Discretionary Hospitalization of Nursing Home Residents With and Without Alzheimer’s Disease

Associations between Length of Stay in Long Term Care Facilities and End of Life Care. Analysis of the PACE Cross-Sectional Study

Long term care facilities (LTCFs) are increasingly a place of care at end of life in Europe. Longer residence in an LTCF prior to death has been associated with higher indicators of end of life care; however, the relationship has not been fully explored. The purpose of this analysis is to explore associations between length of stay and end of life care. The analysis used data collected in the Palliative Care for Older People in care and nursing homes in Europe (PACE) study, a cross-sectional mortality follow-back survey of LTCF residents who died within a retrospective 3-month period, conducted in Belgium, England, Finland, Italy, the Netherlands and Poland. Primary outcomes were quality of care in the last month of life, comfort in the last week of life, contact with health services in the last month of life, presence of advance directives and consensus in care. Longer lengths of stay were associated with higher scores of quality of care in the last month of life and comfort in the last week of life. Longer stay residents were more likely to have advance directives in place and have a lasting power of attorney for personal welfare. Further research is needed to explore the underlying reasons for this trend, and how good quality end of life care can be provided to all LTCF residents.

Relationship between nursing home quality indicators and potentially preventable hospitalisation

Background

Hospitalisations are very common among nursing home residents and many of these are deemed inappropriate or preventable. Little is known about whether clinical care quality is related to hospitalisation, especially potentially preventable hospitalisations (PPHs). Among the few studies that have been conducted, the findings have been inconsistent. The objective of this study was to examine the relationship between quality indicators and overall and PPHs among Medicaid beneficiaries aged 65 years and older receiving care at nursing homes in Minnesota.

Methods

23 risk-adjusted quality indicators were used to assess nursing home quality of care. Quality indicators and other facility-level variables from the Minnesota Nursing Home Report Card were merged with resident-level variables from the Minimum Data Set. These merged data were linked with Medicaid claims to obtain hospitalisation rates during the 2011–2012 period. The sample consisted of a cohort of 20 518 Medicaid beneficiaries aged 65 years and older who resided in 345 Minnesota nursing homes. The analyses controlled for resident and facility characteristics using the generalised linear mixed model.

Results

The results showed that about 44 % of hospitalisations were PPHs. Available quality indicators were not strongly or consistently associated with the risk of hospitalisation (neither overall nor PPH). Among these 23 quality indicators, five quality indicators (antipsychotics without a diagnosis of psychosis, unexplained weight loss, pressures sores, bladder continence and activities of daily living [ADL] dependence) were related significantly to hospitalisation and only four quality indicators (antipsychotics without a diagnosis of psychosis, unexplained weight loss, ADL dependence and urinary tract infections) were related to PPH.

Conclusion

Although general quality indicators can be informative about overall nursing home performance, only selected quality indicators appear to tap dimensions of clinical quality directly related to hospitalisations.

Integrated care for adults with dementia and other cognitive disorders

The importance of better care integration is emphasized in many national dementia plans. The inherent complexity of organizing care for people with dementia provides both the justification for improving care integration and the challenges to achieving it. The prevention, detection, and early diagnosis of cognitive disorders mainly resides in primary care, but how this is best integrated within the range of disorders that primary care clinicians are expected to screen is unclear. Models of integrated community dementia assessment and management have varying degrees of involvement of primary and specialist care, but share an emphasis on improving care coordination, interdisciplinary teamwork, and personalized care. Integrated care strategies in acute care are still in early development, but have been a focus of investigation in the past decade. Integrated care outreach strategies to reduce transfers from long-term residential care to acute care have been consistently effective. Integrated long-term residential care includes considerations of end-of-life care. Future directions should include strategies for training and education, early detection in anticipation of disease modifying treatments, integration of technological developments into dementia care, integration of dementia care into general health and social care, and the encouragement of a dementia-friendly society.

Place of death in patients with dementia and the association with comorbidities: a retrospective population-based observational study in Germany

Background

Due to increasing life expectancy, more and more older people are suffering from dementia and comorbidities. To date, little information is available on place of death for dementia patients in Germany. In addition, the association of place of death and comorbidities is unknown.

Methods

A population-based cross-sectional survey was conducted in Westphalia–Lippe (Germany), based on the analysis of death certificates from 2011. Individuals with dementia ≥ 65 years were identified using the documented cause of death. In this context, all mentioned causes of death were included. In addition, ten selected comorbidities were also analyzed. The results were presented descriptively. Using multivariate logistic regression, place of death was analyzed for any association with comorbidities.

Results

A total of 10,364 death certificates were analyzed. Dementia was recorded in 1646 cases (15.9%; mean age 86.3 ± 6.9 years; 67.3% women). On average, 1.5 ± 1.0 selected comorbidities were present. Places of death were distributed as follows: home (19.9%), hospital (28.7%), palliative care unit (0.4%), nursing home (49.5%), hospice (0.9%), no details (0.7%). The death certificates documented cardiac failure in 43.6% of cases, pneumonia in 25.2%, and malignant tumour in 13.4%. An increased likelihood of dying in hospital compared to home or nursing home, respectively, was found for the following comorbidities (OR [95%-CI]): pneumonia (2.96 [2.01–4.35], p = 0.001); (2.38 [1.75–3.25], p = 0.001); renal failure (1.93 [1.26–2.97], p = 0.003); (1.65 [1.18–2.32], p = 0.003); and sepsis (13.73 [4.88–38.63], p = 0.001); (7.34 [4.21–12.78], p = 0.001).

Conclusion

The most common place of death in patients with dementia is the retirement or nursing home, followed by hospital and home. Specific comorbidities, such as pneumonia or sepsis, correlated with an increased probability of dying in hospital.

(In-)formal caregivers' and general practitioners' views on hospitalizations of people with dementia - an exploratory qualitative interview study

Background

Dementia is an irreversible chronic disease with wide-ranging effects on patients’, caregivers’ and families’ lives. Hospitalizations are significant events for people with dementia. They tend to have poorer outcomes compared to those without dementia. Most of the previous studies focused on diagnoses leading to hospitalizations using claims data. Further factors (e.g. context factors) for hospitalizations are not reproduced in this data. Therefore, we investigated the factors leading to hospitalization with an explorative, qualitative study design.

Methods

We interviewed informal caregivers (N = 12), general practitioners (GPs, N = 12) and formal caregivers (N = 5) of 12 persons with dementia using a semi-structured interview guideline. The persons with dementia were sampled using criteria regarding their living situation (home care vs. nursing home care) and gender. The transcripts were analyzed using the method of structuring content analysis.

Results

Almost none of the hospitalizations, discussed with the (in-)formal caregivers and GPs, seemed to have been preventable or seemed unjustifiable from the interviewees’ points of view. We identified several dementia-specific factors promoting hospitalizations (e.g. the neglect of constricted mobility, the declining ability to communicate about symptoms/accidents and the shift of responsibility from person with dementia to informal or formal caregivers) and context-specific factors promoting hospitalizations (e.g. qualification of nursing home personal, the non-availability of the GP and hospitalizations for examinations/treatments also available in ambulatory settings). Hospitalizations were always the result of the interrelation of two factors: illnesses/accidents and context factors. The impact of both seems to be stronger in presence of dementia.

Conclusions

Points for action in terms of reducing hospitalization rates were: better qualified nurses, a 24-h-GP-emergency service and better compensation for ambulatory monitoring/treatments and house calls. Many hospitalizations of people with dementia cannot be prevented. Therefore, hospital staffs need to be better prepared to handle patients with dementia in order to reduce the negative effects of hospitalizations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2484-9) contains supplementary material, which is available to authorized users.

[Impact of dementia on length of stay and costs in acute care hospitals]

BACKGROUND

The treatment of patients with dementia in acute care hospitals is becoming increasingly more important. The aim of this study was to investigate and demonstrate aspects of the healthcare situation and resource consumption of dementia patients during their hospital stay in a ward for internal medicine.

MATERIAL AND METHODS

Secondary data from a ward of internal medicine were analyzed on a retrospective and case-related basis. For 100 patients a diagnosis of dementia by a general practitioner before hospitalization was identified. The control group was selected by age and sex from the other patients in the ward (n = 100). The costs were calculated on the basis of the German diagnosis-related groups (G-DRG) flat rate case classification. The relationship between dementia, deviation from the average length of stay and costs was investigated under the control of comorbidities using multivariate regression analysis.

RESULTS

Patients with dementia had poorer health at admission with respect to functionality and orientation and a higher risk of falls and pressure ulcers. During hospitalization patients with dementia fell more frequently than patients without dementia (12 % versus 3 %, p = 0.029). Regarding the average length of stay, according to the G‑DRG catalogue patients with dementia stayed 1.4 days longer in hospital than patients without dementia and caused excess costs of 19 %.

CONCLUSION

Patients with dementia are a highly vulnerable patient group with a higher consumption of resources than patients without dementia. The results demonstrate the care-related and economic consequences, which the increasing number of patients with dementia could have in the future.

Trajectories of care home residents during the last month of life: the case of France

This paper examines some demographic and medical factors associated with the likelihood of residing in a care home during the last month of life for persons aged 70 and over in France and, if so, of remaining in the care home throughout or being transferred to hospital. The data are from the Fin de vie en France (End of Life in France) survey undertaken in 2010. During the last month of life, very old people are more likely to be living in a care home but are not less likely to be transferred to hospital. Medical conditions and residential trajectories are closely related. People with dementia or mental disorders are more likely to live in a care home and, if so, to stay there until they die. Compared to care homes, a more technical and medication-based approach is taken in hospitals and care home residents who are transferred to hospital more often receive medication while those remaining in care homes more often receive support from a psychologist. In hospitals as in care homes, few older persons had recourse to advance directives and hospice programmes were not widespread. Promoting these two factors may help to increase the quality of end of life and facilitate an ethical approach to end-of-life care.

The Impact of Medicaid Payer Status on Hospitalizations in Nursing Homes

OBJECTIVES

To examine the association between payer status (Medicaid vs. private-pay) and the risk of hospitalizations among long-term stay nursing home (NH) residents who reside in the same facility.

DATA AND STUDY POPULATION

The 2007-2010 National Medicare Claims and the Minimum Data Set were linked. We identified newly admitted NH residents who became long-stayers and then followed them for 180 days.

ANALYSES

Three dichotomous outcomes-all-cause, discretionary, and nondiscretionary hospitalizations during the follow-up period-were defined. Linear probability model with facility fixed-effects and robust SEs were used to examine the within-facility difference in hospitalizations between Medicaid and private-pay residents. A set of sensitivity analyses were performed to examine the robustness of the findings.

RESULTS

The prevalence of all-cause hospitalization during a 180-day follow-up period was 23.3% among Medicaid residents compared with 21.6% among private-pay residents. After accounting for individual characteristics and facility effects, the probability of any all-cause hospitalization was 1.8-percentage point (P<0.01) higher for Medicaid residents than for private-pay residents within the same facility. We also found that Medicaid residents were more likely to be hospitalized for discretionary conditions (5% increase in the likelihood of discretionary hospitalizations), but not for nondiscretionary conditions. The findings from the sensitivity analyses were consistent with the main analyses.

CONCLUSIONS

We observed a higher hospitalization rate among Medicaid NH residents than private-pay residents. The difference is in part driven by the financial incentives NHs have to hospitalize Medicaid residents.

Hospital admissions, outpatient visits and healthcare costs of community-dwellers with Alzheimer's disease

BACKGROUND

Detailed data on the health care service use of people with Alzheimer's disease (AD) are scarce.

METHODS

We assessed the health care service use of all community-dwelling persons with clinically verified AD diagnosis, residing in Finland on December 31, 2005 (n = 27,948) in comparison to matched cohort without AD. Hospitalization data during 2006-2009 were extracted from the National Hospital Discharge Register.

RESULTS

Comorbidity-adjusted incidence rate ratios; IRR (95% CI) were 1.25 (1.22-1.28) for inpatient admissions and 0.72 (0.68-0.77) for outpatient visits. People with AD had more general health care admissions (IRR, 95%CI 1.73, 1.67-1.80) but less admissions to specialty units 0.82 (0.79-0.85) than the non-AD group, with psychiatry being the only specialty with more admissions in the AD group. People with AD had 16 more hospital days/person-year.

CONCLUSIONS

It would be important to assess whether inpatient hospitalizations of AD patients could be decreased by better targeting of outpatient services and whether other conditions are underdiagnosed or undertreated among persons with AD.

The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations

BACKGROUND

Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services.

METHODS

We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation.

RESULTS

Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant.

CONCLUSIONS

Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.

Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study

Background

Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI.

Methods

We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors.

Results

Twenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations.

Conclusions

ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.

[People with dementia in acute hospitals. Literature review of prevalence and reasons for hospital admission]

People with dementia who are hospitalized depend on hospital care that is tailored to their particular needs. However, the current structural conditions and standardized care plans are often opposed to the needs for familiarity and orientation that people with dementia have. For the development of dementia-specific care concepts, it is important to know the proportion of persons with dementia who are hospitalized as well as the diagnosis that leads to hospital admission. The results of the literature review show prevalence estimates of 3.4-43.3%. The probability or risk of hospitalization for persons with dementia is between 1.4-3.6 times greater than it is for non-dementia persons. In addition, the reasons for admission are different. People with dementia are more frequently hospitalized due to infectious diseases, fractures, or nutritional disorders than non-dementia persons. Based on these results, one can hypothesize that there is a need for cross-sectoral care approaches, since these indicate the necessity for further research in order to establish a reliable database.

Caregiver burden, health utilities, and institutional service use in Alzheimer's disease

OBJECTIVE

This study examined the moderating effect of caregiver burden on the relationship between the health status of Alzheimer's disease (AD) patients and their use of institutional services (i.e., hospitalization, nursing home, and residential care).

METHODS

Data were obtained at baseline and at 3, 6, and 9 months following study entry on 421 community-dwelling patients with AD in the Clinical Antipsychotic Trials of Intervention Effectiveness for AD. The outcome variable includes use of any institutional services. Logistic regression was employed to estimate the interaction between Health Utility Index Mark III score (a general health status measure) and four concurrent caregiver burden measures at outcome. Marginal effects were calculated and plotted using random effects models for observations at multiple time points per individual. Average effects were calculated across all observations using models without random effects.

RESULTS

Random effects results suggest that caregiver burden weakens the inverse relationship between health utilities and institutional service use, leading to greater likelihood of institutional use than would be expected at a given level of health. This is indicated by positive and significant signs on the Health Utility Index Mark III*caregiver burden interaction when burden is measured using the Caregiver Distress Scale, Beck Depression Inventory, and Caregiver Assessment Survey (all p < 0.05). It is reinforced by positive and significant average effects deriving from Caregiver Distress and Beck Depression Inventory models without random effects (both p < 0.10). Results derived from the Burden Interview Scale, although positive, were non-significant and weak by comparison.

CONCLUSION

Caregiver support interventions should be offered to individuals caring for less-advanced AD patients. Otherwise, healthy patients may be at increased risk for institutionalization when caregivers experience high levels of burden.

Decisions about transferring nursing home residents to hospital: highlighting the roles of advance care planning and support from local hospital and community health services

AIMS AND OBJECTIVES

To explore current practice and opportunities to improve practice in decision-making about transfer of nursing home residents to hospital.

BACKGROUND

Nursing home staff are often faced with the decision of whether to send a resident to hospital for medical treatment. While many residents will benefit from going to hospital, there are also several risks associated with this. This study sought to add to the existing body of research on this issue by seeking the views of nursing home managers, who are the persons most frequently involved in making these decisions.

DESIGN

Qualitative design using purposive, quota sampling.

METHOD

Qualitative interviews with 41 nursing home managers from south-western Sydney, Australia.

RESULTS

Factors affecting the decision to transfer a resident to hospital include acuteness of their condition; level and style of medical care available; role of family members; numbers, qualifications and skills mix of staff; and concern about criticism for not transferring to hospital. Two factors that have not featured as strongly in previous research are the roles of advance care planning and support from local hospital and community health services.

CONCLUSION

While transferring a nursing home resident to hospital is often necessary, there are many situations where they could be cared for in the nursing home; therefore, avoid complications associated with being in hospital. Apart from a range of factors already identified in the literature, this study has highlighted the important role that advance care planning and support from local health services can play in reducing unnecessary transfers to hospital.

RELEVANCE TO CLINICAL PRACTICE

There are several strategies that nursing homes and local health authorities can adopt to promote advance care planning and build better support systems between the two sectors, thereby reducing the numbers of residents who need to be transferred to hospital for their health care.

Medicaid bed-hold policy and Medicare skilled nursing facility rehospitalizations

OBJECTIVE

To analyze the effect of states' Medicaid bed-hold policies on the 30-day rehospitalization of Medicare postacute skilled nursing facility (SNF) residents.

DATA SOURCES

Minimum data set assessments were merged with Medicare claims and eligibility files for all first-time SNF admissions (N = 3,322,088) over the period 2000 through 2005; states' Medicaid bed-hold policies were obtained via survey.

STUDY DESIGN

Regression specification incorporating facility fixed effects to examine changes in Medicaid bed-hold policies on the likelihood of a 30-day SNF rehospitalization.

PRINCIPAL FINDINGS

Using a continuous measure of bed-hold generosity, state Medicaid bed-hold was positively related to Medicare SNF rehospitalization. Specifically, the introduction of a bed-hold policy with average generosity increases Medicare rehospitalizations by 1.8 percent, representing roughly 12,000 SNF rehospitalizations at a cost to Medicare of approximately U.S.$100 million over our study period.

CONCLUSIONS

Although facilities do not receive a Medicaid bed-hold payment for Medicare SNF stays, we found that the adoption of more generous policies led to greater SNF rehospitalizations. This type of spillover is largely ignored in current discussions of Medicare payment reforms such as bundled payment. Neither Medicare nor Medicaid has an incentive to internalize the risks and benefits of its actions as they affect the other.

Assessing the relationship between health utilities, quality of life, and health services use in Alzheimer's disease

OBJECTIVES

To examine the relationship between use of multiple health services and health utilities, quality of life and other factors in Alzheimer's disease (AD).

DESIGN

Data were obtained via caregiver proxy at baseline and 3- 6- and 9-months post-random assignment among 421 community-dwelling AD patients participating in the CATIE-AD trial of anti-psychotic medications. Service use includes both institutional and outpatient services. Correlates include the AD-Related Quality of Life Scale (ADRQoL), Health Utilities Index (HUI)-III, Neuropsychiatric Inventory, Mini Mental Status Examination, and AD-Cooperative Study Activities of Daily Living Scale. Chi squared tests, t-tests and logistic regression (using general estimating equations) were used to examine the correlates of service use.

RESULTS

Three quarters (74.2%) used at least one service each month. Average monthly utilization rates for specific service types were: 4.5%, inpatient hospital; 5.6%, nursing home; 3.9%, residential care; 44.0%, AD-related outpatient; 9.4%, mental health outpatient; and 45.5%, medical-surgical outpatient. The likelihood of using any service was higher among older patients [Odds Ratio (OR) = 1.03] and non-Hispanic Whites (OR = 1.61). Each 0.10 increment on the Health Utilities Index (HUI)-III was associated with a 7.0% decrease in the odds of using one or more service (OR = 0.93). The odds of using outpatient and institutional services were 6.0% and 10.0% lower, respectively, for each 0.10 increment on the HUI-III (OR = 0.94, OR = 0.90). The AD-Related Quality of Life Scale proved significantly related to outpatient medical-surgical services only (OR = 1.01).

CONCLUSION

Findings suggest that the HUI-III could be combined with other known correlates of service use to inform population planning associated with AD.

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.

Predictors of nursing home hospitalization: a review of the literature

Hospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm. This article critically reviews the association between the decision to hospitalize and factors related to the residents' welfare and preferences, the providers' attitudes, and the financial implications of hospitalization. Regarding the resident's welfare, factors associated with hospitalization included sociodemographics, health characteristics, nurse staffing, the presence of ancillary services, and the use of hospices. Patient preferences (e.g., advance directives) and provider attitudes (e.g., overburdening of staff) were also associated with increased hospitalization. Finally, financial variables related to hospitalization included nursing home ownership status and state Medicaid policies, such as nursing home payment rates and bed-hold requirements. Most studies relied on potentially confounded research designs, which leave open the issue of selection bias. Nevertheless, the existing literature asserts that nursing home hospitalizations are frequent, often preventable, and related to facility practices and state Medicaid policies.

Nursing home characteristics related to medicare costs for residents with and without dementia

OBJECTIVES

To evaluate the relationship of nursing home characteristics to Medicare costs overall and by dementia status.

DESIGN

New admissions followed for 2 years. Setting. Random stratified sample of 55 Maryland nursing homes.

PARTICIPANTS

Sample of 1257 residents.

MEASURES

Records, interview, and observation.

RESULTS

Medicare costs were lower in facilities that have a better environmental quality, hospice beds, and more food service workers; costs were higher in hospital-based facilities and those that have a higher Medicaid case mix, X-ray, and some specified types of staff. Across all characteristics, costs for residents with dementia were consistently two-thirds the cost of other residents.

DISCUSSION

In terms of dementia status, resident characteristics drive Medicare costs, as opposed to facility characteristics. Using alternative residential settings for individuals with dementia may increase Medicare costs of nursing home residents and Medicare costs of residents with dementia who are cared for in settings less able to attend to medical needs.

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.

Care Outcomes in Long-Term Care Facilities in British Columbia, Canada

OBJECTIVES

This study investigated whether for-profit (FP) versus not-for-profit (NP) ownership of long-term care facilities resulted in a difference in hospital admission and mortality rates among facility residents in British Columbia, Canada.

RESEARCH DESIGN

This retrospective cohort study used administrative data on all residents of British Columbia long-term care facilities between April 1, 1996, and August 1, 1999 (n = 43,065). Hospitalizations were examined for 6 diagnoses (falls, pneumonia, anemia, dehydration, urinary tract infection, and decubitus ulcers and/or gangrene), which are considered to be reflective of facility quality of care. In addition to FP versus NP status, facilities were divided into ownership subgroups to investigate outcomes by differences in governance and operational structures.

RESULTS

We found that, overall, FP facilities demonstrated higher adjusted hospitalization rates for pneumonia, anemia, and dehydration and no difference for falls, urinary tract infections, or DCU/gangrene. FP facilities demonstrated higher adjusted hospitalization rates compared with NP facilities attached to a hospital, amalgamated to a regional health authority, or that were multisite. This effect was not present when comparing FP facilities to NP single-site facilities. There was no difference in mortality rates in FP versus NP facilities.

CONCLUSIONS

The higher adjusted hospitalization rates in FP versus NP facilities is consistent with previous research from U.S. authors. However, the superior performance by the NP sector is driven by NP-owned facilities connected to a hospital or health authority, or that had more than one site of operation.

Vulnerable populations at risk of potentially avoidable hospitalizations: the case of nursing home residents with Alzheimer's disease

This study explores whether nursing home residents with Alzheimer's disease and related dementias (ADRD) are affected differently by facility-level risk factors of ambulatory care-sensitive (ACS) conditions, a measure of timely access to medical care. Three years of quarterly Medicaid reimbursement data from over 525 Massachusetts nursing homes were linked with four years of Medical Provider Analysis and Review hospital claims data and facility-level attribute data to investigate whether facility effects differed by resident ADRD status. The findings suggest that nursing home residents with ADRD are more likely to be hospitalized for certain ACS conditions, including gastroenteritis and kidney/ urinary tract infections. Availability of increased registered nurse staffing levels and on-site nurse practitioners appears to attenuate this risk. Although findings suggest that ACS hospitalization measures may represent a useful approach to monitoring nursing home care, additional effort is needed to understand the extent to which severity of illness and/or comorbidities affect the measurement of these hospitalizations.