Mental disorders among non-elderly nursing home residents

Many Medicaid beneficiaries aged 22 to 64 with serious mental illness may be admitted to nursing facilities rather than psychiatric facilities as a result of Medicaid policies prohibiting coverage of inpatient psychiatric care in institutions of mental disease while requiring states to cover nursing facility care. Using nationwide Medicaid Analytic Extract claims from 2002, we found that nearly 16% of nursing home residents aged 22 to 64 had a diagnosed mental disorder, while 45.5% received antipsychotic medication, but these rates varied widely across states. Further research is necessary to determine whether, among the nation's youngest nursing home residents, care in nursing homes is potentially substituting for care in institutions for mental disease or community-based settings.     

Geropsychiatric education programs. Providing skills and understanding

1. The treatment of mental health problems is a growing concern in long-term care facilities; up to 80% of nursing home residents suffer from some type of mental illness, but most receive no active treatment. 2. Nursing home staff do not receive sufficient training on mental health issues, the aging process, and assessment and management of psychiatric symptoms in the elderly. 3. Psychiatric nurses can provide a number of quality geriatric mental health programs to increase staff knowledge and promote quality of care.     

Nursing Home Deficiencies: An Exploratory Study of Interstate Variations in Regulatory Activity

This study examines nursing home regulatory activity by the states, assesses interstate variations in the volume and severity of nursing home deficiencies, and explores state-level factors that may account for these differences. Nursing home deficiency citation data over a 5-year period (2000–2004) were obtained from the Centers for Medicare and Medicaid Services. We examined interstate variations in regulatory activity and identified predictors of deficiency volume and severity at the state level (demographics, elected officials, industry characteristics, etc.) using the linear mixed model. Deficiency volume remained stable across the 50 states from 2000 to 2004, while deficiency severity decreased significantly. California had the highest volume of deficiencies per nursing home; Wisconsin had the lowest. New Hampshire had the highest percentage of severe deficiencies; California had the lowest. Higher deficiency volume was found in states with lower median household income, a lower proportion of residents aged 85 and older, and a Democratic legislature. Higher deficiency severity was associated with higher median household income and a higher proportion of Medicaid nursing home residents in a state. In contrast, greater state agency funding, higher state standards for nursing home administrators, and a Democratic and more professional legislature predicted lower deficiency severity. Nursing home residents in the United States receive unequal protection from abuse and neglect, and this is partly due to their state of residence. Interstate variations in deficiency volume and severity are due to a complex set of factors beyond nursing home quality.     

Does Home- and Community-Based Care Affect Nursing Home Use?

A study was conducted to assess change in numbers, expenditures, and case mix of nursing home residents as Medicaid investment in home- and community-based services (HCBS) 1915(c) waivers increased in seven states. The seven states provided Medicaid expenditure and utilization data from 2001 to 2005, including waiver and state plan utilization. The Minimum Data Set was used for nursing home residents. For three states, community assessment data were also used. In six states, the number of nursing home clients decreased as the numbers of HCBS clients grew. However, in most states, the number of additional waiver clients often greatly exceeded reductions in nursing home residents. Nursing home payments decreased moderately, but this decrease was offset by increases in HCBS waiver and state plan expenditures, leading to a net increase in long-term support services (LTSS) expenditures from 2001 to 2005. Increases in waiver expenditures outpaced increases in waiver clients, indicating expansion of services on top of expansion in clients. States that showed substantial increases in HCBS showed only modest increases in nursing home case mix. The case mix for nursing home residents was more acute than that for HCBS users. The expectation that greater HCBS use would siphon off less severe LTSS users and hence lead to a higher case mix in nursing homes was partially met. The more acute case mix in nursing homes suggests that HCBS serves some individuals who were previously cared for in nursing homes but many who were not. Efforts to promote substitution of HCBS for institutional care will require more proactive strategies such as diversion.     

Assisted Living:

In their quest to reduce nursing home care expenditures, the various states in this country have looked to assisted living as a potentially preferred and lower-cost housing alternative for their Medicaid patients. For an assisted-living program to save costs, states must recognize that some assisted-living residents will not come from nursing homes, but rather from private residences, resulting in cost increases. This article argues that this "woodwork effect" - new clients appearing - is likely to be smaller than the level reported in the home and community care demonstrations, but that the numbers are difficult to predict with the possibility of divestiture. It also argues that the true savings from substitution, or of one form of care for another, depend on the nursing home reimbursement system in effect at the time.     

Assisted living: will it reduce long-term care costs?

In their quest to reduce nursing home care expenditures, the various states in this country have looked to assisted living as a potentially preferred and lower-cost housing alternative for their Medicaid patients. For an assisted-living program to save costs, states must recognize that some assisted-living residents will not come from nursing homes, but rather from private residences, resulting in cost increases. This article argues that this "woodwork effect"--new clients appearing--is likely to be smaller than the level reported in the home and community care demonstrations, but that the numbers are difficult to predict with the possibility of divestiture. It also argues that the true savings from substitution, or of one form of care for another, depend on the nursing home reimbursement system in effect at the time.     

Controlling the supply of long-term care providers in thirteen states

Many states have responded to growing Medicaid long-term care expenditures by limiting the number of long-term care providers through certificate-of-need (CON) programs and moratoriums on new construction or certification for participation in the Medicaid program. This article focuses on the use of these policies in 13 states. Most of the 13 states control the supply of nursing home beds and hospital conversions with CONs or moratoriums, but they are struggling to adapt the role of supply policy to the growth of home health and residential care. As an increasing proportion of Medicaid long-term care spending goes to these nursing home alternatives, supply policy needs to keep pace with the changing provider market and the changing demographics of the consumer market if it hopes to ensure access to long-term care and control Medicaid expenditures.     

Bringing Assisted Living Services into Congregate Housing

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents—the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.     

Comparing States' Medicaid Nursing Facilities and Home and Community-Based Services Long-Term Care Programs: Quality and Fit with Inclination,Capacity, and Need

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality.     

Chain reaction: an exploratory study of nursing home bankruptcy in California

This paper reports on an exploratory study of nursing home bankruptcy. From state and industry data regarding nearly 1,000 California facilities, it was possible to identify 155 homes in five chains (multi-facility organizations) that were operating in bankruptcy in 2000. When compared with facilities in non-bankrupt chains, while the bankrupt chain facilities had significantly worse financial liquidity, higher administrative costs, and higher payables to related parties, they also had more Medicare residents, fewer Medicaid residents, better solvency, and were located in less competitive county markets and in areas with higher Medicaid reimbursement rates. These findings indicate that, rather than facility characteristics and local market factors, strategic decisions taken at the corporate (chain) level are the major determinants of nursing facility bankruptcy status.     

Resource effects on access to long-term care for frail older people

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Chain Reaction

Abstract

This paper reports on an exploratory study of nursing home bankruptcy. From state and industry data regarding nearly 1,000 California facilities, it was possible to identify 155 homes in five chains (multi-facility organizations) that were operating in bankruptcy in 2000. When compared with facilities in non-bankrupt chains, while the bankrupt chain facilities had significantly worse financial liquidity, higher administrative costs, and higher payables to related parties, they also had more Medicare residents, fewer Medicaid residents, better solvency, and were located in less competitive county markets and in areas with higher Medicaid reimbursement rates. These findings indicate that, rather than facility characteristics and local market factors, strategic decisions taken at the corporate (chain) level are the major determinants of nursing facility bankruptcy status.     

Nursing home admissions and long-stay conversions among persons with and without serious mental illness

The appropriateness of nursing homes for individuals with serious mental illness remains a controversial issue in long-term care policy more than a decade since the landmark U.S. Supreme Court Olmstead decision in 1999 , which affirmed the rights of persons with disabilities to live in their communities. Using national nursing home Minimum Data Set assessments from 2005, the authors compared the demographic, clinical, and functional characteristics of persons with and without serious mental illness newly admitted to nursing homes. They found that newly admitted people with serious mental illness were younger and more likely to become long-stay residents than those admitted with other conditions, despite a higher proportion of residents with serious mental illness, including the elderly, classified as low-care status. The most substantial and clinically significant difference for rates of low-care status 90 days after initial admission are for persons younger than 65 with serious mental illness versus those younger than 65 without serious mental illness (33% vs. 8.5%, or 3.9 times greater). There is a notable difference in low-care status between persons aged 65 and older with serious mental illness and those aged 65 and older without serious mental illness (14% vs. 6.6%, or 2.1 times greater). These results suggest that a substantial number of adults with serious mental illness residing in nursing homes may have the functional capacity to live in less restrictive environments.     

Resource Effects on Access to Long-Term Care for Frail Older People

Abstract

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Celebrating our past. The history of Hamilton Psychiatric Hospital.

1. There is a risk of losing important parts of our psychiatric nursing history as a result of the rapid rate of mental health reform and the closing or changing of governance of major psychiatric facilities. 2. Hamilton Psychiatric Hospital provided leadership in psychiatric nursing in Canada for more than a century and is now changing governance from being a provincial psychiatric hospital to part of a community general hospital. 3. The hospital's tradition includes nonrestrictive care policies that have been in place for more than a century, a humanistic approach to care, being the first facility in Canada to require theory-based nursing care from all nursing staff, innovative practice models, and achieving authorship or co-authorship from more than 17% of the RN staff.     

A profile of middle-aged and older adults admitted to nursing homes: 2000-2008

Middle-aged adults are becoming an increasing share of the nursing home population. Minimum Data Set assessment data for 2000 and 2008 are used to explore similarities and differences in sociodemographic, residential, medical, and psychiatric characteristics of newly admitted middle-aged adults (31-64) compared to their older counterparts (65+). Relative to their share of the state population, Black middle-aged adults are overrepresented in nursing homes across 45 states and the District of Columbia. Chronic conditions, including diabetes, renal failure, chronic obstructive pulmonary disease, asthma, and circulatory/heart disorders, appeared to contribute to the increasing presence of middle-aged adults. There were substantial increases in diagnoses of psychiatric disorders at admission; psychiatric diagnoses were significantly higher among middle-aged adults. Middle-aged adults were also more likely to have residential histories of prior stays in psychiatric facilities relative to older adults. States' rebalancing efforts need to attend to the increasing presence of disability associated with chronic medical and psychiatric conditions among middle-aged adults.     

Examining the Nursing Home Physical Environment Through Policy-Driven Culture Change

A critical need exists to challenge approaches to nursing home care due to rigid organizational factors and hospital-like culture. It has been argued that resident care needs to move toward a person-centered approach by addressing the organizational, social, and physical environments in nursing home facilities, a process often known as culture change. In response to this need, the Centers for Medicare & Medicaid Services (CMS) has created funding for pay for performance (P4P) nursing home incentive programs to allow nursing home providers to receive CMS reimbursements for culture change in the facilities. Through care staff interviews, site observations, and a document review, this qualitative study assesses the impact of a Midwestern state P4P incentive program in three participating nursing homes. Using an environment and behavior (E-B) policy orientation framework, this study examines culture change through a focus on policy, the physical environment, place attachment, and social and psychological processes in the study settings.     

A Profile of Middle-Aged and Older Adults Admitted to Nursing Homes: 2000–2008

Middle-aged adults are becoming an increasing share of the nursing home population. Minimum Data Set assessment data for 2000 and 2008 are used to explore similarities and differences in sociodemographic, residential, medical, and psychiatric characteristics of newly admitted middle-aged adults (31–64) compared to their older counterparts (65+). Relative to their share of the state population, Black middle-aged adults are overrepresented in nursing homes across 45 states and the District of Columbia. Chronic conditions, including diabetes, renal failure, chronic obstructive pulmonary disease, asthma, and circulatory/heart disorders, appeared to contribute to the increasing presence of middle-aged adults. There were substantial increases in diagnoses of psychiatric disorders at admission; psychiatric diagnoses were significantly higher among middle-aged adults. Middle-aged adults were also more likely to have residential histories of prior stays in psychiatric facilities relative to older adults. States' rebalancing efforts need to attend to the increasing presence of disability associated with chronic medical and psychiatric conditions among middle-aged adults.     

Detouring Nursing Home Entrants

Under the Omnibus Budget Reconciliation Bill of 1981, states can apply for waivers to underwrite nonmedical home care services for Medicaid clients who would otherwise enter nursing homes. Ideally, subsidized home services should improve the quality of life for older people, relieve the demand on nursing homes, and reduce overall Medicaid expenditures; yet in Rhode Island the program has served few people. This discussion proposes reasons for the minor impact of "waiver channeling."     

Beyond Clinical Complexity: Nonmedical Barriers to Nursing Home Care for Rural Residents

We conducted a qualitative content analysis of barriers to nursing home admission for rural residents. Data came from semi-structured interviews with 23 rural hospital discharge planners across five states (Georgia, Idaho, Minnesota, Pennsylvania, and Wisconsin). From those, we identified four themes around nonmedical barriers to rural nursing home placement with particular salience in rural areas: financial issues, transportation, nursing home availability and infrastructure, and timeliness. We also identified policy and programmatic interventions across four themes: loosen bureaucratic requirements, improve communication between facilities, increase rural long-term care capacity, and address underlying social determinants of health.