Efforts to improve the quality of care in nursing homes (NHs) are long-standing, but concerns regarding poor quality of care persist. Fundamental change is likely needed to improve NH quality given the challenging and complex environments in which NHs operate. Through NH culture change and its advocated practices, deep systematic change aims to advance resident-centered/directed care and improve NH quality of care and life. The long-term goal of this research is to improve NH care and the quality of life within NHs by providing evidence on how culture change implementation impacts quality. The central hypothesis motivating this proposal is that greater implementation of NH culture change practice results in higher NH quality. The proposed study will be the first to use a diverse national sample of U.S. NHs and data from a longitudinal panel study including data from 2009/10 and 2015/16 survey responses to understand whether increases in culture change practice implementation and increases in critical domains of practices are associated with improved quality. The study will pursue the following three Specific Aims: 1) Describe the extent of culture change practice implementation in U.S. NHs in 2015/16 and the changes in implementation between 2009/10 (Time 1) and 2015/16 (Time 2); 2) Evaluate whether increase in implementation of culture change practice (overall and by critical domains) be- tween Times 1 and 2 is associated with improvements in: a) quality outcomes including lower rates of function- al decline, bedbound [i.e. bedfast] status, weight loss, behavioral problems, incident pressure ulcers, and hospital deaths; b) care processes including lower use of hospitals and of restraints, antipsychotic drugs and feeding tubes; and higher rates of bladder and bowel training; and, c) NH performance including reduced staff turn- over and health-related and quality of life survey deficiencies; and 3) Evaluate whether higher versus lower presence of NH Leadership and Family and Community Practices is associated with a) quality outcomes, b) care processes and c) NH performance (see Aim 2). This study is innovative since it will be the first national longitudinal panel study to examine how implementation of NH culture change practices has changed over time and whether increases in culture change practice implementation are associated with improvements in NH quality. This study is significant because its design and its planned propensity-matched difference- in- differences analyses will provide needed evidence for provider and policy maker decision making, and integral for improving the quality of care and life for vulnerable older adults in U.S. NHs. This knowledge is critical as many states are now implementing or changing their Medicaid NH pay-for-performance programs to acknowledge adoption of culture change practices with inadequate evidence to support these decisions; similarly, providers are implementing practices with inadequate evidence of their effect.

Public Health Relevance

The proposed study is highly relevant to public health because it will generate findings capable of having an important positive impact on the quality of care and life in nursing homes. Making health care more person- centered, a hallmark of nursing home culture change (studied here), is 1 of 6 priorities identified as needed for providing better care in the 'National Strategy for Quality Improvement in Health Care.' This proposal is consistent with the Mission and Vision of the National Institute on Aging in that it will result inthe communication of critical research findings aimed at improving the quality of care and life for older adults living in nursing homes.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Research Project (R01)
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Health Services Organization and Delivery Study Section (HSOD)
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Fazio, Elena
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Brown University
Public Health & Prev Medicine
Schools of Public Health
United States
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Berridge, Clara; Tyler, Denise A; Miller, Susan C (2018) Staff Empowerment Practices and CNA Retention: Findings From a Nationally Representative Nursing Home Culture Change Survey. J Appl Gerontol 37:419-434
Miller, Susan C; Schwartz, Margot L; Lima, Julie C et al. (2018) The Prevalence of Culture Change Practice in US Nursing Homes: Findings From a 2016/2017 Nationwide Survey. Med Care 56:985-993
Miller, Susan C; Mor, Vincent; Burgess Jr, James F (2016) Studying Nursing Home Innovation: The Green House Model of Nursing Home Care. Health Serv Res 51 Suppl 1:335-43