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Objective: To evaluate how post-acute care (PAC) transitions affect minority older adults with Alzheimer's disease or related dementia (ADRD), and the extent to which dual Medicare-Medicaid eligibility may attenuate or exacerbate disparities in PAC outcomes. We examined: (1) PAC referrals by race/ethnicity and dual status; (2) individual, hospital, and market-level factors associated with PAC; (3) the association between PAC and outcomes. Data Sources/Study Setting: We used the following secondary data: Master Beneficiary Summary File (MBSF), Medicare Provider Analysis and Review (MedPAR), Minimum Data Set (MDS), Area Health Resource File (AHRF), hospital Provider of Services (POS) file, and the area deprivation index (ADI). Study Design: This observational study consisted of 619,262 community-residing Medicare fee-for-service (FFS) beneficiaries with ADRD who had a hospital stay in 2017. Data Collection/Extraction Methods: PAC discharge was to skilled nursing facilities (SNF), home health care (HHC) agencies or home without services. Outcomes were 30-day readmission and death. Multinomial logistic regressions with hospital random effects (RE), stratified by dual eligibility, were fit. Principal Findings: Dual-related differences were significantly larger than race/ethnicity differences in PAC transitions. For example, the difference in the probability of SNF transitions between White and Black patients was 3.2% and 6.8%-points for non-duals and duals, respectively. The difference between non-dual/dual White patients was 21.6% points, and among Black patients 18.0%-points. The adjusted risk of 30-day readmission was 5.6 percentage point higher among non-duals discharged to SNF, compared to home, but such risk among duals was not statistically significantly different. The adjusted probabilities of 30-day mortality were larger for duals and non-duals who transitioned to SNF, compared to those discharged home. Conclusions: PAC referrals and the resulting outcomes for Medicare beneficiaries with ADRD are associated with multi-level variables that need to be incorporated in discharge decision making. KEYWORDS Alzheimer's disease or dementia, mortality, post-acute care, readmissions What is known on this topic? * Hospitals and insurers have been shifting post-acute care (PAC) from institutional care settings to home. * Overall, for Medicare beneficiaries, studies have indicated that discharge to home health was associated with higher readmission rates. * Little is known about PAC transitions among community-dwelling Medicare beneficiaries with dementia and their impact on outcomes. What does this study add? * We found differences in PAC transitions to be more pronounced by dual status than by race/ethnicity. * PAC outcomes for hospital readmissions were not statistically significant by race/ethnicity but were by dual status. * Interventions to improve PAC transitions and outcomes for Medicare beneficiaries with ADRD should specifically consider differences duals versus non-duals in care needs and access., 1 | INTRODUCTION Post-acute care (PAC) provided in a skilled nursing home (SNF) or at home with services from a home health care (HHC) agency has been common among Medicare [...]

Objective. To build and test a model that predicts community discharge probabilities for Medicaid-eligible nursing home (NH) residents who remain in the nursing home at 90 days after admission and, thus, would be candidates for the Money Follows the Person (MFP) program. Data Source. The Minimum Data Set, Medicaid Management Information Systems, and Minnesota Vital Statistics file. Data. Cohort of 33, 590 nursing home stays that qualified for Medicaid by the 90th day of their stay from 383 Minnesota nursing homes from July 2011 to June 2013. Study Design. Mixed effects logistic regression model to predict community discharge. Principal Findings. The scoring system had a high level of accuracy in predicting community discharge for both the fitting and validation cohorts. Subpopulations with severe mental illness or intellectual disability were well represented across the entire score range. Conclusions. Findings are being applied in the Minnesota's MFP initiative (Moving Home Minnesota) to target Medicaid-eligible NH residents for transitioning to the community. This approach could be applied to MFP in other states. Key Words. Modeling, multi-level, long-term care, Medicaid, quality improvement, Minnesota has joined 42 other states and the District of Columbia in participating in the Federal Money Follows the Person (MFP) Rebalancing Demonstration Grant. One of the primary goals of [...]

Objective. To determine how alternative statistical risk-adjustment methods may affect the quality measures (QMs) in nursing home (NH) report cards. Data Sources/Study Settings. Secondary data from the national Minimum Data Set files of 2004 and 2005 that include 605,433 long-term residents in 9,336 facilities. Study Design. We estimated risk-adjusted QMs of decline in activities of daily living (ADL) functioning using classical, fixed-effects, and random-effects logistic models. Risk-adjusted QMs were compared with each other, and with the published QM (unadjusted) in identifying high- and low-quality facilities by either the rankings or 95 percent confidence intervals of QMs. Principal Findings. Risk-adjusted (QMs showed better overall agreement (or convergent validity) with each other than did the unadjusted versus each adjusted QM; the disagreement rate between unadjusted and adjusted QM can be as high as 48 percent. The risk-adjusted QM derived from the random-effects shrinkage estimator deviated nonrandomly from other risk-adjusted estimates in identifying the best 10 percent facilities using rankings. Conclusions. The extensively risk-adjusted QMs of ADL decline, even when estimated by alternative statistical methods, show higher convergent validity and provide more robust NH comparisons than the unadjusted QM. Outcome rankings based on ADL decline tend to show lower convergent validity when estimated by the shrinkage estimator rather than other statistical methods. Key Words. Nursing home, quality report cards, activities of daily living, risk adjustment, MDS, The quality of long-term care received by nursing home (NH) residents remains a persistent concern for consumers, their families and policy makers (Vladeck 1980; Institute of Medicine 1986; Capitman and [...]

Objective. To assess longitudinally whether a change in registered nurse (RN) staffing and skill mix leads to a change in nursing home resident outcomes while controlling for the potential endogeneity of staffing. Data Sources. Minimum Data Set (MDS) nursing home resident assessment data from five states merged with Online Survey Certification and Reporting (OSCAR) data from 1996 through 2000. Study Design. Resident-level longitudinal analysis with facility fixed effects and instrumental variables. Outcomes studied are incidence of pressure sores and urinary tract infections. RN staffing was measured as the care hours per resident-day and skill mix was measured as RN staffing hours as a proportion of total staffing hours. Data Extraction Method. We use all quarterly MDS assessments that fall within 120 days of an annual OSCAR data point, resulting in 399,206 resident-level observations. Principal Findings. Controlling for endogeneity of staffing increases the estimated impact of staffing on outcomes in nursing homes. Greater RN staffing significantly decreases the likelihood of both adverse outcomes. Increasing skill mix only reduces the incidence of urinary tract infections. Conclusions. Research that fails to account for endogeneity of the staffing-outcomes relationship may underestimate the benefit from increased RN staffing. Increases in RN staffing are likely to reduce adverse outcomes in some nursing homes. More research using a broader array of instruments and a national sample would be beneficial. Key Words. Staffing, nursing homes, quality of care, instrumental variables, endogeneity, The quality of care in nursing homes has long been an issue of concern to policy makers and the public. Following the Institute of Medicine report that documented serious abuses [...]

Objective. To test the hypothesis that a greater commitment to strategic adaptation, as exhibited by more extensive implementation of a subacute/rehabilitation care strategy in nursing homes, will be associated with superior performance. Data Sources. Online Survey, Certification, and Reporting (OSCAR) data from 1997 to 2004, and the area resource file (ARF). Study Design. The extent of strategic adaptation was measured by an aggregate weighted implementation score. Nursing home performance was measured by occupancy rate and two measures of payer mix. We conducted multivariate regression analyses using a cross-sectional time series generalized estimating equation (GEE) model to examine the effect of nursing home strategic implementation on each of the three performance measures, controlling for market and organizational characteristics that could influence nursing home performance. Data Collection/Abstraction Methods. OSCAR data was merged with relevant ARF data. Principal Findings. The results of our analysis provide strong support for the hypothesis. Conclusions. From a theoretical perspective, our findings confirm that organizations that adjust strategies and structures to better fit environmental demands achieve superior performance. From a managerial perspective, these results support the importance of proactive strategic leadership in the nursing home industry. Key Words. Nursing homes, strategic adaptations, financial performance, The performance of nursing homes, particularly with respect to the quality of care, has been the subject of public policy concern for some time (Institute of Medicine 1986, 2001). Increased [...]

Objective. To examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid reimbursement rates. Data Sources. Facility staffing, characteristics, and case-mix data were from the federal On-Line Survey Certification and Reporting (OSCAR) system and other data were from public sources. Study Design. Ordinary least squares and two-stage least squares regression analyses were used to separately examine the relationship between registered nurse (RN) and total nursing hours in all U.S. nursing homes in 2002, with two endogenous variables: Medicaid reimbursement rates and resident case mix. Principal Findings. RN hours and total nursing hours were endogenous with Medicaid reimbursement rates and resident case mix. As expected, Medicaid nursing home reimbursement rates were positively related to both RN and total nursing hours. Resident case mix was a positive predictor of RN hours and a negative predictor of total nursing hours. Higher state minimum RN staffing standards was a positive predictor of RN and total nursing hours while for-profit facilities and the percent of Medicaid residents were negative predictors. Conclusions. To increase staffing levels, average Medicaid reimbursement rates would need to be substantially increased while higher state minimum RN staffing standards is a stronger positive predictor of RN and total nursing hours. Key Words. Nurse staffing, nursing facilities, Medicaid reimbursement, rates, resident case mix, Many studies have documented the importance of nursing staff in both the process and the outcomes of nursing home care (Aaronson, Zinn, and Rosko 1994; Bliesmer et al. 1998; Carter [...]

Objective. To examine nursing home expenditures on clinical, hotel, and administrative activities during the 1990s and to determine the association between nursing home competition and excess demand on expenditures. Data Sources/Study Setting. Secondary data sources for 1991, 1996, and 1999 for 500 free-standing nursing homes in New York State. Study Design. A retrospective statistical analysis of nursing homes' expenditures. The dependent variables were clinical, hotel, and administrative costs in each year. Independent variables included outputs (inpatient and outpatient), wages, ownership, New York City location, and measures of competition and excess demand. Data Collection/Extraction Method. Variables were constructed from annual financial reports submitted by the nursing homes, the Patient Review Instrument and Medicare enrollment data. Principal Findings. Clinical and administrative costs have increased over the decade, while hotel expenditures have declined. Increased competition was associated with higher clinical and administrative costs while excess demand was associated with lower clinical and hotel expenditures. Conclusions. Nursing home expenditures are sensitive to competition and excess demand conditions. Policies that influence competition in nursing home markets are therefore likely to have an impact on expenditures as well. Key Words. Nursing homes, costs, competition, excess demand, Nursing homes provide a complex array of services to a heterogeneous group of patients. They offer both clinical care and a living environment that serves as the residents' home. Nursing [...]

Objective. To examine variations in hospitalization rates among nursing home residents associated with discretionary hospitalization practices. Data Sources. Quarterly Medicaid case-mix reimbursement data from the state of Massachusetts served as the core data source for dais study, which was linked with data from the Medicare Provider Analysis and Review file (MEDPAR) to specify hospitalization status, nursing facility attribute data from the state of Massachusetts to specify facility-level organizational and structural attributes, and data from the Area Resource File (ARF) to specify area market-level attributes. Data spans three years (1991-1993) to produce a longitudinal analytical file containing 72,319 person-quarter-level observations. Study Design. Two-step, multivariate logistic regression models were estimated for highly discretionary hospitalizations versus those containing less discretion, and low discretionary hospitalizations versus those containing greater amounts of physician discretion. Principal Findings. Findings indicate that facility case-mix levels and area hospital bed supply levels contribute to variations in hospitalization rates among nursing home residents. Highly discretionary hospitalizations appear to be most sensitive to patient diagnoses best described as chronic, ambulatory care sensitive conditions. Conclusions. Findings suggest that defining hospitalizations simply in terms of whether an event occurs versus otherwise may obscure valuable information regarding the contribution of various risk factors to highly discretionary versus low discretionary hospitalization rates. Key Words. Discretionary hospitalizations, nursing home transfers, Findings from the larger body of geographic variations research exploring hospital use rates among community-based populations offers insight regarding methods that are likely to be useful in exploring variations in [...]

Objective. To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care. Data Sources/Study Settings. Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database. Study Design. A cross-sectional analysis of the association among the different measures was performed. Data Collection/Extraction Methods. Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database. Principal Findings. Nursing homes differed significantly (p< .001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p Conclusions. Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain. Key Words. Quality improvement, quality of care, nursing homes, decubitus ulcers improving the quality of nursing home care is a national priority (Institute of Medicine 2001). As with other sectors of the health care industry, nursing homes are increasingly applying industrial quality control principles to the task of improving care (Zinn, Brannon, and Weech 1997). These management principles, known as continuous quality improvement, total quality management, or simply quality improvement (QI), emphasize developing a structured, organization-wide approach to understanding and improving underlying work processes (Blumenthal 1993). Quality improvement implementation in nursing homes, though, has not been extensively studied. Limited past research suggests that more than three-quarters of nursing homes practice some quality improvement activities and that the adoption of these practices is influenced by both institutional and market factors (Zinn, Weech, and Brannon 1998). However, these results were based on s urveys of nursing home administrators and may not capture the true extent of QI implementation within the organization. Additionally, the effects of QI implementation on the adoption of best practices in the nursing home and on improving resident outcomes are uncertain (Institute of Medicine 2001). We therefore set out to examine QI implementation, its association with organizational culture, and its relationships with care within nursing homes maintained by the Department of Veterans Affairs (VA)., BACKGROUND AND HYPOTHESES The VA operates a federally financed health care system for eligible veterans. The system comprises more than 150 medical centers, many of which have associated nursing homes. [...]

Objective. To investigate resident and facility attributes associated with long-term care health outcomes in nursing homes. Data Sources. Quarterly Management Minutes Questionnaire (MMQ) survey data for Medicaid case-mix reimbursement of nursing homes in Massachusetts from 1991 to 1994, for specification of outcomes and resident attributes. Facility attributes are specified from cost report data. Study Design. Multivariate logistic and "state-dependence" regression models are estimated for survival, ADL functional status, incontinence status, and mental status outcomes from longitudinal residence histories of Medicaid residents spanning 3 to 36 months in length. Outcomes are specified to be a function of resident demographic and diagnostic attributes and facility-level operating and nurse staffing attributes. Principal Findings. The estimated parameters for resident demographic and diagnostic attributes showed a great deal of construct validity with respect to clinical expectations regarding risk factors for adverse outcomes. Few facility attributes were associated with outcomes generally, and none was significantly associated with all four outcomes. Conclusions. The absence of uniform associations between facility attributes and the various long-term care health outcomes studied suggests that strong facility performance on one health outcome may coexist with much weaker performance on other outcomes. This has implications for the aggregation of individual facility performance measures on multiple outcomes and the development of overall outcome performance measures. Key Words. Health outcomes, nursing homes, long-term care, Researchers have advocated the use of outcome measures for measuring quality of nursing home care and for reimbursement purposes since the late 1960s (Andersen and Stone 1969). To date, only [...]

Objective. To examine the effect of case mix - adjusted reimbursement policy and market factors on nursing home performance. Data Sources and Study Setting. Data from Medicaid certification inspection surveys, Medicaid cost reports, and the Kentucky State Center for Health Statistics for the years 1989 and 1991, to examine changes in nursing home performance stemming from the adoption of case mix - adjusted reimbursement in 1990. Study Design. In addition to cross-sectional regressions, a first-difference approach to fixed-effects regression analyses was employed to control for facility differences that were essentially fixed during the survey years and to estimate the effects of time-varying predictors on changes in facility expenditures, efficiency, and profitability. Principal Findings. Facilities that increased the proportion of Medicaid residents and eliminated excess capacity experienced higher profitability gains during the beginning phase of case-mix reimbursement. Having a heavy-care resident population was positively related to expenditures prior to reimbursement reform, and it was negatively related to expenditures after the case-mix reimbursement policy was introduced. While facility-level changes in case mix had no reliable influence on costs or profits, nursing homes showing an increased prevalence of poor-quality nursing practices exhibited increases in efficiency and profitability. At the market level, reductions in excess or empty nursing home beds were accompanied by a significant growth in home health services. Moreover, nursing homes located in markets with expanding home health services exhibited higher increases in costs per case-mix unit. Conclusions. Characteristics of the reimbursement system appear to reward a cost minimization orientation with potentially detrimental effects on quality of care. These effects, exacerbated by a supply-constrained market, may be mitigated by policies that encourage the expansion of home health service availability. Key Words. Case-mix reimbursement, excess demand, home health services, Case-mix reimbursement systems are intended to eliminate incentives that discourage nursing homes from admitting heavy-care Medicaid patients by varying the reimbursement rate with the patient's condition (Rosko, Boyles, and Aaronson [...]

Objective. To develop and test a model, based on resource dependence theory, that identifies the organizational and environmental characteristics associated with nursing home participation in managed care. Data Sources and Study Setting. Data for statistical analysis derived from a survey of Directors of Nursing in a sample of nursing homes in eight states (n = 308). These data were merged with data from the On-line Survey Certification and Reporting System, the Medicare Managed Care State/County Data File, and the 1995 Area Resource File. Study Design. Since the dependent variable is dichotomous, the logistic procedure was used to fit the regression. The analysis was weighted using SUDAAN. Findings. Participation in a provider network, higher proportions of resident care covered by Medicare, providing IV therapy, greater availability of RNs and physical therapists, and Medicare HMO market penetration are associated with a greater likelihood of having a managed care contract. Conclusion. As more Medicare recipients enroll in HMOs, nursing home involvement in managed care is likely to increase. Interorganizational linkages enhance the likelihood of managed care participation. Nursing homes interested in managed care should consider upgrading staffing and providing at least some subacute services. Key Words. Nursing home care, Medicare managed care, HMOs, Managed care is rapidly overtaking cost-based, fee-for-service payment as the dominant reimbursement paradigm for the American healthcare system (Group Health Association of America 1993). The dominance achieved by managed care [...]