James H. Swan

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.

Dominant and Competing Paradigms in Gerontology: Towards a Political Economy of Ageing

The origins and influence of social science perspectives have conditioned theoretical and empirical developments in the field of gerontology. Yet little systematic examination has been afforded to the role of social science in the production of gerontological knowledge in providing the underlying rationale for American social policy for the aged. This paper examines the dominant U.S. social science perspectives or paradigms and discusses the reasons for their centrality in American gerontological thought. The paper concludes with a proposal for an alternative line of inquiry — a political economy of ageing — which takes as problematic the effects of social history, the world economy, capitalism and social class on the ageing process and the aged and the policy interventions designed for them.

The effect of certificate of need and moratoria policy on change in nursing home beds in the United States.

OBJECTIVES This study examined the effects of state certificate of need and/or moratorium requirements on the change in nursing home bed growth in states over a 13-year period. METHODS Data were collected from five telephone surveys of state officials about state certificate of need and moratorium policies, state Medicaid nursing home reimbursement rates, and the licensed nursing home beds in each state for the 1979 through 1993 period. Two-stage least squares regression analysis treated certificate of need and/or moratorium and Medicaid reimbursement rates as endogenous variables in predicting the change in nursing home beds per aged population in states. RESULTS States that had a certificate of need and/or moratorium did have significant reductions in the growth in nursing home beds but Medicaid nursing home reimbursement rates were not related to change in bed stock. The percentage of the population living in a metropolitan area, the personal income per 1,000 population, the percent unemployed, a states tax effort, and time were positively associated with change in nursing home beds. The ratio of nursing home beds per 1,000 aged population in the previous year was a negative predictor of change in bed stock in a given year. CONCLUSIONS State regulatory policies have an effect on bed growth in contrast to reimbursement policies.

Parenting stress and mothers of young children with chronic illness: A cross-cultural study

This study examined the sources of parenting stress among mothers from Israel, Japan, Jordan, and the United States who had a young child with a chronic illness. The results indicated mothers from all four countries experienced high levels of child-focused and parent-focused stress that indicated a need for nursing intervention.

Nursing Facility Staffing in the States: The 1991 to 1995 Period

Trends in the average nurse staffing levels are reported for certified nursing facilities in the United States from 1991 through 1995. Data from the federal On-Line Survey Certification and Reporting system show a small overall increase in the staffing levels for registered nurses (RNs), licensed vocational and licensed practical nurses (LVNs/LPNs), and nursing assistants over the 5 years, but there are substantial variations across states and regions. A two-stage least squares panel analysis examined predictors of nurse staff levels in states. States with higher resident case mix levels had higher RN and LVN/LPN hours. States with higher percentages of large facilities had lower RN and LVN/LPN levels and states with higher percentages of for-profit facilities had lower RN staff levels. States with a higher percentage of Medicaid residents had higher LVN/LPN staff levels. These findings indicate the need for more studies of staff variations and public policies that affect staffing.

Medicaid nursing facility reimbursement methods: 1979-1997

This article describes state Medicaid nursing facility reimbursement methods and rates in 1979-1997, using data derived from telephone surveys of state Medicaid reimbursement. The 1980s saw shifts toward prospective methodology. The late 1980s and early 1990s were characterized by adoption of casemix methods. The early 1990s also saw fewer changes in methodology with a hiatus in the mid-1990s followed recently by renewed changes to methodology. Medicaid per diem rates have increased faster than inflation but less rapidly than general health costs. The repeal of the Boren Amendment may now allow states to institute greater cost controls or moratoria on rate increases. Despite states’ tendencies to follow one another’s examples, Medicaid reimbursement remains diverse nationally, with wide differences in policies and rates.

Residential care supply and cognitive and physical problem case mix in nursing homes.

Objectives: Arapid evolution has occurred in state policy and industry practices relative to assisted living and expanded use of residential care facilities for people with physical and cognitive frailty, yet relatively little is known about the interrelationship between this housing supply and nursing-home case mix. Methods:The association between residential care supply and the proportion of cognitively and physically impaired nursing facility residents was examined in more than 1,500 facilities in five states. Results:The proportion of nursing-home cases with only physical and cognitive impairment likely to be affected by emerging long-term care policy appears to be well under 10%. This effect is more persistent among admissions than continuing cases. Discussion:The findings raise caution about the optimistic assumptions of the interplay between residential care/assisted living policy and nursing-home use.

State regulation of the supply of long term care providers

After the removal of the federal reguirements for certificate of need (CON) in 1986, the majority of states (40) and the District of Columbia retained their CON and/or added a moratorium on new nursing facilities and beds. Some states were also regulating the growth of other types of long term care (LTC) facilities and home health agencies. States with a CON and/or moratoria were more likely to have a greater non- White population, to have liberal politicians, and to have a lower capacity to raise taxes. When state financial budgets are limited, policymakers are likely to continue to regulate the supply of LTC providers.

Explaining State Medicaid Nursing Home Reimbursement

Abstract Medicaid nursing home reimbursement methods and per diem rates affect costs, quality, equity, and access. State rate-setting is a laboratory of policymaking, which can inform state and federal Medic-aid reform initiatives. This paper explains state Medicaid nursing facility rates in 1979-1994. Findings suggest that prospective facility-specific methods constrained rates in some but not all periods, particularly when older cost-reports were employed in rate-setting. Analysis failed to show that prospective class rate-setting methods constrained rate increases. Findings suggest that the efficacy of reimbursement methodology to control rates depends upon wider health care policy trends and that future facility-level analyses should consider policy contexts as between states.

Privatization, System Membership, and Access to Home Health Care for the Elderly

Home health agency (HHA) access based on organizational and market factors is considered, employing a theoretical model of isomorphism for organizational factors and ecological and economic theories for market factors. Data derive from 1986 and 1987 telephone surveys that randomly sampled 185 HHAs from nine metropolitan areas in five states. Results show that competition limits restrictions on access; for-profit status and system membership increase the likelihood that clients will be refused for financial reasons. Findings support the isomorphism theory that fewer access and other behavioral differences appear within systems: nonprofits and for-profits tend to behave alike within systems, whereas freestanding nonprofits are less likely than their for-profit counterparts to refuse access. Findings for system members may account for some of the problems of legitimacy experienced by nonprofit health care organizations.