Search

This article describes a pay-for-performance system developed for Minnesota nursing homes. In effect, nursing homes can retain a greater proportion of the difference between their costs and the average costs on the basis of their quality scores. The quality score is a derived and weighted composite measure currently composed of five elements: staff retention (25 points), staff turnover (15 points), use of pool staff (10 points), nursing home quality indicators (40 points), and survey deficiencies (10 points). Information on residents' quality of life and satisfaction, derived from interviews with a random sample of residents in each Minnesota nursing home, is now available for inclusion in the quality measure. The new payment system was designed to create a business case for quality when used in addition to a nursing home report card that uses the same quality elements to inform potential consumers about the quality of nursing homes. Although the nursing home industry has announced general support for the new approach, it has lobbied the legislature to delay its implementation, claiming concerns about operational details.

Purpose: The purpose of this study was to determine the relationship between nursing home staffing level, care received by individual residents, and resident quality-related care processes and functional outcomes. Design and Methods: Nurses recorded resident care time for 5,314 residents on 156 units in 105 facilities in four states (Colorado, Indiana, Minnesota, and Mississippi). We linked residents' care times to their measures of health and functioning from Minimum Data Set assessments. Major variables were unit- and resident-specific minutes of care per day, process measures (physical restraints, range of motion, toileting program, and training in activities of daily living [ADLs]), outcome measures (ADL decline, mobility decline, and worsening behavior between the time study and 90-day follow-up), and covariates such as unit type and resident health status. We used multilevel analysis to examine staffing and quality relationships. Results: Residents with toileting programs, range of motion or ADL training, and restraints received significantly more care from unlicensed but not from licensed staff. However, functional outcomes were not significantly related to care received from licensed or unlicensed staff, except for ADL decline, which was greatest for residents receiving more unlicensed minutes of care. Unit staffing level (licensed and unlicensed) was unrelated to any of the care processes or outcome measures, although higher overall staffing was associated with more time devoted to direct resident care. Implications: Future research into nursing home quality should focus on organization and delivery rather than simply the amount of care available. (Contains 5 tables.)

Purpose: Our objective in this study was to compare the quality of care provided under the Minnesota Senior Health Options (MSHO), a special program designed to serve dually eligible older persons, to care provided to controls who received fee-for-service Medicare and Medicaid managed care. Design and Methods: Two control groups were used; one was drawn from nonenrollees living in the same area (Control-In) and another from comparable individuals living in another urban area where the program was not available (Control-Out). Cohorts living in the community and in nursing homes were included. Quality measures for both groups included mortality rates, preventable hospital admissions, and preventable emergency room (ER) visits. For the community group, nursing home admission rates were also tracked. For nursing home residents, quality measures included quality indicators derived from the Minimum Data Set. Results: There were no differences in mortality rates for either cohort. MSHO had fewer short-stay nursing home admissions but no difference for stays 90 days or longer. MSHO community and nursing home residents had fewer preventable hospital and ER visits compared to Control-In. There were no major differences in nursing home quality indicator rates. Implications: The cost of changing the model of care for dual eligibles from a mixture of fee-for-service and managed care to a merged managed-care approach cannot be readily justified by the improvements in quality observed.

What constitutes a 'good place to grow old'? This study aimed to characterise salient features of built and social environments that are essential to support low-income ageing residents. Seated and mobile interviews were conducted with community-dwelling older participants (aged 55–92, mean = 71 years) in three distinct socio-economic and geographic samples of the Minneapolis (Minnesota, United States of America) metropolitan area. The interviews prompted participants to evaluate their homes and neighbourhoods, and probed for particular socio-spatial characteristics that impact residential wellbeing. Qualitative thematic analyses focused on 38 individuals living in subsidised housing and homeless shelters. Four interrelated themes encompassed essential residential qualities: (a) safety and comfort, (b) service access, (c) social connection, and (d) stimulation. These broad ideals, when achieved, enabled participants to cultivate residential wellbeing and fulfilling place attachment. Analyses of the empirical data complicate theoretical assumptions by recognising unequal access to, irregular opportunities for and potential dangers of place attachment. Rich descriptions of participant homelessness, health hazards, crime, lack of supportive infrastructure and social isolation illustrate how place attachment is not inherently positive or necessarily attainable; rather, it is problematic and can involve risk. This article extends geographical gerontology's address of socio-spatial inequalities by focusing on disadvantaged ageing individuals. [ABSTRACT FROM AUTHOR]

Background Hospitalisations are very common among nursing home residents and many of these are deemed inappropriate or preventable. Little is known about whether clinical care quality is related to hospitalisation, especially potentially preventable hospitalisations (PPHs). Among the few studies that have been conducted, the findings have been inconsistent. The objective of this study was to examine the relationship between quality indicators and overall and PPHs among Medicaid beneficiaries aged 65 years and older receiving care at nursing homes in Minnesota. Methods 23 risk-adjusted quality indicators were used to assess nursing home quality of care. Quality indicators and other facility-level variables from the Minnesota Nursing Home Report Card were merged with resident-level variables from the Minimum Data Set. These merged data were linked with Medicaid claims to obtain hospitalisation rates during the 201 1-2012 period. The sample consisted of a cohort of 20 518 Medicaid beneficiaries aged 65 years and older who resided in 345 Minnesota nursing homes. The analyses controlled for resident and facility characteristics using the generalised linear mixed model. Results The results showed that about 44 % of hospitalisations were PPHs. Available quality indicators were not strongly or consistently associated with the risk of hospitalisation (neither overall nor PPH). Among these 23 quality indicators, five quality indicators (antipsychotics without a diagnosis of psychosis, unexplained weight loss, pressures sores, bladder continence and activities of daily living [ADL] dependence) were related significantly to hospitalisation and only four quality indicators (antipsychotics without a diagnosis of psychosis, unexplained weight loss, ADL dependence and urinary tract infections) were related to PPH. Conclusion Although general quality indicators can be informative about overall nursing home performance, only selected quality indicators appear to tap dimensions of clinical quality directly related to hospitalisations. [ABSTRACT FROM AUTHOR]

Objective: To build and test a model that predicts community discharge probabilities for Medicaid-eligible nursing home (NH) residents who remain in the nursing home at 90 days after admission and, thus, would be candidates for the Money Follows the Person (MFP) program.Data Source: The Minimum Data Set, Medicaid Management Information Systems, and Minnesota Vital Statistics file.Data: Cohort of 33, 590 nursing home stays that qualified for Medicaid by the 90th day of their stay from 383 Minnesota nursing homes from July 2011 to June 2013.Study Design: Mixed effects logistic regression model to predict community discharge.Principal Findings: The scoring system had a high level of accuracy in predicting community discharge for both the fitting and validation cohorts. Subpopulations with severe mental illness or intellectual disability were well represented across the entire score range.Conclusions: Findings are being applied in the Minnesota's MFP initiative (Moving Home Minnesota) to target Medicaid-eligible NH residents for transitioning to the community. This approach could be applied to MFP in other states. [ABSTRACT FROM AUTHOR]

Background There is a general belief that the markers of nursing home quality do not aggregate easily. Identifying consistent and coherent dimensions of quality that usefully summarize the multiplicity of nursing home quality measures is an important goal. It would simplify interpretation and help consumers, their families and advocates to choose nursing facilities. Objectives This study uses quality indicators ( QIs) from a state nursing home report card to explore the dimensionality of quality in nursing homes and to determine whether aggregation at the resident versus facility level yields the same underlying dimensions. Design Cross-sectional study. Setting 382 Medicare- and/or Medicaid-certified nursing homes in Minnesota. Participants Residents admitted to the nursing homes during 2011-2012. Measurements 16 QIs obtained from the Minimum Data Set 3.0 assessment instrument between 2011 and 2012 were used in the exploratory factor analysis. Results Factor analysis results suggest four main factors or dimensions to characterize facility performance: continence care (including 4 QIs), restraints and behavioral symptoms (including 3 QIs), care for specific conditions (including 6 QIs), and physical functioning (including 3 QIs). The resident-level and facility-level results generally agreed for 11 QIs. Conclusion Nursing home quality of care can be captured in summary measures, which can be used by consumers, providers and researchers. Reporting at the resident or facility level will depend on the purpose. These summary measures can be used by policy-makers to identify and reward high-performing facilities and by families to choose nursing facilities for care. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study is to investigate racial differences in nursing home (NH) residents’ quality of life (QOL) at the resident and facility levels. Method: We used hierarchical linear modeling to identify significant resident- and facility-level predictors for racial differences in six resident-reported QOL domains. Data came from the following: (a) resident-reported QOL (n = 10,929), (b) the Minimum Data Set, and (c) facility-level characteristics from the Minnesota Department of Human Services (n = 376). Results: White residents reported higher QOL in five of six domains, but in full models, individual-level racial differences remained only for food enjoyment. On the facility level, higher percentage of White residents was associated with better scores in three domains, even after adjusting for all characteristics. Discussion: Racial differences in QOL exist on individual and aggregate levels. Individual differences are mainly explained by health status. The finding that facility racial composition predicts QOL more than individual race underscores the importance of examining NH structural characteristics and practices. [ABSTRACT FROM AUTHOR]

Improving quality of nursing homes (NHs) is a major social priority, yet few studies examine the role of facility characteristics for residents' quality of life (QOL). This study goes beyond cross-sectional analyses by examining the predictors of NH residents' QOL on the facility level over time. We used three data sources, namely resident interviews using a multidimensional measure of QOL collected in all Medicaid-certified NHs in Minnesota (N = 369), resident clinical data from the minimum data set, and facility-level characteristics. We examined change in six QOL domains from 2007 to 2010, using random coefficient models. Eighty-one facilities improved across most domains and 85 facilities declined. Size, staffing levels (especially activities staff), and resident case mix are some of the most salient predictors of QOL over time, but predictors differ by facility performance status. Understanding the predictors of facility QOL over time can help identify facility characteristics most appropriate for targeting with policy and programmatic interventions. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effect of urinary incontinence ( UI) on elderly nursing home ( NH) residents' self-reported quality of life ( QOL), especially on the specific QOL domains most closely associated with UI. Design Retrospective cross-sectional study using the Minimum Data Set ( MDS) and Minnesota Nursing Home Report Card data in 2010 to compare overall QOL and its domains of residents with and without UI using propensity scores and inverse probability weighting ( IPW) adjustments to reduce selection bias. Setting All Medicare- or Medicaid-licensed NHs in Minnesota. Participants All residents aged 65 and older except those with conditions that could readily overwhelm the effect of UI on QOL, such as coma and cerebral palsy. Measurements Urinary incontinence ( UI) was defined as leakage two or more times a week (score ≥2 on MDS 5-point scale), and continence was defined as continent or usually continent (score 0 or 1 on MDS 5-point scale). QOL was assessed using a self-reported QOL questionnaire that measured general QOL, not QOL specific to UI symptoms. Results Urinary incontinence ( UI) prevalence was 65.8% in 10,683 older NH residents. Self-reported QOL was good (>0.7 on a scale from 0 to 1) in 8,620 eligible residents in 371 NHs. Mood and meaningful activity domains had lower scores; dignity had the highest score. UI was associated with being older and female, ADL dependence, impaired cognitive ability, Alzheimer's disease, non- Alzheimer's dementia, bowel incontinence, diabetes mellitus, and long-term NH stay. Bivariate analysis found that residents with UI had lower QOL than those without. Using IPW to reduce selection bias, it was found that, although UI was not associated with overall QOL, it decreased the QOL domains of dignity, autonomy, and mood. Conclusion To improve the QOL of residents with UI, attention should be paid to dignity, autonomy, and mood. [ABSTRACT FROM AUTHOR]

Background. Existing studies on the relationships between impairments and activities of daily living (ADLs) in nursing home residents have serious limitations. This study examines the relationships among admission impairments, including pain, depression, incontinence, balance, and falls, and follow-up ADLs, as well as the effect of the nursing home on follow-up ADLs of extended-stay nursing home residents. Methods. This longitudinal cohort study consisted of 4,942 extended-stay residents who were admitted into 377 Minnesota nursing homes during 2004. General linear mixed models were used for all analyses. with 14 resident-level and 8 facility-level control variables. Results, Incontinence and balance function at admission were significantly associated with increases in ADL dependence at follow-up. Individual nursing homes had independent effects on all three ADL models. Similar findings were found after facility-level control variables were added. conclusions. Incontinence predicts subsequent ADL functional levels. The relationship between balance dysfunction and subsequent ADL dependence could be causal. Future studies of the causal relationships between impairments and ADL should examine the effectiveness of impairment interventions on ADL as well as these relationships in different subgroups of nursing home residents. [ABSTRACT FROM AUTHOR]

Objective. To demonstrate how multilevel modeling and empirical Bayes (EB) estimates can improve Medicare's Nursing Home Compare quality measures (QMs). Data Sources/Study Setting. Secondary data from July 1 to September 30, 2004. Facility-level QMs were estimated from minimum data set (MDS) assessments for approximately 31,000 Minnesota nursing home residents in 393 facilities. Study Design. Prevalence and incidence rates for 12 nursing facility QMs (e.g., use of physical restraints, pressure sores, and weight loss) were estimated with EB methods and risk adjustment using a hierarchical general linear model. Three sets of rates were developed: Nursing Home Compare's current method, unadjusted EB rates, and risk-adjusted EB rates. Bayesian 90 percent credibility intervals (CIs) were constructed around EB rates, and these were used to flag facilities for potential quality of care problems. Data Collection/Extraction Methods. MDS assessments were performed by nursing facility staff, transmitted electronically to the Minnesota Department of Health, and provided to the investigators. Principal Findings. Facility rates and rankings for the 12 QMs differed substantially using the multilevel models compared with current methods. The EB estimated rates shrank considerably toward the population mean. Risk adjustment had a large impact on some QM rates and a more modest impact on others. When EB CIs were used to flag problem facilities, there was wide variation across QMs in the percentage of facilities flagged. Conclusions. Multilevel modeling should be applied to Nursing Home Compare and more widely in other health care quality assessment systems. [ABSTRACT FROM AUTHOR]

This article describes a pay-for-performance system developed for Minnesota nursing homes. In effect, nursing homes can retain a greater proportion of the difference between their costs and the average costs on the basis of their quality scores. The quality score is a derived and weighted composite measure currently composed of five elements: staff retention (25 points), staff turnover (15 points), use of pool staff (10 points), nursing home quality indicators (40 points), and survey deficiencies (10 points). Information on residents' quality of life and satisfaction, derived from interviews with a random sample of residents in each Minnesota nursing home, is now available for inclusion in the quality measure. The new payment system was designed to create a business case for quality when used in addition to a nursing home report card that uses the same quality elements to inform potential consumers about the quality of nursing homes. Although the nursing home industry has announced general support for the new approach, it has lobbied the legislature to delay its implementation, claiming concerns about operational details. [ABSTRACT FROM AUTHOR]

To compare the use of medical services provided under the Minnesota Senior Health Options (MSHO) (a special program designed to serve dually eligible older persons) with that provided to controls who received fee-for-service Medicare and Medicaid managed care.Quasi-experimental design using two control groups; separate matched cohort and rolling cross-sectional analyses; regression models used to adjust for case-mix differences.Urban Minnesota community and nursing home long-term care.Dually eligible elderly MSHO enrollees in the community and in nursing homes were compared with two sets of controls; one was drawn from nonenrollees living in the same area (control-in) and another from comparable persons living in another urban area where the program was not available (control-out). Cohorts living in the community and in nursing homes were included.Use of hospitals and emergency rooms, physician visits.In the community cohort, there were no significant differences in hospital admission rates or in hospital days. MSHO enrollees had significantly fewer preventable hospital admissions and significantly fewer preventable emergency services than the control-in group. MSHO nursing home enrollees had significantly fewer hospital admissions than either control group with or without adjustment at 12 and 18 months. MSHO enrollees had significantly fewer hospital days and preventable hospitalizations than the control-in group. MSHO enrollees had significantly fewer emergency room visits and preventable emergency room visits than either control group.In general, the results of this evaluation are mixed but favor MSHO. The effect of MSHO was stronger for nursing home enrollees than community enrollees. The lower rate of preventable hospitalizations and emergency room visits of MSHO enrollees suggests that MSHO affected the process of care by providing more of some types of preventive and community-care services for community residents. [ABSTRACT FROM AUTHOR]

Analyzes the changes in various functional and satisfaction measures between older persons enrolled in Minnesota Senior Health Options managed care program. Details of the Program for All-Inclusive Care of the Elderly; Description of the participants in the study; Benefits of the program to the clients.

Background: Duplication of funding and resultant inefficiencies have prompted active consideration of pooling the funding for persons covered by both Medicare and Medicaid into a single managed care program. This study reports the initial results of the first such program.Methods: A sample of enrollees in Minnesota Senior Health Options (MSHO) and two sets of controls (within the same catchment area and outside it) as well as their families were interviewed to assess their functional status and satisfaction with their medical care. Respondents included those living in the community and those living in nursing homes.Results: The MSHO and control samples were generally alike in terms of demographics and illness patterns. The differences that were found reflected those attributable to geographic location more than program. The groups were also similar with regard to functional status. There were few satisfaction differences among the community-dwelling samples, but the MSHO nursing residents and especially their families expressed more satisfaction with several aspects of care.Conclusions: Whereas no causal conclusions about outcomes can be drawn from a cross-sectional sample, there is no indication that managed care for the dually eligible population has profound impacts on care. However, the system of care provided to nursing home residents is appreciated over traditional care. [ABSTRACT FROM AUTHOR]

Examines the effects of Minnesota nursing home attributes such as size and ownership on specific outcomes such as functional ability and home discharge. Use of extant nursing home database to test the effects of care on outcomes; Association of licensed nursing hours with less dependency; Inverse relation between the dependency on admission and probability of discharge home.

Describes the fellowship component of an endeavor designed to improve the education of health professionals with regard to aging in the state of Minnesota. Content and format of the program; Effectiveness of the fellowship program.

Presents a critique of an article published in the September 2001 issue of the 'Journal of Gerontology' concerning the Minnesota Senior Health Options (MSHO) Program. Mandate of the health plans under MSHO; Comparison between the services given by Medicaid and the MSHO; Explanation for the greater extent of advance directives among MSHO enrollees.

Background: Hospitalisations are very common among nursing home residents and many of these are deemed inappropriate or preventable. Little is known about whether clinical care quality is related to hospitalisation, especially potentially preventable hospitalisations (PPHs). Among the few studies that have been conducted, the findings have been inconsistent. The objective of this study was to examine the relationship between quality indicators and overall and PPHs among Medicaid beneficiaries aged 65 years and older receiving care at nursing homes in Minnesota., Methods: 23 risk-adjusted quality indicators were used to assess nursing home quality of care. Quality indicators and other facility-level variables from the Minnesota Nursing Home Report Card were merged with resident-level variables from the Minimum Data Set. These merged data were linked with Medicaid claims to obtain hospitalisation rates during the 2011-2012 period. The sample consisted of a cohort of 20 518 Medicaid beneficiaries aged 65 years and older who resided in 345 Minnesota nursing homes. The analyses controlled for resident and facility characteristics using the generalised linear mixed model., Results: The results showed that about 44 % of hospitalisations were PPHs. Available quality indicators were not strongly or consistently associated with the risk of hospitalisation (neither overall nor PPH). Among these 23 quality indicators, five quality indicators (antipsychotics without a diagnosis of psychosis, unexplained weight loss, pressures sores, bladder continence and activities of daily living [ADL] dependence) were related significantly to hospitalisation and only four quality indicators (antipsychotics without a diagnosis of psychosis, unexplained weight loss, ADL dependence and urinary tract infections) were related to PPH., Conclusion: Although general quality indicators can be informative about overall nursing home performance, only selected quality indicators appear to tap dimensions of clinical quality directly related to hospitalisations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We propose a new claims-computable measure of the primary care treatability of emergency department (ED) visits and validate it using a nationally representative sample of Medicare data., Study Design and Setting: This is a validation study using 2011-2012 Medicare claims data for a nationally representative 5% sample of fee-for-service beneficiaries to compare the new measure's performance to the Ballard variant of the Billings algorithm in predicting hospitalisation and death following an ED visit., Outcomes: Hospitalisation within 1 day or 1 week of an ED visit; death within 1 week or 1 month of an ED visit., Results: The Minnesota algorithm is a strong predictor of hospitalisations and deaths, with performance similar to or better than the most commonly used existing algorithm to assess the severity of ED visits. The Billings/Ballard algorithm is a better predictor of death within 1 week of an ED visit; this finding is entirely driven by a small number of ED visits where patients appear to have been dead on arrival., Conclusions: The procedure-based approach of the Minnesota algorithm allows researchers to use the clinical judgement of the ED physician, who saw the patient to determine the likely severity of each visit. The Minnesota algorithm may thus provide a useful tool for investigating ED use in Medicare beneficiaries., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Frailty, an important prognostic indicator in heart failure (HF), may be defined as a biological phenotype or an accumulation of deficits. Each method has strengths and limitations, but their utility has never been evaluated in the same community HF cohort., Methods: Southeastern Minnesota residents with HF were recruited from 2007 to 2011. Frailty according to the biological phenotype was defined as 3 or more of: weak grip strength, physical exhaustion, slowness, low activity and unintentional weight loss >10 lb in 1 year. Intermediate frailty was defined as 1 to 2. The deficit index was defined as the proportion of deficits present out of 32 deficits., Results: Among 223 patients (mean age 71 ± 14, 61% male), 21% were frail and 48% intermediate frail according to the biological phenotype. The deficit index ranged from 0.02-0.75, with a mean (SD) of 0.25 (0.13). Over a mean follow-up of 2.4 years, 63 patients died. After adjustment for age, sex and ejection fraction, patients categorized as frail by the biological phenotype had a 2-fold increased risk of death compared to those with no frailty, whereas a 0.1 unit increase in the deficit index was associated with a 44% increased risk of death. Both measures predicted death equally (C-statistics: 0.687 for biological phenotype and 0.700 for deficit index)., Conclusion: The deficit index and the biological phenotype equally predict mortality. As the biological phenotype is not routinely assessed clinically, the deficit index, which can be ascertained from medical records, is a feasible alternative to ascertain frailty., (© 2013.)

Growth in Medicare expenditures has forced legislators and policymakers to look for ways to slow spending and get more value for their money. This article reviews previous federal efforts to control Medicare costs as well as current ones required by the Patient Protection and Affordable Care Act. It also describes a proposal for value-based purchasing that the authors developed under contract to the Centers for Medicare and Medicaid Services. This approach uses two measurement systems-one for physicians who practice primarily in outpatient settings and one for physicians who practice primarily in the hospital.

Objectives: To determine whether cognition moderates the association between facility-level characteristics and individual-level impairments and activity of daily living (ADL) dependency., Design: Longitudinal cohort study., Settings: Nursing homes (NHs) in Minnesota., Participants: Four thousand nine hundred forty-two NH residents admitted to 377 Minnesota NHs during 2004 were followed for 4 to 8 months., Measurements: According to the Minimum Data Set (MDS) Cognition Scale 3,132 residents had high cognitive function, and 1,810 had low cognitive function. Total ADL score and scores on three ADL tasks at follow-up were used as outcome variables. MDS-derived impairment measures at admission of pain, depression, incontinence, balance dysfunction, and fall history were used to predict ADL changes. Fifteen resident-level and eight facility-level control variables were included in all four ADL models., Results: Effects of NHs and impairments on ADLs tended to be weaker for residents with low cognitive function. Bladder incontinence significantly predicted more dependence in total ADLs, toileting, and personal hygiene in both cognitive groups. Balance dysfunction significantly predicted worse total ADLs, toileting, and personal hygiene in the high-cognition group but only worse toileting function in the low-cognition group. In neither subgroup did any impairment predict worse eating function. Cognition did not modify the relationships between pain, depression, and recent falls and ADLs., Conclusion: Current NH environments and care processes may be inadequate to facilitate ADL changes for residents with severe cognitive impairment. More innovative structural designs, higher staffing levels, and better care processes may be indicated., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)

Background: Existing studies on the relationships between impairments and activities of daily living (ADLs) in nursing home residents have serious limitations. This study examines the relationships among admission impairments, including pain, depression, incontinence, balance, and falls, and follow-up ADLs, as well as the effect of the nursing home on follow-up ADLs of extended-stay nursing home residents., Methods: This longitudinal cohort study consisted of 4,942 extended-stay residents who were admitted into 377 Minnesota nursing homes during 2004. General linear mixed models were used for all analyses, with 14 resident-level and 8 facility-level control variables., Results: Incontinence and balance function at admission were significantly associated with increases in ADL dependence at follow-up. Individual nursing homes had independent effects on all three ADL models. Similar findings were found after facility-level control variables were added., Conclusions: Incontinence predicts subsequent ADL functional levels. The relationship between balance dysfunction and subsequent ADL dependence could be causal. Future studies of the causal relationships between impairments and ADL should examine the effectiveness of impairment interventions on ADL as well as these relationships in different subgroups of nursing home residents.

Purpose: The purpose of this article is to describe an innovative online system to support long-term-care decision making., Design and Methods: The Long-Term Care Choices tool is a web-based system that uses expert opinion and structures decision making., Results: The system has been well accepted, and most users find it easy to use., Implications: Other states could adopt similar systems to help people navigate the long-term-care system.

Objectives: To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes., Design: Retrospective cohort study using Centers for Medicare and Medicaid Services administrative data for 1998 through 2002., Setting: Minnesota and Texas nursing homes., Participants: Nursing home residents aged 65 and older with severe cognitive impairment who subsequently died during 2000/01., Measurements: Minimum Data Set and Medicare Provider Analysis and Review, Hospice, and Denominator files were used to identify subjects and to assess medical service use. U.S. Department of Agriculture metro-nonmetro continuum county codes defined rural (codes 6-9) and urban (codes 0-2) nursing homes. Nursing home residents with hospice or health maintenance organization benefits were excluded. Use of hospital services at the end of life was adjusted for use of corresponding services before the last year of life. Outcome variables were feeding tube use, any hospitalization, more than 10 days of hospitalization, and intensive care unit (ICU) admission., Results: The population included 3,710 subjects (1,886 rural, 1,824 urban). In multivariable logistic regression analyses (all P<.05), feeding tube use was more common in urban nursing home residents, whereas rural nursing home residents were at greater risk for hospitalization., Conclusion: Rural residence was also associated with lower risk of more than 10 days of hospitalization and ICU admission. Nonwhite race and stroke were associated with higher use of all services. Rural nursing home residence is associated with lower likelihood of use of the most-intensive medical services at the end of life.

Nurses, certified nursing assistants, activity personnel, social workers, and physicians in 5 cities rated their ability to affect each of 17 quality of life (QoL) items for 2 hypothetical cases. Those closest to the residents feel the most empowered to make a difference. Overall, certified nursing assistants were consistently the most optimistic about their ability to influence QoL. Perceptions of ability to influence QoL were correlated with attitudes about nursing homes. These perceptions may be helpful in retaining such staff.

Objectives: To assess how various stakeholders involved with nursing home care rate the importance of various quality-of-life (QoL) items for hypothetical residents with varying types of impairment., Design: A community-based exploratory description of a convenience sample., Setting: Eleven nursing homes in Florida, New Jersey, and Minnesota., Participants: Samples of registered and licensed nurses (RNs and LPNs), certified nursing assistants (CNAs), activities personnel, social workers, physicians, residents, and family members., Measurements: Using a magnitude estimation approach, 17 QoL items were rated in order of importance on each of three hypothetical types of nursing home residents., Results: Overall, there was little variation in the ratings for individual items. Ratings for persons with cognitive impairment were consistently lower. RNs'/LPNs' and CNAs' ratings were generally higher than the others, and physicians' ratings were generally lower. Residents' and families' ratings were generally lower than nurses' ratings., Conclusion: All stakeholders considered QoL to be important and felt that it deserves more attention in practice and regulation. A summary QoL score need not be weighted. Respondents (who were not cognitively impaired) considered QoL less important for residents with cognitive impairment. Value differences between those involved in nursing home care deserve more exploration.

Purpose: Our objective in this study was to compare the quality of care provided under the Minnesota Senior Health Options (MSHO), a special program designed to serve dually eligible older persons, to care provided to controls who received fee-for-service Medicare and Medicaid managed care., Design and Methods: Two control groups were used; one was drawn from nonenrollees living in the same area (Control-In) and another from comparable individuals living in another urban area where the program was not available (Control-Out). Cohorts living in the community and in nursing homes were included. Quality measures for both groups included mortality rates, preventable hospital admissions, and preventable emergency room (ER) visits. For the community group, nursing home admission rates were also tracked. For nursing home residents, quality measures included quality indicators derived from the Minimum Data Set., Results: There were no differences in mortality rates for either cohort. MSHO had fewer short-stay nursing home admissions but no difference for stays 90 days or longer. MSHO community and nursing home residents had fewer preventable hospital and ER visits compared to Control-In. There were no major differences in nursing home quality indicator rates., Implications: The cost of changing the model of care for dual eligibles from a mixture of fee-for-service and managed care to a merged managed-care approach cannot be readily justified by the improvements in quality observed.

We followed 1,810 consecutive admissions for elective total hip arthroplasty (excluding hip fracture repair and revisions) to 27 Minnesota hospitals in a prospective study to assess the factors associated with better outcomes. Patients were interviewed before surgery and at 6 months, and their medical records were reviewed. The operative complication rate was 6.1%. In general, neither surgeon nor hospital volume had any significant association with the likelihood of operative complications. For the cementless prosthesis group, significantly more operative complications were associated with being in Health Maintenance Organizations or with insurance other than Medicare. General complications were associated positively with a higher caseload per surgeon for patients receiving cemented prostheses. Hospital volume had no significant relationship to the general complication rate. Hospital and surgical volume and most other provider characteristics were not associated with walking and pain outcomes; however, follow-up pain scores for patients with cementless prostheses were lower for board-certified orthopaedists even after adjusting for risk factors.