In a groundbreaking national study, Brown University researchers have traced the connections between state nursing home policies and resident hospitalizations rates. The team found that state policies unwittingly create financial incentives for nursing homes to hospitalize their frail elderly residents, even though hospital stays can be disorienting or dangerous. Results are published in Health Services Research.

PROVIDENCE, R.I. — For the first time on a national scale, a team led by Brown University researchers has traced the connections between state nursing home policies and a critical decision in the care of nursing home residents – whether to send these frail elderly to the hospital.

In their groundbreaking analysis, researchers found that state policies unwittingly create financial incentives for nursing homes to hospitalize residents – even though hospital stays can be disorienting or dangerous. Previous studies have shown that about one-third of hospital stays by nursing home residents can be prevented.

This study – which included virtually every nursing home in the nation with 25 or more beds – resulted in two major findings. The lower the state Medicaid reimbursement rate to nursing homes, the more likely those homes were to hospitalize residents. Hospitalization odds were also significantly higher in states that reimburse nursing homes for holding the beds of hospitalized residents. Results are published in the current online edition of Health Services Research.

Hospitalization Rates for Frail Elderly
Average percentage of nursing home residents hospitalized during five-month study

Medicare and Medicaid: Practice and policy in 48 states

A = Five-month hospitalization rate (%)   B = Daily Medicaid rate ($)   C = State bed-hold policy?

“The message is clear: State policies have a significant impact on the lives of very vulnerable people,” said Orna Intrator, an associate professor of community health at Brown and the lead author of the article. “While hospital stays can be life saving for nursing home residents, they remove these seniors from familiar surroundings and expose them to life-threatening infections.”

The study was led by Vincent Mor, chairman of Brown’s Department of Community Health, and conducted by faculty in the University’s nationally recognized Center for Gerontology and Health Care Research.

For the project, Mor and the study team investigated the effects of two types of state policies on nursing home hospitalizations. One was Medicaid payment policies, which determine how much homes are paid per resident, per day for care through the federal program for the poor and disabled. The second was “bed-hold” policies. Currently, 36 states reimburse nursing homes for holding the beds of patients admitted to the hospital in order to guarantee that these residents can return home after recovery. For reserving a bed, states reimburse nursing homes anywhere from 25 percent to 100 percent of the Medicaid daily payment rate to offset lost revenue.

To conduct the study, the Brown team tracked the status of 570,614 residents aged 65 and older living in 8,997 urban, freestanding nursing homes located in 48 states. Residents were followed for a five-month period to see how many were hospitalized. Researchers found that, on average, 17 percent of all residents were admitted to hospitals at least once during those five months, with rates varying from a low of 8 percent in Utah to a high of 25 percent in Louisiana.

Researchers found a strong link between the size of Medicaid payments and the number of hospital admissions. The higher the Medicaid per-diem payment for nursing homes, researchers found, the lower the odds of hospitalization for residents. States with the lowest hospitalization rates tended to be located in the West and in New England – Utah, New Mexico, Maine, New Hampshire and Oregon. States with the highest hospitalization rates tend to be located in the South and the Midwest – Louisiana, Mississippi, Texas, Kentucky, and Oklahoma.

“We think the reason we see this relationship is that in states with higher payment rates, nursing home operators can afford to keep more medical professionals, such as nurse practitioners, on staff,” Mor said. “With more staff, and more skilled staff, homes are better able to treat residents on site and they’re better able to practice preventive care to head off problems such as pneumonia, bed sores or urinary tract infections.”

Researchers saw a similar – and surprising – relationship between bed-hold policies and hospitalizations. The odds of hospitalization were 36 percent higher in states with bed-hold policies. Mor and Intrator explained the result this way: Because homes get some money from the state for holding a bed, the financial penalty for hospitalizing residents is reduced.

“This is a complex problem with no simple solution,” Intrator said. “But one answer is a pay-for-performance system that rewards nursing homes for reducing – and maintaining low –hospital admission rates. This sort of system could improve the quality of life of nursing home residents and avoid preventable illnesses.”

Other members of the Brown team include Zhanlian Feng, senior research analyst, and Susan Miller, associate professor of community health, both of the Center for Gerontology and Health Care Research, and Mark Schleinitz, M.D., an assistant professor of community health at Brown Medical School and a physician at Rhode Island Hospital. David Grabowski of Harvard Medical School and Jaqueline Zinn of the Fox School of Business and Management at Temple University also served as investigators on the team.

The National Institute on Aging funded the work.

Editors: Brown University has a fiber link television studio available for domestic and international live and taped interviews and maintains an ISDN line for radio interviews. For more information, call the Office of Media Relations at (401) 863-2476.

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