Impact of growing numbers of the very old on Medicaid expenditures for nursing homes: a multi-state, population-based analysis

Nutritional considerations in institutionalized elders

PURPOSE OF REVIEW

The aim of this article is to emphasize the importance of malnutrition in frail institutionalized elderly and discuss recent interventions that have been shown to decrease its prevalence.

RECENT FINDINGS

A Medline search was conducted from 1968 to 2007 under the search terms aging, nutrition, and nursing homes. The most current reviews relevant to the care of institutionalized elders were selected for inclusion in this report. Recent reports have shown that application of screening protocols in long-tem care institutions improved nutritional status. A complete physical assessment, with special attention to the oral cavity, should be conducted. Monitoring of weight and intake should be part of the institutional routine, recognizing that there may be differences between prescribed diet and actual intake. Nutritional interventions should be tried as early as possible, including enhancement of environment and increasing staff to assist with feeding, as malnutrition in this population is associated with falls (particularly with deficient vitamin D) and increased morbidity and mortality. To optimally facilitate nutritional care of nursing home patients reforms are needed to facilitate optimal staffing in the institutional setting.

SUMMARY

It is important to educate healthcare workers in the nursing home about simple interventions that could improve nutritional status.

A comparison of financial performance, organizational characteristics and management strategy among rural and urban nursing facilities

Despite efforts to deinstitutionalize long-term care, it is estimated that 43 percent of the elderly will use a nursing facility at some point. Whether sufficient nursing facility services will be available to rural elderly is debatable due to cutbacks in governmental expenditures and recent financial losses among nursing facilities. This paper explores the challenges confronting rural nursing facilities in maintaining their viability and strategies that might be considered to improve their longevity. A comparative analysis of 18 urban and 34 rural nursing facilities in New Mexico is used in identifying promising strategic adaptations available to rural facilities. Among other considerations, rural facilities should strive to enhance revenue streams, implement strict cost control measures, emphasize broader promotional tactics, and diversify services commensurate with the constraints of the communities and populations served.

Financing long-term care. The growing dilemma

The financing of long-term care is one of the largest and most vexing health care problems facing our society. The problem will be further exacerbated when the rate of growth in the number of persons needing long-term care is further accelerated by the graying of those in the "baby boom" generation. The current financing mechanism, which relies almost entirely on concurrent funding through either a means tested welfare program (Medicaid) or self-pay, is inequitable and inadequate even for our present needs. Despite the magnitude of the problem, only recently has sufficient attention been focused on finding alternatives to the current means of financing long-term care. The search for a solution has been hampered by multiple, and sometimes conflicting, policy and political considerations. After reviewing the demographic and social roots of our current dilemma and listing the major alternatives for financing long-term care, a series of basic principles and definitions are reviewed. These elements are meant to serve as guidelines to compare and evaluate the growing number of proposals which seek to create a more effective and equitable system for financing long-term care. Future articles in this section will detail some of the more promising approaches to the dilemma of financing long-term care.

Informal and formal health care systems for the rural elderly

The preceding sections have been an attempt to touch on a broad spectrum of issues related to the health care of older persons living in the rural United States. This article was intended to be an overview of research issues and, as a consequence, we have been unable to go into great depth in any one area of inquiry; we have certainly not included all of the research questions on areas where present knowledge is incomplete. In broad terms, we suggest that future rural health services research on the elderly be concentrated on the following five major categories of inquiry: --A better understanding of the location and distribution of the elderly in rural America --A better understanding of the life conditions affecting the health of the rural elderly --A better understanding of the health status of the rural elderly --A better understanding of the development, delivery, and impact of health services for the rural elderly, and --A better understanding of the methodological and theoretical difficulties of studying the health and health care of the rural elderly.

A systems view of health care for the poor

A systems view is a synthesis of health policy, medical sociology, public health, and common clinical problems to describe the current crisis in health care for the poor. Medical sociology and public health are particularly relevant to understand the complexity of clinical issues. Although preventive medicine is in desuetude, it is crucial if we are to reduce the future liability of postponed medical care among the poor. Medicaid metamorphosed to Medicare, as half of its outlays are spent on care of the elderly in nursing homes. Health care for the poor will remain a moral challenge to the architects of health policy and the medical profession.

Hospital utilization and expenditures in a Medicaid population

Determinants of hospital utilization and expenditures are analyzed for Medicaid enrollees in the State Medicaid household sample portion of the National Medical Care Utilization and Expenditure Survey who were continuously enrolled throughout 1980. Health status measures were the best predictors of both the probability of hospitalization and total hospitalizations. Children covered by Aid to Families with Dependent Children were the Medicaid enrollees least likely to be hospitalized. Number of hospital days, surgery, and California residence directly increased hospital expenditures. Conditions responsible for hospitalization increased hospital expenditures indirectly by increasing the number of hospital days and the probability of surgery.

Experience of a Medicaid nursing home entry cohort

Long-term care cost-containment policies have focused on reducing the numbers of persons entering nursing homes. To provide insight and background for such efforts, the authors studied the experience of Medicaid nursing home entry cohorts in three individual States. They found substantial interstate variation in rates of nursing home entry and subsequent patterns of discharge, suggesting the operation of fundamentally different policies for provision of Medicaid nursing home services. Analysis of the cost effectiveness and quality of care implications of these policies may provide guidance for future cost-containment efforts.

Nursing home costs for those dually entitled to Medicare and Medicaid

The focus of this article is the impact of nursing home care on total Medicare and Medicaid expenditures for the aged population entitled to both programs. To determine these costs for 1981, data in the Health Care Financing Administration's Medicare Statistical System were linked, for the first time, to data in the Medicaid system for four States. Also examined are expenditure patterns for survivors and decedents using nursing home services. Results indicate that the two most significant factors influencing costs or the dually entitled elderly are the use of nursing home services and the costs of care in the last months of life. An unexpected finding was that of the 73 percent who neither died nor were in a nursing home, per capita expenditures were remarkedly constant across all age groups.