1 does organizing nursing home workforce in teams save costs? dana b. mukamel - university of...
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Does organizing nursing home workforce in teams save costs?
Dana B. Mukamel - University of California, Irvine - Center for Health Policy Research
Shubing Cai & Helena Temkin-Greener -University of Rochester School of Medicine -
Department of Community & Preventive Medicine Funding: NIA grant # AG23077
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Team care is viewed as effective
• Especially for chronic and long-term care
• Better patient outcomes
• Lower error rates
• Better care coordination
• Better work environment
• Better staff outcomes
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Teams in nursing homes
• Interdisciplinary care planning–Mandated by CMS
In most facilities
• Daily care teams–Prevalence is unknown–Few studies, mostly convenience
sample
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Less is known about the cost implications of teams in nursing homes
• Physician / nurse practitioner teams were shown to be more cost effective than physicians aloneBurl JB, 1991; 1994 & 1998 and Aigner, 2004.
• Specialized wound teams have been shown to be cost effectiveVu T, 2007.
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Study objective:
• To examine the cost impact of daily care teams in nursing homes
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Daily care teams defined by the direct care staff in the nursing home as:
1.Formal teams: if staff assigned by management
2.Self-managed teams: if staff self-organized their daily work in teams
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Sample:
• 162 free standing nursing homes in New York State with at least 50 beds
• 7,418 direct care staff
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Data:
• Survey of direct care staff
• Medicaid cost reports
• Case mix data from the NYS DOH
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Methods:
Hybrid cost function:
• Weighted regression to account for under response by for profits
• Inference based on robust standard errors and joint F-tests for highly collinear terms
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Composition of daily care teams*
91
71 72
43 4336
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0
50
100
CN
As
RN
s
LP
Ns
Thera
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ts
Socia
lW
ork
ers
Physic
ians
Oth
er
Disciplines included in the team
% C
NA
s r
ep
ort
ing
*Information based on the survey question: “Who else is on your team?” 46% of responders report meeting daily27% of responders report meeting at least weekly
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Sample (N=135) All NYS study eligible nursing homes (N=531)
Mean Standard deviation
Mean Standard deviation
Percent of direct care staff organized in formal teams
8.4 6.4 n/a n/a
Percent of direct care staff in self managed teams
7.4 5.5 n/a n/a
Annual variable costs ($1000) 20,135 17,949 17,988 16,896
Inpatient days 77,071* 48,273 68,709 40,942
Inpatient admissions 408 334 367 303
Average RUG scores 1.18 0.12 n/a n/a
Adult day care days 2,481* 5,041 3,530 17,125
Number of beds 215 136 196 113
Home health care visits 7,964 42,580 8,281 59,039
Outpatient clinics 1,083 7,572 499 4,720
Management hourly wage 43.35* 14.39 49.12 26.72
CNA hourly wage 18.29 4.70 19.04 5.29
Non-profit ownership (%) 66%* 51%
* Significant difference at the 0.05 level
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Independent Variables Coefficient P Value*
Beds 0.214 x 10-2 0.00
Case mix adjusted days/1000:
Linear 0.226 0.00
Squared -0.115 x 10-3 0.00
Cubed 1.76 x 10-7 0.00
Admissions 0.213 x 10-3 0.00
Adult day care days/1000 0.010 0.00
Home health care visits/10000 0.027 0.00
Outpatient clinic visits/1000 0.007 0.00
Log management wages 0.170 0.00
Log CNA wages 0.535 0.00
Non-profit facility 0.093 0.00
Constant 12.620 0.00N = 135R2 = 0.97* Based on robust standard errors.
Estimated annual variable cost function with probability weightsDependent variable: Log of variable cost
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Independent Variables Coefficient P Value*
% direct care staff in formal teams:
Linear 0.012 0.99**
Squared -2.332 0.76**
Cubed 11.956 0.49**
% of direct care staff in self managed teams:
Linear -0.487 0.67***
Squared 11.449 0.39***
Cubed -38.929 0.30***
** P value for the hypotheses that the linear, squared and cubed terms are jointly significant is 0.004.*** P value for the hypotheses that the linear, squared and cubed terms are jointly significant is 0.426.
Estimated annual variable cost function with probability weightsDependent variable: Log of variable cost
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Predicted variable annual costs as function of formal team penetration
(Based on the estimated cost function)
$15,000,000
$15,100,000
$15,200,000
$15,300,000
$15,400,000
$15,500,000
0% 5% 10% 15% 20% 25%
Percent of direct care staff organized in formal teams
Va
ria
ble
co
sts
(p
red
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d f
or
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rsin
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om
e w
ith
av
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ara
cte
ris
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s)
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Conclusions:
• Formal teams are a cost saving strategy
• The range of cost savings estimated at $174,000 per year
• Self-managed teams do not seem to have the same impact on cost
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Why are costs increasing at higher penetration levels?
• Higher quality?
• Pushing teams “too far”?
• Different team types? – more specialists