Survey of <i>C. difficile</i>-Specific Infection Control Policies in Local Long-Term Care Facilities

Introduction: The incidence and severity of Clostridium difficile infection (CDI) has been increasing and long-term care facility (LTCF) residents are at high risk given their age, co-morbidities, and high antibiotic exposure. Infection control policies are crucial for controlling CDI, but there are currently no regulatory guidelines in the United States. Therefore, we evaluated infection control policies in local LTCFs to define the CDI-specific policies and the administrative and staff understanding of CDI, so as to identify perceived barriers for compliance. Methods: IRB approval was sought and exemption granted, all 8 local LTCFs were asked to participate. Each facility was visited by study personnel who interviewed the administrative Infection Control Practitioner (ICP) and 3-4 Licensed Practical Nurses (LPNs) with distinct survey format. Infection control policies were then compared to the SHEA recommendations for CDI in LTCFs. Results: Of the eligible facilities, 75% (n = 6) participated. ICP (n = 6) and LPNs (n = 21) were interviewed. All facilities accept residents with active CDI and 2 had written CDI-specific infection control policies. All facilities had hand hygiene or glove use policies and 2 had policies for the use of sporicidal environmental cleaning. No facility restricted antibiotic use. Each facility has a policy to instruct their staff through in-services, either annually or upon new hire, but 33% (n = 7) LPNs reported no facility-based CDI training. While 80% (n = 17) of LPNs felt comfortable with the facility CDI policies, only 11 accurately restated it. ICPs felt the most relevant barrier to staff compliance was time constraints (n = 4, 67%), however, LPNs felt it was limited knowledge (n = 10, 48%) and poor communication (n = 2, 10%). Discussion and Conclusions: With the increasing incidence and severity of CDI in LCTF, few of the facilities surveyed had CDI-specific policies. Despite CDI-specific training, there is a perceived knowledge and communication gap for staff caring for residents with CDI.

Equity of access to long-term care among the Korean elderly

The aim of the current study is to examine the extent to which equity in the utilization of longterm care services has been achieved in the Republic of Korea (hereafter Korea), based on the Aday—Andersen Access Framework that takes into consideration a series of variables hypothesized as predictive of utilization. The current study used cross-sectional survey data collected and conducted by the Korea Labor Institute (KLI) between August 1 to December 22, 2006. The sample for this study was 5544 persons who are older than 60 years. The study was extracted from a larger nationally representative cross-sectional survey of 10,255 individuals. The stratified cluster sampling technique was used to draw the survey respondents. A self-administered questionnaire was used to collect the data from the sample. Descriptive and logistic regression analysis was performed examining the relationship between the dependent variable and the independent variables and the relative importance of factors. The results indicate that a universal health insurance system has not yielded a fully equitable distribution of services. The limitation of benefit coverage as well as disparities in consumer cost-sharing and associated patterns of utilization across plans high out-of-pocket payment can be a barrier to health care utilization, which results in inequity and differential long-term care utilization between sub-groups of older adults. Health policy reforms in Korea must continue to concentrate on expanding insurance coverage, reducing the inequities reflected in disparities in consumer cost-sharing and associated patterns of utilization across plans, and establishing a financially separate insurance system for poor older adults. The behavioral responses of physicians to the method of reimbursement, and the subsequent impact on overall rates of utilization and expenditures need to be more fully understood. In addition, further research is needed to identify the nonfinancial barriers that persist for certain demographic subgroups, i.e., those 70 and older, men, lacking social network members, those who have four or more family members, and those who have no schooling.

Safety and Quality of Care Evaluation in Japanese Long-Term Facilities Focused on the Activity Condition and Cognitive Function of Residents

Objective: Currently, standards for evaluating long-term care facilities do not exist in Japan. This study aimed to evaluate the quality of healthcare services in Japan’s long-term care facilities and identify the structural and process indicators associated with the facilities’ outcome indicators. Methods: This retrospective study assessed changes in residents’ abilities to participate in physical activities, their cognitive function, and their vulnerability to injuries. From 2012 to 2013, we collected information on the healthcare services at 1067 long-term care facilities registered with Japan’s Welfare, Health and Medical Care Information Network in the Welfare and Medical Service Agency. We examined 12 structural indicators, 26 process indicators, and 7 outcome indicators. We used multivariate linear regression models adjusted to analyze relationships between outcome indicators and structural or process indicators. Results: Residents’ activity and cognitive function indicators either improved by 80% - 90% or were maintained for one year. The Geriatric Functional Independence Measures, the Barthel Index, and holding conferences related to care were all considered activities of daily living. Three adverse events—tumbles and falls, behavioral problems, and aimless wandering or leaving the facility without permission—were factors that restricted residents’ behavior and number of residents per care staff member. Conclusions: Maintaining or improving levels of independence and cognition in daily living requires a care process system that enables ongoing monitoring of residents’ activities of daily living and cognitive functioning. Ensuring the safety of residents and improving the quality of care in long-term care facilities without securing adequate care staff are not possible.

Potential Legal Issues and Care Implications during Care-Prevention Gymnastic Exercises for the Elderly Using Pepper in Long Term Health Care Facilities

In Japan, the shortage of personnel is a problem in long-term care nursing and rehabilitative care prevention. Nevertheless, Japan has taken measures to compensate for these shortages by promoting medical and nursing care activities using robotic technologies, and employing human resources from overseas. The purpose of this study was to determine potential legal issues and subsequent implications for care during prevention gymnastic exercises for the elderly using Pepper in long-term health facilities. The application program of Care-Prevention Gymnastics Exercises for Pepper (Pepper with CPGE) was made by the Xing Company Japan. Currently, care workers become intermediaries for the safe use of Pepper with CPGE. However, it was realized that some legal issues may arise if Pepper with CPGE alone will carry out these preventive care programs for the elderly without the presence of care workers as intermediaries. In this situation, using Pepper with CPGE alone to conduct care prevention gymnastics will require safety measures to prevent these possible practice issues and anticipate implications for care. In this regard, determining detailed target levels of rehabilitation exercise demands and environmental setting safety become essential factors. The use of humanoid robots in healthcare is expected to influence more practice protocols in contemporary and futurist rehabilitative human care. The identification of possible safety issues in performance and environmental situations, and implications for care are critical to ensure safe and valuable rehabilitative health care practices for the elderly population.

Influence Factors of Mobility-Related Activities of Daily Living in Chronic Dialysis Patients Needing Long-Term Care: Analysis of Long-Term Care Eligibility Assessment Survey Data

Background: In the near future in Japan, chronic dialysis patients will likely face a situation where the aging and the lengthening of hemodialysis treatment periods will adversely affect the mobility-related activities of daily living (MR-ADL). The aim of this study was to investigate chronological change in MR-ADL among chronic dialysis patients in need of long-term care and the effect of admission to long-term care facilities on their MR-ADL. Methods: Data were analyzed from a long-term care eligibility assessment survey conducted in late March 2009 of 1000 individuals residing in Niigata City, Japan who were approved to receive long-term care. Then data from those individuals who had undergone the assessment survey ≥4 times over a period of ≥4 years were statistically evaluated. To reveal change in MR-ADL, this study performed a three-way analysis of variance with mean survey scores from assessment categories 2 - 5 containing questions related to MR-ADL as the independent variable and the number of eligibility assessment surveys (within-subjects factor), facility admission, and dialysis therapy (between-subjects factors) as dependent variables. Results: We observed the effect of facility admission in individuals aged >70 years for categories 2 - 5, and observed the effect of the number of assessment surveys taken only in women ≥80 years for categories 2 and 5. Regarding the effect of dialysis therapy, female dialysis patients aged ≥80 years and in need of long-term care scored significantly higher on survey items for transferring, grooming, toileting, eating, and instrumental activities of daily living, all of which are indicators of a moderate decline in ADL. Conclusions: Because dialysis is often initiated in women aged around 80 years, ADL in this group of individuals can be improved by the initiation and proper provision of dialysis.

Clarifying Problems with Emergency Healthcare Systems in Japanese Long-Term Care Facilities for Older People

Background: Long-term care facilities for older people play an important role as alternatives to family care in an aging society. This study aimed to assess staffing problems linked to emergency healthcare for residents of these facilities, and to investigate the relationship between these problems and the characteristics of the facilities. Methods: The study surveyed managers of long-term care facilities for older people in a Japanese urban area between September and December 2014. The type of care facility, the number of staff and any problems providing or accessing emergency healthcare for the residents were evaluated. Multiple logistic regression analysis was used to explore the factors common to facilities reporting staffing problems linked to emergency healthcare of residents. Results: In total, 321 long-term care facilities were eligible for this study and 226 (70%) returned the questionnaire. We compared the characteristics of facilities reporting and not reporting staffing problems in emergency healthcare of residents. The type of care facility was significantly associated with staffing problems in emergency healthcare of residents both during the day (p < 0.01) and at night (p = 0.04). The facilities most likely to report problems were group homes for older people with dementia, because of staffing shortages. Conclusions: Problems in emergency healthcare systems in Japanese long-term care facilities for older people varied by type of care facility. Our data underscore the need for telemedicine and consideration of mergers between smaller facilities such as group homes for older people with dementia.

Impact of the Community-Based Active Monitoring Program on the Long Term Care Services Use and In-Patient Admissions of the Over-74 Population

Introduction: Social isolation increases in the over-74 population and it is a risk factor for death and Long Term Care (LTC) use. In order to prevent the negative consequences of social isolation on this population community interventions focused on strengthening the social network should be intensified. The aim of this paper is to describe the impact on health care use of a Community-based pro-Active Monitoring Program (CAMP) providing phone monitoring to all the clients and home visits according to the individual’s needs. Methodology: In order to provide an evaluation of the program outcomes, the rates of clients’ hospitalization and admissions to Long Term Care facilities during 2011 have been assessed. The observed rates have been compared with expected ones calculated on available information for similar population. A cost-analysis has been also carried out to analyze the program sustainability. Results: The studied sample is made up by 1408 over-74 citizens followed up during 2011 in Rome (Italy) by CAMP. The cumulative observation time was 1362 p/y;61 individuals died during 2011 (death rate 4.3%). The hospital admission rate observed among CAMP’s clients was 254‰ (357/1408;CL95% ± 91‰), lower than the 282‰ reported for the over-74 population of Rome. This translates into 39 averted hospitalization. The LTC admission rate is also reduced among CAMP’s clients (9/1,408, 6.6‰ CL95% ± 0.8‰ vs. 9.7‰ reported for a comparable sample);it translates into 4 averted LTC admissions. The averted cost ranged between 47,153 € and 220,117 € according to the range of services used by the clients, which translates into a percentage of estimated cost reduction on yearly basis ranged between 3% and 12.5% of the whole cost of services used by the studied population. Discussion: The paper suggests the capacity of CAMP to reduce both the over-74 hospitalization rate and use of LTC. Cost analysis also indicates a cost reduction as a consequence of the CAMP implementation. Further studies including a control group and a detailed cost-benefit analysis are needed to check the program sustainability on larger population.

Vitamin D and Number of Falls in a Long-Term Care Facility

Falls represent a significant contribution to the morbidity and mortality of the elderly population. Because vitamin D is important in bone physiology, the use of vitamin D to restore deficient bone and ameliorate the effects of bone fractures due to falls has become a common practice in recent years. Following introduction of widespread use, reports began to emerge that vitamin D not only aided in repair of fall-induced bone fractures, but that it also reduced the occurrence of falls. Vitamin D now has become a routine intervention as a fall-prevention measure. Early analyses found evidence of prevention efficacy (reduced falls), but recent analyses are more equivocal. We retrospectively examined the records of 350 patients in a long-term care facility in which vitamin D administration and the number of falls were recorded as part of a comprehensive database of care. We found a dramatic rise in vitamin D use over the period covered (2006 – 2011) and a corresponding dramatic decrease in the number of falls. However, the number of falls continued to decline after 2008, despite a plateau in number of patients on vitamin D, particularly females. It appears that other factors contribute to the overall decline.

Fitness Age Score and the Risk of Long-Term Care Insurance Certification—The Kyoto-Kameoka Longitudinal Study

Long-Term Care Insurance System has been introduced to provide appropriate care for the elderly who needs nursing care in Japan. Physical function is one of most important function for the elderly to live independently. A previous study had established a Fitness Age Score (FAS) based on a theory for biomarker of aging. This study clarified whether the FAS could be used to predict the need for certification of long-term care (CLTC) in independent elderly people. We included 939 independent, community-dwelling-elderly (average age, 74.4 years) whose physical function was measured and for whom the CLTC was tracked for 24 months. The FAS comprised five physical fitness items: Walking time, grip strength, one-leg standing, vertical jump, and functional reach test. Based on the FAS, we calculated the odds ratio (OR) for the CLTC. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) was used for further analysis. We also used the Youden Index (YI), minimum distance method (MD), and two-graph ROC method (TG) to calculate cutoff values (CVs) for screening. We divided subjects into the low and high physical fitness group with CVs. We developed cumulative CLTC curves using the Kaplan-Meier method. Sixteen people could not be tracked for the full 24 months. The measurement of FAS was completed for 798 people, of whom 28 became CLTC. The measurement of FAS was not completed for 125 people, of whom 21 became CLTC. The CLTC OR for people with incomplete FAS was 5.553. The AUC was 0.72 (p < 0.001). The CVs for the FAS were -0.29 for YI (sensitivity, 92.9% and specificity, 40.4%), -1.23 for MD (57.1% and 73.4%), and -0.81 for TG (60.7% and 60.9%). The cumulative CLTC curves according to CVs all showed significant differences (p = 0.000 - 0.020). In conclusion, the FAS can be used to predict CLTC.

Analysis on Long-Term Care and Influencing Factors of Empty-Nest Differently Abled Elderly People in China —Based on the Data from the Chinese Longitudinal Healthy Longevity Survey

Purpose: This study aimed to understand the actual needs of empty-nest differently abled elderly people and analyze their long-term care status including the factors affecting choice of care mode so adequate resources can be allocated to meet their healthcare needs. Methods: An empty-nest group was compared with a non-empty-nest group based on data from the 2014 Chinese Longitudinal Healthy Longevity Survey. Individual characteristics, family characteristics, and sociological factors were considered as independent variables, and long-term care model was the dependent variable in the three binary logistic regression method. Results: Age, gender, marriage, and disability were the most important factors influencing the choice of long-term care mode, including the willingness of the differently abled elderly. Family care can no longer meet the needs of the severely disabled elderly. Long-term care for such elderly people should be undertaken by professional and specialized social institutions. Conclusion: Multi-level services should be provided according to the elderly peoples’ needs, and the skill and expertise of professional personnel of care institutions should be strengthened. The government should deploy fund-raising initiatives, actively use the power of non-governmental organizations, and strive to resolve the financial issues faced by the empty-nested elderly people with disability.

Path Exploration for Long-term Care of Rural Disabled Elderly: A Case Study of G Town in South Shaanxi

Field survey of G Town in South Shaanxi indicates that current situations and existing problems of rural disabled elderly. According to these situations and problems,this paper analyzes difficulties in long-term care of rural disabled elderly. From the perspective of welfare pluralism,it comes up with development paths for long-term care of rural disabled elderly with joint participation of government,communities,non-profit organizations on the basis of the family endowment.

The Effect of Knowledge and Attitude on Fall Prevention Activities among Nursing Staff in Long-Term Care Hospitals

Background: The fall prevention activities of nursing staff are emphasized more in order to reduce the incidence of falls in elderly people in long-term care hospitals. Objectives: To examine the extent of knowledge and attitude about falls and the degree of fall prevention activities among nursing staff in long-term care hospitals, and to identify the effect of knowledge and attitude about falls on prevention activities. Design: The data collection was, in the period between July 10th, 2017 and August 10th, 2017, accumulated by constructive questionnaires targeting 138 nurses and nurse aids who are employed within five long-term care hospitals. Methods: The statistical processing was as follows: the frequency, percentage, mean and standard deviation, independent t-test, one-way ANOVA, Pearson’s correlation coefficients, and hierarchical regression analysis. Results: The fall prevention activities showed a significant difference statistically in the fields of age (F = 5.33, p = 0.002), working career (F = 3.98, p = 0.014), positions (t = 2.71, p = 0.008), subject’s experience with patient falls (t = 2.15, p = 0.033), fall prevention education (t = 3.32, p = 0.001). As for the correlation between knowledge and attitude towards falls and fall prevention activities, knowledge and attitude towards fall (r = 0.45, p < 0.001), knowledge and fall prevention activities (r = 0.27, p < 0.002), attitude towards falls and fall prevention activities (r = 0.42, p < 0.001) had significantly positive correlations. As for the fall prevention activities of nursing staff in long-term care hospitals, their attitude towards falls (β = 0.32, p < 0.001) had an effect on fall prevention activities. Conclusion: In order to increase fall prevention activities in long-term care hospitals, nursing staff’ attitude towards falls is important. Therefore, we need to explore diverse strategies to promote fall prevention activities of nursing.

The thinking about Shanghai Development “medical pension combined” type of long-term care insurance system

The aging development in Shanghai shows speed, high degree of aging, the number of elderly people living alone increased and other trends, the contradiction between degree of aging and care become more prominent. However, the prevalence of current pension model has a pension without medical care, health care and pension separate and other issues, so the development of ＂medical support combined with pension＂ long-term care insurance system is imperative. Based on the study to explore parts of the country which operate basic pension model of＂medical pension combination＂, we analyze the necessity and feasibility of the implementation of Shanghai ＂medical support combined with pension ＂ long-term care insurance system, by summing up experiences and lessons, put forward some of the recommendations for the development in Shanghai ＂medical support combined with pension＂ type of long-term care system.

Effects of Sustained, Coordinated Activities Programming in Long-Term Care: The Memory in Rhythm® Program

Beneficial effects of providing engaging activities to long-term care residents have been well documented. However, it is important to determine the effects of activities when providing throughout the day, especially as they related to outcomes salient to administrators. We describe the creation and pilot testing of a sustained, coordinated activities program, Memory in Rhythm&#174(MIR), which incorporated Montessori-Based Dementia Programming&#153, in a skilled nursing facility (SNF). Effects of implementing MIR then were examined in memory care units in 16 aged care centers—9 SNFs and 7 assisted living residences in Ohio. For these centers, all data were collected over a period of one year before and one year after implementation of MIR. Results indicate that implementation of MIR was associated with reductions in medication use, increased census, decreased employee turnover, decreased wandering and agitation, and increased sleeping at night, eating and capacity for activities of daily living. In the SNFs, increases in RUGS case mix and use of Medicare Part B (rehabilitation services) were noted, while in assisted living implementation also was related to increased amount of time residents who were able to age in place. Implications of these findings are discussed.

Contemporary Designs for Long-Term Care (LTC) Facilities

In addition to experiencing shortage in LTC workforce, some existing facilities are unable to provide quality service, since they were designed and built decades ago. Thus, the renovation of outdated LTC facilities is currently an unavoidable issue. In this paper, some contemporary practices are presented related to renovating old LTC facilities to improve the quality of service. The most important concept is the person-centered design. Some other elements include the importance of natural lighting for residents, proper practices of flooring and picking doors, some details in home-like design, new guidelines for resident rooms’ design, and other miscellaneous issues. Furthermore, the latest Americans with Disabilities Act (ADA) compliance protocols are reviewed, and some crucial elements are discussed to ensure the renovations will make the facilities compliant with the current standards.

Evaluation of Care Quality Related to Dietary Intake and Swallowing Functions of Residents at Long-Term Facilities in Japan

This study aimed to evaluate the quality of healthcare services pertaining to the dietary intake and swallowing functions of residents, nutrition management practices, and performance of residents at long-term care facilities. We investigated outcome indicators, such as changes in dietary intake and swallowing function levels of residents, and clarified which structural and process indicators were associated with the outcome indicators. This was a retrospective study, analyzing information on healthcare services from 1067 long-term care facilities during the fiscal year 2012, sampled from among those registered with the Welfare, Health and Medical Care Information Network of the Welfare and Medical Service Agency in Japan. Five outcome indicators were identified. Next, we examined the relationships between the outcome indicators and structural or process indicators using a multivariate linear regression model, adjusting for facility type. The findings showed how the five outcome indicators were used in long-term care facilities over a period of one year and determined the independent predictors of these outcome indicators. The amplification of dietary function 1 was associated with “assessment of oral functions using a feeding and swallowing assessment checklist every three months”, “holding care conferences related to ingestion and swallowing every three months”, and “maintaining a 1:2 ratio for meal-time assistants to residents”. To improve the quality of care, it is necessary to increase the number of staff (e.g., to provide meal assistance to residents) and to understand changes in the residents’ status through accurate assessment and monitoring.

Evidence-Based Practice and Job Satisfaction of Nurses in Long-Term Care

Purpose: The purpose of this study was to identify the relationship between evidence-based practice (EBP) and job satisfaction among nurses working in long-term care facilities. Methods: The study used a descriptive cross-sectional design. A total of 146 nurses working in 6 long-term care facilities in South Korea self-reported their perception of EBP implementation, barriers to research utilization, and job satisfaction. Results: The level of job satisfaction was higher in nurses who were single, older, more experienced, and had a higher income. Lower perceived barriers to research utilization were associated with greater job satisfaction. However, there was no significant relationship between a level of EBP implementation and job satisfaction. Factors influencing job satisfaction included lower barriers to the organization and communication domains of research utilization, being unmarried and older. Conclusion: Decreasing barriers to research utilization may improve the job satisfaction of nurses working in long-term care facilities.

两批试点城市长期护理保险政策比较——基于政策工具-福利要素的二维框架

构建长期护理保险政策工具-福利要素二维分析框架,对两批共28个国家级长期护理保险试点城市的长期护理保险政策文本进行计量分析。研究发现,政策工具维度呈现出使用频次差异大且内部结构不均衡的特点;福利要素维度呈现出要素完整且内部结构较为均衡的特点;各政策工具与福利要素耦合度有待提高;两批试点城市长期护理保险政策差异较小,发展阶段具有相似性。对此,提出合理调整三大类政策工具,优化次级政策工具结构;科学配置政策福利要素,完善要素内容;增强政策工具和福利要素耦合度,整合资源协调发展的优化建议。

共同富裕目标下长期护理保险的发展困境与优化路径——基于“路径-目标”理论的分析框架

长期护理保险作为社会保障体系的重要构成,在一定程度上能够有效促进共同富裕,但其逻辑机理、发展困境和优化路径并未得到充分揭示。基于路径-目标理论,将共同富裕和长期护理保险发展目标相结合,从“共同”和“富裕”两个维度分析长期护理保险发展面临如下困境:部分群体未纳入长期护理保险的参保范围,对困难群体的支持力度不足,失能等级评估标准尚不统一,监督和监管机制还不完善,长期护理服务体系不健全,护理费用报销差异大,筹资渠道单一,基金规模整体不大,护理服务人数较少且服务设计缺乏人文关怀,慈善事业和社会互助参与力度不足。鉴于此,应从“共同”和“富裕”两个维度进一步优化,提升长期护理保险的公平性和可持续性,助力实现共同富裕。