By Steve Syre
An LTSS Center fellow studied the effect on quality of care when nursing homes “multitask” by offering both post-acute and long-stay care. Here are the findings.
There’s a theory about multitasking: When one part of a job offers bigger rewards, performance in another area will suffer.
Jennifer Gaudet Hefele, a fellow at the LeadingAge LTSS Center @UMass Boston, applied that multitasking theory to nursing homes. Using 14 different performance measures, Hefele examined whether nursing homes that made a deliberate effort to expand higher paying post-acute care demonstrated declining quality for lower paying long-stay care.
The study’s results, published recently in The Gerontologist, show there was no significant decline in long-stay quality at those nursing homes. The research is supported by the Patrick and Catherine Weldon Donaghue Medical Research Foundation.
“That our study found no negative overall effects of increased Medicare focus on quality of care for long-stay residents is good news,” said Hefele, an assistant professor of gerontology at the University of Massachusetts Boston. “This means most nursing homes can sustain fairly large increases in Medicare census without losing sight of quality for their most frail residents.”
Hefele worked on the study with Christine Bishop from Brandeis University and 2 UMass Boston Gerontology doctoral students, Xaio (Joyce) Wang and Adrita Barooah.
TRACKING A WIDE RANGE OF QUALITY MEASURES
Hefele’s team began its research by looking at the changing mix of care and payment at certified U.S. nursing homes between 2006 and 2009. Researchers selected 7,932 homes that experienced a 1-year increase in the proportion of Medicare-paid care that was equal to at least one standard deviation, or 5.84 percentage points.
Researchers then tracked standard performance measures among those nursing homes to understand how changes in Medicare census affected quality for long-stay residents. They measured the proportion of a home’s long-stay residents with:
- A decline in late-loss Activities of Daily Living (ADL) function.
- Inadequate pain management.
- Pressure ulcers among those who were at high risk for developing them.
- Pressure ulcers among those who were at average risk for developing them.
- Bladder or bowel incontinence, among those who were at low risk for developing this condition.
- An indwelling catheter.
- Worsening locomotion abilities.
- Urinary tract infections.
- Worsening depression or anxiety.
Researchers also measured the proportion of a home’s long-stay resident who were:
- Using physical restraints.
- Losing too much weight.
- Appropriately provided influenza vaccination.
- Appropriately provided the pneumococcal vaccination.
On average, there was no significant decline registered by the nursing home study sample in any of the quality measures associated with increased Medicare census. Quality actually improved in one long-stay category, a rising proportion of residents without pressure ulcers.
While quality measures for long-stay care in the entire group of nursing homes examined did not change, a decline in quality was noted among nonprofit nursing homes. Hefele said she did not find nonprofit home declines in all quality measures. However, those detected in categories such as ADL function were significant.
A BENEFIT FROM QUALITY SPILLOVER
Instead of a multitasking effect, additional analyses not yet published and led by Wang have found greater evidence of a “spillover” effect at the nursing homes in the study sample. Improvements in a specific quality category among an individual home’s post-acute residents were often associated with improvements in long-stay quality.
“We don’t know which came first or what’s behind that,” said Hefele. “For example, it could be that nursing homes engage in quality programs to improve for vaccinations across the board and not just in either post-acute or long-stay care. That’s a likely scenario.”
The work from this study is being published in a series of articles, the first of which is available from The Gerontologist. Hefele and her team are preparing the second piece related to the spillover effects and anticipate submitting a manuscript this spring. Additional examinations of the relationships between Medicare volume and nursing home characteristics are also expected to be submitted for publication in the coming months.