Nursing home staffing and its relationship to deficiencies.

OBJECTIVES: The authors examined the relationships between different types of nursing home staffing and nursing home deficiencies to test the hypothesis that fewer staff hours would be associated with higher numbers of deficiencies. METHODS: Data were from the On-Line Survey, Certification, and Reporting System for all certified nursing homes in the United States. Regression models examined total deficiencies, quality of care, quality of life, and other deficiencies. RESULTS: Fewer registered nurse hours and nursing assistant hours were associated with total deficiencies and quality of care deficiencies, when other variables were controlled. Fewer nursing assistant staff and other care staff hours were associated with quality of life deficiencies. Fewer administrative staff hours were associated with other deficiencies. Facilities that had more depressed and demented residents, that were smaller, and that were nonprofit or government-owned had fewer deficiencies. Facilities with more residents with urinary incontinence and pressure sores and with higher percentages of Medicaid residents had more deficiencies, when staffing and resident characteristics were controlled. DISCUSSION: Facility characteristics and states were stronger predictors of deficiencies than were staffing hours and resident characteristics. Because only a small portion of the total variance in deficiencies could be explained, much work remains to explore factors that influence deficiencies.

Modeling Medicare costs of PACE (Program of All-Inclusive Care for the Elderly) populations.

Historically, Medicare has paid PACE providers a monthly capitated rate equal to 95 percent of the site's county AAPCC multiplied by a PACE-specific frailty adjuster of 2.39. The Balanced Budget Act of 1997 makes PACE a permanent provider category and mandates that future Medicare payments be based upon the rate structure of the Medicare+Choice payment system, adjusted for the comparative frailty of PACE enrollees and other factors deemed to be appropriate by the Secretary of Health and Human Services. This study revisits the calculation of the PACE frailty adjuster and explores the effect of risk adjustment on that frailty adjuster.

Understanding lesbians' mammography utilization.

Lesbians face unique barriers to health care, and may be at higher risk for breast cancer than are other women. Yet, no research on lesbians and mammography utilization exists. We conducted telephone interviews of 107 lesbians aged 51-80, of whom 68 had had mammograms in the last year and 39 had not. Responses to open-ended questions identified the barriers lesbians face in obtaining mammography, lesbians, reasons for obtaining mammograms, and factors that would help lesbians obtain mammograms. Some issues identified were particular to lesbians; many issues were common to those identified by general samples of women (which include lesbians).

Stability of nursing home quality indicators over time.

BACKGROUND: Nursing home quality indicators (QIs) provide a way to support quality assurance and improvement activities and to help ensure that cost savings are based on increased efficiency and not on decreased quality of care. OBJECTIVES: QIs values are expected to change over time. However, to be good indicators of quality, they should be reasonably stable over "short" periods. This paper discusses theoretical and measurement issues affecting stability and examines the stability of QIs over each of two 3-month periods and one 6-month period. SUBJECTS: The study sample included 512 nursing facilities from two states, Kansas and South Dakota. QIs were measured for the first 3 quarters of 1996. MEASURES: Facility level QIs were constructed using three different metrics that each provide a unique perspective of facility performance as follows: the proportion of residents in the facility with the QI condition; the facility's percentile rank in its state; and a variable indicating whether the facility's rank exceeded the 90th percentile in its state. QI stability was assessed using Pearson correlation coefficients, Spearman rank order correlation coefficients, and Cohen's Kappa, as appropriate for the metric. RESULTS: Results indicated high levels of stability for most QIs, with lower levels of stability found to be in keeping with theoretical and measurement considerations. CONCLUSIONS: QIs are reasonably stable over short periods of time. Quality improvement efforts may best be focused on facilities that are consistently poor performers over time, and those that show a large decrease in quality from one quarter to the next.

Nursing home quality indicators and quality improvement initiatives.

Quality indicators and a quality monitoring system developed for use in the regulatory survey process offer a quality improvement tool for nursing home staff. The systematic use of resident assessment data can aid in the identification of quality of care problems and the determination of the nature of those problems. The approach is particularly useful in routine and special quality assurance efforts.

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.

Using indicators to structure quality improvement initiatives in long-term care.

Quality indicators and a quality-monitoring system developed for use in the regulatory survey process offer a quality improvement tool for nursing home staff. The systematic use of resident assessment data can aid in the identification of quality of care problems and the determination of the nature of those problems. This approach is particularly useful for continuous quality improvement efforts.

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 composition of home health care expenditure growth.

During the period 1980 to 1985, growth in the number of persons served by Medicare home health was the largest source of growth in Medicare home health expenditures. Population growth was in part responsible for the increase in beneficiaries using Medicare home health, but more important was growth in the number of persons served per 1000 elderly population. Cost per person served increased only moderately once input price changes are accounted for. Nevertheless, we recommend that cost-containment efforts focus on cost per visit and per case, because restrictions on persons served are likely to limit Medicare beneficiaries' access to needed, covered care.