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.     

Relocation stress syndrome in older adults transitioning from home to a long-term care facility: myth or reality?

Relocation stress syndrome is a nursing diagnosis characterized by symptoms such as anxiety, confusion, hopelessness, and loneliness. It usually occurs in older adults shortly after moving from a private residence to a nursing home or assisted-living facility. The primary purpose of this study was to validate the symptoms of relocation stress syndrome. Eight nursing home residents and 8 assisted-living facility residents were interviewed 2 to 10 weeks after admission, when symptoms of relocation stress syndrome are most likely to appear. Results of this study indicate that the incidence of relocation stress syndrome may be overestimated. More accurate diagnosis and treatment of depression in older adults is needed.     

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.     

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.     

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.     

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."     

Advocating for the Rights of Vulnerable Nursing Home Residents:

The purpose of this article is to describe how advocates continued to work to effect change after the criminal prosecution of one nursing home corporation (referred to in this article as the Corporation). The impact was felt not only by that company but also by area nursing home providers, policymakers, and regulators in long-term care.     

THE EFFECT OF THE MEDICAID HOME CARE BENEFIT ONLONG-TERM CARE CHOICES OF THE ELDERLY

This paper analyses the impact of Medicaid home care benefits on the probability of nursing home entry and the use of formal and informal home care by disabled elderly remaining in the community. Using data from the National Long-Term Care Survey, I find evidence that Medicaid home care subsidies reduced the probability of nursing home entry among at-risk elderly using formal home care. Among non-in-stitutionalized persons, the subsidy increased the use of formal home care but led to substitution of informal with formal care for services that were non-medical in nature.     

Independence in assisted living

The aims of this study were to understand the meaning of independence for residents of assisted living and to identify factors influencing the operationalization of independence in this setting. Qualitative interviews were conducted with 17 providers and 55 residents in 17 assisted-living facilities in Georgia. Data were analyzed by using the grounded theory method. Findings show that assisted-living residents retained a strong value for independence and that independence had multiple dimensions of meaning. Whereas independence in most cases was reduced to performing everyday activities of daily living (ADLs), the multidimensional nature of meaning allowed residents with significant disability both to continue to perceive themselves as independent and to find satisfaction in their remaining abilities. Resident self-care requires significant effort from both residents and providers, but it also has far-reaching potential to help residents maintain intact identities and may hold the key to extending their stay in the assisted-living facility (ALF) environment.     

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.     

A 10-foot rope for a 50-yard drop: the CLASS Act in the patient protection and Affordable Care Act

The Community Living Assistance Services and Supports (CLASS) Act, part of the 2010 health care reform, would have paid a daily cash payment toward the costs of long-term care. This article points out that although the CLASS Act may have been sufficient to cover the costs of most home- and community-based services, it was an inadequate response to the most pressing long-term care financing problem facing baby boomers: nursing home care costs. The risk of needing a nursing home is higher than other catastrophic risks. Boomers lack savings to pay those costs. CLASS aimed to encourage people to use home- and community-based services to substitute for nursing home care, but research spanning decades shows there is little substitution effect.     

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.     

The Long-Term Care Ombudsman Program and Complaints of Abuse and Neglect:

This historical summary demonstrates that concern about elder abuse and neglect in long-term care facilities has played a vital role in the development and expansion of the Long-Term Care Ombudsman Program (LTCOP). Some 15 years after the Older Americans Act mandated ombudsman services in all nursing homes, the 1989-1990 state LTCOP reports were analyzed for information about abuse and neglect of elders in nursing homes nationwide. Following a brief review of the nursing home abuse literature, this paper reports on the findings from the 1989-90 reports about complaints of abuse and neglect and their implications for future research.     

Transnational migration and the commodification of eldercare in urban Ghana

ABSTRACT

Over the past 20 years, organizations to provide commercial nursing services, mainly to the sick and debilitated elderly, have sprung up in Accra, Ghana. This article assesses the degree to which transnational migration has generated social changes in ageing at the level of everyday practices. It argues that a range of social actors differently involved in transnational migration has created and sustained a market for home nursing agencies in Ghana through diverse processes involving the imagination of care work abroad, complex negotiations between the elderly at home and their anxious children abroad, increased financial resources among the middle class and the evaluations of western eldercare services by return and current migrants. These dynamics illustrate the complexity of the role of transnational migration in generating social change and highlight the significance of the needs of local families and the role of the imagination in shaping social remittances from abroad.     

Nursing Home Ownership Trends and Their Impacts on Quality of Care: A Study Using Detailed Ownership Data From Texas

The role of ownership in the provision of nursing home care has long been a challenging issue for policy makers and researchers. Although much of the focus historically has been on differences between for-profit and not-for-profit facilities, this simple distinction has become less useful in recent years as companies have employed more complicated ownership and management structures. Using detailed ownership data from the state of Texas, we describe the evolution of nursing home corporate structures from 2000 to 2007, analyze the effect of these structures on quality of care and staffing in nursing homes, and discuss the policy implications of these changes.     

“It’s a Dignity Thing”: Nursing Home Care Workers’ Use of Emotions1

This article examines how nursing home care workers use emotions to construct dignity at work. Previous scholarship has shown how the financial and organizational characteristics of nursing homes shape and constrain emotion work among staff. Using evidence gathered during 18 months of participant observation in two nursing homes and 65 interviews with staff, this article analyzes how, despite obstacles, nursing home care workers generated authentic emotional attachments to residents. Surprisingly, some staff members said they particularly appreciated working with residents difficult to control. They felt accomplished when such residents successfully transitioned from life at home to life in institutional care. Emotions created dignity for staff and induced compliance among residents. Emotions are not only generated by organizations and imposed on workers; staff themselves produced emotions—sometimes in ways consistent with organizational demands, and sometimes not—and they consistently found in their emotions a resource to manage the strains of their work lives.     

Getting by in the community: lessons from frail elders

This study explores how functionally impaired, elderly persons are able to remain in the community without home- and community- based care (HCBC) under the Medicaid program. Using HCBC administrative data, Medicare data, and survey data, we find the nonparticipants in the community appear to get by through a combination of reliance on informal care, use of Medicare home care, and going without needed services. Despite their efforts to manage their care in the community, non-participants were significantly more likely than the participants to enter a nursing home during the six months following assessment. While our analysis does not allow us to attribute the higher nursing home entry to the absence of HCBC services with certainty, the finding does raise questions about whether the elements of the HCBC program that discourage participation may save Medicaid dollars in the short-run at the expense of future Medicaid costs from more rapid nursing home entry.     

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.