Taewoon Kang

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

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

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

Personal Service Assistance: Musculoskeletal Disorders and Injuries in Consumer-Directed Home Care

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.

Variation in types of service use and expenditures for individuals with developmental disabilities

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.

Disparities in service utilization and expenditures for individuals with developmental disabilities.

BACKGROUND Like other types of care for disabled or elderly adults, consumer-directed personal assistance services may present multi-factorial risks for work-related musculoskeletal disorders (WRMSDs). METHODS Using survey data, we compared providers experiencing WRMSDs in the previous year to those who did not, seeking to identify functional, temporal, physical, and relationship risk factors for transient and chronic conditions. RESULTS Longer work experience with the recipient and more frequent bending increased the risk of being in the most chronic group (≥12 painful episodes), whereas predictable work hours with rest breaks and greater social support from the recipient appeared protective. For transient conditions (one to two episodes), longer work experience with the recipient and predictable hours with rest breaks appeared protective. CONCLUSIONS We offer recommendations to improve hazard assessment as well as training and information distribution related to home care programs. With the population aging, home care jobs require increasing oversight to prevent WRMSDs.

Hidden Owners, Hidden Profits, and Poor Nursing Home Care: A Case Study.

BACKGROUND this study examined the types of services and expenditures for 8 service categories provided by regional centers to 138,336 individuals with developmental disabilities living at home and in the community in California in 2004-2005. METHODS logistic regressions of secondary data were used to predict the types of services received, and ordinary least squares regressions were used to predict types of service expenditures. RESULTS higher client needs generally were associated with higher odds of receiving services and with expenditures, although the types of services varied by client need. Controlling for client needs and other factors, males were more likely to receive out-of-home services. Individuals aged 3-21 years were generally less likely to receive many services but were more likely to receive in-home and out-of-home respite services than were those over age 62. All racial and ethnic minority groups were less likely to receive support and out-of-home services than were whites and had lower expenditures, although these varied by the types of services. The supply of nursing homes, community care facilities, area population characteristics, and regional centers also predicted variations in service use and expenditure patterns. CONCLUSION studies of the underlying reasons for the variations are needed to ensure equity in access to all types of services and expenditures.

The relationship of California's Medicaid reimbursement system to nurse staffing levels.

BACKGROUND The factors that affect access to services for individuals with developmental disabilities (DD) have not received much attention. METHODS This study examined service utilization and expenditures provided by regional centers to individuals with DD living at home and in residential settings in California in 2004-2005. Logistic regressions of secondary data were used to predict the receipt of services, and ordinary least squares regressions were used to examine the predictors of service expenditures. RESULTS Of the 175,595 individuals assessed with DD, 21% did not receive any purchased services from regional centers in 2004-2005. Controlling for client needs, individuals aged 3-21 years were less likely than other age groups to receive services. All racial and ethnic minority groups were less likely to receive any services than were whites. The supply of intermediate care facilities for habilitation and residential care reduced the likelihood of receiving regional center services. Of those who received services, younger individuals and all racial and ethnic minority groups had significantly lower expenditures. Provider supply, area population characteristics, and regional centers also predicted variation in service use and expenditures. CONCLUSION The disparities by age, race/ethnicity, and geographic area require further study, and specific approaches are needed to ensure equity in access to services.

Factors Associated with Alcohol Use and its Consequences

The study examined the ownership transparency, financial accountability, and quality indicators of a regional for-profit nursing home chain in California, using a case study methodology to analyze data on the chains ownership and management structure, financial data, staffing levels, deficiencies and complaints, and litigation. Secondary data were obtained from regulatory and cost reports and litigation cases. Qualitative descriptions of ownership and management were presented and quantitative analyses were conducted by comparing financial and quality indicators with other California for-profit chains, for-profit non-chains, and nonprofit nursing home groups in 2011. The chains complex, interlocking individual and corporate owners and property companies obscured its ownership structure and financial arrangements. Nursing and support services expenditures were lower than nonprofits and administrative costs were higher than for-profit non-chains. The chains nurse staffing was lower than expected staffing levels; its deficiencies and citations were higher than in nonprofits; and a number of lawsuits resulted in bankruptcy. Profits were hidden in the chains management fees, lease agreements, interest payments to owners, and purchases from related-party companies. Greater ownership transparency and financial accountability requirements are needed to ensure regulatory oversight and quality of care.

In-home supportive services for individuals with cerebral palsy in California

Background:Policy initiatives at the Federal and state level are aimed at increasing staffing in nursing homes. These include direct staffing standards, public reporting, and financial incentives. Objective:To examine the impact of California’s Medicaid reimbursement for nursing homes which includes incentives directed at staffing. Research Design:Two-stage limited-information maximum-likelihood regressions were used to model the relationship between staffing [registered nurses (RNs), licensed practical nurses, and certified nursing assistants hours per resident day] and the Medicaid payment rate, accounting for the specific structure of the payment system, endogeneity of payment and case-mix, and controlling for facility and market characteristics. Sample:A total of 927 California free-standing nursing homes in 2006. Measures:The model included facility characteristics (case-mix, size, ownership, and chain affiliation), market competition and excess demand, labor supply and wages, unemployment, and female employment. The instrumental variable for Medicaid reimbursement was the peer group payment rate for 7 geographical market areas, and the instrumental variables for resident case-mix were the average county revenues for professional therapy establishments and the percent of county population aged 65 and over. Results:Consistent with the rate incentives and rational expectation behavior, expected nursing home reimbursement rates in 2008 were associated with increased RN staffing levels in 2006 but had no relationship with licensed practical nurse and certified nursing assistant staffing. The effect was estimated at 2 minutes per

Consumer-Directed Personal Care: Comparing Aged and Non-Aged Adult Recipient Health-Related Outcomes Among Those With Paid Family Versus Non-Relative Providers

10 increase in rate. Conclusions:The incentives in the Medicaid system impacted only RN staffing suggesting the need to improve the state’s rate setting methodology.