Artigos

Conteúdo (article):

Evaluation of Long Term Institutions for Older People in Brazil: an overview of regional inequalities
ABSTRACT
Object: Long-term institutions for older people (LTIE). Objective: To evaluate the Brazilian LTIE, according to the Integrated Multidimensional Theoretical Model of Quality and Service (MIQA), and compare the performance achieved between the regions of the country. Methodology: Descriptive ecological study carried out with public secondary data from the LTIE participating in the 2018 Census of the Unified Social Assistance System. An Evaluation Matrix was constructed from the Census variables and the MIQA Theoretical Model. Quality parameters were used to classify the institutions\' performance for each indicator as “incipient”, “developing” or “desirable”. The disparity index was obtained for each indicator. 1,665 institutions were analyzed. Results: Differences were observed in the percentages of LTIE with “desirable” performance between Brazilian regions, and the need for improvement in most LTIE in relation to the proportion of caregivers of older people, the composition of the multidisciplinary team, accessibility and supply of health promotion actions. There was a need for government support for the suppression of exclusionary differentiation criteria and for the expansion of services to overcome overcrowding.
KEYWORDS:
Aged. Nursing homes. Homes for the Aged. Old age assistance Home Nursing.
INTRODUCTION
The accentuated growth of the older population occurs in a context of accentuated structural transformations in families, resulting from changes in marriage, the drop in fertility and the massive entry of women into the labor market1. These changes impose recognition of the need to establish non-family or formal care alternatives for the frail older population and spark a debate about the provision and quality of long-term care (LTC)1.
Different forms of LTC organizations for older people are observed in the world, depending on political, social and cultural issues, and the levels of responsibility of the State or of the individual/family. Social welfare strategies have been developed by some countries, with the establishment of universal and mandatory social insurance for the older population, with expenses incurred through co-payments, co-insurance and extra charges2. It is a consensus that the long-lived older population is the most exposed to non-transmissible chronic diseases and conditions, many of which culminate in sequelae that limit good functional performance, generating situations of dependence and consequent need for LTC3,4. Studies have indicated that the proportion of unmet needs for basic and instrumental activities of daily living is 65% for older people, with a predominance of economically disadvantaged groups3,5. This scenario, as well as the ongoing changes, require recognition of the need to establish public policies that allow LTC alternatives for certain older people, as well as to encourage the participation of the private market in the provision of these services4.
In Brazil, among the modalities of assistance for LTC to people over 60 years of age are the Long Term Institutions for Older People (LTIE) which, according to the typification of the National Social Assistance Policy, are modalities to satisfy the housing, food, health and social living needs of older people without family ties or unable to provide for their own subsistence6. A national census survey of Brazilian LTIE, carried out between 2007 and 2009, showed a predominance of philanthropic LTIE (65.2%), with a lower percentage of public (6.6%) and private LTIE (28.2)4.
In the field of health, the regulation of Brazilian LTIE provides for the monitoring of mortality rates; incidence rate of acute diarrheal diseases, scabies and dehydration; prevalence rate of decubitus ulcers and malnutrition in the resident older population7. However, evaluating these institutions is a multidimensional and complex issue, which is influenced by the context and the health conditions of the residents. For the purpose of collecting information about Social Assistance services, programs and projects; and provide subsidies for the construction of monitoring and evaluation indicators, the Brazilian Ministry of Social Development established the Census of the Unified Social Assistance System (SUAS Census), starting in 2010, with annual data collection. The LTIE were included in the SUAS Census, starting in 2012, however, a specific model for evaluating and monitoring the results achieved by these institutions was not located, nor determinations to be taken, given the non-conformities found8.
Institutional evaluation has been an encouraged and recognized practice in many countries and constitutes a powerful instrument for the implementation of social policies9. Different theoretical evaluation models were proposed for LTIE1. Rantz et al. (1999)10 elaborated the Integrated Multidimensional Model of Quality and Person-centered Care with seven Dimensions of Quality10. A matrix of indicators, called in this study the Multidimensional Evaluation Matrix (MMA) was built from the variables of the SUAS Census, based on the Theoretical Model of Rantz et al. (1999)10 and validated, in Brazil, by Guimarães et al. (2020)11. The objective of this study was to evaluate the Brazilian LTIE registered with the Unified Social Assistance System, through the MMA, comparing the performance achieved among the five regions of the country.
METHOD
This is a descriptive ecological study, carried out with public secondary data extracted from the SUAS Census Portal, linked to the National Secretariat of Social Assistance of the Ministry of Social Development of Brazil12.
STUDY SAMPLE
All Brazilian LTIE linked to the social, public and philanthropic assistance policy were included, with data from the last SUAS Census available at the time of extraction (base year 2018). The collection of data from the SUAS Census is carried out by municipal and state public agents, by filling out an electronic questionnaire, when visiting the institutions12. Private, for-profit LTIE do not respond to the SUAS Census. Two databases from the SUAS 2018 Census Bank were used: the Municipal and State Welcoming bank: general data and the Municipal Welcoming Human Resources database12. In the first base, the sampling units were the LTIE and in the second, the workers. The two databases were linked by the common variable identifying the LTIE, the Single Social Assistance System Register (CadSUAS)12.
LTIE EVALUATION
The LTIE were evaluated using the MMA, validated in Brazil by Guimarães et al. (2020)11. The MMA is composed of 18 indicators, in seven dimensions of the quality of LTIEs: 1) Central focus on residents, family members, employees and community (4 indicators); 2) Human resources (3 indicators); 3) Family involvement (1 indicator); 4) Individualized care (4 indicators); 5) Environment (2 indicators); 6) Housing (3 indicators); 7) Communication (1 indicator) (Table 1).
The indicators were calculated using data collected in the 2018 SUAS census. The performance of the LTIE for each indicator was classified as: “incipient”, “under development” and “desirable” based on regulatory legislation, literature or statistical criteria (Table 1).
Regional variations in the proportions of LTIE that achieved “desirable” performances were shown using maps. Additionally, to synthesize the result for each dimension, the proportions of LTIE with at least one indicator with desirable performance in each region were calculated. To build the maps, Microsoft Excel 365® software was used..
CALCULATION OF THE DISPARITY INDEX
The Disparity Index (DI) was used to estimate and compare the magnitude of differences between Brazilian regions in the proportions of LTIE with “desirable” performance for the evaluated indicators, as it is a positive reference of quality to be achieved. The values of this index reflect, in percentages, the average of the absolute deviation obtained between the proportion of LTIE with desirable performance and the reference value (region with the highest percentage of LTIE with desirable performance for the indicator) or the value for Brazil. Disparity indices were also calculated to compare LTIE ratios with at least one desirable performing indicator across regions for each dimension. For this calculation, the reference value was always the region with the highest percentage. Its calculation was based on the formula developed by Pearcy and Keppel (2002)13.
The study was approved by the research ethics committee of the Federal University of Minas Gerais through opinion nº 3,143,674. Data analysis was performed using IBM SPSS version 21 and Stata v. 16.
RESULTS
A total of 1,665 LTIE were included in the analysis, 165 (9.91%) from the Midwest region, 189 (11.35%) from the Northeast, 35 (2.10%) from the North, 1016 (61.02%) from the Southeast and 260 (15.62%) from the South region. The non-response rate was 0.18% (indicators 5 and 12); 0.96% (indicators 4, 8, 9, 10 and 18); 74.83% (indicator 7) and 65.47% (indicator 16). The losses observed in these indicators were due to the lack of complete data for the variables “Existence of training in the area of geriatrics” (25%), “The Institution receives provision from some public entity for physical structure, human resources, equipment/materials or transportation” (100%), “Presence of older people with continuous benefit” (11.17%) and “The institution is enrolled in the council for the rights of older people” (3.72%). The indicator variable 16 “The institution receives provision from some public entity for physical structure, HR, equipment/materials or transport” was excluded from the MMA calculation formula validated by Guimarães et al.(2020)11 because it presented 100% of the missing data, adapting the denominator from five to four. The exclusion of this variable from indicator 16 did not have important consequences, since its calculation was carried out with the four variables that made up its original version.
The proportions of LTIE in the Brazilian regions with “incipient”, “developing” and “desirable” performance, for each indicator, are presented in table 1. For most indicators, the highest percentage of LTIE with desirable performance was observed in the Southeast region. The proportions of LTIE with “desirable” performance were 94.10% (indicator Favoring Family Tie); 87.50% (indicator Adequate physical structure) and 76.20% (indicator Valuing the team of professionals). More than 80% (83.81%) of the LTIE showed incipient performance for the indicator Professionals for leisure activities (Table 1). Lower percentages of LTIE with desirable performance were observed for the following indicators: 9.9% (Professionals for leisure activities), 10.3% (Ratio of caregivers per older person), 15.4% (Multiprofessional Team in the area of Health), 18.0% (Accessibility), 22.6% (Materials and equipment that encourage culture) (Table 1).
The indicators “Favoring family ties”, “Adequate physical structure” and “Access without exclusive differentiation” were the ones that showed the lowest magnitude of disparity in terms of “desirable” performance. The greatest disparity was observed for the indicators “Multidisciplinary team in the health area” and “Ratio of caregivers per older person” (Table 1). Differences between the DI of the Brazilian Regions and DI Brazil were not very evident, and the DI for the Social Profile Indicator of the Institution could not be calculated, considering that none of the LTIE showed desirable performance (Table 1).
Variations in the percentages of LTIE with “desirable” performance between Brazilian regions, for the Indicators of the seven Dimensions of Quality, are represented in 18 maps. The different intensities of the colors indicate variations in the percentages reached in the regions, from the lowest to the highest value. There is a predominance of LTIE with “desirable” performance in the southeast and south regions, with the exception of the indicators “Access without exclusive differentiation”, “Ratio of caregivers per older person”, “Permanent Training” and “Professionals for leisure activities”, which predominated in the North region, and “Low turnover of professionals” and “Accessibility”, in the Northeast region (Figures 1 to 3).
Considering the set of indicators of each dimension, it was observed, for the dimensions Central focus on residents, family members, employees and community, Family Involvement, Individualized Care, Environment and Communication, higher percentages of LTIE with at least one of the indicators of the dimension with desirable performance in the Southeast and South regions. In general, worse performance was observed for the indicators of the Communication and Individualized Care dimensions. The quality dimensions with the highest DI were “Communication” (16.4) and “Individualized Care” (14.2) (Table 1).
DISCUSSION
This study described the performance of Brazilian public and philanthropic LTIE in the quality assessment, considering the dimensions of the Integrated Multidimensional Theoretical Model for LTIE by Rantz et al. (1999)10. The data presented revealed aspects that point to the need for a new division of obligations between the State, the family and the private market for the provision of care for the older population.
This study brought approaches that have not yet been demonstrated in the literature, such as the central focus of LTIE, communication in these institutions and the appreciation of family ties. The theoretical model of Rantz et al. (1999)10 adopted in the MMA includes seven dimensions of quality with different concepts. The indicators were developed seeking to assess aspects of each dimension, so that the interpretation of results must be based on these concepts.
The dimension “Central focus on residents, family members, employees and the community” includes the standards related to the service offered by the LTIE to the community, addresses the needs of the residents\' families and recognizes the importance of the team of professionals in the qualified care of the older people. The indicator of this dimension with the highest percentage of incipient performance was “Care for the family of the older person”, considering the presence of psychosocial care for the families of the people sheltered (family orientation), promotion of meetings with groups of families of users or contact and participation of the family in the user\'s life. Even though support actions for family members of older people ensure the rights of the older public and their families, contribute to the autonomy and promotion of the well-being of both14, and are provided for in the programs and services implemented by SUAS, this study showed that such actions are still a challenge in the routine of Brazilian LTIE14. The indicator “access without excluding differentiations” showed that, of the verified variables, mental disorder was the most prevalent excluding category in 30% of the total sample. However, older people with mental health problems have a greater reliance on LTC and are therefore more likely to need an LTIE15. Thus, such exclusionary differentiations may, on the one hand, indicate disregard for the real needs of the older population, and on the other hand, indicate that public and philanthropic LTIE face many difficulties, whether they be the lack of adequate infrastructure, availability of qualified human resources, or others, that limit the ability to offer care to all older people in need. Therefore, the expansion of support and investment in LTIE can enable a greater offer of care without any type of exclusion. A higher percentage of desirable performance in this dimension was observed for the indicator “Valuing the team of professionals”. This indicator considers LTIE data from the perspective of the professional, with regard to labor relations and hiring professionals. The results show that formal work is the predominant employment relationship in these institutions, which can be explained by the fact that public entities provide human resources as a form of support for LTIE4. However, more favorable results were observed in the Southeast and South regions, indicating regional challenges for persistent precarious work situations.
With regard to the indicator “presence of a coordinator at the institution”, approximately half of the LTIE meet the determination of the national legislation, which provides for a technical supervisor with a higher level, with a formal contract of 20 hours. The highest frequencies of LTIE in this situation were identified in the South and Southeast regions, which was expected, possibly due to the reduced number of professionals with the profile to coordinate LTIE in other Brazilian regions, and also due to the cost of hiring this professional, which burdens institutions who are already struggling to maintain themselves.
The Human Resources dimension defines that “The LTIE must have a satisfactory number of professionals. It is important that there is low turnover of professionals, supervision and training. The LTIE must recruit and retain employees who are responsive, compassionate, attentive, clean, well prepared and involved in care”.11 A lower percentage of LTIE with desirable performance was observed for the indicator “Ratio of caregivers per older person” (10.3%), which evaluated the proportion of caregivers recommended by federal legislation7 in LTIE, that is, one caregiver for each group of 20 older people, with the lowest degree of dependence (proportion 0.05%). This result indicates the high percentage of LTIE that do not comply with the legislation. Hiring more caregivers represents a financial expense for LTIE. In this sense, some policy or action by the government would be necessary to encourage the LTIE to comply with the legislation, supporting with additional resources to hire more caregivers, which would also enable greater qualification and psychological support for this group16. Regional disparities are also observed here, mainly due to the smaller proportions observed in the northeast and south regions. Still in the human resources dimension, around 60% of the LTIE presented “desirable” performances for the indicators “Low turnover of professionals” and “Permanent training”. These findings are positive, as they favor the qualification of LTIE. Professional turnover, from an organizational perspective, includes replacement and training costs, lost productivity and compromised quality17. For Pélissier et al (2018)18, a policy to reduce this turnover in homes for older people should involve the organization of work, reduction of psychosocial demand and access to training in the area of geriatrics and gerontology18. The indicators of the “Human Resources” dimension showed regional disparities, probably due to the profile of the labor market in some regions, often marked by the reduced number of qualified labor and the departure of trained professionals in search of better job opportunities19.
The indicator “Favoring family ties”, the only one in the “Family Involvement” dimension, showed a good result, with low regional disparities, suggesting that Brazilian LTIEs would be recognizing the importance of family ties and promoting actions to reduce the feeling of abandonment and loneliness, as found in a study with older people living in LTIE20. Possibly, the favorable results of this indicator are due to the fact that they do not depend on direct financial support for the LTIE. Although these findings seem to contradict the observations found for the indicator “Care for the older person\'s family” in the dimension “Central focus on residents, family members, employees and the community”, it should be noted that the indicator “Favoring the family bond” addresses the provision of coexistence, welcoming people with the same degree of kinship and permission to visit the institution services. The indicator “Care for the older person\'s family” analyzed the presence of psychosocial care for the families of the people sheltered (family orientation), promotion of meetings with groups of users\' families or the contact and participation of the family in the user\'s life. Although support actions for older people\'s relatives ensure the rights of the older public and their families, contribute to the autonomy and promotion of the well-being of both14, and are foreseen in the programs and services implemented by SUAS, this study showed that such actions still constitute a challenge in the routine of Brazilian LTIE14.
The Individualized Care dimension defines that “the LTIE must guarantee basic care and minimize incidents and injuries at home. It is necessary that they take care of residents as people, offering good food and helping them to eat, engaging residents in activities”11. The highest percentage of LTIE with incipient performance was observed for the indicators “Professionals for leisure activities” and “Multidisciplinary team in the area of Health”. Federal legislation6 establishes the proportion of a professional with a university degree for leisure activities, with a workload of 12 hours per week, for each group of 40 older people (proportion of 0.025%). The findings of this study showed little adherence to this legal determination, demonstrating the fragility of institutions regarding health promotion, although recommended by the National Health Policy for Older People21. The high regional disparities supposedly result from the polarization of specialized labor in regions with better socioeconomic indices. Regarding the Multiprofessional Health Team indicator, the scenario proved to be unfavorable, but predictable, as federal legislation6 does not establish the composition of a multiprofessional team to work in LTIE. The aforementioned legal order determines that LTIE must have a relationship with a professional in the health area, without mentioning their workload or their area of expertise6. Silva and Gutierrez (2018)22 drew attention to the requirements of federal legislation6, in relation to human resources in the health area, since, according to the authors, the frequent demand for health care for institutionalized older people cannot be neglected22. The "socialization" indicator sought information on carrying out social activities in the LTIE with bond strengthening, outings and insertion of the older people in existing services and projects in the community. Most of the LTIE showed a desirable performance for this indicator, which is of great relevance, since the stimulation of social interaction is fundamental for the physical and mental capacity of the older person, as well as for the recovery of those who have some functional loss and depression23.
The indicators of the “Environment” dimension sought to portray the aspects related to the physical space of the LTIE. Most of the LTIE obtained a “desirable” performance for the “Adequate physical structure” indicator, with low regional disparity, while for the “Accessibility” indicator, almost 80% of the LTIE presented a “developing” performance, as they were not, in their entirety, according to the specific regulation6. Accessibility is a fundamental condition for human life and, in the case of older people, it can represent more than the possibility of coming and going. Similar data were demonstrated in a study carried out in the Northeast Region that analyzed six LTIE with different management and fundraising systems and infrastructures with their own characteristics. The results showed that most LTIE did not comply with accessibility regulations, with several basic problems and the presence of poor adaptations and improvisations that put the resident population at risk24.
Understanding the factors that contribute to making older people feel as if they were in a home has been the object of study25. The “Housing” dimension sought to demonstrate these aspects through three indicators. The indicator “Occupancy Rate” provided information on the presence of overcrowding in 5.8% of Brazilian LTIE, with percentages ranging from 4.7% in the Southeast region to 8.4% in the Midwest. These data confirmed the findings of the Institute of Applied Economic Research on the need to increase the number of LTIE in the Brazilian territory26. Overcrowding in LTIE is a major problem in Brazil today due to the rapid growth of the older population in the country, which has not prepared for such a phenomenon and this problem is greater in the most impoverished or less inhabited regions. Still in the “Housing” dimension, no LTIE presented a “desirable” performance for the indicator “Social Profile of the Institution”, although it is a Social Assistance policy, revealing the inexpressive government support. In addition, social assistance should be non-contributory for people of all ages who need it, but, in fact, the funding of LTIE depends on the contribution of the residents themselves, and, in the case of philanthropic ones, on the solidarity action of the community26. Performance “in development” for the indicator “Materials and equipment for culture and leisure” was observed in approximately 40% of the LTIE. More than 1/3 of the LTIE showed incipient performance for this same indicator, which includes variables on the availability of bibliographic collection, pedagogical and cultural materials, sports materials and educational and hobby games, in addition to television. This was the indicator of the “Housing” dimension with the greatest regional disparity, with the best results in the South region, as portrayed by Camarano (2008)27. In the institutional context, the physical space and limited hours for activities, the dependency of the older people and established norms and routines, which do not always offer adequate conditions for the practice of leisure, were agents that hindered the adoption of these practices in LTIE, according to a study carried out in the southern region of the country28.
The analysis of the “Communication” Dimension sought data on verbal and behavioral actions with family members and residents, aiming to meet the needs of the older people through two available variables: the unit organizes or promotes discussions with the older people about the unit\'s routines; and the unit holds meetings with the relatives of the older people. The results showed that the majority of LTIE presented “developing” performance and regional disparities, with better results in the Southeast region. Findings in the literature indicate that the listening process is associated with a series of well-being indicators for residents and, in this sense, the profile of professionals working in LTIE is important to make this process possible29. It is worth highlighting the need for the LTIE to promote the use of communication tools as a process of continuous interaction between professionals and residents, observing the opinion of the older person about aspects of their life, for their well-being16.
As a strong point of this study, the use of a representative group from the largest country in Latin America, with data collected by public agents on public and philanthropic LTIE, allows for a direct analysis of the response of public policies to regional inequalities. As a limitation, we highlight the two indicators that showed a high rate of non-response, due to the lack of data on variables from the SUAS Census. In addition, there was an uneven distribution of the non-response rate between regions. For the indicator Social profile of the institution, the non-response rate ranged from 21.1% in the Northeast region to 38.2% in the Midwest region and for the indicator “Permanent Training” from 26.8% in the Southeast region to 80% in the North region. This unequal distribution of missing data also highlights the need to qualify records in national information systems. Another aspect to be considered is the inherent limitation of the MMA, whose indicators were built considering the information contained in the SUAS Census, restricting the evaluation of all concepts presented in the theoretical dimension. However, the MMA allowed the evaluation of a significant number of LTIE, pointing out the aspects that must advance to improve the quality of care, and the regions that need greater investment to reach desirable levels of performance. It is worth highlighting the importance of analyzing the regional context of the LTIE in evaluation processes. Future studies may confront the results of the evaluated indicators with contextual aspects related to aging and the availability of specialists in older people care in Brazil. It also emphasizes the importance of continuity of studies that advance in the conceptualization of the quality of care in LTIE, and of tools to operationalize and measure this concept in complex contexts.
CONCLUSIONS
It was observed that most of the LTIE have a basic physical structure, favor the family bond and that most of its professional team has a formal work bond. However, crucial elements for care need to be improved, such as the proportion of caregivers of older people, the composition of the multidisciplinary team, accessibility and the provision of health promotion actions. There was also a need for governmental and universal support for the suppression of exclusionary differentiation criteria and for the expansion of services to overcome overcrowding. The low funding of LTIE by public management directly and indirectly affects the care provided to the institutionalized older population, as it limits the hiring of human resources in sufficient numbers, qualified professionals, the acquisition of accessibility devices and the expansion of LTIE installed capacity. They observed differences in the percentages of LTIE with “desirable” performance between the Brazilian regions, and for a greater number of indicators, more positive results were observed in the South and Southeast regions. This evidence points to the need to prepare for the growing demands for LTC, mainly due to the very rapid increase in the older population in Brazil, with an increase in financial support for LTIE and equitable interventions and policies for the improvement of existing institutions.

FINANCING
Raquel Conceição Ferreira received financial support from the Pesquisador Mineiro Program (PPM 00603-18). This work was supported by the Coordination for the Improvement of Higher Education Personnel (CAPES) – funding code 001.

ACKNOWLEDGMENT
The National Council for Scientific and Technological Development.
Support Foundation of the State of Minas Gerais.

REFERENCES
1. Scheil- Adlung X. Long-term care protection for older persons: A review of coverage deficits in 46 countries [Internet]. Geneva, Switzerland: ILO; 2015 [cited 2022 Dec 16]. Available from: https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---soc_sec/documents/publication/wcms_407620.pdf
2. Rice T, Rosenau P, Unruh LY, Barnes AJ, Saltman RB, Ginneken E. United States of America: Health system review. Health Syst Transit 2013; 15(3):1-431.
3. Andrade TB, Andrade FB. Unmet need for assistance with activities of daily life among older adults in Brazil, Brasil. Rev Saude Publica 2018; 52:75.
4. Camarano AA, Kanso S, Melo JL, Carvalho DF. As Instituições de Longa Permanência para Idosos no Brasil. In: Camarano AA, Organizadores. Cuidados de longa duração para a população idosa: um novo risco social a ser assumido? Rio de Janeiro: IPEA, 2010; p. 187-212.
5. Duarte YAO, Lebrão ML, Lima FD. Contribuição dos arranjos domiciliares para o suprimento de demandas assistenciais dos idosos com comprometimento funcional em São Paulo, Brasil. Rev Panam Salud Publica 2005; 17(5-6):370-378.
6. Brasil. Decreto nº 9.921 de 18 de julho de 2019. Que consolida atos normativos editados pelo Poder Executivo federal que dispõem sobre a temática da pessoa idosa. Diário Oficial da União 2019;18 jul.
7. Brasil. Resolução da Diretoria Colegiada da Agência Nacional de Vigilância Sanitária- RDC nº 502, de 27 de maio de 2021. Dispõe sobre o funcionamento de Instituição de Longa Permanência para Idosos, de caráter residencial. Diário Oficial da União 2021; 27 mai.
8. Martinelli T, Silva MB, Santos SR. Social Assistance Monitoring in Social Assistance Policy: Conception and Operation, Brasil. Rev Katál 2015;18(1):104-112.
9. Tolson D, Rolland Y, Andrieu S, Aquino JP, Beard J, Benetos A. International Association of Gerontology and Geriatrics: A global agenda for clinical research and quality of care in nursing homes. J Am Med Dir Assoc 2011; 12(3):184-189.
10. Rantz MJ, Zwygart-Stauffacher M, Popejoy L, Grando VT, Mehr DR, Hicks LL. Nursing home care quality: A multidimensional theoretical model integrating the views of consumers and providers. J Nurs Care Qual 1999; 14(1):16-37.
11. Guimarães MRC, Ferreira RC, Giacomin KC, Vargas AMD. Indicators for evaluating long-term care facilities for old people: development and validation, Brasil. Rev Bras Geriatr Gerontol 2020; 23(5):1-14.
12. Brasil. Ministério do Desenvolvimento Social. Secretaria Nacional do Desenvolvimento Social [Internet]. Vigilância socioassistencial: Bases e Resultados. Censo SUAS 2018 Unidades de Acolhimento [cited 2022 Dec 16]. Available from: https://aplicacoes.mds.gov.br/snas/vigilancia/index2.php
13. Pearcy JN, Keppel KG. A summary measure of health disparity. Public Health Rep 2002;117(3):273-280.
14. Spilsbury K, Hewitt C, Stirk L, Bowman C. The relationship between nurse staffing and quality of care in nursing homes: a systematic review. Int J Nurs Stud 2011;48(6):732-750.
15. Kang YS, Miller NA, Tzeng HMH, Zhang T. Race and mental health disorders’ impact on older patients’ nursing home admissions upon hospital discharge. Arch Gerontol Geriatr 2018; (8): 269-274.
16. Garbin CAS, Sumida DH, Moimaz SAS, Prado RLD, Silva MMD. O envelhecimento na perspectiva do cuidador de idosos, Brasil. Cien Saude Colet 2010; (6): 2941-2948.
17. Brannon D, Zinn JS, Mor V, Davis J. An exploration of job, organizational, and environmental factors associated with high and low nursing assistant turnover. Gerontologist 2002; 42(2):159-168.
18. Pélissier C, Charbotel B, Fassier JB, Fort E, Fontana L. Nurses\' occupational and medical risks factors of leaving the profession in nursing homes. Int J Environ Res Public Health 2018;15(9):1850.
19. Neto JDAF, Silva AMT, Catão MHCV. Odontogeriatras, geriatras e idosos brasileiros: uma análise por estados e regiões do país. Arch Health Invest 2016; 5(5): 262-266.
20. Evangelista RA, Bueno ADA, Castro PAD, Nascimento JN, Araújo NTD, Aires GP. Perceptions and experiences of elderly residents in a nursing home. Rev Esc Enferm USP 2014; 48(Esp2):81-86.
21. Creutzberg M, Gonçalves LH, Sobottka EA, Ojeda BS. Long-term care institutions for elders and the health system. Rev. Latino-Am. Enfermagem 2007;15(6):1144-1149.
22. Silva HS, Gutierrez BAO. A educação como instrumento de mudança na prestação de cuidados para idosos. Educ. Rev 2018; 34(67): 283-296.
23. Barbosa LM, Noronha K, Camargos MCS, Machado CJ. Perfis de integração social entre idosos institucionalizados não frágeis no município de Natal, Rio Grande do Norte, Brasil. Cien Saude Colet 2020; 25(6): 2017-2030.
24. Paiva MM, Tavares AS, Oliveira M, Villarouco V. Análise comparativa da acessibilidade em ILPIS. Blucher Engineering Proceedings [Internet]. 2016 [cited 2022 Dec 16]; 3(3):101-112. Available from: http://pdf.blucher.com.br.s3-sa-east-1.amazonaws.com/engineeringproceedings/conaerg2016/8099.pdf
25. Rijnaard MD, Van HJ, Janssen BM, Verbeek H, Pocornie W, Eijkelenboom A, Beerens HC, Molony SL, Wouters EJ. The factors influencing the sense of home in nursing homes: a systematic review from the perspective of residents. J Aging Res. 2016: 6143645.
26. Camarano AA, Barbosa P. Instituições de Longa Permanência para Idosos no Brasil: do que se está Falando? In: Alcantara AO, Camarano AA, Giacomin KC. Política nacional do idoso: velhas e novas questões. Rio de Janeiro: IPEA,2016. p.479-514.
27. Camarano AA. Características das instituições de longa permanência para idosos: região Nordeste. Brasília.IPEA, 2008. p.348.
28. Castro VC, Carreira L. Leisure activities and attitude of institutionalized elderly people: a basis for nursing practice. Rev. Latino-Am. Enfermagem 2015; 23(2): 307-314.
29. Ferrand C, Martinent G, Durmaz N. Psychological need satisfaction and well-being in adults aged 80 years and older living in residential homes: using a self-determination theory perspective. J Aging Stud 2014;(30):104-111.