Long-Term Care
Call for Papers
Payers, Recipients & Providers Respond: Behind the
Trends in Long-Term Care Utilization
Chair: Vincent Mor, Brown University
Monday, June 27 • 9:00 am – 10:30 am
●Impact of LTC Insurance on Setting and Use of Formal
and Informal Care
Christine Bishop, Ph.D., Boryana Dimitrova, Ph.D., Marc
Aaron Cohen, Ph.D.
Presented By: Christine Bishop, Ph.D., Professor and
Director, Ph.D. Program, Schneider Institute for Health Policy,
Heller School, Brandeis University, 415 South Street, Mailstop
035, Waltham, MA 02254-9110; Tel: (781)736-3942; Fax:
(781)736-3905; Email: bishop@brandeis.edu
Research Objective: Using a national sample of elders with
disabilities enriched with a study group consisting of elders
claiming benefit under private long-term care insurance
policies, we investigate 1) the effect of insurance on the
relative use of alternative services covered by insurance,
namely nursing home care and care at home; and 2) the
effect, for persons who remain in the community, of insurance
on use of paid care and informal, unpaid care.
Study Design: Economic theory suggests that private LTC
insurance may affect the service choices of elders with
disability needs, because it provides additional resources to
insured persons when they need care. Because private LTC
insurance has been marketed only relatively recently and is
often not used until many years after coverage begins, we use
a choice-based sample approach to develop a database with
sufficient insured persons to estimate insurance effects on
setting of care at the time of observation and the number of
hours of paid and informal care for community residents. We
account for measured and unmeasured variables that affect
selection into insurance using a recursive bivariate probit
model, estimated using maximum likelihood for two
dichotomous variables: insured status and residence in a
nursing home. Insured status is also included as an
independent variable in the nursing home probit to assess its
effect on choice of setting (Greene 2003). To estimate effects
of insurance on formal and informal care for community
resident elders, we account for selection effects of insurance
and community residence using a Heckman procedure based
on the bivariate probit results (Goux and Maurin, 2000).
Population Studied: The population studied are elders with
disability sufficient to be in benefit under standard LTC
insurance policies: disabilities in two or more activities of daily
living or cognitive impairment. They are drawn from the 1999
National Long-term Care Survey and from a survey of the
elders in benefit under insurance from seven LTC insurance
carriers in 2000.
Principal Findings: Elders holding private long-term care
insurance are more likely to be observed in community
residence than are elders without insurance, after accounting
for age, marital status, race, income and level of disability.
Income has a negative effect on the probability of community
residence. Insured elders use about 20 more hours of paid
care per week than do noninsured elders. An additional paid
hour reduces informal care by about one-half hour, and an
additional unpaid hour reduces paid care by about ¾ hour.
Conclusions: Even though the additional resources available
to insured disabled elders may be used either for nursing
home care or care in the community, elders with insurance are
more likely to be observed in community residence than are
noninsured elders with similar disability and other
characteristics. Community-resident insured elders purchase
substantially more paid hours of care than similar noninsured
elders. Informal care is likely reduced by paid care, but at less
than an hour-for-hour rate.
Implications for Policy, Delivery, or Practice: Private longterm care insurance appears to allow elders to exercise their
preferences, expressed in many surveys, to reside in their
communities despite disability. The increasing penetration of
private LTC insurance, with 9% of elders insured in 2002, may
portend diminishing demand for nursing home services, and
affect public planning and investment for future elder care.
Tradeoffs suggest that more paid care could be provided
without substantially diminishing provision of care by family
and friends, enhancing the well-being of the elderly.
Primary Funding Source: RWJF
●Moral Hazard in Nursing Home Use
David Grabowski, Ph.D., Jonathan Gruber, Ph.D.
Presented By: David Grabowski, Ph.D., Assistant Professor,
Health Care Policy, Harvard Medical School, 180 Longwood
Avenue, Boston, MA 02115; Tel: (617)432-3369; Fax: (617)-4323435; Email: grabowski@hcp.med.harvard.edu
Research Objective: Nursing home expenditures are a rapidly
growing share of national health care spending with the
government being the dominant payer of services. Yet, we
know remarkably little about the effects of government policy
on nursing home utilization. Foremost among the
unanswered questions: is nursing home utilization elastic with
respect to generosity of public programs? Or, is nursing home
an option of last resort that does not respond to public policy?
We address these questions by using substantial variation in
public policy for nursing homes over the past twenty years.
Study Design: We estimate transition models to examine how
Medicaid income and asset rules affect the odds of
community-dwelling elderly entering a nursing home. We also
examine whether the adoption of a medically needy program,
which allows an individual to count nursing home
expenditures against the Medicaid income threshold,
influences nursing home use. Finally, we offer some
differences-in-differences-in-differences results that compare
different spousal protection rules across high and low asset
protection states and single and married individuals.
Population Studied: All five waves of the National Long-Term
Care Survey, a nationally representative sample of Medicare
beneficiaries over the period 1982-1999.
Principal Findings: We found a negligible effect of medically
needy programs on nursing home use. Using the upper limit
of the 95% confidence interval, we found that the introduction
of a medically needy program increases the probability of
nursing home use by 0.44 to 0.9 percentage points (3.4 to
6.9%). Moreover, the income and asset tests employed by
different states did not influence utilization. Finally, the
adoption of more generous spousal impoverishment
protection rules did not affect nursing home use.
Conclusions: Results are consistent with inelastic demand for
nursing home care – that is, the generosity of Medicaid rules
does not influence nursing home utilization.
Implications for Policy, Delivery, or Practice: The large
increase in nursing home expenditures over the past few
decades is not attributable to increased generosity in state
Medicaid payment programs. Our results cannot rule out the
“crowd-out” of private payers by Medicaid, but generous
Medicaid benefits do not attract additional individuals into the
nursing home sector.
Primary Funding Source: National Bureau of Economic
Research
variation in the use of SNFs and IRFs across communities,
our findings suggest that substitution between PAC modalities
is also driven by hospitals’ PAC ownership.
Implications for Policy, Delivery, or Practice: While
discharging patients to hospitals’ own PAC facilities may
improve information sharing during the transitions, it is
unknown whether outcomes are comparable or would be
better in an alternative PAC setting. Medicare expenditures
will be higher if a setting with a higher cost substitutes for
similar care provided in a lower cost setting. The implications
of outcomes and costs of substitution between PAC
modalities warrant further investigation, and future Medicare
PAC payment reform needs to take into account of the
interchangeability between PAC modalities.
Primary Funding Source: AHRQ
●The Effect of Hospitals’ Post-Acute Care Ownership on
Medicare Post-Acute Care Use
Wen-Chieh Lin, Ph.D., Robert L. Kane, M.D., David R. Mehr,
M.D., MS, Richad W. Madsen, Ph.D., Gregory F. Petroski, MS
●Effect of a State Social Insurance Plan on State Medicaid
and Family Support Obligations
Lawrence Nitz, Ph.D., Lisa Maria B. Alecxih, MPA
Presented By: Wen-Chieh Lin, Ph.D., Assistant Professor,
Family and Community Medicine, University of MissouriColumbia, M226 Medical Sciences Building, Columbia, MO
65212; Tel: (573)882-1584; Fax: (573)-882-9096; Email:
linwe@missouri.edu
Research Objective: To examine the influence of hospitals’
post-acute care (PAC) ownership on Medicare PAC use.
Study Design: Cross sectional comparison of PAC use and
hospitals’ PAC ownership, using multinomial logit regression
to control for confounders. Patient, hospital and market area
characteristics, including PAC supply, were controlled for in
the model. We considered ownership of long-term care units
(LTC), swing beds, inpatient rehabilitation facilities (IRFs), and
home health agencies (HHAs).
Population Studied: Hospitalized elderly Medicare
beneficiaries represented in the 5% beneficiary sample of
calendar year 2000, with any of three rehabilitative conditions
(stroke, hip and knee procedures, and hip fracture) or three
medical conditions (chronic obstructive pulmonary disease,
pneumonia, and congestive heart failure).
Principal Findings: PAC use was strongly associated with
PAC ownership; the effect was more prominent for
rehabilitative conditions than for medical conditions.
Hospitals were more likely to discharge patients to the PAC
modality that they owned, while the likelihood of using other
PAC modalities decreased. For hospitals owning IRFs,
patients discharged with rehabilitative conditions had 2.2 to
3.9 times higher odds of using IRFs over other PAC modalities
(SNFs, HHAs, and No PAC) than those discharged from
hospitals not owning IRFs. Similarly, the odds of using SNFs
over other PAC modalities were 1.2 to 2.2 times higher for
patients, either with rehabilitative or medical conditions,
discharged from hospitals owning LTC or swing beds than for
patients discharged from other hospitals. The effect of
hospital ownership of HHAs was less significant.
Conclusions: Across all diseases studied, a hospital’s PAC
ownership was associated with an increased use in this PAC
modality, while the likelihood of using other PAC modalities
decreased. This inverse relationship was especially significant
between SNFs and IRFs, suggesting a substitution effect
between them. While others have previously shown wide
Presented By: Lawrence Nitz, Ph.D., Professor, Political
Science, University of Hawaii at Manoa, 2424 Maile Way,
Room 640, Honolulu, HI 96822; Tel: (808)956-8665; Fax:
(808)956-6877; Email: lnitz@hawaii.edu
Research Objective: This study offers a prospective
examination of the effects on state Medicaid expenditures for
institutional and wavered Long Term Care (LTC) services due
to the introduction of a social insurance package intended to
cover the first year of costs of care. The package was designed
to cover an unrestricted of benefits typically delivered in the
home or in a community setting, up to a maximum of
$70/day (for the first year, 3+% annual increase thereafter).
The actuarial model for the package provided for a $10/month
flat tax, increasing at an annual anticipated inflation rate of
3%, to be levied on all taxpayers with household incomes
above the poverty line. Access to benefits would be graduated
over time, so as to present the same opportunity to long term
residents and to newly arrived residents
Study Design: The study is based on applications the
Brookings-Lewin-ICF Long Term Care Financing Model. The
base run of the model introduces no new social insurance
package, allows retail LTC insurance sales and lapses at typical
market rates, and accounts for Medicaid and Medicare
expenditures at rates which approximate those paid in the
State of Hawaii in 2002. The test runs of the model introduce
the proposed social insurance package, stage the gradual
acquisition of rights to program benefits, and execute a
Monte-Carlo simulation of life stages and LTC-related
morbidity events for a 30 year period for the target population.
Outcomes are tabulated in terms of numbers of users of LTC
services, payments from various sources, age, income and
wealth distribution of beneficiaries, and Medicaid and
Medicare LTC expenditure totals
Population Studied: The original Brookings-Lewin population
was renewed in the late 1990s. This population is based on
CPS and administrative retirement records, and designed to
represent the U.S. population in the aggregate. Each record in
the sample database contains information on a person's age,
sex, marital status, income, assets, and other characteristics.
The model simulates changes for each individual in the
sample population from 1986 to 2050, simulating changes in
age, economic status, disability status, utilization of long term
care, and method of paying for such care. For use in Hawaii,
the population was re-weighted to mirror Hawaii’s observed
and officially projected age/sex distribution. This was critical
because estimates of service utilization and/or cost of services
for the elderly in Hawaii would be underestimated by using
the Mainland, U.S. population, which has shorter longevity
than Hawaii’s. The population size was adjusted to match the
values set by the State Department of Business, Economic
Development and Tourism for the next decades.
Principal Findings: Social insurance programs which offer
LTC services at the beginning of frailty have the capacity to
provide substantial family relief by making third party care
giving possible. The home and community care needs of
about 75% of older residents may be met by such a program
for a relatively small expenditure, provided that the entire nonpoor population is enrolled. Institutional long term care paid
by the social insurance program, though not the focus of its
benefit, is typically three to five times the payment made
under the conventional private LTC insurance system that
exists today. The amount of home and community care paid
for by the one year benefit is more than thirty times that paid
for in the uninsured base case.
Conclusions: A social insurance program for a state's whole
population provides an efficient mechanism for financing early
and lower-intensity LTC needs of the state's frail edlerly
population. Such programs can generate large multiples of
home and community service, compared to the quantities
funded by common long term care insurance. Savings from
the state Medicaid accounts are initially modest, compared to
those available from a social insurance program which paid
for late-stage care. In such programs, however, the question of
how to finance early stage LTC care is unfortunately left open.
Implications for Policy, Delivery, or Practice: Partitioning
the risk pool for LTC care and paying for part of it by a social
insurance pool is an effective mechanism for delivering
services, but one which faces substantial opposition from
existing providers of financing. Making funded care available
through the population, however, increases the opportunity
for the mddle-aged caregivers to continue in their labor force
positions, securing their own retirement benefits. This
opportunity may be critical in states in which larger numbers
of married women have traditionally been in the workforce.
Primary Funding Source: Research funded in part by the
2002 Executive Office on Aging, of Hawaii's Governor
Cayetano Administration.
●Prevention Guidelines and the Risk of Nursing Home
Admission
Louise Russell, Ph.D., Elmira Valiyeva, Ph.D., Jane E. Miller,
Ph.D., Monika M. Safford, M.D.
Presented By: Louise Russell, Ph.D., Research Professor,
Institute for Health, Health Care Policy and Aging Research,
Rutgers University, 30 College Avenue, New Brunswick, NJ
08901; Tel: (732) 932-6507; Fax: (732) 932-6872; Email:
lrussell@ihhcpar.rutgers.edu
Research Objective: National campaigns are directed toward
modifying lifestyle-related factors, such as smoking, elevated
blood pressure, and obesity, which contribute to poor health.
The U.S. Preventive Services Task Force (USPSTF), the Joint
National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC), and other groups
have published recommendations to help primary care
physicians advise their patients. While risks of disease,
hospitalization, and death attributable to these factors have
been well studied, their effects on the risk of nursing home
admission are less well known. This paper examines the risk
of nursing home admission attributable to lifestyle-related
factors in a nationally representative sample of older adults.
Study Design: A multivariable Cox proportional hazards
analysis was conducted using data from the NHANES I
Epidemiologic Followup Study (NHEFS), a nationally
representative sample of U.S. adults whose nursing home use
was tracked for 20 years after baseline (1971-1975). Categorical
variables were defined to distinguish unhealthy from healthy
levels of each baseline risk factor, as defined by the major
national guidelines, and to compare the risks of subsequent
nursing home admission at those levels. For example, since
the USPSTF recommends that physicians counsel patients
whose body mass index (BMI) is 30 or higher, BMI 30+ was
distinguished from lower BMIs. Smoking, systolic blood
pressures 140 mm Hg or higher, lack of regular physical
activity, total cholesterol 240 mg/dL or higher (and 200+),
diabetes and other chronic conditions diagnosed by baseline,
and age, gender, and race were also included in the
regressions.
Population Studied: A cohort of 6462 community-dwelling
adults aged 45-74 at baseline (1971-1975). Persons 45-64
(n=3526) and 65-74 (n=2936) were analyzed separately to
explore whether lifestyle choices were equally important in the
two age groups.
Principal Findings: Persons 45-64 experienced 282 nursing
home admissions and those 65-74 experienced 900
admissions over the 20 years of follow up. Except for total
cholesterol, all lifestyle-related factors were statistically
significant determinants of the risk of nursing home
admission in one or both age groups (P<0.05). Diabetes
tripled the risk of future nursing home admission for persons
45-64, but increased it only about 50% in persons 65-74.
Smoking increased risk by more than 50% among middleaged persons and a third in older persons. Systolic blood
pressure 140+ and BMI 30+ increased risk in both groups by
about 30%. Lack of regular physical activity increased risk in
middle-aged persons, but was not statistically significant in
older persons. In the finished paper, attributable fractions will
also be presented.
Conclusions: Lifestyle-related factors targeted by national
prevention guidelines, especially smoking, elevated blood
pressure, obesity, and diabetes significantly increase the risk
of nursing home admission.
Implications for Policy, Delivery, or Practice: If older
persons followed the national guidelines for lifestyle choices
and management of chronic diseases such as diabetes,
nursing home admissions could be substantially reduced.
Better choices are effective at older ages as well as in middle
age, but the higher rates and numbers of admissions among
the oldest make preventive efforts in this age group
particularly compelling.
Primary Funding Source: AHRQ
Call for Papers
Improving Nursing Home Outcomes:
Measurement & Policy
Chair: Christine Bishop, Brandeis University
Tuesday, June 28 • 8:30 am – 10:00 am
●Nursing Home Quality as a Public Good
David Grabowski, Ph.D., Joseph Angelelli, Ph.D., Jonathan
Gruber, Ph.D.
Presented By: David Grabowski, Ph.D., Assistant Professor,
Health Care Policy, Harvard Medical School, 180 Longwood
Avenue, Boston, MA 02115; Tel: (617) 432-3369; Fax: (617) 4323435; Email: grabowski@hcp.med.harvard.edu
Research Objective: Despite differential payment rates across
different payer types, policymakers and researchers have
generally assumed nursing home quality is common across all
residents within a facility. Surprisingly, there has been little
work challenging this assumption. Thus, we test whether
nursing home quality is in fact a public good.
Study Design: We estimate both nursing home and individual
fixed-effects models to exploit within-home and within-person
(i.e., spend-down) variation in payer type and quality. In the
latter model, we also examine the timing of any potential
Medicaid effect by examining quality in the periods preceding
and following spend-down from private-pay to Medicaid. If
there is a Medicaid causal effect, we would expect no effect in
the periods preceding spend-down, but negative effects
following transition.
Population Studied: All Minimum Data Set assessments for
seven states over the period 1998-2002.
Principal Findings: Using a range of process and outcome
based measures of quality, both estimation strategies do not
suggest large quality differences across Medicaid and privatepay. In the minority of instances where Medicaid quality
appears worse, the timing of the Medicaid effect does not
suggest a causal effect, but rather a continuing (unbroken)
downward trend.
Conclusions: Our results are consistent with the long-held
assumption that quality is common within facilities for
Medicaid and private-paying residents.
Implications for Policy, Delivery, or Practice: State Medicaid
programs typically pay below the private-pay price. Thus, there
is the potential for free-ridership on the part of state Medicaid
programs. Although state Medicaid administrators have
historically used certificate-of-need laws to keep private-paying
residents in joint care settings, two recent trends potentially
undermine the value of private-paying patients to state
Medicaid nursing home programs. First, assisted living and
other nursing home substitutes have siphoned off some
private-paying residents. Second, the nursing home industry
has become more segregated by payer type across facilities
over the last several years.
Primary Funding Source: CMS
●Staffing Levels and Quality of Life Outcomes in Nursing
Facilities
Jiexin (Jason) Liu, Ph.D., MBA, MS, Robert L. Kane, M.D.,
Rosalie A. Kane, Ph.D., Boris Bershadsky, Ph.D., Howard H.
Degenholtz, Ph.D.
Presented By: Jiexin (Jason) Liu, Ph.D., Assistant Director of
Research, Institute for Health Policy Research, West Virginia
University, 3110 MacCorkle Avenue SE, Charleston, WV 25311;
Tel: (304)347-1241; Fax: (304)347-1236; Email:
acjliu@hotmail.com
Research Objective: Investigates relationships between
various staff characteristics (staff levels, pools staff, staff
stability) and quality of life (QOL) in nursing facilities while
controlling for other factors that may influence quality of life
and care.
Study Design: QOL is defined as outcomes on 10
psychosocial domains (e.g. security, autonomy, dignity) that
were collected through personal interviews for a national
Centers for Medicare and Medicaid Services project. QOL is
case-mix adjusted for age, gender, cognitive status, baseline
activities of daily living, and length of stay in the nursing
home. The On-Line Survey and Certification Assessment
Review data were obtained for nursing-home staffing levels
and administrative questionnaires for turnover/stability and
pool use. Latent Variable Structural Equation Modeling
method was used to analyze impact of all factors mentioned
above on QOL simultaneously.
Population Studied: About 2,800 nursing home residents in
100 facilities in 6 states were interviewed.
Principal Findings: The results from this study indicate that
nursing staff level positively and significantly affects QOL.
Among different types of nursing staff, registered nurses play
a major role in nursing staff level construction and have the
greatest positive impact on residents’ QOL. Pool use
negatively affects QOL, but it is not statistically significant.
Administrative stability and ownership (non-profit) positively
affect nursing staff level that nursing facilities use. Financial
constraint negatively affects nursing staff level. Indirect effects
from these factors on QOL were also identified.
Implications for Policy, Delivery, or Practice: Improving RN,
or overall staffing level or offering more medical training to
LPN could result higher resident QOL.
Primary Funding Source: CMS
●How Have Nursing Homes Responded to the Publication
of the CMS “Nursing Home Compare” Quality Report
Cards?
Dana Mukamel, Ph.D., William Spector, Ph.D., Jacqueline
Zinn, Ph.D., Lillian Hsieh, MHS, David Weimer, Ph.D.
Presented By: Dana Mukamel, Ph.D., Associate Professor &
Senior Fellow, Center for Health Policy Research, University of
California, Irvine, 111 Academy Way, Irvine, CA 92697; Tel:
(949) 824-8873; Fax: (949) 824-3388; Email:
dmukamel@uci.edu
Research Objective: In November 2002, the Centers for
Medicare & Medicaid Services began publishing clinical
quality indicators for all nursing facilities on the Nursing
Home Compare web site, as part of the Administration’s
strategy for promoting quality. The objective of this study was
to determine how nursing facilities have responded and what
specific strategies have been adopted following publication.
Study Design: Administrators of nursing homes were
surveyed regarding their facilities’ responses to the reports.
Administrators were queried about 23 specific actions they
might have taken, including advertising high quality scores,
reforming care protocols, strategies designed to change the
organization of the work force, staffing levels, and other
actions such as purchase of new technology, development or
change in quality improvement programs, interaction with the
QIOs, and changes in admission policies. We present the
responses and the associations between responses and the
ranking of the facility by the published quality indicators.
Due to differential response rates by region and profit status,
responses were weighted such that the results are
representative of the national composition of nursing homes.
Population Studied: A random sample of 1,502 nursing
homes was drawn from among the 15,212 nursing facilities
nationally that had at least one quality indicator reported.
Response rate was 48.2%.
Principal Findings: A large majority (82%) of facilities
reviewed their reported quality indicators. The most
important basis for comparison in their view was to their state
average scores (32%), followed by comparison to local
competitors and to their facilities prior scores. Few (2%)
considered a national comparison important. Although they
report only minimal interest by residents and their families,
over 60% of facilities have taken at least some action. The
most common response to the reports (around 30%) was
changes in care protocols to improve a low quality score.
About 20% reported changes in work structure to empower
employees, but less than 10% increased staffing. Those with
quality indicators showing poor quality (at the bottom 20% of
their state distribution) were more likely to take any action
(p<0.01) and were more likely to take more actions (p<0.01).
Less than 4% reported change in admission practices as a
strategy to improve scores.
Conclusions: A majority of nursing homes have acted in
response to the reporting of quality measures. Responses
included changes in the care protocols used.
Implications for Policy, Delivery, or Practice: These findings
suggest that the nursing home report card may have a
positive effect on the quality of care that nursing homes
provide by encouraging changes in care processes. Even
though there does not yet appear to be great interest on the
part of consumers in these measures, providers use these
measures as indicators of care problems and are willing to act
upon them. This suggests that report cards may be an
important tool to encourage nursing homes to improve
quality.
Primary Funding Source: NIA
●Diabetes Quality of Care Among Nursing Home New
Admission Cohort
Charlene Quinn, Ph.D., RN, Conrad May, M.D., Ann GruberBaldini, Ph.D., Jay Magaziner, Ph.D., Bruce Stuart, Ph.D., Van
Doren Hsu, Ph.D.
Presented By: Charlene Quinn, Ph.D., RN, Assistant
Professor, DEPM; Division of Gerontology, University of
Maryland, Baltimore, 660 West Redwood Street, Baltimore,
MD 21201; Tel: (410)706.2406; Fax: (410)706-4433; Email:
cquinn@epi.umaryland.edu
Research Objective: To determine diagnostic and secondary
prevention procedures provided to a diabetic nursing home
(NH) population and adverse utilization outcomes as
indicators of poor quality. A secondary aim was to determine
differences in care and utilization by dementia status.
Study Design: This is a retrospective cohort study of Type 2
diabetes care and utilization among new admissions to NHs.
The “Epidemiology of Dementia in Nursing Homes” studied a
cohort of 2285 new admissions to 59 nursing homes (NHs).
Patients were assessed at admission (1992-1995) and an
expert panel determined whether dementia was present.
Residents were followed through 2 years after admission (in
initial NH) through medical chart abstraction and MDS forms.
Recently, Medicare and Medicaid cost records from 1992 to
1997 have been added to this database such that Medicare
utilization records are available. Indicators of quality
management of diabetes for the period 6 months prior to NH
admission and for 1 year post admission were identified by
CPT code for 8 primary diagnostic/prevention procedures.
Utilization (hospital, emergency room and physician visits)
was determined for 4 categories of adverse outcomes by ICD9 codes.
Population Studied: Among a cohort of 2285 new
admissions, 404 were identified as diabetic by MDS at
baseline and were included in this study (n=404). In the
parent study, over 50% of new admissions had dementia as
determined by an expert panel of psychiatrists, neurologists
and a geriatrician.
Principal Findings: 1. During an 18-month period, NH
diabetics use of diagnostic and secondary prevention services
was less than recommended by diabetes clinical practice
guidelines (42% had one hemoglobin A1c during the period
compared to recommendations for quarterly tests; 35% had an
annual eye exam; 45% had annual lipid level tests). 2. Adverse
outcomes categorized by dehydration, macro and micro
vascular events, metabolic complications and infectious
complications identified poor outcomes for this NH
population. Nearly 40% had a hospitalization for dehydration,
51% had an emergency room visit for hyperglycemia; 27%
received physician visits for diabetic gangrene. 3. Utilization
and total costs by service categories are presented and
observations of findings by dementia status.
Conclusions: 1. Clinical practice guidelines for diagnostic and
secondary prevention procedures for diabetics in NHs is not
followed by providers. 2. Poor quality management of NH
diabetics is related to adverse outcomes in utilization of
hospital admissions, emergency room visits, and physician
visits.
Implications for Policy, Delivery, or Practice: Diabetes is a
common and costly chronic illness among nursing home
residents. Reported prevalence of known diabetes among NH
residents ranges from 7 to 27% of residents. Unlike
community-based older adults where the responsibility is selfmanagement of diabetes, residents of nursing homes rely on
the NH care plan and providers to manage their diabetes.
Although clinical practice guidelines for managing diabetes in
the LTC setting exist (AMDA, 2002), this study determined
providers may not focus on the diagnostic and secondary
prevention evaluation of this chronic disease in a LTC setting.
In the current environment of shorter nursing home lengths of
stay (27 days), adverse outcomes of diabetes contribute to
patient conversion to long stay residents at a cost to all
payors.
Primary Funding Source: NIA
●Using Propensity Stratification to Compare Patient
Outcomes in Hospital-Based versus Freestanding Skilled
Nursing Facilities
Sally Stearns, Ph.D., Kathleen Dalton, Ph.D., George Mark
Holmes, Ph.D., Susanne Seagrave, Ph.D.
Presented By: Sally Stearns, Ph.D., Associate Professor,
Health Policy and Administration, University of North Carolina
at Chapel Hill, CB #7411, Chapel Hill, NC 27599-7411; Tel:
(919) 843-2590; Fax: (919) 966-6961; Email:
sstearns@unc.edu
Research Objective: Hospitalized Medicare patients needing
post-acute care are often discharged to either a hospital-based
or freestanding skilled nursing facility (SNF). Patterns of care
by setting are fairly different, as Medicare patients in hospitalbased skilled nursing units typically have shorter stays but
higher costs per day than patients in freestanding skilled
nursing facilities. This study assesses the extent to which
differences in outcomes by setting may be attributable to
patient selection rather than underlying institutional
differences.
Study Design: The analysis uses a propensity score approach
to group observations according to their predicted probability
of going to a hospital-based or a freestanding SNF.
Stratification by referral probabilities has the potential to
provide additional control for selection bias. OLS and probit
models estimating outcome differences attributable to
hospital-based settings (the HB referral effect) are estimated
within propensity groups, and the results are compared to
those from unstratified estimates. Three outcomes are
selected for illustration: Medicare-covered SNF length of stay;
preventable hospital readmissions; and the likelihood of
discharge to home or community within 30 days of SNF
admission.
Population Studied: The analysis uses a 50% sample of
Medicare SNF admissions from July 2000 through June 2001,
using claims data from qualifying hospital and nursing home
stays combined with nursing assessments contained in the
Minimum Data Set (MDS) and characteristics of the referring
and admitting facilities. The analysis sample is are restricted
to patients coming from the 48% of PPS hospitals that
operated a SNF during the study period because an explicit
choice between type of SNF is most likely for these patients.
Principal Findings: The results indicate that patients who are
good candidates for faster recovery and discharge to the
community are preferentially selected into hospital-based
units. In unadjusted comparisons, hospital-based Medicarecovered SNF patients relative to freestanding SNF patients
have stays that are 58% shorter (13 versus 31 days), are three
times more likely to be discharged to home or community
within 30 days (63% versus 21%), and are half as likely to have
a preventable readmission (7% versus 13%). The unstratified
regression approach reduces the hospital-based differentials
by one-third to one-half. The stratified regressions further
reduce the differences, especially for patients most likely to be
referred to hospital-based units. For these patients, being in a
hospital-based SNF is associated with having a Medicarecovered length of stay that is 17% shorter, being 7 percentage
points more likely to be discharged to home or community,
and being 1.1 percentage points less likely to have a
preventable readmission. These remaining differences are,
however, statistically significant.
Conclusions: While unstratified regressions control for much
of the selection, the results suggest that propensity
stratification further reduces selection bias for estimating
sample average effects of hospital-based settings on the
outcomes studied.
Implications for Policy, Delivery, or Practice: Much but not
all of the difference in outcomes associated with type of SNF
are attributable to patient selection that can be accounted for
by observed patient characteristics. Remaining differences in
outcomes by setting may be due to underlying differences in
facility patterns of care or may reflect residual bias due to
unobserved factors.
Primary Funding Source: Medicare Payment Advisory
Commission
Related Posters
Poster Session A
Sunday, June 26 • 2:00 pm – 3:15 pm
●Unmet Service Needs in a Medicaid Population with
Physical Disabilities
Susan Allen, Ph.D., Susan Wieland, MS, Christine Payne,
Ph.D.
Presented By: Susan Allen, Ph.D., Associate Professor,
Community Health, Brown University, Box G, Providence, RI
02912; Tel: (401) 863-3818; Email: Susan_Allen@brown.edu
Research Objective: Persons with chronic disabilities who are
covered by Medicaid may need a broad array of supportive
services in addition to medical care to manage their
conditions. The purpose of this study was to determine the
prevalence of unmet service needs in a working age Medicaid
population with physical disabilities.
Study Design: A randomly selected sample of 550 Medicaid
recipients drawn from the Rhode Island Medicaid
Management Information System were surveyed by telephone.
The prevalence rates of unmet need for 18 specific services
were calculated for the full sample as well as for the subset of
respondents who reported need for the service in question,
and events/trials logistic regression was used to identify
factors associated with unmet need, including indicators of
program factors that are amenable to change.
Population Studied: The target population of this study was
the fee-for-service working age Rhode Island Medicaid
population with physical disabilities.
Principal Findings: Unmet need for medical services was low
in this population, i.e., 1% reported inability to get a doctor's
appointment when needed, and 8.7% were unable to get
needed specialty medical care. Rates of unmet need for
ancillary and supportive services were substantially higher.
Specifically, 20.2% of the full sample and 31.2% of
respondents who reported needing dental care in the previous
year were unable to get it, and 15.7% of the full sample and
25% of respondents who reported needing eyeglasses in the
past year were not able to get them. Unmet need for other
types of ancillary and social services was lower in the full
sample but similarly high among respondents who reported
needing them. Several program related features were
protective against unmet need, including having one's own
doctor, having a hospital clinic or health center as a usual
source of care, and having help getting services.
Conclusions: Although Medicaid is known as the best
insurance mechanism for covering long term care, there is
inadequate coverage of community-based services hat can
help people with disability successfully manage their
conditions and maintain community residence.
Implications for Policy, Delivery, or Practice: Our findings
speak to the need to develop programs that are a better fit
with the disabled population covered by Medicaid. These data
can be used to target areas of improvement, and speak to the
importance of continuity of care and the potential benefits of
case management in helping meet the needs of this
vulnerable population.
Primary Funding Source: No Funding Source
●The Impact of For-Profit Ownership on the Delivery of
Hospice Care
Melissa D.A. Carlson, MPH, MBA, Elizabeth H. Bradley, Ph.D.,
Mark J. Schlesinger, Ph.D., Theodore Holford, Ph.D.
Presented By: Melissa D.A. Carlson, MPH, MBA, Doctoral
student, Health Policy and Administration, Yale University, 60
College Street, New Haven, CT 06520-8034; Tel: (917)4347293; Email: melissa.carlson@yale.edu
Research Objective: The decade of the 1990’s witnessed
dramatic growth in the number of for-profit hospice providers.
Despite this growth, little is known about the relationship
between ownership (i.e., for-profit and nonprofit) and the
delivery of hospice care and how this relationship may have
changed over time as the prevalence of for-profit hospice
providers increased. This study estimates differences in
hospice care processes for patients of for-profit and nonprofit
hospices over the period 1992-2000.
Study Design: This paper uses data from the National Home
and Hospice Care Survey (NHHCS), a nationally
representative dataset of hospice organizations and their
patients, over the period 1992 to 2000. Hospice care
processes are measured by the range of services received by
patients and the predicted probability of receiving individual
hospice services. Multivariable ordered logistic regression was
used to estimate the association between ownership and
service use, adjusting for potentially confounding patient and
organizational characteristics. Models were also estimated
among subgroups of patients based on hospice certification
status, the patient’s referral source, and whether the hospice
was horizontally and/or vertically integrated.
Population Studied: There were 9,409 discharged hospice
patients surveyed over the 5 years of the NHHCS representing
a national estimate of approximately 2,000,000 hospice
patients after applying the sample weights.
Principal Findings: In the subgroup of non-certified hospices,
patients of for-profit hospices received a significantly narrower
range of services than patients of nonprofit hospices
(OR=0.08, 95% CI 0.02,0.31) and this effect was consistent
over time. In the full sample, there was a significant
interaction between ownership and time (P-value=0.002) on
the delivery of hospice services indicating that in earlier years,
patients of for-profit hospices received a narrower range of
services than patients of nonprofit hospices but this effect was
diminished over time and reversed in the final year of the
study. This trend over time was particularly evident in services
that address the fundamental principles of hospice, including
social and family-related services. Differences in the
probabilities of receiving these types of services in for-profit
compared to nonprofit hospices were substantial, varying up
to 20 percentage points in some years. The dynamic effect of
ownership over time was evident in the subgroup of standalone hospices but not in vertically and/or horizontally
integrated hospices.
Conclusions: The relationship between hospice ownership
and the delivery of services is complex, depending on the time
period, the type of hospice service, and the certification status
of the hospice provider.
Implications for Policy, Delivery, or Practice: The dramatic
and stable effect of ownership in non-certified hospices (and
no effect of ownership in certified hospices) lends support for
policies that seek to use regulation to address ownership
differences in the delivery of healthcare services.
Primary Funding Source: No Funding Source
●Rapid Expansion of the Home- and Community-Based
Personal Assistance Workforce
Susan Chapman, Ph.D., RN, H. Stephen Kaye, Ph.D., Robert
Newcomer, Ph.D., Charlene Harrington, Ph.D., RN
Presented By: Susan Chapman, Ph.D., RN, Assistant Adjunct
Professor, Center for the Health Professions, University of
California San Francisco, 3333 California Street, Suite 410, San
Francisco, CA 94118; Tel: (415) 502-4419; Fax: (415) 476-4113;
Email: susanac@itsa.ucsf.edu
Research Objective: People with disabilities often need
formal personal assistance or long-term care services in order
to live independently in the community. Prior research has
shown that lack of availability of such services can lead to
adverse health consequences, physical or social isolation, or
institutionalization. The objective of this project is to assess
whether the size of the personal assistance service (PAS)
workforce has kept pace with the needs of people with
disabilities for such services, and to study trends in
employment conditions for this workforce.
Study Design: Multiple time series obtained from secondary
analysis of three nationally representative Federal surveys: the
basic monthly Current Population Survey (CPS) for 19942004, along with the annual demographic and biennial job
tenure supplements to the CPS; the annual National Health
Interview Survey (NHIS) for 1994-2003; and the annual
American Community Survey (ACS) for 2000-2003.
Workforce data are obtained from the CPS and ACS, and data
on employment conditions (earnings, job tenure,
unemployment, and health insurance) come from the CPS
and its supplements. Data on the population needing PAS
come from the NHIS.
Population Studied: (1) The home health and personal
assistance workforce, as defined by stated industry and
occupation of employment. (2) Elderly and non-elderly adults
and children needing help with one or more Activities of Daily
Living (ADL), such as bathing, dressing, or transferring.
Principal Findings: There was a rapid expansion in the homeand community-based PAS workforce during the past decade,
from 0.5 million workers in 1994 to more than 0.9 million in
2004. Particularly rapid growth occurred during the mid1990s and between 2001 and 2004. With no commensurate
decline observed among similar workers employed in nursing
homes and residential care facilities, the data suggest that the
growth in the PAS workforce is the result of new workers
entering this field. The growth rate exceeds that of the
community-resident population needing help in ADLs, which
also grew substantially during the period, suggesting
increasing availability of formal PAS to those needing it. Wage
levels for PAS workers remain low, however, and health
insurance benefits remain rare. Job tenure data indicate high
rates of turnover for these workers.
Conclusions: With the expansion in the workforce identified
as providing home health or personal assistance services in
community settings, exceeding the recent growth in the
population needing such services, people with disabilities
should be increasingly able to obtain the paid help they need
in order to live independently in the community rather than
facing institutionalization. High turnover rates, low pay, and
lack of benefits suggest, however, that the quality of help
received may persist as an important concern.
Implications for Policy, Delivery, or Practice: The shift away
from institutional care indicates a need to focus a greater
share of resources toward training and increased retention of
home care workers and personal attendants.
Primary Funding Source: National Institute on Disability and
Rehabilitation Research
●Hard Choices: The Role of Ethics Committees in
Assisted Living
Carol Cirka, Ph.D., Carla M. Messikomer, Ph.D.
Presented By: Carol Cirka, Ph.D., Assistant Professor,
Business and Economics, Ursinus College, 219 Bomberger
Hall, Collegeville, PA 19426; Tel: (610)409-3000 x2842; Fax:
(610)363-3506; Email: ccirka@ursinus.edu
Research Objective: Assess the existence and use of ethics
committees (EC) by assisted living facilities (ALFs), licensed in
Pennsylvania as “personal care homes” (PCHs), in four
suburban Pennsylvania counties adjacent to Philadelphia.
This study evolved from a long-term project that examined
how everyday ethical issues are identified, managed and
resolved in assisted living (AL).
Study Design: This study used a three-pronged approach: 1)
Ethnographic-type interviews, a portion of which focused on
the existence, access to, and use of ethics committees to
resolve everyday ethical dilemmas, with staff of five ALFs that
vary on a number of dimensions; 2) A case study of the
development of an ethics committee in a non-profit CCRC;
and 3) A cross-sectional survey (mail/telephone) to Executive
Directors and Care Coordinators of licensed PCHs in the study
population.
Population Studied: 134 Pennsylvania ALFs with 20+ beds in
Chester, Bucks, Montgomery and Delaware Counties.
Ethnographic-type interviews (averaging two hours each) were
conducted with Executive Directors, Care Coordinators and
Marketing Directors and caregivers in five Chester County
ALFs. Original and current members provided data for the
case study of an ethics committee (EC). Executive Directors
and Care Coordinators at the 134 ALFs were surveyed with
telephone follow up. Questions focused on existence and use
of ECs in resolving ethical dilemmas that arose in AL.
Principal Findings: ECs are not common in ALFs; however,
those that are part of a multi-level system or non-profit are
more likely to have access to ECs. When ECs exist, they are
not used to resolve issues in AL; further, staff does not view
them as a resource for managing everyday problems in AL,
nor are they widely understood or publicized. Common
responses to ethical dilemmas include: 1) Managing the
problem informally and locally; 2) “Calling legal” to determine
what to do; or 3) Involving the local Ombudsperson. The
response depends on the individual(s) involved, personal
values and experiences, and comfort level with the particulars
of the problem. Employee training rarely includes formal
discussion of ethics, which is often left to the immediate
supervisor’s discretion. Staff does not voice significant
concern about the legal consequences of action or inaction;
confusion exists as to the distinction between legal and ethical
dilemmas.
Conclusions: ECs represent one organizational mechanism to
manage ethical dilemmas that emerge from the everyday
operations of ALFs. Evidence indicates that while ECs are
institutionalized in acute-care settings, non-acute care settings
have been slow to establish and use them. Nursing homes
tend to rely on ECs for issues surrounding palliative and endof-life care; however, ALFs, in contrast to both acute care and
nursing homes, have little knowledge of or experience with
them. Even when ECs exist in a multi-level system, ALFs do
not view them as a resource to sort through and manage the
complexities of everyday ethical dilemmas.
Implications for Policy, Delivery, or Practice: Ethical
dilemmas are common in AL; however, resolution often
depends only on people involved in the immediate problem.
There is a need to develop organizational structures and
processes that are not exclusively person-dependent. Doing
so should improve quality of care, equity, and staff morale.
Primary Funding Source: No Funding Source
●Profit Status and the Relationship Between Medicaid
Reimbursement and Quality
Carrie Davidson, MA, Ph.D.
Presented By: Carrie Davidson, MA, Ph.D., Data Analyst,
Ohio KePRO (Medicare QIO), 1495 Woodward Avenue,
Lakewood, OH 44107; Tel: (216)221-6998; Email:
cxd39@case.edu
Research Objective: Determine whether any relationships
between Medicaid payments for direct care and efficiency and
the facility’s nurse staffing are significantly different depending
on the nursing home’s profit status.
Study Design: Retrospective cohort design
Population Studied: 145 non-profit Ohio Medicaid certified
nursing facilities (excluding government-run and hospitalbased facilities) and 391 for-profit facilities with three years of
cost reports where costs justified rates paid in subsequent
rate years.
Principal Findings: Using OLS regression and a stratified
sample on the basis of profit status, three distinct ratios of
nursing minutes provided (RN, LPN, and Nurse Aide) to
nursing minutes needed (using quarterly RUGs-III
classifications at the facility level) were regressed on three
Ohio Medicaid revenue streams (rate per case mix unit,
indirect efficiency payment, and capital efficiency payment)
weighted for the percent Medicaid occupancy in the facility.
Control variables included the prior year's net operating
revenue and non-operating revenue, and current year's
percent Medicare days and concentration of private pay
inpatient days >= 40%. Both facilities had a positive
association between Medicaid-adjusted rates per case mix unit
in the first half of the calendar year and all three nurse staffing
ratios. However, they differed in their reactions to rate
increases that occur in the middle of the calendar year with
non-profits demonstrating a positive and significant
association between the RPCMU and nurse aide staffing ratios
and for-profits a positive and significant association between
the RPCMU and LPN staffing ratios. For both facility types,
indirect efficiency payments had a significant and negative
association with nurse aide staffing and RN staffing ratios.
For FP facilities there was also a significant negative
association with the indirect efficiency payment and LPN
staffing ratios. FP facilities were the only ones that had a
significant (and positive) relationship between the capital
efficiency payment and nurse staffing, specifically the nurse
aide staffing ratio.
Conclusions: There were significant differences between forprofit and non-profit nurse staffing ratios. They also differed
significantly as to when they changed these ratios and their
use of different Medicaid revenue streams for different types
of staff.
Implications for Policy, Delivery, or Practice: In light of
state Medicaid budget crises and impending cuts, it is
important to recognize differences in providers' use of
different components of the Medicaid rate in order to
minimize the effects of budget cuts on quality of care.
Primary Funding Source: AHRQ
●Psychometric Properties of A Brief Quality of Life
Instrument for Nursing Home Residents
Howard Degenholtz, Ph.D., Jules Rosen, M.D., Nicholas
Castle, Ph.D., Vikas Mittal, Ph.D., Rosalie A. Kane, Ph.D.
Presented By: Howard Degenholtz, Ph.D., Assistant
Professor, Health Policy and Management, University of
Pittsburgh, 3708 5th Avenue Suite 300, Pittsburgh, PA 15213;
Tel: (412)647-5860; Fax: (412)647-5877; Email: degen@pitt.edu
Research Objective: The goal of this study was to test a brief
(14 item) quality of life (QOL) instrument for use with nursing
home residents with varying levels of cognitive impairment.
This study specifically examined the impact of different
response options.
Study Design: In person interviews with nursing home
residents. Five interviews, six months apart were conducted
with all residents living in the two study facilities at the time of
data collection. At each time period the complete version and
a brief version of the QOL interview were conducted. The
brief QOL scale was developed by selecting items from the
longer multidimensional scale that reflected a majority of the
dimensions while minimizing length. The response options
for the brief version were changed at each wave to test the
impact on completion rates. Versions included dichotomous
(yes/no) responses, 4-point Likert type scale, and an
‘unfolding’ version of the question that used serial
dichotomous responses rather than a 4-point scale (a ‘yes’
response is followed by ‘often/sometimes’ and a ‘no’
response is followed by ‘rarely/never’). This approach
provides more information than a simple yes/no response.
QOL interview data were merged with the MDS to adjust for
cognitive and functional status.
Population Studied: All residents of two nursing homes in
the Pittsburgh area were eligible to participate. Each facility
had approximately 150 residents Interviews were attempted
with all residents using an algorithm to discontinue the
interview if the resident did not provide coherent responses.
Principal Findings: Response rates were approximately 60%
at all waves. Residents who are not capable of using the 4point Likert type scale were able to provide a yes/no response.
Residents with significant cognitive impairment according to
the MDS were capable of using the unfolding version.
Conclusions: A brief QOL scale can be used with a wide
range of nursing home residents and produces scores that are
highly correlated with the original scale.
Implications for Policy, Delivery, or Practice: Nursing home
operators, clinicians and policy makers are concerned with the
QOL of residents. However, the absence of a widely used
instrument has hampered efforts to study or improve QOL.
This study demonstrates that a brief instrument can produce
reliable data that closely parallels the results using a longer
multidimensional scale, and provides insight into the
response options that maximize participation from residents
with relatively low levels of cognitive function. This brief QOL
scale can be used as a screener that identifies areas for deeper
questioning using the longer scale or it can be used to track
quality improvement activities designed to enhance QOL.
Primary Funding Source: AHRQ
●Comparison of Undertreatment among Aged Medicare
Beneficiaries in Nursing Homes and the Community
Setting: A Case Study of Warfarin Use in Atrial Fibrillation
Jalpa Doshi, Ph.D.
Presented By: Jalpa Doshi, Ph.D., Health Services Research
Scientist, Division of General Internal Medicine, University of
Pennsylvania, 1214 Blockley Hall, Philadelphia, PA 19104; Tel:
(215)898-7989; Fax: (215)898-0611; Email:
jdoshi@mail.med.upenn.edu
Research Objective: Under the Omnibus Budget
Reconciliation Act (OBRA), CMS mandates that the drug
regimen of each nursing home (NH) resident be reviewed at
least once a month by a licensed pharmacist. As a result,
broad oversight of drug therapy is performed by consultant
pharmacists for all NH residents. On the other hand,
outpatient drug use has not been systematically monitored in
the community except for some beneficiaries in Medicare
HMOs and Medicaid. Given the differences in the level of
monitoring of drug prescribing, one should expect that all else
being equal, the prevalence of undertreatment should be
higher among aged Medicare beneficiaries residing in the
community than those in NHs. Yet no studies till date have
directly examined the differences in medication underuse
across the two residential settings. This study compares
underutilization of warfarin among NH and communitydwelling aged Medicare beneficiaries with atrial fibrillation
(AF).
Study Design: The study used the Medicare Current
Beneficiary Survey (1997-2000) supplemented with data from
Medicare claims and a non-publicly available file on
institutional drug administrations for NH beneficiaries in the
MCBS. The main outcome variable was the prevalence of any
warfarin use. A binary variable on the type of residential
setting (i.e. NH versus community) was the main
independent variable of interest. The control variables
included socioeconomic and demographic factors, survey year
of observation, and a host of disease-related factors including
number of AF-related physician visits and hospitalizations,
other CVD risk factors, presence of warfarin contraindications,
number of chronic conditions other than CVD, and selfreported health status. Propensity score techniques were used
to compare underuse between community and nursing home
residents.
Population Studied: NH (n=419) and community-dwelling
(n=2915) fee-for-service Medicare beneficiaries aged 65 years
or older, having Medicare Part B coverage, and one or more
hospital or medical service claims with a diagnosis of atrial
fibrillation (ICD-9-CM 427.31) in the 1997 through 2000 MCBS
files.
Principal Findings: Substantial underuse of warfarin was
found across both residential settings. In the unadjusted
analyses, the warfarin use was substantially higher among
community beneficiaries than nursing home beneficiaries
(47% vs. 33%, p<0.0001). However, there were substantial
differences in the characteristics of the two groups with NH
residents more likely to be female, have lower incomes, and be
in poorer health. After propensity score adjustment, not only
did the warfarin prevalence rates become more similar in the
two groups, but the nursing home sample had a slightly
higher (32.3%) rate of warfarin use than the communitydwelling sample (29.1%), albeit, the difference was not
statistically significant (p=0.395).
Conclusions: Warfarin use is similar across the community
and nursing home setting and is substantially underutilized in
both settings.
Implications for Policy, Delivery, or Practice: The study
findings have direct implications for the Medicare drug benefit
which will provide voluntary prescription drug coverage to all
Medicare beneficiaries, regardless of community or
institutional residence, starting in 2006. The law requires
prescription drug plan sponsors to have a medication therapy
management program furnished by a licensed pharmacist that
includes elements such as detection of adverse drug events
and patterns of overuse and underuse of prescription drugs.
This study raises the need for future studies to evaluate the
success of such programs in improving the quality of
medication use among Medicare beneficiaries once the drug
benefit is implemented in 2006.
Primary Funding Source: No Funding Source
●Staff Turnover and Quality of Care in Nursing Homes
John Engberg, Ph.D., Nicholas Castle, Ph.D.
Presented By: John Engberg, Ph.D., Economist, RAND, 201
North Craig Street, Pittsburgh, PA 15213; Email:
Engberg@RAND.org
Research Objective: The association between nurse aide
(NA) plus licensed practical nurse (LPN) and registered nurse
(RN) turnover and quality indicators in nursing homes is
examined.
Study Design: Indicators of care quality used are the rates of
physical restraint use, catheter use, contractures, pressure
ulcers, psychoactive drug use, and certification survey quality
of care deficiencies. In addition, we use a quality index
combining these indicators. The turnover rates are grouped
into three categories, low, medium, and high, defined as 020%, 21-50%, and greater than 50% turnover, respectively.
Population Studied: Turnover information came from
primary data collected from 354 facilities in four states, and
other information came from the 2003 Online Survey,
Certification And Reporting data.
Principal Findings: Multivariate analysis shows that
decreases in quality are associated with increases in RN
turnover, especially increases from low to moderate levels of
turnover, and with increases in NA and LPN turnover,
especially increases from moderate to high levels of turnover.
Conclusions: The one-year turnover rates identified in this
study were 98.6%, 66.8%, and 55.4% for NAs, LPNs, and
RNs, respectively. This adds to a rather large body of research
over the past 20 years also showing high rates of staff
turnover. Most importantly, we also show that very low or
very high levels of NA+LPN turnover are associated with lower
quality of care and that moderate to high levels of RN turnover
are associated with lower quality of care.
Implications for Policy, Delivery, or Practice: These findings
are significant because the belief that staff turnover influences
quality is pervasive. The cross-sectional results are only able
to show associations, nonetheless, few empirical studies in
the literature have shown this relationship.
Primary Funding Source: No Funding Source
●Preference-Based Selection Effects in Elders with LongTerm Care Insurance
Mary Goldstein, M.D., MS, Jenny Hyun, MPH, Alan Garber,
M.D., Ph.D., Tamara Calvillo, MA, Pamela Mahlow, MA,
Lorene Nelson, Ph.D.
Presented By: Mary Goldstein, M.D., MS, Associate
Professor, Primary Care and Outcomes Research, Stanford
University and Palo Alto VA Health Care System, 117 Encina
Commons, Stanford, CA 94305; Tel: (650) 493-5000 x62105;
Fax: (650) 723-1919; Email: Goldstein@stanford.edu
Research Objective: The asymmetric information model
predicts a positive correlation between insurance and the
occurrence of risky events due to moral hazard or adverse
selection. Adverse selection occurs because those most likely
to purchase insurance are most likely to file a claim; they may
be at a higher health risk of a health event or have stronger
care preferences. Underwriting practices attempt to correct
for selection based on observable risk factors. Insurers,
however, are not privy to information about preferences for
care and risk aversion. We examined elders in a Medicare
managed care program comparing individuals with and
without long-term care insurance (LTCI) on health behavior
and differences in their preferences for nursing home care.
Study Design: The study uses cross-sectional data from a
longitudinal study investigating the impact of ADL
dependency on health utility ratings.
Population Studied: This study used a convenience sample
(n=292) of Medicare managed care enrollees 65-years old and
older, of whom 82 had LTCI. Those with and without LTCI did
not differ significantly in terms of age, number of living
children, ADL and IADL limitations, and total household
income. Those with LTCI were more likely to be White and
had more years of education than those without LTCI.
Principal Findings: Elders with LTCI spent less time
depressed or sad and were more likely to engage in preventive
health behaviors, such as getting a flu shot, within the last 12
months. Ratings of general health, health satisfaction, ADL
and IADL limitations, and chronic disease did not differ
significantly between LTCI and non-LTCI groups. Elders with
LTCI had higher utility ratings for nursing home care than for
care in their own homes given hypothetical ADL
dependencies, controlling for current health utility scores. On
average, those with LTCI rated their preference for nursing
home care 0.12 points (on a 0 to 1 scale) higher than those
without LTCI.
Conclusions: Elders with LTCI spent less time depressed,
engaged in more preventive behaviors, and showed a trend
toward rating their health better than their peers. This study
suggests that individuals with LTCI may have more awareness
of future health events--a concern that is manifested in
preventive health behaviors. Elders with LTCI are much less
averse to nursing home care than those without LTCI, a
preference that may increase the likelihood of nursing home
utilization. The study design did not allow us to determine
whether the preference differences pre-dated the decision to
buy LTCI.
Implications for Policy, Delivery, or Practice: Findings
suggest that those who seek LTCI have risk-aversion
characteristics, manifested in health-seeking behaviors, which
balance preference-based selection effects for nursing home
care. Although these findings are consistent with asymmetric
information, they do not suggest an increased probability of a
health event. LTCI providers should assess the impact of
managed care programs to minimize moral hazard problems
post-insurance purchase and should be more attuned to
potential advantageous selection characteristics.
Primary Funding Source: NIA, Veterans Affairs HSR&D
●Hospice Care in the Nursing Home: Is Diagnosis
Associated with Configuration of Care?
Andrea Gruneir, MS, Ph.D. Candidate, Kate L. Lapane, Ph.D.,
Susan Miller, Ph.D.
Presented By: Andrea Gruneir, MS, Ph.D. Candidate,
Graduate Student, Community Health, Brown Medical School,
Box G-Hemisphere, Providence, RI 02912; Tel: (401) 8639260; Fax: (401) 863-3713; Email: Andrea_Gruneir@brown.edu
Research Objective: Although initially designed for people
with terminal cancer, the increased availability of covered
hospice services along with mainstream recognition of its
benefits, have lead to efforts to improve the provision of such
services to patients with other types of end-stage illnesses. In
the nursing home setting, access to and provision of end-oflife care services to patients with Alzheimer’s disease and
other dementias is of particular interest. We sought to
quantify the effect of a dementia diagnosis on the
configuration of hospice services provided in the nursing
home.
Study Design: We used a cross-sectional study design. All
data were obtained from an administrative database
maintained by a single large hospice provider. Four diagnostic
groups were created based on the primary diagnosis at the
time of hospice enrolment: cancer, dementia, debility, and all
others. Configuration of care was measured as the percent of
patients who received visits, the median total number of
minutes spent with patients, and the median visit length. The
configuration of care of several types of providers (physicians,
RNs, LPNs, aides, social workers, and chaplains) was
examined. We focussed on the first 2 days of care.
Population Studied: We included residents of US nursing
homes who received hospice services from a for-profit hospice
provider between January 1, 1998 and September 1, 2000.
Principal Findings: Twenty-seven % had a diagnosis of
cancer, 23.5% had dementia, 14.9% had a diagnosis of
debility, and 34.5% had other diagnoses. Missing information
regarding pain assessment was common in all patients:
cancer patients (33%), patients with dementia (67%), patients
with debility (51%). Fewer than 20% of all patients were seen
at least once by an aide, social worker, or chaplain in the initial
2 day period of hospice care and this did not differ by
diagnosis group. Patients with dementia and debility were
visited by RNs and LPNs but had less overall care time than
patients with cancer. Physicians appeared to be the least
involved with direct patient care, yet visited patients with
dementia and debility less often than those with cancer.
Conclusions: Major differences in the configuration of
hospice care in the first two days of care were not observed
across diagnosis groups. The extent to which this reflects that
hospice care is not directly responsive to the varying needs of
different groups needs to be explored. Missing information
regarding pain assessment in patients with dementia and
debility was highly prevalent. These data may reflect the
challenges of pain assessment and control, which are
mainstays in hospice care, in patients with communication
difficulties.
Implications for Policy, Delivery, or Practice: The needs of
patients with dementia are likely to be vastly different than
those with cancer, and further knowledge is needed to
determine whether current conceptualizations of hospice
appropriately meet these needs. End-of-life care for patients
with dementia may require a very different approach than that
taken in the same care of patients with other diagnoses,
especially cancer.
Primary Funding Source: No Funding Source
●Outcomes of the Assisted Living Pilot Program
Susan Hedrick, Ph.D., Marylou Guihan, Ph.D., Michael
Chapko, Ph.D., Larry Manheim, Ph.D., Jean Sullivan, B.A., Jane
Tornatore, Ph.D.
Presented By: Susan Hedrick, Ph.D., Research Career
Scientist, Health Services Research and Development Center
of Excellence, Department of Veterans Affairs, 1100 Olive Way,
Suite 1400, Seattle, WA 98108; Tel: (206)764-2085; Fax: (206)
764-2935; Email: susan.hedrick@med.va.gov
Research Objective: Assisted living is the fastest growing
type of non-institutional long-term care, but is available
primarily to those who have sufficient financial resources to
obtain such care on the private market. This study evaluated a
pilot demonstration of assisted living supported by the
Department of Veterans Affairs, the Assisted Living Pilot
Program (ALPP), conducted in 7 Medical Centers in 4
Northwest states. ALPP was designed as a transitional benefit
where VA paid for care for a limited period with a goal of
transitioning to longer term funding through Medicaid or
private pay.
Study Design: We obtained data on all ALPP residents’
demographics, health status, utilization, and cost of care over
a 12-month period from administrative and clinical records.
Data were collected for a comparison group of persons who
were eligible for but did not enter ALPP.
Population Studied: From January 2002 through December
2004, 779 residents were placed in ALPP facilities. The
average ALPP resident was a 70 year-old unmarried white
male who was referred from an inpatient hospital setting and
was living in a private home at referral.
Principal Findings: Residents were admitted as planned to all
types of community-based residential care programs licensed
under state Medicaid-waiver programs: 55% to Assisted Living
Facilities, 30% to Residential Care Facilities, and 16% to Adult
Family Homes. At referral, 21% percent received assistance
with 4 or more Activities of Daily Living and 37% had
indicators of cognitive impairment.
Adult Family Homes enrolled residents requiring much
greater levels of assistance with Activities of Daily Living and
with higher indicators of skilled care needs. ALPP residents
showed very little change in health status over 12 months
post-enrollment. Of the 517 residents who completed the VA
payment period, 232 (45%) stayed in ALPP: 55% on private pay
and 41% on Medicaid. The mean cost per day for the first 515
residents discharged from ALPP was $74.83, and the mean
length of stay in an ALPP facility paid for by the VA was 63.5
days, for a total cost of $5,030 per resident. The total cost per
resident of all health care paid for by VA during the 12-month
follow-up period was significantly higher than per comparison
group member, controlling for baseline differences.
Conclusions: ALPP placed residents with significant
functional impairment and a wide variety of physical and
mental health conditions in settings that varied widely in size
and services. The finding that Adult Family Homes enrolled
residents with much greater care needs supports the decision
to contract with this range of types of settings. As health
status typically deteriorates over time in a population in need
of residential care, one possible interpretation of our finding of
little change in health status is that ALPP may have helped
maintain residents’ health over time.
Implications for Policy, Delivery, or Practice: ALPP could fill
an important niche in the continuum of long-term care
services. However, contracting barriers and cost are
important issues to address.
Primary Funding Source: VA
●Emergency Department Use by the Elderly Living in
Nursing Homes
Esther Hing, MPH, RobinRemsburg, Ph.D.
Presented By: Esther Hing, MPH, Survey statistician,
Department of Health and Human Services, National Center
for Health Statistics, 3311 Toledo Road, Room 3409,
Hyattsville, MD 20782; Tel: (301) 458-4271; Fax: (301) 4584693; Email: ehing@cdc.gov
Research Objective: The frail health of nursing home
residents poses challenges to emergency department staff.
This paper examines ED treatment patterns for nursing home
residents in 2001-2002, and compares this
care with treatment received by community dwelling elderly.
These comparisons were made to investigate whether some
emergency care received by nursing home residents could
more appropriately have been treated in the nursing home.
Study Design: The National Hospital Ambulatory medical
Care Survey (NHAMCS) is an annual 4-stage nationally
representative sample survey of roughly 35,000 sampled ED
medical encounters in about 480 non-Federal, short-stay, and
general hospitals.
Population Studied: Emergency department visits by the
elderly living in nursing homes (n=1,270) and the community
(n=9,316) in 2001-2002.
Principal Findings: During 2001-2002, ED visits by nursing
home residents comprised only 12% of all elderly ED visits,
but the nursing home visit rate (123 visits per 100 persons)
was significantly higher than the rate for community dwelling
elderly (42 per 100 persons). On average, ED patients from
nursing homes were older (82 years) than community
dwelling elders (77 years). ED diagnoses were similar for
community dwellers and nursing home residents with the
following exceptions: ED visits by nursing home residents with
injuries (20%) and alteration of consciousness (10%)
exceeded that of community dwelling elders (16% and 7%,
respectively); community dwelling elderly had more diagnoses
involving diseases of the musculoskeletal and connective
tissue (7% compared with 3% in nursing homes). The
percent of elderly ED visits with ambulatory care sensitive
conditions (ACSC) was similar among nursing home residents
(13%) and the community (14%). On average, nursing home
residents received more diagnostic or screening tests (5.9)
and surgical procedures (1) per ED visit than community
dwelling elderly (4.9 diagnostic tests and 0.7 procedures per
ED visit). Almost half (47%) of ED visits by nursing home
residents resulted in admission to the hospital compared
with 34% from the community. Among the ED visits with
ACSC, nursing home residents were more likely to be
admitted to the hospital (54%) than community dwelling
elders (39%). Nursing home residents spent more time in the
ED (4.5 hours on average) than community dwelling elders (4
hours).
Conclusions: During 2001-2002, elderly nursing home
residents visiting EDs were frailer and sicker than community
dwelling elderly. They were older, had more tests and
procedures performed during the visit, had longer ED visits,
and eventually were admitted to the hospital more often than
community dwelling elderly. Although the proportion of ED
visits with ACSC was similar among nursing home residents
and community dwelling elderly, those living in nursing
homes were more likely to be hospitalized than elders living in
the community.
Implications for Policy, Delivery, or Practice: The acuity
level of nursing home residents treated in ED and the
subsequent higher percentage of visits resulting in hospital
admissions contribute to the strained resources in EDs.
Some nursing home resident ED visits presenting with ACSC,
however, could have been more appropriately treated in the
nursing home. Shifting care for ACSC to other more
appropriate care settings could decrease costs, and free
resources for emergency care.
Primary Funding Source: CDC
●Frontline Workers and Long Term Care Quality
Improvement
Susan Horn, Ph.D., Julie V. Gassaway, MS, RN, Siobhan S.
Sharkey, MBA, Sandra L. Hudak, MS, RN
Presented By: Susan Horn, Ph.D., Senior Scientist, Institute
for Clinical Outcomes Research, 699 East South Temple, Suite
100, Salt Lake City, UT 84102; Tel: (801)466-5595; Fax:
(801)466-6685; Email: shorn@isisicor.com
Research Objective: The objective of Real-time Optimal Care
Plans for Nursing Home QI Project is to design, support, and
facilitate practice change that is associated with
improvements in nursing home health care quality.
Study Design: The project goal is to develop and implement
redesigned clinical care processes using standardized
documentation and timely reporting to promote optimal care
planning using research-based best practices. The Project
Team partnered with frontline clinical staff (RNs and CNAs)
and leadership (administrators, DONs, educators, MDS
coordinators) at 11 nursing facilities to develop comprehensive
CNA documentation that streamlines numerous existing
forms into a single form and promotes CNA involvement in
the resident care team. Standardized, scannable
documentation forms enable implementation of protocoldriven care: thorough documentation, prompts for specific
interventions based on resident needs, and timely feedback on
resident status and corresponding interventions.
Documentation forms are faxed to an electronic project
database and are summarized in useful report formats.
Reports are used by facilities to promote complete
documentation, data-driven resident care planning, and ongoing monitoring of resident status. Evaluation includes staff
satisfaction, development of new in-house acquired pressure
ulcers, hospitalizations, and emergency department visits.
Population Studied: Eleven US long-term care facilities were
selected for participation based on pressure ulcer rates and
willingness to participate. Each facility selected 1-3 long-stay
units to participate. Number of residents per facility ranges
from 25 to 100.
Principal Findings: Participating facilities have redesigned
and standardized CNA documentation practices to reduce
redundancy, support timely and complete communication of
resident status, and promote use of best practices to prevent
pressure ulcers. Practice improvements are integrated
efficiently with existing staff workflow and documentation
processes. CNA documentation is streamlined and
consolidated into a single form used for each resident,
reducing number of CNA forms by 3-7 forms per resident.
Reports, sent to facilities weekly and monthly, facilitate realtime care decisions based on resident needs, enable timely
feedback and monitoring of care delivery, and help to develop
individualized optimal care plans that can be updated to
address changes in resident status. Facilities report that
working as a partnership and sharing experiences increases
their ability to implement new care practices and improve
quality of care. CNAs report that forms are easier to
understand and provide point of care information on resident
needs. Next we are focusing on decreasing time to complete
documentation.
Conclusions: Comprehensive documentation of frontline
CNA observations and reporting information back to clinical
staff contribute to early intervention and care plan
improvements that decrease development of pressure ulcers.
Staff report: “I can see trends that were not apparent
previously.” “More comprehensive CNA documentation
increases accountability.” Frontline workers are empowered
when included in care team processes.
Implications for Policy, Delivery, or Practice: Implementing
standard documentation and reports containing evidencebased best practice information as part of daily work in
nursing homes could greatly improve clinical outcomes,
particularly pressure ulcers, and decrease overall cost.
Sustainability of quality improvement initiative is greatly
enhanced by empowering frontline workers.
Primary Funding Source: AHRQ
●Use of Post-Acute Care by Nursing Home Residents:
How Prevalent and How Appropriate?
Carrie Hoverman, BA, Melinda Beeuwkes Buntin, Ph.D., Lisa
Shugarman, Ph.D., Debra Saliba, M.D., MPH
Presented By: Carrie Hoverman, BA, Research Assistant,
Health, RAND, 1200 South Hayes St, Arlington, VA 22202;
Tel: (703)413-1100x5192; Email: carrie@rand.org
Research Objective: The Medicare program does not cover
long-term care, but it does cover post-acute services aimed at
restoring patient functioning after a hospital stay. There is
concern that long-term nursing home residents, who are
already unable to function independently in the community,
may be using post-acute services even though they may not be
good candidates for rehabilitation. This concern stems from
the fact that facilities are reimbursed at much higher rates for
post-acute services than for long-term nursing home care –
i.e. there is the possibility for payer substitution—patients
getting care similar to the level they received, in the same
location as prior to the acute stay, but with Medicare paying
for it. Whether or not this is a real concern is, however,
unknown. The population that resides in nursing homes prior
to an acute hospital stay has gone largely unstudied in terms
of post-acute care use and outcomes of rehabilitation.
Study Design: We examine nursing home residents’ rates of
use of Medicare-paid post-acute services provided in Inpatient
Rehabilitation Facilities (IRFs), Skilled Nursing Facilities
(SNFs), and by Home Health Care (HHC) agencies, patient
outcomes at 2 months and 4 months after discharge, and the
fraction of patients who return to the same facility after their
acute stay. We examine their post-acute care use and
outcomes using Medicare standard analytic files. We then use
regression models to predict outcomes controlling for
observable differences in case-mix.
Population Studied: We identify elderly Medicare nursing
home residents discharged from acute care facilities between
2001 and 2003 with a diagnosis of hip fracture or stroke who
survived 30 days after their hospital discharge using the
Minimum Data Set (MDS) for nursing home residents.
Principal Findings: Of the nursing home population
hospitalized for hip fracture, 78% use the SNF benefit. The
nursing home residents who are hospitalized for stroke use
the SNF benefit at a slightly lower rate, 59%, while 34% return
directly to the nursing home. Those who use the SNF benefit
and those who return directly to the nursing home are
surprisingly similar in age, complications, and comorbidities;
their mortality rates and rates of resuming long-term nursing
home care are also similar. Approximately 85 percent of these
SNF patients are returning to the same facility they were in
prior to the acute stay, with Medicare paying the bill.
Conclusions: Nursing home residents use post-acute care at
high rates for a population that is not generally considered a
good target for rehabilitation. It is surprising that the
population who uses the SNF benefit is so similar to those
that return directly to the nursing home, and that the rate of
SNF use for the hip fracture cohort is higher than that of the
stroke cohort, a condition where there is consensus that
rehabilitation improves outcomes.
Implications for Policy, Delivery, or Practice: There is
evidence of payer substitution in nursing home residents
returning to the same facility but with Medicare-paid benefits.
This issue needs further analysis to determine the benefits of
Medicare-paid post-acute care and rehabilitation for the
nursing home population.
Primary Funding Source: CMS
●Strategic Behaviors Related to Nursing Home Staffing: A
Care Orientation Framework Using Financial Ratio
Analysis
Bita Kash, MBA, FACHE, Charles D. Phillips, Ph.D., MPH,
Catherine Hawes, Ph.D.
Presented By: Bita Kash, MBA, FACHE, Graduate Research
Assistant, Health Policy and Management, School of Rural
Public Health, Texas A&M University Health Science Center,
3000 Briarcrest Drive Suite 300, Bryan, TX 77802; Tel:
(979)458-0652; Fax: (979)458-0656; Email:
bakash@srph.tamhsc.edu
Research Objective: To identify nursing home organizational
characteristics and strategic behaviors that are associated with
higher direct care staffing levels. Our aim was to identify
measurable organizational characteristics beyond the
traditional for-profit and not-for-profit ownership comparisons
using financial ratio analysis.
Study Design: We used a financial ratio analysis framework to
identify expense ratios that are associated with the construct
of a variable representing the facility’s “care orientation.” A
Care Orientation Scale (COS) was developed by testing ten
expense ratios for significant covariance with ownership status
using ANOVA and two Probit models. We then developed the
COS using the Cronbach Alpha reliability testing method. The
new COS was included as a predictor variable in both OLS
and 2SLS regression models with direct care (DC) staff hours
per resident day as the dependent variable. The new COS as
well as other organizational characteristics and market
variables were evaluated for significance in the prediction
models.
Population Studied: The population of nursing homes was
drawn from the 2002 Texas Medicaid Nursing Facility Cost
Report, which included 1,016 facilities. This study does not
include hospital based facilities. Texas is unique due to the
large number of facilities allowing for a large sample size, high
percentage of for-profit facilities with large variations of
outcomes, and a well established Medicaid cost report
process allowing for a thorough examination of expense and
growth strategies.
Principal Findings: The new COS was developed using three
financial expense ratios - Resident Care Cost Ratio, Food
Expense Ratio and Basic Earning Power - and demonstrated
high reliability measured by alpha at 0.863. For-profit facilities
in Texas seem to be operating at higher occupancy rates,
higher case mix complexity, with more Medicaid residents,
and significantly lower staffing levels than not-for-profits
despite offering higher wages. For-profit facilities are also
more likely to be both vertically and horizontally integrated.
We found that DC staffing is mostly dependent on
organizational factors and less on labor market factors. All
regression models demonstrated a strong positive and
significant relationship between average CMI and DC staffing,
a significant negative effect of Medicaid resident percentages
on DC staffing, and a positive effect of facility size on staffing
levels. As expected, for-profit status had a negative effect on
staffing levels. But, effect size and significance of profit status
was dramatically reduced by 50% once COS was introduced to
the staffing prediction model.
Conclusions: We conclude that the proposed COS is a useful
method of evaluating strategic behaviors of “care orientation”
and a significant predictor of DC staffing levels. We found
that only horizontal integration was a positive predictor of DC
staffing, while vertical integration had a negative effect on DC
staffing levels.
Implications for Policy, Delivery, or Practice: From a policy
formation standpoint, it is important to know that the new
COS can help identify specific strategic behaviors related to
profit status. Therefore, it can be a tool for identifying “good
for-profit” and “bad not-for-profit” facilities before deficiencies
are detected and reported. This allows for the possible use of
the new COS as a “red flag” for early detection of problem
facilities.
Primary Funding Source: No Funding Source
●Personal Care Services: A National Study of Trends in
Programs and Policies
Martin Kitchener, Ph.D., MBA, Terence Ng, MA, Charlene
Harrington, Ph.D.
Presented By: Martin Kitchener, Ph.D., MBA, Associate
Professor, Social and Behavioral Sciences, University of
California, San Francisco, 3333 California Street, Suite 455, San
Francisco, CA 94708; Tel: (415)502-7364; Fax: (415)476-6552;
Email: martink@itsa.ucsf.edu
Research Objective: The expansion of publicly-funded
personal care (PC) is a central goal of policies including the
President's New Freedom Initiative. For the three main
programs that deliver personal care (Medicaid waivers,
Medicaid State Plan personal care services (PCS) optional
benefit, and Older Americans Act Title III), this paper presents
program (participant and expenditure) and policy (eligibility
and cost control) trend data for the period 1999-2002.
Study Design: This study conducted descriptive analyses on a
unique dataset compiled from four sources: (1) CMS Form
372 Medicaid waiver reports for the period 1999-2002, (2) the
authors’ national program data survey of Medicaid state plan
PCS in 1999-2002, (3) the authors’ national policy survey of
waivers and state plan PCS in 2002, and (4) published
program data regarding PC provided under OAA Title III
(1999-2002).
Population Studied: National Medicaid and Older Americans
Act participants
Principal Findings: In 2002, the two Medicaid programs that
deliver personal care (state plan PCS and waivers) combined
nationally to pay for almost 99 percent of formal services and
93 percent of participants. Between 1999 and 2002, the total
number of waivers delivering PC rose by 27 helping to spur an
increase of 82,031 in participants receiving personal care and
46 percent growth in expenditures. Between 1999 and 2002,
the adoption of the Medicaid PCS state plan optional benefit
by four states (Florida, New Mexico, North Dakota, and
Vermont) helped increase national program participation by
164,372 and maintain PCS as the largest single provider of
national PC (61 percent of participants and 63 percent of total
expenditures). Among findings from the policy survey, 49
waivers providing personal care reported waiting lists in 25
states. The national average number of persons reported on
waiver waiting lists is 810 (range 5-47,014) and the average
time spent on a wait list is 5 months (range 2-60 months).
Conclusions: The findings illustrate trends including the
persistance of significant inter-state variations in the provision
of publicly-funded personal care and differential national rates
of growth in the Medicaid waiver and state plan PCS programs
provided that is still only provided in 32 states in 2002.
Implications for Policy, Delivery, or Practice: The program
and policy trend data presented in this paper are increasingly
important in a policy context that includes state buget
deficits, litigation against states following the Olmstead
decision, and the President’s NFI which includes initiatives to
transition Medicaid nursing facility participants to the
community.
Primary Funding Source: Kaiser Family Foundation
●Determining Problem Perception: Direct Care Worker
Turnover and Absenteeism in Long Term Care
Thomas Konrad, Ph.D., Jennifer Craft Morgan, MA, Sara
Haviland, MA
Presented By: Thomas Konrad, Ph.D., Senior Fellow, Cecil G.
Sheps Center for Health Services Research, University of
North Carolina at Chapel Hill, 725 Airport Road CB 7590,
Chapel Hill, NC 27599-7590; Tel: (919) 966-2501; Fax: (919)
966-3811; Email: bob_konrad@unc.edu
Research Objective: Direct care worker turnover (DCW) in
long-term care (LTC) continues to be a problem in many
states despite the recent economic downturn and is expected
to worsen as the baby boomers age and their need for LTC
services increase. This aim of this paper is to identify
environmental, organizational, and structural factors related to
long term care managers' perceptions of human resource
problems (e.g., direct care worker absenteeism and turnover).
Study Design: This paper utilizes data provided by
organizational informants from LTC organizations (nursing
homes, home health/home care agencies, and adult care
homes) across the state of North Carolina (N=602). The full
survey response rates were as follows: nursing homes (57%),
adult care homes (44%), home health, home care agencies
(44%) and hospice agencies (66%). Non-responder analysis
was conducted and no significant differences in the structural
characteristics of the LTC organizations were detected
between non-responding and responding organizations.
These data were analyzed using nested ordered logistic
regression models.
Population Studied: The study population included a
subsample of LTC managers of LTC organizations in North
Carolina.
Principal Findings: Turnover rates and organizational culture
measures appear to be important factors in determining
managers' human resource problem perception. Community
environment and organizational structure variables, excluding
type of LTC setting, were relatively unimportant determinants
of the dependent variables.
Conclusions: The significant impact of our organizational
culture measures suggests that managers feel the reasons for
turnover are outside their immediate control – poor
workforce, competition, high workload and lack of motivation,
rather than those things that might be in their control such as
wages and benefits. This contrasts with DCWs’ perceptions
that, while competition and stress play a part in why aides
report they leave, pay and benefits are consistently identified
as some of the major reasons for DCW turnover.
Implications for Policy, Delivery, or Practice: These findings
emphasize the importance of assessing and addressing the
cultural context of LTC organizations when developing social
and organizational policies/solutions aimed at improving the
situation of DCWs.
Primary Funding Source: RWJF, The Atlantic Philanthropies
●Update: Using Risk Adjustment to Compare Medicaid
Long-term Care Waiver Program Performance
Glenn Landers, MBA, MHA, James P. Cooney, Jr., Ph.D, Mei
Zhou, MS. MA
Presented By: Glenn Landers, MBA, MHA, Senior Research
Associate, Georgia Health Policy Center, 14 Marietta Street,
Atlanta, GA 30303; Tel: (404)463-9562; Fax: (404)651-3147;
Email: glanders@gsu.edu
Research Objective: Compare the 2002 costs and outcomes
of patients in four Medicaid long-term care waiver programs
to 2000 results using risk adjustment methodology.
Study Design: Retrospective cohort analysis of Georgia
Medicaid claims data for the years 1999-2002 using the DCGHCC risk adjustment system.
Population Studied: All 2002 participants of four Georgia
Medicaid waiver programs -Community Care Services
Program (CCSP): N = 14,968; Service Options Using
Resources in Community Environments (SOURCE): N =
1,005; Independent Care Waiver Program (ICWP): N = 428;
Shepherd Care: N = 86
Principal Findings: 1.) All waiver programs experienced
significant growth between 2000 and 2002. 2.) 2002 DCG
HCC scores decreased from 2000 for the CCSP, SOURCE, and
ICWP programs (3.2 v. 3.8, 7 v. 4.0, and 5.4 v. 5.7 respectively)
and increased for the Shepherd Care program (7.3 v. 5.5). 3.)
Most frequently reported primary diagnoses remained
unchanged for all programs except CCSP - CCSP: 2000 Essential Hypertension; 2002 - Diabetes; SOURCE: Essential
Hypertension; ICWP: Other Paralytic Syndromes; Shepherd
Care: Other Paralytic Syndromes; 4.) Lower proportions of
patients across programs experienced inpatient admissions
and ER visits. 5.) Between 2000 and 2002, adjusted Medicaid
costs increased 42% for CCSP, 21% for SOURCE, and 10%
for Shepherd Care, while decreasing 38% for ICWP.
Conclusions: Medicaid waiver programs, as they grow and
mature, are subject to the same inflationary increases as
institutional care. One value of waiver programs may be their
abilities to reduce hospital admissions and ER visits. Risk
adjustment systems allow the comparison of waiver programs
designed to serve different populations.
Implications for Policy, Delivery, or Practice: The Shepherd
Care program, designed to serve severely physically disabled
and brain injured patients, continued to control growth in the
cost of services while the program itself grew and admitted
patients with significantly higher DCG HCC scores than other
waiver program patients. Describing the determinants of the
Shepherd Care program's success may assist other Medicaid
waiver programs in controlling costs and improving
outcomes.
Primary Funding Source: Georgia Department of
Community Health
●Inside the Black Box of Nursing Home Deficiencies
Robert Lee, Ph.D., Sarah Forbes-Thompson, Ph.D., RN, Nancy
Dunton, Ph.D., Byron Gajewski, Ph.D., Marcia Wrona, BSW
Presented By: Robert Lee, Ph.D., Associate Professor, Health
Policy and Management, University of Kansas, Mail Stop
3044, 3901 Rainbow Boulevard, Kansas City, KS 66160; Tel:
(913)908-8202; Fax: (913)588-8236; Email: rlee2@kumc.edu
Research Objective: To estimate the effects on nursing home
deficiencies of differences in nursing home staffing (both
levels and turnover rates), while controlling for differences in
case mix, market structure, and the survey team.
Study Design: The study merged five administrative data sets
for 2001 and 2002: cost reports, deficiency reports, turnover
reports, quality measure reports, and survey agency reports.
The study then used a variety of econometric techniques to
estimate a path model of nursing home deficiencies.
Population Studied: All free-standing nursing homes in a
single state during 2001 and 2002.
Principal Findings: Higher staff turnover consistently
increased deficiencies. Higher staffing levels had variable
effects, reducing deficiencies at very low and very high levels of
staffing, but having little impact at intermediate levels.
Controlling for staffing levels, larger chain facilities in
uncompetitive markets consistently had more deficiencies.
For-profit firms and firms facing high wage rates
systematically had lower staffing levels. Even after controlling
for a rich array of facility characteristics, there were meaningful
and statistically significant survey agency effects.
Conclusions: Staff turnover emerges as a more powerful
predictor of deficiencies than staffing levels. At least part of
the variation in deficiency levels can be traced to agency
characteristics.
Implications for Policy, Delivery, or Practice: Improvements
in management can sharply reduce turnover and should be a
priority. Further standardization of the survey process is
needed to enhance its validity.
●Selectivity Between Two Medicare Capitated Benefit
Programs
Walter Leutz, Ph.D., Nancy Perrin, Ph.D., Kathy Brody, PHN,
Lucy Nonnenkamp, MA, Linda Phelps, MA
Presented By: Walter Leutz, Ph.D., Associate Professor,
Heller School for Social Policy and Management, Brandeis
University, MS035, Waltham, MA 02454; Tel: (781) 736-3934;
Fax: (781) 736-3965; Email: Leutz@Brandeis.edu
Research Objective: To examine selectivity among Medicare
beneficiaries who were offered the choice from 1985 to 2002 of
enrolling in Kaiser Permanente Northwest (KPNW), an HMO
with two benefit programs: a standard HMO and a
demonstration Social HMO (SHMO) with a $5 prescription
drug co-payment, a community care benefit worth up to
$12,000 per year for those dependent on others for daily care,
and a higher member premium.
Study Design: To assess selectivity we chose four points
(expanding the SHMO service area to two new counties,
dramatic premium increase, and a stable period) that
presented distinct benefit/price conditions, where those
offered the choice ("decision makers") could be identified.
Comparison groups were drawn from HMO membership
year-end files of over 337,000 person-years to identify subjects
with continuous enrollment a year before and after the
decision. Administrative databases of hospital, pharmacy, and
nursing facilities were analyzed after creating person-based
variables for each 24-month observation period. Mortality was
observed through 2002. Univariate and logistic regression
tests of significance were run using SAS and SPSS.
Population Studied: 14,927 joined the SHMO over 18 years.
The benefit was offered in periods of open enrollment to
community beneficiaries and to HMO individual members.
Group retirees were not offered the choice.
Principal Findings: (1) With premiums at $49/$75 in 1990,
16.9% of 2,094 decision makers in Clackamas County joined
the SHMO. Switchers had at least 58% higher hospital and
prescription use both prior to and after switching but did not
differ in age. Those who picked the SHMO were 1.6 times
more likely to die. (2) With the premium difference rising to
$66/$125 in 1991, 6,381 had the choice to stay in SHMO,
convert from SHMO to HMO, or convert from HMO into
SHMO. The 986 who left SHMO used fewer hospital days,
prescriptions filled, and days supplied in 1990 than did those
who selected SHMO (441) or chose to remain in SHMO
(4,954). In 1991 those leaving SHMO continued to have lower
utilization than the other two groups. (3) With a premium
difference of $81/$156 in 1995, 11.5% of 3,911 Clark County WA
decision makers chose SHMO. Pre and post utilization
patterns resembled 1990. (4) From 1999-2002 the premium
difference was about $100, and 4,580 decision makers could
switch between the HMO and SHMO at any time. Those
selecting SHMO (either from HMO or community) more
often reported poor health (odds ratio 2.7), recent ED visits
(OR 4.7), and needing IADL help (OR 2.1) than those
choosing HMO. In the post-enrollment year, SHMO choosers
had 97% more hospital use and 64% more days of Rx supply.
Conclusions: Better prescription drug and community care
benefits attracted sicker and more disabled beneficiaries, who
were willing to pay more for better benefits at all study points.
Implications for Policy, Delivery, or Practice: Supported by
a disability-based Medicare payment formula and higher
beneficiary premiums, in 1985 KPNW began offering a highoption supplement, including drugs and community care. As
its membership aged, KPNW maintained the SHMO option
and added geriatric care components for HMO and SHMO
members.
Primary Funding Source: RWJF
●Creating an Entitlement for Expanded Community Care
Walter Leutz, Ph.D., Lucy Nonnenkamp, MA, Kathy Brody,
PHN, Linda Phelps, MA
Presented By: Walter Leutz, Ph.D., Associate Professor,
Heller School for Social Policy and Management, Brandeis
University, MS035, Waltham, MA 02454; Tel: (781) 736-3934;
Fax: (781) 7363-3965; Email: Leutz@Brandeis.edu
Research Objective: To examine the production and
consumption from 1985-2002 of the Social HMO (SHMO)
demonstration’s expanded care (EC) benefit and services at
Kaiser Permanente Northwest (KPNW). The EC benefit
provided up to $12,000 per year per eligible person for inhome services and periodic nursing facility care beyond
Medicare coverage, to maintain frail elders in the community.
We describe the evolution of benefits, eligibility, case mix,
participation, utilization, service and care management costs,
and revenue sources.
Study Design: A longitudinal, in-depth descriptive study using
records maintained by KPNW since 1985 which include
aggregate data on study variables. EC costs came from
records that tracked authorized services (retroactively adjusted
by monthly phone calls to the members to determine actual
use and satisfaction) rather than expenditures. Descriptive
longitudinal data from administrative reports were analyzed
using Excel. SAS was used to merge annual service data and
membership files to form person-based episodes for
descriptive analysis.
Population Studied: Aged, non-ESRD Medicare beneficiaries
residing in counties served in the greater Portland OR area,
and not residing in institutions, were eligible to join SHMO.
From 1985-2002, 14,815 beneficiaries joined, and membership
averaged 4,531.
Principal Findings: Of those enrolled in the demonstration,
80% remained an average of 4.6 years, and 12% remained 10
or more years. Of those who joined, 40% were aged 75 or
older, and as they aged in place, the proportion aged 85 or
older grew from 12% in 1985 to 25% in 2002. Those eligible
for EC rose from 4% to 27%. In recent years, care plans based
on patient and family preferences included personal care 40%
of the time, accounting for more than 40% of spending. Two
services accounted for 39% of spending: homemaking (in 35%
of plans) and periodic respite care in nursing facilities (in
20%). Three services added 8% to spending: personal
emergency response systems (in 30%); special equipment (in
30%) and medical appointment transportation (in 20%). The
remaining services were in 1% to 6% of plans, accounting for
13% of spending: shift care, home nursing, adult day, RCF
respite, dentures, and "other." EC costs rose from $21
PMPM in 1985 to $95 PMPM in 2002. Costs were covered by
member premiums (rising from $49 to $180 from 1985-2002)
and member service plan co-payments (20% since 1992).
Rising costs PMPM reflected increasing eligibility for EC and
higher wages rather than costs per person served, which fell
from a high of $6,164 per year in 1989 to $4,328 in 2002.
Expanded care professional staff providing resource
coordination accounted for about one-quarter of EC costs
since 1992. EC costs were equivalent to 12% to 16% of
reimbursement from Medicare, which used a disability
adjustment to its standard formula.
Conclusions: KPNW served an increasingly disabled
membership by reducing costs per EC plan and shifting
utilization to a broadened range of community care services.
Implications for Policy, Delivery, or Practice: The most
comprehensive Medicare supplement in the USA, including
community long-term care, has been offered since 1985 by
KPNW. Key supports were the demonstration's disabilitybased Medicare payment formula and beneficiaries'
willingness to pay additional premiums.
Primary Funding Source: RWJF
●The Effect of Disease Management/Health Promotion
Information on the Demand for Personal Assistance
Hongdao Meng, Ph.D., Bruce Friedman, Ph.D., Andrew Dick,
Ph.D., Dana Mukamel, Ph.D.
Presented By: Hongdao Meng, Ph.D., Assistant Professor,
Preventive Medicine, Graduate Program in Public Health,
HSC, Level 3, Room 071, Stony Brook, NY 11794; Tel:
(631)444-7281; Fax: (631)444-3480; Email:
hongdao.meng@stonybrook.edu
Research Objective: To assess the effect of a disease selfmanagement/health promotion nurse intervention on the
demand for personal assistance among a sample of elderly
Medicare beneficiaries with chronic conditions.
Study Design: This study used data collected for the Medicare
Primary and Consumer-Directed Care (PCDC) Demonstration.
This was a randomized controlled trial in which patients were
assigned to one of 4 groups. A two-part model was estimated
for annual expenditures on personal assistance services
among individuals who participated in the control (n= 287)
and the nurse (n=283) groups. We controlled for individual
socio-demographic characteristics, health and functional
status, prior use of medical care, and state.
Population Studied: 570 chronically ill elderly Medicare
primary care patients who did not have private long-term care
insurance or Medicaid. Individuals had to be impaired in 2
activities of daily living (ADL) or 3 instrumental activities of
daily living (IADL); have had a hospital admission, nursing
home admission, or Medicare home health use during the
prior year, or two emergency department visits during the
prior 6 months; and be enrolled in both Medicare Parts A and
B. The mean age of the sample was 80 and more than twothirds were female. 57% had less than $20,000 annual
household income. The mean number of ADL and IADL
dependencies was 2.3 and 3.5, respectively. 72% had 3 or more
chronic conditions.
Principal Findings: 81% of the sample had positive
expenditures on personal assistance goods or services during
a 12-month period. Average annual expenditures on personal
assistance totaled $3,430 for the full sample. Parameter
estimates from the two-part model indicate that the health
promotion nurse intervention did not change the likelihood of
using personal assistance, but it reduced expenditures on
personal assistance conditional on any use. The overall effect
of the disease self-management/health promotion
intervention was a 14% reduction in personal assistance
expenditures.
Conclusions: The results suggest that the disease
management/health promotion nurse intervention reduced
the demand for personal assistance among elderly Medicare
beneficiaries with chronic conditions. Further research is
needed to identify the mechanisms responsible for the
reduction and to evaluate whether this intervention leads to
savings for other types of health services.
Implications for Policy, Delivery, or Practice: Providing
disease self-management/health promotion information
through a nurse home visit program can generate cost
savings for personal assistance provided to elderly Medicare
beneficiaries with chronic conditions.
Primary Funding Source: CMS
●Securing the Future: Why Assisted Living Should Focus
on Everyday Ethics
Carla Messikomer, Ph.D., Carol C. Cirka, Ph.D.
Presented By: Carla Messikomer, Ph.D., President, The
Acadia Institute, P.O. Box 251, Exton, PA 19341; Tel: (610)3632366; Fax: (610)363-3506; Email: acadiainstitute@comcast.net
Research Objective: This study builds on Kane and Kane’s
call to focus on “everyday” ethics in long term care by
investigating how “everyday” ethical issues are identified and
managed in assisted living (AL) settings on both individual
and organizational levels.
Study Design: This two-year study employed qualitative
techniques in five assisted living facilities (ALFs) in Chester
County, Pennsylvania. Data were collected through 40
focused interviews (averaging two hours) with AL
administrators and staff. Socio-demographic data on
participants were also collected. Findings were made available
to the ALFs in the Philadelphia area through customized
training sessions.
Population Studied: As a microcosm of the national AL
market, Chester County offered historical, methodological, and
practical advantages. The five participating sites represented
the range of ALFs in the national market.
Principal Findings: Ethical dilemmas arise in every aspect of
AL operations. Few formal mechanisms address how to
manage them; the preferred method is individual and local.
Lack of consensus on the meaning of AL and aging in place
leads to inconsistencies in how ethical issues are defined and
managed. They arise as a result of: 1) Pressures to achieve
profitability compete with pressures to deliver quality care to
an increasingly frail population; 2) Untrained personnel
deliver higher levels of care to frail residents without medical
supervision; 3) Social justice issues arise from limited
affordability and varied responses to depletion of resident
assets; 4) Care coordinators exercise significant discretion
about how and what care is delivered; 5) Recruiting and
retaining qualified staff is a problem at all levels; 6) Confusion
exists about the appropriate AL business model and whether a
social model of care is viable; 7) Staff are unable to define
ethical issues conceptually; 8) Tension exists between
marketing promises and the lived experience in AL.
Conclusions: Multiple industry, philosophical, structural and
process factors give rise to a range of ethical dilemmas, which
occur frequently, across functions and ALF types, and involve
staff, resident and family-centered questions. When
organizational mechanisms exist, they are rarely used to
resolve ethical dilemmas. Experience is rarely translated to
organizational policy and there is an absence of structures
that support development of an ethical culture. Localized and
individual management of ethical issues increases the chance
that decision making around ethical issues will be random and
grounded in individual values, rather than organizational
values. Formal discussion and development of processes to
support effective responses to ethical challenges will positively
impact quality of resident care, market position and
performance, ability to attract and retain staff, occupancy
rates, client satisfaction, and reduce vulnerability to legal
action.
Implications for Policy, Delivery, or Practice: This project is
the first to examine everyday ethical challenges in AL.
Understanding them can make “aging in place” a dignified
reality for residents and staff, and make care giving more
rewarding. Knowledge of the roots of ethical challenges will
enable the industry and individual ALFs to be proactive in
developing structures and processes to anticipate and
effectively manage ethical dilemmas.
Primary Funding Source: Private Donations; Ursinus College
●Doing Better to Do Well: Does Innovation Improve
Nursing Home Performance?
Vincent Mor, Ph.D., Jacqueline Zinn, Ph.D., Zhenlian Feng,
Ph.D., Orna Intrator, Ph.D.
Presented By: Vincent Mor, Ph.D., Professor, Community
Health, Brown University, Box G-H1, Providence, RI 02912;
Tel: (401)863-3492; Fax: (401)863-3713; Email:
Vincent_Mor@brown.edu
Research Objective: The objective of this study is to
determine whether and to what extent innovation associated
with the provision of sub-acute care impacts nursing home
performance and the survival of the nursing facility as a
certified provider.
Study Design: We used the Online Survey, Certification and
Reporting (OSCAR) system data from 1997-2002. Data on 7
different innovations like special care units and specialty
nursing services were used to develop a composite innovation
score based on "early adoption" relative to other providers in
their market. Performance was defined as occupancy rate,
having a high proportion of private pay residents and
regulatory compliance. Termination was defined as no longer
participating in the Medicare/Medicaid program. We used a
cross-sectional time series generalized estimating equation
(GEE) model with a logit link function to predict each of the
four dichotomous outcomes of organizational performance,
controlling for market factors. In analyzing termination, the
performance measures as well as innovation score were
predictors.
Population Studied: We conducted these analyses on all free
standing (non-hospital based) nursing homes located in
standard Metropolitan Statistical areas in the US.
Principal Findings: The proportion of facilities adopting
innovations increased over time, but 40% still had no
innovative features at the end of the study period. Analysis
results revealed high innovation was associated with a 10 to
20% increased likelihood of being in the top quartile on all
performance measures. Furthermore, high innovation was
protective of termination (AoR .632+/-.48-.83) after controlling
for the significant effects of occupancy, payer mix and
regulatory compliance.
Conclusions: The results of our longitudinal analyses indicate
that sub-acute care innovation has a positive impact on a
number of measures of nursing home performance and is
associated with a lower probability of termination.
Implications for Policy, Delivery, or Practice: Little research
exists on nursing home innovation, in stark contrast to the
extensive research on innovation in hospitals. This may be
due to the perception that “nursing home innovation” is an
oxymoron and rare at best. However, our study
demonstrates that innovation is an important contributor to
nursing home performance. Given the key role these
organizations play in caring for frail and vulnerable
populations, innovation needs to be better understood and
encouraged.
Primary Funding Source: NIA
●Deriving and Validating a Model of the Necessity to
Hospitalize Nursing Home Residents
Alistair James O'Malley, Ph.D., Edward Marcantonio, M.D.,
SM, Rachel Murkofsky, M.D., MPH, Daryl J. Caudry, SM, Joan
L. Buchanan, Ph.D.
Presented By: Alistair James O'Malley, Ph.D., Assistant
Professor of Statistics, Health Care Policy, Harvard Medical
School, 180 Longwood Avenue, Boston, MA 02115-5899; Tel:
(617) 432-3493; Fax: (617) 432-2563; Email:
omalley@hcp.med.harvard.edu
Research Objective: To build and evaluate the validity of a
model of the necessity of hospitalizing nursing home
residents.
Study Design: Expert panel methods were used to obtain
information on the necessity of hospitalizing nursing home
residents presenting with different conditions. Twelve
geriatricians with expertise in nursing home practice rated the
necessity of hospitalization for 3000 clinical scenarios using a
9-point scale. Scenarios included information on the primary
presenting condition, secondary diagnoses, cognitive and
functional status, age, gender, and advance directives. The
model included a random effect for expert panelist to account
for multiple respondents and possible systematic differences
in scoring among them. Independent variables included
primary diagnoses, physical and cognitive functioning, age,
and gender. Secondary diagnoses were incorporated as
interactions with the primary diagnoses. Stringent selection
criteria based on effect size and face validity were used to limit
the number of primary-secondary interactions in the models.
To evaluate validity we formulated a theoretical model that
assumes facilities act rationally by generally hospitalizing
cases with the highest necessity, implying that higher quality
homes will hospitalize fewer residents but those that are
hospitalized will have greater necessity. The validity of our
predictive model was evaluated by regressing the average
predicted necessity score (APNS) on the proportion of
residents hospitalized per facility-quarter and on a
hospitalization-related overall facility-level quality score (FQ)
derived from the MDS quality indicators.
Population Studied: The data used to develop clinical
scenarios and for the modeling come from 1996 Medicare
hospital claims linked to the nursing home Minimum Data Set
(MDS) from Kansas, Maine, Mississippi and South Dakota.
Principal Findings: The primary diagnosis with the highest
necessity score was respiratory failure, followed by acute
myocardial infarction (AMI), hip fracture, and brain injury. The
secondary diagnosis interaction having the greatest impact
was respiratory failure on pneumonia. Poor cognitive and
physical functioning lowered the risk of hospitalization, as did
advance directives. The final model explained 62% of the
variation in the expert panelists’ ratings. We found a
significant negative association between the facility-level APNS
and the proportion of patients hospitalized (p < 0.0001), and
a significant positive association between APNS and FQ (p <
0.0001). In a multivariate model both APNS and FQ had
negative associations with hospitalization rate, supporting the
assumption of the theoretical model that more capable
facilities tend to hospitalize the neediest patients.
Conclusions: Using expert panel survey data we derived a
predictive model of the need for hospitalization. Real data
predictions from this model cohere with results predicted
from an underlying theoretical model.
Implications for Policy, Delivery, or Practice: Although often
important to recover from acute medical problems and
exacerbations of chronic illness, there is some evidence that
hospitalization may be costly and traumatic for nursing home
residents. The model we developed can be used to explain the
heterogeneity in hospitalization rates across facilities; to help
determine if there are non-clinical predictors of
hospitalization; and to help construct guidelines of when to
hospitalize.
Primary Funding Source: AHRQ
●Moving from Nursing Home to Community: Texas’s
Rider 37 Initiative in Medicaid
Barbara A. Ormond, Ph.D., Anna S. Sommers, Ph.D.
Presented By: Barbara A. Ormond, Ph.D., Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street NW, Washington, DC 20037; Tel: (202) 261-5782; Fax:
(202) 223-1149; Email: bormond@ui.urban.org
Research Objective: The Texas Community Based
Alternatives program (CBA) is a Medicaid waiver program
with a substantial waiting list. The Rider 37 initiative allows
Medicaid recipients in nursing facilities to return to the
community and receive services under CBA without joining
the waiting list or supplanting someone on it. This study
examines the role of Rider 37 in meeting the long-term care
needs of Texas Medicaid recipients. Specifically, we compare
the characteristics of three types of participants—Rider 37
participants, Medicaid nursing facility clients, and CBA
clients—to understand how observed differences among
participants may contribute to observed differences in service
use and outcomes.
Study Design: Using Texas Medicaid long-term care
administrative data, we compare clients who have moved
from a nursing facility to the CBA program (Rider participants)
to clients who remain in the nursing facility and clients who
entered the CBA program directly from the community rather
than from a nursing facility (CBA clients). We examine
sociodemographic characteristics, primary diagnosis,
prevalence of mental/behavioral conditions, and assigned
level of care (TILE score) across samples. Client outcomes at
six and twelve months after entering CBA are compared for
CBA and Rider samples. Site visits to three counties provide
context for the data analysis.
Population Studied: Participants in the Rider 37 initiative
(n=4,868), non-Rider CBA clients entering CBA after the
inception of Rider 37 (n=16,571), and a representative sample
of nursing facility residents (n=66,475); all restricted to those
age 21 and over.
Principal Findings: We find significant differences with
respect to age, sex, race/ethnicity, rural/urban residence,
diagnosis, and level of care between Rider participants and
adult nursing facility residents and also between Rider
participants and non-Rider CBA clients. The qualitative
findings, particularly those on race/ethnicity, support these
quantitative findings. Rider participants are more likely to
have had a nursing facility stay during their first six or twelve
months on community care than are similar non-Rider CBA
clients and are more likely to have died. Rider participants are
more unstable medically and more likely to have dementia
than non-Rider CBA clients; they are less likely to have family
support and so more often rely on assisted living facilities.
Conclusions: The Rider initiative provides a mechanism for
clients who do not need nursing facility care but who require
some support to be able to live independently in the
community. The Rider serves a population that differs in
important ways from the population served by the CBA
program. Service use and outcomes are related to these
population differences.
Implications for Policy, Delivery, or Practice: How regions
across Texas with different community-based delivery systems
and client populations responded to the Rider serves as a
lesson for other states considering similar initiatives. The
differences between Rider participants and non-Rider CBA
clients have implications for the supply of community-based
care over the long term.
Primary Funding Source: Assistant Secretary for Planning
and Evaluation
●Organizational Work Environment and Adverse Events in
Home Health Care
Timothy Peng, Ph.D., Penny Feldman, Ph.D., John Bridges,
Ph.D., Lori King, BA, Chris Murtaugh, Ph.D., Robert Rosati,
Ph.D.
Presented By: Timothy Peng, Ph.D., Research Associate,
Center for Home Care Policy and Research, Visiting Nurse
Service of New York, 5 Penn Plaza, New York, NY 10001; Tel:
(212)609-5765; Email: tpeng@vnsny.org
Research Objective: This paper examines the effect of work
environment on the rate of (risk-adjusted) adverse events in
home health care using an econometric approach to risk
adjustment and a two-stage regression analysis. The study
aims to provide home health agencies with evidence on which
to base management decisions related to how organizational
work environment may affect patient outcomes.
Study Design: Work environment was measured through a
combination of administrative data and staff surveys
conducted at a prior point in time from patient outcomes.
Staff surveys included a variety of measures, including
perceptions of workload, access to resources, equity,
teamwork, and supervisor’s safety culture. Patient data were
collected over a six-month time frame, resulting in 56,346
episodes of care. The dependent variable was the occurrence
of any of the 13 adverse events defined by Center for Medicare
and Medicaid Services in its Outcome Based Quality
Monitoring Reports. First-stage regression models included
risk-adjustment for episode-level case mix, and used a fixedeffects approach to calculate, for each of 87 teams, a quality
score based on team-attributable adverse events. Secondstage multivariate regressions modeled the impact of work
environment (including volume of episodes, distribution of
workload, and staff perceptions of safety culture, workload,
teamwork, and equity) on team quality scores obtained from
the first regression. The second-stage model also controlled
for workforce characteristics such as education and home
health experience.
Population Studied: Data come from a large urban home
health care agency with 87 different teams, staffed by over
2,000 workers. The patient population averages 71 years of
age, with 66% female, and is highly diverse; 40% white, 26%
black, 24% Hispanic, 4% Asian and 6% other ethnicity.
Clinical diagnoses cover a wide spectrum of conditions, with
the most common being diabetes (13%), hypertension (8%)
and congestive heart failure (5%).
Principal Findings: Team-level factors related to fewer
adverse events (listed with partial R-squares, followed by pvalues) were: higher volume (.01, p<.01); higher
concentration of visits (.02,p<.05); fewer weekend admissions
(.13, p<.05); more experienced clinicians (.04, p<.10); higher
perceived teamwork (.02, p<.10) and equity (.01, p<.05); and
lower perceived supervisor safety culture (.02, p<.01) and
manageability of workload (.05, p<.10). Unrelated factors
included perceptions of: top-down communication, access to
resources, autonomy, and confidence in quality of care.
Conclusions: The finding that higher volume and more
experience have a protective effect is consistent with prior
research. Further, as hypothesized, fewer weekend
admissions, more concentrated work distribution, greater
perceived equity and stronger teamwork were related to fewer
adverse events. Contrary to expectations, greater
dissatisfaction with both supervisor safety culture and the
manageability of workload was related to fewer adverse
events. However, these latter findings are similar to those
from other studies demonstrating higher rates of reported
adverse events where safety culture is emphasized.
Implications for Policy, Delivery, or Practice: Key aspects of
organizational climate that influence risk-adjusted adverse
events are identified. Home care agencies should consider
the importance of staff perceptions of equity and building
teamwork into the quality improvement process. The
association between better outcomes and less manageable
workload raises questions about possible “burnout” among
high performing teams or “complacency” among poorer
performing teams.
Primary Funding Source: AHRQ
●You Get What You Pay For:Using Input Prices To
Validate Quality Of Care Measures
Steven Pizer, Ph.D., Man Wang, MS, Catherine Comstock,
MPH
Presented By: Steven Pizer, Ph.D., Economist, Health Care
Financing & Economics, Dept. of Veterans Affairs, 150 South
Huntington Avevue, Mail Stop 152H, Boston, MA 02130; Tel:
(617) 232-9500 x6061; Fax: (617) 278-4511; Email:
pizer@bu.edu
Research Objective: Economic theory predicts that
improvement in quality of care requires commitment of
resources in a production function. We use this prediction to
validate seven quantitative measures of nursing home quality.
Study Design: This is an analysis of secondary data using
Veterans Health Administration (VA) data to examine seven
quality measures developed for use in both VA and
community nursing homes. Two measures rely primarily on
data collected externally to the nursing home—either when VA
patients receive hospital care or when they die—and the other
five measures rely on patient assessment data, collected by VA
nursing home staff on a semi-annual schedule.
Population Studied: All residents of VA nursing homes
between October 1997 and October 2000.
Principal Findings: Measures based on data external to the
nursing home were positively and significantly associated with
input prices (nurses’ wages) in regression models controlling
for output volume and case mix, and measures based on
facility-reported data were not. These externally reported
quality measures were rates of preventable hospitalization and
mortality. Among the facility-reported quality measures, case
mix effects supported some preference for behavior change
and ADL change, although these effects could have been due
to weak risk adjustment. Dehydration, pressure ulcer
incidence, and urinary tract infection prevalence all failed to
exhibit any relationships predicted by theory.
Conclusions: Quality measures based on externally reported
data appear to be less subject to measurement error than
those relying on facility-reported resident assessments (like
those chosen by the VA and by Medicare).
Implications for Policy, Delivery, or Practice: If the relative
strength of externally based measures found in this study is
borne out with data from community nursing homes, then the
current exclusive reliance on facility-reported quality indicators
in the federal Nursing Home Quality Initiative should be
reconsidered.
Primary Funding Source: VA
●Effects on Quality of Care of a Workforce Development
Demonstration Project: The Massachusetts Extended Care
Career Ladder Initiative
Jones Richard, ScD, Navjeet Singh, MS, William McMullen,
MS, John N. Morris, Ph.D., Johan Uvin, Ph.D.
Presented By: Jones Richard, Sc.D., Associate Director,
Health and Social Policy Research, Hebrew SeniorLife
Research and Training Institute, 1200 Centre Street, Boston,
MA 02131; Tel: (617)363-8493; Fax: (617)363-8926; Email:
jones@mail.hrca.harvard.edu
Research Objective: To evaluate the impact of participation
in the Massachusetts Extended Care Career Ladder Initiative
(ECCLI), a workforce development demonstration project, on
nursing home quality of care.
Study Design: ECCLI was a demonstration project among
Massachusetts nursing homes. Nursing homes, or consortia
of nursing homes, applied to participate. An expert panel
selected the final list of sites to receive ECCLI support for
carrying out workforce development activities targeted at
frontline caregivers. This evaluation of the ECCLI program
compares the outcomes of nursing home residents living in
the 69 facilities that participated in ECCLI to residents living in
189 facilities that did not participate in ECCLI. Comparison
facilities were selected using propensity score methods.
Population Studied: Older adults living in Massachusetts
nursing homes between February 2000 and December 2003.
Sixty-nine facilities (representing about 9,000 beds) took part
in ECCLI. Of the remaining 465 facilities in Massachusetts,
189 were identified as comparison facilities (representing
about 25,000 beds). Information about facilities was obtained
from the CMS Provider of Services file and Minimum Data Set
(MDS). Hospital-based facilities, government-owned facilities,
facilities providing care exclusively to disabled children or head
injury patients, and facilities having extremely high average
casemix (based on resource utilization groups) were not
represented among ECCLI-participating facilities. Among the
remaining facilities, a logistic regression procedure was used
to model participation. County, bed size, non-profit
ownership, average severity of resident’s behavioral problems,
average severity of resident’s functional limitations, and
staffing (the number of RN FTEs) predicted participation.
This model was used to identify up to 4 comparison facilities
per participating facility within deciles of the predicted
probability of participation.
Principal Findings: We compared the rates of change of two
clinical indicators of the quality of care across participating
and non-participating facilities over 2.5 years: walking
performance and behavioral disturbance. We used generalized
estimating equation (GEE) procedures to account for the
clustering of residents in the same facility. We also examined
unadjusted CMS quality indicator scores for mobility decline
and behavioral disturbance at the facility level using
aggregated resident data, and accounted for clustering within
facility over time using GEE methods. Resident-level models
suggested no difference between ECCLI-participating and
comparison facilities. Facility-level models suggested no
difference for mobility decline, but a small difference that was
statistically significant (P=.035) and implied an annual
decrease in the proportion of residents experiencing
worsening behavior in ECCLI-participating facilities relative to
comparison facilities (-0.5%).
Conclusions: Propensity score methods can be used to
identify comparison nursing facilities for evaluation of nonrandomized experiments. A workforce development program
may have small but measurable effects on measures of quality
of care collected using nursing home MDS data.
Implications for Policy, Delivery, or Practice: Policy makers
may be reluctant to carry out demonstration projects as
randomized trials, however, the confidence in causal
inferences based on such designs is stronger than on
methods using statistical modeling. To the extent that
confidence that the selection of comparison facilities is
appropriate, our results suggest that a workforce development
program may yield resident quality of care benefits.
Primary Funding Source: Commonwealth of Massachusetts
●Volunteer Nursing Homes Achieve Better Quality
Improvement
Charles Schade, M.D., MPH, Karen A. Hannah, MBA
Presented By: Charles Schade, M.D., MPH, Medical
Epidemiologist, Scientific Support, West Virginia Medical
Institute, 3001 Chesterfield Place, Charleston, WV 25304; Tel:
(304) 346-9864; Fax: (304) 346-9863; Email:
cschade@wvmi.org
Research Objective: To examine whether agreeing to
participate in organized nursing home quality improvement
efforts was associated with actual improvement in quality
measures achieved during the first three years of the Nursing
Home Quality Initiative (NHQI).
Study Design: Cohort and time series.
Population Studied: 114 Medicare and Medicaid certified
nursing homes in West Virginia with 10 consecutive quarters
of quality information for at least one of the ten original
nursing home quality measures reported through the Centers
for Medicare & Medicaid Services (CMS) NHQI beginning
with the second quarter of CY 2002. We studied a
subpopulation consisting of 20 nursing homes volunteering
to participate in intensive quality improvement work for four
selected measures: prevention of functional decline, pressure
ulcer prevalence, and post acute and chronic pain. Nursing
homes received training in patient care procedures believed to
improve performance in the selected measures, and intensive
group members received individualized attention and
feedback. Volunteer nursing homes had significantly worse
baseline performance in percent of patients with ADL decline
at baseline than the entire state (27% vs. 15%). There were no
significant differences at baseline in other measures.
Principal Findings: Median nursing home performance in
West Virginia improved on both pain measures, mirroring
national trends. There was no significant difference between
the intensive group and others for these measures. Roughly
the same proportion of volunteer group nursing homes
showed significant improvement as of the entire population.
Volunteer group nursing homes reduced the proportion of
patients with ADL decline from 26% to 17%, whereas there
was no change in the rest of the state’s facilities. Six of eight
nursing homes with statistically significant (p<0.05, chi square
for trend) negative trends in ADL decline over all 9 quarters
were in the intensive group. There were no significant overall
changes in either group for pressure ulcer prevalence.
Statewide, ten facilities had significant worsening in pressure
ulcer performance; none was in the volunteer group.
Conclusions: Volunteer nursing home participants performed
as well or better than peers who did not volunteer for quality
improvement work in this uncontrolled study.
Implications for Policy, Delivery, or Practice: These early
results suggest organized efforts to improve nursing home
quality may be effective. Additional research is needed to
determine whether characteristics of nursing homes that led
them to volunteer were also associated with improved
performance, and the extent to which interventions in the
intensive group helped drive the improvement.
Primary Funding Source: CMS
●National Estimates in Use of Over-the-Counter
Medications in Long-Term Care
Linda Simoni-Wastila, BSPharm, Ph.D., Bruce Stuart, Ph.D.,
Thomas Shaffer, MHS
Presented By: Linda Simoni-Wastila, BSPharm, Ph.D.,
Associate Professor, Pharmaceutical Health Services
Research, University of Maryland Baltimore School of
Pharmacy, 515 West Lombard Street, Room 162, Baltimore,
MD 21201; Tel: (410) 706-4352; Fax: (410) 706-1488; Email:
lsimoniw@rx.umaryland.edu
Research Objective: Over-the-counter (OTC) medications are
often a safe and economical therapeutic alternative for treating
many conditions that are treated with prescription drugs that
are both more expensive and more likely to cause adverse
reactions and other problematic consequences. Little is
known, however, about the prevalence of and spending on
OTC medication use in nursing homes. The purpose of this
study is twofold: 1) to provide national estimates of the use of
OTC medications in long-term care facilities, and 2) examine
beneficiary characteristics associated with OTC drug use and
spending.
Study Design: This study is based on the 2001 Medicare
Current Beneficiary Study (MCBS). Drug use information is
derived from a unique MCBS file (the Institutional Drug
Administration file) prepared by the authors for CMS. Our
outcome variables are mean monthly OTC drug mentions and
OTC drug use mentions as a proportion of all drug mentions.
We examine aggregate drug use, as well as use and spending
by select therapeutic classes. Ordinary least squares
regression is used to model our dependent variables,
controlling for gender, age, marital status, educational
attainment, geographic region, poverty status, health status,
and drug insurance coverage. We adjust for severity-of-illness
using CMS-HCC risk adjuster.
Population Studied: Nursing home residents (n=789) from a
nationally-representative sample of the population of
Medicare beneficiaries in 2001.
Principal Findings: Examination of OTC utilization patterns
demonstrates that 95% of nursing home residents used at
least one OTC drug in the study year. OTC use as a proportion
of all medication use was high, accounting for 36% of all
medication claims. On average, individuals used 3.1 OTC
products per month – this varied by type of drug coverage,
with Medicaid recipients using 3.2 OTC products, and those
with private drug coverage using 2.8 different OTC products.
The most frequently used OTC drug classes include
analgesics, gastroprotective agents, and vitamin preparations.
Multivariate findings revealed that females are more likely to
receive OTC medications than males, those living below the
poverty level use more OTCs than more affluent individuals,
and utilization of OTC medications increases with as
individuals become more impaired in their daily activities.
Conclusions: OTC use is omnipresent among nursing home
residents. Although utilization of OTC medications is not
affected by type of drug coverage, gender differences, income
differences, and level of disability are statistically significant
predictors of OTC use.
Implications for Policy, Delivery, or Practice: The new
Medicare Part D prescription benefit does not reimburse for
OTC medications. This lack of coverage may be particularly
problematic for frail beneficiaries residing in nursing homes in
whom OTC medication use is a significant component of their
therapeutic regimens, especially in several therapeutic
categories, such as analgesics and gastroprotective agents,
where more expensive prescription products may be
substituted.
Primary Funding Source: No Funding Source
●Searching for and Selecting an Assisted Living Facility
Kristen Sonon, M.H.A., Nicholas Castle, Ph.D.
Presented By: Kristen Sonon, M.H.A., Health Policy and
Administration, University of Pittsburgh, Pittsburgh, PA 15261;
Email: kes31@Pitt.edu
Research Objective: Recent research has been performed on
the topic of choice in long-term care facilities. To date, most
of this research has come from nursing homes. Researchers
have not yet addressed the topic of choice in assisted living
facilities. In this research, we examine factors associated with
the search, selection, and satisfaction of residents in assisted
living.
Study Design: Face-to-face interviews were conducted with
residents residing in assisted living facilities. These interviews
were used to determine the principal decision maker, the
process of searching for a facility, the factors crucial to facility
selection, the time frame from the relocation decision to
relocation, and satisfaction with selection.
Population Studied: The data was collected from 300
residents of three assisted living facilities surrounding
Pittsburgh, Pennsylvania.
Principal Findings: We find that most elders are influential in
the choice of facility. However, the choices made were
seldom based on the quality of the facility. On the one hand
search and selection processes were involved. However, on
the other hand, in almost all cases, prior knowledge of the
chosen facility was limited, and revolved mainly around
location.
Conclusions: The number of assisted living facilities is
around 12,000 nationwide, and they generate about $15 billion
per year. Moreover, most facilities are less than 10 years old,
reflecting their fast rate of growth. The cost of assisted living
care is also high for consumers. However, we show a great
deal of uncertainty in the market when it comes to choosing
these facilities. Policy implications include the potential need
for a report card; delivery implications include more
family/resident education initiatives; and, facility practice
implications include the potential to improve satisfaction with
care.
Implications for Policy, Delivery, or Practice: The Assisted
Living Federation of America projects that by 2020, as many
as 13 million elders will be living in assisted living. The cost of
assisted living care is also high. However, we show a great
deal of uncertainty in the market when it comes to choosing
these facilities.
Primary Funding Source: No Funding Source
●What Drives the Selection of Long-Term Care Services:
Key Findings of a Qualitative Study in Arkansas
Kate Stewart, M.D., MPH, Holly Felix, MPA, Dana M. Perry,
MA, Nancy Dockter, Jinger Morgan, Al McCullough, MA
Presented By: Kate Stewart, M.D., MPH, Associate Professor,
Health Policy and Management, University of Arkansas for
Medical Sciences College of Public Health, 4301 West
Markham, Slot 820, Little Rock, AR 72205; Tel: (501)526-6625;
Fax: (501)526-6620; Email: stewartmaryk@uams.edu
Research Objective: This study was undertaken to identify
issues and factors that were important to individuals when
they were making decisions about which type of long term
care services (home and community-based or institutional
care) they would utilize. This presentation will report on the
qualitative findings of the study.
Study Design: The study was comprised of two components.
The first component involved analysis of existing quantitative
data to profile the long-term care population in Arkansas. The
second component involved qualitative data collection and
analysis to identify key decision factors. Data was collected
through semi-structured interviews with 59 key informants and
4 focus groups of health and social service providers.
Population Studied: The study focused on adult users of
Medicaid supported long-term care services who had recently
made a decision about use of a long-term care service.
Specifically, the study targeted the elderly (65 years and older),
adults with physical disabilities (18 years and older), and
adults with developmental disabilities (21 years and older).
Attempts were made to balance this study population based
on location (urban and rural), race, gender, and service choice
(institutional and home/community-based care). Data
collected from actual consumers of services were augmented
with data collected from family members/guardians of
consumers, health care providers, and social service providers
who had been involved in or were knowledgeable of the
decision-making process.
Principal Findings: Among the key findings to be reported in
the presentation are: 1. Access to information played a role in
making decisions about long-term care, with many study
participants reporting relying on word of mouth and multiple
sources of information because of a lack of a central source of
information on all long-term care options, 2. The application
process and waiting period for home- and community-based
(H/CB) services more often were burdensome and long in
contrast to that for institutional care, which was relatively
simple and short-term, and 3. Workforce and environmental
issues often affected decisions about services. Perceptions of
quality of care in institutional settings , whether positive or
negative, were often mentioned as a determinant in decisions
to use various services. A few users of H/CB services
mentioned problems finding reliable, dependable home care
workers.
Conclusions: This study provides insights into the decisionmaking process about long-term care services. Although it is
a qualitative study that does not provide generalizable results,
it does provide the context under which individuals make
decisions about long-tem care services and lays the ground
work for further investigations using methods which could
produce generalizable results.
Implications for Policy, Delivery, or Practice: This study
provides implications for policy actions by long-term care
services administrators and state policy makers. Specifically,
the study authors made multiple recommendations around
the three theme areas of: 1. leveling the playing field between
institutional and home/community-based options, 2.
providing information and counseling, and 3. accessing quality
services.
Primary Funding Source: Private Fnd and CMS
●Private Finance of Long Term Care: Market Penetration
and Potential
Eileen Tell, MPH, John A. Cutler, JD
Presented By: Eileen Tell, MPH, Senior Vice President, Long
Term Care Group Inc., 5 Commonwealth Road, Natick, MA
01760; Tel: (508)651-8800; Fax: (508)651-8804; Email:
etell@ltcg.com
Research Objective: To compare the current market
penetration of private long term care insurance with the
market potential, using alternative methodologies to define
both market penetration and market potential.
Study Design: Analyze existing data sources on policies in
force and alternative criteria to use in defining the eligible
population for long term care insurance in order to derive a
viable measure of market penetration. For market potential,
we rely on literature review on affordability as the primary
means of analyzing market potential.
Population Studied: Focus is on the 50+ population which is
the primary target market for private finance of long term care.
Principal Findings: Market penetration using policies in
force, rather than policies sold, is a more valid estimate of
market penetration although this index has not been
previously used. Market penetration varies greatly by state and
is sensitive to varying definitions for the target population.
Market penetration is sensitive to a variety of demographic,
policy and provider variables. Market potential is sensitive to
key assumptions made about and definitions of affordability.
Conclusions: Further analysis of factors driving market
penetration should be explored to identify factors that can be
influenced to create a more favorable environment for
expanded private finance. Examples might include regulatory
reform, tax incentives, agent and consumer education and the
like.
Implications for Policy, Delivery, or Practice: The market
penetration for private finance for long term care can be
expanded through a variety of initiatives addressing consumer
awareness, regulatory reform and other factors. Affordability
of private finance for long term care is more subjective and
therefore subject to influence than previously believed.
Expanding the market for private long term care insurance can
help reduce the burden on Medicaid budgets and improve
freedom of choice and independence for those who need long
term care.
Primary Funding Source: No Funding Source
●Improving Nursing Employee Satisfaction in Long-Term
Care Facilities: Let Nurses do the Nursing
Denise Tyler, MA, Victoria A. Parker, DBA, Ryann L. Engle,
MPH, Gary H. Brandeis, M.D., Elaine C. Hickey, RN, MS, Dan
R. Berlowitz, M.D., MPH
Presented By: Denise Tyler, MA, Ethnographic Interviewer,
Health Services, Boston University School of Public Health,
715 Albany Street, Boston, MA 02118; Tel: (781) 687-2000
x6696; Fax: (781) 687-3106; Email: datyler@bu.edu
Research Objective: This study examined the causes of job
satisfaction and motivation among nursing employees in
long-term care (LTC) facilities in relation to the design of
nursing care tasks.
Study Design: Quantitative and qualitative data were
gathered from LTC employees. Job design characteristics,
employee satisfaction, and motivation were measured with a
modified version of the Job Diagnostic Survey (JDS). To
further illuminate details of task design, interviews and
observations were conducted.
Population Studied: Employees of 20 LTC facilities in eastern
Massachusetts.
Principal Findings: Certified nursing assistants (CNAs) were
found to have significantly higher levels of satisfaction when
compared to nurses and nurses were found to have
significantly higher levels of motivation. An examination of
the causes of satisfaction among LTC employees revealed that
although CNA satisfaction was influenced by several factors
(task identity, autonomy, intrinsic feedback, and job tenure),
satisfaction among nurses was only influenced by intrinsic
feedback, or the amount of feedback the employee perceives is
provided in the course of performing the job. Among
employees in LTC facilities this type of feedback would most
likely result from interactions with patients. Most nurses
reported dissatisfaction with the amount of time available to
interact with patients, while most CNAs reported such
interactions as the most satisfying aspect of their jobs.
Conclusions: It may be possible to improve job satisfaction
among nurses in LTC facilities by increasing the amount of
time they have to interact with their patients.
Implications for Policy, Delivery, or Practice: This could
greatly improve facilities’ ability to retain nurses.
Primary Funding Source: AHRQ
●Government Pressure, Structural Issues and
Organizational Culture: An Analysis of Their Impact on the
Work Environment of Long-Term Care Facilities
Denise Tyler, MA, Victoria A. Parker, DBA, Ryann L. Engle,
MPH
Presented By: Denise Tyler, MA, Ethnographic Interviewer,
Health Services, Boston University School of Public Health,
715 Albany Street, Boston, MA 02118; Tel: (781) 687-2000
x6696; Fax: (781) 687-3106; Email: datyler@bu.edu
Research Objective: The purpose of the study from which
these data were drawn was to understand the causes and
consequences of variation among long-term care (LTC)
facilities in the design of nursing care jobs.
Study Design: Surveys, interviews, and structured
observations were utilized in 20 long-term care facilities in
eastern Massachusetts. For this analysis the constant
comparative method of qualitative data analysis was employed
using N’Vivo software.
Population Studied: One hundred forty-four LTC employees
representing all staffing levels, from nursing directors to
frontline certified nursing assistants (CNAs), were interviewed
and structured observations of thirty-seven frontline nurses
and CNAs were conducted.
Principal Findings: Three distinct domains were shown to
influence working conditions in long-term care facilities.
Governmental pressures were found to be similar across
facilities, affecting most in similar ways. Structural issues,
such as staffing levels, compensation, and worker to resident
ratios, were also surprisingly similar across facilities. It was in
the cultural realm of relationships, teamwork, and worker
interactions where large differences across facilities were
found.
Conclusions: Improving working conditions for long-term
care employees may not necessarily involve making significant
changes to the structural realm, and due to the nature of the
care provided and the governmental regulations which control
it, this may not be possible. However, working conditions
may be greatly impacted by improving the cultural aspects of
the work through greater respect, understanding, and
teamwork.
Implications for Policy, Delivery, or Practice: Improving the
organizational culture of LTC facilities could greatly improve
facilities’ ability to retain nursing employees.
Primary Funding Source: AHRQ
●Beyond Courtesy: Top Satisfaction Scores as a Guide to
Service Improvement in Long Term Care
Robert Wolosin, Ph.D., Laura Vercler, M.S.
Presented By: Robert Wolosin, Ph.D., Research Product
Manager, Research & Development, Press Ganey, 404
Columbia Place, South Bend, IN 46601; Tel: (800)232-8032;
Fax: (574)232-3485; Email: rwolosin@pressganey.com
Research Objective: Many elderly persons make a long-term
care (LTC) facility their home. The number of such persons
will increase in the future, multiplying the need for LTC
facilities and workers. Improving the quality of life for LTC
residents will remain a high priority, and front-line workers
such as nurses and aides will play a key role. The objectives of
this study were: (1) To discover service issues pertaining to
LTC front-line workers that are most in need of improvement,
across a spectrum of US LTC facilities; (2) To prioritize these
issues by their importance for overall service improvement as
measured by resident satisfaction.
Study Design: A retrospective database analysis of LTC
resident satisfaction surveys was undertaken. The analysis
used data from a national patient satisfaction
measurement/management firm that mails psychometricallyvalidated surveys to residents and/or resident families of
client LTC facilities and collects them by return mail. Within
each survey, respondents make ratings of care on a balanced
5-point Likert-type scale (1=very poor, 5=very good). All survey
items pertaining to front-line workers (nurses, aides,
maintenance staff, dining staff, transportation personnel) were
selected for further investigation. For each of these items, the
overall mean score that reflected the 99th percentile of the
national database for each survey type was calculated.
Because these scores represent the best the LTC industry
currently offers, noting their average values yields data on
industry-wide service quality: The lower the mean score, the
more improvement is possible within the LTC industry.
Population Studied: Surveys were sent to random samples of
residents/family members in 96 Independent Living facilities
(n=16,105,), 96 Assisted Living facilities (n=4,387), and 484
Nursing Homes (n=27,336) from November 2003-November
2004. Average response rates were approximately 65%
(Independent Living), 50% (Assisted Living) and 25%
(Nursing Home).
Principal Findings: Average 99th percentile scores on items
measuring courtesy, friendliness, and respect were typically
above 95.3; however, we identified items that measure staff
responsiveness, information provided, and perceived technical
delivery of care that were at or below an average score 95.5 for
the 99th percentile, indicating that there is room for service
improvement, even among the industry’s best. When the
correlation of each of the latter items with overall resident
satisfaction (an index of item importance) is computed and
arranged from most to least correlated, the resulting rank
order prioritizes industry-level changes that would improve
service in LTC facilities.
Conclusions: Top performers in the LTC industry show high
proficiency in delivering courteous, friendly, respectful care to
their residents, but are less adept at responding to residents’
personal issues.
Implications for Policy, Delivery, or Practice: Front-line
staff’s responses to residents’ complaints and requests, their
provision of information to residents, and their attention to
resident perception’s of technical ability show the greatest
potential for improving service quality in LTC facilities.
Primary Funding Source: No Funding Source
●Minimum Nurse Staffing Ratios for Nursing Homes
Ning Zhang, M.D., Ph.D., Lynn Unruh, Ph.D., RN, Thomas
Wan, Ph.D., MS
Presented By: Ning Zhang, M.D., Ph.D., Assistant Professor,
Department of Health Administration/College of Health and
Public Affairs, University of Central Florida, 3280 Progress
Drive, Orlando, FL 32826; Tel: (407)823-3344; Fax: (407)8234895; Email: nizhang@mail.ucf.edu
Research Objective: To explore minimum nurse staffing
ratios for nursing homes for different quality levels.
Study Design: Cross-sectional analyses using multivariate
logistic regression and simulation techniques were used to
determine the minimum nurse staffing for multiple quality
levels. Data were from the On-Line Survey Certification and
Reporting System. Quality was measured through an index
combining three incidence rates: the presence of indwelling
catheters, pressure sores, and physical restraints. Staffing
measures included registered nurses (RNs), licensed practical
nurses (LPNs), licensed nurses (RNs+LPNs), nurse aides
(NAs) and total nurse staffing (including
administrators).Using 2002 data, the relationship between
nurse staffing and quality was first evaluated by examining the
fit of linear and non-linear regressions of these variables.
Given a better fit with the non-linear model, minimum staffing
levels were assessed using simulations of a non-linear
production function to establish the minimum efficient points
at which staffing will provide 50, 75 and 90 percent levels of
quality. Reliability analysis of the minimum staffing thresholds
was completed with 2003 data.
Population Studied: All nursing home facilities federally
certified for Medicare and Medicaid and their residents in
2002 and 2003. After cleaning, 14,113 nursing homes
remained in the study, which represented 85.6% of original
number of nursing homes.
Principal Findings: Non-linear logistic regressions were a
better fit. Minimum levels of registered nurse hours per
resident day were 0.31, 1.83, and 3.3 at 50, 75, and 90 percent
levels of quality respectively. Licensed nurse and total nursing
staff ratios were likewise established. Minimums were similar
in 2002 and 2003. The minimum nursing hours associated
with a 75 percent level of quality in this study are much higher
than the actual average RN hours, or than those suggested by
experts.
Conclusions: Actual staffing ratios are much too low to
support a 75 percent quality level, and that even expert panels
are underestimating the staff needed to produce higher quality
care. In addition, we estimate the added expense in going
from the 50 percent quality level to 75 percent as being: $23.51
per resident per day for RNs, and $71.07 per resident per day
for total nursing staff. In an average facility with 95 residents,
that would translate to increases in daily expenses of $2,233
for added RNs or $6,751 for added total nursing staff.
Implications for Policy, Delivery, or Practice: Our study is
the first investigation of minimum nurse staffing levels that
are efficient and promote quality. It provides evidence-based
information for federal and state governments to adjust their
surveillance and reimbursement policy as well as for nursing
home administrators to guide their cost containment,
personnel management and quality improvement.
Primary Funding Source: NIA
●Do Trends in the Reporting of Nursing Home Compare
Quality Measures Differ by Nursing Home Characteristics?
Jacqueline Zinn, Ph.D., William Spector, Ph.D., Lillian Hsieh,
MHS, Dana B. Mukamel, Ph.D.
Presented By: Jacqueline Zinn, Ph.D., Professor, Risk,
Insurance and Healthcare Management, Temple University,
413 Ritter Annex, Philadelphia, PA 19122; Tel: (215) 204-1684;
Fax: (215) 204-4712; Email: Jacqueline.Zinn@temple.edu
Research Objective: The Center for Medicare and Medicaid
Services (CMS)began publicly reporting scores on quality
measures as part of its quality initiative for nursing homes,
with the expectation that the information will be useful to
consumers when choosing a nursing home and for facilities in
their quality improvement efforts. This study examines the
relationship between scores on the first set of ten quality
measures published by CMS on the Nursing Home Compare
web site and five nursing home structural characteristics:
ownership, chain affiliation, size, occupancy and hospitalbased vs. free-standing status.
Study Design: Using robust linear regressions we examined
quality measure scores on first publication and their change
over the first five reporting periods, in relation to facility
characteristics.
Population Studied: The analysis was at the facility level.
14,827 nursing homes nationwide with data on the Nursing
Home Compare web site are included in the analysis.
Principal Findings: There were significant baseline
differences associated with these facility characteristics. In
addition, there are clear time trends for five of the ten
measures, and all are towards improved outcomes. Pain,
physical restraints and delirium exhibit a clear downword
trend, with differences between the first reporting period and
the fifth ranging from 12.7% to 46%. However, there were only
minimal differences in trends associated with facility
characteristics. The variation by facility type was larger for the
short stay quality measures than for the long stay measures.
Furthermore, any differences associated with facility
characteristics observed initially narrows over time.
Conclusions: Our results suggest that the relative position of
facilities on these measures did not change much within this
time period. However, the variation by facility type was larger
for the short-term quality measures than for the long-term
measures.
Implications for Policy, Delivery, or Practice: Results
suggest that the short-term measures may be more useful to
consumers by enabling them to better differentiate
performance across facilities. They also suggest that, at least
in the short run, publication of these measures did not lead to
large changes in them. The finding that several of the quality
measures have improved over time suggests that report cards
may have an important role to play in promoting high quality
nursing home care. However, the impact was limited to only
some of the measures. Further research is needed to
understand why nursing homes have not been responsive on
some measures, and whether other policies, such as
reforming the state survey process, are needed in tandem with
public quality reporting.
Primary Funding Source: NIA