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
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Canada's aging population: Seizing the opportunity Special Senate Committee on Aging: Final Report..The Senate of Canada, Ottawa, ON2009
- Provinces and Territories 2009 to 2036.Statistics Canada, Ottawa, ON2010
- Long-Term Care for the Elderly: Challenges and policy options. Commentary No. 367: C.D.Howe Institute, Toronto, ON2012
- Help wanted? Providing and paying for long-term care.OECD Publishing, Paris2011
- Uhlenberg P. International Handbook on Population Aging. Springer, The Netherlands2009
- Long-term care services in the United States: 2013 overview.Vital Health Stat 3. 2013; : 1-107
- When time is not on your side: Patient experiences with waiting for home care and admission to a nursing or residential home.Patient. 2008; 1: 55-71
- Health system use by frail Ontario seniors: An in-depth examination of four vulnerable cohorts.in: Bronskill S.E. Camacho X. Gruneir A. Ho M. Institute for Clinical Evaluative Sciences, Toronto, ON2011
- The meaning of “aging in place” to older people.Gerontologist. 2012; 52: 357-366
Challis D, Hughes J, McNiven F, et al. Estimating the balance of care. Personal Social Services Research Unit, 1999. Available at: http://www.pssru.ac.uk/pdf/p047.pdf. Accessed March 21, 2017.
- Residential and nursing home care—Issues of balance and quality of care.Int J Geriatr Psychiatry. 2003; 18: 201-204
- Balancing institutional and community-based care: Why some older persons can age successfully at home while others require residential long-term care.Healthcare Q (Toronto, Ontario). 2009; 12: 95-105
- The Method for Assigning Priority levels (MAPLe): A new decision-support system for allocating home care resources.BMC Med. 2008; 6: 9
- Long-term-care home placement process: Annual Report of the Office of the Auditor General of Ontario.Queen's Printer for Ontario, Toronto, ON2012
- The Champlain Balance of Care Project: Final Report. Balance of Care Research Group.University of Toronto, Toronto2009
- Home care or long-term care? Setting the balance of care in urban and rural Northwestern Ontario, Canada.Health Soc Care Community. 2012; 20: 438-448
- Hospitalization and mortality rates in long-term care facilities: Does for-profit status matter?.J Am Med Dir Assoc. 2015; 16: 874-883
InterRAI (2011). Long-Term Care Facilities (LTCF). Available at: http://www.interrai.org/long-term-care-facilities.html. Accessed October 31, 2014.
- Reliability of the interRAI long-term care facilities (LTCF) and interRAI Home Care (HC).Geriatr Gerontol Int. 2015; 15: 220-228
- Integrating Long-Term Care into a Community-Based Continuum: Shifting from “Beds” to “Places.” IRPP Study 59.Institute for Research on Public Policy, Montreal, Canada2016
- Formal and informal care for older persons: Assessing the balance in Ontario.Canadian Research Network for Care in the Community (CRNCC), Toronto, ON2010: 1-34
InterRAI. Scales: Status and outcomes measures. Available at: http://www.interrai.org/scales.html. Accessed October 21, 2016.
- Validation of the interRAI Cognitive Performance Scale against independent clinical diagnosis and the Mini-Mental State Examination in older hospitalized patients.J Nutr Health Aging. 2013; 17: 435-439
- Data Quality Documentation, Continuing Care Reporting System, 2014-2015.Canadian Institute for Health Information, Ottawa, ON2016
- The impact of multiple chronic diseases on ambulatory care use: A population-based study in Ontario, Canada.BMC Health Serv Res. 2012; 12: 452
- The healthcare cost of dying: A population-based retrospective cohort study of the last year of life in Ontario, Canada.PLoS One. 2015; 10: e0121759
- Identification of physician-diagnosed Alzheimer's disease and related dementias in population-based administrative data: A validation study using family physicians' electronic medical eecords.J Alzheimers Dis. 2016; 54: 337-349
Ministry of Health and Long-Term Care. (2016). Ontario Investing More Than $50 Billion in Health Care [Press release]. Available at: http://www.hnhblhin.on.ca/newsandevents/newsfrommohltc.aspx. Accessed March 21, 2016.
- Community-dwelling older adults with dementia: Tracking encounters with the health system.in: Bronskill S. Camacho X. Gruneir A. Ho M. Health System Use by frail Ontario Seniors: An In-Depth Examination of Four Vulnerable Cohorts. Institute for Clinical Evaluative Sciences, Toronto, ON2011: 47-69
- Predicting nursing home admission in the US: A meta-analysis.BMC Geriatr. 2007; 7: 13
- Profiles of older medicare decedents.J Am Geriatr Soc. 2002; 50: 1108-1112
- Reflections on a visit to a dementia care village.Nurs Older People. 2013; 25: 14-19
- ‘Village of the Demented’ draws praise as new care model.Neurol Today. 2012; 12: 12-13
- Models of home care services for persons with dementia: A narrative review.Int Psychogeriatr. 2015; 27: 1593-1600
- Case management approaches to home support for people with dementia.Cochrane Database Syst Rev. 2015; : Cd008345
- Management of behavioural symptoms of dementia in a specialized unit care.Psychogeriatrics. 2017; 17: 81-88
- Special care units and traditional care in dementia: relationship with behavior, cognition, functional status and quality of life–A review.Dement Geriatr Cogn Dis Extra. 2013; 3: 360-375
- Pharmacologic treatment of behavioral and psychological symptoms of dementia in nursing homes: Update of the 2008 JAMDA Recommendations.J Am Med Dir Assoc. 2015; 16: 527-532
- The PEARL programme: Caring for adults living with dementia.Nurs Stand. 2015; 30: 46-51
- What is the impact of using outdoor spaces such as gardens on the physical and mental well-being of those with dementia? A systematic review of quantitative and qualitative evidence.J Am Med Dir Assoc. 2014; 15: 697-705
- A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia.Health Technol Assess. 2014; 18: 1-226
- International experiments in integrated care for the elderly: A synthesis of the evidence.Int J Geriatr Psychiatry. 2003; 18: 222-235
- Community Care Access Centres– Financial Operations and Service Delivery.Queen's Printer for Ontario, Toronto, ON2015
- Public funding for residential and nursing home care: projection of the potential impact of proposals to change the residential allowance in services for older people.Int J Geriatr Psychiatry. 2003; 18: 211-216
- Quality of Care in Nursing Homes: An Overview: Department of Health and Human Services Office of Inspector General.US Department of Health and Human Services, Washington, DC1999
- Improving quality in Canada's nursing homes requires “more staff, more training”.Healthy Debate. 2013, June 20; (Available at: http://healthydebate.ca/. Accessed March 21, 2017)
- Low-quality nursing homes were more likely than other nursing homes to be bought or sold by chains in 1993–2010.Health Aff (Millwood). 2016; 35: 907-914
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.
Identification
Copyright
© 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine.
