A commitment to change: revision of HCFA's RAI.

BackgroundOral health in nursing home residents is poor. Robust, mandated assessment tools such as the Resident Assessment Instrument – Minimum Data Set (RAI-MDS) 2.0 are key to monitoring and improving quality of oral health care in nursing homes. However, psychometric properties of RAI-MDS 2.0 oral/dental items have been challenged and criterion validity of these items has never been assessed.MethodsWe used 73,829 RAI-MDS 2.0 records (13,118 residents), collected in a stratified random sample of 30 urban nursing homes in Western Canada (2007–2012). We derived a subsample of all residents (n = 2,711) with an admission and two or more subsequent annual assessments. Using Generalized Estimating Equations, adjusted for known covariates of nursing home residents’ oral health, we assessed the association of oral/dental problems with time, dentate status, dementia, debris, and daily cleaning.ResultsPrevalence of oral/dental problems fluctuated (4.8 %–5.6 %) with no significant differences across time. This range of prevalence is substantially smaller than the ones reported by studies using clinical assessments by dental professionals. Denture wearers were less likely than dentate residents to have oral/dental problems (adjusted odds ratio [OR] = 0.458, 95 % confidence interval [CI]: 0.308, 0.680). Residents lacking teeth and not wearing dentures had higher odds than dentate residents of oral/dental problems (adjusted OR = 2.718, 95 % CI: 1.845, 4.003). Oral/dental problems were more prevalent in persons with debris (OR = 2.187, 95 % CI: 1.565, 3.057). Of the other variables assessed, only age at assessment was significantly associated with oral/dental problems.ConclusionsRobust, reliable RAI-MDS 2.0 oral health indicators are vital to monitoring and improving oral health related quality and safety in nursing homes. However, severe underdetection of oral/dental problems and lack of association of well-known oral health predictors with oral/dental problems suggest validity problems. Lacking teeth and not wearing dentures should be considered an indicator for urgent oral/dental treatment needs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12963-016-0108-y) contains supplementary material, which is available to authorized users.

The Effect on Nursing Home Resident Outcomes of Creating a Household Within a Traditional Structure

The study examined 1999-2005 data on first-time nursing home admissions of individuals with mental illness, dementia, or both to identify trends and characteristics. The Minimum Data Set was used to estimate the number and percentage of persons newly admitted to nursing homes who had mental illness (schizophrenia, bipolar disorder, depression, or an anxiety disorder), dementia, or both from 1999 to 2005. Data from 2005 were used to compare demographic characteristics and comorbid conditions of the three groups and treatments received. The number of individuals admitted with mental illness increased from 168,721 in 1999 to 187,478 in 2005. The 2005 number is more than 50% higher than the number admitted with dementia only (118,290 in 2005). The increase was driven by growth in admissions of persons with depression--from 128,566 to 154,262 in 2005. Persons admitted with depression had higher rates of comorbid conditions than those admitted with dementia or with neither dementia nor mental illness. They also had high rates of antidepressant treatment and high rates of receipt of training in skills required to return to the community. Current trends show that the proportion of nursing home admissions with mental illness, in particular depression, has overtaken the proportion with dementia. These changes may be related to increased recognition of depression, availability of alternatives to nursing homes for persons with dementia, and increased specialization among nursing homes in the care of postacute, rehabilitation residents. In light of these trends, it is critical to ensure that nursing homes have resources to adequately treat residents with mental illness to facilitate community reintegration.

Objective: Healthcare aides (unregulated care providers), who deliver the majority of direct care in Canadian nursing homes, have high levels of emotional exhaustion and cynicism. However, they also have remarkably high levels of job efficacy. Strategies to empower this workforce may reduce cynicism and draw on their high levels of job efficacy. The primary objective of this study was to act as proof-of-principle to determine whether quality improvement teams led by healthcare aides could be established in nursing homes and function on a daily basis. Methods: This study was a pilot test of a complex intervention using a mixed methods approach. We used a combination of education, networking and coaching to engage staff teams in quality improvement in 1 of 3 areas (pain control, skin care or behaviour management). We measured healthcare aides’ quality of work life, informal communication and research (best practice) use before and after the intervention. To understand the effect of quality of care at the bedside we used risk-adjusted quality indicators derived from Resident Assessment Instrument - Minimum Data Set 2.0 data. Results: A total of 10 teams participated in the intervention. At least 70% of the teams succeeded in learning and applying the improvement model and methods for local measurement. For 50% of the teams, data showed measurable improvement in the clinical areas. There were no significant differences between pre and post measures of survey variables. Conclusions: We have demonstrated the ability of healthcare aides to engage in quality improvement initiatives at the bedside in a collaborative environment and advance our results as an important contribution to person-centered healthcare.

Nursing home (NH) residents’ Quality of life (QoL) is an important goal of care. However, it is understudied, particularly during the COVID-19 pandemic. Our objective was to examine whether COVID-19 outbreaks, care aide emotional exhaustion, and lack of resident access to geriatric professionals were associated with NH residents’ QoL. In this cross-sectional study (Jul-Dec 2021), we purposefully selected 9 NHs in Alberta, Canada based on their COVID-19 exposure (no or minor/short outbreaks vs repeated or extensive outbreaks). Using a validated questionnaire (DEMQOL-CH), we assessed dementia-specific QoL of 689 residents from 18 care units through video-based interviews with care aides. Independent variables included COVID-19 outbreak in the NH in the last 2 weeks (health authority records), proportion of care aides on a care unit with high emotional exhaustion scores (9-item short form Maslach Burnout Inventory), and resident access to geriatric professionals (validated facility survey). We ran mixed-effects regression models, adjusted for facility and care unit characteristics (validated facility and care unit surveys), and resident covariates (Resident Assessment Instrument – Minimum Data Set 2.0). COVID-19 outbreaks within two weeks of the data collection (β=0.189, 95% confidence interval [CI]: 0.058;0.320), higher proportions of emotionally exhausted care aides on a care unit (β=0.681, 95%CI: 0.246;1.115) and lack of access to geriatric professionals (β=0.216, 95%CI: 0.003;0.428) were significantly associated with poorer resident QoL. Policies aimed at reducing infection outbreaks, better supporting care staff, and increasing access to geriatric specialists, may help to mitigate negative effects of COVID-19 NH residents’ QoL.

Quality indicators (QIs) are used internationally to measure, compare and improve quality in residential long-term care. Public reporting of such indicators allows transparency and motivates local quality improvement initiatives. However, little is known about the quality of QIs. In a systematic literature review, we assessed which countries publicly report health-related QIs, whether stakeholders were involved in their development and the evidence concerning their validity and reliability. Most information was found in grey literature, with nine countries (USA, Canada, Australia, New Zealand and five countries in Europe) publicly reporting a total of 66 QIs in areas like mobility, falls, pressure ulcers, continence, pain, weight loss, and physical restraint. While USA, Canada and New Zealand work with QIs from the Resident Assessment Instrument – Minimal Data Set (RAI-MDS), the other countries developed their own QIs. All countries involved stakeholders in some phase of the QI development. However, we only found reports from Canada and Australia on both, the criteria judged (e.g. relevance, influenceability), and the results of structured stakeholder surveys. Interrater reliability was measured for some RAI QIs and for those used in Germany, showing overall good Kappa values (>0.6) except for QIs concerning mobility, falls and urinary tract infection. Validity measures were only found for RAI QIs and were mostly moderate. Although a number of QIs are publicly reported and used for comparison and policy decisions, available evidence is still limited. We need broader and accessible evidence for a responsible use of QIs in public reporting.

The resident assessment instrument (RAI) as a standardized assessment has become established as the gold standard in homes for the elderly and resident nursing homes in Switzerland. The RAI is an important tool with respect to the clarification of needs in long-term outpatient and inpatient nursing care in compliance with the requirements of the Health Insurance Act. The information collated in the initial assessment, the minimum data set (MDS), can be reliably utilized for the nursing process and measurement of quality. The key to success in long-term inpatient nursing can be attributed to the generalized financial solution of resource utilization groups (RUG), which is generated directly from the assessment. Due to standardized training and documentation and in the inpatient area, a uniform electronic data processing solution, a vast amount of data from the last 15 years of experience are available also for scientific use.

The objective of the paper is to review the effects of the implementation of the Resident Assessment Instrument (RAI) on process measures (quality of care plans and staff satisfaction) and outcome measures (health problems and quality of life) in nursing homes. All available publications on the effects of the RAI were included in the review. The most positive effects of the RAI were found in improvements in the comprehensiveness and accuracy of the care plans. As regards outcome quality, the RAI method had most positive effects on the health condition of nursing home residents with diminished physical and mental functioning. In psychosocial areas of assessment, fewer positive effects were found. We concluded that positive effects have been found, based on pre-test-post-test noncontrolled designs. Control-group designs are needed in future evaluation studies to determine if these positive results will hold.

This study is a comparative analysis of long-term psychogeriatric and mixed-care unit patient characteristics in nursing homes and hospitals in Helsinki. The role of the so-called psychogeriatric nursing homes is still under question and not well developed. The aims of the study were to identify and survey psychogeriatric wards and analyze whether these units differ from the rest of the long-term units/wards in terms of patients’ characteristics. Participants studied were a total of 2828 elderly long-term care residents, of which 372 were living in long-term psychogeriatric and 2456 in ordinary long-term care units. Data were drawn from the Resident Assessment Instrument (RAI) database and had been collected in the project “Benchmarking and implementation of RAI in Elderly Care in Finland”. Scales and items based on Minimum Data Set were used for the comparisons. Resident groups in psychogeriatric units and in ordinary, mixed-client settings were clearly distinguishable. The psychogeriatric residents were younger, had more comorbidity as to psychiatric diseases, and had more often psychiatric symptoms and psychotropic medications. The residents in psychogeriatric units did not differ in cognitive and functional status from those in mixed-client units and had similar comorbidity as to somatic diseases. This study shows that psychiatric symptoms that need to be addressed are common in long-care facilities. The results emphasize the importance of recognition of the multiple care needs of elderly with severe mental symptoms or illness.

the nursing home Resident Assessment Instrument (RAI) includes a set of core assessment items, known as the Minimum Data Set (MDS), for assessment and care screening and more detailed Resident Assessment Protocols in 18 areas that represent common problem areas or risk factors for nursing home residents. Its primary use is clinical, to assess residents on admission to the nursing home, at least annually thereafter and on any significant change in status and to develop individualized, restorative plans of care. to describe the content and development of the RAI, including US testing for MDS item reliability and validity of the RAI, and the results of a 4-year evaluation of the effects of its clinical use. the evaluation found that implementation of the RAI was associated with significant improvements in a variety of measures of process quality, resident functional outcomes and reduced hospitalization. Other uses of the RAI data in the USA-including payment using resident classification systems and, with RAI-based outcome-oriented quality indicators, quality assurance activities-and the status of RAI use in other countries are also summarized.

Physician Behavior Changes Following CME on the Prospective Payment System in Long-Term Care: A Pilot Study

Assuring the quality of care in any healthcare provider is a central concern and finding a robust way of measuring it remains an important challenge. On one hand, quality indicators are frequently used by commissioners of care for performance management and reimbursement and also increasingly as an aid to consumer choice. On the other hand, good measurement helps staff to achieve a virtuous circle of constant improvement. Most high income countries use some sort of composite quality indicators to assure what can be a large and complex system; however, the evidence suggests that indicators are only useful if staff are engaged and committed to collecting data reliably. This paper explores the perceptions held by senior clinical leaders about the attitudes to quality assurance of frontline staff and in particular their attitudes to a standardised assessment system used widely in the USA and internationally. The Resident Assessment Instrument is used to develop care plans and a minimum data set drawn from the assessment is used to monitor quality. Surveying 97 skilled nursing facilities in the USA, the authors found that the leaders believed their staff did not fully understand how the minimum data set is used to create the quality indicators. The clinical leaders’ own perceptions are as revealing as their interpretation of the attitudes of frontline staff. The leaders themselves appear to have placed relatively little emphasis on technical aspects of improvement including trend tools and root cause analysis. They ranked training staff in specific quality improvement techniques such as statistical process control charts as the least important improvement intervention, preferring instead more training of staff to use the indicators as a clinical assessment tool. Knowing that a change is an improvement can be difficult and traditional research statistics are inappropriate due to the lack of power in individual units or organisations. Improvement Science is a relatively new discipline that explores measuring for improvement rather than for judgement and where it is embedded in practice (such as Jonkoping Council Healthcare in Sweden, Intermountain Healthcare in Utah, USA and Salford Royal NHS

The role of estrogen in motor, cognitive, and behavioral functions in Parkinson's disease (PD) remains unclear. To determine differences in functional, cognitive, and behavioral patterns between estrogen users and non-users, we performed an observational study on 10,145 elderly women with PD using the Systematic Assessment in Geriatric drug use via Epidemiology (SAGE) database. The SAGE database consists of the Minimum Data Set (MDS), data collected on a cross-section of over 400,000 nursing home (NH) residents in five US states. Using a cross-sectional study design, we evaluated the demographics, physical and cognitive function, and mortality rates of women with PD who received estrogen (n = 195) versus those who did not receive estrogen (n = 9950). Independent of age, estrogen users were less cognitively impaired and more independent in their activities of daily living. Surprisingly, more estrogen users were depressed and more likely to be on an antidepressant than non-users. One-year death rates were comparable between estrogen users and non-users. This study supports the growing number of recent data suggesting estrogen's potential beneficial effects on PD motor and cognitive functions.

To investigate sociodemographic characteristics (SDCs) and health status of older Chinese newly admitted to a nursing home (NH) and to compare them with the characteristics of residents from other racial/ethnic groups. Secondary analysis of the admission Minimum Data Set Plus (MDS+). A New York City municipal NH near Chinatown. Two hundred fifty-eight (125 Chinese, 57 white, 53 Hispanic, and 23 black) of 292 residents consecutively admitted from November 1992 to May 1997 were selected after excluding those younger than 60 or transferred from another NH. SDCs, health status parameters (cognitive performance, physical functioning, mood/behavior patterns, and psychosocial well-being), and morbidity information (most-frequent diagnoses/conditions and medication use) documented in or generated from the MDS+. The majority of these Chinese were first-generation immigrants and spoke primarily Cantonese or Mandarin Chinese. Compared with whites, they were more likely to be married, less likely to have lived alone, more likely to be using Medicaid, less likely to make medical decision alone, and more likely to depend on family members for decision-making. Nearly three-quarters of Chinese had cognitive impairment. There was an underdiagnosis of dementia in the Chinese subjects on admission. Severe dependence in activity of daily living was identified in more than one-third of Chinese. Fewer Chinese were using psychotropic medications on admission than the whites. Similar to other groups, many of the Chinese subjects were incontinent of bowel and bladder and had chewing or swallowing problems, hypertension, anemia, and stroke. This is the first systematic report of the SDCs and health status of a group of newly admitted older Chinese to an urban NH in the United States using the Minimum Data Set database. These findings suggest that Chinese residents are as frail as other racial/ethnic residents on admission. NHs caring for older Chinese need to be sensitive to the presence of dementia, and require a staff that can speak Cantonese and Mandarin Chinese and is comfortable negotiating with families who are more likely to be the designated decision makers.

The Minimum Data Set (MDS) is a tool used by nursing homes for resident assessment and care planning, indicating facility quality and the extent of residents' care needs. The process by which the MDS is completed by facilities has not been empirically studied. Understanding common strategies and practices for completing the MDS helps further comprehend the validity of the MDS and its relevance for focusing on residents and implementing clinical nursing interventions. This article reports on the responses to a survey questionnaire addressing this process by a sample of nursing homes in Ohio. The MDS assessment was found to be an intensive activity requiring the commitment of multiple staff members. Most facilities employed at least one full-time coordinator for this task. The importance of training was noted by a number of facilities, and the Resident Assessment Instrument manual was highlighted as one of the most valued resources for completing this assessment.