Market competition and the quality of nursing home 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.

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.

Consumer Satisfaction in Long-Term Care: State Initiatives in Nursing Homes and Assisted Living Facilities

PURPOSE

We report the results of a survey of state initiatives that measure resident satisfaction in nursing homes and assisted living facilities, and we describe several model programs for legislators and public administrators contemplating the initiation of their own state programs.

DESIGN AND METHODS

Data on state initiatives and programs were collected during March and April 2000 through a mailed questionnaire and follow-up telephone interviews and were current as of September 2002.

RESULTS

Of the 50 states surveyed, 50 responses were received (response rate = 100%); 12 states (24%) reported the use of consumer satisfaction measures, and 7 (Florida, Iowa, Ohio, Oregon, Texas, Vermont, and Wisconsin) reported using resident satisfaction data within their consumer information systems for nursing homes or assisted living facilities. Additionally, 2 states (Iowa and Wisconsin) use resident satisfaction data for facility licensing and recertification. The design of the instruments and collection methods vary in these states, as do the reported response rates, per-resident cost, and the purpose for satisfaction data collection.

IMPLICATIONS

State satisfaction efforts are in an early stage of development. Well-produced, easily understandable reports on nursing home and assisted living quality could provide information and guidance for patients and families contemplating the utilization of long-term care services. Dissemination of quality information may also facilitate sustained quality and efficiency improvements in long-term care facilities and thus enhance the quality of care for and quality of life of long-term care residents.

Inter-rater reliability of nursing home quality indicators in the U.S

Background

In the US, Quality Indicators (QI's) profiling and comparing the performance of hospitals, health plans, nursing homes and physicians are routinely published for consumer review. We report the results of the largest study of inter-rater reliability done on nursing home assessments which generate the data used to derive publicly reported nursing home quality indicators.

Methods

We sampled nursing homes in 6 states, selecting up to 30 residents per facility who were observed and assessed by research nurses on 100 clinical assessment elements contained in the Minimum Data Set (MDS) and compared these with the most recent assessment in the record done by facility nurses. Kappa statistics were generated for all data items and derived for 22 QI's over the entire sample and for each facility. Finally, facilities with many QI's with poor Kappa levels were compared to those with many QI's with excellent Kappa levels on selected characteristics.

Results

A total of 462 facilities in 6 states were approached and 219 agreed to participate, yielding a response rate of 47.4%. A total of 5758 residents were included in the inter-rater reliability analyses, around 27.5 per facility. Patients resembled the traditional nursing home resident, only 43.9% were continent of urine and only 25.2% were rated as likely to be discharged within the next 30 days.

Results of resident level comparative analyses reveal high inter-rater reliability levels (most items >.75). Using the research nurses as the "gold standard", we compared composite quality indicators based on their ratings with those based on facility nurses. All but two QI's have adequate Kappa levels and 4 QI's have average Kappa values in excess of .80. We found that 16% of participating facilities performed poorly (Kappa <.4) on more than 6 of the 22 QI's while 18% of facilities performed well (Kappa >.75) on 12 or more QI's. No facility characteristics were related to reliability of the data on which Qis are based.

Conclusion

While a few QI's being used for public reporting have limited reliability as measured in US nursing homes today, the vast majority of QI's are measured reliably across the majority of nursing facilities. Although information about the average facility is reliable, how the public can identify those facilities whose data can be trusted and whose cannot remains a challenge.

Nursing home staffing, turnover, and case mix

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

Nursing care quality in nursing homes: cross-sectional versus longitudinal analysis

This empirical study of the relationship between nursing care adequacy and nursing care quality demonstrates that a positive relationship exists between the process and outcome dimensions of quality of nursing care. The results from the analysis of national data on nursing homes' deficiencies highlight the importance of conducting a longitudinal study of the effect of nurse staffing and nursing care adequacy on the quality of care.

"At least Mom will be safe there": the role of resident safety in nursing home quality

When family members admit a loved one to a nursing home, they expect that the facility will assure the physical safety of the residents. However, this does not always occur. Safety concerns persisting in at least some modern American nursing homes involve adverse drug events, injurious falls, pressure ulcers, problems with tube feeding, faulty communications or other breakdowns during transfer to or from hospital, and equipment breakdowns or mix-ups. The adversarial legal, economic, political, and media environment surrounding the US nursing home industry poses serious practical impediments to alleviating these safety concerns more effectively. However, resident safety comprises only one part of the larger quality improvement picture in the nursing home context. While the threat of negative legal repercussions may be necessary to address safety issues, a fuller concern about improving the quality of care and quality of life for nursing home residents will also involve the development and implementation of a combination of positive incentives for facilities to do better.

The nursing home problem in Florida

The nursing home problem in Florida was characterized as a debate over quality of care and the rapid increase of lawsuits against nursing homes that led to a decline in the availability of affordable liability insurance. The staff for Florida's Task Force on Availability and Affordability of Long-Term Care analyzed lawsuit and quality-of-care data from one county in Florida and quality-of-care data statewide to understand the relationship between the two sides of the argument. Analyses showed support for both positions and a middle-ground policy position was achieved. The subsequent nursing home reform legislation and implications for the future of long-term care in Florida are discussed.

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

PURPOSE

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

DESIGN AND METHODS

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

RESULTS

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

IMPLICATIONS

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

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

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

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.

Use of resident-origin data to define nursing home market boundaries

Previous studies of nursing home markets have assumed that a nursing home's market is coincident with the boundaries of the county in which it is located. We test this assumption by using the zip code of residence for Medicare beneficiaries admitted into a nursing home in New York state in the periods 1992-93 and 1996-97. We find that nursing homes located in urban areas have markets that are a fraction of the size of the county in which they are located. We calculate the Herfindahl-Hirschman Index (HHI) to measure the competitiveness of each nursing home's market. This shows that nursing home markets tend to be more concentrated than those that result from assuming countywide markets. These results suggest that studies of nursing home markets should not use counties as markets.

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.

Does prospective payment really contain nursing home costs?

OBJECTIVE

To examine whether nursing homes would behave more efficiently, without compromising their quality of care, under prospective payment.

DATA SOURCES

Four data sets for 1994: the Skilled Nursing Facility Minimum Data Set, the Online Survey Certification and Reporting System file, the Area Resource File, and the Hospital Wage Indices File. A national sample of 4,635 nursing homes is included in the analysis.

STUDY DESIGN

Using a modified hybrid functional form to estimate nursing home costs, we distinguish our study from previous research by controlling for quality differences (related to both care and life) and addressing the issues of output and quality endogeneity, as well as using more recent national data. Factor analysis was used to operationalize quality variables. To address the endogeneity problems, instrumental measures were created for nursing home output and quality variables.

PRINCIPAL FINDINGS

Nursing homes in states using prospective payment systems do not have lower costs than their counterpart facilities under retrospective cost-based payment systems, after quality differences among facilities are controlled for and the endogeneity problem of quality variables is addressed.

CONCLUSIONS

The effects of prospective payment on nursing home cost reduction may be through quality cuts, rather than cost efficiency. If nursing home payments under prospective payment systems are not adjusted for quality, nursing homes may respond by cutting their quality levels, rather than controlling costs. Future outcomes research may provide useful insights into the adjustment of quality in the design of prospective payment for nursing home care.

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.

Regulating U.S. nursing homes: are we learning from experience?

The quality of care in U.S. nursing homes has been a recurrent matter of public concern and policy attention for more than thirty years. A complex regulatory system of state licensure and federal certification is in place, but problems of poor quality and neglect and abuse of patients still appear to be endemic. This paper describes how the current system of regulation developed, examines its impact, and draws on the wider literature on regulation to outline some characteristics that may have detracted from its effectiveness and contributed to its disappointing results. Future regulatory reform should pay more attention to the lessons of regulation in other settings and make more use of research and formative evaluation.

Supply and segregation of nursing home beds in Chicago communities

OBJECTIVE

Previous research suggests that a shortage of nursing home beds in Latino communities and segregation within facilities in urban settings may contribute to low utilization patterns that both Latino and African American elders exhibit. In order to explore structural barriers to nursing home care for African American and Latino families, this study examines the supply and ethnoracial composition of nursing homes in Chicago communities.

DESIGN

With data from the 1990 US Census of Population and Illinois' 1994 Long-Term Care Facility Survey, regression was used to determine if Latino nursing home residents in Chicago follow neighborhood residential patterns in the same way that African American nursing home residents do. Next the availability of nursing home beds by ethnoracial community is examined using analysis of variance. Finally, we present correlations between the racial/ethnic composition of Chicago's facilities, community demographics and facility characteristics that have been associated with quality outcomes.

RESULTS

Both African American and Latino nursing home residents follow residential housing patterns, tending to reside in facilities located in their own communities. Latino communities have the fewest beds. However, Latinos appear to be more mobile in their utilization of nursing facilities in other communities than either African Americans or whites and tend to reside in smaller homes with fewer Medicaid recipients.

CONCLUSION

Health policy makers must actively address racial and ethnic differences in access to long-term care or risk reinforcing the effects of poverty and segregation. In order to ensure that Latino elders living alone are not going without needed care city leaders must promote a range of culturally sensitive alternatives to nursing home care within Latino communities while promoting geographic mobility for African Americans.

Influence of facility characteristics on use of antipsychotic medications in nursing homes

OBJECTIVES

This study investigated the effect of facility and resident characteristics on the use of antipsychotic medications in the long-term care setting.

RESEARCH DESIGN

This research used data available from the On-Line Survey and Certification of Automated Records (OSCAR) for all Medicare/Medicaid-certified nursing homes in the contiguous United States in 1997. The data consisted of 14,631 facilities.

MEASURES

A multiple linear regression model was used to determine the effects of selected facility and resident characteristics on antipsychotic drug use while simultaneously controlling for the effects of resident characteristics and stratifying by ownership type. beta-Coefficients provided measures of effect and represented the per-unit change in the prevalence of antipsychotic use corresponding to the per-unit change in each independent variable.

RESULTS

In for-profit facilities, both the presence of special care units and mental health professionals were associated with increased antipsychotic use (beta = 1.70, SE = 0.23; beta = 0.24, SE = 0.17, respectively), while other facility factors such as increasing size, being part of a chain, and higher occupancy rate were associated with decreased antipsychotic drug use. In the nonprofit environment, facility characteristics (eg, increasing occupancy rate, certified nurses' aides per 100 beds) were associated with decreasing antipsychotic use. Increasing percentages of residents covered by Medicare, those with dementia, and residents with mental retardation (beta = 0.05, SE = 0.01; beta = 0.03, SE = 0.01; beta = 0.08, SE = 0.08, respectively) were predictive of increased drug use.

CONCLUSIONS

Facility and resident characteristics are associated with use of antipsychotic medications, although the extent to which these factors explain variability in use of anti-psychotics may vary on the basis of the underlying financial incentives of the institution.

Controlling the supply of long-term care providers in thirteen states

Many states have responded to growing Medicaid long-term care expenditures by limiting the number of long-term care providers through certificate-of-need (CON) programs and moratoriums on new construction or certification for participation in the Medicaid program. This article focuses on the use of these policies in 13 states. Most of the 13 states control the supply of nursing home beds and hospital conversions with CONs or moratoriums, but they are struggling to adapt the role of supply policy to the growth of home health and residential care. As an increasing proportion of Medicaid long-term care spending goes to these nursing home alternatives, supply policy needs to keep pace with the changing provider market and the changing demographics of the consumer market if it hopes to ensure access to long-term care and control Medicaid expenditures.

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.

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.

Physical restraints in nursing homes: a review of the literature since the Nursing Home Reform Act of 1987

The use of physical restraints is one of the most negative features of nursing home care. Their use significantly affects the quality of life of residents. In an attempt to limit the use of restraints, the Nursing Home Reform Act (NHRA) of 1987 contained provisions regulating their use. In this article, the authors review the literature on the use and consequences of physical restraints in nursing homes since the passage of the NHRA. First, they describe the history behind the use of restraints and define what is considered to be a physical restraint. Second, they examine the four most common justifications for restraint use. Third, they describe the incidence and prevalence of restraint use. Fourth, they address demographic and clinical characteristics of residents that have been found to be associated with restraint use. Fifth, they examine negative outcomes of restraining residents. Finally, they describe alternatives to using restraints.

Quality improvement in nursing care facilities: extent, impetus, and impact

This study examines the extent, motivation, and performance implications of normal quality improvement (QI) programs in Pennsylvania nursing care facilities. Responses to a 20-item survey sent to facility administrators indicate that continuous quality improvement/total quality management (CQI/TQM) adopters are more motivated by quality of care and human resource concerns in implementing QI, more satisfied with the results of QI efforts, and more aware of a competitive environment than are non-adopters. There are few differences between adopters and non-adopters with respect to organizational characteristics or performance on quality of care measures. Comparison with the results of a study of QI implementation in hospitals reveals some differences in motivation, but similarities in satisfaction with results.