The first chapter examines the impacts of health care provider exits on patient outcomes and subsequent reallocation. Using administrative data on the universe of nursing home patients, I estimate the mortality effects of 1,109 nursing home closures on incumbent residents with a matched difference-in-differences approach. I find that displaced residents face a short-run 15.7% relative increase in their mortality risk. Yet this increase is offset by long-run survival improvements, so the cumulative effect inclusive of the initial spike is a net decline in mortality risk. These gains are driven by patients reallocating to higher quality providers. I also find significant heterogeneity by local market conditions: the survival gains accrue only to patients in competitive nursing home markets, whereas residents in concentrated markets experience no survival improvements. I then develop and estimate a dynamic model of the nursing home industry with endogenous exit. Combining the model estimates with the mortality results, I examine the effects of counterfactual reimbursement policy experiments on nursing home closures and resident life expectancy. A universal 10% increase in the Medicaid rate decreases the frequency of closures, but causes some low-quality providers to remain open in competitive areas. In contrast, targeted subsidies for facilities in areas with limited alternatives improves overall life expectancy by averting the costliest nursing home closures. In the second chapter (co-authored with Szymon Sacher), we estimate a mortality-based Bayesian model of nursing home quality accounting for selection. We then conduct three exercises. First, we examine the correlates of quality, and find that public report cards have near-zero correlation. Second, we show that higher quality nursing homes fared better during the pandemic: a one standard deviation increase in quality corresponds to 2.5% fewer Covid-19 cases. Finally, we show that a 10% increase in the Medicaid reimbursement rate raises quality, leading to a 1.85 percentage point increase in 90-day survival. Such a reform would be cost-effective under conservative estimates of the quality-adjusted statistical value of life. The third chapter (co-authored with Michael Barnett and Adam Sacarny) examines why efforts to raise the productivity of the U.S. health care system have proceeded slowly. One potential explanation is the fragmentation of payment across insurers. Each insurer's efforts to improve care could influence how doctors practice medicine for other insurers, leading to unvalued externalities. We study these externalities by examining the unintended private insurance spillovers of a public insurer's intervention. In 2015, Medicare randomized warning letters to doctors to curtail overuse of antipsychotics. Even though the letters did not mention private insurance, they reduced prescribing to privately insured patients by 12%. The reduction to Medicare patients was 17%, and we cannot reject one-for-one spillovers. If private insurers conducted a similar intervention with their own limited information, they would stem half as much prescribing as a social planner able and willing to better target the intervention. Our findings establish that insurers can affect health care well outside their direct purview, raising the question of how to match their private objectives with their scope of influence.

O objetivo geral desse estudo foi desenvolver um protótipo de um software para sistema web e dispositivo móvel para orientação de pacientes sobre Cateterismo Cardíaco e Angioplastia de Artéria Coronária. Tratou-se de estudo de Design Instrucional do tipo Design Centrado no Usuário, aplicado à produção tecnológica para desenvolvimento do protótipo de um software em ambiente web e tecnologia móvel, para consulta de informações sobre Cateterismo Cardíaco e Angioplastia de Artéria Coronária. O estudo foi desenvolvido em quatro etapas, cada qual permitindo o alcance dos objetivos específicos. Para tanto construiu-se o conteúdo sobre esses exames, tendo como base um levantamento bibliográfico, buscando pelas evidências científicas existentes sobre o tema. A primeira versão do conteúdo foi elaborada e apresentada a experts na área de cardiologia para refinamento. Após essa etapa, foi construída a segunda versão do protótipo do software, submetida à avaliação de 30 pacientes que estavam agendados no setor de hemodinâmica de uma instituição hospitalar pública e de ensino e pesquisa para a realização dos procedimentos de Cateterismo Cardíaco e de Angioplastia de Artéria Coronária. Esta etapa de coleta de dados foi realizada em 2018. Após esta avaliação, elaborou-se a terceira versão do protótipo do software, que posteriormente será encaminhada aos procedimentos de ilustração e informatização, para o sistema web. O estudo deixa sua contribuição para a área de cardiologia, para as ciências de saúde, em especial para a Enfermagem e para o avanço tecnológico nas ciências da saúde, por ter apresentado um conteúdo seguro e baseado em evidências científicas, direcionado aos pacientes submetidos a esses complexos exames. Sua contribuição refere-se, também, ao avanço de conhecimento sobre o tema para essa população de indivíduos. Sua aplicação indica que é um instrumento importante para a educação em saúde desses pacientes, podendo suprir as necessidades do pouco conhecimento sobre o Cateterismo Cardíaco e a Angioplastia da Artéria Coronária demonstrada por eles / The general objective of this study was to develop a software prototype to web system and mobile devices for patients orientation about Cardiac Catheterism and Coronary Artery Angioplasty. It was an Instructional Design, much like User Centered Design, applied to the technological production for the software prototype development on web environment and mobile technology, to search information about Cardiac Catheterism and Coronary Artery Angioplasty. The study was developed in four stages, each one allowing the attainment of specific objectives. In order to do that, the examination content was built based on bibliographic research, searching for existent scientific evidences related to the theme. The first content version was elaborated and presented to experts in the cardiology field to its refinement. Following after this stage, a second version of the software prototype was built, submitted to the evaluation of 30 patients scheduled at the hemodynamic sector of a public hospital institution, academics and research, in order to conduct the proceedings of Cardiac Catheterism and Coronary Artery Angioplasty. This stage of data collection was carried out in 2018. After this evaluation, a third version of the software prototype was elaborated, which subsequently will be referred to the illustration and computerisation proceedings, to the web system. The study leaves its contribution to the cardiology field, health sciences, especially to nursing and technological advancements in health sciences, for having presented a safe content, based on scientific evidences, directioned to the patients submitted to these complex examinations. Its contribution also relates to the knowledge advancements about the theme to this individual population. Its application indicates to be an important instrument for patients health education, being able to supply the needs for having little knowledge about Cardiac Catheterism and Coronary Artery Angioplasty, demonstrated by them

The purpose of this randomized control trial (RCT) was to investigate the effects of a story-sharing intervention on older adults transitioning to long-term care (LTC). The specific aims were (1) to determine the effects of story sharing on the health transition outcomes of depression and well-being of adults transitioning to LTC; and (2) to determine if the sociodemographic characteristics (age, gender, ethnicity, marital status, level of education (LOE), months living at LTC facility, choice to move, and health problem(s) that may have resulted in the move) predict depression and/or well-being. Story sharing was defined as the respectful space where one tells and listens to stories of others (Heliker, 2009) while being guided by another (the investigator). Meleis’ middlerange theory of transitions (MMRTT) (Meleis et al., 2000) was used as a guide to understand the transitioning process. A convenience sampling design was used to recruit 100 participants from 11 LTC facilities in Broward County, located in Southeast Florida. The sample included adults, age 65 years and older, who were transitioning to a LTC facility within the past two years. Participants were randomly assigned to the control group (n = 52), who received standard care, or to the intervention group (n = 41), who received story-sharing and standard care. The results indicated there was no significant greater improvement to suggest an Intervention and Time effect for depression and/or well-being. Overall, predictive ability of the sociodemographic variables for depression and well-being were not statistically significant. However, LOE (junior college) did account for a significant portion of unique variance for increased depression, and time, marital status, ethnicity, LOE, and choice to move did account for a significant proportion of unique variance for well-being. Months living in LTC (more months) and marital status (all but divorced) were significant for improved well-being while ethnicity (Hispanic), LOE (high school and junior college), and choice to move (no choice) were significant for reduced well-being. Similar studies using a larger sample size, including non-English speaking participants; lengthier storysharing sessions; and measuring for pain, health, and bereavement may offer additional insights to healthy transition outcomes for this population. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2017. / FAU Electronic Theses and Dissertations Collection

No description available.

Univ., Diss.--Osnabrück, 2005.

Across Scotland, there is a lack of research in care homes. This thesis explores this topic by examining links between inclusion, participation in general and participation in research and whether those who work and live in the care home environment experience social citizenship. Using a national survey and interviews with residents, staff, relatives and experts in care home research, this thesis investigated whether participation generally was linked to participation in research for residents, staff and visitors in a care home setting. The thesis further explored how social citizenship functions in a care home environment and whether there is a link between participation and citizenship. The findings suggest there is a lack of general participation which is connected with the leadership style and management within the care homes. There is misunderstanding about research and legislation amongst the care home staff, residents, visitors, as well as the junior research staff which inhibited staff and resident participation. Furthermore, citizenship is not experienced universally by residents or staff due to disempowerment, and exclusion occurs amongst residents due to age, frailty and dementia. By facilitating good leadership, communication and relationship-building such issues may be overcome. In addition, the analysis suggests a link is evident between inclusion, participation and citizenship. Where choice is provided and residents have their social position maintained, as well as have a degree of responsibility for shaping events, this leads to participation and inclusivity as described in Bartlett and O’Connor’s (2010) definition of social citizenship. Furthermore, if inclusion is adapted for cognition and frailty, then participation leads to the experience of social citizenship, encouraging a culture which can welcome research. The explicit emphasis on inclusion and participation in research has enabled this under-researched area of participation and experience of social citizenship in care homes to be more fully explored.

No description available.

This research provides a feminist perspective on the lowest paid sector of the United States long-term care industry, Certified Nursing Assistants. This research adds to current feminist scholarship on the modern professional caregiving industry by focusing on the perspective of the workers. As the population of older adults requiring care is expected to increase over the coming decades, the demand for paid caregivers will increase as well. Historically, care work was an expected duty done freely by the women of the family, but today much of the vital intimate caring labor is relegated to paid caregivers. I examine how alternative social, political and economic frameworks can transform United States society’s attitude towards the increasingly relevant issue of caring labor. I argue that incorporating a feminist perspective will be helpful in developing a sustainable model for caring labor that acknowledges the dignity of both patients and their caregivers. / Includes bibliography. / Thesis (M.A.)--Florida Atlantic University, 2016. / FAU Electronic Theses and Dissertations Collection

Over the past decade, efforts led by the U.S. Department of Health and Human Services (HHS) have reduced healthcare-associated infections in acute care settings nationally. In 2013, HHS identified that the next phase of these healthcare-associated infection reduction initiatives would target long-term care facilities through the publication of a new chapter in the National Action Plan to Prevent Health Care Associated Infections devoted to this setting. Long-term care facilities are nursing facilities that provide “medical, skilled nursing and rehabilitative services on an inpatient basis to individuals who need assistance preforming activities of daily living, such as bathing and dressing”. These facilities are the primary residence for 2.5 million, predominantly elderly Americans and represented $143 billion nationally in healthcare costs as of 2010. Accordingly, it is a national priority to reduce healthcare-associated infections in this setting and protect this vulnerable population. Healthcare-associated infections caused by multidrug-resistant organisms (MDROs) are a particular burden in the long-term care population. These pathogens, usually bacteria, are defined as being resistant to one or more classes of antimicrobial agents. However, MDROs frequently exhibit resistance to nearly all antimicrobial drugs. Clinical infection control guidelines recommend isolation precautions to prevent MDRO transmission, based on evidence collected in acute care settings. However, the limited evidence that is available from studies in long-term care facilities suggests that isolation precautions may not be effective in this setting. Given that the reduction of antibiotic resistant infections is a priority of the HHS, The White House, Healthy People 2020, and the World Health Organization, it is necessary to confirm and support the appropriate use of isolation precautions for MDROs with evidence specific to long-term care facilities. Therefore, this dissertation describes the current evidence for and use of isolation precautions in long-term care facilities for MDROs. Further, it offers the most comprehensive descriptions of both isolation precautions use and predictors of MDRO infection in nursing homes (NHs), a specific type of long-term care residential setting. To assist the reader, Chapter 1 will provide background for these studies including context for current infection control and prevention practices in long-term care facilities, the importance of MDRO infections and the need for new evidence regarding isolation precautions in long-term care. It will also discuss the aims and significance of this dissertation in context of a conceptual framework, gaps in the literature and potential to improve clinical practice. Next, Chapters 2 and 3 of this dissertation systematically review the current evidence regarding effectiveness of isolation precautions against MDROs and the cost of infection prevention and control in this setting, respectively. These chapters outline how publications focused on long-term care are lacking in quality and quantity and offer suggestions for improvement in future research. Chapter 4 qualitatively describes decision-making process regarding use of isolation-based infection prevention techniques in NHs, which depends on four key considerations: perceived risk of transmission, conflict with quality of life goals, resource availability and lack of understanding. Chapter 5 builds on this qualitative analysis by quantitatively examining predictors of isolation precautions use for MDRO infection in a large, national dataset. This analysis confirms that isolation is rarely used and there is variation across NHs’ practice. However, NH staff may be tailoring infection prevention and control practice to the needs of specific residents, as would be expected based on the results of the qualitative analysis. Chapter 6 presents an analysis of MDRO infection predictors among elderly NH residents across the U.S. This study confirms concepts associated with MDRO infection in previous studies (e.g., low functionality) and provides more specificity in operationalization of these concepts than has been previously determined (e.g., needing support with locomotion), which can inform future use of isolation precautions in NHs. Finally, Chapter 7 contains a synthesis and discussion of these findings, as well as recommendations for health policy and future research regarding contact isolation precautions against MDROs in NHs.

Indiana University-Purdue University Indianapolis (IUPUI) / A move toward care of residents in nursing homes where they are respected and heard is finally emerging. Common strategies used in nursing homes to improve quality of care for residents are integration of person-centered care and assessing care using satisfaction surveys. Although approaches of integrating person-centered care and satisfaction surveys have been valuable in improving nursing home quality, strategies of care that include things that matter from residents’ perspectives while living in nursing homes need investigation. The purpose of this qualitative descriptive study was to describe things that residents age 65 and older state matter to them while living in the long-term care sections of nursing homes. A qualitative mode of inquiry using purposeful sampling led to a natural unfolding of data that revealed things that mattered to residents. Content analysis was used to reduce the data in a manner that kept the data close to the context yet moved the data toward new ideas about including things that mattered to residents in nursing care. The findings revealed residents’ positive and negative experiences and addressed the question: How can nurses manage residents’ positive and negative aspects of care in nursing homes? This study substantiated the importance of developing nursing care strategies derived from residents’ descriptions of care. Finding ways to promote nurses’ investment in attitudes about a person-centered care philosophy is essential for successful person-centered care implementation. Enhancing nurses’ knowledge, skills, and attitudes with an investment in person centeredness will be more likely to put nurses in a position to role-model care that is person-centered from residents’ perspectives.