Long-Term Care

Long-Term Care
Call for Papers
Medical Care Use of Residential Care Patients
Chair: Penny Hollander Feldman, Ph.D., M.P.H.
Sunday, June 6 • 11:30 a.m.-1:00 p.m.
• The Effect of Federal Drug Therapy Guidelines on Patient
Safety in Nursing Homes: A Natural Experiment
Becky Briesacher, Ph.D., Rhona Limcangco, M.Pharm., Linda
Simoni-Wastila, Ph.D., Jalpa Doshi, Ph.D., Jerry Gurwitz, M.D.,
Edward Mortimore, Ph.D.
Presented by: Becky Briesacher, Ph.D., Assistant Professor,
School of Pharmacy, University of Maryland, 515 W. Lombard,
Baltimore, MD 21201; Tel: 410 706.1490; Fax: 410.706.1488; Email: [email protected]
Research Objective: To test if federally mandated drug use
reviews reduce exposure to potentially inappropriate
medications in nursing homes.
Study Design: This is a quasi-experimental, longitudinal study
using the 1997-2000 Medicare Current Beneficiary Survey
(MCBS), a nationally representative dataset on the health
status and medical care utilization of the Medicare
population. We identified institutionalized beneficiaries and
linked their files to a newly available dataset of facility
medication administrations. Our analysis calculated quarterly
exposures to 38 potentially inappropriate medications in
nursing homes (NH) before and after a 1999 policy change to
expand the drug use reviews mandated by the Centers for
Medicare and Medicaid Services (CMS). CMS requires
Medicare- or Medicaid-eligible NHs to submit to surveys of
quality indicators, including the use of inappropriate
medications, any related adverse drug reactions, and medical
record justification for exempted use. Our study compared
the prevalence and incidence use of potentially inappropriate
drugs in NHs to those in assisted living facilities (ALF), which
are not subject to the CMS rules. We used a difference-indifference model and survival regression estimators to
calculate the adjusted hazard of post-policy exposures in NHs
relative to pre-policy levels and ALF exposures. Our analysis
examined criteria drugs restricted for both the entire
institutional population and patients with certain diseases.
We also stratified inappropriate drug use by three levels of
legitimate exceptions: medications always to avoid, rarely
appropriate, or have some acceptable indications.
Population Studied: Nationally representative population
sample of 8 million NH residents [unweighted n=2242], and a
comparison group of 2 million ALF residents [unweighted
Principal Findings: Before the CMS policy change, 28.8%
(95% confidence interval [CI], 27.3-30.3) of Medicare
beneficiaries in NHs and 22.4% (95% CI, 19.8-25.0) in ALFs
received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable
indications: 23.4% in NHs (95% CI, 20.4-26.4) and 18.0% in
ALFs (95% CI, 15.6-20.4). After the policy change, exposures
in NHs declined slightly to 25.6% (95% CI: 24.1-27.1, p<0.05);
however a similar decline occurred in ALFs (19.0%; 95% CI,
16.7-21.3, NS). Post-policy use of potentially inappropriate
medications with some exempted indications remained high
and over half was attributable to incident use: 1 in 5 NH
residents (20.6%; 95% CI, 19.0-22.0) and 1 in 6 ALF residents
(15.6%; 95% CI, 15.2-15.7). Post-policy use of drugs restricted
with certain diseases increased in NH by 33% (13.2%; 95% CI,
12.2-14.2, p<0.05], particularly for seizure disorders or
epilepsy. Multivariate results detected no post-policy
differences in inappropriate drug use between long-term care
facilities with mandatory drug use reviews and those without.
Conclusions: Some post-policy declines were noted in the
NH use of potentially inappropriate medications but the
decrease was uneven and could not be attributed to the
federally-mandated drug use reviews. Lower use of the most
risky medications occurred also in ALFs suggesting a general
prescribing trend rather than policy impact. Prescribing of
medications restricted with certain diseases increased in NHs
after the policy change.
Implications for Policy, Delivery or Practice: Our study is
the first evaluation of the CMS policy and it highlights the
unclear effectiveness of drug use reviews to improve patient
safety in NHs even though this strategy has been widely
adopted by state and federal agencies.
Primary Funding Source: CMS
• Cost-Benefit Analysis of Nursing Home Registered Nurse
Staffing Times
David Dorr, M.D., Susan Horn, Ph.D., Randall Smout, M.S.
Presented by: Susan Horn, Ph.D., Senior Scientist, Institute
for Clinical Outcomes Research, 699 East South Temple, Suite
100, Salt Lake City, UT 84102-1282; Tel: 801.466.5595, Ext. 125;
Fax: 801.466.6685; E-mail: [email protected]
Research Objective: Adequate nurse staffing in hospitals,
ICUs, ambulatory clinics, and nursing homes has been shown
to be critical for quality care. Cost/benefit of better resident
outcomes versus additional wages for nurses is largely
unknown. Our research objective was to perform a costbenefit analysis of societal benefits of decreased adverse
resident outcomes versus additional wages of registered
nurses to achieve adequate staffing in nursing homes.
Study Design: Retrospective chart review was used to collect
data on over 500 resident, treatment, facility, and outcome
variables including Comprehensive Severity Index.
Multivariate regression analyses evaluated significance of
associations between registered nurse staffing times and
outcomes, controlling for severity of illness and other
confounding variables. Outcomes included development of
pressure ulcers (PU), urinary tract infections (UTI), and
hospitalizations. Event rates are from National Pressure Ulcer
Long-Term Care Study (NPULS). Hospital costs are
estimated from Medicare statistics and from charges in the
Health Care Cost and Utilization Project. UTI and PU costs
are from cost-identification studies. Difference in rates of PU,
UTI, and hospitalizations per resident per day were calculated
from low staffing and adequate staffing nursing homes.
Benefits from reductions in these events are calculated in FY
2001 dollars and compared to costs of increasing nurse
staffing. Societal and institutional perspectives are addressed.
Population Studied: Cohort of 1,376 residents from 82 longterm care facilities participating in NPULS; inclusion criteria
were length of stay > 14 days, at risk of developing pressure
ulcers with Braden Scale score < 17, and no pressure ulcer on
study entry.
Principal Findings: Analysis shows net societal benefit of
$319,000 per year for a hundred bed high risk, long stay
nursing home unit, which employs sufficient nurses to achieve
30-40 minutes of per resident direct care registered nurse
time per day versus those nursing homes who have nursing
time of <10 minutes. Sensitivity analyses revealed a robust set
of estimates, with no single or paired elements reaching
cost/benefit equality threshold.
Conclusions: Adequate nurse staffing in nursing homes can
have significant societal quality of care and cost benefits, but
cost benefits may not accrue to nursing homes under current
reimbursement systems.
Implications for Policy, Delivery or Practice: A properly
functioning market system might lead to appropriate support
by consumers of high quality institutions, but existing
information asymmetries have been resistant to appropriate
discernment of quality. Therefore, incentives for improvement
must allow some (or most) of those savings to be returned to
nursing homes that voluntarily improve or maintain
appropriate staffing ratios. Altering reimbursement to more
accurately reflect cost-effectiveness of care has support in the
literature, can be implemented relatively quickly, and may
improve outcomes; effective nursing care to prevent adverse
outcomes must be reflected in these alterations.
Primary Funding Source: National Library of Medicine
(Training Grant 5T15LM007124-07)
• The Effect of Medicaid Rate on Potentially Preventable
Hospitalizations from Nursing Home
O. Intrator, Ph.D., Vincent Mor, Ph.D., Ning Wu, M.D., M.S.,
David Gifford, M.D., M.P.H., David Grabowski, Ph.D.,
Zhanlian Feng, Ph.D.
Presented by: O. Intrator, Ph.D., Assistant Professor
(Research), Center for Gerontology and Health Care Research,
Brown University, Box G-ST2, Providence, RI 02912; Tel:
401.863.3579; Fax: 401.863.9219; E-mail:
[email protected]
Research Objective: Medicaid payment rates are reflected in
the availability of the clinical resources (such as availability of
physician assistants/nurse practitioners) necessary to manage
nursing home residents’ medical conditions. Since over 60%
of all nursing home residents are Medicaid recipients,
differences in reimbursement rates are likely to contribute to
observed inter-state differences in hospitalization rates. This
paper tests the hypothesis that nursing home residents in
states with higher Medicaid rates experience fewer potentially
preventable hospitalizations.
Study Design: Data: Minimum Dataset (MDS) clinical
assessment data merged with inpatient Medicare claims,
Online Survey Certification And Reporting (OSCAR) facility
data, Area Resource File county level market data, and a
survey of state policies conducted at Brown University.
Study Design: Cross sectional study with 6-month
hospitalization operationalized as a hierarchical outcome: any
potentially preventable hospitalization (measured as
ambulatory care sensitive, ACS, diagnoses), any other
hospitalization, death versus remaining in the facility.
Three separate binomial response regressions models for
each of the outcomes compared to remaining in the facility
were constructed. This allows for Markov Chain Monte Carlo
estimation, producing unbiased estimates. Analyses of a fourlevel (resident-facility-market-state) logistic regression model
of any ACS hospitalization are reported here. Analyses were
conducted using Markov-Chain-Monte-Carlo (MCMC)
methods in MLWiN.
Population Studied: All continuous nursing home residents
in freestanding Medicare/Medicaid certified urban facilities in
the 48 contiguous U.S. states during the 2nd quarter of 2000
for 90 days or more were identified from MDS data. Facilities
specializing in pediatric, HIV, MS, or brain injury care were
excluded, as were residents under the age of 65, and residents
who were members of MCOs during any point in 2000.
Principal Findings: Among 571,816 long-stay residents of
9,124 facilities, over a six month period, 7.4% experienced a
potentially preventable hospitalization, 12.6% experienced
other hospitalizations, and 9.2% died. Multilevel, multivariate
results revealed that residents in states with a $20 higher
reimbursement rate than the median $100 were 9.6% less
likely to experience an ACS hospitalization (95% CI of AOR =
0.84-0.97), controlling for many resident, facility and market
characteristics. Residents in facilities with nurse
practitioners/physician assistants and facilities with the
Harrington recommended level of an average of 4.55 nurse
hour per patient day were 6.8% and 6.5% less likely to be
hospitalized, respectively.
Conclusions: States with more generous nursing home
reimbursement rates appear to have lower rates of
preventable hospitalization of long stay nursing home
residents. This direct effect of a higher reimbursement rate is
intensified by the indirect effect of higher reimbursement rates
on increased availability of more skilled staffing (also
associated with reduced hospitalization rates).
Implications for Policy, Delivery or Practice: Recent state
budgets deficits increase the importance of properly aligning
state and Federal policies in the nursing home arena since
state investments in higher reimbursement translates into
hospital savings which benefit Medicare. Unnecessary
hospitalizations for clinical conditions that could be managed
in the nursing home are likely to have a negative quality
impact on residents’ lives, thereby undermining current state
and federal initiatives to improve the quality of nursing home
Primary Funding Source: NIA
• Reduction in Mortality Associated with Influenza and
Pneumococcal Vaccination of Elderly in Nursing Homes
Sophia Kazakova, M.D., Ph.D., M.P.H., Amy Curtis, Ph.D.,
Dale Bratzler, DO, Wato Nsa; Linda Steele; Ph.D., Linda
McKibben; Richard Chesley, M.D., Abby Shefer, John Jernigan
Presented by: Sophia Kazakova, M.D., Ph.D., M.P.H.,
Epidemic Intelligence Officer, Division of Healthcare Quality
Promotion, Centers for Disease Control and Prevention, 57
Executive Park Drive SNE, Atlanta, GA 30329; Tel:
404.498.1128; Fax: 404.498.1101; E-mail: [email protected]
Research Objective: To examine the impact of influenza and
pneumococcal vaccination on mortality among Nursing
Home (NH) residents during two recent influenza seasons.
Study Design: In this retrospective cohort study, individual
vaccination status was assessed for 2000-2001 and 20012002 cohorts of NH residents and linked to the Medicare
enrollment database and Minimum Data Set for each
resident. We used multilevel multivariate logistic regression
analysis, which controls for individual and facility-level factors,
to examine the influence of individual influenza and
pneumococcal vaccination and facility-level influenza and
pneumococcal vaccination coverage on mortality.
Population Studied: 36,227 Nursing Home residents
randomly selected from 277 NHs in 14 states.
Principal Findings: Of the 18,636 residents in the 2000-2001
cohort and 17,591 in the 2001-2002 cohort, 2,935 (15.7%) and
3,020 (17.2%) residents died respectively during the influenza
seasons. In both cohorts, about 60% of residents received
influenza and 40% received pneumococcal vaccination. For
the first cohort, receipt of influenza (RR 0.59; CI 0.53-0.66)
and pneumococcal (RR 0.74; CI 0.67-0.82) vaccination and
being a resident of a facility with 80% or greater influenza
coverage (RR 0.81; CI 0.72-0.91) were independently
associated with a reduced mortality. High facility
pneumococcal vaccination coverage was not associated with
decreased mortality. Similar results were obtained for the
second cohort.
Conclusions: This is the first study demonstrating the
significant protective effect of individual pneumococcal
vaccination on mortality among NH residents. This study
confirms the important role of individual influenza vaccination
in preventing deaths and suggests that residing in a facility
with a high influenza vaccination rate independently reduces
the risk of death.
Implications for Policy, Delivery or Practice: Programs to
increase pneumococcal and influenza vaccination among NH
residents should be encouraged to decrease mortality.
Primary Funding Source: CDC
• Medicare Expenditures for Residents in Assisted Living:
Data from a National Study
Charles Phillips, Ph.D., M.P.H., Scott Holan, M.S., Michael
Sherman, Ph.D., William Spector, Ph.D., Catherine Hawes,
Presented by: Charles Phillips, Ph.D., M.P.H., Professor,
School of Rural Public Health, Texas A&M University System
Health Science Center, 3000 Briarcrest Drive, Suite 310, Bryan,
TX 77802; Tel: 979.458.0080; Fax: 979.458.0656; E-mail:
[email protected]
Research Objective: To investigate the level of Medicare
expenditures for assisted living facility (ALF) residents and
whether an ALF’s characteristics affect residents’ use of
Medicare-covered services.
Study Design: Cross-sectional analyses using multivariate
logistic and ordinary least squares regression techniques were
used to determine the effects of individual and facility
characteristics on Medicare utilization and expenditures.
Population Studied: Primary and secondary data collection.
Primary data come from the National Study of Assisted Living
for the Frail Elderly conducted in 1998-1999. This study
restricted its interest to the approximately 1,200 residents who
remained in an ALF from baseline to follow-up data collection.
Secondary data are six months of post-baseline Medicare
claims acquired for 545 of these residents, who did not differ
significantly from the larger sub-sample.
Principal Findings: On an annualized basis, assisted living
residents incurred Medicare costs of approximately $4,800.
Just under 15% of assisted living residents accounted for over
75% of total Medicare costs. Both the likelihood of utilizing
Medicare-covered services and the intensity of service use
were largely unaffected by the characteristics of the ALF in
which residents lived. The only exception to this general
finding is that those individuals who utilized services and
resided in smaller ALFs had significantly lower expenditures.
However, individual characteristics dominated the multivariate
Conclusions: Both the level of Medicare expenditures and the
distribution of Medicare expenditures among ALF residents
were similar to those among the general Medicare beneficiary
population. Also, assisted living residents had patterns of
Medicare payments that resembled those among other
community-dwelling in the Medicare Current Beneficiary
Implications for Policy, Delivery or Practice: The lack of
impact exhibited by facility characteristics on Medicare
expenditures implies that regulatory efforts aimed at
developing a specific type of facility will have little effect on
affecting Medicare expenditures. Also, the similarity betweeen
Medicare payments for those in assisted living and elsewhere
in the community may imply that assisted livng, as currently
configured, is not a viable alternative to nursing home
Primary Funding Source: AHRQ
Call for Papers
Long-Term Care Community Services & Market Factors
Chair: Barbara Gage, Ph.D., M.P.H.
Tuesday, June 8 • 9:15 a.m.-10:45 a.m.
• Do Children with Developmental Disabilities Benefit
from Consumer-Directed Medicaid Supportive Services
Leslie Foster, M.P.A., Stacy Dale, M.P.A., Randall Brown,
Ph.D., Barbara Phillips, Ph.D., Jennifer Schore, M.S., M.S.W,
Barbara Lepidus Carlson, M.A.
Presented by: Leslie Foster, M.P.A., Researcher, Mathematica
Policy Research, Inc., P.O. Box 2393, Princeton, NJ 08043; Tel:
609.936.3265; Fax: 609.799.0005; E-mail:
[email protected]
Research Objective: To compare the use, quality, and costs
of Medicaid supportive services used by children with
developmental disabilities under Florida's traditional homeand community-based services waiver program, to that
experienced by children under a Cash and Counseling
demonstration program, in which parents directed their
child's use of supportive services.
Study Design: Children who enrolled in the voluntary
demonstration were randomly assigned to participate in
Consumer Directed Care (the treatment group) or to continue
receiving traditional waiver benefits (the control group).
Parents of treatment group children had the opportunity to
receive a monthly allowance, which they could use to hire their
choice of caregivers and to buy other goods and services for
their child, with the help of program counselors and
bookkeepers. Computer-assisted telephone interviews were
conducted at enrollment and nine months later with the
parents (or guardians) of 862 children. The nine-month
interviews were conducted between April 2001 and July 2002.
We used responses to the nine-month follow-up interviews to
measure (1) children's use of paid and unpaid personal care
services, (2) parents' satisfaction with their child's care and
quality of life, (3) children's unmet needs for personal care
services and supplies, and (4) children's disability-related
health problems, adverse events, and general health status.
We used Medicaid claims data to measure the costs of
children's goods and services. Program impacts were
estimated with regression models that controlled for a
comprehensive set of baseline characteristics.
Population Studied: Children aged 3 to 17 who were enrolled
in Florida's Developmental Services waiver program, and
whose parents voluntarily enrolled them in the state's Cash
and Counseling demonstration.
Principal Findings: Compared with children in Florida's
traditional waiver program, children whose parents directed
their waiver benefits were more likely to receive personal care
from someone who was paid to help them, and their parents
were happier with their care and well-being. Treatment group
children received more hours of paid personal care, but fewer
hours of unpaid personal care, than control group children
received. Parents of treatment group children were less likely
than their counterparts in the control group to say their child
had unmet needs for personal care and supplies, and they
were much more satisfied with their child's overall care
arrangements and with the way paid caregivers performed
their jobs. Moreover, children in the treatment group were less
likely than children in the control group to experience certain
disability-related health problems, and their parents were
more satisfied with the way children were spending their lives.
Finally, preliminary claims data suggest that Medicaid waiver
costs increased under Consumer Directed Care, but the
increases may have been offset by savings on other Medicaid
services, especially home health.
Conclusions: Children and their parents seemed to benefit
from the flexibility afforded by Consumer Directed Care,
particularly because they could hire family, friends, or other
providers as caregivers. Not only were parents more satisfied
with their child's care arrangements under the demonstration
program than they would have been under the traditional
waiver program, but those arrangements seemed to protect
children's health. Medicaid waiver costs increased, perhaps
because control group children did not receive all the benefits
they were entitled to in the traditional waiver program.
Implications for Policy, Delivery or Practice: Our findings
should encourage states to consider consumer-directed
supportive services program options, as Consumer Directed
Care increased parents' satisfaction, and did not jeopardize
children's health and safety. Because Consumer Directed Care
increased the likelihood that children received paid personal
care, it did increase Medicaid waiver costs. Policymakers
might find such costs to be warranted, however, since gains in
satisfaction were so great and unmet needs were reduced.
Furthermore, it appears that the net total costs to Medicaid
are small, because of offsetting reductions in children’s use of
other Medicaid services. In an earlier evaluation of Cash and
Counseling in Arkansas, the demonstration program was
found to have similarly positive effects on the satisfaction and
well-being of adult Medicaid beneficiaries who were eligible for
personal care services.
Primary Funding Source: RWJF
• Varied Regional Responses to Medicare Post-Acute Care
Prospective Payment Systems
Wen-Chieh Lin, Ph.D., Robert Kane, Ph.D., David Mehr, M.D.,
M.S., Richard Madsen, Ph.D., Gregory Petroski, M.S.
Presented by: Wen-Chieh Lin, Ph.D., Assistant Professor,
Department of Family and Community Medicine, University of
Missouri-Columbia, M226 Medical Sciences Building,
Columbia, MO 65212; Tel: 573.882.1584; Fax: 573.882.9096; Email: [email protected]
Research Objective: To examine how regions responded to
changes in Medicare post-acute care (PAC) payment systems
as enacted by the Balanced Budget Act (BBA) of 1997.
Study Design: PAC use variations across census divisions
were examined using multinomial logistic regression. The
reference category for the dependent variable (PAC settings)
was “discharged home without formal care.” We controlled
for patient, hospital and market area characteristics.
Interaction terms between Year 2000 (the post-BBA indicator)
and census divisions were included to examine differential
effects of the BBA among regions.
Population Studied: Hospitalized elderly Medicare
beneficiaries represented in the 5% sample of 1996 and 2000
Medicare claims, with one of either three rehabilitative
conditions (stroke, hip procedure, and hip fracture) or three
medical conditions (COPD, pneumonia, and CHF).
Principal Findings: Hip procedure and CHF are used here as
examples. First, data in 1996 and 2000 were analyzed
separately. Major differences in the estimated coefficients
between these two years of data were observed on variables
representing census divisions, while minor differences were
noted for patient, hospital, and PAC supply variables. Second,
data in 1996 and 2000 were combined and an independent
variable indicating the post-BBA period (Year 2000) was
added to the model. IRF utilization following hip procedures
increased (OR=1.12, 95% CI [1.04, 1.21]) and HHA utilization
decreased (OR=0.77, 95% CI [0.71, 0.84]) in 2000; SNF
utilization following CHF increased (OR=1.16, 95% CI [1.09,
1.24]) and HHA utilization decreased (OR=0.68, 95% CI [0.65,
0.72]) in 2000. Finally, we analyzed the full model including
interaction terms of the post-BBA indicator and variables
representing census divisions. Census divisions show
substantial differences in response to the BBA changes. For
example, using the West South Central as the reference
region, SNF use in the New England region increased for both
hip procedure and CHF (OR=0.82 in 1996 and OR=2.80 in
2000 for hip procedure; OR=1.71 in 1996 and OR=3.32 in
2000); HHA use following CHF in the New England region
increased (OR=1.66 in 1996 and OR=2.68 in 2000). After
taking into account for the interaction effects between the
post-BBA indicator and census divisions, SNF utilization
following hip procedures (OR=0.50, 95% CI [0.40, 0.62]) and
HHA utilization following CHF (OR=0.56, 95% CI [0.47, 0.66])
were significant lower in 2000.
Conclusions: Responses to the BBA changes differ
substantially across census divisions. The BBA changes have
minimal differential effects on other patient, hospital, and PAC
supply characteristics, as included in our model. Further
analyses will explore additional market area characteristics
that may explain the area variation.
Implications for Policy, Delivery or Practice: The highly
varied responses to the BBA changes across regions raise the
question of whether patients are discharged to appropriate
settings for PAC services. PAC choice not only depends on
patient characteristics, but also on patients’ residence and
hospital location. Standardized guidelines and optimal
outcomes of PAC utilization need to be developed and
established to guide the utilization of such highly substitutable
and supply-sensitive services. Comparable outcomes
assessment information across settings is critical, if we are to
monitor adverse outcomes resulting from inappropriate
discharge and to address the issue of accountability.
Primary Funding Source: AHRQ
• Access to Medicare Home Health Care: How Has It
Changed Following the Introduction of PPS?
Christopher Murtaugh, Ph.D., Nelda McCall, M.A., Timothy
Peng, Ph.D., Ann Meadow, Sc.D., Stanley Moore, B.S.
Presented by: Christopher Murtaugh, Ph.D., Associate
Director, Center for Home Care Policy and Research, Visiting
Nurse Service of New York, 5 Penn Plaza, 11th Floor, New
York, NY 10001; Tel: 212.609.5777; Fax: 212.290.3756; E-mail:
[email protected]
Research Objective: This paper examines the impact of the
Medicare Home Health Prospective Payment System (PPS)
on beneficiary access to home health care. A pre-post quasiexperimental design is employed to examine changes in the
incidence of use as well as the clinical and sociodemographic
characteristics of beneficiaries admitted to care before and
after the introduction of PPS in October 2000. The study will
provide policymakers with information to evaluate the
possible need for adjustments in the payment system.
Study Design: The study examines changes in access over a
three-year period: federal fiscal year (FFY) 2000 (the last year
before PPS) through FFY 2002. The main dependent variable
is receipt of home health care during the fiscal year.
Sociodemographic measures are from Centers for Medicare
and Medicaid Services’ administrative records and include
basic demographic and geographic information as well as
whether the beneficiary was enrolled in the Medicaid program
(i.e., a dual eligible). Clinical data are from inpatient facility
and physician (Part-B) claims and include whether the
beneficiary had one or more of the diagnoses that lead to a
higher score on the clinical dimension of Home Health
Resource Groups (HHRGs). Regression models are
estimated that control for changes in market conditions and
include interaction terms to test for differential effects of PPS
on selected groups.
Population Studied: The study population is all Medicare
beneficiaries living in the 50 states or the District of Columbia,
except those in a Medicare HMO or without hospital
insurance (Medicare Part-A). The analyses were conducted on
a 1% sample of beneficiaries. Home health users are
individuals with at least one paid home health visit during the
fiscal year.
Principal Findings: The incidence of home health use
declined after the introduction of PPS from 76.2 users per
1,000 beneficiaries in FFY 2000 to 69.8 in FFY 2001.
Preliminary analyses indicate that reductions in use were
greatest among dual eligibles, men, those living in rural areas,
and beneficiaries residing in states with relatively high
historical home health care use. Initial analyses also suggest
that PPS generally increased the admission of persons with
medical conditions that lead to higher HHRG scores relative
to other beneficiaries.
Conclusions: The study provides a first look at the impact of
the PPS on access to home health care. The decline in the
incidence of home health use in the initial year of PPS was not
expected since payment levels for the HHRGs are thought to
be generous. The shift toward the admission of individuals
with orthopedic and other conditions often requiring
rehabilitation therapy and decline in the admission of
beneficiaries with common medical problems that tend to be
clinically difficult to manage (e.g., heart failure) suggest that
the latter group should continue to be monitored for
unintended access changes and outcome problems.
Implications for Policy, Delivery or Practice: Policymakers
can address possible access problems by modifying the
payment system. The paper discusses alternative approaches
including changes in the HHRG scoring system and outlier
policy to respond to any evidence of unintended PPS impacts.
Primary Funding Source: RWJF
• Do Selection or Treatment Effects Explain Differences in
Medicare Costs among Hospice and Normal-Care
Donald Taylor, Jr., Ph.D., M.P.A., Courtney Van Houtven,
Ph.D., Jan Ostermann, Ph.D.
Presented by: Donald Taylor, Jr., Ph.D., M.P.A., Assistant
Professor, Public Policy, Duke University, Box 90253, 122 Old
Chemistry Building, Durham, NC 27708; Tel: 919.684.2361;
Fax: 919.684.6246; E-mail: [email protected]
Research Objective: To determine whether lower end-of-life
Medicare costs observed among decedents are due to
selection or treatment effects.
Study Design: The use of hospice has increased steadily since
it became a covered Medicare benefit in 1982, with nearly 20
percent of Medicare decedents using hospice care in 1999.
Determining whether the hospice benefit truly reduces total
Medicare costs for end-of-life care compared to usual care has
been difficult because it requires disentangling treatment
effects from selection effects. Selection implies that persons
choosing hospice are systematically different utilizers of health
care than usual care decedents, while treatment implies that
hospice truly reduces Medicare costs of end-of-life care after
controlling for selection. We use hazard models to control for
the different propensities to use hospice care among all
decedents, and create a matched control sample based on
daily predicted probabilities of hospice care prior to death
between hospice users and non-users. We then compared
costs per day from hospice entry to death for those using
hospice to costs per day for the same period of time for
matched controls (the usual care sample). We also determine
whether the results differ by diagnosis (cancer, heart disease,
COPD, and neurological degenerative disorders (including
Alzheimer’s disease)).
Population Studied: We analyzed 9,127 members of a
screening sample for the National Long Term Care Survey
who died between July 1, 1991 and December 31, 1999. We
used Medicare claims records of all types (inpatient,
outpatient, home health, physician supplier, SNF, DME, and
hospice) to determine total Medicare-financed costs among
decedents from January 1, 1991 until death or the censor date.
Principal Findings: Bivariate findings show that costs during
the last 30 days of life were lower for those using hospice
($4,498) compared to usual care ($6,227, p-value less than
0.001), a pattern that remained when considering the last 60
days of life ($8,320 versus $9,577, p-value equal to 0.02).
Costs during the last 90 days of life did not differ by hospice
use ($11,421 versus $11,708, p-value equal to 0.19). When
comparing costs among hospice users and usual care
decedents using our matched approach that controls for
selection effects, we found that hospice costs were 6% (pvalue less than 0.01) lower per day compared to controls.
Differences were larger for cancer compared to other reasons
for using hospice.
Conclusions: The results suggest that hospice has a true
treatment effect on total Medicare costs after the point of
entry into hospice; differences are not only due to selection.
Implications for Policy, Delivery or Practice: The results
suggest that expansion of hospice care to a larger proportion
of Medicare beneficiaries needing end-of-life care may reduce
rather than increase the cost to the Medicare program,
especially if the benefit can be targeted to persons within 60
days of death.
Primary Funding Source: RWJF
• Home and Community Based Waivers for Disabled
Courtney Van Houtven, Ph.D., Marisa Elena Domino, Ph.D.
Presented by: Courtney Harold Van Houtven, Ph.D., Health
Economist/Research Assistant Professor, Health Services
Research/General Internal Medicine, VA and Duke Medical
Centers, 508 Fulton Street, Durham, NC 27514; Tel:
919.286.6936; Fax: 919.416.5839; E-mail:
[email protected]
Research Objective: to examine selection effects and true
program effects of a Medicaid Home and Community Based
Waiver, controlling for endogenous selection of persons into
the program.
Study Design: North Carolina Medicaid claims and
enrollment data from Fiscal Years 1999-2000 (July 1998-June
2000) were merged together with county-level health care
supply, demographic and economic characteristics found in
the Area Resource File for North Carolina. We model selection
as a function of an array of coded health conditions, using the
Chronic Illness and Disability Payment System, developed
specifically for the disabled adult population. We then model
actual Medicaid expenditures in three areas: total
expenditures, nursing home expenditures, and hospital
inpatient expenditures, using a two-part model, controlling for
the endogeneity in selection through the use of instrumental
Population Studied: Adults identified as disabled or blind
were identified and selected from Medicaid enrollment data;
only persons with more than $10,000 in Medicaid
expenditures in the base year were selected in order to focus
on those most likely to need facility-based medical care. All
claims for these subjects were selected.
Principal Findings: We find substantial evidence of selection
into the waiver program. Waiver participation leads to a
higher likelihood of having any costs, but no difference in total
costs for users than for non-participant users. Waiver
participants have the same likelihood of any nursing home
expenditures as non-participants, but among nursing home
users, have a large decrease in expenditures. Waiver
participants are no less likely to have any hospital inpatient
expenditures than non-participants, but among inpatient
users, waiver participants have significantly lower levels of
Conclusions: Participation in a Medicaid home and
community-based waiver leads to substantially different
patterns of care. Although no total cost savings are found in
this sample, significant decreases are found in the level of
nursing home and hospital inpatient expenditures for those
on the waiver.
Implications for Policy, Delivery or Practice: Although we
cannot generalize outside the sample of North Carolina
Medicaid waiver participants, the Home and Community
Based Waiver program in this state does not seem to hold
great promise for decreasing total Medicaid expenditures,
especially when those expenditures are not just limited to the
targeted nursing home system. This finding may be due in
part to the more acutely ill population selected for this
analysis, but should also be interpreted as a sign of success.
Savings were seen in both the nursing home and inpatient
sector for persons who accessed these two service types.
Overall costs did not increase, so the combination of results
seems to mean that the CAP waiver has met its designed
goals of keeping people in the community through the greater
use of outpatient or community based services, and not
increasing total costs.
Related Posters
Poster Session A
Sunday, June 6 • 6:45 p.m.-8:00 p.m.
• Correlates of Long-Term Care Use Among Triply
Diagnosed HIV Patients in the HIV/AIDS Treatment
Adherence, Health Outcomes and Cost Study
Susan Ettner, Ph.D., Alfonso Ang, Ph.D., Marcia Weaver,
Ph.D., Chris Conover, Ph.D., Peter Arno, Ph.D.
Presented by: Alfonso Ang, Ph.D., Principal Statistician,
School of Medicine, University of California, Los Angeles, 911
Broxton Plaza, Suite 201, Los Angeles, CA 90095; Tel:
323.463.8850; E-mail: [email protected]
Research Objective: To examine the factors associated with
the use of formal and informal long-term care among triply
diagnosed patients, who account for 13% of all HIV patients
and 27% of their costs.
Study Design: Observational cohort study, based on inperson interviews and medical record review. We estimate a
multinomial logistic regression for whether the patient
received any formal long-term care; informal long-term care
only; or no long-term care. Then we estimate a two-part
model of the number of home care hours received, separately
estimating the probability of any home care use and the
conditional level of home care hours and combining the
estimates to derive predictive margins for unconditional use.
Confidence intervals were derived using bootstrapping
methods. Missing data are multiply imputed using Monte
Carlo Markov Chain methods. All regressions include fixed
effects to adjust for within-site correlation of patients.
Population Studied: 1,046 HIV patients meeting clinical
criteria for at least one mental health and one substance
Principal Findings: 31% of study patients used long-term care
during the 3 months prior to baseline. 2% used nursing
homes, 4% used day hospitals, and 27% used home care.
Patients with either higher Physical Composite (PCS) or
Mental Composite (MCS) Scores were less likely to receive
informal care, relative to no long-term care. However, those
with higher PCS scores were less likely to receive formal care,
while those with higher MCS scores were more likely to receive
it. Patients who abused alcohol only were almost twice as
likely as those abusing both alcohol and drugs to receive
informal care vs. no long-term care. Medicaid beneficiaries
were almost three times as likely to receive formal care,
relative to receiving no long-term care, and dual MedicareMedicaid beneficiaries were almost fivefold as likely. Dual
eligibles were about three times as likely to receive formal
long-term care relative to informal care only, and Medicareonly beneficiaries were over four times as likely. Women were
1½ times more likely than men to receive informal care rather
than no long-term care, but only half as likely to receive formal
care, relative to informal care only. Married persons were
only half as likely as never-married persons to receive formal
care relative to no long-term care. Women, college-educated
patients and patients abusing only a single substance were
more likely to receive any home care; patients with higher PCS
or MCS scores were less likely. Overall, healthier persons and
Latinos received fewer home care hours and women and
married and persons received more.
Conclusions: Medicare and Medicaid are strongly associated
with formal long-term care use among triply diagnosed
patients. While health need and availability of caregivers are
significant predictors of long-term care patterns, so too are
other sociodemographic characteristics that may or may not
be related to need.
Implications for Policy, Delivery or Practice: Access to longterm care may be a policy concern for HIV patients in certain
sociodemographic groups or who lack strong social support
systems. Public insurance programs may play a key role in
facilitating the use of formal long-term care among vulnerable
triply diagnosed patients.
Primary Funding Source: Center for Mental Health Services
• The Impact of Care Coordination on Use and
Expenditures in a Disabled Medicaid Population
Sema Aydede, Ph.D., Pamela Coleman, M.B.A., Don
Haywood, M.A., Gary Young, JD, Elizabeth Shenkman, Ph.D.
Presented by: Sema Aydede, Ph.D., Associate Scholar,
University of Florida, Institute for Child Health Policy, 1329
S.W. 16th Street, 5th Floor, Room 5130, Gainesville, FL 32608;
Tel: 352.265.7220 Ext. 86335; Fax: 352.265.7221; E-mail:
[email protected]
Research Objective: Efficient use of health care resources are
becoming more important in an era of state budget deficits
and increasing health care expenditures. This study explores
how effective integration and coordination of health care
services are in achieving efficient use of health care resources.
The analysis focuses on STAR+PLUS, a pilot program in Texas
for Supplemental Security Income (SSI) beneficiaries.
Integration and coordination become especially crucial for
disabled and chronically ill populations. The STAR+PLUS
program intends to achieve a seamless continuum of care by
integrating acute and long-term care in a managed care
Study Design: A quasi-experimental design with health status
and severity of illness matched intervention and control
groups is employed. Enrollment and encounter data on 2315
Medicaid-only SSI adults (aged 21 and above) receiving
community-based long-term care services with at least 3
months continuous enrollment in the STAR+PLUS program
during September 2001-August 2002 were used in forming
the intervention group. Enrollment and encounter data from
STAR, the Medicaid managed care organization (MCO)
program in Texas, was used in forming a control group with
similar characteristics. Both STAR+PLUS and STAR MCO
enrollees were grouped into nine mutually exclusive Clinical
Risk Group (CRG) categories (such as significant acute, minor
chronic, malignancies and catastrophic conditions) using the
CRG software. It was found that the voluntary nature of
enrollment for SSI beneficiaries in the STAR MCO program
results in a self-selection process and a healthier group of SSI
is enrolled in STAR MCOs when compared to SSI enrollees in
STAR+PLUS. As a result, stratified random sampling at the
severity of illness level within each CRG health status category
was used in matching the case-mix distribution of the
intervention group to that of the control group.
Population Studied: Medicaid-only adult SSI beneficiaries
receiving community-based long-term care services.
Principal Findings: STAR+PLUS enrollees receiving
community-based long-term care services are mostly female
(63.11%) and almost all live alone (95.98%). Multivariable
analyses show that SSI beneficiaries receiving care
coordination services in an integrated environment have lower
rates of inpatient stays (OR 0.75, 95% CI 0.58-0.94, p=0.0310)
and emergency department visits (OR 0.68, 95% CI 0.54-0.86,
p=0.0012) when compared to the use rates for SSI
beneficiaries in nonintegrated environments without care
coordination. Further, PMPM expenditures are lower
(coefficient=-0.2556, p=0.0143) for SSI beneficiaries receiving
care coordination.
Conclusions: Based on findings from this study, integration
and care coordination efforts in the STAR+PLUS program are
having a positive impact on health care expenditures, inpatient
stays and emergency department visits for disabled and
chronically ill populations receiving long-term care services.
Implications for Policy, Delivery or Practice: The results
from this study indicate that state programs would benefit
from adopting an integrated approach coupled with care
coordination in the provision of health care services to
enrollees with complex needs. This approach would not only
help states that are experiencing tightened budgets through
reductions in health care expenditures, but would also benefit
program enrollees through reducing their need for inpatient
stays and emergency department visits.
Primary Funding Source: Texas Health and Human Services
• Long-Term Care Facility Characteristics Predictive of
Increased Influenza and Pneumococcal Vaccination
Coverage for Residents
Barbara Bardenheier, M.P.H., M.A., Abigail Shefer, M.D.,
Linda McKibben, M.D., M.P.H., Henry Roberts, Ph.D., Dale
Bratzler, DO, M.P.H.
Presented by: Barbara Bardenheier, M.P.H., M.A.,
Epidemiologist, National Immunization Program, CDC, 1600
Clifton Road, N.E., MS E-52, Atlanta, GA 30333; Tel:
404.639.8789; Fax: 404.639.8614; E-mail: [email protected]
Research Objective: Identify Long-term care facility (LTCF)
characteristics associated with increased vaccination coverage.
Study Design: Intervention study. Data on LTCF-level
characteristics were collected by mailed, self-administered
surveys of selected facilities in 14 states and from a Federal
administrative database, OSCAR (On-line Survey Certification
and Reporting System.) Immunization coverage was
abstracted from residents’ medical charts using facility-level
samples. Data were collected from a sample of 20 LTCFs in
each of 9 intervention states and 5 control states in 2000 for
baseline and in 2002 for post-intervention.
Population Studied: LTCFs in 9 intervention states (DC, FL,
HI, ID, KY, MA, MN, MT, NM) and 5 control states (OH, PA,
WI, SC, NV).
Principal Findings: 215 (91.9%) facilities participated in the
survey both years. Overall, 106(50%) of the facilities’ coverage
increased for both vaccines. Influenza vaccination coverage
increased an average of 1.4% (range: -35.1%-68.9%) in the
intervention facilities and 0.02% (-47.5% - 48.0%) in the
control facilities (ns). Pneumococcal vaccination coverage
increased an average of 2.4% (range: -95.8% - 87.5%) in the
intervention facilities and 1.9% (range: -54.8% - 80.3%) in the
control facilities (ns). Only 25 (11.9%) of facilities adopted the
ACIP-endorsed standing orders model program (SOP) for
influenza, and 22 (10.4%) did for pneumococcal vaccines
(baseline: <10% for each). Factors associated with a
significant increase in influenza vaccination coverage
included: 1) Small facilities (<60 beds): +4.10% vs large
facilities (>120 beds): -2.46% ; 2) Change in written
immunization protocol to require documentation of refusals
by residents or guardians (+5.28% vs -0.14%); and 3)
Documentation of influenza vaccinations in a consistent place
using a standard form in which the vaccine history could not
be removed (+1.17% vs -7.94%). Factors associated with a
significant increase in pneumococcal vaccination coverage
included: 1) Affiliation with a multi-facility chain (+5.65% vs 1.56%); 2) Adoption of centralized tracking of pneumococcal
immunizations (+9.05% vs -0.19%); and 3) Change to record
pneumococcal immunizations in a consistent place (+14.55%
vs -0.25%).
Conclusions: Though very few facilities adopted the SOP,
factors that are part of a functioning SOP (i.e., chart
documentation and centralized tracking) were associated with
significant improvements in vaccination coverage.
Implications for Policy, Delivery or Practice: To improve the
health of LTCF residents, strategies should be considered that
increase immunization coverage including: centralized
tracking systems, documenting vaccination status in a
consistent place using a standardized form in which the
vaccine history cannot be removed to an archived chart, and
use of SOPs when possible.
Primary Funding Source: CDC
• Project Protect: Pneumococcal Vaccination Policies and
Coverage in Washington State Nursing Homes
M. Patricia DeHart, Sc.D., Leslie Barnette, M.D., Sandra
Salinas, RHIT, Leslie Barnette, Jr., M.D., Henry Mustin, M.D.,
M.P.H., Lewis, Karen, M.P.H., Constance Corbett/ Pamela K.
Green, M.P.H./Ph.D.
Presented by: Leslie Barnette, M.D., Medical Director,
Healthcare Improvement, WA, Medical Affairs, Qualis Health,
10700 Meridian Avenue N., P.O. Box 33400, Seattle, WA
98133; Tel: 206.364.9700 Ext. 7242; Fax: 206.361.5563; E-mail:
[email protected]
Research Objective: 1) Assess the current prevalence of
standing orders or other written guidelines policies and their
impact on vaccination rates in nursing homes in Washington
State; 2)to increase the number of nursing homes with
standing orders or other guidelines for pneumococcal
vaccination 3)to estimate the pneumococcal coverage among
the nursing home resident population over 65 years of age in
Washington, and 4) to increase the percentage of nursing
home residents over 65 years if age who receive
pneumococcal vaccination.
Study Design: In 1999 a baseline survey was developed and
sent to every Washington State nursing home to assess
current pneumococcal vaccination policies, and explore
reasons for not having addressed such a policy. Also tested
was the location of documentation of immunization status,
and whether a permanent (not thinned from current chart)
vaccination record was utilized to facilitate awareness of
immunizationstatus of residents. This study was undertaken
as a collaboration between Qualis Health, the Quality
Improvement Organization for Washington (acting under a
contract with the Centers for Medicare and Medicaid
Services), the Washington State Department of Health, and
the Immunization Action Coalition of Washington. All but
one of the surveys were completed and returned (99.6%). In
the fall of 2001 all Washington State nursing homes in the
OSCAR database were re-surveyed to assess policy changes
occurring in the intervening period. All facilities returned the
second survey. The project baseline and post-intervention
pneumococcal vaccination rates of current residents were
derived using the MDS data. Random samples of 1,800 and
1,487 of 17,500 identified residents were selected for chart
abstraction. Response rates of 82% and 75% were achieved
respectively. Validation samples of 10% of the facilities for
inter-rater reliability yielded a concurrence rate (Kappa
statistic) of 0.703. An educational and process improvement
intervention was undertaked between the surveys. A "toolkit"
of materials for use in creating an in-house standing orders
program (sample orders, policy and procedures, permanent
immunization record for residents, alogrithm for deciding
vaccination eligibility, billing information, supporting articles
and immunization guidelines from the CDC, OIG, and current
immunization medical literature with extensive annotated
bibliography) was provided to each nursing home. An interim
assessment of standing orders/guidelines use, or facility plans
for implementing such a program, was followed by personal
telephone contacts. All facilities were offered personal
consultative site visits, which were made to 12 facilities
requesting them. SAS 8.01 and EpiInfo 6 were used for the
statistical analysis. A (p=<0.05) determined significance on all
statistical tests. Comparisons were made using chi-squared
analyses. Odds ratios were calculated using logistic
regression analysis.
Population Studied: All (269 in 1999, 257 in
2001)Washington State nursing homes (Long-term care
facilities) and a 10% random sample of their 17,500 residents
over 65 years of age.
Principal Findings: The use of standing orders or other
written guidelines policies by nursing homes increased 14
percent from 1999 to 2001. Comparison between
pneumococcal vaccination statistics in 2000 (47%) and 2002
(61%) showed a significant increase in the percentage of
Washington State nursing home residents over 65 years of age
who had received pneumococcal vaccination by 2002 (Chisquared=48.88, p=<0.0001). Residents in facilities having
standing orders or other written guidelines were almost three
times more likely to have been vaccinated against
pneumococcal disease than those in facilities with no
policy/guidelines. There were significant increases in the use
of standing orders or other written guidelines, and in the
percentage of residents vaccinated, between initial and remeasurement periods. Overall, residents were 76% more
likely to have received pneumococcal vaccinations in 2002
than in 2000 (OR= 1.76, 95% CI: 1.49, 2.07) and over 95% of
the vaccinations were documented in the medical record.
Conclusions: In both 2000 and 2002, the odds of a resident
receiving a PPV in a Washington State nursing home having
standing orders or other written guidelines are estimated to be
two and one half times greater than for residents in facilities
without any PPV guidelines. (2000: OR=2.59, 95% CI= 1.54,
4.34; 2002: OR=3.19 CI= 1.68, 6.01). The high response rates
for both phases of this large statewide survey help insure that
the findings can be generalized to the total population of
nursing home residents in the state. The strong agreement
between vaccination information abstracted by nursing home
personnel and project staff, as shown by the kappa statistics,
indicates that the findings are reliable. While the educational
intervention activities were important parts of this project, the
survey was not designed to measure their effect on either the
use of standing orders or other vaccination guidelines, nor on
pneumococcal vaccination coverage in the nursing home
Implications for Policy, Delivery or Practice: The
effectiveness of having standing orders or written guidelines in
effect for the provision of pneumococcal immunizations is
clearly shown in this study. At the time of this study there was
no specific exemption for the general requirement for
physician signature on any order effecting a medical
intervention for patients under the CMS regulations. It is
believed that this contributed to the "interchangeability" of the
terms "standing orders' and "written guidelines" revealed in
these surveys, and to concerns which had led to some
organizations prohibiting standing orders of any kind in their
nursing home facilities. In 2003 CMS has promulgated
specific formal legal exception for orders for pneumococcal
and influenza immunizations, thus facilitating their use.
Further administrative and fiscal policies encouraging
installation of standing orders and in otherwise enhancing
provision of pneumococcal (and other) immunizations should
be helpful in achieving the 2010 healthy people immunization
goals of 90% of the over-65 year old population.
Primary Funding Source: CMS, Washington State
Department of Health
• The Perception of Depression in Long Term Care
Residents: A Qualitative Study Using Residential
Holly Carroll, MSPH, Ken Watkins, Ph.D., Sandra Evans,
Ph.D., Peg Hess, Ph.D.
Presented by: Holly Carroll, MSPH, Graduate Assistant,
Health Promotion Education and Behavior, University of
South Carolina, 550 Harbor Cove Lane, Apartment 1200,
Charleston, SC 29412; Tel: 843.364.5696; Fax: 843.876.1104; Email: [email protected]
Research Objective: The study addresses the following
research questions among residents of LTC:
1. What are the common themes regarding depression and its
surrounding issues (i.e., loss, transition, grief, etc.)?
2. What are perceptions of depression as experienced by
themselves and others? More specifically, how do they
perceive their own emotional well-being, and how do they
perceive other residents’ emotional well- being?
3. What resources are utilized as coping strategies?
4. To what extent is journal writing an effective method of
gaining qualitative data in the older adult population?
5. What is the relationship between scores of a screening
measure for depression (Geriatric Depression Scale, Brink et
al., 1982), and the scores of residents’ perceptions of meaning
of life (Meaning Survey, Pargament 1999)?
6. What are the relationships of the journal themes to
depressive symptoms and perceptions of meaning of life?
Study Design: This is a qualitative study that used the
grounded theory to identify various domains regarding issues
that surround symptoms of depression and long term care
residents. The participants responded to statements in a 5-day
journal, completed the Geriatric Depression Scale (GDS-15),
and the Meaning Survey (MS), and then a follow up interview
regarding their feelings about writing in the journal.
Population Studied: Twenty-four residents in 6 assisted living
facilities and 1 retirement community across three counties in
South Carolina participated in a study to gain an
understanding of older adults’ perception of depression in
long term care (LTC) settings.
Principal Findings: The GDS-15 indicated that 33.33% of the
participants were depressed. An evaluation of the implications
of spiritual meaning regarding the individual’s physical and
mental health was measured using the Meaning Survey (MS).
The mean score was 3.91 out of a 5 point Likert Scale (SD =
.71) Presently there is no interpretation of the scale; however,
this score indicates the degree that participants relied upon
their spirituality in regards to their physical and mental health.
Each participant’s journal consisted of 5- guided questions in
relation to emotional, physical, and social health. The
participants’ journals yielded six domains reflecting their
perceptions of depression: long term care environment,
participant emotional well being, overall residential emotional
well being, coping resources used, journaling as a coping
resource, and enjoyed activities. Follow-up interviews
determined that journal writing was appropriate and beneficial
for some LTC populations.
Conclusions: It was found that for certain populations of
older adults in LTC, journaling is an appropriate investigative
tool that provides qualitative data for researchers.
Implications for Policy, Delivery or Practice: Implications
from the findings indicate that LTC facilities’ efforts should be
channeled to increase the availability and quality of mental
health services to residents. This should include regular
residential depression screenings, as well as the
standardization of mental health care services within LTC
• Hospice Use among Blacks: Health Beliefs, Spirituality
and Social Relationships as Predictive Factors
Norma Conner, Ph.D.
Presented by: Norma Conner, Ph.D., Visiting Assistant
Professor, College of Nursing, University of South Florida,
12901 Bruce B. Downs Boulevard, MDC 22, Tampa, FL 33612;
Tel: 813.974.3337; Fax: 813.974.5418; E-mail:
[email protected]
Research Objective: To examine the differential ability of
demographic variables, beliefs and values aobut end-of-life,
spirituality and social relationships to predict hospice use
among Blacks.
Study Design: Using a prospective, correlational design,
components of The Behavioral Model of Health Services Use
were tested to determine their ability to predict Hospice Use
Among Blacks. Data were gathered from 104 Black men and
women who were determined by their physicians to be
appropriate for hospice level of care. Instruments included
The Spiritual Involvement and Beliefs Scale (SIBS), Treatment
Preferences Scale (TPS), and demographics and follow-up
questionnaires. The instruments were completed while
patients were at routine clinic appointments or were
inpatients. Follow-up for determination of the patient’s
hospice services use took place with the physicians four
months after the initial data collection.
Population Studied: Data were collected and analyzed from
104 Black men and women, recruited between November
2000 and November 2002, from six inpatient and outpatient
settings in metropolitan New York and New Jersey hospitals.
Principal Findings: Only 34% of the 104 subjects participated
in hospice services and even many of those indicated a
preference for the most aggressive life-sustaining treatments.
Chi-square, sequential and stepwise logistic regressions
revealed that the best predictive model consisted of: presence
of a caregiver (Wald = 4.46, sig. .035; O.R. 9.67), religious
affiliation (Wald = 4.96, sig. .026; O.R. 4.74), and gender
(Wald = 3.98, sig. .046; O.R. 2.47). Together these factors
predicted 13.7% to 19% of hospice use among Blacks. There
was a ceiling effect on the SIBS and TPS. Socioeconomic
variables did not vary enough within the sample to be properly
tested in this study.
Additional factors revealed during the study indicated
concerns among potential hospice patients about their family
caregiving responsibilities, safe storage of narcotics in a milieu
of substance-abusing family members, the non-availability of
narcotics at local pharmacies, and terminal prognosis at the
time of diagnosis.
Conclusions: The Behavioral Model of Health Services Use
did not adequately predict hospice use among Blacks.
Presence of a caregiver, religious affiliation, and gender
together predicted only about 20% of Hospice Use among
Blacks. Newer interpretations of the model may be more
appropriate. The inclusion of stage of disease at diagnosis,
and social role of the patient may impact end-of-life decision
making as well.
Implications for Policy, Delivery or Practice: The current
study findings have ramifications for changing health policy,
particularly the Medicare Hospice Benefit. Currently, not all
hospices require the presence of an informal caregiver for a
patient to participate in hospice. Yet among Blacks, in the
absence of an informal caregiver, patients are less likely to
choose hospice. The Medicare Hospice Benefit does not
allow for a patient’s blood or legal relative to become the paid
caregiver. Black caregivers may feel torn between a traditional
value of caring for the family member contemplating hospice
and their own need to earn a living. National policy that
would provide a source of income to the informal caregiver
electing to stay with the hospice patient may break down this
barrier to hospice use among Blacks.
• Policy Implications of Cost and Care Outcome
Differences among Dual Eligibles Using Alternative
Organizational Models for Long-Term Care
James Cooney, Ph.D., Glenn Landers, M.B.A./MHA, Robert
Curry, M.D./M.P.H., Jay Bae, Ph.D.
Presented by: James Cooney, Ph.D., Professor of Health
Administration, Robinson College of Business, Georgia State
University, University Plaza, Atlanta, GA 30303; Tel:
404.842.5024; Fax: 404.842.5223; E-mail: [email protected]
Research Objective: To assist in improving state Medicaid
resource allocation decisions, identify federal and state policy
implications of observed cost and care differences between
traditional and waivered models of LTC delivery programs
Study Design: Retrospective cohort study of long-term and
concomitant acute care among Dual Eligible patients of
Georgia’s nursing facilities (NF) and waivered home and
community-based services (HCBS).
Population Studied: The Study cohort encompassed all of the
more than 23,000 individuals receiving long-term care in
calendar year 1999 in either a Georgia HCBS or NF. All care
services and costs for eighty-eight percent of those, verified as
Dual Eligibles, were documented for twelve months after their
inclusion in the cohort.
Principal Findings: The alternative LTC organizational
models of NFs and HCBSs do share patient populations with
common socio-demographic characteristics (gender, raceethnicity and home of residence), these models also had
statistically significant patient population differences affecting
care needs and service costs: age; severity of illness as
measured by Chronic Illness and Disability Payment and
Diagnostic Cost Group systems; and, length of stay and
mortality status at discharge.
Across the alternative models, it was found that they all
shared patterns of frequent and repetitive transfer of patients
between LTC programs and hospitals; a large proportion of
inter-institutional transfers were for Ambulatory Care Sensitive
Conditions; and, all were found to have high cost of care in the
last months of life.
Over common time periods and across the alternative
models, both public insurance programs do make statistically
significant contributions to the overall (acute and long-term)
care costs of the LTC program clients.
Conclusions: The cohort patterns of long-term and
concomitant, related care costs appear to be influenced more
by parochial payment policies of the public insurers than
potential efficiencies of the service delivery alternatives.
Viewing only one insurer’s costs (e.g., Medicaid) for only one
proportion of a beneficiary’s care (e.g., long-term care) will not
provide a sufficiently complete picture of care or cost for
resource allocation improvement decisions.
Methodologically, an integrated Medicare and Medicaid
database provides a more complete perspective on problem
detection and system improvement. However, significant
problems still exist for integration of the two databases
especially when considering the waivered services component
of Medicaid long-term care.
Implications for Policy, Delivery or Practice: Given the
growing aging population and continued separation of
Medicare and Medicaid reimbursement policy, there needs to
be a greater understanding and use of Inter-institutional
planning for patient transfer and care management;
For quality improvement and costs control purposes, study of
policies facilitating frequent inter-institutional transfers and
their outcomes needs greater emphasis and optimistically,
greater operational changes;
The consequences of HCBS cost-share requirements on care
outcomes need more research emphasis and depending on
those findings, appropriate adjustment of policy to assured
appropriate cost-effective balance;
Greater emphasis at both the federal and state(s) levels on
more uniform, complete and continuous integration of
Medicare and Medicaid long-term care related databases.
Such efforts should also be extended to include enhanced
options for wavered services research
Primary Funding Source: Georgia Department of Community
• Unmet Need for Help with Daily Activities among
Persons 50 and Older with Disabilities
Mary Jo Gibson, M.A.
Presented by: Mary Jo Gibson, M.A., Senior Policy Advisor,
Public Policy Institute, AARP, 601 E. Street, N.W., Washington,
DC 20049; Tel: 202.434.3896; Fax: 202.434.6402; E-mail:
[email protected]
Research Objective: (1) To examine the characteristics of
persons age 50 and older with disabilities who do and do not
report unmet need for help with daily activities; (2) to
determine which socioeconomic and other factors, such as
severity or type of disability, are most closely associated with
unmet need; (3) to identify adverse consequences associated
with unmet need; (4) to identify the changes respondents
report would cause a major improvement in their lives; and
(5) to draw out the implications for policy and practice.
Study Design: This study reports unpublished data from a
survey on independent living and disability conducted by
Harris Interactive for AARP in Sept. 2002 of 1,100 persons 50
and older with disabilities. The survey probed what
respondents perceive as facilitating or impeding their
independence and quality of life. We analyze these data by a
number of variables, including a measure of unmet need for
personal assistance services. The data are supplemented by a
review of the literature on unmet need among persons with
Population Studied: Non-institutionalized adults age 50 and
older with disabilities.
Principal Findings: Almost one quarter (23%) of the sample
reported needing more help than they receive now with daily
activities. Persons with unmet needs were more likely to be
age 50-64 than 65+; to have severe disabilities, to be
black/African American; to have low incomes, to live alone,
and to live in an urban area. A substantial majority (63%) of
those reporting unmet need were receiving help with activities,
predominantly from unpaid family members with whom they
lived. Unmet need is associated with greater life
dissatisfaction, postponing needed health care, having less
control over key decisions, and being completely unable to
work because of a disability. However, persons with unmet
needs are no more pessimistic about their future than their
counterparts who do not report unmet needs. The top three
changes persons with unmet need say would cause a major
improvement in the quality of their lives are: (1) more control
over decisions about services and help needed; (2) someone
known and trusted to help with daily activities; and (3) a way
to pay for long-term services and equipment.
Conclusions: The data paint a picture of both the strengths
and vulnerabilities of persons age 50 and older with
disabilities who have unmet needs, and help us understand
what they need to live with dignity and independence.
Findings will be compared with and discussed in the context
of other published findings on unmet need among persons
with disabilities, such as those from the National Health
Interview Survey on Disability.
Implications for Policy, Delivery or Practice: Among the
many policy implications of the study are the need to: (1)
protect and improve the Medicaid safety-net for home and
community-based services; (2) encourage consumer-directed
services for home and community-based services, including
“cash and counseling” type programs; and (3) insure
individuals against the high costs of long-term services and
Primary Funding Source: AARP Public Policy Institute
• Monitoring and Improving the Quality of Long-Term
Care: A Comparison of 19 Countries
Manfred Huber, Ph.D., Weonjong Kim, Ph.D., Patrick
Hennessy, M.Sc.Econ.
Presented by: Manfred Huber, Ph.D., Head, Health
Indicators, Health and Ageing, Social Policy Division, OECD,
2, rue André-Pascal, Paris, 75775; Tel: 331.4524.7633; Fax:
331.4430.6361; E-mail: [email protected]
Research Objective: To analyse in an international
comparison different regulatory approaches to monitor and
improve the quality of long-term care in different settings of
care (nursing homes and other institutions, home care); to
collect available evidence across countries about quality
deficits; to examine ways to improve the available evidence
base; to consider the implications of better quality for the cost
of long-term care.
Study Design: Based on a review of the literature, a
questionnaire on quality regulation, and widespread concerns
about quality deficits was developed and information was
collected and analysed in co-operation with a network of
national experts. This was done as part of a larger
international study on policy trends in long-term care since
Population Studied: Nineteen OECD countries (Australia,
Austria, Canada, Germany, Hungary, Ireland, Japan, Korea,
Luxembourg, Mexico, the Netherlands, New Zealand, Norway,
Poland, Spain, Sweden, Switzerland, the United Kingdom and
the United States).
Principal Findings: The quality of long-term care services for
older persons in many cases does not meet the expectations
of the public, the users of services and their families, - more
so for institutional care than for home care. Quality
regulations for long-term care have been made more
comprehensive and complex in recent years with a greater
focus on outcomes and continuous quality improvement.
Policy concerns from OECD countries link quality deficits to
workforce shortages and structural quality. Major investments
will be needed to improve quality in dimensions such as the
average number of persons sharing rooms in institutions. This
will exert cost pressure on long-term care services.
Conclusions: The drive to raise quality standards in acute
health care has been accompanied in many countries by
governments taking a more active role in regulating and
inspecting quality of long-term care services. This has two
aims: to reduce the risk of receiving poor-quality care
(including the risk of harmful care), and to raise average
standards of service. Comprehensive publication of quality
assessment could become a key to improving consumer
protection and in fostering a climate of competition for
quality. There is evidence that ad hoc approaches and
fragmentation of quality initiatives may result in less-than
optimal results with a strong case for co-operation on quality
standards and measurement at the national and international
Implications for Policy, Delivery or Practice: Concerns
about severe quality deficits have been important drivers of
long-term care reforms in several countries. The study of
quality regulations and outcomes in international
comparisons, however, is a relatively new field of study. This
study will provide administrations in countries with an
overview and best practice examples of quality strategies as
well as available evidence about their outcomes, to aid the
development of national quality of care strategies.
Primary Funding Source: OECD Health Project
• The Effect of Medicaid Bed-Hold Policies on Hospital
Length of Stay
Mark Schleinitz, M.D., M.S., Orna Intrator, Ph.D., Ning Wu,
M.D., M.S., Vincent Mor, Ph.D.
Presented by: Orna Intrator, Ph.D., Assistant Professor
(Research), Community Health, Brown University, Box G-ST2,
Providence, RI 02912; Tel: 401.863.3579; Fax: 401.863.9219;
E-mail: [email protected]
Research Objective: In some states, Medicaid pays nursing
homes a portion of the daily rate when a resident is
hospitalized. Such payments reserve a bed in the nursing
home, ideally to facilitate hospital discharge. The effect of bedhold policies on hospital length of stay is unknown. We
evaluated the hypothesis that such a policy would reduce
length of stay compared to no policy, but that a very generous
policy may lengthen hospital stays.
Study Design: We surveyed bed-hold policies from the 48
contiguous United States and quantified the generosity of
these policies by calculating equivalent reimbursement days,
or the number of full nursing home days that could be paid for
with the maximum, per hospitalization, bed-hold payment in
each state. As length of stay depends on whether patients are
hospitalized, we used hierarchical modeling to determine the
association between bed-hold policy and length of
hospitalization. We first used logistic regression to determine
the probability of stroke hospitalization for each patient
controlling for their state of residence. We used analysis of
variance to compare the average probability of stroke
hospitalization for each state. We then used a general
estimating equation to determine the effect of bed-hold
equivalent reimbursement days on length of hospital stay,
controlling for the probability of hospitalization. In each
analytic stage we clustered at the facility level and controlled
for demographic variables, comorbidities, and need for
intensive care.
Population Studied: Using the nursing home Minimum Data
Set and Medicare claims data from 2000, we identified 6,710
non-fatal stroke hospitalizations occurring in long-stay
residents of urban, free-standing nursing homes in the 48
contiguous states. After excluding the 12 states with less than
20 such hospitalizations, we further analyzed 6,614 stroke
hospitalizations occurring in 490,000 residents from 36
Principal Findings: States varied in the generosity of bed-hold
policies. Eleven states did not reimburse during
hospitalizations, whereas the most generous state had no
limit on bed-hold reimbursement. Generosity of bed-hold
policy in equivalent reimbursement days did not correlate with
the average per diem reimbursement rate. The probability of
stroke hospitalization varied by state from a minimum of
0.9% to 2.6% (p<0.0001). Bed-hold policies that provided the
average number of equivalent reimbursement days were
associated with the shortest mean length of stay.
Hospitalizations in states without bed-hold reimbursement
were 0.10 days longer, (95% confidence interval 0.03-0.17) and
those in states with the most generous policies were 0.33 days
longer (0.20-0.45) than the shortest average length of stay.
Conclusions: Whereas modest bed hold policies are
associated with shorter length of stay than no such policy, our
study implies that more generous policies are associated with
prolonged hospitalization.
Implications for Policy, Delivery or Practice: While the
consequences of such policies must be explored further, more
generous policies offer no incremental decrease in length of
stay over modest policies, and may be associated with
increased cost.
Primary Funding Source: NIA
• Comparing Medicaid Long-Term Care Waiver Programs
Glenn M. Landers, M.B.A., M.H.A., James Cooney, Jr., Ph.D.
Presented by: Glenn Landers, M.B.A., M.H.A., Senior
Research Associate, Georgia Health Policy Center, Andrew
Young School of Policy Studies, Georgia State University, 1
Park Place South, Atlanta, GA 30303; Tel: 404.463.9562; Fax:
404.651.3147; E-mail: [email protected]
Research Objective: Compare the costs and care outcomes
of two Georgia Medicaid home and community based waiver
programs for older adults.
Study Design: Retrospective, cohort analysis using Medicare
and Georgia Medicaid administrative claims data.
Population Studied: 15,437 Georgians over age 64 who
qualified for institutional placement in 1999 but received
services from one of two Medicaid waiver programs (CCSP
and SOURCE). CCSP is a traditional Medicaid home based
waiver program serving as an alternative to institutional
placement. SOURCE is a demonstration project that
incorporates primary care physician oversight and enhanced
case management.
Principal Findings: *Patients were similar in age.
*Patients were significantly different in race, gender, and
*CCSP clients were more dually eligible, and SOURCE clients
were more Medicaid-only.
*Both CCSP and SOURCE clients used significantly more
Medicare home health prior to program admission.
*Patients of both programs shared the top four principal
diagnoses: essential hypertention, general symptoms,
symptoms involving the respiratory system, and diabetes
*CCSP patients were slightly more likely to experience an
inpatient hospital admission.
*Patients of both programs used ER, outpatient, and therapy
services similarly.
*CCSP patients were more likely to experience three or more
hospital stays over twelve months.
*CCSP had significantly more patients who experienced at
least one ambulatory care sensitive condition resulting in a
hospital stay over twelve months.
*At the end of twelve months, 10 percent of SOURCE patients
and 8 percent of CCSP patients resided in nursing facilities.
*Illness severity scores of SOURCE patients were slightly
higher than CCSP patients.
*Total monthly severity adjusted SOURCE costs were slightly
higher than CCSP ($2,801 vs. $2,626), with total Medicare
costs slightly higher for CCSP and total Medicaid costs slightly
higher for SOURCE.
Conclusions: *Higher rates of inpatient hospitalization for
CCSP clients may be a function of CCSP's higher ratio of
patients with dual eligibility.
*Medicaid financed home health may substitute for Medicare
home health once a patient enters a Medicaid waiver
*Primary care physician oversight and enhanced case
management may reduce ambulatory care sensitive
conditions resulting in hospital admission and frequent
hospitalizations overall when incorporated in a Medicaid
waiver program for elder adults.
Implications for Policy, Delivery or Practice: Introduction of
primary care physician oversight and enhanced case
management to Medicaid waiver programs for older adults
may improve patient care at similar cost. The possible
incentive to hospitalize based on reimbursement should be
investigated further.
Primary Funding Source: Georgia Department of Community
• Do Non-Profit and For-Profit Hospices Behave
Richard Lindrooth, Ph.D., Burton Weisbrod, Ph.D.
Presented by: Richard Lindrooth, Ph.D., Assistant Professor,
Department of Health Administration and Policy, MUSC, 19
Hagood Avenue, P.O. Box 250807, Charleston, SC 29425; Tel:
843.792.2192; Fax: 843.792.3152; E-mail: [email protected]
Research Objective: To test whether non-profit and for-profit
hospices respond differently to the financial incentives of
Medicare payment policy.
Study Design: : A hospice can maximize profit maximizing
patient length of stay (LOS), because while daily costs are
high several days after admission and several days before
impending death, payment is fixed per day and does not vary
be diagnosis. Thus by maximizing LOS, the length of interim
period of relatively low costs (and higher reimbursement) is
also maximized. We posit that a hospice can influence LOS
(i.e. patient mix) in the following ways: it can offer attributes
that are attractive to patients with a diagnosis associated with
a long hospice LOS; market itself to physicians/ discharge
planners who treat patients with diagnoses associated with
long LOS; and encourage physicians to admit patients earlier
in the progression of the disease than they otherwise would.
We test these predictions using a dataset of all Medicare
hospice admissions in 1993. We examine the shares of each
diagnosis in for-profit and non-profit hospices, and test
whether there are more ex-ante profitable patients at for-profit
hospices. In addition, we test whether there are differences in
LOS within each diagnosis.
Population Studied: We use a dataset that consists of all
Medicare reimbursed hospice admissions in 1993 from the
Medicare SAF files. Hospice information was obtained from
the MEDPAR files. We have information from a 720 look back
window as well as a 2.5 year follow-up.
Principal Findings: : Most of the variability in expected LOS
is explained by diagnosis, and thus diagnosis is an easily
observed patient trait that can be used to cream-skim. Of the
diagnoses with relatively high LOS, 12/13 have higher shares at
for-profit hospices 10 of these differences are significantly less
than zero. Of the diagnoses with relatively low expected LOS,
8/14 have lower shares at for-profit hospices, but 3/14 also
had a significantly higher share. The results of the analysis
diagnosis are mixed and no significant pattern emerged.
Conclusions: The results show that for-profit hospices
maximized profit and did attract a higher share of patients
with long expected LOS. The results within diagnosis reveal
that for-profit hospices were not able to differentially draw
relatively profitable patients within each diagnosis; rather they
attracted patients with relatively profitable diagnoses. This is
probably due to the fact that it is notoriously difficult to predict
LOS within a given diagnosis. The results tie directly to the
financial incentives inherent in Medicare reimbursement for
hospice care.
Implications for Policy, Delivery or Practice: Medicare
reimbursement for hospices may cause access problems for
patients with diagnoses with relatively short lengths of stay
because they are unprofitable. We find that if Medicare would
reimburse hospices relatively high upon admissions and again
relatively high upon death, hospices will not have the incentive
to attract certain types of patients. Such a reimbursement
schedule would mirror costs more closely and eliminate the
incentive to admit only those patients with a long expected
Primary Funding Source: RWJF
• The Home as a Site for Long Term Care
Patricia McKeever, Ph.D., Mary Chipman, M.A., Helen Scott,
M.Sc, Kathy Osterlund, M.A.
Presented by: Patricia McKeever, Ph.D., Professor, Faculty of
Nursing, University of Toronto, 50 Street George Street,
Toronto, On, M5S 3H4; Tel: 416.978.2855; E-mail:
[email protected]
Research Objective: This study was designed to illuminate
the living and working conditions in households receiving long
term care services.
Study Design: A computer assisted telephone survey
(CATI)of a random sample of home care clients who had
received at least one publicly funded service at least once a
week, for a minimum of eight weeks.
Population Studied: Eight hundred and eleven (811) long
term home care clients in an urban (n=232), rural (n=267)
and remote (n=242) region in Ontario, Canada were
interviewed in 2001/2002.
Principal Findings: The median age of clients was 77 years
and 75% were female. The majority of respondents had not
completed high school. Almost half of clients were widowed,
had income levels of $20,000 or less, and lived alone. As
expected, older females were most likely to live alone. Home
care clients who shared dwellings were most likely to live with
someone close to their age; more than one third of clients
who shared dwellings, lived with someone else with a
Clients were able to perform most basic activities of daily
living, with the exception of bathing. However, only one
quarter of clients were able to prepare meals, perform routine
housekeeping and shop without help. Few clients were able to
perform heavy housework or yard work, or travel outside of the
neighborhood. There were significant differences between
males and females in terms of the tasks for which they needed
assistance. Family members were most likely to assist home
care clients with most activities of daily living, with the
exception of bathing, where almost 80% of clients relied on
Compared to the Canadian population, clients were more
likely to live in subsidized housing, and had fewer rooms,
bedrooms and bathrooms in their homes. As well, 47% of
clients had difficulty meeting their housing costs.
Furthermore, 16% and 33% of clients lived in homes that
required major and minor repairs, respectively. This study
found that clients who rent their homes, live alone or are
female, are more likely to be in core housing need than other
More than 30% of clients required modification to their
homes in order to adapt to their physical needs. Only
approximately half of homes care clients had completed the
required modifications; cost was sited as the main reason for
not modifying their homes.
Conclusions: These results demonstrate that most home care
clients reside in homes that are less than optimal for both
domestic life and paid and unpaid long term care provisions.
Implications for Policy, Delivery or Practice: Since the
homes of home care recipients function simultaneously as
domestic dwellings and health care work sites, there needs to
be a consideration of the interaction of clients’ needs, workers’
tasks and housing conditions. These results highlight a need
to link housing policy to health and social services policies.
Primary Funding Source: The Social Sciences and
Humanities Research Council of Canada
• The Effect of PACE on Use of Hospital and Nursing
Home Services in the Long-Term
Louise Meret-Hanke, M.A., MOD
Presented by: Louise Meret-Hanke, M.A., MOD, Doctoral
Candidate, Health Policy and Administration, The
Pennsylvania State University, 116 Henderson Building,
University Park, PA 16802; Tel: 814.865.1192; Fax:
814.863.2905; E-mail: [email protected]
Research Objective: The purpose of this study is to evaluate
the effect of the Program of All-inclusive Care for the Elderly
(PACE), a managed long-term care program, on the use of
hospital and nursing home services over the long-term.
Study Design: The conceptual framework of the study is
based on the premise that PACE’s capitated financing of acute
and long-term care services and emphasis on preventative
care is expected to reduce the use of hospital and nursing
home care. The following hypotheses are based on prior
research and literature on PACE and the use of hospital and
nursing home services. H1: PACE enrollees will have lower use
of hospital in-patient services than will members of a
comparison group over a three-year follow-up period; H2:
PACE enrollees will have lower use of nursing home services
than will members of a comparison group over a three-year
follow-up period. Use of hospital and nursing home services
will be measured by admissions and total days. The study will
draw from two secondary data sources, including the PACE
public use data set, DataPACE, and the Medicare Current
Beneficiaries Survey (MCBS), as well as other relevant data
sets. The treatment group will be comprised of PACE enrollees
selected from DataPACE. The comparison group will be
constructed from a subset of the MCBS sample who have
similar characteristics as the treatment group. Propensity
score methodology will be used to select the comparison
group sample in order to minimize differences between the
treatment and comparison group. Two-part model estimation
will be used to analyze the study outcomes.
Population Studied: The population studied is communitydwelling, frail elderly individuals in the United States. The
sample of the proposed study will consist of (1) PACE
enrollees who enrolled between 1989 and 1998 and (2) MCBS
subjects who were first interviewed between 1991 and 1999.
Principal Findings: Currently in progress.
Implications for Policy, Delivery or Practice: Providing longterm care to an aging population presents many challenges
for policy makers and providers. Costs are rapidly rising and
fragmentation and limited coordination jeopardize quality. The
findings of this study will provide greater insight into the effect
of managed long-term care on the utilization of high-cost
services, such as inpatient and nursing home care. The study
findings will also identify long-term effects of PACE on use of
these services. Future policy and delivery These findings can
inform both future policy and service delivery approaches.
• Federal Mandates, Interstate Relations, and Other
Determinants: Explaining State Policy Change in the
Medicaid Nursing Facility Reimbursement Arena, 19801998
Edward Miller, Ph.D., M.P.A.
Presented by: Edward Miller, Ph.D., M.P.A., Postdoctoral
Fellow, Epidemiology and Public Health, Yale University
School of Medicine, 60 College Street, New Haven, CT 065208034; Tel: 734.883.7449; Fax: 203.785.6287; E-mail:
[email protected]
Research Objective: Because nursing home spending
consumes a larger portion of state budgets than almost any
other category, reimbursement reform is a frequent budget
reduction strategy pursued by state officials. As such, this
study sought to explain why states choose the Medicaid
nursing facility reimbursement policies that they do, and in the
process, shed light on a critical policy area that has
implications for many, not least of which include state and
federal officials and nursing home residents and providers.
Study Design: The determinants of state policy adoption arise
from factors within each state’s external and internal
environment, with external factors consisting of federal policy
changes related to the Boren Amendment and prior adoptions
by neighboring states, and internal factors consisting of a
particular state’s economic and political circumstances. To
evaluate the relative influence of the policy making
determinants hypothesized I conducted a series of pooled
cross-sectional time series analyses using event history,
multinomial logit, and mixed modeling techniques. Focusing
on state adoption of more cost containing options during
1980-1998, I predicted incremental changes in Medicaid
nursing facility per diem rates and payments per recipient, and
non-incremental changes in reimbursement methodologies,
including adoption of fair rental methods for reimbursing
capital, case mix methods for adjusting resident per diems,
and general methodologies with stronger incentives for
containing costs.
Population Studied: The unit of analysis is the state-year. All
analyses exclude Arizona, because of missing data and its
unique Medicaid system, Hawaii and Alaska, because they do
not share borders with neighboring states, and Nebraska,
because it has a non-partisan, unicameral legislature. The
analysis predicting use of older cost reports also excludes
New York and Missouri because they were extreme outliers—
neither rebased much during the time period studied.
Principal Findings: Results show that the federal government
influenced states' reimbursement policy choices, though not
always as intended. While court decisions and other federal
actions made it more difficult for states to reduce per diem
rates, they also spurred the adoption of fair rental methods as
states sought alternative ways of meeting their cost
containment goals. By providing states with models of
reimbursement, the federal government spurred case mix
adoption as well. Although results provide evidence of
regional diffusion in the context of the incremental outcomes,
they provide no such evidence in relation to the nonincremental outcomes, the diffusion of which may have been
more national than regional in orientation. Unemployment
and medically needy programs were also positive significant
predictors of incremental outcomes but not of nonincremental outcomes, while governing capacity was a
negative significant predictor of incremental outcomes and a
positive significant predictor of non-incremental outcomes.
Conclusions: Future research should examine whether the
influence of intergovernmental factors, including other states
and the federal government, is moderated by internal state
Implications for Policy, Delivery or Practice: Given the
pervasiveness of federal influence in the past, it is likely that
states will take advantage of available discretion now that the
Boren Amendment has been repealed and they face their
worst fiscal conditions since World War II.
Primary Funding Source: NIA
• Rehabilitation Services Following the Implementation of
the Nursing Home Prospective Payment System
Patrick Murray, M.D., M.S., Neal Dawson, M.D., Thomas
Love, Ph.D., Charles Thomas, BS, Randall Cebul, M.D.
Presented by: Patrick Murray, M.D., M.S., Associate
Professor, Center for Health Care Research and Policy, Case
Western Reserve University, 2500 MetroHealth Drive,
Cleveland, OH 44109; Tel: 216.778.3901; Fax: 216-778-3945; Email: [email protected]
Research Objective: The balanced budget amendment of
1997 (BBA) required that all postacute services supported by
Medicare be placed into a prospective payment system. A
decline in utilization was the expected result. The purpose of
this study was to describe the changes that have occurred in
Ohio nursing homes related to the BBA, controlling for
changes in patient characteristics.
Study Design: Retrospective cohorts from two time periods
were compared, controlling for selection bias using a
predictive model derived and validated in the pre-BBA cohort.
Population Studied: 9246 newly admitted Ohio NH patients
from 1994-6 (pre-BBA) and 76,991 from 2000-1 (post-BBA).
Principal Findings: More patients were provided therapy in
the post BBA period (64.2% pre, 85.6% post, p<0.0001). The
amount of therapy per patient was less (7.0 hrs./wk pre, 6.2
post, p<0.01). The greatest increase in rehabiltation service
rate was is the two quintiles of patients least likely in the preBBA period to have received it. The greatest decline in the
service amount was in the two quintiles most likely to receive
rehabilitation. For profit NHs decreased therapy amount in
the highest three quintiles. Not for profit NHs cut services
only in the highest quintile.
Conclusions: The BBA has not caused fewer patients to
receive rehabilitation services, but rather decreased the
amount of therapy provided. Proprietary status appears to
significantly influence the response of NHs to fiscal change.
Implications for Policy, Delivery or Practice: The clinical and
social outcomes of these changes need to be evaluated.
Based on prior work these changes may be shifting services to
patients who are more likely to benefit from them.
Primary Funding Source: AHRQ
• Implementation and Evaluation of a Systems Approach
for Quality Improvement in Nursing Homes
Sue Nonemaker, R.N., M.S., Katharine Murphy, Ph.D., R.N.,
John Morris, Ph.D.
Presented by: Sue Nonemaker, R.N., M.S., Senior Research
Associate, Research and Training Institute, Hebrew
Rehabilitation Center for Aged (HRCA), 1200 Centre Street,
Boston, MA 02131; Tel: 617.235.5509; Fax: 617-363-8936; Email: [email protected]
Research Objective: 1. To evaluate the effect of a systems
approach for improving nursing home care in the following
areas: ADL functional rehabilitation, pain, and depression.
2. To evaluate the feasibility of use and staffs' satisfaction
with a Quality Improvement program utilizing "Best Practice"
Study Design: Experimental
Population Studied: Nursing home residents
Principal Findings: We implemented "best practice"
programs in the areas of ADL functional rehabilitation, pain,
and depression in test facilities, and evaluated the impact of
each program on resident outcomes using standard indicators
of quality. Results of the project include the following: a 30-40
percent improvement in residents' capabilities in activities of
daily living, such as eating and dressing, and a 22 percent
improvement in depression management compared with a 15
percent decline experienced by facilities in a comparison
group. Residents of facilities participating in the Pain
intervention experienced less pain and exhibited marked
declines in behavioral problems. Staff of participating nursing
homes reported the programs were relatively easy to use and
improved their job satisfaction.
Conclusions: Use of systematic "Best Practice" interventions
and a nurse educator model as part of a general Quality
Improvement program improved resident outcomes in the
areas of ADL functional rehabilitation, pain, and depression.
Implications for Policy, Delivery or Practice: Quality of care
for nursing home residents can be significantly improved
through the systematic, consistent implementation of best
practice protocols. States and CMS should consider
introduction of a "best practice" initiative as a complement to
traditional regulatory enforcement programs.
Primary Funding Source: Pennsylvania Department of Health
• Preventable Hospitalization as a Measure of Quality of
Care in Nursing Homes
Steven Pizer, Ph.D., Man Wang, M.S., Catherine Comstock,
Presented by: Steven Pizer, Ph.D., Health Economist and
Assistant Professor, Health Care Financing & Economics,
Boston University and Department of Veterans Affairs, 200
Springs Road (Mail Stop 152), Bedford, MA 01730; Tel:
781.687.3088; Fax: 781.687.3106; E-mail: [email protected]
Research Objective: To evaluate the rate of potentially
preventable hospitalization as a measure of quality of care in
nursing homes relative to established alternatives including
those based on facility-reported data and those based on data
from external sources.
Study Design: We use the preventable hospitalization rate to
study a new population (nursing home residents) and develop
a new risk-adjustment model. We compare the performance
of the preventable hospitalization rate with six established
measures of nursing home quality of care.
Population Studied: Secondary data were extracted from
acute care hospitalization records and nursing home patient
assessments for all residents in Veterans Health
Administration nursing homes between October of 1997 and
October of 2000.
Principal Findings: Among seven measures, we find the
preventable hospitalization rate to be the second most stable
through time and the third most strongly related to staffing.
Conclusions: The preventable hospitalization rate compares
well with alternative measures of nursing home quality.
Furthermore, because preventable hospitalization and
mortality rates can be constructed from relatively objective
data generated outside the nursing home, they provide
valuable alternatives to measures based on facility-reported
Implications for Policy, Delivery or Practice: Administrators
of the federal nursing home quality initiative ought to reassess
the list of quality measures currently available to the public
and consider adding externally reported measures such as the
preventable hospitalization rate.
Primary Funding Source: VA
• Nursing Homes’ Participation in the Subacute Care
Market in the United States: The Role of Environmental
and Organizational Factors
Amir Qaseem, M.D., Ph.D., M.H.A., Robert WeechMaldonado, Ph.D., M.B.A.
Presented by: Amir Qaseem, M.D., Ph.D., M.H.A., Clinical
Epidemiologist & Research Manager, Scientific Policy, The
American College of Physicians, 1000 Conestoga Road, B123,
Bryn Mawr, PA 19010; Tel: 610.527.1718; E-mail:
[email protected]
Research Objective: Using resource dependence theory and
Porter’s five forces of environmental threats model, this study
examines the impact of environmental and organizational
factors on nursing homes’ participation in the subacute care
Study Design: Data sources include the Online Survey
Certification of Automated Records (OSCAR), the Area
Resource File (ARF), the Medicare managed care market
penetration data files, and the Medicaid reimbursement
surveys. Subacute care services are defined as nursing homes
with specialty beds for hospice, dialysis, head trauma,
Huntington disease, AIDS, and special rehabilitation care. A
quasi-experimental interrupted time-series analysis using
logistic (Glimmix) regression model is employed to test for
change in nursing home participation in the subacute care
market due to various environmental factors (Medicare
prospective payment system [PPS], Medicaid reimbursement
rates, Medicare hospital discharges, Medicare managed care
market penetration, Herfindahl index, excess capacity, entry
barrier, home health agencies, hospital based subacute care
beds) and organizational characteristics (size, ownership,
chain affiliation, occupancy rate).
Population Studied: The sample for this study is all Medicare
and Medicaid certified nursing homes in the United States
during the period of 1993 to 2000.
Principal Findings: Our analysis shows that the nursing
homes offering subacute care decreased significantly since the
implementation of Medicare PPS. Nursing homes located in
markets with a higher Medicaid reimbursement rate were less
likely to offer subacute care. Larger nursing homes and forprofit chain affiliated nursing homes were more likely to have
subacute care units. In addition, nursing homes with a higher
occupancy rate had a lower probability of offering subacute
care services.
Conclusions: Study findings suggest that the Balanced
Budget Act (BBA) of 1997 did not have a significant impact in
the number of nursing homes offering subacute care services.
However, there has been a declining trend in the participation
of nursing homes since the implementation of Medicare PPS
for nursing home care. Results also suggest that nursing
homes have responded strategically to the environmental
demand for subacute care services. Nursing homes located in
markets with higher Medicare managed care penetration and
higher Medicare hospital discharges were more likely to offer
subacute care services. Organizational factors, such as size
and for-profit chain affiliation were important enablers in
predicting nursing home subacute care participation.
Implications for Policy, Delivery or Practice: A reduction in
nursing home subacute care services may affect the continuity
of care and coordination for patients discharged from
hospital. Future research should also examine changes in
nursing home subacute care supply on costs and quality of
care for Medicare population.
• Recruiting and Retaining Nursing Personnel in LongTerm Care Organizations: What are the Role of Financial
and Workplace Incentives?
Kent Rondeau, Ph.D.
Presented by: Kent Rondeau, Ph.D., Associate Professor,
Department of Public Health Sciences, University of Alberta,
13-126H Clinical Sciences Building, Edmonton, Alberta,
T6M1W7; Tel: 780.492.8608; Fax: 780.492.0364; E-mail:
[email protected]
Research Objective: This study reports on the human
resource management activities of long-term care
organizations directed at attracting and retaining its nurses.
Its objective is to assess the predominance and effectiveness
of various financial and non-financial (workplace) strategies
for recruiting and retaining scarce nursing personnel.
Study Design: Strategies aimed at recruiting and retaining
human resources are strongly conditioned by the rate of
employee turnover, as well as by the relative supply of labor in
the marketplace. When RN nursing labor is in short supply,
health care organizations may have difficulty in filling their
vacancies when employees leave or retire. Attracting and
retaining qualified and competent nursing personnel is
problematic for many long-term care organizations—some
have difficulty in attracting staff, while others have difficulty in
retaining them. This study investigates the differential impact
of financial and non-financial (human resource) strategies on
job vacancy (ostensibly a recruitment problem) and job
turnover (primarily a retention issue) for nursing personnel in
long-term care organizations.
Population Studied: In 2003, a mail survey questionnaire was
sent to the directors of nursing care in three hundred (300)
long-term care organizations located in four provinces in
Western Canada. The study database was randomly selected
from all nursing homes. In total, 125 usable questionnaires
were returned, and with 10 returned undeliverable or refused,
produced a response rate of 43.1 percent.
Principal Findings: : Categorical regression analysis was
performed with nursing turnover and nursing job vacancy
serving as the dependent variable. Four categories of nursing
homes were arbitrarily constructed and assessed from our
sample set: a) homes with high nursing personnel turnover
and high job vacancies, b) homes with high nursing staff
turnover but low nursing job vacancies, c) homes with low
nursing staff turnover, but experiencing high nurse job
vacancies, and d) homes with low turnover and few vacancies
(our comparator group of homes). The variety of financial
incentives and workplace (human resource) strategies were
assessed with respect to their relative contributions in
explaining the variation in nursing personnel turnover and
nurse job vacancy rates. A number of control variables were
also entered into our model, including institutional, workforce,
and community characteristics.
Conclusions: : Nursing personnel turnover and nursing job
vacancies are differential indicators for predicting the
effectiveness of recruitment and retention strategies for
nursing home personnel. Financial incentives were generally
found to have weaker or non-significant associations with
nursing staff turnover and nurse job vacancy rates. However,
certain workplace and human resource management
programs are found to be better predictors of job turnover and
job vacancy.
Implications for Policy, Delivery or Practice: A national
shortage of nursing personnel is affecting the ability of many
health care organizations to deliver high quality nursing care.
Financial incentives, although touted as critical for attracting
and retaining nursing staff, may not be effective at reducing
job turnover and job vacancy. Administrators of nursing
homes should consider the adoption of more employeecentered programs to assist in attracting and retaining staff.
• Risk Factors that Predict an Earlier Onset of
Hospitalization in Home Health Care
Robert Rosati, Ph.D., Liping Huang, M.A.
Presented by: Robert Rosati, Ph.D., Director of Outcomes
Analysis and Research, Center for Home Care Policy &
Research, Visiting Nurse Service of New York, 5 Penn Plaza,
11th Floor, New York, NY 10001; Tel: 212.609.5776; Fax:
212.290.3756; E-mail: [email protected]
Research Objective: Hospitalization is a significant quality
indicator in home health care. The ability to predict the
occurrence of hospitalization can help identify appropriate
interventions and improve the management of patient care.
The objective of this study was to examine the risk factors
associated with hospitalization, especially the factors
associated with an earlier onset of hospitalization.
Study Design: Two types of analyses were conducted: logistic
regression analysis was utilized to examine how
sociodemographic, functional and clinical factors from the
Outcomes Assessment Information Set (OASIS) at start of
care predicted the likelihood of hospitalization, and using
Cox’s proportional hazards regression model we assessed the
relative risk of these same factors in explaining an earlier onset
of hospitalization. In addition, a hazard function that
quantifies the adjusted probability of hospitalization over time
was developed.
Population Studied: Data were selected from patients
admitted to the adult (age >=18) acute care program of a
home health care agency in a large urban area between
January 2002 and August 2003, with length of stay less then
365 days. Among the final number of study observations
(N=78,278), there were 18,890 (24.13%) that had one or more
events of hospitalization recorded either by the administrative
data or OASIS transfer/discharge assessments.
Principal Findings: The results from the logistic analysis and
hazard model were relatively consistent and both provided
similar risk factors of hospitalization. However, there were
some differences. The results showed that patients who had
private insurance (HR=1.136, p<.0001) and whose caregivers
were the spouse (HR=1.061, p<.0001) or other family
members (HR=1.073, p<.0001) were more likely to have an
earlier onset of hospitalization event, while these factors were
not positively associated with the prediction of the overall risk
factors of hospitalization (OR=0.754, 0.932 and 0.894,
respectively). The result also illustrated that patients who had
a medical regimen change 14 days prior to admission
(HR=1.077, p=0.0059), lived with family (HR=1.043, p =.011)
and whose primary diagnosis was ischemic heart diseases
(HR=1.159, p<.0001) were more likely to have an earlier onset
of hospitalization, while these factors were not significant in
the logistic regression analysis. Nevertheless, patients whose
primary diagnosis were CHF, HIV, cancer, pressure or stasis
ulcer had approximately 1.5 to 2 times higher risks of an earlier
onset hospitalization as well as the overall risk of
hospitalization then others (p<.0001). Furthermore, an
adjusted hazard function showed that the risk of
hospitalization within 7 days of admission was relatively
higher than other time periods.
Conclusions: The factors of caregiver type, private insurance,
certain types of diagnoses, and presence of ulcers are the
leading components associated with earlier onset of
hospitalizations. Further, the highest probability of the onset
of hospitalization is within 7 days of admission.
Hospitalizations may not be totally avoidable but there
appears to be a clear set of factors on which home health care
agencies need to focus when care begins.
Implications for Policy, Delivery or Practice: Patient
characteristics at start of care for those who receive services
from home health care can be linked to the potential for
hospitalization. Future research may show that focusing on
these factors could reduce hospitalization rates.
• Impact of State Quality Improvement Organizations
(QIO) on Use of Standing Order Immunization Programs
Among Long-Term Care Facilities in the U.S.: Results of
the Immunization Standing Orders Project, 1999-2002
Abigail Shefer, M.D., Barbara Bardenheier, M.P.H., Dale
Bratzler, DO, M.P.H., Linda McKibben, M.D., M.P.H., ABD,
FACPM, Henry Roberts, Ph.D., Paul Stange
Presented by: Abigail Shefer, M.D., Medical Epidemiologist,
NIP, CDC, MS E-52, 1600 Clifton Road, Atlanta, GA 30333; Tel:
404.639.8233; Fax: 404.639.8615; E-mail: [email protected]
Research Objective: Standing order programs (SOPs) are
effective immunization-promoting interventions in which
nurses or pharmacists are authorized to vaccinate by
institution-approved protocol without a physician order or
exam. During 1999-2002, a demonstration project was
conducted in long-term care facilities (LTCFs) that involved
promotion of SOPs for influenza and pneumococcal
vaccination by the Centers for Medicaid and Medicare
Services Quality Improvement Organizations (QIO). To
evaluate impact of QIO promotion on adoption of SOPs in
LTCFs and to describe characteristics of LTCFs associated
with adoption of SOPs.
Study Design: A controlled before-and-after study was
conducted in 13 states (8 intervention and 5 control).
Population Studied: Information about Medicare or
Medicaid-certified LTCFs’ vaccination programs in each state
were collected at baseline (June 1999) and post-intervention
(March 2001). Intervention strategies employed by QIOs
included state-wide conferences, distribution of educational
materials, and on-site visits. Data from the completed surveys
were linked to the On-line Survey and Certification Reporting
System (OSCAR), an administrative database containing
information on all Medicare or Medicaid licensed LTCFs in the
Principal Findings: Of 3,861 LTCFs at baseline, 2,862 (74%)
had complete pre and post survey and OSCAR data (n=1353
intervention; n=1509 control). In the intervention and control
states at baseline, <10% of facilities used SOPs for influenza
or pneumoccocal vaccination. Following the QIO intervention
period, 110 (8.1%) additional LTCFs in the intervention states
adopted influenza SOPs compared to 102 (6.7%) LTCFs in the
control states (ns); for pneumococcal SOPs, the change was
7.8% in the intervention states compared to 5.3% in the
control states (p<.05). In a multivariate logistic regression
model, the characteristics significantly associated with
adopting SOPs for influenza were lack of a consistent place in
the medical record to document influenza vaccination and
having a greater proportion of Medicaid-payer residents; and
for adopting pneumococcal SOPs, the only significant factor
was being an LTCF located in an intervention state.
Conclusions: Despite few changes overall, state QIOs did
appear to positively impact SOP adoption for pneumococcal
vaccination. Factors other than the intervention appeared to
play a more important role in decisions to adopt SOPs for
influenza vaccination in this study. More research is needed to
identify other strategies to further promote SOPs for
vaccinating resident populations in LTCFs nationally.
Implications for Policy, Delivery or Practice: More
aggressive strategies such as state regulations may be needed
to promote use of evidence-based interventions such as SOPs
to improve vaccination of our elderly population.
Primary Funding Source: CDC
• Skilled Nursing Facility Stroke Rehabilitation and
Discharge Home
Walter Wodchis, Ph.D., Gary Teare, Ph.D., Gary Naglie, M.D.,
Susan Bronskill, Ph.D., Sudeep Gill, M.D., Michael Hillmer,
Presented by: Walter Wodchis, Ph.D., Research Scientist,
Research, Toronto Rehabilitation Institute, 130 Dunn Avenue,
Toronto, Ontario, M6K 2R7; Tel: 416.597.3422 Ext. 2242; Fax:
416.530.2470; E-mail: [email protected]
Research Objective: To determine the relationship between
Rehabilitation Therapy (RT) intensity and time to resident
discharge for stroke residents discharged from hospital to
Skilled Nursing Facilities (SNFs).
Study Design: Retrospective cohort study. Hazard (time-toevent) regression analyses were stratified by expected
outcome. Multivariate analyses and propensity score
adjustment techniques were also employed to adjust for nonrandom treatment assignment.
Population Studied: All SNF residents admitted to SNFs in
Ohio and Michigan, U.S.A. and Ontario, Canada during 1998
and 1999 (N=23,824 admissions).
Principal Findings: RT was given to over 95% of residents for
whom discharge was expected within 90 days to over 60% of
residents for whom discharge was uncertain or not expected.
RT increased the relative risk (RR) of discharge for all groups
except residents with an expected discharge within 30 days
(minimum RR= 1.20, maximum RR=1.78). A dose-response
relationship was strongest for residents with either an
uncertain discharge prognosis or no discharge expected. The
relative risk for discharge home was 1.52 for residents with 'no
discharge expected' but who still received the highest levels of
Conclusions: RT leads to faster discharges home for stroke
patients receiving rehabilitation in SNFs. However,
increasingly higher RT intensity does not provide additional
benefits to all residents.
Implications for Policy, Delivery or Practice: Post-acute
residents with an uncertain prognosis are an important target
population for intensive RT.
• The Influence of Patient, Healthcare Provider, and
Organization Characteristics on the Use of Home Hospice
Care versus Traditional Home Care Prior to Death
Ying Xue, M.S.N., Paula Milone-Nuzzo, Ph.D.
Presented by: Ying Xue, M.S.N., Doctoral Student, School of
Nursing, Yale University, 100 Church Street South, P.O. Box
9740, New Haven, CT 06536; Tel: 203.624.6470; Fax:
203.624.6470; E-mail: [email protected]
Research Objective: Most elders express a preference for
receiving terminal care at home. Patients can receive terminal
care at home either from traditional home care (THC) or from
home hospice care (HHC) in the U.S.. Studies indicated that
HHC can provide quality care for dying patient and has the
potential to be cost-effective. In response to the increase of
the elder population and the escalation of healthcare costs,
this study was done to identify strategies to foster appropriate
use of HHC and THC prior to death among the elderly
Study Design: The study employed a cross-sectional research
design using SUDAAN software to perform logistic regression
with variables hierarchically entered to identify patient,
healthcare provider, and organization characteristics on the
use of HHC versus THC prior to death. The data are drawn
from the revised 2000 National Home and Hospice Care
Survey dataset. Discharge data are used because these data
represent a complete episode of care. Discharges refer to
those patients who were discharged from care by the home
health agency or hospice during a designated month between
October 1999 and September 2000 that was randomly
selected for each agency.
Population Studied: A sample of discharged patients who are
at least 65 years old and received either HHC or THC before
discharge, for whom death was the reason for discharge.
Principal Findings: Preliminary analysis revealed that there
were 127,361 discharges using THC and 242,366 using HHC
prior to death among the elderly population. Analysis of
patient, healthcare provider and organization characteristics is
not completed as yet. Final results will be completed in March
and will be available at the time of the conference.
Conclusions: Final results and conclusions will be completed
in March and will be available at the time of the conference.
Implications for Policy, Delivery or Practice: This study will
be important for health care administrators, health care
providers, and policy makers who are in the business of
managing terminal care in the home. As the key variables
associated with the use of HHC versus THC are described, the
opportunity to design home care programs that most
appropriately target the needs of the community can be
developed. From a policy perspective, knowing the factors that
are significantly associated with the use of HHC and THC
prior to death, policymakers will have the data needed to
influence the utilization patterns for improvement in the cost
and quality of care.
• An Examination of the Nursing Homes Profitability Post
the Balance Budget Act (BBA)
Mustafa Younis, Dr.PH., M.A., M.B.A.
Presented by: Mustafa Younis, Dr.PH., M.A., M.B.A.,
Assistant Professor, Healthcare Administration, Jackson State
University, 350 W. Woodrow Wilson Avenue, Jackson, MS
39213; E-mail: [email protected]
Research Objective: To describe and examine the variation of
profitability between for-profit and non-profit nursing homes.
Policy implications due to these variations would be in form of
the level of service for the elderly who depend on Medicare
and Medicaid program.
Study Design: Descriptive statistic and Regression analysis to
examine the variables that influence nursing homes
Population Studied: The research used the Nursing Homes
Minimum Data Set (MDS)for the year 2000. (over 5000
nursing homes facilities)
Principal Findings: Despite the Balance Budget Act, Nursing
homes showed a healthy profit margin. For-Profit Nursing
Homes had a superior performance in comparison to the
Non-Profit counter part. Unlike the hospitals market, nursing
homes market is characterized by excess demand and is
dominated by For Profit entity.
Conclusions: The For-Profit facilities were able to adjust to
new regulations faster than Not-For-Profit nursing homes.
Another reason for the variations that most nursing homes
did not have to comply with the BBA and BBRA immediately.
A further study with more recent data when it become
available is recommended.
Implications for Policy, Delivery or Practice: The
importance of the study stems from the debate over the effect
of ownership on health care services. If the type of ownership
has no effect on the performance and the services provided by
the nursing homes, then society might be better off by
eliminating charitable donations and the tax-exempt status of
N-P nursing homes. The market of skilled nursing facilities
due to the aging of the population. The Service providers
(SNF) and the insurers (Medicare, Medicaid, and Private
insurance) have to come with a payment mechanism that
ensures solvency and profitability of the nursing homes
without sacrificing quality and access to the services need by
• Institutional Factors Influencing Nursing Home Quality
Ning Zhang, Ph.D., M.D., Thomas Wan, Ph.D.
Presented by: Ning Zhang, Ph.D., M.D., Assistant Professor,
Health Administration, University of Central Florida, Doctoral
Program in Public Affairs/College of Health and Public
Affairs/UCF/PO Box 162200, Orlando, FL 32816; Tel:
407.823.3344; Fax: 407.823.4895; E-mail:
[email protected]
Research Objective: The objective of this study is to identify
the relative and interaction effects of institutional mechanisms
on the isomorphism of the quality of nursing homes in United
States and to examine the stability of nursing homes’ quality
as measured by deficiencies in 1997 and 2001, using two-level
Study Design: A longitudinal panel design was employed.
Data obtained from the On-line Survey Certification and
Reporting System (OSCAR) from 1997 and 2001 were the
major source for the study. A balance design was formulated
with 22 homes randomly selected from each of the states.
Population Studied: Using a multi-level design, a sample of
1,056 homes from 48 states was selected. Multi-level analysis
examined the predictor variables at both facility and state
Principal Findings: There were three major findings in this
study. First, nursing home quality is strongly influenced by
coercive pressures. Nursing home quality is substantially
influenced by the Medicaid reimbursement rate, the demand
for nursing home care, the stringency of the Certificate-ofNeed, and the percentage of Medicare patients in nursing
homes. The results of this study indicate that regulatory
control plays an important role in improving nursing home
quality. Higher Medicaid reimbursement rate was found to be
positively related to better nursing home quality. Second, the
number of hours that registered nurses work per patient per
day (RNPRD) is another strong predictor of nursing home
quality, with more RNPRD hours leading to better quality.
Third, the interaction term between the coercive mechanism
and the normative mechanism, as represented by the coercive
variable DEMAND and the normative variable RNPRD, was
found to be positively associated with nursing home quality.
Conclusions: Improvement of nursing home quality depends
on governmental, regulatory and societal forces. These
external coercive mechanisms shape the change of nursing
home practice in a socially desired direction, but not
necessarily in a market-desired direction if the two directions
are not the same. This analysis shows that, regulation and the
government’s role cannot be weakened. On the contrary,
federal and state governments should be more active in
monitoring and improving nursing home quality.
Furthermore, the federal and state governments should
increase state Medicaid reimbursement rates, and maintain
CON and moratorium programs. A quality-based
reimbursement scheme should be developed to provide
financial incentives to deliver better quality of nursing home
Implications for Policy, Delivery or Practice: A quality-based
incentive should be devised when the federal and state
governments consider designing a new payment system, so
that nursing homes will be paid for delivering better quality.
Strengthening coercive mechanisms and increasing nurse
staffing are imperative. Linking financial rewards with
demonstrated quality would reward the best nursing facilities
and encourage others to improve.
Invited Papers
Long-Term Care Financing: Private Sector Solutions &
International Comparisons
Chair: Vincent Mor, Ph.D.
Monday, June 7 • 4:00 p.m.-5:30 p.m.
Panelists: Manfred Huber, Organization for Economics
Cooperation and Development (OECD); Jeanne Lambrew,
George Washington University; Christopher Murtaugh,
Visiting Nurse Service of New York; Judith Feder,
Georgetown University (no abstracts provided)