Tracing Impact
Another Look
In 2013, the Donaghue Foundation launched the Another Look: Better Health for Elders in Care Facilities grant program, aimed at improving the quality of care and life for elderly residents in nursing homes and other long-term care settings.
2023 Annual Report
Welcome Message
With the guidance of our trustees and advisers, we look forward to continuing to explore and integrate new ideas and current trends into our processes, and research programs to advance the mission of the Donaghue Foundation.
Tracing Impact
Another Look
In 2013, the Donaghue Foundation launched the "Another Look: Research to Improve Health for Older Adults in Long-Term Care Facilities" grant program, aimed at improving the quality of care and life for older adult residents in nursing homes and other long-term care settings. This innovative program distinguished itself by focusing on the use of existing data sets to extract new insights that could be quickly applied to enhance care. The approach required researchers to collaborate with stakeholders in care delivery or policy, ensuring practical applications of the findings. The foundation invested $520,000 to fund five two-year projects.
Another Look
Grant Timeline
2014
The inaugural cohort of the Another Look Grant Program funded innovative research projects aimed at improving care quality and health outcomes for vulnerable populations in nursing homes and long-term care settings. These projects addressed critical issues such as reducing avoidable hospital re-admissions through value-based payment models, improving dementia care by minimizing inappropriate anti-psychotic use, and enhancing end-of-life care through better communication and advanced care planning. Additionally, the cohort included evaluations of specialized care for marginalized populations, such as individuals with serious mental illness or a history of incarceration, and the ECHO-AGE program, which leverages video consultations to improve dementia care in resource-limited nursing homes. Collectively, these projects advanced person-centered care, foster systemic improvements, and provide scalable, data-driven models to address disparities and promote equitable, high-quality elder care nationwide.
519640
in grants awarded
Key Themes and Collective Impact
- Care Quality and Equity: Focus on reducing disparities and improving outcomes for vulnerable and underserved populations, such as dementia patients, individuals at the end of life, and marginalized groups like those with mental illness or incarceration histories.
- Innovation and Scalability: Exploration of novel care models and payment systems with the potential for broad application and policy influence.
- Data-Driven Insights: Leveraging robust datasets and analytical methods to inform systemic improvements in elder care.
- Empowerment of Providers and Families: Promoting person-centered care through workforce development, communication improvements, and shared decision-making.
2015
In its second funding cycle, the Another Look Grant Program funded four innovative projects aimed at advancing elder care through systemic improvements and person-centered approaches. These projects addressed critical issues such as integrating residents’ everyday preferences into care planning, reducing avoidable hospitalizations through validated performance metrics, and examining the impact of nursing home specialization in Medicare post-acute care on the quality of long-term resident care. Additionally, one study analyzed the relationship between cumulative central nervous system (CNS) medication use and fall-related injuries, providing actionable insights to improve prescribing practices. Together, these projects emphasized quality improvement, resident-centered care, and data-driven solutions, offering scalable recommendations to enhance care delivery and outcomes for vulnerable populations in long-term care settings.
477545
in grants awarded
across four projects
Key Themes and Collective Impact
- Person-Centered Approaches: Advancing individualized care by aligning services with resident preferences and needs.
- Quality Improvement: Developing data-driven metrics and strategies to improve outcomes and reduce risks in long-term care settings.
- Systemic Insights: Addressing the broader impact of healthcare policies and practices on care quality and equity.
- Scalable Solutions: Generating actionable recommendations that can be implemented regionally and nationally to drive meaningful change in elder care.
2016
The 2016 Another Look Grant Program funded nine innovative projects addressing critical challenges in elder care, with a focus on improving health outcomes, safety, and quality of life for nursing home residents. These projects explored dementia care, emphasizing the impact of delirium, rehabilitation practices, and medication use, while advancing safer behavioral and medication management strategies to reduce antipsychotic overuse. Research on resident-to-resident mistreatment and medication-related delirium highlighted critical safety issues, while studies on Accountable Care Organizations and hospice integration provided actionable policy insights. Other projects examined end-of-life decision-making for "unbefriended" residents and the relationship between satisfaction surveys and quality measures, empowering consumers and policymakers to make informed decisions. Collectively, this diverse portfolio advanced person-centered care, systemic improvements, and equitable resource allocation, setting the stage for transformative change in long-term care.
1292303
in grants awarded
across nine projects
Key Themes and Collective Impact
- Person-Centered and Evidence-Based Care: Many projects emphasized individualized care approaches, enhancing quality of life for nursing home residents, particularly those with dementia or other vulnerabilities.
- Safety and Quality Improvement: Research focused on reducing harm, such as medication-related delirium and elder mistreatment, while addressing systemic challenges like overuse of antipsychotics.
- Policy-Relevant Insights: Projects examining ACOs, hospice integration, and satisfaction metrics provide actionable recommendations for policymakers to improve elder care systems.
- Equity and Accessibility: Efforts to enhance care for marginalized groups, such as those without family advocates, and improve resource allocation for high-risk facilities demonstrate a commitment to equitable care.
2017
The 2017 Another Look Grant Program supported five projects addressing critical issues in nursing homes and long-term care facilities, focusing on improving health outcomes, care coordination, and medication safety. These studies explored enhanced primary care models using nurse practitioners, assessed the adverse effects of diuretics in residents with dementia, and investigated unintended consequences of reduced antipsychotic use, such as increased reliance on alternative psychotropic medications. Additional projects developed mental health quality measures to improve care for residents with behavioral health disorders and evaluated the impact of Accountable Care Organizations (ACOs) on care coordination, spending, and outcomes. Collectively, these projects advanced person-centered care, safer prescribing practices, and systemic improvements, providing actionable insights to improve elder care nationwide.
635605
in grants awarded
across five projects
Key Themes and Collective Impact
- Improving Care Quality and Safety: Projects focused on reducing medication-related harms, hospitalizations, and improving mental health and dementia care for nursing home residents.
- Advancing Person-Centered Care: Research emphasized tailoring care to the unique needs of vulnerable populations, particularly those with dementia or mental health disorders.
- Informing Policy and Practice: Findings supported evidence-based improvements in care delivery models, including the impact of Accountable Care Organizations (ACOs) and national dementia care initiatives.
- Leveraging Data for Systemic Change: Studies utilized robust datasets to identify trends and guide systemic improvements in care quality, safety, and coordination.
- Promoting Equity and Sustainability: Efforts highlighted disparities in care and proposed scalable solutions to ensure equitable, high-quality care for all nursing home residents.
2018
The two projects funded in this cycle focused on reducing unnecessary medical interventions and improving care quality for vulnerable populations in elder care. One study evaluated the use of telemedicine in senior living communities to reduce avoidable emergency department (ED) transfers, aimed at enhancing care coordination and reducing healthcare costs. Another project investigated the risks and benefits of de-prescribing acetylcholinesterase inhibitors (AchEIs) in nursing home residents with advanced dementia, aiming to guide safer medication practices and minimize polypharmacy. Together, these projects leveraged innovative, data-driven approaches to advance patient-centered, cost-effective, and sustainable improvements in elder care.
250564
in grants awarded
across two projects
Key Themes and Collective Impact
- Enhancing Care Quality and Safety: Both projects aim to reduce avoidable interventions, with telemedicine improving emergency care coordination and de-prescribing reducing risks of polypharmacy and adverse drug effects in vulnerable populations.
- Innovative and Cost-Effective Solutions: By leveraging technology and data-driven approaches, these studies align with value-based care principles, offering scalable strategies to improve outcomes and reduce healthcare costs.
2019
The 2019 funding cycle of the Another Look Grant Program supported six projects aimed at advancing elder care through innovative research and systemic improvements. These projects addressed critical issues, including substance abuse recovery, disparities in pressure ulcer outcomes, and the adoption of person-centered care in nursing homes. Efforts to amplify consumer voices were highlighted through studies analyzing the role of complaints in quality ratings for nursing homes and assisted living facilities, offering insights for refining public-use metrics and grievance practices. Additionally, the adaptation of the CANDOR program for elder care emphasized improving safety culture, transparency, and adverse event resolution. Collectively, these projects leveraged robust data and evidence-based practices to enhance care quality, safety, and equity in elder care settings, while providing actionable solutions for policymakers, providers, and advocates.
822392
in grants awarded
across two projects
Key Themes and Collective Impact
- Improving Care Quality and Resident Outcomes: Projects focused on enhancing quality of care in nursing homes and assisted living facilities, addressing issues like pressure ulcer disparities, person-centered care, and engagement in recovery programs.
- Amplifying the Consumer Voice: Multiple studies emphasized the importance of incorporating consumer perspectives, such as analyzing complaint data to refine nursing home quality ratings and using grievances to identify systemic issues in assisted living facilities.
- Addressing Health Disparities: Research highlighted disparities in outcomes among minority populations, particularly in pressure ulcer management and culturally competent care delivery.
- Advancing Safety and Transparency: The adaptation of the CANDOR program for elder care settings aimed to foster a culture of safety, improve communication around adverse events, and resolve issues transparently.
- Data-Driven Policy and Practice Improvements: Projects leveraged robust datasets, including regulatory compliance, consumer complaints, and program participation, to inform evidence-based interventions and guide policy decisions.
2021
The 2021 Another Look Grant Program supported eight innovative projects addressing critical challenges in long-term care. These studies advanced person-centered care, improved end-of-life transitions, and identified strategies to mitigate transfer trauma and pandemic-related challenges. By focusing on health disparities, neighborhood disadvantages, and effective communication strategies, the grantees provided actionable insights for enhancing equity, care quality, and safety in nursing homes and assisted living facilities. Collectively, these projects contributed to creating evidence-based solutions to improve outcomes and quality of life for vulnerable older adults nationwide.
528107
in grants awarded
across eight projects
Key Themes and Collective Impact
- Enhancing Person-Centered and Quality Care: Several projects focused on improving person-centered care (PCC), quality of life (QoL), and quality of care (QoC) by addressing disparities, end-of-life care, and transfer trauma.
- Addressing Health Disparities: Studies highlighted socioeconomic and racial disparities, providing data to advocate for policy changes that promote equity in long-term care.
- Improving Communication and Collaboration: Research emphasized the importance of communication between family caregivers and formal care providers to improve resident outcomes.
- Mitigating the Impact of COVID-19: Projects addressed the challenges posed by the pandemic, offering insights into managing public health crises in long-term care facilities.
2022
By 2022, the program had awarded over $4.5 million since its inception. The Foundation funded one project this funding year which examined the recovery of older adults transferred to long-term acute care hospitals for COVID-19, identifying risk factors and disparities in recovery to inform medical care and policy.
186247
in grants awarded
across four projects
2023
The 2023 funding cycle, marking the culmination of the first decade of the Another Look Grant Program, supported innovative projects that addressed critical gaps in elder care and long-term care systems. These studies advanced understanding of specialty care access for residents with SMI/DD, evaluated Medicaid managed care’s impact on behavioral health equity, and highlighted the transformative role of APRNs in nursing homes. Additionally, research on loneliness and social determinants underscored the importance of addressing systemic barriers for vulnerable populations. Collectively, the projects exemplify the program’s mission to improve care quality, equity, and policy-driven innovations in elder and long-term care settings.
703545
in grants awarded
Key Themes and Collective Impact
- Addressing Health and Behavioral Care Disparities: Projects emphasized reducing inequities in access and outcomes, particularly for vulnerable populations like those with SMI, DD, and Alzheimer’s Disease.
- Innovative Care Models: Studies explored the role of APRNs, telemedicine, and Medicaid reforms in improving care delivery, coordination, and emergency preparedness.
- Impact of Social Determinants and Loneliness: Research highlighted the role of social support, living arrangements, and systemic barriers in shaping health outcomes.
- Policy and Practice Implications: Findings from these projects aim to guide improvements in care quality, workforce roles, and equity-focused policies.
The Another Look program has consistently supported research that not only advances understanding of elder care but also translates into real-world improvements in the health and well-being of older adults in long-term care facilities
Over the years, the program has funded research aimed at reducing hospitalizations, improving mental health care, addressing medication risks, and adapting care models to meet the evolving needs of the elderly. The program's emphasis on practical, data-driven insights ensures that the findings can be directly applied to enhance the quality of life for older adults in care facilities.
Another Look
Key Changes
Expansion of Scope
The program's scope expanded from focusing on elderly care in nursing homes in 2013 to including assisted living and other congregate care settings by 2020 and 2024. This reflected broader trends in long-term care delivery.
Increased Funding
The budget for the program increased from $450,000 in 2013 to $750,000 in 2020 to present, allowing for more extensive research projects.
Allowance for New Data Collection
The 2020 announcement introduced the possibility of limited new data collection, a departure from the 2013 restriction to solely existing data.
Stakeholder Engagement
The role of stakeholders became more prominent over the years, with increasing expectations for their involvement in both the research process and the development of practical tools for care improvement.
Geographic Eligibility
The eligibility criteria broadened from New England and New York in 2013 to the entire United States by 2020, reflecting a more inclusive approach.
Introduction of Priority Topics
By 2020, the program had identified specific priority topics, guiding researchers toward areas of critical need identified through environmental scans.
Another Look
Accomplishments
The Another Look grant program has facilitated several significant accomplishments from its grantees, reflecting the program's commitment to advancing research in innovative and impactful ways. Some of the major accomplishments include:
Breakthrough Research Findings
Grantees have produced cutting-edge research that has led to new insights in various fields, including public health, clinical practices, and healthcare policy. These findings have been published in high-impact journals, contributing to the broader academic and professional discourse.
Transfer Trauma in Nursing Home Long-Term Care Residents
Developed new insights into the impact of facility transfers on nursing home residents, particularly during the COVID-19 pandemic. The study revealed increased risks and negative outcomes associated with these transfers (Chang/Montoya)
End-of-Life Care for Nursing Home Residents with Guardians
Provided the first empirical data on medical decision-making under guardianship, challenging assumptions about the intensity of care provided to residents with professional guardians (Cohen)
Policy Influence
Several grantee projects have had a direct impact on shaping public policy. For instance, research funded by the Another Look program has informed legislative changes and influenced healthcare policies at both state and national levels, particularly in areas such as health equity and access to care.
Community-Based Skilled Nursing Facility for Difficult-to-Place Patients
The research outcomes from the 60 West facility have informed state-level policy discussions about rebalancing long-term care systems and providing appropriate care settings for complex populations such as aging ex-offenders and individuals with serious mental illness.
Impact of COVID-19 in Nursing Homes
The findings on job satisfaction and the well-being of CNAs during the pandemic have influenced discussions on workforce policies and the need for better support systems in long-term care facilities. (Cimarolli)
Community Engagement and Impact
Grantees have successfully engaged with communities to implement their research findings, leading to tangible improvements in community health outcomes. This includes the development of community-based interventions that have been adopted by local organizations and health systems.
RAFT COVID Study
Collaborated closely with the National Association of Long Term Hospitals (NALTH) to gather data and share preliminary findings, directly involving the community of long-term care facilities in the research process and ensuring the practical application of the study result. (Makam)
Severe neighborhood deprivation and nursing home staffing in the United States
Engaged with nursing home administrators and policymakers to discuss the practical implications of funding strategies aimed at reducing staffing disparities, leading to more equitable resource allocation in the long-term care sector. (Travers/Falvey)
Capacity Building
The program has helped grantees build research capacity within their institutions, fostering the development of new research teams, securing additional funding, and establishing long-term research agendas. This has also included the mentoring of early-career researchers and the development of collaborative networks.
Hospice and Special Needs Plans (I-SNPs) in Nursing Homes
Enabled the development of new research capacity within the MJHS Institute for Innovation in Palliative Care, leading to subsequent studies on barriers to hospice care and the development of educational interventions for nursing homes. In addition, this research fostered collaboration between researchers and stakeholders, creating a foundation for future research and the development of practical tools to improve end-of-life care in various settings (Dhingra)
Improving End-of-Life Care in the Nursing Home
Strengthened the capacity of nursing home staff to deliver high-quality end-of-life care through the implementation of the MOLST protocol and extensive training in palliative care principles, ensuring sustained improvement in care practices. (Reinhardt)
Innovative Methodologies
Grantees have produced cutting-edge research that has led to new insights in various fields, including public health, clinical practices, and healthcare policy. These findings have been published in high-impact journals, contributing to the broader academic and professional discourse.
Communication Among Family and Formal Caregivers
The study utilized data from the National Health and Aging Trends Study (NHATS) and the National Study on Caregiving (NSOC) to investigate the impact of caregiver communication on resident outcomes, employing advanced statistical analyses to understand these dynamics across different care settings. (Falzarano)
ECHO-AGE Pilot Stidu
Implemented a novel videoconference consultation model to connect geriatric specialists with long-term care providers, improving care management through real-time, case-based discussions and iterative learning. (BIDMC, Lipsitz)
Topical Analysis
The Impact of the Another Look Program on Elder Care Practices
Since its inception in 2013, the Donaghue Foundation's Another Look: Better Health for Elders in Care Facilities grant program has made strides in transforming elder care practices. This initiative focused on improving the quality of life for elderly residents in nursing homes and other care facilities, has emphasized the use of existing data to drive research with immediate practical applications. Over the years, the program has not only shaped the way care is delivered to older adults but has also highlighted emerging trends and fostered shifts in focus that are reshaping the field of elder care.
Promoting Evidence-Based Practices
One of the most significant impacts of the Another Look program has been its promotion of evidence-based practices. By requiring researchers to leverage existing data sets, the program has championed a data-driven approach to elder care, ensuring that interventions are grounded in robust evidence. This has led to the development of best practices and performance measures that are directly applicable in care settings. For example, research funded by the program has been instrumental in reducing the use of antipsychotic medications in nursing homes, a critical step in improving the safety and well-being of residents with dementia.
Reducing Unnecessary Hospitalizations
A clear trend that has emerged from the program's funded research is the focus on reducing unnecessary hospitalizations among nursing home residents. Several projects, particularly those funded in 2014 and 2016, have addressed the need to manage acute care within nursing home settings, rather than relying on hospital transfers. This aligns with broader healthcare goals of reducing costs and minimizing the risks associated with hospital stays for frail elderly patients. The development of financial models and care protocols to incentivize high-quality acute care within nursing homes has been one of the program's key contributions, and these practices are increasingly being adopted across the industry.
Advancing Person-Centered Care Models
The Another Look program has also played a role in advancing person-centered care models. Research funded through the program, such as studies on the Preferences for Everyday Living Inventory (PELI) and evaluations of person-centered care practices in Kansas nursing homes, has emphasized the importance of tailoring care to the individual preferences and needs of residents. This shift towards person-centered care has led to improvements in resident satisfaction and quality of life, reinforcing the resident's voice and autonomy as central elements of elder care.
Addressing Disparities in Care
Another critical focus of the program has been addressing disparities in care, particularly for minority populations and those in rural areas. Studies on racial and ethnic disparities in outcomes, such as pressure ulcers, and the impact of neighborhood socioeconomic factors on nursing home quality have brought attention to the inequities that exist in elder care. These findings have driven efforts to develop targeted interventions and policies aimed at reducing these disparities, ensuring that all residents receive equitable care, regardless of their background or location.
Expanding Telemedicine and Remote Care
The COVID-19 pandemic accelerated the adoption of telemedicine, and the Another Look program has been at the forefront of this shift. Research funded by the program has provided valuable insights into how telemedicine can improve access to care for older adults, particularly in reducing emergency department visits. This has led to a broader acceptance and integration of telemedicine in long-term care settings, a trend that is likely to continue as technology advances and the need for remote care grows.
Enhancing Mental Health Care for the Elderly
Mental health care for elderly residents, particularly those with dementia or serious mental illness, has become a more prominent focus within the program. Research projects addressing the quality of mental health services in nursing homes and the unintended consequences of reducing antipsychotic use have highlighted the critical need for specialized mental health care in elder care settings. This focus has encouraged the development of new care models and training programs that better address the mental health needs of elderly residents.
Emerging Trends and Future Directions
Over the years, the Another Look program has fostered several emerging trends that continue to shape the field of elder care:
Data-Driven Decision Making
The program's emphasis on using existing data has led to more efficient and cost-effective research, with faster implementation of findings into practice. This trend is likely to continue, with data-driven decision-making becoming increasingly integral to elder care.
Holistic Approaches to Care
There is a growing recognition of the need for holistic, multidimensional approaches to care, considering the physical, mental, and social aspects of a resident's well-being. This comprehensive perspective is reflected in both the research funded by the program and the resulting care practices.
Improved End-of-Life Care
The program has placed a strong emphasis on enhancing end-of-life care, with several projects specifically targeting hospice care utilization and the management of care transitions. This focus underscores the importance of ensuring quality care at the end of life, a priority that is expected to gain further traction in the coming years.
Equity in Elder Care
Addressing disparities in care has become a central theme in the program's later years, reflecting an increased awareness of the need for equity in elder care. This focus on social determinants of health is likely to remain a key area of research and intervention moving forward.
Another Look
Metrics
47
Total Number
Grant Awards
27
Total Unique
Institutions
142559
Avg. Project Cost
2023 Grant Awards
Another Look
Research to Improve Health for Older Adults in Long Term Care Facilities
The Effect of the Green House Model of Nursing Home Care on Patient Outcomes
Norma Coe, PhD
University of Pennsylvania
Stakeholder Organization: The Green House Project
The Effect of the Green House Model of Nursing Home Care on Patient Outcomes
Norma Coe, PhD
University of Pennsylvania
Stakeholder Organization: The Green House Project
About this Project
This project seeks to evaluate the impact of the Green House Model, an innovative small-scale alternative to traditional nursing homes, on patient outcomes. The Green House Model emphasizes personalized care in a home-like setting, offering single bedrooms and a unique staffing approach where Certified Nursing Assistants (CNAs) take on broader roles, including cooking and housekeeping. Early studies have shown promising results, with Green House residents experiencing more direct care, lower rates of depression, and fewer pressure ulcers compared to those in traditional nursing homes. The project will extend this research by comparing patient outcomes between Green House homes and traditional nursing homes, accounting for patient selection factors. This study will provide insights into whether the Green House Model’s successes are due to the model itself or the types of residents it attracts.
The Problem
Nursing home residents often experience challenges related to the quality of care, particularly in traditional, large-scale institutions. The Green House Model of care, which focuses on smaller, more homelike environments and enhanced staff-resident interactions, has been associated with better physical and mental health outcomes for residents. However, it remains unclear whether these positive outcomes are due to the care model itself or the types of residents these facilities attract. This study seeks to address this gap by comparing patient outcomes in Green House and traditional nursing homes while accounting for potential biases in resident selection.
Stakeholder Role
The Green House Project, a national organization dedicated to revolutionizing eldercare, will serve as a key stakeholder in this project. Led by CEO Susan Ryan, the Green House Project will provide crucial data on Green House-certified nursing homes, including operational dates and contextual details regarding the model’s implementation. The organization will also assist with interpreting findings and translating them for both academic and non-academic audiences, ensuring the results are accessible to policymakers, nursing home administrators, and consumers. This partnership will enhance the practical relevance of the research and help drive the dissemination of results.
Description of Dataset(s) and Research Design
This study will merge multiple administrative datasets from the Centers for Medicare and Medicaid Services (CMS) with data from Green House-certified nursing homes and demographic information from the U.S. Census. The datasets include the Minimum Data Set (MDS), Medicare Provider Analysis and Review (MedPAR), and Payroll-Based Journal (PBJ) data, covering resident health and functional status, staffing levels, and facility characteristics from 2011 to 2022. The primary analysis will use propensity score weighting to account for differences in resident characteristics and will compare outcomes such as cognitive function, physical health, and length of stay between Green House residents and those in traditional nursing homes.
Knowledge Translation, Dissemination, and Integration
The findings from this research will be shared through both academic and non-academic channels. The project will produce a Practitioner Guide for nursing home staff and a Policy Brief aimed at informing federal and state policymakers on the benefits of the Green House Model. The results will be presented at national conferences, published in peer-reviewed journals, and disseminated via issue briefs and webinars. Through collaboration with the Green House Project, the research team will ensure that the findings are accessible to a broad audience, including policymakers, nursing home administrators, and healthcare consumers.
Improving Hospice Use in the Connecticut Medicaid Population with Nursing Home Stays
Ellis Dillon, PhD and Julie Robison, PhD
University of Connecticut Health Center
Stakeholder Organization: Connecticut Department of Social Services
Improving Hospice Use in the Connecticut Medicaid Population with Nursing Home Stays
Ellis Dillon, PhD and Julie Robison, PhD
University of Connecticut Health Center
Stakeholder Organization: Connecticut Department of Social Services
About this Project
This project seeks to address the complex challenges faced by nursing home residents and their caregivers by focusing on improving end-of-life care and health outcomes. Through a comprehensive analysis of healthcare utilization, care delivery, and family caregiving dynamics in nursing home settings, the study aims to identify barriers and facilitators to better end-of-life care. The research is informed by population science data and focuses on rural settings where healthcare access is limited, making it critical to enhance both resident care and caregiver support. By understanding these dynamics, the project seeks to drive policy and practice changes that will improve the quality of life for nursing home residents and alleviate the burden on family caregivers.
The Problem
Connecticut ranks 40th in hospice use and 1st in very short hospice enrollment (≤7 days), a key indicator of poor end-of-life care. Medicaid recipients, particularly those in nursing homes, often miss out on the benefits of hospice care due to underutilization. This disparity stems from multiple factors, including a lack of understanding of hospice services and systemic barriers in nursing home settings. The study aims to identify individual, nursing home, and systemic factors that impact hospice use and short hospice enrollments among Medicaid-insured nursing home residents, to improve access and quality of care at the end of life.
Stakeholder Role
The Connecticut Department of Social Services (CT DSS), led by Dr. Bradley Richards, serves as a key stakeholder in this project. CT DSS will assist in policy interpretation and is expected to use the findings to influence state-level policy improvements for Medicaid recipients in nursing homes. Other stakeholders, such as LeadingAge Connecticut, the Connecticut Association of Health Care Facilities, and the Connecticut Association for Health Care at Home, will help guide the project, contribute to data interpretation, and disseminate findings among policymakers and healthcare providers, ensuring broader community engagement and policy advocacy.
Description of Dataset(s) and Research Design
The study will employ a mixed-methods approach using quantitative and qualitative data. It will analyze Medicaid and Medicare claims, Minimum Data Set (MDS) assessments, and nursing home/hospice provider data from 2017 to 2024, covering approximately 30,000 Connecticut residents. Multivariate logistic regression models will be used to evaluate hospice use and short hospice enrollment (≤7 days) based on individual and nursing home characteristics. In-depth interviews with 14 nursing home and hospice professionals will provide qualitative insights into barriers and facilitators of hospice use. The study aims to create actionable solutions to improve hospice care access for Medicaid recipients in nursing homes.
Knowledge Translation, Dissemination, and Integration
The results of this study will be shared with CT DSS and other stakeholders to inform potential policy changes that enhance hospice access for Medicaid patients in nursing homes. Findings will be disseminated through peer-reviewed publications, presentations at national conferences such as the Gerontological Society of America and the American Academy of Hospice and Palliative Medicine, and reports to policymakers. The study’s outcomes will contribute to improving end-of-life care by addressing the underutilization of hospice services, thus enhancing both the quality of life for patients and resource allocation in Connecticut’s nursing homes.
The CARE Project: Addressing Conflicts between Safety and Autonomy in Nursing Homes
Dr. Angela K. Perone, JD, MSW, MA, PhD
University of California
Stakeholder Organization: The California Advocates for Nursing Home Reform (CANHR)
The CARE Project: Addressing Conflicts between Safety and Autonomy in Nursing Homes
Dr. Angela K. Perone, JD, MSW, MA, PhD
University of California
Stakeholder Organization: The California Advocates for Nursing Home Reform (CANHR)
About this Project
This project examines the conflicts nursing home staff encounter when balancing the safety of residents with their autonomy, a pervasive challenge in long-term care settings. While federal regulations mandate both the protection of residents’ safety and the preservation of their autonomy, there is little guidance on how staff should navigate conflicts between these two priorities. This study seeks to provide an empirical basis for understanding how safety-autonomy conflicts are managed in nursing homes, identify gaps in current practices, and propose policy solutions and best practices to improve care. The project will analyze data from nursing home administrators, staff, and residents, as well as stakeholder organizations, to develop a Practitioner Guide and Policy Brief on resolving these conflicts.
The Problem
Nursing home residents often face a delicate balance between safety and autonomy. Federal and state regulations require nursing homes to uphold both, but staff frequently encounter situations where these goals conflict, such as when a resident’s desire for independence may increase their risk of injury. Currently, there is little structured guidance on how to navigate these conflicts, leading to inconsistent care practices and negative outcomes for residents. This project aims to systematically analyze how nursing homes address these conflicts and develop actionable solutions to improve both safety and autonomy in long-term care settings.
Stakeholder Role
The California Advocates for Nursing Home Reform (CANHR), led by Executive Director Patricia McGinnis, plays a critical role as a stakeholder in this project. CANHR will help interpret the study findings and guide the development of materials that can be used to inform policymakers and practitioners. Additionally, CANHR will aid in the dissemination of the Practitioner Guide and Policy Brief, ensuring that the results of the study reach nursing homes and policymakers throughout California and beyond. This collaboration will help improve care delivery, advocating for better safety and autonomy practices in nursing homes.
Description of Dataset(s) and Research Design
This project will employ a mixed-methods approach, combining data from interviews, surveys, and document analysis. Interviews and surveys will be conducted with nursing home administrators, staff, and residents to gain insights into how safety-autonomy conflicts are handled on a day-to-day basis. Additionally, the project will analyze relevant legal and policy documents to identify where existing regulations may hinder or support better care practices. Data will be analyzed using qualitative content analysis and multivariate statistical techniques to determine patterns in how safety-autonomy conflicts are managed across different nursing homes.
Knowledge Translation, Dissemination, and Integration
The study’s findings will be disseminated through two key outputs: a Practitioner Guide for nursing home staff that provides actionable steps for resolving safety-autonomy conflicts, and a Policy Brief aimed at state and federal policymakers to influence long-term care regulations. These materials will be shared at conferences, through CANHR’s network, and via publications in both academic and policy journals. The goal is to create lasting improvements in nursing home care practices, balancing residents’ autonomy and safety while ensuring compliance with regulatory frameworks. By addressing this critical issue, the project will contribute to improved quality of life for nursing home residents.
Population Science Informs Rural Nursing Home Resident & Caregiver Health Initiatives
Caroline Stephens, PhD
University of Utah
Stakeholder Organization: Comagine Health, Utah's Quality Improvement Organization (QIO)
Population Science Informs Rural Nursing Home Resident & Caregiver Health Initiatives
Caroline Stephens, PhD
University of Utah
Stakeholder Organization: Comagine Health, Utah's Quality Improvement Organization (QIO)
About this Project
This study addresses the unique health challenges faced by rural nursing home residents and their first-degree family (FDF) caregivers. It focuses on the interplay between the availability of family caregivers and the end-of-life (EOL) healthcare outcomes for nursing home residents, and how these outcomes affect the caregivers' health. Using data from the Utah Caregiving Population Science (Utah C-PopS) study, this research will explore how family caregiving dynamics influence healthcare utilization for both residents and caregivers in rural settings. The project aims to examine the health disparities in EOL care outcomes for rural nursing home residents and assess the impact of caregiving on the health of FDF caregivers, especially in the context of rural healthcare challenges. By investigating these dynamics, the project seeks to inform the development of strategies that improve both resident and caregiver health outcomes.
The Problem
Rural nursing home residents often face significant barriers to receiving high-quality end-of-life (EOL) care, and their family caregivers bear the brunt of this gap in services. Studies have shown that family caregivers in rural areas are more vulnerable to poor health outcomes due to the physical and emotional burdens of caregiving. The disparities in EOL care for nursing home residents are exacerbated by the limited availability of healthcare resources in rural settings, leading to increased healthcare utilization and poorer outcomes for both residents and caregivers. This study aims to address these issues by exploring the health impacts of caregiving and EOL care disparities in rural nursing homes.
Stakeholder Role
Comagine Health, Utah’s Quality Improvement Organization (QIO), plays a critical role as a stakeholder in this project. Comagine Health will assist in data interpretation, guide the development of educational materials for caregivers, and help disseminate findings to healthcare providers and policymakers. Through their engagement, Comagine Health will ensure that the findings are effectively translated into actionable strategies to improve healthcare delivery in rural nursing homes. Stakeholder Advisory Boards (SAB) will also be involved in guiding the creation of palliative care (PC) training tools to address the specific needs of rural communities.
Description of Dataset(s) and Research Design
This study leverages the Utah Population Database (UPDB), which links individual healthcare utilization records with life history data for both nursing home residents and their caregivers. The project will use a retrospective cohort design, analyzing healthcare utilization and EOL outcomes for approximately 30,000 residents and their family caregivers in rural Utah. Data from the Minimum Data Set (MDS 3.0) and Medicare/Medicaid claims will be merged with caregiver health data from UPDB. Advanced statistical models, such as Poisson and negative binomial regression, will be used to evaluate the relationships between caregiving, healthcare utilization, and EOL outcomes.
Knowledge Translation, Dissemination, and Integration
The results of this study will be shared with healthcare providers, policymakers, and rural healthcare organizations through a comprehensive dissemination plan. Findings will be presented at national conferences and published in peer-reviewed journals. Educational materials and training tools will be developed and shared with rural nursing homes and palliative care providers. These efforts will help optimize care delivery and improve health outcomes for rural nursing home residents and their caregivers. The results will also inform future policy development aimed at reducing healthcare disparities in rural settings.
Greater Value Portfolio
Advancing promising approaches to achieve a higher-value healthcare system
AIMEPCCo: American Indian Men’s Experiences with Prostate Cancer Communication
Christopher Gillette, PhD
Wake Forest University School of Medicine
Partner Organizations: Wake Forest University School of Medicine, the University of North Carolina at Chapel Hill, University of South Carolina
AIMEPCCo: American Indian Men’s Experiences with Prostate Cancer Communication
Christopher Gillette, PhD
Wake Forest University School of Medicine
Partner Organizations: Wake Forest University School of Medicine, the University of North Carolina at Chapel Hill, University of South Carolina
About this Project
The project titled AIMEPCCo: American Indian Men's Experiences with Prostate Cancer Communication seeks to address significant health disparities in prostate cancer (PC) screening among American Indian/Alaska Native (AIAN) men, focusing specifically on the Lumbee Tribe of North Carolina. Prostate cancer is a leading cause of death among AIAN men, with disparities driven by low screening rates and late-stage diagnoses. This study aims to improve PC-related communication and shared decision-making (SDM) strategies, which are critical for increasing screening uptake and improving early detection rates among AIAN men. The research leverages a mixed-methods design to explore and characterize the preferences and barriers that impact AIAN men's engagement with PC screening.
The Problem
AIAN men experience some of the worst PC outcomes in the United States, largely due to reduced access to timely screening. Despite the high risk and rising incidence of prostate cancer, there is a significant gap in culturally relevant communication and decision-making interventions tailored to this population. Existing research has shown that poor clinician communication and historical trauma contribute to mistrust in healthcare systems among AIAN men, exacerbating disparities in cancer outcomes. Prostate cancer screening decisions are preference-sensitive, meaning that they require individualized discussions about the benefits and risks with primary care physicians, consistent with the guidelines of the United States Preventive Services Task Force (USPSTF). However, AIAN preferences and values related to PC screening are poorly understood.
Study Design
This study is a sequential mixed-methods investigation that includes qualitative interviews and a Discrete Choice Experiment (DCE) survey. In the first phase, the research team will conduct in-depth interviews with Lumbee men to identify barriers, facilitators, and cultural factors that influence PC communication and screening preferences. The DCE will then quantify these preferences and predict the demand for specific screening strategies, helping to shape culturally relevant SDM interventions. The final phase involves talking circles, a culturally appropriate method for validating the findings with community members and co-developing future interventions.
Contribution to Improved Value
The research will generate actionable insights into the factors that drive PC screening preferences among AIAN men, particularly Lumbee men. By developing culturally relevant communication strategies and SDM tools, the study aims to improve screening rates, reduce late-stage PC diagnoses, and ultimately enhance health outcomes for AIAN men. Findings from this study will support the creation of targeted interventions, which will be shared with the Lumbee Tribe, healthcare providers, and policymakers, contributing to greater health equity in cancer care.
Engaging Hospital Systems to Increase Colorectal Cancer Screening Persistency & Follow-Up
Sarah Roth, PhD
Center for Outcomes Research and Education (CORE)
Engaging Hospital Systems to Increase Colorectal Cancer Screening Persistency & Follow-Up
Sarah Roth, PhD
Center for Outcomes Research and Education (CORE)
About this Project
This project aims to improve colorectal cancer (CRC) screening persistency and follow-up care through the utilization of mailed fecal immunochemical tests (FIT) as part of a large-scale screening program. The primary research goal is to evaluate whether the FIT program enhances CRC screening adherence and follow-up care across various sociodemographic populations, addressing disparities and enhancing healthcare access for underserved groups. This study will assess patient engagement, persistency with FIT kit usage, and their experience with follow-up care, focusing on disparities in CRC screening across racial, ethnic, and socioeconomic groups. Findings from this research will inform strategies to refine and scale the FIT program for increased access and improved patient outcomes.
The Problem
Colorectal cancer is a leading cause of cancer morbidity and mortality in the U.S. Despite being a cost-effective strategy to reduce CRC incidence, current screening rates remain below national benchmarks, particularly among underserved populations. Barriers such as affordability, accessibility, and acceptability prevent widespread use of colonoscopy, the gold standard for CRC screening. FIT, a non-invasive stool-based test, provides a viable alternative, but persistency in screening and follow-up care remain challenges, especially for racial/ethnic minorities and lower-income groups.
Study Design
This study will employ a mixed-methods observational design to evaluate outcomes across a large health system. Quantitative analysis will assess FIT program engagement, persistency, and follow-up after abnormal results using electronic health record (EHR) data from patients across Oregon and Washington. Additionally, qualitative interviews with a diverse subset of patients will explore the barriers and facilitators to participation and follow-up care in the FIT program. By leveraging data from over 28,000 patients, this research aims to uncover disparities in screening rates and outcomes, improving the value of healthcare provided to underserved populations.
Contribution to Improved Value
The research addresses key barriers to CRC screening, including affordability and access, with the goal of increasing FIT screening rates and follow-up testing. By focusing on underserved groups, including racial/ethnic minorities, Medicaid patients, and non-English speakers, the study seeks to reduce disparities in CRC screening outcomes. Findings will guide enhancements in the FIT program, ensuring that healthcare systems provide equitable and effective screening services to all populations. The study's outcomes have the potential to improve health equity and reduce CRC-related mortality in underserved communities.
Testing effectiveness of Her Health Program to add healthcare value in fourth trimester
Elizabeth Sutton, PhD
Woman's Hospital
Partner Organization: Woman’s Hospital
Testing effectiveness of Her Health Program to add healthcare value in fourth trimester
Elizabeth Sutton, PhD
Woman's Hospital
Partner Organization: Woman’s Hospital
About this Project
The proposed project, "Testing the Effectiveness of the Her Health Program to Add Healthcare Value in the Fourth Trimester," aims to address disparities in postpartum care for Medicaid-enrolled women in Louisiana. The Her Health program, a patient navigation intervention, seeks to improve access to care, increase medical trust, and enhance health literacy among underserved postpartum women. By targeting racial and socioeconomic inequities, this study will evaluate how navigation and culturally competent education influence postpartum healthcare attendance, medical trust, and healthcare costs over the first year after delivery.
The Problem
Postpartum care for women of racial and ethnic minorities and those from low socioeconomic backgrounds often suffers from inadequate access and high healthcare costs, leading to increased risks of poor long-term health outcomes. Despite modern practices aimed at supporting women after pregnancy, significant inequities persist in postpartum care. These inequities lead to disparities in health outcomes, compounded by variations in care quality and lack of trust in the medical system.
Study Design
This randomized controlled trial will involve 450 Medicaid-enrolled postpartum women, who will be randomized into either the Her Health program or standard care. The intervention consists of patient navigation by community health workers combined with educational sessions to build medical trust and advocacy skills. Primary outcomes will focus on healthcare access, measured by postpartum visit attendance, primary care appointments, emergency room visits, and hospitalizations. Secondary outcomes include improvements in medical trust, health literacy, and self-efficacy. Additionally, healthcare costs will be analyzed to assess the financial impact of the intervention.
Contribution to Improved Value
The Her Health program aims to bridge the gap in healthcare access and trust for underserved populations, addressing core issues of equity, cost, and care quality in postpartum health. If successful, the intervention could be scaled to other healthcare systems to improve maternal health outcomes nationally, offering a replicable solution to the current disparities in postpartum care. The findings will inform healthcare policies that prioritize equitable access and reduce the financial burden on low-income families while ensuring high-quality postpartum care.
Accountable Care Organizations in Medicaid: Reducing Low-Value Care for Working-Age Adults
Rishi Wadhera, MD, MPP, MPhil
Beth Israel Deaconess Medical Center
Partner Organization: MassHealth
Accountable Care Organizations in Medicaid: Reducing Low-Value Care for Working-Age Adults
Rishi Wadhera, MD, MPP, MPhil
Beth Israel Deaconess Medical Center
Partner Organization: MassHealth
About this Project
This project aims to investigate the impact of Medicaid Accountable Care Organizations (ACOs) on reducing the use of low-value healthcare services for working-age adults. Specifically, the study focuses on understanding whether the Massachusetts Medicaid ACO model, implemented in 2018, has led to a significant reduction in the utilization of 13 low-value services, such as unnecessary imaging for lower back pain, antibiotics for upper respiratory infections, and non-recommended cancer screenings. The research targets vulnerable subgroups, including racial and ethnic minorities, women, and individuals with multiple chronic conditions, who are more likely to experience disparities in care and may benefit most from improvements in healthcare value. Findings from this study will offer critical insights for policymakers, health systems, and Medicaid administrators, enabling them to optimize Medicaid ACO models and enhance care delivery for socially and medically complex populations.
The Problem
Low-value healthcare services, which provide minimal or no clinical benefit to patients, remain widespread in the U.S. healthcare system and represent a significant driver of unnecessary healthcare spending. Medicaid enrollees, particularly working-age adults from disadvantaged backgrounds, are especially vulnerable to receiving such services, contributing to healthcare inefficiencies and poorer outcomes. While ACOs in Medicare populations have demonstrated potential in reducing both costs and unnecessary services, little is known about their effectiveness in the Medicaid population. The Massachusetts Medicaid ACO model, one of the first of its kind, provides a unique opportunity to assess whether this approach can meaningfully reduce low-value care for working-age adults.
Study Design
This study will employ a rigorous difference-in-differences (DiD) research design to compare the use of low-value healthcare services in Massachusetts, where the Medicaid ACO model was implemented in 2018, to a set of control states without similar ACO interventions. The research will leverage administrative claims data from the Transformed Medicaid Statistical Information System (T-MSIS) and the CMS Virtual Research Data Center (VRDC) to track healthcare utilization patterns over time. The primary outcomes of interest are the use of 13 identified low-value services, and secondary outcomes include subgroup analyses that focus on disparities in care among racial and ethnic minorities, women, and patients with multiple chronic conditions. Advanced statistical methods will be used to account for baseline differences between states and to ensure robust conclusions regarding the impact of ACOs on healthcare utilization.
Contribution to Improved Value
This research has the potential to provide vital evidence on the effectiveness of Medicaid ACOs in reducing low-value care, particularly for populations that experience significant healthcare disparities. By analyzing the differential impact of ACO implementation on vulnerable subgroups, including racial and ethnic minorities, this study will help identify key factors that influence the success of ACOs in promoting high-value care. The findings will be critical for informing policy discussions at the state and national levels, as they will reveal whether Medicaid ACO models can achieve meaningful reductions in unnecessary care and help guide future efforts to scale ACOs across Medicaid programs nationwide. Ultimately, this work will contribute to broader efforts to reduce healthcare costs, improve the quality of care for Medicaid beneficiaries, and address longstanding inequities in the healthcare system.
R3
Helping researchers better prepare their health interventions for adoption and use in real-world settings
Developing and Disseminating Strategies for Nursing Homes to Fully Implement the PELI
Kathrene Abbott, PhD
Miami University
Developing and Disseminating Strategies for Nursing Homes to Fully Implement the PELI
Kathrene Abbott, PhD
Miami University
Previous Research
The original project advanced the understanding of the impact of implementing the Preferences for Everyday Living Inventory (PELI) in Ohio nursing homes. Researchers validated a pragmatic indicator for the extent of PELI implementation and explored the organizational characteristics associated with full adoption of the PELI. Findings revealed that nursing homes fully implementing the PELI were more likely to have higher deficiency star ratings, lower deficiency scores, and fewer substantiated complaints compared to partial implementers.
Purpose of Continuation
The continuation of this project aims to promote the broader adoption of full PELI implementation in nursing homes. Evidence indicates that providers who comprehensively implement the PELI—by assessing resident preferences, integrating them into care plans, and evaluating these efforts—experience better outcomes than those with partial or no implementation. The project seeks to utilize additional funding to disseminate these findings and extend PELI’s adoption nationwide, as Ohio nursing homes are considered representative of providers across the country due to the consistency of nursing home regulations.
Project Value and Intended Users
This continuation project will focus on identifying the strategies nursing homes with different resource levels use to achieve full PELI implementation. Through in-depth qualitative interviews and case studies, the project will provide practical tools and insights for nursing home providers aiming to adopt this preference-based care model. The project will also address the need for more effective communication of findings to nursing home leaders, beyond academic dissemination. Collaborating with Strategic Communications and Planning (SCP), the project will develop clear messaging to engage decision-makers and encourage widespread implementation.
Long-Term Implications
The outcomes of this project have far-reaching implications for both policymakers and nursing home providers. By identifying the stages of successful PELI implementation, the project can inform policy initiatives that incentivize providers through pay-for-performance models, such as the Kansas PEAK 2.0 initiative. Additionally, the case studies will offer practical examples for providers to follow, particularly given the similar regulatory contexts and nationwide staffing challenges faced by nursing homes. The project also aims to engage stakeholders, including Ombudsmen and family members, to further advocate for the adoption of PELI in nursing homes, ensuring a resident-centered approach to care.
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