University of Southern California
University of Southern California
Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Natalie Leland PhD, OTR/L, BCG, FAOTA

Natalie Leland

Associate Professor, joint appointment with the USC Davis School of Gerontology

Room: CHP 133
(323) 442-1307
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Natalie Leland is an outstanding researcher in gerontology with a focus on improving post-acute care services for older adults. Dr. Leland received her BS degree in Occupational Therapy from the University of New Hampshire and her MS and PhD degrees in Gerontology from the University of Massachusetts Boston. She completed a postdoctoral fellowship at the Center for Gerontology and Health Care Research at Brown University. Dr. Leland has extensive geriatric clinical experience in a variety of rehabilitation settings.
She has joint faculty appointments in the USC Chan Division of Occupational Science and Occupational Therapy and the USC Davis School of Gerontology. Dr. Leland holds leadership positions both within occupational therapy and within the broader discipline of gerontology. She was President of the Rhode Island Occupational Therapy Association, currently serves on the Board for Advanced and Specialty Certification (BASC) for the American Occupational Therapy Association (AOTA) and is on the Emerging Scholar and Professional Organization (ESPO) Executive Committee for the Gerontological Society of America (GSA). She was named to the AOTA Roster of Fellows in 2012.
Dr. Leland's recent scholarship includes the American Occupational Therapy Association's newly released "Occupational Therapy Practice Guidelines for Productive Aging for Community-Dwelling Older Adults" and trends in access and outcomes of post-acute care for patients post-hip fracture surgery. She has received international attention for her work on falls among new-admitted nursing home patients. She is expert in the use of large administrative datasets, longitudinal data analysis and geographic variation in rehabilitation services. Dr. Leland has received funding from the Agency for Healthcare Research and Quality (AHRQ) as a T32 Postdoctoral Research Fellow and Rehabilitation Research Career Development (RRDC) Program (#5T32HS000011, P.I. Vincent Mor, PhD), and from the National Center for Medical Rehabilitation Research (NICHD) as a K12 Rehabilitation Research Career Development Program Scholar (K12 HD055929, P.I. Kenneth Ottenbacher, PhD, OTR).

Research Interests

Dr. Leland's research is focused on understanding and improving post-acute care quality for older adults and with a particular interest in how occupational therapy can contribute to fall prevention. Dr. Leland is an expert in secondary data analysis and evaluating the impact of health services on quality of care for older adults in post-acute settings.


Postdoctoral Fellowship
2011 | Brown University, Center for Gerontology and Health Care Research

Doctor of Philosophy (PhD) in Gerontology
2009 | University Massachusetts Boston

Master of Science (MS) in Gerontology
2006 | University Massachusetts Boston

Bachelor of Science (BS) in Occupational Therapy
2000 | University of New Hampshire



Leland, N. E., Elliott, S. J., & Johnson, K. J. (2012). Occupational therapy practice guidelines for productive aging for community-dwelling older adults. Bethesda, MD: AOTA Press. Full text Show abstractHide abstract

GUIDELINE OBJECTIVES: To help occupational therapists and occupational therapy assistants, as well as the people who manage, reimburse, or set policy regarding occupational therapy services, to understand the contribution of occupational therapy in treating community-living older adults to facilitate productive aging.
To serve as a reference for health care professionals, health care facility managers, education and health care regulators, third-party payers, and managed care organizations to assist in understanding the role of occupational therapy services in the community.

Journal Articles

Fogelberg, D. J., Leland, N. E., Blanchard, J., Rich, T. J., & Clark, F. A. (2017). Qualitative experience of sleep in individuals with spinal cord injury. OTJR: Occupation, Participation and Health, 37, 89-97. Show abstractHide abstract

Poor sleep contributes to adverse health outcomes making it important to understand sleep in medically vulnerable populations, including those with spinal cord injury (SCI). However, little attention has been paid to circumstances specific to SCI that may negatively affect sleep, or to consequences of poor sleep in this population. The objective of this study was to examine the experience of sleep among individuals with SCI. Secondary analysis using thematic coding of qualitative data from an ethnographic study of community-dwelling adults with SCI was conducted. Sleep-related data were found in transcripts for 90% of the sample. Participants described diminished sleep duration and irregular sleep patterns. Several factors contributing to poor sleep were identified, including SCI-related circumstances and sleep environment. Participants also discussed how poor sleep affected occupational engagement. This study highlights the extent of sleep disturbance experienced after SCI and the subsequent impact on occupational performance, and provides direction for clinical practice.

Leland, N. E., Lepore, M., Wong, C., Chang, S. H., Freeman, L., Crum, K., Gillies, H., & Nash, P. (2017). Delivering high quality hip fracture rehabilitation: The perspective of occupational and physical therapy practitioners. Disability and Rehabilitation. Advance online publication. Show abstractHide abstract

AIM: The majority of post-acute hip fracture rehabilitation in the US is delivered in skilled nursing facilities (SNFs). Currently, there are limited guidelines that equip occupational and physical therapy practitioners with a summary of what constitutes evidence-based high quality rehabilitation. Thus, this study aimed to identify rehabilitation practitioners' perspectives on the practices that constitute high quality hip fracture rehabilitation.
METHODS: Focus groups were conducted with 99 occupational and physical therapy practitioners working in SNFs in southern California. Purposive sampling of facilities was conducted to capture variation in key characteristics known to impact care delivery for this patient population (e.g., financial resources, staffing, and patient case-mix). Questions aimed to elicit practitioners' perspectives on high quality hip fracture rehabilitation practices. Each session was audio-recorded and transcribed. Data were systematically analyzed using a modified grounded theory approach.
RESULTS: Seven themes emerged: objectives of care; first 72?h; positioning, pain, and precautions; use of standardized assessments; episode of care practices; facilitating insight into progress; and interdisciplinary collaboration.
CONCLUSIONS: Clinical guidelines are critical tools to facilitate clinical decision-making and achieve desired patient outcomes. The findings of this study highlight the practitioners' perspective on what constitutes high quality hip fracture rehabilitation. This work provides critical information to advance the development of stakeholder-driven rehabilitation clinical guidelines. Future research is needed to verify the findings from other stakeholders (e.g., patients), ensure the alignment of our findings with current evidence, and develop measures for evaluating their delivery and relationship to desired outcomes. Implications for Rehabilitation This study highlights occupational and physiotherapy therapy practitioners' perspectives on the cumulative best practices that reflect high quality care, which should be delivered during hip fracture rehabilitation. While this study was limited to two professions within the broader interdisciplinary team, consistently occupational and physiotherapy therapy practitioners situated their role and practices within the team, emphasizing that high quality care was driven by collaboration among all members of the team as well as the patient and caregivers. Future research needs to evaluate the (a) frequency at which these practices are delivered and the relationship to patient-centered outcomes, and (b) perspectives of rehabilitation practitioners working in other PAC settings, patients, caregivers, as well as the other members of the interdisciplinary PAC team.

Kim, L. H., & Leland, N. E. (2017). Rehabilitation practitioners' prioritized care processes in hip fracture post-acute care. Physical & Occupational Therapy in Geriatrics. Advance online publication. Show abstractHide abstract

AIMS: Occupational and physical therapy in post-acute care (PAC) has reached the point where quality indicators for hip fracture are needed. This study characterizes the practitioners' prioritized hip fracture rehabilitation practices, which can guide future quality improvement initiatives.
METHODS: Ninety-two practitioners participating in a parent mixed methods study were asked to rank a series of evidence-based best practices across five clinical domains (assessment, intervention, discharge planning, caregiver training, and patient education).
RESULTS: Prioritized practices reflected patient-practitioner collaboration, facilitating an effective discharge, and preventing adverse events. The highest endorsed care processes include: developing meaningful goals with patient input (84%) in assessment, using assistive devices in intervention (75%) and patient education (65%), engaging the patient and caregiver (50%) in discharge planning, and fall prevention (60%) in caregiver education.
CONCLUSIONS: Practitioners identified key care priorities. This study lays the foundation for future work evaluating the extent to which these practices are delivered in PAC.

Wong, C., & Leland, N. E. (2016). Non-pharmacological approaches to reducing negative behavioral symptoms: A scoping review. OTJR: Occupation, Participation and Health, 36, 34-41. Show abstractHide abstract

The management of negative behavioral symptoms among residents with dementia is a challenge that nursing homes face in delivering quality care. This study examines evidence documenting non-pharmacological interventions that reduce negative behavioral symptoms among nursing home residents with dementia and the role occupational therapy practitioners have in this area. A scoping review was completed for intervention studies published from 1987 to 2014, targeting negative behavioral symptoms among nursing home residents above 60 years of age with dementia. Interventions were categorized based on the American Occupational Therapy Association (AOTA) Occupational Therapy Practice Framework. Twenty-two studies met the inclusion criteria. Four types of interventions were identified: occupation-based interventions, context and environment interventions, exercise interventions, and daily routine-based interventions. The non-pharmacological interventions were found to align with the scope of occupational therapy. This suggests that occupational therapy practitioners can contribute to the development and evaluation of non-pharmacological interventions aimed to reduce negative behavioral symptoms.

Leland, N. E., Fogelberg, D. J., Halle, A. D., & Mroz, T. M. (2016). Occupational therapy and management of multiple chronic conditions in the context of health care reform. American Journal of Occupational Therapy, 71, 7101090010p1-7101090010p6. Full text Show abstractHide abstract

One in four individuals living in the United States has multiple chronic conditions (MCCs), and the already high prevalence of MCCs continues to grow. This population has high rates of health care utilization yet poor outcomes, leading to elevated concerns about fragmented, low-quality care provided within the current health care system. Several national initiatives endeavor to improve care for the population with MCCs, and occupational therapy is uniquely positioned to contribute to these efforts for more efficient, effective, client-centered management of care. By integrating findings from the literature with current policy and practice, we aim to highlight the potential role for occupational therapy in managing MCCs within the evolving health care system.

Leland, N. E., Fogelberg, D., Sleight, A., Mallinson, T., Vigen, C., Blanchard, J., Carlson, M., & Clark, F. (2016). Napping and nighttime sleep: Findings from an occupation-based intervention. American Journal of Occupational Therapy, 70, 7004270010p1-7. Show abstractHide abstract

OBJECTIVE: To describe sleeping behaviors and trends over time among an ethnically diverse group of community-living older adults.
METHOD: A descriptive secondary data analysis of a subsample (n = 217) from the Lifestyle Redesign randomized controlled trial was done to explore baseline napping and sleeping patterns as well as 6-mo changes in these outcomes.
RESULTS: At baseline, the average time sleeping was 8.2 hr daily (standard deviation = 1.7). Among all participants, 29% reported daytime napping at baseline, of which 36% no longer napped at follow-up. Among participants who stopped napping, those who received an occupation-based intervention (n = 98) replaced napping time with nighttime sleep, and those not receiving an intervention (n = 119) experienced a net loss of total sleep (p < .05).
CONCLUSION: Among participants who stopped napping, the occupation-based intervention may be related to enhanced sleep. More research examining the role of occupation-based interventions in improving sleep is warranted.

Leland, N. E., Gozalo, P., Bynum, J., Mor, V., Christian, T. J., & Teno, J. M. (2015). What happens to patients when they fracture their hip during a skilled nursing facility stay? Journal of the American Medical Directors Association, 16, 767-774. Show abstractHide abstract

OBJECTIVES: To characterize outcomes of patients experiencing a fall and subsequent hip fracture while in a nursing home receiving skilled nursing facility (SNF) services.
DESIGN: Observational study.
PARTICIPANTS: Short-stay fee-for-service Medicare beneficiaries who experienced their first hip fracture during an SNF stay.
MEASUREMENTS: Outcomes measured in the 90 days after the hip fracture hospitalization included community discharge (with a stay in the community <30 days), successful community discharge (in the community ≥30 days), death, and institutionalization.
RESULTS: Between 1999 and 2007, 27,305 hip fractures occurred among short-stay nursing home patients receiving SNF care. After surgical repair of the hip fracture, 83.9% of these patients were discharged from the hospital back to an SNF, with most (99%) returning to the facility where the hip fracture occurred. In the first 90 days after hospitalization, 24.1% of patients died, 7.3% were discharged to the community but remained fewer than 30 days, 14.0% achieved successful community discharge, and 54.6% were still in a health care institution with almost 46.4% having transitioned to long-term care.
CONCLUSION: SNF care aims to maximize the short-stay patient's independence and facilitate a safe community transition. However, experiencing a fall and hip fracture during the SNF stay was a sentinel event that limited the achievement of this goal. There is an urgent need to ensure the integration of fall prevention into the patient's plan of care. Further, falls among SNF patients may serve as indicator of quality, which consumers and payers can use to make informed health care decisions.

Lepore, M., & Leland, N. E. (2015). Nursing homes that increased the proportion of Medicare days saw gains in quality outcomes for long-stay residents. Health Affairs, 34, 2121-2128. Show abstractHide abstract

Nursing homes are increasingly providing rehabilitative care to short-stay residents under Medicare's skilled nursing facility coverage, which is much more generous than Medicaid's coverage for long-stay residents. This shift creates the potential for both beneficial and detrimental effects on outcomes for such residents. Examining nationwide facility-level nursing home data for the period 2007-10, we found that increasing the proportion of Medicare-covered patient days in a nursing home was significantly associated with improvements in the quality of the three outcomes we considered for long-stay residents. We saw significant decreases in the percentages of long-stay residents with daily pain (from 5.1 percent to 3.4 percent), with worsening pressure ulcers (from 2.5 percent to 2.0 percent), and with a decline in performing activities of daily living (from 15.9 percent to 14.9 percent). These findings reinforce previous research indicating that quality outcomes tend to be superior in nursing homes with greater financial resources. They also bolster arguments for financial investments in nursing homes, including increases in Medicaid payment rates, to support better care for long-stay residents.

Leland, N. E., Gozalo, P., Christian, T. J., Bynum, J., Mor, V., Wetle, T. F., & Teno, J. M. (2015). An examination of the first 30 days after patients are discharged to the community from hip fracture postacute care. Medical Care, 53, 879-887. Show abstractHide abstract

BACKGROUND: Postacute care (PAC) rehabilitation aims to maximize independence and facilitate a safe community transition. Yet little is known about PAC patients' success in staying home after discharge or differences on this outcome across PAC providers.
OBJECTIVES: Examine the percentage of PAC patients who remain in the community at least 30 days after discharge (ie, successful community discharge) after hip fracture rehabilitation and describe differences among PAC facilities based on this outcome.
RESEARCH DESIGN: Retrospective observational study.
SUBJECTS: Community-dwelling, Medicare fee-for-service beneficiaries 75 years of age and above who experienced their first hip fracture between 1999 and 2007 (n=880,779). PAC facilities admitting hip fracture patients in 2006.
MEASURES: Successful community discharge, sites of readmission after PAC discharge.
RESULTS: Between 1999 and 2007, 57% of patients achieved successful community discharge. Black were less likely (adjusted odds ratios=0.84; 95% confidence interval, 0.82-0.86) than similar whites to achieve successful community discharge. Among all who reentered the community (n=581,095), 14% remained in the community <30 days. Acute hospitals (67.5%) and institutional PAC (16.8%) were the most common sites of reentry. The median proportion of successful community discharge among facilities was 49% (interquartile range, 33%-66%). Lowest-quartile facilities admitted older (85.9 vs. 84.1 y of age), sicker patients (eg, higher rates of hospital complications 6.0% vs. 4.6%), but admitted fewer annually (7.1 vs. 19.3), compared with the highest quartile.
CONCLUSIONS: Reentry into the health care system after PAC community discharge is common. Because of the distinct care needs of the PAC population there is a need for a quality measure that complements the current 30-day hospital readmission outcome and captures the objectives of PAC rehabilitation.

Gozalo, P., Leland, N. E., Christian, T. J., Mor, V., & Teno, J. M. (2015). Volume matters: Returning home after hip fracture. Journal of the American Geriatric Society, 63, 2043-2051. Show abstractHide abstract

OBJECTIVES: To examine the effect of the relationship between volume (number of hip fracture admissions during the 12 months before participant's fracture) and other facility characteristics on outcomes.
DESIGN: Prospective observational study.
SETTING: U.S. skilled nursing facilities (SNFs) admitting individuals discharged from the hospital after treatment for hip fracture between 2000 and 2007 (N = 15,439).
PARTICIPANTS: Community-dwelling fee-for-service Medi-care beneficiaries aged 75 and older admitted to U.S. hospitals for their first hip fracture and discharged to a SNF for postacute care from 2000 to 2007 (N = 512,967).
MEASUREMENTS: Successful discharge from SNF to community, defined as returning to the community within 30 days of hospital discharge to the SNF and remaining in the community without being institutionalized for at least 30 days, was examined using Medicare administrative data, propensity score matching, and instrumental variables.
RESULTS: The overall rate of successful discharge to the community was 31%. Of the 15,439 facilities, the facility interquartile range varied from 0% (25th percentile) to 42% (75th percentile). An important determinant of variation in discharge rate was SNF volume of hip fracture admissions. Unadjusted successful discharge from SNF to community was 43.7% in high-volume facilities (>24 admissions/year), versus 18.8% in low-volume facilities (1-6 admissions/year). This facility volume effect persisted after adjusting for participant and facility characteristics associated with outcomes (e.g., adjusted odds ratio = 2.06, 95% confidence interval = 1.91-2.21 for volume of 25 vs 3 admissions per year).
CONCLUSION: In community-dwelling persons with their first hip fracture, successful return to the community varies substantially according to SNF provider volume and staffing characteristics.

Mroz, T. M., Pitonyak, J. S., Fogelberg, D., & Leland, N. E. (2015). Client centeredness and health reform: Key issues for occupational therapy. American Journal of Occupational Therapy, 69, 6905090010p1-6905090010p8. Show abstractHide abstract

Health reform promotes the delivery of patient-centered care. Occupational therapy's rich history of client-centered theory and practice provides an opportunity for the profession to participate in the evolving discussion about how best to provide care that is truly patient centered. However, the growing emphasis on patient-centered care also poses challenges to occupational therapy's perspectives on client-centered care. We compare the conceptualizations of client-centered and patient-centered care and describe the current state of measurement of client-centered and patient-centered care. We then discuss implications for occupational therapy's research agenda, practice, and education within the context of patient-centered care, and propose next steps for the profession.

Martinez, J., & Leland, N. (2015). Language discordance and patient-centered care in occupational therapy: A case study. OTJR: Occupation, Participation and Health, 35, 120-128. Show abstractHide abstract

The accumulative burden of a growing non-English speaking minority population and health disparities in the United States demonstrate the urgency of examining occupational therapy practices and defining care that is timely, effective, safe, and patient-centered. In this context, we investigate an occupational therapy episode of care from the perspectives of patient, caregiver, and primary occupational therapy care provider. Treatment sessions were observed and one-on-one semistructured interviews were conducted with the participants. Several themes describing areas of concern in communication and care delivery emerged, including expectations for care, the therapy relationship, professional identity, and pragmatic constraints. The use of untrained interpreters compromised treatment effectiveness and safety. This case highlights potential areas of concern in therapy when working with a diverse patient population. Abundant opportunities exist for occupational therapy to situate itself as an equitable, responsive, valuable, and essential service.

Mallinson, T., & Leland, N. E. (2015). The need for uniform quality reporting across post-acute care rehabilitation settings: An examination of accidental falls. Journal of the American Geriatrics Society, 63, 195-197. Show abstractHide abstract

To the Editor: A fall during post-acute care (PAC) rehabilitation can limit an individual's ability to make functional gains and safely return home, two of the primary goals of rehabilitation services. Public reporting of falls, which are a Medicare "Never Event," is not mandated in all PAC rehabilitation settings. Consequently, little is known about the similarities or differences in the occurrence of this adverse event and its risk factors in these settings. Thus, stakeholders do not have important information necessary to make informed decisions about PAC service use. This study used a unique dataset to examine variations in accidental falls and risk factors between individuals in PAC receiving rehabilitation services in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home health agencies (HHAs).

Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2015). Advancing the value and quality of occupational therapy in health service delivery. American Journal of Occupational Therapy, 69, 6901090010p1-6901090010p7.

Mallinson, T., Schepens Niemiec, S. L., Carlson, M., Leland, N., Vigen, C., Blanchard, J., & Clark, F. (2014). Development and validation of the activity significance personal evaluation (ASPEn) scale. Australian Occupational Therapy Journal, 61, 384-393. Show abstractHide abstract

BACKGROUND/AIM: Engagement in desired occupations can promote health and wellbeing in older adults. Assessments of engagement often measure frequency, amount or importance of specific activities. This study aimed to develop a scale to measure older adults' evaluation of the extent to which their everyday activities are contributing to their health and wellness.
METHODS: Eighteen items, each scored with a seven-point rating scale, were initially developed by content experts, covering perceptions of how daily activities contribute to physical and mental health, as well as satisfaction and activity participation in the last six months. Rasch analysis methods were used to refine the scale using the pencil and paper responses of 460 community-living older adults.
RESULTS: Initial Rasch analysis indicated three unlabelled rating scale categories were seldom used, reducing measurement precision. Five items were conceptually different by misfit statistics and principal component analysis. Subsequently, those items were removed and the number of rating scale steps reduced to 4. The remaining 13-item, 4-step scale, termed the Activity Significance Personal Evaluation (ASPEn), formed a unidimensional hierarchy with good fit statistics and targeting. Person separation reliability (2.7) and internal consistency (.91) indicated the tool is appropriate for individual person measurement. Relative validity indicated equivalence between Rasch measures and total raw scores.
CONCLUSIONS: ASPEn is a brief, easily administered assessment of older adults' perception of the contribution of everyday activities to personal health and wellness. ASPEn may facilitate occupational therapy practice by enabling clinicians to assess change in meaning of an older adult's activity over time.

Leland, N. E., Marcione, N., Schepens Niemiec, S. L., Kelkar, K., & Fogelberg, D. (2014). What is occupational therapy’s role in addressing sleep problems among older adults? OTJR: Occupation, Participation and Health, 34, 141-149. Show abstractHide abstract

Sleep problems, prevalent among older adults, are associated with poor outcomes and high health care costs. In 2008, rest and sleep became its own area of occupation in the American Occupational Therapy Association’s Occupational Therapy Practice Framework. The current scoping review examined a broad context of sleep research to highlight efficacious interventions for older adults that fall within the occupational therapy scope of practice and present an agenda for research and practice. Four sleep intervention areas clearly aligned with the practice framework, including cognitive behavioral therapy for insomnia, physical activity, and multicomponent interventions. Occupational therapy is primed to address sleep problems by targeting the context and environment, performance patterns, and limited engagement in evening activities that may contribute to poor sleep. Occupational therapy researchers and clinicians need to work collaboratively to establish the evidence base for occupation-centered sleep interventions to improve the health and quality of life of older adults.

Tyler, D. A., Feng, Z., Leland, N. E., Gozalo, P., Intrator, O., & Mor, V. (2013). Trends in postacute care and staffing in US nursing homes, 2001-2010. Journal of the American Medical Directors Association, 14, 817-840. Show abstractHide abstract

OBJECTIVE: The objective of this study was to document the growth of postacute care and contemporaneous staffing trends in US nursing homes over the decade 2001 to 2010.
DESIGN: We integrated data from all US nursing homes longitudinally to track annual changes in the levels of postacute care intensity, therapy staffing and direct-care staffing separately for freestanding and hospital-based facilities.
SETTING: All Medicare/Medicaid-certified nursing homes from 2001 to 2010 based on the Online Survey Certification and Reporting System database merged with facility-level case mix measures aggregated from resident-level information from the Minimum Data Set and Medicare Part A claims.
MEASUREMENTS: We created a number of aggregate case mix measures to approximate the intensity of postacute care per facility per year, including the proportion of SNF-covered person days, number of admissions per bed, and average RUG-based case mix index. We also created measures of average hours per resident day for physical and occupational therapists, PT/OT assistants, PT/OT aides, and direct-care nursing staff.
RESULTS: In freestanding nursing homes, all postacute care intensity measures increased considerably each year throughout the study period. In contrast, in hospital-based facilities, all but one of these measures decreased. Similarly, therapy staffing has risen substantially in freestanding homes but declined in hospital-based facilities. Postacute care case mix acuity appeared to correlate reasonably well with therapy staffing levels in both types of facilities.
CONCLUSIONS: There has been a marked and steady shift toward postacute care in the nursing home industry in the past decade, primarily in freestanding facilities, accompanied by increased therapy staffing.

Teno, J. M., Gozalo, P. L., Bynum, J. P., Leland, N. E., Miller, S. C., Morden, N. E., Scupp, T., Goodman, D. C., & Mor, V. (2013). Change in end-of-life care for Medicare beneficiaries: Site of death, place of care, and health care transitions in 2000, 2005, and 2009. Journal of the American Medical Association, 309, 470-477. Show abstractHide abstract

IMPORTANCE: A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care.
OBJECTIVE: To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009.
DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270 202), 2005 (n = 291 819), or 2009 (n = 286 282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life.
MAIN OUTCOME MEASURES: Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life).
RESULTS: Our random 20% sample included 848 303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%).
CONCLUSION AND RELEVANCE: Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.

Leland, N. E., Teno, J. M., Gozalo, P., Bynum, J., & Mor, V. (2012). Decision making and outcomes of a hospice patient hospitalized with a hip fracture. Journal of Pain and Symptom Management, 44, 458-465. Show abstractHide abstract

CONTEXT: Hospice patients are at risk for falls and hip fracture with little clinical information to guide clinical decision making.
OBJECTIVES: To examine whether surgery is done and survival of hip fracture surgery among persons receiving hospice services.
METHODS: This was an observational cohort study from 1999 to 2007 of Medicare hospice beneficiaries aged 75 years and older with incident hip fracture. We studied outcomes among hospice beneficiaries who did and did not have surgical fracture repair. Main outcomes included the trends in the proportion of those undergoing surgery, the site of death, and six-month survival.
RESULTS: Between 1999 and 2007, approximately 1% (n=14,400) of patients aged 75 years and older admitted with a diagnosis of their first hip fracture were receiving hospice services in the 30 days before that admission and 83.4% underwent surgery. Among patients on hospice at the time of the hip fracture, 8.8% died during the initial hospitalization and an additional two-thirds died within the first six months on hospice. The median survival from hospital admission was 25.9 days for those forgoing surgery compared with 117 days for those who had surgery, adjusted for age, race, and other covariates (P<0.001).
CONCLUSION: Despite being on hospice services, the majority underwent surgery with improved survival. Sixty-six percent of all individuals on hospice at the time of the fracture died in the first six months, with the majority returning to hospice services.

Leland, N. E., & Elliott, S. J. (2012). Special issue on productive aging: Evidence and opportunities for occupational therapy practitioners. American Journal of Occupational Therapy, 66, 263-265.

Leland, N. E., Gozalo, P., Teno, J., & Mor, V. (2012). Falls in newly admitted nursing home residents: A national study. Journal of the American Geriatrics Society, 60, 939-945. Show abstractHide abstract

OBJECTIVES: To examine the relationship between nursing home (NH) organizational characteristics and falls in newly admitted NH residents.
DESIGN: Observational cross-sectional study from January 1, 2006, to December 31, 2006.
SETTING: NHs in the United States in 2006.
PARTICIPANTS: Individuals (n = 230,730) admitted to a NH in 2006 without a prior NH stay and with a follow-up Minimum Data Set (MDS) assessment completed 30 days or more after admission.
MEASUREMENTS: The relationship between experiencing a fall noted on the MDS assessment and NH characteristics (e.g., staffing, profit and chain status, religious affiliation, hospital-based facility status, number of beds, presence of a special care unit, funding) was examined, adjusting for NH resident characteristics.
RESULTS: Twenty-one percent of this cohort (n = 47,750) had experienced at least one fall in the NH at the time of the MDS assessment, which was completed for newly admitted NH residents who had at least a 30-day stay. NHs with higher certified nursing assistant (CNA) staffing had lower rates of falls (adjusted odds ratio = 0.97, 95% confidence interval = 0.95–0.99).
CONCLUSION: For newly admitted NH residents, NHs with higher CNA staffing had a lower fall rate. In an effort to maximize fall prevention efforts, further research is needed to understand the relationship between CNA staffing and falls in this NH population.

Leland, N. E., Elliott, S. J., O’Malley, L., & Murphy, S. L. (2012). Occupational therapy in fall prevention: Current evidence and future directions. American Journal of Occupational Therapy, 66, 149-160. Show abstractHide abstract

Falls are a serious public health concern among older adults in the United States. Although many fall prevention recommendations exist, such as those published by the American Geriatrics Society (AGS) and the British Geriatrics Society (BGS) in 2010, the specific role of occupational therapy in these efforts is unclear. This article presents a scoping review of current published research documenting the role of occupational therapy in fall prevention interventions among community-dwelling older adults, structured by the AGS and BGS guidelines. We identified evidence for occupational therapy practitioner involvement in fall prevention in environmental modifications, exercise, and multifactorial and multicomponent interventions. Although research documenting the efficacy of occupational therapy interventions is identified as part of the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; American Occupational Therapy Association, 2008), we identified little or no such research examining interventions to modify behaviors (e.g., fear of falling), manage postural hypotension, recommend appropriate footwear, and manage medications. Although occupational therapy is represented in the fall prevention research, the evidence for the profession’s role in many areas is still lacking.

Elliott, S. J., Ivanescu, A., Leland, N. E., Fogo, J., Painter, J. A., & Trujillo, L. G. (2012). Feasibility of interdisciplinary community-based fall risk screening. American Journal of Occupational Therapy, 66, 161-168. Show abstractHide abstract

OBJECTIVE: This pilot study examined the feasibility of (1) conducting interdisciplinary fall risk screens at a community-wide adult fall prevention event and (2) collecting preliminary follow-up data from people screened at the event about balance confidence and home and activity modifications made after receiving educational information at the event.
METHOD: We conducted a pilot study with pre– and post-testing (4-mo follow-up) with 35 community-dwelling adults ≥55 yr old.
RESULTS: Approximately half the participants were at risk for falls. Most participants who anticipated making environmental or activity changes to reduce fall risk initiated changes (n = 8/11; 72.7%) during the 4-mo follow-up period. We found no significant difference in participants’ balance confidence between baseline (median = 62.81) and follow-up (median = 64.06) as measured by the Activities-specific Balance Confidence scale.
CONCLUSION: Conducting interdisciplinary fall risk screens at an adult fall prevention event is feasible and can facilitate environmental and behavior changes to reduce fall risk.

Tyler, D. A., Leland, N. E., Lepore, M., & Miller, S. C. (2011). Effect of increased nursing home hospice use on nursing assistant staffing. Journal of Palliative Medicine, 14(11), 1-4. Show abstractHide abstract

BACKGROUND: Since 1999, there has been a significant increase in hospice providers and hospice use in nursing homes. A 1997 Office of Inspector General (OIG) report warned of possible kickbacks, monetary and otherwise, that might be paid by hospices to nursing homes in exchange for referrals. One possible kickback mentioned in the report was nursing homes receiving additional staff hours at no cost, which could lead to decreases in nursing home staffing. The purpose of this study was to determine if changes in nursing home hospice volume were related to changes in certified nursing assistant (CNA) staffing.
METHODS: The study included free-standing nursing homes with at least 3 years of observation between 1999 and 2006, no fewer than five deaths in any year, and between 30 and 500 beds (n=10,759). We examined the longitudinal relationship between changing hospice volume and CNA minutes per resident day (MPRD), utilizing nursing home fixed-effects regression analysis and adjusting for resident case mix and changing organizational characteristics.
RESULTS: The introduction of hospice services in a nursing home did not result in statistically significant changes in CNA staffing. Instead, increases in hospice volume resulted in small increases in CNA staffing. Specifically, the addition of 1000 hospice days, in a given year, resulted in an additional 0.79 (95% confidence interval [CI] 0.373–1.211) CNA MPRD.
CONCLUSIONS: The proposition that nursing homes may be decreasing their staffing as a result of receiving additional hospice staff was not supported by this study and, in fact, nursing homes were found to only slightly increase CNA staffing with increasing hospice volume.

Steinman, B. A., Nguyen, A. Q., Pynoos, J., & Leland, N. E. (2011). Falls-prevention interventions for persons who are blind or visually impaired. INSIGHT: Research and Practice in Visual Impairment and Blindness, 4(2), 83-91. Show abstractHide abstract

The purpose of this article is to describe four main areas of falls-prevention intervention for older adults who are blind or visually impaired. When integrated into multifactorial programs, interventions pertaining to education, medical assessment, exercise and physical activity, and environmental assessment and modification have been shown to be effective in falls reduction. These areas of intervention are discussed with respect to specific concerns of older adults who are blind or visually impaired. In describing these areas of intervention, the increasing need for cross-disciplinary falls-prevention programs designed specifically for older persons with vision loss, as well as research demonstrating the efficacy of multidisciplinary programs designed for this group, are emphasized.

Leland, N. E., Porell, F., & Murphy, S. L. (2011). Does fall history influence residential adjustments? The Gerontologist, 51(2), 190-200. Show abstractHide abstract

PURPOSE OF THE STUDY: To determine whether reported falls at baseline are associated with an older adult’s decision to make a residential adjustment (RA) and the type of adjustment made in the subsequent 2 years.
DESIGN AND METHODS: Observations (n = 25,036) were from the Health and Retirement Study, a nationally representative sample of community-living older adults, 65 years of age and older. At baseline, fall history (no fall, 1 fall no injury, 2 or more falls no injury, or 1 or more falls with an injury) and factors potentially associated with RA were used to predict the initiation of an RA (i.e., moving, home modifications, increased use of adaptive equipment, family support, or personal care assistance) during the subsequent 2 years.
RESULTS: Compared with those with no history of falls, individuals with a history of falls had higher odds of making any RA. Among those making an RA, individuals with an injurious fall were more likely than those with no history of a fall to start using adaptive equipment or increase their use of personal care assistance.
IMPLICATIONS: The higher initiation of RAs among fallers may indicate proactive steps to prevent future falls and may be influenced by interactions with the health care system. To optimize fall prevention efforts, older adults would benefit from education and interventions addressing optimal use of RAs before falls occur.

Other Articles

Bogenrief, J., & Leland, N. (2017, June 26). How will Medicare pay for SNF therapy in the future? [Capital briefing]. OT Practice, 22(11), 6. Full text

Lee, I., & Leland, N. E. (2013, September 9). Fall prevention for community-living older adults [Research update]. OT Practice, 18(16), 19, 22. Full text