August 2020 Interim EuGMS guidance to prepare European Long-Term Care Facilities for COVID-19

PURPOSE

The European Geriatric Medicine Society (EuGMS) is launching a second interim guidance whose aim is to prevent the entrance and spread of COVID-19 into long-term care facilities (LTCFs).

METHODS

The EuGMS gathered experts to propose a guide of measures to prevent COVID-19 outbreaks in LTCFs. It is based on the specific features of SARS-CoV-2 transmission in LTCFs, residents' needs, and on experiences conducted in the field.

RESULTS

Asymptomatic COVID-19 residents and staff members contribute substantially to the dissemination of COVID-19 infection in LTCFs. An infection prevention and control focal point should be set up in every LTCF for (1) supervising infection prevention and control measures aimed at keeping COVID-19 out of LTCFs, (2) RT-PCR testing of residents, staff members, and visitors with COVID-19 symptoms, even atypical, and (3) isolating subjects either infected or in contact with infected subjects. When a first LCTF resident or staff member is infected, a facility-wide RT-PCR test-retest strategy should be implemented for detecting all SARS-CoV-2 carriers. Testing should continue until no new COVID-19 cases are identified. The isolation of residents should be limited as much as possible and associated with measures aiming at limiting its negative effects on their mental and somatic health status.

CONCLUSIONS

An early recognition of symptoms compatible with COVID-19 may help to diagnose COVID-19 residents and staff more promptly. Subsequently, an earlier testing for SARS-CoV-2 symptomatic and asymptomatic LTCF staff and residents will enable the implementation of appropriate infection prevention and control. The negative effects of social isolation in residents should be limited as much as possible.

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

OBJECTIVE

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

SETTING

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence and characteristics of nursing homes residents requiring light-care

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

Impact of long-term care insurance on institutional dementia care in Japan

Japan started long-term care insurance for nursing and home help services in April 2000 to cope with growing medical expenditures for the population aged over 65. To study the impact of the new insurance on utilization of dementia care, we compared demographic and clinical characteristics including diagnosis, degree of disability and behavioral disturbance before and after the launch among people with dementia covered by either long-term care or medical insurance. The subjects of the study were randomly selected patients/residents of specialized dementia care units in both psychiatric hospitals and geriatric care facilities before (1145 patients/residents in early 2000) and after (262 for medical insurance and 205 for long-term care insurance in 2001) the new system was launched. Although patients/residents in 2000 and 2001 were similar as a whole, the 2001 sample showed differences between patients in each of the types of insurance systems. Logistic regression analysis revealed that patients/residents covered by long-term care insurance were significantly more likely to be females and require higher levels of care. Patients covered by long-term care insurance were significantly less likely to be transferred from a psychiatric department nor did they display behavioral disturbance or an inability to put out or deal with fire. These results suggest that health care facilities have shifted to the new insurance system for patients requiring higher levels of care but without behavioral disturbances as it was intended. On the other hand, there were policy concerns of that demented persons with moderate activities of daily living impairments and behavioral disturbances would be at risk being excluded from the long-term care scheme.

[Medical characteristics of patients in long-term care facilities and predictions on the weight of their management]

The objective of this study was to highlight the heterogeneous nature of the medical profiles of patients living in long term care units (LCU) and to present the morbidity factors associated with-the weight and burden of ensuring long term medical care and treatment. Typology analysis, performed on a group of 600 LCU patients, highlights two types of patients: one who is characterised by having few or no serious diseases, and the other (representing nearly one-third of the sample population) corresponding to patients with serious poly-pathologies and requiring a high level of medical attention and nursing care. Factors associated with a higher level of care are diseases such as those related to cardiac or respiratory deficiencies. This predictive model for the burden of care could be used to measure the suitability between the state of the patients and the their optimum structures for care.

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

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

Nursing home 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.

State long-term care screening and assessment programs

Long-term care screening and assessment programs were designed by states to control long-term care costs and to prevent unnecessary institutionalization of Medicaid participants. This study reports data collected by telephone survey of state officials in all 50 states and Washington, D.C. on state variation in LTC screening and assessment programs. The majority of the state screening and assessment programs cover an array of LTC services but this has resulted in multiple separate screening programs for different long-term care services and eligibility groups. Only three states coordinated screening and assessment across long-term care programs by operating a single state administrative agency, using uniform need criteria and standard tools, and having automated databases (Arizona, Colorado, and Maine). The design and implementation of multiple and separate screening and assessment programs in most states may create potential barriers to client access, information about services and choice of services.

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.

The use of long-term care services by the Dutch elderly

The main focus of this paper is the development of an appropriate framework to characterize the process of long-term care utilization by the Dutch elderly. Three broad categories of care services are considered, namely, informal care, formal care at home, and institutional care. The use of these care alternatives is modelled jointly, and stochastic dependence is allowed between the various care options. Special attention is given to the concept of health status and to the potential endogeneity of this variable in the model. We apply a flexible non-parametric method to summarize the multidimensional concept of health status into a limited set of interpretable indices. The model is applied on the Longitudinal Ageing Study Amsterdam (LASA). We find strong effects of health status, gender, socio-economic variables, and prices on the utilization of long-term care services.

The implementation of the EverCare demonstration project

EverCare represents a creative approach to providing medical services to long-stay nursing home patients. It offers a capitated package of Medicare-covered services with more intensive primary care provided by nurse practitioners. The program's underlying premise is that better primary care will result in reduced hospital use. This work examines the implementation of the program in six locations. It identifies some of the issues that must be addressed if the program is to succeed both operationally and financially.

Nursing interventions in crisis-oriented and long-term psychiatric home care

Psychiatric nurses in The Netherlands are moving out of residential mental health institutions and are pioneering home care for the acutely and chronically mentally ill. The purpose of this study was to identify the interventions nurses currently use and to describe the differences between crisis-oriented and long-term psychiatric home care. Data was collected of 159 nursing care plans from four participating crisis-oriented and two long-term psychiatric home care teams. All stated nursing activities were identified and subsequently labelled and classified using the Nursing Intervention Classification (NIC). Results revealed that in both crisis-oriented and long-term psychiatric home care, nurses used a wide range of nursing interventions. Medication Management, Coping Assistance and Activity Therapy were the most frequently undertaken nursing interventions in both types of care. Within crisis-oriented care, Emotional Support and Self-esteem Enhancement dominated, whereas long-term care focused on Socialization Enhancement and Home Maintenance Assistance. The results will be used for further research and for standardization of nursing care plans within these categories of nursing practice.

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.

Elderly community residents' evaluative criteria and preferences for formal and informal in-home services

This article focuses on the evaluative criteria of elderly community residents regarding their preferences in cases of long-term care decision-making. An overall picture of the evaluative criteria which the elderly use to evaluate various alternatives for long-term care are assessed. Furthermore, we determined which of these evaluative criteria may be considered as the most important by the elderly. A good relationship with informal carers appears almost pre-conditional to a preference for informal support. The desire not to burden acquaintances, as well as a positive previous experience with this type of care, are the most important reasons stated for choosing formal or private services. Insights into criteria that are used to evaluate different care arrangements clarify and refine our perspective on future developments.

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.

Long-term care eligibility criteria for people with Alzheimer's disease

Long-term care (LTC) eligibility criteria are applied to a sample of 8,437 people with dementia enrolled in the Medicare Alzheimer's Disease Demonstration. The authors find that mental-status-test cutoff points substantially affect the pool of potential beneficiaries. Functional criteria alone leave out people with relatively severe dementia and with behavioral problems. It is therefore important to consider both behavioral and mental-status-test criteria in establishing eligibility for community-based services for people with dementia.

Privacy Act of 1974; report of new system--HCFA. Notice of new system of records

In accordance with the requirements of the Privacy Act of 1974, we are proposing to establish a new system of records, "Long Term Care Minimum Data Set (LTC MDS)," HHS/ HCFA/CMSO System No. 09-70-1516. We have provided background information about the proposed system in the "Supplementary Information" section below. Although the Privacy Act requires only that the "routine use" portion of the system be published for comment, HCFA invites comments on all portions of this notice. See "Effective Dates" section for comment period.

Eligibility criteria for NHS long stay care: the relationship between clinical need, dependency, and staff perception

A study was undertaken by a Scottish Health Authority to determine future provision of NHS long stay in-patient beds for young physically disabled people (aged < 65), and eligibility criteria for admission to such care. As part of the development of care in the community, only patients requiring specialist medical and nursing care should continue to be placed in NHS care. Resources freed from the resulting closure of NHS beds will be transferred to Social Services to develop alternative packages of care in the community, based on need rather than precedent. Achieving the balance, in terms of the correct level of continuance of NHS long stay care and redeployment of resources, requires careful planning. This study, involving all young physically disabled patients in NHS care in Argyll and Clyde Health Board, combined the assessment of dependency using validated scales (CAPE, FIM, and ERSS), with staff perception of dependency and with clinical criteria developed for a series of balance of care studies in this authority. These clinical criteria indicate the need for specialist medical and nursing care. By examining the relationship between dependency and staff perception, it has been possible to plan long stay provision on a population basis. The criteria for admission have been adopted for local clinical use and form the basis for appeals procedures for patients deemed appropriate for discharge.

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).

Low-care cases in long-term care settings: variation among nations

METHOD

residents of long-term care settings without major activity of daily living (ADL) deficits are often referred to as 'low-care cases' and are deemed inappropriately placed in an institution. We compare the prevalence and characteristics of this population in Denmark, Iceland, Italy, Japan, Sweden and the USA, using the Resident Assessment Instrument Minimum Data Set.

RESULTS

among the six nations, the percentage of low-care cases ranged from 27 to 52% using a broad definition of no physical assistance required in late-loss ADLs (bed mobility, toileting, transfer and eating). With a more narrow definition which additionally excludes those falling into the Resource Utilization Groups, version III categories of rehabilitation, clinically complex, impaired cognition and behaviour problems, the percentages seen range from 9 to 35%. Finally, 2-14% meet the most restrictive definition, which further excluded residents requiring any supervision in late-loss ADLs, with any deficits in early-loss ADLs (dressing or grooming) or needing medical and psychiatric supervision.

CONCLUSION

although long-term care settings differ, making comparison by country difficult, the use of the same standard assessment form makes it possible to compare the many reasons for institutionalization.

RUG-III and resource allocation: comparing the relationship of direct care time with patient characteristics in five countries

BACKGROUND

resource use by different types of patients is of increasing interest to health care services all over the world. Case-mix systems that group together individuals with similar patterns of resource use have been developed to address these questions. Resource Utilization Groups version III (RUG-III) was developed in the USA to address the issue in the care of elderly people and has been validated in a number of countries.

METHOD

this paper synthesizes the results of RUG-III validation studies performed in the USA, Japan, Spain, Sweden and England and Wales, showing the consistency of the system in spite of different skill-mix and total time spent with patients. Data from the validation studies of five countries were compared. Percentage of time given by trained nurses and mean nursing time per patient was compared overall and between selected RUG-III groups.

RESULTS

mean time per patient ranged from 84.4 min per day in Japan, to 155.6 min in England and Wales. Trained nurse time ranged from 7.5% of total time in the USA to 53.2% of total time in England and Wales. The inter-group relationship was very similar in all countries. The RUG-III system appears robust in a wide variety of settings and countries. Future research should address the relationship between skill-mix and total time spent with patients with respect to outcome and quality of care.

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.

Involving stakeholders in health services research: developing Alberta's resident classification system for long-term care facilities

Little attention has been directed in Canada to identifying stakeholders at the administrative policy level to whom relevant health services research information can be targeted. This article describes a case study in which key stakeholders (long-term care facility owners, operators, and care providers) were explicitly defined not only as targets of original research information to inform administrative public policy but also as collaborators in the research process and dissemination of results. The research involved development of a classification system to measure resident care requirements in the province's nursing homes and auxiliary hospitals. The classification system formed the basis of a new government administrative policy for allocating public funds to these facilities based on levels of care. The authors describe the rationale for involving stakeholders in the research process, the role of stakeholders as collaborators, and lessons learned from the Alberta experience. Examples are presented of how stakeholders can contribute to the health services research process and outcome: by providing experiential knowledge related to the research outcome, anticipating and overcoming potential problems with policy implementation, facilitating policy-oriented learning across stakeholder groups, assisting in the transfer of research information to wider stakeholder audiences, and promoting acceptance for policy change.

Applying RUG-III in Japanese long-term care facilities

A U.S. nursing home case-mix system, Resource Utilization Group, Version III (RUG-III), was tested in a variety of Japanese long-term care facilities. Staff time and resident characteristics were measured for a sample of 871 patients. Acceptable reliability was found for items defining RUG-III, and the system explained 44% of the variance in wage-weighted staff time (cost). Also, Japanese and U.S. costs had similar patterns across RUG-III categories. However, there was wide discrepancy between the stated purpose of Japanese facilities and their patient populations, and the current payment mechanism did not reflect actual use of resources.

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

A case-mix classification system for nursing home residents is developed, based on a sample of 7,658 residents in seven states. Data included a broad assessment of resident characteristics, corresponding to items of the Minimum Data Set, and detailed measurement of nursing staff care time over a 24-hour period and therapy staff time over a 1-week period. The Resource Utilization Groups, Version III (RUG-III) system, with 44 distinct groups, achieves 55.5% variance explanation of total (nursing and therapy) per diem cost and meets goals of clinical validity and payment incentives. The mean resource use (case-mix index) of groups spans a nine-fold range. The RUG-III system improves on an earlier version not only by increasing the variance explanation (from 43%), but, more importantly, by identifying residents with "high tech" procedures (e.g., ventilators, respirators, and parenteral feeding) and those with cognitive impairments; by using better multiple activities of daily living; and by providing explicit qualifications for the Medicare nursing home benefit. RUG-III is being implemented for nursing home payment in 11 states (six as part of a federal multistate demonstration) and can be used in management, staffing level determination, and quality assurance.

US nursing-home population composition in the PPS-era

This paper uses the 1987 National Medical Expenditure Survey-Institutional Population Component baseline public use data to compare US nursing-home population residents who were admitted in years adjacent to the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA). This Act has been associated with claims of hospitals discharging Medicare patients quicker and sicker in order to gain financially under the prospective payment system (PPS), which would change the composition of nursing-home populations. The working hypothesis was that if PPS had an effect on the composition of nursing-home populations, those admitted during the PPS-era would have more reported deficits than those who were admitted in the pre-PPS period. Although the data are cross-sectional it was expected that differences in trends could be observed. The data do not show any general change in the composition of nursing-home populations that could be attributed to PPS. The explanation is that while PPS may have a discernible effect on short stayers, there have not been any clear effects to date on the long-stayer population represented by these data.

Activities of daily living and costs in nursing homes

Functionality, as measured by activities of daily living (ADL), is the most important predictor of the cost of nursing home care. Data from a field-test version of the federally mandated Minimum Data Set (MDS) were examined using analysis of variance (ANOVA) and recursive partitioning methods to determine the relationships between ADL limitations and nursing cost (wage-weighted nursing time) among nursing home residents (n = 6,663). From this analysis, an index based on limitations in four ADLs was created. The developed ADL index is a readily determined measure of functional status useful in allocating nursing staff within nursing homes and in comparing the functional status of groups of residents, explaining 30 percent of variance in nursing costs among nursing home residents.

Creating a MEDPAR (Medicare provider analysis and review) analog to the RUG-III (Resource Utilization Groups, Version III) classification system

As Medicare payments for post-acute institutional care continue to rise sharply, policy interest in the clinical characteristics of beneficiaries admitted to nursing homes and their variation across facilities has stimulated research into case mix. Measures of Medicare skilled nursing facility (SNF) case mix are important in relating payments to the care requirements of residents. The Resource Utilization Groups, Version III (RUG-III) classification system uses a new minimum data set that is not currently available nationally. In preparation for a multi-State demonstration, we needed to simulate at least the first-level splits at the national, State, and facility level. Therefore, we developed proxy measures using comparable data available on the National Claims History files. The analog is an easily programmed measure of the acuity/severity of beneficiaries' conditions across a Medicare Part A SNF stay in 75 percent of the SNF providers. This can be a method for estimating changes in case mix over the years, and differences across provider types and States.

RUG-II (Resource Utilization Group, Version II) impacts on long-term care facilities in New York

This article observes changes during the first 5 years of Resource Utilization Group, Version II (RUG-II) system utilization by the New York State Department of Health (NYDOH) for Medicaid program reimbursement. Findings include a dramatic increase in the number of residents scoring in the highest intensity resident-care categories, a substantial increase in staffing and expenditures for rehabilitation therapies, and a possible negative impact on the financial performance of New York long-term care (LTC) facilities. RUG-II appears to have been successful in improving access to nursing homes for individuals with heavy-care needs and in encouraging the appropriate utilization of institutionalized skilled nursing care.

Long-term care reform in Alberta, Canada: the role of the resident classification system

In 1988 the Alberta government, Canada, introduced a patient (now called resident) classification system (RCS) to measure the care requirements of residents in long-term care facilities and provide case-mix information so that funding could be based on resident need rather than a system of global funding. The RCS is described and issues relating to the measurement of patient/resident need are discussed, together with some suggestions as to how the tool might be used in quality assurance and outcome measurement.