A comparison of the level of care predictions of six long-term care patient assessment systems

Assessment to guide placement, plan care, and track change in individuals with Alzheimer's disease

Appropriate placement of residents is of critical concern. Multi-dimensional assessment is a complexprocess that could more precisely guide the placement and care of elderly persons withAlzheimer's disease. The use of the HaycoxDementia Rating Scale with 11 individuals withAlzheimer's disease in a closed unit, has assisted staf in the placement of residents in a protective unit at a tine when such a unit could increase or deter functional loss in selected areas of functioning. Moreover, the assessment tool has helped to identify the impact of dementia in the functional capabilities of individuals. Dressing and grooming was most impaired on admission to the unit, but changed very little during the ensuing 12 months. Functions dealing with social skills and awareness tended to increase. Increase of motor coordination impairment heralded a decrease in function for three residents.

Review of nurse home visiting interventions for community-dwelling older persons with existing disability

Despite there being a considerable number of meta-analyses and reviews synthesizing the nurse in-home visiting literature, there have been no reviews examining nurse in-home visiting for patients who are already disabled. This article presents a literature review and synthesis of 10 trials targeted on older adults with disability. The review is organized into structure and process components related to the outcome variable disability based on the classic Donabedian model. The review suggests that the components of in-home visiting associated with favorable disability outcomes include multiple home visits, geriatric training and experience, health provider collaboration, multidimensional assessment, and theory use. In contrast, lack of process measures, physician collaboration, training, and specific intervention components targeting disability are associated with ineffective interventions. This review helps provide insight into variables that influence disability outcomes as well as the development of best-practice models of in-home visiting to older adults with existing disability.

Cross-cultural validation of the St. Louis Inventory of Community Living Skills for Chinese patients with schizophrenia in Hong Kong

AIM

The study validated a culturally sensitive community living skills rating scale for Chinese patients by adapting the St. Louis Inventory of Community Living Skills (SLICLS).

METHOD

The Chinese version (SLICLS-C) was produced by forward and backward translation. An expert panel evaluated its content validity. Its internal consistency, inter-rater reliability, construct and concurrent validity were tested on 80 DSM-IV schizophrenia inpatients in a long-term facility. For predictive validity, the above sample was extended to ensure at least 20 subjects discharged to each of three levels of community care were included in the study sample.

RESULTS AND CONCLUSION

The SLICLS-C was psychometrically sound and could be used for predicting level of community care, program evaluation and measuring outcome.

Factors influencing long-term home care utilization by the older population: implications for targeting

This research was designed to explore factors that affect the choice of long-term care modalities in the older population and to discuss the appropriate target population of home health care services within the entire long-term care system. The study subjects' activities of daily living limitations, cognitive status, and sociodemograhic data at the time of admission were obtained from retrospective chart reviews. The sample included 134 older subjects who were receiving long-term care from a Long-Term Home Health Care Program or a nursing home in New York City. The results indicated that Long-Term Home Health Care Program use by older persons was characterized by a higher rate of being admitted from private homes, less cognitive impairments, less limitations in activities of daily living, and younger age than older patients who were nursing home residents. Consequently, in the choice of different care modalities, health-related factors of the older population were found to be more important predictors than sociodemographic characteristics or support system. The implication to both nurses and researchers is the development of eligibility criteria that captures the unique characteristics of disabled older persons in each of the different long-term care programs to serve them better in a cost-effective manner.

A validity study of the St. Louis Inventory of Community Living Skills

Clinicians who work with the long term mentally ill often need an instrument which measures the level of community living skills. Independent raters scored 60 clients of the St. Louis Community Placement Program on the St. Louis Inventory of Community Living Skills (SLICLS), a 15-item instrument that requires little training and only a few minutes to complete. There was good inter-rater reliability and internal consistency. Construct validity was demonstrated for clients in three types of residences. Concurrent validity was demonstrated in relation to the longer Missouri Level of Care Instrument.

Discharge-ready patients who remain hospitalized: a re-emerging problem for mental health services

There is evidence that mentally ill patients nationwide are retained in state hospitals in spite of the fact that they are discharge-ready. New Jersey provided a unique opportunity to study this phenomenon, since it has been using specific procedures to identify discharge-ready patients in state hospitals. An analysis of New Jersey state hospital data found that about 45% of the state hospital patients were designated by either the legal or the clinical system, or both, as discharge-ready. Although a substantial number of these patients were disabled, they were assessed as being able to manage in the community with appropriate support. Characteristics and service needs of these patients are described, and the differences between those designated as discharge-ready and those who were not are examined. Recommendations are made for future research addressing the legal, clinical and social processes that affect discharge readiness.

Rates, patterns, causes, and costs of hospitalization of nursing home residents: a population-based study

OBJECTIVES

Hospitalization of nursing home residents is a growing, poorly defined problem. The purposes of this study were to define rates, patterns, costs, and outcomes of hospitalizations from nursing homes and to consider implications for reducing this problem as part of health care reform.

METHODS

Communitywide nursing home utilization review and hospital discharge data were used to define retrospectively a cohort of 2120 patients newly admitted to nursing homes; these patients were followed for 2 years to identify all hospitalizations. Resident characteristics were analyzed for predictors of hospitalization. Charges and outcomes were compared with hospitalization of community-dwelling elders.

RESULTS

Hospitalization rates were strikingly higher for intermediate vs skilled levels of care (566 and 346 per 1000 resident years, respectively). Approximately 40% of all hospitalizations occurred within 3 months of admission. No strong predictors were identified. Length of stay, charges, and mortality rates were higher than for hospitalizations from the community.

CONCLUSIONS

Hospitalizations from nursing homes are not easily predicted but may in large part be prevented through health care reforms that integrate acute and longterm care.

A community ability scale for chronically mentally ill consumers: Part I. Reliability and validity

The authors describe the development, reliability testing, and validation of a 17-item instrument that measures the level of functioning of chronically mentally ill persons living in the community. The Multnomah Community Ability Scale is designed to be completed by case managers. The instrument provides a measure of the consumer's severity of disability which can, in turn, be used to: (a) describe an agency's "case mix" of clients; (b) measure consumer progress; (c) assign clients to different levels of service; and (d) assist payors in determining reimbursement. The Multnomah Community Ability Scale is aimed specifically at persons with chronic mental illness, is sensitive to differences among individuals within this special population, and is quick and easy to complete. The scale's reliability and validity have been examined in detail. Inter-rater and test-retest reliability are good. Criterion variables such as length of psychiatric hospitalization and clinicians' global ratings correlated highly with scale scores. Finally, the instrument predicts subsequent state and local hospital admissions.

Case management: a randomized controlled study comparing a neighborhood team and a centralized individual model

This randomized controlled study compared two types of case management for skilled nursing level patients living at home: the centralized individual model and the neighborhood team model. The team model differed from the individual model in that team case managers performed client assessments, care planning, some direct services, and reassessments; they also had much smaller caseloads and were assigned a specific catchment area. While patients in both groups incurred very high estimated health services costs, the average annual cost during 1983-85 for team cases was 13.6 percent less than that of individual model cases. While the team cases were 18.3 percent less expensive among "old" patients (patients who entered the study from the existing ACCESS caseload), they were only 2.7 percent less costly among "new" cases. The lower costs were due to reductions in hospital days and home care. Team cases averaged 26 percent fewer hospital days per year and 17 percent fewer home health aide hours. Nursing home use was 48 percent higher for the team group than for the individual model group. Mortality was almost exactly the same for both groups during the first year (about 30 percent), but was lower for team patients during the second year (11 percent as compared to 16 percent). Probable mechanisms for the observed results are discussed.

Applying insurance claims data to assess quality of care: a compilation of potential indicators

Insurance claims records, which document many aspects of the process and outcome of medical care, are a practical and unobtrusive source of data for monitoring the quality of care provided to enrollees--a purpose for which they are rarely used. Data for these potential indicators could be drawn from claims or other administrative data systems. The authors established categories of care that could be used to develop claims-based indicators and compiled an annotated list of broad indicators for assessing the quality of care. The compilation of indicators is preceded by a discussion of some of the issues and challenges facing those who use and interpret claims-based indicators of quality.

The dependency at discharge instrument as a measure of resource use in home care

The dependency at discharge instrument, developed to evaluate the needs for care of hospitalized patients on the day of discharge, was tested for its usefulness in measuring resource consumption in home health care. The instrument evaluates dependency in relation to bathing/hygiene, activity, technical procedures, and monitoring signs and symptoms. The sample used in this study consisted of 150 subjects admitted to one of three types of home health care agencies. Interrater reliability and internal consistency of the instrument were high. Factor analysis produced results similar to those of the developers for three of the four scale items. The item concerning need for assistance with procedures had a much lower loading, indicating that it had little in common with the other items. Criterion-based validity was measured by testing the instrument's ability to predict the number of registered nurse and home health aide visits, and length of enrollment. Findings indicated that the instrument had a modest level of criterion-based validity in predicting the use of registered nurse and home health aide services for the hospital-affiliated agency, but was relatively ineffective for public health and for-profit agencies.

Individual versus team case management in optimizing community care for chronically ill patients with dementia

Secondary analyses of a randomized trial comparing two models of case management of community residing chronically ill elderly showed that the greatest cost savings of the more intensive neighborhood-based team model, as opposed to the centralized individual model, were in the group with dementia. Estimated costs of health care in the team group were 41% lower than costs for the control group. No differences in survivorship, functional and care need status, or in caregiver satisfaction were found, suggesting no negative effect of reduction in use. Team case managers had much smaller caseloads, made many more home visits, (with much more counseling for family support), and made more referrals for medical evaluation, respite, and day care than did case managers for the control group.

From models to measures in assessment of mature families

Although assessment of families as guided by nursing conceptual models is gaining impetus in the field of nursing, the incorporation of psychometrically sound clinical research measures into assessment protocols is a relatively recent phenomenon in family health nursing. Therefore, the purpose of this article is to describe an educational approach for students enrolled in a graduate nursing course focusing on mature and aging families. In this course, valid and reliable clinical research measures were incorporated into assessment protocols for practice based on nursing models. Criteria for selection of clinical research measures emphasized appropriateness for nursing assessment of families, age and ethnic relevancy of the measures, strength of psychometric properties, ease of administration and understandability, and potential for delineating nursing diagnoses and nursing intervention foci. The methods used to incorporate this approach into a graduate-level family nurse clinician course are presented. Theoretical issues include (1) the fit between the selected measures and the nursing conceptual model of choice and (2) the use of individual-focused versus family-focused paradigms. Clinical issues include student involvement in instrument selection, ethical implications of use of the measures, interpretation of data, and sharing of results with families.

The Community Placement Scale: an adaptation of the Community Competence Scale for placement of the deinstitutionalized mentally ill

The Community Placement Scale (CPS), an abbreviated form of the Community Competence Scale (Anderten, 1979) suitable for placement of deinstitutionalized mental patients in the community, was developed in a combined sample of 87 subjects placed in the community in California and Missouri. Although the Community Competence Scale has shown considerable promise as a placement instrument with the deinstitutionalized mentally ill, a briefer measure is needed in order to increase acceptance by both patients and professional staff. Other improvements sought were determining the acceptability of items to placement personnel nationwide, eliminating nondiscriminating items, and heightening internal consistency reliability of subscales. In a series of discriminant analyses, remaining subscales were used to predict community placement with minimal and maximal degrees of structure. From these analyses, a measure that consisted of 5 subscales and 41 items and required approximately 20 minutes to administer was selected. This short form has many similarities to and a few important differences from the previously published short form.

Nursing homes as acute care providers. A pilot study of incentives to reduce hospitalizations

This program was designed to encourage treatment of episodes of acute illness in skilled nursing facilities in order to avoid costly and potentially traumatic admission to hospital. It is part of the Monroe County Long Term Care Program, Inc, system of case management and Medicare and Medicaid waivers, and consists of financial incentives, paid by Medicare, to facilities and to responsible physicians to evaluate and care for acutely ill patients in the SNF's when medically safe and feasible. A retrospective evaluation using a physician assessment committee concluded that among the first 112 patients in the program, 76% were very probably saved hospitalization or at least an emergency room visit. Acute bacterial infection was the most common category of episode, occurring in 46% of cases. Considerable savings to both Medicare and Medicaid were estimated to have resulted.

Geriatric patient outcomes and costs in three settings: nursing home, foster family, and own home

Forty-nine matched triads of geriatric patients were compared after three months in their respective placement settings: nursing homes, geriatric foster homes, and own homes with supportive services. Compared to similarly disabled patients in nursing homes, patients in the two community settings made greater improvements in self-care skills and mobility, expressed greater well-being, had similar types and amounts of morbidity, and entailed lower costs. The results support the expansion of home and community-based services as alternatives to institutional care for a substantial number of geriatric patients.

Evaluation research in long-term care. Scope and methodology

Several policy issues pertaining to long-term care (LTC) were assessed, and they include (1) What are the cost-effective alternatives in long-term care? (2) What are the major societal and individual factors that are amenable to program interventions for reducing unnecessary and inappropriate institutionalization of the chronically ill? (3) What are the critical elements of a successful evaluation research design in long-term care? (4) How can LTC research findings be transmitted into policy relevant guides for program planning and development? The strengths and weaknesses of a variety of evaluation designs in long-term care research were discussed.

Simulating the impact of case-mix adjusted hospice rates

The Medicare hospice benefit prospectively reimburses hospices based on the inpatient status of the patient, whether or not the patient is at home, and whether the patient is receiving round-the-clock nursing. Using national Hospice Study data, two case-mix adjusters based on patient functioning and living arrangement were found to be significantly related to per diem cost. These were tested by simulating their impact on hospice revenues. Increasing per diem reimbursements 35 percent for nonambulatory patients living alone only increases hospice revenues by 4 percent; hospices with sicker patients benefit the most.

A quantitative method of identifying older persons at risk for increasing long term care services

The purpose of this study was to test the utility of upper and lower extremity performance, grip strength, and mental status as predictors of stability or chronic deterioration in a cohort of frail older persons. The study population consisted of a random sample of forty patients selected from residents of an intermediate level care facility. Demographic information, manual ability, mental status, grip strength, mobility, active and resolved medical problems, medications, and professional's estimate of each participant's likelihood of requiring skilled nursing care were obtained within 2 weeks after identifying the sample. Manual ability, mental status, grip strength, and mobility were included in a Performance Index to predict functional ability. Study participants were followed for 2 years to observe which individuals remained at the intermediate care level and which persons required transfer to skilled nursing care. Of the 27 persons who completed the study, 21 persons remained stable (Group 1) and 6 individuals were transferred to skilled nursing care (Group 2) over the 2 year follow-up period. Group comparisons of the mean values revealed statistically significant differences for age, manual ability and the Performance Index. The Performance Index was a statistically significant predictor of increasing dependency (p less than 0.005). Within Group 1, no patients had a performance score which suggested a poor outcome; only one person in Group 2 had a prediction of the favorable outcome. Professional judgement correctly predicted 16 of the 21 persons in Group 1 and 2 of the 6 persons in Group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of level of care: implications of interrater reliability on health policy

In Wisconsin, level-of-care assessments are used to set Medicaid reimbursement and determine nursing home eligibility. This study examined three methods of assessing level of care: 1) the Wisconsin quality assurance project (QAP) method, based on observations of patients, patient records, and staff interviews; 2) the Wisconsin standard (STD) method, based primarily on a clinical record review; and, 3) an adaptation of New York's "DMS-I," a checklist with numerical weights used to set level of care. Results address interrater reliability, the agreement between assessments by research teams and actual levels of care set by the State, and the implications that agreement has for reimbursement.

Nursing home pre- admission screening: a review of state programs

From January through March of 1981, the Health Care Financing Administration (HCFA) surveyed the agencies of 49 States and the District of Columbia responsible for the administration of the Medicaid program. The purpose of the survey was to determine if the agencies had a nursing home pre-admission screening program for Medicaid patients. Twenty-eight States and the District of Columbia responded that there was a state-wide, pre-admission screening program for Medicaid patients prior to their entry into a nursing home, or that there was a program operating in a portion of the State. HCFA collected information on the scope of the programs, the agencies responsible for conducting pre-admission screening, the composition of the screening teams, and the characteristics of the client assessment instruments. Two States, Virginia and Massachusetts, provided information on program impact. This article presents the findings of the survey and explores several aspects of the Medicaid program influencing the effectiveness of pre-admission screening. It begins with an overview of the policy issues which have influenced the development of pre-admission screening and defines the core components of these programs.

Institutionalized and the non-institutionalized elderly

A survey covering all the elderly over 65 years of age at home and in institutions was made in a rural town of Japan in order to reveal the physical and socio-psychological factors which were related to their current placement status. The proportion of those over 65 in this town is 13%, of which 53% are living either alone or with spouse only, which anticipates the future national trend. Of the 3039 enumerated, 6.0% were hospitalized, 1.5% in the Home for the aged and only one in a Nursing home. As the level of disability became more serious, the proportion institutionalized increased; however, even at the severe level only half were in institutions. This situation could only be understood when the family caring capacity was taken into consideration. Those at home had a greater possibility of having a healthy, not employed caring person. Economic factors were relevant only for the Home for the aged subjects. At the same disability level, the family of the institutionalized expressed a greater subjective burden in caring compared with those at home. A tentative criteria for evaluating institutional care need based on the level of disability and family caring capacity is proposed.

Inconsistency in level of care assignment decisions in skilled nursing facilities

In Arizona, a non-Medicaid state, we investigated the extent to which unregulated level of care assignments in Skilled Nursing Facilities consistently reflect level and nature of patient impairment. Using Multiple Discriminant Analysis (MDA) to develop optimal prediction functions, approximately 70 per cent of patients could be correctly classified. Factors identified by MDA as discriminating among patients at different levels of care are an Activities of Daily Living (ADL) impairment factor, and a factor defined by confusion, transitory contact with the social environment, and propensity to wander. Results are compared with those of studies using MDA to replicate Multidisciplinary Review Team (MRT) or other expert level of care assignments intended to develop patient classification functions for clinical use. MRT assignments appear to reflect patient impairment characteristics only slightly better than do unregulated institutional assignments, suggesting that such utilization review efforts may result in minimal net gains in appropriateness of placement.