COMPARING OUTCOMES OF MICHIGAN NURSING HOME RESIDENTS AND HOME CARE CLIENTS:

1. SOME PRELIMINARY RESULTS COMPARING OUTCOMES OF MICHIGAN NURSING HOME RESIDENTS AND HOME CARE CLIENTS:

2. Study Context • Increasing number of seniors in all developed countries • Projected increase in demand for long term care • Increased burden on public purse • Shift world wide towards deinstituitionalisation of long term care - growing demand for home care • Ongoing debate regarding home versus nursing home care

3. Changes in population structure in selected countries, health consumption and earnings

4. Literature • Extensive literature on quality and efficiency in nursing home care • Less developed literature in relation to quality and efficiency in home care • No reliable literature comparing quality or efficiency of nursing home versus home care

5. “There is insufficient evidence to estimate the likely benefits, harms and costs of institutional (versus) at home care for functionally dependent older people.” “Research needs to be conducted into…what is the effectiveness and efficiency of at-home compared with institutional care” Mottram P, Pitkala K, Lees C. Institutional versus at-home long term care for functionally dependent older people (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford Conclusions of a Cochrane Review

6. Study goals • Compare the outcomes of home care with those of nursing home care among seniors.

7. Data • Resident Assessment Instrument (RAI) for nursing home residents and RAI-HC for home care clients. These provide a uniform, comprehensive assessments of residents/clients. • Information from these are used to help monitor residents/clients, develop care plans and assess care quality. • Both RAI and RAI-HC have been validated internationally .

8. Data continued • Individual level data were extracted from RAI and RAI-HC for all nursing home and home care agencies in Michigan. • Data related to full assessments taken on or about July 1st 2000 and follow-up assessments made approximately 90 days later. From assessments quality indicators (risk adjusted measures of outcome) are derived. These were also extracted. • Data for 23 home care agencies serving a total of 10,111 over 65 year old clients and 439 nursing homes serving 38,435 over 65 year old residents were available.

9. Outcome Measures • QIs Used: • Weight loss: new weight loss at follow-up • Incontinence: failure to improve • Depression: failure to improve and/or new incidence • Communication: failure to improve • Pain: failure to improve and/or new incidence • ADL decline: failure to improve • Falls: any fall within quarter • Cognition: failure to improve • Delirium: any incident within quarter

10. Previous work compared outcomes examining • Medicaid individuals - to increase likelihood of comparing like with like • Averaged QI scores over 4 quarters (5 quarters of data) - decline/death versus stable/improved • Comparisons overall, and by RUG group to control for case-mix differences in populations • Tested difference in scores between home care and nursing home (t-statistic)

11. Populations, by RUG-III/HC Group • Insert tables Mary and Brandt gave me here (these will take up 3 slides, I’m not sure why the N is different between this and the data file I have. Maybe because you looked over more quarters you picked up more observations. I have (over 65) QIs for around 6,900 HC and 31,000 NH people).

12. Findings These findings indicate that controlling for differences in populations using RUGs, across all RUGs groupings : • HC performs at least as well as (and often better than) NH in relation to Weight loss, Incontinence, Communication, Pain, Falls, Cognition and Delirium. • In relation to ADL decline and depression results are more mixed

13. Problems with this analysis • Some individuals included may be post-acute rather than long stay • Some individuals may be lost to follow-up because they got better (right censoring) • It may not be appropriate to include individuals in facilities that are predominantly post-acute or predominantly Medicare in comparison

14. Problems with this analysis cont’d • It may not be appropriate to combine death and decline together as a category of outcome to address left censoring • The analysis fails to control for differences in access to NH and HC or other market effects • Instruments may not be used in the same way in NH and HC

15. Solutions to these problems • Exclude individuals who are post-acute - though care is warranted • Identify individuals lost to follow-up and compare outcomes between NH and HC at a minimum • Exclude individuals in facilities that are predominantly post-acute or Medicare - though care is warranted

16. Solutions to these problems cont’d • Experiment with a polychotomous formulation of outcomes to address censoring • Control for total number of nursing home and waiver slots available per head of the population in the county to address access • Examine the consistency of relationships between QIs and a range of independent variables in HC and NH to assess validity

17. Results

18. Issues and Solutions, cont. • Problem: within RUG-III groups, may be population differences that explain differences in outcomes • Solution: • prepared “profiles” for each group to identify such differences • Run more sophisticated multivariate models for each outcome • Outcome: in progress