Rebalance Without the Balance: A Research Note on the Availability of Community-Based Services in Areas Where Nursing Homes Have Closed

Nursing home closures and access to post-acute care and long-term care services in rural areas

PURPOSE

Nursing home closures have raised concerns about access to post-acute care (PAC) and long-term care (LTC) services. We estimate the additional distance rural residents had to travel to access PAC and LTC services because of nursing home closures.

METHODS

We identify nursing home closures and the availability of PAC and LTC services in nursing homes, home health agencies, and hospitals with swing beds using the Medicare Provider of Services file (2008-2018). Using distances between ZIP codes, we summarize distances to the closest provider of PAC and LTC services for rural and urban ZIP codes with nursing home closures from 2008 to 2018 and no nursing homes in 2018.

FINDINGS

Compared to urban ZIP codes, rural ZIP codes experiencing nursing home closure had higher distances to the closest nursing home providing PAC (6.4 vs. 0.94 miles; p < 0.05) and LTC services (7.2 vs. 1.1 miles; p < 0.05), and these differences remain even after accounting for the availability of home health agencies and hospitals with swing beds. Distances to the closest providers with PAC and LTC services were even higher for rural ZIP codes with no nursing homes in 2018. About 6.1%-15.7% of rural ZIP codes with a nursing home closure or with no nursing homes had no PAC or LTC providers within 25 miles.

CONCLUSIONS

Nursing home closures increased distances to nursing homes, home health agencies, and hospitals with swing beds for rural residents. Access to PAC and LTC services is a concern, especially for rural areas with no nursing homes.

COVID-19 Pandemic Impact on Nursing Homes Financial Performance

Nursing homes expressed concern about potential severe adverse financial outcomes of COVID-19, with worries extending to the possibility of some facilities facing closure. Maintaining a strong financial well-being is crucial, and there were concerns that the pandemic might have significantly impacted both expenses and income. This longitudinal study aimed to analyze the financial performance of nursing homes during COVID-19 pandemic. Specifically, we examined the impact of the pandemic on nursing home operating margins, operating revenue per resident day, and operating cost per resident day. The study utilized secondary data from various sources, including CMS Medicare cost reports, Brown University's Long Term Care Focus (LTCFocus), CMS Payroll-Based Journal, CMS Care Compare, Area Health Resource File, Provider Relief Fund distribution data, and CDC's NH COVID-19 public file. The sample consisted of 45 833 nursing home-year observations from 2018 to 2021. Fixed-effects regression analysis was employed to assess the impact of the pandemic on financial performance while controlling for various organizational and market characteristics. The study found that nursing homes' financial performance deteriorated during the COVID-19 pandemic. Operating margins decreased by approximately 4.3%, while operating costs per resident day increased by $26.51, outweighing the increase in operating revenue per resident day by about $17. Occupancy rates, payer mix, and staffing intensity were found to impact financial performance. The study highlights the significant financial impact of the COVID-19 pandemic on nursing homes. While nursing homes faced substantial financial strains, the findings offered lessons for the future, underscoring the need for nursing homes to improve the accuracy of their cost reports and enhance financial transparency and accountability.

Family Ties at End-of-Life: Characteristics of Nursing Home Decedents With and Without Family

Background

Little is known about nursing home (NH) residents' family characteristics despite the important role families play at end-of-life (EOL).

Objective

To describe the size and composition of first-degree families (FDFs) of Utah NH residents who died 1998-2016 (n = 43,405).

Methods

Using the Utah Population Caregiving Database, we linked NH decedents to their FDF (n = 124,419; spouses = 10.8%; children = 55.3%; siblings = 32.3%) and compared sociodemographic and death characteristics of those with and without FDF members (n = 9424).

Results

Compared to NH decedents with FDF (78.3%), those without (21.7%) were more likely to be female (64.7% vs. 57.1%), non-White/Hispanic (11.2% vs. 4.2%), less educated (<9th grade; 41.1% vs. 32.4%), and die in a rural/frontier NH (25.3% vs. 24.0%, all p < 0.001). Despite similar levels of disease burden (Charlson Comorbidity score 3 + 37.7% vs. 38.0%), those without FDF were more likely to die from cancer (14.2% vs. 12.4%), Chronic Obstructive Pulmonary Disease (COPD) (6.0% vs. 4.0%), and dementia (17.1% vs. 16.6%, all p < 0.001), and were less likely to have 2+ hospitalizations at EOL (20.5% vs. 22.4%, p < 0.001).

Conclusions

Among NH decedents, those with and without FDF have different sociodemographic and death characteristics-factors that may impact care at EOL. Understanding the nature of FDF relationship type on NH resident EOL care trajectories and outcomes is an important next step in clarifying the role of families of persons living and dying in NHs.

Who Will Care for Rural Older Adults? Measuring the Direct Care Workforce in Rural Areas

Using the 2021 Occupational Employment and Wage Statistics (OEWS) dataset, we calculate the ratio of direct care workers relative to the population of older adults (ages 65+) across rural and urban areas in the US. We find that there are, on average, 32.9 home health aides per 1000 older adults (age 65+) in rural areas and 50.4 home health aides per 1000 older adults in urban areas. There are, on average, 20.9 nursing assistants per 1000 older adults in rural areas and 25.3 nursing assistants per 1000 older adults in urban areas. There is substantial regional variation. Greater investment needs to be made in improving wages and job quality for direct care workers to attract workers to these critical occupations, especially in rural areas where the need for direct care is greater.

Changes in Nursing Home Use Following Medicaid-Supported Expanded Access to Home- and Community-Based Services for Older Adults With Dementia

Importance

New York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care.

Objective

To evaluate changes in nursing home use among older adults with dementia following MLTC implementation.

Design, Setting, and Participants

This cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019.

Exposure

Mandatory MLTC enrollment.

Main Outcomes and Measures

Longitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators.

Results

This sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year).

Conclusions and Relevance

The findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.

The effect of nursing home closure on local employment in the United States

OBJECTIVE

To estimate the effect of nursing home closure on local employment, overall, and by rurality.

DATA SOURCES AND STUDY SETTING

We obtained 2008-2018 county-level data from the Quarterly Workforce Indicators, Medicare Provider of Services, Area Health Resource, and Urban Influence Codes files. From 2008 to 2018, 878 counties experienced at least one nursing home closure, and 2055 counties did not experience a closure.

STUDY DESIGN

Using a difference-in-difference study design, we compare the changes of total employment, health sector employment and non-health sector employment over time between counties with and without a nursing home closure. We utilize the variation in the year and quarter of nursing home closures to estimate subsequent employment changes as well as employment trends before closure. We also account for contemporaneous events including nursing home entries and hospital entries and closures, and evaluate heterogeneity by rurality.

DATA EXTRACTION

We include data on nursing home closure from the Medicare Provider of Service file. Quarterly county-level employee counts were obtained from the Quarterly Workforce Indicators provided by the Census Bureau. County-level demographic data were obtained from the Area Health Resource Files. We use Urban Influence Codes from the Economic Research Service, Department of Agriculture, to classify metropolitan, micropolitan, and rural (noncore) counties.

PRINCIPAL FINDINGS

Health sector employment decreased by about 3.2%-4.1% (p < 0.01) in counties with a nursing home closure. The reduction was largest in rural counties (approximately 7.2%-9.4%, p < 0.01). The reduction in health sector employment persisted over time, particularly in rural counties. Overall, there was no discernable effect on non-health sector employment.

CONCLUSIONS

Nursing home closure is associated with a persistent decline in health sector employment, particularly in rural counties, suggesting a reduction in the health care workforce and in the ability to sustain health care services supply, particularly in rural areas.

Acuity Differences Among Newly Admitted Older Residents in Rural and Urban Nursing Homes

BACKGROUND AND OBJECTIVES

Our primary objective was to assess rural-urban acuity differences among newly admitted older nursing home residents.

RESEARCH DESIGN AND METHODS

Data included the 2015 Minimum Data Set v3.0, the Area Health Resources File, the Provider of Services File, and Rural-Urban Commuting Area codes. Activities of daily living, the Cognitive Function Scale, and aggression/wandering indicators were used to assess functional, cognitive, and behavioral status, respectively. Excluding assessments for short stays (less than 90 days), assessments for 209,719 newly admitted long-stay residents aged 65 and older across 14,834 facilities in 47 states were evaluated. Difference in differences (DID) generalized linear models with state-fixed effects and clustering by facilities were used to assess the interaction effect of older age (75 plus) on rural-urban acuity differences, controlling for socioeconomic factors, admission source, and market characteristics.

RESULTS

Residents admitted to rural facilities were less functionally impaired (incidence rate ratio: 0.973-0.898) but had more cognitive (odds ratio [OR]: 1.03-1.22) and problem behaviors (OR: 1.19-1.48) than urban. Although older age was predictive of higher acuity, in DID models, the expected decline in functional status was comparable in rural and urban facilities, while the cognitive and behavioral status for older admissions was 8.0% and 8.5% lower in rural versus urban facilities, respectively.

DISCUSSION AND IMPLICATIONS

Although the higher prevalence of cognitive impairment and problem behaviors among rural admissions was attributable in part to older age, rural facilities admitted less complex individuals among older age residents than urban facilities. Findings may reflect less capacity to manage older, complex individuals in rural facilities.

Factors Associated with Assisted Living Facility Closure

BACKGROUND AND OBJECTIVES

Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing home market for the ALF market to examine the organizational, internal, and external factors associated with closure.

RESEARCH DESIGN AND METHODS

Data on 1,939 ALFs operating in 2013 from Florida were used to estimate a logistic regression to examine the organizational, internal, and external factors that were associated with closure between 2013 and 2015.

RESULTS

During the two-year study period, 141 ALFs (7.3%) closed. Significant factors associated with increased odds of closure included fewer beds, not accepting Medicaid, and more deficiencies. Two factors (market concentration and population density) were marginally significant.

DISCUSSION AND IMPLICATIONS

The results of this study confirm the usefulness of a model that includes organizational, internal, and external factors to predict ALF closure. These outcomes highlight the concerns that closure can affect access to community based long-term care, especially for rural older adults, and indicate an expansion of Medicaid acceptance in ALFs could be protective against closure.

Urban Neighborhood Characteristics and the Spatial Distribution of Home and Community-Based Service Organizations in Michigan Metropolitan Statistical Areas

Living in a neighborhood with dense HCBS organizations can promote older adults' health and well-being and may mitigate health disparities generated by living in materially deprived urban neighborhoods. Using 2016 US County Business Patterns and the American Community Survey (2013-2017), focused on 516 ZIP Codes in Michigan Metropolitan Statistical Areas, this study examines the association between neighborhood characteristics and the relative density of businesses offering services for older adults and persons with disabilities (e.g., senior centers, adult day service centers, personal care) and businesses offering home health care. Results from a series of spatial econometric models show that social care organization density tends to be high in neighborhoods with a greater number of residents who have a bachelor's degree, who are older, and who are in poverty. Home health care density was not explained by neighborhood factors. Multiple neighborhood socio-demographic indicators explain the spatial distribution of social care organizations.

Long-Term Care Options in Florida: Their Availability by County Demographics

Older people express a preference for home and community-based care over skilled nursing, realizing that preference, however, is dependent upon having those options available. The present exploratory study uses publicly available data to understand if the geographic availability of long-term care options-skilled nursing, assisted living, home health, and homemaker/companion services-are equally distributed by demographics in Florida. Regression analyses showed that the percent 65 and older and the percent in poverty in a county were not related to long-term care availability or quality. Findings indicate that Hispanic older people have less access to nursing home beds, greater access to home health and homemaker/companion agencies, and tend to live in counties with a greater number of assisted living facility (ALF) deficiencies while Black older people have greater access to homemaker services. Rural counties had lower rates of home health and homemaker/companion agencies and fewer ALF deficiencies. The 65 and older population would benefit from the increased availability of long-term care options near the communities in which they live.

Location Matters: Disparities in the Likelihood of Receiving Services in Late Life

Moving beyond typical dichotomous rural-urban categorizations, this study examines older adults' likelihood of receiving home- and community-based services. Data from 1608 individuals aged 60+ who requested assistance from Area Agencies on Aging in Virginia in 2014-2015 were analyzed; 88% of individuals received at least one service. Receiving services was associated with geographic-based factors. Individuals living in completely rural areas were significantly less likely to receive any service compared to individuals in mostly rural (OR = 2.46, p = .003) and mostly urban (OR = 1.97, p = .024) areas. There were subtle but significant geographic-based differences in the likelihood of receiving specific services including food/meal, fresh food, information and referral, in-home care, utilities support, and transportation. Findings provide nuanced insights about geographic-based disparities in the receipt of services and suggest the need for new and modified service delivery strategies that maximize older adults' ability to live.

Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports: Stakeholder Perspectives From 14 States

OBJECTIVES

Trends over time in the United States show success in rebalancing long-term services and supports (LTSS) toward increased home- and community-based services (HCBS) relative to institutionalized care. However, the diffusion and utilization of HCBS may be inequitable across rural and urban residents. We sought to identify potential disparities in rural HCBS access and utilization, and to elucidate factors associated with these disparities.

DESIGN

We used qualitative interviews with key informants to explore and identify potential disparities and their associated supply-side factors.

SETTING AND PARTICIPANTS

We interviewed 3 groups of health care stakeholders (Medicaid administrators, service agency managers and staff, and patient advocates) from 14 states (n = 40).

MEASURES

Interviews were conducted using a semistructured interview guide, and data were thematically coded using a standardized codebook.

RESULTS

Stakeholders identified supply-side factors inhibiting rural HCBS access, including limited availability of LTSS providers, inadequate transportation services, telecommunications barriers, threats to business viability, and challenges to caregiving workforce recruitment and retention. Stakeholders perceived that rural persons have a greater reliance on informal caregiving supports, either as a cultural preference or as compensation for the dearth of HCBS.

CONCLUSIONS/IMPLICATIONS

LTSS rebalancing efforts that limit the institutional LTSS safety net may have unintended consequences in rural contexts if they do not account for supply-side barriers to HCBS. We identified supply-side factors that (1) inhibit beneficiaries' access to HCBS, (2) affect the adequacy and continuity of HCBS, and (3) potentially impact long-term business viability for HCBS providers. Spatial isolation of beneficiaries may contribute to a perceived lack of demand and reduce chances of funding for new services. Addressing these problems requires stakeholder collaboration and comprehensive policy approaches with attention to rural infrastructure.

Long-Term Services and Supports Use Among Older Medicare Beneficiaries in Rural and Urban Areas

State and federal policies have shifted long-term services and support (LTSS) priorities from nursing home care to home and community-based services (HCBS). It is not clear whether the rural LTSS system reflects this system transformation. Using the Medicare Current Beneficiary Survey, we examined nursing home use among rural and urban Medicare beneficiaries aged 65 and older. Study findings indicate that even after controlling for known predictors of nursing home use, rural Medicare beneficiaries exhibited greater odds of nursing home residence and that the higher odds of rural nursing home residence are, in part, associated with higher rural nursing home bed supplies. A complex interplay of policy, LTSS infrastructure, and social, cultural, and other factors may be influencing the observed differences. Federal and state efforts to build rural HCBS capacity may be necessary to mitigate stubbornly persistent rural-urban differences in the patterns of institutional and community-based LTSS use.