Department of Health Sciences, Towson University, Towson, MD, USA.
Department of Health Sciences, Towson University, Towson, MD, USA.
J Am Med Dir Assoc. 2021 May;22(5):1081-1087.e1. doi: 10.1016/j.jamda.2020.09.009. Epub 2020 Oct 31.
The purpose of this study was to identify patterns of nurse staffing and skill mix and estimate the impact of these patterns on rehospitalization and emergency department (ED) visits in nursing home (NH) residents. We also estimated the relative contribution of unique staffing patterns on variations in hospital and ED use rates.
Retrospective secondary data analysis at the facility level, using administrative data.
Data from Medicare/Medicaid certified NHs in the 2018 Certification and Survey Provider Enhanced Reporting System were merged with the NH Compare Claims-Based Quality Measures file, for those facilities with complete data available (N = 14,325).
Cluster analysis was performed to identify groups of NHs with similar nursing skill mix patterns, using measures that captured hours per resident day (HPRD) for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). We estimated the impact of cluster assignment on unplanned rehospitalization and ED visits using multivariate generalized estimating equations. Plots were generated to visualize simulation models that showed the relative contribution of unique staffing strategies to the outcomes, while holding other factors constant.
We identified 3 nursing skill mix clusters: high-RN, high-LPN, and high-CNA, relative to national staffing averages. After controlling for regional and organizational characteristics, residents in NHs in the high-RN cluster had significantly lower rehospitalization and ED use compared with those in the high-LPN cluster, with a similar nonsignificant trend for the high-CNA vs high-LPN clusters. Though the high-RN cluster had CNA HPRD similar to the high-CNA cluster, it relied much less on LPN staffing. Whereas NHs in the high-LPN cluster had proportionally fewer hours of care by both CNAs and RNs.
NHs that emphasize LPN care in place of either RN or CNA care appears to exhibit higher rates of unplanned rehospitalization and ED visits among residents.
本研究旨在确定护士人员配备和技能组合模式，并评估这些模式对疗养院居民再住院和急诊部（ED）就诊的影响。我们还估计了独特人员配备模式对医院和 ED 使用率差异的相对贡献。
使用行政数据进行设施水平的回顾性二次数据分析。
将 2018 年认证和调查提供者增强报告系统中的医疗保险/医疗补助认证疗养院的数据与 NH 比较基于索赔的质量措施文件合并，对于那些具有完整可用数据的设施（N=14325）。
使用聚类分析来识别具有相似护理技能组合模式的 NH 组，使用每居民日（HPRD）的小时数来衡量注册护士（RN）、执业护士（LPN）和认证护理助理（CNA）。我们使用多变量广义估计方程来估计聚类分配对计划外再住院和 ED 就诊的影响。生成了图表，以可视化模拟模型，该模型显示了在保持其他因素不变的情况下，独特人员配备策略对结果的相对贡献。
我们确定了 3 种护理技能组合集群：高 RN、高 LPN 和高 CNA，相对于全国人员配备平均水平。在控制了区域和组织特征后，与高 LPN 集群相比，高 RN 集群的居民再住院和 ED 使用显著降低，高 CNA 与高 LPN 集群之间存在类似的非显著趋势。虽然高 RN 集群的 CNA HPRD 与高 CNA 集群相似，但它对 LPN 的人员配备依赖程度要低得多。而高 LPN 集群的护理人员中，CNA 和 RN 的护理时间比例都较少。
强调 LPN 护理而不是 RN 或 CNA 护理的 NH 似乎表现出居民计划外再住院和 ED 就诊率较高。
