Outcomes for Long-Stay Nursing Facility Residents Following On-Site Acute Care under a CMS Initiative.

OBJECTIVES: The goal of this study was to describe outcomes of long-term nursing facility (NF) residents treated for one of 6 conditions on-site in the NF and to compare outcomes to those treated for the same conditions in the hospital. DESIGN: Cross-sectional retrospective study. SETTINGS AND PARTICIPANTS: The Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents-Payment Reform enabled participating NFs to bill Medicare for providing on-site care to eligible long-stay residents meeting specified severity criteria due to any of 6 medical conditions, as an alternative to hospitalization. For billing purposes, residents were required to meet clinical criteria severe enough to warrant hospitalization. METHODS: We used the Minimum Data Set assessments to identify eligible long-stay NF residents. We used Medicare data to identify residents who were treated, either on-site or in the hospital, for the 6 conditions and measure outcomes including subsequent hospitalization and death. To compare residents treated in the 2 modes, we used logistic regression models and adjusted for demographics, functional and cognitive status, and comorbidities. RESULTS: Among residents treated on-site for the 6 conditions, 13.6% were subsequently hospitalized and 7.8% died, within 30 days, compared to 26.5% and 17.0%, respectively, among those treated in the hospital. Based on multivariate analysis, those treated in the hospital were more likely to be readmitted (OR = 1.666, P < .001) or to die (OR = 2.251, P < .001). CONCLUSIONS AND IMPLICATIONS: Although unable to fully account for differences in unobserved severity of illness between residents treated on-site vs in the hospital, our results do not indicate any harm, but rather a possible benefit, to being treated on-site.

Implementation of a CMS Nursing Facility Initiative: Differences by Racial Minority Resident Population.

Objectives: The CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: Payment Reform (NFI 2) provided billing opportunities to incentivize participating facilities to keep long-stay residents onsite for acute care, rather than hospitalizing them. We examined cross-facility differences in NFI 2 implementation by racial composition of facility resident populations. Methods: We analyzed Medicare claims in conjunction with in-person and telephone interviews among facility staff to assess NFI 2 engagement in relation to racial minority resident population. Results: Participating facilities with larger racial minority resident populations faced additional barriers to NFI 2 implementation. These facilities submitted fewer NFI 2 claims, reported more challenges engaging resident families, and experienced greater facility staff and leadership instability, compared to facilities with predominantly white resident populations. Discussion: Addressing structural differences within facilities with larger populations of racial minority residents may encourage future development of targeted programs to support diverse nursing facilities.

CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned.

Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone. CONTEXT: In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only). METHODS: Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. FINDINGS: Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations. CONCLUSIONS: Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.

Treating in Place: Acute Care for Long-Stay Residents in Nursing Facilities Under a CMS Initiative.

BACKGROUND/OBJECTIVES: Nursing facility (NF) residents are commonly hospitalized, and many of these hospitalizations may be avoidable. A Centers for Medicare & Medicaid Services (CMS) initiative enables participating NFs to bill Medicare for providing on-site acute care to long-stay residents diagnosed with one of six ambulatory care sensitive conditions (pneumonia, congestive heart failure, chronic obstructive pulmonary disease, dehydration, skin infection, and urinary tract infection) that account for many avoidable hospitalizations. This study describes the frequency of initiative-related treatment for the six conditions, both on site and in the hospital, and the health status of residents who were treated. DESIGN: We used the Minimum Data Set V3.0 and Medicare data to identify eligible residents, detect on-site treatment under the initiative as well as in-hospital treatment both before and during the initiative, and measure health status. SETTING: Participating NFs during fiscal years 2017 to 2018. PARTICIPANTS: There were 47,202 long-stay NF residents from 260 facilities in seven states. INTERVENTION: CMS initiative to reduce avoidable hospitalizations among NF residents-payment reform. MEASUREMENTS: Percentage per year who received on-site treatment (2017-2018), and who received in-hospital treatment (2014-2018), for the six conditions. RESULTS: Each year, approximately 20% of residents received treatment on site during 2017 to 2018, and under 10% received treatment in the hospital during 2014 to 2018, with little change over these years. Residents treated on site had less chronic illness than those treated in the hospital. CONCLUSION: Although the initiative sought to reduce hospitalizations, in-hospital treatment for the six conditions did not substantially change after initiative implementation, despite substantial new billing for on-site treatment for those conditions. These findings suggest that many residents treated on site would likely not have been hospitalized even absent the initiative. The residents treated on site tended to have fewer chronic conditions than those treated in the hospital.

Nursing Facilities Can Reduce Avoidable Hospitalizations Without Increasing Mortality Risk For Residents.

Implementation of the Centers for Medicare and Medicaid Services' Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents reflected recognition of the adverse impacts of excess hospitalizations on the cost of care and the well-being of long-stay residents. Prior studies of the initiative have found favorable effects on reducing hospitalizations and costs, but were these accompanied by unintended consequences for well-being? We tracked all-cause mortality rates in each year for the period 2014-16 among long-stay residents at nursing facilities in seven states that participated in the initiative, and we found no evidence of excess mortality. The initiative's effects on mortality rates were small-ranging from a reduction of 0.8 percentage points to an increase of 1.5 percentage points, relative to changes in mortality rates at comparison-group facilities-and none of the effects was significant. This suggests that efforts to reduce unnecessary hospitalizations among nursing facility residents can succeed without increasing mortality rates.

Initiative To Reduce Avoidable Hospitalizations Among Nursing Facility Residents Shows Promising Results.

Nursing facility residents are frequently admitted to the hospital, and these hospital stays are often potentially avoidable. Such hospitalizations are detrimental to patients and costly to Medicare and Medicaid. In 2012 the Centers for Medicare and Medicaid Services launched the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, using evidence-based clinical and educational interventions among long-stay residents in 143 facilities in seven states. In state-specific analyses, we estimated net reductions in 2015 of 2.2-9.3 percentage points in the probability of an all-cause hospitalization and 1.4-7.2 percentage points in the probability of a potentially avoidable hospitalization for participating facility residents, relative to comparison-group members. In that year, average per resident Medicare expenditures were reduced by $60-$2,248 for all-cause hospitalizations and by $98-$577 for potentially avoidable hospitalizations. The effects for over half of the outcomes in these analyses were significant. Variability in implementation and engagement across the nursing facilities and organizations that customized and implemented the initiative helps explain the variability in the estimated effects. Initiative models that included registered nurses or nurse practitioners who provided consistent clinical care for residents demonstrated higher staff engagement and more positive outcomes, compared to models providing only education or intermittent clinical care. These results provide promising evidence of an effective approach for reducing avoidable hospitalizations among nursing facility residents.

What Are Nursing Facilities Doing to Reduce Potentially Avoidable Hospitalizations?

OBJECTIVES: Hospitalizations among nursing facility residents are frequent and often potentially avoidable. A number of initiatives and interventions have been developed to reduce excessive hospitalizations; however, little is known about the specific approaches nursing facilities use to address this issue. The objective of this study is to better understand which types of interventions nursing facilities have introduced to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. DESIGN: Cross-sectional survey. SETTING: 236 nursing facilities from 7 states. PARTICIPANTS: Nursing facility administrators. MEASUREMENTS: Web-based survey to measure whether facilities introduced any policies or procedures designed specifically to reduce potentially avoidable hospitalizations of long-stay nursing facility residents between 2011 and 2015. We surveyed facilities about seven types of interventions and quality improvement activities related to reducing avoidable hospitalizations, including use of Interventions to Reduce Acute Care Transfers (INTERACT) and American Medical Directors Association tools. RESULTS: Ninety-five percent of responding nursing facilities reported having introduced at least one new policy or procedure to reduce nursing facility resident hospitalizations since January 2011. The most common practice reported was hospitalization rate tracking or review, followed by standardized communication tools, such as Situation, Background, Assessment, Recommendation (SBAR). We found some variation in the extent and types of these reported interventions. CONCLUSIONS: Nearly all facilities surveyed reported having introduced a variety of initiatives to reduce potentially avoidable hospitalizations, likely driven by federal, state, and corporate initiatives to decrease hospital admissions and readmissions.

Experience, Knowledge, and Concerns About Long-Term Services and Supports: Implications for Financing Reform.

Using the 2014 Survey of Long-Term Care Awareness and Planning, this article examines Americans' experiences, knowledge, and concerns about long-term services and supports (LTSS) and actions they are willing to take if they become disabled. The survey included 15,298 non-institutionalized respondents aged 40 to 70 years drawn from a nationally representative sample. Although many reported some experience with LTSS, knowledge of how LTSS worked was low. Respondents reported widespread concerns about becoming disabled. They preferred informal care over paid care, with a strong desire to remain in their homes. These results can be used to design reform initiatives and to motivate political support.

Obesity and people with disabilities: the implications for health care expenditures.

OBJECTIVE: This study estimates additional average health care expenditures for overweight and obesity for adults with disabilities vs. without. DESIGN AND METHODS: Descriptive and multivariate methods were used to estimate additional health expenditures by service type, age group, and payer using 2004-2007 Medical Expenditure Panel Survey data. RESULTS: In 2007, 37% of community-dwelling Americans with disabilities were obese vs. 27% of the total population. People with disabilities had almost three times ($2,459) the additional average obesity cost of people without disabilities ($889). Prescription drug expenditures for obese people with disabilities were three times as high and outpatient expenditures were 74% higher. People with disabilities in the 45- to 64-year age group had the highest obesity expenditures. Medicare had the highest additional average obesity expenditures among payers. Among people with prescription drug expenditures, obese people with disabilities had nine times the prevalence of diabetes as normal weight people with disabilities. Overweight people with and without disabilities had lower expenditures than normal-weight people with and without disabilities. CONCLUSIONS: Obesity results in substantial additional health care expenditures for people with disabilities. These additional expenditures pose a serious current and future problem, given the potential for higher obesity prevalence in the coming decade.

Urinary incontinence, functional status, and health-related quality of life among Medicare beneficiaries enrolled in the program for all-inclusive care for the elderly and dual eligible demonstration special needs plans.

The Health Outcomes Survey-Modified is a brief annual survey completed by enrollees in the Program for All-Inclusive Care for the Elderly and selected special needs plans to collect functional status information used to adjust Medicare payments to these plans. We examined the relationship between urinary incontinence, functional limitations, and health-related quality of life among 16 387 respondents to the 2009 Health Outcomes Survey-Modified. Measures were the physical and mental components scores and self-rated general health derived from the Veterans RAND 12-Item Health Survey (VR-12). Urinary incontinence is prevalent among frail community-dwelling adults and has substantial impact on quality of life.

The living arrangements of older immigrants from the former Soviet Union: a comparison of Israel and the United States.

With the unprecedented emigration from the former Soviet Union (FSU) during the 1990s as context, this study described the living arrangements of older FSU immigrants living in Israel and the US. Living arrangement choices represented an important strategy for coping with the migration process. Census data from Israel and the US were employed to examine the relationships among living arrangements (independent households, multigenerational households, and extended households) and personal characteristics, including duration of residence, Jewish identity, education, and home ownership. Results showed that the less time older immigrants lived in the host country, the more likely they lived in a multigenerational or extended household. The residency length and household relationship was stronger in Israel than in the US. Also, older FSU immigrants who owned their own home and who lived in a metropolitan area were more likely to live in a complex household than in an independent household. We discussed how the economic and social environments in each country contributed to the variability in living arrangement options among these older immigrants.

Immigrant and non-immigrant certified nursing assistants in nursing homes: how do they differ?

This study analyzes the 2004 National Nursing Assistant Survey and other survey data to examine the characteristics and experiences of immigrant and non-immigrant certified nursing assistants (CNAs) in nursing facilities. Descriptive results focus on differences in personal characteristics, working conditions, extrinsic rewards, work experiences, job satisfaction, and workplace discrimination. The findings indicate that immigrant CNAs are older, better educated, and somewhat more highly paid than their non-immigrant counterparts but also experience substantial levels of discrimination and language-related communication barriers at work. The paper discusses major policy issues that arise from the increase in immigrant labor in long-term care.

Why do they stay? Job tenure among certified nursing assistants in nursing homes.

PURPOSE: This study identifies factors related to job tenure among certified nursing assistants (CNAs) working in nursing homes. DESIGN AND METHODS: The study uses 2004 data from the National Nursing Home Survey, the National Nursing Assistant Survey, and the Area Resource File. Ordinary least squares regression analyses were conducted with length of job tenure as the dependent variable. Tenure of CNAs was hypothesized to be motivated by the extrinsic rewards of their job, initial training and mentoring, reasons for being a CNA, organizational culture, and personal, facility, and market characteristics. Separate analyses were conducted for the overall sample and for CNAs who worked for the facility for more than 1 year. RESULTS: Among policy-relevant domains, extrinsic rewards had the largest number of significant variables (4). Only 1 training and 1 organizational culture variable significantly affected CNA job tenure. Significant variables in domains not readily influenced by policy (e.g., personal characteristics and characteristics of the facility and surrounding market area) were often significant in both regressions. IMPLICATIONS: This study underscores the importance of the basic economics of job choice by low-income workers. Wages, fringe benefits, job security, and alternative choices of employment are important determinants of job tenure that should be addressed, in addition to training and organizational culture.

Are consumer-directed home care beneficiaries satisfied? Evidence from Washington state.

PURPOSE: This study analyzed the effect of consumer-directed versus agency-directed home care on satisfaction with paid personal assistance services among Medicaid beneficiaries in Washington State. DESIGN AND METHODS: The study analyzed a survey of 513 Medicaid beneficiaries receiving home- and community-based services. As part of a larger study, we developed an 8-item Satisfaction With Paid Personal Assistance Scale as the measure of satisfaction. In predicting satisfaction with personal assistance services, we estimated an ordinary least squares regression model that was right-censored to account for the large percentage of respondents who were highly satisfied with their care. RESULTS: Among the older population, but not younger people with disabilities, beneficiaries receiving consumer-directed services were more satisfied than individuals receiving agency-directed care. There was no evidence that quality of care was less with consumer-directed services. In addition, overall satisfaction levels with paid home care were very high. IMPLICATIONS: This study supports the premise that consumer satisfaction, an important measure of quality, in consumer-directed home care is not inferior to that in agency-directed care. The positive effect of consumer direction for older people underlines the fact that this service option is relevant for this population. In addition, this research provides evidence that home- and community-based services are of high quality, at least on one dimension.

Mode of administration effects on disability measures in a sample of frail beneficiaries.

PURPOSE: To compare disability rates resulting from several modes of survey administration in a single sample of frail elders. DESIGN AND METHODS: Using the same battery of six ADL questions we compared the resulting level of disability across several modes of administration: mail survey with telephone follow-up, in person interview, and evaluation by a registered nurse, further comparing self and proxy responses where both were available. We also created a crosswalk between these measures and clinical evaluations by rehabilitation therapists, allowing another point of comparison. RESULTS: Disability rates varied substantially by mode of survey administration and all survey modes yielded lower rates of disability than those we derived from clinical assessments. IMPLICATIONS: Relying on self-report in evaluating functional status may underestimate disability in clinical evaluations, level of care determinations and service planning. Researchers and policymakers should also take mode of administration effects into account when estimating or comparing disability rates.

Impact of nonresponse on Medicare Current Beneficiary Survey estimates.

The Medicare Current Beneficiary Survey (MCBS) has been used by policymakers and research analysts to provide information on a wide array of topics about the Medicare Program. Nonresponse bias is potentially one of the most important threats to the validity of the estimates from the MCBS. In this article we present results of our methodological study that analyzes the impact of nonresponse on MCBS estimates, including initial round unit nonresponse, panel attrition, and item nonresponse. Our findings indicate that for most of the measures studied, the bias caused by differences between nonrespondents and respondents in the MCBS was substantially reduced or eliminated by the nonresponse procedures currently employed.

Personal care satisfaction among aged and physically disabled Medicaid beneficiaries.

We analyzed survey data from 2,325 Medicaid home and community-based services (HCBS) beneficiaries in six States to estimate satisfaction with personal care services. We constructed an eight-item scale rating various aspects of paid assistance and estimated satisfaction for the total sample and for older and younger persons with disabilities. Younger persons with significant health problems and those residing in group settings were less satisfied. Higher unmet need for assistance with activities of daily living (ADLs), and instrumental activities of daily living (IADLs) was associated with decreased satisfaction, and matching race between a client and paid caregiver was associated with significantly increased satisfaction in all age groups.

Workforce issues and consumer satisfaction in Medicaid personal assistance services.

This study used a survey of older people and younger persons with disabilities who were receiving Medicaid-financed home and community-based services (HCBS) to assess the effect of workforce issues on consumer satisfaction. We found that recruitment problems had very strong negative and significant effects on consumer satisfaction. An interruption in service was a more important and significant indicator of consumer dissatisfaction than not having the same worker over time. We also found that problems with worker training and respect and treatment of consumers strongly and significantly affected satisfaction with paid care. Efforts to improve workforce issues are needed to improve the quality of care of these services.