Special Article
The Increased Needs of Patients in Nursing Homes and Patients Receiving Home Health Care
N Engl J Med 1990; 322:21-27January 4, 1990
- Abstract
- Abstract
To evaluate the effects of Medicare's prospective payment system and Medicaid's preadmission regulations on long-term care, we constructed clinical profiles in 1982 and 1986 of about 500 randomly selected patients from each of three types of facilities: nursing homes with relatively high proportions of Medicare patients (high-Medicare nursing homes; n = 23), traditional nursing homes (n = 19), and home health agencies (n = 18). Data were obtained directly from the care givers on the medical problems, problems requiring skilled nursing, and functional problems of these representative patients from 12 states.
For Medicare patients in high-Medicare nursing homes, the prevalence of medical problems and problems requiring skilled nursing increased substantially, whereas the prevalence of functional problems remained relatively unchanged. For example, from 1982 to 1986 there was a marked increase in the frequency of tube feedings (21 to 29 percent), oxygen use (6 to 14 percent), urinary tract infection (7 to 13 percent), and diastolic hypertension (1 to 10 percent), but not difficulty in eating (48 to 51 percent) or speaking (28 to 29 percent). In contrast, in traditional nursing homes there was an increase in the prevalence of functional disability, but virtually no change in that of problems requiring medical and skilled nursing care. In home health care the functional care needs of Medicare patients increased significantly, and there was a slight increase in the prevalence of problems requiring medical and skilled nursing care.
We conclude that from 1982 to 1986 the needs of patients in long-term care increased substantially. This trend appears to result from Medicare's prospective payment system, which encourages earlier hospital discharge to long-term care settings, and from Medicaid's policy of deinstitutionalization. Meeting this greater need for care will be costly. We require a better system of reimbursing for long-term care and ensuring its quality. (N Engl J Med 1990; 322:21–7.)
Media in This Article
Table 1
Profiles of Medicare and Non-Medicare Patients in High-Medicare Nursing Homes in 1982 and 1986.*Table 2
Profiles of Patients in Traditional Nursing Homes in 1982 and 1986.*Article Activity
- Article
THE rising demand for geriatric and long-term care in the United States as a result of increases in the elderly population1 , 2 may be straining our already overtaxed and fragmented long-term care delivery system. Anecdotal evidence suggests that recent Medicare and Medicaid reimbursement and regulatory practices have increased the need for patient care in nursing homes and home health agencies. Evidence of the effect of such practices on hospital care is now available,3 4 5 6 but their effect, if any, on long-term care is unclear.
Implemented in 1983, Medicare's prospective payment system provides reimbursement based on diagnosis-related groups. It has reduced the length of stays for hospital care and lowered rates of hospital occupancy, raising concern that some patients may receive inadequate hospital care; they may be discharged prematurely or provided with too few services because of incentives to contain costs.7 8 9 A parallel concern has emerged about the ripple effects of the prospective payment system on long-term care.10 , 11 Some providers contend that nursing homes and home health agencies now admit patients with greater medical and nursing care needs. There is only scattered evidence to support this contention,12 but if it is substantiated, an awareness of its effects will be essential to revising the delivery and financing of both long-term and geriatric care.13 14 15 16
Other program and policy changes have also affected long-term care.17 , 18 Since 1980 several states have implemented a policy of stringent preadmission review of nursing home patients19 , 20 to divert Medicaid patients needing less intense long-term care to community care programs. Medicaid home- and community-based care programs have also been implemented in a number of states, providing alternatives to nursing homes for Medicaid patients who are less functionally impaired.21 After reimbursement limits on the number of home health care visits were removed in 1980, the number of Medicare-certified home health agencies increased from 3012 in 1981 to 5517 in 1985.22 23 24
If these agencies and facilities are required to meet a need for more intensive medical care, it is not clear that they will have the capacity to provide it adequately. If further resources are required, the question of whether our current reimbursement systems for long-term care will be able to provide them must also be addressed. As a first step, our study was designed to provide empirical evidence about how the needs of patients receiving long-term care have changed since the early 1980s.
Methods
Base-Line Data
Base-line data for this analysis were collected in the early 1980s to identify and compare the characteristics of patients in hospital-based and free-standing nursing homes and home health agencies.25 In 1986 we looked at the same facilities to ascertain whether the prevalence of specific conditions and problems among their patients had changed. We used the same methods to collect data that we had used in the earlier study, thus obtaining patient-specific data for the two periods from 42 nursing homes and 18 home health agencies in 12 states. Our findings are based on cross-sectional random samples of patients in the facilities in 1982 and 1986. Some of the 1982 data collection was completed early in 1983. The patient was our unit of analysis because our primary hypothesis focused on whether problems and the need for care had grown among patients receiving long-term care. We took the characteristics of the facilities into consideration by stratifying the facilities according to type.
Types of Providers
We classified providers as high-Medicare nursing homes, traditional nursing homes, and home health agencies. The term "high-Medicare nursing home" referred to a Medicare-certified skilled-nursing facility in which the percentage of days covered by Medicare (i.e., the rate of Medicare use) was at least 15 percent. In this study, the high-Medicare nursing homes had average rates of Medicare use of 25 percent, ranging from 15 to 65 percent.
The term "traditional nursing home" referred to a facility that admitted relatively high proportions of patients covered by Medicaid and private payers. The rates of Medicare use for the traditional nursing homes in this study ranged between 0 and 10 percent, averaging 3 percent.
We classified nursing homes in this way primarily because the two types have different goals and therefore care for different sorts of patients. High-Medicare nursing homes are oriented toward and staffed to care for patients with more complex needs, typically after treatment for acute conditions. They therefore tend to admit a considerably higher proportion of Medicare patients, who generally require more medical and skilled nursing care than other nursing home patients, since nursing home benefits under Medicare are usually available only to patients after treatment for acute conditions. Because of this orientation, even non-Medicare patients in these facilities have more substantial medical and skilled-nursing needs than non-Medicare patients in traditional nursing homes. By contrast, traditional nursing homes usually admit patients with less need for medical and skilled nursing care. Both high-Medicare and traditional nursing homes are usually certified as both skilled-nursing and intermediate care facilities. Because their differing orientations greatly affect the type of patients they serve — independent of the source of payment — we did not pool Medicare patients (or non-Medicare patients) across types of facilities for this analysis.
All of the home health agencies in the study were Medicare certified. An average of 70 percent of admissions were covered by Medicare, a rate typical of Medicare-certified home health agencies.
Facilities were selected to be representative of nursing homes and certified home health agencies throughout the United States, within the strata of hospital-based and free-standing facilities. These strata were used to account for previously verified differences in the needs of patients in hospital-based and free-standing facilities.26 27 28 Within strata, facilities were selected from states with representative ranges of Medicaid-reimbursement systems, hospitals and long-term care facilities, and demographic diversity.
Sampling Procedures
At least 20 study patients were randomly selected from each facility or agency each time data were collected (1982 and 1986). For high-Medicare facilities, stratified random samples were used to ensure adequate numbers of Medicare and non-Medicare patients. In the study's 23 high-Medicare nursing homes (11 hospital-based and 12 free-standing), primary data were collected on 615 patients in 1983 and 555 patients in 1986. In the 19 traditional nursing homes (10 hospital-based and 9 free-standing), primary data were collected on 620 patients in 1982 and 604 patients in 1986. In the 18 home health agencies (10 hospital-based and 8 free-standing), data were collected on 584 patients in 1982 and 491 patients in 1986.
Data Collection
Two research-center nurses collected data on each patient at the participating facilities and agencies. They recorded each item prospectively, in relation to the patient's condition at the time, after asking structured questions of the patient's primary nurse and reviewing the patient's record to verify appropriate information. For all patient-specific information, the nurses relied primarily on the answers of the respondent or care giver. Thus, although charting practices had changed in a few of the facilities between 1982 and 1986, our method of eliciting data was relatively immune to the changes. In addition to collecting data on the patients, the nurses conducted a survey among administrators and staff members to verify information about the facilities obtained from other sources and to collect reimbursement data about the patients.
Indicators
The development of indicators has been described previously.25 The original data items were selected as appropriate for measuring patients' problems and conditions (and thus their need for care). They included the following areas: basic characteristics, such as age, diagnosis at admission, and payer; functional impairment in the activities of daily living, such as bathing, dressing, and eating; impairment in such areas as the ability to use the telephone and the ability to communicate; and conditions such as dyspnea at rest, orthopnea, diastolic hypertension, confusion, skin ulcer, and those requiring a urinary catheter. Items selected for analysis were defined identically in 1982 and 1986. The indicators and variables discussed here are a subset of those for which data were collected. We selected them using the criteria of clinical relevance, ability to reflect the general pattern of results for all variables, and implications for reimbursement or quality-of-care policy. The pattern of results for the indicators discussed here directly reflected the pattern of results for all the indicator variables.
The responses to specific questions regarding the indicators of a patient's status were rated according to scales on which 0 represented the absence of a condition and 4 or 5 its most extreme level. With the assistance of clinical consultants, we converted these scales to 0–1 dichotomies for statistical analysis. The dichotomies usually corresponded to a condition's absence or presence or to its presence at a low rather than a higher level. This type of dichotomy was useful in identifying severe conditions or disabilities that required more resources than the problem typically needed. Four dichotomies warrant explanation: incontinence was defined in such a way as to exclude patients with catheters, whereas urinary tract infection was defined in such as way as to include them; congestive heart failure was defined in terms of the diagnosed condition under treatment; and the defining condition for diastolic hypertension was an average pressure over the previous two weeks higher than 90 mm Hg.
Aggregate Indicators
Aggregate indicators were used to reflect the overall need for resources. Three such indicators, the functional resource-needs indicator, the New York resource-needs indicator, and the medical and skilled-nursing resource-needs indicator, reflected the need for staff members' time or services, and each corresponded to a different type of need. They were constructed through iterative statistical analyses designed to subdivide patients into a reasonable number of distinct groups (20 or fewer) on the basis of patient-status variables.
We developed the functional resource-needs indicator by associating the characteristics of the patients with the time nurses' aides — the primary providers of functional care — spent caring for them. This indicator was sensitive predominantly to patients' functional care needs. The New York resource-needs indicator approximated the resource-utilization-group index the New York Medicaid program currently uses in reimbursing nursing homes.29 , 30 It reflected both functional problems and certain types of problems requiring medical and skilled nursing care. The medical and skilled-nursing-resource needs indicator approximated the resource-utilization-group index developed for Medicare patients.31 It reflected the need for medical and skilled nursing care more closely than the others. We developed each indicator using data on nursing home patients (not home health care patients), and each reflected the cost of care, with higher values representing a greater need for resources.
A fourth aggregate measure, the skilled-nursing-problem indicator, reflected whether a patient had at least 1 of 11 problems requiring skilled nursing, such as recent myocardial infarction, the need for tube feeding, or skin ulcer. All the problems were defined by a level of severity generally associated with the need for skilled nursing care. A fifth indicator, the activities-of-daily-living summary score, was the sum of the prevalence indicators of dependence in five activities — bathing, dressing, eating, using the toilet, and transferring from bed to chair —and the presence of either bowel or bladder incontinence.
The variables and indicators of the patients' status were divided into three groups: indicators of the need for medical and skilled nursing care, indicators of the need for functional and unskilled care, and composite indicators of the need for skilled and unskilled care. The composite indicators reflected a broad and somewhat balanced spectrum of the needs filled by the combined services of physicians, skilled nurses, and aides.
Statistical Analysis
To test two-group differences involving dichotomous variables, we used the chi-square test or, when an expected cell frequency was less than five, Fisher's exact test. For continuous or other ordinal variables we used a two-sample Wilcoxon test, because the underlying distributions for all such variables were found to be non-normal when Kolmogorov–Smirnov tests were used.
Because two-sample tests of variables in multivariate profiles can result in single variables that appear significant by chance, our inferences were based on the overall pattern of results rather than the results for a single variable or a few variables. To assess the extent to which key two-group differences for single variables persisted in multivariate analyses, we used multiple-T2 tests (from discriminant-function analysis). Variables that yielded the most significant univariate results were always among the most significant factors in multivariate analyses. We thus verified their contribution to the patterns of results while also taking into consideration their interrelations with other attributes of the patients.
Results
High-Medicare Nursing Homes
Table 1Table 1
Profiles of Medicare and Non-Medicare Patients in High-Medicare Nursing Homes in 1982 and 1986.* shows the profiles of Medicare and non-Medicare patients in high-Medicare nursing homes. For Medicare patients, the medical and skilled-nursing resource-needs indicator increased by 15.5 percent between 1982 and 1986. The substantial increase in the indicator of skilled-nursing problems further implied a large increase in the need for medical and skilled nursing care. The prevalence rates for the individual medical and skilled care indicators also exhibited uniform increases, although not all the increases were statistically significant.Unlike the medical and skilled care indicators, however, the functional indicators showed little change in the need for functional care among Medicare patients in high-Medicare nursing homes. The two aggregate functional indicators were virtually unchanged, whereas the individual functional indicators for dependence in bathing and dressing decreased slightly in prevalence, probably due to a decrease in the average age of patients. Bowel incontinence was the only functional indicator with a slight increase in prevalence.
"Bedfast" is included as a composite indicator of the need for skilled and unskilled care because bedfast patients typically require medical and skilled nursing care for medical reasons or after surgery (e.g., tube feeding, catheter care, and administration of medications) as well as functional care. The increased need for skilled and unskilled care shown by the New York resource-needs indicator and the bedfast indicator is attributable to the increased need for medical and skilled nursing care (especially for conditions that required physical therapy and more complex care) rather than functional care, in view of the trends discussed above.
A comparison of the profiles of Medicare and non-Medicare patients in Table 1 demonstrates the greater need for medical and skilled nursing care among Medicare patients, but the similar functional needs in the two groups. The table also shows that changes in the prevalence of medical and skilled-nursing problems were more pronounced among Medicare patients than non-Medicare patients in high-Medicare nursing homes. This difference was largely due to Medicare's skilled-nursing benefit, which is restricted to patients with greater medical needs, and the fact that 99 percent of the Medicare patients had come to the nursing homes from hospitals, as compared with 89 percent of the non-Medicare patients.
Traditional Nursing Homes
The results shown in Table 2Table 2
Profiles of Patients in Traditional Nursing Homes in 1982 and 1986.* were based on all patients admitted to traditional nursing homes and therefore pertained predominantly to patients covered by Medicaid and private payers, rather than Medicare. (Only 55 of 620 patients in 1982 and 37 of 604 patients in 1986 were Medicare patients.) The increase in the indicator of medical and skilled-nursing-resource needs is statistically significant owing to the relatively large sample sizes and small standard deviation, but the magnitude of the increase, 0.01, is inconsequential. The only other skilled care indicator that changed significantly, diastolic hypertension, decreased in prevalence between 1982 and 1986.There were strong increases in all functional care indicators and therefore in the composite indicators of skilled and unskilled care. This pattern was even more pronounced than the analogous pattern among home health care patients (discussed below), because the base-line prevalence rates for 1982 were substantially higher among nursing home patients than home health care patients. In addition, the significant increase in the constant-confusion indicator among patients in traditional nursing homes as compared with home health care patients suggests that these facilities treat more cognitively impaired patients now than in the past. We examined patterns of change for various types of patients in traditional nursing homes and found that the increasing prevalence of functional needs was attributable more to problems among Medicaid patients than non-Medicaid patients (chiefly patients covered by private payers), whose needs increased to a lesser extent.
Home Health Agencies
The increase in the indicator of medical and skilled-nursing-resource needs for Medicare home health care patients (Table 3Table 3
Profiles of Medicare and Non-Medicare Home Health Care Patients in 1982 and 1986.*), although significant, was slight as compared with the increase for Medicare patients in high-Medicare facilities (Table 1). Nonetheless, the increases in the percentage of patients receiving tube feeding or having urinary catheters or skin ulcers were substantial.The means for the two aggregate functional care indicators increased substantially — by more than 25 percent — for Medicare home health care patients. With the exception of urinary incontinence, the functional care indicators also increased in a uniform and pronounced pattern. Although the prevalence of urinary incontinence decreased, the prevalence of urinary catheterization among home health care patients increased. The high rates of catheterization may have resulted from a tendency to treat chronic incontinence in home health care patients with catheterization because timed voiding routines require constant supervision.
The two composite skilled and unskilled care indicators further substantiated the trend toward increased resource needs. These increases were associated with increases in both functional care needs and medical and skilled nursing care needs among Medicare home health care patients; the increases in functional care needs were largest.
For the most part, the changes in the prevalence of clinical problems among patients served by home health agencies were due to changes in the needs of Medicare patients. The profiles of non-Medicare patients in Table 3 show that indicators of functional disability actually decreased for non-Medicare patients between 1982 and 1986. There was, however, a slight but statistically insignificant increase in certain problems requiring medical and skilled nursing care among non-Medicare patients over this period.
Previous research has shown that hospital-based home health agencies (and nursing homes) admit patients with more medical and skilled-nursing problems than do free-standing facilities.26 For this reason, we performed separate analyses for hospital-based and free-standing facilities. Because changes in the prevalence of problems between 1982 and 1986 followed the same general pattern for hospital-based and free-standing nursing homes, we pooled most results for both types of facilities. Hospital-based home health agencies did differ in some ways: there was a slightly larger increase in the prevalence of medical and skilled-nursing problems and a substantially larger increase in the prevalence of functional care problems. The differences were largely attributable to differential changes in the needs of Medicare patients.
Discussion
Substantial changes have taken place in the types of patients admitted to long-term care facilities and agencies since the early 1980s. Patients entering nursing homes that serve those who need medical and skilled nursing care after treatment for acute conditions (high-Medicare nursing homes) now have even greater clinical needs. For example, the large increase between 1982 and 1986 in the proportion of bedfast patients (from 10 to 25 percent) in high-Medicare nursing homes appears to be attributable predominantly to the increased prevalence of patients with medical and skilled-nursing problems associated with recent hospitalization for acute conditions rather than patients with chronic debilitating conditions associated with functional and cognitive impairments. Analogous increases in the prevalence of Medicare patients who require tube feeding, have diastolic hypertension, or require oxygen support the same conclusion. More is now expected of the skilled nursing staff in such facilities. Similar increases in the need for medical and skilled care, although not as substantial, occurred among Medicare home health care patients.
In the same period functional needs increased for patients entering traditional nursing homes that admit predominantly patients covered by Medicaid and private payers, and for patients of certified home health agencies. For example, patients in both traditional nursing homes and home health agencies became more dependent in terms of eating, dressing, using the telephone, and dealing with bowel incontinence. In admitting patients to such facilities and arranging for their care by such agencies, it is important that we recognize the change that has occurred in the extent of functional care that nurses and especially nurses' aides must provide. Surveys administered at the time these data were collected indicated that a large majority of the physicians and nurses associated with nursing homes and home health care agencies believed that the need for both unskilled and skilled care (especially skilled nursing care) had increased since the implementation of the prospective payment system.
Although the facilities in our study were chosen to be representative of those throughout the country rather than randomly selected, the pattern of results was uniform within provider categories. Despite the fact that our statistical estimates are influenced by our stratification and selection procedures, this uniformity renders it likely that changes in the profiles of patients reflect national trends.
Other recent research based on Medicare claims sheds light on some of the reasons for these changes.32 , 33 Between 1981 and 1985 the percentage of hospital discharges to Medicare skilled-nursing facilities and Medicare home health agencies increased from 2.5 to 3.1 percent and from 8.5 to 13.3 percent, respectively. Physicians now discharge younger patients who would previously have stayed in the hospital for a few more days to skilled-nursing facilities for brief but intensive periods of rehabilitation (thus the decrease in the average age of Medicare patients shown in Table 1 ). These studies found that decreases in hospital length of stay were larger among Medicare patients who used skilled-nursing facilities or home health agencies. Crude mortality rates and rates of hospital readmission among patients in Medicare skilled-nursing facilities declined over this period. However, the rates were not adjusted for age or the condition of the patient in these studies.
Several factors appear to be responsible for the changing needs of long-term care patients. First, the prospective payment system has directly affected the prevalence of problems requiring medical and skilled nursing care in high-Medicare nursing homes and certified home health agencies: stays for the treatment of acute conditions are shorter, and the rates of discharge to such facilities are higher. Since the supply of traditional nursing homes has not expanded very much over this time, this effect of the prospective payment system has probably influenced traditional nursing homes because patients who are more functionally dependent (but relatively independent in terms of medical and skilled-nursing needs) have been diverted from high-Medicare nursing homes to traditional nursing homes. Another reason for this increase in the prevalence of functional problems in traditional nursing homes has been the emphasis many state Medicaid programs have placed on intensifying their preadmission screening and their home- and community-based care programs to keep patients who are less functionally dependent out of Medicaid nursing homes. As a result, Medicaid home health care increased in volume. Consequently, there was a modest decrease in functional dependency among non-Medicare patients in Medicare-certified agencies, but a significant increase among Medicare patients, due to the prospective payment system.
Physicians should be aware of these pronounced changes and the constraints they can impose on nursing homes and home health agencies. In particular, the skilled-nursing staff in some Medicare home health agencies and nursing homes may have been overtaxed by the substantial increases in the need for medical and skilled nursing care. The aggregate indicators associated with nursing-staff requirements also increased, indicating that for all three types of providers, resource needs — and therefore costs — increased.
Because of limitations on reimbursement, increased costs may result in decreased services and poorer patient care. This may have happened among patients with hip fracture in short-term care facilities under the prospective payment system.34 , 35 Medicare reimbursement and some types of Medicaid reimbursement for both nursing homes and home health care are based on cost subject to certain limits, but a large proportion of providers are already at these limits. For a given provider — especially in states that reimburse nursing homes on the basis of case mix or patient characteristics — increases in the needs of patients result in increased reimbursement only to the extent that the provider's cost has not reached the limits imposed by payers. If, however, a nursing home or home health agency has reached its reimbursement limits, it may be forced to ration services. Such issues clearly call for a thorough analysis of long-term care reimbursement and the quality of care. If, for example, a large proportion of the country's providers have reached their reimbursement ceilings and their patients' needs are still increasing, reimbursement is insufficient, if the providers are operating efficiently.
Both the prospective payment system and Medicaid reimbursement and regulatory policies appear to have substantially changed the nature of long-term care at a time when demand for such care is increasing. Physicians and other care givers must recognize that different types of care are now required of long-term care providers. Payers, regulators, and providers alike must understand the need for a careful analysis of the way we pay for long-term care and ensure its quality.
Supported by grants and cooperative agreements ( 18-P-97145/8–01, 18-C-97712/8–04, and 15-C-98971/8–01) from the Health Care Financing Administration, and (14004) the Robert Wood Johnson Foundation. The opinions and recommendations reported here are those of the authors alone.
We are indebted to Philip Cotterill and Marnie Hall of the Office of Research and Demonstrations of the Health Care Financing Administration and to Alan Cohen and Andrea Kabcenell of the Robert Wood Johnson Foundation for their helpful suggestions and support over the course of this research.
Source Information
From the Center for Health Services Research, University of Colorado Health Sciences Center, and the Department of Internal Medicine, University of Colorado School of Medicine, Denver. Address reprint requests to Dr. Shaughnessy at the Center for Health Services Research, Suite 706, 1355 South Colorado Blvd., Denver, CO 80222.
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