Admission Sources, Length of Stay, and Discharge Status
The first-time admission cohort varied in their admission sources, discharge status, and length of stay. The majority of admissions (87 percent) came from acute care hospitals. Smaller percentages of admission were from a private residence (9 percent), assisted living or board and care home (2 percent), or other source (2 percent). Most persons were discharged over the course of the year: 67 percent (16,441) were still in the facility at 14 days, 19 percent (4,549) were in the facility at 90 days, 13 percent (3,238) at 180 days, and 10 percent (2,481) at 1 year. Over two-thirds of discharges went to a private residence with home health (32 percent), private residence without home health (29 percent), or assisted living (8 percent). Nine percent of discharges went to another nursing home, 17 percent died, 4 percent went to an acute-care hospital, and 2 percent went to another discharge setting.
Discharges to the community were concentrated early in the nursing home stay (). Eighty-five percent of the community discharges occurred within 30 days of admission, 10 percent were in 31–90 days, 4 percent in 91–180 days, and only 1 percent in 181–365 days. In contrast, 55 percent of deaths occurred in the first 30 days, 22 percent in 31–90 days, 11 percent in 91–180 days, and 12 percent in 181–365 days. At approximately 45 days the community discharge and mortality curves crossed over; the likelihood of mortality became increasingly greater than community discharge after that point.
Number of Residents Remaining in the Nursing Home by Length of Stay and Discharge Status (n=24,648)
Characteristics of Residents at Admission, 90, 180, and 365 Days
presents characteristics of all admissions and those remaining in the facility for 90, 180, and 365 days. The first set of variables was measured only at admission but reported for residents still remaining at 90, 180, and 365 days; the second set of variables was both measured and reported for residents at each length of stay. Members of the admission cohort were likely to be female, unmarried, living with someone else before admission, admitted from an acute-care setting and with Medicare paying the per diem. Their most prevalent conditions at admission were Alzheimer's or other forms of dementia, depression, behavioral problems, incontinence, diabetes, cancer, and hip fracture. Very high percentages of admissions preferred (84 percent) or had support for community discharge (69 percent). Having support was strongly associated with preference: 67 percent of residents had both preference and support for community discharge, 14 percent had neither preference nor support, 17 percent had preference without support, and only 2 percent had support without preference. Comparing all admissions with residents in the facility at 90, 180, or 365 days, the longer stay residents were much more likely to have had diagnoses of dementia or depression, moderate to severe cognitive impairment, behavioral problems, incontinence, low-care needs either broadly or narrowly defined, and to have converted to Medicaid. Longer stay residents were less likely to have preferred or had support for returning to the community, been admitted from an acute-care hospital or had Medicare as a per diem pay source.
Resident Characteristics for All Admissions and Those Still in the Nursing Home at 90, 180, and 365 Days
Predictors of Preference for and Actual Community Discharge
Because preference and support for community discharge on admission had such a strong relationship to actual discharge, we wanted to determine what resident characteristics might be related to residents' preferences or support for returning to the community. Also, we wanted to determine the relationships between preferences or support for community discharge, other resident characteristics and actual community discharge. Because we anticipated that preferences or community discharge status might be related to facility characteristics, we included facility-level variables that were aggregates of resident-level variables. The postacute emphasis of the facility was represented by the proportion of admissions from acute-care hospital, with Medicare per diem, or falling into either of the higher RUG-III categories of Extensive or Rehabilitation that indicated postacute service need. We also hypothesized that facilities with a higher proportion of residents with a preference for or support for discharge to community would have higher discharge rates.
shows results from HGLM models with correlates of the residents' preferences or support for community discharge at admission (yes=1, no=0). The sample consisted of all members of the admission cohort and all variables were measured at admission. Admissions from an acute-care hospital, with Medicare per diem, living alone prior to admission, in the RUG Extensive or Rehabilitation category, and with a hip fracture diagnosis were more likely to have a preference or support for community discharge. Admissions who were unmarried, older, receiving a Medicaid per diem, cognitively impaired and Alzheimer's or other dementia diagnosis, ADL dependent, incontinent, and suffering from cancer or an end-stage disease were less likely to have preference or support. Residents entering the facility in a low-care group were also less likely to prefer or have support for community discharge. In addition, admissions to facilities that admit a higher proportion of persons from acute-care hospitals were more likely to prefer or have support for community discharge. Finally, we found a significant interaction effect between resident and facility-level variables. Residents admitted from acute-care hospitals were more likely to prefer or have support for community discharge if they were admitted to a facility with a higher proportion of admissions from acute care.
HGLM Results for Resident's Preference or Support for Returning to the Community Based on Resident Characteristics at Nursing Home Admission (N=24,648)
The HGLM model for community discharge within 90 days after admission is presented in . Again, the sample consisted of the entire admission cohort with variables measured at admission. As we had anticipated preferring or having support to return to the community was a significant predictor of actual community discharge, even after controlling for other factors. Most of the same factors related to preference or support for community discharge were significantly related to actual discharge. Admission from an acute-care hospital, in the RUG Extensive or Rehabilitation category, and with a hip fracture diagnosis were more likely to be discharged to the community. Admissions who were unmarried, older, receiving Medicaid per diem, cognitively impaired or Alzheimer's or other dementia diagnosis, ADL dependent, incontinent, and with a psychiatric disorder, diabetes, cancer, or an end-stage disease diagnosis were less likely to be discharged to the community. Residents entering the facility in a low-care group were also less likely to be discharged to the community. Two facility-level variables were significant. A person was more likely to be discharged to the community if he or she entered a facility admitting a higher proportion of persons from acute-care hospitals and a facility where a higher proportion of admissions either preferred or had support for community discharge. Again, we found a significant interaction effect between resident- and facility-level variables. Residents who preferred or had support for community discharge were more likely to be discharged to the community if they were admitted to a facility with a high proportion of admissions preferring or having support for community discharge. We also tested multinomial models predicting community discharge, death, or remaining in the facility at 90 days. The same factors were significantly related to community discharge.
HGLM Results for Community Discharge within 90 Days Based on Resident Characteristics at Nursing Home Admission (N=24,648)
Drawing from prior research and the findings of our study, we selected three targeting criteria: preference or support for community discharge (Q1a or Q1b=yes), low-care requirements (RUG-III group IA1, IA2, BA1, BA2, PA1, PA2), and fitting a community discharge profile. The discharge profile was operationalized as the resident having a >50 percent likelihood of being discharged to the community within 90 days after admission. Conditional probability of community discharge was estimated from an HGLM model similar to the model described above with the following predictor variables all measured at admission: younger, married; Medicare per diem; admitted from an acute-care hospital; hip fracture; RUG Extensive or Rehabilitation category; minimal cognitive impairment (CPS); minimal ADL dependence (ADL dependency scale); continent; absent weekly behavioral problems; and absent a diagnosis of Alzheimer's or other dementia, depression, other mental disorder, diabetes, cancer, or end-stage disease. Details of the model are contained in Appendix SA2.
Targeting criteria were applied to the 4,549 residents in the admission cohort still in the nursing home at 90 days who presumably were at risk of becoming long-stay. Seventy-seven percent of residents met one or more of the three criteria. Sixty-four percent had preference or support for community discharge (at admission), 40 percent fit the community discharge profile (at admission), and 20 percent fell into the low-care category (at 90 days). shows the intersection of the three criteria. Although there was some overlap in targeting criteria, a sizeable proportion (36 percent) met only one criterion and the majority of these residents (27 percent) had preference or support but did not fit the profile or have low-care requirements. Thirty-two percent of residents (26+6 percent) met both the preference/support and profile criteria, 11 percent (6+5 percent) met the preference/support and low-care criteria, 10 percent (6+4 percent) met the discharge profile and low-care criteria, and only a small percentage (6 percent) met all three criteria.
Percentage Meeting Targeting Criteria among Residents Still in the Facility at 90 Days after Admission (n=4,549)