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Research Studies is a monthly compilation of research articles funded by AHRQ or authored by AHRQ researchers and recently published in journals or newsletters.
Results1 to 25 of 295 Research Studies Displayed
Konetzka RT, Davila H, Brauner DJ
The quality measures domain in Nursing Home Compare: is high performance meaningful or misleading?
The Federal Centers for Medicare and Medicaid Services publishes a Nursing Home Compare (NHC) web site that provides information to compare nursing homes across the nation. Since NHC began reporting the percent of nursing home residents suffering adverse outcomes, the negative outcomes decreased dramatically. However, the validity of scores has been questioned for nursing homes that score well on facility-reported measures but scored poorly on inspections. The study purpose was to determine whether nursing homes with these “discordant” scores are better than nursing homes that score poorly across all domains. The researchers analyzed national data from 2012- 2016, conducted in-depth interviews and observations of 12 nursing homes in 2017 to 2018, and studied nursing home performance trajectories over time. Both qualitative and quantitative methods were utilized and interpreted together. The study found that facilities identified as discordant took part in more quality improvement (QI) activities than those identified as poor performers, but those QI activities were lower-resource improvements and not of the type and scope that would impact improvements across other quality domains. It was determined that the poor-performing facilities appeared to lack the leadership and staff continuity required for even low-resource improvements. The study concluded that while high performance on quality measures using facility-reported data is mostly meaningful, and the quality measures domain should continue to be utilized in Nursing Home Compare, facilities identified as discordant still have quality defects.
Citation: Konetzka RT, Davila H, Brauner DJ . The quality measures domain in Nursing Home Compare: is high performance meaningful or misleading? Gerontologist 2022 Feb 9;62(2):293-303. doi: 10.1093/geront/gnab054..
Keywords: Nursing Homes, Long-Term Care, Provider Performance, Quality Indicators (QIs), Quality Measures, Quality of Care
Li Y, Cheng Z, Cai X
State social distancing restrictions and nursing home outcomes.
This study examined how state orders for social distancing to curb COVID-19 morbidity and mortality affected nursing home patients and what potential negative health consequences they may have had. The authors examined state social distancing restrictions from June to August of 2020 and their associations with the weekly numbers of new COVID cases, new COVID deaths, and new non-COVID deaths in nursing homes across the US. They found that stronger state social distancing measures were associated with improved outcomes, reduced across-facility disparities in COVID outcomes, and somewhat increased non-COVID-19 death rates. The estimates for non-COVID-19 deaths were sensitive to alternative model specifications.
AHRQ-funded; HS026893; HS024923.
Citation: Li Y, Cheng Z, Cai X . State social distancing restrictions and nursing home outcomes. Sci Rep 2022 Jan 20;12(1):1058. doi: 10.1038/s41598-022-05011-6..
Keywords: COVID-19, Nursing Homes, Prevention, Public Health
Rosenthal M, Poling J, Wec A
"Medication is just one piece of the whole puzzle": how nursing homes change their use of antipsychotic medications.
This article investigated health professionals’ experiences with decision-making during changes under the National Partnership to Improve Dementia Care in Nursing Homes and its companion coalitions. These programs were introduced in 2012 for the purpose of encouraging reductions in antipsychotic use and increasing use of nonpharmacological treatments for dementia. Interviews were conducted with 40 nursing home physicians and staff in seven states. The authors found that reducing antipsychotics is more time and resource-intensive than relying on medication. However, respondents supported reductions in antipsychotic use. They indicated that with supported staffing, effective communications, and training, they could create or implement individualized treatments.
Citation: Rosenthal M, Poling J, Wec A . "Medication is just one piece of the whole puzzle": how nursing homes change their use of antipsychotic medications. J Appl Gerontol 2022 Jan;41(1):62-72. doi: 10.1177/0733464820958919..
Keywords: Elderly, Medication, Nursing Homes, Dementia, Neurological Disorders, Long-Term Care, Decision Making
Fashaw-Walters SA, McCreedy E, Bynum JPW
Disproportionate increases in schizophrenia diagnoses among Black nursing home residents with ADRD.
Investigators examined how race and Alzheimer's and related dementia (ADRD) status influenced the rate of schizophrenia diagnoses among nursing home (NH) residents following the CMS National Partnership to Improve Dementia Care. Using 2011-2015 Minimum Data Set 3.0 assessments, they found that, following the partnership, black NH residents with ADRD were more likely to have a schizophrenia diagnosis documented on their minimum data set assessments, and schizophrenia rates increased for black NH residents with ADRD only.
Citation: Fashaw-Walters SA, McCreedy E, Bynum JPW . Disproportionate increases in schizophrenia diagnoses among Black nursing home residents with ADRD. J Am Geriatr Soc 2021 Dec;69(12):3623-30. doi: 10.1111/jgs.17464..
Keywords: Elderly, Dementia, Nursing Homes, Racial / Ethnic Minorities, Long-Term Care
Goodwin JS, Agrawal P, Li S
Growth of physicians and nurse practitioners practicing full time in nursing homes.
This retrospective cohort study examined the growth of physicians and nurse practitioners (NPs) and physician assistants (PAs) who work full time in nursing homes, and to assess resident and nursing home characteristics associated with receiving care from full-time providers. Researchers looked at a 20% national sample of Medicare data on long-term care residents in 2008 and 2018 and the physicians, NPs, and PAs who submitted charges for services rendered in nursing homes. Full-time nursing home providers increased from 26% in 2008 to 44.6% in 2017. The largest increase from 2008 to 2017 was in NPs with 1986 total in 2008 increasing 44.6% in 2017. Residents with an NP primary care provider were 23 times more likely to have a full-time provider. Residents who received care from both a physician and an NP or PA increased from 33.5% in 2008 to 62.5% in 2018. There was large variation in the percentage of residents with full-time providers, with 5.72% of residents in the bottom quintile of facilities to 91.4% in the top quintile.
Citation: Goodwin JS, Agrawal P, Li S . Growth of physicians and nurse practitioners practicing full time in nursing homes. J Am Med Dir Assoc 2021 Dec;22(12):2534-39.e6. doi: 10.1016/j.jamda.2021.06.019..
Keywords: Nursing Homes, Long-Term Care, Provider: Clinician, Provider: Physician, Provider: Nurse, Workforce
Davila H, Shippee TP, Park YS
Inside the black box of improving on nursing home quality measures.
This qualitative study investigated how nursing homes (NHs) interact with quality measures (QMs) used by Nursing Home Compare (NHC) as part of its 5-star rating system. Semistructured interviews were conducted with 110 NH personnel and 23 NH provider association representatives. Observations of organizational processes in 12 NHs in three states were also done. The authors found that most NHs are working to improve the quality of care they provide, not merely to improve their QM scores. They also found limitations with the QMs, suggesting that the QMs on their own may not accurately reflect the quality of care that NHs provide. The findings suggest several changes to improve NHC.
Citation: Davila H, Shippee TP, Park YS . Inside the black box of improving on nursing home quality measures. Med Care Res Rev 2021 Dec;78(6):758-70. doi: 10.1177/1077558720960326..
Keywords: Nursing Homes, Quality Indicators (QIs), Quality Measures, Quality Improvement, Quality of Care, Provider Performance, Long-Term Care
Werner RM, Templeton Z, Apathy N
Trends in post-acute care in US nursing homes: 2001-2017.
The purpose of this retrospective cohort study was to describe recent trends in post-acute care provision within nursing homes, focusing specifically on nursing homes' degree of specialization in post-acute care. The investigators concluded that over the last 2 decades, post-acute care has become increasingly concentrated in a subset of nursing homes, which tend to be for-profit, part of a chain, and less likely to serve racial and ethnic minorities and persons on Medicaid.
Citation: Werner RM, Templeton Z, Apathy N . Trends in post-acute care in US nursing homes: 2001-2017. J Am Med Dir Assoc 2021 Dec;22(12):2491-95.e2. doi: 10.1016/j.jamda.2021.06.015..
Keywords: Elderly, Nursing Homes, Racial / Ethnic Minorities
Tandan M, Zimmerman S, Sloane PD
Which nursing home residents with pneumonia are managed on-site and which are hospitalized? Results from 2 years' surveillance in 14 US homes.
Pneumonia is a frequent cause of hospitalization among nursing home (NH) residents, but little information is available as to how clinical presentation and other characteristics relate to hospitalization, and the differential use of antimicrobials based on hospitalization status. This study examined how hospitalized and nonhospitalized NH residents with pneumonia differ. The investigators concluded that respiratory rate was associated with hospitalization but was not documented for more than a quarter of residents.
Citation: Tandan M, Zimmerman S, Sloane PD . Which nursing home residents with pneumonia are managed on-site and which are hospitalized? Results from 2 years' surveillance in 14 US homes. J Am Med Dir Assoc 2020 Dec;21(12):1862-68.e3. doi: 10.1016/j.jamda.2020.07.028..
Keywords: Elderly, Nursing Homes, Pneumonia, Respiratory Conditions, Hospitalization
Orth J, Li Y, Simning A
Nursing home residents with dementia: association between place of death and patient safety culture.
This study examined the association of place of death and patient safety culture among nursing home (NH) residents with dementia. The authors examined the estimated effects of patient safety culture (PSC) among 11,957 long-stay NH residents with dementia, aged 65+ who died in NHs or hospitals shortly following discharge from one of 800 US NHs in 2017. Residents with dementia in NHs with higher PSC scores in communication openness had lower odds of in-hospital death, with the strongest effect in NHs located in states with higher minimum NH nurse staffing requirements.
Citation: Orth J, Li Y, Simning A . Nursing home residents with dementia: association between place of death and patient safety culture. Gerontologist 2021 Nov 15;61(8):1296-306. doi: 10.1093/geront/gnaa188..
Keywords: Elderly, Dementia, Nursing Homes, Mortality, Patient Safety
Jones K, Mantey J, Washer L
When planning meets reality: COVID-19 interpandemic survey of Michigan nursing homes.
This survey examined conditions at Michigan nursing homes (NHs) during the COVID-19 pandemic period. This survey evaluated preparedness, staffing, testing, and adaptations made due to COVID. Of 452 Michigan NHs contacted via email, 145 opened the survey of those,143 responded from May 1-12, 2020. Two-thirds reported shortages of personal protective equipment. Half lacked sufficient testing resources with only 36% able to test residents and staff when needed. A majority (55%) experienced staffing shortages, with 63% experiencing resignations with front-line clinical staff more likely to resign. Facilities showed rapid adaptation, with 78% creating COVID-19 units to care for patients on site. To reduce isolation, most NHs facilitated communication via phone calls, videoconferencing, and window visits. The majority continued to provide normal required therapies (90%).
Citation: Jones K, Mantey J, Washer L . When planning meets reality: COVID-19 interpandemic survey of Michigan nursing homes. Am J Infect Control 2021 Nov;49(11):1343-49. doi: 10.1016/j.ajic.2021.03.016..
Keywords: COVID-19, Nursing Homes, Public Health, Emergency Preparedness
Guo W, Li Y, Temkin-Greener H. W, Li Y, Temkin-Greener H
Community discharge among post-acute nursing home residents: an association with patient safety culture?
Researchers examined whether better patient safety culture (PSC) in skilled nursing facilities was associated with higher likelihood of successful community discharge for post-acute care residents. PSC scores were obtained from a national, random survey conducted in 2017. They found that post-acute care residents who were successfully discharged to community were more likely to be female, white, Medicare-only, cognitively intact, and admitted following a surgery. The multivariable analyses showed that teamwork and supervisor expectations and actions promoting resident safety were significantly associated with the increased likelihood of successful community discharge.
Citation: Guo W, Li Y, Temkin-Greener H. W, Li Y, Temkin-Greener H . Community discharge among post-acute nursing home residents: an association with patient safety culture? J Am Med Dir Assoc 2021 Nov;22(11):2384-88.e1. doi: 10.1016/j.jamda.2021.04.022..
Keywords: Elderly, Nursing Homes, Patient Safety
de Cordova PB, Johansen ML, Zha P
Does public reporting of staffing ratios and Nursing Home Compare ratings matter?
This study’s objective was to examine the association between publicly available staffing ratios and the Five-Star Quality Ratings from Nursing Home Compare over time. Findings showed that decreasing the number of residents assigned to a registered nurse in nursing homes resulted in an increase in staffing ratings. Mandatory public reporting held nursing homes accountable for quality outcomes but did not improve staffing ratios. Recommendations included continuing to focus on improving quality in nursing homes, which may improve staffing ratios across shifts.
Citation: de Cordova PB, Johansen ML, Zha P . Does public reporting of staffing ratios and Nursing Home Compare ratings matter? J Am Med Dir Assoc 2021 Nov;22(11):2373-77. doi: 10.1016/j.jamda.2021.03.011..
Keywords: Nursing Homes, Quality of Care, Provider Performance
Baughman AW, Renton M, Wehbi NK
Building community and resilience in Massachusetts nursing homes during the COVID-19 pandemic.
Researchers discuss the partnership of the Massachusetts Senior Care Association and Hebrew SeniorLife with AHRQ ECHO National Nursing Home COVID-19 Action Network (the Network). This educational program provided 16 weeks of free weekly virtual sessions to 295 eligible nursing homes. The Network weekly meetings were a source of connection, emotional support, and validation and may be a valuable mechanism to support resilience and wellbeing for nursing home staff.
Citation: Baughman AW, Renton M, Wehbi NK . Building community and resilience in Massachusetts nursing homes during the COVID-19 pandemic. J Am Geriatr Soc 2021 Oct;69(10):2716-21. doi: 10.1111/jgs.17389..
Keywords: COVID-19, Elderly, Nursing Homes, Evidence-Based Practice, Provider: Health Personnel, Education: Continuing Medical Education, Training
Werner NE, Rutkowski RA, Krause S
Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.
Care transitions that occur across healthcare system boundaries represent a unique challenge for maintaining high quality care and patient safety, as these systems are typically not aligned to perform the care transition process. In this article, the investigators explored healthcare professionals' mental models of older adults' transitions between the emergency department (ED) and skilled nursing facility (SNF).
Citation: Werner NE, Rutkowski RA, Krause S . Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility. Appl Ergon 2021 Oct;96:103509. doi: 10.1016/j.apergo.2021.103509..
Keywords: Elderly, Transitions of Care, Emergency Department, Nursing Homes, Healthcare Delivery
Field TS, Fouayzi H, Crawfo TS, Fouayzi H, Crawford S
The association of nursing home characteristics and quality with adverse events after a hospitalization.
This prospective cohort analysis measured the association of long-stay nursing home residents returning to the facility after a hospitalization and adverse events (AEs). Thirty-two nursing homes in New England states participated with a total of 555 long-stay residents contributing 762 returns from hospitalizations. The authors measured the association between AEs developing in the 45 days following discharge back to long-term care and characteristics of the nursing homes including bed size, ownership, 5-star quality ratings, registered nurse and nursing assistant hours, and the individual Centers for Medicare & Medicaid Services (CMS) quality indicators. They found no association of AEs with most nursing home characteristics. Several individual quality indicators were associated with AEs. The highest tertile of residents with depression had a hazard ratio (HR) of 1.65 and the highest tertile of the percentage taking antipsychotic medications had an HR of 1.58. Residents needing increased assistance with activities of daily living was statistically significant, but not monotonic.
Citation: Field TS, Fouayzi H, Crawfo TS, Fouayzi H, Crawford S . The association of nursing home characteristics and quality with adverse events after a hospitalization. J Am Med Dir Assoc 2021 Oct;22(10):2196-200. doi: 10.1016/j.jamda.2021.02.027..
Keywords: Elderly, Nursing Homes, Adverse Events, Hospitalization
Alexander GL, Madsen RW
A report of information technology and health deficiencies in U.S. nursing homes.
The goal of this study was to investigate the impact of nursing home (NH) information technology (IT) sophistication on publicly reported health safety deficiency scores documented during standard inspections. The sample included nursing homes from every U.S. state, with 2187 health inspections documented in these facilities. Findings showed that deficiency scores decreased as total IT sophistication increased, and deficiency scores decreased as registered nurse hours per resident day increased.
Citation: Alexander GL, Madsen RW . A report of information technology and health deficiencies in U.S. nursing homes. J Patient Saf 2021 Sep 1;17(6):e483-e89. doi: 10.1097/pts.0000000000000390..
Keywords: Nursing Homes, Health Information Technology (HIT)
Abrahamson K, Davila H, Kirk L
Can a nursing home psychotropic reduction project be successfully implemented in assisted living?
This study’s objective was to compare implementation of a psychotropic medication reduction project across nursing homes (NH) and assisted living (AL) facilities. Fifteen NHs and 14 AL facilities within a single corporate chain participated. In-person and telephone interviews with 62 staff members from participating NH and AL facilities were conducted to investigate project implementation experience. Implementation at nursing homes made more dramatic changes in residents’ lives and medication use than at assisted living facilities. AL staff identified numerous barriers to implementation.
Citation: Abrahamson K, Davila H, Kirk L . Can a nursing home psychotropic reduction project be successfully implemented in assisted living? J Appl Gerontol 2021 Sep;40(9):1071-79. doi: 10.1177/0733464820948328..
Keywords: Elderly, Nursing Homes, Long-Term Care, Medication, Dementia
Powell KR, Alexander GL
Consequences of rapid telehealth expansion in nursing homes: promise and pitfalls.
Expectations regarding use and potential benefits of telehealth (TH) in nursing homes (NHs) are high; however, unplanned and unexpected consequences can occur as a result of major policy and technological changes. The goal of this study was to elicit stakeholder perspectives of consequences of rapid TH expansion in NHs. The investigators concluded that clinicians and NH administrators should consider leveraging the desirable consequences of rapid TH expansion and implement mitigation strategies to address the undesirable/unanticipated consequences.
Citation: Powell KR, Alexander GL . Consequences of rapid telehealth expansion in nursing homes: promise and pitfalls. Appl Clin Inform 2021 Aug;12(4):933-43. doi: 10.1055/s-0041-1735974..
Keywords: Telehealth, Health Information Technology (HIT), Nursing Homes
Manges KA, Ayele R, Leonard C
Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach.
This study’s objective was to explore differences between low- and high-performing hospitals and skilled nursing facilities (SNFs) pairs and postacute care outcomes. The authors used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals. Hospitals were classified based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals and five corresponding SNFs. High-performing sites differed in each stage from low-performing sites by focusing on 1) earlier, ongoing, systematic identification of high-risk patients; 2) discussing the decision to go to an SNF as an iterative team-based process and 3) anticipating barriers with knowledge of transitional and SNF care processes.
Citation: Manges KA, Ayele R, Leonard C . Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach. BMJ Qual Saf 2021 Aug;30(8):648-57. doi: 10.1136/bmjqs-2020-011204..
Keywords: Transitions of Care, Hospitals, Nursing Homes, Hospital Readmissions, Hospital Discharge
Shepard V, Chou LN, Kuo YF, et al.
Characteristics associated with feeding tube placement: retrospective cohort study of Texas nursing home residents with advanced dementia.
The purpose of this retrospective cohort study was to investigate resident-level, provider-type, nursing home (NH), and regional factors associated with feeding tube (FT) placement in advanced dementia. The investigators concluded that regional, race, and ethnic variations in prevalence of FT use among NH residents suggested opportunities for clinicians and policy makers to improve the quality of end-of-life care by especially considering other palliative care measures for minorities living in border towns.
Citation: Shepard V, Chou LN, Kuo YF, et al.. Characteristics associated with feeding tube placement: retrospective cohort study of Texas nursing home residents with advanced dementia. J Am Med Dir Assoc 2021 Jul;22(7):1471-76.e4. doi: 10.1016/j.jamda.2020.10.033..
Keywords: Elderly, Nursing Homes, Long-Term Care, Dementia, Neurological Disorders
Measuring caregiver retention in nursing homes.
This study examined the retention of nursing home caregivers using a survey of nursing home administrators conducted in 2016 from 2,898 facilities. Survey data was matched with Nursing Home Compare and the Certification and Survey Provider Enhanced Reporting data. Four measures of retention were associated with each of three types for caregivers: nurse aids (NAs), registered nurses (RNs), and licensed practical nurses with six quality indicators. Retention rates at 5 years was shown to be low for all three of these caregiver types. Regression estimates showed some support for the theory that different measures of retention were more/less associated with quality. The 3- and 5-year retention measures had the strongest associations with quality of care.
Citation: Castle NG . Measuring caregiver retention in nursing homes. Gerontologist 2021 Jun 2;61(4):e118-e28. doi: 10.1093/geront/gnab012..
Keywords: Nursing Homes, Long-Term Care, Provider: Health Personnel, Workforce
Panagiotou OA, Keeney T, Ogarek JA
Prevalence of functional limitations and their associations with systemic cancer therapy among older adults in nursing homes with advanced non-small cell lung cancer.
The purpose of this study was to determine the relationship of self-care task disabilities with the use of systemic cancer therapies for advanced non-small cell lung cancer (NSCLC) in nursing home patients. The investigators concluded that systemic cancer therapy was not commonly used in this population and was strongly predicted by disability in self-care tasks.
Citation: Panagiotou OA, Keeney T, Ogarek JA . Prevalence of functional limitations and their associations with systemic cancer therapy among older adults in nursing homes with advanced non-small cell lung cancer. J Geriatr Oncol 2021 Jun;12(5):765-70. doi: 10.1016/j.jgo.2021.02.007..
Keywords: Elderly, Cancer: Lung Cancer, Cancer, Nursing Homes
Anderson MC, Evans E, Zonfrillo MR
Rural/urban differences in discharge from rehabilitation in older adults with traumatic brain injury.
This study compared differences in outcomes for older adults with traumatic brain injury (TBI) in rural and urban settings by 1) comparing the rates of successful community discharge; and 2) reasons for not achieving successful discharge. This retrospective national cohort study looked at skilled nursing facility (SNF) patients aged 66 and older using Medicare inpatient claims with Minimum Data Set assessments. A total of 11,771 SNFs were identified with a total population of 61,021 Medicare beneficiaries discharged to a SNF following hospitalization for TBI between 2011 and 2015. Patients in rural settings had lower rates of successful discharge compared with patients in urban settings (52.1% vs 58.5%). Reasons for unsuccessful discharge differed between rural and urban settings with rural patients less likely to discharged from SNF within 100 days although they were less likely to be rehospitalized within 30 days of SNF discharge.
Citation: Anderson MC, Evans E, Zonfrillo MR . Rural/urban differences in discharge from rehabilitation in older adults with traumatic brain injury. J Am Geriatr Soc 2021 Jun;69(6):1601-08. doi: 10.1111/jgs.17065..
Keywords: Elderly, Brain Injury, Trauma, Rural Health, Urban Health, Rehabilitation, Nursing Homes
Savitz ST, Falk K, Stearns SC
Coronary revascularization outcomes in relation to skilled nursing facility use following hospital discharge.
Observational analyses comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) among elderly or frail patients are likely biased by treatment selection. PCI is typically chosen for frail patients, while CABG is more common for patients with good recovery potential. In this study. The investigators hypothesized that skilled nursing facility (SNF) use after revascularization was a measure of relative frailty associated with outcomes following coronary revascularization.
Citation: Savitz ST, Falk K, Stearns SC . Coronary revascularization outcomes in relation to skilled nursing facility use following hospital discharge. Clin Cardiol 2021 May;44(5):627-35. doi: 10.1002/clc.23583..
Keywords: Elderly, Heart Disease and Health, Cardiovascular Conditions, Surgery, Outcomes, Nursing Homes
Olivieri-Mui B, McGuire J, Griffith J
Exploring the association between the quality of HIV care in nursing homes and hospitalization.
Persons living with HIV/AIDS (PLWH) are living long enough to need age-related and HIV-related nursing home (NH) care. Nursing home quality of care has been associated with risk for hospitalization, but it is unknown if quality of HIV care in NHs affects hospitalization in this population. In this study, the investigators assessed HIV care quality with four national measures adapted for the NH setting.
AHRQ-funded; R36 HS025662.
Citation: Olivieri-Mui B, McGuire J, Griffith J . Exploring the association between the quality of HIV care in nursing homes and hospitalization. J Healthc Qual 2021 May-Jun;43(3):174-82. doi: 10.1097/jhq.0000000000000277..
Keywords: Elderly, Human Immunodeficiency Virus (HIV), Nursing Homes, Long-Term Care, Quality of Care, Quality Measures