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Journal Highlights From the November Issue of JAMDA

        Therapy Payments

        Skilled nursing facilities significantly reduced the amount of individual occupational and physical therapy (OT and PT) given to short-stay Medicare patients while increasing group therapy after the Patient Driven Payment Model, or PDPM, went into effect, according to a study in Oregon.
        The Centers for Medicare & Medicaid Services implemented PDPM in October 2019. The model now bases reimbursement on an individual’s diagnosis and other characteristics rather than the volume of services provided.
        Led by Wei Zhang, PhD, of Oregon State University’s College of Public Health and Human Sciences, researchers used Minimum Data Set assessments to compare the use of both therapies and the quality of care among 35,540 short stays (27,967 patients) at all SNFs in Oregon before implementation of PDPM and the first five months after.
        Before undertaking this study, Dr. Zhang’s team developed an annual report for nursing facilities in Oregon every year. They noticed significant changes in admissions, discharges, assessments, and therapy utilization in 2021.
        “Initially, we assumed that COVID contributed to those changes while we observed some of the changes happened before COVID,” Dr. Zhang told Caring. “This triggered our team to further explore whether some events or policies affect nursing facilities.”
        More than 90% of short-stay individuals — both Medicare and non-Medicare patients — received individual OT and PT before and after CMS implemented the model, the researchers found. Difference-in-differences analysis, however, showed that individual OT and PT per week decreased by 38.35 minutes (19.3%) and 40.14 minutes (19%), respectively, after implementation while group OT and PT increased by 1.67 and 1.77 minutes, respectively.
        Although the amount of group OT and PT remained essentially unchanged, the researchers found that the probability of individuals receiving group OT and PT increased by 0.026 and 0.030 percentage points, respectively. “These changes may reflect [SNFs] seeking more efficient ways to meet patients’ therapy needs under PDPM,” Dr. Zhang said.
        The researchers also found that the implementation of PDPM was not associated with statistically significant changes in length of stay, discharge to the community, or readmission within 30 days.
        “Simply speaking, our results showed that individual therapy utilization decreased under PDPM without statistically significant degradation in outcomes such as length of stay, readmission, and discharge rate to community,” Dr. Zhang said. “Those results indicated that the new model is promising. However, the quality measures were limited to three measures in a short time frame. Broader quality measures are necessary to evaluate the effect of PDPM, particularly in a longer time frame. Unfortunately, the effect of PDPM will be mixed with the impact of COVID in the post–COVID-19 era.”
        Also, PDPM has granted therapists autonomy to determine when and how therapies can be provided. “However, therapists need to adapt to make good use of tools to assist with planning and tracking for a longer time frame,” Dr. Zhang said. “SNFs might also need more time to refine protocols for group therapy provision.”
        The annual report from Dr. Zhang’s team is available at https://health.oregonstate.edu/research/skilled-nursing-facilities.
        Source: Zhang W, et al. Changes in Therapy Utilization at Skilled Nursing Facilities Under Medicare’s Patient Driven Payment Model [published online July 7, 2022]. J Am Med Dir Assoc. DOI: https://doi.org/10.1016/j.jamda.2022.06.003.

        COVID-19 Experiences

        The COVID-19 pandemic has led to severe mental distress and extremely heavy workloads for nursing home leaders, a Canadian study found.
        Led by Amber Savage, PhD, of the University of Alberta, researchers conducted semistructured interviews via Zoom with 14 nursing home managers and seven directors of care from eight sites in two Canadian provinces.
        During the interviews, the managers and directors reported:
        • They felt responsible for infection control even though this greatly increased their workloads and led them to avoid social situations outside of work.
        • They experienced administrative chaos and were consumed with planning and implementing changes to comply with the ever-changing public health guidelines.
        • They experienced anxiety, depression, insomnia, and exhaustion.
        • They felt guilty for not allowing family members to visit residents and devastated when they were unable to prevent outbreaks.
        “With pandemic workloads and stresses, some leaders considered retiring months or years early,” the researchers said. “Others, typically early career leaders, saw their work and organization as their calling regardless of personal cost.”
        The interviewees did identify some positive changes, including team cohesion and growth.
        Source: Savage A, et al. This Was My Crimean War: COVID-19 Experiences of Nursing Home Leaders [published online Aug. 11, 2022]. J Am Med Dir Assoc. DOI: https://doi.org/10.1016/j.jamda.2022.08.001.

        Depressive Symptoms

        Although most nursing home residents have mild or moderate depression, individuals with severe dementia and a lower level of functioning are more likely to have severe depression, according to a study from Norway.
        Led by Tom Borza, MD, PhD, of Innlandet Hospital Trust in Ottestad, the researchers conducted a 36-month longitudinal study in which they assessed 696 newly admitted nursing home residents within the first month after admission and then biannually. Among the participants, 583 (83.8%) had dementia, 96 (13.8%) had mild cognitive impairment, and 16 (2.3%) were cognitively healthy.
        Using the Cornell Scale for Depression in Dementia, the researchers found that 225 individuals (32.6%) had “persistent mild symptoms” of depression, 351 (50.8%) had “persistent moderate symptoms,” 35 (5.1%) had “increasing symptoms,” and 80 (11.6%) had “severe but decreasing symptoms.”
        “More severe dementia, lower level of functioning, poorer physical health, more pain, use of antidepressants, and younger age at admission were associated with more depressive symptoms,” the researchers said.
        Symptoms of depression decreased at six months, then increased at 12 months, possibly due to non-mood symptoms such as irritability, loss of appetite, and lack of energy, the researchers found. The scores flattened and decreased toward the end of the study period, possibly due to “survivor effect” in which survivors in nursing homes display fewer depressive symptoms, the researchers said.
        “Further research should aim to investigate the importance of personalized treatment programs for depression in nursing home residents,” they added.
        Source: Borza T, et al. The Course of Depressive Symptoms Over 36 Months in 696 Newly Admitted Nursing Home Residents [published online Sept. 15, 2022]. J Am Med Dir Assoc. DOI: https://doi.org/10.1016/j.jamda.2022.08.007.
        Jeffrey S. Eisenberg, a freelance writer in the Philadelphia area, compiled this report.