Nursing home ownership revisited: market, cost and quality relationships

The relationship between healthcare service provision models and patient experience

Purpose

User experience is key for measuring and improving the quality of services, especially in high personal and relation-intensive sectors, such as healthcare. However, evidence on whether and how the organizational model of healthcare service delivery can affect the patient experience is at an early stage. This study investigates the relationship between healthcare service provision models and patient experience by focusing on the nursing care delivery.

Design/methodology/approach

65 nurses' coordinators were involved to map the nursing models adopted in the healthcare organizations of in an Italian region, Tuscany. This dataset was merged with patient experience measures reported by 9,393 individuals discharged by the same organizations and collected through a Patient-Reported Experience Measures Observatory. The authors run a series of logistic regression models to test the relationships among variables.

Findings

Patients appreciate those characteristics of care delivery related to a specific professional nurse. Having someone who is in charge of the patient, both the reference nurse and the supervisor, makes a real difference. Purely organizational features, for instance those referring to the team working, do not significantly predict an excellent experience with healthcare services.

Research limitations/implications

Different features referring to different nursing models make the difference in producing an excellent user experience with the service.

Practical implications

These findings can support managers and practitioners in taking decisions on the service delivery models to adopt. Instead of applying monolithic pure models, mixing features of different models into a hybrid one seems more effective in meeting users' expectations.

Originality/value

This is one of the first studies on the relationship between provision models of high-contact and relational-intensive services (the healthcare services) and users' experience. This research contributes to the literature on healthcare service management suggesting to acknowledge the importance of hybridization of features from different, purely theoretical service delivery models, in order to fit with providers' practice and users' expectations.

Highlights

This is one of the first studies on the relationship between provision models of nursing care and patient experience.

Healthcare services' users appreciate service delivery characteristics identified with “be cared by,” or in other words with having a reference nurse.

Nursing models' features that relate to the organizations and that providers tend to judge as professionalizing and evolutive, such as team working, appear not key in relation to patient experience.

Pure models of service delivery are theoretically useful, but hybrid models can better meet users' expectations.

Where's the evidence? a systematic review of economic analyses of residential aged care infrastructure

BACKGROUND

Residential care infrastructure, in terms of the characteristics of the organisation (such as proprietary status, size, and location) and the physical environment, have been found to directly influence resident outcomes. This review aimed to summarise the existing literature of economic evaluations of residential care infrastructure.

METHODS

A systematic review of English language articles using AgeLine, CINAHL, Econlit, Informit (databases in Health; Business and Law; Social Sciences), Medline, ProQuest, Scopus, and Web of Science with retrieval up to 14 December 2015. The search strategy combined terms relating to nursing homes, economics, and older people. Full economic evaluations, partial economic evaluations, and randomised trials reporting more limited economic information, such as estimates of resource use or costs of interventions were included. Data was extracted using predefined data fields and synthesized in a narrative summary to address the stated review objective.

RESULTS

Fourteen studies containing an economic component were identified. None of the identified studies attempted to systematically link costs and outcomes in the form of a cost-benefit, cost-effectiveness, or cost-utility analysis. There was a wide variation in approaches taken for valuing the outcomes associated with differential residential care infrastructures: 8 studies utilized various clinical outcomes as proxies for the quality of care provided, and 2 focused on resident outcomes including agitation, quality of life, and the quality of care interactions. Only 2 studies included residents living with dementia.

CONCLUSIONS

Robust economic evidence is needed to inform aged care facility design. Future research should focus on identifying appropriate and meaningful outcome measures that can be used at a service planning level, as well as the broader health benefits and cost-saving potential of different organisational and environmental characteristics in residential care.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) registration number CRD42015015977 .

Correlates of Complaints Made to the Connecticut Long-Term Care Ombudsman Program

Using Long-Term Care Ombudsman Program complaint data ( N = 3,360) from all of Connecticut's 261 nursing facilities, this study investigated facility characteristics that may be correlated with resident complaints. Complaints per 100 beds and four subcategories of complaints established by the Administration on Aging (AoA) were the dependent variables. The presence of volunteers trained by the Ombudsman Pro-gram significantly predicted total complaints. At the bivariate level, profit status, size, location, citations, and the presence of a volunteer resident advocate were associated with the rate of complaints. However, multivariate analysis exposed a more complex pattern of relationships. The strongest model explained slightly more than 9% of the variance using the nine predictors. This indicates that other factors such as psychosocial characteristics of complainants may influence complaint reporting, rather than structural/organizational components of the facility.

The Effects of For-Profit and Not-for-Profit Facility Status on the Quality of Care for Nursing Home Residents with Mental Illnesses

This article examines whether a relationship exists between ownership status (for-profit and not-for-profit) of nursing homes and the quality of care for residents who are mentally ill. Rather than looking for an overall indicator of differences in quality between these ownership types, as other studies have done, three quality indicators are examined: structure, process, and outcome. Also, different types of nursing homes are examined by size and certification level. The authors fail to find consistent evidence that for-profit nursing homes provide poorer quality care to mentally ill residents using measures of structure, process, and outcome; they did find, however, that nursing homes may modify their approach to caring for these residents. That is, the size of the facility and the certification level could be important factors in the quality of the mental health care of nursing home residents.

Nursing Home Profit Status and Quality of Care: Is There Any Evidence of an Association?

This article critically reviews the association between the profit status of North American nursing homes and the quality of care. Studies were identified by searching MEDLINE (January 1990-October 2002), reference lists, letters, commentaries, and editorials. The quality indicator(s) used to measure quality of care, and its relationship to profit status, was extracted from each publication. The study design and risk-adjustment methodologies used were also extracted. The interrater reliability for the extraction of these three items was determined to be 1.0, 0.6, and 0.8, respectively. Aqualitative systematic review was performed using Donabedian’s framework of structure, process, and outcome for analyzing medical quality of care. Empirical research in the past 12 years has found that systematic differences exist between for-profit and not-for-profit nursing homes. Forprofit nursing homes appear to provide lower quality of care in many important areas of process and outcome.

The Effect of Administrative Resources on Care in Nursing Homes

This article evaluates whether the hours spent on the job by nursing home administration have an effect on the quality of care. Administration with more hours on the job were expected to be actively involved in developing market strategies, implementing continuous, quality improvement, and in developing stricter facility guidelines for care—all of which contribute to improved care processes. The proportion of residents who were restrained, catheterized, had pressure ulcers, or were given psychoactive drugs and the number of health-related deficiencies and nonhealth-related deficiencies were used as measures of quality in 15,834 nursing facilities. We examined effects separately for facilities that belong to a chain and those that are freestanding. Overall, the results indicate that the quality indicators are associated with the number of full-time equivalent hours of administration in both chain and freestanding facilities. This study provides preliminary evidence that the intensity of facility administration can have an important effect on the quality of care residents receive.

Nursing home financial performance: the role of ownership and chain affiliation

BACKGROUND

The nursing home industry serves one of the most vulnerable populations, and its financial sustainability is a matter of public concern. However, limited empirical evidence exists on the impact of ownership and chain affiliation on nursing home financial performance.

PURPOSES

The aim of this study was to examine the joint effects of ownership and chain affiliation on the financial performance of the nursing home industry for the study period 1999-2004 on a national sample of 11,236 nursing homes per year.

METHODOLOGY/APPROACH

Data included the Medicare Cost Reports; the Online Survey, Certification, and Reporting file; and the Area Resource File. Dependent variables included operating and total margins. Independent variables included four ownership/chain affiliation combinations: for-profit chain, for-profit independent, not-for-profit chain, and not-for-profit independent. Random effects generalized least square regressions were performed.

FINDINGS

Results show that for-profit nursing homes delivered better financial performance than not-for-profit facilities did across both operating and total margins. However, the relationship between chain affiliation and financial performance was more nuanced. In the case of operating margin, chain-affiliated facilities delivered superior financial performance irrespective of ownership type; however, in the case of total margin, independents outperformed chain-affiliated facilities among for-profits.

PRACTICE IMPLICATIONS

Our findings show an interactive effect of ownership and chain affiliation on nursing home financial performance, suggesting the pursuit of different organizational strategies by different ownership/chain affiliation subgroups (for-profit chain, for-profit independent, not-for-profit chain, and not-for-profit independent), with implications for financial performance. For-profit independent nursing homes managed to be the top performing group in terms of overall financial despite the operating financial advantage of for-profit chain-affiliated nursing homes. Similarly, not-for-profit independent nursing homes and not-for-profit chain homes had comparable overall financial performance despite the operating financial advantage of chain homes.

The effects of California minimum nurse staffing laws on nurse labor and patient mortality in skilled nursing facilities

This article investigates how a change in minimum nurse staffing regulation for California skilled nursing facilities (SNFs) affects nurse employment and how induced changes in nurse staffing affect patient mortality. In 2000, legislation increased the minimum nurse staffing standard and altered the calculation of nurse staffing, which created incentives to shift employment to lower skilled nurse labor. SNFs constrained by the new regulation increase absolute and relative hours worked by the lowest skilled type of nurse. Using this regulation change to instrument for measured nurse staffing levels, it is determined that increases in nurse staffing reduce on-site SNF patient mortality.

Exploring the relationship between private equity ownership and nursing home performance: a review

Private equity has acquired multiple large nursing home chains within the past few years; by 2007, it owned 6 of the 10 largest chains. Despite widespread public and policy interest, evidence on the purported impact of private equity on nursing home performance is limited. In our review, we begin by briefly reviewing the organizational and environmental changes in the nursing home industry that facilitated private equity investments. We offer a conceptual framework to hypothesize the relationship between private equity ownership and nursing home performance. Finally, we offer a research agenda focused on the important parameters of nursing home performance: financial performance, and quality of care.

Nursing homes: a health-promoting or dependency-promoting environment?

Health promotion and disease prevention in nursing homes (NHs) are important but highly neglected issues. This study compares the care of residents in 2 proprietary NHs (a dependency-promoting environment) with the care of residents on a hospice unit at a government-owned facility (a health-promoting environment). Inadequate staffing, supervision, and education contributed to the lack of health promotion and ultimately a low quality of care. The care in proprietary NHs, however, must be examined within the context of NH corporations, a multibillion dollar profit-making industry. When making profits is a priority, it is challenging for staff to provide quality care.

Does the public sector outperform the nonprofit and for-profit sectors? Evidence from a national panel study on nursing home quality and access

Are public and private organizations fundamentally different? This question has been among the most enduring inquiries in public administration. Our study explores the impact of organizational ownership on two complementary aspects of performance: service quality and access to services for impoverished clients. Derived from public management research on performance determinants and nursing home care literature, our hypotheses stipulate that public, nonprofit, and for-profit nursing homes use different approaches to balance the strategic tradeoff between two aspects of performance. Panel data on 14,423 facilities were analyzed to compare measures of quality and access across three sectors using different estimation methods. Findings indicate that ownership status is associated with critical differences in both quality and access. Public and nonprofit organizations are similar in terms of quality, and both perform significantly better than their for-profit counterparts. When compared to nonprofit and, in some cases, for-profit facilities, public nursing homes have a significantly higher share of Medicaid recipients. The paper proposes strategies to address the identified long-term care divide.

RN Staffing Time and Outcomes of Long-Stay Nursing Home Residents

OBJECTIVE

A clear link has been demonstrated between lower nurse staffing levels in hospitals and adverse patient outcomes, but the results of studies of such relationships in long-term care facilities haven't been as clear. This study explored the time nurses spent in direct care and how it affected outcomes in long-stay (two weeks or longer) nursing home residents.

METHODS

In a retrospective study of data collected as part of the National Pressure Ulcer Long-Term Study (NPULS), we analyzed data on 1,376 residents of 82 long-term care facilities whose lengths of stay were 14 days or longer, who were at risk of developing pressure ulcers but had none at study entry, and who had a Braden Scale score of 17 or less. Primary data came from residents' medical records during 12-week periods in 1996 and 1997. Dependent variables included development of pressure ulcer or urinary tract infection (UTI), weight loss, deterioration in the ability to perform activities of daily living (ADLs), and hospitalization. Independent variables included resident demographics, severity of illness, nutritional and incontinence interventions, medications, and nurse staffing time.

RESULTS

More RN direct care time per resident per day (examined in 10-minute increments up to 30 to 40 minutes per resident per day) was associated with fewer pressure ulcers, hospitalizations, and UTIs; less weight loss, catheterization, and deterioration in the ability to perform ADLs; and greater use of oral standard medical nutritional supplements. More certified nursing assistant and licensed practical nurse time was associated with fewer pressure ulcers but did not improve other outcomes.

CONCLUSIONS

The researchers controlled for important variables in long-stay nursing home residents at risk for pressure ulcers and found that more RN direct care time per resident per day was strongly associated with better outcomes. There's an urgent need for further research to confirm these findings and, if confirmed, for improving RN staffing in nursing homes to decrease avoidable adverse outcomes and suffering.

Facility charter and quality of care for board and care residents

In this investigation structure, process, and outcome measures of quality in for-profit and not-for-profit board and care homes are compared. We find one structural measure (providing nursing care), three process measures (food quality, staff treat residents with respect, and staff verbally abuse residents), and two outcomes measures (cleanliness of the facility and complaints to Ombudsman) to be significant. Moreover, the directions of these effects are all consistent, with for-profit facilities rated more poorly that not-for-profit facilities. These results are discussed emphasizing their implications for efficient and effective resident care.

A systems framework for evaluating nursing care quality in nursing homes

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

Nurse staffing patterns and quality of care in nursing homes

Using the structure-process-outcome framework and the resource-based view of the firm, this study considers both direct and indirect effects of registered nurse staffing patterns on the quality of patient care outcomes. Consistent with theory, registered nurse staffing patterns were found to affect quality of patient care both directly and indirectly through their positive effect on the processes of delivering care.

The impact of litigation on nursing home quality

Government reports indicate that regulations have been ineffective in improving quality of care in many nursing homes. Some analysts feel that litigation against nursing homes may be the result of quality problems that are monitored during the inspection process, some contend litigation merely causes quality problems by diverting financial resources away from patient care, and some argue that litigation is duplicating the efforts of the inspection process. Given that the relationship between litigation and inspection-oriented measures of quality is not clear, this article explores the relationship empirically. When a significant relationship is found, the empirical results suggest that litigation is associated with a decline in inspection-oriented measured quality in the nursing home facing the legal claim. In contrast, litigation against a chain has a very different relationship to firm-level quality, where firms within a chain that is being sued have higher levels of inspection-oriented quality. Our results suggest that legal claims may result from quality problems that go unmeasured during the inspection process. However, more research in this area is warranted.

Quality of Care in Nursing Homes

BACKGROUND

Recent work has highlighted a negative correlation between proprietary status and nursing home quality of care. This relationship might be explained by the context in which proprietary homes operate. However, another possible explanation is that some proprietary homes take excessive profit to the detriment of care quality.

OBJECTIVE

To examine the relationship between profit levels and quality in proprietary and nonproprietary nursing homes (NHs), accounting for resident and market characteristics.

METHODS

Data on 1098 free-standing NHs were taken from the California Office of Statewide Health Planning and Development, the On-line Survey Certification and Reporting System, and California licensing and statistical reports for 1998 and 1999. Tobit multivariate techniques were used to examine the relationship between deficiency citations and a range of explanatory variables, including profit.

RESULTS

Proprietary homes in California had significantly lower quality of care than nonproprietary homes. A stratified analysis revealed that, controlling for resident, facility, and market characteristics, profits located within the highest 14% of the proprietary sector's profit distribution were associated with significantly more total deficiencies and serious deficiencies. This relationship was not found in nonproprietary facilities. Other factors related to deficiencies included the ethnic mix of residents and facility size.

CONCLUSIONS

Within the context in which proprietary homes operate, profit above a given threshold is associated with a higher number of deficiencies. Given this and the role of the proprietary sector in NH care, careful monitoring of profit levels in this sector appears warranted.

Organizational efficiency and quality in Texas nursing facilities

Profit-seeking nursing facilities have been found to be overwhelmingly more cost efficient than nonprofit facilities. However, the question remains as to whether these organizational-efficiency differences are the result of operating structural differences (i.e., agency relationship costs) or differences in the quality of care rendered. Using traditional cost- and profit-function regression analyses which include a new index measure for quality, we conclude that quality influences costs and profits marginally, efficiency differences reflect agency costs and differences in organizational goals, and the belief that increases in quality require increases in cost does not hold when facility capacity is significantly underutilized.

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.

Regulation of nursing facilities in the United States: an analysis of resources and performance of state survey agencies

PURPOSE

This study was undertaken to examine the resources, staffing, and performance of the state survey agencies that have primary responsibility for regulating nursing facilities-licensing them at a state level and certifying them for participation in Medicare and Medicaid on behalf of the Center for Medicare and Medicaid Services (CMS; formerly the Health Care Financing Administration).

DESIGN AND METHODS

A telephone and fax survey of survey agencies in all 50 states and the District of Columbia was used, supplemented by secondary data collected from CMS's On-Line Certification and Reporting (OSCAR) system.

RESULTS

Total state agency expenditures on nursing facility regulation in 2000 were $382.2 million, which is less than one half of 1% of the total expenditures on nursing facilities in the United States. About 3,000 full-time equivalent surveyors are employed to regulate more than 17,000 nursing facilities in the United States. Nursing facility licensing and certification dominates the work of state survey agencies, although they are responsible for regulating many other health care organizations. Spending has risen recently, but resource levels vary greatly across states, and most state agencies report significant funding shortfalls that impact on their ability to perform their regulatory function. On a range of indicators, the performance of state survey agencies varies fivefold. Some of that state variation is explained by differences in resource levels for regulation, but most is not.

IMPLICATIONS

State survey agencies probably need more funding to fulfill their responsibilities properly, but other changes are also needed to improve their performance, including more support and oversight by CMS and more effective regulatory design.

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.

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.

Asymmetric information, ownership and quality of care: an empirical analysis of nursing homes

Theoretically, when asymmetric information exists, nonprofit organizations, due to the attenuation of the property right, provide better quality of service than do the for-profits. Despite extensive theoretical examination of the behavior of nonprofits, there has been very little empirical testing of the plausibility of these theories. This article addresses the effect of ownership type on the quality of service in the nursing home industry, an environment particularly conducive to identifying the existence of asymmetric information. The study shows that the differences between for-profit and nonprofit homes do become manifest when asymmetric information is present.

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.

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.

Nursing home costs and risk-adjusted outcome measures of quality

BACKGROUND

The inadequacy of quality of care in nursing homes has been and continues to be a focus of public concerns. Understanding the relationship between quality and costs can offer guidance to policies designed to encourage high quality.

OBJECTIVES

To investigate the relationship between costs and quality of care in nursing homes, and to test the hypothesis that higher quality may be associated with lower costs.

RESEARCH DESIGN

Statistical regression techniques were used to estimate nursing home variable-cost functions that included three risk-adjusted outcome measures of quality. Quality measures were based on decline in functional status, worsening pressure ulcers, and mortality. The study hypothesis was tested by an F test for the exclusion of nonlinear quality variables in the cost functions.

SUBJECTS

The study included 525 free-standing private and public nursing homes in New York State, or 84% of all nursing homes in the state during 1991.

RESULTS

F tests rejected the hypotheses that the three quality measures could be excluded from the cost function and that the association between costs and quality was linear. An inverted U-shaped relationship between quality and costs suggests that there are quality regimens in which higher quality is associated with lower costs.

CONCLUSIONS

Policies that encourage research to identify care protocols and management strategies leading to better outcomes and lower costs, as well as policies that encourage dissemination of such practices, may prevent decline in quality despite the continued financial constraints faced by nursing homes.

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.

The relationship between nursing staffing levels and nursing home outcomes

This study examined the effects of selected Minnesota nursing home attributes (size, ownership, noncompliance with a state correction order, and licensed and nonlicensed nursing hours) on specific outcomes (functional ability, discharge home, and death) for residents ages 65 and older, controlling for residents' age and previous functional ability. The functional outcome was operationalized by calculating the resident's Total Dependence Score (TDS), the total score on the assessment of eight activities of daily living (score range: 0-33). Ordinary least squares regression analysis was used to estimate the effects of facility attributes, admission TDS, and age on resident outcomes, and nonlinear probability analyses were used to estimate the effects of facility attributes, admission TDS, and age on the probability of death or discharge home. In the year after admission, licensed (but not nonlicensed) nursing homes were significantly related to improved functional ability, increased probability of discharge home, and decreased probability of death, but when limited to chronic residents, the role of professional nursing hours virtually disappears. Overall, the findings support greater use of licensed nurses in the nursing home setting.

Adverse outcomes and variations in organization of care delivery

OBJECTIVES

This article evaluates the state of the science with respect to morbidity, mortality, and adverse effects as outcomes indicative of variations in organizational variables in care delivery systems.

METHODS

Eighty-one research papers research examining relations among organizational structures or processes and mortality/adverse effects were reviewed, assembled from electronic and manual searches of the biomedical and health services research literature.

RESULTS

Most research relating mortality and other adverse outcomes to organizational variables has been conducted in acute care hospitals since 1990, with these outcome indicators linked more frequently to organizational structures than to organizational or clinical processes. There is support in some studies, but not in others, that nursing surveillance, quality of working environment, and quality of interaction with other professionals distinguish hospitals with lower mortality and complications from those with higher rates of these adverse effects. Increasing sophistication of risk adjustment methods suggests that variations in mortality and complications are influenced by patient variables more than by organizational variables. Adverse events may be a more sensitive marker of differences in organizational quality in acute care hospitals and long-term care.

CONCLUSIONS

Taken together, the acute care studies are not conclusive regarding the extent to which the organizational features of care delivery systems positively influence such bottom-line outcomes as mortality. As severity-adjustment methods become more refined for hospital patients, many of the small differences currently seen in mortality and complications may disappear. However, given that adverse events appear more closely related to organizational factors than in mortality, researchers need to refine and better define such events that are logically related to the coordinative organizational processes among caregivers. Finally, researchers need to go much beyond mortality, morbidity, and adverse events in evaluating the linkage between the organization of care and outcomes.