Rural-Urban Differences in Mortality among Mechanically Ventilated Patients in Intensive and Intermediate Care

Rationale: Intermediate care (also termed "step-down" or "moderate care") has been proposed as a lower cost alternative to care for patients who may not clearly benefit from intensive care unit admission. Intermediate care units may be appealing to hospitals in financial crisis, including those in rural areas. Outcomes of patients receiving intermediate care are not widely described. Objectives: To examine relationships among rurality, location of care, and mortality for mechanically ventilated patients. Methods: Medicare beneficiaries aged 65 years and older who received invasive mechanical ventilation between 2010 and 2019 were included. Multivariable logistic regression was used to estimate the association between admission to a rural or an urban hospital and 30-day mortality, with separate analyses for patients in general, intermediate, and intensive care. Models were adjusted for age, sex, area deprivation index, primary diagnosis, severity of illness, year, comorbidities, and hospital volume. Results: There were 2,752,492 hospitalizations for patients receiving mechanical ventilation from 2010 to 2019, and 193,745 patients (7.0%) were in rural hospitals. The proportion of patients in rural intermediate care increased from 4.1% in 2010 to 6.3% in 2019. Patient admissions to urban hospitals remained relatively stable. Patients in rural and urban intensive care units had similar adjusted 30-day mortality, at 46.7% (adjusted absolute risk difference -0.1% [95% confidence interval, -0.7% to 0.6%]; P = 0.88). However, adjusted 30-day mortality for patients in rural intermediate care was significantly higher (36.9%) than for patients in urban intermediate care (31.3%) (adjusted absolute risk difference 5.6% [95% confidence interval, 3.7% to 7.6%]; P < 0.001). Conclusions: Hospitalization in rural intermediate care was associated with increased mortality. There is a need to better understand how intermediate care is used across hospitals and to carefully evaluate the types of patients admitted to intermediate care units.

Short-Term Outcomes of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Kidney Transplant Recipients (from the US Nationwide Representative Study)

Kidney transplant recipients (KTRs) are considered high-risk patients for surgical interventions. Transcatheter aortic valve implantation (TAVI) has been introduced as an alternative to surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) at high operative risk. However, the outcomes of TAVI compared with SAVR KTRs have not been well-studied in nationally representative data. Patients with prior history of functioning kidney transplant who were hospitalized for TAVI and SAVR between January 2012 and December 2017 were identified retrospectively in the Nationwide Readmissions Database. Our study included 762 TAVI and 1,278 SAVR KTRs. Compared with SAVR, TAVI patients generally had higher rates of co-morbidities with lower risk of in-hospital mortality (3.1% vs 6.3, p = 0.002), blood transfusion (11.5% vs 38.6%, p <0.001), acute myocardial infarction (3.9% vs 6.5%, p = 0.16), acute kidney injury (24.5% vs 42.1%, p <0.001), sepsis (3.9% vs 9.5%, p <0.001) and discharge with disability (42.6% vs 68.4%, p <0.001). However, the rate of permanent pacemaker implantation was significantly higher in TAVI group (11.4% vs 3.9%, p <0.001). Of note, in-hospital stroke and 30-day readmission were comparable between both groups. These findings were confirmed after adjusting for other co-morbidities. TAVI is growing as a valid and safe alternative for KTRs with severe AS.

In-hospital dementia-related deaths following implementation of the national dementia plan: observational study of national death certificates from 1996 to 2016

OBJECTIVE

To examine changes in places of dementia-related death following implementation of the national dementia plan and other policy initiatives.

DESIGN

Observational study.

SETTING

Japan between October 1996 and September 2016. Four major changes in health and social care systems were identified: (1) the public long-term care insurance programme (April 2000); (2) community centres as a first access point for older residents (April 2006); (3) medical care system for older people (April 2008) and (4) the national dementia plan (April 2013).

PARTICIPANTS

9 60 423 decedents aged 65 years or older whose primary cause of death was Alzheimer's disease, vascular or other types of dementia or senility.

MAIN OUTCOME MEASURES

Place of death which was classified into 'hospital', 'intermediate geriatric care facility' (rehabilitation facility aimed at home discharge), 'nursing home' or 'own home'.

RESULTS

The annual number of deaths at hospital was consistently increased over time from 1996 to 2016 (age-adjusted OR: 6.01; 95% CI 5.81 to 6.21 versus home deaths). Controlling for individual characteristics, regional supply of hospital and nursing home beds and other changes in health and social care systems, death from dementia following the national dementia plan was likely to occur in hospital (adjusted OR: 1.21; 95% CI 1.18 to 1.24), intermediate geriatric care facility (adjusted OR: 1.53; 95% CI 1.48 to 1.58) or nursing home (adjusted OR: 1.64; 95% CI 1.60 to 1.69) rather than at home.

CONCLUSIONS

As the number of deaths from dementia increased over the decades, in-hospital deaths increased regardless of the national dementia plan. Further strategies should be explored to improve the availability of palliative and end-of-life care at patients' places of residence.

Average Cost of VA Rehabilitation, Mental Health, and Long-Term Hospital Stays

This article describes the development of a database for the cost of inpatient rehabilitation, mental health, and long-term care stays in the Department of Veterans Affairs from fiscal year 1998 forward. Using “bedsection,” which is analogous to a hospital ward, the authors categorize inpatient services into nine categories: rehabilitation, blind rehabilitation, spinal cord injury, psychiatry, substance abuse, intermediate medicine, domiciliary, psychosocial residential rehabilitation, and nursing home. For each of the nine categories, they estimated a national and a local (i.e., medical center) average per diem cost. The nursing home average per diem costs were adjusted for case mix using patient assessment information. Encounter-level costs were then calculated by multiplying the aver-age per diem cost by the number of days of stay in the fiscal year. The national cost estimates are more reliable than the local cost estimates.

Rehabilitation Profiles of Older Adult Stroke Survivors Admitted to Intermediate Care Units: A Multi-Centre Study

BACKGROUND

Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units.

METHODS

We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient's classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes).

RESULTS

Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54-8.63 and OR = 3.0, 95%CI = 1.52-5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81-10.75 and OR = 3.45, 95%CI = 1.31-9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65-17.03 and OR = 3.87, 95%CI = 1.69-8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23-0.75) and HCC (OR = 0.37, 95%CI = 0.19-0.73), for LOS lower Vs higher tertiles.

CONCLUSION

Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients.

Appropriate Admissions to the Appropriate Unit: A Decision Tree Approach

An intermediate care decision tree tool was developed to meet the demand for intermediate care beds. Concurrently, a charging process was developed to support the acuity adaptable model of care, allowing the patient to remain in the same bed from admission to discharge, regardless of level of care required, adjusting nurse-to-patient ratios as acuity changes. Since beginning this pilot, 96% to 100% of the patients admitted to intermediate care from the emergency department met the criteria. Wait time from request to admission was reduced from 5.5 hours to 2.5 hours. A reduction in nursing costs was noted. The average number of patients waiting daily in the emergency department for an intermediate care bed has been reduced by approximately 80%. A significant difference in length of stay was not noted.

The influence of an intermediate care hospital on health care utilization among elderly patients--a retrospective comparative cohort study

BACKGROUND

An intermediate care hospital (ICH) was established in a municipality in Central Norway in 2007 to improve the coordination of services and follow-up among elderly and chronically ill patients after hospital discharge. The aim of this study was to compare health care utilization by elderly patients in a municipality with an ICH to that of elderly patients in a municipality without an ICH.

METHODS

This study was a retrospective comparative cohort study of all hospitalized patients aged 60 years or older in two municipalities. The data were collected from the national register of hospital use from 2005 to 2012, and from the local general hospital and two primary health care service providers from 2008 to 2012 (approx. 1,250 patients per follow-up year). The data were analyzed using descriptive statistics and analysis of covariance (ANCOVA).

RESULTS

The length of hospital stay decreased from the time the ICH was introduced and remained between 10% and 22% lower than the length of hospital stay in the comparative municipality for the next five years. No differences in the number of readmissions or admissions during one year follow-up after the index stay at the local general hospital or changes in primary health care utilization were observed. In the year after hospital discharge, the municipality with an ICH offered more hour-based care to elderly patients living at home (estimated mean = 234 [95% CI 215-252] versus 175 [95% CI 154-196] hours per person and year), while the comparative municipality had a higher utilization of long-term stays in nursing homes (estimated mean = 33.3 [95% CI 29.0-37.7] versus 21.9 [95% CI 18.0-25.7] days per person and year).

CONCLUSIONS

This study indicates that the introduction of an ICH rapidly reduces the length of hospital stay without exposing patients to an increased health risk. The ICH appears to operate as an extension of the general hospital, with only a minor impact on the pattern of primary health care utilization.

[Intermediate geriatric care in Geneva: experience of ten years]

Population aging has generated an increased demand for acute healthcare services in persons aged over 65, who may represent up to half of all patients treated in intensive care units (ICU). However, the number of available ICU beds is limited. Intermediate care units (IntCU) require less human and technical resources, and may represent an interesting alternative to intensive care in the geriatric population. This article describes a 10-year, single centre experience at a geriatrics IntCU in Geneva. We observed a significant reduction in in-hospital mortality after the creation of the IntCU (2000-2001) compared to the 2 years immediately preceding its inception (1998-1999).

[Reasons for inappropriate prescribing of antibiotics in a high-complexity pediatric hospital]

OBJECTIVE

Determine the reasons for inappropriate prescription of antibiotics and identify opportunities to improve prescription of these drugs in pediatric patients hospitalized in intermediate and intensive care units.

METHODS

A prospective, descriptive longitudinal study was conducted of pediatric patients in intermediate and intensive care units who received parenteral administration of antibiotics, with the exception of newborns, burn unit patients, and surgical prophylaxis patients. A univariate analysis and multiple logistic regression were performed.

RESULTS

A total of 376 patients with a median of age of 50 months were studied (interquartile range [IQR] 14.5-127 months). Out of the total patients studied, 75% had one or more underlying conditions. A total of 40.6% of these patients had an oncologic pathology and 33.5% had neurological conditions. The remaining 25.9% had other underlying conditions. Antibiotic treatment was inappropriate in 35.6% of the patients studied (N = 134). In 73 (54.4%) of the 134 cases, inappropriate use was due to the type of antibiotic prescribed, the dose administered, or the treatment period. The 61 (45.5%) remaining cases did not require antibiotic treatment. In the multivariate analysis, the risk factors for inappropriate use of antibiotics were: administration of ceftriaxone OR 2 (95% CI, 1.3-3.7; P = 0.02); acute lower respiratory tract infection OR 1.8 (95% CI, 1.1-3.3; P < 0.04); onset of fever of unknown origin in hospital inpatients OR 5.55 (95% CI, 2.5-12; P < 0.0001); and febrile neutropenia OR 0.3 (95% CI, 0.1-0.7; P = 0.009).

CONCLUSIONS

Inappropriate use of antibiotics was less common in the clinical conditions that were well-characterized. Prescribing practices that could be improved were identified through the preparation and circulation of guidelines for antibiotic use in hospital inpatients.

Post-acute care services received by older adults following a cardiac event: a population-based analysis

BACKGROUND

Post-acute care (PAC) is available for older adults who need additional services after hospitalization for acute cardiac events. With the aging population and an increase in the prevalence of cardiac disease, it is important to determine current PAC use for cardiac patients to assist health care workers to meet the needs of older cardiac patients. The purpose of this study was to determine the current PAC use and factors associated with PAC use for older adults following hospitalization for a cardiac event that includes coronary artery bypass graft and valve surgeries, myocardial infarction (MI), percutaneous coronary intervention (PCI), and heart failure (HF).

METHODS AND RESULTS

A cross-sectional design and the 2003 Medicare part A database were used for this study. The sample (n = 1493521) consisted of patients 65 years and older discharged after their first cardiac event. Multinomial logistic regression was used to examine factors associated with PAC use. Overall, PAC use was 55% for cardiac valve surgery, 50% for MI, 45% for HF, 44% for coronary artery bypass graft, and 5% for PCI. Medical patients use more skilled nursing facility care, and surgical patients use more home health care. Only 0.1% to 3.4% of the cardiac patients use intermediate rehabilitation facilities. Compared with those who do not use PAC, those who use home health care and skilled nursing facility care are older and female, have a longer hospital length of stay, and have more comorbidity. Asians, Hispanics, and Native Americans were less likely to use PAC after hospitalization for an MI or HF.

CONCLUSIONS

The current rate of PAC use indicates that almost half of nondisabled Medicare patients discharged from the hospital following a cardiac event use one of these services. Health care professionals can increase PAC use for Asians, Hispanics, and Native Americans by including culturally targeted communication. Optimizing recovery for cardiac patients who use PAC may require focused cardiac rehabilitation strategies.

Factors associated with living in developmental centers in California

This study examined need, predisposing, market, and regional factors that predicted the likelihood of individuals with developmental disabilities living in state developmental centers (DCs) compared with living at home, in community care, or in intermediate care (ICFs) and other facilities. Secondary data analysis using logistic regression models was conducted for all individuals ages 21 years or older who had moderate, severe, or profound intellectual disability. Client needs were the most important factors associated with living arrangements, with those in DCs having more complex needs. Men had higher odds of living in DCs than in other settings, whereas older individuals had lower odds of living in DCs than in ICFs for persons with developmental disabilities and other facilities. Asians/Pacific Islanders, African Americans, and Hispanics were less likely to live in DCs than to live at home. The supply of residential care beds for the elderly reduced the likelihood of living in DCs, and the odds of living in a DC varied widely across regions. Controlling for need, many other factors predicted living arrangements. Policymakers need to ensure adequate resources and provider supply to reduce the need by individuals with intellectual disability to live in DCs and to transition individuals from DCs into other living arrangements.

Costs and health outcomes of intermediate care: results from five UK case study sites

The objectives of this study were to explore the costs and outcomes associated with different types of intermediate care (IC) services, and also to examine the characteristics of patients receiving such services. Five UK case studies of 'whole systems' of IC were used, with data collected on a sample of consecutive IC episodes between January 2003 and January 2004. Statistical differences in costs and outcomes associated with different IC services and patient groups were explored. Factors associated with variation in IC episode outcomes (EuroQol EQ-5D and Barthel Index) were explored using an econometric framework. Data were available for 2253 episodes of IC. In terms of Department of Health criteria, a large proportion of patients (up to 47% of those for whom data were available) in this study were inappropriately admitted to IC services. As regards service function, compared to supported discharge, admission avoidance services were associated with both lower costs and greater health and functional gains. These gains appear to be driven, in part, by illness severity (more dependent patients tended to gain most benefit). In addition, these gains appear to be larger where the admission was appropriate. Our work suggests a need for the development and application of robust and reliable clinical criteria for admission to IC, and close co-operation between hospital and community service providers over selection of patients and targeting of IC and acute care services to meet defined clinical need.

[Intermediate care units. Health care consequences in a reference hospital]

INTRODUCTION

Intermediate Care Units are forms to provide health care services to potentially critical patients that allow for improved cost-benefit ratio of the care offered by Intensive Medicine Departments.

OBJECTIVE

Analyze heart care repercussion that the permanent opening of this type of unit had in a reference teaching center.

DESIGN

Prospective.

PERIOD

From the beginning of 2003 to the end of 2005.

SCOPE

Intensive Medicine Department (IMD), with teaching accreditation, which has 15 conventional ICU beds and 4 intermediate care beds.

PATIENTS AND METHODS

Analysis of demographic data (gender and age, type of patient, and origin or admission), of severity (SAPS 2), prognosis (MPM II 0 and SAPS2) and health care burden (NEMS) in 3,392 consecutive admissions to IMD. Specific analysis of the stay and mortality (intra- and post ICU).

RESULTS

Permanent opening of an intermediate care unit is associated with an increase of patients seen by the IMD and makes it possible to clearly identify two different types of patients according to the site linked to the cause of the admission. The patients seen in the Intermediate Care Unit have a shorter stay, less seriousness, greater survival prognosis and less care burden. However, the initiation of this service does not decrease the interval of total mortality (intra+post- ICU).

CONCLUSION

Initiating an intermediate care unit depending on an IMD increases its health care capacity and that of the center it gives service to without affecting global mortality.

Intermediate care at a community hospital as an alternative to prolonged general hospital care for elderly patients: a randomised controlled trial

Background

Demographic changes together with an increasing demand among older people for hospital beds and other health services make allocation of resources to the most efficient care level a vital issue. The aim of this trial was to study the efficacy of intermediate care at a community hospital compared to standard prolonged care at a general hospital.

Methods

In a randomised controlled trial 142 patients aged 60 or more admitted to a general hospital due to acute illness or exacerbation of a chronic disease 72 (intervention group) were randomised to intermediate care at a community hospital and 70 (general hospital group) to further general hospital care.

Results

In the intervention group 14 patients (19.4%) were readmitted for the same disease compared to 25 patients (35.7%) in the general hospital group (p = 0.03). After 26 weeks 18 (25.0%) patients in the intervention group were independent of community care compared to seven (10.0%) in the general hospital group (p = 0.02). There were an insignificant reduction in the number of deaths and an insignificant increase in the number of days with inward care in the intervention group. The number of patients admitted to long-term nursing homes from the intervention group was insignificantly higher than from the general hospital group.

Conclusion

Intermediate care at a community hospital significantly decreased the number of readmissions for the same disease to general hospital, and a significantly higher number of patients were independent of community care after 26 weeks of follow-up, without any increase in mortality and number of days in institutions.

Critical care medicine use and cost among Medicare beneficiaries 1995-2000: major discrepancies between two United States federal Medicare databases

OBJECTIVE

A comparison of federal Medicare databases to identify critical care medicine (CCM) use, cost discrepancies, and their possible causes.

DESIGN

A 6-yr (1995-2000) retrospective analysis of Medicare hospital and CCM use and cost, comparing the Hospital Cost Report Information System (HCRIS) with Medicare Provider Analysis and Review File (MedPAR) supplemented when necessary by Health Care Information System (HCIS) (identified herein as MedPAR/HCIS).

SETTING

All nonfederal U.S. hospitals.

SUBJECTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data are presented as days (M = million) and costs ($; B = Billion) for both hospitals and CCM. Between 1995 and 2000, the number of hospital days decreased in both databases: HCRIS (-13.2%; 78M to 67.7M) and MedPAR/HCIS (-14.1%; 82.8M to 71.1M). CCM days decreased in HCRIS (-4.6%; 8.3M to 7.9M). In contrast, CCM days increased in MedPAR/HCIS (7.2%; 13.9M to 14.9M). The discrepancy in CCM days between HCRIS and MedPAR/HCIS increased from 40% (5.6M days) in 1995 to 47% (7M days) in 2000. Two CCM billing codes (intensive care unit and coronary care unit "post/intermediate") used in MedPAR/HCIS were responsible for 73% on average per year, over the study period, for this CCM discrepancy. The use of these two codes progressively increased (44%; 3.9M to 5.6M days) by the end of the study. The cumulative 6-yr discrepancy in CCM days between HCRIS and MedPAR/HCIS (37.3M days) had a calculated cost of $92.3B.

CONCLUSIONS

We have identified major, and progressively increasing, discrepancies between two U.S. federal databases tabulating hospital and CCM use and cost for Medicare beneficiaries. Two CCM "post/intermediate" billing codes in MedPAR/HCIS were predominantly responsible for the CCM discrepancy. To accurately assess Medicare CCM use and cost, either HCRIS, or MedPAR/HCIS without the "post/intermediate" codes, should be used.

Managing postacute hospital care: a case for biopsychosocial needs

OBJECTIVE

This study aimed to investigate whether, for an identical diagnosis, patients who were transferred to a postacute care (PAC) facility had a higher biopsychosocial complexity than patients who were discharged home.

METHODS

This prospective study employed group comparison that included 166 patients who were consecutively admitted to an acute care internal medicine ward for acute congestive heart failure, pneumonia or exacerbation of chronic obstructive pulmonary disease, and malaise or fall. Patients were evaluated within their first 48 h of stay. Biomedical, functional, quality of life, and case complexity data were collected. Factors associated with a transfer to the PAC facility were identified through logistic regression modeling.

RESULTS

Fifty-eight patients (34.9%) were transferred. In the multivariate analyses, case complexity score [per point: odds ratio (OR)=1.29; 95% CI=1.18-1.41] and nursing workload (OR=1.06; 95% CI=1.01-1.12) were associated with the transfer. At a cutoff point of > or =33, the case complexity score predicted transfer to the PAC facility with a sensitivity of 79% and a specificity of 84% (positive predictive value=73.0%; negative predictive value=88.4%) and correctly classified 83% of the cases.

CONCLUSIONS

Biomedical characteristics alone did not differentiate patients who were transferred versus those who were discharged home, nor did it predict PAC use. This was also true for specific severity scores of cardiac failure and pneumonia as well as for the comorbidity index. Psychosocial parameters were significantly associated to this process as well as a higher nursing workload.

Networks and governance: the case of intermediate care

The present paper describes a novel approach to the study of services conceptualised as networks. It uses data collected as part of a case study evaluation of intermediate care, a 'joined-up government' policy that was explicitly intended to dissolve the boundaries between health and social care services. The evaluation was undertaken in five localities in England. Routine service use data were collated and standardised for the 12-month period from November 2002 to October 2003. A cohort of 258 service users was recruited during a census month (June 2003), and more detailed data on their personal characteristics and experiences prior to and during their intermediate care episode were collected. Information was obtained for 153 of these people, covering their experience during the 6 months following discharge. A graphical method of depicting individuals' movements between services was devised and a number of measures were used to investigate the network-like features of the data. User outcomes were explored by examining the relationship of characteristics of service users to their location at 6 months after discharge. The results of the analyses show that the five sites were developing service configurations that facilitated transitions between health, social care and other services, and that individual needs were taken into account in the decisions made about which people transferred into which services. While the results cannot be said to show that joined-up government works, they are consistent with the argument that joined-up government goes beyond partnership-type concepts, and in practice, involves the creation of what might be termed integrated service networks.

Short- and long-term outcomes of older patients in intermediate care units

OBJECTIVE

To evaluate short- and long-term outcomes of elderly patients (>or=65 years) treated at an intermediate care unit (IMCU) and to identify outcome predictors.

DESIGN AND SETTING

Prospective observational study in the IMCU of a university teaching hospital.

PARTICIPANTS

We studied 412 patients over 8 months, classified into three groups: under 65years (control group, n=158), 65-80 (n=186), and >80 (n=68).

MEASUREMENTS

At admission: APACHE II, TISS-28 first day, Charlson Index, diagnosis, and prior Barthel Index.

OUTCOME MEASURES

in-hospital mortality, length of stay, discharge destination, and 2-year mortality and readmissions. Data analysis included multivariate logistic regression and receiver operating characteristics area under the curve (ROC AUC).

RESULTS

No statistically significant differences between groups were observed in hospital mortality (14.1%), discharge to a long-term facility (2.7%), or 2-year readmissions (1.2+/-2.1). However, hospital stay was longer in patients aged 65-80years (14 vs.10 days) and 2-year mortality was higher in those 65 or over (34% vs.10.6%). In the overall series in-hospital mortality was predicted by APACHE II, first-day TISS-28, and diagnosis (ROC AUC 0.81), and 2-year mortality by Charlson Index and age (ROC AUC 0.77). In the elderly patients 2-year mortality was predicted by Charlson and Barthel indices (ROC AUC 0.70).

CONCLUSIONS

Illness severity and therapeutic intervention at admission to IMCU were predictors of short-term mortality, whereas the strongest predictor of long-term mortality was comorbidity. Our results suggest that comprehensive assessment of elderly patients at admission to IMCUs may improve outcome prediction.

[Factors that influence home return from health care facilities for the elderly--related to the attitude of family caregivers]

AIM

The number of users of long-term care insurance has been increasing rapidly since it started in 2000. The number of those who want to enter the long-term care insurance facilities has increased. Although the basic philosophy of long-term care insurance is independence support and self-decision, to enter a facility or home return from facilities is likely to be decided by family caregivers, not by the elderly themselves. Moreover, the number of elderly who return home from welfare facilities is decreasing. We investigated the intension of caregivers who are willing to accept the institutionalized elderly at home and analyzed the factors affecting the acceptance of caregivers.

METHODS

Subjects were elderly who were in long-term care insurance facility in June 2004, and their caregivers. The study was conducted between June 2004 and September 2004 in Ibaraki Prefecture in Japan. A face-to-face interview based on a questionnaire was conducted for the institutionalized elderly and by the mail for the caregivers.

RESULTS

The caregivers of 34.6% of the elderly who hoped to return home intended to accept them home. There were differences between the plans of the elderly and caregivers. The risk factors (OR, 95% CI) to make the intention of the caregivers to accept the institutionalized elderly home difficult were level of cooperation with other family members to take care of elderly (OR 15.37, 2.05-115.24), dementia behavior disturbance category with more than one (OR 8.34, 1.02-68.05), time spending in bed of a day (OR 1.31, 1.01-1.71), few knowledge of long-term care insurance system of caregivers (OR 3.65,0.81-16.38).

CONCLUSION

It has been suggested that more physical activities in the facility, establishment of a care-system for the demented elderly living in the community and an educational campaign by the long-term care insurance system are necessary to increase the willingness of caregivers to accept home return of institutionalized elderly.

Buying Time I: a prospective, controlled trial of a joint health/social care residential rehabilitation unit for older people on discharge from hospital

The study's objective was to determine the effectiveness of a joint NHS/Social Services rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital, compared with 'usual' community services. This was a controlled clinical trial in a practice setting. The intervention was 6 weeks in a rehabilitation unit where individuals worked with care/rehabilitation assistants and occupational therapists to regain independence. Controls went home with the health/social care services they would ordinarily receive. Participants were from two matched geographical areas in Devon: one with a rehabilitation unit, one without. Recruitment was from January 1999 to October 2001 in 10 community hospitals. Study eligibility was assessed using the unit's inclusion/exclusion criteria: 55 years or older and 'likely to benefit from a short-term rehabilitation programme' ('potential to improve', 'realistic and achievable goals' and 'motivation to participate'). Ninety-four people were recruited to the intervention and 112 to the control. The mean (standard deviation) age was 81.8 (8.0) years. The main outcome measure was prevention of institutionalisation assessed by the number of days from baseline interview to admission to residential/nursing care or death ('survival-at-home time'). Secondary outcome measures were time to hospital re-admission over 12 months, quality of life and coping ability. There were no significant differences between the groups on any outcome measure. Adjusted hazard ratio (95% CI) for 'survival-at-home time' was 1.13 (0.70-1.84), and 0.84 (0.53-1.33) for 'time to hospital re-admission'. However, attending the unit was associated with earlier hospital discharge. Median (interquartile range) days in hospital for the intervention graph was 27 (20, 40), and for the control graph was 35 (22, 47) (U = 4234, P = 0.029). These findings suggest a stay in a rehabilitation unit is no more effective than 'usual' care at diverting older people from hospital/long-term care. Alternative service configurations may be as effective, having implications for tailoring services more specifically to individual need and/or user preferences. However, the unit did appear to facilitate earlier discharges from community hospital.

Mapping care pathways for the elderly

PURPOSE

Aims to describe a project carried out within Hampshire Social Services investigating potential care pathways for older people after discharge from hospital and to show the potential of the simulation methodology in such situations.

DESIGN/METHODOLOGY/APPROACH

A discrete-event simulation was used to determine the system capacities and to estimate the likely associated reimbursement costs.

FINDINGS

A prototype simulation model was developed showing the potential value of this approach.

RESEARCH LIMITATIONS/IMPLICATIONS

Restrictions in data access shifted the focus from quantitative service mapping to a more descriptive approach.

PRACTICAL IMPLICATIONS

Currently, many older patients experience delayed discharge from acute beds because of capacity limitations in Social Services' traditional post-acute care services. At the same time, new regulations require Local Authorities to reimburse NHS Acute Trusts if hospital discharge is delayed solely due to inadequate provision of social care assessments and services. In order to overcome the so-called "bed-blocking" problem, a new range of services termed "Intermediate Care" has been introduced to offer alternative options for older patients. These services are examined in terms of capacity and appropriateness.

ORIGINALITY/VALUE

This paper fulfils an identified need to record and evaluate the new post-acute packages introduced by the Social Services and NHS and proposes simulation as one of the most suitable methodologies for such objectives.

Are we on track - can we monitor bed targets in the NHS plan for England?

The NHS plan announced sustained increases in funding accompanied by wide ranging reform, the success of which would be measured by targets set across the board, including increases in numbers of beds, staff, hospitals and equipment. In this article we assess progress towards the target of 7,000 extra beds in hospitals and intermediate care to be achieved by 2004. Summary points are as follows. (1) Although the 2003/2004 target for availability of general and acute NHS beds in England was achieved, the increase did not offset the overall decrease in all categories of beds. Bed availability fell by 2083, from 1,86,290 in 1999/2000 to 1,84,207 in 2003/2004, following a fall of 12,558 from 1996/1997 to 1999/2000. (2) Lack of standardized definitions and data collection systems both within the NHS and for the independent sector, compounded by ambiguity over the funding of extra capacity for the NHS, call into question the accuracy of data collected about intermediate care beds. (3) Systems for collecting data about intermediate care should be made subject to the same code of practice as official NHS statistics in order to monitor future targets and plan for provision of care. (4) Changes in definitions, lack of detail about criteria used in setting targets and lack of data about private sector care, make it impossible to monitor the overall capacity available to the NHS and assess whether bed availability targets have been met.

Factors associated with staff injuries in intermediate care facilities in British Columbia, Canada

BACKGROUND

Large variations in staff injury rates across intermediate care facilities suggest that injuries may be driven by facility-specific work environment factors.

OBJECTIVES

To identify work organization, psychosocial, and biomechanical factors associated with staff injuries in intermediate care facilities, to pinpoint management practices that may contribute to lower staff injuries, and to generate a provisional conceptual framework of work organization characteristics.

METHODS

Four representative intermediate care facilities with high staff injury rates and four facilities with comparable low staff injury rates were selected from Workers' Compensation Board (WCB) databases. Methods included on-site injury data collection and review of associated WCB data, ergonomic study of workloads, a telephone survey of resident care staff, manager-staff interviews, and focus groups. Pearson product-moment correlation coefficients identified associations between variables. Analysis of variance and t tests were used to determine differences between low and high staff injury rate facilities. Content analysis guided the qualitative analysis.

RESULTS

There were no significant differences between low and high staff injury rate facilities in terms of workers' characteristics, residents' characteristics, and per capita public funding. The ergonomic study supported the survey data in demonstrating a relation among low staffing levels, greater muscle loading, and greater risk of injury. As compared with facilities that had high staff injury rates, facilities with low staff injury rates had significantly more favorable staffing levels and supportive work environments. Perceived quality of care was strongly correlated with burnout, health, and satisfaction.

CONCLUSIONS

Safer work environments are promoted by favorable staffing levels, convenient access to mechanical lifts, workers' perceptions of employer fairness, and management practices that support the caregiving role.

Delayed discharge--a solvable problem? The place of intermediate care in mental health care of older people

The National Service Framework for Older People envisages the development of intermediate care for older people. This study examined the possible role of intermediate care beds within mental health trusts. We interviewed senior clinicians in an inner city old age psychiatry service about the 91 current in-patients on the old age psychiatric wards. Sixty-five were classified as acute patients and the remaining 26 were continuing care patients. Structured instruments were used to collect information regarding neuropsychiatric symptoms, activities of daily living and current met and unmet needs. Where discharge was delayed an assessment was made regarding the appropriateness for an intermediate care setting according to the criteria set by the Department of Health guidelines. A total of 30 (46%) patients' discharges were delayed. Of these, 19 (29%) patients met the DOH criteria for intermediate care; 10 (53%) had dementia, five (26%) affective disorder, and four (21%) with schizophrenia. The 11 other delayed discharges were because of lack of availability of finance for placements. The study found that the prompt discharge of older patients from acute psychiatric care was a significant problem and many of those patients may benefit from the therapeutic and rehabilitative process afforded by intermediate care.

Development and evaluation of intermediate care

Intermediate care is being developed as part of the national strategy for older people in England and Wales to prevent their admission to hospital and facilitate early discharge. Evaluation of intermediate care is implicit within current policy directives. This project evaluated the client information across a number of intermediate care schemes within one National Health Service community trust for 3 months and disseminated the results to staff as part of a reflective workshop which also provided an opportunity for additional data collection. Rates of referral and acceptance on intermediate care were high for all the schemes except one, indicating reliable referral and inclusion criteria. Older people were the recipients of intermediate care with nearly half of them having experienced falls. A number of developments were identified by staff covering both current services and long-term strategy for intermediate care and indicating the importance of involving providers in the evaluation and development of services. Fall prevention initiatives and involvement of users and carers in the evaluation and development of intermediate care were also identified.

Bed-blocking. Discharge of the late brigade

Delayed discharges are seen as a litmus test for how the whole health and social care system is working. The problem has been exacerbated by delays in developing intermediate care schemes. There has been less use of the private nursing homes for intermediate care than envisaged a year ago, possibly because of NHS concerns about standards. More support should be given to people with chronic conditions to keep them out of hospital.

A multicenter description of intermediate-care patients: comparison with ICU low-risk monitor patients

STUDY OBJECTIVES

To describe the characteristics and outcomes of patients admitted to intermediate-care areas (ICAs) and to compare them with those of ICU patients who receive monitoring only on day 1 and are at a low risk (i.e., < 10%) for receiving subsequent active life-supporting therapy (i.e., low-risk monitor patients).

DESIGN

Nonrandomized, retrospective, cohort study.

SETTING

Thirteen US teaching hospitals and 19 nonteaching hospitals.

PATIENTS

A consecutive sample of 8,971 patients at 37 ICAs and 5,116 low-risk (i.e., < 10%) monitor patients at 59 ICUs in 32 US hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We recorded demographic and clinical characteristics, resource use, and outcomes for the ICA and ICU low-risk monitor patients. Patient data and outcomes for this study were collected concurrently or retrospectively. ICA and ICU low-risk monitor patients were similar in regard to gender, race, and frequency of comorbitities, but ICA patients were significantly (p < 0.001) older, had fewer physiologic abnormalities (mean acute physiology score, 16.7 vs 19.8, respectively), and were more frequently admitted due to nonoperative diagnoses. The mean length of stay for ICA patients was significantly longer (3.9 days) than for ICU low-risk monitor patients (2.6 days; p < 0.001). The hospital mortality rate was significantly higher for ICA patients (3.1%) compared to ICU low-risk monitor patients (2.3%; p = 0.002).

CONCLUSIONS

The clinical features of ICA patients are similar, but not identical to, those of less severely ill ICU monitor patients. Comparisons of hospital death rates and lengths of stay for these patients should be adjusted for characteristics that previously have been shown to influence these outcomes.

Intermediate care. Halfway home

A pilot scheme involving 30 nursing home places provided intermediate care for 118 elderly people over four months last winter. The average length of stay was 21 days. Two-thirds of patients were discharged to their own home. Patients rated the nursing care highly. Concerns were raised about the availability of therapists.

District nurse-led beds: an alternative to care at home

Intermediate care is a key feature of the Government's plans for the development of the health service. The intermediate care scheme described here offers a district nurse-led bed (DNLB) stay in a community hospital to patients in the community who require short-term nursing help. District nurses are given the opportunity to admit patients from their community caseloads into a DNLB in a community hospital and are responsible for their admission, care and discharge. This article describes the pilot study that monitored the first 30 patients who used the DNLBs. Patients included younger people with multiple sclerosis who were admitted for respite care, but the principal beneficiaries were those aged over 65 years with chronic conditions.

The prediction of mental health service use in residential care

The purpose of this study was to characterize the clinical and psychosocial factors of residents living in psychiatric nursing homes, assess residents' levels of mental health service utilization, and examine the factors that predict the utilization of mental health services. Data were collected from 200 randomly selected residents with schizophrenia living in four intermediate care facilities. Fewer than 60% of residents received mental health services beyond medication and nearly one-half of the residents were readmitted to the hospital in the course of a year. Family contact and involvement in activities were associated with mental health service utilization. Hospital readmission was predicted, not by substance use, but rather by not using substances. There is a growing need among service providers to better identify relevant factors that are important in treatment planning and service delivery. Attention to these issues may impact treatment provision and outcomes for persons with schizophrenia and their families.

Sudden unexpected death in epilepsy in adults with mental retardation

The medical records of residents of a facility for persons with mental retardation from January 1, 1978, through December 31, 1997, were analyzed to identify incidence of sudden unexpected death for groups of 180 individuals with and 125 without comorbid epilepsy. Eighty deaths were identified, with 55 occurring in the epilepsy group and 25 in the nonepilepsy group. The rate of sudden unexpected death was 1.3 deaths per 1,000 patient years in the nonepilepsy group and 3.6 deaths per 1,000 patient years in the epilepsy group. The risk factors for sudden unexpected death in the epilepsy group were nonambulatory status and poorly controlled seizure disorder (increased seizure rate and increased number of antiepileptic drugs).

Characteristics and outcomes of dementia residents in an assisted living facility

BACKGROUND

Assisted living (AL) is the fastest growing segment of residential long-term care in the US. At least half of the estimated 1 million AL residents have dementia or cognitive impairment, with many AL facilities offering specialized dementia services. Little research has been done on the demographics, outcomes, or clinical variables of this population.

METHODS

Participants were a cohort of 144 residents admitted to the AL unit of Copper Ridge, a specialized dementia-care facility. Comparison samples included 737 patients with dementia residing in other locations (home, nursing home, and other assisted living facilities). Selected measures of cognition, behavior, medical health, and function were taken at admission to AL and at 6-month intervals.

RESULTS

When compared with residents of the dementia-specialized AL facility, dementia patients at home were younger, less cognitively impaired, and less likely to exhibit wandering, delusions, or aggression. Residents of a dementia-specialized nursing home had more cognitive impairment, greater medical comorbidity, and were more dependent on caregivers. The 2-year mortality rate in the dementia-specialized AL was 23%, significantly lower than rates reported for nursing homes. Primarily due to increasing care needs, most residents in the specialized AL relocated to a nursing home after a median stay of 10.9 months. Depression, falling, and wandering were significant predictors of the transition.

CONCLUSION

Dementia-specialized AL facilities occupy a unique position in the long-term care continuum that is distinct from home-care and nursing home facilities. This research is the first step toward understanding the significant dementia population residing in assisted living.

Quality of life of persons with severe mental illness living in an intermediate care facility

This study examined resident characteristics, clinical factors, and mental health service utilization associated with quality of life (QOL) for residents living in an Intermediate Care Facility (ICF). This study also utilized published literature to compare the QOL of ICF residents to persons with psychiatric disorders living in other residential settings. Chart review and interviews were used to study 100 randomly selected residents living in an ICF with a chart diagnosis of schizophrenia. Multivariate analyses suggest that higher levels of QOL are associated with reports that psychological problems did not interfere with work and activities and with lower levels of being a danger to others. Also, a comparison of the QOL scores reported by ICF residents to other published mentally ill populations suggests that residents of the ICF report somewhat higher QOL scores than state hospital patients, but lower scores as compared to other community samples. Data provide insight into the types of problems faced by residents of an intermediate care facility. These findings have implications for understanding the importance of mental health service utilization on QOL.

Further support for using the dementia rating scale in the assessment of neuro-cognitive functions of individuals with mental retardation

The utility of the Dementia Rating Scale (DRS) when administered to individuals with mental retardation (MR) was examined. Our sample was comprised of individuals residing in an intermediate care facility in the southeastern United States, included individuals diagnosed with mild, moderate, or severe MR, and consisted of both Caucasians (50%) and individuals of African-American descent (50%). Descriptive statistics for the DRS Total Score and five subtests (e. g., Attention, Initiation/Perseveration, Construction, Conceptualization, and Memory) obtained from our sample of individuals with mild MR compared favorably with previously published values. The group with mild MR performed significantly better than the group with moderate MR on the Total Score and all subtests except Construction, and the group with moderate MR performed significantly better than individuals with severe MR on all measures. These results show that the DRS can provide information about the cognitive strengths and weaknesses of individuals with mental retardation, and they show that the DRS can be administered to a wide range of individuals diagnosed with MR.

Functional improvement of elderly residents of institutions

Studies have shown that some elderly persons who suffer decline in activities of daily living (ADL) functioning experience an improvement. This phenomenon has been examined mainly among elderly persons in the community using summary ADL indices. This article examines functional improvement among 2,527 residents of institutions for semi-independent and frail elders in Israel in four specific ADLs--bathing, eating, bladder continence, and mobility--at two points in time, 2 to 4 years apart. Demographic, functional, and institutional variables were used to predict functional improvement through logistic regression. The variables were found to differentially affect each ADL, highlighting two opposite aspects of institutionalization--deterioration, on the one hand, and rehabilitation through intervention by highly trained staff, on the other.

Clinical characteristics and service use of persons with mental illness living in an intermediate care facility

OBJECTIVE

The study examined the characteristics of residents living in a 450-bed intermediate care facility for persons with severe mental illness in Illinois and sought to determine the factors predicting their utilization of mental health services.

METHODS

Data on 100 randomly selected residents with a chart diagnosis of schizophrenia were collected using chart review and interviews. Data for 78 residents whose diagnosis of schizophrenia or schizoaffective disorder was confirmed using the Structured Clinical Interview for DSM-IV were included in the analyses.

RESULTS

Fifty-three percent of the residents used facility-based specialty mental health services beyond medication management, such as group therapy or a day program. Persons with the least severe psychiatric illnesses and with higher levels of motivation for overall care used the most mental health services. Thirty-five percent of the residents had been discharged to an inpatient psychiatric unit during the previous year. Residents most likely to be discharged to those settings were young men with a history of homelessness who refused facility-based health services.

CONCLUSIONS

Despite recent policy-driven efforts to improve care in this intermediate care facility for persons with mental illness, the facility continues to have problems addressing the mental health needs of the residents.

Simplified acute physiology score II for measuring severity of illness in intermediate care units

OBJECTIVES

To assess the efficacy of the Simplified Acute Physiology Score (SAPS II) in intermediate care units. A number of patients hospitalized in the intensive care unit (ICU) could be hospitalized in alternative structures, intermediate care units, which are equipped to handle their monitoring needs and able to provide adequate treatment at a lower cost. Characterization of the patients relies on the assessment of their severity of illness by severity scores. The efficiency of severity scores has been established in ICU patients, but not in the setting of intermediate care units.

DESIGN

Prospective study.

SETTING

Intermediate care unit of a multidisciplinary hospital.

PATIENTS

Four hundred thirty-three patients admitted to the intermediate care unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 561 consecutive patients admitted to the intermediate care unit during a 12-mo period, 433 patients could be included in the analysis. Patients were admitted from the emergency ward (60.9%). Of the study patients, 60.9% were admitted from the emergency ward for mostly (96%) medical reasons. Average length of stay was 3.1 +/- 2.3 (SD) days. Death rate in the intermediate care unit was 2.7% (n = 11). Average SAPS II was 22.3 +/- 12.0 (range 6 to 73). Hospital death rate was 8.1%, whereas the expected mortality rate derived from SAPS II was 8.7%. To assess the performance of the system, a formal goodness-of-fit test was performed to evaluate calibration. Calibration was accurate using the C coefficient of Hosmer-Lemeshow statistics (C = 2.4; p> 0.5). The discriminant power of SAPS II, measured by the area under the receiver operating characteristic curve was excellent (0.85 +/- 0.04).

CONCLUSIONS

The SAPS II assessment of severity of illness in patients admitted to an intermediate care unit is reliable. These results will need to be confirmed, using different patient samplings from intermediate care units.

How a regression artifact makes ICFs/MR look ineffective

Based on a simple matched-control group quasi-experiment, Conroy (1996) concluded that small ICFs for persons with mental retardation have negative quality-of-life impacts. Our analysis of Conroy's design suggests, in contrast, that the reported effect is a pure regression artifact. The flaw in Conroy's design is selecting a control group on the basis of pretest matching. Although selecting a subsample of controls by matching on static characteristics such as age or gender can reduce the confounding influence of these variables, selection on the basis of pretest scores leads invariably to a large, spurious effect. The literature on this issue dates back a century, with warnings against pretest matching by Galton, Thorndike, McNemar, Stanley, Campbell, Cronbach, and Cook. We reviewed this historical literature and then used a Monte Carlo experiment to estimate the spurious effect that Conroy would observe from pretest matching alone. The magnitude of the artifact is as large as the quality-of-life reduction that Conroy attributed to the effects of living in an ICF. We discussed the methodological logic involved in matching and the broader policy issues raised by this evaluation.

Break the data-bank with Monte Carlo? Statistical problems in the dispute between Conroy (1996) and Crinella, McCleary, and Swanson (1998)

In drawing entirely different conclusions from the same bank of data, Conroy saw consistent evidence favoring the alternative CLAs over the small ICFs in Pennsylvania while Crinella et al. found a large regression artifact produced by matching the ICF and CLA residents on adaptive behavior scores. Ten areas of flawed logic, analysis, and interpretation have undermined both sides of the argument. Conroy's matching--which might not have been necessary in the first place--does not pose a serious threat of regression artifacts. Because of two subtle but fatal errors, the Monte Carlo experiment of Crinella et al. provides no important evidence against Conroy's findings. Other problems, however, require a small reduction in his pro-CLA results, along with a substantial limit on their generalizability.

The role of geriatric intermediate care facilities in long-term care for the elderly in Japan

Geriatric intermediate care facilities (GICFs) were first established in 1987 to help the hospitalized elderly return home within 3 months. Users of the GICFs are the elders who do not require hospitalization, but are mentally or physically impaired. Rather than providing unnecessary medical services, GICFs emphasize nursing care and rehabilitation so that users can carry out their daily tasks independently. Due to the limited supply of institutional and in-home services for the elderly in long-term care systems in Japan, only half of the discharged users were able to return home and a quarter stayed at GICFs for over 1 year, contrary to the initial purpose. This suggests that in addition to serving as an intermediate facility between institutions and private homes, GICFs should enlarge their role of home care supporting facilities in ways that would enable them to provide frail elderly patients at home with respite care and daycare services.

A systematic review of the cost-effectiveness of noncardiac transitional care units

OBJECTIVE

To critically appraise and summarize the studies examining the cost-effectiveness of noncardiac transitional care units (TCUs).

DATA SOURCES

We conducted a computerized literature search using MEDLINE, and Current Contents from January 1, 1986 to December 31, 1995 and HealthSTAR from January 1, 1989 to December 31, 1995 with the key words intermediate care unit, respiratory care unit, and step-down unit. Bibliographies of all selected articles and review articles were examined. Personal files were also reviewed.

STUDY SELECTION

(1) POPULATION: patients in a noncardiac TCU of an acute-care institution; (2) intervention: addition of a noncardiac TCU to the institution; and (3) outcomes: patient outcome-survival and associated costs.

DATA EXTRACTION

The necessary data were abstracted and study validity was evaluated by two independent reviewers using a modification of previously published criteria.

DATA SYNTHESIS

The studies were summarized qualitatively; upon inspection, they were too heterogeneous to allow quantitative analysis. While the studies all claimed that their TCUs were cost-effective, the economic evaluation designs were flawed to such an extent that the validity of the conclusions is suspect.

CONCLUSIONS

To date, the evidence in the literature is insufficient to determine under which circumstances, if any, TCUs are a cost-effective alternative technology to the traditional institution with only ICU and general ward beds.

A resident-based reimbursement system for intermediate care facilities for the mentally retarded

In this article, the authors present a resident-based reimbursement system for intermediate care facilities for the mentally retarded (ICFs-MR), which represent a large and growing proportion of the medicaid budget. The statistical relationship between resident disability level and the expected cost of caring for the individual is estimated, allowing for the prediction of expected resource use across the population of ICF-MR residents. The system incorporates an indirect cost rate, a base direct care rate (constant across all providers), and an individual-specific direct care rate, based on the expected cost of care.

Predictors of nursing home placement and mortality of residents in intermediate care

Assessments of sensorimotor function, cognitive status and health measures were made in 95 intermediate-care (hostel) residents (mean age 82.7 years). The residents were then followed up for 3 years to determine which measures were associated with nursing-home placement and/or death. Information on the outcome of 92 participants was available at the end of the 3-year period. At this time, 53 residents (58%) were still residing at the hostel, seven (8%) had been transferred to nursing homes and 32 residents (35%) had died. Sixteen of the 32 subjects who had died had been transferred to nursing homes. Discriminant function analysis identified tactile sensitivity, ankle dorsiflexion strength, reaction time, sway with eyes open on a compliant (foam rubber) surface and cognitive impairment as the variables that significantly discriminated between subjects who were still in intermediate care and subjects who had been transferred to nursing homes. This procedure correctly classified 88% of subjects into intermediate care or nursing home groups. These variables, with the exception of ankle dorsiflexion strength, were also included in the final discriminant model when predicting mortality, correctly classifying 71% of the subjects. The findings indicate that cognitive impairment and reduced functioning in a number of sensorimotor factors are strongly related to poor outcomes for residents in hostel care.

Strategic groups, performance, and strategic response in the nursing home industry

OBJECTIVE

This study examines the effect of strategic group membership on nursing home performance and strategic behavior.

DATA SOURCES AND STUDY SETTING

Data from the 1987 Medicare and Medicaid Automated Certification Survey were combined with data from the 1987 and 1989 Pennsylvania Long Term Care Facility Questionnaire. The sample consisted of 383 Pennsylvania nursing homes.

STUDY DESIGN

Cluster analysis was used to place the 383 nursing homes into strategic groups on the basis of variables measuring scope and resource deployment. Performance was measured by indicators of the quality of nursing home care (rates of pressure ulcers, catheterization, and restraint usage) and efficiency in services provision. Changes in Medicare participation after passage of the 1988 Medicare Catastrophic Coverage Act (MCCA) measured strategic behavior. MANOVA and Turkey HSD post hoc means tests determined if significant differences were associated with strategic group membership.

FINDINGS

Cluster analysis produced an optimal seven-group solution. Differences in group means were significant for the clustering, performance, and conduct variables (p < .0001). Strategic groups characterized by facilities providing a continuum of care services had the best patient care outcomes. The most efficient groups were characterized by facilities with high Medicare census. While all strategic groups increased Medicare census following passage of the MCCA, those dominated by for-profits had the greatest increases.

CONCLUSIONS

Our analysis demonstrates that strategic orientation influences nursing home response to regulatory initiatives, a factor that should be recognized in policy formation directed at nursing home reform.

Contextual factors associated with disturbing behaviors in institutionalized elders

Data from a longitudinal clinical trial funded by the National Institute of Aging, testing the effects of staff education and consultation on restraint reduction in nursing homes, were used to examine disturbing behaviors in institutionalized elders and to identify related environmental and personal characteristics. Subjects were 586 residents from three well-matched nursing homes. Kayser-Jone's (1989) model on environment and quality of life in long-term care institutions served as the organizing framework. Data on disturbing behaviors from the Psychogeriatric Dependency Rating Scale were factor analyzed. Three factors, Agitated Psychomotor Behaviors, Aggressive Interpersonal Communication, and Expressive Difficulty, emerged from the principal factor analysis and accounted for 35% of the variance. The Kayser-Jones model partially explained Agitated Psychomotor Behavior (R2 = .22). A model comparison approach indicated that the addition of an organizational variable, staff mix, significantly increased the amount of variance explained over and above that contributed by the personal variables.

Prevalence of advance directives and guardianship in nursing home patients

The Patient Self-Determination Act (PSDA) now requires federally funded nursing homes to inform newly admitted patients of their right to determine their future medical care. Many nursing home patients may not be able to understand these rights, given the high prevalence of mental disorders, particularly dementia, in this population, and well need family members for assistance. Prior to the onset of the PSDA we surveyed the families of all residents of a large, proprietary nursing home to determine whether family members understood the concept of advance directives and guardianship. We also ascertained the rate of use of these instruments in the population studied. We found that the majority of family member respondents understood these concepts, but that substantial proportions of both competent and incompetent patients lacked surrogate decision-making authority, either in the form of a court-appointed guardian or a written advance-directive instrument. Informing newly admitted patients and their families about advance directives is warranted because many lack these plans. However, the high proportion of incompetent patients among nursing home patients indicates the need to encourage currently competent patients to formulate advance directives prior to nursing home placement.