The effect of state medicaid case-mix payment on nursing home resident acuity

Organizational and Geographic Nursing Home Characteristics Associated With Increasing Prevalence of Resident Obesity in the United States

Nursing home resident obesity increases the complexity of nursing care, and nursing homes report avoiding residents with obesity when choosing which prospective residents to accept. The objective of this study was to examine the associations between nursing home obesity prevalence rate and nursing home organizational, staffing, resident, and geographic factors within a profit maximization framework. The study cohort included U.S. Centers for Medicare and Medicaid Services data from U.S. nursing homes in 2013. Study findings supported hypothesized associations between obesity prevalence rate and higher occupancy, higher bed capacity, and multi-facility affiliation, but findings did not support a relationship between obesity prevalence rate and for-profit status.

Quality of Nursing Homes and Admission of Residents With Alzheimer's Disease and Related Dementias: The Potential Influence of Market Factors and State Policies

OBJECTIVES

This study aimed to examine the associations between nursing home (NH) quality and prevalence of newly admitted NH residents with Alzheimer's disease and related dementias (ADRD), and to assess the extent to which market-level wages for certified nursing assistants (CNAs) and state Medicaid behavioral and mental health add-on policy may influence such associations.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The analytical sample included 2777 NHs with either high or low quality, located in urban areas of 41 states from 2011 to 2014.

METHODS

The outcome variable was the prevalence of ADRD among newly admitted NH residents. NH quality was defined as dichotomous, based on the Nursing Home Compare (NHC) star rating system. We considered an NH with 5-star rating as having high quality and with 1-star rating as having low quality. Information on county-level CNA wages and state Medicaid behavioral and mental health add-on policies was included. Linear regression models with NH random effects and robust standard errors were estimated. A set of sensitivity analyses were performed.

RESULTS

After accounting for NH-level aggregated resident characteristics and market/state-level factors, the prevalence of ADRD among newly admitted residents was 3% lower in high-quality NHs compared with low-quality NHs (P < .01). A 1-dollar increase in CNA hourly wage was associated with a 0.9-percentage point decrease in the prevalence of ADRD among newly admitted residents (P < .01). State Medicaid behavioral and mental health add-on policy was associated with a 2.5-percentage point increase in the prevalence of ADRD in high-quality NHs (P < .05), but not in low-quality NHs.

CONCLUSIONS AND IMPLICATIONS

Our findings suggest that high-quality NHs are less likely to admit residents with ADRD. The effect size of this relationship is modest and may be influenced by state Medicaid behavioral and mental health add-on policies. Future studies are needed to better understand reasons leading to these associations so that effective interventions can be developed to incentivize high-quality NHs to more readily serve residents with ADRD.

Family Satisfaction With Nursing Home Care: Findings and Implications From Two State Comparison

Family satisfaction, while recognized as important, is frequently missing from validated measures of long-term care quality. This is the first study to compare family satisfaction across two states using validated measures and to compare the organizational and structural factors associated with higher family satisfaction with nursing home care. Data sources are family satisfaction surveys from Minnesota (MN) and Ohio (OH), linked to facility characteristics from Certification and Survey Provider Enhanced Reports (CASPER) for both states (N = 378 facilities for MN; N = 926 facilities for OH). Activities and food were among lowest rated items in both states. Relationships with staff were the highest rated domain. Higher occupancy rates, smaller facility size, and non-profit ownership consistently predicted better satisfaction in both states. Our findings show consistent organizational factors associated with family satisfaction and provide further evidence to the validity of family satisfaction as a person-centered measure of quality. This lays the foundation for tool development on the national level.

Thirty-Year Trends in Nursing Home Composition and Quality Since the Passage of the Omnibus Reconciliation Act

OBJECTIVE

In 1987, the Omnibus Reconciliation Act (OBRA) called for a dramatic overhaul of the nursing home (NH) quality assurance system. This study examines trends in facility, resident, and quality characteristics since passage of that legislation.

METHODS

We conducted univariate analyses of national data on US NHs from 3 sources: (1) the 1985 National Nursing Home Survey (NNHS), (2) the 1992-2015 Online Survey Certification and Reporting (OSCAR) Data, and (3) LTCfocUS data for 2000-2015. We examined changes in NH characteristics, resident composition, and quality.

SETTING AND PARTICIPANTS

US NH facilities and residents between 1985 and 2015.

RESULTS

The proportion of NHs that are Medicare and Medicaid certified, members of chains, and operating not-for-profit has increased over the past 30 years. There have also been reductions in occupancy and increases in the share of residents who are racial or ethnic minorities, admitted for post-acute care, in need of physical assistance with daily activities, primarily supported by Medicare, and diagnosed with a psychiatric condition such as schizophrenia. With regard to NH quality, direct care staffing levels have increased. The proportion of residents physically restrained has decreased dramatically, coupled with changes in inappropriate antipsychotic (chemical restraint) use.

CONCLUSIONS AND IMPLICATIONS

Together with changes in the long-term care market, the NHs of today look very different from NHs 30 years ago. The 30th anniversary of OBRA provides a unique opportunity to reflect, consider what we have learned, and think about the future of this and other sectors of long-term care.

Staff mix and nursing home quality by level of case mix in Korea

AIM

The purpose of the present study was to identify the relationship between staff mix in nursing homes and quality of care by level of case mix in Korea.

METHODS

Data used in the present study came from Long-Term Care Insurance claims data with basic information of nursing homes with >29 beds (n = 1137) and quality evaluation reports. Staff mix was calculated as the number of nursing staff, social workers and care workers per total staff number.

RESULTS

In multinomial logistic regression analyses, institutions with a higher ratio of social workers were classified as top-quality class institutes after controlling ownership, location, size and percentage of high level of care needs residents. In analyzing the higher case mix nursing homes, institutions with a high ratio of nursing staff and social workers were more likely to be classified as top-quality class than the lowest class institutions. However, there was no significant association between quality of care and ratio of staff mix in the lower case mix nursing homes.

CONCLUSIONS

A higher staff mix was positively related to nursing home quality of care, but the relationship was affected by case mix of residents' care demand. Therefore, the current minimum staffing standard for personnel in nursing homes should be modified considering the acuity of the residents. Geriatr Gerontol Int 2019; 19: 438-443.

The Impact of Chain Standardization on Nursing Home Staffing

BACKGROUND

Standardization in production is common in multientity chain organizations. Although chains are prominent in the nursing home sector, standardization in care has not been studied. One way nursing home chains may standardize is by controlling the level and mix of staffing in member homes.

OBJECTIVES

To examine the extent to which standardization occurred in staffing, its relative presence across different types of chains, and whether facilities became more standardized following acquisition by a chain.

RESEARCH DESIGN

We estimated predictors of the difference between facility and chain staffing using Generalized Estimating Equations with 2000-2010 data.

SUBJECTS

This study included nursing homes nationally, excluding hospital-based homes and homes in Alaska, Hawaii, and the District of Columbia.

MEASURES

Chain ownership was coded from text identifying chain names. Two nurse staffing measures were used: staff hours per resident day and staff mix.

RESULTS

Very large for-profit chain nursing homes and large nonprofits had less variation in staff hours per resident day (P<0.001) but greater variation in staffing mix (P<0.001) compared with the chain average nationally. Large for-profit chains and medium nonprofit chains had greater dispersion on staff hours per resident day (P<0.001), while large nonprofit chains had greater dispersion in staffing mix (P<0.001). The difference between facility and chain staffing decreased over time.

CONCLUSIONS

The largest chains (for-profit and nonprofit) had less staffing variation compared with national standards, suggesting they were best at implementing corporate practices. Following ownership changes, staffing converged towards chain averages over time, suggesting standardization takes time to implement.

The effect of political control on financial performance, structure, and outcomes of US nursing homes

Objective

To evaluate the effect of partisan political control on financial performance, structure, and outcomes of for‐profit and not‐for‐profit US nursing homes.

Data Sources/Study Setting

Nineteen‐year panel (1996‐2014) of state election outcomes, financial performance data from nursing home cost reports, operational and aggregate resident characteristics from OSCAR of 13 737 nursing homes.

Study Design

A linear panel model was estimated to identify the effect of Democratic and Republican political control on next year's outcomes. Nursing home outcomes were defined as yearly facility revenues, expenses, and profits; the number of Medicaid, Medicare, and private‐pay residents; staffing levels; and selected resident outcomes.

Principal Findings

Democratic political control leads to an increase in financial flows to for‐profit nursing homes, boosting profits without producing observable improvements in resident outcomes. Republican political control leads to lower revenues and profits of for‐profit nursing homes. A shift from Medicaid to more profitable private‐pay residents following Republican political control is observed for all nursing homes. Financial performance of not‐for‐profit nursing homes is not significantly affected by changes in political control.

Conclusion

Political control of the two legislative chambers—but not of the governorship—shapes the structure of the nursing home industry as seen in provider behavior.

Medicare Advantage enrollees' use of nursing homes: trends and nursing home characteristics

OBJECTIVES

To examine temporal trends in the prevalence of nursing home (NH) patients participating in Medicare Advantage (MA) and to identify the characteristics of both these patients and the NHs that provide care for them.

STUDY DESIGN

Retrospective cohort study.

METHODS

Data sources included the Medicare enrollment file, Minimum Data Set, and facility-level data from the Certification and Survey Provider Enhanced Reporting system. Longitudinal trends of NH use by MA enrollees were examined over the period 2000 to 2013 and logistic regression models were used to identify facility characteristics associated with having a high proportion of MA patients.

RESULTS

The proportion of MA enrollees in NHs more than doubled between 2000 and 2013, increasing 125% during this period. Notable differences in facility characteristics were found between NHs that serve high proportions of MA enrollees and other NHs. High-MA NHs tended to be larger facilities affiliated with chains. These NHs also had better quality indicators, such as higher staffing levels, lower use of antipsychotics, and lower odds of rehospitalization. Additionally, high-MA NHs were more likely to be in counties with higher Medicare managed care penetration and less market concentration.

CONCLUSIONS

MA plans may be selectively contracting with NHs, as evidenced by the larger shares of MA patients who have been placed in facilities with better performance on quality measures. This may reflect MA plans concentrating enrollees in specific facilities and building "networks" of postacute and long-term care providers that provide better and more efficient care.

The Role of Assisted Living Capacity on Nursing Home Financial Performance

The rapid growth of the assisted living industry has coincided with decreased levels of nursing home occupancy and financial performance. The purpose of this article is to examine the relationships among assisted living capacity, nursing home occupancy, and nursing home financial performance. In addition, we explore whether the relationship between assisted living capacity and nursing home financial performance is mediated by nursing home occupancy. This research utilized publicly available secondary data, for the state of Florida from 2003 through 2015. General descriptive statistics were used to assess the relationships among financial performance, assisted living capacity, and occupancy. To explore the relationships among financial performance, assisted living capacity and occupancy, and test potential mediation of occupancy, we followed Baron and Kenny's approach and estimated 3 models examining the relationships between (1) assisted living capacity and nursing home financial performance, (2) assisted living capacity and nursing home occupancy, and (3) nursing home occupancy and financial performance after assisted living capacity is included in the model. We used generalized estimating equations, to adjust for repeated measures and to model the above relationships. Year fixed effects control for time trend. The independent variable, assisted living beds, was lagged for 1 year to account for the potential influence on financial performance. The final analytic sample consisted of 7688 nursing home-year observations from 657 unique nursing homes. Our findings suggest that assisted living capacity does have a negative impact on nursing homes' financial performance. Even though, assisted living capacity seems not to significantly decrease nursing home occupancy. The relationship between assisted living capacity and financial performance was not mediated through occupancy. These findings suggest that assisted living communities may not be able to significantly reduce nursing home occupancy; however, the presence of assisted living communities may create additional financial/competitive pressures that result in decreased nursing home financial performance.

Variations Among Medicare Beneficiaries Living in Different Settings: Demographics, Health Status, and Service Use

Older people with complex health issues and needs for functional support are increasingly living in different types of residential care environments as alternatives to nursing homes. This study aims to compare the demographics and health-care expenditures of Medicare beneficiaries by the setting in which they live: nursing homes, residential care settings, and at home using data from the 2002 to 2010 Medicare Current Beneficiary Study (MCBS), a nationally representative survey of the Medicare population. All Medicare beneficiaries aged 65 years or older who participated in the fall MCBS interview (years 2002-2010) and were alive for the full year (N = 83,507) were included in the sample. We found that there is a gradient in health status, physical and cognitive functioning, and health-care use and spending across settings. Minority elderly are overrepresented in facilities and underrepresented in alternative living settings.

Racial/Ethnic Disparities in Nursing Home Quality of Life Deficiencies, 2001 to 2011

Objectives: Racial/ethnic disparities in nursing homes (NHs) are associated with lower quality of care, and state Medicaid payment policies may influence NH quality. However, no studies analyzing disparities in NH quality of life (QoL) exist. Therefore, this study aims to estimate associations at the NH level between average number of QoL deficiencies and concentrations of racial/ethnic minority residents, and to identify effects of state Medicaid payment policies on racial/ethnic disparities. Method: Multivariable Poisson regression with NH random effects was used to determine the association between NH minority concentration in 2000 to 2010 and average number of QoL deficiencies in 2001 to 2011 at the NH level, and the effect of state NH payment policies on QoL deficiencies and racial/ethnic disparities in QoL deficiencies across NH minority concentrations. Results: Racial/ethnic disparities in QoL between high and low minority concentration NHs decrease over time, but are not eliminated. Case mix payment was associated with an increased disparity between high and low minority concentration NHs in QoL deficiencies. Discussion: NH managers and policy makers should consider initiatives targeting minority residents or low-performing NHs with higher minority concentrations for improvement to reduce disparities and address QoL deficiencies.

Does Assisted Living Capacity Influence Case Mix at Nursing Homes?

Assisted living facilities (ALFs) have grown over the past few decades. If they attract residents with lower care needs away from nursing homes (NHs), NHs may be left with higher case mix residents. We study the relationship between ALF bed market capacity and NH case mix in a state (Virginia) where ALF bed capacity stabilized after a period of growth. Similarly, NH capacity and use had been stable. While it is interesting to study markets in flux, for planning purposes, it is also important to examine what happens after periods of turbulence and adaptation. Our findings show some substitution of ALF for NH care, but the relationship is not linear with ALF market capacity. Communities need to consider the interplay of ALFs and NHs in planning for long-term care services and supports. Policies supporting ALFs may enable care needs to be met in a lower cost setting than the NH.

Frequency and costs of hospital transfers for ambulatory care-sensitive conditions

OBJECTIVES

Nursing home (NH) patients are frequently transferred to emergency departments (EDs) and/or hospitalized in situations in which transfer might have been avoided. This study describes the frequency of NH transfers for ambulatory care-sensitive conditions (ACSCs) and estimates associated expenditures.

STUDY DESIGN

Retrospective cohort study of 62,379 NH patients with Medicare coverage receiving care in South Carolina between 2007 and 2009.

METHODS

Subjects were analyzed to determine the frequency of acute ED or hospital care for conditions. Comparison is made to similar patients transferred for acute treatment of non-ACSCs. Generalized linear models were used to estimate the costs attributable to treating ACSCs.

RESULTS

Over 3 years, 20,867 NH subjects were transferred from NHs to acute care facilities, and 85.3% of subjects had at least 1 episode of care for an ACSC. An average of 13,317 subjects per year were transferred for an average of 17,060 episodes of ED or hospital care per year between 2007 and 2009. More ACSC patients transferred to EDs were subsequently admitted to the hospital (50.4% vs 25%; P < .0001). In adjusted analyses, mean ED costs per episode of care ($401 vs $294; P < .0001) were higher, but mean hospitalization costs per episode of care were lower ($8356 vs $10,226; P < .0001) for ACSC patients compared with non-ACSC patients.

CONCLUSIONS

A significant proportion of Medicare NH patients are treated acutely for ACSCs, which are associated with higher healthcare utilization and costs. Better access to onsite evaluation might enable significant cost savings and reduce morbidity in this population.

Surveying multiple health professional team members within institutional settings: an example from the nursing home industry

Quality improvement and cost containment initiatives in health care increasingly involve interdisciplinary teams of providers. To understand organizational functioning, information is often needed from multiple members of a leadership team since no one person may have sufficient knowledge of all aspects of the organization. To minimize survey burden, it is ideal to ask unique questions of each member of the leadership team in areas of their expertise. However, this risks substantial missing data if all eligible members of the organization do not respond to the survey. Nursing home administrators (NHA) and directors of nursing (DoN) play important roles in the leadership of long-term care facilities. Surveys were administered to NHAs and DoNs from a random, nationally representative sample of U.S. nursing homes about the impact of state policies, market forces, and organizational factors that impact provider performance and residents' outcomes. Responses were obtained from a total of 2,686 facilities (response rate [RR] = 66.6%) in which at least one individual completed the questionnaire and 1,693 facilities (RR = 42.0%) in which both providers participated. No evidence of nonresponse bias was detected. A high-quality representative sample of two providers in a long-term care facility can be obtained. It is possible to optimize data collection by obtaining unique information about the organization from each provider while minimizing the number of items asked of each individual. However, sufficient resources must be available for follow-up to nonresponders with particular attention paid to lower resourced, lower quality facilities caring for higher acuity residents in highly competitive nursing home markets.

Obesity and pressure ulcers among nursing home residents

OBJECTIVES

To examine the prevalence of obesity and its relationship with pressure ulcers among nursing home (NH) populations, and whether such relationship varies with certified nursing assistant (CNA) level in NHs. DATA AND STUDY POPULATION: The 1999-2009 nationwide Minimum Data Sets were linked with Online Survey of Certification and Reporting records. We identified newly admitted NH residents who became long-stayers and followed them up to 1 year.

ANALYSES

The outcome variable was presence of pressure ulcers during the 1-year follow-up period. Residents were categorized as normal [18.5 ≤ body mass index (BMI)<30 kg/m2], mild obesity (30 ≤ BMI <35 kg/m2), and moderate or severe obesity (BMI ≥ 35 kg/m2). Pooled and stratified analyses were performed to examine the relationship between obesity and pressure ulcers, and how it varied by facility CNA level.

RESULTS

The prevalence of obesity increased from 16.9% to 25.8% among newly admitted NH residents over the last decade. Obesity was associated with higher risks of pressure ulcers among long-stay residents. The relationship between obesity and pressure ulcers persisted after accounting for individual health conditions at the baseline and facility-level variations. Further, the within-facility relationship between obesity and pressure ulcers varied by facility CNA levels. The odds of pressure ulcers were 18.9% higher for residents with moderate or severe obesity than for nonobese residents within NHs with low CNA levels. The percents for medium and high CNA level facilities were 14.0% and 12.8%, respectively.

CONCLUSION

To prepare for the growing obesity epidemic in NHs, policies should focus on strategies to improve care provided for obese residents.

Medicaid bed-hold policies and hospitalization of long-stay nursing home residents

OBJECTIVE

To evaluate the effect of Medicaid bed-hold policies on hospitalization of long-stay nursing home residents.

DATA SOURCES

A nationwide random sample of long-stay nursing home residents with data elements from Medicare claims and enrollment files, the Minimum Data Set, the Online Survey Certification and Reporting System, and Area Resource File. The sample consisted of 22,200,089 person-quarters from 754,592 individuals who became long-stay residents in 17,149 nursing homes over the period beginning January 1, 2000 through December 31, 2005.

STUDY DESIGN

Linear regression models using a pre/post design adjusted for resident, nursing home, market, and state characteristics. Nursing home and year-quarter fixed effects were included to control for time-invariant facility influences and temporal trends associated with hospitalization of long-stay residents.

PRINCIPAL FINDINGS

Adoption of a Medicaid bed-hold policy was associated with an absolute increase of 0.493 percentage points (95% CI: 0.039-0.946) in hospitalizations of long-stay nursing home residents, representing a 3.883 percent relative increase over the baseline mean.

CONCLUSIONS

Medicaid bed-hold policies may increase the likelihood of hospitalization of long-stay nursing home residents and increase costs for the federal Medicare program.

National newspaper portrayal of U.S. nursing homes: periodic treatment of topic and tone

CONTEXT

Although observers have long highlighted the relationship of public distrust, government regulation, and media depictions of nursing-home scandals, no study has systematically analyzed the way in which nursing homes have been portrayed in the national media. This study examines how nursing homes were depicted in four leading national newspapers-the New York Times, Washington Post, Chicago Tribune, and Los Angeles Times-from 1999 to 2008.

METHODS

We used keyword searches of the LexisNexis database to identify 1,704 articles pertaining to nursing homes. We then analyzed the content of each article and assessed its tone, themes, prominence, and central actor. We used basic frequencies and descriptive statistics to examine the articles' content, both cross-sectionally and over time.

FINDINGS

Approximately one-third of the articles were published in 1999/2000, and a comparatively high percentage (12.4%) appeared in 2005. Most were news stories (89.8%), and about one-quarter were on the front page of the newspaper or section. Most focused on government (42.3%) or industry (39.2%) interests, with very few on residents/family (13.3%) and community (5.3%) concerns. Most were negative (45.1%) or neutral (37.0%) in tone, and very few were positive (9.6%) or mixed (8.3%). Common themes were quality (57.0%), financing (33.4%), and negligence/fraud (28.1%). Both tone and themes varied across newspapers and years.

CONCLUSIONS

Overall, our findings highlight the longitudinal variation in the four widely read newspapers' framing of nursing-home coverage, regarding not only tone but also shifts in media attention from one aspect of this complex policy area to another. The predominantly negative media reports contribute to the poor public opinion of nursing homes and, in turn, of the people who live and work in them. These reports also place nursing homes at a competitive disadvantage and may pose challenges to health delivery reform, including care integration across settings.

Serious mental illness and nursing home quality of care

OBJECTIVE

To estimate the effect of a nursing home's share of residents with a serious mental illness (SMI) on the quality of care.

DATA SOURCES

Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims.

STUDY DESIGN

We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects.

PRINCIPAL FINDINGS

An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents.

CONCLUSIONS

Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.

Assisted living expansion and the market for nursing home care

OBJECTIVE

To analyze the effect of market-level changes in assisted living supply on nursing home utilization and resident acuity.

DATA SOURCES

Primary data on the supply of assisted living over time were collected from 13 states from 1993 through 2007 and merged with nursing home-level data from the Online Survey Certification and Reporting System and market-level information from the Area Resource File.

STUDY DESIGN

Least squares regression specification incorporating market and time-fixed effects.

PRINCIPAL FINDINGS

A 10 percent increase in assisted living capacity led to a 1.4 percent decline in private-pay nursing home occupancy and a 0.2-0.6 percent increase in patient acuity.

CONCLUSIONS

Assisted living serves as a potential substitute for nursing home care for some healthier individuals with greater financial resources, suggesting implications for policy makers, providers, and consumers.

Comparison of the effectiveness of two protocols for treating nursing home residents with advanced dementia

The Serial Trial Intervention (STI) is a decision support tool to address the problem of underassessment and undertreatment of pain and other unmet needs of people with dementia. This study compared the effectiveness of the 5-step and 9-step versions of the STI using a two-group repeated measures quasi-experimental design with randomization of 12 matched nursing homes. The sample consisted of 125 residents with moderate to severe dementia. Both the 5- and 9-step STIs significantly decreased discomfort and agitation from pre- to posttest (effect sizes = 0.45 to 0.90). The 9-step version was more effective for comorbid burden and increased cortisol slope (effect sizes = 0.50 and 0.49). Process variables were all statistically significantly improved using the 9-step STI. Nurse time was not different between the two groups. The clinical decision support rules embedded in the STI, particularly the 9-step version, helped nurses change practice and improved resident outcomes.

Effect of influenza on functional decline

OBJECTIVES

To examine the relationship between influenza and activity of daily living (ADL) decline and other clinical indicators in nursing home (NH) residents.

DESIGN

Retrospective NH-aggregated longitudinal study.

SETTING

Two thousand three hundred fifty-one NHs in 122 U.S. cities from 1999 to 2005.

PARTICIPANTS

Long-stay (>90 days) NH residents.

MEASUREMENTS

Quarterly city-level influenza mortality and state-level influenza severity. Quarterly incidence of Minimum Data Set-derived ADL decline (≥ 4 points), weight loss, new or worsening pressure ulcers (PUs), and infections. Outcome variables chosen as clinical controls were antipsychotic use, restraint use, and persistent pain.

RESULTS

City-level influenza mortality and state-level influenza severity were associated with higher rates of large (≥ 4 points) ADL decline (mortality β = 0.20, P < .001; severity β = 0.18, P < .001), weight loss (β = 0.19, P < .001; β = 0.24, P < .001), worsening PUs (β = 0.04, P = .08; β = 0.12, P < .001), and infections (β = 0.41, P < .001; β = 0.47, P < .001) but not with restraint use, antipsychotic use, or persistent pain. NH influenza vaccination rates were weakly associated with the outcomes (e.g., β = -0.009, P = .03 for ADL decline, β = 0.008, P = .07 for infections). Compared with the summer quarter of lowest influenza activity, the results for the other quarters translate to an additional 12,284 NH residents experiencing large ADL decline annually, 15,168 experiencing significant weight loss, 6,284 new or worsening PUs, and 29,753 experiencing infections due to influenza.

CONCLUSION

The results suggest a substantial and potentially costly effect of influenza on NH residents. The effect of influenza vaccination on preventing further ADL decline and other clinical outcomes in NH residents should be studied further.

Nursing home medical staff organization: correlates with quality indicators

OBJECTIVES

Little is known about the relationship between how medical care is organized and delivered in nursing homes. Taking a lead from the acute care arena, we hypothesize that nursing home medical staff organization (NHMSO) is an important predictor of clinical outcomes in the nursing home.

METHODS

A total of 202 usable surveys from a 2-wave survey process using the Dillman Method were returned from medical directors who were randomly selected from the AMDA membership and were asked to fill out a survey on the structure of medical organization in their primary nursing home practice. Quality measures that are likely to be affected by physician practice patterns were culled from NH Compare and OSCAR data sets and matched to the physician surveys, ie, long stay residents' prevalence of pain, restraint use, catheter use, pressure ulcers, pneumococcal vaccination, influenza vaccination, presence of advanced directives, prescription of antibiotics, and prevalence of depression.

RESULTS

Using a series of hierarchical multiple regressions, significant R(2) changes were found when the medical staff organization dimensions were added in the regressions after controlling for nursing home structural characteristics for the following outcomes: pneumococcal vaccination and restraint use. Near significant findings were noted for pain prevalence among long-stay residents, catheter use, and prevalence of pressure ulcers.

CONCLUSIONS

This study is the first to demonstrate a relationship between medical staff organizational dimensions and clinical outcomes in the nursing home setting and as such represents an initial "proof of concept." NHMSO should be considered as a potentially important mediating or moderating variable in the quality of care equation for nursing homes.

The effect of Medicaid nursing home reimbursement policy on Medicare hospice use in nursing homes

OBJECTIVE

To understand how changes in Medicaid nursing home (NH) reimbursement policy and rates affect a NH's approach to end-of-life care (ie, its use of hospice).

METHODS

This longitudinal study merged US NH decedents' (1999 to 2004) resident assessment data (MDS) with Part A claims data to determine the proportion of a NH's decedents using hospice. Freestanding NHs across the 48 contiguous US states were included. A NH-level analytic file was merged with NH survey (ie, OSCAR) and area resource file data, and with annual data on state Medicaid NH rates, case-mix reimbursement policies, and hospice certificate of need (CON). NH fixed-effect (within) regression analysis examined the effect of changing state policies, controlling for differing time trends in CON and case-mix states and for facility-level and county-level attributes. Models were stratified by urban/rural status.

RESULTS

A $10 increase in the Medicaid rate resulted in a 0.41% [95% confidence interval (CI): 0.275, 0.553] increase in hospice use in urban NHs and a 0.37% decrease (95% CI: -0.676, -0.063) in rural NHs not adjacent to urban areas. There was a nonstatistically significant increase in rural NHs adjacent to urban areas. Introduction of case-mix reimbursement resulted in a 2.14% (95% CI: 1.388, 2.896) increase in hospice use in urban NHs, with comparable increases in rural NHs.

CONCLUSIONS

This study supports and extends previous research by showing changes in Medicaid NH reimbursement policies affect a NH's approach to end-of-life care. It also shows how policy changes can have differing effects depending on a NH's urban/rural status.

To evacuate or shelter in place: implications of universal hurricane evacuation policies on nursing home residents

OBJECTIVE

To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf hurricanes.

METHODS

Observational study using Medicare claims and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 nonhurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days.

RESULTS

Among 36,389 NH residents exposed to a storm, the 30- and 90-day mortality/hospitalization rates increased compared with nonhurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7% to 5.3% and hospitalization by 1.8% to 8.3%, independent of other factors.

CONCLUSION

Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.

The effect of state policies on nursing home resident outcomes

OBJECTIVES

To test the effect of changes in Medicaid reimbursement on clinical outcomes of long-stay nursing home (NH) residents.

DESIGN

Longitudinal, retrospective study of NHs, merging aggregated resident-level quality measures with facility characteristics and state policy survey data.

SETTING

All free-standing NHs in urban counties with at least 20 long-stay residents per quarter (length of stay > 90 days) in the continental United States between 1999 and 2005.

PARTICIPANTS

Long-stay NH residents

INTERVENTIONS

Annual state Medicaid average per diem reimbursement and the presence of case-mix reimbursement in each year.

MEASUREMENTS

Quarterly facility-aggregated, risk-adjusted quality-of-care measures surpassing a threshold for functional (activity of daily living) decline, physical restraint use, pressure ulcer incidence or worsening, and persistent pain.

RESULTS

All outcomes showed an improvement trend over the study period, particularly physical restraint use. Facility fixed-effect regressions revealed that a $10 increase in Medicaid payment increased the likelihood of a NH meeting quality thresholds by 9% for functional decline, 5% for pain control, and 2% for pressure ulcers but not reduced use of physical restraints. Facilities in states that increased Medicaid payment most showed the greatest improvement in outcomes. The introduction of case-mix reimbursement was unrelated to quality improvement.

CONCLUSION

Improvements in the clinical quality of NH care have been achieved, particularly where Medicaid payment has increased, generally from a lower baseline. Although this is a positive finding, challenges to implementing efficient reimbursement policies remain.

Incremental cost of postacute care in nursing homes

OBJECTIVES

To determine whether the case mix index (CMI) based on the 53-Resource Utilization Groups (RUGs) captures all the cross-sectional variation in nursing home (NH) costs or whether NHs that have a higher percent of Medicare skilled care days (%SKILLED) have additional costs. DATA AND SAMPLE: Nine hundred and eighty-eight NHs in California in 2005. Data are from Medicaid cost reports, the Minimum Data Set, and the Economic Census.

RESEARCH DESIGN

We estimate hybrid cost functions, which include in addition to outputs, case mix, ownership, wages, and %SKILLED. Two-stage least-square (2SLS) analysis was used to deal with the potential endogeneity of %SKILLED and CMI.

RESULTS

On average 11 percent of NHs days were due to skilled care. Based on the 2SLS model, %SKILLED is associated with costs even when controlling for CMI. The marginal cost of a one percentage point increase in %SKILLED is estimated at U.S.$70,474 or about 1.2 percent of annual costs for the average cost facility. Subanalyses show that the increase in costs is mainly due to additional expenses for nontherapy ancillaries and rehabilitation.

CONCLUSION

The 53-RUGs case mix does not account completely for all the variation in actual costs of care for postacute patients in NHs.

Nursing home organizational change: the "Culture Change" movement as viewed by long-term care specialists

A decade-long grassroots movement aims to deinstitutionalize nursing home (NH) environments and individualize care. Coined "NH Culture Change" the movement is often described by its resident-centered/directed care focus. While empirical data of "culture change's" costs and benefits are limited, it is broadly viewed as beneficial and widely promoted. Still, debate abounds regarding barriers to its adoption. We used data from a Web-based survey of 1,147 long-term care specialists (including NH and other providers, consumers/advocates, state and federal government officials, university/academic, researchers/consultants, and others) to better understand factors associated with perceived barriers. Long-term care specialists view the number-one barrier to adoption differently depending on their employment, familiarity with culture change, and their underlying policy views. To promote adoption, research and broad-based educational efforts are needed to influence views and perceptions. Fundamental changes in the regulatory process together with targeted regulatory changes and payment incentives may also be needed.

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.

Annual expenditures for nursing home care: private and public payer price growth, 1977 to 2004

BACKGROUND

Long-term nursing home care is primarily funded by out-of-pocket payments and public Medicaid programs. Few studies have explored price growth in nursing home care, particularly trends in the real cost of a year spent in a nursing home.

OBJECTIVES

To evaluate changes in private and public prices for annual nursing home care from 1977 to 2004, and to compare nursing home price growth to overall price growth and growth in the price of medical care.

RESEARCH DESIGN

We estimated annual private prices for nursing home care between 1977 and 2004 using data from the National Nursing Home Survey. We compared private nursing home price growth to public prices obtained from surveys of state Medicaid offices, and evaluated the Bureau of Labor Statistics Consumer Price Indexes to compare prices for nursing homes, medical care, and general goods and services over time.

RESULTS

Annual private pay nursing homes prices grew by 7.5% annually from $8645 in 1977 to $60,249 in 2004. Medicaid prices grew by 6.7% annually from $9491 in 1979 to $48,056 in 2004. Annual price growth for private pay nursing home care outpaced medical care and other goods and services (7.5% vs. 6.6% and 4.4%, respectively) between 1977 and 2004.

CONCLUSIONS

The recent rapid growth in nursing home prices is likely to persist, because of an aging population and greater disability among the near-elderly. The result will place increasing financial pressure on Medicaid programs. Better data on nursing prices are critical for policy-makers and researchers.

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.

Does the presence of a dementia special care unit improve nursing home quality?

OBJECTIVE

This study quantifies the effect of a new dementia special care unit (D-SCU) on the provision of care to all residents in a nursing home (NH).

METHOD

The authors use data from the On-line Survey Certification and Reporting system to identify free-standing NHs that first reported a D-SCU between 1996 and 2003 (N = 1,519). Fixed-effects models estimate the effect of a new D-SCU on the prevalence of each outcome (physical restraints, feeding tubes, and psychotropic medications) while controlling for secular trends.

RESULTS

For all NHs, the use of physical restraints declined, the use of antipsychotics increased, and other measures remained relatively constant. The introduction of a D-SCU was not associated with changes in trends for any measure.

DISCUSSION

Differences in care processes between NHs with and without D-SCUs are the result of differences in their underlying approach to care, not the result of care practice diffusion from the D-SCU.

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.

Has the Medicare prospective payment system led to increased nursing home efficiency?

RESEARCH OBJECTIVE

To assess the impact of recent Medicare prospective payment system (PPS) changes on efficiency in skilled nursing homes.

DATA SOURCE/STUDY SETTING

Medicare Cost Reports (MCR), On-line Survey Certification and Reporting System (OSCAR), Area Resource Files (ARF), a Centers for Medicare and Medicaid Services (CMS) hospital wage index website, a Consumer Price Index (CPI) database, and a survey of state Medicaid reimbursement rates. The sample was 8,361 nursing homes in the Medicare Cost Report databases from the years 1997 to 2003.

STUDY DESIGN

Data-envelopment analyses (DEA) calculated efficiency scores for three separate DEA models: unadjusted, acuity-adjusted, and acuity-and-quality-adjusted efficiency. The efficiency scores from these models were regressed on the Medicare PPS changes (the Balanced Budget Act [BBA], the Balanced Budget Refinement Act [BBRA] and the Benefits Improvement and Protection Act) and other organizational and market explanatory variables using a panel-data truncated regression.

PRINCIPAL FINDINGS

Mean values for all efficiency measures decreased over time, the acuity-quality-adjusted efficiency measures decreasing the most. All policy variables were significantly negatively related to all efficiency measures. Higher nurse staffing was negatively related to efficiency in all but the acuity-quality-adjusted model. Other explanatory variables varied in their relationships to the efficiency variables.

CONCLUSIONS

The results suggest that the reimbursement policy changes had a significantly negative impact on efficiency. Higher nurse staffing contributed to lower efficiency only when efficiency was not adjusted for quality. Various organizational and market factors also played significant roles in all efficiency models.

Medicare expenditures for nursing home residents triaged to nursing home or hospital for acute infection

OBJECTIVES

To compare Medicare payments of nursing home residents triaged to nursing home with those of nursing home residents triaged to the hospital for acute infection care.

DESIGN

Observational study with propensity score matching.

SETTING

Fifty-nine nursing homes in Maryland.

PARTICIPANTS

Two thousand two hundred eighty-five individuals admitted to the 59 nursing homes and followed between 1992 and 1997.

MEASUREMENTS

Demographic and clinical data were obtained from interviews and medical record review and linked to Medicare payment records. Incident infection was ascertained according to medical record review for new infectious diagnoses or prescription of antibiotics. Hospital triage was defined as hospital transfer within 3 days of infection onset. Hospital triage patients were paired with similar nursing home triage patients using propensity score matching. Medicare expenditures for triage groups were compared in 1997 dollars.

RESULTS

Of 3,618 infection cases, 28% were genitourinary infections, 20% skin, 14% upper respiratory, 12% lower respiratory, 4% gastrointestinal, and 2% bloodstream. Two hundred fifty-six pairs of hospital and nursing home triage cases fulfilled matching criteria. Mean Medicare payments+/-standard deviation were $5,202+/-7,310 and $996+/-2,475 per case in the hospital and nursing home triage groups, respectively, for a mean difference of $4,206 (95% confidence interval=$3,260-5,151). Mean payments per case in the hospital triage group were $3,628 higher in inpatient expenditures, $482 higher in physician visit expenditures, $161 higher in emergency department expenditures, and $147 higher in skilled nursing day expenditures.

CONCLUSION

Per-case Medicare expenditures are higher with hospital triage than for nursing home triage for nursing home residents with acute infection. This result may be used to estimate cost savings to Medicare of interventions designed to reduce hospital use by nursing home residents.

Do financial incentives of introducing case mix reimbursement increase feeding tube use in nursing home residents?

OBJECTIVES

To determine whether adoption of Medicaid case mix reimbursement is associated with greater prevalence of feeding tube use in nursing home (NH) residents.

DESIGN

Secondary analysis of longitudinal administrative data about the prevalence of feeding tube insertion and surveys of states' adoption of case mix reimbursement.

SETTING

NHs in the United States.

PARTICIPANTS

NH residents at the time of NH inspection between 1993 and 2004.

MEASUREMENTS

Facility prevalence of feeding tubes reported at the state inspection of NHs reported in the Online Survey, Certification and Reporting database and interviews with state policy makers regarding the adoption of case mix reimbursement.

RESULTS

Between 1993 and 2004, 16 states adopted Resource Utilization Group case mix reimbursement. States varied in the prevalence of feeding tubes in their NHs. Although the use of feeding tube increased substantially over the years of the study, once temporal trends and facility fixed effects were accounted for, case mix reimbursement was not associated with greater prevalence of feeding tube use.

CONCLUSION

The adoption of Medicaid case mix reimbursement was not associated with an increase in the prevalence of feeding tube use.

Restructuring in response to case mix reimbursement in nursing homes: a contingency approach

BACKGROUND

Resident-based case mix reimbursement has become the dominant mechanism for publicly funded nursing home care. In 1998 skilled nursing facility reimbursement changed from cost-based to case mix adjusted payments under the Medicare Prospective Payment System for the costs of all skilled nursing facility care provided to Medicare recipients. In addition, as of 2004, 35 state Medicaid programs had implemented some form of case mix reimbursement.

PURPOSE

The purpose of the study is to determine if the implementation of Medicare and Medicaid case mix reimbursement increased the administrative burden on nursing homes, as evidenced by increased levels of nurses in administrative functions.

METHODOLOGY/APPROACH

The primary data for this study come from the Centers for Medicare and Medicaid Services Online Survey Certification and Reporting database from 1997 through 2004, a national nursing home database containing aggregated facility-level information, including staffing, organizational characteristics and resident conditions, on all Medicare/Medicaid certified nursing facilities in the country. We conducted multivariate regression analyses using a facility fixed-effects model to examine the effects of the implementation of Medicaid case mix reimbursement and Medicare Prospective Payment System on changes in the level of total administrative nurse staffing in nursing homes.

FINDINGS

Both Medicaid case mix reimbursement and Medicare Prospective Payment System increased the level of administrative nurse staffing, on average by 5.5% and 4.0% respectively. However, lack of evidence for a substitution effect suggests that any decline in direct care staffing after the introduction of case mix reimbursement is not attributable to a shift from clinical nursing resources to administrative functions.

PRACTICE IMPLICATIONS

Our findings indicate that the administrative burden posed by case mix reimbursement has resource implications for all freestanding facilities. At the margin, the increased administrative burden imposed by case mix may become a factor influencing a range of decisions, including resident admission and staff hiring.

Facility service environments, staffing, and psychosocial care in nursing homes

Using 2003 Online Survey Certification and Reporting (OSCAR) data for Medicare and Medicaid certified facilities (N = 14, 184) and multinomial logistic regression this study investigated if (1) psychosocial care quality was better in facilities where State requirements for qualified social services staffing exceeded Federal minimum regulations and (2) facility service environments are associated with psychosocial care quality. For-profit status and higher percentage of Medicaid residents are associated with lower quality. Staffing, market demand, and market competition are associated with better quality. Psychosocial care quality is more associated with payer status and market forces and less with regulatory requirements.

Doing better to do good: the impact of strategic adaptation on nursing home performance

OBJECTIVE

To test the hypothesis that a greater commitment to strategic adaptation, as exhibited by more extensive implementation of a subacute/rehabilitation care strategy in nursing homes, will be associated with superior performance.

DATA SOURCES

Online Survey, Certification, and Reporting (OSCAR) data from 1997 to 2004, and the area resource file (ARF).

STUDY DESIGN

The extent of strategic adaptation was measured by an aggregate weighted implementation score. Nursing home performance was measured by occupancy rate and two measures of payer mix. We conducted multivariate regression analyses using a cross-sectional time series generalized estimating equation (GEE) model to examine the effect of nursing home strategic implementation on each of the three performance measures, controlling for market and organizational characteristics that could influence nursing home performance. DATA COLLECTION/ABSTRACTION METHODS: OSCAR data was merged with relevant ARF data.

PRINCIPAL FINDINGS

The results of our analysis provide strong support for the hypothesis.

CONCLUSIONS

From a theoretical perspective, our findings confirm that organizations that adjust strategies and structures to better fit environmental demands achieve superior performance. From a managerial perspective, these results support the importance of proactive strategic leadership in the nursing home industry.