Rurality and nursing home quality: results from a national sample of nursing home admissions

Metro-Nonmetro Differences in Adverse Events in Residential Care Communities: Results From the National Post-Acute and Long-Term Care Study

More than 1 in 5 older Americans live in rural areas (10.6 million of the 46.2 million aged 65 and older). Long-term care for aging rural populations is a growing challenge in the United States. Research on long-term care services in nonmetro areas has focused almost exclusively on nursing home care, despite growth of residential care alternatives. This paper uses unique facility-level data from the 2020 National Post-acute and Long-term Care Study (NPALS) to examine the relationship of residential care community (RCC) features in metro and nonmetro settings with adverse outcomes (emergency department visits, overnight hospital stays, and falls). Nationally, in 2020, about 13.5% of RCC residents made visits to the emergency department, 8.6% had overnight hospital stays, and 21.3% had falls. Controlling for facility characteristics, RCCs in metro areas had higher risks of overnight hospital stays (p < .001) but lower risks of falls (p = .06).

Decomposing Differences in Risk-Adjusted Rates of Emergency Department Visits Between Micropolitan and Urban Nursing Homes

OBJECTIVES

Nursing homes (NHs) in micropolitan areas are reported to have different facility and market factors than urban NHs, but how these factors contribute to differences in emergency department (ED) visits remains unknown. This study examined and quantified sources of micropolitan-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED (PAED) visits of long-stay residents.

DESIGN

The 2011-2013 national Medicare claims and NH Minimum Data Set (MDS) 3.0 were analyzed. We implemented generalized estimating equation models to examine micropolitan-urban differences in ED rates and Blinder-Oaxaca decompositions to quantify the contributions of NH and market factors.

SETTING AND PARTICIPANTS

The study cohort included 12,883 unique privately owned, freestanding NHs from urban and micropolitan areas.

MEASURES

Quarterly risk-adjusted rates of any ED visits, outpatient ED visits, and PAED visits were calculated from Medicare claims and MDS. NH and market characteristics were extracted from the Certification And Survey Provider Enhanced Reporting and Area Health Resources File.

RESULTS

Over the study period, risk-adjusted rates averaged 10.2%, 3.4%, and 3.3% for any ED, outpatient ED, and PAED visits, respectively. Compared with urban NHs, micropolitan NHs reported similar rates of any ED, but significantly higher rates of outpatient ED and PAED (β = 0.20% and 0.27%; both P < .05). Observable differences in NH characteristics (eg, number of beds, percentage Medicare or Medicaid residents, and employment of nurse practitioners and physician assistants) explained more than 20% of the micropolitan-urban differences in rates of outpatient ED and PAED visits; market factors (mainly Medicare Advantage penetration) explained about 46% of the differences in rates of outpatient ED visits.

CONCLUSIONS AND IMPLICATIONS

Compared with urban NHs, micropolitan NHs tend to utilize more avoidable emergency care that can be partially explained by facility size, payer mix, use of nurse practitioners and physician assistants, and market structure.

Differences in Care Provided in Urban and Rural Nursing Homes in the United States: Literature Review

Despite evidence acknowledging disadvantages in care provided to older adults in rural nursing homes (NHs) in the United States, since 2010, no literature review has focused on differences in care provided in urban versus rural NHs. In the current study, we examined these differences by searching U.S. English-language peer-reviewed articles published after 2010 on differences in care quality in urban and rural NHs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used the Newcastle-Ottawa Scale for quality appraisal. We conducted full-text abstraction of 56 (of 286) articles, identifying 10 relevant studies. Metric specification of urban/rural location varied, and care quality measures were wide-ranging, making it difficult to interpret evidence. Limited evidence supported that rural NHs, compared to urban NHs, provided sparse mental health support and limited access to hospice care after controlling for facility and resident characteristics. Our review highlights the need for more research examining differences in quality of care between urban and rural NHs and raises several issues in current research examining urban/rural NH differences where future work is needed. [Journal of Gerontological Nursing, 47(12), 48-56.].

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

BACKGROUND AND OBJECTIVES

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

DISCUSSION AND IMPLICATIONS

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

Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis

BACKGROUND

Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents.

OBJECTIVES

To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents.

RESEARCH DESIGN

We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors.

SUBJECTS

Privately owned, free-standing NHs in the United States (N=13,260).

RESULTS

Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (β=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED.

CONCLUSIONS

Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.

Nursing Home and Market Factors and Risk-Adjusted Hospitalization Rates Among Urban, Micropolitan, and Rural Nursing Homes

OBJECTIVES

Hospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3).

DESIGN

The longitudinal associations of NH and market factors and hospitalization rates were modeled separately on urban, micropolitan, and rural NHs using generalized estimating equation models and a fully interacted model of all NH and market characteristics with micropolitan and rural indicators to test significance of differences compared with urban NHs.

SETTING AND PARTICIPANTS

In total, 14,600 unique NHs.

MEASURES

Risk-adjusted hospitalization rates were calculated from 2011 to 2013 national Medicare claims and NH Minimum Data Set 3.0. Rurality was defined based on the 2010 Rural Urban Commuting Area codes. NH and market characteristics were extracted from Certification and Survey Provider Enhanced Reporting and Area Health Resources File.

RESULTS

Over the study period, risk-adjusted hospitalization rates averaged 9.8% (standard deviation = 8.2%). No difference was found in the overall hospitalization rates of long-stay NH residents among urban, micropolitan, and rural NHs. Generalized estimating equation models show that urban NHs with higher percentages of Medicare and Medicaid residents and any nurse practitioner/physician assistant were associated with lower rates, but these associations were insignificant in rural settings. Higher registered nurse to total nurses ratio was only associated with lower hospitalization rates in urban settings. Higher median household income was associated with lower hospitalization rates in micropolitan and rural NHs.

CONCLUSIONS/IMPLICATIONS

Rurality is not associated with hospitalization rates of long-stay residents, but NH and market factors (eg, payer distribution, staffing, and population income) may affect hospitalization differently in micropolitan/rural NHs than urban NHs. Future intervention on hospitalization should target factors unique to micropolitan/rural NHs which adopt strategies appropriate to their setting.

Use of post-acute care after hospital discharge in urban and rural hospitals

OBJECTIVES

Geographic variation in the use of post-acute care (PAC - skilled nursing facility and home health care) after hospital discharge is substantial, but reasons for this remain largely unexplored. PAC use in urban hospitals compared to rural hospitals may be one key contributor. We aimed to describe PAC use, explore substitution of one type of PAC for another, and identify how PAC use varies by diagnosis in urban and rural settings.

STUDY DESIGN

Secondary analysis of the 2012 National Inpatient Sample including adult discharges to PAC after a hospitalization.

METHODS

We adjusted for differences in patient demographics, comorbidities, hospital care provided, and hospital information, comparing use of PAC in urban and rural settings in multivariable logistic regression.

RESULTS

Rural patients discharged from rural hospitals constituted 188,137 (12.1%) of the 1.56 million discharges in the sample. Rural discharges received less home health care (0.85; 0.80-0.90) than urban discharges, resulting in less rural PAC use overall (0.95; 0.91-0.99). Rural discharges received more overall PAC for stroke (OR 1.11; 95% CI 1.03-1.19) and less PAC for sepsis (0.92; 0.86-0.98), hip fracture (0.82; 0.70-0.96), and elective joint arthroplasty, where rural discharges had 41% lower odds of receiving PAC (0.59; 0.49-0.71).

CONCLUSIONS

The striking differences in receipt of post-acute care in urban and rural patients may constitute a disparity. Evaluation of costs and outcomes of PAC use in these settings is urgently needed as Medicare expands bundled payments for this care.

Variation in Emergency Department Transfer Rates from Nursing Homes in Ontario, Canada

BACKGROUND

Nursing home (NH) residents are frequently transferred to the emergency department (ED) but there is little data on inter-facility variation, which has implications for intervention planning and implementation.

OBJECTIVES

To describe variation in ED transfer rates (TRs) across NHs and the association with NH characteristics.

DESIGN/SETTING

Retrospective cohort study using linked administrative data from Ontario.

PARTICIPANTS

71,780 residents of 604 NHs in 2010 and followed for one year.

MEASUREMENTS

Funnel plots were used to identify high transfer NHs and logistic regression to test the association with NH location, size, ownership and historical ED transfer rate.

RESULTS

One-year ED transfer rates ranged from 4.3% to 58.6% (mean 28.4%); 115 (19%) NHs were considered high. Being within five minutes of an ED, larger size and high historical ED transfer rate were associated with being a high ED transfer home.

CONCLUSION

There was substantial variation across NHs. Consideration of characteristics such as proximity to an ED may be important in the development and targeting of different interventions for NHs.

Urban and rural differences in end-of-life pain and treatment status on admission to a nursing facility

Individuals receiving end-of-life (EOL) care may have needs that are unrecognized or treated inappropriately. Yet, very little is known about differences in pain and special-care needs of EOL patients admitted to rural nursing facilities compared with urban nursing facilities, and whether the differing payer mix in urban and rural facilities affects the treatment ordered on admission. We examine a nationally representative sample of 6,084 EOL patients upon admission to nursing homes to examine differences in diseases, pain assessments, and treatment orders. We found that rural EOL residents have higher rates of congestive heart failure, cancer, renal failure, and emphysema than urban EOL residents and are significantly more likely to report frequent pain, however, they are less likely to receive treatments such as IV medications, dialysis, and wound care.

Pioneering a Nursing Home Quality Improvement Learning Collaborative: A Case Study of Method and Lessons Learned

OBJECTIVES

To describe the development of a nursing home (NH) quality improvement learning collaborative (QILC) that provides Lean Six Sigma (LSS) training and infrastructure support for quality assurance performance improvement change efforts.

DESIGN

Case report.

SETTING/PARTICIPANTS

Twenty-seven NHs located in the Greater Rochester, NY area.

INTERVENTION

The learning collaborative approach in which interprofessional teams from different NHs work together to improve common clinical and organizational processes by sharing experiences and evidence-based practices to achieve measurable changes in resident outcomes and system efficiencies.

MEASUREMENTS

NH participation, curriculum design, LSS projects.

RESULTS

Over 6 years, 27 NHs from urban and rural settings joined the QILC as organizational members and sponsored 47 interprofessional teams to learn LSS techniques and tools, and to implement quality improvement projects.

CONCLUSIONS

NHs, in both urban and rural settings, can benefit from participation in QILCs and are able to learn and apply LSS tools in their team-based quality improvement efforts.

The urban-rural disparity in nursing home quality indicators: the case of facility-acquired contractures

OBJECTIVE

To identify and quantify the sources of the urban-rural disparity in facility-acquired contracture rates in nursing homes.

DATA SOURCES

Survey inspection data of U.S. nursing homes from 1999 to 2008 and standardized national rural definition file from the Rural-Urban Commuting Area Codes.

STUDY DESIGN

We estimated regressions of facility-level contracture rate as a function of urban-rural categories (urban, micropolitan, small rural town, and isolated small rural town) and other related facility characteristics to identify size of the urban-rural disparity. We used Blinder-Oaxaca decomposition techniques to determine the extent to which the disparity is attributable to the differences in facility and aggregate resident characteristics.

PRINCIPAL FINDINGS

Rural nursing homes have higher contracture rates than urban nursing homes. About half of the urban-rural disparity is explained by differences in observable characteristics among urban and rural nursing homes. Differences in staffing levels explain less than 5 percent of the disparity, case-mix explains 6-8 percent, and structure and operational characteristics account for 10-22 percent of the disparity.

CONCLUSION

While a lower level and quality of staffing are a concern for rural nursing homes, facility structure and funding sources explain a larger proportion of the urban-rural disparity in the quality of care.

Rural-urban differences in end-of-life nursing home care: facility and environmental factors

PURPOSE OF THE STUDY

This study examines urban-rural differences in end-of-life (EOL) quality of care provided to nursing home (NH) residents.

DATA AND METHODS

We constructed 3 risk-adjusted EOL quality measures (QMs) for long-term decedent residents: in-hospital death, hospice referral before death, and presence of severe pain. We used CY2005-2007 100% Minimum Data Set, Medicare beneficiary file, and inpatient and hospice claims. Logistic regression models were estimated to predict the probability of each outcome conditional on decedents' risk factors. For each facility, QMs were calculated as the difference between the actual and the expected risk-adjusted outcome rates. We fit multivariate linear regression models, with fixed state effects, for each QM to assess the association with urban-rural location.

RESULTS

We found urban-rural differences for in-hospital death and hospice QMs, but not for pain. Compared with NHs located in urban areas, facilities in smaller towns and in isolated rural areas have significantly (p < .001) worse EOL quality for in-hospital death and hospice use. Whereas the differences in these QMs are statistically significant between facilities located in large versus small towns, they are not statistically significant between facilities located in small towns and isolated rural areas.

IMPLICATIONS

This study provides empirical evidence for urban-rural differences in EOL quality of care using a national sample of NHs. Identifying differences is a necessary first step toward improving care for dying NH residents and for bridging the urban-rural gap.

Rurality and nursing home quality: evidence from the 2004 National Nursing Home Survey

PURPOSE OF THE STUDY

To evaluate the impact of rural geographic location on nursing home quality of care in the United States.

DESIGN AND METHODS

The study used cross-sectional observational design. We obtained resident- and facility-level data from 12,507 residents in 1,174 nursing homes from the 2004 National Nursing Home Survey. We used multilevel regression models to predict risk-adjusted rates of hospitalization, influenza and pneumococcal vaccination, and moderate to severe pain while controlling for resident and facility characteristics.

RESULTS

Adjusting for covariates, residents in rural facilities were more likely to experience hospitalization (odds ratio [OR] = 1.50, 95% confidence interval [CI] = 1.16-1.94) and moderate to severe pain (OR = 1.68, 95% CI = 1.35-2.09). Significant facility-level predictors of higher quality included higher percentage of Medicaid beneficiaries, accreditation status, and special care programs. Medicare payment findings were mixed. Significant resident-level predictors included dementia diagnosis and being a "long-stay" resident.

IMPLICATIONS

Rural residents were more likely to reside in facilities without accreditations or special care programs, factors that increased their odds of receiving poorer quality of care. Policy efforts to enhance Medicare payment approaches as well as increase rural facilities' accreditation status and provision of special care programs will likely reduce quality of care disparities in facilities.

MDS-based state Medicaid reimbursement and the ADL-decline quality indicator

PURPOSE

We examined the relationship between the quality indicator for decline in activities of daily living (ADL) and the use of the Minimum Data Set (MDS) for determining Medicaid skilled nursing facility reimbursement.

DESIGN AND METHODS

We conducted a cross-sectional analysis using the 2004 National MDS Facility Quality Indicator reports as the dependent variable in a multilevel regression model. Our primary explanatory variable was a state-level binary variable distinguishing whether or not the state used an MDS-based Medicaid-reimbursement system in 2004. We obtained control variables through the Online Survey, Certification, and Reporting System.

RESULTS

Skilled nursing facilities located in states that used the MDS for Medicaid reimbursement reported more ADL decline than did facilities in states that did not use the MDS for reimbursement.

IMPLICATIONS

The finding suggests that the ADL-decline quality indicator captures more than just quality, including state-level policy differences. Therefore, the ADL-decline quality indicator should be investigated and refined prior to being relied on for pay-for-performance initiatives.

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.

Differences in Resident Characteristics and Prevalence of Urinary Incontinence in Nursing Homes in the Southeastern United States

BACKGROUND

Relatively little is known about differences in the prevalence of urinary incontinence (UI) by race and region in the United States.

OBJECTIVES

To use the 1999-2002 Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS), Atlanta Region, to investigate the prevalence of UI among African American and Caucasian residents of nursing homes (NH) in the southeastern United States.

METHODS

A repeated-measures, two time-period design was employed. Data for 95,911 residents in 7,640 NH were extracted using the study's inclusion and exclusion criteria. Residents' admission and annual assessment records were accessed; UI presence and relevant indicators were captured; and admission and postadmission UI prevalence rates were determined by region, state, race, and gender. Logistic regression, adjusting for residents' demographics, morbidity status, bed mobility, and cognitive and functional statuses, was conducted also.

RESULTS

The majority of residents were Caucasian (82.4%) and women (76.5%) with mean (+/-SD) age of 82.7 +/- 7.58 years. Regional UI prevalence was 65.4% at admission and 74.3% postadmission. Postadmission, 73.5% of Caucasian and 78.1% of African Americans were incontinent. Similarly, 72.2% of men and 75% of women were incontinent. For African Americans postadmission, adjusted odds of UI were OR = 1.07 (95% CI: 1.01, 1.14).

DISCUSSION

Prevalence of UI was high in this region and the odds of UI was significantly higher among African Americans in two of eight states, suggesting racial disparity in this condition in these states. Factors contributing to this disparity should be explored to increase quality care to vulnerable populations.

Measuring health status and decline in at-risk seniors residing in the community using the Health Utilities Index Mark 2

PURPOSE

The purpose of this study was to assess the responsiveness of one measure of HRQL, the HUI Mark 2 (HUI2), to changes in health status over time in an older community-based population.

METHODS

The sample consisted of 192 individuals age 65 and over residing in their homes and receiving health and support services in Calgary, Canada. Subjects received three assessments at 6-month intervals using the HUI2, to measure health-related quality of life (HRQL), and the Minimum Data Set for Home Care (MDS-HC) for demographic and health status information. Change scores were calculated as the difference between scores at the second and third assessments. The relationship between the HUI2 and other measures of health status were examined using t-tests and ANOVA. Associations between the magnitude of decline in HUI2 and declines on other measures were examined using multiple linear regression.

RESULTS

Lower HUI2 scores were significantly associated with the presence of depressive symptoms, impairment in activities of daily living (ADL), and clinical instability at baseline. Over 6 months of follow-up, HUI2 decline was associated with worsening depressive symptoms, increase in the number of chronic conditions, and age 85 and over.

CONCLUSION

The HUI2 measure of HRQL in older persons at risk for institutionalization appears to reflect health status at a point in time and to be responsive to changes in health status over time.

The quality of care in Norwegian nursing homes

BACKGROUND

Promoting the quality of life is an importing aim of the long-term care for the elderly, and the quality of life is related to quality of care (QoC). This way the QoC in nursing homes, and its correlates, is an interesting subject.

AIM

To describe to what degree Norwegian nursing homes provide services in line with the core areas of the 'regulation of care' and whether patient or ward characteristics are associated with the QoC.

METHODS AND MATERIAL

Cross-sectional study where data were collected in structured interview of the nursing staff in 251 wards regarding 1926 patients.

RESULTS

Most of the patients receive good basic care in Norwegian nursing homes, but taking part in leisure activities and having the opportunity to go out for a walk are more often neglected. Acceptable QoC had a strongly negative association with patient characteristics such as low function in mental capacity, low function in activities of daily living and aggressive behaviour. In most of the measured areas of QoC, ward characteristics, such as type of ward, size of ward and staffing ratio, do have an influence on QoC.

Differences Between Newly Admitted Nursing Home Residents in Rural and Nonrural Areas in a National Sample

PURPOSE

Previous research in specific locales indicates that individuals admitted to rural nursing homes have lower care needs than individuals admitted to nursing homes in urban areas, and that rural nursing homes differ in their mix of short-stay and chronic-care residents. This research investigates whether differences in acuity are a function of differences in resident payer status and occur for both individuals admitted for short stays, with Medicare as payer, and those needing chronic care.

DESIGN AND METHODS

We used a representative 10% sample of national resident assessments (Minimum Data Set) for calendar year 2000 (N = 197,589). We conducted statistical analyses (means, percentages, and logistic regression) to investigate differences in Medicare and non-Medicare admissions to facilities in metropolitan and nonmetropolitan areas.

RESULTS

Non-Medicare residents admitted to rural nursing facilities have lower acuity scores than non-Medicare residents admitted to metropolitan nursing homes. However, individuals admitted under Medicare were similar in rural and urban areas.

IMPLICATIONS

Differences in resident acuity at admission among facilities in different locales were largely a function of lower acuity levels for individuals admitted to rural nursing homes for long-term or chronic care, although differences in Medicare census also played some role in facility-level differences in acuity. Other factors must be explored to determine why this lower acuity occurs and whether higher use of rural nursing homes by less impaired older persons meets their needs and preferences and represents good public policy.