William J. Foley

Refining a Case-mix Measure for Nursing Homes: Resource Utilization Groups (rug-iii)

A case-mix classification system for nursing home residents is developed, based on a sample of 7,658 residents in seven states. Data included a broad assessment of resident characteristics, corresponding to items of the Minimum Data Set, and detailed measurement of nursing staff care time over a 24-hour period and therapy staff time over a 1-week period. The Resource Utilization Groups, Version III (RUG-III) system, with 44 distinct groups, achieves 55.5% variance explanation of total (nursing and therapy) per diem cost and meets goals of clinical validity and payment incentives. The mean resource use (case-mix index) of groups spans a nine-fold range. The RUG-III system improves on an earlier version not only by increasing the variance explanation (from 43%), but, more importantly, by identifying residents with “high tech” procedures (e.g., ventilators, respirators, and parenteral feeding) and those with cognitive impairments; by using better multiple activities of daily living; and by providing explicit qualifications for the Medicare nursing home benefit. RUG-III is being implemented for nursing home payment in 11 states (six as part of a federal multistate demonstration) and can be used in management, staffing level determination, and quality assurance.

Restraint Reduction Reduces Serious Injuries Among Nursing Home Residents

OBJECTIVES: To describe how removing physical restraints affected injuries in nursing home settings.

Mental dysfunction and resource use in nursing homes.

The role of dementia and other mental disorders in nursing home case-mix classification systems has been an area of controversy. The role of mental dysfunctions was considered in developing a new case-mix measurement system for facility payment in a national demonstration to understand staff time use in nursing homes. Nursing staff (nurses and aides) time and resident assessment data were collected for 6,663 nursing home residents in 6 states. Measures of signs and symptoms of cognitive impairment (dementia), depression, and delirium were created based on items from the new National Minimum Data Set. These measures then were used to determine whether mental dysfunctions were predictive of resource use (nursing staff times and costs) when controlling for other case-mix variables. Cognitive impairment was associated with slightly higher staff time only in less physically-impaired residents without serious medical conditions and not receiving heavy rehabilitation. Similarly, depression and delirium were associated with higher resource use only in selected types of residents. Based on these findings, the new Resource Utilization Groups Version III (RUG-III) contain a major category of residents who are cognitively impaired but not severely dependent in Activities of Daily Living. Depression is used to differentiate subgroups of residents with major medical conditions such as hemiplegia and aphasia. Delirium, when used together with other resident characteristics, was not found useful in explaining resource use. Case-mix groups defined by mental dysfunctions can foster improved care, but careful consideration must be given to appropriate incentives and documentation requirements for providers.

Case-mix classification of Medicare residents in skilled nursing facilities: resource utilization groups (RUG-T18).

Medicare residents in Skilled Nursing Facilities (SNFs) represent a small but unique population about which little is known. Data collected in a national sample of 2,564 Medicare residents in 38 SNFs were used to derive a resident classification system appropriate for use in a payment system. The classification system, Resource Utilization Groups-Medicare (RUG-T18) explains 55.5% of the per-diem resource cost differences of Medicare SNF residents. No classification system could be derived to provide significant explanation of per-episode costs. Although Medicare residents are admitted to SNFs immediately following an acute stay that is paid according to their diagnosis-related groups, the DRGs were ineffective in explaining SNF resource costs.

Can Physically Restrained Nursing-Home Residents Be Untied Safely? Intervention and Evaluation Design

OBJECTIVE: To develop an intervention that will enable nursing home personnel to remove physical restraints from nursing‐home residents safely and cost effectively.

Taking charge. The role of nursing administrators in removing restraints.

The leadership and commitment of nursing administrators play a pivotal role in minimizing the use of restraints and maintaining a restraint-free environment. This article describes the role of nursing administrators in reducing the use of physical restraints as part of a 2-year, national nursing home restraint-reduction project. It reviews important information about restraint-free care the benefits of restraint-free care, and strategies to reduce the use of restraints in nursing homes, much of which is applicable to settings other than nursing homes.

Impact of Interruptions on Schedule Execution in Flexible Manufacturing Systems

Finite capacity scheduling software packages provide a detailed advance plan of production events. However, the execution of this advance plan is disrupted by a myriad of unanticipated interruptions, such as machine breakdowns, yield variations, and hot jobs. The alternatives available to respond to such interruptions include modifying the existing schedule, regenerating the complete schedule, or doing nothing and letting the production system gradually absorb the impact of the interruption. This article reports on a simulation study aimed at understanding the impact of an interruption on a schedule in order to build a knowledge base for intelligent selection of a response from a set of alternatives. The results of the experimental study are used to identify significant major factors and their interactions. The results are discussed to draw insights into the performance of a flexible manufacturing system following an interruption. The causes leading to particular performance anomalies are extensively discussed and mechanisms for propagation and absorption of the effect of interruptions in manufacturing systems are inferred. Practical implications for the development and implementation of schedules are deduced and areas for further research proposed. This study provides the groundwork necessary to proceed with the development of strategies for responding to interruptions.

A Systems Analysis of the Impact of Physician Extenders on Medical Cost and Manpower Requirements

This paper presents a descriptive narrative of a mathematical manpower model and the results of an analysis of the effect physician extenders have on medical costs and manpower requirements. The model is extensively developed, through the use of a new medical classification system in the area of delegation of specific task areas and patient visits to physician extenders. Additionally the models incorporate a complete cost structure for a group practice. Field trials in seven HMOs indicate that the models accurately represent the actual sysem and can be used effectively as planning aids. Results are presented that analyze the use of physician extenders from the following viewpoints: minimum cost solution for adult medicine, pediatrics and obstetrics/gynecology (OB/GYN); maximum physician extender use; effect of physician extender salary on minimum cost utilization; level of independence exercised; size of clinic and regional manpower planning; and a case study of HMO planning. The type of results presented include cost analysis, manpower analysis, and the types of patient visits best delegated to physician extenders (PE).