Charlene Harrington

Does investor ownership of nursing homes compromise the quality of care

OBJECTIVES Two thirds of nursing homes are investor owned. This study examined whether investor ownership affects quality. METHODS We analyzed 1998 data from state inspections of 13,693 nursing facilities. We used a multivariate model and controlled for case mix, facility characteristics, and location. RESULTS Investor-owned facilities averaged 5.89 deficiencies per home, 46.5% higher than nonprofit facilities and 43.0% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes. CONCLUSIONS Investor-owned nursing homes provide worse care and less nursing care than do not-for-profit or public homes.

Long-Term Care: Who Gets It, Who Provides It, Who Pays, And How Much?

Long-term care in the United States is needed by 10.9 million community residents, half of them nonelderly, and 1.8 million nursing home residents, predominantly elderly. Ninety-two percent of community residents receive unpaid help, while 13 percent receive paid help. Paid community-based long-term care services are primarily funded by Medicaid or Medicare, while nursing home stays are primarily paid for by Medicaid plus out-of-pocket copayments. Per person expenditures are five times as high, and national expenditures three times as high, for nursing home residents compared to community residents. This suggests that a redistribution of spending across care settings might produce substantial savings or permit service expansions.

Nursing Home Staffing, Turnover, and Case Mix:

This study examined the predictors of total nurse and registered nurse (RN) staffing hours per resident day separately in all free-standing California nursing homes (1,155), using staffing data from state cost reports in 1999. This study used a two-stage least squares model, taking into account nursing turnover rates, resident case mix levels, and other factors. As expected, total nurse and RN staffing hours were negatively associated with nurse staff turnover rates and positively associated with resident case mix. Facilities were resource dependent in that a high proportion of Medicare residents predicted higher staffing hours, and a higher proportion of Medicaid residents predicted lower staffing hours and higher turnover rates. Nursing assistant wages were positively associated with total nurse staffing hours. For-profit facilities and high-occupancy rate facilities had lower total nurse and RN staffing hours. Medicaid reimbursement rates and multifacility organizations were positively associated with RN staffing hours.

Estimating Paid and Unpaid Hours of Personal Assistance Services in Activities of Daily Living Provided to Adults Living at Home

OBJECTIVE To estimate the total hours of paid and unpaid personal assistance of daily living provided to adults living at home in the United States using nationally representative household survey data. DATA SOURCES The Disability Followback Survey of the National Health Interview Survey on Disability (NHIS-D) conducted from 1994 to 1997. DATA COLLECTION/EXTRACTION METHODS Data were obtained on persons receiving help with up to 5 ADLs and 10 IADLs, for up to 4 helpers, including the activities they helped with, whether the helper was paid or not, and the number of hours of help provided in the two weeks prior to the survey. The sample consists of 8,471 household-resident adults ages 18 and older receiving help with personal assistance. About 22 percent of the sample has missing data on hours, which we impute by multiple regression models using demographic, ADL, and IADL variables. FINDINGS We estimate that 13.2 million noninstitutionalized adults receive an average of 31.4 hours per week of personal assistance in ADLs and IADLs per week, with 3.2 million people receiving an average of 17.6 hours of paid help and 11.7 million receiving an average of 30.7 hours of unpaid help. More persons ages 18-64 received help than those ages 65 and older (6.9 versus 6.2 million), but working-age recipients had fewer hours (27.4 versus 35.9) per week, due in part to less severe levels of disability. CONCLUSIONS Personal assistance provided to adults with disabilities amounts to 21.5 billion hours of help per year, with an economic value in 1996 approaching

The Regulation and Enforcement of Federal Nursing Home Standards, 1991-1997

200 billion. Only 16 percent of this total is paid, representing

Nursing Home Staffing Standards and Staffing Levels in Six Countries

32 billion in home health services spent annually. This study, the first to estimate hours of assistance for both working-age and older adults, documents that older persons are more likely to receive paid personal assistance, while working-age people rely to a greater extent on unpaid help. This study begins to articulate the division of labor in the provision of personal assistance. Estimates of paid and unpaid hours of help by number of ADLs should inform policy concerning eligibility boundaries in long term care.

Do Noninstitutional Long-Term Care Services Reduce Medicaid Spending?

This article reports historical trend data on resident characteristics and conditions, problems, and deficiency patterns for nursing facilities from 1991 through 1997 from Health Care Financing Administration (HCFA) administrative records from the On-Line Survey, Certification, and Reporting System (OSCAR). Over this period, residents show some increases in dependency and conditions, although there was a decline in the use of restraints. The deficiencies reveal continued quality problems in some nursing homes, although the average number of deficiencies given to facilities declined by 44 percent between 1991 and 1997. The discussion considers possible explanations for the decline in deficiencies, including whether the quality of care in nursing homes has improved or whether the enforcement process has gradually been weakened.

Nurse Staffing and Deficiencies in the Largest For-Profit Nursing Home Chains and Chains Owned by Private Equity Companies

PURPOSE This study was designed to collect and compare nurse staffing standards and staffing levels in six counties: the United States, Canada, England, Germany, Norway, and Sweden. DESIGN The study used descriptive information on staffing regulations and policies as well as actual staffing levels for registered nurses, licensed nurses, and nursing assistants across states, provinces, regions, and countries. METHODS Data were collected from Internet searches of staffing regulations and policies along with statistical data on actual staffing from reports and documents. Staffing data were converted to hours per resident day to facilitate comparisons across countries. FINDINGS We found wide variations in both nurse staffing standards and actual staffing levels within and across countries, although comparisons were difficult to make due to differences in measuring staffing, the vagueness of standards, and limited availability of actual staffing data. Both the standards and levels in most countries (except Norway and Sweden) were lower than the recommended levels by experts. CONCLUSIONS Our findings demonstrate the need for further attention to nurse staffing standards and levels in order to assure the quality of nursing home care. CLINICAL RELEVANCE A high quality of nursing home care requires adequate levels of nurse staffing, and nurse staffing standards have been shown to improve staffing levels.

Staffing Characteristics, Turnover Rates, and Quality of Resident Care in Nursing Facilities

Medicaid spending on home and community-based services (HCBS) has grown dramatically in recent years, but little is known about what effect these alternatives to institutional services have on overall long-term care costs. An analysis of state spending data from 1995 to 2005 shows that for two distinct population groups receiving long-term care services, spending growth was greater for states offering limited noninstitutional services than for states with large, well-established noninstitutional programs. Expansion of HCBS appears to entail a short-term increase in spending, followed by a reduction in institutional spending and long-term cost savings.

A Panel Data Analysis of the Relationships of Nursing Home Staffing Levels and Standards to Regulatory Deficiencies

OBJECTIVE To compare staffing levels and deficiencies of the 10 largest U.S. for-profit nursing home chains with five other ownership groups and chain staffing and deficiencies before and after purchase by four private equity (PE) companies. DATA SOURCES Facilities for the largest for-profit chains were identified through Internet searches and company reports and matched with federal secondary data for 2003-2008 for each ownership group. STUDY DESIGN Descriptive statistics and generalized estimation equation panel regression models examined staffing and deficiencies by ownership groups in the 2003-2008 period, controlling for facility characteristics, resident acuity, and market factors with state fixed effects. PRINCIPAL FINDINGS The top 10 for-profit chains had lower registered nurse and total nurse staffing hours than government facilities, controlling for other factors. The top 10 chains received 36 percent higher deficiencies and 41 percent higher serious deficiencies than government facilities. Other for-profit facilities also had lower staffing and higher deficiencies than government facilities. The chains purchased by PE companies showed little change in staffing levels, but the number of deficiencies and serious deficiencies increased in some postpurchase years compared with the prepurchase period. CONCLUSIONS There is a need for greater study of large for-profit chains as well as those chains purchased by PE companies.