Publications on Nursing Homes Initiative

Expanding the Knowledge Base of resident and Facility Outcomes of care Delivered by Advanced Practice Nurses in Long-Term Care: Expert Panel Recommendations
In 2003, a panel of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care convened to examine and make recommendations about care quality and safety issues related to advanced practice nurses (APNs) in nursing home practice. This article reports on the panel recommendation that addressed expanding the evidence base of resident and facility outcomes of APN nursing home practice. A review of the small but important body of research related to nursing home APN practice suggests a positive impact on resident care and facility outcomes. Recommendations are made for critically needed research in four key areas: (a) APN nursing home practice, (b) relative value unit coding, (c) outcomes related to geropsychiatric and mental health nursing services, and (d) outcomes related to geriatric specialization. The APN role could be significantly enhanced and executed if its specific contribution to resident and facility outcomes was more clearly delineated through the recommended rigorous research. (Pub Med)

Bourbonniere, M., Mezey; M., Burger, S., Mitty, E., Bonner, A., Bowers, B., Burl, J., Carter, D., Dikmant, J., Kerro, S., Reinhard, S., Ter Maat, M., Nicholson, N. Expanding the Knowledge Base of resident and Facility Outcomes of care Delivered by Advanced Practice Nurses in Long-Term Care: Expert Panel Recommendations. Policy, Politics & Nursing Practice,10; 64 -70, DOI: 10.1177/1527154409332289

Health Care Professional Training: A Comparison of Geriatric Competencies Across Disciplines
Health professionals specializing in geriatrics are a unique but scarce resource who nevertheless play a critical role in shaping the care of older adults. An interdisciplinary didactic and clinical training milieu would have the potential to maximize training opportunities for geriatric healthcare professionals. The fact that little is known about the concordance between discipline-specific geriatric competencies hampers the creation of interdisciplinary geriatric training opportunities. Discipline-specific geriatric experts compared the geriatric competencies specified by geriatric-certifying bodies of five healthcare professions: dentistry, medicine, nursing, pharmacy, and social work. Overlap and differences in geriatric competencies across disciplines are presented, and opportunities and barriers to interdisciplinary geriatric education are discussed. (Pub Med)

Mezey, M.., Mitty, E., & Burger, S. (2008). Health Care Professional Training: A Comparison of Geriatric Competencies Across Disciplines.” The Journal of the American Geriatrics Society, 56 (9), 1724-1729.

A Panel Data Analysis of the Relationships of Nursing Home Staffing levels and Standards to Regulatory Deficiencies
OBJECTIVE: To examine the relationships between nursing staffing levels and nursing home deficiencies. METHODS: This panel data analysis employed random-effect models that adjusted for unobserved, nursing home-specific heterogeneity over time. Data were obtained from California's long-term care annual cost report data and the Automated Certification and Licensing Administrative Information and Management Systems data from 1999 to 2003, linked with other secondary data sources. RESULTS: Both total nursing staffing and registered nurse (RN) staffing levels were negatively related to total deficiencies, quality of care deficiencies, and serious deficiencies that may cause harm or jeopardy to nursing home residents. Nursing homes that met the state staffing standard received fewer total deficiencies and quality of care deficiencies than nursing homes that failed to meet the standard. Meeting the state staffing standard was not related to receiving serious deficiencies. CONCLUSIONS: Total nursing staffing and RN staffing levels were predictors of nursing home quality. Further research is needed on the effectiveness of state minimum staffing standards. (Pub Med)

Kim, H., Kovner, C., Harrington, C., Greene, W., Mezey, M. (2009). A Panel Data Analysis of the Relationships of Nursing Home Staffing levels and Standards to Regulatory Deficiencies. Journal of Gerontology: Social Sciences, 64B(2), 269-278.

Nursing Homes as a Clinical Site for Training Geriatric Healthcare Professionals
Nursing homes can be ideal clinical teaching and learning environments for acquiring geriatric specialty and interdisciplinary team skills, particularly those regarding assessment, care planning, management, monitoring, and collaborating in an interdisciplinary milieu. Little is known as to how geriatric specialty training programs use nursing homes to meet expected specialty competencies, or the types of clinical experiences in nursing homes required by academic geriatric training programs. This article describes the expectations of 5 clinical health care disciplines (dentistry, medicine, nursing, pharmacy, and social work) and nursing home administration regarding desirable nursing home characteristics that support gaining geriatric competencies. The issues involved in using nursing homes as supportive educational environments in geriatric education are discussed. (Pub Med)

Mezey, M., Mitty E., Burger, S. Nursing Homes as a Clinical Site for Training Geriatric Healthcare Professionals. (2009). Journal of the American Medical Directors Association, 10(3), 196-203. DOI:10.1016/j.jamda.2008.11.002

Rethinking Teaching Nursing Homes: Potential for Improving Long-Term Care
To meet the special needs of and provide quality health care to nursing home residents, the health care workforce must be knowledgeable about the aging process. Health professionals are minimally prepared in their academic programs to care for older adults, and few programs have required rotations in geriatrics. Teaching nursing homes (TNHs) have shown promise as sites for the preparation of a health workforce to care for older adults in nursing homes as well as improvement of quality outcomes. This article reports on the process and recommendations of a TNH summit of experts in geriatric education and practice as to the feasibility of developing a sustainable and replicable TNH model that would prepare a professional workforce knowledgeable about and prepared to work in long-term care. The TNH summit identified characteristics of partnerships between academia, nursing home(s), and other stakeholders that would constitute a successful TNH collaboration. Goals of a TNH partnership between service and academia include interdisciplinary education and practice, research and dissemination of evidence-based practices, and benchmarks of a nursing home professional learning environment. (Pub Med)

Mezey, M., Mitty, E., Burger, S. (2008). Rethinking Teaching Nursing Homes: Potential for Improving Long-Term Care.  The Gerontologist, 48(1), 8-15

Use of a falls incident reporting system to improve care process documentation in nursing homes
BACKGROUND: Falls are the most frequently reported adverse event among frail nursing home residents and are an important resident safety issue. Incident reporting systems have been successfully used to improve quality and safety in healthcare. The purpose of this study was to test the effect of a systematically guided menu-driven incident reporting system (MDIRS) on documentation of post-fall evaluation processes in nursing homes. METHODS: Six for-profit nursing homes in southeastern USA participated in the study. Over a 4-month period, MDIRS was used in three nursing homes matched with another three nursing homes which continued using their existing narrative incident report to document falls. Trained geriatric nurse practitioner auditors used a data collection audit tool to collect medical record documentation of the processes of care for residents who fell. Multivariate analysis of covariance was used to compare the post-fall nursing care processes documented in the medical records. RESULTS: 207 medical records of resident who fell were examined. Over 75% of the sample triggered at high risk for falls by the minimum data set. An adequate neurological assessment was documented for only 18.4% of residents who had experienced a fall. Although two-thirds of the sample had a diagnosis of incontinence, less than 20% of the records had incontinence-related interventions in the nursing care plan. Overall, there was more complete documentation of the post-fall evaluation process in the medical records in nursing homes using the MDIRS than in nursing homes using standard narrative incident reports (p<0.001). CONCLUSION: Further improvements are necessary in reporting mechanisms to improve the post-fall assessment in nursing home residents. (Pub Med)

Wagner, L..M., Capezuti, E., Clark, P.C., Parmelee, P. A., Ouslander, J.G. (2008). Use of a falls incident reporting system to improve care process documentation in nursing homes. Qual Saf Health Care,17(2),104-8.

Contractures in Frail Nursing Home Residents
Wagner, L.M., Capezuti, E., Brush, B.L., Clevenger, C., Boltz, M., & Renz, S. (in press). Contractures in frail nursing home residents. Geriatric Nursing.

Bed and Toilet Height as Potential Environmental Risk Factors for Falls in Older Nursing Home Residents: A Descriptive Study
Capezuti, E., Wagner, L.M., Brush, B.L., Boltz, M., Renz, S., &  Secic, M. (in Press). Bed and toilet height as potential environmental risk factors for falls in older nursing home residents: A descriptive study. International Journal of Nursing Studies.

Description of an Advanced Practice Nursing Consultation Model to Reduce Siderail Use in Nursing Homes
Researchers have demonstrated that the use of physical restraints in nursing homes can be reduced, particularly where advanced practice nurses (APNs) are utilized. We examined the link between APN practice, siderail reduction, and the costs of siderail alternatives in 273 residents in four Philadelphia nursing homes. The majority of participants were cognitively and physically impaired with multiple co-morbidities. APNs recommended a total of 1,275 siderail-alternative interventions aimed at reducing fall risk. The median cost of siderail alternatives to prevent falls per resident was $135. Residents with a fall history experienced a significantly higher cost of recommendation compared to non-fallers. Findings suggest that an APN consultation model can effectively be implemented through comprehensive, individualized assessment without incurring substantial costs to the nursing home. (c) 2007 Wiley Periodicals, Inc. (Pub Med)

Wagner, L.M., Capezuti, E., Brush, B.L., Boltz, M., Renz, S., & Talerico, K.A. (2007). An advanced practice nursing consultation model to reduce siderail use in nursing homes. Research in Nursing and Health, 30(2), 131-40.

Consequences of an Intervention to Reduce Restrictive Side Rail use in Nursing Homes
OBJECTIVES: To examine the effect of an advanced practice nurse (APN) intervention on restrictive side rail usage in four nursing homes and with a sample of 251 residents. A secondary question explored the association between restrictive side rail reduction and bed-related falls. DESIGN: Pre- and posttest design. SETTING: Four urban nursing homes. PARTICIPANTS: All nursing home residents present in the nursing home at three time points (n=710, 719, and 707) and a subset of residents (n=251) with restrictive side rail use at baseline. INTERVENTION: APN consultation with individual residents and facility-wide education and consultation. MEASUREMENTS: Direct observation of side rail status, resident and nurse interview for functional status, mobility, cognition, behavioral symptoms, medical record review for demographics and treatment information, and incident reports for fall data. RESULTS: At the institutional level, one of the four nursing homes significantly reduced restrictive side rail use (P=.01). At the individual participant level, 51.4% (n=130) reduced restrictive side rail use. For the group that reduced restrictive side rails, there was a significantly (P<.001) reduced fall rate (-0.053; 95% confidence interval (CI)=-0.083 to -0.024), whereas the group that continued restrictive side rail did not demonstrate a significantly (P=.17) reduced fall rate (-0.013; 95% CI=-0.056-0.030). CONCLUSION: An APN consultation model can safely reduce side rail use. Restrictive side rail reduction does not lead to an increase in bed-related falls. Although side rails serve many purposes, routine use of these devices to restrict voluntary movement and prevent falls is not supported. (Pub Med)

Capezuti, E., Wagner, L. M., Brush, B.L., Boltz, M., Renz, S., Talerico, K.A. (2007). Consequences of an intervention to reduce restrictive side rail use in nursing homes. Journal of the American Geriatrics Society, 55(3), 334-41.

Challenges to Implementing an APN-facilitated Falls Management Program in Long-term Care
Although several clinical studies have demonstrated success in reducing falls among nursing home residents, the degree of adherence to these strategies varies widely among studies and facilities, especially following the removal of external consultants or advance practice nurses (APNs). This article identified contextual factors that challenged the effective implementation of a falls reduction program. For nurses, the major problems with implementing the project involved inadequate nursing assessment and clinical decision making. APNs who influence nursing staff behavior via education and individual resident consultation may fill the critical gap in professional nursing care in nursing homes.

Capezuti, E., Taylor, J., Brown, H., Strothers III, H. S., & Ouslander, J. O. (2007). Challenges to implementing an APN-facilitated falls management program in long-term care. Applied Nursing Research. 20(1), 2-9.

Nursing Home Involuntary Relocation: Clinical Outcomes and Perceptions of Residents and Families
OBJECTIVES: To examine the physical and mental health characteristics of 120 residents 3 months following their discharge from 1 transferring nursing home to 23 facilities, to compare these characteristics to their pre-transfer status, and to describe resident and family perceptions of the transfer. DESIGN: Secondary analysis of a longitudinal, prospective quasi-experimental intervention and a qualitative description of resident and family views. SETTING: The setting was 23 nursing homes in the Philadelphia metropolitan area. PARTICIPANTS: Participants included 120 nursing home residents and 56 family members. MEASUREMENTS: Minimum Data Set (MDS) and data from the Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare Web site RESULTS: There was a statistically significant increase in the number of residents who fell during the post-transfer (76.9%) compared to the pre-transfer (51.2%) period (P = .0001): 76.3% of those with a history of falling prior to transfer fell during the post-transfer period while 77.4% of those without a history of falling prior to transfer fell. Residents were 3.78 times more likely to fall if they required more than supervision while walking (95% confidence interval [CI] 1.57-9.06) and 2.65 times more likely if they required more than supervision while transferring (95% CI 1.09-6.44). Logistic regression demonstrated that the mobility was also associated with falls (odds ratio 1.15, 95% CI 1.05-1.26). Residents did not demonstrate any other significant physical or mental health changes during the 3 months following the involuntary transfer when compared with their pre-transfer status. Residents and family members clearly voiced their dismay over the process of involuntary relocation. CONCLUSION: Relocation is a stressful event; however, a move to a higher quality care environment does not result in any significant physical or mental health changes. The high incidence of falls post-transfer in both those with and without a fall history points to the need for extra fall precautions in newly admitted residents. In particular, frequent reorientation reminders for the cognitively intact and a high level of staff surveillance for all new residents is indicated during the first few weeks of admission. (Pub Med)

Capezuti, E., Boltz, M., Renz, S., Hoffman, D., Norman, R. G. (2006). Nursing home involuntary relocation: clinical outcomes and perceptions of residents and families. Journal of the American Medical Directors Association. 7(8), 486-92.

Reporting Near-miss Events in Nursing Homes
Since the Institute of Medicine report To Err Is Human was published in 1999, improving patient safety has become a major initiative for nurses working in all care settings. Nursing homes are a fertile environment for both a high frequency of adverse events to occur and a high number of institutional barriers to reporting them. This article outlines the barriers to reporting adverse events in nursing homes and provides support for why reporting near-miss events can serve as a means of reducing these barriers. It also provides recommendations and specific strategies for how to implement near-miss reporting systems in nursing homes such as policy changes, supportive leadership, and educating nurses about near-miss events. Further nursing research in this evolving area of patient safety is warranted. (Pub Med)

Wagner, L. M., Capezuti, E., Ouslander, J. G. (2006). Reporting near-miss events in nursing homes. Nursing Outlook. 54(2), 85-93

Nursing Home Involuntary Relocation: Clinical Outcomes and Perceptions of Residents and Families
OBJECTIVES: To examine the physical and mental health characteristics of 120 residents 3 months following their discharge from 1 transferring nursing home to 23 facilities, to compare these characteristics to their pre-transfer status, and to describe resident and family perceptions of the transfer. DESIGN: Secondary analysis of a longitudinal, prospective quasi-experimental intervention and a qualitative description of resident and family views. SETTING: The setting was 23 nursing homes in the Philadelphia metropolitan area. PARTICIPANTS: Participants included 120 nursing home residents and 56 family members. MEASUREMENTS: Minimum Data Set (MDS) and data from the Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare Web site RESULTS: There was a statistically significant increase in the number of residents who fell during the post-transfer (76.9%) compared to the pre-transfer (51.2%) period (P = .0001): 76.3% of those with a history of falling prior to transfer fell during the post-transfer period while 77.4% of those without a history of falling prior to transfer fell. Residents were 3.78 times more likely to fall if they required more than supervision while walking (95% confidence interval [CI] 1.57-9.06) and 2.65 times more likely if they required more than supervision while transferring (95% CI 1.09-6.44). Logistic regression demonstrated that the mobility was also associated with falls (odds ratio 1.15, 95% CI 1.05-1.26). Residents did not demonstrate any other significant physical or mental health changes during the 3 months following the involuntary transfer when compared with their pre-transfer status. Residents and family members clearly voiced their dismay over the process of involuntary relocation. CONCLUSION: Relocation is a stressful event; however, a move to a higher quality care environment does not result in any significant physical or mental health changes. The high incidence of falls post-transfer in both those with and without a fall history points to the need for extra fall precautions in newly admitted residents. In particular, frequent reorientation reminders for the cognitively intact and a high level of staff surveillance for all new residents is indicated during the first few weeks of admission.

Capezuti, E., Boltz, M., Renz, S., Hoffman, D., & Norman, R.G. (2006). Nursing home involuntary relocation: Clinical outcomes and perceptions of residents and families. Journal of the American Medical Directors Association, 7, 486-492. (Pub Med)

Experts Recommend Strategies for Strengthening the Use of Advanced Practice Nurses in Nursing Homes
In 2003, The John A. Hartford Foundation Institute for Geriatric Nursing, New York University Division of Nursing, convened an expert panel to explore the potential for developing recommendations for the caseloads of advanced practice nurses (APNs) in nursing homes and to provide substantive and detailed strategies to strengthen the use of APNs in nursing homes. The panel, consisting of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care, developed six recommendations related to caseloads for APNs in nursing homes. The recommendations address educational preparation of APNs; average reimbursable APN visits per day; factors affecting APNs caseload parameters, including provider characteristics, practice models, resident acuity, and facility factors; changes in Medicare reimbursement to acknowledge nonbillable time spent in resident care; and technical assistance to promote a climate conducive to APN practice in nursing homes. Detailed research findings and clinical expertise underpin each recommendation. These recommendations provide practitioners, payers, regulators, and consumers with a rationale and details of current advanced practice nursing models and caseload parameters, preferred geriatric education, reimbursement strategies, and a range of technical assistance necessary to strengthen, enhance, and increase APNs' participation in the care of nursing home residents. (Pub Med)

Mezey M, Burger SG, Bloom HG, Bonner A, Bourbonniere M, Bowers B, Burl JB, Capezuti E, Carter D, Dimant J, Jerro SA, Reinhard SC, Ter Maat M. (2005). Experts Recommend Strategies for Strengthening the Use of Advanced Practice Nurses in Nursing Homes. Journal of the American Geriatrics Society, 53, 1790-1797.

Impact of a Falls Menu-driven Incident-reporting System on Documentation and Quality Improvement in Nursing Homes
PURPOSE: Data from incident-reporting systems have been used successfully in disciplines other than health care to improve safety. This study tested the effect of a falls menu-driven incident-reporting system (MDIRS) on quality-improvement efforts in nursing homes. DESIGN AND METHODS: Following instrument development and testing, the intervention occurred over a 4-month period in three intervention nursing homes using the MDIRS matched with three homes using their existing narrative incident report to document falls. Data on fall incidents were collected from facility incident reports, and comparisons in incident-report documentation were made between the intervention and control groups. The minutes from quality-improvement meetings were examined to see how incident-report data were used for fall-prevention strategies. RESULTS: Almost one third of nursing home residents among the six facilities fell during the 4-month study period. Intervention nursing homes had significantly better documentation of fall characteristics on the incident reports than did the control nursing homes. Although only one nursing home fully implemented the MDIRS intervention, all three facilities identified strengths of the system. IMPLICATIONS: The MDIRS can have a significant impact in improving how nursing staff assess residents following a fall incident. Traditional narrative methods of documenting adverse incidents are time consuming and may not yield sufficient and accurate data. This model has the potential to enhance quality-improvement efforts and augment the current system of adverse incident reporting in nursing homes. (Pub Med)

Wagner, L. M., Capezuti, E., Taylor, J. A., Sattin, R. W., Ouslander, J. G. (2005). Impact of a falls menu-driven incident-reporting system on documentation and quality improvement in nursing homes. Gerontologist, 45(6), 835-42..

Evolving Models of Geriatric Nursing Care
Outcomes of care improve when older patients are cared for by nurses with demonstrated competence in geriatrics and in environments that structure nursing care around the needs of older adults. The past twenty years has seen the development of a number of exciting new nursing models in the delivery of care for older adults. This article highlights some of these evolving models of nursing practice in assisted living, home care, hospitals, and nursing homes. (Pub Med)

Mezey, M., Boltz, M., Esterson, J., Mitty, E. (2005). Evolving Models of Geriatric Nursing Care.  Geriatric Nursing, 26(1), pp. 11-15.

Utilization of Nurse Practitioners in Long-Term Care: Findings and Implications of a National Survey
OBJECTIVES: The objective of this study was to determine the national practice patterns of nurse practitioners (NPs) providing care in long-term care (LTC) facilities, including the number and characteristics of LTC facilities that use NPs for any portion of care to residents, NP activities, and employment arrangements between NPs, physicians, and facilities. DESIGN: Mailed survey. PARTICIPANTS: Participants included all physicians who are members of the American Medical Directors Association (AMDA). MEASUREMENT: The survey instrument was constructed to obtain information in the following six domains: (1) the number of LTC facilities that have NPs involved in providing care; (2) the number of NPs engaged in care at these facilities; (3) the types of employment/financial arrangements between NPs and LTC facilities; (4) the types of services provided by the NPs; (5) the effectiveness of the NPs as perceived by the medical directors; and (6) the perceived future demand for NPs in LTC. RESULTS: Of a total of 870 respondents (response rate 19%), 546 respondents (63%) reported the involvement of NPs in the care of residents in their facilities. In total, respondents identified 1160 NPs involved in care, with a median of two NPs per responding facility (range, 1-10). Respondents reported that NPs make sick/urgent resident visits (96%), provide preventive care to long-stay residents (88%), and perform alternating required regulatory 30/60 (88%), hospice care (80%), and wound care (78%). Significant variations in practice patterns were found between NPs employed by a LTC facility (19% of respondents) as compared with those NPs employed in other arrangements. Large majorities of medical directors stated that NPs are particularly effective in maintaining physician satisfaction (90%), resident satisfaction (87%), and family satisfaction (85%). An additional 34% of the respondents projected an increased need for NPs in nursing homes in the future. CONCLUSION: NPs involved in LTC are more likely to be involved in the care of residents in the nation's larger (>100-bed) LTC facilities. The substantial number and types of services provided by these NPs, coupled with the high resident, family, and physician satisfaction with their services, suggests the need for educational, policy, and reimbursement strategies to encourage the further involvement of NPs in the care of residents in nursing homes. (Pub Med)

Rosenfeld, P., Kobayashi, M., Barber, P., Mezey, M. (2004). Utilization of Nurse Practitioners in Long-Term Care: Findings and Implications of A National Survey. Journal of the American Medical Directors Association, 5(1), 9-15.

Transferring Dying Nursing Home Residents to the Hospital: DON Perspectives on the Nurse’s Role in Transfer Decisions
This qualitative study elicits factors that influence decision-making by nurses about transferring a dying resident from the nursing home to the hospital. Focus groups with directors of nursing (DONs) from long-term care facilities revealed those decisions are influenced by knowledge (or lack thereof) of resident or family preferences, nurse interactions with physicians, nursing home technological and personnel resources, and nurse concerns about institutional liability. DONs can improve transfer decisions by communicating with all parties, clarifying nursing home processes for end-of-life care, and scheduling early and thorough conversations with residents and families about end-of-life care. DONs can implement improvements through staff education on communication issues, rigorous evaluation and performance outcome measures related to patient transfer, and conveyance to staff of the institution's mission and the nursing service's values. (Pub Med)

Bottrell, M., O’Sullivan, J., Robbins, M., Mitty, E., Mezey, M. (2001). Transferring Dying Nursing Home Residents to the Hospital: DON Perspectives on the Nurse’s Role in Transfer Decisions. Geriatric Nursing, 22(6), 313-317.

Hospital Transfer Decision-making Model
Post, L.F. and Mitty, E. (2001). Hospital transfer decision-making model. In M.D. Mezey and N.N. Dubler, eds. Voices of Decision in Nursing Homes: Respecting Residents Preferences for End-of-Life Care. NY: United Hospital Fund.

http://www.hartfordign.org/resources/policy/voices.html

Guidelines for End-of-Life Care in Nursing Facilities: Principles and Recommendations. Position paper funded by The John A. Hartford Foundation Institute for Geriatric Nursing
Mezey, M., Dubler, N., Bottrell, M., Mitty, E., Ramsey, G., Farber Post, L., et. al. (2001). Guidelines for End-of-Life Care in Nursing Facilities: Principles and Recommendations. Position paper funded by The John A. Hartford Foundation Institute for Geriatric Nursing.

http://www.hartfordign.org/resources/policy/guidelines_end_of_life.html

Research Priorities for Staffing, Case Mix, and Quality of Care in U.S. Nursing Homes
Kovner, C., Mezey, M., Harrington, C. (2000). Research Priorities for Staffing, Case Mix, and Quality of Care in U.S. Nursing Homes. Image, 32(1), 77-80.

Experts Recommend Minimum Nurse Staffing Standards for Nursing Facilities in the US
The experts concluded that current data show that the average nurse staffing levels (for RNs, LVN/LPNs, and NAs) in nursing homes are too low in some facilities to provide high quality of care. Caregiving, the central feature of a nursing home, needs to be improved to ensure high quality of care to residents. Because detailed time studies have not been conducted on the amount of time that is required to provide high quality of care to residents, expert opinion is currently the best approach to addressing the problem of inadequate staffing. Increases in the education level and training of nursing staff are also strongly recommended as a step to improving quality of care and reducing turnover rates in nursing homes. These recommendations are designed for consideration by Congress, HCFA regulators, policymakers, nursing home administrators, and nurses. Ideally, Congress would pass legislation establishing these recommendations as minimum standards for all nursing homes or direct HCFA to establish detailed minimum nurse staffing standards to ensure that staffing levels take into account the number and the case-mix of the residents. Alternatively, HCFA could introduce minimum staffing standards through the regulatory process. In 1999 there were a number of efforts at the state level to increase minimum staffing levels. Mohler (1999) surveyed selected states and found that 21 states had either proposed new legislation or were considering proposals for new legislation or new regulations. In California, for example, in 1999 the state budget approved $31 million in new state funds (to be matched with $31 million in federal Medicaid dollars) to increase nursing home staffing minimum requirements from 2.8 to 3.2 hr per resident day and to increase wage rates. Overall, nursing facilities need to be held accountable by HCFA for providing adequate levels and types of staffing to meet the needs of their residents, especially because government is paying for 61% of the expenditures. Adopting these minimum standards will have an important impact on improving the quality of the nation's nursing home care. Additional research is needed to determine appropriate levels and types of staff to provide high quality of care to residents. These studies could test the proposed staffing standards against existing staffing levels to examine the impacts on quality. As new data become available on staffing levels, revisions of staffing standards should be made if necessary to ensure that high standards are maintained. (Pub Med)

Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Burger, S., Mohler, M., et. al. (2000). Experts Recommend Minimum Nurse Staffing Standards for Nursing Facilities in the US. The Gerontologist, 40(1), 5-16.

Decision Making Capacity to Execute a Health Care Proxy: Development and Testing of Guidelines
OBJECTIVE: To evaluate the reliability and validity of guidelines to determine the capacity of nursing home residents to execute a health care proxy (HCP). DESIGN: A cross-sectional study. SETTING: A 750-bed not-for-profit nursing home located in New York City. PARTICIPANTS: A random sample of 200 nursing home residents: average age, 87; 99% white; 83% female; average length of stay, 3.05 years; mean Mini-Mental State Exam (MMSE) score, 15.9. MEASUREMENTS: Demographic characteristics (Minimum Data Set (MDS)); function and cognitive status (Institutional Comprehensive Assessment and Referral Evaluation (INCARE)); Reisberg Dementia Staging; MMSE; Minimum Data Set-Cognitive Performance Scale (MDS-COGS)); an investigator-developed measure of a nursing home resident's capacity to execute a health care proxy (Health Care Proxy (HCP) Guidelines.) RESULTS: The internal consistency of the decision-making scales in the HCP Guidelines, paraphrased recall and recognition, reached acceptable levels, alphas of .85 and .73, respectively. Interrater reliability estimates were .92 and .94, respectively, for the recall and recognition scales; test-retest reliability estimates were .83 and .90. The discriminant validity of these scales is promising. For example, the MMSE correlation was .51 with the Recall scale and .57 with the Recognition scale. Of residents with severe cognitive impairment (MMSE < 10), 71% completed 50% or more of the scaled items in the HCP guidelines and 95% consistently named a proxy. CONCLUSIONS: Seventy-three percent of testable residents, approximately three-quarters of whom were cognitively impaired, evidenced sufficient capacity to execute an HCP. Of residents with severe cognitive impairment, the HCP guidelines are potentially useful in identifying those with the capacity to execute a HCP. The guidelines are more predictive than the MMSE in identifying residents able to execute a HCP. (Pub Med)

Mezey, M., Teresi, J., Ramsey, G., Mitty, E., Bobrowitz, T. (2000). Decision Making Capacity to Execute a Health Care Proxy: Development and Testing of Guidelines. Journal American Geriatric Society, 48:2, pp. 179-187.

Nurse Assistants in Nursing Homes
Mitty E.  (2000). Nurse Assistants in nursing homes. Geriatric Nursing Research Digest. NY: Springer Publishing Co.

The Teaching Nursing Home Program: Enduring Educational Outcomes
Mezey, M., Mitty, E., Bottrell, M. (1997). The Teaching Nursing Home Program: Enduring Educational Outcomes. Nursing Outlook, 45(3), 133-139.

Implementation of the Patient Self-Determination Act (PSDA) in Nursing Homes in New York City
OBJECTIVE: To examine implementation of the Patient Self Determination Act (PSDA), verbal directives, procedures for determination of resident' decision-making capacity, and role of ethics committees in nursing homes in New York City. DESIGN: Telephone survey. PARTICIPANTS: Social workers in 109 (69%) nursing homes in New York City. MEASUREMENT: An 80-item instrument addressing: (1) social worker knowledge of the PSDA; (2) informing residents about advance directives (living wills and durable power of attorney for health care [health care proxies]); (3) determination of decision-making capacity to be informed about advance directives; (4) estimates of advance directives executed; (5) perceptions of PSDA effect; (6) ethics committees; (7) follow-up and documentation; and (8) staff and community education. MAIN RESULTS: Virtually all social workers in nursing homes stated that they made what they perceived to be a "serious effort" to inform residents about advance directives and to have residents execute directives (preferentially a health care proxy). More residents were thought to have executed a directive pursuant to the PSDA law than before the Act went into effect. Social workers in most homes informed residents about directives through face-to-face discussions. Most homes, however, did not inform residents who were thought to lack decision-making capacity about their right to execute a directive. Only 37% of homes had written procedures to determine a resident's decision-making capacity to be informed about directives; most homes relied on physician and social work assessments. Voluntary homes differed significantly from proprietary homes in that they were larger, more likely to have an ethics committee, and more aggressive in their implementation of the PSDA. Forty-five percent of homes with an ethics committee had written procedures for determination of resident decision-making capacity compared with 26% of homes without a committee. Overall, 24% of residents were thought to have executed an advance directive. The number of directives per bed did not vary significantly by facility size, ownership, religious affiliation, or whether they did or did not have an ethics committee. CONCLUSIONS: The fact that social workers in nursing homes speak with most residents about advance directives has the potential to improve resident understanding around end of life decisions. The practice of not informing residents about advance directives when they are perceived to lack decision-making capacity is problematic given that most homes have no clear procedures for determining residents' cognitive capacity to execute a directive. There is a need to replicate the benefits achieved by homes with ethics committees in implementing the PSDA in other homes. (Pub Med)

Mezey, M., Mitty, E., Rappaport, M., Ramsey, G. (1997). Implementation of the Patient Self-Determination Act (PSDA) in Nursing Homes in New York City. Journal of the American Geriatrics Society, 45:1, pp. 43-49.