Improving Quality of Care for Persons with Dementia in Nursing Homes – Evaluation of the National Background Check Program

长期以来，政策制定者和研究人员一直对养老院的居民福利表示担忧，因为虐待，忽视和剥削。养老院的居民特别容易受到虐待和忽视，因为他们的年龄，以及身体和认知能力的下降。由于患有阿尔茨海默病（AD）和阿尔茨海默病相关痴呆（ADRD）的个体具有较差的功能状态、更严重的认知障碍，并且在日常活动中严重依赖于护理者，因此他们更可能面临虐待和不当对待。每年有超过20%的养老院因虐待、忽视和剥削而被引用。国家背景调查计划（NBCP）是一个州一级的自愿计划，旨在减少虐待，忽视和剥削弱势居民在长期护理环境，包括养老院。作为参与NBCP的计划要求的一部分，各州必须检查a）潜在雇员居住的所有州的滥用登记，B）州犯罪历史记录，c）基于指纹的FBI记录，以及d）该州可能有取消资格信息的任何其他记录。联邦立法允许每个州获得高达300万美元的赠款来实施NBCP。自2010年以来，29个州和地区获得了在不同年份实施NBCP的资金，并处于不同的实施阶段。然而，背景调查和虐待/居民结果之间的联系尚不清楚。有证据表明，背景调查可能会在潜在的虐待者被雇用之前抓住他们。此外，背景调查也可能阻止潜在的虐待者申请养老院的工作。然而，背景调查可能无法抓住所有虐待行为的肇事者，实施NBCP也可能导致劳动力短缺。我们的目标是评估NBCP的有效性，在降低居民虐待，忽视和剥削，改善病人的安全结果，在疗养院，整体，AD/ADRD普查。为了实现这一目标，我们提出了三个具体目标的计量经济学分析：1）估计NBCP对犯有虐待，忽视和剥削罪的工作人员就业的影响，2）估计NBCP对虐待，忽视和剥削引用的影响，总体和分层高与低AD/ADRD普查，3）估计NBCP对不良患者质量结局的影响：营养不良、脱水、抑郁、福尔斯、压疮、感染和抗精神病药物的使用，总体和AD/ADRD个体。研究结果将产生重要的新知识NBCP在降低居民虐待，忽视和剥削和改善病人的安全结果在养老院，整体，和AD/ADRD的人的有效性。我们的研究结果有可能影响国家使用NBCP的CMS政策，以改善AD/ADRD人群的结局。

Policymakers and researchers have long expressed concerns about resident wellbeing in nursing homes because of abuse, neglect, and exploitation. Nursing home residents are particularly susceptible to abuse and neglect because of their age, as well as physical and cognitive decline. Since individuals with Alzheimer ’s disease (AD) and Alzheimer’s Disease Related-Dementias (ADRD) have poorer functional status, more severe cognitive impairment, and are heavily dependent on caregivers for their daily activities, they are more likely to face abuse and mistreatment. Over 20% of nursing homes are cited for abuse, neglect, and exploitation every year. The National Background Check Program (NBCP) is a state-level voluntary program aimed at reducing abuse, neglect, and exploitation of vulnerable residents in long-term care settings including nursing homes. As part of the program requirements for participation in NBCP, states are required to check a) abuse registries of all states in which the prospective employee lived, b) state criminal history records, c) fingerprint-based FBI records, and d) any other records in the state that may have disqualifying information. Federal legislation allows each state to obtain up to $3 million in grants to implement NBCP. Since 2010, 29 states and territories have obtained the funding to implement NBCP over different years and are in various stages of implementation. However, link between background checks and abuse/resident outcomes is not clear. There is some evidence to show that background checks may catch potential abusers before they are hired. Moreover, background checks may also deter potential abusers from applying for jobs in nursing homes. However, background checks may not catch all perpetrators of abuse and implementation of NBCP may also lead to workforce shortages. Our objective is to evaluate the effectiveness of NBCP in lowering resident abuse, neglect, and exploitation and improving patient safety outcomes in nursing homes, overall, and by AD/ADRD census. To achieve this goal, we propose an econometric analysis for three specific aims: 1) To estimate the effect of NBCP on employment of staff who are guilty of abuse, neglect, and exploitation, 2) To estimate the effect of NBCP on citations for abuse, neglect, and exploitation, overall and stratified by high vs. low AD/ADRD census, and 3) To estimate the effect of NBCP on adverse patient quality outcomes: malnutrition, dehydration, depression, falls, pressure sores, infections, and utilization on antipsychotic drugs, overall and for individuals with AD/ADRD. The study results will yield important new knowledge about the effectiveness of NBCP in lowering resident abuse, neglect, and exploitation and improving patient safety outcomes in nursing homes, overall, and for persons with AD/ADRD. Our results have the potential to affect CMS policies on states’ use of NBCP to improve outcomes for AD/ADRD population.