Case-mix reimbursement for nursing home services: simulation approach.

Nursing home reimbursement based on case mix is a matter of growing interest. Several States either use or are considering this reimbursement method. In this article, we present a method for evaluating key outcomes of such a change for Connecticut nursing homes. A simulation model is used to replicate payments under the case-mix systems used in Maryland, Ohio, and West Virginia. The findings indicate that, compared with the system presently used in Connecticut, these systems would better relate dollar payments to measure patient need, and for-profit homes would benefit relative to nonprofit homes. The Ohio methodology would impose the most additional costs, the West Virginia system would actually be somewhat less expensive in terms of direct patient care payments.     

Foster home care for the frail elderly as an alternative to nursing home care: an experimental evaluation.

This paper describes a program (Community Care Program) in which some elderly hospital patients who were candidates for nursing home placement were placed in foster homes. Caregivers were carefully trained and supervised. A total of 112 elderly inpatients were randomly assigned to placement in a nursing home or a foster care home. Patients and caregivers were interviewed at 3, 6, 9, and 12 months after placement. Community Care Program patients were more likely to maintain or improve ADL (activities of daily living) and mental status scores. They also had better nursing outcomes and were more likely to get out of the house than were nursing home patients. Nursing home patients had higher life satisfaction, and participated in more social and recreational activities. The Community Care Program was 17 per cent less costly than nursing home care. The results suggest that foster care may be a viable alternative for a segment of the nursing home population.     

The joint operating company: an innovative approach to collaboration

Hospitals interested in horizontal integration often run into difficulties. In spite of otherwise sound business logic for two organizations to merge, there may be political, legal or financial reasons why a merger option cannot be pursued. Increasingly, enterprises are turning to a joint operating company structure as the solution to their needs. Scott A. Mason and Donald W. Seymour, partners with consulting firm National Health Advisors, explore situations where a JOC model of collaboration may be appropriate.     

The intergenerational spectrum: an innovative approach to end-of-life care

Our experiences color our practice lens, motivating and guiding our efforts. They define our need to renew and refocus interventions and energies. The unique nature of these efforts prompts us to validate the individuality of issues faced with clients. My respect for this principle of self-determination drives my case management practice in how I approach that intimate world of client systems during their death and dying processes. From the earliest phase of awareness to anticipatory grief and mourning, through death itself and then bereavement, the critical importance of examining the course of themes from an intergenerational perspective sets a tone for practice-a tone that embraces age-specific concepts for our clients and their support community, including the professionals involved.     

Standards of care: an innovative approach

Clinical nutrition services at the Henderson General Division of Hamilton Civic Hospitals has taken a unique approach to standards of care. The Henderson General Division Standards of Care (HGDSC) focus on important issues in the evaluation of care including the goals, intensity and outcome of care. The HGDSC are based on populations defined by the level of nutrition care required and can easily be applied to patients with multiple medical and nutritional concerns. The standards operate under the premise that the process and intensity of care are determined by the goals of care. Thus, the standards assist in the delivery of equitable care to patients of similar nutritional risk. The goal-oriented focus of the standards is a benefit as the impact of nutrition care can be measured using the goals of care as expected outcomes. Outcome measures are considered important in the measurement of quality care since they focus on the patient's health status after intervention. The changing focus of health care in hospitals makes the identification of valid process criteria a priority for clinical dietitians. The purpose of this article is to provide insight into the unique features of the HGDSC and to explore the benefits of standards that focus on the goals and outcomes of nutrition care.     

The Kentucky plan: an innovative approach to professional doctoral education in public health.

The Doctor of Public Health (Dr.P.H.) degree is designed to prepare graduates for the highest levels of leadership in public health related careers in both public and private settings. The Kentucky School of Public Health has developed an innovative generalist professional degree program offering an extensive battery of courses based on the body of professional public health knowledge. The degree includes extensive supervised field experience as part of the academic training, linking theory with practice. Issues related to professional degrees, curriculum, accreditation and certification, admission, evaluation, plans for institutional cooperation, and demand are addressed.     

Effect of nursing home ownership on hospitalization of long-stay residents: an instrumental variables approach

Hospitalizations among nursing home residents are frequent, expensive, and often associated with further deterioration of resident condition. The literature indicates that a substantial fraction of admissions is potentially preventable and that nonprofit nursing homes are less likely to hospitalize their residents. However, the correlation between ownership and hospitalization might reflect unobserved resident differences rather than a causal relationship. Using national minimum data set assessments linked with Medicare claims, we use a national cohort of long-stay residents who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for ownership status, we found that IV estimates of the effect of nonprofit ownership on hospitalization are at least as large as the non-instrumented effects, indicating that selection bias does not explain the observed relationship. We also found evidence suggesting the lower rate of hospitalizations among nonprofits was due to a different threshold for transfer.     

Hospitalization risk following admission to an academic nursing home

OBJECTIVES: Nursing home residents are at risk for experiencing acute illness and hospitalization early in nursing home stay. The objectives of this study were (1) to measure the probability of hospitalization over time from nursing home admission, and (2) to determine resident risk factors for early hospitalization. DESIGN: Prospective observational study. SETTING: 409-bed urban, not-for-profit academic nursing home. PARTICIPANTS: 204 consecutive newly admitted residents who did not previously reside in the nursing home. MEASUREMENTS: Demographic profile, chronic comorbidity, physical function, recent medical events, admission condition and anticipated length of stay were ascertained on admission to the nursing home. Hospitalization and acute illness were recorded each week after nursing home admission. Data were collected primarily by chart review except for acute illness, which was identified by nurse report and chart review according to previously established criteria. RESULTS: Subjects were 69% female and 62% white. The mean age was 83. The percentage of residents experiencing their first hospitalization peaked 2 and 7 weeks after nursing home admission and after 14 weeks plateaued at a low rate. The percentage with acute illness (commonly gastroenteritis, urinary tract infection, and pneumonia) paralleled that of hospitalization. In multivariate proportional hazards analysis, resident factors independently associated with early first hospitalization were atrial fibrillation (21% of subjects, 2.6 risk ratio), history of stroke (26%, 2.5), history of depression (25%, 1.9), absence of dementia (62%, 2.3), and receiving antibiotics on admission (23%, 3.3). Residents with 0, 1, 2,> or = 3 of these characteristics had 9%, 19%, 34% and 62% probability, respectively, of being hospitalized in the first 8 weeks of nursing home stay. CONCLUSIONS: In a large, urban, academic nursing home, residents' risk of hospitalization varied over time from admission and among different subgroups of residents. These results can be used to develop interventions to prevent acute illness and hospitalization early in nursing home stay and to enhance the communication of prognostic risk to nursing home residents, their caregivers and medical providers.     

Managing for quality in a nursing home: a resident-directed approach

As the population ages, the need for nursing care services will increase. Consumer focus on quality of life as well as reduction of expenditures poses a major challenge to the traditional nursing home, which often reinforces dependent resident behavior. The authors propose various strategies for improving life satisfaction and functional status of residents as well as efficiency and productivity of staff.     

What matters most to nursing home elders: quality of life in the nursing home

ObjectiveA growing number of nursing homes across the country are embarking on culture change transformations that focus on maximizing elder residents’ quality of life (QOL). Challenges to culture change implementation include the wide range of possible interventions as well as a lack of research-based evidence to guide these choices. The purpose of this study was to determine those components of nursing home QOL that are associated with elder satisfaction so as to provide direction in the culture change journey.DesignA cross-sectional study using a survey administered face-to-face.SettingThree large urban nursing homes within a long term care system in New York State.ParticipantsSixty-two elder nursing home residents participated in face-to-face interviews. All elders had resided in their nursing communities for at least 3 months before participation.MeasurementsThe survey included the Quality of Life Scales for Nursing Home Residents, which examines elder QOL in 11 domains: autonomy, dignity, food enjoyment, functional competence, individuality, meaningful activity, physical comfort, privacy, relationships, security, and spiritual well-being. Elder satisfaction with the nursing home and nursing home staff were also examined.ResultsAfter accounting for cognitive and physical functioning, among the QOL domains, dignity, spiritual well-being, and food enjoyment remained predictors of overall nursing home satisfaction. Additionally, dignity remained a significant predictor of elder satisfaction with staff.ConclusionThese results provide one possible path in the culture change journey based on empirical findings.