis included descriptive statistics and directed content analysis of open-ended responses, guided by the National Institute on Aging Health Disparities Research Framework. RESULTS: Most participants (n = 294) identified as White (79.5%), 33.8% identified as Hispanic, 8.1% identified as Black, and 12.4% identified as Other. Two thirds of respondents were male (68.6%), and the median age was 67 years. Five key themes emerged: Availability and Accessibility, Information, Cost, Safety and Side Effects, and Sense of Security. CONCLUSION: Barriers and facilitators to accessing COVID-19 vaccines for older populations paralleled those seen in other demographics. Similar needs likely exist for access to other vaccines and health care in general. Vaccine rollouts, particularly in public health emergencies, must be carried out with care and an awareness of the barriers faced by vulnerable groups.

Abstract

Objective: To describe “What Matters” to older adults seeking emergency department (ED) care and to identify patient characteristics associated with meeting desired outcomes. Background: As part of the 4Ms framework, identifying “What Matters” has been captured across healthcare settings, yet limited attention has been directed to older adults in the ED. Methods: We performed a secondary analysis of a multicenter prospective observational study. The study enrolled 1013 patients aged 65 and older during an ED encounter and performed 90-day follow-up interviews. The primary outcome was the quantification of “What Matters” (concerns and desired outcomes) to older adults during emergency care. As secondary outcomes, we assessed concerns at day 90, if desired outcomes were met at follow-up, and patient characteristics associated with outcome achievement by estimating multivariable logistic regression models. Results: Older adults reported specific concerns at the time of the ED visit including: (1) symptom identification and/or persistence (31.4%), (2) ability to take care of oneself (19.4%), and (3) end-of-life (17.8%). Desired outcomes expressed by participants included: (1) getting well and symptom resolution (72.0%), (2) obtaining a diagnosis (25.7%), and (3) functional independence (19.5%). At day 90 follow-up, concerns remained similar to the initial ED visit, and the majority of participants (66.2%) achieved their desired outcome. Frailty (adjusted odds ratio = 0.56, 95% CI: 0.38–0.83, P < 0.01) was associated with older adults not meeting their desired outcomes. Conclusions: Older adults identified a variety of concerns during emergency care, and two-thirds reported that desired outcomes were met at longitudinal day 90 follow-up.

Abstract

~

Abstract

Importance: Staffing shortages in nursing homes (NHs) threaten the quality of resident care, and the COVID-19 pandemic magnified critical staffing shortages within NHs. During the pandemic, the US Congress enacted the Paycheck Protection Program (PPP), a forgivable loan program that required eligible recipients to appropriate 60% to 75% of the loan toward staffing to qualify for loan forgiveness. Objective: To evaluate characteristics of PPP loan recipient NHs vs nonloan recipient NHs and whether there were changes in staffing hours at NHs that received a loan compared with those that did not. Design, Setting, and Participants: This economic evaluation used national data on US nursing homes that were aggregated from the Small Business Administration, Nursing Home Compare, LTCFocus, the Centers for Medicare & Medicaid Services Payroll Based Journal, the Minimum Data Set, the Area Deprivation Index, the Healthcare Cost Report Information System, and the US Department of Agriculture Rural-Urban Continuum Codes from January 1 to December 23, 2020. Exposure: Paycheck Protection Program loan receipt status. Main Outcome and Measures: Staffing variables included registered nurse, licensed practical nurse (LPN), and certified nursing assistant (CNA) total hours per week. Staffing hours were examined on a weekly basis before and after loan receipt during the study period. An event-study approach was used to estimate the staffing total weekly hours at NHs that received PPP loans compared with NHs that did not receive a PPP loan. Results: Among 6008 US NHs, 1807 (30.1%) received a PPP loan and 4201 (69.9%) did not. The median loan amount was $664349 (IQR, $407000-$1058300). Loan recipients were less likely to be part of a chain (733 [40.6%] vs 2592 [61.7%]) and more likely to be for profit (1342 [74.3%] vs 2877 [68.5%]), be located in nonurban settings (159 [8.8%] vs 183 [4.4%]), have a greater proportion of Medicaid-funded residents (mean [SD], 60.92% [21.58%] vs 56.78% [25.57%]), and have lower staffing quality ratings (mean [SD], 2.88 [1.20] vs 3.03 [1.22]) and overall quality star ratings (mean [SD], 3.08 [1.44] vs 3.22 [1.44]) (P

Abstract

For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee's vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments.

Abstract

~

Abstract

COVID-19 vaccination and regular testing of nursing home staff have been critical interventions for mitigating COVID-19 outbreaks in US nursing homes. Although implementation of testing has largely been left to nursing home organizations to coordinate, vaccination occurred through a combination of state, federal, and organization efforts. Little research has focused on structural variation in these processes. We examined whether one structural factor, the primary shift worked by staff, was associated with differences in COVID-19 testing rates and odds of vaccination, using staff-level data from a multistate sample of 294 nursing homes. In facility fixed effects analyses, we found that night-shift staff had the lowest testing rates and lowest odds of vaccination, whereas day-shift staff had the highest testing rates and odds of vaccination. These findings highlight the need to coordinate resources and communication evenly across shifts when implementing large-scale processes in nursing homes and other organizations with shift-based workforces.

Abstract

COVID-19 vaccination and regular testing of nursing home staff have been critical interventions for mitigating COVID-19 outbreaks in US nursing homes. Although implementation of testing has largely been left to nursing home organizations to coordinate, vaccination occurred through a combination of state, federal, and organization efforts. Little research has focused on structural variation in these processes. We examined whether one structural factor, the primary shift worked by staff, was associated with differences in COVID-19 testing rates and odds of vaccination, using staff-level data from a multistate sample of 294 nursing homes. In facility fixed effects analyses, we found that night-shift staff had the lowest testing rates and lowest odds of vaccination, whereas day-shift staff had the highest testing rates and odds of vaccination. These findings highlight the need to coordinate resources and communication evenly across shifts when implementing large-scale processes in nursing homes and other organizations with shift-based workforces.