Much attention has been paid to factors influencing quality of care in nursing home facilities, but less attention has been paid to what contributes to quality of life for nursing home residents. A recent study in the Gerontologist looks at which aspects of nursing home residents and nursing home facilities correlate with the different aspects of quality of life.
To address this question, interviews with nursing home residents were examined in conjunction with clinical data about the residents and the characteristics of the facilities in which they lived. This data was collected from the entire population in Medicaid-certified nursing homes in Minnesota, one of the few states that collects quality of life data from such facilities. Overall, data was collected from 10,969 residents in 396 nursing home facilities. The domains of quality of life examined here were environment (perspectives on the arrangement of personal living spaces), personal attention (treatment by employees), food, engagement (activities and personal connections to other residents and staff), negative mood, and positive mood.
The average length of stay for residents in this study was just over three years. The majority of residents were not cognitively impaired, and the average score for residents on a 28-point scale of activities of daily living was 14. Sixty-four percent of all residents were classified as having anxiety or a mood disorder. The residents also averaged having one chronic condition. Over 70 percent of residents had some self-pay or private insurance on admission, 69 percent had Medicare on admission, and 14 percent had Medicaid on admission.
As for the facilities, 14 percent were attached to a hospital. One-third of the facilities had unionized staff. The facilities averaged a 94 percent occupancy rate and a 74 percent staff retention rate. CNAs at these facilities averaged 2.3 direct care hours per resident day. The average CMS rating for facilities was 4.5 out of five stars, and the average quality of care score was three on a five-point scale. About half of the facilities were parts of a chain, and 63 percent were nonprofit.
Although both resident and facility characteristics predicted resident opinions on a number of quality of life domains, overall the researchers found that most of the variability in reported quality of life was much more associated with resident characteristics than characteristics of the facility. Facility characteristics accounted for at most 3 percent of the variance observed in quality of life score.
Of the resident characteristics, higher age was associated with lower quality of life scores in the areas of environment, engagement, mood, and overall quality of life score. Residents with higher education were more likely to report receiving more personal attention, but they also reported being less engaged. Longer lengths of stay were associated with better scores on environment, food, and engagement, but with lower scores on mood and their overall quality of life score. Greater problems with activities of daily life were associated with lower scores on all quality of life domains. Individuals with more serious medical conditions reported lower environmental quality of life, but higher engagement. In terms of mental health problems, Alzheimer’s Disease was positively associated with environment and food scores, but negatively associated with engagement and mood. Better cognitive performance was associated with higher personal attention, mood, and overall quality of life scores.
For facility characteristics, larger facilities were associated with lower scores on personal attention, food, engagement, and overall quality of life scores. Nonprofits, being attached to a hospital, low administrative turnover, high star ratings, quality improvement scores, and the percentage of private rooms all predicted higher quality of life for at least one factor. Activity staff hours per day were associated with better quality of life in all domains, and a higher percentage of licensed social worker hours was associated with better quality of life in personal attention, food, and engagement domains. In contrast, higher LPN hours per resident day were associated with worse mood and overall quality of life scores. The researchers suggest that this is due to higher LPN hours reflecting higher need among patients or more medicalized facilities. Those facilities with a higher percentage of Medicaid showed lower quality of life scores for personal attention, engagement, and the overall quality of life score.
Even though the individual characteristics of residents are beyond the control of facilities, the researchers in this study suggest that there are a number of implications for nursing homes. In particular, they suggest that nursing homes pay particular attention to those residents with characteristics that are associated with lower quality of life scores to ensure that their quality of life is being adequately addressed. They also suggest that greater hours for activities staff could have a positive impact on nursing homes, in light of activity staff hours’ positive association with all quality of life domains studied. Greater hours or resources for activity staff could also permit greater attention to residents whose individual characteristics are associated with lower quality of life scores.