Objective. To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patien... more Objective. To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states' Medicaid long-term care policies. Data Sources/Collection. We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009. Study Design. We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-ofneed (CON) laws; and Medicaid home and community-based services (HCBS) spending. Principal Findings. Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps. Conclusions. Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid.
Aging, Health, and Longevity in the Mexican-Origin Population, 2012
This chapter will review several important themes concerning long term care availability, quality... more This chapter will review several important themes concerning long term care availability, quality of care, and market changes, with special reference to frail aging Hispanics. This review will be based on work performed by Brown University researchers under the aegis ...
The mass media can exert considerable influence over the relative saliency of different public po... more The mass media can exert considerable influence over the relative saliency of different public policy concerns. Because emotional resonance can have a strong impact on how the general public and policy makers perceive specific issues, the purpose of this study is to characterize the tone of nursing home coverage in the national media. Keyword searches of LexisNexis were used to identify 1562 articles published in 4 national newspapers from 1999 to 2008. The content of each article was analyzed and tone, themes, prominence, focal entity, and geographic focus assessed. Multinomial logit was used to examine the correlates of tone. Most articles were negative (49.2%) or neutral (40.3%); few were positive (10.5%). Both positive and negative articles were considerably more likely than neutral articles (>10 times) to be an opinion piece. Negative articles were three quarters more likely to be on the front page and two thirds more likely to focus on industry actors. Positive articles wer...
Journal of the American Medical Directors Association, 2014
The objective of this study was to determine whether the Minimum Data Set (MDS) 3.0 discharge rec... more The objective of this study was to determine whether the Minimum Data Set (MDS) 3.0 discharge record accurately identifies hospitalizations and deaths of nursing home residents. We merged date of death from Medicare enrollment data and hospital inpatient claims with MDS discharge records to check whether the same information can be verified from both the sources. We examined the association of 30-day rehospitalization rates from nursing homes calculated only from MDS and only from claims. We also examined how correspondence between these 2 data sources varies across nursing homes. All fee-for-service (FFS) Medicare beneficiaries admitted for Medicare-paid (with prospective payment system) skilled nursing facility (SNF) care in 2011. Some 94% of hospitalization events in Medicare claims can be identified using MDS discharge records and 87% of hospitalization events detected in MDS data can be verified by Medicare hospital claims. Death can be identified almost perfectly from MDS disc...
The purposes of this study were to compare proxy-patient responses on each domain of the Stroke I... more The purposes of this study were to compare proxy-patient responses on each domain of the Stroke Impact Scale (SIS) and the SIS-16, estimate the bias, and evaluate the validity of proxy scores. Two hundred eighty-seven patient and proxy pairs from the Kansas City Stroke Registry participated in the study. All patients were assessed in their home or nursing facility between 90 and 120 days after stroke with the use of the modified Rankin Scale Motricity Index (strength), Barthel Index (activities of daily living), Lawton assessment (instrumental activities of daily living), Folstein Mini-Mental State Examination (cognition), and the SIS. Eligible proxies were individuals who were aged > or =18 years, had known the patient for at least 1 year, and saw the patient at least once each week. All proxy interviews were conducted within 7 days of (before or after) the patient's interview. Three hundred seventy-seven patients from the Kansas City Stroke Registry were eligible for the study. Seventy-seven patients or proxies refused participation. Thirteen patients of the consenting patient-proxy pairs were too aphasic or cognitively impaired to complete the interviews and were dropped from the study. Proxies scored patients as more severely affected than patients scored themselves on the SIS-16 and in 7 of 8 domains of the full SIS (5 were statistically significant at alpha=0.05). The proxy bias toward overrating the severity of the patient's condition tended to increase as the severity of the stroke increased. However, the magnitude of the biases between patient and proxy means, as measured by effect size, was small (range, -0.1 to 0.4). The strength of the agreement, as measured by intraclass correlation coefficients, between proxy and patient ranged from 0.50 to 0.83. Agreement was best for the observable physical domains. Both patient and proxy scores in all domains were significantly different across Rankin categories. Concurrent validity for both patient and proxy correlations with the Folstein Mini-Mental State Examination, Barthel Index, Lawton instrumental activities of daily living, and Motricity Index was good to excellent (range, 0.37 to 0.78). Proxies provide valid information for assessment of stroke outcomes. There are significant differences between patient and proxy reporting on SIS domains and the SIS-16. However, the observed biases are small and not clinically meaningful.
The purpose of this study was to describe the organizational factors associated with high and low... more The purpose of this study was to describe the organizational factors associated with high and low amounts of teamwork among direct-care workers in long-term care (LTC) facilities. A systematic analysis of observation data collected at 20 LTC facilities was first used to categorize facilities as high-, moderate-, or low-teamwork facilities. Next, qualitative analysis of 59 interviews collected in 4 high-teamwork and 5 low-teamwork facilities was used to identify the organizational factors associated with high and low teamwork. Findings showed that high- and low-teamwork LTC facilities in this study differed in three organizational areas: management style, training, and feedback and recognition. As such, improved teamwork in LTC facilities may result from changes to basic management practices, such as training and employee feedback.
BACKGROUND-Health care transitions in the last months of life can be burdensome and potentially o... more BACKGROUND-Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment.
Although observers have long highlighted the relationship of public distrust, government regulati... more Although observers have long highlighted the relationship of public distrust, government regulation, and media depictions of nursing-home scandals, no study has systematically analyzed the way in which nursing homes have been portrayed in the national media. This study examines how nursing homes were depicted in four leading national newspapers-the New York Times, Washington Post, Chicago Tribune, and Los Angeles Times-from 1999 to 2008. We used keyword searches of the LexisNexis database to identify 1,704 articles pertaining to nursing homes. We then analyzed the content of each article and assessed its tone, themes, prominence, and central actor. We used basic frequencies and descriptive statistics to examine the articles' content, both cross-sectionally and over time. Approximately one-third of the articles were published in 1999/2000, and a comparatively high percentage (12.4%) appeared in 2005. Most were news stories (89.8%), and about one-quarter were on the front page of the newspaper or section. Most focused on government (42.3%) or industry (39.2%) interests, with very few on residents/family (13.3%) and community (5.3%) concerns. Most were negative (45.1%) or neutral (37.0%) in tone, and very few were positive (9.6%) or mixed (8.3%). Common themes were quality (57.0%), financing (33.4%), and negligence/fraud (28.1%). Both tone and themes varied across newspapers and years. Overall, our findings highlight the longitudinal variation in the four widely read newspapers' framing of nursing-home coverage, regarding not only tone but also shifts in media attention from one aspect of this complex policy area to another. The predominantly negative media reports contribute to the poor public opinion of nursing homes and, in turn, of the people who live and work in them. These reports also place nursing homes at a competitive disadvantage and may pose challenges to health delivery reform, including care integration across settings.
Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse heal... more Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients' SNF length of stay. Using a set of fee-forservice beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid.
Journal of the American Medical Directors Association, 2013
The objective of this study was to document the growth of postacute care and contemporaneous staf... more The objective of this study was to document the growth of postacute care and contemporaneous staffing trends in US nursing homes over the decade 2001 to 2010. We integrated data from all US nursing homes longitudinally to track annual changes in the levels of postacute care intensity, therapy staffing and direct-care staffing separately for freestanding and hospital-based facilities. All Medicare/Medicaid-certified nursing homes from 2001 to 2010 based on the Online Survey Certification and Reporting System database merged with facility-level case mix measures aggregated from resident-level information from the Minimum Data Set and Medicare Part A claims. We created a number of aggregate case mix measures to approximate the intensity of postacute care per facility per year, including the proportion of SNF-covered person days, number of admissions per bed, and average RUG-based case mix index. We also created measures of average hours per resident day for physical and occupational therapists, PT/OT assistants, PT/OT aides, and direct-care nursing staff. In freestanding nursing homes, all postacute care intensity measures increased considerably each year throughout the study period. In contrast, in hospital-based facilities, all but one of these measures decreased. Similarly, therapy staffing has risen substantially in freestanding homes but declined in hospital-based facilities. Postacute care case mix acuity appeared to correlate reasonably well with therapy staffing levels in both types of facilities. There has been a marked and steady shift toward postacute care in the nursing home industry in the past decade, primarily in freestanding facilities, accompanied by increased therapy staffing.
Background: Since 1999, there has been a significant increase in hospice providers and hospice us... more Background: Since 1999, there has been a significant increase in hospice providers and hospice use in nursing homes. A 1997 Office of Inspector General (OIG) report warned of possible kickbacks, monetary and otherwise, that might be paid by hospices to nursing homes in exchange for referrals. One possible kickback mentioned in the report was nursing homes receiving additional staff hours at no cost, which could lead to decreases in nursing home staffing. The purpose of this study was to determine if changes in nursing home hospice volume were related to changes in certified nursing assistant (CNA) staffing. Methods: The study included free-standing nursing homes with at least 3 years of observation between 1999 and 2006, no fewer than five deaths in any year, and between 30 and 500 beds (n = 10,759). We examined the longitudinal relationship between changing hospice volume and CNA minutes per resident day (MPRD), utilizing nursing home fixed-effects regression analysis and adjusting for resident case mix and changing organizational characteristics. Results: The introduction of hospice services in a nursing home did not result in statistically significant changes in CNA staffing. Instead, increases in hospice volume resulted in small increases in CNA staffing. Specifically, the addition of 1000 hospice days, in a given year, resulted in an additional 0.79 (95% confidence interval [CI] 0.373-1.211) CNA MPRD. Conclusions: The proposition that nursing homes may be decreasing their staffing as a result of receiving additional hospice staff was not supported by this study and, in fact, nursing homes were found to only slightly increase CNA staffing with increasing hospice volume.
Objective. To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patien... more Objective. To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states' Medicaid long-term care policies. Data Sources/Collection. We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009. Study Design. We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-ofneed (CON) laws; and Medicaid home and community-based services (HCBS) spending. Principal Findings. Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps. Conclusions. Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid.
Aging, Health, and Longevity in the Mexican-Origin Population, 2012
This chapter will review several important themes concerning long term care availability, quality... more This chapter will review several important themes concerning long term care availability, quality of care, and market changes, with special reference to frail aging Hispanics. This review will be based on work performed by Brown University researchers under the aegis ...
The mass media can exert considerable influence over the relative saliency of different public po... more The mass media can exert considerable influence over the relative saliency of different public policy concerns. Because emotional resonance can have a strong impact on how the general public and policy makers perceive specific issues, the purpose of this study is to characterize the tone of nursing home coverage in the national media. Keyword searches of LexisNexis were used to identify 1562 articles published in 4 national newspapers from 1999 to 2008. The content of each article was analyzed and tone, themes, prominence, focal entity, and geographic focus assessed. Multinomial logit was used to examine the correlates of tone. Most articles were negative (49.2%) or neutral (40.3%); few were positive (10.5%). Both positive and negative articles were considerably more likely than neutral articles (>10 times) to be an opinion piece. Negative articles were three quarters more likely to be on the front page and two thirds more likely to focus on industry actors. Positive articles wer...
Journal of the American Medical Directors Association, 2014
The objective of this study was to determine whether the Minimum Data Set (MDS) 3.0 discharge rec... more The objective of this study was to determine whether the Minimum Data Set (MDS) 3.0 discharge record accurately identifies hospitalizations and deaths of nursing home residents. We merged date of death from Medicare enrollment data and hospital inpatient claims with MDS discharge records to check whether the same information can be verified from both the sources. We examined the association of 30-day rehospitalization rates from nursing homes calculated only from MDS and only from claims. We also examined how correspondence between these 2 data sources varies across nursing homes. All fee-for-service (FFS) Medicare beneficiaries admitted for Medicare-paid (with prospective payment system) skilled nursing facility (SNF) care in 2011. Some 94% of hospitalization events in Medicare claims can be identified using MDS discharge records and 87% of hospitalization events detected in MDS data can be verified by Medicare hospital claims. Death can be identified almost perfectly from MDS disc...
The purposes of this study were to compare proxy-patient responses on each domain of the Stroke I... more The purposes of this study were to compare proxy-patient responses on each domain of the Stroke Impact Scale (SIS) and the SIS-16, estimate the bias, and evaluate the validity of proxy scores. Two hundred eighty-seven patient and proxy pairs from the Kansas City Stroke Registry participated in the study. All patients were assessed in their home or nursing facility between 90 and 120 days after stroke with the use of the modified Rankin Scale Motricity Index (strength), Barthel Index (activities of daily living), Lawton assessment (instrumental activities of daily living), Folstein Mini-Mental State Examination (cognition), and the SIS. Eligible proxies were individuals who were aged > or =18 years, had known the patient for at least 1 year, and saw the patient at least once each week. All proxy interviews were conducted within 7 days of (before or after) the patient's interview. Three hundred seventy-seven patients from the Kansas City Stroke Registry were eligible for the study. Seventy-seven patients or proxies refused participation. Thirteen patients of the consenting patient-proxy pairs were too aphasic or cognitively impaired to complete the interviews and were dropped from the study. Proxies scored patients as more severely affected than patients scored themselves on the SIS-16 and in 7 of 8 domains of the full SIS (5 were statistically significant at alpha=0.05). The proxy bias toward overrating the severity of the patient's condition tended to increase as the severity of the stroke increased. However, the magnitude of the biases between patient and proxy means, as measured by effect size, was small (range, -0.1 to 0.4). The strength of the agreement, as measured by intraclass correlation coefficients, between proxy and patient ranged from 0.50 to 0.83. Agreement was best for the observable physical domains. Both patient and proxy scores in all domains were significantly different across Rankin categories. Concurrent validity for both patient and proxy correlations with the Folstein Mini-Mental State Examination, Barthel Index, Lawton instrumental activities of daily living, and Motricity Index was good to excellent (range, 0.37 to 0.78). Proxies provide valid information for assessment of stroke outcomes. There are significant differences between patient and proxy reporting on SIS domains and the SIS-16. However, the observed biases are small and not clinically meaningful.
The purpose of this study was to describe the organizational factors associated with high and low... more The purpose of this study was to describe the organizational factors associated with high and low amounts of teamwork among direct-care workers in long-term care (LTC) facilities. A systematic analysis of observation data collected at 20 LTC facilities was first used to categorize facilities as high-, moderate-, or low-teamwork facilities. Next, qualitative analysis of 59 interviews collected in 4 high-teamwork and 5 low-teamwork facilities was used to identify the organizational factors associated with high and low teamwork. Findings showed that high- and low-teamwork LTC facilities in this study differed in three organizational areas: management style, training, and feedback and recognition. As such, improved teamwork in LTC facilities may result from changes to basic management practices, such as training and employee feedback.
BACKGROUND-Health care transitions in the last months of life can be burdensome and potentially o... more BACKGROUND-Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment.
Although observers have long highlighted the relationship of public distrust, government regulati... more Although observers have long highlighted the relationship of public distrust, government regulation, and media depictions of nursing-home scandals, no study has systematically analyzed the way in which nursing homes have been portrayed in the national media. This study examines how nursing homes were depicted in four leading national newspapers-the New York Times, Washington Post, Chicago Tribune, and Los Angeles Times-from 1999 to 2008. We used keyword searches of the LexisNexis database to identify 1,704 articles pertaining to nursing homes. We then analyzed the content of each article and assessed its tone, themes, prominence, and central actor. We used basic frequencies and descriptive statistics to examine the articles' content, both cross-sectionally and over time. Approximately one-third of the articles were published in 1999/2000, and a comparatively high percentage (12.4%) appeared in 2005. Most were news stories (89.8%), and about one-quarter were on the front page of the newspaper or section. Most focused on government (42.3%) or industry (39.2%) interests, with very few on residents/family (13.3%) and community (5.3%) concerns. Most were negative (45.1%) or neutral (37.0%) in tone, and very few were positive (9.6%) or mixed (8.3%). Common themes were quality (57.0%), financing (33.4%), and negligence/fraud (28.1%). Both tone and themes varied across newspapers and years. Overall, our findings highlight the longitudinal variation in the four widely read newspapers' framing of nursing-home coverage, regarding not only tone but also shifts in media attention from one aspect of this complex policy area to another. The predominantly negative media reports contribute to the poor public opinion of nursing homes and, in turn, of the people who live and work in them. These reports also place nursing homes at a competitive disadvantage and may pose challenges to health delivery reform, including care integration across settings.
Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse heal... more Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients' SNF length of stay. Using a set of fee-forservice beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid.
Journal of the American Medical Directors Association, 2013
The objective of this study was to document the growth of postacute care and contemporaneous staf... more The objective of this study was to document the growth of postacute care and contemporaneous staffing trends in US nursing homes over the decade 2001 to 2010. We integrated data from all US nursing homes longitudinally to track annual changes in the levels of postacute care intensity, therapy staffing and direct-care staffing separately for freestanding and hospital-based facilities. All Medicare/Medicaid-certified nursing homes from 2001 to 2010 based on the Online Survey Certification and Reporting System database merged with facility-level case mix measures aggregated from resident-level information from the Minimum Data Set and Medicare Part A claims. We created a number of aggregate case mix measures to approximate the intensity of postacute care per facility per year, including the proportion of SNF-covered person days, number of admissions per bed, and average RUG-based case mix index. We also created measures of average hours per resident day for physical and occupational therapists, PT/OT assistants, PT/OT aides, and direct-care nursing staff. In freestanding nursing homes, all postacute care intensity measures increased considerably each year throughout the study period. In contrast, in hospital-based facilities, all but one of these measures decreased. Similarly, therapy staffing has risen substantially in freestanding homes but declined in hospital-based facilities. Postacute care case mix acuity appeared to correlate reasonably well with therapy staffing levels in both types of facilities. There has been a marked and steady shift toward postacute care in the nursing home industry in the past decade, primarily in freestanding facilities, accompanied by increased therapy staffing.
Background: Since 1999, there has been a significant increase in hospice providers and hospice us... more Background: Since 1999, there has been a significant increase in hospice providers and hospice use in nursing homes. A 1997 Office of Inspector General (OIG) report warned of possible kickbacks, monetary and otherwise, that might be paid by hospices to nursing homes in exchange for referrals. One possible kickback mentioned in the report was nursing homes receiving additional staff hours at no cost, which could lead to decreases in nursing home staffing. The purpose of this study was to determine if changes in nursing home hospice volume were related to changes in certified nursing assistant (CNA) staffing. Methods: The study included free-standing nursing homes with at least 3 years of observation between 1999 and 2006, no fewer than five deaths in any year, and between 30 and 500 beds (n = 10,759). We examined the longitudinal relationship between changing hospice volume and CNA minutes per resident day (MPRD), utilizing nursing home fixed-effects regression analysis and adjusting for resident case mix and changing organizational characteristics. Results: The introduction of hospice services in a nursing home did not result in statistically significant changes in CNA staffing. Instead, increases in hospice volume resulted in small increases in CNA staffing. Specifically, the addition of 1000 hospice days, in a given year, resulted in an additional 0.79 (95% confidence interval [CI] 0.373-1.211) CNA MPRD. Conclusions: The proposition that nursing homes may be decreasing their staffing as a result of receiving additional hospice staff was not supported by this study and, in fact, nursing homes were found to only slightly increase CNA staffing with increasing hospice volume.
Uploads
Papers by Denise Tyler