Refining a case-mix measure for nursing homes: Resource Utilization Groups (RUG-III)

Mental health outcomes and physical restraint use in nursing homes {private}

We investigate the nexus between mental health outcomes in nursing home residents and the use of physical restraints. Previous studies in this area used limited statistical tests such as correlations and t-tests, that could not account for potential biases, such as residents who become mentally disturbed may be most likely to be restrained. We use propensity matching models that are less susceptible to this bias and data from the Minimum Data Set, representing approximately 2,000 residents over a period of 6 years. Our results clearly show that restrained residents are more likely to become more impaired with respect to cognitive performance, depression, and social engagement. We conclude that if facilities reduce restraint use then the prevalence of resident mental health problems will also likely decline.

Assessing the Registered Nursing Care Contribution for older people in care homes: issues of reliability and validity

The present paper reports on a study designed to investigate the validity and reliability of the Registered Nursing Care Contribution (RNCC) tool for assessing the level of nursing care required by care home residents. Care plan data from 186 residents in participating care homes were assessed by multiple assessors using the RNCC tool (i.e. care home registered nurses, a nurse researcher, an external care home expert and a nurses consultant). The Minimum Data Set (MDS) rating was used as a validated comparison. The findings from the study indicated that there were disparities between the RNCC and MDS bandings, and between different raters, with the external care home expert achieving the closest agreement with the MDS. This suggests that the use of the RNCC tool varies considerably according to the assessor, which also suggests that training of users is needed to ensure consistency and reliability. However, the difference between the outcomes of using the RNCC tool and the MDS suggests that assessment of nursing need may need to be re-examined to ensure validity.

Defining and Measuring Quality Outcomes in Long-Term Care

The US health care industry increasingly agrees that sharing information about quality of care is necessary to stimulate providers' efforts to improve the quality of health care. The availability of mandated, uniform clinical data in all nursing homes and home health agencies has facilitated the rapid adoption of public reporting of comparative quality data. This paper examines the conceptual and technical challenges underlying the application of information about long-term care provider quality to judge and compare the quality of care provided by nursing homes and home health agencies. In general, the impetus to apply the emerging set of quality "tools" based on mandated clinical assessments may have outstripped the evidence for their valid application in selecting top providers or for rewarding their superior performance.

A Quality-Based Payment Strategy for Nursing Home Care in Minnesota

This article describes a pay-for-performance system developed for Minnesota nursing homes. In effect, nursing homes can retain a greater proportion of the difference between their costs and the average costs on the basis of their quality scores. The quality score is a derived and weighted composite measure currently composed of five elements: staff retention (25 points), staff turnover (15 points), use of pool staff (10 points), nursing home quality indicators (40 points), and survey deficiencies (10 points). Information on residents' quality of life and satisfaction, derived from interviews with a random sample of residents in each Minnesota nursing home, is now available for inclusion in the quality measure. The new payment system was designed to create a business case for quality when used in addition to a nursing home report card that uses the same quality elements to inform potential consumers about the quality of nursing homes. Although the nursing home industry has announced general support for the new approach, it has lobbied the legislature to delay its implementation, claiming concerns about operational details.

The effect of state medicaid case-mix payment on nursing home resident acuity

OBJECTIVE

To examine the relationship between Medicaid case-mix payment and nursing home resident acuity.

DATA SOURCES

Longitudinal Minimum Data Set (MDS) resident assessments from 1999 to 2002 and Online Survey Certification and Reporting (OSCAR) data from 1996 to 2002, for all freestanding nursing homes in the 48 contiguous U.S. states.

STUDY DESIGN

We used a facility fixed-effects model to examine the effect of introducing state case-mix payment on changes in nursing home case-mix acuity. Facility acuity was measured by aggregating the nursing case-mix index (NCMI) from the MDS using the Resource Utilization Group (Version III) resident classification system, separately for new admits and long-stay residents, and by an OSCAR-derived index combining a range of activity of daily living dependencies and special treatment measures.

DATA COLLECTION/EXTRACTION METHODS

We followed facilities over the study period to create a longitudinal data file based on the MDS and OSCAR, respectively, and linked facilities with longitudinal data on state case-mix payment policies for the same period.

PRINCIPAL FINDINGS

Across three acuity measures and two data sources, we found that states shifting to case-mix payment increased nursing home acuity levels over the study period. Specifically, we observed a 2.5 percent increase in the average acuity of new admits and a 1.3 to 1.4 percent increase in the acuity of long-stay residents, following the introduction of case-mix payment.

CONCLUSIONS

The adoption of case-mix payment increased access to care for higher acuity Medicaid residents.

Feeding assistance needs of long-stay nursing home residents and staff time to provide care

OBJECTIVES

To describe the staff time requirements to provide feeding assistance to nursing home residents who require three different types of assistance to improve oral food and fluid intake (social stimulation, verbal cuing, or both; physical guidance; or full physical assistance) and to determine whether physically dependent residents require more staff time, as defined in the national Resource Utilization Group System (RUGS) used for reimbursement.

DESIGN

Descriptive.

SETTING

Six skilled nursing homes.

PARTICIPANTS

Ninety-one long-stay residents with low oral intake who responded to improved feeding assistance.

MEASURMENTS

Research staff conducted direct observations of usual nursing home care for 2 consecutive days (total of six meals) to measure oral food and fluid consumption (total percentage eaten) and staff time spent providing assistance (minutes and seconds). Research staff then implemented a standardized graduated-assistance protocol on 2 separate days (total of six meals) that enhanced residents' oral food and fluid intake.

RESULTS

Staff time to provide feeding assistance that improved food and fluid consumption was comparable across different levels of eating dependency. Across all levels, residents required an average of 35 to 40 minutes of staff time per meal; thus, residents who needed only supervision and verbal cuing required just as much time as those who were physically dependent on staff for eating.

CONCLUSION

The current RUGS system used for reimbursement likely underestimates the staff time required to provide feeding assistance care that improves oral intake.

Functional status measures for integrating medical and social care

Purpose

Identify standard self-report questions about functioning suitable for measuring disability across integrated health and social services.

Theory

Functional activities can be validly grouped according to the International Classification of Functioning, Disability and Health (ICF) chapters of mobility, self-care, and domestic life.

Methods

Cross-sectional analysis using information on 112,601 persons interviewed as part of the United States National Health Interview Survey on Disability. We combined related sets of questions and tested the appropriateness of their groupings through confirmatory factor analyses. Construct validity was addressed by seeking to confirm clinically logical relationships between the resulting functional scales and related health concepts, including number of physician contacts, number of bed days, perception of illness, and perception of disability.

Results

Internal consistency for the summed scales ranged from 0.78 to 0.92. Correlations between the functional scales and related concepts ranged from 0.12 to 0.52 in directions consistent with expectations.

Conclusions

Analyses supported the 3 ICF chapters.

Discussions

The routine collection of this core set of functions could enhance decision-making at the client, professional, organizational, and policy levels encouraging cooperation among the medical and social service sectors when caring for people with disabilities.

Effect of educational level and minority status on nursing home choice after hospital discharge

OBJECTIVES

The movement to publicly report data on provider quality to inform consumer choices is predicated on assumptions of equal access and knowledge. We examine the validity of this assumption by testing whether minority/less educated Medicare patients are at greater risk of being discharged from a hospital to the lowest-quality nursing homes in a geographic area.

METHODS

We used the 2002 national Minimum Data Set to identify 62601 new Medicare admissions to nursing homes in 95 hospital service areas with at least 4 freestanding nursing homes and at least 50 African Americans aged 65 years or older with Medicare admissions to nursing homes.

RESULTS

The probability of African Americans' being admitted to nursing homes in the lowest-quality quartile in the area was greater (relative risk [RR]=1.26; 95% confidence interval [CI]=1.0, 8.45) in comparison with Whites. Individuals without a high-school degree were also more likely to be admitted to a low-quality nursing home (RR=1.22; 95% CI=1.0, 1.46).

CONCLUSIONS

African American and poorly educated patients enter the worst-quality nursing facilities. This finding raises concerns about the usefulness of the current public reporting model for certain consumers.

Factors influencing use of home care and nursing homes

AIM

This paper reports a study comparing the characteristics of patients who use home care services and those who are cared for in nursing homes, and identifying the factors that influence the use of these care settings.

BACKGROUND

The increase in the functionally dependent older population has led to an increase in the number of nursing homes and home care agencies. It has become clear that, rather than disputing which is the better of these options, it would be better to determine the characteristics of patients who use the two long-term care services. Gaining an understanding of the unique characteristics of patients who are cared for by home care agencies and those who are cared for in nursing homes will be imperative for reforming and developing long-term care systems.

METHOD

The research model was based on the Anderson Model of Health Services Utilization. Interviews were conducted with 99 stroke survivors from two home care agencies and four nursing homes, and their family members, between May and December 2001.

RESULTS

The patient characteristics that predicted greater use of home care rather than nursing home services were: being married, poor physical function, impaired cognitive function, higher rates of comorbidity, various medical complications, and/or number of catheters (e.g. urinary catheter, naso-gastric tube).

CONCLUSION

Contrary to the findings of previous studies conducted in countries with ageing populations, our findings indicate that in South Korea home care agencies, rather than nursing homes, provide care for severely impaired patients. This may be due to differences between countries in their long-term care systems and cultural attitudes toward end-of-life care. Our results will contribute to the development or reformation of long-term care systems in countries with ageing populations, and to the development of strategies for increasing access to these services.

Using the Resource Utilization Groups (RUG-III) System as a Staffing Tool in Nursing Homes

Nurse managers working in nursing homes are challenged to develop strategies that maintain a balance among quality of care, nurse staffing levels, and workload within the context of federal and state nurse staffing requirements for nursing homes. One strategy to consider is the use of the Resource Utilization Groups (RUG-III) staffing benchmarks that are associated with each of the 44 resident classification groupings that comprise the RUG-III system. The RUG-III system is described. Three examples of the use of RUG-III as a staffing tool by nurses working in Veterans Health Administration nursing homes are described. The lessons learned about the advantages and limitations in using RUG-III as a staffing tool are summarized. These lessons are applicable to RUG-53, the January 2006 refinement of RUG-III.

A Nurse-staffing Taxonomy for Decision Making in Long-term Care Nursing Facilities

A nurse-staffing taxonomy is proposed to facilitate informed staffing decisions in long-term care nursing facilities and to set forth construct components for empirically related research. Recommendations from an expert workgroup were synthesized with current staffing research to define a staffing taxonomy. Refinements were made, incorporating on-site nursing home quality assessments and concepts founded on psychometric theory and Donabedian's model. A quality monitoring protocol, based on the staffing taxonomy, was used to assess quality improvement systems. Results from 48 US nursing facilities indicate that most long-term care facilities struggle with staffing allocation and the integration of staffing into a quality monitoring process.

Classification of residents in nursing homes in Tuscany (Italy) using Resource Utilization Groups Version III (RUG-III)

BACKGROUND AND AIMS

Samples of nursing homes in Tuscany (Italy) classify their residents and determine their case-mix according to the Resource Utilization Groups System, Version III (RUG-III).

METHODS

A large sample of nursing homes was selected, based on willingness to participate, representation of both public and private institutions, and wide geographic representation. Two registered nurses assessed all residents using the RUG questionnaire. The information collected was then used to group residents into 44 RUGs, and facility-specific case-mix indices were calculated using the RUG-specific weights previously validated in Italy.

RESULTS

A total of 3981 residents from 93 nursing homes were assessed. Most residents were over 75 years old (87.4%) and women (68.6%). A large percentage was classified into RUGs within the following primary categories: reduced physical function (33.6%), impaired cognition (17.6%) and clinically complex (17.6%). The resulting nursing home case-mix indices ranged from 0.627 to 1.108 (mean 0.807+/-0.110). No significant association was found between type of facility, level of fees, or extent of staff in the nursing homes and their case-mix indices.

CONCLUSIONS

RUGIII can provide information on types of nursing home residents and their care needs. This is useful for monitoring and evaluating long-term care services for the elderly, and allows for more effective planning and allocation of staffing and financial resources.

Would people with Parkinson's disease benefit from palliative care?

Parkinson's disease (PD) is a chronic, progressive, degenerative disorder of the nervous system, causing substantial morbidity and has the capacity to shorten life. People with PD and their families can find the disease devastating. Nevertheless, this population of patients is not usually considered a group to be supported by palliative care specialists. But the nature of the illness and the challenges of managing its many physical and psychological effects raises questions about the potential benefits of a palliative care approach. The purpose of this project was to describe the experience of PD and consider the relevance of palliative care for this population. Semi-structured interviews were conducted with eight people with PD, 21 family caregivers and six health professionals. Five themes were developed from the data analysis: (1) emotional impact of diagnosis; (2) staying connected; (3) enduring financial hardship; (4) managing physical challenges; and (5) finding help for advanced stages. These data revealed that people with PD and family caregivers are confronted with similar issues to people with typical palliative care diagnoses, such as advanced cancer, and that a palliative approach may be helpful in the care of people with PD and their families.

Resident care needs and work stressors in special care units versus non-specialized long-term care units

Differences in how elderly residents' care needs affect staff's experiences of work stressors between special care units (SCUs) for dementia and psychiatric residents and non-SCUs were investigated. The data were drawn from 390 staff members in 38 long-term care SCUs, and 587 staff in 53 non-SCUs in Finland. Residents' care needs were based on the Resident Assessment Instrument (RAI) system measured by the Minimum Data Set 2.0. Work stressors (time-pressure and role-conflicts) were assessed with a staff survey questionnaire. Multiple-group regression analysis showed that residents' dependency in activities of daily living (ADL) was related to increased work stressors only in SCUs. A high proportion of behavioral problems was related to fewer work stressors for SCU staff, but more for non-SCU staff. Work stressors may be reduced by specializing, so that residents with similar care needs are placed together and care is focused.

Outcome After Rehabilitation for Total Joint Replacement at IRF and SNF

OBJECTIVE

The objective of this study was to determine whether outcomes differed between patients with single knee or hip joint replacement surgery undergoing rehabilitation in an inpatient rehabilitation facility (IRF) vs. skilled nursing facilities (SNFs).

DESIGN

A retrospective chart review was performed on 87 pairs of patients treated in either an IRF or a SNF matched for age, gender, type of surgery, and Functional Independent Measure (FIM) motor score at admission. All patients discharged from the IRF for rehabilitation following single hip or knee replacement surgery in 2004 were eligible for comparison with index cases discharged from SNFs with the same diagnosis in 2004. At discharge, FIM motor scores, device used for ambulation, ambulation distance, disposition, and length of stay (LOS) were recorded.

RESULTS

The mean LOS of IRF-treated patients was 10.3 +/- 3.3 days, compared with 20.0 +/- 10.8 days for SNF-treated patients (P < 0.005). A significantly higher percentage of IRF-treated patients were discharged directly home (IRF: 89.5%; SNF: 79.1%; P < 0.029). The mean discharge locomotion FIM score for IRF-treated patients was 5.71 +/- 0.91 compared with 4.90 +/- 1.92 for the SNF-treated patients (P < 0.004). At discharge, the mean ambulation distance of patients treated at the IRF was of 380 +/- 168 feet compared with 289 +/- 212 feet for patients treated at SNFs (P < 0.005). Significantly more of the SNF-treated patients required a walker (80.2%) for ambulation at discharge compared with patients treated at the IRF (38.3%, P < 0.001). Of the patients who were discharged home, 75% of the SNF-treated patients required homecare services compared with 41.2% of the IRF-treated patients (P < 0.001).

CONCLUSION

When patients were matched for age, gender, operative diagnosis, and admission ambulation FIM, those who received rehabilitation in the IRF had, on average, a shorter length of stay and superior functional outcomes than those treated in SNFs.

A Taxonomy and Economic Consequences of Nursing Home Falls

BACKGROUND

Falls are a primary cause of injury and disability in the nursing home environment and can be costly to treat. We propose a taxonomy of nursing home falls that accounts for both the severity of fall consequences and the duration of the treatment episode. No other systematic approach of this kind has been previously described.

METHODS

We defined a 9-level taxonomy of fall types and outcomes. Components of each fall category include resource use during the acute, convalescent, and long-term phases of treatment. Three variants of each category describe typical, best-case and worst-case fall episodes. Treatment costs were estimated for each fall category by applying unit costs from national databases and published sources to projected medical resource utilisation. Long-term costs reflect adjustment in Medicare per diem reimbursement rates associated with change in patient status subsequent to the fall.

RESULTS

The most common and least costly fall category was category 1 -- non-injurious, which accounted for 30% of falls and a 1-year cost of US dollars 319 per event (range US dollars 71-550). The least common and most costly was fall category 9 -- multiple injuries, which accounted for 1% of falls and a 1-year cost of US dollars 22,368 (range US dollars 9,969-64,382).

CONCLUSIONS

The falls taxonomy represents a unique approach to estimating the cost of nursing home falls and offers a tool for evaluating the cost-effectiveness of fall prevention strategies. A validation study should be performed to confirm the magnitude of fall frequency and cost estimates.

Long-term care in the St. John's region: impact of single entry and prediction of bed need

In 1996, the St. John's region had a population of 8,435 > or = 75 years, with 996 nursing home (NH) beds and 550 supervised care (SC) beds. A single entry system to these institutions was implemented in 1995. To determine the impact of the single entry system, the demographic and clinical characteristics of NH residents were assessed in 1997 (N = 1,044) and in 2003 (N = 963). To determine the efficiency of placement and the need for long-term care beds, two incident cohorts requesting placement were studied in 1995/96 (N = 467) and in 1999/2000 (N = 464). Degree of disability was determined using the Residents Utilization Groups III classification (RUG-III) and the Alberta Resident Classification Score (ARCS), and time to placement and to death was measured. In prevalent NH residents, the percentage without RUGS-III disability decreased from 18.5% in 1997 and to 9.9% in 2003. The proportion recommended for NH was 75% in 1995/96 and 72% in 1999/2000, despite the fact that the proportion with RUGS-III disability was 64% in both periods. Using a decision tree, optimal placement for the 1999/2000 cohort was 36% to SC, 20% to SC for the cognitively impaired, and 44% to NH. Predicted need for long-term care beds in 2004 matched poorly with current provision of NH and SC beds, and the mismatch will be worse in 2014. It was concluded that the single entry system was associated with improved appropriateness of NH bed utilization. However, there was a mismatch in need for and provision of institutional long-term care. Investment in the reconfiguration of long-term care beds by case mix and by geography is necessary.

Improving the quality of long-term care with better information

Publicly reporting information stimulates providers' efforts to improve the quality of health care. The availability of mandated, uniform clinical data in all nursing homes and home health agencies has facilitated the public reporting of comparative quality data. This article reviews the conceptual and technical challenges of applying information about the quality of long-term care providers and the evidence for the impact of information-based quality improvement. Quality "tools" have been used despite questions about the validity of the measures and their use in selecting providers or offering them bonus payments. Although the industry now realizes the importance of quality, research still is needed on how consumers use this information to select providers and monitor their performance and whether these efforts actually improve the outcomes of care.

Quality of care in nursing home organizations: Establishing a health services research agenda

Health services research has led to exciting new findings about the critical importance of the amount and type of nursing staff in nursing homes for improving the processes and outcomes of care. This paper reviews recent theoretical and research issues and outlines areas where research is needed. The nursing home research agenda for the future needs to concentrate on: (1) the relationship between structural measures of nursing (eg, staffing levels, education, turnover rates) and the outcomes and processes of care; (2) adequate processes of care and ways to improve the reliability of clinical outcome measures; (3) better ways to risk-adjust for resident characteristics; (4) the impact of nursing home characteristics (eg, ownership) and public policies (eg, reimbursement) on structural factors, processes, and outcomes; and (5) cost-effectiveness studies of nursing care at the organizational or system level.

Chain Reaction

This paper reports on an exploratory study of nursing home bankruptcy. From state and industry data regarding nearly 1,000 California facilities, it was possible to identify 155 homes in five chains (multi-facility organizations) that were operating in bankruptcy in 2000. When compared with facilities in non-bankrupt chains, while the bankrupt chain facilities had significantly worse financial liquidity, higher administrative costs, and higher payables to related parties, they also had more Medicare residents, fewer Medicaid residents, better solvency, and were located in less competitive county markets and in areas with higher Medicaid reimbursement rates. These findings indicate that, rather than facility characteristics and local market factors, strategic decisions taken at the corporate (chain) level are the major determinants of nursing facility bankruptcy status.

Disability-based classification system for older people in integrated long-term care services: the Iso-SMAF profiles

This study was conducted to develop and evaluate a disability-based classification system for management of long-term care (LTC) needs in an integrated service delivery system. We collected cross-sectional data on 29 items of the Functional Autonomy Measurement System (SMAF) from a stratified multistage sampling of 1977 elderly people with disabilities living in different environments. Disability profiles were identified using statistical clustering techniques combined with advice form a panel of experts. Their clinical meaningfulness, stability, reproducibility, homogeneity, heterogeneity and predictive validity were evaluated. The Iso-SMAF classification consisted of 14 homogeneous disability profiles characterized by a gradual progression in the severity of disabilities in instrumental activities of daily living (IADL) and activities of daily living (ADL) accompanied by predominant limitations either in mobility or mental functions. The profiles achieved a Kappa reproducibility coefficient of 0.67 through cross validation. A stable cluster structure emerged when the items were analyzed using different methods. They explained 82% of the variance in nursing care time, 80% of the variance in cost of nursing care (skilled and unskilled) and 57% of the variance in total costs including both formal and informal sources of LTC services. The conclusion recommends their use for planning, managing and predicting LTC service needs in an integrated care system.

The cost efficiency and clinical quality of institutional long-term care for the elderly

This study applied the stochastic frontier cost function with inefficiency effects to estimate the association between quality of care and cost efficiency in institutional long-term care wards for the elderly in Finland. We used several clinical quality indicators for indicating adverse care processes and outcomes, based on the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS). Average cost inefficiency among the wards was 22%. We found an association between the clinical quality indicators and cost inefficiency. Higher prevalence of pressure ulcers was associated with higher costs, whereas the higher prevalence of use of depressants and hypnotics increased inefficiency.

Care needs of residents in community-based long-term care facilities in Taiwan

AIM

The purpose of this study is to gain an understanding both of the characteristics of residents who receive the services of nursing assistants and the service intensity (service tasks, service time and cost) of nursing assistants as a means of developing a patient classification based upon resource consumption.

BACKGROUND

Most people in Taiwan send their disabled older family members to community-based long-term care facilities instead of nursing homes because they are much cheaper, and because they are generally closer to their homes, making visits more convenient. Nursing assistants make up the largest group of personnel in long-term care facilities. To determine resource use, both the service time and the actual activities performed for a resident by nursing assistants need to be assessed and this will help to develop a patient classification system to predict resource use and patient outcomes.

METHODS

A descriptive survey method was used to identify the tasks performed by nursing assistants in community-based long-term care facilities in Taiwan. Nursing assistants were recruited from 10 long-term care facilities in the Shihlin and Peitou Districts of Taipei City. Thirty-four nursing assistants and 112 residents participated in this study.

RESULTS

Findings showed that each nursing assistant spent 5.05 hours per day doing direct service care, which is much higher than the 2.08 hours for nursing assistants in the United States. Among service tasks provided by nursing assistants, personal care consumed 35.1% of their time. Non-complex treatments were second (33.3%). Skilled nursing and medical services were third (31.6%). The service intensity required of nursing assistants was strongly related to the residents' activities of daily living and their needs.

CONCLUSION

Complex nursing procedures are normally provided by Registered Nurses in nursing homes and consumed almost as much of the nursing assistants' time as did personal care activities in this study.

RELEVANCE TO CLINICAL PRACTICE

It is suggested that a training program for nursing assistants, especially for foreigners in community-based long-term care facilities, should be mandated to assure the quality of service.

A Proposal for a Voucher System for Long-Term Care in Hong Kong

Over the next three decades, due to a rapidly aging population coupled with the recent economic downturn, Hong Kong society will face severe challenges in establishing a sustainable aged care system. We identify four principles: the encouragement of family care, service integration, a mixed mode of financing, as well as a "small government and large market" approach to guide the development of aged care services. After a brief description of existing Hong Kong long-term care services for the elderly, we evaluate this service according to these principles. We examine how a proposed voucher system could tackle problems in the current system of long-term care. Finally, we propose solutions to alleviate the possible negative consequences of the voucher system and describe the essential preconditions for the full implementation of the system.

The association between quality of care and technical efficiency in long-term care

OBJECTIVE

To analyse the association between quality of care and technical (productive) efficiency in institutional long-term care wards for the elderly.

SETTING

One hundred and fourteen public health centre hospitals and residential homes in Finland.

STUDY DESIGN

Wards were divided into two categories according to their rank in the quality distribution, considering 41 quality variables separately. The technical efficiency scores of the good- and poor-quality groups were compared using cross-sectional data.

METHODS

Data envelopment analysis was used for calculating technical efficiency. The Mann-Whitney test and correlation coefficients were used to explore the association between quality and efficiency.

RESULTS

The wards where quality indicators indicated less pro-active (passive) nursing practice and more dependent patients-for instance, in terms of very high prevalence of bedfast residents or very high prevalence of daily physical restraints-performed more efficiently than the comparison group.

CONCLUSION

The results suggest that an association may exist between technical efficiency and unwanted dimensions of quality. Hence, the efficiency and quality of care are essential aspects of management and performance measurement in elderly care.

Cost-effectiveness of long-term care services in South Korea

This study examines the economic validity of home health-care and nursing-home care with the aim of providing guidelines for efficient use of limited health-care resources. Data collection took place over 8 months in 2001 (from May to December) at six institutions: two home health-care service providers and four nursing homes. A total of 99 stroke patients (49 from home health-care service providers and 50 from nursing homes) participated in the study. The findings indicate that patients with a lower level of physical/cognitive dependency (activities of daily living (ADL) >or= 9.3, cognitive performance scale (CPS) >or= 3.3) tend to benefit more from home health-care service, while those with a high dependency level (ADL < 9.3, CPS < 3.3) receive more suitable care at nursing homes. The study confirms that the economic value of health-care providers varies with the level of physical/cognitive function of the patients. That is, higher efficiency is achieved when those with a lower and higher levels of dependency are provided with home health-care services and nursing-home care, respectively. When assigning long-term care services, it is suggested that the level of physical/cognitive function of patients should be taken into consideration.

Care-needs certification in the long-term care insurance system of Japan

The introduction of Japan's long-term care insurance (LTCI) system in April 2000 has made long-term care an explicit and universal entitlement for every Japanese person aged 65 and older based strictly on physical and mental status. At the start of the program, more than two million seniors were expected to apply for services to approximately 3,000 municipal governments, which are the LTCI insurers. The LTCI implementation required a nationally standardized needs-certification system to determine service eligibility objectively, fairly, and efficiently. The current computer-aided initial needs-assessment instrument was developed based on data collected in a large-scale time study of professional caregivers in long-term care institutions. The instrument was subsequently tested and validated by assessing data of 175,129 seniors involved in the national model programs before the start of LTCI. The computer-aided initial assessment (an 85-item questionnaire) is used to assign each applicant to one of seven need levels. The Care Needs Certification Board, a committee of medical and other professionals, reviews the results. Three years after implementation, the LTCI system and its needs-assessment/certification system have been well accepted in Japan. Despite the overall successes, there remain challenges, including area variations, growing demands for services, and the difficulty of keeping the needs certification free of politics. The LTCI computer network that links municipalities and the central government is instrumental in continuously improving the needs-certification system. Future challenges include promoting evidence-based system improvements and building incentives into the system for various constituencies to promote seniors' functional independence.

Routine measurement of outcomes in Australia's public sector mental health services

Objective

This paper describes the Australian experience to date with a national 'roll out' of routine outcome measurement in public sector mental health services.

Methods

Consultations were held with 123 stakeholders representing a range of roles.

Results

Australia has made an impressive start to nationally implementing routine outcome measurement in mental health services, although it still has a long way to go. All States/Territories have established data collection systems, although some are more streamlined than others. Significant numbers of clinicians and managers have been trained in the use of routine outcome measures, and thought is now being given to ongoing training strategies. Outcome measurement is now occurring 'on the ground'; all States/Territories will be reporting data for 2003–04, and a number have been doing so for several years. Having said this, there is considerable variability regarding data coverage, completeness and compliance. Some States/Territories have gone to considerable lengths to 'embed' outcome measurement in day-to-day practice. To date, reporting of outcome data has largely been limited to reports profiling individual consumers and/or aggregate reports that focus on compliance and data quality issues, although a few States/Territories have begun to turn their attention to producing aggregate reports of consumers by clinician, team or service.

Conclusion

Routine outcome measurement is possible if it is supported by a co-ordinated, strategic approach and strong leadership, and there is commitment from clinicians and managers. The Australian experience can provide lessons for other countries.

Measuring the productive efficiency and clinical quality of institutional long-term care for the elderly

The authors consider the association between productive efficiency and clinical quality in institutional long-term care for the elderly. Cross-sectional data were collected from 122 wards in health-centre hospitals and residential homes in Finland in 2001. Productive efficiency was measured in terms of technical efficiency, which was defined as the unit's distance from the (best practice) production frontier. The analysis employed stochastic production frontier estimation, where technical inefficiency in the production function was specified to be a function of ward characteristics and clinical quality of care. Several quality indicators based on the Resident Assessment Instrument, such as prevalence of pressure ulcers and depression with no treatment, were used in the analysis. The results did not reveal systematic association between technical efficiency and clinical quality of care. However, the prevalence of pressure ulcers, indicating poor quality of care was associated with technical efficiency, a fact which highlights the importance of including quality measures in the assessment of efficiency in long-term care.

A national study showed that diagnoses varied by age group in nursing home residents under age 65

OBJECTIVE

Those aged <65 in nursing homes (NHs) are substantially different from elderly residents. This study uses data gathered from the Resident Assessment Instrument's Minimum Data Set (MDS) to describe these relatively rare residents.

STUDY DESIGN AND SETTING

The study uses MDS assessments of close to three-quarter million residents in nine states from 1994 to 1996. Residents are described within chronological age group (0-4, 5-14, etc.). Factor analysis is used to develop diagnostic clusters, and the prevalence of these clusters, functional problems, other conditions, and treatments is described for each group.

RESULTS

Thirteen diagnostic clusters describe nearly 85% of all NH residents and highlight differences between age groups. Pediatric residents are substantially more physically and cognitively impaired than young adult residents, and have the highest case mix burden of care. The youngest population primarily has diagnoses related to mental retardation and developmental disabilities, young adults have the highest prevalence of hemi- and quadriplegia, while older residents are typified by increasing prevalence of neurological diagnoses.

CONCLUSION

This study offers an initial description of NH residents <65. The prevalence of residents with unique conditions may suggest the need to modify the MDS assessment instrument.

A system of patient classification in long-term psychiatric inpatients: Resource Utilization Groups T-18 (RUG T-18)

This paper shows the application of a 'case mix' system (Resources Utilization Groups T18 or RUG-T18) to a Spanish long-term inpatient psychiatric sample.

OBJECTIVE

To examine the capacity of RUG-T18 to predict patient resource use (spent time of care) in a long-term psychiatric sample.

SUBJECTS AND RESEARCH DESIGN

Data included an assessment of 163 patients' characteristics, corresponding to groups of the RUG-T18, and detailed measurement of nursing staff care over a 24-h period.

RESULTS

'Severe behavioural problems' was the most frequent RUG-T18 category. There were significant differences in the spent time of care in the different groups and high variability in the distribution of time of care within groups and in the total sample.

CONCLUSIONS

The RUG T-18 system should be improved to become a useful case mix system in long-term psychiatric inpatients. The high variance intragroups could be minimized improving the psychopathological aspects of the system.

Recent trends in state nursing home payment policies

State Medicaid programs pay for a sizable portion of overall nursing home expenditures. The repeal of the Boren amendment in 1997 gave states greater freedom to set Medicaid nursing home policy. This study presents data from a comprehensive survey of state nursing home payment policies during 1999-2002. Aggregate inflation-adjusted Medicaid payment rates rose steadily, and there was no sizable increase in the adoption of other cost-cutting policies. Although these findings can be interpreted with some optimism from a nursing home financing perspective, areas of concern remain for state nursing home policy during the next several years.

Prevalence and characteristics of nursing homes residents requiring light-care

Rising nursing home (NH) costs and the poor quality of NH care make it important to recognize elders for whom NH care may be inappropriate. As a first step in developing a method to identify these elders, we examined the characteristics of NH residents requiring light-care and changes in their care level from NH admission to 12-months. Using data from the Missouri Minimal Data Set electronic database, we developed three care-level categories based on Resource Use Groups, Version III (RUG-III) and defined light-care NH residents as those requiring minimal assistance with late-loss ADLs (bed mobility, transfer, toilet use, or eating) and having no complex clinical problems. Approximately 16% of Missouri NH residents met the criteria for light-care. They had few functional problems with mobility, personal care, communication, or incontinence; approximately 33% had difficulty maintaining balance without assistance; and 50% of those admitted as light-care were still light-care at 12-months. Findings suggest that many NH residents classified as light-care by these criteria could be cared for in community settings offering fewer services than NHs.

Rurality and nursing home quality: results from a national sample of nursing home admissions

OBJECTIVES

We examined differences in quality of care among nursing homes in locales of varying degrees of rurality.

METHODS

We classified locales into 4 classes according to rurality. We analyzed a 10% sample of nursing home admissions in the United States in 2000 (n=198613) to estimate survival models for 9 quality indicators.

RESULTS

For postacute admissions, we observed significant differences in rates of decline for residents in facilities in large towns compared with urban areas, but differences in quality were both negative and positive. Among admissions for long-term or chronic care, rates of decline in 2 of 9 quality areas were lower for residents in isolated areas.

CONCLUSIONS

We observed significant differences in a number of quality indicators among different classes of nursing home locations, but differences varied dramatically according to type of admission. These differences did not exhibit the monotonicity that we would have expected had they derived solely from rurality. Also, quality indicators exhibited more similarities than differences across the 4 classes of locales. The results underscore the importance, in some instances, of emphasizing the effects of specific settings rather than some continuum of rurality and of moving beyond the assumption that nursing home residents constitute a homogeneous population.

Physical rehabilitation following medicare prospective payment for skilled nursing facilities

OBJECTIVE

To examine the effect of the Medicare prospective payment system (PPS) for skilled nursing facilities (SNF) on the delivery of rehabilitation therapy to residents.

DATA SOURCES

Resident-level data are based on the Resident Assessment Instrument Minimum Data Set for nursing facilities. All elderly residents admitted to SNFs in Michigan and Ohio in 1998 and 1999 form the study population (n=99,952).

STUDY DESIGN

A differences-in-differences identification strategy is used to compare rehabilitation therapy for SNF residents before and after a change in Medicare SNF payment. Logistic and linear regression analyses are used to examine the effect of PPS on receipt of physical, occupational, or speech therapy and total therapy time.

DATA EXTRACTION

Data for the present study were extracted from the University of Michigan Assessment Archive Project (UMAAP). One assessment was obtained for each resident admitted to nursing facilities during the study period.

PRINCIPAL FINDINGS

The introduction of PPS for all U.S. Medicare residents in July of 1998 was associated with specific targeting of rehabilitation treatment time to the most profitable levels of therapy. The PPS was also associated with increased likelihood of therapy but less rehabilitation therapy time for Medicare residents.

CONCLUSIONS

The present results indicate that rehabilitation therapy is sensitive to the specific payment incentives associated with PPS.

A systems framework for evaluating nursing care quality in nursing homes

Given the ongoing concerns about the quality of care in nursing homes, a theoretical framework to guide a systems approach to quality is important. Existing frameworks either do not model causality, or do so in a linear fashion in which the actual linkages between components of quality may not be well specified. Through a review of frameworks for nursing home quality, and empirical studies on the subject, the authors construct a framework for nursing home quality that links contextual components of quality with structure, structure with process, and process with outcomes, focusing on nursing care quality. Intrastructural relationships and feedback mechanisms are also modeled. The framework is matched with a discussion of multilevel structural equation analysis for statistical application. Future research should expand the framework to include non-nursing components of quality.

Effects of Medicare payment changes on nursing home staffing and deficiencies

OBJECTIVE

To investigate the effects of Medicare's Prospective Payment System (PPS) for skilled nursing facilities (SNFs) and associated rate changes on quality of care as represented by staffing ratios and regulatory deficiencies.

DATA SOURCES

Online Survey, Certification and Reporting (OSCAR) data from 1996-2000 were linked with Area Resource File (ARF) and Medicare Cost Report data to form a panel dataset.

STUDY DESIGN

A difference-in-differences model was used to assess effects of the PPS and the BBRA (Balanced Budget Refinement Act) on staffing and deficiencies, a design that allows the separation of the effects of the policies from general trends. Ordinary least squares and negative binomial models were used.

DATA COLLECTION METHODS

The OSCAR and Medicare Cost Report data are self-reported by nursing facilities; ARF data are publicly available. Data were linked by provider ID and county.

PRINCIPAL FINDINGS

We find that professional staffing decreased and regulatory deficiencies increased with PPS, and that both effects were mitigated with the BBRA rate increases. The effects appear to increase with the percent of Medicare residents in the facility except, in some cases, at the highest percentage of Medicare. The findings on staffing are statistically significant. The effects on deficiencies, though exhibiting consistent signs and magnitudes with the staffing results, are largely insignificant.

CONCLUSIONS

Medicare's PPS system and associated rate cuts for SNFs have had a negative effect on staffing and regulatory compliance. Further research is necessary to determine whether these changes are associated with worse outcomes. Findings from this investigation could help guide policy modifications that support the provision of quality nursing home care.

Living with Huntington's disease: Need for supportive care

Huntington's disease is a genetic, neurological disorder characterized by mid-life onset, involuntary movements, cognitive decline, behavioral disturbance, and inexorable progression. The impact of Huntington's disease is devastating for individuals and their families as it is a disease with a long trajectory; many young people are aware that they may develop the illness for years before there are obvious symptoms. There is therefore ample opportunity to plan and choreograph the care and supportive services for people with Huntington's disease and their families. The present study was conducted to explore the needs for palliative (supportive) care service provision of people with Huntington's disease and their families/informal carers. Six people with the disease, 19 informal carers and seven health care workers with specialized knowledge took part in individual, semistructured interviews, which were analyzed thematically. Themes were: (i). adjusting to the impact of the illness; (ii). surviving the search for essential information; (iii). gathering practical support from many sources; (iv). bolstering the spirit; (v). choreographing individual care and; (vi). fearing the future. Our findings demonstrate that palliative care services for people with Huntington's disease and their informal carers need to provide expert psychological and practical support and perhaps most importantly, be flexible, adequately planned and choreographed.

Daily Pain That Was Excruciating at Some Time in the Previous Week: Prevalence, Characteristics, and Outcomes in Nursing Home Residents

OBJECTIVES

To examine the prevalence, correlates, and consequences of nursing home (NH) staff reports of "excruciating" level of pain at some time in the previous week in persons with daily pain reported on the Minimum Data Set (MDS).

DESIGN

Cross-sectional study.

SETTING

NHs in the United States.

PARTICIPANTS

A total 2,138,442 persons who resided in 15,745 nursing homes in the United States.

MEASUREMENTS

Pain reported as daily and at its most excruciating in the previous week on the MDS at initial and follow-up assessment. Associations were examined with demographic characteristics, functioning, and measures of disease burden reported on the MDS.

RESULTS

NH staff noted that 80,512 (3.7%) of residents had daily pain that was at one or more times excruciating in the previous week. This level of pain was more prevalent in younger residents. Nearly two-thirds (62.1%) of persons with this level of pain were no longer independent in activities of daily living, but 48.8% were rated to have normal cognitive status. In contrast, those without daily pain that was sometimes excruciating were less likely to be cognitively intact (25.7%P<.001) and less likely to have declined in their functioning (30.1%, P=.001). More than one in five with daily pain that was excruciating at times had a cancer diagnosis, and 21.5% experienced weight loss. Of the 24,300 persons with a second assessment, 10,284 (42.3%) still had excruciating pain at some time in the previous week.

CONCLUSION

NH residents with daily pain that was sometimes excruciating were younger and seriously ill with functional decline and weight loss. Too often, persons remain in this level of pain.

A comprehensive clinical assessment tool to inform policy and practice: applications of the minimum data set

The Minimum Data Set (MDS) for nursing home (NH) resident assessment, designed to assess elders functional status and care needs, exemplifies how the information needs of clinical practice are congruent with those of research. Building on a review of the published literature, this article describes the development of the MDS, its reliability and validity testing, as well as the variety of different policy and research uses to which it has been applied. Interrater reliability of items and internal consistency of MDS summary scales is generally good to excellent. Validation studies reveal good correspondence to research quality instruments for cognition, activities of daily living, and diagnoses with more variable results for vision, pain, mood, and behavior scales. To date, no consistent evidence suggests that applications of MDS data for case-mix reimbursement and quality indicator monitoring systematically bias the data. Although facility variation in data quality could compromise some applications, creation of the MDS as a clinical tool for care planning provides an example of how assessment tools with clinical use can be used in administrative databases for research and policy applications.

Nursing home staffing and quality under the nursing home reform act

PURPOSE

We examine whether the Nursing Home Reform Act (NHRA) improved nursing home staffing and quality.

DESIGN AND METHODS

Data from 5,092 nursing homes were linked across the 1987 Medicare/Medicaid Automated Certification System and the 1993 Online Survey, Certification and Reporting system. A dummy-year model was used to examine the effects of the NHRA on pressure ulcers, physical restraints, and urinary catheters, and a first-difference approach to fixed-effects regression analyses was used to estimate the effects of time-varying staffing on the quality of care.

RESULTS

Overall, we found a significant increase in nursing home staffing levels from 1987 to 1993. Moreover, after controlling for other facility, resident, market, and state factors, there was a significant decrease in the proportion of residents with pressure ulcers, physical restraints, and urinary catheters following the implementation of the NHRA. Across all facilities, the increase in staffing was not directly related to the improvement in quality over the period of our study, but there was a positive relationship between registered nurse staffing and quality for facilities that were particularly deficient prior to the NHRA.

IMPLICATIONS

Following the NHRA, quality improvements were found in nursing homes nationwide, and these results suggest that part of this improvement was due to the quality and staffing regulations within the NHRA.

Risk Adjusting Rehabilitation Outcomes

The complexity and mix of rehabilitation patients varies across clinicians and institutions. Comparisons of outcomes across providers must therefore adjust for differences in risk factors across patient populations. Research on risk adjustment has generally focused on acute care hospital outcomes, although techniques for risk adjusting financial outcomes are fairly well developed in rehabilitation, primarily to support Medicare and other prospective payment systems. This article reviews important methodologic issues in risk adjusting rehabilitation outcomes in observational studies of routine clinical practice or for management, such as assessing quality or costs of care. Risk adjusting rehabilitation outcomes is more difficult than risk adjusting other clinical results, such as outcomes of many acute care services. At the outset, characterizing rehabilitation interventions is frequently difficult. Furthermore, outcomes are diverse and depend on myriad factors, including patients' physical and cognitive abilities, underlying medical diseases, sensory and emotional factors, willingness to participate in care, and supportive environments. No risk-adjustment approach can control for every factor affecting outcomes of care. Knowing which risk factors are missing helps guide interpretation of the results and determines how well risk-adjusted outcomes fairly compare providers or treatments.

An Australian casemix classification for palliative care: lessons and policy implications of a national study

OBJECTIVES

To provide a nontechnical discussion of the development of a palliative care casemix classification and some policy implications of its implementation.

SAMPLE

3866 palliative care patients who, in a three month period, had 4596 episodes of care provided by 58 palliative care services in Australia and New Zealand.

METHOD

A detailed clinical and service utilization profile was collected on each patient with staff time and other resources measured on a daily basis. A statistical summary of the clinical variables was compiled as the first stage of the analysis.

RESULTS

Palliative care phase was found to be a good predictor of resource use, with patients fairly evenly distributed across the five categories. Clients treated in an inpatient setting had poorer function and higher symptom severity scores than those treated in an ambulatory setting, a result that is not surprising in this Australian setting.

DISCUSSION

Implementation of the resultant AN-SNAP classification has been proceeding since 1998 in some Australian jurisdictions. The development and implementation of a classification such as AN-SNAP provides the possibility of having a consistent approach to collecting palliative care data in Australia as well as a growing body of experience on how to progressively improve the classification over time.

An Australian casemix classification for palliative care: technical development and results

OBJECTIVES

To develop a palliative care casemix classification for use in all settings including hospital, hospice and home-based care.

SAMPLE

3866 palliative care patients who, in a three-month period, had 4596 episodes of care provided by 58 palliative care services in Australia and New Zealand.

METHOD

A detailed clinical and service utilization profile was collected on each patient with staff time and other resources measured on a daily basis. Each day of care was costed using actual cost data from each study site. Regression tree analysis was used to group episodes of care with similar costs and clinical characteristics.

RESULTS

In the resulting classification, the Australian National Sub-acute and Non-acute Patient (AN-SNAP) Classification Version 1, the branch for classifying inpatient palliative care episodes (including hospice care) has 11 classes and explains 20.98% of the variance in inpatient palliative care phase costs using trimmed data. There are 22 classes in the ambulatory palliative care branch that explains 17.14% variation in ambulatory phase cost using trimmed data.

DISCUSSION

The term 'subacute' is used in Australia to describe health care in which the goal--a change in functional status or improvement in quality of life--is a better predictor of the need for, and the cost of, care than the patient's underlying diagnosis. The results suggest that phase of care (stage of illness) is the best predictor of the cost of Australian palliative care. Other predictors of cost are functional status and age. In the ambulatory setting, symptom severity and the model of palliative care are also predictive of cost. These variables are used in the AN-SNAP Version 1 classification to create 33 palliative care classes. The classification has clinical meaning but the overall statistical performance is only moderate. The structure of the classification allows for it to be improved over time as models of palliative care service delivery develop.

Payer incentives and physical rehabilitation therapy for nonelderly institutional long-term care residents: evidence from Michigan and Ontario

OBJECTIVE

To examine the effect of payment incentives on the provision of rehabilitation therapy to non elderly nursing home residents.

DESIGN

Retrospective cross-sectional study.

SETTING

Nursing homes in Michigan or complex continuing care facilities in Ontario, Canada, in 1998 or 1999.

PARTICIPANTS

Non elderly nursing home residents (N=5189) admitted to nursing homes.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The effect of payment on access to physical therapy (PT) and occupational therapy (OT) and total weekly time for each therapy type.

RESULTS

A Medicare policy change from cost-based to a patient-specific case-mix payment method was associated with greater likelihood of receiving OT but reduced weekly minutes of PT and OT provided to residents. Medicare cost-based and private insurance were associated with greater likelihood of receiving OT and PT and more therapy time for both types of therapy compared with private-pay residents. Global budget payment was associated with greater access to PT but fewer weekly minutes of OT and PT.

CONCLUSIONS

Little information exists to describe the characteristics and treatment of non elderly nursing home residents. This study found that many of these residents received rehabilitation and that residents whose care was paid for by more generous payers, such as Medicare, received more therapy than those paid for by less generous payers.