Table 3 Facility characteristics associated with APM use
Factors increasing use | Probable Etiologies | References | ||
|---|---|---|---|---|
| Â | Â | Expert panel inferences | Article Explanations | Â |
Physical Facility Characteristics | ||||
Physical Location | Located in metropolitan area | - Possible greater share of for-profit facilities - Different organizational culture in urban locations - More crowded NH may result in less medication screens -Less staff per resident | -No explanation given | Stevenson, 2010 |
Not located in the West or Midwest OR Located in the central South or Northeast | - Different state laws and regulation regarding NHs -Regional variation in training/org. cultures/hiring patterns/staffing levels and mix may all affect quality of care -Difference in provider practice pattern | - Approaches may differ regionally - Facilities in the East used a psychiatrist more often than those in the West - Note: Briesacher, 2005 et al. found lower APM rates in southern U.S. | Briesacher, 2005, Briesacher, 2013, Chen, 2010, Hughes, 2000 & Stevenson, 2010 | |
Facility Size | Smaller facility size | -Economies of scale. As a result, larger facilities may be able to have more specialization and devote greater resources to quality care/improvement | -Larger facilities may be able to provide more comprehensive services due to economies of scale and may be more able to implement change processes | Chen, 2010, Hughes, 2000 & Kamble, 2009 |
Business Type | For-profit status | - Maximize profit and minimize cost - APMs may substitute for staff, education or training - For profits minimize expenditure which leads to low quality of staffing - Non-teaching environment can be slower to adopt clinical guidelines | -APMs may be used to maximize profits and minimize the need for hands-on care -APMs may be used in for-profit facilities as chemical restraints | Castle, 2009, Hughes, 2000, Lester, 2011, Miller, 2006 & Lucas, 2014 |
Presence of Acuity Services | Alzheimer’s disease special care unit or other special care units | -The proportion of patients with Alzheimer’s disease or dementia may be larger than in other NHs -Dementia- related behavioral symptoms may occur more often | - A result of the impact of case-mix that is not completely captured in the aggregate diagnostic and behavioral variables included as controls | Hughes, 2000 |
Staffing Characteristics | ||||
Staff Ratios | Lower RN Staffing | - Lower staff to patient ratios means less time spent with patients resulting in increased APM use | - Greater use of APMs has been consistently associated with lower staff to patient ratios | Hughes, 2000, Lucas, 2014, Miller, 2006, & Svarstad, 2001 |
Lower nurse aid staffing | - Nurse aides spend more time with the patients, which results in less need for pharmacological treatment | - Nurse aides may have more patient time, resulting in less APM use | Hughes, 2000 | |
Higher LPN staffing | - Less time spent with the patients -Different level of training could play a role | - LPNs do not spend as much time with the patient | Lucas, 2014 | |
BH Expertise | Increasing number of mental health professionals and physicians | - Physicians typically spend very little time with nursing home patients - NHs with more mental health professionals may accept more patients with BH issues | - Consultant psychiatry is often identified with higher APM use - Lucas et al. found however that the presence of mental health staff did not affect APM use | Bonner, 2015, Hughes, 2000 & Lucas, 2014 |
Facilities served by the highest-ranked psychiatric consultant group | - High ranked psychiatric consultant groups make take on NHs with more BH problem patients, resulting in higher APM use | - Characteristics of psychiatric consultant groups can influence prescribing | Tija, 2014 | |
Less SS support | Minimal involvement of social services | - Social services may caution against the use of antipsychotic medications or involve the family | - Social services influence decision making regarding antipsychotic medication use. | Bonner, 2015 |
Occupancy characteristics | ||||
Resident Mix | Greater Facility share of Medicaid residents | -Lower funding results in less quality of care and increased use of APMs | - Medicaid provides less funding than private insurance resulting in fewer overall funds, possibly resulting in higher APM use -Lower Medicaid reimbursement is associated with increased APM use | Castle, 2009, Hughes, 2000, Lucas, 2014 & Stevenson, 2010 |
Lower Medicare census | No explanation | No explanation given | Stevenson, 2010 | |
Increased racial diversity | -Less funds are associated with lower quality of care in NHs | - Less funds, less resources, aligning with the idea of two tiers of USA NH care | Bonner, 2015 & Miller, 2006 | |
Occupancy rate | Low occupancy rate | - Maybe NHs with high APM use become less favorable for the elder population and their families | - Less funds are available and APMs may be used as a cheaper alternative for staff | Hughes, 2000 |
Market Characteristics | ||||
Competition | Minimal or no presence of competition | - Competition may force NHs to improve quality of care to maintain occupancy | - The presence of competition has shown to increase the quality of care in NHs | Castle, 2009 |
Chain membership | Independent Ownership (not part of a chain) | - May have less resources, standardization, and accountability, which may lower quality of care | - Chain membership may result in a higher degree of corporate standardization and oversight | Castle, 2009 |
Quality Characteristics | ||||
Reporting deficiencies | NH subject to reporting of physical restraints | - Facilities used chemical restraints instead of physical restraints in place of addressing root causes of the overuse | - The result of subjecting NHs to report physical restraint use was an increase of antipsychotic use as a substitution | Konetzka, 2014 |
Deficiency citations | Facilities with a higher number of deficiency citations | - Facilities ranked in the highest quartile for deficiencies most likely provide lower quality of care, which could result in the use of APMs as chemical restraints | -Multitasking incentive problem. The efforts to improve quality are spread to multiple areas of concern | Lucas, 2014 & Bowblis, 2012 |