1. THE URBAN INSTITUTE Measuring the Size and Characteristics of the Older Residential Care Population: Evidence from Three National Surveys Brenda C. Spillman The Urban Institute Supported by funding from the Office of Disability, Aging, and Long-Term Care Policy, ASPE/DHHS

2. THE URBAN INSTITUTE 2 Background Growth in residential care alternatives to nursing homes Census definitions do not reflect residential care settings of today – Unclear demarcation between private homes and residential care, institutional and noninstitutional settings Existing provider frames inadequate No consensus on names, characteristics of residential care

3. THE URBAN INSTITUTE 3 Relationship of Census definitions to residential care settings

4. THE URBAN INSTITUTE 4 Project Purpose Review existing estimates, data, and methods (http://aspe.hhs.gov/daltcp/reports/ltcpopsz.pdf) – Review estimates of nursing home and alternative residential care residents from all types of data – Identify issues contributing to differences in estimates – Identify surveys for empirical investigation Empirical analysis (http://aspe.hhs.gov/daltcp/reports/3natlsur.pdf) – Produce estimates narrowing methodological differences – Improve understanding of the size and characteristics of the LTC population across settings

5. THE URBAN INSTITUTE 5 Key Methodological Issues Age of the population examined Methods of assigning individuals to "facility" or "institutional" population Methods of identifying nursing homes Methods of identifying alternative residential care settings Sample representation and weighting.

6. THE URBAN INSTITUTE 6 Surveys Selected for Analysis Medicare Current Beneficiary Survey Cost and Use 2002 – Ever enrolled age 65+ in Medicare during year – "Facility" and "community" settings identified National Long Term Care Survey 1999 – Medicare enrollees weighted to represent all 65+ – "Institutional" and "community" settings identified Health and Retirement Study 2002 – "Noninstitutional" population age 65+

7. THE URBAN INSTITUTE 7 Identifying Nursing Homes MCBS – Facility type is nursing home on survey, or – All beds in facility identified as certified beds NLTCS – Facility type is nursing home on survey – Facility type is unclear (i.e. not MRDD, mental health or other place) but identified on screener as resident’s unit in nursing, convalescent or rest home or home for the aged

8. THE URBAN INSTITUTE 8 Defining Residential Care Facilities Hawes definition: – Facility self identifies as "assisted living," or – Offers 24 hour supervision, housekeeping, meals and help with 2 of medication supervision, bathing or dressing Operationally: – Named residential care type, or – Closest feasible identification by service package

9. THE URBAN INSTITUTE 9 Identifying Residential Care HRS : Offers ADL help (bathing, dressing, or eating) or nursing or "oversight," meals, and housekeeping MCBS – Community: "Assisted living," or place provides all of meals, laundry or housekeeping, and medication supervision – Facility: Certified/licensed as a nursing home/other LTC or provide at least one personal care service or 24/7 supervision and self-identified by name associated with alternative residential care NLTCS – Community: No medical/health supervision and  Interviewer identified as assisted living, resident unit in LTC facility or other institution  Respondent identified as foster/family care home; group home/community residential facility/assisted living – Facility: Nursing/health supervision by definition and not a nursing home, MR/DD, mental health or other place

10. THE URBAN INSTITUTE 10 Population Distribution by Residential Setting

11. THE URBAN INSTITUTE 11 ADL disability with help by setting

12. THE URBAN INSTITUTE 12 Percent with income < $10,000 by setting

13. THE URBAN INSTITUTE 13 Summary About 6.5 percent of the population age 65+ currently in residential care – 1.45 million (4.2 percent) in nursing homes – 750,000 (2.2-2.3 percent) in alternative residential care But, we may have missed an unknown proportion of "community" residential care because of data limitations HRS estimate for "community" residential care approaches total in community and facility settings on MCBS and NLTCS

14. THE URBAN INSTITUTE 14 Implications for data collection Best practice : – Screen broadly for services, "special" setting – collect both facility- or respondent-reported place type and services offered and used Services should include ADL, IADL, other hallmark services, including medical/other oversight (Hawes criteria) Data collected should be as consistent as feasible across settings Larger samples are needed to better understand settings and their residents

15. THE URBAN INSTITUTE 15 Broader Implications Better measurement would improve identification, but wouldn't solve the small sample size problem. Larger sample sizes require sound methods to allow oversampling in national surveys – better Census guidance – a reliable frame cutting across community/facility definitions – identifying characteristics that can be replicated by national surveys