1. 1 Does organizing nursing home workforce in teams save costs? Dana B. Mukamel - University of California, Irvine - Center for Health Policy Research Shubing Cai & Helena Temkin-Greener - University of Rochester School of Medicine - Department of Community & Preventive Medicine Funding: NIA grant # AG23077

2. 2 Team care is viewed as effective Especially for chronic and long-term care Better patient outcomes Lower error rates Better care coordination Better work environment Better staff outcomes

3. 3 Teams in nursing homes Interdisciplinary care planning –Mandated by CMS In most facilities Daily care teams –Prevalence is unknown –Few studies, mostly convenience sample

4. 4 Less is known about the cost implications of teams in nursing homes Physician / nurse practitioner teams were shown to be more cost effective than physicians alone Burl JB, 1991; 1994 & 1998 and Aigner, 2004. Specialized wound teams have been shown to be cost effective Vu T, 2007.

5. 5 Study objective: To examine the cost impact of daily care teams in nursing homes

6. 6 Daily care teams defined by the direct care staff in the nursing home as: 1.Formal teams: if staff assigned by management 2.Self-managed teams: if staff self-organized their daily work in teams

7. 7 Sample: 162 free standing nursing homes in New York State with at least 50 beds 7,418 direct care staff

8. 8 Data: Survey of direct care staff Medicaid cost reports Case mix data from the NYS DOH

9. 9 Methods: Hybrid cost function: Weighted regression to account for under response by for profits Inference based on robust standard errors and joint F-tests for highly collinear terms

10. 10 *Information based on the survey question: “Who else is on your team?” 46% of responders report meeting daily 27% of responders report meeting at least weekly

11. 11 Sample (N=135)All NYS study eligible nursing homes (N=531) MeanStandard deviation MeanStandard deviation Percent of direct care staff organized in formal teams 8.46.4n/a Percent of direct care staff in self managed teams 7.45.5n/a Annual variable costs ($1000)20,13517,94917,98816,896 Inpatient days77,071*48,27368,70940,942 Inpatient admissions408334367303 Average RUG scores1.180.12n/a Adult day care days2,481*5,0413,53017,125 Number of beds215136196113 Home health care visits7,96442,5808,28159,039 Outpatient clinics1,0837,5724994,720 Management hourly wage43.35*14.3949.1226.72 CNA hourly wage18.294.7019.045.29 Non-profit ownership (%)66%*51% * Significant difference at the 0.05 level

12. 12 Independent VariablesCoefficientP Value* Beds0.214 x 10 -2 0.00 Case mix adjusted days/1000: Linear0.2260.00 Squared-0.115 x 10 -3 0.00 Cubed1.76 x 10 -7 0.00 Admissions0.213 x 10 -3 0.00 Adult day care days/10000.0100.00 Home health care visits/100000.0270.00 Outpatient clinic visits/10000.0070.00 Log management wages0.1700.00 Log CNA wages0.5350.00 Non-profit facility0.0930.00 Constant12.6200.00 N = 135 R2 = 0.97 * Based on robust standard errors. Estimated annual variable cost function with probability weights Dependent variable: Log of variable cost

13. 13 Independent VariablesCoefficientP Value* % direct care staff in formal teams: Linear0.0120.99** Squared-2.3320.76** Cubed11.9560.49** % of direct care staff in self managed teams: Linear-0.4870.67*** Squared11.4490.39*** Cubed-38.9290.30*** ** P value for the hypotheses that the linear, squared and cubed terms are jointly significant is 0.004. *** P value for the hypotheses that the linear, squared and cubed terms are jointly significant is 0.426. Estimated annual variable cost function with probability weights Dependent variable: Log of variable cost

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15. 15 Conclusions: Formal teams are a cost saving strategy The range of cost savings estimated at $174,000 per year Self-managed teams do not seem to have the same impact on cost

16. 16 Why are costs increasing at higher penetration levels? Higher quality? Pushing teams “too far”? Different team types? – more specialists