Training and Research Inc

Scotts Valley, CA, United States

Training and Research Inc

Scotts Valley, CA, United States
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Aldridge M.D.,Mount Sinai School of Medicine | Schlesinger M.,Yale University | Morrison R.S.,Mount Sinai School of Medicine | Morrison R.S.,Geriatric Research | And 3 more authors.
JAMA Internal Medicine | Year: 2014

IMPORTANCE The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery. OBJECTIVE To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States. EXPOSURES For-profit or nonprofit hospice ownership. MAIN OUTCOMES AND MEASURES Provision of community benefits; setting and timing of the hospice population served; and community outreach. RESULTS A total of 591 hospices completed our survey (84%response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55%vs 82%; adjusted relative risk [ARR], 0.67 [95%CI, 0.59-0.76]), conducting research (18%vs 23%; ARR, 0.67 [95%CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95%CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare's aggregate annual cap (22%vs 4%; ARR, 3.66 [95%CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P < .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61%vs 46%; ARR, 1.23 [95%CI, 1.05-1.44]) and minority communities (59%vs 48%; ARR, 1.18 [95%CI, 1.02-1.38]) and less likely to partner with oncology centers (25%vs 33%; ARR, 0.59 [95%CI, 0.44-0.80]). CONCLUSIONS AND RELEVANCE Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare's aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase. Copyright © 2014 American Medical Association. All rights reserved.


Dain A.S.,Mount Sinai School of Medicine | Hurzeler R.,Training and Research Inc. | Aldridge M.D.,Mount Sinai School of Medicine
Journal of Pain and Symptom Management | Year: 2015

Context Complementary and alternative medicine (CAM) provides clinical benefits to hospice patients, including decreased pain and improved quality of life. Yet little is known about the extent to which U.S. hospices employ CAM therapists. Objectives To report the most recent national data regarding the inclusion of art, massage, and music therapists on hospice interdisciplinary teams and how CAM therapist staffing varies by hospice characteristics. Methods A national cross-sectional survey of a random sample of hospices (n = 591; 84% response rate) from September 2008 to November 2009. Results Twenty-nine percent of hospices (169 of 591) reported employing an art, massage, or music therapist. Of those hospices, 74% employed a massage therapist, 53% a music therapist, and 22% an art therapist, and 42% expected the therapist to attend interdisciplinary staff meetings, indicating a significant role for these therapists on the patient's care team. In adjusted analyses, larger hospices compared with smaller hospices had significantly higher odds of employing a CAM therapist (adjusted odds ratio 6.38; 95% CI 3.40, 11.99) and for-profit hospices had lower odds of employing a CAM therapist compared with nonprofit hospices (adjusted odds ratio 0.52; 95% CI 0.32, 0.85). Forty-four percent of hospices in the Mountain/Pacific region reported employing a CAM therapist vs. 17% in the South Central region. Conclusion Less than one-third of U.S. hospices employ art, massage, or music therapists despite the benefits these services may provide to patients and families. A higher proportion of large hospices, nonprofit hospices, and hospices in the Mountain/Pacific region employ CAM therapists, indicating differential access to these important services.


PubMed | Training and Research Inc. and Mount Sinai School of Medicine
Type: Journal Article | Journal: Journal of pain and symptom management | Year: 2015

Complementary and alternative medicine (CAM) provides clinical benefits to hospice patients, including decreased pain and improved quality of life. Yet little is known about the extent to which U.S. hospices employ CAM therapists.To report the most recent national data regarding the inclusion of art, massage, and music therapists on hospice interdisciplinary teams and how CAM therapist staffing varies by hospice characteristics.A national cross-sectional survey of a random sample of hospices (n=591; 84% response rate) from September 2008 to November2009.Twenty-nine percent of hospices (169 of 591) reported employing an art, massage, or music therapist. Of those hospices, 74% employed a massage therapist, 53% a music therapist, and 22% an art therapist, and 42% expected the therapist to attend interdisciplinary staff meetings, indicating a significant role for these therapists on the patients care team. In adjusted analyses, larger hospices compared with smaller hospices had significantly higher odds of employing a CAM therapist (adjusted odds ratio 6.38; 95% CI 3.40, 11.99) and for-profit hospices had lower odds of employing a CAM therapist compared with nonprofit hospices (adjusted odds ratio 0.52; 95% CI 0.32, 0.85). Forty-four percent of hospices in the Mountain/Pacific region reported employing a CAM therapist vs. 17% in the South Central region.Less than one-third of U.S. hospices employ art, massage, or music therapists despite the benefits these services may provide to patients and families. A higher proportion of large hospices, nonprofit hospices, and hospices in the Mountain/Pacific region employ CAM therapists, indicating differential access to these important services.


PubMed | Repace Associates Inc., Stanford University, Win River Resort &amp; Casino, Buchting Consulting and 3 more.
Type: Journal Article | Journal: International journal of environmental research and public health | Year: 2016

Most casinos owned by sovereign American Indian nations allow smoking, even in U.S. states such as California where state laws restrict workplace smoking. Collaborations between casinos and public health workers are needed to promote smoke-free policies that protect workers and patrons from secondhand tobacco smoke (SHS) exposure and risks. Over seven years, a coalition of public health professionals provided technical assistance to the Redding Rancheria tribe in Redding, California in establishing a smoke-free policy at the Win-River Resort and Casino. The coalition provided information to the casino general manager that included site-specific measurement of employee and visitor PM2.5 personal exposure, area concentrations of airborne nicotine and PM2.5, visitor urinary cotinine, and patron and staff opinions (surveys, focus groups, and a Town Hall meeting). The manager communicated results to tribal membership, including evidence of high SHS exposures and support for a smoke-free policy. Subsequently, in concert with hotel expansion, the Redding Rancheria Tribal Council voted to accept a 100% restriction of smoking inside the casino, whereupon PM2.5 exposure in main smoking areas dropped by 98%. A 70% partial-smoke-free policy was instituted ~1 year later in the face of revenue loss. The success of the collaboration in promoting a smoke-free policy, and the key element of air quality feedback, which appeared to be a central driver, may provide a model for similar efforts.


Jiang R.-T.,Stanford University | Acevedo-Bolton V.,Stanford University | Cheng K.-C.,Stanford University | Klepeis N.E.,Stanford University | And 4 more authors.
Journal of Environmental Monitoring | Year: 2011

The amount of light scattered by airborne particles inside an aerosol photometer will vary not only with the mass concentration, but also with particle properties such as size, shape, and composition. This study conducted controlled experiments to compare the measurements of a real-time photometer, the SidePak™ AM510 monitor (SidePak), with gravimetric mass. PM sources tested were outdoor aerosols, and four indoor combustion sources: cigarettes, incense, wood chips, and toasting bread. The calibration factor for rescaling the SidePak measurements to agree with gravimetric mass was similar for the cigarette and incense sources, but different for burning wood chips and toasting bread. The calibration factors for ambient urban aerosols differed substantially from day to day, due to variations in the sources and composition of outdoor PM. A field evaluation inside a casino with active smokers yielded calibration factors consistent with those obtained in the controlled experiments with cigarette smoke. © The Royal Society of Chemistry.


Wang S.-Y.,Yale University | Aldridge M.D.,Mount Sinai School of Medicine | Aldridge M.D.,James ters Va Medical Center | Gross C.P.,Yale University | And 4 more authors.
Journal of Palliative Medicine | Year: 2015

Background: Little is known about state-level variation in patterns of hospice use, an important indicator of quality of care at the end of life. Findings may identify states where targeted efforts for improving end-of-life care may be warranted. Objective: Our aim was to characterize the state-level variation in patterns of hospice use among decedents and to examine state, county, and individual factors associated with these patterns. Methods: We conducted a retrospective analysis of Medicare fee-for-service decedents. The primary outcome measures were state-level hospice use during the last 6 months of life and the state's proportion of hospice users with very short hospice enrollment (≤7 days), very long hospice enrollment (≥180 days), and hospice disenrollment prior to death. Results: In 2011, the percentage of decedents who used hospice in the last 6 months of life nationally was 47.1%, and varied across states from 20.3% in Alaska to 60.8% in Utah. Hospice utilization patterns also varied by state, with the percentage of hospice users with very short hospice enrollment ranging from 23.0% in the District of Columbia to 39.9% in Connecticut. The percentage of very long hospice use varied from 5.7% in Connecticut to 15.9% in Delaware. The percentage of hospice disenrollment ranged from 6.2% in Hawaii to 19.0% in the District of Columbia. Nationally, state-level hospice use among decedents was positively correlated with the percentage of potentially concerning patterns (including very short hospice enrollment, very long hospice enrollment, and hospice disenrollment) among hospice users (the Pearson correlation coefficient=0.52, p value<0.001). Oregon was the only state in the highest quartile of hospice use and the lowest quartiles of both very short and very long hospice enrollment. Conclusions: The percentage of decedents who use hospice may mask important state-level variation in these patterns, including the timing of hospice enrollment, a potentially important component of the quality of end-of-life care. © Copyright 2015, Mary Ann Liebert, Inc. 2015.


Nearly all California casinos currently allow smoking, which leads to potentially high patron exposure to secondhand tobacco smoke pollutants. Some argue that smoking restrictions or bans would result in a business drop, assuming > 50% of patrons smoke. Evidence in Nevada and responses from the 2008 California tobacco survey refute this assertion. The present study investigates the proportion of active smokers in southern California tribal casinos, as well as occupancy and PM(2.5) levels in smoking and nonsmoking sections. We measured active-smoker and total-patron counts during Friday or Saturday night visits (two per casino) to smoking and nonsmoking gaming areas inside 11 southern California casinos. We counted slot machines and table games in each section, deriving theoretical maximum capacities and occupancy rates. We also measured PM(2.5) concentrations (or used published levels) in both nonsmoking and smoking areas. Excluding one casino visit with extremely high occupancy, we counted 24,970 patrons during 21 casino visits of whom 1,737 were actively smoking, for an overall active- smoker proportion of 7.0% and a small range of ~5% across casino visits (minimum of 5% and maximum of 10%). The differences in mean inter-casino active-smoker proportions were not statistically significant. Derived occupancy rates were 24% to 215% in the main (low-stakes) smoking-allowed slot or table areas. No relationship was found between observed active-smoker proportions and occupancy rate. The derived maximum capacities of nonsmoking areas were 1% to 29% of the overall casino capacity (most under 10%) and their observed occupancies were 0.1 to over 3 times that of the main smoking-allowed casino areas. Seven of twelve visits to nonsmoking areas with no separation had occupancy rates greater than main smoking areas. Unenclosed nonsmoking areas don't substantially protect occupants from PM2.5 exposure. Nonsmoking areas encapsulated inside smoking areas or in a separate, but unenclosed, area had PM(2.5) levels that were 10 to 60 μg/m(3) and 6 to 23 μg/m(3) higher than outdoor levels, respectively, indicating contamination from smoking. Although fewer than roughly 10% of casino patrons are actively smoking on average, these individuals substantially increase PM(2.5) exposure for all patrons in smoking and unenclosed nonsmoking areas. Nonsmoking areas may be too inconvenient, small, or undesirable to serve a substantial number of nonsmoking patrons. Imposing indoor smoking bans, or contained smoking areas with a maximum capacity of up to 10% of the total patronage, would offer protection from PM2.5 exposures for nonsmoking patrons and reduce employee exposures.


Wang S.-Y.,Yale University | Aldridge M.D.,Mount Sinai School of Medicine | Aldridge M.D.,James ters Veterans Affairs Medical Center | Gross C.P.,Yale University | And 4 more authors.
Journal of the American Geriatrics Society | Year: 2016

Objectives To characterize the number and types of care transitions in the last 6 months of life of individuals who used hospice and to examine factors associated with having multiple transitions in care. Design Retrospective cohort study. Setting One hundred percent fee-for-service Medicare decedent claims data. Participants Medicare beneficiaries aged 66 and older who died between July 1, 2011, and December 31, 2011, and were enrolled in hospice at some time during the last 6 months of life. Measurements Hierarchical generalized linear modeling was used to identify individual, hospice, and regional factors associated with transitions. The sequence of transitions across healthcare settings was described. Healthcare transitions after hospice enrollment included from and to the hospital, skilled nursing facility, home health agency program, hospice, or home without receiving any service in these four healthcare settings. Results Of 311,090 hospice decedents, 31,675 (10.2%) had at least one transition after hospice enrollment, and this varied substantially across the United States; 6.6% of all decedents had more than one transition in care after hospice enrollment (range 2-19 transitions). Of hospice users with transitions, 53.4% were admitted to hospitals, 17.7% were admitted to skilled nursing facilities, 9.6% used home health agencies, and 25.8% had transitions to home without receiving the services from the healthcare settings examined. In adjusted analyses, decedents who were younger, nonwhite, enrolled in a for-profit or small hospice program, or had less access to hospital-based palliative care had significantly higher odds of having at least one transition. Conclusion A notable proportion of hospice users experience at least one transition in care in the last 6 months of life, suggesting that further research on the effect of transitions on users and families is warranted. © 2016, The American Geriatrics Society.


Cherlin E.J.,Yale University | Carlson M.D.A.,Mount Sinai School of Medicine | Herrin J.,Yale University | Schulman-Green D.,Yale University | And 4 more authors.
Journal of Palliative Medicine | Year: 2010

Background: Interdisciplinary care is fundamental to the hospice philosophy and is a key component of high-quality hospice care. However, little is known about how hospices differ in their interdisciplinary staffing patterns, particularly across nonprofit and for-profit hospices. The purpose of this study was to examine potential differences in the staffing patterns of for-profit and nonprofit hospices. Subjects and design: Using the 2006 Medicare Provider of Services (POS) survey, we conducted a cross-sectional analysis of staffing patterns within Medicare-certified hospices operating in the United States in 2006. In bivariate and multivariable analyses, we examined differences in staffing patterns measured by the existence of a full range of interdisciplinary staff (defined as having at least 1 full-time equivalent (FTE) staff in each of 4 disciplines ascertained by the survey: physician, nursing, psychosocial, and home health aide) and by the professional mix of staff within each discipline. Results: For-profit hospices had a winder range of paid staff but there were no differences by ownerships when volunteer staff were included. For-profit hospices had significantly fewer registered nurse FTEs as a proportion of nursing staff, fewer medical social worker FTEs as a proportion of psychosocial staff, and fewer clinician FTEs as a proportion of total staff (p values <0.05). Compared to nonprofit hospices, for-profit and government-owned hospices also used proportionally fewer volunteer FTEs. Conclusions: Hospice staffing patterns differed significantly by ownership type. Future research should evaluate the impact of these differences on quality of care and satisfaction among patients and families using hospice. © Mary Ann Liebert, Inc.


PubMed | Training and Research Inc., Yale University and Mount Sinai School of Medicine
Type: Journal Article | Journal: Journal of the American Geriatrics Society | Year: 2016

To characterize the number and types of care transitions in the last 6 months of life of individuals who used hospice and to examine factors associated with having multiple transitions in care.Retrospective cohort study.One hundred percent fee-for-service Medicare decedent claims data.Medicare beneficiaries aged 66 and older who died between July 1, 2011, and December 31, 2011, and were enrolled in hospice at some time during the last 6 months of life.Hierarchical generalized linear modeling was used to identify individual, hospice, and regional factors associated with transitions. The sequence of transitions across healthcare settings was described. Healthcare transitions after hospice enrollment included from and to the hospital, skilled nursing facility, home health agency program, hospice, or home without receiving any service in these four healthcare settings.Of 311,090 hospice decedents, 31,675 (10.2%) had at least one transition after hospice enrollment, and this varied substantially across the United States; 6.6% of all decedents had more than one transition in care after hospice enrollment (range 2-19 transitions). Of hospice users with transitions, 53.4% were admitted to hospitals, 17.7% were admitted to skilled nursing facilities, 9.6% used home health agencies, and 25.8% had transitions to home without receiving the services from the healthcare settings examined. In adjusted analyses, decedents who were younger, nonwhite, enrolled in a for-profit or small hospice program, or had less access to hospital-based palliative care had significantly higher odds of having at least one transition.A notable proportion of hospice users experience at least one transition in care in the last 6 months of life, suggesting that further research on the effect of transitions on users and families is warranted.

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