Long-Term Care
Call for Papers
New Evidence on Innovative Approaches to Expanding
Community-Based Long-Term Care
Chair: Sally Stearns, University of North Carolina, Chapel Hill
Sunday, June 25 • 5:45 pm – 7:15 pm
●An Evaluation of the Advanced Illness Management
(AIM) Program: Increasing Hospice Utilization in the San
Francisco Bay Area
Elizabeth Ciemins, Ph.D., M.P.H., Brad Stuart, M.D.,
Rosemary Gerber, BSN, RN, Jeff Newman, M.D., M.P.H.,
Marjorie Bauman, BSN, MS, RN
Presented By: Elizabeth Ciemins, Ph.D., M.P.H., Health
Services Researcher, Institute for Research and Education,
Sutter Health, 345 California Street, Suite 2000, San Francisco,
CA 94104; Tel: (415) 296-1805; Fax: (415) 296-1844; Email:
CieminE@sutterhealth.org
Research Objective: In the Medicare population, chronic
disease and end-of-life care is fragmented and hospice is
underutilized. Evidence suggests that hospice care is
associated with increased patient and family satisfaction and
reductions in overall health care costs. Advanced Illness
Management (AIM) is a home-based program established to
ease the transition between curative and comfort care for
chronically ill patients who lack coordinated hospital, home
health and hospice care. Nursing and social work staff focus
on symptom management, advance care planning, disease
process education, treatment choices, and helping patients
and families identify goals of care. The objective of this study
was to measure the impact of the AIM program on the
discharge disposition of participating home health patients.
Study Design: Utilizing a retrospective cohort study design,
univariate and multivariate analyses were conducted
comparing intervention and usual care patients on the
outcome variable of discharge disposition. Additional
variables included in the analyses models were patient
demographics, symptom status and length of stay.
Population Studied: Patients who received home health
services through the Sutter Visiting Nurse Association and
Hospice at the Emeryville, California home health site and
were discharged between March 2003 and August 2004 were
included in this study. Participants were selected based on a
prognosis of six months or less as determined by home health
staff. Patients who received the AIM intervention were
compared to those receiving usual home health care.
Principal Findings: A nearly two-fold difference was observed
in the number of hospice referrals between patients who
received the AIM intervention and usual care patients (49%
AIM; 25% UC, p<.0001). Among African American patients, a
six-fold increase in hospice referrals was observed among AIM
patients (49% AIM, 9% UC, p<.0001). These differences
persisted after controlling for symptom status, patient
demographics and length of stay.
Conclusions: The AIM program was successful at increasing
hospice utilization through a targeted intervention focused on
palliative and end-of-life care, increased patient education and
decision making, and a dynamic treatment approach. The
finding of increased utilization by African Americans, a
population traditionally reluctant to use hospice, was
particularly impressive.
Implications for Policy, Delivery, or Practice: The findings
from this study provide the necessary preliminary evidence
that could eventually affect Medicare reimbursement policy.
An improvement in the transition from home health to
hospice suggests that fewer patients will rely on costly
emergency department and inpatient health care resulting
from the lack of a successful care continuum. Because this
application of home health services is not currently recognized
as valid by Medicare, this demonstrated improvement in the
coordination of end-of-life care may affect future Medicare
reimbursement policymaking.
Primary Funding Source: RWJF
●Community Integration Litigation As a Policy Lever
Martin Kitchener, M.B.A., Ph.D., Micky Willmott, MA,
Charlene Harrington, Ph.D.
Presented By: Martin Kitchener, M.B.A., Ph.D., Associate
Professor, Social and Behavioral Sciences, University of
California, San Francisco, 3333 California Street, Suite 455, San
Francisco, CA 94118; Tel: 415-502-7364; Fax: 415-476-6552;
Email: Martin.Kitchener@ucsf.edu
Research Objective: To anayze litigation brought to enable
the aged and disabled to remain integrated in their
communities by expanding Medicaid home and communitybased (HCBS) alternatives to institutional care.
Study Design: The conceptual framework for this study
differentiates among two forms of community integration
litigation: (1) 'Olmstead' cases, brought or decided after the
1999 Olmstead Supreme Court ruling and citing either
Olmstead or the 1990 American's with Disabilities Act (ADA).
All other community integration cases are termed 'Medicaid
HCBS'. A dataset of community-integration cases was
assembled from a variety of on-line sources including legal
databases (e.g., LexisNexis) and a literature search.
Comparative features of the cases were coded and analyzed
including: timing, location, status, and target group.
Population Studied: Community integration lawsuits in all
U.S. states, 1999-2004
Principal Findings: Fifty seven 'Olmstead' suits have been
brought in 27 States with a peak of 19 in 2000. There is large
inter-state variation in distribution with 5 in Washington, 4
suits in 4 states, 3 cases in 4 states, 2 suits in 6 states and 1
suit in 12 states. The most frequently represented target
population in Olmstead suits is persons with MR/DD (44%).
The majority of 'Medicaid HCBS' suits concerned waiting lists
and again there was large inter-state variation with 14 cases in
Pennsylvania alone
Conclusions: Although community-integration lawsuits
existed for at least a decade before 1999, after the Olmstead
ruling they increased nationally but with large interstate
variation.
Implications for Policy, Delivery, or Practice: Frustrated by
limited policy changes following the ADA and Olmstead
ruling, consumers have used community integration litigation
as a policy lever unevenly throughout the US. Further research
is required to examine and compare the outcomes of suits
and to explain inter-state variation in litigation patterns.
Primary Funding Source: No Funding
●Primary Care Visits Reduce Hospital Utilization of
Medicare Beneficiaries at the End Of Life
Andrea Kronman, M.D., MSc, Karen M. Freund, M.D., M.P.H.,
Arlene Ash, Ph.D., Amresh Hanchate, Ph.D., Ezekiel Emanuel,
M.D., Ph.D.
Presented By: Andrea Kronman, M.D., MSc, fellow; clinical
investigator, General Internal Medicine, Boston University
Medical Center, 720 Harrison Ave, DOB 1108, Boston, MA
02118; Tel: 617-638-8188; Fax: 617-638-8026;
Email: andrea.kronman@bmc.org
Research Objective: To examine the relationship between
primary care physician visits and subsequent hospital
utilization at the end of life.
Study Design: Retrospective analysis. Outcome measures
were measured during the last 6 months of life: total hospital
days, and presence of each of 4 types of potentially
preventable hospital admissions (Ambulatory Care Sensitive
Conditions, ACSC). Our predictor variable, number of primary
care physician visits, and potential confounders were
measured during the 12 preceding months. We used bivariate
and multivariate analyses to identify and address county-level
variations in healthcare utilization, and adjust for nursing
home use, Medicaid receipt, comorbidity, and demographics.
Population Studied: National sample of Medicare
beneficiaries over 65 years of age who died in the second half
of 2001; Blacks and Hispanics were over-sampled.
Beneficiaries not in the fee-for-service Medicare parts A and B,
and those in the End Stage Renal Disease Program were
excluded.
Principal Findings: Study sample (N=162,992)
characteristics: mean age, 81 (range 66 - 98); female, 56%;
White, 40%; Black 36%; Hispanic, 10%; Other, 14%. The
number of primary care visits in the 6 - 18 months prior to
death were inversely associated with total hospital days in the
final 6 months of life (15 days for those with no primary care
visits vs. 13.8 days for those with 6 - 8 visits vs. 12.8 for those
with > 9 visits); the inverse association persisted after
adjusting for all covariates (P < .001). Among those with an
ACSC diagnosis, those with more preceding primary care
visits were also less likely to be hospitalized for the respective
ACSC: diabetes mellitus, congestive heart failure, and chronic
obstructive pulmonary disease (ORs from .7 - .8, P < .001).
Conclusions: More primary care visits in the preceding year
are associated with fewer days in the hospital, and admissions
for ACSC during the last 6 months of life.
Implications for Policy, Delivery, or Practice: Increased
primary care access to Medicare beneficiaries may decrease
costs and improve quality of care at the end of life.
Primary Funding Source: NRSA
●The Demand for Personal Assistance for Medicare
Beneficiaries with Chronic Disability: Evidence from a
Randomized Experiment
Hongdao Meng, Ph.D., Andrew W. Dick, Ph.D.
Presented By: Hongdao Meng, Ph.D., Assistant Professor,
Preventive Medicine, State University of New York at Stony
Brook, HSC, Level 3, Rm071, Stony Brook, NY 11794-8338; Tel:
631-444-7281; Fax: 631-444-3480;
Email: hongdao.meng@stonybrook.edu
Research Objective: To assess the effect of voucher on the
demand for personal assistance among Medicare beneficiaries
with chronic illness. To quantify the impact of financial
subsidy on out-of-pocket expenditures for personal assistance.
Study Design: This study used secondary data collected by a
CMS demonstration entitled “A Randomized Controlled Trial
of Primary and Consumer-Directed Care for People with
Chronic Illnesses”. A reduced-form demand function was
estimated to predict the annual expenditures on personal
assistance among 609 individuals who participated in the
control group and voucher group of the demonstration. I
controlled for individual socio-demographic variables, health
and functional status variables, prior use of medical care, and
supply side variables. I specified a four-part model to account
for characteristics of expenditure data and the characteristics
of the voucher benefit (capped at $3000 annually).
Population Studied: Older Medicare beneficiaries with
chronic conditions.
Principal Findings: The mean age of the sample was 81 and
more than two-thirds were female. 58% participants have less
than $20,000 annual household income. The mean ADL
impairment score was 5.7 on a 0 to12 scale. 72% participants
have 3 or more chronic conditions. 87.5% of the sample had
non-zero out-of-pocket expenditure on personal assistance
during a 12-month period. The average annual expenditure
totaled $3626. The $250 monthly personal assistance voucher
benefit increased the probability of using personal assistance
and the amount of expenditure conditional on non-zero use.
The elasticity of demand for personal assistance is estimated
at -0.36.
Conclusions: The results confirmed consumer demand
theory in the demand for personal assistance. Voucher
recipients who faced a lower effective price are more likely to
use personal assistance and they also spend more conditional
on any use. The price elasticity of demand for personal
assistance is similar to the elasticity for dental care reported
by the RAND Health Insurance Experiment.
Implications for Policy, Delivery, or Practice: Voucher can
be an effective mechanism to provide goods and services to
chronically ill elderly who need personal assistance. The
increased cost associated with voucher benefits can be
justified if it is accompanied by better health and functional
outcomes and/or satisfaction.
Primary Funding Source: CMS
●Selection Bias and Utilization in the Minnesota Senior
Health Options Demonstration
Hui Zhang, Ph.D., Robert L. Kane, M.D.
Presented By: Hui Zhang, Ph.D., Reporting Manager, CA
EQRO, APS Healthcare, 560 J Street, Suite 390, Sacramento,
CA 95814; Tel: 9162662575; Fax: 9162662542;
Email: hzhang@apshealthcare.com
Research Objective: Medicare and Medicaid dually eligible
beneficiaries (DEBs) are among the frailest, most vulnerable
and most costly populations in the United States. DEBs often
are disadvantaged by the complicated Medicare and Medicaid
programs and the fragmented care systems. The Minnesota
Senior Health Options (MSHO) demonstration pools
Medicare and Medicaid funding to managed care
organizations to provide integrated, coordinated and flexible
primary, acute, long term care and social services to DEBs. A
prior evaluation of MSHO found the program was more
effective in reducing inpatient hospital utilization, emergency
room and physician visits for nursing home residents than for
community residents compared with control groups during its
first three years of operation. However, administrative data
limitations, such as missing inpatient diagnosis and
functional status, raise concerns about possible selection bias
from those unobserved variables and their effects on the
findings of the MSHO evaluation study. This study examined
the existence and degree of selection bias in the MSHO
evaluation study, its impacts on MSHO evaluation results,
and the MSHO effects on utilization after adjusting for
selection bias on unobservables.
Study Design: This study uses a quasi-experimental study
design like the MSHO evaluation study, comparing the
MSHO nursing home and community enrollees with controls
living in the same area, but applies different statistical and
econometric models for panel and longitudinal data.
Population Studied: The study sample is the dually eligible
beneficiaries living in 4 counties of the Minneapolis-Saint Paul
Twin Cities metropolitan area, whose eligibility status, frailty
status and living arrangements are known between March
1997 and December 2000. The utilization data ran from
January 1995 through December 2000.
Principal Findings: The panel data models find minor
favorable MSHO selection on unobserved chronic health
status for the nursing home and community nursing home
certifiable groups and minor adverse MSHO selection on
unobserved chronic health status for the community nonnursing home certifiable group. The longitudinal data models
find little significant selection bias on observed variables, and
that the MSHO effects, which lowered some utilization
measures, did not significantly increase with longer MSHO
enrollment time during the MSHO evaluation period.
Conclusions: Overall, the various models applied in this
study do not find that selection bias on unobserved variables
was important enough to change the general conclusions of
the MSHO evaluation study. One possible reason for the lack
of greater MSHO effects on utilization may be that the present
MSHO care coordination is not sufficiently proactive in
providing intensive care to the frail DEBs by incorporating
innovative geriatric care models and effectively changing the
behavior of the primary care physicians of DEBs.
Implications for Policy, Delivery, or Practice: In addition to
pooling Medicare and Medicaid payments to manager care
organizations, more effective integrated chronic care models
are especially needed in MSHO like programs for DEBs to
maintain and improve the health status of the frailest dualeligible senior population in the nation.
Primary Funding Source: No Funding
Call for Papers
Taking the Pulse of Nursing Homes in a
Changing Policy Environment
Chair: Christopher Murtaugh,
Visiting Nurse Service of New York
Tuesday, June 27 • 8:45 am – 10:15 am
●Trends in Cost and Service Intensity for Medicare Skilled
Nursing Care in Freestanding, Hospital-Based and SwingBed Settings, 1997-2003
Kathleen Dalton, Ph.D., Jeongyoung Park
Presented By: Kathleen Dalton, Ph.D., Senior Health Services
Researcher, Health Care Finance & Payments, RTI
International, 3040 Cornwallis Road, Research Triangle Park,
NC 27709; Tel: (919) 451-5919; Fax: (919) 541-7384;
Email: kdalton@rti.org
Research Objective: Inpatient skilled nursing care for
Medicare beneficiaries can be provided in skilled nursing
facilities (SNFs) that are either freestanding or hospital-based,
or in swing beds on acute-care units of small rural hospitals.
Intensity of care has historically been highest in hospitalbased units and lowest in swing beds. To reduce incentives
for unnecessary ancillary services, Medicare shifted from costbased to prospective (SNF-PPS) payments in certified SNFs
beginning 1998. Swing-bed payments to PPS hospitals will
come under SNF-PPS after 2003. This study examines per
diem costs and intensity of services in each of three skilled
nursing settings for the periods surrounding SNF-PPS
implementation. It is part of a larger study examining
variation in institutions’ strategic responses to Medicare
payment incentives.
Study Design: Descriptive analyses of retrospective
observational data from Medicare nursing facility cost reports
from 1997-2003, linked to certification and county data.
Outcomes studied include Medicare payments and costs,
including routine, rehab therapy, and non-therapy ancillary
service per-diems. Median payments and costs are analyzed
by type of setting, by ownership and by metropolitan status for
all facilities and for the subset that remained open throughout
the study period.
Population Studied: All skilled nursing facilities filing
Medicare cost reports 1996-2003.
Principal Findings: In the first SNF-PPS year, freestanding
per-diem costs dropped 27% from $283 to $206, declining
37% in therapy, 19% in non-therapy ancillaries and 4% in
routine costs/day. Small but steady increases were seen in
median costs in all subsequent years. Patterns were similar
across ownership type and urban/rural location. In contrast,
per-diem costs in hospital-based units were $461 in 1998 yet
continued to increase by 3% per year over the following five
years, even though payments were much lower. From 1997 to
2003 the number of hospital-based facilities declined by 43%
in metropolitan and 20% in non-metropolitan areas. Yet
among those that remained open there was no evidence of
reduced intensity of care or extension of average stays. Swingbed services were not yet under PPS and costs increased
rapidly from 1997 to 2003, with therapy per-diems growing by
10% per year and non-therapy ancillaries by 12% per year. By
2003, median total ancillary cost in swing beds was $211/day,
compared to $170 in hospital-based and $104 in freestanding
settings.
Conclusions: Hospital-based SNFs appear to have responded
to lower payments either by closing or absorbing losses, but
not by changing care patterns. Freestanding SNFs responded
by immediately reducing ancillary cost per/day to levels that
assured good payment margins, even while they may have had
to absorb more complex patients as a result of hospital-based
closures. Median SNF-PPS payment margins remain positive
in freestanding settings but negative for hospital-based
settings except in very rural areas, where their costs are more
similar to those found in freestanding SNFs. Swing-beds have
gone from the least to the most intensive skilled nursing
setting for ancillary costs/day. Some increased swing-bed
costs might reflect changes in case-mix following hospitalbased closures, but by 2003 swing-bed ancillary per-diems
were 80% higher than those in remaining rural hospital-based
units.
Primary Funding Source: HRSA
medications considered potentially inappropriate for the
elderly and other medications currently excluded from
Medicare Part D Drug Benefit reimbursement, such as
benzodiazepines and prescription vitamin and mineral
products, were also administered to residents.
Conclusions: Elderly nursing home residents take numerous
medications for various medical conditions. The large number
of medications taken per resident, many of whom are
potentially very frail and sick, may raise patient safety
concerns, such as drug interactions. The data also reveal that
some residents took medications currently excluded from
Medicare Part D reimbursement.
Implications for Policy, Delivery, or Practice: Using the
2004 NNHS medication data, long-term care planners,
researchers, and policy makers can gain a better
understanding of the medications taken, therapeutic classes,
the reasons they were prescribed, the prevalence of polypharmacy and potential interactions and thus implications for
patient safety and quality of care. Current medication practices
in U.S. nursing homes demonstrate that (1) patient safety
initiatives are critical to monitoring the number and types of
medications administered to residents and addressing their
potential negative consequences and (2) the Medicare Part D
Drug Benefit exclusions affect nursing home residents and the
long-term care industry
Primary Funding Source: CDC
●Medication Practices for the Elderly in U.S. Nursing
Homes
Lisa Dwyer, M.P.H., Robin E. Remsburg, Ph.D., R.N.
●Quality of Care for Veterans in Community Nursing
Homes
Christopher Johnson, Ph.D., Robert Weech-Maldonado, Ph.D.,
Charlie Jia, Ph.D., Dean Reker, Ph.D., Robert Buchanan, Ph.D.,
Alexandre Laberge, B.S.
Presented By: Lisa Dwyer, M.P.H., Health Scientist, Longterm Care Statistics Branch, CDC, National Center for Health
Statistics, 3311 Toledo Road, Hyattsville, MD 20782; Tel: 301458-4714; Fax: 301-458-4693; Email: ldwyer@cdc.gov
Research Objective: (1) Present preliminary estimates of the
use of medications by nursing home residents. (2) Determine
the top ten therapeutic classes of medications taken by
residents; and (3) Determine if nursing home residents are
taking selected medications that are currently excluded from
Medicare Part D Drug Benefit reimbursement.
Study Design: Cross-sectional analysis of preliminary, unweighted data on medication usage by a sub-sample of
nursing homes residents in the 2004 National Nursing Home
Survey (NNHS). The specific survey questions were as
follows: (1) what medications did the resident receive
yesterday, including standing, routine, and as-needed
medications; (2) what medications does the resident receive
on a regularly scheduled basis but were not administered
yesterday; (3) why were the medications prescribed; and (4)
did the resident have any type of reaction to a drug or
medication since admission or during the past 30 days.
Population Studied: 11,885 nursing home residents, 65 or
older, who were sampled in the 2004 National Nursing Home
Survey (NNHS) and taking at least one medication.
Principal Findings: Preliminary un-weighted data reveal the
mean number of medications per resident was 9.0. Residents
took prescription medications, over-the-counter medications,
and vitamin/mineral and herbal supplements. The top ten
therapeutic drug classes taken by these nursing home
residents included vitamins/minerals, laxatives, analgesics,
antidepressants, diuretics, and antipsychotics. Some
Presented By: Christopher Johnson, Ph.D., Associate
Professor, Health Policy and Management, TAMUS School of
Rural Public Health, 3000 Briarcrest Drive, Suite 300, Bryan,
TX 77802; Tel: 979-458-4165; Fax: 979-862-8371;
Email: cejohnson@srph.tamhsc.edu
Research Objective: This study examines the quality of care
of nursing homes with Veterans Affairs (VA) per diem
residents versus those without VA per diem residents. We
hypothesize that because of VA oversight, nursing homes that
serve per-diem veterans will maintain higher levels of multidimensional quality.
Study Design: Data consist of the Online Survey Certification
and Reporting (OSCAR) for 1999-2002. The dependent
variables include 1) structural measures of quality (whether a
facility met the Center for Medicare and Medicaid Services’
recommended staffing levels for certified nursing assistants
(CNAs) and registered nurses (RNs)); 2) process measures of
quality (number of residents that required tube feeding, new
catheterization, and mobility restraints); and 3) outcome
measures of quality (quality of care deficiencies, quality of life
deficiencies, total deficiencies, actual harm citations, and
number of new pressure sores). The independent variable
consists of whether the facility has any veterans (when
analyzing all facilities) or whether the facility has a high
proportion of veterans (when analyzing VA per-diem facilities
only). Control variables include size (beds), for-profit status,
proportion of Medicaid and Medicare residents, chain
affiliation, and proportion of residents that are bladder
incontinent, bowel incontinent, and bedfast. Logistic
regression or negative binomial regression is used to model
the relationship between presence of VA per-diem residents
and quality of nursing home care.
Population Studied: Veterans whose care is being paid for by
the Department of Veterans Affairs Community Nursing
Home Program.
Principal Findings: Facilities with any veterans were less likely
to meet nurse (CNA/RN) staffing standards; more likely to
have patients that require tube feeding, new catheterizations,
and mobility restraints; and were more likely to have actual
harm citations and new pressure sores, plus quality of care,
quality of life, and total deficiencies, than facilities without
veterans. However, among VA per diem facilities, those with
higher proportions of VA residents were less likely to have
patients with restraints or with new pressure sores or to have
an actual harm citation.
Conclusions: These results raise some initial concerns about
the quality of care for veterans within community nursing
homes under the VA per-diem program. However, additional
VA oversight, as implied by a greater proportion of VA
residents, may make a difference in terms of quality of care.
Implications for Policy, Delivery, or Practice: Community
nursing homes may be using veteran residents as "bed fillers".
This implies that certain types of nursing homes may not be
interested in participating in the VA community Nursing
Home Program. Policymakers and VA management should
carefully examine the implications of its nursing home
qualification system because veteran care may be
compromised.
Primary Funding Source: VA
●Area Variation in Rehabilitation Use in Nursing Homes
Wen-Chieh Lin, Ph.D., Gregory F. Petroski, Ph.D., David R.
Mehr, M.D., MS, Steven C. Zweig, M.D., MSPH, Robert L.
Kane, M.D.
Presented By: Wen-Chieh Lin, Ph.D., Assistant Professor,
Family and Community Medicine, University of MissouriColumbia, M226 Medical Sciences Building, Columbia, MO
65212; Tel: 573-884-2119; Fax: 573-884-6172;
Email: linwe@missouri.edu
Research Objective: To examine factors associated with the
area variation in the proportion of residents using
rehabilitation services during Medicare covered skilled nursing
facility (SNF) stays.
Study Design: Cross sectional comparison of the proportion
of SNF stays in each state classified into rehabilitation
Resource Utilization Groups (RUGs). Using logit regression
on grouped data at the state level, the dependent variable was
the log of the odds of the proportion in rehabilitation RUGs
and the model produced weighted least square estimates,
(STATA Reference manual) which is also known as minimum
logit chi-square method. (G.S. Maddala, 1983) We considered
the following supply, need, and population factors that are
potentially associated with variation across states: the
proportion of for-profit SNFs, the numbers of SNF beds and
inpatient rehabilitation facility (IRF) beds per 1,000 elderly, the
ratio of SNF use to IRF use in patients discharged from
hospitals for major rehabilitative conditions, the proportion of
people aged 65 and older, and the proportion of Medicare and
Medicaid dually eligible elderly.
Population Studied: Medicare covered SNF stays in calendar
year 2000. RUG-III classification system is based on the
federally mandated Minimum Data Set outcomes assessment
in nursing homes. Rehabilitation RUGs include five levels of
intensity (low, medium, high, very high, and ultra high).
Principal Findings: At the national level in year 2000, 64.9%
of SNF stays were classified into one of the five rehabilitation
RUGs, but the proportions ranged from 40.7% in North
Dakota to 73.5% in Michigan. The proportion of rehabilitation
RUGs was negatively associated with the number of IRF beds
per 1,000 elderly, the ratio of SNF use to IRF use, and the
proportion of dually eligible elderly. For example, the odds of
rehabilitation use in SNFs decreased 25% when the IRF beds
per 1,000 elderly increased one unit. The adjusted R-square
for the weighted least square logit estimation was 0.44.
However, the predicted proportions of rehabilitation RUGs
ranged from 51.4% in Louisiana to 74.3% in Arizona with a
median of 64.3%.
Conclusions: Evidence strongly suggests the potential
substitution between SNF and IRF use: increased IRF bed
supply was associated with reduced proportion of
rehabilitation RUGs during SNF stays. Nevertheless,
substantial state variation in the distribution of rehabilitation
RUGs in SNFs remained after we controlled for supply, needs,
and population characteristics at the state level in the model.
Implications for Policy, Delivery, or Practice: Rehabilitation
charges account for a quarter of Medicare SNF charges, and
6.1% of total Medicare program payment was for SNF stays
($11 billion) in 2000. Admitting patients to SNFs under
rehabilitation RUGs is potentially financial advantageous for
SNFs. However, outcomes from rehabilitation use are not
clear, particularly considering that SNF residents consist of
heterogeneous groups including residents needing restorative
or rehabilitative care for community discharge, transiting
through to continue or initiate long-term nursing home stays,
and needing palliative care to bridge to Medicare hospice for
end-of-life care. The large variation across states warrants
further investigation on the appropriateness and outcomes of
rehabilitation therapy in SNFs, with controlling for additional
patient and facility characteristics.
Primary Funding Source: AHRQ
●Nurses as Power Brokers: Changing Roles and Culture
Change in Nursing Homes
Dana Weinberg, Ph.D., Almas Dossa, M.P.H., MS, Susan
Pfefferle, MEd, Ph.D., Rebekah Zincavage, MA
Presented By: Dana Weinberg, Ph.D., Assistant Professor,
Sociology, Queens College - CUNY, 65-30 Kissena Blvd.,
Flushing, NY 11367; Tel: (718)997-2915; Fax: (718)997-2820;
Email: dana.weinberg@qc.cuny.edu
Research Objective: Rather than focusing on long-term care
residents’ medical care needs, the culture change model
espouses resident-centered care. Integral to this model is
empowerment of frontline direct care staff, particularly
certified nursing assistants (CNAs). Nurses, who wield
significant power under the medical model with its focus on
nursing interventions and a hierarchy of nurses supervising
CNAs, may resist adoption of culture change. As the bridge
between management and frontline workers, nurses play a
pivotal role in the success or failure of culture change as an
everyday practice. We elucidate nurses’ role in facilitating or
impeding greater involvement and power for CNAs in the
delivery of care. We also examine the determinants of this role
and implications for the CNA workforce and care quality.
Study Design: This cross-sectional study, conducted as part
of the Better Jobs Better Care Initiative, uses both qualitative
and quantitative data from a sample of 36 units from 18
different nursing homes.
Population Studied: We draw on 247 interviews with frontline
staff, nurse supervisors and charge nurses, and nursing home
administrators in high-end nursing homes in Massachusetts.
We also use unit-based surveys of 255 certified nursing
assistants, 90 nurses, and 148 residents and proxies.
Principal Findings: We find considerable variation, both
within units and between nursing homes, in nurses’ stance
toward CNA empowerment. Nurses broker the culture change
process, often independent of management’s position or
wishes. Nurses may manipulate the culture change process,
making it flourish in facilities where it is not supported by
upper management or, alternatively, stifling it even in facilities
where management and nurses themselves support culture
change efforts. CNAs are more satisfied with their jobs and
their ability to provide resident-centered care when their
supervising nurses support their involvement and autonomy.
Conclusions: Often overlooked, nurses’ buy-in to the culture
change model is necessary but not sufficient to ensure
successful adoption of culture change. Nurses’ reasons for
opposing or supporting culture change extend beyond selfinterested protection of power and control in the nursing
home. Additionally, we detect a discordance between nurses’
intentions to implement culture change and their actual
practices; this discordance often reflects constraints related to
regulations, time, training, and ability.
Implications for Policy, Delivery, or Practice: Intentions and
practices often do not match, in part due to lack of
management savvy on the part of both administrators and
nurses. In order to create true culture change in nursing
homes, administrators must consider the role of nurses as
middle managers. In order to successfully empower the entire
nursing home workforce, administrators and supervisory
nurses both require training in participatory management.
Primary Funding Source: RWJF, Atlantic Philanthropies
Related Posters
Long-Term Care
Poster Session A
Sunday, June 25 • 2:00 pm – 3:30 pm
●Prevalence of Medication Problems in High-Risk, DuallyEligible Older Adults: Results from the Community-Based
Medication Management Intervention
Gretchen Alkema, M.S.W., Kathleen H. Wilber, Ph.D., Dennee
Frey, Pharm.D.
Presented By: Gretchen Alkema, M.S.W., Doctoral Candidate,
Davis School of Gerontology, University of Southern
California, 3715 McClintock Avenue, Los Angeles, CA 900890191; Tel: 213-740-9685; Email: alkema@usc.edu
Research Objective: To identify the prevalence of medication
problems in high-risk, dually-eligible, community-dwelling
older adults participating in a Medicaid waiver care
management program.
Study Design: The Community-Based Medication
Management Intervention, part of the Administration on
Aging’s Evidence-Based Prevention Initiative, used evidence
from a randomized controlled trial in home health (Meredith
et al., 2002) to implement an interdisciplinary medication
management intervention in a Medicaid waiver care
management program. The study employed the Home
Health Criteria protocols for four medication problem types:
therapeutic duplication, cardiovascular problems, and
psychotropic and NSAID use with risk factors. Using these
protocols, subjects were screened for problems through
consultant pharmacist review of medication lists and relevant
clinical data.
Population Studied: Sample included 615 older adults aged
65+ who were nursing home certifiable, dually-eligible, and
community-dwelling, drawn from three Los Angeles-based
sites of a California Medicaid-waiver care management
program.
Principal Findings: Results showed that those in the
Medicaid waiver program had double the prevalence of any
medication problem (39.5%) compared to home health (19%).
Therapeutic duplication was 4 times greater, and
inappropriate psychotropic and NSAID use were more than
twice as prevalent. Over 13% of clients had 2+ medication
problems; findings were consistent across sites.
Conclusions: Consistent with the literature, this study
corroborates an emergent concern that medication-related
problems are highly prevalent in high-risk, communitydwelling, dually-eligible older adults.
Implications for Policy, Delivery, or Practice: High
prevalence and potential severity of medication problems
among frail, dually-eligible elders demonstrate the need to
improve medication management among health and social
care providers. Given the implementation of the Medicare
Modernization Act of 2003 that includes a drug benefit,
effective interventions to improve medication management
are imperative.
Primary Funding Source: Administration on Aging
●Stability and Change in Community Care Networks
Susan Allen, Ph.D., Julie Lima, M.P.H., Frances Goldscheider,
Ph.D.
Presented By: Susan Allen, Ph.D., Associate Professor,
Community Health, Brown University, Box G-ST, Providence,
RI 02912; Tel: (401) 863-3818; Fax: (401) 863-3489; Email:
Susan_Allen@brown.edu
Research Objective: Recognizing the importance of informal
caregiving networks to maintaining the health status and
community residence of elderly people with disabilities, the
objective of this study is to examine stability and change in
arrangements for care in a national sample of individuals age
70 and older who require help with activities of daily living,
and to identify caregiver characteristics that predict the
transfer of care to other caregivers or to an institution over a
two year period.
Study Design: Data used for this study were collected as part
of the Longitudinal Study on Aging II. Three interviews were
conducted at two year intervals, for a total of four years of
panel data. Wave II data was utilized to enable us to capture
prior caregiving history from Wave I data in multivariate
analyses. Mulitnomial logistic regression was conducted to
identify caregiver characteristics (gender, relationship to care
recipient, caregiving history) associated with transitions to no
care, to another informal caregiver, to a formal primary
caregiver, and to institutionalization vs. stability in primary
caregivers from Wave II to Wave III of the LSOA II.
Characteristics of the patient are included as controls.
Population Studied: The analytic sample consists of 1041
LSOA II respondents who reported difficulty in at least one
daily living activity (ADL and/or IADL) at Wave II and who
received help from at least one informal caregiver.
Principal Findings: Preliminary regression results indicate
substantial instability in informal caregiving networks with
approximately 45% of sample members reporting transitions
in care arrangements over a two year period. Respondents
cared for by men at Time 2 were twice as likely as respondents
cared for by women to have a new informal caregiver two
years later, and three times more likely to be institutionalized.
"Other" relatives (not children) and non-relatives were
significantly more likely than spousal caregivers to transfer
care to other informal relatives, and non-relatives were 10
times more likely to transfer care to a formal caregiver. Time 2
caregivers who had also provided care at Time 1 were less
likely to transfer care to other caregivers at Time 3, while
caregivers who had "inherited" the role from another Time 1
caregiver were twice as likely as caregivers of people who had
no previous caregivers to transfer care to another informal
caregiver or to an institution. The strongest predictor of
transition to no care was improvement in physical functioning.
Conclusions: Caregiving networks are clearly not static, and
reflect the difficulty of meeting care needs over extended
periods of time. It appears that some elderly people may
experience a variety of caregiving arrangements as care needs
escalate and/or caregiving resources are depleted. Male
caregivers, and caregivers who are not related to the care
recipient, represent key indicators of likely network instability.
Further research is needed to determine whether network
instability is associated with poorer health outcomes for the
care receiver.
Implications for Policy, Delivery, or Practice: The
considerable instability in care arrangements observed in this
study indicates the need to expand access to alternative care
arrangements (e.g., day care, assisted living) to reduce the risk
of nursing home placement.
Primary Funding Source: NIA
●Empirical Analysis of Predictors of Falling in Nursing
Home Residents Based on the MDS-2.0
Jenya Antonova, M.S., David Zimmerman, Ph.D.
Presented By: Jenya Antonova, M.S., Research Assistant,
Industrial and Systems Engineering, UW-Madison, CHSRA,
1175 WARF Bldg., 610 Walnut St., Madison, WI 53726; Tel:
(608) 263-7455; Fax: (608) 263-4523; Email:
jenya@chsra.wisc.edu
Research Objective: To build and validate an empirical mixed
effect model for identifying nursing home residents’
probability of falling based on non–aggregated items related
to multiple health conditions included in the Minimum Data
Set (MDS) 2.0.
Study Design: Secondary analysis of the MDS 2.0 in II quarter
of 2000 was performed. The MDS 2.0 was chosen because it
provides mandatory, regular, and comprehensive nursing
home residents’ health and care plan assessments. The
assessments were voluntary provided by nursing homes in
2000. Hierarchical logistic regression with random slopes and
intercepts was performed to model probability of a fall in a
resident. Potential predictors were selected based on extensive
literature review and ad hoc expert interviews. The model is
currently validated based on year 2005 MDS-2.0; the results
will be reported.
Population Studied: 76429 residents admitted into 588
participating nursing homes in II quarter of year 2000,
predominantly women (72%) with average age of 82 years (±
12.5).
Principal Findings: Without any predictors included, the
probability of falling in a resident was 0.39. After including
predictors into the model, the probability of falling for a male
resident younger than 70 without any investigated
characteristics present, was 0.16. Women were less likely to
fall (OR=0.88, CI: 0.84-0.94). Older age increased the odds of
falling: for individuals 70-79 y.o. OR=1.64 (CI: 1.48, 1.81), 80-89
y.o. OR=2.01 (CI: 1.82, 2.23), and 90+ y.o. OR=2.36 (CI: 2.11,
2.64). Among other predictors the strongest effect on odds of
fall was associated with traumatic brain injury (OR=1.74, CI:
1.15, 2.62), followed by: unstable status (OR=1.59, CI: 1.50,
1.68), medications initiated within past 90 days (OR=1.52, CI:
1.43, 1.62), syncope (fainting) (OR=1.44, CI: 1.02, 2.01),
dizziness/vertigo (OR=1.40, CI: 1.20, 1.63), side vision
problems (OR=1.35, CI: 1.19, 1.53), Alzheimer's disease
(OR=1.34, CI: 1.24, 1.46), Parkinson's disease (OR=1.29, CI:
1.17, 1.42), urinary tract infection(OR=1.28, CI: 1.19, 1.38),
balance unsteadiness (OR=1.27, CI: 1.23, 1.31), transient
ischemic attack (OR=1.24, CI: 1.10, 1.38), dementia (OR=1.21,
CI: 1.15, 1.28), seizure disorder (OR=1.15, CI: 1.04, 1.27),
functional limitation in voluntary leg movement (OR=1.10, CI:
1.03, 1.18), and bowel incontinence (OR=1.08, CI: 1.06, 1.11).
The number of taken medications did not increase odds of
falling, but taking certain type of medications once a week,
did: Antidepressants (OR=1.03, CI: 1.02, 1.04), Antipsychotic
(OR=1.04, CI: 1.03, 1.05), Antianxiety (OR=1.02, CI: 1.01, 1.03).
These odds ratios increased proportionally to the frequency of
medication: taking these medications 7 days a week increased
the corresponding odds ratios 7-fold.
Conclusions: Numerous health conditions reflected in the
MDS-2.0 are associated with increased risk of falling in
nursing home residents. The MDS-2.0 can be utilized for
assessment of probability of falling in nursing home residents.
Implications for Policy, Delivery, or Practice: Utilization of
the suggested model will help care providers identify nursing
home residents with high probability of falling in order to
utilize fall prevention strategies, which will improve quality of
nursing home care and residents’ quality of life. As the result,
it will help save resources that would be otherwise spend on
treatment of negative consequences of falls.
Primary Funding Source: No Funding
●Factors Influencing Staff Turnover in Long-Term Care
Mark Atkin, MMedSci, BSc (Hons.), Pam Enderby, Ph.D., Dr S
Davies, Ph.D.
Presented By: Mark Atkin, MMedSci, BSc (Hons.), Project
Manager, Institute of General Practice, University of Sheffield,
Community Sciences, Northern General Hospital, Sheffield,
S5 7AU; Tel: 00441142229882; Email: m.atkin@shef.ac.uk
Research Objective: Throughout the UK and elsewhere, the
high turnover of care staff working within long-term care
remains to be an issue that results in implications for both
costs and the quality of care provision. This study looks to
define and establish interconnectivities between the various
factors that contribute to high staff turnover within long-term
care in order that new practices may be put in place to limit
future staff turnover.
Study Design: Initially, qualitative methodology was utilised
to construct the key domains that constitute the multi-factorial
concept of staff turnover. This information was then used to
create an assessment tool that could be administered to a
large number of long-term care facilities. To ascertain the
effects of various corrective measures that may be taken in
response to high staff turnover a randomised control
intervention trial has been established within a care provider
within the UK. Subsequently, quantitative techniques have
been used to evaluate the intervention study.
Population Studied: This study has been conducted in
partnership with a provider from the UK independent care
sector. In total, 106 long-term care facilities have been
involved in the program, with the randomised intervention
trial containing a total of 60 sites, and inputs from more than
800 care and nursing staff have contributed to the
development of the study.
Principal Findings: It is clear from our study, based on the
opinions of several hundred care and nursing staff, that the
importance of non-monetary rewards plays a huge part in
determining the success of staff retention within long-term
care facilities. Such findings have been incorporated into a
conceptual framework that will be described, which proposes
how the various factors relate to each in contributing to staff
retention.
Conclusions: By highlighting potential development gaps that
may exist within long-term care facilities through use of a
targeted assessment tool, it is possible to prioritise and
implement new corrective practices that aim to limit future
staff turnover.
Implications for Policy, Delivery, or Practice: The
assessment tool developed provides targeted information to
management and administrators within long-term care on the
key contributing factors to staff turnover. This then presents
an opportunity to make adjustments to practices in order to
optimise staff retention and therefore service delivery.
Primary Funding Source: UK Knowledge Transfer
Partnerships
●Hospice: From Grassroots Movement to National
Industry – Have Services Changed?
Melissa Carlson, Ph.D., M.B.A., R. Sean Morrison, M.D.,
Elizabeth H. Bradley, Ph.D.
Presented By: Melissa Carlson, Ph.D., M.B.A., Assistant
Professor, Geriatrics and Adult Development, Mount Sinai
School of Medicine, One Gustave L. Levy Place, Box 1020,
New York, NY 10029; Tel: (212) 241-8994; Fax: (212) 426-9108;
Email: Melissa.Carlson@mssm.edu
Research Objective: The Medicare Hospice Benefit was
designed to meet the needs of patients and families with
serious advanced illness. During the past decade, there has
been dramatic growth in providers, users, and resources
devoted to hospice care. Financial pressure has also increased
due to declining hospice lengths of stay and increasing
pharmaceutical costs; however, little is known about
corresponding changes over time in service delivery within
hospice. This study evaluates trends in the range and types of
services received by hospice patients during the past decade
and examines geographic and urban/rural variation in these
trends.
Study Design: Observational study.
Population Studied: A nationally representative sample of
9,409 patients from 2,066 hospices in the National Home
and Hospice Care Survey, 1992-2000. Data regarding patient
demographics, clinical characteristics, and service use were
obtained via interview with hospice staff and medical record
review.
Principal Findings: In 2000, only 22% of hospice patients
received care across the multiple domains that hospice is
intended to address (i.e., nursing care, physician care,
medications, counseling, and caregiver support). However,
marked variation in service delivery across providers existed.
The overall range of services received by patients using
hospice, adjusted for patient clinical and demographic
characteristics, increased from 1992 to 2000 (Odds Ratio 1.16;
95% Confidence Interval 1.06-1.26). The largest percentage
point (pp) increases occurred in medications (21 pp), spiritual
care (20 pp), durable medical equipment and supplies (16
pp), and social services (12 pp), although the prevalence of
medications (59% in 2000) and respite care (7% in 2000)
remain low. Regional variation in the range of services
delivered to patients was also observed.
Conclusions: Service delivery in hospice has generally
increased in scope and frequency over time. Yet the majority
of hospice patients do not receive services across the basic
domains of palliative care.
Implications for Policy, Delivery, or Practice: Whether these
findings are the result of inadequate Medicare Hospice per
diem reimbursement rates or are related to other factors, is a
subject for future research.
Primary Funding Source: No Funding
●Skilled Nursing and Swing-Bed use in Rural Areas
Following Major Payment Regulatory Changes
Kathleen Dalton, Ph.D., Jeongyoung Park, Becky Slifkin, Ph.D.
Presented By: Kathleen Dalton, Ph.D., Senior Health Services
Researcher, Health Care Finance & Payments, RTI
International, 3040 Cornwallis Road, Research Triangle Park,
NC 27709; Tel: (919) 451-5919; Fax: (919) 541-7384; Email:
kdalton@rti.org
Research Objective: The supply and organization of postacute care is sensitive to changes in Medicare payment
regulation. Between 1998 and 2003 a number of regulatory
changes affected Medicare payments for skilled nursing and
acute care, including a change from cost-based to prospective
payments for nursing care affecting all skilled nursing facilities
(SNFs), and a return from prospective to cost-based
payments for acute and swing-bed care affecting nearly half of
rural hospitals as they became Critical Access Hospitals
(CAHs). Cost-based swing-bed payments can far exceed SNFPPS payments, and CAHs face additional incentives to close
SNF units and expand swing-bed care in order to maximize
hospital cost-based payments. This project tracks changes in
availability and use of inpatient skilled nursing services in rural
areas before and after these regulatory changes, and examines
CAH participation in post-acute care before and after their
conversion from PPS to CAH status.
Study Design: : Retrospective, observational study combining
data from CMS certification files through September 2004
with hospital and nursing facility cost reports from 1996-2003.
Descriptive analyses are conducted by core-based statistical
areas (CBSAs), supplemented by multivariate models of the
probability of hospital-based SNF closure and of average
swing-bed census as functions of size, location, CAH status,
SNF case-mix and survey findings.
Population Studied: All short-stay hospitals and Medicarecertified SNFs that were open between 1996 and 2003.
Principal Findings: Contrary to expectation hospital-based
SNFs have not closed more often in CAHs than in other rural
hospitals, and swing bed use has grown only slightly faster in
CAH settings than elsewhere. In the six years following 1998
implementation of SNF-PPS, 15% of hospital-based facilities in
very rural counties closed compared to 26% in micropolitan
rural and 43% in metropolitan. Only 8% of CAH converters
that operated SNFs in 2000 had closed their units by end of
2004, compared with 19% of other rural hospitals with SNFs.
The proportion of Medicare SNF days in swing-bed or
hospital-based settings declined steadily in both rural and
urban counties; Medicare skilled nursing days increased each
year, but the increases occurred in newly certified freestanding
SNF beds. Multivariate models found hospital-based unit
closure was associated with for-profit ownership, higher
Medicare utilization, higher wage-adjusted cost/day and lower
average therapy case-mix. Closure was not significantly
associated with CAH status, swing-bed participation or a
history of survey deficiencies. Although large increases in
swing-bed use occurred at a few CAHs, in regressions with
multi-year data, average skilled swing census was not
associated with CAH conversion.
Conclusions: Introduction of SNF-PPS had less effect on
supply and use of SNF services in rural than in urban areas. In
both, an increasing proportion of Medicare skilled care is
being delivered in freestanding facilities. Reintroduction of
cost reimbursement to rural hospitals created strong
reimbursement incentives to close non-cost-based units, but
there is no evidence yet that CAHs are more likely to close
their SNF units or substitute swing-bed for SNF care, nor that
cost-based swing-bed care is crowding out care from rural
SNFs that are under PPS.
Primary Funding Source: HRSA
●Nursing Staff and the Outcomes of Nursing Home Stays
Frederic Decker, Ph.D.
Presented By: Frederic Decker, Ph.D., Social Scientist, LongTerm Care Statistics Branch, National Center for Health
Statistics, CDC, 3311 Toledo Road, Room 3435, Hyattsville, MD
20782; Tel: (301) 458-4263; Fax: (301) 458-4693; Email:
FDecker@cdc.gov
Research Objective: Findings on the relationship between
nurse staffing and nursing home outcomes (e.g., dying versus
discharges to the community) have been inconsistent.
Although some studies show outcomes are related to staffing
ratios, many do not show a relationship. Studies showing a
staffing effect have been on admission cohorts, and studies
showing no effect have been on samples of current residents.
Admissions cohorts are primarily short-stay residents and
samples of current residents are primarily longer-stay
residents. The purpose of this study was to discern if the
effect of nursing staffing on discharge status, after controlling
for other factors, varies between short and longer stays.
Finding different staffing effects across short and longer stays
would indicate inconsistent findings in research likely relates
to differences in populations studied.
Study Design: Models were constructed for short stays (less
than 60 days) and longer stays (60 days or greater) applying
multinomial logistic regression. Odds ratios were reported in
models comparing outcomes such as dying and
hospitalizations to the outcome of leaving the nursing home
recovered or stabilized, assumed the most favorable outcome.
Marginal effects were also calculated to show the change in
mean probability of each discharge status occurring with
changes in the values of independent variables.
Population Studied: Data on discharges came from the 1999
National Nursing Home Survey (n=6,386).
Principal Findings: For stays less than 60 days, but not
among longer stays, the probability of leaving the nursing
home in a recovered or stabilized condition increased, and
that of dying decreased, as the staffing ratio of registered
nurses (RNs) increased but was unrelated to the staffing
ratios of licensed practical nurses and nursing assistants.
One outcome, hospitalization, was affected by staffing in
longer stays. A greater staffing level may reduce
hospitalizations among longer stays but does not impact
upon whether a longer-stay resident dies or is discharged
recovered/stabilized. Clinical condition was the major risk
factor in differentiating discharge status among both short
and longer stays.
Conclusions: Results indicate a likely reason for past
inconsistent findings on staffing. Nurse staffing may affect
the disposition at discharge the most for short stays.
Research suggests short stays are primarily admissions for
recuperative care with recovery the treatment objective.
Longer stays more signify impaired function and limited
community support where accommodation to impaired
functioning is the focus of care. Thus, outcomes sought in
and possible from treatment likely varies by duration of stay.
One implication of the findings is that in studies on staffing
and nursing home outcomes more consideration should be
given to the relationship between the sample characteristics
and outcomes investigated.
Implications for Policy, Delivery, or Practice: The finding
that discharge disposition is unrelated to staffing when the
sample is long-stay residents does not mean staffing is
unimportant. Other outcomes may be more directly related to
the processes of care affected by staffing ratios related to
caring for longer-stay residents. More research is needed on
how, or whether, the sensitivity of outcomes—discharge
status as well as other outcomes—to staffing ratios varies
across short- and longer-stay residents.
Primary Funding Source: No Funding
●Effects of Medicaid Policy on Long-Term Care Decisions
and Medical Services Utilization Among the Low Income
Elderly
Song Gao, M.P.H., Ph.D. Candidate
Presented By: Song Gao, M.P.H., Ph.D. Candidate,
Economics & Public Health, State University of New York at
Stony Brook, 700 Health Sciences Drive, E2072A, Stony Brook,
NY 11790; Tel: 631-216-2262; Email: sgao@ic.sunysb.edu
Research Objective: This study will provides evidence on
long-term
care decisions and health services utilization among lowincome senior citizens with respect to the largest meanstested program in the United States: the Medicaid program.
Study Design: Nearly all senior citizens have health insurance
coverage through Medicare, but those poor seniors with lowincome may also be eligible for the Medicaid program that
can fill many gaps in Medicare coverage especially in longterm care coverage. This study is to test the impact of
Medicaid coverage on long-term care decisions and medical
services utilization. I will also explore the roles of health
status, other health insurance plans, family structures using
the panel structures of HRS (The Health and Retirement
Study) data. My hypotheses are that Medicaid subsidies have
positive effects on formal long-term care use and Medicaid
take-up is influenced by health care needs and the availability
of substitutes for long-term care. The objective is to assess
target efficiency of the program.
Often, we examine policy effects by comparing the policies
before and after expansion. In my study, the data are after
1992 and after Medicaid policies have undergone reform.
Given the lack of data to study take-up using structural
program change, I will rely on variation in take-up among the
homogeneous eligibles. Thus, I narrow my sample to those
elderly people with sufficiently low-income to be eligible for
the Medicaid program.
Population Studied: This paper will use the panel data from
HRS (Health and Retirement Study). Population in this study
includes everyone aged over 65 in year 1992, 1994, 1996,
1998,2000, and 2002.
Principal Findings: The Medicaid take-up rates were around
50%. Sicker people are more likely to participate in Medicaid
program. Household memebers are substitutes of formal
long-term care givers. Medicaid is the major force for low
income people to use formal long-term care.
Conclusions: Medicaid program has relatively higher
participation rates compared with other welfare programs due
to its health care benefits. Medicaid does assist poor elderly
with their long-term care utilization.
Implications for Policy, Delivery, or Practice: Around 50\%
of those people took up Medicaid while the other 50% didn't. I
examine the take-up decision in the context of their long-term
care decisions and medical services utilization among those
two comparison groups under different Medicaid coverage to
test the Medicaid effects on their decisions. Therefore, I can
evaluate the Medicaid program on the designed beneficiaries-the low-income elderly. This is a policy efficieny examination.
Primary Funding Source: Health and Retirement Study
●The Relationship Between Paid Home Care and Informal
Home Care among Older Adults with Functional
Limitations
Ezra Golberstein, B.A., Michael E. Chernew, Ph.D.,
Mohammed U. Kabeto, M.S., Kenneth M. Langa, M.D., Ph.D.
Presented By: Ezra Golberstein, B.A., Doctoral Student,
Health Management and Policy, University of Michigan
School of Public Health, 109 Observatory, Ann Arbor, MI
48109; Tel: (734)936-5344; Fax: (734)764-4338; Email:
egolber@umich.edu
Research Objective: The research literature on the
relationship between paid and unpaid home care is equivocal.
Some studies find that the two forms of home care are
substitutes, and some studies find that they are complements.
This research takes two approaches to assess the extent to
which paid home care substitutes for informal home care.
Study Design: The primary approach estimates the
relationship between state-level trends in paid home care and
informal home care using weighted least squares regression.
Separate equations are estimated for the intervals of 19931995, 1995-1998, and 1998-2000. Because of data limitations,
our measure of informal home care only includes non-spousal
care. Estimates of state level trends in both types of home
care are derived from multivariate models that adjust the
aggregate trends for changes in demographic variables,
functional status, and health states. The secondary approach
estimates the effect of exogenous policy-induced changes in
paid home care on informal home care using instrumental
variables analysis.
Population Studied: Data come from the 1993, 1995, 1998,
and 2000 waves of the HRS/AHEAD study, a nationally
representative longitudinal study of older Americans who were
not institutionalized at baseline. Due to the nature of the
home care measures, individuals were included in a wave only
if they had at least one ADL or IADL limitation in that wave.
This yielded a sample of 3,311, 2,789, 2,550, and 2,800 in each
respective wave. State-level identifiers were linked to
individuals from the HRS/AHEAD limited use dataset.
Principal Findings: The state-level analysis indicates a
negative association between trends in paid home care and
informal home care in all three intervals. In the 1993-1995 and
1998-2000 intervals, for every hour of increased paid home
care we estimate a 0.7 hour reduction in informal home care
(p<.05). This association is weaker and not statistically
significant in the 1995-1998 interval. Preliminary findings from
the individual-level instrumental variables analysis are
consistent with these results, but less precise.
Conclusions: There is some evidence for substitution
between paid home care and informal home care. This
suggests that increases in paid home care will be partially
offset by reductions in informal home care. The benefits of
publicly financed home care therefore accrue, in part, to
caregivers.
Implications for Policy, Delivery, or Practice: Public
programs to provide home care to Americans with disabilities
are likely to become increasingly controversial as financial
pressures to limit care compete with increased demand for
care arising from an aging population. Normative opinions
about the amount of resources that are devoted to home care
will depend, in part, on whether those resources are used to
increase the amount of care given to individuals with
disabilities versus to allow a respite for unpaid care givers.
Both may be valued policy objectives, but it is unlikely they will
be viewed as equivalent goals. This work, while unable to
determine the optimal policy regarding public provision of
paid home care, is relevant to policy makers because it helps
illuminate the extent to which greater paid home care leads to
more care versus less caregiver burden.
Primary Funding Source: No Funding
●Federal and State Civil Money Penalties and Fines for
Nursing Homes
Charlene Harrington, Ph.D., Theodore Tsoukalas, Ph.D.,
Cynthia Rudder, Ph.D., Richard Mollot, Ph.D., Helen Carrillo,
M.S.
Presented By: charlene Harrington, Ph.D., Professor, Social &
Behavioral Sciences, University of California, 3333 California
Street Suite 455, San Francisco, CA 94118; Tel: 415-476-4030;
Fax: 415-476-6552; Email: charlene.harrington@ucsf.edu
Research Objective: The purpose of the study was to
examine the variations in state nursing home regulatory
practices related to issuing and collecting federal and state
civil money penalties (CMPs) and fines.
Study Design: First, the study described states’ use of federal
and state CMPs and fines for nursing homes, whether states
have a special fund from CMPs/fines, what funds are
available, and how the funds from CMPs/fines have been used
by the states, based on primary data from a survey of state
officials and freedom of information requests. Second, the
study examined factors related to the variation in collection of
CMPs/fines by states, using regression analyses of federal and
state CMP data.
Population Studied: State licensing and certification
programs responsible for federal and state CMPs/fines.
Principal Findings: The findings showed that 41 states
(including the District of Columbia) collected federal CMPs
and 21 states collected state CMPs/ fines for a total of 3,057
CMPs/fines worth $21 million in 2004. Forty-six states had a
fund account from CMPs/fines with $60 million available in
2005. Of the states with fund accounts from CMPs/fines, 32
states spent $28 million between 1999 and 2005 on a wide
range of projects, although 8 states had not used any funds (6
states did not report). Information on the CMPs/fines
collected, the fund balances, and the uses of funds are largely
unavailable to policy makers and the public.
Logistic regressions on whether states collected federal CMPs
found that the positive predictors were: the percent of
nonwhite population, the SSI/SSP participation rate per 1000
population, the percent of for-profit and chain-owned facilities,
and nursing home beds per 1,000 population. Negative
predictors of collecting federal CMPs were the number of
complaints per nursing home bed, the percent of hospitalbased facilities, the percent of Medicaid nursing home
residents, facility occupancy rate, and the certified home
health agencies per 1,000 population. Panel regressions for
the number of federal CMPs collected per 100 nursing home
beds showed a positive relationship with: personal income
per capita, facility occupancy rate, and survey and certification
budget per nursing home beds in a state.
Conclusions: Federal and state CMPs/fines are an important
but seldom used intermediate sanction and wide variations in
state policies and practices for using CMPs/fines continue to
exist. States appear to take facility characteristics and provider
supply into account in whether to issue CMPs/fines and in the
number of CMPs/fines issued.
Implications for Policy, Delivery, or Practice: Funds from
federal and state CMPs/fines represent a sizeable resource
available to state to use to improve quality of care. Greater
attention is needed to develop standard policies and practices
for states and to remove barriers to use of CMPs/fines in
states.
Primary Funding Source: CWF
●Creating Needs-based Tiered Models For Assisted Living
Reimbursement
Sandra Howell, Ph.D., Dorothy Gaboda, M.S.W., Ph.D., Nancy
Scotto Rosato, M.A., Judith A. Lucas, R.N., Ed.D.
Presented By: Sandra Howell, Ph.D., Sr. Policy Anyl/ Asst.
Res. Prof, Center for State Health Policy, Rutgers University, 55
Commercial Ave, New Brunswick, NJ 08901; Tel: 732-932-4657;
Fax: 732-932-0069; Email: showell@ifh.rutgers.edu
Research Objective: This research provides state policy
makers and others considering developing needs-based
reimbursement models for Medicaid-funded assisted living
(AL) an evaluation of how different needs-based
methodologies (count, rule, and weighted) affect the models’
structures and outcomes. Models were developed with
commonly accepted measures to show how using various
scoring methods can discriminate cases into appropriate tiers
or levels.
Study Design: Univariate analyses detailed the sample’s
characteristics and variables to be used in the models.
Ordinary least squares regression analyses were used to
evaluate each model’s ability to predict the time needed to
care for individuals with varying types of needs (e.g., Activities
of daily living [ADL], Dementia, Special Services.) The
Adjusted Coefficient of Multiple Determination (Adjusted-R2)
was used to compare the fit of alternative models
Population Studied: Assessment data from Medicaidenrolled AL residents and waiver-eligible community
individuals (n =726) were used to evaluate count, rule, and
weighted methodologies in the design of five needs-based
models.
Principal Findings: New Jersey’s Medicaid-enrolled AL
residents were generally similar demographically and
functionally to a national AL resident profile. They required
assistance with an average of 2.22 ADLs, were predominately
female (72.3%), and widowed (55.6%). Approximately onethird were 76-85 years old, and another one-third was over 85.
The test models ranged in fit from .127 to a high of .357 using
the adjusted-R2 statistic.
Conclusions: Count and weighted models both adequately
predict service needs and discriminate individuals into their
appropriate tiers. While simple count models are easiest to
use and interpret, they neither adjust for severity of need nor
provide a broad range of scores. Response options for ADL
and IADL scales (independent vs. dependent or by degree of
dependency) play a major role in determining whether
functional need is captured. Thus, states should use caution
in developing tiered reimbursement strategies based on a
simple count of physical limitations or dependencies. Broader
scaled scoring factors provide wider ranges of cumulative
scores, recognize differences in each area of care’s level of
need, and can accurately predict the amount of care required.
Count models providing for degrees of impairment or
performance offer the same ease of use, but are better able to
account for impairment or performance variation. Since
weighted models have greater score ranges than count
models, they offer more flexibility in tier definition, account for
severity.
Implications for Policy, Delivery, or Practice: Generic tiered
models developed with these methods can be tailored to a
state’s population. States considering adopting a needs-based
tiered model should refine their model based on their state’s
resources, AL population characteristics, and the fit of these
models their long-term care systems. For the industry, these
models can identify levels of care needed in planning for staff
time and skill-mix required for AL as well as other long-term
care populations.
Primary Funding Source: RWJF, CMS
●Hospital and other Palliative Services Used by Nursing
Home Residents at End of Life with Cancer and
Congestive Heart Failure
Grace Johnston, Ph.D., Meaghan O'Brien, M.H.S.A., Dion
Mouland, M.H.S.A., Jun Gao, M.Sc., Beverley Lawson, M.Sc.,
Ron Dewar, M.Sc.
Presented By: Grace Johnston, Ph.D., Associate Professor,
School of Health Services Administration, Dalhousie
University, 5599 Fenwick Street, Halifax, Nova Scotia, B3H
1R2; Tel: (902)494-1309; Fax: (902)494-6849; Email:
Grace.Johnston@Dal.Ca
Research Objective: To understand services provided to
nursing home (NH) residents at end of life with cancer and
congestive heart failure (CHF) in Nova Scotia (NS), Canada.
Study Design: For cancer studies, an algorithm was
developed using death certificate to identify persons NH
residents, and for CHF studies, place of family physician visits
was used. Linked databases were vital statistics, physician
billing and hospital admissions files for CHF. For cancer, vital
statistics, Cancer Centre, Palliative Care Program (PCP), and
census were linked. There is no province-wide electronic
database of NH residents. Multivariate logistic regression
analysis was used to identify likelihood and predictors of care.
Population Studied: In Nova Scotia, approximately 10,000
adults died of cancer from 2000 to 2003; of these, 648 were
NH residents. 2809 individuals died of CHF from 1998 to
2001 and a third were NH residents.
Principal Findings: For persons with cancer, residing in a NH
appeared to be an enabler of dying out of hospital (Odds Ratio
[OR] 24.0, 95% Confidence Interval [CI] 18.6-30.9). Access to
other palliative services varied with age and NH status. Of
2809 persons dying of CHF, 618 were longer-term NH
residents, ie all physician visits in the last six months of life
were in NH. In contrast, 1,886 persons dying of CHF dying
had no NH physician visit, ie NH non-residents. 305 had both
NH and office or home visits; these recent NH residents
include persons admitted to NH in their last six months of
life. NH residents were more likely to be female and older than
other persons dying of CHF. Both longer-term and recent NH
residents were more likely to die out-of-hospital of CHF
(Longer-term OR= 2.67, CI: 2.08-3.45; Recent OR=3.85, CI:
2.80-5.29), to have fewer specialist visits and more family
physician visits when compared to non-NH residents. Longer
term, but not recent NH residents had significantly fewer
hospital days in the last six months of life. Recent NH
residents were more likely than non-NH residents and longer
term NH residents to have spent more than a month in
hospital in the last six months of life with CHF.
Conclusions: Exploring end of life care the NH residents is
viable using non-NH administrative data. In province wide
studies, associations between age and end of life care should
take NH status into account. There is a need to further explore
the role and adequacy of NH care for persons dying of cancer.
Implications for Policy, Delivery, or Practice: Since 50% of
people diagnosed with cancer die of cancer, palliative care has
been developed to a greater extent through the oncology and
hospital based palliative care services; however, little is known
about palliative cancer care for NH residents. CHF is
progressive and eventually fatal with death typically at 80+
years. Palliative care is limited for persons with CHF. Given
the aging baby boomers, and consequent needs for increased
palliative care, linked administrative data can be used to plan
and monitor end of life care provision.
Primary Funding Source: Canadian Institutes for Health
Research, and Heart and Stroke Foundation
●The Cost of Hospice Care: Are There Differences in
Pateint Costs Across Diseases?
Brad Killaly, Ph.D., Thomas C. Buchmueller, Ph.D., Paul J.
Feldstein, Ph.D.
Presented By: Brad Killaly, Ph.D., Assistant Professor,
Strategy, Organization and Management, University of
California - Irvine, 333 GSM - UC Irvine, Irvine, CA 92697-3125;
Tel: 949-824-8782; Email: bkillaly@uci.edu
Research Objective: End-of-life hospice care has grown
considerably with the number of Medicare beneficiaries using
hospice service tripling from 1992 to 2000. Access and quality
of hospice care are crucial policy issues as most Americans
are Medicare beneficiaries when they die. A cornerstone of the
Medicare hospice benefit is that hospices receive a per-diem
payment from Medicare for each beneficiary day. While the
per-diem varies by location and is updated annually, it does
not vary according to patient disease. There is growing
qualitative research suggesting that hospice care costs vary by
disease. If true, there are potentially adverse effects on access
and quality of hospice care as providers seek to constrain
costs by searching for lower cost patients. Our paper is the
first to systematically measure and test cost differentials in
hospice care across different diseases, in this case cancer
versus non-cancer patients.
Study Design: We use multivariate analysis to estimate a
translog cost function of free-standing hospice unit variable
costs using cancer and non-cancer patient days as outputs
and include the Medicare wage index and local nursing wages
as prices. The estimates are then used to construct marginal
costs for cancer and non-cancer patients.
Population Studied: We estimate our model on two
populations. First we model costs within a large, multi-unit,
multi-state, Medicare reimbursed for-profit hospice over 25
quarters. This setting is valuable as cost data are detailed and
standardized across units, and are available as a complete
multiple unit panel. Second we examine costs on a crosssection of free-standing hospices from the Healthcare Cost
Report Information System Dataset over 1999-2003
(maximum of 1,396 hospices, 4,832 hospice-years). We
combine the HCRIS cost data with aggregate disease volume
data calculated from CMS’s Standard Analytical File to
estimate the cost function.
Principal Findings: We find that cancer patients are more
costly than non-cancer. Our results reveal that the mean
cancer patient marginal cost is $64/patient day and
$54/patient day for non-cancer patients (at mean level of
patient days). Further analysis indicates that over 80% of the
cost difference is due to direct labor and prescription drug
costs.
Conclusions: Our results suggest that in the provision of
hospice care in free-standing hospices that cancer patients are
more costly than non-cancer patients. To our knowledge this
study is the first large scale empirical investigation of this
important issue.
Implications for Policy, Delivery, or Practice: Our findings
have important implications for policy and delivery. Systematic
cost differences across two broad disease classes imply that
adverse incentives may arise in hospice delivery and access
under the Medicare system of fixed patient per-diem
payments. If cancer patients are relatively more costly, then
hospices face incentives that encourage search for lower cost
(non-cancer) patients. Additionally, hospices with a greater
proportion of cancer patients face relatively stronger
incentives to substitute lower cost, possibly less skilled labor,
which may adversely and differentially affect patient quality of
care across diseases. In general, these findings suggest that
the policy of disease agnostic fixed per-diem Medicare hospice
payment should be reconsidered in favor of a disease based
per-diem payment.
Primary Funding Source: No Funding
●Medicaid Home and Community-Based Services: Trends
in Programs and Policies
Martin Kitchener, M.B.A., Ph.D., Terence Ng, MA, Charlene
Harrington, Ph.D.
Presented By: Martin Kitchener, MBA, Ph.D., Associate
Professor, Social and Behavioral Sciences, University of
California, San Francisco, 3333 California Street, Suite 455, San
Francisco, CA 94118; Tel: 415-502-7364; Fax: 415-476-6552;
Email: Martin.Kitchener@ucsf.edu
Research Objective: To anlayse the most recent national
trends in participants, expenditures and policies concerning
the three main Medicaid home and communitybased(HCBS)programs: 1915(c)waivers,home health, and
state plan personal care services(PCS)
Study Design: Descriptive anlaysis of CMS Form 372 reports
for all waivers (1992-2003)and authors' annual surveys of
home health and PCS programs (1999-2003)
Population Studied: Medicaid HCBS programs
Principal Findings: While the participant and expenditure
trend data show annual national increases through 2003 in
each program except home health, growth rates are uneven
across the states and in some cases slowing. Findings from
surveys of cost control policies used on each program
illustrate how states are increasing waiver waiting lists and
imposing more stringent cost caps. Caps on spending and
services provided are also used in almost half the state plan
PCS programs and almost a third of all home health
programs.
Conclusions: Although total Medicaid HCBS spending and
particiaption continue to rise, the increased use of cost control
policies such as wait lists restrcits access in some states
Implications for Policy, Delivery, or Practice: Targeted
research is required to examine the outcomes of the inreased
use of cost control polices on Medicaid HCBS programs.
Primary Funding Source: Kaiser Family Foundation, NIDDR
●Urinary Incontinence: A Neglected Geriatric Syndrome in
Nursing Facilities
Larry Lawhorne, M.D., CMD, Joseph Ouslander, M.D., CMD,
Patricia Parmelee, Ph.D., Barbara Resnick, Ph.D., CRNP,
AMDA-F Research Network members
Presented By: Larry Lawhorne, M.D., CMD, Assoc Prof of
Family mMedicine, College of Human Medicine, MSU, B113
Clinical Center, East Lansing, MI 48824; Tel: (517) 353-0851;
Fax: (517) 355-7700; Email: lawhorne@msu.edu
Research Objective: The purpose of the present study is to
identify resident-level and facility-level factors that foster costeffective, sustainable approaches to the recognition,
assessment, and management of UI in the NF setting.
Study Design: The resident-level pilot study provides
participating Network facilities with a framework to facilitate
implementation of the essential steps of the AMDA UI clinical
practice guideline, then measures the following outcomes:
percent residents with UI classified; percent residents with
classification-specific UI care plan in place; number of
episodes of incontinence, pressure ulcers and infections;
resource utilization; quality of life; and resident, family, and
CNA satisfaction. The facility-level study compares Network
facilities that perform well on the UI intervention Quality
Indicator with those that perform poorly with respect to the
following characteristics and outcomes: ownership; residentdays; elements of UI policy and procedures; presence of UI
process improvement team; availability of bladder scanner;
performance on 9 or more medication Quality Indicators;
OSCAR data on: percent dementia, percent foleys, percent
dependencies, percent cholinesterase inhibitors, percent
“bladder meds;” incontinence product costs; and staff
turnover.
Population Studied: Physicians, Geriatric Nurse Practitioners,
Directors of Nurses, Nursing Assistants
Principal Findings: Urinary incontinence (UI) is common but
inadequately assessed and treated in nursing facility (NF)
residents. Previous work by the American Medical Directors
Association (AMDA) Foundation Long Term Care Research
Network examined survey responses from 401 physicians
(32% response rate), 118 Geriatric Nurse Practitioners (GNP)
(23%), 152 Director of Nurses (DONs) (30%), and 277
Nursing Assistants (NAs) (60%) and determined that these 4
groups of health care workers have different views of the
importance of UI compared to 5 other geriatric syndromes
(behavioral symptoms, falls, unintended weight loss, pain,
and delirium) as well as different perceptions about barriers to
improving the assessment and management of UI. For
example, nursing assistants are more likely to be involved in
UI care and more likely to select UI as having an adverse effect
on quality of life than physicians, GNPs or DONs. With
respect to barriers to improved UI care, physicians see
anticholinergic effects, particularly, cognitive function
impairment, as the most important while GNPs cite
inadequate implementation of behavioral interventions, and
DONs and NAs see time constraints as the most important
barrier.
Conclusions: The Network’s previous work suggests that
physicians, GNPs, and DONs are more likely to be involved in
evaluating and managing behavioral symptoms, pain, falls,
delirium, and unintended weight loss than UI in the NF
setting. This leaves NAs as first-line managers for a condition
that they (and probably residents) perceive to have an
important impact on quality of life. Perceived barriers to
improved UI care differ among physicians, GNPs, DONs, and
NAs suggesting that approaches to overcoming the barriers
should be multi-faceted.
Implications for Policy, Delivery, or Practice: Findings from
the current study of resident- and facility-level factors should
provide guidance in the development of cost-effective,
sustainable approaches to the recognition, assessment, and
management of UI in the nursing facility setting.
Primary Funding Source: Novartis
●Modeling Efficiency at the Process Level
Robert Lee, Ph.D., Roma Lee Taunton, Ph.D., Byron Gajewski,
Ph.D., Marge Bott, Ph.D.
Presented By: Robert Lee, Ph.D., Associate Professor, Health
Policy and Management, University of Kansas, 321 Thorn
Street, Sewickley, PA 15143; Tel: 913-908-8202; Email:
rlee2@kumc.edu
Research Objective: This paper examines the efficiency of a
single process: how nursing homes complete a standardized,
mandatory assessment of residents. This is an important
process that drives resource allocation for individual residents
and the organization as a whole. One might expect that
nursing homes would use similar processes for this
assessment, but earlier studies demonstrated that this was
not true.
Study Design: The data collection process started with
construction and validation of a process map for each facility.
This identified the steps in the process for each nursing home
and drove primary data collection. It is unlikely that data on
any significant inputs into the production process are missing.
Moreover, these data allow us to identify at which steps
production is inefficient, not just which resources appear to be
overused. These primary data were merged with survey and
MDS data to allow quality and case mix controls. These data
were augmented with data from Medicaid cost reports, the
Minimum Data Set, and the Online Survey Certification and
Reporting System. As a result, we have the data needed to
conduct a variety of case mix-adjusted and quality-adjusted
Data Envelopment and Stochastic Frontier Analyses.
Population Studied: Care planning processes at a stratified
random sample of 107 of nursing homes in two states.
Principal Findings: Nursing homes varied widely in their
efficiency. For example, three facilities with perfect quality
scores that averaged 10 care plans per week used 5.6, 8.1, and
16.4 employee hours per plan, meaning that costs varied
nearly three-fold. Put differently, the least efficient home
wasted the services of more than two FTE employees. In
addition, nearly 10% of the homes used more than 16.4 hours
per plan and had citations for multiple care planning
deficiencies. Preliminary analyses suggest that more efficient
homes tended to have an assistant for the MDS nurse and
have tightly structured, interdisciplinary care planning
meetings.
Conclusions: Quality and cost vary widely for the care
planning process. Direct analysis of process efficiency is
feasible.
Implications for Policy, Delivery, or Practice: Inefficient
processes result in high costs and low quality throughout
health care. By showing that the “business case” for process
improvement is compelling, this study extends and confirms
earlier findings of widespread inefficiency. Because it controls
for quality and validates process structures, this study directly
engages Newhouse’s (1994) concerns that earlier studies may
have omitted important inputs or ignored important sources
of heterogeneity. The techniques developed in this study and
its detailed findings are clearly applicable to other areas. The
results imply that, whatever their objectives, managers should
focus on improving their core processes and policy makers
should take steps to facilitate this.
Primary Funding Source: National Institute of Nursing
Research
●Cost Driver Analysis for Dialysis: Lessons from Renal
Clinics in Taiwan
Shuen-Zen Liu, Ph.D., Chia-Ching Cho, Ph.D. candidate,
James Romeis, Ph.D.
Presented By: Shuen-Zen Liu, Ph.D., Professor, Accounting,
National Taiwan University, Room 1009, Building II, College of
Management, National Taiwan University, No. 1, Sec. 4,
Roosevelt Rd. Taipei 106, Taiwan, Taipei, 106; Tel: 886-233661122; Fax: 886-2-23638038;
Email: sliu@management.ntu.edu.tw
Research Objective: Care for patients with End-Stage Renal
Disease (ESRD) is an important issue of medical care. The
prevalence and incidence of dialysis patients are rapidly
increasing worldwide, so is the size of ESRD budget. The
objective of our study is to analyze cost drivers for dialysis
using administrative data obtained from a large renal clinic
chain in Taiwan.
Study Design: We use multiple linear regression analysis to
examine factors that influence costs of dialysis in our study. In
the analysis, we employ two different measures for dependent
variables: total variable costs and total medical variable costs.
Concerning the independent variables, we consider potential
cost drivers such as patient characteristics (e.g., age, sex, and
the existence of hepatitis B, diabetes, and hypertension),
medical treatments (e.g., reusing artificial kidney, EPO), and
clinic properties (e.g. location, affiliate of hospital, and shares
held by the company).
Population Studied: The data used in the study comes from
internal administrative sources of a large renal clinic chain.
The company is the leading provider of dialysis and related
services in Asia. It owns or operates about sixty dialysis
facilities across Asia, treating nearly four thousand patients. In
our analysis, there are 1043 observations of dialysis treatments
drawn from 15 dialysis facilities in Taiwan. All of these internal
administrative data are from May, 2005; they are the most
reliable data source available.
Principal Findings: In the multiple linear regression, we find
several interesting empirical results. First, male and younger
patients consume more dialytic variable costs. Second, clinics
located in larger cities use less total medical variable cost per
patient. Third, the percentage of shares held by the company
is positively associated with dialytic variable costs, indicating
that agency problem might exist in renal clinics. Fourth, clinics
affiliated with big hospitals are found to incur less variable
costs but more total medical variable cost. Finally, we find that
quality is positively related with dialytic variable costs.
Conclusions: Our analysis indicates that treatment costs of
dialysis are influenced by various medical and non-medical
factors. The finding is crucial to cost control and performance
evaluation for renal clinics. In addition, the positive
association between medicare quality and dialytic variable
costs indicate that we need to develop some payment scheme
for maintaining quality.
Implications for Policy, Delivery, or Practice: The Bureau of
National Health Insurance (BNHI) in Taiwan has set a stable
payment rate for hemodialysis procedures per time. However,
we find dialytic variable costs are affected by multiple cost
drivers. The results mean that the potential reimbursement
distortion from using a single cost driver for allocating
treatment costs of dialysis. From a healthcare policy
perspective the findings are interesting for the authorities
concerned to reconsider the simplistic payment policy.
Furthermore, better understanding of the cost drivers can
improve future management and potential merger &
acquisition strategy for renal clinics.
Primary Funding Source: No Funding
●Deteriorating Health Over Time and Its Effects on the
Need for Institutional Care
Hongji Liu, Ph.D., Hongji Liu, Rick Apodaca, Yuki Jao
Presented By: Hongji Liu, Ph.D., Senior Study Director,
Survey Operations, WESTAT, 1650 Research Boulevard,
Rockville, MD 20850; Tel: 301-294-2055;
Email: liuh1@westat.com
Research Objective: Data from Medicare Current
Beneficiaries Survey (MCBS) indicate that over 9 percent of
Medicare beneficiaries (3.7 million) use institutional care.
These beneficiaries are the high-cost users of health care
services in the Medicare Program. This paper intends to
investigate the effects of deteriorating health on the need for
institutional care and to estimate subgroups’ rate of change in
their institutional needs over 4 years. Specifically, it will: 1)
compare the rates of deteriorating health among subgroups;
and 2) examine subgroup differences in their rates of
institutional care over time.
Study Design: The paper uses data from CY1999 – CY 2002
MCBS Access to Care Public Use Files (PUFs). We follow the
1999 panel in MCBS for 4 years. We track the changes in their
major health indicators by age subgroups, including
prevalence of major diseases, functional limitations, and
perceived health status. Then, we evaluate the changes in their
need for institutional care with the lapse of time and identify
the subpopulation with highest risks. Multivariate analyses are
conducted to identify subgroups with most risk factors.
Population Studied: Medicare beneficiaries
Principal Findings: Preliminary results indicate health status
changed at different rates for different age groups. Those aged
85 and over indicated fastest deterioration of health over 4
years. Approximately 10 percent of them reported a change
from relatively healthy to poor health; and 14 percent were
impacted by some kind of functional limitations. By the end of
4 years, one third of them reported poor health and over three
quarters reported functional limitations. Interestingly enough,
this subgroup does not show the highest rate of major
diseases, including heart diseases, hypertension, cancer, and
diabetes. The association between deteriorating health and
need for institutional care can be seen from the increasing
institutional rate for Medicare beneficiaries as they are aging.
Those aged 85 and over group showed the highest rate of new
institutional admissions (18 percent) over the 4 years,
increasing from the initial 10.8 percent to 28.8 percent;
followed by those aged 75-84 (4.4 percent), increasing from
2.9 percent to 7.3 percent. Those aged 65-74 showed the
lowest institutional rate (from 1.3 percent in 1999 to 2.9 in
2002) and lowest cumulative rate of new admission (1.5
percent). Multivariate analyses indicate that functional
limitation is the primary determinant of the need for
institutional care.
Conclusions: These findings confirm that health status is the
key determinant of institutional care. For certain vulnerable
subgroups with significantly higher rate of poor health, such
as those aged 85 and over, and those with Medicaid, their
need for institutional care is considerably greater.
Implications for Policy, Delivery, or Practice: The aging of
the population drives up the need for long term care.
Institutional care is probably the most resource intensive type
of long term care. The understanding of the association
between the aging process and the need for institutional care
is important in anticipating future health care needs among
the Medicare population.
Primary Funding Source: CMS
●Consumer Preferences in the Reporting of Long-term
Care Satisfaction Data
Judith Lucas, Ed.D., Timothy Lowe, Ph.D., Carrie Levin, Ph.D.,
Stephen Crystal, Ph.D
Presented By: Judith Lucas, Ed.D., Rutgers, Division on
Aging, 30 College Avenue, New Brunswick, NJ 08540; Tel:
732-932-6940; Email: jlucas@rci.rutgers.edu
Research Objective: A few states have initiated reporting
programs of Long-term Care (LTC) satisfaction survey results
primarily to help consumers make informed choices among
LTC providers and to promote quality improvement (QI)
efforts. However, there is little information available about
how satisfaction survey results should be reported. This study
aims to describe family member preferences in reporting LTC
satisfaction data and to compare these with the reporting
preferences of facility administrators.
Study Design: As part of the development and testing of
resident and family satisfaction instruments in multiple state
projects of nursing home (NH) and assisted living (AL)
facilities, we surveyed (mail and telephone) both family
members and facility administrators about their preferences in
reporting satisfaction data for use in provider selection and QI
efforts. We included the same core items about format,
scoring, comparisons, and media presentation for all
respondents.
Population Studied: NH Family members (n= 380) and
administrators (n= 142) and AL family members (n= 69) and
administrators (n= 7). We defined family member broadly to
include: any relative, the listed responsible party, or the legally
appointed guardian or conservator.
Principal Findings: Both NH and AL family members prefer
to: see scores for each area of care and life (domain) and an
overall scores vs. item scores; show satisfaction scores over a
minimum of three years to see trends; and to be able to
compare facilities within a county and by ranking (e.g.,
symbols or top 20%, mid 70% , bottom 10%); and over half
feel confident using results published in booklet form or on a
web page, yet they still wanted a toll-free number available for
questions. Both NH and AL administrators prefer: to see
overall satisfaction scores on the web, and domain scores and
item scores (with range and means) on facility reports; facility
reports using a percent score, symbols, and graphics; to view
the current score and at least one past measure for internal QI
efforts; comparisons by county, across peer groups (i.e., by
size or ownership) and to the highest score in a domain; and
they want to be able to view verbatim comments organized by
domain and specific units for internal QI.
Conclusions: Less detailed satisfaction reports in printed or
web form that allow family members to make comparisons
between facilities within a chosen county and over multiple
measurement points, would appear to be useful for consumer
LTC decisions, especially during time-pressured selection
events. LTC administrators prefer more detailed data and
comparisons with county scores and with similar facility types
for QI.
Implications for Policy, Delivery, or Practice: : LTC
satisfaction measurement initiatives need to design LTC
satisfaction reports for multiple users that provide options
that allow comparisons between facilities (for consumers)
and that allow users to seek more detailed information for QI
efforts (for facilities).
Primary Funding Source: Other
●The Same, Only Different: Influenza and Pneumococcal
Immunization in Nursing Homes
Jill Marsteller, Ph.D., MPP, Ronald Tiggle, Ph.D., Robin
Remsburg, Ph.D., Abigail Shefer, M.D., Barbara Bardenheier,
M.P.H., MA
Presented By: Jill Marsteller, Ph.D., MPP, Assistant Professor,
Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, 624 N. Broadway St., Room 433,
Baltimore, MD 21205; Tel: 410-614-2602; Fax: 410-955-6959;
Email: jmarstel@jhsph.edu
Research Objective: Influenza and pneumococcal vaccines
are often paired in statistical reporting and in immunization
policy making. However, the two vaccines are administered on
different schedules and immunization rates achieved thus far
for the two vaccines are widely disparate. Thus the two
immunizations may merit individual attention. This
presentation will compare the determinants of receiving
pneumococcal polysaccharide vaccine (PPV) with those of
influenza immunization among elderly nursing home
residents to inform immunization policy making.
Study Design: A comparison of the results of two
multinomial logistic regressions. The outcomes are recordbased staff report of whether nursing home residents 1)
received influenza vaccination during the past 12 months
(yes/no/unknown) or 2) had ever received pneumococcal
immunization (yes/no/unknown). Variables tested included
resident and facility characteristics and facility practices.
Population Studied: A nationally representative sample of
7,350 nursing home residents >65 years old in 1,423 facilities
from the 1999 National Nursing Home Survey.
Principal Findings: Immunization coverage for influenza was
much higher than for pneumococcal vaccine. Twenty-two
percent of residents aged 65 and older had never received a
pneumococcal immunization (SE=0.81%), and 39% had an
unknown status (SE=1.04%). By contrast, only 15%
(SE=0.60%) of residents had not received an influenza
immunization in the previous 12 months, and 19% had
unknown status (SE= 0.77%). Regression results indicated
that the facility practices of recording immunizations in the
patient’s medical chart and screening for immunizations upon
admission had consistent positive effects across both
vaccines. Also, for each type of vaccine, immunization with the
one increased the likelihood of immunization with the other.
Otherwise, the covariates of each type of immunization are
different. Younger age and being newly admitted reduce the
likelihood of receiving an influenza immunization, but are not
related to receipt of PPV. The likelihood of PPV receipt is lower
for blacks, residents in southern and western facilities and
those in non-governmental homes, but these variables are not
related to influenza immunization. Residence in a Medicaidonly certified facility raises the odds of influenza immunization
but lowers odds of receiving PPV.
Conclusions: Screening for immunizations upon admission
and recording immunizations in the resident’s medical chart
raise immunization rates for both vaccines. Failure to receive
one immunization is associated with failure to receive the
other.
Implications for Policy, Delivery, or Practice: Facilities may
do well to address PPV immunization during annual influenza
immunization campaigns. In addition, differences in the
covariates of the two immunization types may suggest
exploring supplemental strategies tailored to each vaccine
type, such as reviewing the records of young and newly
admitted residents for influenza immunization but focusing
on specific facility types for facility-wide PPV education.
Differences between the two immunizations may suggest that
reaching the same 90 percent Healthy People 2010 coverage
goals within the same timeframe may be difficult.
Primary Funding Source: No Funding
●Risk of Nursing Home Admission in Association with
Mental Illness
Edward Miller, Ph.D., M.P.A., Robert A. Rosenheck, M.D.
Presented By: Edward Miller, Ph.D., M.P.A., Assistant
Professor, Taubman Center for Public Policy, Brown
University, 67 George Street, Box 1977, Providence, RI 029121977; Tel: 401-863-9311; Fax: 401-863-2452;
Email: edward_a_miller@brown.edu
Research Objective: To determine whether patients with
mental health diagnoses in the Department of Veterans Affairs
(VA) are more likely to be admitted to nursing homes, and to
identify sociodemographic, utilization, and clinical
characteristics, especially indicators of mental illness severity,
associated with nursing home admission among mentally ill
patients.
Study Design: Patients receiving treatment in the VA system
nationally during FY2000 and having no evidence of nursing
home utilization during FY1999 or FY 2000 were followed
through FY2003 using administrative claims data. Three-year
incidence rates and unadjusted odds ratios were estimated for
each diagnosis. Logistic regression was used to examine the
correlates of admission among mentally patients, including
analyses stratified by age.
Population Studied: Patients receiving treatment in the VA
system nationally with no previous evidence of nursing home
utilization.
Principal Findings: Of 3,952,229 VA patients with no prior
nursing home use, 15.2% received a mental health diagnosis,
of which, 4.6% were eventually admitted to a nursing home.
Among mentally ill patients, risk of admission was highest for
those with any inpatient medical/surgical days (odds ratio
[OR]=2.28), followed by 3+ outpatient medical visits
(OR=1.48), inpatient mental health days (OR=1.31), and
outpatient mental health visits (OR=1.09). Patients diagnosed
with dementia were 58 percent more likely to be admitted.
Patients diagnosed schizophrenia (OR=1.26), other psychosis
(OR=1.15), and personality disorder (OR=1.14) had the next
highest probabilities. Elderly patients with bipolar disorder
(OR=1.28) were also more likely to enter.
Conclusions: Although factors leading to nursing home entry
among the mentally ill are similar to those driving entry in the
general population, those with more severe mental health
problems are still more likely to be admitted.
Implications for Policy, Delivery, or Practice: This study
highlights the role of mental health care in preventing future
institutionalization among veterans with certain psychiatric
conditions. It also highlights the need for continued vigilance
in assessing nursing home applicants for mental illness and
for ensuring adequate provision of mental health services to
those who eventually enter such facilities.
Primary Funding Source: No Funding
●Nursing Home Community Discharge Rates are not
Affected by Prospective Payment System
Patrick Murray, M.D., MS, Randall Cebul, M.D., Charles
Thomas, BS, Thomas Love, Ph.D., Neal Dawson, M.D.
Presented By: Patrick Murray, M.D., MS, associate professor,
Center for Health Care Research and Policy, Case Western
Reserve University, 2500 MetroHealth Dr., Cleveland, OH
44118; Tel: 216-778-3901; Fax: 216-778-3945; Email:
pkmurray@metrohealth.org
Research Objective: Previous studies demonstrate that
following the implementation of a prospective payment
system for Medicare supported skilled nursing care there was
a decline in the intensity of rehabilitation therapy provided, but
an increase in the proportion of patients receiving
rehabilitation following nursing home admission. The
objective of this study is to examine how the changes in
rehabilitation service provision affected community discharge
rates.
Study Design: A retrospective review was conducted of
Minimum Data Set and Medicare Current Status Files before
and after the implementation of the prospective payment
system to ascertain receipt and intensity of rehabilitation
services and community discharge within three months of
admission. A logistic model of patient characteristics
predictive of the likelihood of receiving rehabilitation was
developed and validated in the pre-prospective payment
sample and applied to the post-prospective payment sample.
The two samples were divided into quintiles based on the
individual predicted likelihood to receive rehabilitation services
and into diagnostic groups. Community discharge rates were
compared in the two time periods.
Population Studied: First time admissions to free standing
Ohio nursing homes during 1994-6 numbered 7006, and
during 2000-1, 44,770.
Principal Findings: Rehabilitation services were provided to
69 percent and 90 percent of new admissions in the preprospective payment and post-prospective payment period
respectively. The intensity of therapy was 7.1 and 6.2 hours
per week respectively. The overall community discharge rate
was 49.3 percent in the pre-prospective payment period and
50.7 percent in the post-prospective payment period which
was significantly different at the p = 0.03 level. Two quintiles,
the first or least likely to receive therapy services and third,
demonstrated statistically significant but relatively small
declines in community discharge rates in the post-prospective
payment period. The relative rate of community discharge was
0.79 with 95 percent confidence intervals from 0.72 to 0.88 in
quintile 1 and 0.93 with 95 percent confidence intervals from
0.88 to 0.98 in quintile 3. In the fourth and fifth quintiles
where the intensity of therapy declined, community discharge
rates did not decline. Among patients with diabetes and
significant cognitive deficits community discharge rates were
higher in the post-prospective payment period.
Conclusions: Despite an increased rate of rehabilitation
services upon admission to nursing home there has been little
change in community discharge rates. There has been no
decline in community discharge rates among the groups who
received lower intensity services in the post-prospective
payment period. The increase in rehabilitation services in
patients with medical reasons for admission appears to be
associated with a modest increase in community discharge
rates.
Implications for Policy, Delivery, or Practice: The
prospective payment system changes implemented in 1998
does not appear to have changed community discharge rates.
While there may be benefits to expanded rehabilitation
services if one examined other outcomes, e.g., activities of
daily living, the selection of patients to receive rehabilitation in
nursing homes deserves further study.
Primary Funding Source: AHRQ
●Organizational Characteristics Associated with the Use
of Computerized Medical Records in Healthcare Agencies
providing Home Health Services in the US
William S. Pearson, Ph.D., M.H.A., Anita R. Bercovitz, Ph.D.,
M.P.H.
Presented By: William S. Pearson, Ph.D., M.H.A., Health
Scientist, Long-term Care Statistics Branch, Centers for
Disease Control and Prevention/National Center for Health
Statistics, 3311 Toledo Road, Hyattsville, MD 20782; Tel: 301458-4699; Fax: 301-4584693; Email: wpearson@cdc.gov
Research Objective: The objectives of this study are to
estimate the extent of computerized medical record use
among agencies providing home health services in the US and
to determine organizational characteristics associated with
their use.
Study Design: Secondary analysis of the 2000 National
Home Health and Hospice Care Survey. Population estimates
were made for the numbers and types of agencies using
computerized medical records. Significant associations
between agency characteristics and use of a computerized
medical record were determined by using chi-square analyses
and adjusted logistic regressions.
Population Studied: Nationally representative sample of 621
home health agencies and 312 mixed service (providing both
home health and hospice services) agencies in the US, derived
from the 2000 National Home Health and Hospice Care
Survey (NHHCS). This sample represented 7,265 home health
agencies and 1,766 mixed service agencies nationally.
Principal Findings: Over 2,300 home health agencies
reported using a computerized medical record in 2000. This
represented 32% of health home agencies in the US at that
time. Just over 700, (40%) of all mixed service agencies
reported using a computerized medical record. Among all
agencies that provided home health services, chi-square
analyses suggested that the number of patients being served
(p<.01) and the provision of skilled clinical (respiratory
therapy, I.V. therapy, eterostomal therapy, dialysis, enteral
nutrition) services (p<.01) were found to be significantly
associated with CMR use.
Among all agencies providing home health services, an
adjusted logistic regression showed that number of patients
being served and provision of skilled clinical services were
significant predictors of using a CMR while controlling for
group or chain membership, hospital ownership, number of
services offered and geographic location of the agency.
Agencies that served more than 100 patients were two and a
half times more likely to be using a CMR compared to
agencies serving 50 patients or less (2.55 O.R., 1.54-4.21 95%
C.I.). Agencies that provided skilled clinical services were
nearly three times as likely use a CMR than agencies that did
not provide skilled clinical services (2.79 O.R., 1.51-5.19 95%
C.I.).
Conclusions: Number of patients being served and the ability
to offer skilled clinical services are significant predictors of
CMR use in agencies that provide home health services. These
characteristics may be indicative of the agencies’ level of
resources that can be devoted to increasing the quality of care
by means of investing in newer technologies.
Implications for Policy, Delivery, or Practice: The use of
information technology, primarily in the form of electronic
medical records, has been proposed as a way to increase the
efficiency of delivered services, raise the level of the quality of
care provided and decrease the number of medical errors.
However in home health care, an area where CMR’s would be
especially useful (e.g. coordination of multiple providers),
fewer than 40% of agencies were using this technology.
Further research should be conducted to determine the
organizational characteristics that contribute to the adoption
of CMR’s and whether the use of this technology is associated
with quality and safety differences in patient outcomes.
Primary Funding Source: CDC
●Electronic Information Systems Use for Patient Care in
US Nursing Homes: Data from the 2004 National Nursing
Home Survey
William S. Pearson, Ph.D., M.H.A.
Presented By: William S. Pearson, Ph.D., M.H.A., Health
Scientist, Long-term Care Statistics Branch, CDC, National
Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD
20782; Tel: 301-458-4699; Fax: 301-458-4693;
Email: wpearson@cdc.gov
Research Objective: To estimate the number of US nursing
homes using electronic information systems and to examine
how these systems were used.
Study Design: Cross-sectional analysis of the 2004 National
Nursing Home Survey. National estimates were made for the
numbers of homes using an electronic information system
and the specific patient care activities they performed. These
activities included management of patient records,
management of medication orders and drug dispensing,
physician order entry, laboratory orders and procedures,
management of medication administration records, nursing
assistant notes, and dietary notes.
Population Studied: Nationally representative sample of 1,174
nursing homes from the 2004 National Nursing Home
Survey, which represented 16,079 nursing homes nationally.
Principal Findings: Almost one-half (47.2%) of the estimated
16,079 US nursing homes in 2004 were using an electronic
information system for the management of patient records.
51.1% of all nursing homes were using an electronic system for
medication orders and drug dispensing; 48.4% for physician
order entry; 41.4% for laboratory orders and procedures, 38.1%
for management of medication administration records, 17.5%
for daily nursing assistant notes and 51.2% for dietary notes.
Approximately 20% of all US nursing homes were not using
an electronic information system for any of seven patient care
activities. Seventeen percent were using their information
system for at least one activity, and approximately 55% of
nursing homes were using their information systems for 2 to
6 patient care activities. Just over seven percent of all homes
were using their information system for all seven of the
patient care activities.
Conclusions: By 2004, many US nursing homes had adopted
the use of an electronic information system for some type of
patient care activity. However, the use of the information
systems for patient care varied among the homes.
Implications for Policy, Delivery, or Practice: This study
presents data that allow researchers and policy makers to see
where nursing homes stand at the beginning of our nation’s
move toward a wired health information network. The use of
information technology, primarily in the form of an electronic
health record, has been proposed as a way to increase the
efficiency of delivered services, raise the level of the quality
care provided and decrease the number of medical errors.
This study suggests that many nursing homes are using the
technology for patient care services, although at varied levels.
In 2004 Executive Order 1335 set forth a Federal Health IT
initiative with the goal of having the majority of the US health
care system wired and having most Americans covered by an
interoperable health record within the next decade. Nursing
homes are a large sector of the overall US healthcare system
that provides care to an especially vulnerable population.
Therefore, the use of electronic health records may help to
ensure quality of care to this population. This survey will allow
researchers to conduct studies on outcomes of patients that
were treated in homes which utilized electronic information
systems for patient care and will help to determine how the
use of electronic information systems for patient care affect
quality and outcomes.
Primary Funding Source: CDC
●The Consistency of Transitions in Residential Living
Settings in Medicare Beneficiaries during 1998 - 2001
Thomas Shaffer, M.H.S., Ilene Zuckerman, PharmD, Ph.D.
Presented By: Thomas Shaffer, MHS, Research Analyst, The
Peter Lamy Center on Drug Therapy and Aging,
515 W. Lombard, Baltimore, MD 21201; Tel: 410-706-2747;
Email: tshaffer@rx.umaryland.edu
Research Objective: To develop a typology of transitions in
residential living and to quantify the degree and types of
changes in living situations for the Medicare population both
in cross-section and longitudinally.
Study Design: Using monthly residence history constructed
from survey and administrative data, we analyzed four annual
cross-sections (1998-2001) and two longitudinal cohorts each
who able to be followed for three years. Transitions were
stratified by the number of transitions with a year. Residential
settings used to identify and categorize transitions were
Community, Skilled Nursing Facility (SNF), and Facility.
Within the Facility setting, four specific types of institutional
settings (Nursing Home, Assisted Living, Congregate Care
Settings, and Miscellaneous –MRDD/Psych/Rehab) were
further identified. Acute hospitalizations were not considered
a change in residential setting.
Population Studied: The study population comprised
participants of the Medicare Current Beneficiary Survey
(MCBS), a nationally representative sample of the Medicare
insured population.
Principal Findings: The proportions of individuals making
transitions in residential setting were constant across 19982001. Approximately 93% experienced no changes in settings;
4% experienced a single change in residential setting; 2% had
two changes, and 1% experienced more than two changes in a
year. This was constant across four years despite a 33%
infusion of newly sampled persons in each year due to survey
sample design with a complete 100% replenishment of entire
sample by 2001.
Within common strata, changes of specific settings
combinations were found across time. For example, within
the 2-setting stratum the Community-to-Facility transition
decreased from a relative proportion of 30% in 1998 to 15%
during 2001. So while the overall proportion experiencing a
transition remains constant, the relative proportions of
specific combinations of transitions within a stratum changed.
Longitudinal stability as measured by the number of
transitions encountered across the three years also showed no
statistically significant differences in stratified analyses.
Conclusions: Transitions of residential living situations are
remarkably constant over time and by the types of transitions
made. Cross-sectionally, similar proportions of individuals
experienced one, two, or more than two transitions per year.
Longitudinally, similar progressions of the number of
transitions across time were found. This suggests that
although different individuals are involved in transitions, the
numbers and types of residential transitions are essentially
constant by individual year and across time.
Implications for Policy, Delivery, or Practice: Transitions in
living situations are stressful times for the individual involved
and also mark potential sources of discontinuities in care.
Understanding the patterns of transitions that can be
developed from what appears to be a constant incidence in a
large population can create a typology of transitions that can,
in turn, be used to identify periods of risk and potentially
minimize the consequences of discontinuity of care across
residential settings.
Primary Funding Source: No Funding
●Variations in “Comfort-Measures-Only” Status
Designation Across Acute Care Hospitals and Implications
for Assessing the Quality of End-of-Life Care
Ying Tabak, Ph.D., Karen Derby, BA, Martha Hays, RHIT,
Steve Kurtz, MS, Richard Johannes, M.D., MS
Presented By: Ying Tabak, Ph.D., Director, Biostatistics, CTS Clinical Research, Cardinal Health, 500 Nikerson Road,
Marlborough, MA 01752; Tel: 508-571-5120; Fax: 508-571-6101;
Email: ying.tabak@cardinal.com
Research Objective: With an expanding aged population,
healthcare professionals face the challenge in providing “endof-life” care to dying patients. The “Comfort-Measures-Only”
is designated by physicians to “relieve suffering”. It includes
pain management, retaining dignity, and spiritual fulfillment.
The clinical decision of “Comfort-Measures-Only” is
complicated by patient/family preference, legal, ethical, and
cultural factors. To date, little is known on how “ComfortMeasures-Only” is used across hospitals in spite of its
importance in quality assessment, especially to end-of-life
care. We sought to evaluate whether “Comfort-MeasuresOnly” designation is used uniformly across acute care
hospitals.
Study Design: We used retrospectively collected clinical data
in the Cardinal Health Research Database to examine the
distribution of “Comfort-Measures-Only” designated within 24
hours of admission, the in-hospital mortality for those with
“Comfort-Measures-Only” status, and discharge destinations
by disease groups and hospitals. We focused only on
“Comfort-Measures-Only” designated early in the
hospitalization because it is more likely related to the
admission severity and less confounded with care process.
Population Studied: We analyzed 86,100 admissions at 49
Pennsylvania hospitals (23 teaching, 26 non-teaching) in 20032004 with a principal diagnosis of ischemic stroke (n=10,378,
621 deaths), cerebral hemorrhage (n=2,223, 700 deaths),
pneumonia (21,852, 806 deaths), respiratory failure (n=4,497,
1,045deaths), acute myocardial infarction (n=10,027, 1,015
deaths) heart failure (n=29,066, 989 deaths), and septicemia
(8,057, 1,535 deaths).
Principal Findings: Overall the rate of “Comfort-MeasuresOnly” designated within 24 hours was 1.3% for the study
population. The “Comfort-Measures-Only” patients were
significantly older compared to non-”Comfort-Measures-Only”
patients (median age of 83 vs. 76, p < .0001). They were also
sicker as indicated by significantly higher admission severity in
acute physiologic presentation and severe chronic diseases
(median predicted probability of death .29 vs. .03, p < .0001).
At the hospital level, there was a wide range in “ComfortMeasures-Only” designation rates (0.23-19.6%), and
“Comfort-Measures-Only” in-hospital mortality rates (14.388.9%). There was a general trend that hospitals with higher
“Comfort-Measures-Only” rates had lower “ComfortMeasures-Only” in-hospital mortality. Compared to nonteaching hospitals, teaching hospitals had significantly lower
“Comfort-Measures-Only” rates (1.0% vs. 1.9%, p <.0001) but
higher “Comfort-Measures-Only” mortality rates (65.7% vs.
46.3%, p <.0001). For the 1152 patients with “ComfortMeasures-Only” designated within 24 hours of admission,
56% died in the hospital, 21% were discharged to a skilled
nursing facility, 10% to home; 7% to hospice, and 5% to other
destinations. For those who died in the hospital, the length of
stay was significantly shorter than those discharged alive
(average LOS of 2.2 days vs. 5.2 days, p <.0001).
Conclusions: There is a wide variation in “Comfort-MeasuresOnly” designation rates and “Comfort-Measures-Only”
mortality rates across hospitals. Hospitals with higher
“Comfort-Measures-Only” designation rates tended to have
lower “Comfort-Measures-Only” mortality.
Implications for Policy, Delivery, or Practice: Our findings
of large variation in “Comfort-Measures-Only” utilization
across hospitals highlight the need for open discussions on
whether there should be a uniform definition and application
of “Comfort-Measures-Only” status in the acute care settings.
Further research on extended mortality (e.g. 30 day mortality)
and a survey of patients/families regarding their experience
can be potentially beneficial in assessing the quality and
appropriateness of “end-of-life care” in general and “ComfortMeasures-Only” designation in particular.
Primary Funding Source: No Funding
●Barriers to Medical Care in Community-Dwelling Elderly
With Dementia: The Role of Informal Caregiver Life
Satisfaction
Joshua Thorpe, Ph.D., M.P.H., Courtney Van Houtven, Ph.D.,
Betsy Sleath, Ph.D., Carolyn Thorpe, M.P.H., Elizabeth Clipp,
Ph.D.
Presented By: Joshua Thorpe, Ph.D., M.P.H., Assistant
Research Professor, Duke University School of Nursing, Trent
Drive, DUMC 3322, Durham, NC 27710; Tel: (919) 684-0395;
Fax: (919) 681-8899; Email: joshua.thorpe@duke.edu
Research Objective: An estimated 50-70% of dementia
patients reside in the community, where the majority of care is
provided by informal caregivers. Dementia patients often rely
on informal caregivers to act as “access to care” agents on
their behalf. The negative toll of caregiving on caregiver
emotional health and life satisfaction is well-documented, but
little is known about how this impacts the caregiver’s ability to
facilitate medical care for the care-recipient. The primary aim
of this study was to assess whether caregiver life satisfaction
influences access to outpatient care in community-dwelling
elderly with dementia.
Study Design: VA outpatient utilization was linked to data
from the 1998 National Longitudinal Caregiver Survey. The
sample consisted of 1,264 community-dwelling older male
veterans with dementia, and their co-residing female
caregivers. Independent variables, collected in early 1998,
were used to predict VA outpatient utilization over a 12 month
period. The dependent variable, care-recipient outpatient
utilization, was classified as (1) primary care, (2) specialty
care, and (3) mental health, using clinic stop codes. We
dichotomized utilization as any versus none. Our primary
independent variable was caregiver satisfaction with life as
measured by their response to the question, “Taking all things
together, how would you say you find life these days?” The
three response categories were: Not Satisfying, Fairly
Satisfying, and Very Satisfying. The selection of other
independent variables was guided by the Andersen behavioral
model of health service use (BMHSU). Predisposing variables
included caregiver (CG) age, CG education, care-recipient
(CR) race, CG relationship to CR, and CR age. Enabling
variables included CG income, CR insurance, CG physical
health, assistance from secondary caregivers, distance to
nearest VA facility, and region of country. Care-recipient need
variables included ADLs and IADLs, behavioral disturbance,
duration of symptoms, and comordid conditions.
Multivariable logistic regression estimated the association
between caregiver life satisfaction and care-recipient
outpatient care use, adjusting for BMHSU variables.
Population Studied: 1,264 community-dwelling male veterans
with dementia and their co-residing informal caregivers.
Veterans less than 65 years of age, those with no VA
outpatient visits in the previous year, and those who died or
entered a nursing home anytime during the 12 month period
were excluded.
Principal Findings: For primary and specialty care, results
support our hypothesis that greater caregiver life satisfaction
was associated with increased access. Compared to carerecipients with caregivers who found life “very satisfying,” the
odds of care-recipient receipt of primary care were lower when
the caregiver was unsatisfied (OR: 0.38; 95% CI: 0.23, 0.65).
The adjusted percentage point difference was 10%, (92% for
very satisfied, 82% for unsatisfied). A similar pattern was
found for specialty care (OR: 0.67; 95% CI: 0.47, 0.96). The
adjusted percentage point difference was 9% (66% for very
satisfied, 57% for unsatisfied).
Conclusions: We found that lower informal caregiver life
satisfaction was significantly associated with decreased access
to primary and specialty care in community-dwelling elderly
with dementia.
Implications for Policy, Delivery, or Practice: Interventions
to improve caregiver’s quality of life may also improve their
ability to facilitate medical care for their care-recipient.
Primary Funding Source: AHRQ, VA HSR&D
●Depression and Missed Work among Informal Caregivers
of Older Individuals with Dementia
Courtney Van Houtven, Ph.D., Michele Wilson, MSPH, Sally C
Stearns, Ph.D., Elizabeth C Clipp, Ph.D. RN
Presented By: Courtney Van Houtven, Ph.D., Health
Economist, Durham VA and Duke, HSR&D, General Internal
Medicine, 508 Fulton Street, Durham, NC 27705;
Tel: (919)286-6936; Fax: (919)416-5836;
Email: courtney.vanhoutven@duke.edu
Research Objective: Providing informal care can negatively
affect caregiver emotional health and lead to depression, yet
the association between caregiver depression and missed
work is unknown. Our objective is to examine the relationship
between caregiver depression and missed work among
working informal caregivers for older veterans with
Alzheimer's disease or vascular dementia.
Study Design: We use observational data from the National
Longitudinal Caregiver Survey to examine the relationship
between caregiver depression and missed work among
informal caregivers. Two-part models were used to estimate
the expected hours of work missed among working caregivers.
Depression was estimated using a modified form of the
Center for Epidemiologic Studies of Depression score, or CESD score, a validated measure of depression. Modifications
were to collapse responses to a yes or no format.
Population Studied: The full sample in the National
Longitudinal Caregiver Survey consisted of 2,268 communitydwelling older male veterans with dementia and their coresiding female caregivers. Working caregivers, totaling 453,
were identified for this study. Most working caregivers were
female, 90 percent, 80 percent were white, 17 percent were
black, and 3 percent were Latino. Average household income
was $36,000.
Principal Findings: Over half of working caregivers report
missing work in the past 30 days due to their caregiving
responsibilities. Mean C-ESD scores were 6 (9 or over
indicates depression). Among those who missed any, they
missed 7 hours on average. Caregiver depression is
significantly associated with both the likelihood of missing
work and the amount of time missed at work. A one-unit
increase in CES-D score was associated with a 1.84 percentage
point increase in probability of missing any work, and a 4.6
percent increase in time missed among those who missed any
work. Working caregivers with depression were expected to
have an average of an extra half day of work missed per month
compared to those without depression. Other important
factors, such as having higher income, being a female
caregiver, and having relatively intense caregiving
responsibilities, also were associated with missed work.
Conclusions: The finding on depression supports our
hypothesis that depression would be positively associated
with missed work. Making assumptions about average hourly
wages from the sample’s salary information, our findings
represent an average cost to employers of $792 annually for a
dementia caregiver without depression who becomes
depressed. This calculation does not consider concerns about
causality, or the availability of vacation or sick leave to protect
against a caregiver’s income losses.
Implications for Policy, Delivery, or Practice: From a policy
perspective, the relationship between caregiver depression
and missed time at work due to caregiving responsibilities is
important because missing work results in physical and
financial costs to the individual caregivers, to the care
recipients in the form of reduced quality of care, to employers
in terms of lost productivity, and to overall welfare in society.
If the full costs to society were sufficiently high, it would be
important for policymakers to consider an intervention
strategy targeted at identifying depressed caregivers and
providing treatment to minimize depression and consequently
the amount of work time missed. First, however, further
exploration of this topic is needed, including establishing
causality.
Primary Funding Source: VA
●Informal Care and Medicare Expenditures
Courtney Van Houtven, Ph.D., Edward C Norton, Ph.D.
Presented By: Courtney Van Houtven, Ph.D., Health
Economist, HSR&D and General Internal Medicine, Durham
VAMC and Duke, 508 Fulton Street, Durham, NC 27705; Tel:
(919)286-6936; Fax: (919)416-5836;
Email: courtney.vanhoutven@duke.edu
Research Objective: To measure the effect of informal care
provided by adult children on Medicare expenditures of their
single elderly parents. Secondarily, to examine whether the
effect differs by the source of informal care such as sons
versus daughters, children versus others, or whether the effect
is smaller for a sample including married parents.
Study Design: Two-part expenditures models are used to
model Medicare home health care expenditures, skilled
nursing expenditures, and inpatient expenditures. We control
for endogeneity using instrumental variables probit estimation
and two-stage least squares. Characteristics of the children in
the family are used as identifying instruments: number of
daughters, sons, and children with less than a high school
education. We also estimate latent average treatment effects
by running simulations on instrument characteristics.
Population Studied: The data set consisted of information
from the Standard Analytic Files of Medicare Claims and
1994/95 waves of the Asset and Health Dynamics Among the
Oldest-Old Panel Survey, AHEAD, a nationally representative
sample of non-institutionalized persons over age 70 in the
United States. We examine the subset of elderly respondents
from the HRS/AHEAD survey who provided their Medicare
number to HRS interviewers. The sample consists of 3249
single parent-waves and 8182 married and single parentwaves.
Principal Findings: Informal care is a net substitute for
Medicare long-term care expenditures, significantly reducing
the likelihood of having any home health expenditures, and
any skilled nursing home expenditures. Informal care is also a
net substitute to inpatient care, reducing amount of Medicare
expenditures for inpatient care.
Conclusions: Informal care is an effective substitute for
Medicare long-term care, even highly skilled care such as
skilled nursing. Informal care results in no change in the
likelihood of having any inpatient expenditures but reduces the
total amount among users, perhaps because patients can be
discharged to their homes faster. Number of daughters and
number of adult children with less than a high school
education significantly increase provision of informal care.
Implications for Policy, Delivery, or Practice: The cost to
the public purse of policies that support caregivers, such as
tax credits, may be offset by the Medicare savings that
informal care provides. Given that family structure is an
important factor in the provision of informal care for the
elderly, policy makers should consider the differential
influence of having daughters and low educational attainment
when designing policies to support caregivers.
Primary Funding Source: NIH, National Institute on Aging
●Cost and Quality: Evidence from Ontario Long Term Care
Walter Wodchis, Ph.D., Geoff Anderson, Ph.D., Gary Teare,
Ph.D.
Presented By: Walter Wodchis, Ph.D., Assistant Professor,
Health Policy Management and Evaluation, University of
Toronto, 155 College Street - 4th floor, Toronto, ON, M5T
3M6; Tel: 416-946-7387; Fax: 416-978-7350;
Email: walter.wodchis@utoronto.ca
Research Objective: To examine the relationship between
clinical quality and costs of care in Long Term Care Settings.
Study Design: Cross-sectional time series analysis. Quality
assessed by five prevalence and two incidence measures
based on the Minimum Data Set for nursing homes.
Population Studied: Data represent all long term care
hospitals in Ontario, Canada from 1996 through 2001. Quality
measures are individually assessed and aggregated to the
facility level where they are compared to facility expenditures.
Principal Findings: Cost and quality measures showed a high
degree of serial correlation. Reduced costs were associated
with lower prevalence of pressure ulcers and incontinent
residents without toileting plans. Consistent results with
mixed significance values were found in several specifications
for 5 other quality measures
Conclusions: The results indicate opportunities for facilities
to improve both cost and quality performance
Implications for Policy, Delivery, or Practice: Facilities with
an active prevention strategies for pressure ulcer and
incontinence care may also find cost savings.
Primary Funding Source: Canadian Institutes for Health
Research
●Does Medicare Reimbursement Changes Influence
Nursing Home Efficiency of Care?
Jackie (Ning) Zhang, M.D., Ph.D., Lynn Unruh, Ph.D., RN,
Thomas Wan, Ph.D.
Presented By: Jackie (Ning) Zhang, M.D., Ph.D., Assistant
Professor, Department of Health Administration, University of
Central Florida, 3280 Progress Drive, Orlando, FL 32826; Tel:
407-823-3344; Email: nizhang@mail.ucf.edu
Research Objective: Prior studies regarding impacts of the
Balanced Budget Act (BBA) in nursing homes have examined
the issue of quality, but not efficiency. Furthermore, to our
knowledge, studies of efficiency in nursing homes do not
consider the possible changes in quality as efficiency changes.
It is possible that as efficiency increases, quality decreases.
Yet to be able to have a true improvement in efficiency, quality
must be held constant. This study assesses the impact of
recent Medicare reimbursement changes on efficiency in
nursing homes when efficiency is adjusted for quality.
Research questions are: 1) Has the implementation of a
Medicare prospective payment system (PPS) under the 1997
BBA improved efficiency in U.S. nursing homes when
efficiency is adjusted for quality? 2) Has the implementation of
the 1999 Balanced Budget Reconciliation Act (BBRA) or the
2000 Benefits Improvement and Protection Act (BIPA)
counteracted BBA (reduced efficiency) when efficiency is
adjusted for quality? 3) Have other market and facility factors
in the years 1997-2003 influenced efficiency?
Study Design: Data were from the On-Line Survey
Certification and Reporting System (OSCAR) for nursing
facilities, Medicare Cost Report, and Area Resource Files for
the years 1997-2003. The efficiency variable is a ratio of qualityadjusted total resident days (outputs) to total costs for each
facility. Quality was measured by a resident-severity-adjusted
deficiency variable derived from OSCAR surveillance system.
The deficiency variable was a sum of the number of all
deficiency citations. The efficiency score was computed by
using input-oriented variable returns to scale method provided
by Data Envelopment Analysis software. Trend analysis was
conducted to find the changing pattern of efficiencies over
time. Finally, the impacts of the policy variables on nursing
home efficiency were estimated using generalized repeatedmeasure mixed model with seven-years of longitudinal data.
Market and organizational factors were examined as well.
Future analyses will include analyzing a model using a nonquality adjusted efficiency variable and comparing results with
the quality-adjusted model.
Population Studied: We obtained a national random sample
of Medicare-certified nursing homes in the U.S. Approximately
7,000 homes were studied each year.
Principal Findings: Trend analysis shows that mean values
for quality-adjusted efficiency decreased significantly and the
standard deviation narrowed over time. The mixed model
regression results show that the BBA was significantly
negatively related to quality-adjusted efficiency. Subsequent
policies (BBRA and BIPA) were not significantly related to
efficiency. Licensed nurses per resident days, nursing home
size, percent Medicaid patients, and non-profit status were
positively related to efficiency. Population income and area
competition (Hefindahl Index) were also positively related to
efficiency. The fit statistics Chi-square was large and
significant. Future analyses will compare these results to those
from a model using a non-quality adjusted efficiency variable.
Conclusions: The results suggest that the BBA had a
significantly negative impact on quality-adjusted efficiency, but
the subsequent reimbursement policies had no significant
impact on it. Various organizational and market factors also
play a significant role.
Implications for Policy, Delivery, or Practice: When
efficiency is adjusted for quality, efficiency-oriented policy
changes, such as the BBA, may have unintended opposite
affects on efficiency.
Primary Funding Source: NIA
●Clinical Characteristic Associated with Direct Costs in
AD: Longitudinal Analysis from the Predictors Study
Carolyn Zhu, Ph.D., Nikolaos Scarmeas, M.D., Rebecca
Torgan, MA, Mary Sano, Ph.D., Yaakov Stern, Ph.D.
Presented By: Carolyn Zhu, Ph.D., Health Science Specialist,
GRECC/Geriatrics, Bronx VA Medical Center/Mount Sinai
School of Medicine, 130 west kingsbridge road, Bronx, NY
10468; Tel: 718-584-9000x3810;
Email: carolyn.zhu@mssm.edu
Research Objective: Alzheimer’s disease (AD) is the third
most costly disease to society in the US. Most cost studies
have been cross-sectional and thus limited in their ability to
estimate long-term disease cost trajectories. The goals of this
study are 1) to estimate long-term trajectories of the direct
costs of caring for patients with AD, and 2) to examine the
effects of patients’ clinical and socio-demographic
characteristics on direct costs over time.
Study Design: Random effect regression models were used to
estimate the effects of patients’ characteristics on direct costs
of caring for patients with AD. Direct costs included costs
associated with medical care (hospitalizations, outpatient
treatment and procedures, assistive devices, and medications)
and non-medical care (home health aides, respite care, and
adult day care). Patients’ clinical characteristics included
measures of cognitive status (Folstein Mini-Mental State
Examination, MMSE), functional capacity (Blessed Dementia
Rating Scale, BDRS), comorbidities, and presence and
absence of psychotic symptoms, behavioral problems,
depressive symptoms, and extrapyramidal signs. Patients’
demographic characteristics included sex, age at intake, and
living arrangements. All clinical variables and patients’ living
arrangements were measured at each visit and therefore time
variant.
Population Studied: The sample (n=198) was drawn from the
Predictors Study, a large, multi-center cohort of patients with
probable AD, followed annually for up to 7 years in three
University-based AD centers in the US. Enrollment required a
modified Mini-Mental State Examination (mMMS) score =30,
equivalent to a score of approximately =16 on MMSE. Because
patients were followed at academic AD centers, they were well
characterized with high degrees of certainty in their AD
diagnosis.
Principal Findings: Total direct cost increased substantially
over time, from approximately $9,239 per patient per year at
baseline, when all patients were at the early stages of the
disease, to $19,925 by year 4 (an average of 13% increase each
year). In particular, cost of medications rose steadily from
$2,872 to $4,301 (a 50% increase), and costs of non-medical
care rose from $1,349 to $9,348 (a 6.9 fold increase).
Multivariate results show that after controlling for patients’
clinical and socio-demographic variables, the time effect
became insignificant and was only associated with a 1.2%
increase in cost each year. A one-point increase in BDRS
increased total cost by 7.7%, and one more comorbidity
increased total cost by 14.3%. Total costs were 20.8% lower
for patients living at home compared to those living in
institutional settings.
Conclusions: With longitudinal data, this study confirms what
has been suggested in cross-sectional studies. Specifically,
most of the cost increases were explained by comorbidities,
functional capacity, and living arrangement. Moreover, these
relationships were consistent over time.
Implications for Policy, Delivery, or Practice: Interventions
aimed at delaying or preventing institutionalization could
reduce direct cost of care for AD patients and may be
particularly useful if targeted in the areas of basic and
instrumental activities of daily living. However, potential cost
savings in direct cost of care need to be balanced with the
potential increase in informal caregiving costs.
Primary Funding Source: VA, NIH