Hospitalization of Nursing Home Residents with Cognitive Impairment Influence of Facility Features and State Policies Andrea Gruneir, M.Sc. Susan C. Miller, Ph.D. Vincent Mor, Ph.D. Brown Medical School

Acknowledgements  Financial Support: AARP Scholar’s Award NIA (AG 20557)  Assistance: Orna Intrator, Ph.D. Zhanlian Feng, Ph.D. David Grabowski, Ph.D. Jacqueline Zinn, Ph.D. Mark Schleinitz, M.D.

Background: Dementia  Affects nearly 4 million Americans  Projected to affect 10 million by 2040  Nursing Homes (NH) as a major site of care Over 90% cared for within a NH at some point before death The most common diagnosis among NH residents

Background: NH Care  Hot topic: Hospitalization  WHY? Very common Often unnecessary or preventable Potential for severe negative consequences Costly Not always driven by resident need or preference

Objective To quantify the effect of NH features pertinent to dementia care on hospitalization of residents with cognitive impairment To quantify the effect of state Medicaid reimbursement policies on hospitalization of residents with cognitive impairment

Methods: Data  Medicare Claims Data Outcome: Hospitalization  Minimum Data Set 2.0 (MDS) Resident data  On-line Survey, Certification, and Reporting System (OSCAR) NH data  Area Resource File (ARF)  Survey of State Medicaid Offices

Methods: Sample  County Restrictions (n = 810) Non-rural counties  NH Restrictions (n = 8,293) Free-standing ≥50 beds  Resident Restrictions (n = 359,474) Long-stay (≥90 days) 65 years or older Cognitively Impaired (CPS ≥3)

Methods: Variables  Outcome: Hospitalization within 150 days of baseline assessment  Determinants: NH Features Related to Dementia care 1. Presence of dementia SCU 2. High prevalence of dementia among long-stay residents (≥35%) State Medicaid Policies 1. Average per diem reimbursement rate 2. Bed hold policy (yes/no)

Statistical Analyses S = stateNH = nursing home C = countyR = resident  Multilevel Model Stratified by Diagnosis of Dementia

Results: Residents Dementia N = 174,563 No Dementia N = 184,911 Hospitalized,% Died,% CPS 5-6,% Do Not Hospitalize,%

Results: NH & State Policies Nursing Homes N = 8,293 Dementia SCU,%20.3 ≥35% w/dementia,%50.3 States N = 48 Medicaid Per Diem, mean (SD) $ (19.52) Bed hold policy,%77.1

Results: Multilevel Analysis Dementia OR (95% CI) No Dementia OR (95% CI) SCU0.9 ( ) 0.93 ( ) ≥35% dementia 0.96 ( ) 0.93 ( ) Medicaid Per Diem ($10) 0.95 ( ) 0.95 ( ) Bed hold1.44 ( ) 1.47 ( )

Summary  Presence of SCU affects all residents, not just those on the SCU  Investment in dementia care (SCU) has stronger effect than experience in dementia care (prevalence)  Small differences in Medicaid payment ($10) associated with decreased risk of hospitalization  Bed hold policies create incentives for lower hospitalization threshold

Limitations  No distinction by type of hospitalization  Cross-sectional design  Excluded residents that died from multilevel analyses  Definition of SCU not standard across NHs

Implications  Directed care for chronic conditions reduces: The occurrence of acute flare-ups The severity of acute flare-ups The need for hospitalization  BUT Medicare pays for hospital use only  SO Medicaid has no incentive to pay for directed care in the NH

Implications  Current reimbursement scheme does not meet the needs of an increasingly complex resident population.  Time to move to an integrated system in which all payers invest in chronic illness management AND all benefit from reductions in hospitalization.