Challenges With Quality of Care

Chisholm, an associate professor in the College of Community Innovation and Education �鶹��Ʒ S�s , studies nursing home residents living with advanced dementia. She says many facilities struggle to identify the right end-of-life-care transition time due to lack of resources caused by differences in reimbursement.

�鶹��Ʒ S�The way nursing homes are reimbursed creates a two-tiered system, �鶹��Ʒ S� Chisholm says. �鶹��Ʒ S�You have nursing homes paid for privately or through Medicare, where the reimbursement is higher, and nursing homes with mostly Medicaid residents, where the reimbursement is lower. When you have this difference in reimbursements, you have differences in resources available to facilities, which creates imbalances in quality of care. �鶹��Ʒ S�

But there �鶹��Ʒ S�s also another issue at hand �鶹��Ʒ S� a lack of discussions taking place about hospice options. Chisholm says these conversations can be challenging for patients, families and nursing home staff alike.

�鶹��Ʒ S�We don �鶹��Ʒ S�t like to talk about death, even though it �鶹��Ʒ S�s going to happen to all of us, �鶹��Ʒ S� Chisholm says. �鶹��Ʒ S�Staff may not feel knowledgeable enough to have these discussions, and patients and their families may have �鶹��Ʒ S� religious [beliefs or perspectives based on their backgrounds] that make them uncomfortable with the subject. �鶹��Ʒ S�

While these conversations may be difficult, they are important. Chisholm says patients who never express their wishes for end-of-life care leave those big decisions to their families and care providers.

�鶹��Ʒ S�Many patients with advanced dementia can no longer speak for themselves, and family members are usually proxies to discuss their care needs, �鶹��Ʒ S� Chisholm says. �鶹��Ʒ S�When you �鶹��Ʒ S�re no longer able to speak for yourself and you haven �鶹��Ʒ S�t expressed your wishes, your family can only assume what you want. You could end up receiving unnecessary care that neither improves your quality of life nor helps you live longer. �鶹��Ʒ S�

Resources for Support, Communication and Planning

Inspired to foster this critical dialogue and help prepare dementia patients for a smoother transition, Chisholm and a cross-collaborative team are working with nursing homes to establish a standardized process for determining when to transition residents into hospice. Through a series of stakeholder interviews, the team proposed using the Mitchell Index �鶹��Ʒ S� a data-collecting tool that calculates the mortality risk of dementia patients �鶹��Ʒ S� to predict which residents have the greatest need for advanced-care planning conversations, helping staff give those residents a timely opportunity to discuss their desires.

Chisholm says the care providers the team has worked with have responded positively, indicating that the Mitchell Index could be successfully adapted for use in long-term care settings. Now, they need a tool to help promote and facilitate end-of-life-care planning conversations �鶹��Ʒ S� and that �鶹��Ʒ S�s where her research comes in.

�鶹��Ʒ S�One nursing home found that the Mitchell Index facilitated their need to have discussions about advanced-care planning, and they want more information on how to do that, �鶹��Ʒ S� Chisholm says. �鶹��Ʒ S�Our next step is to link the Mitchell Index study with my research, which talks about promoting goals-of-care discussions. Combining these two will create a full picture and help us give people a more comfortable, respectful death. �鶹��Ʒ S�

Going forward, Chisholm says the goal of her research is to improve the quality of care for all nursing home residents.

�鶹��Ʒ S�In the last 10 to 20 years, we �鶹��Ʒ S�ve seen a shift in nursing homes from hospital-like care to more of a home-like environment, �鶹��Ʒ S� Chisholm says. �鶹��Ʒ S�I love this move toward person-centered care �鶹��Ʒ S� really trying to understand who the resident is, listening to them, and focusing not just on their physical needs but on their overall well-being. Nursing homes often get a bad rap, and there �鶹��Ʒ S�s a lot we can do to improve both the quality of care and how people perceive them. �鶹��Ʒ S�

University of Central Florida assistant professor Latarsha Chisholm and colleagues conducted a study, which found that nursing homes that serve predominantly black residents tend to struggle financially and provide lower quality care than nursing homes with no black residents. Results were recently published in the Health Services Research journal.

�鶹��Ʒ S�There is no simple fix, �鶹��Ʒ S� Chisholm said. �鶹��Ʒ S�It is a complex issue, but we need to address it because disparities are everyone �鶹��Ʒ S�s issue. �鶹��Ʒ S�

The team analyzed financial and quality data of more than 11,500 nursing homes nationwide from 1999 to 2004.  The data was obtained from several secondary data sources. Unlike prior studies that used percent Medicaid as a proxy for financial performance, this study used actual financial performance measures, such as total profit and operating margin.

So how can this disparity exist and why does it play out along racial lines?

Racial/ethnic disparities in health care settings are complex, Chisholm said.  Black residents �鶹��Ʒ S� concentration in Medicaid-reliant nursing homes has been documented as a potential contributor to health care disparities. However, understanding factors that contribute to the over representation of black residents in nursing homes is unclear. Chisholm suggests that residential segregation and admission practices are also possible contributors of racial/ethnic disparities in nursing homes.

Blacks tend to reside in nearby community nursing homes, which may serve mostly black residents covered by Medicaid. Nursing homes with a high proportion of black residents may encounter financial challenges to invest in staffing and staff training, which can influence racial/ethnic disparities in care.

Statistically, blacks rely on Medicaid more than non-blacks to pay for nursing home needs. And because reimbursement rates for Medicaid are lower, these nursing homes tend to have issues with finances, Chisholm said. With less financial resources, there are fewer resources available for clients, which impacts the quality of care.

The other contributing factor is related to the admission process nursing homes use. Some nursing homes may be reluctant to take Medicaid residents because of the low reimbursement from Medicaid. These homes will take clients who have private insurance that pays better. With more financial resources, these homes are likely to have more resources that can enhance the delivery of quality care.

With the Baby Boomers expected to hit their golden years in droves within the next decade, the challenge of affordable and high-quality nursing homes will only intensify, Chisholm said. By 2015, those 50 or older will represent 45 percent of the U.S. population and by 2050 there were be more than 88 million people 65 years or older.

Chisholm said several potential solutions to mitigate racial/ethnic disparities in nursing homes exist. The ideas range from giving nursing homes financial incentives to perform better �鶹��Ʒ S� think pay for performance. Others suggest Medicaid needs to be restructured to provide better reimbursement rates.

The Affordable Care Act currently being implemented in several states may do little to remedy healthcare disparities found in long-term care settings.

�鶹��Ʒ S�An indirect benefit of the healthcare plan I see is that perhaps there will be better continuity of care in a person �鶹��Ʒ S�s earlier years, �鶹��Ʒ S� said. �鶹��Ʒ S�So their problems may be better managed early on and that could reduce costs and complications as they age and enter a nursing home. But other than that, the plan doesn �鶹��Ʒ S�t address the financing of long-term care.

Chisholm joined UCF in 2012 after completing a National Research Service Award Postdoctoral Fellowship at the University of North Carolina-Chapel Hill. She has multiple degrees including a bachelor �鶹��Ʒ S�s in psychology and a Ph.D. in Health Services Research, Management and Policy from the University of Florida and a master �鶹��Ʒ S�s degree from the University of South Florida. She �鶹��Ʒ S�s made several presentations to professionals groups including the Academy Health, the NRSA and the Gerontological Society of America.