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BackgroundIn order to optimize interventions and services in the community, it is important to identify the profile of persons who are able to stay at home and of those who are being admitted into residential care. Understanding their needs and their use of resources is essential. The main objective of the study is to identify persons who are likely to enter residential care based upon their needs and resource utilization, so that care providers can plan interventions effectively and optimize services and resources to meet the persons’ needs.MethodsThis is a longitudinal quasi-experimental study. The data consists of primary data from the community setting collected every six months during the period of 2010–2016. Interventions had the goal of keeping older people longer at home. Participants were at least 65 years old and were living in the community. The interRAI Resource Utilization Group system (RUG-III) was used to calculate the case-mix indexes (CMI) of all participants. Comparisons were made between the case-mix of those who were still living at home and those who were admitted into residential care at follow-up.ResultsA total of 10,289 older persons participated in the study (81.2 ± 7.1 yrs., 69.1% female). From this population, 853 participants (8.3%) were admitted into residential care. The CMI of the persons receiving night care at home were the highest (1.6 at baseline and 1.7 at the entry point of residential care), followed by persons receiving occupational therapy (1.5 at baseline and 1.6 at the entry point of residential care) and persons enrolled in case management interventions with rehabilitation (1.4 at baseline and 1.6 at the entry point of residential care). The CMIs at follow-up were significantly higher than at baseline and the linear regression model showed that admission to residential care was a significant factor in the model.ConclusionsThe study showed that the RUG-III system offers possibilities for identifying persons at risk of institutionalization. Interventions designed to avoid early nursing home admission can make use of the RUG-III system to optimize care planning and the allocation of services and resources. Based on the RUG-III case-mix, resources can be allocated to keep older persons at home longer, bearing in mind the complexity of care and the availability of services in the community.

Limited funding across health and social service programs presents a challenge regarding how to best match resources to the needs of the population. There is increasing consensus that differences in individual characteristics and care needs should be reflected in variations in service costs, which has led to the development of case-mix systems. The present study sought to develop a new approach to allocate resources among children and youth with intellectual and developmental disabilities (IDD) as part of a system-wide Medicaid payment reform initiative in Arkansas. To develop the system, assessment data collected using the interRAI Child and Youth Mental Health-Developmental Disability instrument was matched to paid service claims. The sample consisted of 346 children and youth with developmental disabilities in the home setting. Using automatic interactions detection, individuals were sorted into unique, clinically relevant groups (ie, based on similar resource use) and a standardized relative measure of the cost of services provided to each group was calculated. The resulting case-mix system has 8 distinct, final groups and explains 30% of the variance in per diem costs. Our analyses indicate that this case-mix classification system could provide the foundation for a future prospective payment system that is centered around stability and equitability in the allocation of limited resources within this vulnerable population.

Background Down syndrome (DS) is characterised by premature ageing that affects selected organ systems, and persons with this condition can present patterns of co-morbidities and deficits often observed in the older population without DS. However, information on the characteristics of adult persons with DS is limited. The objective of the study is to describe characteristics of adults with DS collected with a standardised, comprehensive assessment instrument. Methods Cross-sectional study. Four hundred thirty adults with DS (age range 18/75 years) from three countries (Italy, n = 95; USA, n = 175; and Canada, n = 160). A standardised assessment instrument (interRAI intellectual disability) was used to assess sample characteristics. Results Mean age ranged from 35.2 (standard deviation 12.0) years in the US sample to 48.8 (standard deviation 9.0) years in the Canadian sample. Most participants in the Italian and US sample were living in private homes, while more than half of those in the Canadian sample were institutionalised. Prevalences of geriatric conditions, including cognitive deficits, disability in the common activities of daily living, symptoms of withdrawal or anhedonia, aggressive behaviour, communication problems, falls and hearing problems were high in the study sample. Gastrointestinal symptoms, skin and dental problems and obesity were also frequently observed. Conclusions Adults with DS present with a high level of complexity, which may suggest the need for an approach based on a comprehensive assessment and management that can provide adequate care. Further research is needed to understand better the effectiveness of such an approach in the DS population.

Cognitive decline impacts older adults, particularly their independence. The goal of this project was to increase understanding of how short-term, everyday lifestyle options, including physical activity, help an older adult sustain cognitive independence. Using a secondary analysis of lifestyle choices, we drew on a dataset of 4,620 community-dwelling elders in the US, assessed at baseline and one year later using 2 valid and reliable tools, the interRAI Community Health Assessment and the interRAI Wellness tool. Decline or no decline on the Cognitive Performance Scale was the dependent variable. We examined sustaining one’s status on this measure over a one-year period in relation to key dimensions of wellness through intellectual, physical, emotional, social, and spiritual variables. Engaging in physical activity, formal exercise, and specific recreational activities had a favorable effect on short-term cognitive decline. Involvement with computers, crossword puzzles, handicrafts, and formal education courses also were protective factors. The physical and intellectual domains of wellness are prominent aspects in protection from cognitive decline. Inherent in these two domains are mutable factors suitable for targeted efforts to promote older adult health and well-being.

Few studies have examined the effects of smoking on nursing home utilization, generally using poor data on smoking status. No previous study has distinguished utilization for recent from long-term quitters.Using the Health and Retirement Study, we assessed nursing home utilization by never-smokers, long-term quitters (quit3 years), recent quitters (quit ≤3 years), and current smokers. We used logistic regression to evaluate the likelihood of a nursing home admission. For those with an admission, we used negative binomial regression on the number of nursing home nights. Finally, we employed zero-inflated negative binomial regression to estimate nights for the full sample.Controlling for other variables, compared with never-smokers, long-term quitters have an odds ratio (OR) for nursing home admission of 1.18 (95% CI: 1.07-1.2), current smokers 1.39 (1.23-1.57), and recent quitters 1.55 (1.29-1.87). The probability of admission rises rapidly with age and is lower for African Americans and Hispanics, more affluent respondents, respondents with a spouse present in the home, and respondents with a living child. Given admission, smoking status is not associated with length of stay (LOS). LOS is longer for older respondents and women and shorter for more affluent respondents and those with spouses present.Compared with otherwise identical never-smokers, former and current smokers have a significantly increased risk of nursing home admission. That recent quitters are at greatest risk of admission is consistent with evidence that many stop smoking because they are sick, often due to smoking.

Purpose: When government funding for long-term care is reduced, participant outcomes may be adversely affected. We investigated the effect of program resources on individuals enrolled in the Michigan Home- and Community-Based Services (HCBS) waiver program for elderly and disabled adults. Design and Methods: Using dates of major policy and budget changes, we defi ned 4 distinct time periods between October 2001 and December 2005. Minimum Data Set for Home Care assessment records for HCBS participants ( n = 112,182) were used to examine temporal trends in formal care hours and 6 outcomes: emergency room (ER) use, hospitalization, caregiver burden, death, nursing facility (NF) use, and permanent NF placement. Controlling for demographics, functional status, and cognitive status, adjusted odds of outcomes were obtained using discrete-time survival analysis. Results: As resources diminished, mean formal care hours decreased, declining most for persons with moderate functional or cognitive impairment, for up to an approximately 30% decrease. In the most fi nancially restricted period, 3 adverse outcomes increased relative to baseline: hospitalization (odds ratio [OR] = 1.10; 95% confi dence interval [CI] = 1.03 – 1.18), ER use (OR = 1.13; 95% CI = 1.03 – 1.24), and permanent NF placement (OR = 1.20; 95% CI = 1.00 – 1.42). Implications: Reductions in resources for home care were associated with increased probability of adverse outcomes. Cutting funds to home care programs can increase utilization of other more costly services, thus offsetting potential health care savings. Policymakers must consider all ways in which budget reductions and policy changes can affect participants.

OBJECTIVES: To examine the frequency distributions and interrater reliability of individual items of the interRAI Acute Care instrument. DESIGN: Observational study of a representative sample of older inpatients; duplicate assessments conducted on a subsample by independent assessors to examine interrater reliability. SETTING: Acute medical, acute geriatric and orthopedic units in 13 hospitals in nine countries. PARTICIPANTS: Five hundred thirty-three patients aged 70 and older (mean age 82.4, range 70–102) with an anticipated stay of 48 hours or longer of whom 161 received duplicate assessments. MEASUREMENTS: Sixty-two clinical items across 11 domains. Premorbid (3-day observation period before onset of the acute illness) and admission (the first 24 hours of hospital stay) assessments were conducted. RESULTS: The frequency of deficits exceeded 30% for most items, ranging from 1% for physically abusive behavior to 86% for the need for support in activities of daily living after discharge. Common deficits were in cognitive skills for daily decision-making (38% premorbid, 54% at admission), personal hygiene (37%, 65%), and walking (39%, 71%). Interrater reliability was substantial in the premorbid period (average κ=0.61) and admission period (average κ=0.66). Of the 69 items tested, less than moderate agreement (κ 0.8) for nine (13%). CONCLUSION: Initial assessment of the psychometric properties of the interRAI Acute Care instrument provided evidence that item selection and interrater reliability are appropriate for clinical application. Further studies are required to examine the validity of embedded scales, diagnostic algorithms, and clinical protocols.

Purpose: The U.S. Department of Veterans Affairs has adopted two functional assessment systems that guide care planning: one for nursing home residents (the Resident Assessment Instrument [RAI]) and a compatible one for home care clients (RAI-HC). The purpose of this article is to describe the RAI-HC (often referred to as the Minimum Data Set-Home Care or MDS-HC) and its uses and offer lessons learned from implementation experiences in other settings. Design and Methods: We reviewed implementation challenges associated both with the RAI and the RAI-HC in the United States, Canada, and other adopter countries, and drew on these to suggest lessons for the Department of Veterans Affairs as well as other entities implementing the RAI-HC. Results: Beyond its clinical utility, there are a number of evidence-based uses for the assessment system. The resident-level data can be aggregated and analyzed, and scales identify clinical conditions and risk for various types of negative outcomes. In addition, the data can be used for other programmatic and research purposes, such as determining eligibility, setting payment rates for contract care, and evaluating clinical interventions. At the same time, there are a number of implementation challenges the Department of Veterans Affairs and other organizations may face. Implications: Policy makers and program managers in any setting, including state long-term-care programs, who wish to implement an assessment system must anticipate and address a variety of implementation problems with a clear and consistent message from key leadership, adequate training and clinical support for assessors, and appropriate planning and resources for data systems.

OBJECTIVES: To examine the relationship between in-somnia,hypnoticuse,falls,andhipfracturesinolderpeople.DESIGN: Secondary analysis of a large, longitudinal, as-sessment database.SETTING: Four hundred thirty-seven nursing homes inMichigan.PARTICIPANTS: Residents aged 65 and older in 2001withabaselineMinimumDataSetassessmentandafollow-up 150 to 210 days later.MEASUREMENTS: Logistic regression modeled any fol-low-up report of fall or hip fracture. Predictors were base-line reports of insomnia (previous month) and use ofhypnotics (previous week). Potential confounds taken intoaccount included standard measures of functional status,cognitive status, intensity of resource utilization, proximitytodeath,illnessburden,numberofmedications,emergencyroom visits, nursing home new admission, age, and sex.RESULTS: In 34,163 nursing home residents (76% wom-en, mean age standard deviation 84 8), hypnotic usedid not predict falls (adjusted odds ratio (AOR)51.13,95% confidence interval (CI)50.98, 1.30). In contrast, in-somnia did predict future falls (AOR51.52, 95%CI51.38, 1.66). Untreated insomnia (AOR51.55, 95%CI51.41, 1.71) and hypnotic-treated (unresponsive) in-somnia (AOR51.32, 95% CI51.02, 1.70) predictedmore falls than did the absence of insomnia. After adjust-mentforconfoundingvariables,insomniaandhypnoticusewere not associated with subsequent hip fracture.CONCLUSION: Inelderlynursinghomeresidents,insom-nia, but not hypnotic use, is associated with a greater riskof subsequent falls. Future studies will need to confirmthese findings and determine whether appropriate hypnoticuse can protect against future falls. J Am Geriatr Soc53:955–962, 2005.Key words: insomnia; accidental falls; hip fractures;aged; nursing homes; Minimum Data Set; interRAI

Wodchis WP, Teare GF, Naglie G, Bronskill SE, Gill SS, Hillmer MP, Anderson GM, Rochon PA, Fries BE. Skilled nursing facility rehabilitation and discharge to home after stroke. Objective To determine the relation between rehabilitation therapy (RT) intensity and time to discharge home for stroke patients in skilled nursing facilities (SNFs). Design Retrospective cohort study. We used regression analyses, stratified by expected outcome, and propensity score adjustment. Setting All SNFs in Ohio, Michigan, and Ontario, Canada. Participants A cohort of residents, aged 65 and over, admitted from hospitals to SNFs with a diagnosis of stroke (N=23,824). Interventions Not applicable. Main outcome measure Time to discharge home from an SNF. Results RT was given to more than 95% of residents for whom discharge was expected within 90 days and to more than 60% of residents for whom discharge was uncertain or not expected. RT increased the likelihood of discharge to the community for all groups except those expected to be discharged within 30 days. The dose-response relation was strongest for residents with either an uncertain discharge prognosis or no discharge expected. Conclusions Postacute residents with an uncertain prognosis are an important target population for intensive RT.

This study examines how case managers identify and respond to home care client needs through chart reviews of 169 randomly selected clients in a homecare program. Algorithms from the Minimum Data Set for Home Care to identify client needs were applied to the existing data to determine whether a potential problem existed in any of 23 broad categories of need. The authors also determine whether these problems were noted by the case manager and identify various types of responses made in the care plan. Compared to the range of problems identified with the algorithms, case managers were more likely to note functional and mental health problems than clinical health problems. Some problem categories (e.g., functional performance and brittle support) almost always received a response, whereas others (e.g., sensory performance, mental health, and some clinical problems) remained unmet even when the problem was noted. Implications for training case managers and resource development in the community are discussed.

Wodchis WP, Fries BE, Pollack H. Payer incentives and physical rehabilitation therapy for nonelderly institutional long-term care residents: evidence from Michigan and Ontario. Arch Phys Med Rehabil 2004;85:210–7. Objective To examine the effect of payment incentives on the provision of rehabilitation therapy to nonelderly nursing home residents. Design Retrospective cross-sectional study. Setting Nursing homes in Michigan or complex continuing care facilities in Ontario, Canada, in 1998 or 1999. Participants Nonelderly nursing home residents (N=5189) admitted to nursing homes. Interventions Not applicable. Main outcome measures The effect of payment on access to physical therapy (PT) and occupational therapy (OT) and total weekly time for each therapy type. Results A Medicare policy change from cost-based to a patient-specific case-mix payment method was associated with greater likelihood of receiving OT but reduced weekly minutes of PT and OT provided to residents. Medicare cost-based and private insurance were associated with greater likelihood of receiving OT and PT and more therapy time for both types of therapy compared with private-pay residents. Global budget payment was associated with greater access to PT but fewer weekly minutes of OT and PT. Conclusions Little information exists to describe the characteristics and treatment of nonelderly nursing home residents. This study found that many of these residents received rehabilitation and that residents whose care was paid for by more generous payers, such as Medicare, received more therapy than those paid for by less generous payers.

The number of patients in nursing homes with severe cognitive impairment (SCI) is growing. The authors compared the characteristics and 6-month outcomes of a sample of nursing home residents with SCI to those of other residents. This cross-sectional and 6-month follow-up study used data from pooled 1990 and 1993 cohorts in the Resident Assessment Instrument Evaluation Study. The authors compared baseline characteristics of residents with SCI (n = 1304) with all others and evaluated 6-month improvement and associated factors in the SCI group. SCI residents had poorer nutrition and lower frequencies of most symptoms and chronic diseases. Fourteen percent showed 6-month cognitive improvement, associated with higher baseline function, antidepressant medication, and recent falls. Nursing home residents with SCI had possible underrecognition of medical problems and poor nutritional status. Measured improvement may indicate possible misclassification for some residents and potential for improvement for others. ( J Geriatr Psychiatry Neurol 2003; 16:100-108)

Purpose: The aim of this study was to validate a pain scale for the Minimum Data Set (MDS) assessment instrument and examine prevalence of pain in major nursing home subpopulations, including type of admission and cognitive status. Design and Methods: This study considered validation of the MDS pain items and derivation of scale performed against the Visual Analogue Scale (VAS), using Automatic Interaction Detection. The derivation data describe 95 postacute care nursing home patients who are able to communicate. The scale is then used in retrospective analysis of 34,675 Michigan nursing home residents. Results: A four-group scale was highly predictive of VAS pain scores (variance explanation 56%) and therefore quite valid in detecting pain. In the prevalence sample, only 47% of postacute patients compared to 63% of postadmission patients reported no pain, and these percentages rose with increasing cognitive impairment. Implications: Pain is prevalent in nursing home residents, especially in those with cognitive dysfunction, and often untreated. The Omnibus Budget Reconciliation Act of 1987 mandated that a comprehensive and uniform resident assessment system be implemented nationwide in all United States nursing homes. The Resident Assessment Instrument (RAI) system, with its Minimum Data Set (MDS) assessment, was implemented in 1991 (Morris et al., 1990). The purpose of the RAI was mandated in the original law: to improve care. It was assumed that improved, individualized assessment of a resident’s condition would lead to better care planning that would, in turn, lead to better care and improved outcomes. This logic of achieving improved care requires at least that the assessment is accurate and valid. In this context, pain is a domain acknowledged to be critical yet underrecognized in older people. Prevalence estimates of pain among nursing home resi

OBJECTIVE: To describe the differences in prevalence of tube feeding among states and to examine possible factors that could explain practice patterns. DESIGN: Analysis of random samples from an interstate data bank comprised of the Minimum Data Set (MDS), a standardized, federally mandated assessment instrument for nursing home residents. SETTING: Nursing homes in four states participating in a federal demonstration project of case mix payment plus five others with existing MDS data systems. PARTICIPANTS: Individuals 65 years of age and older (N 5 57,029), who had very severe cognitive impairment, including total dependence in eating, and who resided in nursing homes during 1994, the most recent year for which uniform data were available. MEASUREMENTS: State-by-state differences in prevalence of tube feeding, controlling for demographic and clinical variables. RESULTS: The prevalence of tube feeding ranged from 7.5% in Maine to 40.1% in Mississippi. Each state had a significantly elevated prevalence of tube feeding compared with Maine, with odds ratios (ORs) ranging from 1.50 to 5.83, P , .001. Specific directives not to provide tube feeding (OR 0.41, P , .001), and white race (OR 0.45, P , .001) were strongly and negatively associated with tube feeding. CONCLUSIONS: Wide regional variations exist in the use of tube feeding of nursing home residents with equivalent impairments. Sociodemographic factors could be important, but more study is needed to determine whether physician characteristics, such as race, attitudes, or knowledge, have an impact and to clarify medical standards for the use of tube feeding in this population. J Am Geriatr Soc 49:148‐152, 2001.

Admission cohorts from the Michigan Medicaid Home and Community-Based Waiver program and Ohio nursing homes were compared on measures of resource utilization including a modified Resource Utilization Groups (RUG-III) system, Activities of Daily Living (ADLs), and overall case mix. We found that, contrary to previous research, the two samples were remarkably similar across RUG-III categories. However, the nursing home sample was more functionally impaired on measures of ADL functioning and overall case mix. Results of this study may inform policymakers and providers of the potential for maintaining the appropriate population in the home with government-funded home care.

RÉSUMÉLe système de classification de la composition de la clientèle des maisons de soins infirmiers, Resource Utilization Groups Version III (RUG-III), a été éprouvé et raffiné pour les bénéficiaires de soins de longue durée à domicile. Lapos;échantillonnage étudié regroupe 804 personnes recevant des soins à domicile par l'entremise du Michigan Care Management Program ou du Home and Community Based Waiver for the Elderly and Disabled. On a catégorisé les clients et établi des modèles de RUG-III à partir du Minimum Data Set for Home Care (MDS-HC). On a établi un modèle raffiné de soins à domicile, RUG-III/HC, en incorporant les activités instrumentales de la vie quotidienne (AIVQ) à la classification RUG-EH des établissements de soins. Le modèle explique 33,7 pour cent de la variance des coûts quotidiens, à partir de la variable dépendante du coût pondéré des soins structurés ou non. L'utilisation des ressources à l'égard des différents groupes est relativement homogène. Le CMI (case-mix index) du temps pondéré des soins structurés ou non couvre une échelle de 8. Il faudra songer à effectuer des analyses plus poussées du coût de l'inclusion des soins non structurés à l'égard des patients recevant des soins à domicile de longue durée.

Background. Dependency in activities of daily living (ADLs) is a reality within nursing homes, and we describe ADL measurement strategies based on items in the Minimum Data Set (MDS) and the creation and distributional properties of three ADL self-performance scales and their relationship to other measures. Methods. Information drawn from four data sets for a multistep analysis was guided by four study objectives: (I) to identify the subcomponents of ADLs that are present in the MDS battery; (2) to demonstrate how these items could be aggregated within hierarchical and additive ADL summary scales; (3) to describe the baseline and longitudinal distributional properties of these scales in a large, seven-state MDS database; and (4) to evaluate how these scales relate to two external criteria. Results. Prevalence and factor structure findings for seven MDS ADL self-performance variables suggest that these items can be placed into early, middle, and late loss ADL components. Two types of summary ADL self-performance measures Were created: additive and hierarchical. Distributional properties of these scales are described, as is their relationship to two external ADL criteria that have been reported in prior studies: first as an independent variable predicting staff time involved in resident care; second as a dependent variable in a study of the efficacy of two programs to improve resident functioning. Conclusions. The new ADL summary scales, based on readily available MDS data, should prove useful to clinicians, program auditors, and researchers who use the MDS functional self-performance items to determine a resident's ADL status. ACTIVITIES of daily living (ADLs) are among the most J-\.basic building blocks of life and are central to our ability to comprehend the experience of residents in nursing homes (1,2). Although ADL dependency is rare in the community, it is pervasive in the nursing home; and once in a nursing home, the specter of continued decline sets the tone that drives much of nursing and rehabilitative care. In U.S. nursing homes, the mea­ surement of ADLs is based on the items in the mandated Minimum Data Set (MDS) assessment instrument-an inte­ grated information battery with many dimensions and associ­ ated summary measures (1,3-12). The individual ADL items in the MDS have been shown to cross-walk with elements in the Functional Independence Measure (AM) rehabilitation tracking system (13), to be pow­ erful predictors of resource utilization in the Resource Utilization Groups (RUG-III) system recently adopted as part of the federal Medicare Prospective Payment System (14), and to have high interassessor reliability values (6,9). For those who desire to track a single ADL area, e.g., locomotion or eating, the current scoring of the individual MDS ADL items is quite satisfactory. There are five progressive levels of dependency, and given the demonstrated reliabilities for these items, even a single category change in status can have real meaning. At the same time, for the vast majority of applications, there is a need to go beyond the resident's status in a single ADL area. Clinical and programmatic initiatives are almost always focused on a broader conceptualization of the self-performance status of the resident. What is needed is a system for summariz­ ing the individual ADLs. Is the resident improving or declining in some holistic sense? Is a program effective or ineffective in improving resident status or slowing down decline? These are

Resource Utilization Groups, Version III (RUG-III) is a case-mix system developed in the USA for classification of long-term care residents. This paper examines the validity and reliability of an adapted 22-group version of RUG-III (RUG-III/22) for use in long-term care facilities in Finland. Finnish cost weights for RUG-III/22 groups are calculated and different methods for their computation are evaluated. The study sample (1,964 residents) was collected in 1995 - 96 from ten long-term care facilities in Finland. RUG-III/22 alone explained 38.2% of the variance of total patient-specific (nursing + auxiliary staff) per diem cost. Resource use within RUG groups was relatively homogeneous. Other predictors of resource use included age, gender and length of stay. RUG-III/22 also met the standard for good reliability (i.e. a kappa value of 0.6 or higher) for crucial classification items, such as activities of daily living and high correlation between assessments based on relative cost.

OBJECTIVE: To evaluate the effect of the implementation of the National Resident Assessment Instrument (RAI) system on selected conditions representing outcomes for nursing home residents. DESIGN: Quasi-experimental, pre-/post-design, with assessments at baseline and 6-month follow-up. SAMPLE: Two thousand one hundred twenty-eight residents from 268 nursing homes in 10 states before RAI implementation, and 2,088 from 254 of the same nursing homes after implementation. MEASURES: From the full RAI Minimum Data Set, measures of dehydration, falls, decubitus, vision problems, stasis ulcer, pain, dental status (poor teeth), and malnutrition were examined at baseline and 6 months later. Poor nutrition was evaluated using a body mass index score below 20 and vision using a 4-level scale; other conditions were represented by their presence or absence. Decline and improvement were computed as the changes in level between baseline and follow-up, limiting the sample to those who could manifest each such change. MAIN RESULTS: Of eight health conditions representing poorer health status, dehydration and stasis ulcer had significantly lower prevalence after the implementation of the RAI (1993) compared with 1990. At the same time, there was an increase in the prevalence of daily pain. Fewer residents declined over 6 months in nutrition and vision after implementation. Although for these two conditions there were also significantly reduced rates of improvement, the net was an overall reduction in the 6-month rate of decline for all residents. Pain also demonstrated a decline in the postimplementation rate of improvement. The combined eight conditions showed reductions in the rates of both decline and improvement. CONCLUSIONS: Several outcomes for nursing home residents improved after implementation of the RAI. Of the four conditions for which there are significant declines in prevalence or outcome changes, three are specifically addressed in the care planning guidelines incorporated the RAI system (all except stasis ulcer, although there is a RAP for decubitus ulcer). Pain, the only other condition with a significant result — an increase in baseline prevalence — also has no RAP. Although the changes might be ascribed otherwise, they support the premise that the RAI has directly contributed to improved outcomes for nursing home residents.

OBJECTIVE: To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC. DESIGN: Independent, dual assessment of clients of homecare agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients. SETTING AND PARTICIPANTS: Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States. MEASUREMENTS: The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses, health conditions and preventive health measures, nutrition/ hydration, dental status, skin condition, environmental assessment, service utilization, and medications. RESULTS: Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels. CONCLUSION: Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second generation problem and care plan-driven assessment instrument, disability assessment can be pet-formed consistently across the world.

OBJECTIVE: The Patient Self-Determination Act (PSDA) implemented in 1991 has focused national attention on the right of patients to be involved in decision-making and on the use of written advance directives. We report changes in advance care planning with the PSDA and other historical events in nursing homes in 10 states. DESIGN: Pre- and Post-observational cohort study PATIENTS: Nursing home residents, residing in 270 long-term care facilities in 10 states, stratified to ensure representation of urban and rural facilities in each state. In 1990, 2175 patients were sampled, and 2088 different patients from the same facilities were sampled in 1993. Six-month follow-up was obtained at both time periods. MAIN OUTCOME MEASURES: Advance care planning was defined as the documentation in the medical record of a living will, a durable power of attorney, a “Do Not Resuscitate” (DNR) order, a “Do Not Hospitalize” (DNH) order, or an order to forgo artificial nutrition or hospitalization. RESULTS: The rate of chart documentation of living wills increased from 4.2% in 1990 to 13.3% in 1993, and DNR orders increased dramatically from 31.1% to 51.5%. The rates of DNH and orders to forgo artificial hydration and nutrition remained less than 8% in both years. We found striking variations in advance care planing among the 10 states. In 1990, having a DNR order varied from 10.1% to 69.2% across the 10 states. With the exception of Oregon, where 69.2% of patients already had a DNR order, the states saw a 1.5 to 3.1 times increase in the rate of DNR orders in 1993 compared with 1990. CONCLUSION: With the implementation of the PSDA, there was modest increase in documentation of living wills, but DNH and orders to forgo artificial hydration and nutrition remained the same. There was a substantial increase in DNR orders that began before the PSDA implementation. This increase was associated both with the implementation of the PSDA and the increased debate about the appropriateness of CPR for nursing home residents. This increase varied considerably among geographic areas from the 10 states. Future research is needed to understand this geographic variation.

OBJECTIVE: To describe the reliability of new assessment items and their clinical utility as judged by experienced nurse assessors, based on the results from the field test of Version 2.0 of the Resident Assessment Instrument (RAI). DESIGN: Independent dual assessment of residents of nursing facilities by staff nurses using a draft of Version 2.0 of the minimum data set (MDS). SETTING AND PARTICIPANTS: A total of 187 randomly selected residents from 21 nursing homes in seven states volunteered to test Version 2.0 of the MDS. MEASUREMENT: The full array of MDS assessment items included measures in the following areas: Background information, cognitive patterns, communication/hearing, vision, mood and behavior, psychosocial well-being, physical functioning and structural problems, continence, disease diagnoses, health condition, oral/nutritional status, dental status, skin condition, activity pursuit patterns, medications, special treatments and procedures, and discharge potential and overall status. RESULTS: Evaluative data address issues of MDS item utility and reliability. For new items, almost all achieved a reasonably high-weighted Kappa interrater reliability; revised items also surpassed earlier items, and with the updated training materials, even the non-changed items had higher average reliability levels. Based on the success of the field test and the positive response of the industry, Version 2.0 of the RAI has been adopted, and HCFA has initiated a more long-range process to update further the RAI when necessary. CONCLUSION: Findings support the reliability and clinical utility of the new and revised assessment items incorporated by HCFA in Version 2.0 of the MDS.

OBJECTIVE: To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI). SAMPLE: Subjects were nursing home residents chosen from 268 facilities in major Metropolitan Statistics Areas in 10 states and representing more than 1500 facilities and 60,000 residents. Two resident cohorts (1990 and 1993) were sampled (8 to 16 residents per facility, depending upon facility size) as part of an evaluation of the impact of implementing the RAI. METHODS: Research nurses reviewed records, interviewed staff, observed patients, and completed an RAI at baseline and 6 months later. All transitions during this interval (hospital admissions, nursing home transfers, returns home, death, etc.) were tracked. Using polytomous logistic regression, we tested the effect of cohort on the probability of being hospitalized in light of the competing risks of dying or remaining in the home, controlling for demographic and case-mix variables, and having a DNR order in the chart. RESULTS: A total of 4196 residents were studied, 2118 in 1990 (age 81.3, female 77.7%, LOS 6+ months 49.8%) and 2078 in 1993 (age 81.7, females 75.5%, LOS 6+ months 50.2%). The unadjusted probability of hospitalization dropped from .205 to .151. Multivariate analyses revealed a significant adjusted odds of hospitalization of .74 (95% CI .60-.91) and no cohort effect on home discharge or death. Among severely cognitively impaired residents, the adjusted odds of hospitalization in 1993 compared with the 1990 cohort was 0.74 (.53–1.03). Finally, among survivors in both cohorts who had a follow-up MDS performed, and whose ADL remained stable, 15.9% were hospitalized in 1990, whereas only 10.9% were hospitalized in 1993. On the other hand, ADL decliners were more likely to have been hospitalized in 1993 than in 1990 (40.6% vs 25.2%). CONCLUSIONS: Although other changes in the industry, clinical practice, and health care policy may have influenced hospitalization of nursing home residents, the substantial reductions observed among the cognitively impaired and those with stable ADL suggest superior and uniform assessment information in the form of the RAI contributed significantly to this decline.

OBJECTIVE: To evaluate the impact of the Resident Assessment Instrument (RAI) on changes in nursing home residents' functional status, cognitive status, and psychosocial well-being. DESIGN: A quasi-experiment involving the collection of longitudinal data on two cohorts of nursing home residents. One cohort was assessed before the implementation of the RAI, and the other was assessed after the implementation of the new assessment process. SETTING AND PARTICIPANTS: Over 2000 nursing home residents in 267 nursing homes located in 10 geographic areas were assessed during the pre-RAI period. In the post-RAI period, 2000 new residents in 254 of the same facilities were assessed. INTERVENTION: RAI implementation began in October 1990 and continued until October 1991. The RAI includes a structured, multidimensional resident assessment and problem identification system designed to form the basis for residents' care plans. MEASUREMENTS: All residents were assessed at baseline and at 6 months using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS) and its protocols. All data were collected by research nurses employed and trained by the research team. RESULTS: Implementation of the RAI significantly reduced the rate of decline in seven of the nine outcomes under consideration. Reductions in improvement were also observed in all outcomes. In activities of daily living, social engagement, and cognitive function, the reduced decline far outweighed any reductions in improvement. In mood problems, problem behaviors, and understanding others, however, reductions in improvement were greater than any reductions in decline. Changes in the rates of decline and improvement were not uniform across all residents. CONCLUSION: The RAI may have improved the quality of care of nursing home residents by reducing overall rates of decline in important areas of resident function. However, this innovation may have generated trade-offs in that it may have reduced improvement rates in some areas of function. The system's implementation also seems to have focused staff's attention on the needs and strengths of specific subpopulations of residents. Revisions of the RAI must assist staff in generalizing their efforts to all residents and to increasing improvement rates, especially in areas related to mood and behavior.

This study examined relationships between three sensory and communication abilities and two areas of nursing home resident behavior. Data from 18,873 nursing home residents include measures of hearing, visual, and communication abilities, and social engagement and time spent in activities. Increasing level of visual impairment is associated with low levels of social engagement and low time in activities. Both moderate and severe hearing impairment are associated with low time in activities, while inadequate communication is associated with limits in both social engagement and time in activities. The combined effects of visual and communications impairments are associated with low social engagement. Increasing attention to sensory and communication losses may lead to improve quality of life in this population.

This article's purpose was to identify predictors of discharge outcomes of VA nursing home stays. Using data tapes, diagnostic and assessment data were assembled on elderly individuals admitted to VA nursing homes nationwide during Fiscal Year 1987. Six-month outcomes for 3 groups were considered: all residents (n = 5,895), and those remaining in care after 6 (n = 2,815) and 12 months (n = 1,812), respectively. Logistic regression was used to evaluate predictors of death and community discharge. Limited activities of daily living (ADL) dependency, younger age, and receipt of rehabilitation services most consistently predicted community discharge. ADL dependency, older age, oxygen use, terminally ill prognosis, malignancy, and congestive heart failure most consistently predicted mortality. For both dependent variables, predictive ability declined as stay length increased. Predicting death and community discharge become increasingly problematic as stay lengthens. Comparing observed versus expected discharge outcomes has limited usefulness as a quality-improvement tool.

Background: since its original implementation in the USA, the Resident Assessment Instrument (RAI) has been used in many countries in languages other than English. This paper describes the efforts that have been made to test the inter-rater reliability of the core set of items forming the minimum data set items in the USA and in non-English speaking countries (Denmark, Iceland, Italy, Japan, Sweden and Switzerland). Results: a large proportion (from 70 to 96%) of the items in the RAI achieved an adequate to excellent level of reliability, with no substantial differences across countries. The RAI met the standard for good reliability (i.e. a K value of 0.6 or higher) in crucial areas of functional status, such as memory, activities of daily living self-performance and support, and bowel and bladder continence in most of the countries. Indicators of mood and behavioural problems achieved adequate reliability levels of 0.4 or higher.

Method: residents of long-term care settings without major activity of daily living (ADL) deficits are often referred to as 'low-care cases' and are deemed inappropriately placed in an institution. We compare the prevalence and characteristics of this population in Denmark, Iceland, Italy, Japan, Sweden and the USA, using the Resident Assessment Instrument Minimum Data Set. Results: among the six nations, the percentage of low-care cases ranged from 27 to 52% using a broad definition of no physical assistance required in late-loss ADLs (bed mobility, toileting, transfer and eating). With a more narrow definition which additionally excludes those falling into the Resource Utilization Groups, version III categories of rehabilitation, clinically complex, impaired cognition and behaviour problems, the percentages seen range from 9 to 35%. Finally, 2-14% meet the most restrictive definition, which further excluded residents requiring any supervision in late-loss ADLs, with any deficits in early-loss ADLs (dressing or grooming) or needing medical and psychiatric supervision. Conclusion: although long-term care settings differ, making comparison by country difficult, the use of the same standard assessment form makes it possible to compare the many reasons for institutionalization.

This project used the interRAI based, community health assessment (CHA) to develop a model for identifying current elder drivers whose driving behavior should be reviewed. The assessments were completed by independent housing sites in COLLAGE, a non-profit, national senior housing consortium. Secondary analysis of data drawn from older adults in COLLAGE sites in the United States was conducted using a baseline assessment with 8042 subjects and an annual follow-up assessment with 3840 subjects. Logistic regression was used to develop a Driving Review Index (DRI) based on the most useful items from among the many measures available in the CHA assessment. Thirteen items were identified by the logistic regression to predict drivers whose driving behavior was questioned by others. In particular, three variables reference compromised decision-making abilities: general daily decisions, a recent decline in ability to make daily decisions, and ability to manage medications. Two additional measures assess cognitive status: short-term memory problem and a diagnosis of non-Alzheimers dementia. Functional measures reflect restrictions and general frailty, including receiving help in transportation, use of a locomotion appliance, having an unsteady gait, fatigue, and not going out on most days. The final three clinical measures reflect compromised vision, little interest or pleasure in things normally enjoyed, and diarrhea. The DRI focuses the review process on drivers with multiple cognitive and functional problems, including a significant segment of potentially troubled drivers who had not yet been publicly identified by others. There is a need for simple and quickly identified screening tools to identify those older adults whose driving should be reviewed. The DRI, based on the interRAI CHA, fills this void. Assessment at the individual level needs to be part of the backdrop of science as society seeks to target policy to identify high risk drivers instead of simply age-based testing.

Risk factors for institutionalization and death for up to four years for a nationwide cohort (n = 6,488) of males discharged alive from Department of Veterans Affairs (DVA) nursing homes were identified through linked records of the DVA. Two-year cumulative probabilities of nursing home readmission, hospitalization, and death among nursing home discharges were 0.30, 0.61, and 0.24, respectively. Using multivariate survival analyses, chronic functional impairments and past nursing home use were important predictors of nursing home readmission, whereas hospitalizations for exacerbations of chronic medical conditions were predictors of hospitalization and death. Past hospitalizations predicted all three outcomes. Differences in risk factors for nursing home readmission as compared with hospitalization or death among DVA nursing home dischargees suggest that high-risk patients can be identified at nursing home discharge and that different types of interventions will be necessary to decrease nursing home readmission as compared with hospitalization or death. Future development of linked record systems across multiple settings, both within and outside the DVA, will help to further characterize persons at high risk of institutionalization or death and to design and evaluate targeted interventions to decrease this risk.

Background This paper describe the development of interRAI’s second-generation home care quality indicators (HC-QIs). They are derived from two of interRAI’s widely used community assessments: the Community Health Assessment and the Home Care Assessment. In this work the form in which the quality problem is specified has been refined, the covariate structure updated, and two summary scales introduced. Methods Two data sets were used: at the client and home-care site levels. Client-level data were employed to identify HC-QI covariates. This sample consisted of 335,544 clients from Europe, Canada, and the United States. Program level analyses, where client level data were aggregated at the site level, were also based on the clients from the samples from Europe, Canada, and the United States. There were 1,654 program-based observations – 22% from Europe, 23% from the US, and 55% from Canada. The first task was to identify potential HC-QIs, including both change and prevalence measures. Next, they were reviewed by industry representatives and members of the interRAI network. A two-step process adjustment was followed to identify the most appropriate covariance structure for each HC-QI. Finally, a factor analytic strategy was used to identify HC-QIs that cluster together and thus are candidates for summary scales. Results The set of risk adjusted HC-QIs are multi-dimensional in scope, including measures of function, clinical complexity, social life, distress, and service use. Two factors were identified. The first includes a set of eleven measures that revolve around the absence of decline. This scale talks about functional independence and engagement. The second factor, anchored on nine functional improvement HC-QIs, referenced positively, this scale indicates a return to clinical balance. Conclusions Twenty-three risk-adjusted, HC-QIs are described. Two new summary HC-QI scales, the “Independence Quality Scale” and the “Clinical Balance Quality Scale” are derived. In use at a site, these two scales can provide a macro view of local performance, offering a way for a home care agency to understand its performance. When scales perform less positively, the site then is able to review the HC-QI items that make up the scale, providing a roadmap for areas of greatest concern and in need of targeted interventions.

A multistate nursing home data base was used to compare resource use by residents on Alzheimer's Special Care Units (SCUs) and on other nursing home units. Overall, staff time expended per resident was less on SCUs. However, facilities with an SCU used considerably more staff time than facilities without. Unexpectedly, after accounting for case mix, SCU residents actually used the same amount of resources as other residents in facilities with an SCU. SCUs appear to be an attractive alternative for caring for demented nursing home residents. In assessing their cost effectiveness, appropriate comparison groups will be crucial.

Objectives Dual sensory impairment (DSI) is a combination of vision and hearing impairments that represents a unique disability affecting all aspects of a person’s life. The rates of DSI are expected to increase due to population aging, yet little is known about DSI among older adults (65+). The prevalence of DSI and client characteristics were examined among two groups, namely, older adults receiving home care services or those residing in a long-term care (LTC) facility in four countries (Canada, US, Finland, Belgium). Methods Existing data, using an interRAI assessment, were analyzed to compare older adults with DSI to all others across demographic characteristics, functional and psychosocial outcomes. Results In home care, the prevalence of DSI across the four countries ranged from 13.4% to 24.6%; in LTC facilities, it ranged from 9.7% to 33.9%. Clients with DSI were more likely to be 85+, have moderate/severe cognitive impairment, impairments in activities of daily living, and have communication difficulties. Among residents of LTC facilities, individuals with DSI were more likely to be 85+ and more likely have a diagnosis of Alzheimer’s disease. Having DSI increased the likelihood of depression in both care settings, but after adjusting for other factors, it remained significant only in the home care sample. Conclusions While the prevalence of DSI cross nationally is similar to that of other illnesses such as diabetes, depression, and Alzheimer’s disease, we have a limited understanding of its affects among older adults. Raising awareness of this unique disability is imperative to insure that individuals receive the necessary rehabilitation and supportive services to improve their level of independence and quality of life.

Background Outcome quality indicators are rarely used to evaluate mental health services because most jurisdictions lack clinical data systems to construct indicators in a meaningful way across mental health providers. As a result, important information about the effectiveness of health services remains unknown. This study examined the feasibility of developing mental health quality indicators (MHQIs) using the Resident Assessment Instrument - Mental Health (RAI-MH), a clinical assessment system mandated for use in Ontario, Canada as well as many other jurisdictions internationally. Methods Retrospective analyses were performed on two datasets containing RAI-MH assessments for 1,056 patients from 7 facilities and 34,788 patients from 70 facilities in Ontario, Canada. The RAI-MH was completed by clinical staff of each facility at admission and follow-up, typically at discharge. The RAI-MH includes a breadth of information on symptoms, functioning, socio-demographics, and service utilization. Potential MHQIs were derived by examining the empirical patterns of improvement and incidence in depressive symptoms and cognitive performance across facilities in both sets of data. A prevalence indicator was also constructed to compare restraint use. Logistic regression was used to evaluate risk adjustment of MHQIs using patient case-mix index scores derived from the RAI-MH System for Classification of Inpatient Psychiatry. Results Subscales from the RAI-MH, the Depression Severity Index (DSI) and Cognitive Performance Scale (CPS), were found to have good reliability and strong convergent validity. Unadjusted rates of five MHQIs based on the DSI, CPS, and restraints showed substantial variation among facilities in both sets of data. For instance, there was a 29.3% difference between the first and third quartile facility rates of improvement in cognitive performance. The case-mix index score was significantly related to MHQIs for cognitive performance and restraints but had a relatively small impact on adjusted rates/prevalence. Conclusions The RAI-MH is a feasible assessment system for deriving MHQIs. Given the breadth of clinical content on the RAI-MH there is an opportunity to expand the number of MHQIs beyond indicators of depression, cognitive performance, and restraints. Further research is needed to improve risk adjustment of the MHQIs for their use in mental health services report card and benchmarking activities.

Background Chronic cognitive impairment is a major problem in U.S. nursing homes, yet traditional assessment systems in most facilities included only limited information on cognitive status. Following the Congressional mandate in the Omnibus Reconciliation Act of 1987 (OBRA '87), U.S. nursing homes now complete the Minimum Data Set (MDS), a standardized, comprehensive assessment of each resident's functional, medical, psychosocial, and cognitive status. We designed a Cognitive Performance Scale (CPS) that uses MDS data to assign residents into easily understood cognitive performance categories. Methods Information was drawn from three data sets, including two multistate data sets constructed for the Health Care Financing Administration. The prevalence and reliability of the MDS cognitive performance variables were established when assessed by trained nursing personnel. Five selected MDS items were combined to create the single, functionally meaningful seven-category hierarchical Cognitive Performance Scale. Results The CPS scale corresponded closely with scores generated by the Mini-Mental State Examination and the Test for Severe Impairment, nursing judgments of disorientation, and neurological diagnoses of Alzheimer's disease and other dementias. Conclusions The new CPS provides a functional view of cognitive performance, using readily available MDS data. It should prove useful to clinicians and investigators using the MDS to determine a resident's cognitive assets.

Since 1991, the Minimum Data Set 2.0 (MDS 2.0) has been the mandated assessment in US nursing homes. The Resource Utilization Groups III (RUG—III) case-mix system provides person-specific means of allocating resources based on the variable costs of caring for persons with different needs. Retrospective analyses of data collected on a sample of 9707 nursing home residents (2.4% had an intellectual disability) were used to examine the fit of the RUG—III case-mix system for determining the cost of supporting persons with intellectual disability (intellectual disability). The RUG—III system explained 33.3% of the variance in age-weighted nursing time among persons with intellectual disability compared to 29.6% among other residents, making it a good fit among persons with intellectual disability in nursing homes. The RUG—III may also serve as the basis for the development of a classification system that describes the resource intensity of persons with intellectual disability in other settings that provide similar types of support.

Objective: To identify similarities and differences between VA nursing home residents and other nursing home residents. Design: Comparison of cross-sectional data from three sources. Participants: Residents of VA nursing homes nationwide in early October 1986 (n = 10,117); participants in the 1985 National Nursing Home Survey (NNHS) (n = 5,243); residents assessed in New York State nursing homes in 1988 (n = 94,840). Measures: Age-stratified comparisons were made between the VA and the NNHS for gender, marital status, race, ethnicity, length of stay, activities of daily living (ADL) status, and selected diagnoses and conditions. Additionally, case-mix data were compared between the VA and the New York State populations. Main Results: The population of VA nursing homes is over-whelmingly men (96.1% versus 28.4% in the NNHS), and 31.2% of the VA population is under 65 years of age compared with 11.6% in the NNHS. Young (

To examine the patterns and determinants of length of stay among residents of nursing homes of the Department of Veterans Affairs (VA), the authors conducted a retrospective follow-up study of all persons ( n = 4,918) admitted to VA nursing homes between October 1986, and April 1987, using computerized records of the VA. Brief-stay (< 1 month; n = 1,139) residents had most often had previous admissions to VA nursing homes and were usually discharged alive from the nursing home. Medium-stay (1-6 months; n = 1,947) residents were the least functionally impaired and most likely to receive rehabilitative services. Long-stay residents (> 6 months; n = 1,832) were older and more functionally impaired than other residents. Medium- and long-stay residents of VA nursing homes most resembled "short-" and "long-stay" residents among non-VA nursing home residents, respectively. Brief-stay residents may be persons admitted for "respite" services or may be serial users of both VA and non-VA health services. Further study of this population may identify opportunities to decrease "revolving-door" use of nursing home services.

Nursing homes that have both special care units (SCUs) and traditional units were examined to determine the factors that cause homes to place cognitively impaired residents on the specialized units. Wandering, other problem behaviors, and Medicaid status were not significant predictors of placement. Logistic regression results indicated that functional status was the critical placement factor.

Background Population ageing, the emergence of chronic illness, and the shift away from institutional care challenge conventional approaches to assessment systems which traditionally are problem and setting specific. Methods From 2002, the interRAI research collaborative undertook development of a suite of assessment tools to support assessment and care planning of persons with chronic illness, frailty, disability, or mental health problems across care settings. The suite constitutes an early example of a "third generation" assessment system. Results The rationale and development strategy for the suite is described, together with a description of potential applications. To date, ten instruments comprise the suite, each comprising "core" items shared among the majority of instruments and "optional" items that are specific to particular care settings or situations. Conclusion This comprehensive suite offers the opportunity for integrated multi-domain assessment, enabling electronic clinical records, data transfer, ease of interpretation and streamlined training.

Differences between long-term care facilities in Stockholm (1134 residents) and New York (95,000 residents statewide) were examined. The comparison employed a resident classification system, Resource Utilization Groups (RUG-II), which links individuals' characteristics to resource use. Distributions of Activity of Daily Living functionality and RUG-II categories demonstrated significant differences between these two populations, with the Stockholm facilities more akin to the heavier care skilled nursing facilities in New York. These differences may indicate different uses of long-term care beds in the United States and Sweden and demonstrate the need for resident-level classification systems in cross-national studies.

Purpose: Although the nursing facility transition literature is growing, little research has analyzed the characteristics of individuals so assisted or compared participants to those who remain institutionalized. This article describes an analytic method that researchers can apply to address these knowledge gaps, using the Arkansas Passages nursing facility transition program as a case study. Design and Methods: This study employed Arkansas Minimum Data Set 2.0 data for 111 transitioned individuals, a derivation sample of 1,000 other residents, and a validation sample of all residents from the transitioned individuals’ nursing facilities. Tree classification techniques identified distinct groups of transitioned and nontransitioned residents. Results: Nearly two thirds of transitionees were part of a group comprising only 1.5% of all Arkansas nursing facility residents. Five characteristics identified this group: age, day of stay (i.e., current day of stay at the time of the assessment), having hemiplegia/paraplegia, cognitive impairment level, and classification into one of eight Resource Utilization Groups (RUG-III) case-mix groups associated with the least nursing staff time. Another group containing 92% of the transitionees comprised 22% of all residents. Two characteristics identified this group: being younger than age 65 or being in the eight low-resource RUG-III groups. Implications: Given that the majority of individuals assisted by this pilot represent a small and unusual nursing facility subpopulation, policy makers may wish to exercise caution in utilizing these data to forecast future transition populations, costs, or outcomes. Replicating this analysis using additional states’ data could increase understanding about the characteristics of those assisted across transition programs and could help construct a more robust definition of what constitutes a transition success.

Background The objective of this study was to assess the responsiveness of the Minimum Data Set Activities of Daily Living (MDS-ADL) Scale to change over time by examining the change in physical function in adults with moderate to severe dementia with no comorbid illness who had been resident in a nursing home for over 90 days. Methods Longitudinal data were collected on nursing home residents with moderate (n = 7001) or severe (n = 4616) dementia in one US state from the US national Minimum Data Set (MDS). Severity of dementia was determined by the MDS Cognitive Performance Scale (CPS). Physical function was assessed by summing the seven items (bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene) on the MDS activities of daily living (ADL) Long Form scale. Mean change over time of MDS-ADL scores were estimated at three and six months for residents with moderate (CPS score of 3) and severe (CPS score of 4 or 5) dementia. Results Physical function in residents with moderate cognitive impairment deteriorated over six months by an average of 1.78 points on the MDS-ADL Long Form scale, while those with severe cognitive impairment declined by an average of 1.70 points. Approximately one quarter of residents in both groups showed some improvement in physical function over the six month period. Residents with moderate cognitive impairment experienced the greatest deterioration in early-loss and mid-loss ADL items (personal hygiene, dressing, toilet use) and residents with severe cognitive impairment showed the greatest deterioration in activities related to eating, a late loss ADL. Conclusion The MDS-ADL Long Form scale detected clinically meaningful change in physical function in a large cohort of long-stay nursing home residents with moderate to severe dementia, supporting its use as a research tool in future studies.

Purpose: Adjusting for sociodemographic characteristics and disability levels, this study examines whether differences exist in the structure and function of community-dwelling Black and White frail elders' informal care networks. Design and Methods: Data from in-person assessments of Michigan's Home and Community-Based Medicaid Waiver applicants were analyzed by using logistic and ordinary least squares regression. The sample consisted of 936 Black and 3,182 White frail elderly persons. Results: When sociodemographic characteristics were controlled for, racial differences were found in all informal care components except out-of-home chores. Differences in functional components (amount of care, scope of assistance, and personal care) were largely accounted for by disability, whereas racial differences in the structural components (source of care, living arrangement, and sole caregiver) and in-home chores were not. Implications: Findings suggest that Blacks are not better off than Whites in the receipt of informal care. Although Black elders receive more informal help, this difference is primarily because Blacks are more disabled. This study calls for heightened awareness of disability among low-income Blacks and the potential burden experienced by their caregivers.

Those aged65 in nursing homes (NHs) are substantially different from elderly residents. This study uses data gathered from the Resident Assessment Instrument's Minimum Data Set (MDS) to describe these relatively rare residents.The study uses MDS assessments of close to three-quarter million residents in nine states from 1994 to 1996. Residents are described within chronological age group (0-4, 5-14, etc.). Factor analysis is used to develop diagnostic clusters, and the prevalence of these clusters, functional problems, other conditions, and treatments is described for each group.Thirteen diagnostic clusters describe nearly 85% of all NH residents and highlight differences between age groups. Pediatric residents are substantially more physically and cognitively impaired than young adult residents, and have the highest case mix burden of care. The youngest population primarily has diagnoses related to mental retardation and developmental disabilities, young adults have the highest prevalence of hemi- and quadriplegia, while older residents are typified by increasing prevalence of neurological diagnoses.This study offers an initial description of NH residents65. The prevalence of residents with unique conditions may suggest the need to modify the MDS assessment instrument.

Purpose: This study aimed to develop home care quality indicators (HCQIs) to be used by a variety of audiences including consumers, agencies, regulators, and policy makers to support evidence-based decision making related to the quality of home care services. Design and Methods: Data from 3,041 Canadian and 11,252 U.S. home care clients assessed with the Minimum Data Set—Home Care (MDS-HC) were used to evaluate a series of indicators suggested by international experts and by focus groups conducted in Canada and the United States. Risk adjustment methods were derived and validated using data from Ontario and Michigan. Results: Of the 73 original candidate HCQIs, 22 were retained for the final list of recommended indicators. All but three indicators include risk adjusters based on individual-level covariates. An agency-level risk adjustment was developed to correct for selection and ascertainment bias. Implications: The HCQIs are new tools providing a first step along the path of quality improvement for home care. These indicators can provide high-quality evidence on performance at the agency level and on a regional basis.

Purpose: To determine the accuracy of a telephone-screening system to identify persons eligible for home- and community-based long-term care. Design and Methods: Data from Michigan telephone screens were compared to data from in-person assessments using the Minimum Data Set for Home Care (MDS-HC). Weighted kappa statistics measured the level of agreement between the two assessments. Results: Overall, recommendations based on the telephone screen produced a marginal match compared to recommendations based on in-person assessment. "False positives" (individuals scoring as more impaired on the telephone screen than in person) occurred in 27% of all cases, while "false negatives" (individuals scoring as less impaired on the telephone screen) only occurred among 6% of the callers. Neither individual screen questions, source of information, location of the individual, timing between screen and assessment, nor temporal changes accounted for mismatches. Telephone screens resulted in an 11% savings over the cost of providing in-person assessments to all program seekers. Implications: The telephone screen has utility as a broad targeting mechanism that allows agencies to avoid costly in-person assessments for all program seekers. Evidence does not support use of the telephone screen alone to determine either medical eligibility or a specific level of care.

ContextSurvival varies for patients with advanced dementia, and accurate prognostic tools have not been developed. A small proportion of patients admitted to hospice have dementia, in part because of the difficulty in predicting survival.ObjectivesTo identify factors associated with 6-month mortality in newly admitted nursing home residents with advanced dementia and to create a practical risk score to predict 6-month mortality in this population.Design, Setting, and ParticipantsThis was a retrospective cohort study of data from the Minimum Data Set (MDS). All Medicare or Medicaid licensed nursing homes in New York and Michigan were included. Participants had advanced dementia and were admitted to New York nursing homes between June 1, 1994, and December 30, 1998 (derivation cohort, n = 6799), and to Michigan nursing homes from October 1, 1998, through July 30, 2000 (validation cohort, n = 4631).Main Outcome MeasuresMDS factors associated with 6-month mortality were determined in the derivation group, and the resulting mortality risk score was evaluated in the validation cohort. Risk score performance was compared with the cut point of 7c on the Functional Assessment Staging (FAST) scale.ResultsAmong residents with advanced dementia, 28.3% (n = 1922) died within 6 months of nursing home admission in the derivation cohort; 35.1% (n = 1626) died in the validation cohort. The 6-month mortality rate increased across risk scores (possible range, 0-19): 0 points, 8.9% mortality; 1 to 2, 10.8%; 3 to 5, 23.2%; 6 to 8, 40.4%; 9 to 11, 57.0%; and at least 12, 70.0% in the validation cohort. The area under the receiver operating characteristic (AUROC) curve for predicting 6-month mortality was 0.74 and 0.70 in the derivation and validation cohorts, respectively. Our risk score demonstrated better discrimination to predict 6-month mortality (AUROC, 0.64 for a cutoff of ≥6 points vs 0.51 for FAST stage 7c).ConclusionA risk score based on 12 variables from the MDS estimates 6-month mortality for nursing home residents with advanced dementia with greater accuracy than existing prognostic guidelines.

OBJECTIVES: To study a cohort of participants in homeand community-based services (HCBS) in Michigan to evaluate the relationship between (1) caregiver attitudes and participant characteristics and (2) the risk of hospitalization. DESIGN: A population-based study. SETTING: HCBS programs funded by Medicaid or state/ local funds in Michigan. PARTICIPANTS: Five hundred twenty-seven individuals eligible for HCBS in Michigan were studied. These HCBS participants were randomly selected clients of all agencies providing publicly funded HCBS in Michigan from November 1996 to October 1997. MEASUREMENTS: Data for this study were collected using the Minimum Data Set for Home Care. Assessments were collected longitudinally, and the baseline (initial admission assessment) and 90-day follow-up assessments were used. Key measures were caregiver attitudes (distress, dissatisfaction, and decreased caregiving ability) and HCBS participant characteristics (cognition, functioning, diseases, symptoms, nutritional status, medications, and disease stability). Multinomial logistic regression was used to evaluate how these characteristics were associated with the competing risks of hospitalization and death within 90 days of admission to HCBS. RESULTS: We found a strong association between caregiver dissatisfaction (caregiver dissatisfied with the level of care the home care participant was currently receiving) and an increased likelihood of hospitalization. HCBS participant cancer, chronic obstructive pulmonary disease, pain, and flare-up of a chronic condition were also associated with increased hospitalization. Poor food intake and prior hospitalization were associated with hospitalization and death. CONCLUSIONS: We conclude that, within a cohort of people receiving HCBS who are chronically ill, highly disabled, and at high risk for hospitalization and death, interventions addressing caregiver dissatisfaction, pain control, and medical monitoring should be evaluated for their potential to decrease hospitalization. J Am Geriatr Soc 50: 1079‐1085, 2002.