Hospitalization of Nursing Home Residents with Cognitive Impairment

Influence of Facility Features and State Policies

Andrea Gruneir, M.Sc.Susan C. Miller, Ph.D.Vincent Mor, Ph.D.

Brown Medical School

Acknowledgements

Financial Support: AARP Scholar’s Award NIA (AG 20557)

Assistance: Orna Intrator, Ph.D. Zhanlian Feng, Ph.D. David Grabowski, Ph.D. Jacqueline Zinn, Ph.D. Mark Schleinitz, M.D.

Background: Dementia

Affects nearly 4 million Americans Projected to affect 10 million by

2040 Nursing Homes (NH) as a major site

of care Over 90% cared for within a NH at

some point before death The most common diagnosis among NH

residents

Background: NH Care

Hot topic: Hospitalization WHY?

Very common Often unnecessary or preventable Potential for severe negative

consequences Costly Not always driven by resident need or

preference

Objective

To quantify the effect of NH features pertinent to dementia care on hospitalization of residents with cognitive impairment

To quantify the effect of state Medicaid reimbursement policies on hospitalization of residents with cognitive impairment

Methods: Data

Medicare Claims Data Outcome: Hospitalization

Minimum Data Set 2.0 (MDS) Resident data

On-line Survey, Certification, and Reporting System (OSCAR) NH data

Area Resource File (ARF) Survey of State Medicaid Offices

Methods: Sample

County Restrictions (n = 810) Non-rural counties

NH Restrictions (n = 8,293) Free-standing ≥50 beds

Resident Restrictions (n = 359,474) Long-stay (≥90 days) 65 years or older Cognitively Impaired (CPS ≥3)

Methods: Variables

Outcome: Hospitalization within 150 days of baseline assessment

Determinants: NH Features Related to Dementia care1. Presence of dementia SCU2. High prevalence of dementia among

long-stay residents (≥35%) State Medicaid Policies1. Average per diem reimbursement rate2. Bed hold policy (yes/no)

Statistical Analyses

S = state NH = nursing homeC = county R = resident

ijklRijklNHjklCklSlijkly

Multilevel Model Stratified by Diagnosis of Dementia

Results: Residents

DementiaN = 174,563

No DementiaN = 184,911

Hospitalized,% 15.9 16.6

Died,% 12.5 10.8

CPS 5-6,% 42.6 33.5

Do Not Hospitalize,%

6.0 3.3

Results: NH & State Policies

Nursing Homes N = 8,293

Dementia SCU,% 20.3

≥35% w/dementia,% 50.3

States N = 48

Medicaid Per Diem, mean (SD)

$103.51 (19.52)

Bed hold policy,% 77.1

Results: Multilevel Analysis

DementiaOR (95% CI)

No DementiaOR (95% CI)

SCU 0.9 (0.86-0.94)

0.93(0.9-0.98)

≥35% dementia

0.96(0.88-1.03)

0.93(0.86-1.0)

Medicaid Per Diem ($10)

0.95 (0.9-1.0)

0.95 (0.91-1.0)

Bed hold 1.44 (1.12-1.86)

1.47 (1.19-1.82)

Summary

Presence of SCU affects all residents, not just those on the SCU

Investment in dementia care (SCU) has stronger effect than experience in dementia care (prevalence)

Small differences in Medicaid payment ($10) associated with decreased risk of hospitalization

Bed hold policies create incentives for lower hospitalization threshold

Limitations

No distinction by type of hospitalization

Cross-sectional design Excluded residents that died from

multilevel analyses Definition of SCU not standard

across NHs

Implications

Directed care for chronic conditions reduces: The occurrence of acute flare-ups The severity of acute flare-ups The need for hospitalization

BUT Medicare pays for hospital use only

SO Medicaid has no incentive to pay for directed care in the NH

Implications

Current reimbursement scheme does not meet the needs of an increasingly complex resident population.

Time to move to an integrated system in which all payers invest in chronic illness management AND all benefit from reductions in hospitalization.