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Prioritising part-time workers can boost consistency of care – study

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Long-term care facilities should prioritise part-time employees in order to boost consistency of care, new research shows.

In the United States, a multi-billion-dollar industry employs nurses and nursing assistants to provide long-term care in facilities such as nursing homes, residential care facilities, and home health agencies. 

A new study examined how these facilities — some of which have residents receiving care from more than 40 different nursing assistance in a month — should assign workers to resident groups on each shift to maximise the consistency of care. 

The study found that scheduling practices for part-time, per diem, and contract workers can drive poor consistency of care in long-term care facilities; prioritising the consistent assignment of these workers can significantly improve consistency of care, which is associated with better quality of life for both residents and workers.

Conducted by researchers at Carnegie Mellon University (CMU) and Cornell University, the study is published in Manufacturing & Service Operations Management.

“Our findings are relevant to the daily staffing practices of more than 15,600 nursing homes in the United States, especially for the more labour-intensive nursing assistant role, but also for nursing roles,” explains Alan A Scheller-Wolf, Professor of Operations Management at CMU’s Tepper School of Business, who co-authored the study. 

“We find that relatively simple changes in how facilities schedule workers can have a significant impact on consistency of care, which should also improve quality of care, and the satisfaction of residents, their families, and staff.” 

The amount of hands-on care delivered and the extended time horizon of care have important implications for long-term care staffing practices. In particular, concerns about quality of care have led practitioners to emphasise the idea of consistency of care, focusing on such matters as building relationships between staff and residents, reducing residents’ distress, and improving clinical outcomes.

During the pandemic, consistency of care (minimising the number of unique caregivers seen by any given resident) has also been emphasised to limit the spread of Covid-19.

Yet based on the authors’ analysis of shift rosters from three mid-Atlantic nursing homes, common practices in assigning part-time and contract workers significantly impair consistency of care: In many facilities, full-time workers are first assigned to the same unit over a period of time, and part-time workers are then assigned to fill in gaps. 

Researchers examined the relationship between consistency of care and rostering decisions, that is, how caregivers are assigned to different units for each shift. 

Specifically, they analysed data from more than 15,000 shifts worked by nursing assistants at the three nursing homes over several months, comparing actual rosters to optimal schedules that maximise consistency. Then they compared the performance of the optimised rosters to the facilities’ schedules.

Repeatedly assigning full-time workers to a home unit and giving low priority for home-unit assignment to part-time workers can result in high levels of inconsistent care, the study found. 

In contrast, consistently assigning part-time workers and having some flexible full-time workers can significantly increase consistency of care. 

Flexibility among full-time workers helps achieve consistency because their higher frequency of work makes a reassignment away from their home unit less likely to cause a problem in inconsistency since full-time workers can often work multiple shifts in a single non-home unit.

The authors’ studies indicate that nursing homes that prioritise part-time workers can significantly improve consistency of care, potentially reducing the average number of different nursing assistants a resident interacts with by 20 to 30 per cent each month. 

Most of the benefits of improved consistency of care can be achieved even if many of the full-time employees are still granted scheduling priority to work in their home unit.

Furthermore, for facilities that house residents in large units (four to six nursing assistants per day or evening shift), splitting these units into smaller ones and prioritising part-time employees can potentially reduce the level of inconsistency by 50 per cent.

The researchers provide strategies for nursing homes that schedule shifts manually, and strategies for software companies that are automating scheduling long-term care shifts. Further work is needed to bring the principles of the study into practice; work with assisted care homes and software companies is ongoing.

 “Facilities should seek as much flexibility as practicable from full-time workers to allow part-time workers to be assigned more consistently and improve their overall inconsistency level,” suggests Vincent W. Slaugh, Assistant Professor of Operations Management at Cornell’s S.C. Johnson College of Business, who led the study. 

“The insights from our analysis offer a simple cost-free solution to improve quality of life for both residents and caregivers. Nursing homes that use more part-time and contract workers due to the labour shortage can use these insights to improve the experience of those workers.”

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Air pollution linked to increased hospital admission for heart and lung diseases

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Exposure to fine particulate matter (PM2.5) air pollution is linked to an increased risk of hospital admission for major heart and lung diseases, find two large US studies, published by The BMJ.

Together, the results suggest that no safe threshold exists for heart and lung health.

According to the Global Burden of Disease study, exposure to PM2.5 accounts for an estimated 7.6% of total global mortality and 4.2% of global disability adjusted life years (a measure of years lived in good health).

In light of this extensive evidence, the World Health Organization (WHO) updated the air quality guidelines in 2021, recommending that an annual average PM2.5 levels should not exceed 5 μg/m3 and 24 hour average PM2.5 levels should not exceed 15 μg/m3 on more than 3-4 days each year.

In the first study, researchers linked average daily PM2.5 levels to residential zip codes for nearly 60 million US adults (84 per cent white, 55 per cent women) aged 65 and over from 2000 to 2016. They then used Medicare insurance data to track hospital admissions over an average of eight years.

After accounting for a range of economic, health and social factors, average PM2.5 exposure over three years was associated with increased risks of first hospital admissions for seven major types of cardiovascular disease – ischemic heart disease, cerebrovascular disease, heart failure, cardiomyopathy, arrhythmia, valvular heart disease, and thoracic and abdominal aortic aneurysms.

Compared with exposures of 5 μg/m3 or less (the WHO air quality guideline for annual PM2.5), exposures between 9 and 10 μg/m3, which encompassed the US national average of 9.7 μg/m3 during the study period, were associated with a 29% increased risk of hospital admission for cardiovascular disease.

On an absolute scale, the risk of hospital admission for cardiovascular disease increased from 2.59% with exposures of 5 μg/m3 or less to 3.35% at exposures between 9 and 10 μg/m3.

“This means that if we were able to manage to reduce annual PM2.5 below 5 µg/m3, we could avoid 23% in hospital admissions for cardiovascular disease,” say the researchers.*

These cardiovascular effects persisted for at least three years after exposure to PM2.5, and susceptibility varied by age, education, access to healthcare services, and area deprivation level.

The researchers say their findings suggest that no safe threshold exists for the chronic effect of PM2.5 on overall cardiovascular health, and that substantial benefits could be attained through adherence to the WHO air quality guideline.

“On February 7, 2024, the US Environmental Protection Agency (EPA) updated the national air quality standard for annual PM2.5 level, setting a stricter limit at no more than 9 µg/m3. This is the first update since 2012. However, it is still considerably higher than the 5 µg/m3 set by WHO. Obviously, the newly published national standard was not sufficient for the protection of public health,” they add.*

In the second study, researchers used county-level daily PM2.5 concentrations and medical claims data to track hospital admissions and emergency department visits for natural causes, cardiovascular disease, and respiratory disease for 50 million US adults aged 18 and over from 2010 to 2016.

During the study period, more than 10 million hospital admissions and 24 million emergency department visits were recorded.

They found that short term exposure to PM2.5, even at concentrations below the new WHO air quality guideline limit, was statistically significantly associated with higher rates of hospital admissions for natural causes, cardiovascular disease and respiratory disease, as well as emergency department visits for respiratory disease.

For example, on days when daily PM2.5 levels were below the new WHO air quality guideline limit of 15 μg/m3, an increase of 10 μg/m3 in PM2.5 was associated with 1.87 extra hospital admissions per million adults aged 18 and over per day.

The researchers say their findings constitute an important contribution to the debate about the revision of air quality limits, guidelines, and standards.

Both research teams acknowledge several limitations such as possible misclassification of exposure and point out that other unmeasured factors may have affected their results. What’s more, the findings may not apply to individuals without medical insurance, children and adolescents, and those living outside the US.

However, taken together, these new results provide valuable reference for future national air pollution standards.

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Home health care linked to increased hospice use at end-of-life – study

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Patients who had previously received home health care had a higher likelihood of accessing hospice care at the end of their life, according to a new study.

Researchers, whose findings are published in the Journal of Palliative Medicine, examined the home health care and hospice care experiences of more than two million people.

Using Medicare data, researchers found when individuals received home health care before the last year of their life, they had higher odds of using hospice care than those who had never received home health care.

Researchers said this association underscores the potential benefits of receiving end-of-life care in the comfort of one’s home.

As the aged population increases, the findings also show the need for more resources in the health care sector and staff training in end-of-life care.

Home health care services including skilled nursing, therapy, social work and aide services are used to maintain functioning or slow decline in health. Hospice care provides similar services but is intended for those with life expectancies of six months or less and is focused on pain relief, minimising hospital visits and providing comfort and support. Both services provide patients the opportunity to receive more personalised care in their home.

Researchers say home-based care also encourages greater involvement of family caregivers in the caregiving process.

Olga Jarrín, senior author of the study, the Hunterdon Professor of Nursing Research at the Rutgers School of Nursing and director of the Community Health and Aging Outcomes Laboratory within the Rutgers Institute for Health, Health Care Policy and Aging Research, commented: “In addition to benefits for the patient, hospice care also provides resources and support to help family caregivers cope with the physical, emotional and practical challenges of caring for a loved one at the end of life.”

Hyosin (Dawn) Kim, research assistant professor at Oregon State University and first author of the study, added: “By providing personalised care, reducing hospitalisations, fostering family involvement and support, and improving symptom management, home-based care can enhance the quality of end-of-life experiences for patients with terminal illnesses and their families.”

 

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Sleep programme shows promise in those with memory problems – study

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A new study has shown promising results in improving sleep and quality of life in individuals living with memory problems.

A group of researchers from Penn Nursing, Penn Medicine, Rutgers School of Nursing, and Drexel University’s College of Nursing and Health Professions, have delved into the efficacy of a non-pharmacological approach in a trial known as the Healthy Patterns Sleep Program.

The study involved 209 pairings of community-residing individuals with memory problems and their care partners. Participants were assigned to either the Healthy Patterns Sleep Program, which consisted of one-hour home activity sessions administered over four weeks, or a control group that received sleep hygiene training, plus education on home safety and health promotion.

The Healthy Patterns Sleep Program trained care partners in timed daily activities such as reminiscence in the morning, exercise in the afternoon and sensory activities in the evening that can decrease daytime sleepiness and improve nighttime sleep quality.

Nancy Hodgson, PhD, RN, FAAN, the Claire M. Fagin Leadership Professor in Nursing and Chair of Department of Biobehavioral Health Sciences, who led the study, said: “The results from this study provide fundamental new knowledge regarding the effects of timing activity participation and can lead to structured, replicable treatment protocols to address sleep disturbances. Overall, the Healthy Patterns program resulted in improved QOL compared to an attention-control group.”

The findings also indicate that, compared to a control group, the four-week Healthy Patterns program improved sleep quality among persons living with memory issues who had depressive symptoms or poor sleep quality.  The study indicates the Healthy Patterns Intervention might need a longer dose to induce improvements in other sleep-wake activity metrics.

The study’s significance lies in its confirmation of the effectiveness of behavioural interventions in not only improving quality of life and addressing sleep quality issues in this population, but also potentially reducing care partner burden and overall care costs for persons living at home with memory problems.

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