Dataset Information

Geographic Disparities in Access to Nursing Home Services: Assessing Fiscal Stress and Quality of Care.

ABSTRACT:

Objective

We test whether nursing homes serving predominately low-income and racial minority residents (compositional explanation) or located in neighborhoods with higher concentrations of low-income and racial minority residents (contextual explanation) have worse financial outcomes and care quality.

Data sources

Healthcare Cost Report Information System, Nursing Home Compare, Online Survey Certification and Reporting Certification, and American Community Survey.

Study design

A cross-sectional study design of nursing homes within U.S. metropolitan areas.

Data collection/extraction methods

Data were obtained from Centers for Medicare & Medicaid Services and U.S. Census Bureau.

Principal findings

Medicaid-dependent nursing homes have a 3.5 percentage point lower operating ratio. Those serving primarily racial minorities have a 2.64-point lower quality rating. A 1 percent increase in the neighborhood population living in poverty is associated with a 1.20-point lower quality rating, on a scale from 10 to 50, and a 1 percent increase in the portion of neighborhood black residents is associated with a 0.8 percentage point lower operating ratio and a 0.37 lower quality rating.

Conclusions

Medicaid dependency (compositional effect) and concentration of racial minority residents in neighborhoods (contextual effect) are associated with higher fiscal stress and lower quality of care, indicating that nursing homes' geographic location may exacerbate long-term care inequalities.

SUBMITTER: Park YJ

PROVIDER: S-EPMC6056600 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Geographic Disparities in Access to Nursing Home Services: Assessing Fiscal Stress and Quality of Care.

Park Young Joo YJ Martin Erika G EG

Health services research 20171112

<h4>Objective</h4>We test whether nursing homes serving predominately low-income and racial minority residents (compositional explanation) or located in neighborhoods with higher concentrations of low-income and racial minority residents (contextual explanation) have worse financial outcomes and care quality.<h4>Data sources</h4>Healthcare Cost Report Information System, Nursing Home Compare, Online Survey Certification and Reporting Certification, and American Community Survey.<h4>Study design< ...[more]

PMID: 29131339

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Project description:ImportanceNew York State's Medicaid managed long-term care (MLTC) program expanded access to home- and community-based services, providing an alternative to nursing home care for people with dementia. Between 2012 and 2015, the state implemented mandatory MLTC for dual Medicare and Medicaid enrollees requiring more than 120 days of community-based long-term care.ObjectiveTo evaluate changes in nursing home use among older adults with dementia following MLTC implementation.Design, setting, and participantsThis cohort study used longitudinal data from January 1, 2011, to December 31, 2019, from the Minimum Data Set and Medicare administrative data. The study sample included New York State Medicare beneficiaries 65 years and older with dementia. New York City residents were excluded due to insufficient pre-study period data. Data were analyzed from January 1, 2011, to December 31, 2019.ExposureMandatory MLTC enrollment.Main outcomes and measuresLongitudinal models were used to evaluate changes in annual days of nursing home use following the staggered implementation of MLTC across 13 regions of the state. Two models were estimated: (1) a logistic regression model for any nursing home use in a given year and (2) a linear regression model of total nursing home days, conditional on any nursing home use. Models included annual event-time indicators specified as years until or since MLTC implementation. To capture MLTC effects for dual enrollees relative to non-dual Medicare enrollees, models included interaction terms for dual enrollment and event-time indicators.ResultsThis sample included 463 947 Medicare beneficiaries with dementia who lived in New York State between 2011 and 2019 (50.2% younger than 85 years; 64.4% women). Implementation of MLTC was associated with lower odds of nursing home use among dual enrollees, ranging from 8% lower odds 2 years post implementation (adjusted odds ratio, 0.92 [95% CI, 0.86-0.98]) to 24% lower odds 6 years post implementation (adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]). Compared with a scenario of no MLTC, MLTC implementation was associated with an 8% reduction in annual days of nursing home use between 2013 and 2019 (mean, -5.6 [95% CI, -6.1 to -5.1] days per year).Conclusions and relevanceThe findings of this cohort study suggest that implementation of mandatory MLTC in New York State was associated with less nursing home use among dual enrollees with dementia and that MLTC may help prevent or delay nursing home placement among older adults with dementia.

Project description:BACKGROUND:Availability of nursing home care has declined and national efforts have been initiated to improve the quality of nursing home care in the U.S. Yet, data are limited on whether there are geographic variations in declines of availability and quality of nursing home care, and whether variations persist over time. We sought to assess geographic variation in availability and quality of nursing home care. METHODS:Retrospective study using Medicaid/Medicare-certified nursing home data from the Centers for Medicare & Medicaid Services, 1996-2016. Outcomes were 1) availability of all nursing home care (1996-2016), measured by the number of Medicaid/Medicare-certified beds for a given county per 100,000 population aged ≥65 years, regardless of nursing home star rating; 2) availability of 5-star nursing home care, measured by the number of Medicaid/Medicare-certified beds provided by 5-star nursing homes; and 3) utilization of nursing home beds, defined as the rate of occupied Medicaid/Medicare-certified beds among the total Medicaid/Medicare-certified beds. RESULTS:From 1999 to 2016, availability of all nursing home care declined from 4882 (standard deviation: 931) to 3480 (912) beds, per 100,000 population aged ≥65 years. Persistent geographic variation in availability of nursing home care was observed; the correlation coefficient of county-specific availabilities from 1996 to 2016 was 0.78 (95% CI 0.77-0.79). From 2011 to 2016, availability of 5-star nursing home beds increased from 658 (303) to 895 (661) per 100,000 population aged ≥65 years. The correlation coefficient for county-specific availabilities from 2011 to 2016 was 0.54 (95% CI 0.51-0.56). Availability and quality of nursing home care were not highly correlated. In 2016, the correlation coefficient for county-specific availabilities between all nursing home and 5-star nursing home beds was 0.33 (95% CI 0.30-0.36). From 1996 to 2016, the utilization of certified beds declined from 78.5 to 72.2%. This decline was consistent across all census divisions, but most pronounced in the Mountain division and less in the South-Atlantic division. CONCLUSION:We observed persistent geographic variations in availability and quality of nursing home care. Availability of all nursing home care declined but availability of 5-star nursing home care increased. Availability and quality of nursing home care were not highly correlated.

Project description:ImportanceWhile the number of prescribing clinicians (physicians and nurse practitioners) who provide any nursing home care remained stable over the past decade, the number of clinicians who focus their practice exclusively on nursing home care has increased by over 30%.ObjectivesTo measure the association between regional trends in clinician specialization in nursing home care and nursing home quality.DesignRetrospective cross-sectional study.Setting and participantsPatients treated in 15,636 nursing homes in 305 US hospital referral regions between 2013 and 2016.MeasuresClinician specialization in nursing home care for 2012-2015 was measured using Medicare fee-for-service billings. Nursing home specialists were defined as generalist physicians (internal medicine, family medicine, geriatrics, and general practice) or advanced practitioners (nurse practitioners and physician assistants) with at least 90% of their billings for care in nursing homes. The number of clinicians was aggregated at the hospital referral region level and divided by the number of occupied Medicare-certified nursing home beds. Nursing Home Compare quality measure scores for 2013-2016 were aggregated at the HHR level, weighted by occupied beds in each nursing home in the hospital referral region. We measured the association between the number of nursing home specialists per 1000 beds and the clinical quality measure scores in the subsequent year using linear regression.ResultsAn increase in nursing home specialists per 1000 occupied beds in a region was associated with lower use of long-stay antipsychotic medications and indwelling bladder catheters, higher prevalence of depressive symptoms, and was not associated with urinary tract infections, use of restraints, or short-stay antipsychotic use.Conclusions and implicationsHigher prevalence of nursing home specialists was associated with regional improvements in 2 of 6 quality measures. Future studies should evaluate whether concentrating patient care among clinicians who specialize in nursing home practice improves outcomes for individual patients. The current findings suggest that prescribing clinicians play an important role in nursing home care quality.

Dataset Information

Geographic Disparities in Access to Nursing Home Services: Assessing Fiscal Stress and Quality of Care.

Objective

Data sources

Study design

Data collection/extraction methods

Principal findings

Conclusions

Publications

Geographic Disparities in Access to Nursing Home Services: Assessing Fiscal Stress and Quality of Care.

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