The proposed project relies upon a combination of primary and secondary data sources assembled at the facility and resident level to test the proposition that residents of nursing homes with formalized, protocol driven approaches to caring for the physiological needs of residents will experience reduced rates of pressure ulcers and lower extremity contractures compared with homes that allow autonomy and clinical decision making discretion but that the opposite relationship will be observed for psychosocial outcomes, such as well-being and distressed mood. A sample of 360 facilities, stratified by ownership, size and urban location will be drawn from the 6 states participating in HCFA's Multi-State Case-Mix Demonstration project. MDS+ data available longitudinally (at 6 and 12 months post-baseline) in computerized form for all residents of homes will be obtained for participating homes as will the most recent MMACS data. Directors of nursing and a unit charge nurse in all homes will be interviewed by telephone to characterize the internal management structure, lines of communication and responses to changes in the environment as well as about the nursing care processes in place to guide staff behavior viz. care planning, service delivery and interaction with residents. The Area Resource File (ARF) will be used to describe the health care and resource environment in which the facility is situated. These four sources of data will be merged and analyses undertaken with the resident as the unit of analysis. We will ascertain whether the data are consistent with our hypothesis that, contingent upon the type of resident outcome (e.g. physiologic vs. psychologic), the relative importance of the type of control and communication strategies in place predict the two types of resident outcome will vary. Further, we will explore the various aspects of nursing home functioning and operation, including staff turnover and other indicators of leadership, and their relationship to whether homes achieve good outcomes in several, or only one, resident outcome domain. This latter exploratory data analysis step is crucial to derive from the theoretical results insights about how to intervene in a nursing home to improve the chance of achieving positive outcomes.
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