Resource allocation and resident outcomes in nursing homes: Comparisons between the best and worst

Abstract

The purpose of this study was to identify patterns of resource allocation that related to resident outcomes in nursing homes. Data on structure, staffing levels, salaries, cost, casemix, and resident outcomes were obtained from state-level, administrative databases on 494 nursing homes. We identified two sets of comparison groups and showed that the group of homes with the greatest percentage of improvement in resident outcomes had higher levels of RN staffing and higher costs. However, comparison groups based on best/worst average outcomes did not differ in resource allocation patterns. Additional analysis demonstrated that when controlling for RN staffing, resident outcomes in high and low cost homes did not differ. The results suggest that, although RN staffing is more expensive, it is key to improving resident outcomes. Keywords Resident outcomes; Nursing homes; Staffing; Costs Resource Allocation and Resident Outcomes in Nursing Homes: Comparisons between the Best and WorstThere are 23,000 U.S. nursing homes with 1.5 million residents and estimates are that one-half of them provide substandard care (Maraldo, 1991). These conditions exist after more than a decade of efforts to change regulations and provide reimbursement incentives intended to improve quality of care (Cohen & Dubay, 1990). Financial incentives and regulation, however, have done little to improve quality of care. Weissert and Musliner (1992) show, in a review of research on case mix reimbursement systems in six states, that financial incentives have improved access for heavy-care residents, but costs increased with no measurable change in quality. Heavy care residents require more resources and, with reimbursement incentives, nursing homes are willing to care for them. Such increased access with no changes in quality could be interpreted as successful until evidence about the general quality of care in nursing homes is revealed.Regulations also have failed to make appreciable improvements in quality. Lieberman (1995) examined 4 years of Health Care Financing Administration (HCFA) reports finding that "about 40 percent of all facilities certified by the HCFA have repeatedly violated Federal 1 An earlier version of this paper was presented at the Sixth National Nursing Administration Research Conference, Minneapolis, MN, October 27, 1995. We thank the Texas Health Care Association and the Texas Department of Human Services for their assistance in obtaining the data for the study. We also thank Drs. Glenda Joiner-Rogers, Reuben McDaniel, Jr., and Shirin Catterson for their comments on drafts of this paper. Requests for reprints should be made to the first author at The University of Texas at Austin, School of Nursing, 1700 Red River, Austin, Texas 78701. NIH Public Access Author ManuscriptRes Nurs Health. Author manuscript; available in PMC 2007 September 25. Published in final edited form as:Res Nurs Health. 1998 August ; 21(4): 297-313. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript standards over the last f...

Case Study Research: The View From Complexity Science

“…Complexity theory, however, suggests that it may be fruitful to pay greater attention to outliers because they may be a source of new structural arrangements and patterns of behavior. Thus, in choosing cases for comparison, it is often useful to look to the extremes-comparing the very best with the very worst (Anderson, Hsieh, & Su, 1998). …”

The Institutional Practice

“…Similarly, findings indicate that for-profit nursing homes hospitalize their residents more often than non-profit nursing homes (Anderson et al 1998, Carter 2003a, Carter & Porell 2003, Konetzka et al 2004, OIG 2013, McGregor et al 2014, Zimmerman et al 2002. A majority, but not all, of chain-affiliated homes are for-profit, hence the division.…”

“…A majority, but not all, of chain-affiliated homes are for-profit, hence the division. In different ways, financing has been shown to be associated with rates of hospitalizations (Anderson et al 1998, Coleman & Berenson 2004, Grabowski et al 2008, Konetzka et al 2004, Mor et al 2010a, Mor et al 2010b. As many of the financing methods are specific to regions or countries, and therefore lack a general relevance, a detailed account will not be given 1 .…”

“…Nursing home size: In many of the research articles nursing home size is said to be more directly correlated to rates of hospitalization (Anderson et al 1998, Barker et al 1994, McGregor et al 2014, OIG 2013; larger nursing homes hospitalize more often than smaller ones. Research articles that analyze a variety of facility specific factors and their respective effect on rates of hospitalization, of which there are several, usually highlight size as the factor with the highest correlation.…”

“…Nurse staffing patterns: The ways in which nursing home staff influence hospitalization has been covered extensively by the research literature (Anderson et al 1998, Anderson et al 2003, Carter 2003a, Carter 2003b, Decker 2006, Decker 2008, Dellefield 2000, Harrington et al 2000, Intrator et al 1999, Konetzka et al 2008, Weech-Maldonado et al 2004, Zimmerman et al 2002. The literature typically focuses on a) whether or not an isolated professional category influences hospitalization or b) the composition of the different professional categories and what composition is optimal.…”