Defining and Measuring Nursing Home Placement

The Role of Individual-Level Socioeconomic Status on Nursing Home Placement Accounting for Neighborhood Characteristics

OBJECTIVE

Independent living is desirable for many older adults. Although several factors such as physical and cognitive functions are important predictors for nursing home placement (NHP), it is also reported that socioeconomic status (SES) affects the risk of NHP. In this study, we aimed to examine whether an individual-level measure of SES is associated with the risk of NHP after accounting for neighborhood characteristics.

DESIGN

A population-based study (Olmsted County, Minnesota, USA).

SETTING AND PARTICIPANTS

Older adults (age 65+ years) with no prior history of NHP.

METHODS

Electronic health records (EHR) were used to identify individuals with any NHP between April 1, 2012 (baseline date) and April 30, 2019. Association between the (HOUsing-based index of SocioEconomic Status (HOUSES) index, an individual-level SES measure based on housing characteristics of current residence, and risk of NHP was tested using random effects Cox proportional hazard model adjusting for area deprivation index (ADI), an aggregated SES measure that captures neighborhood characteristics, and other pertinent confounders such as age and chronic disease burden.

RESULTS

Among 15,031 older adults, 3341 (22.2%) experienced NHP during follow-up period (median: 7.1 years). At baseline date, median age was 73 years old with 55% female persons, 91% non-Hispanic Whites, and median number of chronic conditions of 4. Accounting for pertinent confounders, the HOUSES index was strongly associated with risk of NHP (hazard ratio 1.89; 95% confidence interval 1.66‒2.15 for comparing the lowest vs highest quartiles), which was not influenced by further accounting for ADI.

CONCLUSIONS AND IMPLICATIONS

This study demonstrates that an individual-level SES measure capturing current individual-specific socioeconomic circumstances plays a significant role for predicting NHP independent of neighborhood characteristics where they reside. This study suggests that older adults who are at higher risk of NHP can be identified by utilizing the HOUSES index and potential individual-level intervention strategies can be applied to reduce the risk for those with higher risk.

Risk factors for nursing home admission among older adults: Analysis of basic movements and activities of daily living

This retrospective study aimed to clarify the risk of older adults' nursing home placement in terms of basic movements and activities of daily living (ADLs) by analyzing data from a long-term care insurance certification survey in 2016‒2018 in City A. Of the 21,520 people certified as needing care, 16,865 could be followed up until 2018. Data on sex, age, household structure, and level of care required were obtained. Those who lived at home and at nursing homes were categorized as the "Unchanged group" and the "Changed group," respectively. Multivariate binomial logistic regression analysis was performed, with group type as the dependent variable and basic movement and ADL scores as the independent variables. For factor analysis according to care level, participants were classified into support need levels 1 and 2, care need levels 1 and 2, and care need levels 3, 4, and 5. For those categorized into support need levels 1 and 2, standing on one leg and transferring (basic movements) and urination and face cleaning (ADLs) were associated with nursing home placement. For those in care need levels 1 and 2, getting up and transferring (basic movements) and bathing, urination, face cleaning, and hair styling (ADL) were significantly associated with nursing home placement. For those in care need levels 3, 4, and 5, sitting and transferring (basic movements) and self-feeding and defecation (ADL) were significant. Occupational therapists must focus on older adults' declining ADLs and basic movements and relay the necessary information to patients, families, and other healthcare professionals to ensure appropriate and prompt care delivery.

Health Care Use and Outcomes in Assisted Living Communities: Race, Ethnicity, and Dual Eligibility

Assisted Living (AL) has become an important residential long-term care option in the United States, yet very little is known about the nature and quality of care received in this setting by racial/ethnic minorities or residents dually eligible for Medicare and Medicaid. Using calendar year 2018 Medicare data, we identified 255,564 fee-for-service Medicare beneficiaries age 55+ who resided in 24,108 ALs across the United States. We fit several logistic regression models with individual-level covariates and AL-level fixed effects, to examine the association between race/ethnicity and dual status with inpatient hospital admission, 30-day readmission, emergency room use, and nursing home placement. Significant variations in these measures were found both within and across ALs for racial/ethnic minority and dual residents. Our results suggest that disparities in outcomes are most significant by dual eligibility status rather than by race/ethnicity alone. These findings provide important implications for providers, policy makers, and researchers.

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.