Factors affecting conversion rates to Medicaid among new admissions to nursing homes.

OBJECTIVE. This study examines conversion to Medicaid as a payment source among a cohort of newly admitted nursing home residents. DATA SOURCE. The longitudinal data used came from regular assessments of residents in the National Health Corporation's 43 for-profit nursing homes in Missouri, Kentucky, South Carolina, and Tennessee. This information system tracked all residents who were discharged, providing a comprehensive record that may have spanned multiple admissions. STUDY DESIGN. Using survival analysis methods, Cox regression, and survival trees, we contrasted the effect of state, initial payment source, education, age, and functional status on the rate of spend-down to Medicaid. DATA EXTRACTION METHODS. New-admission cohorts were created by linking an admission record for a newly admitted resident with all subsequent assessments and follow-up records to ascertain the precise dates of any payment source changes and other discharge transitions. PRINCIPAL FINDINGS. For the 1,849 individuals who were admitted as self-payers and who were still in the nursing home at the end of one year, there is a 19 percent probability of converting to Medicaid. All analytic methods revealed that education, age, and state of residence were predictive of spend-down among residents who were admitted as self-payers. CONCLUSIONS. Our results confirm the effect of education as an SES indicator and state as a proxy for Medicaid policy on spend-down. Future research should model the effects and duration of intervening hospitalizations and other transitions on Medicaid spend-down among new admissions.     

Determinants of the use of specialist mental health services by nursing home residents.

OBJECTIVE. This study examines the effects of resident and facility characteristics on the probability of nursing home residents receiving treatment by mental health professionals. DATA SOURCES/STUDY SETTING. The study uses data from the Institutional Population Component of the 1987 National Medical Expenditure Survey, a secondary data source containing data on 3,350 nursing home residents living in 810 nursing homes as of January 1, 1987. STUDY DESIGN. Andersen's health services use model (1968) is used to estimate a multivariate logistic equation for the effects of independent variables on the probability that a resident has received services from mental health professionals. Important variables include resident race, sex, and age; presence of several behaviors and reported mental illnesses; and facility ownership, facility size, and facility certification. DATA COLLECTION/EXTRACTION METHODS. Data on 188 residents were excluded from the sample because information was missing on several important variables. For some additional variables residents who had missing information were coded as negative responses. This left 3,162 observations for analysis in the logistic regressions. PRINCIPAL FINDINGS. Older residents and residents with more ADL limitations are much less likely than other residents to have received treatment from a mental health professional. Residents with reported depression, schizophrenia, or psychoses, and residents who are agitated or hallucinating are more likely to have received treatment. Residents in government nursing homes, homes run by chains, and homes with low levels of certification are less likely to have received treatment. CONCLUSIONS. Few residents receive treatment from mental health professionals despite need. Older, physically disabled residents need special attention. Care in certain types of facilities requires further study. New regulations mandating treatment for mentally ill residents will demand increased attention from nursing home administrators and mental health professionals.     

Targeting Residents for Transitions from Nursing Home to Community

Objective. To analyze nursing home utilization patterns in order to identify potential targeting criteria for transitioning residents back to the community. Data Sources. Secondary data from minimum data set (MDS) assessments for an annual cohort of first‐time admissions (N=24,648) to all Minnesota nursing homes (N=394) from July 2005 to June 2006. Study Design. We conducted a longitudinal analysis from admission to 365 days. Major MDS variables were discharge status; resident's preference and support for community discharge; gender, age, and marital status; pay source; major diagnoses; cognitive impairment or dementia; activities of daily living; and continence. Principal Findings. At 90 days the majority of residents showed a preference or support for community discharge (64 percent). Many had health and functional conditions predictive of community discharge (40 percent) or low‐care requirements (20 percent). A supportive facility context, for example, emphasis on postacute care and consumer choice, increased transition rates. Conclusions. A community discharge intervention could be targeted to residents at 90 days after nursing home admission when short‐stay residents are at risk of becoming long‐stay residents.     

The use of acute hospital services by elderly residents of nursing and residential care homes

The objective of this study was to compare hospitalisation rates by cause of admission, hospital death rates and length of stay for residents from nursing and residential care homes with those in the community. This is a retrospective study of acute hospital emergency admissions in one health district, Merton, Sutton and Wandsworth between April 1996 and March 1997. Data linkage and manual look up were used to derive emergency hospital admissions for residents of care homes aged 65 and over. Admission rates were calculated for cause, length of stay and hospital death for residents of care homes and in the community with relative risks. The relative risk of emergency admission from a care home compared with the community was 1.39 for all diagnoses, 2.68 for all injuries, and 3.96 for fracture of neck of femur. The relative risk of dying in hospital for care home residents was 2.58 overall, and 3.64 in the first 48 hours of a hospital stay (all P-values <0.0001). Admission rates were higher from residential than from nursing homes. There was some increase in admissions from homes during holiday periods and over Christmas. In conclusion, there are major difficulties in monitoring admissions from nursing and residential care homes due to poor quality recording and inaccuracies in NHS coding. This was compounded by an absence of data on the age and sex profile and healthcare needs of the resident population in care homes. Prospective studies are required to ascertain when admission is avoidable and when it is appropriate. The information strategy needs to ensure that routine data sources are capable of monitoring the use of hospital services by residents of care homes.     

Interactions between hospital and nursing home use.

National estimates are provided, for the first time, of the number of hospitalizations in a year for elderly persons who also experience some nursing home use, and patterns for this interaction are described. In 1987, 816,000 persons were transferred from nursing homes to hospitals, constituting 8.5 percent of all Medicare hospital admissions for persons ages 65 and older. Another 347,000 hospital stays involved people admitted from the community and discharged to a nursing home. The reporting of discharge destination on Medicare hospital bill data in 1987 also is analyzed. It was found that these data may have underreported a nursing home as the destination by between 15 and 20 percent. The magnitude of hospitalizations of nursing home residents suggests that programs aimed at improving nursing home care might have an important impact on total days of hospital care, and that it is important to learn more about the optimal use of expensive hospital care.     

Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality

Objectives

To compare risks of hypernatraemia on admission to hospital in persons who were with those who were not identified as care home residents and evaluate the association of hypernatraemia with in-hospital mortality.

Design

Retrospective observational study.

Setting

A National Health Service Trust in London.

Participants

A total of 21,610 patients aged over 65 years whose first admission to the Trust was between 1 January 2011 and 31 December 2013.

Main outcome measures

Hypernatraemia on admission (plasma Na > 145 mmol/L) and in-hospital death.

Results

Patients admitted from care homes had 10-fold higher prevalence of hypernatraemia than those from their own homes (12.0% versus 1.3%, respectively; odds ratio [OR]: 10.5, 95% confidence interval [CI]: 8.43–13.0). Of those with hypernatraemia, nine in 10 cases were associated with nursing home ECOHOST residency (attributable fraction exposure: 90.5%), and the population attributable fraction of hypernatraemia on admission associated with care homes was 36.0%. After correcting for age, gender, mode of admission and dementia, care home residents were significantly more likely to be admitted with hypernatraemia than were own-home residents (adjusted odds ratio [AOR]: 5.32, 95% CI: 3.85–7.37). Compared with own-home residents, care home residents were also at about a two-fold higher risk of in-hospital mortality compared with non-care home residents (AOR: 1.97, 95% CI: 1.59–2.45). Consistent with evidence that hypernatraemia is implicated in higher mortality, the association of nursing homes with in-hospital mortality was attenuated after adjustment for it (AOR: 1.61, 95% CI: 1.26–2.06).

Conclusions

Patients admitted to hospital from care homes are commonly dehydrated on admission and, as a result, appear to experience significantly greater risks of in-hospital mortality.     

Survival in a cohort of social services placements in nursing and residential homes: factors associated with life expectancy and mortality

The aim of this study was to examine the life expectancy of elderly people in nursing and residential care over a 20-month period and its relationship to specific risk factors. Using a retrospective cohort design, data obtained on 1888 residents placed between 1 July 1997 and 30 April 1999 in residential, nursing and dual registered homes within Nottingham Health Authority boundaries were examined. Additional data on physical and mental disability at placement were available for 514 residents. Main outcome measures comprised survival rate overall, and in relation to gender, age, home type (nursing, residential or dual), source of placement (hospital or community) and various disability factors.One-year survival rates were: overall, 66%; nursing homes, 59%; dual homes, 58%; and residential homes 76%. Median survival in nursing homes was 541 days, but was not reached in residential homes. Male gender, admission to nursing or dual registered homes, placement from hospital, decreased mobility and increased age were associated with decreased life expectancy. Although no association was found between length of survival and level of cognitive function, lack of cognitive impairment was associated with lower survival. In conclusion, mortality is high in nursing, dual and residential homes where life expectancy has been shown to be associated with gender, home type, origin of placement and mobility. Rates of survival are related to higher comorbidity and disability. Important data for planning and assessing care needs can be yielded through the analysis of mortality data.     

Characteristics of elderly nursing home residents: data from the 1995 National Nursing Home Survey

OBJECTIVE: This report presents the sociodemographic characteristics, functional dependencies in the activities of daily living (ADL) and instrumental activities of daily living (IADL), dental status, primary admission diagnosis, types of services used, and source of payment of elderly nursing home residents. METHODS: The data used for this report are from the National Center for Health Statistics' 1995 National Nursing Home Survey's (NNHS) sample of current residents age 65 years and above. The 1995 NNHS is the fourth annual survey of nursing homes. The first survey was conducted from August 1973 through April 1974, the second was conducted from May through December 1977, and the third was conducted from August 1985 through January 1986. The 1995 NNHS was conducted from July 1995 through December 1995. RESULTS: The overall results of the survey indicate that elderly nursing home residents were predominantly women, 75 years old and over, white, non-Hispanic, and widowed. A large portion of residents needed assistance in their ADL's and IADL's. A shifting of the primary source of payment to Medicaid occurred among residents who used Medicare as their source of payment at the time of admission.     

An overview of nursing home facilities: data from the 1997 National Nursing Home Survey

OBJECTIVE: This report presents estimates on the number and distribution of nursing home facilities, their services, current residents, and discharges in the United States during 1997. METHODS: Data presented in this report are estimates based on a sample of nursing home facilities, residents, and discharges from the 1997 National Nursing Home Survey (NHHS). The survey collects information about providers and recipients of care from nursing home facilities. NHHS has been periodically conducted by the National Center for Health Statistics since 1973. RESULTS: In 1997 there were an estimated 1.6 million current residents and 2.4 million discharges from 17,000 nursing homes nationwide. These facilities were predominantly proprietary and certified by both Medicare and Medicaid. There was an average of 107 beds per nursing home with an occupancy rate of 88 percent and a discharge rate of 130 patients per 100 beds. The majority of nursing home residents and discharges were elderly, white, and female.     

A Comparative Analysis of Comprehensive Geriatric Assessments for Nursing Home Residents Receiving Palliative Care: A Systematic Review

Background/ObjectivesNursing homes become important locations for palliative care. By means of comprehensive geriatric assessments (CGAs), an evaluation can be made of the different palliative care needs of nursing home residents. This review aims to identify all CGAs that can be used to assess palliative care needs in long-term care settings and that have been validated for nursing home residents receiving palliative care. The CGAs are evaluated in terms of psychometric properties and content comprehensiveness.DesignA systematic literature search in electronic databases MEDLINE, Web of Science, EMBASE, Cochrane, CINAHL, and PsycInfo was conducted for the years 1990 to 2012.SettingNursing homes.ParticipantsNursing home residents with palliative care needs.MeasurementsPsychometric data on validity and reliability were extracted from the articles. The content comprehensiveness of the identified CGAs was analyzed, using the 13 domains for a palliative approach in residential aged care of the Australian Government Department of Health and Aging.ResultsA total of 1368 articles were identified. Seven studies met our inclusion criteria, describing 5 different CGAs that have been validated for nursing home residents with palliative care needs. All CGAs demonstrate moderate to high psychometric properties. The interRAI Palliative Care instrument (interRAI PC) covers all domains for a palliative approach in residential aged care of the Australian Government Department of Health and Aging. The McMaster Quality of Life Scale covers nine domains. All other CGAs cover seven domains or fewer.ConclusionsThe interRAI PC and the McMaster Quality of Life Scale are considered to be the most comprehensive CGAs to evaluate the needs and preferences of nursing home residents receiving palliative care. Future research should aim to examine the effectiveness of the identified CGAs and to further validate the CGAs for nursing home residents with palliative care needs.     

Variations in Nursing Home Discharge Rates for Urban and Rural Nursing Facility Residents With Hip Fracture

CONTEXT: The more limited availability and use of community-based long-term care services in rural areas may be a factor in higher rates of nursing home use among rural residents. PURPOSE: This study examined differences in the rates of nursing home discharge for older adults receiving posthospital care in a nursing facility. METHODS: The study sample was comprised of a cohort of rural and urban residents newly admitted to nursing home care in Maine following surgery for hip fracture. FINDINGS: The results indicated that rural residents who were hospitalized for hip fracture and subsequently admitted to a nursing facility for rehabilitation were significantly less likely than urban residents to be discharged within the first 30 days of their admission. Rural residents who stayed in the nursing facility beyond 30 days were also less likely to be discharged in the first 6 months. These geographic differences were not explained by service use and resident characteristics such as age, health, or functional status. CONCLUSIONS: The finding of lower discharge rates among rural nursing facility residents appears to be consistent with previous studies demonstrating higher rates of nursing home use among rural residents. There continues to be a need for a better understanding of the role that service supply and accessibility and other factors play in the patterns and outcomes of rural long-term care.     

Hospital DRGs and the need for long-term care services: an empirical analysis.

The Medicare DRG-based Prospective Payment System (PPS) encourages hospitals to reduce length of stay for elderly patients. Thus, discharges to long-term care services are expected to increase. Maryland hospital data for 1980 are used to identify those DRGs which most frequently represent patients discharged to nursing home and home health care services; explores the incentive to discharge earlier under PPS those patients needing long-term care versus short-term care; and describes characteristics of patients most likely to face increased pressure of earlier discharge to nursing homes and home health programs. Because only a limited set of patient characteristics are available from Maryland hospitals, data from a study of San Diego nursing homes are used to explore further the sociodemographic and health status measures associated with unusually long stays in a hospital prior to nursing home placement. This research suggests that the DRG reimbursement system gives hospitals a strong incentive for earlier discharge of patients needing long-term care services. However, hospitals that target only long-term care patients for early discharge will not substantially gain under PPS because these patients represent a small portion of the cases treated in the hospital and a small percentage of unreimbursed days.     

Rural-Urban Comparisons of Age and Health at the Time of Nursing Home Admission

This study re-examines the contention that rural elders admitted to nursing homes are younger and healthier than their counterparts who enter urban facilities. The analysis uses interview data gathered in both urban and rural nursing homes. Residents were interviewed at or near the time of admission regarding their health and circumstances immediately prior to entering the nursing home. The findings indicate few and modest differences between urban and rural residents. In those instances where differences are observed, there is ambiguity--some measures indicate lower health status in the case of rural residents, while others suggest that urban residents are more likely to report health impairments. The divergence of these findings from earlier research may be due to differences in the study populations, measurement differences, or, more likely, that policies and processes have changed over time.     

Living and dying: responsibility for end‐of‐life care in care homes without on‐site nursing provision ‐ a prospective study

The aim of the study was to describe the expectations and experiences of end‐of‐life care of older people resident in care homes, and how care home staff and the healthcare practitioners who visited the care home interpreted their role. A mixed‐method design was used. The everyday experience of 121 residents from six care homes in the East of England were tracked; 63 residents, 30 care home staff with assorted roles and 19 National Health Service staff from different disciplines were interviewed. The review of care home notes demonstrated that residents had a wide range of healthcare problems. Length of time in the care homes, functional ability or episodes of ill‐health were not necessarily meaningful indicators to staff that a resident was about to die. General Practitioner and district nursing services provided a frequent but episodic service to individual residents. There were two recurring themes that affected how staff engaged with the process of advance care planning with residents; ‘talking about dying’ and ‘integrating living and dying’. All participants stated that they were committed to providing end‐of‐life care and supporting residents to die in the care home, if wanted. However, the process was complicated by an ongoing lack of clarity about roles and responsibilities in providing end‐of‐life care, doubts from care home and primary healthcare staff about their capacity to work together when residents’ trajectories to death were unclear. The findings suggest that to support this population, there is a need for a pattern of working between health and care staff that can encourage review and discussion between multiple participants over sustained periods of time.     

Rates, patterns, causes, and costs of hospitalization of nursing home residents: a population-based study.

OBJECTIVES. Hospitalization of nursing home residents is a growing, poorly defined problem. The purposes of this study were to define rates, patterns, costs, and outcomes of hospitalizations from nursing homes and to consider implications for reducing this problem as part of health care reform. METHODS. Communitywide nursing home utilization review and hospital discharge data were used to define retrospectively a cohort of 2120 patients newly admitted to nursing homes; these patients were followed for 2 years to identify all hospitalizations. Resident characteristics were analyzed for predictors of hospitalization. Charges and outcomes were compared with hospitalization of community-dwelling elders. RESULTS. Hospitalization rates were strikingly higher for intermediate vs skilled levels of care (566 and 346 per 1000 resident years, respectively). Approximately 40% of all hospitalizations occurred within 3 months of admission. No strong predictors were identified. Length of stay, charges, and mortality rates were higher than for hospitalizations from the community. CONCLUSIONS. Hospitalizations from nursing homes are not easily predicted but may in large part be prevented through health care reforms that integrate acute and longterm care.     

Health status,staffing, and medicaid reimbursement in nursing homes: 1985 to 1995

CONTEXT: Policy changes implemented by Medicaid and Medicare in the early 1980s resulted in a functionally more dependent nursing home population. OBJECTIVES: This paper contends that (1) staffing in nursing homes has become more efficient; (2) nursing home residents are functionally more dependent;(3) Medicaid per diem reimbursement is inadequate. DATA SOURCES: Staffing data came from the National Nursing Home Facility Survey conducted by the National Center for Health Statistics (NCHS) in 1985 and 1995. Functional dependency data, defined as assistance with any of six Activities of Daily Living (ADLs), came from the NCHS National Nursing Home Current Resident Surveys in 1985 and 1995. Reimbursement rates came from the State Medicaid Reimbursement Surveys conducted by the University of California at San Francisco to which the Consumer Price Index, Hospital and Related Services Item was applied. DATA SYNTHESIS: Administration decreased by 4.4 full-time equivalents (FTEs) (80.0%) per 100 beds, whereas patient care increased by 8.2 FTEs (18.9%). Residents requiring assistance with four or more ADLs increased by 9.9%, and the mean number of ADLs per patient increased from 3.9 to 4.3. Applying the Consumer Price Index to the 1984 reimbursement rate indicated an annual deficit of 5526.00 dollars for each Medicaid patient by 1995. CONCLUSIONS: This research strongly supports its contentions but fails to demonstrate them conclusively. The data indicate that long-term care facilities have reallocated staffing to accommodate the requirements of more functionally dependent residents and that Medicaid reimbursement has failed to maintain its initial purchasing power.