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Article Excerpt
The Omnibus Budget Reconciliation Act, or Nursing Home Reform Act of 1987, mandated that nursing homes adopt a bed-hold policy during acute hospitalization of residents. For a fee, nursing homes reserve the resident's bed during acute hospitalizations. The goals of this policy were twofold: to prevent facilities from discharging "difficult" or expensive patients, and to encourage continuity of residence for the nursing home client (Taylor 2004). Some state Medicaid programs assumed the responsibility for such payments for eligible nursing home residents in various ways, while other states did not.
Recent budget difficulties have led several states to decrease or eliminate bed-hold payments (Maryland 1999; Williams 2003; Correira 2004). Massachusetts has been in a flux regarding its bed-hold policies, changing the number of days and the rates paid several times, discontinuing payment for any bed-hold in 2003, and reinstating it 2 years later. The most attention to the flux in bed-hold policies was garnered in Florida, home to the second largest population of Americans older than 65, where the Medicaid program made $23 million in bed-hold payments annually in 2004 and 2005, roughly the equivalent of 4 days a year per Medicaid nursing home resident (Florida 2005). As statewide nursing home occupancy was under 90 percent, it was argued that bed-hold payments were superfluous, and could be eliminated (Freeman 2004; Nohlgren 2004). A similar argument was made recently in Pennsylvania where policy makers were considering the removal of bed-hold payments (Rotstein 2006).
Nursing home administrators counter that occupancy rates vary by region and by facility, and that elimination of bed-hold payments would increase hospital discharges to facilities other than the resident's original "home," with potential consequences of relocation stress, including disorientation and dissatisfaction (Freeman 20(14; Nohlgren 2004).
Historically, nursing home residents have taken legal action to prevent the closure of a substandard facility in order to avoid relocation, clearly implying social value to familiar surroundings (Cohen 1986). There is some literature suggesting that "relocation trauma" has a lasting negative effect on nursing home residents (Friedman et al. 1995; Capezuti et al. 2006; Laughlin et al. 2007). For example, change of venue alone has transiently increased fall rates (Friedman et al. 1995). Relocation may also lead to the duplication of tests and increased likelihood of medical errors (Boockvar et al. 2004; Coleman et al. 2004; Ma et al. 2004), both of which may be associated with morbidity and cost. A recent Presidential Council of Bioethics report emphasizes that hospitalizations at the end of life, a time at which more comfort and care are needed, are particularly traumatic to nursing home residents and families, exposing them to the possibility of relocation not only to a hospital, but to other nursing homes (Kass 2005).
Although the rationale for bed-hold policies was to facilitate residents' return to their original nursing home, this effect has never been demonstrated. Hospital discharge destination is more complex than bed availability alone, and may be affected by other patients, nursing homes, market, and state factors, as has been shown for other transitions (Intrator et al. 2004, 2007). For specific diagnoses, and for sicker residents, discharge destinations other than nursing homes must be considered. Some patients or families may choose a different facility. For some patients, hospitalization may indicate that their condition is too severe to be managed in the originating nursing home, and indeed, possibly in any nursing home. Residents discharged with rehabilitation needs, such as following a hospitalization for hip fracture, stroke, or psychiatric diagnoses, may have limited facilities that can more appropriately serve them. Facilities with more available beds, advanced clinical capabilities, or higher staffing levels may be more likely to readmit their hospitalized residents. Within a given market, the availability of alternative nursing homes may affect discharge locale. Moreover, differences in the hospitalization rates of nursing home residents have been reported to vary with state policies (Intrator and Mor 2004; Nohlgren 2004). In particular, residents in states with any bed-hold payment policies were reported to have higher odds of being hospitalized (Intrator et al. 2007). Higher Medicaid reimbursement rates have been associated with fewer hospitalizations (Intrator et al. 2007) possibly because higher reimbursement allows facilities to invest in infrastructure and staffing that facilitate care within the nursing home environment as demonstrated in several papers (Intrator et al. 2005; Feng et al. 2008). The purpose of this paper was therefore to study the intended effect of bed-hold policies within the context of today's nursing home market, in light of the reported unintended consequences of associated increased hospitalization rates, while controlling for Medicaid reimbursement rates.
METHODS
Data Sources
We obtained resident characteristics from the Minimum Data Set (MDS), a federally mandated assessment for all nursing home residents that includes approximately 400 data elements, including demographics, diagnoses, treatments and measures of both physical and cognitive functions (Morris et al. 1990; Hawes et al. 1995). We used the Centers for Medicare and Medicaid Services' (CMS's) Standard Analytic Files for part A claims for inpatient hospital, skilled nursing facility (SNF), hospice, home health, and outpatient services to determine other locations of care using the Residential History File methodology (Intrator et al. 2003). The CMS Online Survey Certification and Reporting (OSCAR) system provided nursing home data. We aggregated OSCAR data and used the Area Resource File to obtain market data (Stambler 1988). State Medicaid policies for the period of our study were available from a survey of the 48 contiguous states (Grabowski et al. 2004). We matched all data at the level of the resident, and performed our evaluation at the level of the hospitalization.
Subject Sample
We used MDS data from the second quarter of calendar year 2000 from freestanding urban nursing homes to identify a cohort of all long-stay (> 90 days) residents. This established the nursing home of origin for each of 549,472 residents.
We matched residents to Medicare claims to identify the first acute hospitalization over the ensuing 5 months (N= 97,141). We limited our analysis to 5 months to avoid hospitalizations that extended beyond the calendar year 2000. When hospitalization at one hospital was immediately followed by hospitalization at another, we considered this as a single hospitalization. We excluded hospitalizations in long-term hospitals or rehabilitation facilities (N = 6,067), and hospitalizations not definitively originating from the baseline nursing home (N = 1,485). Hospitalizations with discharges due to death were excluded as mortality was not relevant to the purpose of this study (N = 8,942). Finally, hospitalizations with no matching resident, nursing home, or county information were excluded, and ambiguous discharge locations were censored (N = 2,692). The final cohort included 77,955 residents served in 8,652 facilities in 812 counties in the 48 contiguous U.S. states. Figure 1 presents the framework for this paper in which the first hospitalization of long-stay residents was identified and followed for hospital discharge destination. Sample selection is denoted on the left part of the flow chart, and study outcomes on the right.
[FIGURE 1 OMITTED]
Outcomes
We used the MDS assessment dates, Medicare claims, and discharge location information to determine each resident's first location within 7 days after hospital discharge using the Residential History File methodology (Intrator et al. 2003). We considered three possibilities for discharge destination: the original nursing home, a different nursing home, and a nonnursing home institutional provider (including long-term hospitals, rehabilitation facilities or home hospice-care). Figure 1 presents these outcomes.
Variable Definitions
The main research question in this study was to examine the effect of two state policies on the post-hospital...
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