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

Effect of State Medicaid Reimbursement Rates on Hospitalizations from Nursing Homes

OBJECTIVES

To estimate the effect of state Medicaid nursing home reimbursement rates on hospitalizations of nursing home residents.

DESIGN

Cross-sectional sample of nongovernment-owned nursing homes with 25 beds or more in one Metropolitan Statistical Area in each of 10 states in 1993, with 6 months follow-up on mortality and hospitalizations.

SETTING

Two hundred fifty-three nursing homes.

PARTICIPANTS

Eight to 16 randomly selected residents from each facility, totaling 2,080.

MEASUREMENTS

Minimum Data Set assessments conducted by research nurses at baseline. A three-category 6-month outcome was defined as (1) any hospitalization; for those not hospitalized, (2) death versus (3) alive in the facility.

RESULTS

Using multinomial logistic regression, adjusted to survey design, controlling for resident and facility characteristics, a 10 dollar increase in 1993 Medicaid reimbursement rate above the mean rate of approximately 75 dollars resulted in a 9% reduction in a resident's risk of hospitalization (P<.05).

CONCLUSION

State Medicaid reimbursement rates appear to affect clinical decisions regarding the need for hospital admission and thresholds for nursing home use. The findings from this study reemphasize the importance of properly aligning state Medicaid and federal Medicare long-term care policies because, currently, states have no incentive to increase reimbursement rates to avoid hospitalization.

Nursing Home Quality, Cost, Staffing, and Staff Mix

PURPOSE

The purpose of this study was to describe the processes of care, organizational attributes, cost of care, staffing level, and staff mix in a sample of Missouri homes with good, average, and poor resident outcomes.

DESIGN AND METHODS

A three-group exploratory study design was used, with 92 nursing homes randomly selected from all nursing homes in Missouri and classified into resident outcome groups. Resident outcomes were measured by use of quality indicators derived from nursing home Minimum Data Set resident assessment data. Cost and staffing information were derived from Medicaid cost reports. Participant observation methods were used to describe the care delivery processes.

RESULTS

In facilities with good resident outcomes, there are basics of care and processes surrounding each that staff consistently do: helping residents with ambulation, nutrition and hydration, and toileting and bowel regularity; preventing skin breakdown; and managing pain. The analysis revealed necessary organizational attributes that must be in place in order for those basics of care to be accomplished: consistent nursing and administrative leadership, the use of team and group processes, and an active quality improvement program. The only facility characteristic across the outcome groups that was significantly different was the number of licensed beds, with smaller facilities having better outcomes. No significant differences in costs, staffing, or staff mix were detected across the groups. A trend in higher total costs of 13.58 dollars per resident per day was detected in the poor-outcome group compared with the good-outcome group.

IMPLICATIONS

For nursing homes to achieve good resident outcomes, they must have leadership that is willing to embrace quality improvement and group process and see that the basics of care delivery are done for residents. Good quality care may not cost more than poor quality care; there is some evidence that good quality care may cost less. Small facilities of 60 beds were more likely to have good resident outcomes. Strategies have to be considered so larger facilities can be organized into smaller clusters of units that could function as small nursing homes within the larger whole.

Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care

Nursing home care is currently a two-tiered system. The lower tier consists of facilities housing mainly Medicaid residents and, as a result, has very limited resources. The nearly 15 percent of U.S. nonhospital-based nursing homes that serve predominantly Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies. They are more likely to be terminated from the Medicaid/Medicare program, are disproportionately located in the poorest counties, and are more likely to serve African-American residents than are other facilities. The public reporting of quality indicators, intended to improve quality through market mechanisms, may result in driving poor homes out of business and will disproportionately affect nonwhite residents living in poor communities. This article recommends a proactive policy stance to mitigate these consequences of quality competition.

Les soins de longue durée aux personnes âgées: Choix d'un système clinico-administratif dans le contexte d'un réseau de soins intégrés

For the past 10 years, in long-term care systems, we have witnessed the accelerated deployment of casemix management systems. A casemix is formed by clusters, defined by individual characteristics that explain similar resource use. However, certain questions regarding the development of these systems must be raised. Moreover, none of these systems was developed in the context of an integrated care organization that can track the progress of a dependent elderly person through every kind of care arrangement available—from own home, through intermediate facility, to long-term care institution. This article emphasizes the necessity of being well informed about the features of existing systems, in order to choose or develop the system that best answers the goals of a particular health care system. Finally, it underlines important elements that should be considered in each step of the development of a casemix system in this context.

Getting the Basics Right: Care Delivery in Nursing Homes

In this study, the key exemplar processes of care in facilities with good resident outcomes were described. It follows that with description of these processes, it is feasible to teach facilities about the basics of care and the ways to systematically approach care so they can adopt these care processes and improve resident outcomes. However, for this to happen key organizational commitments must be in place for staff to consistently provide the basics of care. Nursing leadership must have a consistent presence over time, they must be champions of using team and group processes involving staff throughout the facility, and they must actively guide quality improvement processes. Administrative leadership must be present and express the expectation that high quality care is expected for residents, and that workers are expected to contribute to the quality improvement effort. If facilities are struggling with achieving average or poor resident outcomes, they must first make an effort to find nursing and administrative leaders who are willing to stay with the organization. These leaders must be skilled with team and group processes for decision-making and how to implement and use a quality improvement program to improve care. These leaders must be skilled at building employee relations and at retention strategies so residents are cared for by consistent staff who know them. The results of this study illustrate the simplicity of the basics of care that residents in nursing facilities need. The results also illustrate the complexity of the care processes and the organizational systems that must be in place to achieve good outcomes. Achieving these outcomes is the challenge facing those currently working in and leading nursing facilities.

Medicaid case-mix nursing home reimbursement in three states

Case-mix nursing facility payment raises issues of access, quality, equity, and cost. Case-mix should better match payment to costs, improve access, and provide incentives to increased staffing and quality of care; but it may also increase costs. This paper reports analysis of Medicaid cost-report data from three case-mix states. Case-mix did not discourage capacity building and was more equitable for providers. Medicaid access declined in one state but increased in another. There were shifts toward greater skilled care in two states, with evidence of greater focus of resources on patient care. Case-mix showed no evidence of cost-constraint and some signs of increased costs. Whether such mixed outcomes are viable in the current era remains to be seen.

Nursing Indicators of Quality in Nursing Homes

This article is an examination of websites providing consumer information about nursing home quality of care, including existing federal and state websites and a new comprehensive website designed for California nursing homes. The article focuses on research and information related to nursing indicators of quality used for the California nursing home website. It includes staffing levels (e.g., hours, types, turnover rates), financial indicators (e.g., direct care expenditures, wages, benefits), and complaints and deficiencies. Overall, nursing indicators of quality are a major approach for evaluating nursing home quality and can be used by nurses, consumers, and advocates.

Nursing home staffing, turnover, and case mix

This study examined the predictors of total nurse and registered nurse (RN) staffing hours per resident day separately in all free-standing California nursing homes (1,555), using staffing data from state cost reports in 1999. This study used a two-stage least squares model, taking into account nursing turnover rates, resident case mix levels, and other factors. As expected, total nurse and RN staffing hours were negatively associated with nurse staff turnover rates and positively associated with resident case mix. Facilities were resource dependent in that a high proportion of Medicare residents predicted higher staffing hours, and a higher proportion of Medicaid residents predicted lower staffing hours and higher turnover rates. Nursing assistant wages were positively associated with total nurse staffing hours. For-profit facilities and high-occupancy rate facilities had lower total nurse and RN staffing hours. Medicaid reimbursement rates and multifacility organizations were positively associated with RN staffing hours.

Long-term care research and policy

This article provides a framework for understanding how long-term care (LTC) research contributes to policy, develops a typology of research contributions to policy with examples of each type, and suggests ways to ensure that contributions continue in the future. The article draws on in-depth interviews with LTC experts working at the interface between research and policy, as well as a small, informal Internet survey and the relevant political science and health policy literature. LTC research makes important contributions to policy, but its contributions easily go unrecognized because they are subtle and often depend on research investments made many years before policy is affected. Thus, it is important to consider what investments in LTC research initiatives and infrastructure are needed to ensure the future contributions of research to policy and to identify barriers to funding such investments. A number of steps that researchers can take to enhance the future contribution of research to LTC policy are proposed.

Outcomes of rehabilitation services for nursing home residents

OBJECTIVE

To examine survival and community discharge outcomes related to rehabilitation services among patients admitted to nursing homes before the implementation of the Balanced Budget Amendment of 1997.

DESIGN

Retrospective cohort.

SETTING

A total of 945 Medicaid-certified nursing homes in Ohio.

PARTICIPANTS

A total of 11,150 patients admitted for the first time to a nursing home from 1994 to 1996.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Community discharge and survival rates among patients who did or did not receive rehabilitation services, using multivariable techniques to adjust for patients' propensity to receive rehabilitation and for other potential confounders. In secondary analyses, we also examined dose-response effects and analyzed the effects of rehabilitation when patients were divided into 5 diagnostic groups (stroke, hip fracture, congestive heart failure, chronic lung disease, other).

RESULTS

Rehabilitation was provided to 58% of the patients and was associated with higher community discharge rates (relative risk=1.48; 95% confidence interval [CI], 1.40-1.57) and a lower hazard of death (hazard ratio=.81; 95% CI,.75-.88). Dose-response effects were observed for both outcomes (P<.001) among patients receiving rehabilitation. Rehabilitation was associated with improved community discharge rates in each of the 5 diagnostic groups.

CONCLUSIONS

New reimbursement policies that discourage the provision of rehabilitation services may have adverse effects on patients, their families, and societal costs of care.

Does quality of care lead to better financial performance?: the case of the nursing home industry

The study describes the relationship between quality of care and financial performance (operating profit margin) as it pertains to the nursing home industry. We found that nursing homes that produce better outcomes and process of care were able to achieve lower patient care costs and report better financial performance.

Cognitive impairment and resource use of nursing home residents: a structural equation model

BACKGROUND

Only a few studies have examined relationships between cognitive impairment and resource use of nursing home residents, and these studies have yielded mixed results.

METHODS

To develop and test structural equation models for relationships between cognitive impairment, covariates, and resource use of nursing home residents on Alzheimer special care units (SCUs) and conventional units.

RESEARCH DESIGN

Analysis of data obtained in 1999 from an Indiana nursing facility time study that measured resident-specific direct care minutes per day, and assessment data from the Minimum Data Set (version 2.0).

PARTICIPANTS

Participants were 1290 residents without specialized nursing requirements or licensed therapies: 447 drawn from 22 SCUs in 16 facilities, 485 from 16 conventional units in the same facilities, and 358 from units in 13 facilities without SCUs.

MEASURES

Direct care resource use (weighed minutes/d), Cognitive Performance Scale, activities of daily living (ADLs), clinically complex conditions, daily behavioral problems, physical restraints, psychotropic medication, and Alzheimer or dementia diagnosis.

RESULTS

Cognitive impairment had a substantial indirect effect on resource use in facilities with and without SCUs. This effect was mediated largely through ADL dependency and SCU placement. Severity of cognitive impairment was strongly related to ADL dependency, and ADL, in turn, was a strongly related to resource use. Also, residents on SCUs used significantly more direct care resources than residents on conventional units.

CONCLUSIONS

This study demonstrates relationships between cognitive impairment, covariates, and resource use for nursing home residents on SCUs and conventional units. It also raises issues about reimbursement for care of dementia residents.

What would VA nursing home care cost? Methods for estimating private sector payments

OBJECTIVES

To describe the methods used to validate Veterans Health Administration (VA) nursing home acuity data and estimate hypothetical payments for nursing home patients in VA-based and community-based units.

METHODS

For a sample of VA-based and community-based nursing home patients at six sites, auditors validated the resource utilization classifications from the most recent complete full or quarterly assessments. Scores were averaged to obtain an acuity index for each nursing home population. Per diem rates were calculated for a fully phased-in Medicare prospective payment system, a transitional prospective payment system for free-standing and hospital-based nursing homes, and average national Medicaid benefits based on VA patients in community nursing facilities. Days of care came from each site's end of year gains and losses financial statement. Nursing home estimates were calculated by multiplying together the number of days of care, the per diem, and the acuity index.

RESULTS

The VA acuity information was valid. Generally, veterans' dependencies and depression were underscored (similar to the practice for non-VA patients). The cost of patients' nursing home care absent VA facilities would depend on the types of nursing homes in which they were placed. The most costly option (hospital-based facilities with cost exemptions) would cost 3.5 times the least costly. Only the Medicaid-only estimate was lower than actual VA expenditures.

DISCUSSION

Future research on nursing homes must relate quality to the cost of care to help policy makers assess the value of different options for providing that care.

Understanding the roles of registered general nurses and care assistants in UK nursing homes

BACKGROUND

The recent government decision to fund the costs of Registered nursing time in long-term care facilities in England through the Registered Nurse Contribution to Care renders the need to distinguish the role of Registered General Nurses (RGNs) from that of Care Assistants (CAs) in nursing homes increasingly important.

AIM

The objective of this qualitative study was to obtain an in-depth understanding of the main differences between the roles and functions of RGNs and CAs working in nursing homes in the United Kingdom (UK).

DESIGN

Data were collected through interviews with nine RGNs and 12 CAs employed in four different nursing homes across England.

FINDINGS

Our findings suggest that RGNs have difficulty defining and limiting their roles because they have all-embracing roles, doing everything and anything within the home. By contrast, CAs define their role in terms of what they are not allowed to do. This difficulty in limiting their role, in addition to their sense of professional accountability for residents' care, leads RGNs to experience difficulty in delegating tasks to CAs. Both RGNs and CAs agreed that an increase in the number of assistive staff is needed to provide residents with good quality care and suggested that a measure of resident dependency would be a good method by which to determine staffing levels.

CONCLUSIONS

We recommend that job descriptions that clearly define the roles and responsibilities of both RGNs and CAs are developed so that caregivers at all levels understand each others' roles and work together to co-ordinate, plan and provide residents' care.

Nursing home case-mix instruments: validation of the RUG-III system in Italy

BACKGROUND AND AIMS

The current Italian reimbursement system for long-term care does not adequately consider the great variability in the health and functional status of older persons who are admitted to long-term care institutions. Furthermore, no procedure is implemented to monitor the quality of care provided to older residents. We conducted this study to verify whether the RUG-III (Resource Utilization Groups-version III), a tool for assessing the case-mix of nursing home residents, which is widely used in the United States and in many European countries, can be effectively used in the Italian health care system.

METHODS

We administered an Italian version of the RUG-III to 1000 older residents of 11 intermediate- and long-term care institutions. We also collected objective information on the amount of care provided directly or indirectly to each resident by nurses, physical therapists, and other health professionals.

RESULTS

The RUG-III 44 group classification system explained 61 and 44% of the variance in rehabilitative and nursing wage-adjusted care time, respectively.

CONCLUSIONS

Our findings provide strong evidence that the RUG-III classification, applied to Italian intermediate- and long-term care institutions, provides a robust estimate of the amount of nursing and rehabilitation resources consumed by older residents.

Rehabilitation therapy in skilled nursing facilities: effects of Medicare's new prospective payment system

In 1998 the Centers for Medicare and Medicaid Services (CMS) began phasing in a new prospective payment system (PPS) for Medicare payments to skilled nursing facilities (SNFs). I examine the effects of the new PPS on the level of rehabilitation therapy provided in SNFs. The percentage of residents of freestanding SNFs receiving extremely high levels of rehabilitation therapy dropped significantly, and the percentage receiving moderate levels increased. Freestanding SNFs, particularly for-profits, dramatically altered the services they provided in response to new financial incentives. This responsiveness underscores the importance of efforts now under way to refine the SNF PPS.

Designing a report card for nursing facilities: what information is needed and why

PURPOSE

This article presents a rationale and conceptual framework for making comprehensive consumer information about nursing facilities available. Such information can meet the needs of various stakeholder groups, including consumers, family/friends, health professionals, providers, advocates, ombudsman, payers, and policy makers.

DESIGN AND METHODS

The rationale and framework are based on a research literature review of key quality indicators for nursing facilities.

RESULTS

The findings show six key areas for information: (a) facility characteristics and ownership; (b) resident characteristics; (c) staffing indicators; (d) clinical quality indicators; (e) deficiencies, complaints, and enforcement actions; and (f) financial indicators. This information can assist in selecting, monitoring, and contracting with nursing facilities.

IMPLICATIONS

Model information systems can be designed using existing public information, but the information needs to be enhanced with improved data.

Sociodemographic and health characteristics of older Chinese on admission to a nursing home: a cross-racial/ethnic study

OBJECTIVES

To investigate sociodemographic characteristics (SDCs) and health status of older Chinese newly admitted to a nursing home (NH) and to compare them with the characteristics of residents from other racial/ethnic groups.

DESIGN

Secondary analysis of the admission Minimum Data Set Plus (MDS+).

SETTING

A New York City municipal NH near Chinatown.

PARTICIPANTS

Two hundred fifty-eight (125 Chinese, 57 white, 53 Hispanic, and 23 black) of 292 residents consecutively admitted from November 1992 to May 1997 were selected after excluding those younger than 60 or transferred from another NH.

MEASUREMENTS

SDCs, health status parameters (cognitive performance, physical functioning, mood/behavior patterns, and psychosocial well-being), and morbidity information (most-frequent diagnoses/conditions and medication use) documented in or generated from the MDS+.

RESULTS

The majority of these Chinese were first-generation immigrants and spoke primarily Cantonese or Mandarin Chinese. Compared with whites, they were more likely to be married, less likely to have lived alone, more likely to be using Medicaid, less likely to make medical decision alone, and more likely to depend on family members for decision-making. Nearly three-quarters of Chinese had cognitive impairment. There was an underdiagnosis of dementia in the Chinese subjects on admission. Severe dependence in activity of daily living was identified in more than one-third of Chinese. Fewer Chinese were using psychotropic medications on admission than the whites. Similar to other groups, many of the Chinese subjects were incontinent of bowel and bladder and had chewing or swallowing problems, hypertension, anemia, and stroke.

CONCLUSION

This is the first systematic report of the SDCs and health status of a group of newly admitted older Chinese to an urban NH in the United States using the Minimum Data Set database. These findings suggest that Chinese residents are as frail as other racial/ethnic residents on admission. NHs caring for older Chinese need to be sensitive to the presence of dementia, and require a staff that can speak Cantonese and Mandarin Chinese and is comfortable negotiating with families who are more likely to be the designated decision makers.

Federal and state nursing facility websites: just what the consumer needs?

Since the introduction of the Medicare Nursing Home Compare website in 1999, some states have begun to develop their own websites to help consumers compare nursing facilities (NFs). This article presents a brief conceptual framework for the type of information needed for an Internet-based information system and analyzes existing federal and state NF websites, using data collected from a survey completed in 2002. Twenty-four states and the District of Columbia have a variety of information on NFs, similar to the information on the Medicare website. Information on characteristics and deficiencies of a facility is the most commonly available, but a few states have data on ownership, staffing indicators, quality indicators, complaints, and enforcement actions. Other types of data, such as resident characteristics, staff turnover rates, and financial indicators, are generally not available. Although many states are making progress toward providing consumers with information, there are gaps that exist, which if filled, could provide consumers with a better tool for facility selection and monitoring the quality of care.

Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison

OBJECTIVE

To compare the costs associated with caring for severely demented residents nursing homes with and without feeding tubes.

DESIGN

Retrospective cohort study.

SETTING

A 700-bed long-term care facility in Boston Participants: Nursing home residents aged 65 years and over with advanced dementia and eating problems for whom long-term feeding tube had been discussed as a treatment option.

MEASUREMENTS

Costs were compared over the 6 months that followed the tube-feeding decision for those residents who did and did not undergo feeding tube placement for the following items: nursing time, physician assessments, food, hospitalizations, emergency room visits, diagnostic tests, treatment with antibiotics and parenteral hydration, and feeding tube insertion.

RESULTS

Twenty-two subjects were included, 11 were tube-fed (mean age 84.3 years +/- 6.0) and 11 were hand-fed (mean age 90.2 years +/- 9.1). The daily costs of nursing home care were higher for the residents without feeding tubes compared with residents with tubes ($4219 +/- 1546 vs $2379 +/- 1032, P = 0.006). Nonetheless, Medicaid reimbursement to nursing homes in at least 26 states is higher for demented residents who are tube-fed than for residents with similar deficits who are not tube-fed. Costs typically billed to Medicare were greater for the tube-fed patients ($6994 +/- 5790 vs. $959 +/- 591, P < 0.001), primarily because of the high costs associated with initial feeding tube placement and hospitalizations or emergency rooms visits for the management of complications of tube-feeding.

CONCLUSIONS

Nursing homes are faced with a potential fiscal incentive to tube-feed residents with advanced dementia: tube-fed residents generate a higher daily reimbursement rate from Medicaid, yet require less expensive nursing home care. From a Medicare perspective, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications. Further work is needed to determine whether these potential financial incentives influence tube-feeding decisions in practice.

Competitive spillovers across non-profit and for-profit nursing homes

The importance of non-profit institutions in the health care sector has generated a vast empirical literature examining quality differences between non-profit and for-profit nursing homes. Recent theoretical work has emphasized that much of this empirical literature is flawed in that previous studies rely solely on dummy variables to capture the effects of ownership rather than accounting for the share of non-profit nursing homes in the market. This analysis considers whether competitive spillovers from non-profits lead to higher quality in for-profit nursing homes. Using instrumental variables to account for the potential endogeneity of non-profit market share, this study finds that an increase in non-profit market share improves for-profit and overall nursing home quality. These findings are consistent with the hypothesis that non-profits serve as a quality signal for uninformed nursing home consumers.

The economic implications of case-mix Medicaid reimbursement for nursing home care

In recent years, there has been large growth in the nursing home industry in the use of case-mix adjusted Medicaid payment systems that employ resident characteristics to predict the relative use of resources in setting payment levels. Little attention has been paid to the access and quality incentives that these systems provide in the presence of excess demand conditions due to certificate-of-need (CON) and construction moratoria. Using 1991 to 1998 panel data for all certified U.S. nursing homes, a fixed-effects model indicates that adoption of a case-mix payment system led to increased access for more dependent residents, but the effect was modified in excess demand markets. Quality remained relatively stable with the introduction of case-mix reimbursement, regardless of the presence of excess demand conditions. These results suggest that CON and construction moratoria are still important barriers within the nursing home market, and recent quality assurance activities related to the introduction of case-mix payment systems may have been effective.

Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors

OBJECTIVES

Determine the relationship between a broad array of structure and process elements of nursing home care and (a) resident infection and (b) hospitalization for infection.

DESIGN

Baseline data were collected from September 1992 through March 1995, and residents were followed for 2 years; facility data were collected at the midpoint of follow-up.

SETTING

A stratified random sample of 59 nursing homes across Maryland.

PARTICIPANTS

Two thousand fifteen new admissions aged 65 and older.

MEASUREMENTS

Facility-level data were collected from interviews with facility administrators, directors of nursing, and activity directors; record abstraction; and direct observation. Main outcome measures included infection (written diagnosis, a course of antibiotic therapy, or radiographic confirmation of pneumonia) and hospitalization for infection (indicated on medical records).

RESULTS

The 2-year rate of infection was 1.20 episodes per 100 resident days, and the hospitalization rate for infection was 0.17 admissions per 100 resident days. Except for registered nurse (RN) turnover, which related to both infection and hospitalization, different variables related to each outcome. High rates of incident infection were associated with more Medicare recipients, high levels of physical/occupational therapist staffing, high licensed practical nurse staffing, low nurses' aide staffing, high intensity of medical and therapeutic services, dementia training, staff privacy, and low levels of psychotropic medication use. High rates of hospitalization for infection were associated with for-profit ownership, chain affiliation, poor environmental quality, lack of resident privacy, lack of administrative emphasis on staff satisfaction, and low family/friend visitation rates. Adjustment for resident sex, age, race, education, marital status, number of morbid diagnoses, functional status, and Resource Utilization Group, Version III score did not alter the relationship between the structure and process of care and outcomes.

CONCLUSIONS

The association between RN turnover and both outcomes underscores the relationship between nursing leadership and quality of care in these settings. The relationship between hospitalization for infection and for-profit ownership and chain affiliation could reflect policies not to treat acute illnesses in house. The link between social factors of care (environmental quality, prioritizing staff satisfaction, resident privacy, and facility visitation) and hospitalization indicates that a nonmedical model of care may not jeopardize, and may in fact benefit, health-related outcomes. All of these facility characteristics may be modifiable, may affect healthcare costs, and may hold promise for other, less-medical, forms of residential long-term care.

Prospective payment, prospective challenge

The Centers for Medicare and Medicaid Services has implemented an inpatient rehabilitation facility prospective payment system (IRF-PPS) based on case-mix groups (CMGs). The CMGs, now almost identical in structure to the Functional Independence Measure-Function-Related Groups (FIM-FRGs), will measure patients' functional severity by the FIM trade mark instrument, rather than by the Minimum Data Set for Post-Acute Care, as was initially planned. Although this late change in plans is a major triumph for physical medicine and rehabilitation and for the patients we serve, economic incentives inherent in the IRF-PPS may still transform inpatient rehabilitation as it is currently practiced in the United States. This commentary compares the CMGs with the FIM-FRGs; addresses the implications of the CMGs' implementation for patients, researchers, and clinicians; and highlights ways of adapting previous FIM-FRG applications and research to help meet the challenges presented by the new IRF-PPS.

The drive for quality care in US nursing homes in the era of the prospective payment system

The quality of nursing home care has often given rise to concern from many interested stakeholders. In the US, this has led to the implementation of a major legislative framework in the form of the Nursing Home Reform Act, which sought to improve the quality of care through regulation and inspections. Research has shown that certain elements of care have improved but much remains to be done. Additional pressure is now being placed on the nursing home sector through the introduction of a prospective payment system (PPS), which sets limits on reimbursement for services for Medicare-covered stays. It has been proposed that this new system of payment may lead to difficulties in accessing nursing home care for patients who are deemed to be costly, and initial assessments suggest that patients are now carefully screened before being admitted to nursing homes. This may have major implications for patients who require multiple and expensive drug therapy and other interventions. Although the Nursing Home Reform Act seeks to drive forward the quality agenda in nursing home care, research is urgently required to evaluate the impact of the PPS which may force this healthcare sector to emphasise reducing costs at the expense of residents' needs.

Long-term care funding in Canada: a policy mosaic

When Canada was founded, health care was delegated as a provincial responsibility. Although the federal government shares a portion of health care costs, it is not directly responsible for the planning, delivery, and governance of health services. The 1984 Canada Health Act set national standards for the provision of physician and hospital services, but it does not apply to home care and long-term care facilities. Consequently, each province has established a unique approach to long-term care, resulting in a health policy mosaic. This paper examines different approaches to funding long-term care with a particular emphasis on the impacts of regionalization and of the implementation of case-mix-based funding systems.

The Resident Assessment Instrument-Mental Health (RAI-MH): inter-rater reliability and convergent validity

An important challenge facing behavioral health services is the lack of good quality, clinically relevant data at the individual level. The article describes a multinational research effort to develop a comprehensive, multidisciplinary mental health assessment system for use with adults in facilities providing acute, long-stay, forensic, and geriatric services. The Resident Assessment Instrument-Mental Health (RAI-MH) comprehensively assesses psychiatric, social, environmental, and medical issues at intake, emphasizing patient functioning. Data from the RAI-MH are intended to support care planning, quality improvement, outcome measurement, and case mix-based payment systems. The article provides the first set of evidence on the reliability and validity of the RAI-MH.

Oral status, cognitive and functional capacity versus oral treatment need in nursing home residents: a comparison between assessments by dental and ward staff

OBJECTIVES

The aim of this study was to study the relationships between cognitive and functional capacity versus oral health and treatment need and to compare oral status assessments and oral treatment need, assessed by nurses and dental professionals, respectively.

DESIGN

Cross-sectional survey.

SETTING

Nursing home.

SUBJECTS

One hundred and ninety-two nursing home residents were examined in 1997.

MAIN OUTCOME MEASURES

Cognitive and functional capacity in different groups of residents regarding oral health and treatment need, measured by a comprehensive assessment with the Resident Assessment Instrument (RAI) and dental status in a separate examination protocol, recorded by a dentist.

RESULTS

There was a significant correlation between being dentate and having need of oral treatment. Those who were able to chew also had significantly better cognitive and functional capacity. Oral treatment need was identified most often by the dentist, intermediately by the RAI assessment and least frequently by the residents themselves.

CONCLUSIONS

Being dentate and having a loss of cognitive and functional capacity is predictive of oral treatment need among nursing home residents. Enhanced interaction between nurses and dental professionals needs to be promoted for better awareness of preventive measures and better regular oral care for frail and dependent elderly persons.

Nursing informatics. Applications for long-term care

Long-term care (LTC) settings, specifically nursing homes, have found it difficult to manage the regulatory process and provide quality resident care without computerization. Clinical information systems in the current health care environment, including LTC, need to provide five functions. These five functions are providing the legal record of care; supporting clinical decision-making; capturing costs for financial purposes; accumulating a database for administrative queries, quality assurance, and research; and supporting data exchange between systems. While computerization may have occurred in LTC, the application of the informatics concepts with nursing standardized languages and financial and database usage may not have occurred. To succeed in the current health care environment, nursing informatics concepts need to be implemented in LTC. As a result, the quality of care for older adults in nursing homes will be improved. The purpose of this article is to identify application for nursing informatics use in the LTC setting.

Access to postacute nursing home care before and after the BBA. Balanced Budget Act

Anecdotal reports in the wake of the Balanced Budget Act (BBA) of 1997 raised concerns about restricted access to postacute nursing facility care for Medicare beneficiaries requiring costly, medically complex services. Using all Medicare Part A hospital and nursing facility claims for providers in the state of Ohio and a refined method of identifying hospitalized beneficiaries who were the most at risk, we observed only a small decrease in the proportion of the costliest patients discharged to nursing facilities in 1999 compared with pre-BBA years. Average hospital length-of-stay increased only slightly in 1999, and there were no changes in rehospitalization rates for the costliest patient types. However, reduced rates of admission were concentrated in specific types of nursing facilities, suggesting a need to closely monitor the effects of ongoing post-BBA policy updates.

A screening system for Michigan's home- and community-based long-term care programs

PURPOSE

To develop a screening system for Michigan's MI Choice publicly funded home- and community-based services programs, to aid in identifying both individuals eligible for services and their most appropriate level of care (LOC).

DESIGN AND METHODS

Identify assessment items from the Minimum Data Set for Home Care (MDS-HC) assessment instrument that are predictive of five LOCs determined by expert care managers: nursing home, home care, intermittent personal care, homemaker, and information and referral (without services).

RESULTS

The algorithm based on approximately 30 client characteristics agrees with expert opinions substantially better (kappa =.62) than systems based on activities of daily living and instrumental activities of daily living only (kappa <.40).

IMPLICATIONS

The screening algorithm can be used both over the telephone to identify clients who will not be fully assessed (as they are unlikely to receive services) and in person to recommend the appropriate LOC.

Does investor-ownership of nursing homes compromise the quality of care?

Quality problems have long plagued the nursing home industry. While two-thirds of U.S. nursing homes are investor-owned, few studies have examined the impact of investor-ownership on the quality of care. The authors analyzed 1998 data from inspections of 13,693 nursing facilities representing virtually all U.S. nursing homes. They grouped deficiency citations issued by inspectors into three categories ("quality of care," "quality of life," and "other") and compared deficiency rates in investor-owned, nonprofit, and public nursing homes. A multivariate model was used to control for case mix, percentage of residents covered by Medicaid, whether the facility was hospital-based, whether it was a skilled nursing facility for Medicare only, chain ownership, and location by state. The study also assessed nurse staffing. The authors found that investor-owned nursing homes provide worse care and less nursing care than nonprofit or public homes. Investor-owned facilities averaged 5.89 deficiencies per home, 46.5 percent higher than nonprofit and 43.0 percent higher than public facilities, and also had more of each category of deficiency. In the multivariate analysis, investor-ownership predicted 0.679 additional deficiencies per home; chain-ownership predicted an additional 0.633 deficiencies per home. Nurse staffing ratios were markedly lower at investor-owned homes.

Stroke patients in nursing homes: eating, feeding, nutrition and related care

The purpose of this study was to explore eating, feeding and nutrition among stroke patients in nursing homes as described by their nurses and by assessments. Registered Nurses were interviewed about an individual stroke patient's state of health, care needs and nursing care received and nursing records were reviewed. Information on eating, feeding and nutrition was extracted from the interviews and nursing records. A comprehensive instrument, the Resident Assessment Instrument, was also used to assess these patients' state of health. The domains of eating, feeding and nutrition were focused on in this study. Manifest content analysis was used. The results showed that more than 80% of the stroke patients in nursing homes were assessed as having some sort of dependence in eating. According to the Registered Nurses, 22 out of 40 patients demonstrated different eating disabilities. The number of eating disabilities in individual patients ranged from 1 to 7, which emphasized the complexity of eating disabilities in stroke patients. Dysphagia was reported in almost one-fourth of the patients and 30% were described and/or assessed as having a poor food intake or poor appetite. The Registered Nurses' descriptions of the eating disabilities, nutritional problems and their care were often vague and unspecific. Only six weights were documented in the nursing records and there were no nutritional records. The findings highlight the importance of making careful observations and assessments, and of maintaining documentation about eating and nutrition early after a patient's arrival in the nursing home to enable appropriate care and promotion of health.

Why older adults with light care needs enter and remain in nursing homes

Many patients in nursing homes receive limited services. In 1996, approximately 17% of the 1.6 million nursing home residents received assistance with two or less activities of daily living (ADL). This descriptive study addressed this issue by investigating why residents with light care needs enter and remain in nursing homes. Residents with light care needs (N = 20) identified by directors of nursing were interviewed to elicit why they entered and remain in nursing homes. Their care level was estimated using the Minimum Data Set (MDS) and Resource Utilization Groups, Version III (RUG-III). In this study, older adults with light care needs who decide to enter and remain in nursing homes were found to be influenced by a prior hospitalization or a health event; the perceived inability to manage instrumental ADLs (IADLs), ADLs, or health monitoring at home; and lack of knowledge about alternatives to nursing home care. This study demonstrates the vital role nurse case managers can play in both acute care settings and nursing homes. They can help older adults with light care needs to make informed decisions about long-term care, seek out community options, and set in place assistive care systems that can help them age in the community.

Using administrative data to study persons with disabilities

Administrative data result from administering health plans--tracking service utilization, paying claims, monitoring costs and quality--and have been used extensively for health services research. This article examines the strengths and limitations of administrative data for health services research studies of people with disabilities. Administrative data offer important advantages: encompassing large populations over time, ready availability, low cost, and computer readability. Questions arise about how to identify people with disabilities, capture disability-related services, and determine meaningful health care outcomes. Potentially useful administrative data elements include eligibility for Medicare or Medicaid through Social Security disability determinations, diagnosis and procedure codes, pharmacy claims, and durable medical equipment claims. Linking administrative data to survey or other data sources enhances the utility of administrative data for disability studies.

Why are hospital-based nursing homes so costly? Relative importance of acuity and treatment setting

OBJECTIVES

To determine the extent to which higher costs in hospital-based skilled nursing facilities (HBSNF) can be explained by observable resident characteristics and unobservable selection effects, implying a design shortcoming of the skilled nursing facility prospective payment system (SNF PPS) implemented for Medicare-covered stays by the Balanced Budget Act of 1997 (BBA 1997).

RESEARCH DESIGN

Data on resident characteristics from the Minimum Data Set (MDS) are combined with staff time costs from the Centers for Medicare and Medicaid Services' (CMS, formerly HCFA) 1995 and 1997 SNF Staff Time Measurement (STM) studies and nontherapy ancillary claim costs extracted from CMS SNF claim records. An endogenous switching model was estimated to measure the effect on costs of the relatively high acuity of HBSNF residents, net of differences purely attributable to the treatment setting.

RESULTS

It was found that virtually the entire HBSNF differential is attributable to setting effects with resident characteristics and selection effects playing a negligible role. In addition, it was found that marginal costs associated with particular services and conditions are often lower in hospital-based than in freestanding facilities.

CONCLUSIONS

HBSNFs incur high costs regardless of the characteristics of their residents. Their high fixed costs accompany relatively low marginal costs associated with admitting high-acuity residents. Consequently, a PPS casemix system that depends on resident characteristics and excludes consideration of facility characteristics (as mandated by BBA 1997) need not unfairly penalize HBSNFs, provided a powerful casemix system is used and HBSNFs specialize in the care of high-acuity residents.

Nursing home case-mix reimbursement in Mississippi and South Dakota

OBJECTIVE

To evaluate the effects of nursing home case-mix reimbursement on facility case mix and costs in Mississippi and South Dakota.

DATA SOURCES

Secondary data from resident assessments and Medicaid cost reports from 154 Mississippi and 107 South Dakota nursing facilities in 1992 and 1994, before and after implementation of new case-mix reimbursement systems.

STUDY DESIGN

The study relied on a two-wave panel design to examine case mix (resident acuity) and direct care costs in 1-year periods before and after implementation of a nursing home case-mix reimbursement system. Cross-lagged regression models were used to assess change in case mix and costs between periods while taking into account facility characteristics.

DATA COLLECTION

Facility-level measures were constructed from Medicaid cost reports and Minimum Data Set-Plus assessment records supplied by each state. Resident case mix was based on the RUG-III classification system.

PRINCIPAL FINDINGS

Facility case-mix scores and direct care costs increased significantly between periods in both states. Changes in facility costs and case mix were significantly related in a positive direction. Medicare utilization and the rate of hospitalizations from the nursing facility also increased significantly between periods, particularly in Mississippi.

CONCLUSIONS

The case-mix reimbursement systems appeared to achieve their intended goals: improved access for heavy-care residents and increased direct care expenditures in facilities with higher acuity residents. However, increases in Medicare utilization may have influenced facility case mix or costs, and some facilities may have been unprepared to care for higher acuity residents, as indicated by increased rates of hospitalization.

Optimising drug utilisation in long term care

Providing quality long term care for the elderly while containing costs is presenting major challenges for governments and policy makers. Although international variability exists with respect to the number of medications and other factors influencing suboptimal pharmacotherapy, suboptimal pharmacotherapy among elderly persons is common. This international problem requires a creative and multifaceted approach to improve and rationalise prescribing. We outline the non-regulatory efforts and regulatory means to approaching this problem. The recent introduction of a prospective payment system for long-term care in the US has underscored the importance of a regulatory approach to counter-balance the cost containment efforts which bundle the cost of medications into a prospectively set per diem rate. An examination of how US regulatory bodies are considering improving prescribing is provided. Considering the case of coronary heart disease, we provide data regarding the performance of a quality indicator aimed at stimulating quality prescribing for this medical condition. Although the use of regulatory approaches can improve prescribing, it is also recognised that a more holistic approach involving multidisciplinary teams and greater focus on the patient is the ultimate aspiration. This is particularly the case with the elderly in whom appropriate drug therapy can have a major impact on outcomes. A major cultural shift in the way society views and treats the elderly may be required in order to produce dramatic improvements in long term care for older people.

Nutritional status and chewing capacity in nursing home residents

Chronically ill elderly persons sustain a high risk for protein-energy malnutrition (PEM). In this study we explored some of the complex associations between nutritional status, dental health and cognitive and physical function in 192 nursing home residents (mean age 84+/-8 years, 80% female). Nutrition-related data from the Resident Assessment Instrument (RAI) were compiled into a Nutrition Score (NuSc; 0-1 = non-PEM, 2 = risk for PEM, and 3-7 = PEM). Chewing capacity, according to number and condition of occlusal contacts, was determined by a Clinical Dental Functionality score (CDF). The Cognitive Performance Scale (CPS) and activities of daily living (ADL) were determined according to the RAI. Fifty percent of the residents had NuSc > or = 2, and 25% had NuSc > or = 3. One third did not have the dental prerequisites for chewing. i.e., < 4 occlusal contacts. Almost half of the residents had severe cognitive dysfunction, and over two thirds were severely limited in their ADL activities. Subjects with > or = 4 occlusal contacts, i.e., technical chewing capacity, had better NuSc (1.5+/-1.4) than those not able to chew (2.4+/-1.6, p=0.0005). In univariate logistic regression, the odds for NuSc > or = 2 increased with reduced ADL functions. inability to chew and poor cognition. In multivariate logistic regression, ADL and chewing capacity were significantly related to NuSc > or = 2. When NuSc > or = 3 was chosen as cut-off, only ADL was related to malnutrition. In conclusion, half of this group of nursing home residents appeared to be malnourished, or were at risk for PEM. Reduced physical function was the strongest predictor of PEM, while impaired chewing capacity was associated with risk for PEM.

Does investor ownership of nursing homes compromise the quality of care?

OBJECTIVES

Two thirds of nursing homes are investor owned. This study examined whether investor ownership affects quality.

METHODS

We analyzed 1998 data from state inspections of 13,693 nursing facilities. We used a multivariate model and controlled for case mix, facility characteristics, and location.

RESULTS

Investor-owned facilities averaged 5.89 deficiencies per home, 46.5% higher than nonprofit facilities and 43.0% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes.

CONCLUSIONS

Investor-owned nursing homes provide worse care and less nursing care than do not-for-profit or public homes.

Measuring efficiency of long-term care units in Finland

Data Envelopment Analysis (DEA) was used to measure the nursing care efficiency of 64 long-term care units in Finland. New approaches introduced for evaluating efficiency were unit/ward level analysis, and the case-mix classification Resource Utilization Groups (RUG-III). Efficiency determinations were based on four DEA measures: cost, technical, allocative, and scale efficiency. The results indicated considerable variation in efficiency between units, suggesting that efficiency could be improved through better management and allocation of resources. Larger units seemingly operated more efficiently than smaller units. Allocative inefficiency resulted from using too many registered nurses and aides, and too few licensed practical nurses.

Prospective payment for nursing homes increased therapy provision without improving community discharge rates

OBJECTIVES

To determine the impact of the prospective payment system (PPS) for skilled nursing facilities (SNFs) on therapy use and community discharge rates.

DESIGN

Quasi-experimental study examining the predemonstration (1994) to demonstration (1997) change in amount of therapy provided, and in community discharge rates at PPS participating and nonparticipating facilities.

SETTING

Eighteen PPS participating and 17 nonparticipating SNFs in five states.

PARTICIPANTS

Two thousand sixty-seven admissions to 18 PPS participating and 17 nonparticipating SNFs in five states.

MEASUREMENTS

We compared changes in number of physical and occupational therapy visits per stay for patients receiving therapy and likelihood of being located in the community 60 days after admission between 1994 and 1997. Analyses were stratified by functional category and risk adjusted using multivariate methods.

RESULTS

Demographics and percentage of patients in each stratum were similar in participating and nonparticipating sites and between 1994 and 1997. Amount of therapy received by the highest-functioning patients increased in participating sites (19.3 to 26.5 visits per stay, P = .005), but not in nonparticipating sites (23.3 to 18.2, P = .98). After adjusting for covariates, likelihood of community discharge for the highest-functioning patients did not change between participating and nonparticipating sites.

CONCLUSIONS

The highest-functioning patients treated under the SNF PPS demonstration experienced great increases in therapy, without any improvement in rate of community discharge.

Randomized clinical trial of a quality improvement intervention in nursing homes

PURPOSE

The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practices and subsequently improve resident outcomes, or if a stronger intervention, expert clinical consultation with nursing facility staff, is needed.

DESIGN AND METHODS

Nursing facilities (n = 113) were randomly assigned to one of three groups: workshop and feedback reports only, workshop and feedback reports with clinical consultation, and control. Minimum Data Set (MDS) Quality Indicator (QI) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year. Clinical consultation by a gerontological clinical nurse specialist (GCNS) was offered to those in the second group.

RESULTS

With the exception of MDS QI 27 (little or no activity), no significant differences in resident assessment measures were detected between the groups of facilities. However, outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls, behavioral symptoms, little or no activity, and pressure ulcers (overall and for low-risk residents).

IMPLICATIONS

Simply providing comparative performance feedback is not enough to improve resident outcomes. It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly.

Residential care supply and cognitive and physical problem case mix in nursing homes

OBJECTIVES

A rapid evolution has occurred in state policy and industry practices relative to assisted living and expanded use of residential care facilities for people with physical and cognitive frailty, yet relatively little is known about the interrelationship between this housing supply and nursing-home case mix.

METHODS

The association between residential care supply and the proportion of cognitively and physically impaired nursing facility residents was examined in more than 1,500 facilities in five states.

RESULTS

The proportion of nursing-home cases with only physical and cognitive impairment likely to be affected by emerging long-term care policy appears to be well under 10%. This effect is more persistent among admissions than continuing cases.

DISCUSSION

The findings raise caution about the optimistic assumptions of the interplay between residential care/assisted living policy and nursing-home use.