The Employment of Nurse Practitioners and Physician Assistants in U.S. Nursing Homes

Advanced practice nurses' daily practices delivering primary care to residents in long-term care facilities: a qualitative study

BACKGROUND

Globally, there is a growing shortage of primary care professionals, including those who serve residents in long-term care facilities (LTCFs). In recent decades, numerous new care models have been implemented to improve these residents' care. Many incorporate Advanced Practice Nurses (APNs) into interprofessional healthcare teams. In Switzerland, little is known about how these models function, and few facilities have integrated APNs. This study aims to explore the everyday practice of APNs employed at a medical centre in the Bernese Seeland region delivering care to LTC residents and collaborating with LTCFs staff.

METHODS

This qualitative study uses the "Interpretive Description" methodology, which builds on existing knowledge and examines phenomena interpreted through a social constructivist approach. We conducted six semi-structured individual interviews, one semi-structured focus group interview, and an examination of secondary data. Our thematic analysis followed Braun and Clarke's guidelines for data analysis.

RESULTS

In LTCFs, APNs perform tasks similar to those of primary care physicians, e.g., patient visits and therapy adjustments, within the limits set by their supervising physicians. In addition, they contribute significantly to facility-wide quality improvement. We identified three fundamental elements for successful collaboration between APNs and LTCF staff: 1) clarifying roles and responsibilities; 2) establishing well-defined communication methods and pathways; and 3) building and maintaining trust. Together with LTCF staff, APNs provide multidimensional, person-centred care that focuses on medical, social, and nursing issues with the goal of maintaining the residents' best possible quality of life.

CONCLUSIONS

Our results suggest that integrating APNs into the LTCF care system improves care quality for residents and increases staff members' job satisfaction.

State scope of practice restrictions and nurse practitioner practice in nursing homes: 2012-2019

Increased engagement of nurse practitioners (NPs) has been recommended as a way to address care delivery challenges in settings that struggle to attract physicians, such as primary care and rural areas. Nursing homes also face such physician shortages. We evaluated the role of state scope of practice regulations on NP practice in nursing homes in 2012-2019. Using linear probability models, we estimated the proportion of NP-delivered visits to patients in nursing homes as a function of state scope of practice regulations. Control variables included county demographic, socioeconomic, and health care workforce characteristics; state fixed effects; and year indicators. The proportion of nursing home visits conducted by NPs increased from 24% in 2012 to 42% in 2019. Expanded scope of practice regulation was associated with a greater proportion and total volume of nursing home visits conducted by NPs in counties with at least 1 NP visit. These relationships were concentrated among short-stay patients in urban counties. Removing scope of practice restrictions on NPs may address clinician shortages in nursing homes in urban areas where NPs already practice in nursing homes. However, improving access to advanced clinician care for long-term care residents and for patients in rural locations may require additional interventions and resources.

CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned

Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone.

CONTEXT

In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only).

METHODS

Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality.

FINDINGS

Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations.

CONCLUSIONS

Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.

Assessment of changes in place of death of older adults who died from dementia in the United States, 2000-2014: a time-series cross-sectional analysis

BACKGROUND

As the mortality attributable to dementia-related diseases in the United States escalates, providing quality and equitable end-of-life care for dementia patients across care settings has become a major public health challenge. Previous research suggests that place of death may be an indicator of quality of end-of-life care. This study aims to examine the geographical variations and temporal trends in place of death of dementia decedents in the US and the relationships between place of death of dementia decedents and broad structural determinants.

METHODS

Using nationwide death certificates between 2000 and 2014, we described the changes in place of death of dementia decedents across states and over time. Chi-square test for trend in proportions was used to test significant linear trend in the proportion of dementia decedents at difference places. State fixed effects models were estimated to assess the relationships between the proportion of dementia decedents at difference places and state-level factors, particularly availability of care facility resources and public health insurance expenditures.

RESULTS

Dementia decedents were more likely to die at home and other places and less likely to die at institutional settings over the study period. There was wide inter-state and temporal variability in the proportions of deaths at different places. Among state-level factors, availability of nursing home beds was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on institutional long term supports and services was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on home and community based services, however, had a positive association with rates of home deaths.

CONCLUSIONS

There was a persistent shift in the place of death of dementia decedents from institutions to homes and communities. Increased investments in home and community based health services may help dementia patients to die at their homes. As home becomes an increasingly common place of death of dementia patients, it is critical to monitor the quality of end-of-life care at this setting.

High Medicaid Nursing Homes: Organizational and Market Factors Associated With Financial Performance

High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower quality and poorer financial performance. However, there is significant variation in performance among high Medicaid nursing homes. The purpose of this study is to examine the organizational and market factors that may be associated with better financial performance among high Medicaid nursing homes. Data sources included Long-Term Care Focus (LTCFocus), Centers for Medicare and Medicaid Services' (CMS) Medicare Cost Reports, CMS Nursing Home Compare, and the Area Health Resource File (AHRF) for 2009-2015. There were approximately 1108 facilities with high Medicaid per year. The dependent variables are nursing homes operating and total margin. The independent variables included size, chain affiliation, occupancy rate, percent Medicare, market competition, and county socioeconomic status. Control variables included staffing variables, resident quality, for-profit status, acuity index, percent minorities in the facility, percent Medicaid residents, metropolitan area, and Medicare Advantage penetration. Data were analyzed using generalized estimating equations with state and year fixed effects. Results suggest that organizational and market slack resources are associated with performance differentials among high Medicaid nursing homes. Higher financial performing facilities are characterized as having nurse practitioners/physician assistants, more beds, higher occupancy rate, higher Medicare and Medicaid census, and being for-profit and located in less competitive markets. Higher levels of Registered Nurse (RN) skill mix result in lower financial performance in high Medicaid nursing homes. Policy and managerial implications of the study are discussed.

Precision of provider licensure data for mapping member accessibility to Medicaid managed care provider networks

BACKGROUND

In July 2018, the Centers for Medicare and Medicaid Services (CMS) updated its Medicaid Managed Care (MMC) regulations that govern network and access standards for enrollees. There have been few published studies of whether there is accurate geographic information on primary care providers to monitor network adequacy.

METHODS

We analyzed a sample of nurse practitioner (NP) and physician address data registered in the state labor, licensing, and regulation (LLR) boards and the National Provider Index (NPI) using employment location data contained in the patient-centered medical home (PCMH) data file. Our main outcome measures were address discordance (%) at the clinic-level, city, ZIP code, and county spatial extent and the distance, in miles, between employment location and the LLR/NPI address on file.

RESULTS

Based on LLR records, address information provided by NPs corresponded to their place of employment in 5% of all cases. NP address information registered in the NPI corresponded to their place of employment in 64% of all cases. Among physicians, the address information provided in the LLR and NPI corresponded to the place of employment in 64 and 72% of all instances. For NPs, the average distance between the PCMH and the LLR address was 21.5 miles. Using the NPI, the distance decreased to 7.4 miles. For physicians, the average distance between the PCMH and the LLR and NPI addresses was 7.2 and 4.3 miles.

CONCLUSIONS

Publicly available data to forecast state-wide distributions of the NP workforce for MMC members may not be reliable if done using state licensure board data. Meaningful improvements to correspond with MMC policy changes require collecting and releasing information on place of employment.

Financial performance, employee well-being, and client well-being in for-profit and not-for-profit nursing homes: A systematic review

BACKGROUND

Expanding the opportunities for for-profit nursing home care is a central theme in the debate on the sustainable organization of the growing nursing home sector in Western countries.

PURPOSES

We conducted a systematic review of the literature over the last 10 years in order to determine the broad impact of nursing home ownership in the United States. Our review has two main goals: (a) to find out which topics have been studied with regard to financial performance, employee well-being, and client well-being in relation to nursing home ownership and (b) to assess the conclusions related to these topics. The review results in two propositions on the interactions between financial performance, employee well-being, and client well-being as they relate to nursing home ownership.

METHODOLOGY/APPROACH

Five search strategies plus inclusion and quality assessment criteria were applied to identify and select eligible studies. As a result, 50 studies were included in the review. Relevant findings were categorized as related to financial performance (profit margins, efficiency), employee well-being (staffing levels, turnover rates, job satisfaction, job benefits), or client well-being (care quality, hospitalization rates, lawsuits/complaints) and then analyzed based on common characteristics.

FINDINGS

For-profit nursing homes tend to have better financial performance, but worse results with regard to employee well-being and client well-being, compared to not-for-profit sector homes. We argue that the better financial performance of for-profit nursing homes seems to be associated with worse employee and client well-being.

PRACTICAL IMPLICATIONS

For policy makers considering the expansion of the for-profit sector in the nursing home industry, our findings suggest the need for a broad perspective, simultaneously weighing the potential benefits and drawbacks for the organization, its employees, and its clients.

Trends in Nurse Practitioner and Physician Assistant Practice in Nursing Homes, 2000-2010

OBJECTIVE

To examine nurse practitioner (NP) and physician assistant (PA) practice in nursing homes (NHs) during 2000-2010.

DATA SOURCES

Data were derived from the Online Survey Certification and Reporting system and Medicare Part B claims (20 percent sample).

METHODS

NP/PA state average employment, visit per bed year (VPBY), and providers per NH were examined. State fixed-effect models examined the association between state regulations and NP/PA use.

PRINCIPAL FINDINGS

NHs using any NPs/PAs increased from 20.4 to 35.0 percent during 2000-2010. Average NP/PA VPBY increased from 1.0/0.3 to 3.0/0.6 during 2000-2010. Average number of NPs/PAs per NH increased from 0.2/0.09 to 0.5/0.14 during 2000-2010. The impact of state scope-of-practice regulations was mixed.

CONCLUSIONS

NP and PA scope-of-practice regulations impact their practice in NHs, not always as intended.

Trends in state regulation of nurse practitioners and physician assistants, 2001 to 2010

Nurse practitioners and physician assistants can alleviate some of the primary care shortage facing the United States, but their scope-of-practice is limited by state regulation. This study reports both cross-sectional and longitudinal trends in state scope-of-practice regulations for nurse practitioners and physician assistants over a 10-year period. Regulations from 2001 to 2010 were compiled and described with respect to entry-to-practice standards, physician involvement in treatment/diagnosis, prescriptive authority, and controlled substances. Findings indicate that most states loosened regulations, granting greater autonomy to nurse practitioners and physician assistants, particularly with respect to prescriptive authority and physician involvement in treatment and diagnosis. Many states also increased barriers to entry, requiring high levels of education before entering practice. Knowledge of state trends in nurse practitioner and physician assistant regulation should inform current efforts to standardize scope-of-practice nationally.

Open source EMR software: profiling, insights and hands-on analysis

BACKGROUND

The use of open source software in health informatics is increasingly advocated by authors in the literature. Although there is no clear evidence of the superiority of the current open source applications in the healthcare field, the number of available open source applications online is growing and they are gaining greater prominence. This repertoire of open source options is of a great value for any future-planner interested in adopting an electronic medical/health record system, whether selecting an existent application or building a new one. The following questions arise. How do the available open source options compare to each other with respect to functionality, usability and security? Can an implementer of an open source application find sufficient support both as a user and as a developer, and to what extent? Does the available literature provide adequate answers to such questions? This review attempts to shed some light on these aspects.

OBJECTIVE

The objective of this study is to provide more comprehensive guidance from an implementer perspective toward the available alternatives of open source healthcare software, particularly in the field of electronic medical/health records.

METHODS

The design of this study is twofold. In the first part, we profile the published literature on a sample of existent and active open source software in the healthcare area. The purpose of this part is to provide a summary of the available guides and studies relative to the sampled systems, and to identify any gaps in the published literature with respect to our research questions. In the second part, we investigate those alternative systems relative to a set of metrics, by actually installing the software and reporting a hands-on experience of the installation process, usability, as well as other factors.

RESULTS

The literature covers many aspects of open source software implementation and utilization in healthcare practice. Roughly, those aspects could be distilled into a basic taxonomy, making the literature landscape more perceivable. Nevertheless, the surveyed articles fall short of fulfilling the targeted objective of providing clear reference to potential implementers. The hands-on study contributed a more detailed comparative guide relative to our set of assessment measures. Overall, no system seems to satisfy an industry-standard measure, particularly in security and interoperability. The systems, as software applications, feel similar from a usability perspective and share a common set of functionality, though they vary considerably in community support and activity.

CONCLUSION

More detailed analysis of popular open source software can benefit the potential implementers of electronic health/medical records systems. The number of examined systems and the measures by which to compare them vary across studies, but still rewarding insights start to emerge. Our work is one step toward that goal. Our overall conclusion is that open source options in the medical field are still far behind the highly acknowledged open source products in other domains, e.g. operating systems market share.

Antipsychotic medication use in nursing homes: a proposed measure of quality

OBJECTIVE

The potential misuse of antipsychotic medications (APMs) is an ongoing quality concern in nursing homes (NHs), especially given recent black box warnings and other evidence regarding the risk of APMs when used in NH populations. One mechanism regulators could use is public reporting of APM use by NHs; however, there is currently no agreed-upon measure of guideline-inconsistent APM use. In this paper, we describe a proposed measure of quality of APM use that is based on Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines, Food and Drug Administration (FDA) indications for APMs, and severity of behavioral symptoms.

METHODS

The proposed measure identifies NH residents who receive an APM but do not have an approved indication for APM use. We demonstrate the feasibility of this measure using data from Medicaid-eligible long-stay residents aged 65 years and older in seven states. Using multivariable logistic regressions, we compare it to the current CMS Nursing Home Compare quality measure.

RESULTS

We find that nearly 52% of residents receiving an APM lack indications approved by CMS/FDA guidelines compared with 85% for the current CMS quality measure. APM guideline-inconsistent use rates vary significantly across resident and facility characteristics, and states. Only our measure correlates with another quality indicator in that facilities with higher deficiencies have significantly higher odds of APM use. Predictors of inappropriate use are found to be consistent with other measures of NH quality, supporting the validity of our proposed measure.

CONCLUSION

The proposed measure provides an important foundation to improve APM prescribing practices without penalizing NHs when there are limited alternative treatments available.

The urban-rural disparity in nursing home quality indicators: the case of facility-acquired contractures

OBJECTIVE

To identify and quantify the sources of the urban-rural disparity in facility-acquired contracture rates in nursing homes.

DATA SOURCES

Survey inspection data of U.S. nursing homes from 1999 to 2008 and standardized national rural definition file from the Rural-Urban Commuting Area Codes.

STUDY DESIGN

We estimated regressions of facility-level contracture rate as a function of urban-rural categories (urban, micropolitan, small rural town, and isolated small rural town) and other related facility characteristics to identify size of the urban-rural disparity. We used Blinder-Oaxaca decomposition techniques to determine the extent to which the disparity is attributable to the differences in facility and aggregate resident characteristics.

PRINCIPAL FINDINGS

Rural nursing homes have higher contracture rates than urban nursing homes. About half of the urban-rural disparity is explained by differences in observable characteristics among urban and rural nursing homes. Differences in staffing levels explain less than 5 percent of the disparity, case-mix explains 6-8 percent, and structure and operational characteristics account for 10-22 percent of the disparity.

CONCLUSION

While a lower level and quality of staffing are a concern for rural nursing homes, facility structure and funding sources explain a larger proportion of the urban-rural disparity in the quality of care.

Provider staffing effect on a decision aid intervention

This study examined the association between Nurse Practitioner (NP) and Physician Assistant (PA) staffing in nursing homes and the effect of a decision aid regarding feeding options in dementia on the frequency of surrogate-provider discussions and on surrogates' decisional conflict. We compared these outcomes for facilities that had no NPs/PAs, part-time-only NP/PA staffing, and full-time NP/PA staffing. The sample included 256 surrogate decision makers from 24 nursing homes. The decision aid was associated with significant increases in discussion rates in facilities with part-time or no NP/PA staffing (26% vs. 51%, p < .001, and 13% vs. 41%, p < .001, respectively) and decreases in decisional conflict scores (-0.08 vs. -0.047, p = .008, and -0.30 vs. -0.68, p = .014, respectively). Sites with full-time NP/PA staffing had high baseline rates of discussions (41%). These findings suggest that the decision aid and full-time NP/PA staffing can enhance surrogate decision making in nursing homes.

Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay

BACKGROUND

Policymakers are exploring ways to reduce readmission rates. Much attention has been given to readmissions for conditions such as heart failure, acute myocardial infarction, and pneumonia, but little attention has been given to readmissions of patients with injury-related index admissions.

METHODS

This analysis is a retrospective cohort study of elderly persons who are admitted to a community hospital for a principal diagnosis of injury. We use 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases from 11 States. With logistic regression we identify factors associated with a 30-day, all-cause inpatient readmission. Factors include: patient characteristics, injury characteristics, clinical experiences during the hospital stay, and hospital characteristics.

RESULTS

About 1 in 7 elderly patients with an injury-related admission were readmitted in 30 days (13.7%). We found that severe injuries had higher predicted readmission rates. Patients receiving transfusions, experiencing a Patient Safety Indicator event, and with infections had higher readmission rates. Patients discharged to nursing homes or home health care had higher readmission rates compared with patients discharged to the community.

CONCLUSIONS

This study expands evidence for the influence of injury characteristics on readmission rates. It also provides evidence about hospital experiences that affect readmissions. These findings suggest that a focus on preventing complications during the hospital stay may help reduce hospital-specific readmissions for patients with injury-related conditions. It also suggests that a strategy to reduce readmission rates should not only focus on hospitals but also nursing homes and home health care.

Race, education, and the treatment of depression in nursing homes

OBJECTIVES

We investigate, among older adult nursing home residents diagnosed with depression, whether depression treatment differs by race and schooling, and whether differences by schooling differ by race. We examine whether Blacks and less educated residents are placed in facilities providing less treatment, and whether differences reflect disparities in care.

METHOD

Data from the 2006 Nursing Home Minimum Data Set for 8 states (n = 124,431), are merged with facility information from the Online Survey Certification and Reporting system. Logistic regressions examine whether resident and/or facility characteristics explain treatment differences; treatment includes antidepressants and/or psychotherapy.

RESULTS

Blacks receive less treatment (adj. OR = .79); differences by education are small. Facilities with more Medicaid enrollees, fewer high school graduates, or more Blacks provide less treatment.

DISCUSSION

We found disparities at the resident and facility level. Facilities serving a low-SES (socioeconomic status), minority clientele tend to provide less depression care, but Blacks also receive less depression treatment than Whites within nursing homes (NHs).

Response to regulatory stringency: the case of antipsychotic medication use in nursing homes

This paper studies the impact of regulatory stringency, as measured by the statewide deficiency citation rate over the past year, on the quality of care provided in a national sample of nursing homes from 2000 to 2005. The quality measure used is the proportion of residents who are using antipsychotic medication. Although the changing case-mix of nursing home residents accounts for some of the increase in the use of antipsychotics, we find that the use of antipsychotics by nursing homes is responsive to state regulatory enforcement in a manner consistent with the multitasking incentive problem. Specifically, the effect of the regulations is dependent on the degree of complementarity between the regulatory deficiency and the use of antipsychotics.

Factors associated with the use of advanced practice nurses/physician assistants in a fee-for-service nursing home practice: a comparison with primary care physicians

The purpose of this research was to examine factors associated with the use of advanced practice nurse and physician assistant (APN/PA) visits to nursing home (NH) patients compared with those by primary care physicians (PCPs). This was a secondary analysis using Medicare claims data. General estimation equations were used to determine the odds of NH residents receiving APN/PA visits. Ordinary least squares analyses were used to examine factors associated with these visits. A total of 5,436 APN/PAs provided care to 27% of 129,812 residents and were responsible for 16% of the 1.1 million Medicare NH fee-for-service visits in 2004. APN/PAs made an average of 33 visits annually compared with PCPs (21 visits). Neuropsychiatric and acute diagnoses and patients with a long-stay status were associated with more APN/PA visits. APN/PAs provide a substantial amount of care, but regional variations occur, and Medicare regulations constrain the ability of APN/PAs to substitute for physician visits.

Do Medicaid wage pass-through payments increase nursing home staffing?

OBJECTIVE

To assess the impact of state Medicaid wage pass-through policy on direct-care staffing levels in U.S. nursing homes.

DATA SOURCES

Online Survey Certification and Reporting (OSCAR) data, and state Medicaid nursing home reimbursement policies over the period 1996-2004.

STUDY DESIGN

A fixed-effects panel model with two-step feasible-generalized least squares estimates is used to examine the effect of pass-through adoption on direct-care staff hours per resident day (HPRD) in nursing homes.

DATA COLLECTION/EXTRACTION METHODS

A panel data file tracking annual OSCAR surveys per facility over the study period is linked with annual information on state Medicaid wage pass-through and related policies.

PRINCIPAL FINDINGS

Among the states introducing wage pass-through over the study period, the policy is associated with between 3.0 and 4.0 percent net increases in certified nurse aide (CNA) HPRD in the years following adoption. No discernable pass-through effect is observed on either registered nurse or licensed practical nurse HPRD.

CONCLUSIONS

State Medicaid wage pass-through programs offer a potentially effective policy tool to boost direct-care CNA staffing in nursing homes, at least in the short term.

Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: expert panel recommendations

In 2003, a panel of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care convened to examine and make recommendations about care quality and safety issues related to advanced practice nurses (APNs) in nursing home practice. This article reports on the panel recommendation that addressed expanding the evidence base of resident and facility outcomes of APN nursing home practice. A review of the small but important body of research related to nursing home APN practice suggests a positive impact on resident care and facility outcomes. Recommendations are made for critically needed research in four key areas: (a) APN nursing home practice, (b) relative value unit coding, (c) outcomes related to geropsychiatric and mental health nursing services, and (d) outcomes related to geriatric specialization. The APN role could be significantly enhanced and executed if its specific contribution to resident and facility outcomes was more clearly delineated through the recommended rigorous research.

A review of demographic and infrastructural factors and potential solutions to the physician and nursing shortage predicted to impact the growing US elderly population

This review highlights several of the key demographic, infrastructural, and cultural factors associated with the predicted labor force shortage in the healthcare field. Population dynamics play a significant role in exacerbating the healthcare labor force shortage. These factors work to simultaneously increase the size and proportion of the population needing the most care, namely, the elderly, and also to reduce the availability of physicians and nurses to provide adequate care for the growing elderly population. Physicians and nurses have expressed consistent dissatisfaction with healthcare infrastructure and have cited decreased job satisfaction, further exacerbating the shortage. Potential solutions to the shortage, aside from dramatic changes to the healthcare system, include increased medical and nursing training in geriatrics and gerontology to increase interest, competency, and knowledge of health issues specifically pertaining to the elderly. Other solutions include monetary incentives for geriatric training for nurses and physicians. Any specific measures to remedy this growing problem should be implemented in a timely manner to reduce this critical shortage of healthcare workers that will only continue to grow in the coming decades.

The devil's in the details: trading policy goals for complexity in medicaid nursing home reimbursement

There is great variability in how much nursing home providers are paid for a day of care for a Medicaid recipient, how the payment level is set, and what mechanisms are used to reimburse facilities. Given the absence of recent, comprehensive in-depth analyses of state reimbursement systems, this article undertakes a comparative case analysis of Medicaid nursing facility reimbursement in Alabama, California, Minnesota, Texas, Washington, and Wisconsin. Findings indicate that states design their methods of reimbursement to achieve desired policy outcomes related to facility cost and quality, access to care, payment equity, service capacity, and budgetary control. The result, however, has been the development of enormously complex and demanding rate-setting methodologies, the adverse consequences of which can outweigh and overwhelm the discrete policy objectives contained in the reimbursement formula. This complexity highlights the potential trade-off between achieving desired goals and costly administrative burdens, opportunities for appeal and disagreement, difficulties understanding the ramifications of system changes, reliance on simplified decision-making rules, and exclusion of otherwise interested parties from the policy process.

Maintaining continuity of care for nursing home residents: effect of states' Medicaid bed-hold policies and reimbursement rates

OBJECTIVE

Recent public concern in response to states' intended repeal of Medicaid bed-hold policies and report of their association with higher hospitalization rates prompts examination of these policies in ensuring continuity of care within the broader context of Medicaid policies.

DATA SOURCES/STUDY DESIGN

Minimum Data Set assessments of long-stay nursing home residents in April-June 2000 linked to Medicare claims enabled tracking residents' hospitalizations during the ensuing 5 months and determining hospital discharge destination. Multinomial multilevel models estimated the effect of state policies on discharge destination controlling for resident, hospitalization, nursing home, and market characteristics.

RESULTS

Among 77,955 hospitalizations, 5,797 (7.4 percent) were not discharged back to the baseline nursing home. Bed-hold policies were associated with lower odds of transfer to another nursing home (AOR=0.55, 95 percent CI 0.52-0.58) and higher odds of hospitalization (AOR=1.36), translating to 9.5 fewer nursing home transfers and 77.9 more hospitalizations per 1,000 residents annually, and costing Medicaid programs about $201,311. Higher Medicaid reimbursement rates were associated with lower odds of transfer.

CONCLUSIONS

Bed-hold policies were associated with greater continuity of NH care; however, their high cost compared with their small impact on transfer but large impact on increased hospitalizations suggests that they may not be effective.

Maintaining continuity of care for nursing home residents: effect of states' Medicaid bed-hold policies and reimbursement rates

OBJECTIVE

Recent public concern in response to states' intended repeal of Medicaid bed-hold policies and report of their association with higher hospitalization rates prompts examination of these policies in ensuring continuity of care within the broader context of Medicaid policies.

DATA SOURCES/STUDY DESIGN

Minimum Data Set assessments of long-stay nursing home residents in April-June 2000 linked to Medicare claims enabled tracking residents' hospitalizations during the ensuing 5 months and determining hospital discharge destination. Multinomial multilevel models estimated the effect of state policies on discharge destination controlling for resident, hospitalization, nursing home, and market characteristics.

RESULTS

Among 77,955 hospitalizations, 5,797 (7.4 percent) were not discharged back to the baseline nursing home. Bed-hold policies were associated with lower odds of transfer to another nursing home (AOR=0.55, 95 percent CI 0.52-0.58) and higher odds of hospitalization (AOR=1.36), translating to 9.5 fewer nursing home transfers and 77.9 more hospitalizations per 1,000 residents annually, and costing Medicaid programs about $201,311. Higher Medicaid reimbursement rates were associated with lower odds of transfer.

CONCLUSIONS

Bed-hold policies were associated with greater continuity of NH care; however, their high cost compared with their small impact on transfer but large impact on increased hospitalizations suggests that they may not be effective.

The market for long-term care services

Although a large literature has established the importance of market and regulatory forces within the long-term care sector, current research in this field is limited by a series of data, measurement, and methodological issues. This paper provides a comprehensive review of these issues with an emphasis on identifying initiatives that will increase the volume and quality of long-term care research. Recommendations include: the construction of standard measures of long-term care market boundaries, the broader dissemination of market and regulatory data, the linkage of survey-based data with market measures, the encouragement of further market-based studies of noninstitutional long-term care settings, and the standardization of Medicaid cost data.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Where people die: a multilevel approach to understanding influences on site of death in America

Despite documented preferences for home death, the majority of deaths from terminal illness occur in hospital. To better understand variation in place of death, we conducted a systematic literature review and a multilevel analysis in which we linked death certificates with county and state data. The results of both components revealed that opportunities for home death are disproportionately found in certain groups of Americans; more specifically, those who are White, have greater access to resources and social support, and die of cancer. From the multilevel analysis, the higher the proportion minority and the lower the level of educational attainment, the higher the probability of hospital death while investment in institutional long-term care, measured by regional density of nursing home beds and state Medicaid payment rate, was associated with higher probability of nursing home death. These results reinforce the importance of both social and structural characteristics in shaping the end-of-life experience.

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies

OBJECTIVE

Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations.

DATA SOURCES/STUDY SETTING

Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently.

STUDY DESIGN

Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics.

PRINCIPAL FINDINGS

Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63).

CONCLUSIONS

State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

Hospitalization of Nursing Home Residents With Cognitive Impairments: The Influence of Organizational Features and State Policies

PURPOSE

The purpose of this study was to quantify the effect of specific nursing home features and state Medicaid policies on the risk of hospitalization among cognitively impaired nursing home residents.

DESIGN AND METHODS

We used multilevel logistic regression to estimate the odds of hospitalization among long-stay (>90 days) nursing home residents against the odds of remaining in the nursing home over a 5-month period, controlling for covariates at the resident, nursing home, and county level. We stratified analyses by resident diagnosis of dementia.

RESULTS

Of 359,474 cognitively impaired residents, 49% had a diagnosis of dementia. Of those, 16% were hospitalized. The probability of hospitalization was negatively associated with the presence of a dementia special care unit (adjusted odds ratio [AOR] = 0.90, 95% confidence interval [CI] = 0.86-0.94) and with a high prevalence of dementia in the nursing home (AOR = 0.96, 95% CI = 0.88-1.03). Higher Medicaid payment rates were associated with reduced likelihood of hospitalization (AOR = 0.95, 95% CI = 0.90-1.00), whereas any bed-hold policy substantially increased that likelihood (AOR = 1.44, 95% CI = 1.12-1.86). We observed similar results for residents without a dementia diagnosis.

IMPLICATIONS

Directed management of chronic conditions, as indicated by facilities' investment in special care units, reduces the risk of hospitalization, but the effect of bed-hold policies illustrates how fragmentation in the financing system impedes these efforts.

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies

OBJECTIVE

Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations.

DATA SOURCES/STUDY SETTING

Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently.

STUDY DESIGN

Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics.

PRINCIPAL FINDINGS

Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63).

CONCLUSIONS

State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

Improving the quality of long-term care with better information

Publicly reporting information stimulates providers' efforts to improve the quality of health care. The availability of mandated, uniform clinical data in all nursing homes and home health agencies has facilitated the public reporting of comparative quality data. This article reviews the conceptual and technical challenges of applying information about the quality of long-term care providers and the evidence for the impact of information-based quality improvement. Quality "tools" have been used despite questions about the validity of the measures and their use in selecting providers or offering them bonus payments. Although the industry now realizes the importance of quality, research still is needed on how consumers use this information to select providers and monitor their performance and whether these efforts actually improve the outcomes of care.