Abstract
Objectives
This study examines the association between nursing home residents’ perceived importance of family involvement in overall care planning and the administration of physical and occupational therapy.
Design:
Cross-sectional study.
Setting and Participants:
The study focused on all newly admitted nursing home residents aged 50 years and older who transferred from acute care facilities in 2019.
Methods:
We analyzed data from the Minimum Data Set 3.0 for 2,112,330 residents aged 50+ years in U.S. nursing homes. We assessed family involvement in care planning based on the resident’s perceived importance of family involvement in care planning, ranging from “Not important at all” to “Very Important”. Exclusions were residents in hospice, comatose, or life expectancy of less than 6 months. The outcome was defined as a sum of physical and occupational therapy minutes. Adjusted linear regression models were utilized.
Results:
Residents who reported ‘Very Important’ family involvement were older (mean age 78 years) and received more therapy minutes compared to other groups. Those with a lesser preference for family involvement were younger and had higher BMI, better continence, and less functional impairment. Fewer therapy minutes were received by residents with less family involvement. Residents who considered family involvement “Not Important at All” received 15 fewer minutes of therapy (95% CI: −18 to −13) compared to those who deemed it “Very Important”, after adjusting for confounders.
Conclusions and Implications:
The study highlights a link between family involvement in care planning and increased therapy administration in nursing homes. Residents reporting higher preference for family engagement received more therapy minutes, with this pattern consistent across various demographic and health conditions. This finding underscores the importance of family involvement in receipt of therapy and highlights the need for incorporating family engagement strategies in nursing home care planning to ensure equitable and effective care.
Keywords: Nursing Home Care, Occupational Therapy, Post-hospitalization Rehabilitation, Physical Therapy, Family Involvement in Care Planning
Summary -
This study on nursing home residents found more therapy minutes were received by residents who perceived family involvement as more important in care planning. The findings support the need for family-oriented policies.
Introduction:
In the United States, over sixteen thousand nursing homes provide essential care to approximately 1.3 million older adults1,2. These institutions serve a dual role: as centers for medical care and as crucial environments for maintaining and improving residents’ physical well-being and independence3. Highlighted by the Federal Nursing Home Reform Act of 1987, it is of paramount importance to preserve or enhance residents’ abilities in daily activities of living4. Physical independence in nursing home settings hinges on several factors, with rehabilitative therapy being the cornerstone approach. Particularly for patients in skilled nursing facilities recovering from events like strokes5. Rehabilitation efforts need to address a wide range of challenges that older adults face, from physical weakening and joint stiffness to neurological disorders like dementia or autism, and evidence supporting the benefits of therapy is robust and extensive6–8. The COVID-19 pandemic further emphasized the need for effective rehabilitative strategies to ensure residents maintain their independence and quality of life9.
While the clinical benefits of rehabilitation are well-documented, less is known about how family involvement influences the administration of rehabilitative therapies in nursing home settings. There also exists variability in therapy participation, intensity, and individual responses, leading to diverse outcomes in patient independence10–12. A significant gap in the literature is the role of family involvement in enhancing therapy effectiveness. There is ample evidence for the clinical value and effectiveness of family-involved rehabilitation strategies13,14. For example, previous studies have explored the multifaceted roles of family members in caregiving within long-term care settings15, and Other studies identified family involvement as a critical dimension of nursing home care quality16,17, there remains a scarceness of quantitative evidence examining the specific impact of family involvement on the administration of rehabilitative therapies. These gaps in literature underscore the importance of understanding the multifaceted nature of rehabilitation and the potential impact of family and environmental factors on resident well-being and independence.
To address this gap, this study examines the association between nursing home residents’ perceived importance of family involvement in care planning and the administration of physical and occupational therapy.
Methods:
Data Source:
We used data from the Minimum Data Set (MDS) 3.0 assessment of 2019. The MDS 3.0 collects comprehensive data on the clinical and functional screening of nursing home residents18–20 and includes information from more than 97% of Medicare/Medicaid-eligible nursing homes in the United States. The Centers for Medicare & Medicaid instituted the MDS 3.0 as the standardized evaluation for all individuals in facilities approved by Medicare or Medicaid20. MDS 3.0 collects information on more than 350 items, and is assessed upon nursing home entry, annually, or if there is a notable change in the resident’s clinical status21,22. A subset of items are assessed quarterly20. MDS assessments involve a collaborative effort by a range of health professionals, including nurses and social workers, who gather information from resident records, interactions with residents and their families, and direct observation. This research study has been approved by the Institutional Review Board.
Study Sample
We identified newly admitted residents aged 50 years and older who were transferred from an acute hospital to a nursing home. Transfer from an acute hospital was identified using MDS item A1800-“Entered From”. Our focus on residents with new admissions from acute care hospital was intended to identify residents most in need of rehabilitation therapy. We excluded residents who were comatose, in hospice care, or had a life expectancy of less than 6 months. We only included residents who were in nursing homes that provided physical and occupational therapy. Nursing homes with no MDS-documented residents receiving physical or occupational therapy were excluded. Lastly, we excluded residents with missing data on family involvement, physical therapy, or occupational therapy (Figure 1).
Figure 1:
Sample selection flow chart. Residents aged 49 years or younger, residents that were readmitted or did not come form an acute hospital, residents who were comatose, in hospice care, had a life prognosis of 6 months or less, were in nursing homes that did not offer therapy, or had missing data for outcome or exposure were excluded.
Definition of Family Involvement
This primary exposure variable was conceptually defined as the presence of family, spouse, or family who are involved in care planning for the resident. Operationally, we defined the exposure variable using MDS item F0400. F. “how important is it to you to have your family or a close friend involved in discussions about your care?”, which is reported by the resident or the family member. The response was coded as a categorical variable: 1) Very important, 2) Somewhat Important, 3) Not very Important, 4) Not important at all, and 5) Important, but can’t do or no choice. We analyzed the responses in the original five categories (without further grouping) because we hypothesized that increasing the importance of family involvement may increase the benefits associated with resident behavioral attributes (motivation and compliance) and facility quality of care (advocacy and accountability).
Definition of Rehabilitative Therapy
Rehabilitative therapy was assessed on the admitting MDS form conducted within the first 14 days of admission. We used MDS items O0400 B. 1–3 for occupational therapy and O0400 C. 1–3 for physical therapy as our principal study outcomes. Items 1–3 report: 1) individual minutes of exercise in the last 7 days, 2) concurrent minutes of exercise in the last 7 days, and 3) group minutes of exercise in the last 7 days. Individual minutes of therapy were defined as the treatment of one resident at a time. Group minutes of therapy were defined as the treatment of four (or more) residents who are performing the same or similar activity. Lastly, concurrent minutes of therapy were defined as two residents supervised by one therapist where the residents are not performing the same or similar activities. The outcome variable was the sum of all types of physical and occupational therapy minutes.
Study Variables
Information on an extensive set of variables was examined, including demographic information, health status indicators, clinical characteristics, and details of family involvement in care planning, for purposes of describing the study population and adjusting for potential confounding variables.
In the study, residents were categorized by age (50–64, 65–74, 75–84, 85+ years) and ethnicity (Non-Hispanic White, Black or African American, Hispanic, or Latino, Asian, American Indian, or Alaska Native, Pacific Islander, Multiple Races, Unknown Race). Body Mass Index (BMI) categories ranged from less than 18.5 kg/m2 to more than 30 kg/m2 and included an unknown BMI category. Nutritional status was evaluated based on malnutrition and dehydration over the past 7 days. Continence was assessed on a scale ranging from full continence to requiring an ostomy. Mobility impairments, including hemiplegia, paraplegia, quadriplegia, and hip fractures, along with comorbidities listed in Table 1, were documented using a 7-day look-back period. These variables were recorded in the MDS Section I ‘Active Diagnoses,’ which identifies diagnoses that were active within the past seven days according to the residents’ medical records.
Table 1.
Characteristics of Nursing Home Residents According to the Degree of Reported Family Involvement Preference, US Nursing Home Residents From 2019
| Imporance of Family Involvement in Care Planning | |||||
|---|---|---|---|---|---|
| Characteristics (Sample Size) | Very Important (N=1,722,481) | Somewhat Important (N = 263,541) | Not Very Important (N = 91,336) | Not Important at All (N = 31,374) | Important, but No Choice (N = 3,598) |
| Mean age in years (St. dev) | 78 (11) | 76 (11) | 73 (11) | 72 (11) | 74 (11) |
| Age Categories (Years) | |||||
| 50 – 64 | 12% | 17% | 24% | 27% | 23% |
| 65 – 74 | 23% | 27% | 31% | 32% | 29% |
| 75 – 84 | 33% | 30% | 27% | 25% | 27% |
| ≥ 85 | 32% | 25% | 18% | 15% | 22% |
| Sex | |||||
| Female | 61% | 56% | 50% | 49% | 53% |
| Race/Ethnicity | |||||
| Non-Hispanic White | 76% | 77% | 79% | 80% | 78% |
| Non-Hispanic Black or African American | 12% | 12% | 11% | 10% | 10% |
| Hispanic or Latino | 5% | 4% | 3% | 3% | 5% |
| Non-Hispanic Asian | 2% | 1% | 1% | 1% | 1% |
| Non-Hispanic American Indian,Alaska Native, Pacific Islander, or Multiple Races | 0% | 1% | 1% | 1% | 1% |
| Race Unknown | 5% | 5% | 5% | 5% | 5% |
| Body Mass Index (BMI), kg/m2 & Nutritional Status | |||||
| Underweight (< 18.5) | 7% | 7% | 7% | 7% | 9% |
| Normal (18.5 ≤ BMI < 25.0) | 35% | 34% | 32% | 32% | 36% |
| Overweight (25.0 ≤ BMI < 30.0) | 27% | 26% | 25% | 24% | 24% |
| Obese (≥ 30.0) | 31% | 33% | 35% | 36% | 31% |
| BMI information not known | 1% | 1% | 1% | 1% | 1% |
| Malnutrition | 8% | 8% | 8% | 8% | 9% |
| Urinary Continence | |||||
| Always continent | 29% | 32% | 38% | 39% | 33% |
| Occasionally Incontinent | 29% | 29% | 30% | 30% | 27% |
| Frequently Incontinent | 25% | 23% | 20% | 18% | 22% |
| Always Incontinent | 9% | 8% | 6% | 6% | 11% |
| No Urine Output in the past7 days or had a urineostomy/catheter | 8% | 8% | 7% | 7% | 8% |
| Bowel Continence | |||||
| Always continent | 47% | 49% | 55% | 57% | 48% |
| Occasionally Incontinent | 14% | 14% | 13% | 13% | 12% |
| Frequently Incontinent | 25% | 24% | 21% | 20% | 23% |
| Always Incontinent | 12% | 11% | 9% | 8% | 15% |
| No Bowel Movement or had an ostomy | 2% | 2% | 3% | 3% | 2% |
| Mobility | |||||
| Hip Fracture | 9% | 8% | 7% | 7% | 7% |
| Activities of Daily Living (ADL) Impairment | |||||
| Minimal ADL impairment | 15% | 19% | 25% | 27% | 24% |
| Moderate ADL impairment | 69% | 67% | 63% | 60% | 59% |
| Severe ADL impairment | 16% | 14% | 12% | 12% | 17% |
| Cognitive Impairment | |||||
| Intact | 61% | 65% | 68% | 68% | 59% |
| Mild Impairment | 23% | 22% | 20% | 21% | 21% |
| Moderate impairment | 15% | 13% | 11% | 10% | 16% |
| Severe impairment | 2% | 1% | 1% | 1% | 4% |
| Frailty | |||||
| Non-Frail | 14% | 16% | 20% | 21% | 18% |
| Pre-Frail | 41% | 42% | 43% | 42% | 38% |
| Frail | 44% | 40% | 35% | 35% | 42% |
| Frailty Status Unknown | 1% | 1% | 1% | 2% | 2% |
| Comorbidities (Past 7 days) | |||||
| Diabetes Mellitus | 37% | 37% | 37% | 37% | 35% |
| Cancer | 11% | 11% | 9% | 9% | 9% |
| Cirrhosis/Liver Failure | 1% | 2% | 2% | 2% | 3% |
| Heart Failure | 26% | 24% | 23% | 23% | 21% |
| End Stage Renal Disease | 24% | 24% | 22% | 22% | 21% |
| Asthma | 26% | 28% | 29% | 30% | 26% |
| Respiratory Failure | 8% | 7% | 7% | 7% | 8% |
| Anemia | 30% | 29% | 28% | 27% | 26% |
| Hypertension | 79% | 77% | 75% | 73% | 72% |
| Alzheimer’s disease | 4% | 3% | 2% | 2% | 4% |
| Parkinson’s disease | 4% | 4% | 3% | 3% | 4% |
| Peripheral Vascular Disease | 8% | 9% | 9% | 9% | 8% |
| Anxiety Disorders | 18% | 19% | 20% | 21% | 20% |
| Depression | 32% | 33% | 34% | 34% | 34% |
| Infection | |||||
| Pneumonia | 8% | 8% | 7% | 7% | 8% |
| Urinary Tract Infection | 13% | 12% | 11% | 10% | 12% |
| Pain Management | |||||
| Scheduled Pain Medicine | 37% | 36% | 38% | 38% | 35% |
| PRN Pain Meds | 59% | 59% | 60% | 61% | 55% |
| Non-Pharmacological Pain treatments | 27% | 27% | 29% | 29% | 26% |
| Fall History | |||||
| Fall with no injury | 6% | 6% | 6% | 6% | 6% |
| Fall Resulted in injury | 2% | 2% | 2% | 2% | 2% |
| Falls that resulted in Major Injuries | 0% | 0% | 0% | 0% | 0% |
| Pressure Ulcers | |||||
| Risk of Pressure Ulcers | 89% | 87% | 85% | 83% | 83% |
| Stage 1 or higher-pressure Ulcers | 14% | 13% | 12% | 11% | 13% |
Activities of Daily Living (ADL) impairments were quantified on a four-tier scale23, and cognitive function was measured on a four-level scale ranging from intact to severe impairment, using Brief Interview for Mental Status and cognitive performance scales24. Frailty was assessed using the FRAIL-NH scale, scoring factors like Fatigue, Resistance, Ambulation, and others to categorize residents from non-frail to frail25–27. Comorbidities including diabetes, heart failure, respiratory failure, and psychiatric disorders were recorded, along with infections like pneumonia and urinary tract infections. Pain management strategies and the history and severity of falls were noted. The study also evaluated the risk and presence of pressure ulcers to assess skin integrity.
Data Analysis
We described the characteristics of the residents according to their level of preference for family involvement. We provided data on the means and standard deviations of the continuous variables and percentages for the categorical variables. We described the quantity, as expressed by the total combined minutes of physical therapy and occupational therapy (PT/OT), according to the resident’s preference for family involvement. To quantify the unadjusted and multivariable-adjusted relationship between the extent of self-reported family involvement and PT/OT therapy minutes, we used linear regression models estimated via generalized estimating equations (GEE) to account for clustering of residents within nursing home facilities. Potential confounders were selected for inclusion in the multivariable model based on substantive knowledge and analytical identification of meaningful confounding magnitude (defined as a 5% change in effect estimate for any of the family involvement estimates). The confounders that met the criteria were age, sex, race/ethnicity, cognitive impairment, activities of daily living impairments, frailty status, and urinary incontinence. To rule out collinearity between potential confounders, the variance inflation factor (VIF) was calculated. The analysis was completed using SAS version 9.4 (SAS Institute, Inc., Cary, NC).
Results:
Population Characteristics
The study sample consisted of 2,112,330 NH residents. Among these residents, 82% reported that family involvement in care planning was “Very Important,” 12% indicated it was “Somewhat Important,” and the remaining 6% were distributed among the categories “Not Very Important,” “Not Important at All,” and “Important, but no choice.” The mean age of this sample was 78 years, 61% were women, and 76% were non-Hispanic white. About 85% of the study population had moderate to severe ADL impairment, 42% had mild to severe cognitive impairment, and 44% were classified as frail.
Resident Characteristics and Family Involvement
Most residents (93% to 98%) self-reported family involvement. Women, along with non-Hispanic White residents, were more likely to indicate that family involvement was important (Table 1). Between-group differences in various demographic factors were observed. Residents who were 84 years old and younger reported less perceived importance of family involvement compared to the residents 85 years or older. Health characteristics, including malnutrition and continence issues, varied notably with the level of importance residents assigned to family involvement, indicating a correlation between family engagement and health outcomes.
Differences in health conditions and functionality, such as ADL impairments, were observed across categories of perceived importance of family involvement. Residents who reported family involvement as ‘Very Important’ were more likely to have moderate to severe ADL impairments compared to those in other categories. Specifically, 85% of residents in the ‘Very Important’ group had moderate to severe ADL impairments, compared to 72% in the ‘Not Important at All’ group (Table 1). This highlights that residents with greater functional impairments may perceive family involvement as more important in their care planning.
Therapy Administration
Residents rating family involvement as ‘Very Important’ received the highest mean individual minutes of physical therapy (247 minutes) and occupational therapy (236 minutes), whereas the ‘Important, but no choice’ group reported the least (222 minutes of physical therapy and 215 minutes of occupational therapy) (Table 2). Despite these differences in individual therapy minutes, the mean number of group and concurrent minutes remained similar across all categories, averaging 3 minutes of group therapy and 5 minutes of concurrent therapy. In general, residents who preferred higher family involvement received more therapy across all categories—including overall therapy minutes and within subgroups such as those with hip fractures, stroke or traumatic brain injuries, and moderate to severe cognitive impairments (Table 2). These patterns suggest a consistent trend linking higher perceived importance of family involvement with greater therapy exposure, even when therapy day counts remain largely unchanged across groups.
Table 2.
Therapy Administered to Nursing Home Residents According to Varying Degrees of Self-Reported or Family-Reported Family Involvement, US Nursing Home Residents From 2019
| Importance of Family Involvement in Care Planning | |||||
|---|---|---|---|---|---|
| Characteristics | Very Important (N=1,722,481) | Somewhat Important (N = 263,541) | Not Very Important (N = 91,336) | Not Important at All (N = 31,374) | Important, but No Choice (N = 3,598) |
| Physical Therapy Administered (In past 7 days) | Mean (St. Dev) | ||||
| Mean of Individual Minutes (St. Dev) | 247 (106) | 242 (110) | 235 (112) | 229 (117) | 222 (114) |
| Mean of Group Minutes (St. Dev) | 3 (14) | 3 (13) | 3 (14) | 3 (14) | 2 (14) |
| Mean of Concurrent Minutes (St. Dev) | 5 (26) | 5 (22) | 5 (24) | 5 (22) | 4 (20) |
| Occupational Therapy Administered (In past 7 days) | Mean (St. Dev) | ||||
| Mean of Individual Minutes (St. Dev) | 236 (102) | 230 (105) | 225 (108) | 218 (111) | 215 (110) |
| Mean of Group Minutes (St. Dev) | 3 (14) | 3 (13) | 3 (14) | 3 (14) | 2 (11) |
| Mean of Concurrent Minutes (St. Dev) | 5 (22) | 5 (20) | 4 (20) | 4 (19) | 4 (19) |
| Combined Physical and Occupational Minutes * | Mean (St. Dev) | ||||
| Overall | 498 (191) | 487 (198) | 475 (205) | 461 (213) | 449 (211) |
| With Hip Fracture | 527 (180) | 520 (181) | 514 (182) | 516 (201) | 485 (195) |
| With Stroke or Traumatic Brain Injury | 476 (183) | 463 (189) | 451 (196) | 442 (213) | 425 (197) |
| With Moderate to Severe Cognitive Impairment | 460 (188) | 448 (197) | 436 (208) | 418 (208) | 411 (204) |
Combined PT/OT minutes include recorded individual, group, and concurrent minutes for either PT or OT in the past 7 days.
Trends in Therapy Minutes Across Resident Subgroups
The unadjusted and multivariable analyses consistently showed that residents received fewer therapy minutes as the reported importance of family involvement decreased. Residents in the ‘Somewhat Important’ category received 6 fewer minutes unadjusted and 5 fewer minutes adjusted compared to those in the ‘Very Important’ group, with these differences persisting, albeit attenuated, after adjustment for potential confounders (Table 3). Subgroup analyses revealed less pronounced differences in therapy minutes among residents with a history of hip fracture, particularly in the ‘Somewhat Important’ (adjusted: −5 [95% CI: −7, −2]) and ‘Not very Important’ (adjusted: −8 [95% CI: −12, −4]) categories. Conversely, residents with stroke or traumatic brain injury saw larger differences in therapy minutes as family involvement diminished, with the most significant drops in the ‘Not Important at All’ (adjusted: −19 [95% CI: −26, −11]) and ‘Important, but no choice’ (adjusted: −19 [95% CI: −38, 0]) categories. For residents with moderate to severe cognitive impairment, the trend closely followed the overall pattern observed in the full sample, with adjusted differences ranging from −5 to −21 minutes across categories of declining perceived family involvement (Table 3).
Table 3.
Family Involvement and Combined Physical and Occupational Therapy Minutes, US Nursing Home Residents From 2019
| Family Involvement Categories | Mean Difference (95% CI) | |
|---|---|---|
| Overall | Unadjusted | Adjusted* |
| Very Important | Referent | Referent |
| Somewhat Important | −6 (−7 to −5) | −5 (−6 to −4) |
| Not Very Important | −11 (−12 to −9) | −9 (−10 to −8) |
| Not Important at All | −18 (−21 to −16) | −15 (−18 to −13) |
| Important, but No Choice | −27 (−33 to −20) | −21 (−27 to −15) |
| By Subgroup | ||
| Hip-Fracture History | ||
| Very Important | Referent | Referent |
| Somewhat Important | −4 (−7 to −2) | −5 (−7 to −2) |
| Not Very Important | −7 (−11 to −3) | −8 (−12 to −4) |
| Not Important at All | −6 (−14 to 2) | −5 (−13 to 3) |
| Important, but No Choice | −30 (−50 to −9) | −24 (−44 to −3) |
| Stroke/TBI | ||
| Very Important | Referent | Referent |
| Somewhat Important | −7 (−10 to −5) | −8 (−11 to −5) |
| Not Very Important | −15 (−19 to −11) | −14 (−18 to −10) |
| Not Important at All | −21 (−29 to −14) | −19 (−26 to −11) |
| Important, but No Choice | −30 (−50 to −11) | −19 (−38 to 0) |
| Moderate to high cognitive impairment | ||
| Very Important | Referent | Referent |
| Somewhat Important | −6 (−7 to −5) | −5 (−6 to −4) |
| Not Very Important | −11 (−12 to −9) | −9 (−10 to −8) |
| Not Important at All | −18 (−21 to −16) | −15 (−18 to −13) |
| Important, but No Choice | −27 (−33 to −20) | −21 (−27 to −15) |
Adjusted for age, sex, race/ethnicity, cognitive and functional impairment, frailty, urinary incontinence, and facility clustering (GEE).
Discussion:
Family Involvement and Therapy in Nursing Homes
Our study found an inverse relationship between the extent of family involvement and the allocation of therapy minutes. After adjusting for the confounders, residents reporting ‘Very Important’ family involvement received more individual therapy minutes than residents reporting family involvement as “Not Very Important” or “Not Important at all”. The clinical relevance of the differences in therapy minutes observed by resident’s perception of family involvement is unclear. Regardless, our findings may suggest that engaged family members influence therapy administration. The observed decline in therapy minutes with decreasing family involvement may reflect on the broader issues of communication barriers and resident advocacy within the nursing home setting. Family members often act as intermediaries between residents and healthcare providers, facilitating better-personalized care28,29. Without this advocacy, residents may not receive care that is as closely aligned with their personal needs and preferences, which could explain our findings. This is especially relevant given the demographic trends toward an increasingly aged population, where personalized care becomes even more critical to the maintenance of independence and quality of life29,30. Family members play a crucial role in the care of nursing home residents, bringing a deep understanding of the resident’s history, values, and preferences based on their relationship before admission. This intimate knowledge underscores the importance of amplifying the role of families in the care provided in nursing homes28–30.
Our study observed that the desire for family involvement increased with age among nursing home residents. This trend may be partly due to the heightened risk of cognitive decline associated with aging in such settings31. As residents’ decision-making capacities diminish, the role of family members in care planning gains importance. Consequently, a stronger desire for family involvement may lead to more active family advocacy, which aligns with our observation of a dose-response reduction in therapy minutes correlating with the decreasing importance residents placed on family involvement. The lowest therapy minutes were noted in the group that valued family involvement but found it unfeasible, likely due to the absence of family advocates. These findings echo prior research, highlighting how therapy staffing and care approaches in nursing homes are shaped by family engagement32.
Study Strengths and Limitations
The study’s strengths are grounded in its utilization of national Minimum Data Set (MDS) 3.0 assessments, which provide a comprehensive and standardized evaluation of nursing home residents, ensuring a broad and representative sample that enhances the generalizability of the findings. The involvement of diverse healthcare professionals in data collection offers a thorough and multidimensional portrayal of each resident’s health status. The methodological rigor is further supported by using robust statistical methods, including linear regression and careful confounder selection, which solidify the reliability of the analyses.
The exclusion of certain resident groups could limit the applicability of the findings to the broader nursing home population. There is potential for subjective bias in self-reported measures of family involvement. Resident’s preference for family involvement is not a direct measurement of family involvement in care planning which can lead to non-differential misclassification, potentially biasing the results toward the null. Furthermore, the cross-sectional design of the MDS assessments precludes causal inferences, and the systematic exclusion of residents with missing data might introduce selection bias.
Conclusions and Implications:
The findings of this study, combined with observed increases in physician engagement for residents who highly value family involvement, highlight the critical need for healthcare policies that encourage family participation in care planning. Furthermore, increased emphasis on the importance of designated advocates for residents without the benefit of family involvement may be warranted. This is especially important in developing personalized care strategies and ensuring comprehensive medical oversight. For instance, family members have been shown to play a crucial role in advocating for timely rehabilitative interventions after events such as strokes or hip fractures. These conditions often require significant coordination between healthcare providers and caregivers to optimize outcomes. Similarly, in conditions like advanced dementia, where communication barriers limit residents’ ability to advocate for themselves, family involvement ensures that care plans reflect the resident’s needs and preferences. By engaging families in decision-making, facilities can enhance not only therapy adherence but also overall resident satisfaction and quality of life. Healthcare providers can empower family caregivers, providing them with tools and knowledge to improve care outcomes. This two-way relationship between families and healthcare professionals is fundamental to the success of family-centered care programs, underscoring the need for policies and practices that promote family involvement, ultimately contributing to better quality of care, resident satisfaction, and overall health outcomes33–35.
In conclusion, this study identifies a potentially important role of the perceived importance of family involvement in the care planning of nursing home residents and its association with the administration of rehabilitative therapies. While the research underscores the potential benefits of family engagement, it also points to the necessity of ensuring equitable care for those without family involvement. As the aging population grows and the dynamics of care evolve, recognizing the value of family presence in the care continuum is paramount. Future research should aim to explore the causal pathways of these associations and develop interventions to bolster family engagement in care planning. The goal should be to harness the power of family involvement to enhance the quality and effectiveness of care for all nursing home residents.
Funding Resources:
This study was funded by National Institute of Health grants to Dr. Lapane (1R01AG071692, T32GM135701). The funding sponsors had no role in designing, writing, or reviewing this work.
Footnotes
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Conflicts of Interest: The authors declare no conflicts of interest.
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