Therapy use and discharge outcomes for elderly nursing home residents.

This study examines therapy use and discharge outcomes (community discharge, mortality, or remaining in the facility) over a 90-day period for 1,419 elderly, post-acute care nursing home admissions in South Dakota. Subjects met criteria as rehabilitation candidates (i.e., absence of serious behavioral or medical conditions that would limit rehabilitation potential). Receipt of therapies was related significantly to age (younger), Medicare coverage, hip fracture or stroke diagnosis, absence of cancer diagnosis, and resident or staff expectations for functional improvement. Therapy use was related positively to community discharge and negatively to mortality when controlling for covariates such as age, marital status, payment source, functional status, cognitive status, and major diagnoses. Also, community discharge was related positively to the facility's volume of therapy provision and percentage of Medicare-covered stays.

Risk adjustment of nursing home quality indicators.

The purpose of this study was to develop a method for risk adjusting nursing home quality indicators (QI's). The QI's measure incidence and prevalence of resident-level care processes and outcomes which are indicative of care quality. Risk adjustment was carried out by stratifying residents into risk groups (high and low), calculating QI rates within groups, and then drawing comparisons across facilities. The method was examined through analysis of data from over 800 nursing homes in four states. Results showed that facilities differed substantially in QI rates even after risk had been taken into account. Also, results suggested differences in care quality which may not have been apparent without controlling for risk.

Development and testing of nursing home quality indicators.

In this article, the authors report on the development and testing of a set of indicators of quality of care in nursing homes, using resident-level assessment data. These quality indicators (QIs) have been developed to provide a foundation for both external and internal quality-assurance (QA) and quality-improvement activities. The authors describe the development of the QIs, discuss their nature and characteristics, address the development of a QI-based quality-monitoring system (QMS), report on a pilot test of the QIs and the system, comment on methodological and current QI validation efforts, and conclude by raising further research and development issues.

The feasibility of a public-private long-term care financing plan.

In this study, the feasibility of a public-private long-term care (LTC) financing plan that would combine private LTC insurance with special Medicaid eligibility requirements was assessed. The plan would also raise the Medicaid asset limit from the current $2,000 to the value of an individual's insurance benefits. After using benefits the individual could enroll in Medicaid. Thus, insurance would substitute for asset spend-down, protecting individuals against catastrophic costs. This financing plan was analyzed through a computer model that simulated lifetime LTC use for a middle-income age cohort beginning at 65 years of age. LTC payments from Medicaid, personal income and assets, Medicare, and insurance were projected by the model. Assuming that LTC use and costs would not grow beyond current projections, the proposed plan would provide asset protection for the cohort without increasing Medicaid expenditures. In contrast, private insurance alone, with no change in Medicaid eligibility, would offer only limited asset protection. The results must be qualified, however, because even a modest increase in LTC cost growth or use of care (beyond current projections) could result in substantially higher Medicaid expenditures. Also, private insurance might increase personal LTC expenditures because of the added cost of insuring.

Mental illness and psychotropic medication use in the nursing home.

The authors examined mental illness and psychotropic medications use among nursing home residents. Data were drawn from the Texas Long-Term Care Reimbursement Project, a 1986 study of nearly 2,000 residents in 49 nursing homes. The study measured the use of antipsychotics and other psychotropic medications, physical health conditions, mental illness diagnoses, behavior, and nursing and other direct-care time for sampled residents. The findings indicated that 45% of the sample was receiving an antipsychotic or other psychotropic medication. Although psychotropics were prescribed more extensively for those with a psychiatric diagnosis, nearly one half of persons without a psychiatric diagnosis were receiving psychotropic medications at the time of the survey. Moreover, psychotropics were quite prevalent among those with unstable medical conditions and/or severe activities of daily living impairment. Neither a mental illness diagnosis, evidence of a behavioral problem, nor use of psychotropics was significantly correlated with the amount of nursing or other direct-care time received by residents. The findings raise concerns about the widespread prescribing of these medications, especially among residents who have no supporting psychiatric diagnosis and/or who have physical health conditions making them vulnerable to adverse drug effects.

Medicaid spenddown among nursing home residents in Wisconsin.

We examined Medicaid spenddown among nursing home residents from 72 facilities in Wisconsin during 1988. Results indicate that only a small proportion (12%) of discharges from these facilities had spent down to Medicaid eligibility. This represents about one-fourth (23%) of persons who had been admitted private pay. Moreover, we estimated that over 40% of those who spent down to Medicaid did so within 6 months, 58% spent down within a year, and 76% spent down within 2 years. Even though a relatively small percentage of residents spent down, this group had very long stays (median stay greater than 3 years) and thus contributed quite heavily to nursing home days.

Nursing home case mix in Wisconsin. Findings and policy implications.

Along with many other states, Wisconsin is considering a case mix approach to Medicaid nursing home reimbursement. To support this effort, a nursing home case mix model was developed from a representative sample of 410 Medicaid nursing home residents from 56 facilities in Wisconsin. The model classified residents into mutually exclusive groups that were homogeneous in their use of direct care resources, i.e., minutes of direct care time (weighted for nurse skill level) over a 7-day period. Groups were defined initially by intense, Special, or Routine nursing requirements. Within these nursing requirement categories, subgroups were formed by the presence/absence of behavioral problems and dependency in activities of daily living (ADL). Wisconsin's current Skilled/Intermediate Care (SNF/ICF) classification system was analyzed in light of the case mix model and found to be less effective in distinguishing residents by resource use. The case mix model accounted for 48% of the variance in resource use, whereas the SNF/ICF classification system explained 22%. Comparisons were drawn with nursing home case mix models in New York State (RUG-II) and Minnesota. Despite progress in the study of nursing home case mix and its application to reimbursement reform, methodologic and policy issues remain. These include the differing operational definitions for nursing requirements and ADL dependency, the inconsistency in findings concerning psychobehavioral problems, and the problem of promoting positive health and functional outcomes based on models that may be insensitive to change in resident conditions over time.

Nursing home cost and ownership type: evidence of interaction effects.

Due to steadily increasing public expenditures for nursing home care, much research has focused on factors that influence nursing home costs, especially for Medicaid patients. Nursing home cost function studies have typically used a number of predictor variables in a multiple regression analysis to determine the effect of these variables on operating cost. Although several authors have suggested that nursing home ownership types have different goal orientations, not necessarily based on economic factors, little attention has been paid to this issue in empirical research. In this study, data from 150 Virginia nursing homes were used in multiple regression analysis to examine factors accounting for nursing home operating costs. The context of the study was the Virginia Medicaid reimbursement system, which has intermediate care and skilled nursing facility (ICF and SNF) facility-specific per diem rates, set according to facility cost histories. The analysis revealed interaction effects between ownership and other predictor variables (e.g., percentage Medicaid residents, case mix, and region), with predictor variables having different effects on cost depending on ownership type. Conclusions are drawn about the goal orientations and behavior of chain-operated, individual for-profit, and public and nonprofit facilities. The implications of these findings for long-term care reimbursement policies are discussed.

Strain, social support, and distress in old age.

This analysis examined the relationship between life-strain (e.g., physical health problems, economic deprivation, and ADL impairment) and psychosomatic and emotional distress in old age, while taking into account the effects of age, race, sex, education, social support, and other measures of social resources. The data was drawn from a statewide household survey (N = 2,146) of noninstitutionalized older people. Using multiple regression analysis with tests for statistical interaction, the findings revealed that women, whites, those living alone, and those with less education had greater sources of strain. Individuals with greater sources of strain were also more likely to receive social support, although they tended to have smaller social networks and less social contact. Health status and ADL were the strongest predictors of distress. Social support was positively related whereas social contact was negatively related to distress. Social support had a moderating influence on the relationship between ADL impairment and psychosomatic symptoms of distress. Other measures of social resources, such as living arrangement and support network size, had neither main nor interactive effects on distress. The findings were discussed in light of their implications for future research.

Nursing home case mix. Patient classification by nursing resource use.

A model is presented for classifying nursing home patients according to nursing resource use. The model is derived from a study of 558 Medicaid nursing home patients in 12 facilities in Virginia. Data were obtained from self-reports of nursing staff for care delivered over a 52-hour period. The measure of care time was validated through concurrent work sampling. Project staff also assessed the patients' health and functional status using a standardized instrument. Using AID analysis patients were classified into six groups that were homogeneous in their use of nursing resources. Patients were initially categorized by presence or absence of conditions requiring specialized care (e.g., nutritional intake problems, quadriplegia, wounds or lesions, coma, and physical rehabilitation potential). For the specialized care category, two groups were formed by presence or absence of a catheter/ostomy. In the nonspecialized care category, four groups were formed by ADL impairment score and assistance required in eating/feeding. Mean resource use for the highest group was nearly four times that of the lowest group. The model accounted for 53% of the variance in nursing resource use.

Interaction effects in a multivariate model of physician visits by older people.

Previous studies using multivariate models of physician visits by the general population and by older people have failed to take into account the interaction between health, functional impairment, and economic status. Further, they have not inquired fully into effects of psychologic distress and social support on the use of services. Based on the analysis of data from a statewide crosssectional survey of noninstitutionalized older people (N = 2,146), it was discovered that: economic deprivation had a negative main effect and a negative interaction effect (with medical conditions) on the number of self-reported physician visits; both psychosomatic and emotional distress had independent positive effects; the number and self-perceived severity of medical conditions, along with psychosomatic symptoms, were important predictors of the number of visits for older people without ADL impairments, but these factors were nonsignificant among functionally impaired respondents; and social support and emotional distress were the major factors accounting for visits among the severely functionally impaired. The findings point to the importance of integrating concepts from illness-behavior studies into multivariate models of health service use and considering access to medical care within the total context of long-term care services.

Resistance to isolation among elderly widows.

The widow's ability to resist isolation in old age-to either maintain the involvement of earlier years or develop new social networks-may be conditioned by a number of different factors. Drawing upon a survey of 409 widows, age sixty-five and older, from the Piedmont region of South Carolina, this study concludes that good health and the availability of economic resources are the primary factors which facilitate involvement with family, neighbors and friends, and participation in a number and variety of daily activities. In addition, those widows who were more educated participated in more activities; those living in small towns and rural areas were more involved with family and friends; and white widows saw more of their children, while black respondents were more active and knew more of their neighbors. Finally, the availability and degree of contact with children was unrelated to other activities, while friendship and neighboring was positively associated with taking walks, shopping, and attendance at religious services and other organizational meetings.