kali Thomas | Brown University (original) (raw)

Papers by kali Thomas

Journal of nutrition in gerontology and geriatrics

The nation's home-delivered meals program is an important service strategy to provide nutriti... more The nation's home-delivered meals program is an important service strategy to provide nutrition and socialization to hundreds of thousands of homebound older adults. However, data limitations have prevented the formation of an evidence-base for these programs beyond measuring outputs. This article discusses our need to have a better way to measure and analyze need, unmet need, and outcomes associated with receipt of services in order to ensure that this valuable program receives the level of support required to continue to serve homebound older adults. In order to shape the discussion about the best ways to provide evidence of these programs' impact, it is important to think about what outcomes could and should be measured, the best possible sources of data, and how providers can collect this information effectively and uniformly.

Current Psychology, 2015

ABSTRACT Abstract The study examined Florida assisted living facility staff perspectives of disas... more ABSTRACT Abstract The study examined Florida assisted living facility staff perspectives of disaster preparedness, response, and recovery after the 2004 and 2005 hurricanes. A descriptive study using qualitative and quantitative approaches. One hundred seventy Florida assisted living facility staff who worked in areas under hurricane threat and provided care to residents during a hurricane. A questionnaire that was mailed or administered to staff attending a regional planning conference with quantitative and qualitative items. Of the 143 facilities that were affected by a hurricane, 77%reported that they sheltered residents in place, while 23 % indicated that they evacuated for one or more of the hurricanes. Almost one-third of facilities lost telephone service and almost half lost electrical power during one or more of the hurricanes. Key topics noted by both evacuating facilities and those that sheltered in place were 1) decision-making, 2) planning, support, and supplies, 3) communication, and 4) electricity. Unique to assisted living facilities is the role of residents’ family in assuming responsibility for evacuation and shelter during hurricanes. Facility staff at both evacuating and sheltering facilities indicated that the decision to evacuate or to shelter in place was difficult and the electrical power was critical to resident well-being. Assisted living facilities should develop disaster preparedness plans in conjunction with local and state emergency offices. Adequate disaster preparedness has implications for residents’ safety as well as assisted living facility staff during disasters.

Rhode Island medical journal (2013), 2014

Health care transitions are often dangerous for older patients. Interviews with older adults abou... more Health care transitions are often dangerous for older patients. Interviews with older adults about their health care moves in Rhode Island (RI) were conducted to develop an Internal Medicine (IM) curriculum designed to provide IM interns with insights about the impact of transitions on patients. This paper describes some ways patients talk about their transitional experiences. Following pilot interviews, 10 nursing home residents were interviewed about their care transitions, conversations with physicians, and advice to doctors beginning their careers. The interviews were analyzed to identify themes. Patients described multiple moves, often did not know what to expect, appreciated help from a family member and desired effective communications with physicians. Learning about patient experiences may help new physicians appreciate the experiences of transitions on patients. [Full text available at http://rimed.org/rimedicaljournal-2015-04.asp, free with no login].

Medical Care, 2015

The Minimum Data Set (MDS) 3.0 introduced the Brief Interview for Mental Status (BIMS), a short p... more The Minimum Data Set (MDS) 3.0 introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents. Not all residents are able to complete the BIMS and are consequently assessed by staff. We designed a Cognitive Function Scale (CFS) integrating self-report and staff-report data and present evidence of the scale's construct validity. A retrospective cohort study. The subjects consisted of 3 cohorts: (1) long-stay NH residents (N=941,077) and (2) new admissions (N=2,066,580) during 2011-2012, and (3) residents with the older MDS 2.0 assessment in 2010 and the newer MDS 3.0 assessment (n=688,511). MDS 3.0 items were used to create a single, integrated 4-category hierarchical CFS that was compared with residents' prior MDS 2.0 Cognitive Performance Scale scores and other concurrent MDS 3.0 measures of construct validity. The new CFS suggests that 28% of the long-stay cohort in 2011-2012 were cognitively intact, 22% were mildly impaired, 33% were moderately impaired, and 17% were severely impaired. For the admission cohort, the CFS noted 56% as cognitively intact, 23% as mildly impaired, 17% as moderately impaired, and 4% as severely impaired. The CFS corresponded closely with residents' prior MDS 2.0 Cognitive Performance Scale scores and with performance of Activities of Daily Living, and nurses' judgments of function and behavior in both the admission and long-stay cohorts. The new CFS is valuable to researchers as it provides a single, integrated measure of NH residents' cognitive function, regardless of the mode of assessment.

Journal of the American Medical Directors Association, Jan 3, 2015

To examine the completeness of the activities of daily living (ADL) items on admission and discha... more To examine the completeness of the activities of daily living (ADL) items on admission and discharge assessments and the improvement in ADL performance among short-stay residents in the newly adopted Minimum Data Set (MDS) 3.0. Retrospective analysis of MDS admission and discharge assessments. Nursing homes from July 1, 2011, to June 30, 2012. New nursing home residents admitted from acute hospitals with corresponding admission and discharge assessments between July 1, 2011, and June 30, 2012, who had a length of stay of 100 days or less. ADL self-performance items, including bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, at admission and discharge. The ADL self-performance items are complete at both admission and discharge, with less than 1% missing for any item. More than 60% of residents improved over the course of their post-acute stay. New short-stay nursing home resident...

American Journal of Public Health, 2014

We used fixed-effect models to examine the relationship between local spending on home- and commu... more We used fixed-effect models to examine the relationship between local spending on home- and community-based services (HCBSs) for cash-assisted Medicaid-only disabled (CAMOD) adults and younger adult admissions to nursing homes in the United States during 2001 through 2008, with control for facility and market characteristics and secular trends. We found that increased CAMOD Medicaid HCBS spending at the local level is associated with decreased admissions of younger adults to nursing homes. Our findings suggest that states' efforts to expand HCBS for this population should continue.

Disaster Medicine and Public Health Preparedness, 2010

The study was designed to examine the 30-and 90-day mortality and hospitalization rates among nur... more The study was designed to examine the 30-and 90-day mortality and hospitalization rates among nursing facility (NF) residents in the affected areas of Louisiana and Mississippi following Hurricane Katrina and to assess the rate of significant posthurricane functional decline. Methods: A secondary data analysis was conducted using Medicare claims merged with NF resident data from the Minimum Data Set. Thirty-and 90-day mortality and hospitalization rates for long-stay (Ͼ90 days) residents residing in 141 at-risk NFs during Hurricane Katrina were compared to rates for residents residing at the same facilities during the same time period in prior nonhurricane years (2003 and 2004). Functional decline was assessed as a 4ϩ drop in function using a 28-point Minimum Data Set Activities of Daily Living Scale. Results: There were statistically significant differences (all P Ͻ .0001) in mortality, hospitalization, and functional decline among residents exposed to Hurricane Katrina. At 30 days, the mortality rate was 3.88% among the exposed cohort compared with 2.10% and 2.28% for residents in 2003 and 2004, respectively. The 90day mortality rate was 9.27% compared with 6.71% and 6.31%, respectively. These mortality differences translated into an additional 148 deaths at 30 days and 230 deaths at 90 days. The 30-day hospitalization rate was 9.87% compared with 7.21% and 7.53%, respectively. The 90-day hospitalization rate was 20.39% compared with 18.61% and 17.82%, respectively. Finally, the rate of significant functional decline among survivors was 6.77% compared with 5.81% in 2003 and 5.10% in 2004. Conclusions: NF residents experienced a significant increase in mortality, hospitalization, and functional decline during Hurricane Katrina.

Medical Care Research and Review, 2010

Research on nursing staff ratios and quality of care in nursing homes prompted Florida to impleme... more Research on nursing staff ratios and quality of care in nursing homes prompted Florida to implement minimum nursing staff ratios for certified nursing assistants (CNAs) in 2001. Using the contingency theory, the authors investigated the response to this mandate and its potential effects on indirect-care staff. This study used the Online Survey, Certification, and Reporting (OSCAR) staffing data for freestanding Florida nursing homes between the years 1999 and 2004. Piecewise regression growth curve models were investigated to test whether the percentage of Medicaid residents is associated with change in indirectcare staffing levels. The number of indirect-care staff hours per 100 residents declined significantly following the mandated increase in nursing staff, particularly among facilities with a low percentage of Medicaid residents. This may have stemmed from a partial transfer of indirect-care to CNAs and was exacerbated in facilities that received less additional reimbursement to pay for CNA increases.

Journal of the American Medical Directors Association, 2012

Objective: To examine the differential morbidity/mortality associated with evacuation versus shel... more Objective: To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf hurricanes. Methods: Observational study using Medicare claims and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 nonhurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days. Results: Among 36,389 NH residents exposed to a storm, the 30-and 90-day mortality/hospitalization rates increased compared with nonhurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7% to 5.3% and hospitalization by 1.8% to 8.3%, independent of other factors. Conclusion: Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.

Journal of the American Geriatrics Society, 2013

To evaluate the use of medications classified as inappropriate according to the Health Plan Emplo... more To evaluate the use of medications classified as inappropriate according to the Health Plan Employer Data and Information Set (HEDIS) in elderly veterans residing in Department of Veterans Affairs (VA) nursing homes from 2004 to 2009 and to identify participant-specific correlates of use. Retrospective, cross-sectional study using VA administrative data merged with participant-specific data from the Minimum Data Set. VA nursing homes (community living centers (CLCs)). Veterans aged 65 and older residing in CLCs at the time of the prescribed medication use (N = 176,168). The number of exposed veterans aged 65 and older per facility receiving at least one HEDIS high-risk medication was determined. Between 2004 and 2009, 28,970 of 176,168 (mean 16.4 ± 9.5%) veterans received at least one HEDIS high-risk medication. Over the period, the number of veterans receiving high-risk medications decreased steadily from 23.9 ± 10.0% in 2004 to 10.0 ± 6.6% in 2009. Nevertheless, large facility variations remained in 2009, with rates from 0% to 44.4%. Certain characteristics were also associated with HEDIS high-risk medication use, including female sex (odds ratio (OR) = 1.6; 95% confidence interval (CI) = 1.25-2.04), cancer (OR = 1.19, 95% CI = 1.08-1.32), renal disease (OR = 1.16, 95% CI = 1.01-1.33), chronic obstructive pulmonary disease (OR = 1.16, 95% CI = 1.05-1.28), and diabetes mellitus (OR = 1.11, 95% CI = 1.02-1.22). Protective characteristics included age 75 and older (OR = 0.81, 95% CI = 0.73-0.90) and having a diagnosis of moderate (OR = 0.72, 95% CI = 0.64-0.82) or severe (OR = 0.72, 95% CI = 0.61-0.85) cognitive impairment. The use of HEDIS medications among elderly veterans residing in VA nursing homes has markedly improved. Nevertheless, significant variations between facilities and certain subpopulations remain. A low percentage of women at VA CLCs make comparisons with community nursing homes difficult.

Journal of Aging and Health, 2014

The aim of the study was to investigate the relationship between supportive services provided und... more The aim of the study was to investigate the relationship between supportive services provided under Title III-B of the Older Americans Act (OAA) and the prevalence of low-care residents in nursing homes (NHs). State Program Reports (state-level expenditure and utilization data for each OAA service) and NH facility-level data were analyzed using a two-way fixed effects model. Results suggest that every additional 1% of the population age 65+ that receives personal care services is associated with a 0.8% decrease in the proportion of low-care residents in NHs. Despite efforts to rebalance long-term care, there are still many NH residents who have the functional capacity to live in a less restrictive environment. This is among the first studies to suggest that states that have invested in their in-home supportive services, particularly personal care services provided through the OAA, have proportionally fewer of these people.

Health Services Research, 2013

The Gerontologist, 2010

Purpose: This study describes Florida's model of Medicaid nursing home (NH) reimbursement to comp... more Purpose: This study describes Florida's model of Medicaid nursing home (NH) reimbursement to compensate NHs for disaster-related expenses incurred as a result of 8 hurricanes within a 2-year period. This Florida model can serve as a demonstration for a national model for disaster-related reimbursement. Design and Methods: Florida reimburses NHs for approved disaster-related costs through hurricane interim rate requests (IRRs). The state developed its unique Medicaid per diem rate temporary add-on by adapting its standard rate-setting reimbursement methodology. To understand the payment mechanisms and the costs that facilities incurred as a result of natural disasters, we examined the IRRs and cost reports for facilities requesting and receiving reimbursement. Results: Cost reports and IRR applications indicated that Florida Medicaid spent close to $16 million to pay for hurricanerelated costs to NHs. Implications: Without Florida's Hurricane IRR program, many facilities would have not been reimbursed for their hurricanerelated costs. Florida's model is one that Medicare and other states should consider adopting to ensure that NHs receive adequate reimbursement for disaster-related expenses, including tornadoes, earthquakes, floods, blizzards, and other catastrophic events.

Evidence-Based Nursing, 2012

Clinical Gerontologist, 2011

Applied Nursing Research, 2009

This article documents the experience of 291 Florida nursing homes during the 2004 hurricane seas... more This article documents the experience of 291 Florida nursing homes during the 2004 hurricane season. Using quantitative and qualitative methods, the authors described and compared the challenges nurses encountered when evacuating residents with their experiences assisting residents of facilities that sheltered in place. The primary concerns for evacuating facilities were accessing appropriate evacuation sites for residents and having ambulance transportation contracts honored. The main issue for facilities that sheltered in place was the length of time it took for power to be restored. Barriers to maintaining resident health during disasters for those who evacuated or sheltered in place are identified.

Journal of nutrition in gerontology and geriatrics

The nation's home-delivered meals program is an important service strategy to provide nutriti... more The nation's home-delivered meals program is an important service strategy to provide nutrition and socialization to hundreds of thousands of homebound older adults. However, data limitations have prevented the formation of an evidence-base for these programs beyond measuring outputs. This article discusses our need to have a better way to measure and analyze need, unmet need, and outcomes associated with receipt of services in order to ensure that this valuable program receives the level of support required to continue to serve homebound older adults. In order to shape the discussion about the best ways to provide evidence of these programs' impact, it is important to think about what outcomes could and should be measured, the best possible sources of data, and how providers can collect this information effectively and uniformly.

Current Psychology, 2015

ABSTRACT Abstract The study examined Florida assisted living facility staff perspectives of disas... more ABSTRACT Abstract The study examined Florida assisted living facility staff perspectives of disaster preparedness, response, and recovery after the 2004 and 2005 hurricanes. A descriptive study using qualitative and quantitative approaches. One hundred seventy Florida assisted living facility staff who worked in areas under hurricane threat and provided care to residents during a hurricane. A questionnaire that was mailed or administered to staff attending a regional planning conference with quantitative and qualitative items. Of the 143 facilities that were affected by a hurricane, 77%reported that they sheltered residents in place, while 23 % indicated that they evacuated for one or more of the hurricanes. Almost one-third of facilities lost telephone service and almost half lost electrical power during one or more of the hurricanes. Key topics noted by both evacuating facilities and those that sheltered in place were 1) decision-making, 2) planning, support, and supplies, 3) communication, and 4) electricity. Unique to assisted living facilities is the role of residents’ family in assuming responsibility for evacuation and shelter during hurricanes. Facility staff at both evacuating and sheltering facilities indicated that the decision to evacuate or to shelter in place was difficult and the electrical power was critical to resident well-being. Assisted living facilities should develop disaster preparedness plans in conjunction with local and state emergency offices. Adequate disaster preparedness has implications for residents’ safety as well as assisted living facility staff during disasters.

Rhode Island medical journal (2013), 2014

Health care transitions are often dangerous for older patients. Interviews with older adults abou... more Health care transitions are often dangerous for older patients. Interviews with older adults about their health care moves in Rhode Island (RI) were conducted to develop an Internal Medicine (IM) curriculum designed to provide IM interns with insights about the impact of transitions on patients. This paper describes some ways patients talk about their transitional experiences. Following pilot interviews, 10 nursing home residents were interviewed about their care transitions, conversations with physicians, and advice to doctors beginning their careers. The interviews were analyzed to identify themes. Patients described multiple moves, often did not know what to expect, appreciated help from a family member and desired effective communications with physicians. Learning about patient experiences may help new physicians appreciate the experiences of transitions on patients. [Full text available at http://rimed.org/rimedicaljournal-2015-04.asp, free with no login].

Medical Care, 2015

The Minimum Data Set (MDS) 3.0 introduced the Brief Interview for Mental Status (BIMS), a short p... more The Minimum Data Set (MDS) 3.0 introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents. Not all residents are able to complete the BIMS and are consequently assessed by staff. We designed a Cognitive Function Scale (CFS) integrating self-report and staff-report data and present evidence of the scale's construct validity. A retrospective cohort study. The subjects consisted of 3 cohorts: (1) long-stay NH residents (N=941,077) and (2) new admissions (N=2,066,580) during 2011-2012, and (3) residents with the older MDS 2.0 assessment in 2010 and the newer MDS 3.0 assessment (n=688,511). MDS 3.0 items were used to create a single, integrated 4-category hierarchical CFS that was compared with residents' prior MDS 2.0 Cognitive Performance Scale scores and other concurrent MDS 3.0 measures of construct validity. The new CFS suggests that 28% of the long-stay cohort in 2011-2012 were cognitively intact, 22% were mildly impaired, 33% were moderately impaired, and 17% were severely impaired. For the admission cohort, the CFS noted 56% as cognitively intact, 23% as mildly impaired, 17% as moderately impaired, and 4% as severely impaired. The CFS corresponded closely with residents' prior MDS 2.0 Cognitive Performance Scale scores and with performance of Activities of Daily Living, and nurses' judgments of function and behavior in both the admission and long-stay cohorts. The new CFS is valuable to researchers as it provides a single, integrated measure of NH residents' cognitive function, regardless of the mode of assessment.

Journal of the American Medical Directors Association, Jan 3, 2015

To examine the completeness of the activities of daily living (ADL) items on admission and discha... more To examine the completeness of the activities of daily living (ADL) items on admission and discharge assessments and the improvement in ADL performance among short-stay residents in the newly adopted Minimum Data Set (MDS) 3.0. Retrospective analysis of MDS admission and discharge assessments. Nursing homes from July 1, 2011, to June 30, 2012. New nursing home residents admitted from acute hospitals with corresponding admission and discharge assessments between July 1, 2011, and June 30, 2012, who had a length of stay of 100 days or less. ADL self-performance items, including bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, at admission and discharge. The ADL self-performance items are complete at both admission and discharge, with less than 1% missing for any item. More than 60% of residents improved over the course of their post-acute stay. New short-stay nursing home resident...

American Journal of Public Health, 2014

We used fixed-effect models to examine the relationship between local spending on home- and commu... more We used fixed-effect models to examine the relationship between local spending on home- and community-based services (HCBSs) for cash-assisted Medicaid-only disabled (CAMOD) adults and younger adult admissions to nursing homes in the United States during 2001 through 2008, with control for facility and market characteristics and secular trends. We found that increased CAMOD Medicaid HCBS spending at the local level is associated with decreased admissions of younger adults to nursing homes. Our findings suggest that states' efforts to expand HCBS for this population should continue.

Disaster Medicine and Public Health Preparedness, 2010

The study was designed to examine the 30-and 90-day mortality and hospitalization rates among nur... more The study was designed to examine the 30-and 90-day mortality and hospitalization rates among nursing facility (NF) residents in the affected areas of Louisiana and Mississippi following Hurricane Katrina and to assess the rate of significant posthurricane functional decline. Methods: A secondary data analysis was conducted using Medicare claims merged with NF resident data from the Minimum Data Set. Thirty-and 90-day mortality and hospitalization rates for long-stay (Ͼ90 days) residents residing in 141 at-risk NFs during Hurricane Katrina were compared to rates for residents residing at the same facilities during the same time period in prior nonhurricane years (2003 and 2004). Functional decline was assessed as a 4ϩ drop in function using a 28-point Minimum Data Set Activities of Daily Living Scale. Results: There were statistically significant differences (all P Ͻ .0001) in mortality, hospitalization, and functional decline among residents exposed to Hurricane Katrina. At 30 days, the mortality rate was 3.88% among the exposed cohort compared with 2.10% and 2.28% for residents in 2003 and 2004, respectively. The 90day mortality rate was 9.27% compared with 6.71% and 6.31%, respectively. These mortality differences translated into an additional 148 deaths at 30 days and 230 deaths at 90 days. The 30-day hospitalization rate was 9.87% compared with 7.21% and 7.53%, respectively. The 90-day hospitalization rate was 20.39% compared with 18.61% and 17.82%, respectively. Finally, the rate of significant functional decline among survivors was 6.77% compared with 5.81% in 2003 and 5.10% in 2004. Conclusions: NF residents experienced a significant increase in mortality, hospitalization, and functional decline during Hurricane Katrina.

Medical Care Research and Review, 2010

Research on nursing staff ratios and quality of care in nursing homes prompted Florida to impleme... more Research on nursing staff ratios and quality of care in nursing homes prompted Florida to implement minimum nursing staff ratios for certified nursing assistants (CNAs) in 2001. Using the contingency theory, the authors investigated the response to this mandate and its potential effects on indirect-care staff. This study used the Online Survey, Certification, and Reporting (OSCAR) staffing data for freestanding Florida nursing homes between the years 1999 and 2004. Piecewise regression growth curve models were investigated to test whether the percentage of Medicaid residents is associated with change in indirectcare staffing levels. The number of indirect-care staff hours per 100 residents declined significantly following the mandated increase in nursing staff, particularly among facilities with a low percentage of Medicaid residents. This may have stemmed from a partial transfer of indirect-care to CNAs and was exacerbated in facilities that received less additional reimbursement to pay for CNA increases.

Journal of the American Medical Directors Association, 2012

Objective: To examine the differential morbidity/mortality associated with evacuation versus shel... more Objective: To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf hurricanes. Methods: Observational study using Medicare claims and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 nonhurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days. Results: Among 36,389 NH residents exposed to a storm, the 30-and 90-day mortality/hospitalization rates increased compared with nonhurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7% to 5.3% and hospitalization by 1.8% to 8.3%, independent of other factors. Conclusion: Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.

Journal of the American Geriatrics Society, 2013

To evaluate the use of medications classified as inappropriate according to the Health Plan Emplo... more To evaluate the use of medications classified as inappropriate according to the Health Plan Employer Data and Information Set (HEDIS) in elderly veterans residing in Department of Veterans Affairs (VA) nursing homes from 2004 to 2009 and to identify participant-specific correlates of use. Retrospective, cross-sectional study using VA administrative data merged with participant-specific data from the Minimum Data Set. VA nursing homes (community living centers (CLCs)). Veterans aged 65 and older residing in CLCs at the time of the prescribed medication use (N = 176,168). The number of exposed veterans aged 65 and older per facility receiving at least one HEDIS high-risk medication was determined. Between 2004 and 2009, 28,970 of 176,168 (mean 16.4 ± 9.5%) veterans received at least one HEDIS high-risk medication. Over the period, the number of veterans receiving high-risk medications decreased steadily from 23.9 ± 10.0% in 2004 to 10.0 ± 6.6% in 2009. Nevertheless, large facility variations remained in 2009, with rates from 0% to 44.4%. Certain characteristics were also associated with HEDIS high-risk medication use, including female sex (odds ratio (OR) = 1.6; 95% confidence interval (CI) = 1.25-2.04), cancer (OR = 1.19, 95% CI = 1.08-1.32), renal disease (OR = 1.16, 95% CI = 1.01-1.33), chronic obstructive pulmonary disease (OR = 1.16, 95% CI = 1.05-1.28), and diabetes mellitus (OR = 1.11, 95% CI = 1.02-1.22). Protective characteristics included age 75 and older (OR = 0.81, 95% CI = 0.73-0.90) and having a diagnosis of moderate (OR = 0.72, 95% CI = 0.64-0.82) or severe (OR = 0.72, 95% CI = 0.61-0.85) cognitive impairment. The use of HEDIS medications among elderly veterans residing in VA nursing homes has markedly improved. Nevertheless, significant variations between facilities and certain subpopulations remain. A low percentage of women at VA CLCs make comparisons with community nursing homes difficult.

Journal of Aging and Health, 2014

The aim of the study was to investigate the relationship between supportive services provided und... more The aim of the study was to investigate the relationship between supportive services provided under Title III-B of the Older Americans Act (OAA) and the prevalence of low-care residents in nursing homes (NHs). State Program Reports (state-level expenditure and utilization data for each OAA service) and NH facility-level data were analyzed using a two-way fixed effects model. Results suggest that every additional 1% of the population age 65+ that receives personal care services is associated with a 0.8% decrease in the proportion of low-care residents in NHs. Despite efforts to rebalance long-term care, there are still many NH residents who have the functional capacity to live in a less restrictive environment. This is among the first studies to suggest that states that have invested in their in-home supportive services, particularly personal care services provided through the OAA, have proportionally fewer of these people.

Health Services Research, 2013

The Gerontologist, 2010

Purpose: This study describes Florida's model of Medicaid nursing home (NH) reimbursement to comp... more Purpose: This study describes Florida's model of Medicaid nursing home (NH) reimbursement to compensate NHs for disaster-related expenses incurred as a result of 8 hurricanes within a 2-year period. This Florida model can serve as a demonstration for a national model for disaster-related reimbursement. Design and Methods: Florida reimburses NHs for approved disaster-related costs through hurricane interim rate requests (IRRs). The state developed its unique Medicaid per diem rate temporary add-on by adapting its standard rate-setting reimbursement methodology. To understand the payment mechanisms and the costs that facilities incurred as a result of natural disasters, we examined the IRRs and cost reports for facilities requesting and receiving reimbursement. Results: Cost reports and IRR applications indicated that Florida Medicaid spent close to $16 million to pay for hurricanerelated costs to NHs. Implications: Without Florida's Hurricane IRR program, many facilities would have not been reimbursed for their hurricanerelated costs. Florida's model is one that Medicare and other states should consider adopting to ensure that NHs receive adequate reimbursement for disaster-related expenses, including tornadoes, earthquakes, floods, blizzards, and other catastrophic events.

Evidence-Based Nursing, 2012

Clinical Gerontologist, 2011

Applied Nursing Research, 2009

This article documents the experience of 291 Florida nursing homes during the 2004 hurricane seas... more This article documents the experience of 291 Florida nursing homes during the 2004 hurricane season. Using quantitative and qualitative methods, the authors described and compared the challenges nurses encountered when evacuating residents with their experiences assisting residents of facilities that sheltered in place. The primary concerns for evacuating facilities were accessing appropriate evacuation sites for residents and having ambulance transportation contracts honored. The main issue for facilities that sheltered in place was the length of time it took for power to be restored. Barriers to maintaining resident health during disasters for those who evacuated or sheltered in place are identified.