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Cox MB, McGregor MJ, Poss J, Harrington C. The association of facility ownership with COVID-19 outbreaks in long-term care homes in British Columbia, Canada: a retrospective cohort study. CMAJ Open 2023; 11:E267-E273. [PMID: 36944427 PMCID: PMC10035665 DOI: 10.9778/cmajo.20220022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Long-term care (LTC) in Canada is delivered by a mix of government-, for-profit- and nonprofit-owned facilities that receive public funding to provide care, and were sites of major outbreaks during the early stages of the COVID-19 pandemic. We sought to assess whether facility ownership was associated with COVID-19 outbreaks among LTC facilities in British Columbia, Canada. METHODS We conducted a retrospective observational study in which we linked LTC facility data, collected annually by the Office of the Seniors Advocate BC, with public health data on outbreaks. A facility outbreak was recorded when 1 or more residents tested positive for SARS-CoV-2 between Mar. 1, 2020, and Jan. 31, 2021. We used the Cox proportional hazards method to calculate the adjusted hazard ratio (HR) of the association between risk of COVID-19 outbreak and facility ownership, controlling for community incidence of COVID-19 and other facility characteristics. RESULTS Overall, 94 outbreaks involved residents in 80 of 293 facilities. Compared with health authority-owned facilities, for-profit and nonprofit facilities had higher risks of COVID-19 outbreaks (adjusted HR 1.99, 95% confidence interval [CI] 1.12-3.52 and adjusted HR 1.84, 95% CI 1.00-3.36, respectively). The model adjusted for community incidence of infection (adjusted HR 1.12, 95% CI 1.07-1.17), total nursing hours per resident-day (adjusted HR 0.84, 95% CI 0.33-2.14), facility age (adjusted HR 1.01, 95% CI 1.00-1.02), number of facility beds (adjusted HR 1.20, 95% CI 1.12-1.30) and facilities with beds in shared rooms (adjusted HR 1.16, 95% CI 0.73-1.85). INTERPRETATION Findings suggest that ownership of LTC facilities by health authorities in BC offered some protection against COVID-19 outbreaks. Further study is needed to unpack the underlying pathways behind this observed association.
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Affiliation(s)
- Michelle B Cox
- Department of Family Practice (Cox, McGregor), Faculty of Medicine, University of British Columbia; Centre for Clinical Epidemiology and Evaluation (McGregor), Vancouver Coastal Health Research Institute, Vancouver, BC; School of Public Health Sciences (Poss), University of Waterloo, Waterloo, Ont.; Department of Social and Behavioral Sciences (Harrington), University of California - San Francisco, San Francisco, Calif
| | - Margaret J McGregor
- Department of Family Practice (Cox, McGregor), Faculty of Medicine, University of British Columbia; Centre for Clinical Epidemiology and Evaluation (McGregor), Vancouver Coastal Health Research Institute, Vancouver, BC; School of Public Health Sciences (Poss), University of Waterloo, Waterloo, Ont.; Department of Social and Behavioral Sciences (Harrington), University of California - San Francisco, San Francisco, Calif.
| | - Jeffrey Poss
- Department of Family Practice (Cox, McGregor), Faculty of Medicine, University of British Columbia; Centre for Clinical Epidemiology and Evaluation (McGregor), Vancouver Coastal Health Research Institute, Vancouver, BC; School of Public Health Sciences (Poss), University of Waterloo, Waterloo, Ont.; Department of Social and Behavioral Sciences (Harrington), University of California - San Francisco, San Francisco, Calif
| | - Charlene Harrington
- Department of Family Practice (Cox, McGregor), Faculty of Medicine, University of British Columbia; Centre for Clinical Epidemiology and Evaluation (McGregor), Vancouver Coastal Health Research Institute, Vancouver, BC; School of Public Health Sciences (Poss), University of Waterloo, Waterloo, Ont.; Department of Social and Behavioral Sciences (Harrington), University of California - San Francisco, San Francisco, Calif
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Chang CH, Mainor A, Colla C, Bynum J. Utilization by Long-Term Nursing Home Residents Under Accountable Care Organizations. J Am Med Dir Assoc 2020; 22:406-412. [PMID: 32693998 DOI: 10.1016/j.jamda.2020.05.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Nursing home care is common and costly. Accountable care organization (ACO) payment models, which have incentives for care that is better coordinated and less reliant on acute settings, have the potential to improve care for this high-cost population. We examined the association between ACO attribution status and utilization and Medicare spending among long-term nursing home residents and hypothesized that attribution of nursing home residents to an ACO will be associated with lower total spending and acute care use. DESIGN Observational propensity-matched study. SETTING AND PARTICIPANTS Medicare fee-for-service beneficiaries who were long-term nursing home residents residing in areas with ≥5% ACO penetration. METHODS ACO attribution and covariates used in propensity matching were measured in 2013 and outcomes were measured in 2014, including hospitalization (total and ambulatory care sensitive conditions), outpatient emergency department visits, and Medicare spending. RESULTS Nearly one-quarter (23.3%) of nursing home residents who survived into 2014 (n = 522,085, 76.1% of 2013 residents) were attributed to an ACO in 2013 in areas with ≥5% ACO penetration. After propensity score matching, ACO-attributed residents had significantly (P < .001) lower hospitalization rates per 1000 (total: 402.9 vs 419.9; ambulatory care sensitive conditions: 64.4 vs 71.4) and fewer outpatient ED visits (29.9 vs 33.3 per 100) but no difference in total spending ($14,071 vs $14,293 per resident, P = .058). Between 2013 and 2014, a sizeable proportion of residents' attribution status switched (14.6%), either into or out of an ACO. CONCLUSIONS AND IMPLICATIONS ACO nursing home residents had fewer hospitalizations and ED visits, but did not have significantly lower total Medicare spending. Among residents, attribution was not stable year over year.
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Affiliation(s)
- Chiang-Hua Chang
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
| | - Alexander Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Carrie Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Julie Bynum
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
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Berish DE, Bornstein J, Bowblis JR. The Impact of Long-Term Care Ombudsman Presence on Nursing Home Survey Deficiencies. J Am Med Dir Assoc 2019; 20:1325-1330. [PMID: 30922864 DOI: 10.1016/j.jamda.2019.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/29/2019] [Accepted: 02/03/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Each year states are required to survey nursing homes (NHs), including issuing deficiency citations when regulatory standards are not met. These deficiency citations can have substantial consequences for NHs. Because it is imperative that the survey process is conducted consistently across facilities, this study aims to determine whether deficiency outcomes vary with the presence of a long-term care ombudsman at the survey. DESIGN A retrospective secondary data analysis of facility-level data using panel regression techniques was used to determine whether the presence of an ombudsman at a survey affected deficiency outcomes. Additional analysis assured the results were not due to ombudsmen being more likely to be present at poorer performing facilities. SETTING AND PARTICIPANTS The data include freestanding NHs in the United States with at least 2 surveys between 2009 and 2015, resulting in 95,237 surveys from 14,996 unique NHs. MEASURES The number and deficiency score were analyzed for 4 types of deficiencies: all deficiencies and the broad categories of quality of care, quality of life, and administration. The key explanatory variable is the presence of an ombudsman at survey. The regression model controlled for other important facility-level covariates. RESULTS The presence of an ombudsman varied across states (range: 0.8%-82.0%; mean: 29.9%). Regression analysis found ombudsman presence was associated with a 0.2 increase in the number of deficiencies and 2.2-point increase in deficiency score. These correspond to a 3.9% and 5.9% increase, respectively. On a percentage basis, the largest effects were found for quality of life and administration deficiencies. CONCLUSIONS/IMPLICATIONS By being present at surveys, ombudsmen may bring issues to the attention of state surveyors, resulting in worse deficiency outcomes during annual surveys. This can have consequences for NHs, and further work is needed to assure that ombudsmen are using their resources where they are most needed.
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Affiliation(s)
- Diane E Berish
- College of Nursing, Penn State University, University Park, PA.
| | | | - John R Bowblis
- Department of Economics and Scripps Gerontology Center, Miami University, Oxford, OH
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Hansen KE, Hyer K, Holup AA, Smith KM, Small BJ. Analyses of Complaints, Investigations of Allegations, and Deficiency Citations in United States Nursing Homes. Med Care Res Rev 2017; 76:736-757. [DOI: 10.1177/1077558717744863] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Quality of care in nursing homes has been evaluated from varying perspectives, but few studies analyze complaints made to surveyors. This study analyzed complaints, investigations, and citations for nursing homes nationwide. Using the complaint and survey data sets, analyses match nursing home complaints with findings of investigations conducted. Results showed the average complaint rate was 13.3 complaints per 100 residents and that 43.2% of complaint allegations were substantiated, with complaints about care and services provided being the most prevalent. Variability was noted among the Centers for Medicare and Medicaid Services regions and, on average, 47.5% of facilities had five or more complaints in a given year. While additional research could evaluate the effect of complaint investigations on nursing home quality, results indicated that complaints and subsequent investigations provide further information regarding quality for residents. Results also suggest improvements in the training for surveyors and more consistency across Centers for Medicare and Medicaid Services survey regions.
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Smith KM, Thomas KS, Johnson S, Meng H, Hyer K. Dietary Service Staffing Impact Nutritional Quality in Nursing Homes. J Appl Gerontol 2017; 38:639-655. [DOI: 10.1177/0733464816688309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To examine the relationship between dietary service staff and dietary deficiency citations in nursing homes (NHs). Method: 2007-2011 Online Survey and Certification and Reporting data for 14,881 freestanding NHs were used to examine the relationship between dietary service staff and the probability of receiving a dietary service–related deficiency citation. An unconditional logit model with random effects was employed. Results: Findings suggest that higher staffing levels for dietitians (odds ratio [OR] = .955; p < .01), dietary service personnel (OR = .996; p < .01), and certified nursing assistants (CNAs; OR = .981; p < .05) decrease the likelihood of receiving a dietary service deficiency citation. Conclusion: Higher levels of dietary service and CNA staffing levels have the potential to improve the quality of nutritional care in NHs. Findings help substantiate the Centers for Medicare and Medicaid Services’ proposed rules for more stringent Food and Nutrition Services in the NH setting and signify the need for further research relative to the impact of dietary service staff on nutritional and clinical outcomes.
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Affiliation(s)
| | - Kali S. Thomas
- U.S. Department of Veterans Affairs Medical Center, Providence, RI, USA
- Brown University, Providence, RI, USA
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Ronald LA, McGregor MJ, Harrington C, Pollock A, Lexchin J. Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change? PLoS Med 2016; 13:e1001995. [PMID: 27093442 PMCID: PMC4836753 DOI: 10.1371/journal.pmed.1001995] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Margaret McGregor and colleagues consider Bradford Hill's framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.
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Affiliation(s)
- Lisa A. Ronald
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Margaret J. McGregor
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
| | - Charlene Harrington
- School of Nursing, University of California, San Francisco, San Francisco, California, United States of America
| | - Allyson Pollock
- Queen Mary, University of London, London, United Kingdom
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Joel Lexchin
- School of Health Policy and Management at York University, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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The effects of RN staffing hours on nursing home quality: A two-stage model. Int J Nurs Stud 2014; 51:409-17. [DOI: 10.1016/j.ijnurstu.2013.10.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 10/01/2013] [Accepted: 10/04/2013] [Indexed: 11/20/2022]
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Shield R, Rosenthal M, Wetle T, Tyler D, Clark M, Intrator O. Medical staff involvement in nursing homes: development of a conceptual model and research agenda. J Appl Gerontol 2014; 33:75-96. [PMID: 24652944 PMCID: PMC3962951 DOI: 10.1177/0733464812463432] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Medical staff (physicians, nurse practitioners, physicians' assistants) involvement in nursing homes (NH) is limited by professional guidelines, government policies, regulations, and reimbursements, creating bureaucratic burden. The conceptual NH Medical Staff Involvement Model, based on our mixed-methods research, applies the Donabedian "structure-process-outcomes" framework to the NH, identifying measures for a coordinated research agenda. Quantitative surveys and qualitative interviews conducted with medical directors, administrators and directors of nursing, other experts, residents and family members and Minimum Data Set, the Online Certification and Reporting System and Medicare Part B claims data related to NH structure, process, and outcomes were analyzed. NH control of medical staff, or structure, affects medical staff involvement in care processes and is associated with better outcomes (e.g., symptom management, appropriate transitions, satisfaction). The model identifies measures clarifying the impact of NH medical staff involvement on care processes and resident outcomes and has strong potential to inform regulatory policies.
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Affiliation(s)
- Renée Shield
- Health Services, Policy & Practice, Brown University, Providence, RI, USA
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Nace DA, Perera S, Handler SM, Muder R, Hoffman EL. Increasing influenza and pneumococcal immunization rates in a nursing home network. J Am Med Dir Assoc 2010; 12:678-84. [PMID: 21450182 DOI: 10.1016/j.jamda.2010.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 04/30/2010] [Accepted: 05/03/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND RATIONALE Influenza and pneumonia remain serious health concerns for long-term care (LTC) residents. Vaccination of LTC residents and health care workers are reasonable preventive strategies, although most facilities fall short of Healthy People 2010 goals. Improving immunization rates across multiple LTC facilities remains an elusive challenge. This quality improvement study sought to improve immunization rates across 6 LTC facilities and identify persistent barriers to better performance. METHODS In 2002, 6 facilities associated with the University of Pittsburgh Institute on Aging established a quality improvement network addressing immunization rates. The facilities were provided with a written educational toolkit and shared information through an e-mail distribution list. To help determine optimal program structure in future years, 3 of the facilities participated in a single half-day collaborative training session. Change in immunization rates from baseline to year 2 were compared between those participating in the collaborative training and those not participating. Barriers to improved performance were sought from all groups through focus group analysis. RESULTS Facilities participating in the single collaborative training program improved immunization rates modestly, whereas facilities not participating in the collaborative training saw decreases in immunization rates. Staff turnover was cited as a significant barrier to improved performance. DISCUSSION It may be possible to improve immunization rates in LTC facilities, at least modestly, using a collaborative training process. Staff turnover may be an important barrier to improved LTC immunization rates.
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Affiliation(s)
- David A Nace
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Castle NG, Ferguson JC. What is nursing home quality and how is it measured? THE GERONTOLOGIST 2010; 50:426-42. [PMID: 20631035 PMCID: PMC2915498 DOI: 10.1093/geront/gnq052] [Citation(s) in RCA: 203] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Accepted: 06/07/2010] [Indexed: 11/14/2022] Open
Abstract
PURPOSE In this commentary, we examine nursing home quality and indicators that have been used to measure nursing home quality. DESIGN AND METHODS A brief review of the history of nursing home quality is presented that provides some context and insight into currently used quality indicators. Donabedian's structure, process, and outcome (SPO) model is used to frame the discussion. Current quality indicators and quality initiatives are discussed, including those included in the Facility Quality Indicator Profile Report, Nursing Home Compare, deficiency citations included as part of Medicare/Medicaid certification, and the Advancing Excellence Campaign. RESULTS Current quality indicators are presented as a mix of structural, process, and outcome measures, each of which has noted advantages and disadvantages. We speculate on steps that need to be taken in the future to address and potentially improve the quality of care provided by nursing homes, including report cards, pay for performance, market-based incentives, and policy developments in the certification process. Areas for future research are identified throughout the review. IMPLICATIONS We conclude that improvements in nursing home quality have likely occurred, but improvements are still needed.
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Affiliation(s)
- Nicholas G Castle
- Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA.
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Werner RM, Tamara Konetzka R, Liang K. State Adoption of Nursing Home Pay-for-Performance. Med Care Res Rev 2009; 67:364-77. [DOI: 10.1177/1077558709350885] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Whereas numerous policies have been adopted to improve quality of care in nursing homes over the past several decades—with varying degrees of success—health care payment has been a largely untapped but potentially powerful policy tool to improve quality of care. Recently, however, payers have invested significant resources in the development and implementation of pay-for-performance (P4P) programs for nursing homes. The authors present results from a survey of state Medicaid agencies documenting the use and structure of P4P in nursing homes. Although the number of states that are implementing nursing home P4P is growing, the structure of these incentives varies across states, and little evidence exists to guide the planning or implementation of these initiatives.
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Konetzka RT, Werner RM. Disparities in long-term care: building equity into market-based reforms. Med Care Res Rev 2009; 66:491-521. [PMID: 19228634 DOI: 10.1177/1077558709331813] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
A growing body of evidence documents pervasive racial, ethnic, and class disparities in long-term care in the United States. At the same time, major quality improvement initiatives are being implemented that rely on market-based incentives, many of which may have the unintended consequence of exacerbating disparities. We review existing evidence on disparities in the use and quality of long-term care services, analyze current market-based policy initiatives in terms of their potential to ameliorate or exacerbate these disparities, and suggest policies and policy modifications that may help decrease disparities. We find that racial disparities in the use of formal long-term care have decreased over time. Disparities in quality of care are more consistently documented and appear to be related to racial and socioeconomic segregation of long-term care facilities as opposed to within-provider discrimination. Market-based incentives policies should explicitly incorporate the goal of mitigating the potential unintended consequence of increased disparities.
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Affiliation(s)
- R Tamara Konetzka
- Department of Health Studies, University of Chicago, 5841 S. Maryland Avenue, MC2007, Chicago, IL 60637, USA.
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Arling G, Job C, Cooke V. Medicaid Nursing Home Pay for Performance: Where Do We Stand? THE GERONTOLOGIST 2009; 49:587-95. [DOI: 10.1093/geront/gnp044] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
In this research, the author reviewed 70 studies that had examined the relationship between staffing levels and quality in nursing homes (covering the years 1991 to 2006). The results of the review including all of this literature show that approximately 40% of the quality indicators examined show an association with nursing home staffing levels. Nevertheless, this finding is further interpreted in the context of the limitations of many of these prior studies. The author discusses the limitations of poor quality staffing data, small sample size, quality indicators used, methodological concerns, and underspecified models inherent to many prior studies. The author finds no study representing a “gold standard” exists in this area. Still, the few studies that seem methodologically most robust would seem to indicate that an association between nursing home staffing levels and quality exists. However, the author concludes that studies in this area need to be further enhanced.
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Abstract
OBJECTIVE To examine the effects of ownership conversions on nursing home performance. DATA SOURCE Online Survey, Certification, and Reporting system data from 1993 to 2004, and the Minimum Data Set (MDS) facility reports from 1998 to 2004. STUDY DESIGN Regression specification incorporating facility fixed effects, with terms to identify trends in the pre- and postconversion periods. PRINCIPAL FINDINGS The annual rate of nursing home conversions almost tripled between 1994 and 2004. Our regression results indicate converting facilities are generally different throughout the pre/postconversion years, suggesting little causal effect of ownership conversions on nursing home performance. Before and after conversion, nursing homes converting from nonprofit to for-profit status generally exhibit deterioration in their performance, while nursing homes converting from for-profit to nonprofit status generally exhibit improvement. CONCLUSIONS Policy makers have expressed concern regarding the implications of ownership conversions for nursing home performance. Our results imply that regulators and policy makers should not only monitor the outcomes of nursing home conversions, but also the targets of these conversions.
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Affiliation(s)
- David C Grabowski
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115-5899, USA.
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Zimmerman S, Gruber-Baldini AL, Hebel JR, Burton L, Boockvar K, Taler G, Quinn CC, Magaziner J. Nursing home characteristics related to medicare costs for residents with and without dementia. Am J Alzheimers Dis Other Demen 2008; 23:57-65. [PMID: 18276958 PMCID: PMC10846144 DOI: 10.1177/1533317507308778] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Sheryl Zimmerman
- Program on Aging, Disability and Long-Term Care, Cecil G. Sheps Center for Health Services Research and the School of Social Work, University of North Carolina at Chapel Hill, North Carolina 27514, USA.
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Abstract
The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.
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Abstract
The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.
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Abstract
OBJECTIVE Many studies have examined quality effects of nursing facility (NF) staffing, but few have examined effects of unionization. Concerned with possible effects of unionization on quality, we analyzed unionization and local market climate of unionization, predicting both complaints (reflecting either quality problems or better monitoring and advocacy) and the substantiation of serious complaints (indicating major quality problems). METHOD Data were analyzed on California freestanding NFs in 1999 (N = 1,155). OLS regression was employed to predict both quality complaints and serious violations, the latter both controlling and not controlling for numbers of complaints. RESULTS Unionized NFs showed more complaints than did non-unionized NFs. Non-unionized NFs had more serious violations, particularly when the proportion of other county facilities unionized was higher. DISCUSSION These findings suggest that unionization enhances problem reporting while, especially in stronger union environments, reducing the incidence of serious quality violations.
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Degenholtz HB, Kane RA, Kane RL, Bershadsky B, Kling KC. Predicting nursing facility residents' quality of life using external indicators. Health Serv Res 2006; 41:335-56. [PMID: 16584452 PMCID: PMC1702527 DOI: 10.1111/j.1475-6773.2005.00494.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE A newly developed brief measure of nursing facility (NF) resident self-reported quality of life (QOL) has been proposed for inclusion in a modified version of the minimum data set (MDS). There is considerable interest in determining whether it is possible to develop indicators of QOL that are more convenient and less expensive than direct, in-person interviews with residents. DESIGN AND METHODS QOL interview data from 2,829 residents living in 101 NFs using a 14-item version of a longer instrument were merged with data from the MDS and the Online Survey and Certification Automated Record (OSCAR). Bivariate and multivariate hierarchical linear modeling were used to assess the association of QOL with potential resident and facility level indicators. RESULTS Resident and facility level indicators were associated with self-reported QOL in the expected direction. At the individual resident level, QOL is negatively associated with physical function, visual acuity, continence, being bedfast, depression, conflict in relationships, and positively associated with social engagement. At the facility level, QOL is negatively associated with citations for failing to accommodate resident needs or providing a clean, safe environment. The ratio of activities staff to residents is positively associated with QOL. This study did not find an association between QOL and either use of restraints or nurse staff levels. Approximately 9 percent of the total variance in self-reported QOL can be attributed to differences among facilities; 91 percent can be attributed to differences among residents. Resident level indicators explained about 4 percent of the variance attributable to differences among residents, and facility factors explained 49 percent of the variance attributable to differences among NFs. However, the different variables explained only 10 percent of the variance in self-reported QOL. IMPLICATIONS A brief self-report measure of NF resident QOL is consistently associated with measures that can be constructed from extant data sources. However, the level of prediction possible from these data sources does not justify reliance on external indicators of resident QOL for policy purposes.
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Affiliation(s)
- Howard B Degenholtz
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, PA 15213, USA
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Abstract
Publicly reporting information stimulates providers' efforts to improve the quality of health care. The availability of mandated, uniform clinical data in all nursing homes and home health agencies has facilitated the public reporting of comparative quality data. This article reviews the conceptual and technical challenges of applying information about the quality of long-term care providers and the evidence for the impact of information-based quality improvement. Quality "tools" have been used despite questions about the validity of the measures and their use in selecting providers or offering them bonus payments. Although the industry now realizes the importance of quality, research still is needed on how consumers use this information to select providers and monitor their performance and whether these efforts actually improve the outcomes of care.
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Affiliation(s)
- Vincent Mor
- Department of Community Health and Center for Gerontology and Health Care Research, Brown University School of Medicine, Box G-A418, Providence, RI 02192, USA.
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24
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Abstract
PURPOSE We first describe which states have produced nursing home report cards; second, we compare what information is provided in these report cards; third, we identify data sources used to produce the report cards; and, finally, we examine seven factors previously shown to be associated with the usefulness of report-card information and provide several examples from current reporting efforts to illustrate how nursing home report cards could be improved. DESIGN AND METHODS We searched the Web sites for each state agency responsible for elder affairs-nursing homes. For those states identified as having a nursing home report card, we further examined the information presented. RESULTS We identified 19 states as having nursing home report cards (AZ, CO, FL, IL, IN, IO, MD, MA, MS, NV, NJ, NY, OH, PA, RI, TX, UT, VT, and WI). The information presented in these report cards differs quite substantially across states, although the data sources for report cards do not differ substantially. How the information is presented and our evaluation of the usefulness of the information is also highly varied. IMPLICATIONS Providing nursing home report-card information may be important in helping elders and their families choose a nursing facility. With 19 states identified in our research as providing nursing home report-card information on the World Wide Web, we were surprised and encouraged at this number of initiatives. We give some insight into the kinds of information that can be found on these report cards and what steps could be taken to improve how the information is presented.
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Affiliation(s)
- Nicholas G Castle
- University of Pittsburgh, Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA 15261, USA.
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25
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Grabowski DC, Angelelli JJ, Mor V. Medicaid payment and risk-adjusted nursing home quality measures. Health Aff (Millwood) 2004; 23:243-52. [PMID: 15371395 DOI: 10.1377/hlthaff.23.5.243] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Various studies have observed low quality in the nursing home industry. Although Medicaid is the dominant payer of U.S. nursing home services, the association of Medicaid payment rates and quality is not entirely clear, in part because resident-level, risk-adjusted information on quality is lacking. This study examined the relationship between Medicaid payment rates and three risk-adjusted quality measures, controlling for market and facility characteristics. Higher payment was associated with lower incidence of pressure ulcers and physical restraints but not daily pain. Quality of nursing home care may suffer if budget shortfalls force state legislatures to freeze or reduce Medicaid rates.
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