Feng, Fennell, Tyler, Clark, Mor. Growth of Racial and Ethnic Minorities in US Nursing Homes Driven by Demographics and Possible Disparities in Options, Health Affairs, 30(7); 1358-1365
Between 1999 and 2008, the number of elderly Hispanics and Asians living in US nursing homes grew by 54.9 percent and 54.1 percent, respectively, while the number of elderly black residents increased 10.8 percent. During the same period, the number of white nursing home residents declined 10.2 percent. These shifts have been driven in part by changing demographics, especially the fast growth of older minority populations. However, the numbers of minority residents in nursing homes increased more rapidly than the minority population overall, even in areas with high concentrations of minority populations. Thus, these results may indicate unequal minority access to home and community-based alternatives, which are generally preferred for long-term care. When designing initiatives to balance institutional and non-institutional long-term care, policy makers should take steps to reduce racial and ethnic disparities.
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Miller, Lima, Mitchell. Hospice Care for Persons with Dementia: The Growth of
Access in U.S. Nursing Homes, Journal of Alzheimer’s Disease and Other Dementias,
25(8): 666- 673.
Background/Rationale: Persons with dementia often die in nursing homes (NHs); however, concerns exist about their low use of Medicare hospice.
Methods: For 1999 through 2006 in all US states and DC we merged NH resident assessment data with Medicare claims and enrollment data to identify NH decedents with dementia and hospice use. We studied two groups, those with advanced dementia and those with mild-to-moderately severe dementia.
Results: Across study years, 22.2% of all NH decedents had mild-to-moderately severe dementia and 19.6% had advanced dementia. In 1999, 14.5% of decedents with advanced and 13.2% with mild-to-moderately severe dementia accessed hospice, increasing to 42.5% and 37.9% respectively in 2006. Between 1999 and 2006, mean days of hospice stays increased from 46 to 118 for advanced dementia and from 39 to 79 for mild-to-moderately severe dementia. These mean length of stay differences resulted from a relatively lower proportion of short hospice stays (≤ 7 days) together with higher proportions of longer stays (≥ 181 days) among advanced versus mild-to-moderately severe dementia decedents. Hospice access and lengths of stay among US states varied widely.
Conclusions: Over 40% of US NH decedents have mild-to-moderately severe or advanced dementia. For these NH decedents, access to and duration of Medicare hospice has increased. However, there is considerable variation in hospice use across US states.
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Tyler, Shield, Rosenthal, Wetle, Miller, Clark. How valid are the responses to nursing home survey questions? Some issues and concerns. The Gerontologist, 51(2): 201-211
Purpose: Although
surveys are usually piloted before fielding, cognitive-based testing of
surveys is not standard practice in nursing home (NH) research. Many
terms used in the literature do not have standard definitions and may be
interpreted differently by researchers, respondents, and policy makers.
The purpose of this study was to ensure that survey respondents
understood questions as intended, determine whether the Nursing Home
Administrator (NHA) or the Director of Nursing (DON) was better able to
answer questions on certain topics, and to inform the answer choices
provided for questions. Methods: Using existing survey
questions and input from experts, we developed surveys to be
administered to DONs and NHAs. Cognitive-based interviews were conducted
with 45 participants. We took detailed notes during all interviews, and
2 researchers independently coded these notes for key themes.
Results: Many
terms and concepts routinely used by NH researchers and policy makers,
such as “direct-care workers” and “palliative care,” were not uniformly
interpreted by those managing NHs. For example, respondents’ definitions
of direct-care workers ranged from nursing assistants to broader
categories of clinical and other staff members, including nurses,
activities staff, and social workers. We also found NHAs and DONs, at
times, did not possess or have access to information the researchers
expected them to.
Implications: Our
results may help explain discrepant findings across NH studies. They
also underscore the necessity of cognitive-based testing for survey
development and have important implications for policy decisions.
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Lepore, Miller, Gozalo, Feng, Rhodes. Hospice Use among Black and White U.S. Nursing Home Decedents in 2006. The Gerontologist, 51(2): 251-260.
Purpose: Medicare hospice is a valuable source of quality care at the end of life, but its lower use by racial minority groups is of concern. This study identifies factors associated with hospice use among urban Black and White nursing home (NH) decedents in the United States.
Design and Methods: Multiple data sources are combined and multilevel logistic regression is utilized to examine hospice use among urban Black and White NH residents who had access to hospice and died in 2006 (N = 288,202).
Results: In NHs, Blacks are less likely to use hospice than Whites (35.4% vs. 39.3%), even when controlling for covariates, interactions, and clustering of decedents in NHs and counties (adjusted odds ratio = 0.81, 95% confidence interval = 0.77-0.86). Variation in hospice use is greater among subgroups of Blacks than between Blacks and Whites, and these variations are predominantly due to individual-level factors, with some influence of NH-level factors. Hospice use is higher for Blacks versus Whites with do-not-resuscitate orders and lower for Blacks versus Whites with congestive heart failure (CHF). Additionally, hospice use is greater among Blacks with versus without do-not-resuscitate or do-not-hospitalize orders or cancer and those in low-tier versus other NHs. There was also lower hospice use among Blacks with versus without CHF.
Implications: Efforts to reduce racial differences in hospice use should attend to individual-level factors. Heightening use of advance directives and targeting Blacks with CHF for hospice could be particularly helpful.
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Teno, Gozalo, Mitchell, Bynum, Dosa, Mor. Terminal Hospitalizations of Nursing Home Residents: Does Facility Increasing the Rate Do Not Resuscitate Orders Reduce Them? Journal of Palliative Medicine, 41(6): 1040-1047
Context: Terminal hospitalizations are costly and often avoidable with appropriate advance care planning.
Objectives: This study examined the association between advance care planning, as measured by facility rate of do not resuscitate (DNR) orders in U.S. nursing homes (NHs) and changes in terminal hospitalization rates.
Methods: Retrospective cohort study of the changing prevalence of DNR orders in U.S. NHs. Using a fixed effect multivariate model, we examined whether increasing facility rate of DNR orders correlates with reductions in terminal hospitalizations in the last week of life, controlling for changes in facility characteristics (staffing, use of NP/PA, case mix of nursing residents, admission volume, racial composition, payer mix).
Results: The average facility rate of terminal hospitalizations was 15.5%, fluctuating between 1999 (15.0%) and 2007 (14.8%). NHs starting with low rates of DNR orders that increased their rates had fewer terminal hospital admissions in 2007 (11.2%) than facilities with continuously low DNR usage. Even after applying a multivariate fixed effect model, the effect of changes in facility DNR order rate on terminal hospitalization was −0.056 (95% confidence interval: −0.061, −0.050), indicating that for every 10% increase in DNR orders there was 0.56% decrease in terminal hospitalizations. This rate can be compared with the increase of 0.70% in the terminal hospitalization rate when an NH became disproportionately dependent on Medicaid funding or the 0.40% decrease in terminal hospitalization rate associated with adding a nurse practitioner to the clinical staff complement.
Conclusion: NHs that changed their culture of decision making by increasing their facility rate of DNR orders decreased their rate of terminal hospitalizations.
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Mor, Intrator, Unruh, Cai. Temporal and Geographic variation in the validity and internal consistency of the Nursing Home Resident Assessment Minimum Data Set 2.0. BMC, 11:78
Background: The Minimum Data Set (MDS) for nursing home resident assessment has been required in all U.S. nursing homes since 1990 and has been universally computerized since 1998. Initially intended to structure clinical care planning, uses of the MDS expanded to include policy applications such as case-mix reimbursement, quality monitoring and research. The purpose of this paper is to summarize a series of analyses examining the internal consistency and predictive validity of the MDS data as used in the “real world” in all U.S. nursing homes between 1999 and 2007.
Methods: We used person level linked MDS and Medicare denominator and all institutional claim files including inpatient (hospital and skilled nursing facilities) for all Medicare fee-for-service beneficiaries entering U.S. nursing homes during the period 1999 to 2007. We calculated the sensitivity and positive predictive value (PPV) of diagnoses taken from Medicare hospital claims and from the MDS among all new admissions from hospitals to nursing homes and the internal consistency (alpha reliability) of pairs of items within the MDS that logically should be related. We also tested the internal consistency of commonly used MDS based multi-item scales and examined the predictive validity of an MDS based severity measure viz. one year survival. Finally, we examined the correspondence of the MDS discharge record to hospitalizations and deaths seen in Medicare claims, and the completeness of MDS assessments upon skilled nursing facility (SNF) admission.
Results: Each year there were some 800,000 new admissions directly from hospital to US nursing homes and some 900,000 uninterrupted SNF stays. Comparing Medicare enrollment records and claims with MDS records revealed reasonably good correspondence that improved over time (by 2006 only 3% of deaths had no MDS discharge record, only 5% of SNF stays had no MDS, but over 20% of MDS discharges indicating hospitalization had no associated Medicare claim). The PPV and sensitivity levels of Medicare hospital diagnoses and MDS based diagnoses were between .6 and .7 for major diagnoses like CHF, hypertension, diabetes. Internal consistency, as measured by PPV, of the MDS ADL items with other MDS items measuring impairments and symptoms exceeded .9. The Activities of Daily Living (ADL) long form summary scale achieved an alpha inter-consistency level exceeding .85 and multi-item scale alpha
levels of .65 were achieved for well being and mood, and .55 for behavior, levels that were sustained even after stratification by ADL and cognition. The Changes in Health, End-stage disease and Symptoms and Signs (CHESS) index, a summary measure of frailty was highly predictive of one year survival.
Conclusion: The MDS demonstrates a reasonable level of consistency both in terms of how well MDS diagnoses correspond to hospital discharge diagnoses and in terms of the internal consistency of functioning and behavioral items. The level of alpha reliability and validity demonstrated by the scales suggest that the data can be useful for research and policy analysis. However, while improving, the MDS discharge tracking record should still not be used to indicate Medicare hospitalizations or mortality. It will be important to monitor the performance of the MDS 3.0 with respect to consistency, reliability and validity now that it has replaced version 2.0, using these results as a baseline that should be exceeded.
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Feng , Lee , Foster , Mor , Kuo , Intrator. 2010. Do Medicaid Wage Pass-Through Payments Increase Staffing? Health Services Research, 45(3): 728-747
Objective: To assess the impact of state Medicaid wage pass-through policy on direct-care staffing levels in U.S. nursing homes.
Data Sources: Online Survey Certification and Reporting (OSCAR) data, and state Medicaid nursing home reimbursement policies over the period 1996–2004.
Study Design: A fixed-effects panel model with two-step feasible-generalized least squares estimates is used to examine the effect of pass-through adoption on direct-care staff hours per resident day (HPRD) in nursing homes.
Data Collection/Extraction Methods: A panel data file tracking annual OSCAR surveys per facility over the study period is linked with annual information on state Medicaid wage pass-through and related policies.
Principal Findings: Among the states introducing wage pass-through over the study period, the policy is associated with between 3.0 and 4.0 percent net increases in certified nurse aide (CNA) HPRD in the years following adoption. No discernable pass-through effect is observed on either registered nurse or licensed practical nurse HPRD.
Conclusions: State Medicaid wage pass-through programs offer a potentially effective policy tool to boost direct-care CNA staffing in nursing homes, at least in the short term.
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Intrator, Hiris, Berg, Miller, Mor. 2010. The Residential History File: Studying Nursing Home Residents’ Long Term Care Histories. Health Services Research
Objective. To construct a data tool, the Residential History File (RHF), that summarizes information from Medicare claims and nursing home (NH) Minimum Data Set (MDS) assessments to track people through health care locations including non-Medicare paid Nursing Home (NH) stays.
Data Sources. Online Survey Certification and Reporting (OSCAR) data for 202 free-standing NHs, Medicare Denominator, claims (Parts A and B) and MDS assessments for 60,984 people who were present in one of these NHs in 2006.
Methods. The algorithm creating the RHF is outlined and the RHF for the study data is used to describe place of death. The identification of residents in nursing homes is compared to the reports in OSCAR and part B claims.
Principal Findings. The RHF correctly identified 84.8% of part B claims with place-of-service in NH, and identified 18.3 less residents on average than reported in the OSCAR on the day of the survey. The RHF indicated that 17.5% non-Medicare NH decedents were transferred to the hospital to die versus 45.6% SNF decedents.
Conclusions. The population-based design of the RHF makes it possible to conduct policy relevant research to examine the variation in the rate and type of health care transitions across the U.S.
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Teno, Mitchell , Gozalo, Dosa, Hsu, Intrator, Mor. 2010. Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment. JAMA, 303(6):544-550
Context: Tube-feeding is of questionable benefit for nursing home residents with advanced dementia. Approximately two-thirds of US nursing home residents who are tube fed had their feeding tube inserted during an acute care hospitalization.
Objective: To identify US hospital characteristics associated with higher rates of feeding tube insertion in nursing home residents with advanced cognitive impairment.
Design, Setting, and Patients: The sample included nursing home residents aged 66 years or older with advanced cognitive impairment admitted to acute care hospitals between 2000 and 2007. Rate of feeding tube placement was based on a 20% sample of all Medicare Claims files and was assessed in hospitals with at least 30 such admissions during the 8-year period. A multivariable model with the unit of the analysis being the hospital admission identified hospital-level factors independently associated with feeding tube insertion rates, including bed size, ownership, urban location, and medical school affiliation. Measures of each hospital's care practices for all patients with serious chronic illnesses were evaluated, including intensive care unit (ICU) use in the last 6 months of life, the use of hospice services, and the ratio of specialist to primary care physicians. Patient-level characteristics were also considered.
Main Outcome Measure: Endoscopic or surgical insertion of a gastrostomy tube during a hospitalization.
Results: In 2797 acute care hospitals with 280 869 admissions among 163 022 nursing home residents with advanced cognitive impairment, the rate of feeding tube insertion varied from 0 to 38.9 per 100 hospitalizations (mean [SD], 6.5 [5.3]; median [interquartile range], 5.3 [2.6-9.3]). The mean rate of feeding tube insertions per 100 admissions was 7.9 in 2000, decreasing to 6.2 in 2007. Higher insertion rates were associated with the following hospital features: for-profit ownership vs government owned (8.5 vs 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.21-1.46), larger size (>310 beds vs <101 beds: 8.0 vs 4.3 insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35-1.63), and greater ICU use in the last 6 months of life (highest vs lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20-3.06). These differences persisted after controlling for patient characteristics. Specialist to primary care ratio and hospice use were weakly or not associated with feeding tube placement.
Conclusion: Among nursing home residents with advanced cognitive impairment admitted to acute care hospitals, for-profit ownership, larger hospital size, and greater ICU use was associated with increased rates of feeding tube insertion, even after adjusting for patient-level characteristics.
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Teno, Mitchell, Skinner, Kuo, Fisher, Intrator, Mor. 2009. Churning: The Association between Health Care Transitions and Feeding Tube Insertion for Nursing Home Residents with Advanced Cognitive Impairment. Journal of Palliative Medicine, 12(4):359-62
Background: There is a tenfold variation across U.S. states in the prevalence of feeding tube use among elderly nursing home residents (NHR) with advanced cognitive impairment. The goal of this study was to examine whether regions with higher rates of health care transitions at the end of life are more likely to use feeding tubes in patients with severe cognitive impairment.
Methods: A retrospective cohort study of U.S. nursing home residents with advanced cognitive impairment. The incidence of feeding tube insertion was determined by Medicare Part A and B billing data. A count of the number of health care transition in the last 6 months of life was determined for nursing home residents. A multivariate model examined the association of residing in a geographic region with a higher rates of health care transition and the insertion of a feeding tube in nusing home resident with advance cognitive impairment.
Results: Hospital Referral Region (HRR) health care transitions varied from 192 (Salem, Oregon) to 509 per 100 decedents (Monroe, Louisiana) within the last 6 months of life. HRRs with higher transition rates had a higher incidence of feeding tube insertion (Spearman correlation = 0.58). Subjects residing in regions with the highest quintile of transitions rates were 2.5 times (95% confidence interval [CI] 1.9–3.2) more likely to have a feeding tube inserted compared to those that resided in the lowest quintile.
Conclusions: Regions with higher rates of care transitions among nursing home residents are also much more likely to have higher rates of feeding tube placement for patients with severe cognitive impairment, a population in whom benefit is unlikely.
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Kuo, Rhodes, Mitchell, Mor, Teno. 2009. Natural history of feeding-tube use in nursing home residents with advanced dementia. Journal of the American Medical Directors Association, 10(4):264-70
Objectives: Despite the evidence that feeding tube use in persons with advanced dementia is not associated improved outcomes, there remains striking area variation in their use. Yet, little is known about the national incidence of feeding tube insertions, the circumstances of their insertion, and post-insertion health care utilization.
Design: Secondary analysis of Minimum Data Set merged onto Medicare Claims Files
Setting and Participants: Nursing home residents (NHR) without a feeding tube
Measurements: NHR were followed for up to one year to see whether a feeding tube was inserted and then followed for one year post insertion to examine health care utilization and survival.
Results: The incidence of feeding tube insertion was 53.6/1000 residents. The majority (68.1%) of feeding tube insertions were performed in an acute care hospital with the most common reasons for admission being pneumonia, dehydration, and dysphagia. One year post-insertion mortality was 64.1% with median survival of 56 days. Within one year, 19.3% of those who had a feeding tube inserted required a tube replacement or repositioning within a median 145 days after the initial insertion. Over one year, tube-feeding was associated with an average of 9.1 hospitalized days per person, 1.0 hospitalizations, 0.3 emergency room visits that did not result in a hospital admission.
Conclusion: The majority of feeding tubes are inserted in an acute care hospital. Feeding tube insertions are also associated with poor survival and significant rate of health care utilization post insertion.
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Smith, Feng, Fennell, Zinn, Mor. 2008. Racial Disparities in Access to Long-Term Care: The Illusive Pursuit of Equity. Journal of Health Politics, Policy & Law, 33(5): 861-882.
While nursing homes were insulated from civil-rights enforcement at the time of the implementation of the Medicare program and lagged behind other parts of the health sector in providing comparable access to minorities, they are the only providers for which current reporting requirements make it possible to fully assess racial disparities in use and quality of care. We find that African Americans' use of nursing homes in 2000 in the United States was 14 percent higher than Caucasians' use. The largest relative African American use of nursing homes in 2000 took place in the South and West. Average nursing-home case-mix acuity for African Americans and Caucasians were essentially identical, suggesting that shifts in payment incentives have eliminated the selective admission of easy-care private-pay (predominantly Caucasian) patients and helped fuel the growth of private pay home care and assisted living for this segment of the population. While these shifts in incentives helped increase the use of nursing homes by African Americans, a high degree of segregation and disparity in the quality of the nursing homes used by African Americans persists. Parity in use is an elusive benchmark for measuring progress in assuring equity in treatment.
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Fennell, Feng, Clark, Mor. 2010. Elderly Hispanics More Likely to Reside in Poor Quality Nursing Homes. Health Affairs, 29(1): 65-73
The proportion of Hispanics age sixty-five and older who are living in nursing homes rose from 5 percent in 2000 to 6.4 percent in 2005. Although segregation in nursing homes seems to have declined slightly, elderly Hispanics are more likely than their non-Hispanic white peers to reside in nursing homes that are characterized by severe deficiencies in performance, understaffing, and poor care.
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Katz, Karuza , Intrator, Zinn, Mor, Caprio, Caprio, Dauenhauer, Lima. 2009. Medical Staff Organization in Nursing Homes: Scale Development and Validation. Journal of the American Medical Directors Association, 10(7): 498-504.
Purpose: To construct a multidimensional self-report scale to measure nursing home (NH) medical staff organization (NHMSO) dimensions and then pilot the scale using a national survey of medical directors to provide data on its psychometric properties.
Design and Methods: Instrument development process consisting of the proceedings from the Nursing Home Physician Workforce Conference and focus groups followed by cognitive interviews, which culminated in a survey of a random sample of American Medical Directors Association (AMDA) affiliated medical directors. Analyses were conducted on surveys matched to Online Survey Certification and Reporting (OSCAR) data from freestanding nonpediatric nursing homes. A total of 202 surveys were available for analysis and comprised the final sample.
Results: Dimensions were identified that measured the extent of medical staff organization in nursing homes and included staff composition, appointment process, commitment (physiciancohesion; leadership turnover/capability), departmentalization (physician supervision, autonomy and interdisciplinary involvement), documentation, and informal dynamics. The items developed to measure each dimension were reliable (Cronbach's alpha ranged from 0.81 to 0.65).Intercorrelations among the scale dimensions provided preliminary evidence of the construct validity of the scale.
Implications: This report, for the first time ever, defines and validates NH medical staff organization dimensions, a critical first step in determining the relationship between physician practice and the quality of care delivered in the NH.
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Tyler, Jung, Feng, Mor. 2010. Nurse aide training & certification within nursing homes, 1997-2007. The Gerontologist, 50 (4): 550-555.
Purpose: The purpose of this study was to describe how the prevalence of nurse aide training, certification, and evaluation programs (NATCEP) provided in the nursing home setting changed between 1997 and 2007, to explore the environmental factors that may be influencing the prevalence of these programs, and examine how the changing prevalence of NH-based NATCEPs may be affecting those considering certified nursing assistant (CNA) work.
Methods: We used the Online Survey Certification and Reporting (OSCAR) data to generate descriptive statistics for three groups of NHs from 1997 to 2007: NHs that never provided a NATCEP, those that provided the program throughout the study period, and those that provided the program intermittently. We gathered information on states’ policies regarding CNA training by telephone and internet. Data from the National Nursing Assistant Survey were also utilized to describe where CNAs are receiving their training and what proportion of costs they are paying.
Results: Prevalence of NH-based programs dropped throughout the study period. It is likely that most CNAs are now receiving their pre-employment training outside the NH setting and paying a greater share of their training costs.
Implications: The shifting of CNA training to venues other than NHs raises important questions about the quality of training and states’ ability to monitor training programs. In addition, CNAs receiving training outside NHs pay a greater share of their training costs, possibly creating a disincentive to enter the field.
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Miller, Lima, Gozalo, Mor. 2010. The growth of hospice care in U.S. nursing homes.
Journal of American Geriatrics Society, 58(8): 1481-1488.
OBJECTIVES: To inform efforts aimed at reducing Medicare hospice expenditures by describing the longitudinal use of hospice care in nursing homes (NHs) and examining how hospice provider growth is associated with use.
DESIGN: Longitudinal study using NH resident assessment (Minimum Data Set) and Medicare denominator and claims data for 1999 through 2006.
SETTING: NHs in the 50 U.S. states and the District of Columbia.
PARTICIPANTS: Persons dying in U.S. NHs.
MEASUREMENTS: Medicare beneficiaries dying in NHs, receipt of NH hospice, and lengths of hospice stay were identified. The number of hospices providing care in NHs was also identified, and a panel data fixed-effect (within) regression analysis was used to examine how growth in providers affected hospice use.
RESULTS: Between 1999 and 2006, the number of hospices providing care in NHs rose from 1,850 to 2,768, and rates of NH hospice use more than doubled (from 14% to 33%). With this growth came a doubling of mean lengths of stay (from 46 to 93 days) and a 14% increase in the proportion of NH hospice decedents with noncancer diagnoses (69% in 1999 to 83% in 2006). Controlling for time trends, for every 10 new hospice providers within a state, there was an average state increase of 0.58% (95% confidence interval=0.383–0.782) in NH hospice use. Much state variation in NH hospice use and growth was observed.
CONCLUSION: Policy efforts to curb Medicare hospice expenditures (driven in part by provider growth) must consider the potentially negative effect of changes on access for dying (mostly noncancer) NH residents.
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Mor, Intrator, Feng, Grabowski. 2010. From Hospital to Skilled Nursing Care and Back Again: A Revolving Door for Medicare Beneficiaries. Health Affairs , 29(1): 57-64.
Medicare policymakers have recently become interested in changing the payment incentives around rehospitalizations. Using merged claims data, our analyses indicate 23.45% of Medicare beneficiaries discharged from the hospital to a skilled nursing facility (SNF) were directly readmitted within 30 days at a cost to Medicare of $4.34 billion in 2006. Although these results indicate significant potential savings, we also found that SNF rehospitalizations were heterogeneous in nature and
varied considerably across local areas based on practice patterns, suggesting Medicare payment reform will need to account for incentives that vary geographically and by type of hospitalization in order to be effective.
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Grabowski, Feng, Mor, Intrator. 2010. Medicaid bed-hold policy and Medicare SNF re-hospitalizations. Health Services Research, online advanced access published April 6
Objective: To analyze the effect of states’ Medicaid bed-hold policies on the 30-day rehospitalization of Medicare post acute skilled nursing facility (SNF) residents.
Data Sources: Minimum data set assessments were merged with Medicare claims and eligibility files for all first-time SNF admissions (N53,322,088) over the period 2000 through 2005; states’ Medicaid bed-hold policies were obtained via survey.
Study Design: Regression specification incorporating facility fixed effects to examine changes in Medicaid bed-hold policies on the likelihood of a 30-day SNF rehospitalization.
Principal Findings: Using a continuous measure of bed-hold generosity, state Medicaid bed-hold was positively related to Medicare SNF rehospitalization. Specifically, the introduction of a bed-hold policy with average generosity increases Medicare rehospitalizations by 1.8 percent, representing roughly 12,000 SNF rehospitalizations at a cost to Medicare of approximately U.S.$100 million over our study period.
Conclusions: Although facilities do not receive a Medicaid bed-hold payment for Medicare SNF stays,we found that the adoption ofmore generous policies led to greater SNF rehospitalizations. This type of spillover is largely ignored in current discussions of Medicare payment reforms such as bundled payment. Neither Medicare nor Medicaid has an incentive to internalize the risks and benefits of its actions as they affect the other.
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Sterns, Miller, Allen. 2010. The Complexity of Implementing Culture Change in Nursing Homes. Journal of the American Medical Directors Association, 11(7): 511-518.
Purpose: The culture change (CC) movement aims to transform the traditional nursing home (NH) that is institutional in design with hierarchical management structure into a homelike environment that empowers residents and frontline staff. This study examines differences in adoption of CC practices according to a NH's self-reported extent of CC implementation and its duration of CC adoption. Furthermore, it examines differences in adoption by whether a CC practice is considered less versus more complex, using complexity theory as the theoretical framework for this classification.
Design and Methods: Using data from a 2007 Commonwealth-funded study, we analyzed a national sample of 291 US nursing homes that identified as being “for the most part” or “completely” CC facilities for “1 to 3 years” or “3+ years.” Also, using a complexity theory framework, we ranked 16 practices commonly associated with CC as low, moderately, or highly complex based on level of agreement needed to actuate the process (number of parties involved) and the certainty of intended outcomes. We then examined the prevalence of CC-associated practices in relation to their complexity and the extent and duration of a NH's CC adoption.
Results: We found practices ranked as less complex were implemented more frequently in NHs with both shorter and longer durations of CC adoption. However, more complex CC practices were more prevalent among NHs reporting “complete” adoption for 3+ years versus 1 to 3 years. This was not observed in NHs reporting having CC “for the most part.”
Conclusions/Implications: Less complex practices may be more economical and easier to implement. These early successes may result in sufficient momentum so that more complex change can follow. A nursing home that more completely embraces the culture change movement may be more likely to attempt these complex changes.
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Miller, Miller, Jung, Sterns, Clark, Mor. 2010. Nursing home organizational change: the ‘culture change’ movement as viewed by long-term care specialists. Medical Care Research and Review, 67(4): 65S-81S
A decade-long grassroots movement aims to deinstitutionalize nursing home (NH) environments and individualize care. Coined “NH Culture Change” the movement is often described by its resident-centered/directed care focus. While empirical data of “culture change’s” costs and benefits are limited, it is broadly viewed as beneficial and widely promoted. Still, debate abounds regarding barriers to its adoption. We used data from a Web-based survey of 1,147 long-term care specialists (including NH and other providers, consumers/advocates, state and federal government officials, university/academic, researchers/consultants, and others) to better understand factors associated with perceived barriers. Long-term care specialists view the number-one barrier to adoption differently depending on their employment, familiarity with culture change, and their underlying policy views. To promote adoption, research and broad-based educational efforts are needed to influence views and perceptions. Fundamental changes in the regulatory process together with targeted regulatory changes and payment incentives may also be needed.
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Grabowski, Aschbrenner, Feng, Mor. 2009. Mental illness in nursing homes: variations across the states. Health Affairs, 28(3): 689-700
Placing people with mental illnesses in nursing homes is an important policy concern. Using nursing home Minimum Data Set assessments from 2005, we found much variation across states in both the rates of mental illness among nursing home admissions and the estimated rates of admission among people with mental illnesses. We also found that newly admitted people with mental illnesses were younger and more likely to become long-stay residents than those admitted with other conditions. Taken together, these results suggest that state-level mental health and nursing home factors may influence the likelihood of long-term nursing home use for people with mental illnesses.
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Stevenson & Mor. 2009. Targeting nursing homes under the QIO Program's 9th statement of work. Journal of the American Geriatrics Society, 57(9):1678-1684.
In the Quality Improvement Organization (QIO) program's latest Statement of Work, the Centers for Medicare and Medicaid Services (CMS) is targeting its nursing home activities toward facilities that perform poorly on two quality measures—pressure ulcers and restraint use. The designation of target facilities is a shift in strategy for CMS and a direct response to criticism that QIO program resources were not being targeted effectively to facilities or clinical areas that most needed improvement. Using administrative data, this article analyzes implications of using narrowly defined criteria to identify facilities that need improvement, particularly in light of considerable evidence showing that nursing home quality is multidimensional and may change over time. The analyses show that one in four facilities is targeted for improvement nationally but that approximately half of some states' facilities are targeted while other states have almost none targeted. The analyses also convey deeper limitations to using threshold values on individual measures to identify poorly performing homes. Target facilities can be among the top performers on a range of other quality measures, and their performance on targeted measures themselves may change over time. The implication of these features is that a very different group of facilities would have been chosen had the QIO program targeted other measures or examined performance at a different point in time. Ultimately, CMS has chosen a blunt instrument to identify poorly performing nursing homes, and supplemental strategies—such as soliciting input from state survey agencies and more closely aligning quality improvement and quality assurance efforts—should be considered to address potential limitations.
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