Trends in State Certificate of Need and Moratoria Programs for Long-Term Care Providers

Assessment of changes in place of death of older adults who died from dementia in the United States, 2000-2014: a time-series cross-sectional analysis

BACKGROUND

As the mortality attributable to dementia-related diseases in the United States escalates, providing quality and equitable end-of-life care for dementia patients across care settings has become a major public health challenge. Previous research suggests that place of death may be an indicator of quality of end-of-life care. This study aims to examine the geographical variations and temporal trends in place of death of dementia decedents in the US and the relationships between place of death of dementia decedents and broad structural determinants.

METHODS

Using nationwide death certificates between 2000 and 2014, we described the changes in place of death of dementia decedents across states and over time. Chi-square test for trend in proportions was used to test significant linear trend in the proportion of dementia decedents at difference places. State fixed effects models were estimated to assess the relationships between the proportion of dementia decedents at difference places and state-level factors, particularly availability of care facility resources and public health insurance expenditures.

RESULTS

Dementia decedents were more likely to die at home and other places and less likely to die at institutional settings over the study period. There was wide inter-state and temporal variability in the proportions of deaths at different places. Among state-level factors, availability of nursing home beds was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on institutional long term supports and services was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on home and community based services, however, had a positive association with rates of home deaths.

CONCLUSIONS

There was a persistent shift in the place of death of dementia decedents from institutions to homes and communities. Increased investments in home and community based health services may help dementia patients to die at their homes. As home becomes an increasingly common place of death of dementia patients, it is critical to monitor the quality of end-of-life care at this setting.

Stability and changes in living arrangements: relationship to nursing home admission and timing of placement

OBJECTIVES

To examine whether stability of living arrangements and changes in household composition-both types and frequency-influence nursing home placement or timing to entry among older people.

METHODS

Data from the first 5 waves of the Assets and Health Dynamics of the Elderly (1993-2002) on 8,093 persons aged 70 years or older at baseline are used in probit and hazard models to predict nursing home entry and time to entry.

RESULTS

Stable living arrangements carry different risks of institutionalization. Those living continuously alone or with others were at highest risk; at lowest risk were those living continuously with a spouse or the same child (lowest overall). Changes in household composition were protective against nursing home entry and slowed time to entry; types of change were not influential when number of changes was taken into account.

DISCUSSION

Results suggest that stability of living arrangements in and of itself is not protective against institutionalization. Having options that allow one to change living arrangements over time in response to changing needs for assistance is of importance if the goal is to avoid institutional care or extend community residence prior to entry.

Operating environment and USA nursing homes' participation in the subacute care market: a longitudinal analysis

We examined the impact of environmental factors on USA nursing homes' participation in the subacute care market. Findings suggest that the Balanced Budget Act of 1997 did not have a significant impact in the participation of nursing homes in the subacute care market from 1998 to 2000. However, there was a declining trend in the participation of nursing homes in the subacute care market after the implementation of Medicare prospective payment system (PPS). Furthermore, nursing homes with a higher proportion of Medicare residents were more likely to exit the subacute care market after PPS. Results also suggest that nursing homes have responded strategically to the environmental demand for subacute care services. Nursing homes located in markets with higher Medicare managed care penetration were more likely to offer subacute care services. Environmental munificence was also an important predictor of nursing home innovation into subacute care. Nursing homes in states with higher Medicaid reimbursement and those in less competitive markets were more likely to participate in the subacute care market.

Medicaid 1915(c) Waiver Use and Expenditures for Persons Living With HIV/AIDS

States' use of Medicaid 1915(c) waiver services for persons living with HIV/AIDS (PLWHA) has been limited. The authors examine state-level factors related to the decision to offer waiver services, as well as waiver use and expenditures in states offering waivers for PLWHA. They use fixed effects cross-sectional time series models to explore these state factors. States with Democratic governors were more likely to offer waiver services and were found to have higher rates of use and greater expenditures and to devote a larger share of long-term care dollars to waiver services for PLWHA. State supply of both institutional and residential care beds was negatively related to use and expenditures. Medicaid community-based care has been found to be related to improved outcomes and reduced costs of care. Ways to foster 1915(c) waiver expansion are important so as to increase access to care for PLWHA.

State strategies to support community based long term care for the elderly

States play a principal role in designing and implementing publicly funded long term care programs. They are in a key position to determine what setting, from whom, and under what philosophy of care individuals can access long term care. State long term care systems have evolved over the past 25 years to support increased availability of community based care for older individuals. States have pursued three broad strategies to increase availability. One set of strategies aims to increase capacity through expanding the supply, public funding and eligibility for a wide array of home and community based services (HCBS). A second set of strategies seeks to constrain institutional growth in order to increase the dollars available for HCBS. Managed/capitated long term care is a third strategy that is a hybrid of the other two approaches. Empirically, increased capacity through use of Medicaid and Medicare resources and growth in the supply of community based care providers, combined with moderation of institutional bed supply, are associated with enhanced access and expenditures for community based long term care. The effectiveness of capitated or managed systems of care varies by model and in some cases is still under study. State fiscal resources are key to the ability to support community based care for the elderly. Targeted federal support may be critical to the continued expansion of community based care, given heterogeneity in state resources, coupled with an increasing demand for long term care.

Health planning in the United States and the decline of public-interest policymaking

In the 1960s and 1970s, health planning formed a major theme of American health policy. Planners aimed to improve health services and make them broadly available while using resources efficiently. This article provides a history, both intellectual and political, of the origins of planning, its rise, and--in the face of mounting problems--its decline. The story also illustrates broader changes in the culture of policymaking in American health care. From the Progressive Era through the 1960s, reform-minded experts in health worked to advance the public interest. Thereafter, they increasingly left behind public-interest ideals and their underlying extramarket values in favor of organizing and improving health care markets. Whatever the deficiencies of traditional policymaking may be, this study suggests the need to resurrect extramarket values in health policy.

Variation by Disability in State Predictors of Medicaid 1915c Waiver Use and Expenditures

PURPOSE

States are increasingly using the Medicaid 1915c waiver program to provide community-based long-term care. A substantially greater share of long-term-care dollars supports community-based care for individuals with intellectual and developmental disabilities, relative to older and working-age persons with primarily physical disabilities.

DESIGN AND METHODS

We used state-level data for the period from 1992 to 2001 to estimate fixed-effects panel models. We compared state predictors of waiver utilization and expenditures for waivers serving both older and working-age individuals (O/WAIs) relative to waivers serving individuals with intellectual and developmental disabilities (IDDs).

RESULTS

We found community-based-care capacity to predict use and expenditures for both target groups. Although regulation of institutional supply was positively related to expenditure measures for IDDs, it was not related to use or expenditures for O/WAIs. Demand variables (e.g., the size of a state's African American population) predicted use and expenditures for IDD waivers, but they were less consistent for O/WAI waivers. State resources were a robust predictor of use and expenditures for both groups.

IMPLICATIONS

Increased community-based-care capacity appears to be an important factor in efforts to expand the availability of Medicaid community-based care. Federal policies that address state resource issues may also spur growth in community-based long-term care.

Ranking the 'balance' of state long-term care systems: a comparative exposition of the SMARTER and CaRBS Techniques

The use of attribute sets to rank units of health provision (e.g., states, organizations) against policy goals is an essential task within decision-making and analysis. This paper elucidates and compares two techniques, SMARTER (Simple Multiattribute Rating Technique Exploiting Ranks) and CaRBS (Classification and Ranking Belief Simplex), within an expositional ranking of US states' long-term care (LTC) systems against the policy goal of providing a balance between (traditionally dominant) institutional care, and alternative home and community-based services (HCBS). While the (more established) SMARTER technique is used primarily for comparative purposes, greater emphasis is placed on elucidating CaRBS which is based on the Dempster-Shafer theory of evidence. It is shown that CaRBS offers four appealing features for health policy analysis: (1) the capacity to rank using either of two confidence measures (DST-related belief and plausibility values), (2) a systematic approach to managing missing data, (3) the production of stable rankings, and (4) the simplex plot method of data representation. In addition to discussing the LTC policy implications of the study findings, the issues of rank order stability and the management of missing data are discussed with respect to the two techniques employed.