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\"Nursing homes are where some of the most vulnerable live and work. In too many homes, the conditions of work make it difficult to make care as good as it can be. For the last eight years an international team from Germany, Sweden, Norway, the UK, the US and Canada have been searching for promising practices that treat residents, families and staff with dignity and respect in ways that can also bring joy. While we did find ideas worth sharing, we also saw a disturbing trend toward privatization. Privatization is the process of moving away not only from public delivery and public payment for health services but also from a commitment to shared responsibility, democratic decision-making, and the idea that the public sector operates according to a logic of service to all. This book documents moves toward privatization in the six countries and their consequences for families, staff, residents, and, eventually, us all. None of the countries has escaped pressure from powerful forces in and outside government pushing for privatization in all its forms. However, the wide variations in the extent and nature of privatization indicate privatization is not inevitable and our research shows there are alternatives\"-- c Provided by publisher.

Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost. This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen's D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI -7.39, -1.15; Cohen's D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI -7.07,-2.02; Cohen's D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen's D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group. These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting. ISRCTN Registry ISRCTN62237498.

The 5-Star Quality Rating System for nursing homes plays a central role in evaluating quality of care, although it has both strengths and limitations. This system relies heavily on the Minimum Data Set and derives several quality measures (QMs) from it. In this study, we validated the effectiveness of the 5-Star Quality Rating System for nursing homes and its underlying QMs in estimating quality of care. We constructed a panel dataset of US nursing homes (n=15,416) active from May 2020 to June 2023, retrieving data from three major sources: (1) COVID-19 nursing home data, (2) Payroll-Based Journal data, and (3) nursing home QM snapshots. The outcome variables included (1) resident infection, (2) staff infection, or (3) resident and staff deaths. The predictor variables were the 5-Star Quality Rating System for nursing homes and its underlying QMs classified as structure, process, or outcome (SPO) QMs. This study aims to evaluate the effectiveness of nursing home QMs by regressing nursing home COVID-19 outcomes on nursing home QMs, classified using the Donabedian SPO framework. We hypothesized that nursing homes with better structural quality (eg, greater staff availability, better skill mix, and so on), better process quality (eg, lower restraint use and higher vaccination rates), and better outcome quality (eg, lower number of residents with pressure ulcers and a lower number of resident falls) experienced better COVID-19 performance in terms of resident and staff infections and deaths. To examine the association between the COVID-19 outcomes and SPO QMs, we imputed missing values in the dataset using random forest. Subsequently, we modeled the imputed dataset using hurdled zero-inflated negative binomial mixed effects models. The zero inflation model included factors influencing initial susceptibility to COVID-19 or factors influencing the possibility of death after COVID-19 had been contracted. The model estimates were conditioned on zero inflation and random effects. Staffing measures (P<.001 for all variables in all models), health deficiency scores (P<.001 for all variables in at least 1 model), COVID-19 hospitalization rates (P<.001 for all variables in at least 2 models), and vaccinations (P<.001 for all variables in at least 2 models) exhibited meaningful relationships with the COVID-19 outcomes, while the 5-star components, Medicaid dependency, and ownership showed no clear relationships. Although widely used, the 5-Star Quality Rating System for nursing homes is an unreliable performance measure. Concerted efforts from lawmakers, policy makers, and lobbyists are needed to refine and enhance the measure, thereby ensuring its reliability and effectiveness.

\"Rose Dennis wakes up in a hospital gown, her brain in a fog, only to discover that she's been committed to an Alzheimer's unit in a nursing home. With no memory of how she ended up in this position, Rose is sure that something is very wrong. When she overhears one of the administrators saying about her that she's 'not making it through the week,' Rose is convinced that if she's to survive, she has to get out of the nursing home\"--Dust jacket flap.

On April 22, 2024, the Centers for Medicare & Medicaid Services (CMS) announced new staffing mandates for long-term care (LTC) facilities in an effort to improve care quality in nursing homes (NHs). The guidelines require a minimum of 3.48 h of daily care per resident, including 0.55 h provided by registered nurses (RNs), 2.45 h by nurse aides (NAs), and an additional 0.48 h by other care staff. These requirements, including a 24/7 RN presence, aim to address chronic understaffing that has been linked to poor outcomes such as increased emergency visits and lower compliance with quality standards. However, concerns from for-profit NHs and the American Healthcare Association (AHCA) suggest that many facilities are ill-prepared to meet these standards, citing financial and staffing challenges, particularly in rural areas. In addition, a lawsuit from Texas Attorney General Warren Paxton argues that CMS overstepped its regulatory authority. Despite these challenges, workforce shortages may be alleviated by the CMS initiatives, which include a $75 million national campaign to grow the NH workforce. This commentary discusses the implications of the CMS staffing rule, the legal challenges it faces, and the potential to improve RN work conditions and resident care. The paper concludes with recommendations for expanding workforce capacity and enhancing compliance through financial investment and policy reform.

Twenty one year old nursing student Teun Toebes decided to rent a room in a care home to find out what it's like to live in one as a resident not as a nurse or a carer. He was curious - and he was broke. The experience changed his life, as well as the lives of his new housemates. He introduced Friday drinks, camping evenings, trips to visit grown up children, and he reintroduced pleasure in the small things in life a laugh, a dance, a cup of good coffee, a chance to sit in the sun. As he became embedded in the community Teun became, however, devastated by the insight gained; at how society and the care system diminishes people living with dementia.

Background Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable. Methods Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract. Results Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital. Conclusions The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

Background Against the backdrop of an increasingly aging global population, improving the quality of life and end-of-life care for older adults has become a critical public health concern. Advance care planning(ACP) offers potential benefits, including enhancing the quality of end-of-life care, reducing unnecessary medical interventions, and alleviating the burden on family members. However, in the unique context of nursing homes, the willingness and actual participation of residents and their families in ACP are influenced by various factors. Aim This systematic review and meta-synthesis aims to comprehensively explore the experiences, perceptions, challenges, and facilitators related to ACP participation among older adults and their families in nursing homes, in order to provide an evidence base for developing more effective ACP implementation strategies. Methods A qualitative meta-synthesis was conducted to systematically review and synthesize existing qualitative studies, guided by the ENTREQ statement and PRISMA guidelines. A systematic search was conducted across PubMed, Web of Science, Embase, EBSCO, The Cochrane Library, Sinomed, CNKI, and WanFang databases (from inception to October 2024) identified qualitative studies pertaining to the experiences and perspectives of nursing home residents and their families regarding ACP. The search was based on three key concepts: advance care planning, nursing homes, and qualitative research. Eligibility criteria included (1) participants being nursing home residents or their family members discussing ACP experiences; (2) studies published in English or Chinese; and (3) qualitative or mixed-method studies (qualitative data only extracted from mixed-methods). The methodological quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. The data was synthesized using thematic synthesis method. Results A total of 1,097 articles were retrieved through database searches, and 21 studies met the inclusion criteria. Three overarching themes were identified: (1) Attitudes of older adults and their families towards ACP; (2) Individualized needs for ACP; and (3) Factors affecting the implementation of ACP. Most older adults and their families perceived ACP as a facilitator of emotional expression and communication and acknowledged its educational value. However, some family members expressed avoidance, ambivalence, or uncertainty toward ACP. Moreover, ACP was found to be highly individualized, with varying needs among participants. Key facilitators of ACP in nursing homes included the provision of clear and concise information, adequate cognitive functioning among residents, supportive policies, an open cultural environment, a compassionate multidisciplinary team, and strong trusting relationships. Conclusion An increasing number of older adults and their families in nursing homes have recognized the value of ACP in facilitating communication and expressing care preferences. However, implementing ACP in these settings remains challenging due to cultural sensitivities around death and broader sociocultural influences. To improve ACP uptake in nursing homes, relevant authorities should strengthen legal frameworks and refine policy measures to enhance standardization and support the active participation of older adults. Tailored decision-support tools and materials should be developed to meet the diverse needs of nursing home populations. Additionally, the healthcare system should provide compassion-focused training to enhance staff empathy and promote interdisciplinary collaboration.