1. Explaining Transfers from Home & Community Based Waiver Program to Nursing Home: Can Patients Stay at Home? Midwest Nursing Research Society March 25, 2011 Sandra L. Spoelstra, PhD, MSN, RN Michigan State University College of Nursing

2. Goal of Presentation 1)To explain risk factors that predict transfer from a Home and Community Based Waiver program to a nursing home. 2) To explain identify modifiable factors that may delay transition to nursing home. 3) To identify potential interventions that may delay nursing home transfer. 9.755

3. Background Adults aged 65 & older currently comprising 15% of the population (Administration on Aging, 2009). Most older adults prefer to remain in their own homes but are forced to transfer to nursing homes because community-based supports are inadequate to meet their needs. (American Association of Retired Persons, 2010) Factors that predictor of nursing home placement are advanced age, female gender, education level, low socioeconomic status, unavailability of informal care, living alone, no spouse, three or more dependencies in activities of daily living, cognitive impairment, & prior nursing home use. (Gaugler et al., 2004)

4. Significance Nursing homes are costly, averaging over $70,000 per year. Nursing home costs in US totaled $138.4 billion in 2008. –Medicaid payments amounting to $56.3 billion. –Medicare payments $25.7 billion. By 2020, BH costs are projected to exceed $250 billion annually. Dually-eligible Medicare and Medicaid consume a large portion of healthcare expenditures and are a particular challenge. (Center for Medicare and Medicaid Services)

5. Purpose This research examined the risk of nursing home placement among an inception cohort of vulnerable group of low-income elderly persons entering a statewide home & community based waiver program between 2002—2007.

6. Problem Statement That nursing home placement can be explained by:  Age, sex, & race. *  Functional & cognitive status. *  Falls. *  Behavioral problems.  Numbers of chronic conditions.  Hospitalizations.  Situational factors such as recent moves.  Preferences for a different living arrangements. * As well as by deteriorations in each over time

7. Service Providers Patient Needs Caregivers Capacity A Model of Factors Accounting for Transfers to Nursing Homes

8. Methodology & Design An inception cohort of persons 65 years of age and older who entered this waiver program between 2002—2007.  Multiple linear logistic regression models to identify factors that significantly predicted nursing home placement.  In a large sample small differences in the sample could cause significant effects. Checked the estimated odds ratio & 95% CI.  After adjusting for the number of months in the program, chi-square likelihood value was used to identify predictors.  The risk groups were identified based on the accumulated impacts on these factors.

9. Setting Home and Community-Based Waiver program A large state in the Midwest Federal 1915(c) waiver program Must meet the Federal Medicaid requirements for nursing home placement. –This includes a need for assistance with activities of daily living and/or instrumental activities of daily living. Must be at 300% of Federal poverty level. Provided a menu of 14 services (aide, chore, transportation, meals, adult day care, home modifications) Must have a caregiver who agrees to provide assistance to the patients at home.

10. Sample Inclusion Persons 65 years of age or older Dually-eligible for Medicare and Medicaid Enrolled in the waiver program Between January 1 st of 2002 & December 31 st, 2007 Had at least one Minimum Data Set-HC assessment Exclusion Those who did not die but were dropped from the waiver program. Those who left the program after 1 MDC-HC observation.

11. Study Schematic 1,729 One Assessment 14,568 Eligible with MDS Evaluation 12,839 2+ Assessments 4,678 Unknown Drop from Program 3,817 Transfer Nursing Home 4,344 Remain in HCBW Sample 8161 (6836 with two assessments after Sept 30, 2003) 9.757

12. RESULTS

13. Sociodemographic Characteristics  Mean age 76.4 years; 62% being 76 years of age or older  75% were White  70% female  35% widowed  97% reported having a primary caregiver at the first MDS-HC assessment after eligibility  56% of the patients’ caregivers were adult children or children-in-law, with the remaining being other relative, friend, or neighbor Persons >76 years of age and white were more likely to transfer to a nursing home.

14. Entries into Waiver Program & Transfer to Nursing Home 9.758 Year Enrolled in Waiver Number Transferred to Nursing Home Percent Transferred to Nursing Home 20022357104844.46% 200376641053.52% 200482340549.21% 2005104236434.93% 200694520421.59% 2007903626.87%

15. Months in The Waiver Program Number of Patients Mean Months in Program Standard Deviation Stayed in Program 434338.7524.61 Transferred to Nursing Home 249327.5917.49 9.759

16. Results (Factors Included in the Final Model) 1.Age 2.ADL deterioration 3.Increase in falls 4.Increase of home services 5.Better in another living arrangement 6.Cognitive skill deterioration 7.Behavior problem 7 Days Before Last Assessment 8.Hospitalized 30 Days Before Last Assessment 9.Moved in with another person 90 Days Before Last Assessment 10.Months stay in the waiver program

17. Analytical Model to Predict Transfers to Nursing Home Effect LevelN Transfer to Nursing Home N (%) Odds Ratio 95% Wald Confidence Limits Chi Sq p-value Age 65 to 752573 651 (25.3) 0.438 0.3900.491199<0.0001 76+4263 1842 (43.2) Ref Increase Falls No5622 1926 (34.3) Ref 1.4071.85047<0.0001 Yes1214 567 (46.7) 1.613 9.774

18. Analytical Model to Predict Transfers to Nursing Home Effect LevelN Transfer to Nursing Home N (%) Odds Ratio 95% Wald Confidence Limits Chi Sq p-value Increased Days of Home Service Yes4041 1271 (31.5) 0.608 0.5450.67781<0.0001 No2795 1222 (43.7) Ref Hospitalized -Last Yes286 132 (46.2) 1.482 1.1441.92190.0029 No6550 2361 (36.1) Ref 9.775

19. Analytical Model to Predict Transfers to Nursing Home Effect LevelN Transfer to Nursing Home N (%) Odds Ratio 95% Wald Confidence Limits Chi Sq p-value MONTH in the Program -- 0.9750.9720.977366<0.0001 ADL Deterioration Yes2301 913 (39.7) 1.475 1.3111.65942<0.0001 No4535 1580 (34.8) Ref 9.776

20. Analytical Model to Predict Transfers to Nursing Home Effect Level N Transfer to Nursing Home N (%) Odds Ratio 95% Wald Confidence Limits Chi Sq p-value Cognitive Deterioration Yes662 284 (42.9) 1.521 1.2691.82221<0.0001 No6174 2209 (35.8) Ref Better in Another Living -Last Yes472 301 (63.8) 2.613 2.1203.21981<0.0001 No6364 2192 (34.4) Ref 9.777

21. Summary Overall 2493 36% transferred to a nursing home –74% were 76 years of age or older –37% had one or more deteriorations in ADL –12% wanted to change to another living arrangement –49% of patients with NO increase in home care services –23% increase in falls 74% of those who want to change living arrangements went to a nursing home Patients who deteriorated in ADL’s, are dissatisfied with their living arrangements, & have no increase or a decrease in services are at high risk of a transfer to a nursing home.

22. Limitations 1.The duration of time persons remained in the program was accounted for by introducing the numbers of months in the program rather than time intervals for each variable or the time during which deteriorations occurred. 2.These data cover a period of time where Michigan experienced a range of economic changes that influenced the rates of enrollment into the program 3.Assessments were observational & self reported & in many cases were categorized in a manner that signified crude levels of change. Had more finely rated instruments been employed more carefully framed indicators might have emerged.

23. Discussion A goal of this research was to develop risk models that could inform waiver agencies to anticipate how changes in the assessment may indicate pending nursing home placement. This will allow agencies to focus on strategies to retain older dually-eligible patients in waiver programs as long as possible. This will allow the elderly prefer to remain at home with family members & care in a waiver program is a less-costly alternative to nursing homes.

24. Discussion These findings support speculation that deterioration over independence places persons at a greater risk of nursing home placement when compared to persons with deficits who deteriorate only by degree. This suggests that it is the onset event that leads patients to transfer to a setting that can better meet their needs. However, persons and families who remain at home following these initial deteriorations appear able to cope, despite these additional deficits & the increased demands for care that they generate.

25. Implications for Future Research Despite examination of the caregiver relationships & whether the caregiver resided in or out of the home, we were unable to isolate an association with nursing home placement. We were unable to establish how out of home caregivers were related to transfers considering the level or changes in deteriorations in either cognition or ADL performance. Before dismissing this relationship as unimportant, more detailed evaluations of how caregivers respond to the increases and the continuing needs for care is warranted.

26. Implications for Practice Awareness of the important thresholds may alert older adults, their caregivers, and service providers prior to a potential admission event. Earlier intervention, as these important thresholds arise, may prompt the mobilization of community-based resources or clinical services to forestall nursing home placement. (Gaugler, Kane, Kane, & Newcomer, 2005) Prior research on interventions in the earlier stages of a chronic disease trajectory that offers respite & support to the elderly & their caregivers may help to delay nursing home placement. (Gaugler, et al., 2005; Gaugler, Kane, Kane, Clay, & Newcomer, 2005)

27. Conclusion The evidence strongly suggests when & how to initiate short, targeted interventions. –As persons experience & report declines from independence to a deficit is a sentinel time to offer assistance to patients and training to caregivers in order to help patients modify their activities & caregivers to provide care & assistance that will delay further deterioration. This work classifies 72% of the persons who transfer to a nursing home & identifies possible responses that agencies might consider to better retain patients at home.