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.     

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.     

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.     

Constructing Deservingness

Abstract

This study examines the influence of financial incentives and the racial status of the patient on the use of extended care following an episode of hospitalization. Post-hospital care (PHC) is defined as the services provided by a skilled nursing facility (SNF) or intermediate care facility (ICF) following discharge. The focus of the analysis is on the use or nonuse of PHC, the presence or absence of a delay in transfer to an ICF or SNF and, limited to those who experienced a postponement, the length of the delayed discharge. After controlling for multiple factors, the results indicate that Medicare beneficiaries were more likely to use PHC, less likely to experience a delay in discharge, and used fewer days of prolonged care. Medicaid recipients and uninsured patients experienced reduced access to PHC. The results also indicated that the access of Native Americans and Americans to PHC was impeded.     

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.     

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.     

Quality indicator survey versus traditional survey in New York State: a comparison of results from annual nursing home surveys

Despite the passage of OBRA’87 for nursing home reform, concerns about care in facilities continue. The Centers for Medicare and Medicaid developed new regulations and the Traditional Survey (TS) process for annual nursing home survey. The survey is conducted by state regional offices to determine facility compliance with federal regulations. Despite the regulations and new survey process, the TS inconsistently identified problems. A computerized process called the Quality Indicator Survey (QIS) was subsequently developed. This study was designed to compare results from TS and QIS on overall deficiencies, select quality indicators, high-severity deficiencies, and severity differences of seven quality indicators in New York State over a 6-year period from 2010 through 2015. Results of t-tests determined a significant difference in the overall mean number of deficiencies (p < .001), and on four indicators: choices (p < .001), nursing staff (p < .001), dental (p < .001), and dignity (p < .05). Facilities using the TS showed a higher mean number of harm level or higher deficiencies (p < .001). Chi-square tests for severity levels showed significantly more higher severity deficiencies on two quality indicators: nutrition (p < 0.001) and hydration (p < 0.05). Thus, the QIS produced a greater mean number of deficiencies, while TS produced more higher severity deficiencies in New York State.     

Marital Status and Other Correlates of Personal Bankruptcy, 1986–2004

ABSTRACT

Relying on National Longitudinal Survey (NLS) data, this retrospective cohort study found that 11.6% (n = 882) of the eligible study sample (N = 7,609) declared personal or nonbusiness, nonentrepreneurial between 1986 and 2004. These debtors had average annual incomes that were about 2.5 times official poverty thresholds. Those who were divorced in 2004 were most likely to have declared bankruptcy (16.4%), followed by separated (13.9%), married with spouses present (11.2%), and never–married (7.0%) persons. Specific correlates of bankruptcy varied by year. Marital status was associated with likelihood of declaring bankruptcy in only 6 of 14 survey years: Never-married persons at the time of declared bankruptcy were less likely than married persons to declare, whereas formerly married persons, whether divorced or separated, were more likely than married persons to do so. Formerly married persons who declared bankruptcy bounced back economically to a lesser degree than did married persons, even though their predeclared bankruptcy levels of economic well-being were roughly equivalent. Interaction effects showed that formerly married women were more likely to declare bankruptcy than their male counterparts.     

Facility Ownership and Resident Satisfaction with Assisted Living

Abstract

Although the majority of assisted living facilities operate as for-profit organizations and serve increasingly frail elderly populations, little is known about the impact of ownership on the quality of care in assisted living. This study examines the relationship between facility ownership and the quality of care in assisted living, using resident satisfaction as a quality indicator. The assessed aspects of satisfaction include health care, housekeeping, physical environment, relationships with staff, and social life/activities. The relationship of facility ownership to resident satisfaction is examined controlling for resident psychological well-being, functional ability, facility size, and staff resources. Data were collected in personal interviews with 156 residents, including 96 residents in eight for-profit facilities and 60 residents in five nonprofit facilities in Maryland. Residents in the sampled nonprofit facilities were more satisfied with assisted living than were residents in the for-profit facilities. In particular, residents in nonprofit facilities were more satisfied with health care, physical environment, and social life/activities in the facility. Better understanding of the relationship between facility ownership and resident satisfaction can help administrators create environments that maximize resident satisfaction in both nonprofit and for-profit facilities.     

Declining Physical Activity Levels as an Unintended Consequence of Abolishing Mandatory Campus Service Fees

Abstract

Objective: This study investigates the effect of the introduction of voluntary student unionism and subsequent increase in campus facility fees on engagement in physical activity on campus. Participants: Participants were 1,904 students from a large regional NSW (Australia) university across 3 time periods (926 in 2005, 504 in 2006, and 474 in 2007). Methods: Students completed a survey across the 3 time periods, responding to questions about physical activity levels, use of on-campus and off-campus facilities, and barriers to facility use. Results: Participation in physical activity at university facilities was low overall, and declined substantially between 2005 and 2007, with the proportion of students identifying cost as a barrier more than doubling over this time period. Conclusions: There is a need for policy makers to consider the unintended health impacts of such policy changes, particularly in relation to the impact on already insufficient levels of physical activity.     

The Centers for Medicare and Medicaid Services' Nursing Home Case-Mix and Quality Demonstration

Abstract

This paper presents the first comprehensive account of a major national demonstration designed to integrate skilled nursing facilities (SNF) prospective case-mix payment and quality of care. It describes the Centers for Medicare and Medicaid Services' Nursing Home Case-Mix and Quality (NHCMQ) Demonstration—the template for Medicare's SNF Prospective Payment System (PPS) implemented July 1998. The NHCMQ Demonstration provided the basis for one of the most significant changes in SNF reimbursement and quality monitoring policies to date. Prospective reimbursement policies created positive incentive for providers to admit Medicare residents under more equitable payment rates. However, controversy regarding unanticipated perverse provider incentives remains. The quality management system designed under the NHCMQ Demonstration is currently used in over 17,000 nursing homes. Furthermore, under the NHCMQ Demonstration, one standardized assessment tool—the MDS—was used to assess a resident's clinical condition, to monitor quality, and to calculate provider reimbursement. Experiences from the NHCMQ Demonstration and continued evaluation of the current national PPS, along with state systems, provide a rich information source regarding prospective, case-mix reimbursement, and provider incentives.     

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.     

Utility of the Maryland Assisted Living Functional Assessment Tool

Abstract

The purpose of this study was to consider the utility of the Maryland Assisted Living Functional Assessment (MALFA) in terms of predicting successful living in an assisted living facility. Consideration of utility of this tool was based on the predictive ability of the measure at baseline to explain length of stay and level of care needed for residents (nursing home versus assisted living) over a five year period. A total of 76 residents from a single ALF in the Baltimore area were tested annually over five years. Those who transitioned to a nursing home at some point during the 5-year period (47%) had higher mean scores on admission with regard to need for nursing interventions because of cognitive and psychiatric problems or to perform medical treatments. Medical illness influenced number of years in assisted living and accounted for 7% of the variance (F = 7.2, p < .05). The assessment tool provides a wealth of information about the resident and can be used to alert providers to consider individuals with high scores in subscales such as need for monitoring of cognitive and psychiatric problems or need for medical treatments in terms of being at risk for nursing home placement. Future work should consider how to optimally use the MALFA to implement interventions in assistive living that will prevent decline in areas that seem likely to result in a need for a higher level of care.     

Nursing home performance on select publicly reported quality indicators and resident risk of hospitalization: grappling with policy implications

This study examines how resident risk of hospitalization varies in relation to facility performance on select quality indicators (QIs). Using a 15% sample, three years of Medicaid reimbursement data from over 525 nursing homes (NHs) were linked with four years of hospital claims data and facility-level data to investigate whether residents of NHs with worse (better) than expected performance on QIs experienced increased (decreased) risk of hospitalization. Logistic regression results indicate that variations in hospitalization risk among NH residents are explained in part by facility performance on QIs. Residents from NHs with more decubitus ulcers, with greater use of physical restraints, and with a higher than expected incidence of unexplained weight loss/gain experienced increased risk of hospitalization.     

The effects of organizational context on autonomy-enhancing policies in assisted living

This study examines the effects of facility size, ownership, chain membership, and residents' characteristics on autonomy-enhancing policies in assisted living. The theoretical framework for the study is based on the open systems perspective, which views organizations as being influenced by environmental context (e.g., ownership and chain membership). Data were collected from interviews with administrators of 60 facilities in Maryland. Autonomy-enhancing policies were assessed with the MEAP Policy Choice and Resident Control scales. Facility size and residents' disability were strong predictors of autonomy-enhancing policies (R² = .39, p < .001). Higher levels of policies that foster resident autonomy were associated with larger facility size (β = .54, p < .001) and lower residents' disability (β = .23, p < .05). Chain membership had an indirect influence on autonomy-enhancing via facility size and residents' disability. Chain-related facilities were larger, and their residents were less disabled. The study contributes to a better understanding of the mechanism through which organizational factors influence resident-oriented policies.     

Being a man in long term care

PurposeMen tend to represent a distinct minority in long term care (LTC) facilities. Here we explore men's seldom examined experience in LTC.Design and methodsAs part of a major study of Bereavement in Long Term Care, we focus on 21 men who live in five LTC facilities (assisted living facilities and nursing homes). Transcribed qualitative, in-person interviews are examined using standard qualitative analytic methods.ResultsThrough multiple rounds of coding three inter-related themes emerged as salient. (1) Men's work experience as central to their sense of identity. (2) The presence of a wife often is associated with men's sense of couplehood and of feeling protective. (3) Men often regulate their relationships with other LTC residents.ImplicationsDiscussion examines how these three themes are related to men's maintenance of a masculine role in LTC.     

Administrators and Quality of Care in Long-Term Care Facilities

This exploratory study investigated administrator and facility-related predictors of quality of care in long-term care facilities. Quality was measured using several unmet standards of care identified in the last inspection report of the Ontario Ministry of Health and Long-Term Care (2007). Supplemental data were gathered from surveys mailed to all 602 long-term care administrators in Ontario, Canada, 302 of whom completed the questionnaire. Multiple regression analyses were conducted to test sets of hypotheses linking characteristics of administrators and those of the long-term care facility to quality of care. Education and experience as an administrator in a participant's current position had a moderate positive influence on quality of care; however, negative associations were found between administrator salary and effort devoted to resident care problems and quality of care. In addition, smaller facilities, being located in less populated communities, and administrators with a nursing background significantly affected quality of care in a positive manner.     

Differences in Facilities' Acceptance of Patients Under Long-Term Care Insurance in Japan

Abstract

Objectives. In April 2000, Japan launched a public, long-term care insurance (LTCI) plan for elderly people who need support. This study describes how medical support for the elderly is delivered at LTCI care facilities in Japan now and gaps between system goals and current activity. Recommendations are made for enhancing the implementation of LTCI.

Methods. We mailed questionnaires to all health service facilities for the elderly (HSF) and special nursing homes for the elderly (SNH) located in the Kyushu area of Japan, asking whether they would accept patients with nine specific conditions.

Results. We found that HSFs, which are required to employ a full-time doctor and are reimbursed at a higher rate, accept significantly fewer patients with four conditions that need medical support than are accepted by SNHs, which are not required to employ a full-time doctor.

Discussion. In this study, we find discrepancies between system goals and current activities at LTCI care facilities. For the Japanese LTCI system to work well in the limitation of medical resources, we must understand how it really works and to reform the system continuously.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.