Abstract
Objectives
To describe the level of need and divertibility of newly admitted nursing home residents,
describe the factors that drive need, and describe the outcomes of residents across
different levels of need.
Design
Retrospective cohort study.
Setting
A total of 640 publicly funded nursing homes (also known as long-term care facilities)
in Ontario, Canada.
Participants
All newly admitted residents between January 1, 2010 and March 1, 2012.
Measurements
We categorized residents into 36 groups based on different levels of (1) cognitive
impairment, (2) difficulty in activities of daily living (ADL), (3) difficulty in
instrumental ADLs, and (4) whether or not they had a caregiver at home. Residents
were then categorized as having low, intermediate, or high needs; applying results
from previous “Balance of Care” studies, we also captured the proportion who could
have been cost-effectively diverted into the community. We then contrasted the characteristics
of residents across the needs and divertible groupings, and compared 4 outcomes among
these groups: hospital admissions, emergency department visits, mortality, and return
to home.
Results
A population-level cohort of 64,105 incident admissions was captured. About two-thirds
had great difficulty performing ADLs (65%) and had mild to severe cognitive impairment
(66%); over 90% had great difficulty with instrumental ADLs. Just less than 50% of
the new admissions were considered to be residents with high care needs (cognitively
impaired with great ADL difficulty), while only 4.5% (2880 residents) had low care
needs (cognition and ADL intact). Those with dementia (71.0%) and previous stroke
(21.5%) were over-represented in the high needs group. Those that cannot be divertible
to anywhere else but an institution with 24 hour nursing care comprised 41.3% (n = 26,502)
of residents. Only 5.4% (n = 3483), based on community resources available, could
potentially be cost-effectively diverted to the community. Those at higher needs experienced
higher rates of mortality, higher total cost across all health sectors, and lower
rates of return to home.
Conclusions
The majority of those admitted into nursing homes have high levels of need (driven
largely by dementia and stroke) and could not have their needs met cost-effectively
elsewhere, suggesting that the system is at capacity. Caring for the long-term care
needs of the aging population should consider the balance of investments in institution
and community settings.
Keywords
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Article info
Publication history
Published online: April 01, 2017
Footnotes
This research was supported by a research grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC) to the Bruyère Center of Learning Research and Innovation in Long-Term Care (CLRI). This study was also supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario MOHLTC. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by MOHLTC is intended or should be inferred. The funders had no influence in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
This study has been approved by the research ethics board at the Institute for Clinical Evaluative Sciences (ICES), at Sunnybrook Health Sciences Centre in Toronto, Ontario, and by the research ethics board at the Ottawa Hospital Research Institute at Ottawa, Ontario (Protocol #20130579-01H).
Using encrypted health card numbers as unique identifiers, records of healthcare use and costs were linked across various administrative databases. No written consent was obtained; all data were encrypted using health card numbers as unique identifiers. Thus, all records used were deidentified and anonymized. All data were housed and analyzed at ICES, a prescribed entity for the purposes of section 45 Ontario's Personal Health Information Privacy Act.
The authors declare no conflicts of interest.
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© 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine.
