Bolda, Elise J.

Coburn, Andrew F.

Keith, Robert G.

English

University of Southern Maine: Digital Commons@USM

University of Southern Maine USM Digital Commons Long Term Services and Supports Maine Rural Health Research Center (MRHRC) 5-2000 Multiple Hospitalizations Among Elderly Nursing Facility Residents: Is Rural Residence a Risk Factor? Andrew F. Coburn Robert G. Keith Elise J. Bolda Follow this and additional works at: https://digitalcommons.usm.maine.edu/longterm_care Recommended Citation Coburn, Andrew F.; Keith, Robert G.; and Bolda, Elise J., "Multiple Hospitalizations Among Elderly Nursing Facility Residents: Is Rural Residence a Risk Factor?" (2000). Long Term Services and Supports. 21. https://digitalcommons.usm.maine.edu/longterm_care/21 This Policy Brief is brought to you for free and open access by the Maine Rural Health Research Center (MRHRC) at USM Digital Commons. It has been accepted for inclusion in Long Term Services and Supports by an authorized administrator of USM Digital Commons. For more information, please contact jessica.c.hovey@maine.edu. Maine Rural Health Research Center    •    Institute for Health Policy May, 2000Research & Policy BriefThis study was funded by a grant from the federal Office of Rural Health Policy, Health Resources and ServicesAdministration, DHHS (Grant #CSUR00003-04).  The conclusions and opinions expressed in the paper are theauthors’ and no endorsement by the University of Southern Maine or the funding source is intended or should beinferred. Working Paper #17, Multiple Hospitalizations Among Elderly Nursing Facility Residents: Is Rural Residence a RiskFactor? describes the policy and research background, methods and findings in depth, and is available from theMaine Rural Health Research Center.Multiple Hospitalizations Among Elderly Nursing Facility Residents:Is Rural Residence a Risk Factor?The problem of hospitalizationsof nursing facility (NF) residents hasimportant implications for both thecost and quality of care. Hospitaliza-tions of NF residents pose serious healthrisks for residents, often placing themat greater risk of “cascading depen-dency.” Although we know that overone quarter of all NF residents are hos-pitalized annually, geographic varia-tions in hospitalization rates have notbeen reported in the literature. Thisproblem may be more prevalent amongrural NF residents due to the higherrates of nursing home use, greater sup-plies of hospital beds, and lower physi-cian supplies in rural areas.Recent Medicare payment policy changes may haveimportant effects on the problem of multiple hospitaliza-tions of nursing home residents. In 1997 the BalancedBudget Act required the implementation of a MedicareSkilled Nursing Facility (SNF) prospective payment system(PPS) beginning in 1998. Under this system, SNFs havebeen paid a case mix adjusted per diem rate which, withlower annual adjustments than had been experiencedunder prior payment rules, has resulted in significantreductions in the growth of payments to SNFs. In responseto concerns about access to SNF services for high acuitypatients, Congress modified some of the BBA changes inSNF payment policy in the Balanced Budget RefinementAct of 1999 (BBRA) increasing per diem payment rates forselected high acuity case mix categories and increasing theannual increases in per diem rates for fiscal years 2001 and2002 to 4%.Notwithstanding these changes, there continue to beserious concerns about the ability of many skilled facilitiesto achieve the significant cost reductions required underthe BBA and the impact these reductions may have on SNFaccess and quality for Medicare beneficiaries. Smaller, ruralSNFs may have a more limited ability to absorb cuts in SNFpayment without significant reductions in staff or otherservices critical to the quality of care.This StudyThis study addresses two main questions: (1) Do ruralNF residents experience higher rates of NF re-admissionfrom a hospital than urban residents? and (2) If they do, towhat extent do resident, facility and market/area charac-teristics contribute to NF re-admission rates from hospital-izations among rural and urban residents?  Differences inrates of NF re-admissions from a hospital have importantpotential implications for the quality and outcomes of carefor older rural residents. Understanding whether and whythese rates differ is also important for gauging the potentialimpact of payment and other policy changes on the qual-ity of care in rural NFs.Study MethodsThis study uses resident assessment data from theMinimum Data Set  (MDS+) collected by states participat-ing in the Health Care Financing Administration’s, Multi-by Andrew F. Coburn, Ph.D, Robert G. Keith, Ph.D.,  and Elise J. Bolda, Ph.D., Muskie School of Public ServiceThis problemmay be moreprevalentamong ruralNF residentsdue to thehigher rates ofnursing homeuse, greatersupplies ofhospital beds,and lowerphysiciansupplies inrural areasUniversity of Southern MaineMaine Rural Health Research CenterEdmund S. Muskie School of Public Service96 Falmouth StreetP.O. Box 9300Portland, Maine 04104-9300Research & Policy BriefMaine Rural Health Research Center • Institute for Health PolicyNonprofit Org.U.S. PostageP A I DPortland, Maine 04101Permit No. 370Edmund S. Muskie School of Public Service  • 96 Falmouth Street, P. O. Box 9300, Portland, Maine 04104-9300Tel: (207) 780-4430  • Fax: (207) 780-4417 • TDD: (207) 780-5646 • www.muskie.usm.maine.edu/mrhrcEstablished in 1992, the Maine Rural Health Research Center (MRHRC) is one of five national rural health servicesresearch and policy analysis centers funded by the federal Office of Rural Health Policy. The Center is also one offive rural managed care centers funded by the federal Agency for Health Care Policy and Research (AHCPR). TheCenter has three areas of special interest in its research agenda: (1) the availability,  organization, and financingof rural mental health services, (2) institutional and community-based services for rural elders, and (3) changes inthe organization and financing of rural health services.Recently Published and Forthcoming Working Papers:Medicaid Managed Behavioral Healthcare in Rural Areas  (#24 forthcoming)Strategies for Measuring and Increasing the Supply of Mental Health Professionals in Underserved Rural Areas   (#23 forthcoming)Rural Long-term Care Integrations: Developing Service Capacity  (#22 forthcoming)Financing and Payment Issues in Rural Long-term Care Integration  (#21 forthcoming)Models for Integrating and Managing Acute and Long-term Care Services in Rural Areas (#20 forthcoming)Creating Affordable Rural Housing with Services: Strategies and Options  (#19 forthcoming)Developing Affordable Non-Medical Residential Care in Rural Communities: Barriers and Opportunities   (#18 forthcoming)Multiple Hospitalizations Among Nursing Home Residents: Is Rural Residence a Risk Factor?  (#17)Effects of Managed Mental Health Care on Service Use in Rural Areas  (#16)Best Practices in Rural Medicaid Managed Behavioral Health  (#15)APRIL, 2000Multiple Hospitalizations AmongElderly Nursing Facility Residents:Is Rural Residence a Risk Factor?The limitedavailabilityof physiciansin rural areas,their heavierworkloads,and the limited reimbursement forcare provided innursing facilities will make it moredifficult in rural areasto obtain greaterphysician attentionto NF residents. Expandedavailabilityand use of videoand computer-based technologies such astelehealth may beuseful in overcoming these limitations.Rural NF residentsare more likelyto have multiple re-admissionsfroma hospital.…Theeffect of ruralresidence on theprobability ofmultiple NF re-admissionsis greater amongnewly admittedrural residentsthan among ruralresidents notclassified as newadmissions.state Case Mix Demonstration. MDS+ information in-cludes: admission and discharge data, demographic char-acteristics, prior living arrangements and residential his-tory, functional and cognitive status, vision, hearing, andcommunication patterns, mood and behavior, psychoso-cial well being, health status, oral and dental status,medications, and treatments. We used resident assessmentdata from calendar years 1994 and 1995 covering allresidents and nursing facilities in Maine, Mississippi, andSouth Dakota and all skilled nursing facilities (SNFs) inNew York.  These data are linked with the Area Resource Fileand facility information from the states to obtain informa-tion on facility and area characteristics.Summary of ResultsStudy results indicate that rural NF residents aremore likely to have multiple re-admissions from a hospital.This association is evident in all four states and persistseven after controlling for other factors, including state ofresidence and resident, facility and market-levelcharacteristics. Further analysis indicates that the effect ofrural residence on the probability of multiple NF re-admissions is greater among newly admitted rural residentsthan among rural residents not classified as new admissions.In addition to rural residence, other factors associatedwith an increased likelihood of multiple NF re-admissionsfrom a hospital include: state of residence, diagnosis ofcongestive heart failure, and no discharge planned at thetime of admission. Residents classified in the “Rehab”,Special Care”, and “Clinically Complex” case mix groupsall had a significantly greater likelihood of multiple NF re-admissions from a hospital. Older age (80+) and being inthe “Cognitive” case mix group are associated with a lowerlikelihood of multiple hospitalization.Conclusions and PolicyImplicationsThe literature leaves little doubtthat multiple hospitalization of nurs-ing home residents poses a signifi-cant health risk for residents (Castleand Mor 1996). The findings of thisstudy, therefore, raise important qual-ity of care concerns. Addressing thisproblem is complicated by severalfactors. Disentangling the many fac-tors that contribute to this problem isdifficult. In addition, implementa-tion of facility-level or policy rem-edies may be compromised by staff-ing shortages, the need for staff education and training,and/or the need for greater physician involvement andsupport for medically complex NF residents.  Changingand sometimes conflicting Medicare and Medicaid pay-ment and regulatory policies and incentives may alsomake solving this problem more difficult.The patterns of findings from this and other researchsuggest that there are a number of key factors influencingthe decision to hospitalize a nursing home resident, in-cluding the clinical capacity of the facility, the overallacuity of the facility’s residents, and the individual char-acteristics of residents. Other studies (Intrator et al. 1999)indicate that the presence of additional medical resources,either physicians or physician ex-tenders, significantly reduces therisk of hospitalizations.This finding suggests a strat-egy of enhancing the availabilityand use of physician and other medi-cal services to reduce hospitaliza-tions (Garrard et al. 1990). Imple-menting such an approach in ruralnursing homes may be difficult,however. The availability of quali-fied health personnel (e.g. geriatricnurse practitioners, RNs) has typi-cally been a problem in many ruralareas.  Likewise, the limited avail-ability of physicians in rural areas,their heavier workloads, and thelimited reimbursement for care pro-vided in nursing facilities will makeit more difficult in rural areas toobtain greater physician attentionto NF residents.Expanded availability and useof video and computer-based tech-nologies such as telehealth may beuseful in overcoming these limitations. Telehealth tech-nologies can and are being used for home care and otherapplications that have the potential for enabling offsitediagnosis of medical and other problems, thereby reduc-ing unnecessary emergency room use or hospitalization ofNF residents (Cluff 1996). These technologies may havepotentially useful applications in rural nursing homes(and other residential care settings) where access to spe-cialty services is a known problem and likely contributorto the problem of hospitalizations.The clinical and other char-acteristics of nursing facility resi-dents are likely to continue tochange as Medicare and state Med-icaid programs move toward casemix-based payment systems fornursing facility care which encour-age facilities to admit patients withheavier care needs. State efforts torestrict eligibility for nursing homecare to those with the greatest medi-cal need, to create new residentialcare alternatives, such as assistedliving, and to expand home andcommunity-based service optionsfor patients who might otherwisehave been admitted to a nursingfacility, will further contribute tothese trends.For all of these reasons, it is critical that we under-stand better the challenges of, and potential strategies for,caring for medically complex residents in rural NFs and toidentify potential strategies for doing so more effectively.Such strategies might include greater use of geriatric nursepractitioners and other physician extenders, and increas-ing payments to physicians providing services in nursinghomes (Freiman and Murtaugh 1995).The feasibility and effectiveness of these strategies foraddressing the problem of multiple hospitalization of NFresidents will be significantly affected by the response ofrural NFs to the SNF payment policy provisions of the BBAand the BBRA. There are serious concerns about the abilityof many skilled facilities, including those in rural areas, toachieve the significant cost reductions required withoutreducing beneficiary access and/or the quality of care.Smaller, rural SNFs may be less able to absorb cuts in SNFpayment without significant reductions in staff. Any staffing reductions would, of course, run counterto the need suggested by this and other studies for increas-ing clinical resources. Similarly, for some financially vul-nerable rural hospitals which have diversified into SNFlevel care, cuts in SNF payments will be difficult to absorband may result in reductions in staffing or other behav-ioral responses that could jeopardize the quality of care.The clinicaland other characteristicsof nursing facilityresidents are likelyto continueto change asMedicare and stateMedicaid programsmove toward casemix-basedpayment systemsfor nursingfacility carewhich encouragefacilities to admitpatients with heavier care needsEdmund S. Muskie School of Public Service  • 96 Falmouth Street, P. O. Box 9300, Portland, Maine 04104-9300Tel: (207) 780-4430  • Fax: (207) 780-4417 • TDD: (207) 780-5646 • www.muskie.usm.maine.edu/mrhrcReferencesCastle, N.G. and Mor V.  (1996)  "Hospitalization of Nursing Home Residents: A Review of the Literature, 1980-1995."Medical Care Research and Review. 53:2:123-148.Intrator O., Castle, N., and Mor, V. "Facility Characteristics Associated with Hospitalization of Nursing Home Residents"Medical Care 37:228-237.Cluff L. E. (1996) "The Role of Technology in Long Term Care" in The Future of Long Term Care: Social and PolicyIssues, Binstock R.H., Cluff L.E. and von Mering O. (Ed),  Baltimore MD. Johns Hopkins University Press.Freiman, M.P. and Murtaugh, C.M.  (1995)  "Interactions Between Hospital and Nursing Home Use."  Public HealthReports. 110:546-554.It is critical that we understand betterthe challenges of, and potential strategies for,caring for medically complex residents in ruralNFs and to identify potential strategies for doingso more effectively. Such strategies  mightinclude greater use of geriatric nursepractitioners and other physician extenders,and increasing payments to physiciansproviding services in nursing homes.(Freiman and Murtaugh 1995).

Multiple Hospitalizations Among Elderly Nursing Facility Residents: Is Rural Residence a Risk Factor?

https://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1015&context=longterm_care

Multiple Hospitalizations Among Elderly Nursing Facility Residents: Is Rural Residence a Risk Factor?

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