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

Clinical characteristics and six-month outcomes of nursing home residents with low activities of daily living dependency

BACKGROUND

Up to 30% of nursing home residents have very little dependency in activities of daily living (ADLs). We compared the characteristics and six-month outcomes of a sample of low-ADL--dependent nursing home residents (LDR) with other residents.

METHODS

This is a cross-sectional, six-month follow-up study using secondary data analysis. We combined the separate 1990 and 1993 cohorts in the Resident Assessment Instrument evaluation study. In each case these data were collected in the same 254 nursing homes in 10 states. We studied residents with a length of stay greater than 60 days and age 65 years and older (N = 3955). We compared the baseline characteristics of LDR (n = 985) with all other residents. We then compared six-month outcomes of LDR with other residents and characteristics of LDR with poor outcomes (death or worsened ADL disability) with LDR who remained stable.

RESULTS

The LDR had a significantly decreased frequency of geriatric syndromes (i.e., cognitive impairment, urinary incontinence, under-nutrition, vision problems, poor balance, and pressure ulcers) and neurological disease but had the same frequency of non-neurological chronic diseases and were on more medications. Thirty-one percent had poor six-month outcomes associated with baseline poor cognition, incontinence, poor appetite, and presence of vascular disease, daily pain, shortness of breath, and multiple medications.

CONCLUSION

Our research identified 29% of nursing home residents with higher physical function (LDR) who had fewer geriatric syndromes and neurological disease diagnoses; 69% of these remained stable at 6 months. Those LDR with a higher risk of poor outcomes could be prospectively identified. LDR who remained stable for 6 months may represent a group who could potentially be maintained in the community.

Pain in U.S. nursing homes: validating a pain scale for the minimum data set

PURPOSE

The aim of this study was to validate a pain scale for the Minimum Data Set (MDS) assessment instrument and examine prevalence of pain in major nursing home subpopulations, including type of admission and cognitive status.

DESIGN AND METHODS

This study considered validation of the MDS pain items and derivation of scale performed against the Visual Analogue Scale (VAS), using Automatic Interaction Detection. The derivation data describe 95 postacute care nursing home patients who are able to communicate. The scale is then used in retrospective analysis of 34,675 Michigan nursing home residents.

RESULTS

A four-group scale was highly predictive of VAS pain scores (variance explanation 56%) and therefore quite valid in detecting pain. In the prevalence sample, only 47% of postacute patients compared to 63% of postadmission patients reported no pain, and these percentages rose with increasing cognitive impairment.

IMPLICATIONS

Pain is prevalent in nursing home residents, especially in those with cognitive dysfunction, and often untreated.

The story of function-related groups--please, first do no harm

In November 2000, the Health Care Financing Administration (HCFA) published a proposed rule announcing their intention to implement a prospective payment system for rehabilitation inpatient facilities and hospital units. In this system, payments are to be scaled to patient complexity through a classification system referred to as case-mix groups (CMGs) modeled after the Functional Independence Measure-Function Related Groups, which were developed from the FIM instrument. Under the HCFA proposal, CMGs will be derived from the Minimum Data Set for Post-Acute Care (MDS-PAC). This shift to the MDS-PAC, with little scientific evidence to support it, can have a negative impact on how the system expresses patient need, on how patients access services, and on the equity of hospital payments.

Medical care for nursing home residents: differences by dementia status. Epidemiology of Dementia in Nursing Homes Research Group

OBJECTIVE

To understand the use of medical services by nursing home residents.

DESIGN

Descriptive, longitudinal study comparing medical service use of residents by dementia status and describing the use of medical services following detection of fever or infection.

SETTING

Fifty-nine randomly selected nursing homes in Maryland from 1992 to 1995.

PARTICIPANTS

2,153 residents admitted to one of 59 randomly selected nursing homes.

MEASUREMENT

A panel of psychiatrists and neurologists ascertained dementia based on review of medical records, interview data with significant others and nursing staff, and results of a cognitive exam. Medical service use was abstracted from medical records.

BACKGROUND

Understanding the use of medical services by nursing home residents as distinct from services provided by the nursing home is important, particularly as new medical care models are tested. This study compares the medical service use of residents by dementia status and describes the use of medical services following detection of fever or infection.

RESULTS

Residents with dementia compared with those without dementia had lower annual rates of physician visits (10.2 vs 12.7, P < .001) and hospitalizations (0.9 vs 1.2, P < .001), virtually the same rate of emergency department visits, and similar lengths of stay in the hospital. Subsequent to infection, a lower proportion of residents with dementia had either a physician visit, an emergency department visit, or a hospital admission compared with residents without dementia (27.2% vs 32.2%, P < .001). In 87% of infections, an antibiotic was used, implying meaningful contact with a physician. Residents with dementia compared with those without dementia had fewer physician visits subsequent to fevers (20.6% vs 29.9%, P < .001) and infections (21.8% vs 27.5%, P < .001).

CONCLUSIONS

The association of less medical service use by individuals with dementia compared with those without dementia may reflect differences in health status or implicit end-of-life decision-making and a proclivity toward less-aggressive treatment for these individuals.

The RUG-III case mix classification system for long-term care nursing facilities: is it adequate for nurse staffing?

The purpose of this study was to explore the validity of the nursing time associated with the Resource Utilization Group Version III (RUG-III) case mix classification system by determining its potential usefulness for making nurse staffing decisions in long-term care (LTC) facilities. Experts in LTC nursing administration were asked to determine the amount of nursing time required by nursing home residents. The estimates were significantly higher than the RUG-III nursing time for all case mix groups. This finding suggests that the nursing time associated with the RUG-III system may not meet the needs of nursing home residents if used as a basis for nurse staffing. Further analysis questions the wisdom of mandating minimum staffing standards for LTC facilities without taking into account the individual needs of residents.

Therapy use and discharge outcomes for elderly nursing home residents

This study examines therapy use and discharge outcomes (community discharge, mortality, or remaining in the facility) over a 90-day period for 1,419 elderly, post-acute care nursing home admissions in South Dakota. Subjects met criteria as rehabilitation candidates (i.e., absence of serious behavioral or medical conditions that would limit rehabilitation potential). Receipt of therapies was related significantly to age (younger), Medicare coverage, hip fracture or stroke diagnosis, absence of cancer diagnosis, and resident or staff expectations for functional improvement. Therapy use was related positively to community discharge and negatively to mortality when controlling for covariates such as age, marital status, payment source, functional status, cognitive status, and major diagnoses. Also, community discharge was related positively to the facility's volume of therapy provision and percentage of Medicare-covered stays.

Nursing home staffing and its relationship to deficiencies

OBJECTIVES

The authors examined the relationships between different types of nursing home staffing and nursing home deficiencies to test the hypothesis that fewer staff hours would be associated with higher numbers of deficiencies.

METHODS

Data were from the On-Line Survey, Certification, and Reporting System for all certified nursing homes in the United States. Regression models examined total deficiencies, quality of care, quality of life, and other deficiencies.

RESULTS

Fewer registered nurse hours and nursing assistant hours were associated with total deficiencies and quality of care deficiencies, when other variables were controlled. Fewer nursing assistant staff and other care staff hours were associated with quality of life deficiencies. Fewer administrative staff hours were associated with other deficiencies. Facilities that had more depressed and demented residents, that were smaller, and that were nonprofit or government-owned had fewer deficiencies. Facilities with more residents with urinary incontinence and pressure sores and with higher percentages of Medicaid residents had more deficiencies, when staffing and resident characteristics were controlled.

DISCUSSION

Facility characteristics and states were stronger predictors of deficiencies than were staffing hours and resident characteristics. Because only a small portion of the total variance in deficiencies could be explained, much work remains to explore factors that influence deficiencies.

A framework for nurse staffing in long-term care facilities

Nurse staffing is complex and requires the nurse administrator to consider multiple factors. The Framework for Nurse Staffing in Long-term Care (LTC) Facilities provides a comprehensive perspective of those factors and their interrelatedness. The purpose of the framework is to provide nurse administrators and managers with ways to analyze and evaluate nurse staffing in their own facilities and develop solutions and approaches that are specific to their needs and circumstances. The framework also can serve as the basis for developing and testing research questions that will guide nurse administrators in making informed decisions to determine, allocate, and deliver the resources necessary to provide quality care for residents.

Medicaid nursing facility reimbursement methods: 1979-1997

This article describes state Medicaid nursing facility reimbursement methods and rates in 1979-1997, using data derived from telephone surveys of state Medicaid reimbursement. The 1980s saw shifts toward prospective methodology. The late 1980s and early 1990s were characterized by adoption of casemix methods. The early 1990s also saw fewer changes in methodology with a hiatus in the mid-1990s followed recently by renewed changes to methodology. Medicaid per diem rates have increased faster than inflation but less rapidly than general health costs. The repeal of the Boren Amendment may now allow states to institute greater cost controls or moratoria on rate increases. Despite states' tendencies to follow one another's examples, Medicaid reimbursement remains diverse nationally, with wide differences in policies and rates.

A comparison of home care clients and nursing home residents: can community based care keep the elderly and disabled at home?

Admission cohorts from the Michigan Medicaid Home and Community-Based Waiver program and Ohio nursing homes were compared on measures of resource utilization including a modified Resource Utilization Groups (RUG-III) system, Activities of Daily Living (ADLs), and overall case mix. We found that, contrary to previous research, the two samples were remarkably similar across RUG-III categories. However, the nursing home sample was more functionally impaired on measures of ADL functioning and overall case mix. Results of this study may inform policymakers and providers of the potential for maintaining the appropriate population in the home with government-funded home care.

Characteristics of aggressive subjects in Australian (Melbourne) nursing homes

BACKGROUND

Aggressive behavior is common in nursing homes for the elderly. It causes distress to carers and can lead to hospitalization, overmedication, and physical restraint.

METHOD

A 6-month prospective study examining the characteristics of aggressive subjects in 11 nursing homes in Melbourne using validated, reliable instruments.

RESULTS

During the study, 121 and 143 subjects were rated aggressive on the Rating Scale for Aggressive Behavior in the Elderly and the Staff Observation Aggression Scale, respectively. Aggressive behavior was associated with younger age, men, subsequent mortality, and prescription of psychotropic drugs including neuroleptics, antidepressants, and benzodiazepines.

CONCLUSIONS

Educational programs in the use of psychotropic drugs directed at staff involved in the care of nursing home residents may be of value because these drugs have modest efficacy, have significant side effects, and may simply sedate the patient rather than treat aggressive behavior.

[Patient classification systems in intermediate and long-term stay institutions: evolution and future perspectives]

The importance of long term care sector is increasingly growing. Actually, the use of patient classification systems is a useful tool for the planning and management of health services for chronic and geriatric patients. Despite being much less known, patient classification systems have had a richer and earlier development in the long term care sector than in the acute care sector. Thus, one could could see the evolution from classifications based on the assessment of functional dependency to classifications progressively including variables corresponding to clinical complexity, and finally to complex systems such as RUG-III. Patient classification systems were first utilised as tools for the financing of long term centres, based on the patients' characteristics. Later, their applications have spread out to objectives related to the management of centres, assessment of quality of care, staff allocation level, control of access and national policies. In Spain, the only experience in the use of a patient classification system is the one used by the Catalan Health Care Administration which uses a classification for the financing of their centres.

Aging in place: a new model for long-term care

It is expected that at least 40 percent of the population over 75 will need extensive health care services late in their lives. The public has a negative view of nursing home placement that has, to some extent, been confirmed by research finding that the health of a frail older person deteriorates each time he or she is moved. The Aging in Place model of care for the elderly offers care coordination (case management) and health care services to older adults so they will not have to move from one level of care delivery to another as their health care needs increase. University Nurses Senior Care (UNSC) is the service entity of this project and provides as its core service care coordination with a variety of service options. These options include care packages or services at an hourly rate to meet individual client needs. The Aging in Place project will be evaluated by comparing project clients to residents of similar acuity in nursing homes and to similar clients receiving standard community support services. Data from this project will be important to consumers, researchers, providers, insurers, and policy makers.

The regulation and enforcement of federal nursing home standards, 1991-1997

This article reports historical trend data on resident characteristics and conditions, problems, and deficiency patterns for nursing facilities from 1991 through 1997 from Health Care Financing Administration (HCFA) administrative records from the On-Line Survey, Certification, and Reporting System (OSCAR). Over this period, residents show some increases in dependency and conditions, although there was a decline in the use of restraints. The deficiencies reveal continued quality problems in some nursing homes, although the average number of deficiencies given to facilities declined by 44 percent between 1991 and 1997. The discussion considers possible explanations for the decline in deficiencies, including whether the quality of care in nursing homes has improved or whether the enforcement process has gradually been weakened.

Validity and reliability of Resource Utilization Groups (RUG-III) in Finnish long-term care facilities

Resource Utilization Groups, Version III (RUG-III) is a case-mix system developed in the USA for classification of long-term care residents. This paper examines the validity and reliability of an adapted 22-group version of RUG-III (RUG-III/22) for use in long-term care facilities in Finland. Finnish cost weights for RUG-III/22 groups are calculated and different methods for their computation are evaluated. The study sample (1,964 residents) was collected in 1995-96 from ten long-term care facilities in Finland. RUG-III/22 alone explained 38.2% of the variance of total patient-specific (nursing + auxiliary staff) per diem cost. Resource use within RUG groups was relatively homogeneous. Other predictors of resource use included age, gender and length of stay. RUG-III/22 also met the standard for good reliability (i.e. a kappa value of 0.6 or higher) for crucial classification items, such as activities of daily living and high correlation between assessments based on relative cost.

Case mix adjustment in nursing systems research: the case of resident outcomes in nursing homes

Case mix indicates, for a resident population, the degree of risk for developing favorable or unfavorable outcomes. In a study of 164 nursing homes, we explored two methods for combining resident assessment data into a case mix index (CMI). We compared a facility-level, composite CMI to a prevalence-based CMI comprised of 22 separate resident characteristics for their adequacy in explaining resident outcomes. The prevalence-based CMI consistently explained more variance in outcomes than the facility level, composite CMI. This study indicates a reasonable method for using administrative databases containing resident assessment data to adjust for the influence of case mix on nursing home resident outcomes.

Minimum Data Set and Resident Assessment Instrument. Can using standardized assessment improve clinical practice and outcomes of care?

Regulating and standardizing the assessment of residents was envisioned by the 1986 Committee on Nursing Home Reform to have many advantages for facility management, government regulatory agencies, and clinical staff to evaluate changes in resident status and adjust the care plans accordingly. Standardized assessment data was viewed as a source of management information to be used to track case mix (i.e., acuity) of residents, allocate resources such as staff, and evaluate care quality. The Resident Assessment Instrument is a clinically relevant assessment process that can facilitate effective care planning, interventions, and quality improvement. It is a clinically complex process requiring care delivery systems developed by RNs to support the implementation of individualized care.

Applying activity-based costing in long-term care

As greater numbers of the elderly use health services, and as health care costs climb, effective financial tracking is essential. Cost management in health care can benefit if costs are linked to the care activities where they are incurred. Activity-based costing (ABC) provides a useful approach. The framework aligns costs (inputs), through activities (process), to outputs and outcomes. It allocates costs based on client care needs rather than management structure. The ABC framework was tested in a residential care facility and in supportive housing apartments. The results demonstrate the feasibility and advantages of ABC for long term care agencies, including community-based care.

Efficiency of institutional long-term care and annual demands for placement

The objective of this study was to determine the efficiency of and annual demands for institutional long-term care placement in the St. John's region. The study population comprised all applicants assessed for institutional long-term care through the Community Health St. John's Region Single Entry System in 1995-96. The outcome measures used for the study included estimates of client resource utilization employing the RUGs III and Alberta Resident Classification System; hospital beds occupied; time to placement; and annual demands on long-term care. The study concludes that objective criteria for admission to supervised care and nursing home care may help reduce the number of inappropriate placements (thus maximizing the use of existing nursing home beds) and decrease annual demands. Investment in alternatives to nursing home care for those with modest disability is suggested.

Nursing facility staffing in the states: the 1991 to 1995 period

Trends in the average nurse staffing levels are reported for certified nursing facilities in the United States from 1991 through 1995. Data from the federal On-Line Survey Certification and Reporting system show a small overall increase in the staffing levels for registered nurses (RNs), licensed vocational and licensed practical nurses (LVNs/LPNs), and nursing assistants over the 5 years, but there are substantial variations across states and regions. A two-stage least squares panel analysis examined predictors of nurse staff levels in states. States with higher resident case mix levels had higher RN and LVN/LPN hours. States with higher percentages of large facilities had lower RN and LVN/LPN levels and states with higher percentages of for-profit facilities had lower RN staff levels. States with a higher percentage of Medicaid residents had higher LVN/LPN staff levels. These findings indicate the need for more studies of staff variations and public policies that affect staffing.

Application of functional independence measure-function related groups and resource utilization groups-version III systems across post acute settings

OBJECTIVES

The present study evaluated alternative patient classification systems for skilled nursing facility and rehabilitation facility patients.

METHODS

Medicare patients were selected from a random sample of 27 rehabilitation facilities and 65 skilled nursing facilities participating in a national longitudinal study of subacute care. Detailed casemix and resource use data was obtained on 513 patients with hip fracture and 483 stroke patients. The Functional Independence Measure-Function Related Groups (FIM-FRGs) classification system for rehabilitation facilities was replicated on length of stay and tested on resource use for rehabilitation facility patients as well as for skilled nursing facility patients. Modifications to the FIM-FRGs also were tested. The Resource Utilization Groups-Version III classification was tested on rehabilitation facility patients.

RESULTS

The FIM-FRGs explained the same amount of variance in length of stay as in the original FIM-FRGs development sample (R2 hip fracture = 0.14, R2 stroke = 0.28), and similar variance in resource use. A modified version of the FIM-FRGs explained more variance in length of stay (R2 hip fracture = 0.19, R2 stroke = 0.39) and resource use (R2 hip fracture = 0.20, R2 stroke = 0.41). Neither model adequately predicted length of stay or resource use in skilled nursing facility patients. The Resource Utilization Groups-Version III rehabilitation groups accounted for little variance in rehabilitation facility patients' per-diem resource use (R2 = 0.11).

CONCLUSIONS

The FIM-FRGs are valid for resource use as well as length of stay for rehabilitation facility patients, but are not valid for skilled nursing facility patients. Similarly, the Resource Utilization Groups-Version III system does not apply to rehabilitation facility patients. Related work, however, suggests that development of a single episode-based patient classification system for skilled nursing facility and rehabilitation facility patients is possible and should be pursued.

Validity of diagnostic and drug data in standardized nursing home resident assessments: potential for geriatric pharmacoepidemiology. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology

OBJECTIVES

The Health Care Financing Administration requires that patients admitted to certified nursing homes be assessed with the Minimum Data Set, a data collection instrument containing more than 300 demographic, diagnostic, clinical, and treatment variables. Long-term care databases potentially may be used to assess the outcomes of specific treatments as well as drug effectiveness. The authors sought to ascertain reliability and validity of diagnostic and drug data in a database obtained by merging the Minimum Data Set with detailed information on drugs consumed by each resident.

METHODS

A population of 296,379 residents of 1,492 nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota participated in the study between 1992 and 1994. Minimum Data Set clinical diagnoses were contrasted with selected resident characteristics and a variety of symptoms and treatments. Limited to individuals who had been hospitalized in the 6 months preceding the first assessment, Minimum Data Set diagnoses were compared with those on the hospital discharge claims maintained in the Medicare Provider Analysis and Review database. Finally, the probability that the use of selected drugs predicted the correspondent gender-specific, age-specific, or unique labeled indication was estimated.

RESULTS

The positive predictive value for Minimum Data Set diagnoses compared with gender or function measures exceeded 0.9, and it was 0.8 for specific symptoms and 0.6 for virtually all other comparisons. The positive predictive value for Minimum Data Set diagnoses compared with those from hospital claims was approximately 0.7 for all chronic medical conditions, except for depression and asthma/chronic obstructive pulmonary disease/emphysema. The positive predictive value for acute/subacute diagnoses (ie, pneumonia, urinary tract infection, anemia) that may resolve during hospital stay was less than 0.5. The positive predictive value for selected drugs, except estrogens, compared with age and gender was close to 1.0 in all cases. When compared to their labeled indication, the positive predictive value was more than 0.6 for all drugs considered, with 0.97, 0.91, and 0.87 for tacrine and Alzheimer's disease, antidiabetics and diabetes mellitus, and L-dopa and Parkinson's disease, respectively.

CONCLUSIONS

These findings point to the overall validity of the drug and clinical data in this Minimum Data Set-based data set. Additional validation efforts will determine whether this data set can be used for studies of geriatric pharmacoepidemiology and for analyses of the influence of different policies and practices on residents' outcomes.

Pressure ulcer prevalence in Ohio nursing homes: clinical and facility correlates

Pressure ulcers remain a common medical problem in nursing homes, despite the development of clinical guidelines for prevention and treatment. Prevention involves low technology but vigilant care. If the disease progresses, infections can develop, and surgery may be necessary to prevent death. This article examines pressure ulcer correlates in a representative sample of 15,121 nursing home residents in 1994 in the state of Ohio. The prevalence of pressure ulcers was 12%, 8% for Stage 2 or greater. The study found that many nursing home residents remain at great risk of developing pressure ulcers. Important risk factors included a history of cured pressure ulcers, new admission and readmissions, dependencies in activities of daily living, weight loss and dehydration, diabetes, edema, and incontinence. After controlling for clinical factors, residents in rural facilities were less likely to have a pressure ulcer. These findings suggest that the quality of pressure ulcer care in nursing homes could improve.

Development of a crosswalk from the Minimum Data Set 2.0 to the Alberta Resident Classification System

Ontario has mandated the use of the Minimum Data Set 2.0 (MDS) to classify patients in all chronic care hospital beds as of July 1996. The MDS, widely used in several other jurisdictions, has been shown to have several advantages over other assessment systems. However, Ontario currently classifies residents of homes for the aged and nursing homes under the Alberta Resident Classification System (ARCS). Since there is not a single system to assess the elderly in institutional settings, it is not possible to create a funding system for all institutions based on patient rather than facility characteristics. The author reports on the development of a crosswalk algorithm to compute ARCS levels of care based on clinical items from the MDS. This algorithm may be used to support a transitional approach to move to a funding system for long-term care based on Resource Utilization Groups (RUG-III).

Need assessment of visiting nursing and rehabilitation services for noninstitutionalized elderly

The author assessed the potential need for visiting nursing and rehabilitation services on a national level to estimate the volume of services expected for Japan's proposed new long-term care insurance. Baseline data were obtained from the national survey on freestanding visiting nursing stations conducted in September 1994, in which the population of 18,500 patients was professionally assessed by visiting nurses. The baseline data were then applied to the national sampling survey on households conducted in June 1992, in which respondents self-reported their activities of daily living (ADL) and health status. There are estimated to be 836,000 noninstitutionalized elderly with disability. Their need for visiting nursing and rehabilitation services is expressed as 48.26 million visits or 57.33 million working hours annually. Current service volume accounts for only 5% of the potential need, suggesting a sharp rise in demand once the new insurance is fully implemented.

Discharge motor FIM-function related groups

OBJECTIVE

To develop a patient classification system that groups patients achieving similar functional outcome scores by discharge from medical rehabilitation.

DESIGN

Patient groups were developed using a recursive partitioning algorithm and clinical input. Results were validated in a separate set of patient records.

SETTING

Two hundred fifty-two free-standing rehabilitation hospitals and distinct part units that participate in the Uniform Data System for Medical Rehabilitation.

PATIENTS

The 84,492 rehabilitation inpatients discharged in 1992 were grouped into 20 impairment categories.

MAIN OUTCOME MEASURE

Discharge score on the motor subscale of the Functional Independence Measure (FIM).

RESULTS

In the Discharge Motor FIM-Function Related Groups (DMF-FRGs) system, patients are first classified into one of 20 impairment categories and then into FRGs by their admission motor FIM scores. Some FRGs are also subdivided on the basis of admission cognitive FIM scores and age. The entire system consists of 139 patient groups that explain 63% of the variation in motor FIM discharge scores in the validation data set. Nontraumatic brain injury and joint replacement DMF-FRGs are provided as examples.

CONCLUSION

Clinicians can use the DMF-FRGs to identify groups of patients whose motor FIM scores at discharge are below, within, or above nationally established ranges of values for the purpose of outcomes management, guideline development, and quality improvement. The DMF-FRGs can also be considered in the design of an outcome-based payment system for medical rehabilitation.

The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality

OBJECTIVE

To characterize changes in key aspects of process quality received by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms.

DESIGN

A quasi-experimental study using a complex, multistage probability-based sample design, with data collected before (1990) and after (1993) implementation of the RAI and other OBRA provisions.

SETTING AND PARTICIPANTS

Two independent cohorts (n > 2000) of residents in a random sample of 254 nursing facilities located in metropolitan statistical areas in 10 states.

INTERVENTION

OBRA-87 enhanced the regulation of nursing homes and included new requirements on quality of care, resident assessment, care planning, and the use of neuroleptic drugs and physical restraints. One of the key provisions, used to help implement the OBRA requirements in daily nursing home practice, was the mandatory use of a standardized, comprehensive system, known as the RAI, to assist in assessment and care planning. OBRA provisions went into effect in federal law on October 1, 1990, although delays issuing the regulations led to actual implementation of the RAI during the Spring of 1991. MEASUREMENTS AND ANALYSES: Research nurses spent an average of 4 days per facility in each data collection round, assessing a sample of residents, collecting data through interviews with and observations of residents, interviews with multiple shifts of direct staff caregivers for the sampled residents, and review of medical records, including physician's orders, treatment and care plans, nursing progress notes, and medication records. The RNs collected data on the characteristics of the sampled residents, on the care they received, and on facility practices. The effect of being a member of the 1990 pre-OBRA or the 1993 post-OBRA cohort was assessed on the accuracy of information in the residents' medical records, the comprehensiveness of care plans, and on other key aspects of process quality while controlling for any changes in resident case-mix. The data were analyzed using contingency tables and logistic regression and a special statistical software (SUDAAN) to assure proper variance estimation.

RESULTS

Overall, the process of care in nursing homes improved in several important areas. The accuracy of information in residents' medical records increased substantially, as did the comprehensiveness of care plans. In addition, several problematic care practices declined during this period, including use of physical restraints (37.4 to 28.1% (P < .001)) and indwelling urinary catheters (9.8 to 7% (P < .001)). There were also increases in good care practices, such as the presence of advanced directives, participation in activities, and use of toileting programs for residents with bowel incontinence. These results were sustained after controlling for differences in the resident characteristics between 1990 and 1993. Other practices, such as use of antipsychotic drugs, behavior management programs, preventive skin care, and provision of therapies were unaffected, or the differences were not statistically significant, after adjusting for changes in resident case-mix.

CONCLUSION

The OBRA reforms and introduction of the RAI constituted an unprecedented implementation of comprehensive geriatric assessment in Medicare- and Medicaid-certified nursing homes. The evaluation of the effects of these interventions demonstrates significant improvements in the quality of care provided to residents. At the same time, these findings suggest that more needs to be done to improve process quality. The results suggest the RAI is one tool that facility staff, therapists, pharmacy consultants, and physicians can use to support their continuing efforts to provide high quality of care and life to the nation's 1.7 million nursing home residents.

Effect of the National Resident Assessment Instrument on selected health conditions and problems

OBJECTIVE

To evaluate the effect of the implementation of the National Resident Assessment Instrument (RAI) system on selected conditions representing outcomes for nursing home residents.

DESIGN

Quasi-experimental, pre-/post-design, with assessments at baseline and 6-month follow-up.

SAMPLE

Two thousand one hundred twenty-eight residents from 268 nursing homes in 10 states before RAI implementation, and 2,088 from 254 of the same nursing homes after implementation.

MEASURES

From the full RAI Minimum Data Set, measures of dehydration, falls, decubitus, vision problems, stasis ulcer, pain, dental status (poor teeth), and malnutrition were examined at baseline and 6 months later. Poor nutrition was evaluated using a body mass index score below 20 and vision using a 4-level scale; other conditions were represented by their presence or absence. Decline and improvement were computed as the changes in level between baseline and follow-up, limiting the sample to those who could manifest each such change.

MAIN RESULTS

Of eight health conditions representing poorer health status, dehydration and stasis ulcer had significantly lower prevalence after the implementation of the RAI (1993) compared with 1990. At the same time, there was an increase in the prevalence of daily pain. Fewer residents declined over 6 months in nutrition and vision after implementation. Although for these two conditions there were also significantly reduced rates of improvement, the net was an overall reduction in the 6-month rate of decline for all residents. Pain also demonstrated a decline in the postimplementation rate of improvement. The combined eight conditions showed reductions in the rates of both decline and improvement.

CONCLUSIONS

Several outcomes for nursing home residents improved after implementation of the RAI. Of the four conditions for which there are significant declines in prevalence or outcome changes, three are specifically addressed in the care planning guidelines incorporated the RAI system (all except stasis ulcer, although there is a RAP for decubitus ulcer). Pain, the only other condition with a significant result --an increase in baseline prevalence--also has no RAP. Although the changes might be ascribed otherwise, they support the premise that the RAI has directly contributed to improved outcomes for nursing home residents.

Association of the Resident Assessment Instrument (RAI) with changes in function, cognition, and psychosocial status

OBJECTIVE

To evaluate the impact of the Resident Assessment Instrument (RAI) on changes in nursing home residents' functional status, cognitive status, and psychosocial well-being.

DESIGN

A quasi-experiment involving the collection of longitudinal data on two cohorts of nursing home residents. One cohort was assessed before the implementation of the RAI, and the other was assessed after the implementation of the new assessment process.

SETTING AND PARTICIPANTS

Over 2000 nursing home residents in 267 nursing homes located in 10 geographic areas were assessed during the pre-RAI period. In the post-RAI period, 2000 new residents in 254 of the same facilities were assessed.

INTERVENTION

RAI implementation began in October 1990 and continued until October 1991. The RAI includes a structured, multidimensional resident assessment and problem identification system designed to form the basis for residents' care plans.

MEASUREMENTS

All residents were assessed at baseline and at 6 months using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS) and its protocols. All data were collected by research nurses employed and trained by the research team.

RESULTS

Implementation of the RAI significantly reduced the rate of decline in seven of the nine outcomes under consideration. Reductions in improvement were also observed in all outcomes. In activities of daily living, social engagement, and cognitive function, the reduced decline far outweighed any reductions in improvement. In mood problems, problem behaviors, and understanding others, however, reductions in improvement were greater than any reductions in decline. Changes in the rates of decline and improvement were not uniform across all residents.

CONCLUSION

The RAI may have improved the quality of care of nursing home residents by reducing overall rates of decline in important areas of resident function. However, this innovation may have generated trade-offs in that it may have reduced improvement rates in some areas of function. The system's implementation also seems to have focused staff's attention on the needs and strengths of specific subpopulations of residents. Revisions of the RAI must assist staff in generalizing their efforts to all residents and to increasing improvement rates, especially in areas related to mood and behavior.

Changes in hospitalization associated with introducing the Resident Assessment Instrument

OBJECTIVE

To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI).

SAMPLE

Subjects were nursing home residents chosen from 268 facilities in major Metropolitan Statistics Areas in 10 states and representing more than 1500 facilities and 60,000 residents. Two resident cohorts (1990 and 1993) were sampled (8 to 16 residents per facility, depending upon facility size) as part of an evaluation of the impact of implementing the RAI.

METHODS

Research nurses reviewed records, interviewed staff, observed patients, and completed an RAI at baseline and 6 months later. All transitions during this interval (hospital admissions, nursing home transfers, returns home, death, etc.) were tracked. Using polytomous logistic regression, we tested the effect of cohort on the probability of being hospitalized in light of the competing risks of dying or remaining in the home, controlling for demographic and casemix variables, and having a DNR order in the chart.

RESULTS

A total of 4196 residents were studied, 2118 in 1990 (age 81.3, female 77.7%, LOS 6+ months 49.8%) and 2078 in 1993 (age 81.7, females 75.5%, LOS 6+ months 50.2%). The unadjusted probability of hospitalization dropped from .205 to .151. Multivariate analyses revealed a significant adjusted odds of hospitalization of .74 (95% CI .60-.91) and no cohort effect on home discharge or death. Among severely cognitively impaired residents, the adjusted odds of hospitalization in 1993 compared with the 1990 cohort was 0.74 (.53-1.03). Finally, among survivors in both cohorts who had a follow-up MDS performed, and whose ADL remained stable, 15.9% were hospitalized in 1990, whereas only 10.9% were hospitalized in 1993. On the other hand, ADL decliners were more likely to have been hospitalized in 1993 than in 1990 (40.6% vs 25.2%).

CONCLUSIONS

Although other changes in the industry, clinical practice, and health care policy may have influenced hospitalization of nursing home residents, the substantial reductions observed among the cognitively impaired and those with stable ADL suggest superior and uniform assessment information in the form of the RAI contributed significantly to this decline.

Human and financial costs of noninvasive mechanical ventilation in patients affected by COPD and acute respiratory failure

STUDY OBJECTIVES

It has been suggested that noninvasive mechanical ventilation (NIMV) may be a time-consuming procedure for medical and paramedical personnel. We carried out a prospective trial in 10 consecutive COPD patients aimed at assessing the human and economic resources needed to ventilate patients by NIMV and we compared these with those needed by a group of six patients receiving invasive mechanical ventilation (InMV).

DESIGN

The daily cost and the minutes spent by medical doctors (MDs), respiratory therapists (RTs), and nurses (Ns) were recorded during the first 48 h of ventilation in 10 patients during NIMV (group A) and in six who received InMV (group B) after an initial unsuccessful attempt with NIMV. In two subgroups of patients (five for group A and four for group B), the analysis was also performed, except for RTs, for the total length of mechanical ventilation.

SETTING

A respiratory ICU.

PATIENTS

At hospital admission, the two groups of COPD patients did not differ for blood gas values (PaCO2 = 88.2+/-9.8 mm Hg for group A vs 90.5+/-12.8 mm Hg for group B, and pH = 7.21+0.08 vs 7.20+0.08, respectively) or for clinical and neurologic status, but patients of group B had not tolerated NIMV.

MEASUREMENTS AND RESULTS

The total time spent at the bedside in the first 6 h did not differ between group A and B (group A = 72.3 min [MD], 87.2 min [RT], and 178.8 min [N] vs 98.8 min [MD], 12.5 min [RT], and 197.6 min [N] for group B). In the following 42 h, a plateau was reached so that there was a significant reduction for both groups in the time of assistance given by Ns (p<0.001) but not by MDs or RTs. The total costs were also not different between the two groups ($806+/-73 [US dollars per day] vs $864+/-44 for group A and B, respectively). In the subgroups monitored for the entire period of ventilation, a significant reduction in the time of assistance, for both MDs and Ns, was observed after approximately the first half.

CONCLUSIONS

We conclude that in the first 48 h of ventilation, daily NIMV is neither more expensive nor time-consuming and staff demanding than InMV. After the first few days of ventilation, NIMV was significantly less time-consuming than InMV, for MDs and Ns, so that medical and paramedical time expenditure seems not to be a major problem during NIMV.

Measuring casemix, severity, and complexity in geriatric patients undergoing rehabilitation

Geriatric rehabilitation is intended to maintain or restore function, maximize life satisfaction, enhance psychologic well-being, and maintain the social status of older persons. For clinical services to operate efficiently and equitably, payment must be based on rules that are clinically sound and thus reinforce the objectives of the services provided. This article presents a theoretical basis for casemix measurement in medical rehabilitation, contrasts structure of the functional independence measure-function-related groups (FIM-FRGs) intended for casemix measurement to the diagnosis-related groups (DRGs) and resource utilization groups (RUG) III systems designed for acute and long-term care settings, focuses on special issues of relevance to the rehabilitation of older persons, and provides four challenges in an effort to stimulate discussion.

The influence of age on length of stay, functional independence and discharge destination of rehabilitation inpatients in Italy

Advanced age in itself does not predict a poor functional outcome or a longer length of stay in rehabilitation units. Seven hundred and sixty-four adult cases were analysed, from 14 post-acute rehabilitation facilities throughout Italy. Data came from the national database run by the agency distributing the Italian version of an internationally validated scale of disability, the FIM [symbol: see text] sm (Functional Independence Measure). The FIM is an 18-item scale rating independence in the domains of selfcare, sphincter control, mobility, locomotion, communication and social cognition. The total FIM score may range from 18 to 126 (higher score = greater independence). Patients were classified with respect to the cut-off age of 75 years (76+ and 75-, mean age 82 and 57 years, n = 203 and 561, 27% and 73% of the cases, respectively). The median interval between onset of disability and admission to the facility (onset-to-admission delay, OAD) was 36 and 45 days in the 76+ and the 75- group, respectively (p < 0.001). Mean admission FIM score was 70 (+/- 28) in the 76+ and 71 (+/- 27) in the 75- group. Discharge FIM scores were 84 +/- 29 and 93 +/- 26, respectively (p < 0.001). Median length of stay (LOS) was 34 days in the 76+ and 41 days in the 75- group, respectively (p < 0.005). The 76+ and 75- groups were discharged home in 86% and 90% of the cases, respectively (p = 0.053). The results suggest that inpatient rehabilitation is substantially effective and efficient for older as well as for younger patients.

Identifying an appropriate case mix measure for chronic care: evidence from an Ontario pilot study

With the move toward rate-based funding for chronic care hospitals, a case mix measure that describes chronic care patients in a valid and reliable manner is needed. A pilot study was done in Ontario to evaluate the effectiveness of three classification systems that have been implemented elsewhere. It was recommended that work continue on the basis that Ontario will implement the Resource Utilization Groups (RUG-III) system for activity measurement and funding of chronic care patients.

Predicting nursing home length of stay and outcome with a resource-based classification system

The anticipated demographic changes with an increasing number of elderly force us to plan and use health care resources more efficiently. In this study we have used the components of a case-mix measure for nursing homes; the Resource Utilization Groups (RUG-II), to predict length of stay (LOS) and outcome in geriatric institutions. We have shown that the RUG categories and an activities of daily living (ADL) index differ significantly in both respects, but that other variables might be of more clinical value when establishing a prospective payment system, based on LOS in geriatric institutions.

Case-mix measurement in medical rehabilitation

Case-mix measurement offers a way to take patient characteristics into account in the determination of payment rates. This article begins with an overview of major case-mix measures across inpatient hospital and other institutional settings and describes ways to measure the suitability and relative strengths of these measures. It then briefly discusses issues of payment and the appropriateness of alternative case-mix measures to inpatient rehabilitation. The literature review extends back to the 1970s, thus preceding advent of the Diagnosis-Related Groups, which was the first major case-mix measure developed and implemented in a hospital setting.

Can physically restrained nursing-home residents be untied safely? Intervention and evaluation design

OBJECTIVE

To develop an intervention that will enable nursing home personnel to remove physical restraints from nursing-home residents safely and cost effectively.

DESIGN

A multicenter prospective pre-post study.

SETTING

Sixteen high-restraint-use nursing homes, four each from California, Michigan, New York, and North Carolina. The 16 facilities have 2075 beds.

INTERVENTION

A 2-year educational demonstration study, including a 2-day workshop, specially prepared written and video materials, and telephone and on-site clinical consultations. Each nursing home designated a nurse to be the clinical coordinator and to lead a multidisciplinary team in conducting a restraint assessment and devising interventions for removal.

OUTCOME MEASURES

We compared pre- and post-study aggregate and individual facility rates of restraint use, incidents and accidents, family attitudes, financial impact, serious injuries, and staff attitudes and work patterns.

CONCLUSION

Preliminary data suggest that this intervention was well received and appears to be effective in achieving restraint-free care.

Inappropriate use of nonpsychotropic medications in nursing homes

OBJECTIVES

To determine the prevalence and patient-specific predictors of the use of 10 presumptively inappropriate medications used to treat medical conditions among nursing home residents, and to use this information to examine alternative screening strategies using computerized assessment data to identify residents who are at high risk of receiving inappropriate medications.

DESIGN

Retrospective, cross-sectional study.

PATIENTS

All persons residing in all 252 nursing homes in two states during the last 6 months of 1991 (N = 21,884).

MEASUREMENTS

Data were from Minimum Data Set Plus (MDS+) assessments, gathered as part of the Health Care Financing Administration (HCFA) Multistate Nursing Home Casemix and Quality Demonstration Project. The MDS+ is an expanded version of the federally mandated Minimum Data Set (MDS) that includes additional information on medications and their doses and schedules (frequency, standing vs prn). The reliability of the MDS has been demonstrated previously. Medications were defined as inappropriate using explicit criteria from published literature. Outcome measures were the standing use of each or any of 10 presumptively inappropriate medications used to treat medical (rather than psychiatric or behavioral) conditions. Potential predictors of inappropriate medication use included patient demographic characteristics, payer, a proxy measure for length of stay and admission source, functional status, number of standing medications, and state.

MAIN RESULTS

A total of 12% of residents were prescribed one or more of 10 presumptively inappropriate medications on a standing basis, a figure that differed substantially between states (14.0% vs 7.4% (P < .001)). The most prevalent inappropriate medications were dipyridamole (5.4% of residents), amitriptyline (3.3%), and methyldopa (1.8%). Among patients receiving 0 to 3, 4 to 6, and 7+ medications, 5%, 12%, and 19%, respectively, were receiving at least one inappropriate medication. In multivariate logistic regression analyses, the strongest predictors of inappropriate medication use were state and the total number of standing medications prescribed. Including other statistically significant predictors of inappropriate medication use (age > 65 years, never having been married, severe functional limitations, being a long-stay patient, and medical diagnosis) did not substantially improve the overall predictive ability of the model.

CONCLUSIONS

A substantial proportion of nursing home residents receives presumptively inappropriate medications to treat medical conditions. Selecting persons prescribed large numbers of medications for further review may be the most efficient method for nursing home or pharmacy personnel to identify residents at high risk of receiving inappropriate medications. Extensive additional information on residents' characteristics, although widely available through the Minimum Data Set, does not significantly improve the ability to identify residents receiving inappropriate medications for medical conditions. State-specific policies or provider practices also influence the likelihood of presumptively inappropriate medication use among nursing home residents and deserve further investigation.