Are Rural Pennsylvanian Medicare Home Health Agencies and Beneficiaries at Risk?
The Polisher Research Institute at the Madlyn and Leonard Abramson Center for Jewish Life in collaboration with the Pennsylvania Office of Rural Health undertook this study to evaluate whether the recent changes in the way Medicare pays agencies for the home health services they deliver had adversely affected agencies and beneficiaries in rural Pennsylvania counties, and delineate the types of actions, if any, that needed to be taken by the Commonwealth to ameliorate these impacts. The focus of the evaluation was the combined impacts of Medicare's Interim (IPS) and Prospective (PPS) Payment Systems.
Bereavement in Long-Term Care
The goal of this ethnographic study was to explore the experience and meaning of dying, death and bereavement in the nursing home setting. Drawing on theory and method from cultural anthropology, the project sought to learn and describe this experience from the perspectives of residents, staff, and family members in four ethnically and religiously different nursing homes. Findings have practice and policy implications for increasing numbers of older persons who live and die in nursing homes.
Building Relationships to Enhance Resident-Centered Care: Taking Care of Your Feelings First and Taking Care of Residents' Feelings
The purpose of this project was to pilot a training workshop with nursing home staff, and to polish it by undertaking extensive editing and adding graphics to create a manual that may be shared with others for both clinical and research purposes.
The Contribution of Changes in Medication Use to Improvements in Functioning Among Older Adults
After nearly a decade of debate among academics and policymakers over trends in elderly disability rates, a consensus has emerged that rates have declined over the last fifteen years or so. At least one study suggests this phenomenon extends to the near-old (50-64 year olds) as well. The debate is therefore now moving from addressing the question of whether or not elderly disability rates have fallen to understanding the reasons for the decline, the likelihood of declines continuing into the future, and the policy implications of these changes. This research investigated the potential contribution of one aspect of disease management-medication use-to observed changes in functioning. Using data from the 1992 and 1998 waves of the Health and Retirement Survey, a nationally representative survey of Americans ages 51 - 61, we found medication use increased at the same time functioning improved; however, the two trends do not appear to be linked.
Dementia: A Case Study Exemplar In Long-Term Care
The purpose of this project was to create an exemplar case study on dementia within the context of the long-term care continuum. Students selecting this senior-level course were offered opportunities to observe and participate in the care of physically and cognitively frail older adults across the dementia trajectory in the Madlyn and Leonard Abramson Center for Jewish Life. The blending of the strengths of the Penn School of Nursing and the Madlyn and Leonard Abramson Center for Jewish Life supported the intent to highlight care of older adults with dementia in long-term care settings. The intent of the course was grounded in an understanding of the shortage of well-prepared nurses in long-term care settings who have the knowledge and skills to provide quality care to older adults with dementia. Creating a high-profile elective course that required invitation and permission to enter and offered an exciting clinical placement and opportunity to build speaking skills was the mechanism to attract qualified, committed students. Ten nursing students with specific interest (5 junior and 5 senior with varying interest intensity and career commitment) in care of older adults participated in this 1 credit-unit course in Spring Semester 2004.
Depression in Dementia: A pilot project to develop a psychotherapeutic approach for persons residing in the nursing home
This project was a subcontract with the University of Pennsylvania. The project was designed to develop a psychotherapeutic approach for nursing home residents with dementia and depression and to begin testing its feasibility.
Development of an Assistive Technology and Environmental Assessment Instrument for National Surveys
The purpose of this project is to develop, evaluate, and disseminate an instrument to be used in national surveys to collect assistive device and environmental information from older and adult disabled persons living in the community. Separate instruments will be developed to focus on the home and workplace. The project is funded by the Office of the Assistant Secretary of Planning and Evaluation of the Department of Health and Human Services in cooperation with the National Institute on Aging and the National Center for Health Statistics.
Effects of Risperidone and Haldol for the treatment of psychotic and aggressive symptoms in nursing home residents with Alzheimer's disease with respect to the patient's quality of life after treatment
This double blind drug study examined positive aspects of quality of life outcomes of treatment, as well as its effects on negative aspects of quality of life. The hypothesis was that the efficacy of Risperidone would be greater or equal to Haloperidol with respect to the psychotic or behavioral symptoms. We further hypothesized that the Risperidone group would be greater than the Haloperidol group with respect to positive affect, motivational, and social functioning after treatment. Twelve subjects with probable or possible AD (NINCDS-ADRDA criteria) with psychotic and/or non-cognitive behavioral symptoms (agitation or aggression) were recruited. Entry criteria were defined as a Behave-AD score of 8 or more; at least 4 on the FAST; less than or equal to 23 on the MMSE; and residing in the NH at least 1 month. (PI: Ira Katz, MD)
Emotion in Dementia: Its Measurement and Comprehension by Caregivers
This project developed a measure of observed emotion in Alzheimer patients and investigated the way family members and institutional staff comprehended and interpreted emotion in such residents.
This qualitative research project was designed by M. Powell Lawton to construct a lexicon of the design art for professionals engaged in the planning, design, administration, professional care, and research on nursing home facilities for people with dementia. An expert panel of consultants and the PIs directed a process of literature review and preliminary dictionary construction. This was followed by a period of observation and interview study at 6 nursing homes. The data gathered was used in a next lexicon draft, whose final form is a website. The website allows design actors to look up spaces, objects, functions, systems, and user needs and see state-of-the-art comments about the advantages and disadvantages of each.
Forecasting Hospitalization Needs in the Medicare Cancer Population
This pilot study estimated a statistical forecasting model and illustrated its use in projecting the characteristics of Medicare cancer patients who are likely to need hospitalizations. The specific aims were to: 1) estimate the probability of requiring hospitalization in a given year among Medicare patients with an incident diagnosis of cancer, and 2) identify the factors that influence the probability of requiring unnecessary or preventable hospitalizations in a given year. The Medicare claims data from a 5% random sample of all 1997 beneficiaries were used to yield estimates on the probability of hospitalization in a given year. Cancer of four leading types (lung, breast, prostate, colorectal) were identified from claim files having a hospital episode that contain ICD9-CM codes for cancers. All hospital episodes were reviewed in which cancer was coded as primary or secondary. Procedures, length of hospitalization, patient age, gender, marital status, ethnicity, hospital region, population density, and hospital code (teaching or community) were extracted from the identified files. Development of these models is an important precursory step in approximating hospitalization utilization in elderly cancer patients and for the conceptualization of secondary and tertiary prevention activities for the older population in the future.
Health and Care Trajectories of Older Disabled Americans
The goal of this NIA-funded FIRST award is to understand the dynamic process driving long-term care decisions, particularly the ways in which older persons and their families respond over time to changes in the health of older family members. Using a dynamic, interdisciplinary framework, two overarching research questions are being explored: 1) How do older disabled Americans and their families shift care arrangements in response to various health trajectories and what are the critical junctures in the health progression of older disabled Americans when families shift the intensity and structure of care? and 2) How do various health trajectories affect the balance of informal and formal care over time? That is, under what circumstances do changes in health lead to the displacement of formal for informal care over time and what is the magnitude of that displacement? To address these issues, the project will use multiple waves from two nationally representative panel surveys: the Study of Asset and Health Dynamics of the Oldest Old (AHEAD) and the Medicare Current Beneficiary Survey (MCBS). Answers to these questions will provide critical information on the underlying process by which older disabled persons and their families cope with disability over time.
Hearts and Hands: Providing Palliative Care to Nursing Home Residents
The purpose of the Hearts and Hands project is providing palliative care services to nursing home residents near the end of life. The goal is to help residents achieve and maintain the maximum physical, emotional, spiritual, and social potential, however limited they may be as a result of disease progression. Grounded in the belief that excellent care and training go hand-in-hand.
The Impact of Passive Nurse Call Technology on Nursing Home Fall Rates
Our intent was to evaluate the clinical efficacy of a passive nurse monitoring and call system in identifying nursing home residents for adverse outcomes such as falls, infections and hospitalizations. The sample included 27 nursing home residents with advanced dementia. Participants had an average age of 87.2 years and demonstrated severe cognitive impairment and a moderate amount of ADL limitations, withdrawal, agitation, and depressive symptomatology. Participants' affective, behavioral, cognitive and physical functioning and socialization were measured at baseline, 3 months and 6 months. Sleep was assessed and movement profiles were gathered using staff reports and passive monitoring technology data. In addition, participants' medical records were reviewed for incidents of infections, hospitalizations, and falls. Afternoon movement profiles were significantly associated with fall risk and depressive sympomatology. Participants with increased afternoon activity were at increase risk for falls (OR 1.87, 95% CI 1.049-3.351). Although nighttime movement profiles were significantly associated with decreased physical, cognitive and social functioning, no significant relationship existed between nighttime movement and risk for adverse events.
Incorporating Technology into Long Term Care
The goal of this NIA-funded R01 was to provide the first directly focused, comprehensive study of the use of assistive technology in community-based long-term care for older persons. The project, funded through a subcontract with Johns Hopkins University (PI: Emily Agree) analyzed the 1994-95 National Health Interview Survey Disability Supplement, Phase 2 and the Second Longitudinal Study on Aging to answer the following questions 1) How is assistive technology combined with personal care to meet the functional needs of disabled individuals in the community; 2) What factors facilitate the use of assistive technology as part of the long-term care arrangement? 3) To what extent does assistive technology substitute for or augment the use of personal long-term care services? and, 4) does the use of assistive technology in community-based long-term care affect the well being of disabled individuals, both by reducing disability, and by forestalling disability decline, mortality, and institutionalization?
Individualized Positive Psychosocial Interventions: Impact on Staff and ADRD Residents
The project examined the effectiveness of an intervention designed to enhance the affective and behavioral quality of life for persons residing in a nursing home who suffer from Alzheimer's Disease or related disorders.
Lawton Digital Archive Planning
The purpose of this project was to create a plan to digitize, catalog, store, publicize and display unpublished documents of M. Powell Lawton, Ph.D. (1923-2001). Dr. Lawton was a senior research scientist and Director Emeritus of the Polisher Research Institute of Philadelphia Geriatric Center (PGC), now the Madlyn and Leonard Abramson Center for Jewish Life. The goals of this project were to learn how Dr. Lawton's documents will be used and how to best make these documents available to researchers. Professionals familiar with Dr. Lawton’s work were surveyed to determine the types and subjects of documents that would be useful to them in their research. The library staff investigated the state-of-the-art procedures for scanning documents, supplying metadata and presenting digitized information on the Internet. The resulting plan will be used to request funding for resources to perform the digitization tasks and market the resulting digital archive.
Lawton Digital Archive Implementation
An online collection of a selection of presentations by the late M. Powell Lawton, Ph.D.. is now available on the AccessPA Digital Repository. These documents represent presentations that Dr. Lawton made throughout his career at conferences for researchers on aging. The principles Dr. Lawton developed in his studies in environmental psychology influenced design innovations in nursing homes, special dementia units, and community-based programs all over the world. The planning and implementation were partially funded with federal Library Services and Technology Act (LSTA) funds administered by the Pennsylvania Office of Commonwealth Libraries.
Long Term Care Needs of Holocaust Survivors
The major purpose of this research was to identify and document the special needs of Holocaust survivors in LTC. The four specific objectives included: 1) the identification of special needs of LTC service users who are holocaust survivors (including home based and institutional based LTC); 2) the comparison of survivors using LTC services with a cross-section of older Jewish persons of similar socio-demographic status who did not experience the Holocaust and who are also using LTC services; 3) the development of a model for working with victims of similar traumas who are receiving long term care. The situation facing older Holocaust survivors also faces survivors of other traumatic events such as Rwanda, Bosnia, Cambodia and others whose refugees have reached American shores; and 4) a first attempt at developing practice guidelines for professionals working with elderly victims of the trauma in LTC settings.
Palliative Care in the Nursing Home: An Ethnographic Study
The purpose of this project was to advance our understanding of palliative care delivery in the long-term care setting by developing a model of how a palliative care program (PCP) is developed and introduced. The specific aims were to identify the circumstances and conditions that give rise to the development of a PCP, to learn how this process was experienced by core members of the PCP team, and to learn how participants' beliefs and attitudes about end-of-life-care shape program development. The project offered a unique opportunity to capture the multifaceted context in which a palliative care program is introduced in a nursing home.
Palliative Care Outreach
The purpose of this project is to enhance the exportability of the Madlyn and Leonard Abramson Center for Jewish Life's Palliative Care training curriculum. The specific aims of this project are to: 1) produce a training guide for local not-for-profit nursing homes. The manual will include information needed to start a program: course materials, workbooks, forms, documentation system and trainer's guide for in-service training of staff designed to minimize the need for external expertise, and 2) conduct a one-day North Penn Palliative Care conference. The aim of the conference, entitled "Hearts and Hands: Providing Palliative Care to Nursing Home Residents," was to share information about proven quality end-of-life practices that are improving the care of local nursing home residents. This conference included formal presentations by local nursing homes in the North Penn community recognized for the implementation of quality practices in one or more key areas related to quality care of nursing home residents at the end-of-life education packets were distributed, containing case examples and materials to guide staff training at the various nursing homes that take part in the event. Some photos of the event are available on this website.
Palliative Dementia Care Studies
The goals of the Center for Palliative Dementia Care Studies are to: Foster research on palliative dementia care through pilot project funding, Facilitate collaborations among palliative care practitioners and reseachers, and Disseminate practical findings to practitioners, policy makers, and researchers. Findings from the pilot research projects will be used to build a compelling data base that will serve to substantiate submission of grants to Federal agencies. Examples of funded pilot projects include: The Efficacy of Reflexology as a Palliative Treatment in Nursing Home Residents, Keeping Vigil, Palliative Dementia Care Resources. Our vision is that over time, through the completion of meaningful research projects, we can influence the provision, practice and policies affecting end of life care to dementia residents in long term care settings.
PANPHA Continuous Quality Improvement Project
Polisher Research Institute worked with the PANPHA Continuous Quality Improvement Task Force to examine quality issues in long-term care nursing facilities by examining Centers for Medicare and Medicaid Services (CMS) Quality Indicator (QI) Reports. The Institute assembled the data in the reports for individual PANPHA facilities into one combined database, which then were used to produce summary statistics and to evaluate whether there were facility characteristics that were linked with either high percentile rankings, flagging of sentinel events, or low percentile rankings. The results were used to guide the efforts of the task force in such areas as educational programming and investigating various practice standards and guidelines.
PANPHA Department of Health Nursing Facility Survey Analysis
The purpose of this project was to evaluate the results of the Department of Health’s nursing facility surveys of PANPHA facilities. The analysis task was sub-divided into two sets of analyses. The first set involved data runs that lead to the preparation of tables for a report that was made available for public distribution. The second involves a set of analyses that are run exclusively for the internal use of PANPHA. There were three types of analyses prepared for the report: (1) summaries of information from the questionnaires organized by Department of Health field office; (2) tables that identify the 5 most frequently cited deficiencies by field office; and (3) a table of all deficiencies cited in the questionnaires. The second set of analyses for the internal use of PANPHA identified patterns of deficiencies by individual surveyors at specific field offices.
The Madlyn & Leonard Abramson Center for Jewish Life had a passive monitoring and nurse call system installed in two 27-bed households of their nursing home facility. This technology provided an innovative system of signal assistance based on resident movement. It continuously gathers and records data for each resident through an array of passive bedroom sensors, including bed exit, incontinence, and general motion detection sensors, placed for continuous monitoring of resident activity. No electronic bracelets or tags are required. Based on the system data, the software identified expected patterns of behavior for each resident and set up rules to interpret and respond to the vast amount of data gathered. Care providers used this information to refine and improve individualized care plans for preventative and proactive strategies. When a resident departs from their expected behavior, appropriate caregivers were notified immediately through silent pocket pagers, minimizing noise and contributing to a quiet, home-like environment. The Center’s Polisher Research Institute compared this system to a more traditional nurse call system in terms of impact on resident safety, quality of care and quality of life on the two households in the nursing home. Each household had both the passive nurse call technology and a more traditional wireless nurse call pager system. However, the passive monitoring system on one household did not initially provide feedback or calls to the staff, making it a control by which to compare the second household. Multiple methods were used to evaluate resident physical, cognitive, emotional, and social functioning and staff impressions. Assessments were made at baseline, 6-month, and 12-month follow-up.
Pennsylvania Transition to Home (PATH)
Pennsylvania Transition to Home, or PATH, was a demonstration project involving the Pennsylvania Departments of Aging, Public Welfare and Health, community-based service providers, nursing home associations, consumers, advocates, and other interested stakeholders. The overarching goal of the PATH project was to learn about perceived or real barriers that nursing home residents face when considering alternatives to living in a nursing home, and was expected to strengthen the Commonwealth’s overall efforts to expand and improve home and community-based options for both older Pennsylvanians and Pennsylvanians with disabilities. Specifically, the PATH project was intended to assist and support 95 people to transition from a nursing home into their own home in the community in the four Pennsylvania counties targeted in the project proposal: Dauphin, Cumberland, Lehigh and Schuylkill. Polisher Research Institute was responsible for data managementincluding the development of a distributed database and the ability of PATH coordinators and managers to synchronize the field databases over the Internetin addition to assisting with analysis of the collected data.
Physiological Stress and Health Outcomes in A Frail Elderly Population
This project was designed to enhance our understanding of the link between physiological reactions to stress and subsequent health outcomes among physically and cognitively frail elderly persons. The study took advantage of a unique, naturally occurring, experimental design: the relocation of approximately 225 residents of the Madlyn and Leonard Abramson Center for Jewish Life (formerly Philadelphia Geriatric Center) from its existing campus to a new facility. Residents were moved in two randomly assigned groups, one in the fall of 2001 and the second in the spring of 2002. Salivary specimens were obtained from residents before, during, and after the fall move. In addition, observational and interview-based measures of cognitive and psychosocial functioning and other physiological measures were collected multiple times before, during, and after the fall move period. Comparisons of diurnal patterns of salivary cortisol between experimental and control groups over time allowed us to evaluate the physiological reaction of an extremely frail population to environmental stress. We also explored how the reaction is mediated by internal and external coping resources. The repeated collection of saliva samples, observations, interview data, and other physiological measures, before and after the move, coupled with planned follow-up linkages to medical, pharmaceutical, and administrative records, provided a rich and highly unique data set for further analyses of 1) the role of salivary cortisol in predicting mortality and health outcomes within a frail elderly population; and 2) the usefulness of a more comprehensive measure of cumulative wear-and-tear on the body in predicting mortality and health outcomes in a frail elderly population.
Predicting Turnover of Certified Nursing Assistants
Nursing home staff turnover takes a tremendous toll in terms of financial costs, staff morale, and resident quality of life. Efforts to identify the qualities of those who remain on the job have examined demographic and attitudinal characteristics of staff as well as qualities of institutions. Staff abilities also play a central role in job motivation; neglected in previous studies in this area are CNAs' emotional skills. Skill in recognizing the subtle indicators of emotion in persons with dementia might be critical in ensuring successful work experiences that discourage turnover and might reinforce a sense of agency in caregivers, reminding them that their behavior has an impact on residents who at times appear unresponsive. This study measured CNAs' skill in recognizing emotions in persons with dementia and related their level of skill to whether they remain on the job for at least one year. We interviewed and assessed 150 CNAs within one week of their being hired to work in a nursing home and followed them for one year. In addition to assessing emotion recognition skill, we gathered data regarding CNA demographic characteristics, personality, general intelligence, emotional intelligence, and empathy, and facility characteristics such as size, non-profit status, and provision of staff orientation. Logistic regression was used to identify which variables significantly predict whether a CNA remains on the job after one year, with special attention to the incremental utility of including emotion recognition skill as a predictor.
Preferences for Every Day Living: Developing an Instrument to Inventory Lifestyle
Past studies have documented that control over the details of one's everyday life and the provision of preference congruent care is related to better quality of life for elders. The purpose of this study was to develop an instrument to assess psychosocial preferences for everyday living. Related work by this group shows that psychosocial preferences can be conceptually mapped into six domains, indicating that people think about categories of psychosocial preferences in similar ways. In contrast, the expression of preferences is inherently idiosyncratic presenting a challenge to traditional, factor-analytic approaches to categorization. The current study assessed preferences for everyday living in a group of 580 community dwelling elders. The sample has been stratified to reflect differing levels of experience in the home health service delivery system. A factor analysis identified 9 clusters of individuals who expressed distinct combinations of psychosocial preferences, providing a preliminary typology of expressed preference. These factors are characterized by specific patterns of demographic, functional, and physical and mental health variables. Implications for individualization of care are discussed.
Quality of Life, Health, and Valuation of Life by Elders
The object of this NIA-funded R01 has been to study the trajectories of quality of life (QOL) in a group of 600 people ages 70+ in good and poor physical health over a 6-year period. A subjective construct, "Valuation of Life," is suggested as the moderating variable that subsumes many aspects of QOL and in turn leads to the wish to continue to live in spite of possible physical decline and symptoms of poor mental health. Our major hypotheses are that the wish to live is not only decremented by distress but may be incremented by some positive features in the person's daily life. 600 elders in good and poor health were recruited for participation in a structured interview, and are beginning the third round of interviews. The present project will extend the followup period to 6 years with 140 expected to remain independent, 170 to be ADL-dependent, and 160 to die. Changes over 6 years in Years of Desired Life will be analyzed in terms of changes in health, quality of life, mental health, and VOL. Although multiple comorbidities are the rule, disease-specific trajectories will be sought for 5 illness groups: congestive heart failure, bowel cancer, diabetes, arthritis, and renal disease among dialysis patients. All analyses will be performed by race (52% African American) and gender. The results will contribute both to clinical practice directed toward the well-being of individuals and to social policy issues where quality of life is involved as a rationale for the distribution of health-care costs. This project is being continued at Drexel University with Jana Mossey as Principal Investigator.
SES Differences in HMO Utilization
This project was a three-year observational study of the influence of socioeconomic status on the medical care utilization of elderly Medicare beneficiaries enrolled in HMOs, and represents a collaborative effort between RAND, PGC, and the Center for Health Care Policy and Evaluation at United Health Care, a leading managed care organization. The objectives of the project were to evaluate the impact of SES on a number of utilization outcomes including physician visits, hospitalization rates, emergency room usage, home health care, rates of mammography and influenza vaccination, and total charges for medical care. A secondary goal was to provide information on the pathways through which SES affects utilization among elders in managed care plans. The project assessed the utilization experiences of enrollees in three geographically dispersed Medicare HMOs that are affiliated with UHC. Data sources included a telephone survey of enrollees and administrative data from the study HMOs. The team investigated socioeconomic differences in home health utilization, preventive care, physician visits, emergency room visits, and medical expenditures.
A Stimulation-Retreat Program for Alzheimer's Patients
The project performed a randomized evaluation of the efficacy of an individualized program for Alzheimer patients, based on matching appropriate levels of stimulation with needs of the resident. The program in a special care unit was compared with a similar unit without the program and with similar groups of Alzheimer patients living in heterogeneous units.
Sustainable Culture Change for Persons with Dementia in the Nursing Home
The culture change project sought to enhance quality of life for nursing home residents and the quality of care delivered by staff by implementing a program of culture change in three nursing homes. The goal of the culture change is to create healthy, person-centered relationships at all levels within the organization through a creative, multifaceted training program. The training program used innovative, experiential techniques that have been demonstrated to promote optimal learning. These techniques included the inclusion of persons with early Alzheimers disease as teachers, intensive exposure to programs in other facilities that already deliver new culture care, and the observation of nurturing relational role models for new culture care on the unit initiating culture change. Relationships were sustained over time by the implementation of an internal peer support group for direct care staff and an external peer network for both direct care staff and managerial staff. The project advanced the science of dementia care through the development of a theoretical model specific to the nursing home organizational system, allowing future studies to test specific hypotheses and linkages between levels of culture change.