An Estimation of the Impact of OBRA-87 on Nursing Home Care in the United States kssness and continuing a pattern offailure to adequately serve patients with serious mental illness.
Avellone Eichmann, M.A. Brian P. Griffin, Ph.D. John S. Lyons, Ph.D. David B. Larson, M.D., M.S.P.H. Sanford Finkel, M.D. Mary
In the past 25 years, the number of nursing home beds has tripled to 1.3 million,
Omnibus Budget ReconciiaAct of1987 (OBRA-87) establisbed criteria for Medicareor Medicaid-certified nursing homes to use in admitting or retaining mentally iipatients. In effect, the law createdflve dispositional categoriesfor residents orpotential residents of nursing homes. Using data from the 1 985 National Nursing Home Survey conducted by the National Centerfor Health Statistics, the authors estimate what proportion of nursing home residents wouldfall into each of the categories. They suggest that the initial impact of the law will be to shift costs from federal programs to the states. Nursing homes will be expected to provide more mental health services, in the absence of other services, the regulations have a high potent ial for creating homeThe
tion
Ms.
Eichmann and Drs. Griffin, Lyons, and Finkel are affiliated with the department of psychiatry and behavioral sciences at Northwestern University Medical School in Chicago. Dr. Larson is with the National Institute of Mental Health in Rockvilie, Maryland. Address correspondence to Ms. Eichmann at Northwestern Memorial Hospital, Institute of Psychiatry, 303 East Superior Street, linois
Hospital
Passavant 60611.
555,
and Community
Chicago,
Psychiatry
II-
and
expenditures
for patient
care in nursing homes have increased more than 20-fold (1). Although primarily designed and staffed for physical health care, nursing homes have become de facto sites for the placement of patients with chronic mental illness (2). Since the early 1980s, the federal government has been striving to develop new regulations for nursing homes to reduce rising costs and to deliver appropriate services to mdividuals in need (3). A paucity of high-quality research on the mental health needs of nursing home residents may have contributed to stagnation of reregulation efforts (4). An Institute of Medicine study of the quality ofcare in nursing homes represented a consensus of experts who addressed nursing care issues (5). The esteem accorded the institute’s general recommendations helped generate politically viable, specific regulations (3). Thus in response to concerns about the quality ofcare received by nursing home residents, especially mentally ill and developmentally disabled residents, Congress included nursing home regulations in the Omnibus Budget Reconciliation Act of 1987 (OBRA-87) (6,7). Implemented on October 1, 1990, the OBRA-87 regulations delineate criteria for long-term-care facilities that receive Medicare and Medicaid reimbursement. OBRA87 applies to all residents of Medicare- or Medicaid-certified facilities regardless of residents’ actual source
August
1992
Vol.43
No.8
of payment. The law requires that nursing homes assess each resident’s need for skilled nursing care and mental health care; only those who need skilled nursing care may be admitted or retained. To minimize disruption to residents, the law allows individuals who require narrowly defined intensive mental health treatment and who have lived in a nursing home for more than 30 months to remain in the facility if they so choose, even if they do not need skilled nursing care. As outlined below, the law establishes five major dispositional categories for potential residents or residents of nursing homes, depending on patients’ disorders and their need for various types of care. Although some studies have estimated the effects oIOBRA-87 on a specific state (8), none have attempted to assess its potentially profound national impact on nursing homes and their residents. Furthermore, the processes mandated by OBRA-87 have not yet been explicated in the psychiatric literature. Using data obtained from the 1985 National Nursing Home Survey conducted by the National Center for Health Statistics (NCHS) (9,10), the study reported here classified the 1985 nursing home population using the OBRA-87 dispositional categories. The study addressed the following questions: What proportion of current nursing home residents fall into each of the dispositional categories? What are the demographic characteristics of patients in each category, and are they significantly associated with disposition? What are the psychiatric diagnoses and behavioral problems of residents in each category? and, What are the mental
781
Table 1 Dispositional dents
categories
defined
Disposition Discharge
or not admit
by OBRA-87
for nursing
home
candidates
Level of need
Description
need for nursing care; neither mentally illnor mentally retarded
The resident
mental illness (excluding senile dementia) or mental retardation in certified nursing facilities are based on the screening and review process. These placement and care decisions are complex. Table 1 describes the five major dispositional categories that result from this process. That persons with severe mental disorders receive quality care in the most appropriate treatment setting is the overall intent ofthe process. OBRA-87 allows for admission or retention of patients with severe mental illness or severe mental retardation in nursing facilities if they have nursing care needs that can be met only in such settings. OBRA-87 specifies that “active treatment” for mentally ill or retarded residents be provided by the states. Active treatment is defined in narrow terms as the level ofcare typically provided in an inpatient psychiatric unit. Thus nursing home residents who need active treatment but have no need for nursing care must be discharged to other settings (except for those whose length of stay exceeds 30 months). Nursing homes are required to provide active treatment to mentally disabled residents who also need nursing care. For less severely impaired mentally disabled residents who require nursing care, OBRA-87 prescribes the provision ofless intensive psychiatric services so as to “attam or maintain the highest practicable physical, mental, and psychosocial well-being ofeach resident.” For current residents of nursing homes, OBRA-87 requires that an annual review be conducted. The review involves a complete evaluation of the resident’s physical and mental condition. Based on the results, the
or resi-
of disposition
or candidate is discharged from the facility or not admitted. Residents whose length of stay is less than 30 months and who need active treatment are referred to an alternative care facility.
No
immediately
need for nursing care; either mentally ill or mentally retarded but no need for active treatment No
No need for nursing care; either mentally ill or mentally retarded and in need
of active treatment, with a length of stay of less than 30 months Choose current fcility or elsewhere, needs active treatment
No nursing care needed; either mentally ill or mentally retarded and in need of active treatment, with a length of stay greater than
Nursing care needed; neither mentally ill nor mentally retarded
The resident isappropriately placed in a nursing home.
Stay, needs active treatment
Nursing care needed; either mentally ill or mentally retarded and in need of active treatment
The resident has nursing care needs and requires intensive treatment ftr a major mental illness or a severe level of retardation. The facility must provide such treatment.
Stay, needs mental health care
Nursing
The resident has nursing care needs and a mental illness or levelof retardation not requiring intensivetreatment. Less intensive treatment must be incorporated into the plan of care.
Stay,
no need
for active
30 months
Jfthe length ofstay exceeds 30 months, a resident has the choice of continued residence in the current facility or placement in an alternative facility. If the resident remains, the state must atinge to provide active treatment.
treatment
health needs of residents egory and the psychiatric provided to them?
care
needed;
either mentally ill or mentally retarded and in need of mental health care but not active treatment
in each catservices
patients health
state’s
receive appropriate mental care (1 1 ,12). To address this
Summary and rationale of categories Several studies have estimated that 50 to 94 percent of residents of longterm-care facilities have a diagnosable mental illness; few of these
situation, OBRA-87 mandated that the states institute a preadmission screening of nursing home candidates and an annual review of nursing home residents to assess their needs for nursing care and mental health care. Decisions for admitting or retaining individuals with serious
782
August
1992
Vol. 43
No.
authority
must
determine
whether the resident requires the level of care provided by a nursing facility. It must also determine whether active treatment or less intensive mental health care is required to treat any diagnosable mental disorder or developmental disability. Residents found not to require nursing care must be discharged. The only exception to this rule about discharge is the continued care of a resident whose length of stay exceeds 30 months and who requires
8
Hospital
and
Community
Psychiatry
questionnaires completed by a trained interviewer who visited the facility and interviewed a staff person. The staff person referred to the resident’s chart and was familiar with the resident. A detailed description ofthe sampling methodology may be found elsewhere (9,10). Projections. Projections-that is, the total number of all residents of certified nursing homes-rather than percentages of surveyed residents are the focus of this study because the projections best represent the actual magnitude of the impact of OBRA-87 (8,9). For multiple projections, the relative standard error (RSE) is the appropriate estimate of the stability of each projection or percentage. The standard error (SE) of the projection (or percentage) equals the RSE multiplied by the projection (or percentage). The RSE is more useful because it may be directly compared from one projection or percentage to another, whereas the SE cannot be. For the data reported here, the projections and percentages in which the RSE is less than .30 are stable in accordance with the methods presented by the NCHS (9,10). In 1985 a total of 1,489,508 patients lived in nursing homes in the U.S.; 88.6 percent (RSE=.01) of these patients lived in Medicareand Medicaid-certified nursing homes.
Data essential for dispositional decision making were missing for some surveyed residents, resulting in a projected proportion of 1 .4 percent (RSE= 1 5) of the larger population. Thus a subpopulation of 1,298,979 (RSE=.01) residents was derived from the total population of patients living in nursing homes in 1985 in the 48 contiguous states. The size of the subpopulation was based on the proportion of surveyed residents in certified homes and the number of surveyed residents for whom data was sufficient. The subpopulation represented 87.2 percent (RSE= .01) ofthe total population ofresidents of nursing homes in 1985. (For reasons ofconfidentiality, data for five of the residents surveyed were omitted from the data set open to public access [Mathis E, NCHS, personal communication, Aug 1989]. This omission accounted for trivial differences in frequencies and percentages between data available for this report and data published by the NCHS [9,10].) Chi square tests were used to determine whether significant demographic differences existed between patients in the five dispositional categories. The chi square statistics were adjusted in each case to account for the complex sampling design by dividing the chi square value by the average design effect (13,14). indicators of need. To decide which of the five dispositional categories residents should be assigned to, various data were required. Information was needed about the resident’s length of stay; in this study, nursing home stays of more than 900 days were regarded as meeting the OBRA-87 criterion of more than 30 months. Whether the resident had a primary or secondary diagnosis of mental illness or mental retardation needed to be known. Other information was needed to determine the degree of mental health care needed by the resident-active treatment, less intensive mental health care, or no treatment-and the need for nursing care. The areas of need assessed are described below. Need for nursing care. To determine the need for nursing care, the resident’s medical diagnosis was re-
Hospital
August
active treatment because of a major mental disorder or a severe level of mental retardation. In this instance, the resident would be given a choice about placement. Regardless of the resident’s choice, the state would still be obligated to provide active treatment for publicly funded residents and arrange for such treatment for others.
Methods Sample. The data examined were a weighted projection ofclata from the 1985 National Nursing Home Survey of residents of nursing homes (N=5,238). The survey data were based on a stratified random sample designed to include a representative group of residents of nursing homes across the United States (excluding Alaska and Hawaii). Information was gathered between August 1985 and
January
1986
using
and Community
structured
Psychiatry
.
1992
Vol.43
No.8
quired. 1CD-9 medical diagnoses were derived from the resident’s medical record. A patient’s level of activities of daily living has been found to be associated with the degree ofnursing care required ( 1 5). In the study reported here, the level of activities ofdaily living-the resident’s dependency level-was used to identify the level ofneed for nursing care. The dependency level was based on whether the resident needed help and therefore was dependent in the areas ofbathing, dressing, transferring (that is, getting in and out of bed), toileting, and eating. Another factor was whether the resident was incontinent. The resident’s dependency level was the total number of dependencies in these six areas. For mentally retarded residents, three additional instrumental activities of daily living were evaluated: making a phone call, managing money, and acquiring personal supplies. Katz and associates (16,17) demonstrated that the measure of activities ofdaily living has a hierarchical structure in that a person who is incontinent or requires help eating is highly likely to need help with tasks that require higher functioning, such as bathing and dressing. Senile dementia or other organic brain disorders, conditions that in general qualify a person for nursing care, were among the medical conditions reported. In addition to the resident’s dependency level and the presence ofa medical diagnosis, the presence of senile dementia was used to assess the need for nursing care. Either of two criteria was sufficient to qualify a resident as being in need of nursing care. One criterion was a medical diagnosis plus either three or more dependencies, incontinence of the bladder or bowel, or need for help in eating. The second qualifying criterion was the presence of dementia. However, according to the regulations, dementia alone does not qualify mentally retarded patients for nursing care (18). For such dually diagnosed persons, the need for nursing care is demonstrated by only the first criterion, in which the medical diagnosis is other than dementia.
783
Table 2 Demographi
c characteristics
Discharge, admission
ofa 11residents
non-
of certifi ed nursing
Choose, needs active treatment
homes
in 1985
Stay, no need for active treatment
(N=
1 , 298,9
needs active treatment Stay,
79),
by OBRA
Stay,
-87 d ispositio
nal category
needs
mental health care
Characteristic
N’
Age Under65 65-74 75-84 85, over Gender Female Race White Location Urban
RSE
N
%
RSE
N
%
RSE
64 23 11 2
.16 .38 .60 1.33
33.2 73.3 239.5 354.4
5 11 34
.12 .08 .04
23.8 18.7 32.5
24 19 32
.13 .15
.10
51
.03
25.7
26
6.1
53
.20
530.5
76
.02
63.8
.01
10.0
87
.08
642.1
92
.01
62
.04
6.8
59
.17
479.2
68
2.5
22
.40
147.5
%
RSE2
N
%
33.9 37.3 79.9 76.1
15 16 35 34
.11 .11 .06 .07
7.3 2.7 1.3 .3
148.6
65
.03
212.0
93
140.7
N
%
RSE
26.3
10
.13
44.9
17
.10
95.2
37
.06
.12
92.8
36
63
.05
190.5
93.4
93
.02
.02
61.5
61
21
.05
24.2
Total
%
RSE
124.5
10
.06
176.9
14
.05
448.4
35
.03
.06
549.2
42
.02
74
.03
939.6
72
.01
235.0
91
.01
1,192.6
92
.01
.06
180.7
70
.03
868.8
67
.01
24
.13
56.1
22
.08
283.7
22
.04
North-
east
53.5
24
.09
North Central
83.1
37
.06
5.2
45
.23
231.3
33
.04
27.4
27
.12
92.9
36
.06
439.9
34
.03
South West
62.7 27.9
28 12
.08 .13
2.5 1.3
22 12
.40 .58
216.0 105.6
31 15
.04 .06
34.3 14.8
34 15
.10 .17
71.1 39.1
27 15
.07 .10
386.7 188.7
30 15
.03 .05
Stay
(months) < 1
9.7
4
.22
-
-
-
-
-
-
3.5 46.9
4 47
.37 .08
12.5 152.0
5 59
.08
.04
.10 .02
5
62
6 58
69.7
139.6
44.0 407.0
.20
1-30
.04
745.6
57
.02
>30
77.8
34
.08
-
249.3
36
.04
50.3
50
.07
94.7
37
.06
483.7
37
.03
1 2
In thousands Relative standard
11.5
100
error
Mental disorder. The presence or absence of mental illness or mental retardation was determined by a staff review of the resident’s medical record. One or more ofthe following conditions were taken to indicate mental illness: depressive disorder, schizophrenia or other psychosis, anxiety disorder, alcohol abuse or dependence, drug abuse or dependence, and personality or character disorders. Needforactive treatment. According to OBRA-87 regulations, determination ofthe need for active treatment must be independent of the need for nursing care. Because active treatment is defined as the level of care typically provided in an inpatient psychiatric unit, it does not include intermittent or periodic psychiatric services for nursing home
orders that normally would not warrant active treatment and therefore would not serve as barriers to continued residence in a nursing fitcility. For residents with schizophrenia,
residents
self
who
do not
require
24-hour
paranoia,
major
affective
disorder,
and other psychotic conditions, mdividualized evaluations must be conducted to determine ifthe mental illness
is of sufficient
rant
active
treatment.
severity For
to warthis
study,
the need for active treatment was indicated by the presence ofany of the mental illnesses listed above plus evidence that the resident was a danger to selfor others. For mentally retarded patients, the need for active treatment was indicated by severe impairment in the three instrumental activities of cornrnunity living (the ability to make a phone call and so forth) or danger to or others.
supervision by qualified mental health professionals. OBRA-87 specifies that the state’s authority may devise a list ofminor mental dis-
Needfor mental dents who did not ment but who had were identified as
784
August
1992
health care. Resineed active treata mental disorder needing mental
Vol. 43
No.
health care. Residents requiring mental health care were those with a diagnosis of mental illness or mental retardation who were not currently deemed dangerous to themselves or others and who had fewer than three dependencies. Additional d,escr:tors and indicators ofneed. Other factors were assessed to estimate the needs of residents in each category. They included whether the resident was receiving mental health
treatment
(at least
one
mental
health visit in the past month) and whether the resident had a disabling mood disturbance or problematic behaviors. Mood disturbance was assessed by questioning the staff respondent about whether the resident displayed depression, anxiety, or fearfulness and worry “to such degree that the resident is distressed or restricted in functioning nearly every day.”
Behaviors disruptive dency were
8
Hospital
and
generally or indicative noted. (For
considered of depenresidents on
Community
Psychiatry
Table 3 Indicators category
ofdisability
and need among
Discharge,
non-
admission
Indicator
N’
Receives mental healthcare Has three or more dependencies Needs active treatment3 Needs mental health care3 Disabling
%
RSE2
all residents
ofcertified
nursing
homes
in 1985 (N= 1 ,298,979),
Choose, needs active
Stay, no need for active
Stay,
active
mental
treatment
treatment
treatment
health
N
%
RSE
N
%
RSE
needs
N
Stay,
%
RSE
19.0
8
.16
2.3
20
.41
22.1
3
.15
10.6
11
.21
1.5
1
.61
.3
2
1.40
640.0
91
.01
93.3
93
.02
11.6
5
.20
11.5
100
-
-
100.7
100
79.9
35
.06
69.7
31
.07
-
-
by OBRA-87
needs
N
care
%
19.2
-
RSE
7 .16
226.6
-
dispositional
259.2
100
181.7
71
%
RSE
73.1
6
.08
.02
961.4
74
.01
-
123.9
10
.06
-
339.1
26
.03
560.1
43
.02
87 -
Total
depression
oranxiety4 ,
In thousands
2
Relative
standard
3.3
.33
234.5
34
70.8
.04
71
.05
.03
error
3 Except 4
29
for these mutually exclusive N=1,291,722 (7,257 missing data)
categories,
medications, the presence of these behaviors while on medications was observed.) The behaviors included screaming, disrobing or exposing oneself, being physically abusive to selfor others, stealing, getting lost or wandering into unacceptable places, and displaying an inability to avoid simple dangers.
residents
may be represented
in more
than one disability
Results Projections from the 1 985 nursing home survey data were used to estimate what proportion ofthe population of 1 ,298,979 residents of cerrifled nursing homes fell into each of the five OBRA-87 dispositional categories described in Table 1 In the category requiring immediate discharge were 227,160 residents (18 percent, RSE = .04); 1 1 ,527 patients (1 percent, RSE = .20) had stays exceeding 30 months and were in need ofactive treatment for mental illness or mental retardation but not in need of nursing care, allowing them to choose whether to remain in the nursing home; 700,380 residents (54 percent, RSE< .01) needed nursing care but not active treatment or mental health care; 100,716 residents (8 percent, RSE=.02) needed
both nursing care and active treatment, which OBRA-87 requires the flicility to provide; and 259,195 residents (20 percent, RSE=.04) required nursing care in addition to mental health care (but not active treatment) for mental illness or retardation. The projected demographic characteristics ofthe nursing home population are summarized in Table 2 by dispositional category. Overall, of residents ofpublicly funded nursing homes in 1 985, some 10 percent were below age 65; 14 percent were between the ages of 65 and 74; 35 percent were between the ages of 75 and 84; and 42 percent were over age 84. The median age was 81. Women represented 72 percent of the residents. Whites constituted 92 percent. Most residents of certified nursing homes in 1985 (67 percent) were projected to live in nursing homes in metropolitan areas. Twenty-two percent were projected to live in the Northeast, 34 percent in the North Central region, 30 percent in the South, and 1 5 percent in the West. In addition, it was estimated that 94 percent (RSE= .01) of residents of
Hospital
August
.
and Community
Psychiatry
1992
Vol. 43
No.8
or need category.
publicly funded homes were recipients of Medicare or Medicaid. Residents’ length of stay was distributed as follows: 5 percent for up to one month, 57 percent for one to 30 months, and 37 for more than 30 months. There were significant demographic differences between the residents in the five dispositional categories. They differed in age (adjusted X26155, df=12, p
Avellone Eichmann, M.A. Brian P. Griffin, Ph.D. John S. Lyons, Ph.D. David B. Larson, M.D., M.S.P.H. Sanford Finkel, M.D. Mary
In the past 25 years, the number of nursing home beds has tripled to 1.3 million,
Omnibus Budget ReconciiaAct of1987 (OBRA-87) establisbed criteria for Medicareor Medicaid-certified nursing homes to use in admitting or retaining mentally iipatients. In effect, the law createdflve dispositional categoriesfor residents orpotential residents of nursing homes. Using data from the 1 985 National Nursing Home Survey conducted by the National Centerfor Health Statistics, the authors estimate what proportion of nursing home residents wouldfall into each of the categories. They suggest that the initial impact of the law will be to shift costs from federal programs to the states. Nursing homes will be expected to provide more mental health services, in the absence of other services, the regulations have a high potent ial for creating homeThe
tion
Ms.
Eichmann and Drs. Griffin, Lyons, and Finkel are affiliated with the department of psychiatry and behavioral sciences at Northwestern University Medical School in Chicago. Dr. Larson is with the National Institute of Mental Health in Rockvilie, Maryland. Address correspondence to Ms. Eichmann at Northwestern Memorial Hospital, Institute of Psychiatry, 303 East Superior Street, linois
Hospital
Passavant 60611.
555,
and Community
Chicago,
Psychiatry
II-
and
expenditures
for patient
care in nursing homes have increased more than 20-fold (1). Although primarily designed and staffed for physical health care, nursing homes have become de facto sites for the placement of patients with chronic mental illness (2). Since the early 1980s, the federal government has been striving to develop new regulations for nursing homes to reduce rising costs and to deliver appropriate services to mdividuals in need (3). A paucity of high-quality research on the mental health needs of nursing home residents may have contributed to stagnation of reregulation efforts (4). An Institute of Medicine study of the quality ofcare in nursing homes represented a consensus of experts who addressed nursing care issues (5). The esteem accorded the institute’s general recommendations helped generate politically viable, specific regulations (3). Thus in response to concerns about the quality ofcare received by nursing home residents, especially mentally ill and developmentally disabled residents, Congress included nursing home regulations in the Omnibus Budget Reconciliation Act of 1987 (OBRA-87) (6,7). Implemented on October 1, 1990, the OBRA-87 regulations delineate criteria for long-term-care facilities that receive Medicare and Medicaid reimbursement. OBRA87 applies to all residents of Medicare- or Medicaid-certified facilities regardless of residents’ actual source
August
1992
Vol.43
No.8
of payment. The law requires that nursing homes assess each resident’s need for skilled nursing care and mental health care; only those who need skilled nursing care may be admitted or retained. To minimize disruption to residents, the law allows individuals who require narrowly defined intensive mental health treatment and who have lived in a nursing home for more than 30 months to remain in the facility if they so choose, even if they do not need skilled nursing care. As outlined below, the law establishes five major dispositional categories for potential residents or residents of nursing homes, depending on patients’ disorders and their need for various types of care. Although some studies have estimated the effects oIOBRA-87 on a specific state (8), none have attempted to assess its potentially profound national impact on nursing homes and their residents. Furthermore, the processes mandated by OBRA-87 have not yet been explicated in the psychiatric literature. Using data obtained from the 1985 National Nursing Home Survey conducted by the National Center for Health Statistics (NCHS) (9,10), the study reported here classified the 1985 nursing home population using the OBRA-87 dispositional categories. The study addressed the following questions: What proportion of current nursing home residents fall into each of the dispositional categories? What are the demographic characteristics of patients in each category, and are they significantly associated with disposition? What are the psychiatric diagnoses and behavioral problems of residents in each category? and, What are the mental
781
Table 1 Dispositional dents
categories
defined
Disposition Discharge
or not admit
by OBRA-87
for nursing
home
candidates
Level of need
Description
need for nursing care; neither mentally illnor mentally retarded
The resident
mental illness (excluding senile dementia) or mental retardation in certified nursing facilities are based on the screening and review process. These placement and care decisions are complex. Table 1 describes the five major dispositional categories that result from this process. That persons with severe mental disorders receive quality care in the most appropriate treatment setting is the overall intent ofthe process. OBRA-87 allows for admission or retention of patients with severe mental illness or severe mental retardation in nursing facilities if they have nursing care needs that can be met only in such settings. OBRA-87 specifies that “active treatment” for mentally ill or retarded residents be provided by the states. Active treatment is defined in narrow terms as the level ofcare typically provided in an inpatient psychiatric unit. Thus nursing home residents who need active treatment but have no need for nursing care must be discharged to other settings (except for those whose length of stay exceeds 30 months). Nursing homes are required to provide active treatment to mentally disabled residents who also need nursing care. For less severely impaired mentally disabled residents who require nursing care, OBRA-87 prescribes the provision ofless intensive psychiatric services so as to “attam or maintain the highest practicable physical, mental, and psychosocial well-being ofeach resident.” For current residents of nursing homes, OBRA-87 requires that an annual review be conducted. The review involves a complete evaluation of the resident’s physical and mental condition. Based on the results, the
or resi-
of disposition
or candidate is discharged from the facility or not admitted. Residents whose length of stay is less than 30 months and who need active treatment are referred to an alternative care facility.
No
immediately
need for nursing care; either mentally ill or mentally retarded but no need for active treatment No
No need for nursing care; either mentally ill or mentally retarded and in need
of active treatment, with a length of stay of less than 30 months Choose current fcility or elsewhere, needs active treatment
No nursing care needed; either mentally ill or mentally retarded and in need of active treatment, with a length of stay greater than
Nursing care needed; neither mentally ill nor mentally retarded
The resident isappropriately placed in a nursing home.
Stay, needs active treatment
Nursing care needed; either mentally ill or mentally retarded and in need of active treatment
The resident has nursing care needs and requires intensive treatment ftr a major mental illness or a severe level of retardation. The facility must provide such treatment.
Stay, needs mental health care
Nursing
The resident has nursing care needs and a mental illness or levelof retardation not requiring intensivetreatment. Less intensive treatment must be incorporated into the plan of care.
Stay,
no need
for active
30 months
Jfthe length ofstay exceeds 30 months, a resident has the choice of continued residence in the current facility or placement in an alternative facility. If the resident remains, the state must atinge to provide active treatment.
treatment
health needs of residents egory and the psychiatric provided to them?
care
needed;
either mentally ill or mentally retarded and in need of mental health care but not active treatment
in each catservices
patients health
state’s
receive appropriate mental care (1 1 ,12). To address this
Summary and rationale of categories Several studies have estimated that 50 to 94 percent of residents of longterm-care facilities have a diagnosable mental illness; few of these
situation, OBRA-87 mandated that the states institute a preadmission screening of nursing home candidates and an annual review of nursing home residents to assess their needs for nursing care and mental health care. Decisions for admitting or retaining individuals with serious
782
August
1992
Vol. 43
No.
authority
must
determine
whether the resident requires the level of care provided by a nursing facility. It must also determine whether active treatment or less intensive mental health care is required to treat any diagnosable mental disorder or developmental disability. Residents found not to require nursing care must be discharged. The only exception to this rule about discharge is the continued care of a resident whose length of stay exceeds 30 months and who requires
8
Hospital
and
Community
Psychiatry
questionnaires completed by a trained interviewer who visited the facility and interviewed a staff person. The staff person referred to the resident’s chart and was familiar with the resident. A detailed description ofthe sampling methodology may be found elsewhere (9,10). Projections. Projections-that is, the total number of all residents of certified nursing homes-rather than percentages of surveyed residents are the focus of this study because the projections best represent the actual magnitude of the impact of OBRA-87 (8,9). For multiple projections, the relative standard error (RSE) is the appropriate estimate of the stability of each projection or percentage. The standard error (SE) of the projection (or percentage) equals the RSE multiplied by the projection (or percentage). The RSE is more useful because it may be directly compared from one projection or percentage to another, whereas the SE cannot be. For the data reported here, the projections and percentages in which the RSE is less than .30 are stable in accordance with the methods presented by the NCHS (9,10). In 1985 a total of 1,489,508 patients lived in nursing homes in the U.S.; 88.6 percent (RSE=.01) of these patients lived in Medicareand Medicaid-certified nursing homes.
Data essential for dispositional decision making were missing for some surveyed residents, resulting in a projected proportion of 1 .4 percent (RSE= 1 5) of the larger population. Thus a subpopulation of 1,298,979 (RSE=.01) residents was derived from the total population of patients living in nursing homes in 1985 in the 48 contiguous states. The size of the subpopulation was based on the proportion of surveyed residents in certified homes and the number of surveyed residents for whom data was sufficient. The subpopulation represented 87.2 percent (RSE= .01) ofthe total population ofresidents of nursing homes in 1985. (For reasons ofconfidentiality, data for five of the residents surveyed were omitted from the data set open to public access [Mathis E, NCHS, personal communication, Aug 1989]. This omission accounted for trivial differences in frequencies and percentages between data available for this report and data published by the NCHS [9,10].) Chi square tests were used to determine whether significant demographic differences existed between patients in the five dispositional categories. The chi square statistics were adjusted in each case to account for the complex sampling design by dividing the chi square value by the average design effect (13,14). indicators of need. To decide which of the five dispositional categories residents should be assigned to, various data were required. Information was needed about the resident’s length of stay; in this study, nursing home stays of more than 900 days were regarded as meeting the OBRA-87 criterion of more than 30 months. Whether the resident had a primary or secondary diagnosis of mental illness or mental retardation needed to be known. Other information was needed to determine the degree of mental health care needed by the resident-active treatment, less intensive mental health care, or no treatment-and the need for nursing care. The areas of need assessed are described below. Need for nursing care. To determine the need for nursing care, the resident’s medical diagnosis was re-
Hospital
August
active treatment because of a major mental disorder or a severe level of mental retardation. In this instance, the resident would be given a choice about placement. Regardless of the resident’s choice, the state would still be obligated to provide active treatment for publicly funded residents and arrange for such treatment for others.
Methods Sample. The data examined were a weighted projection ofclata from the 1985 National Nursing Home Survey of residents of nursing homes (N=5,238). The survey data were based on a stratified random sample designed to include a representative group of residents of nursing homes across the United States (excluding Alaska and Hawaii). Information was gathered between August 1985 and
January
1986
using
and Community
structured
Psychiatry
.
1992
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No.8
quired. 1CD-9 medical diagnoses were derived from the resident’s medical record. A patient’s level of activities of daily living has been found to be associated with the degree ofnursing care required ( 1 5). In the study reported here, the level of activities ofdaily living-the resident’s dependency level-was used to identify the level ofneed for nursing care. The dependency level was based on whether the resident needed help and therefore was dependent in the areas ofbathing, dressing, transferring (that is, getting in and out of bed), toileting, and eating. Another factor was whether the resident was incontinent. The resident’s dependency level was the total number of dependencies in these six areas. For mentally retarded residents, three additional instrumental activities of daily living were evaluated: making a phone call, managing money, and acquiring personal supplies. Katz and associates (16,17) demonstrated that the measure of activities ofdaily living has a hierarchical structure in that a person who is incontinent or requires help eating is highly likely to need help with tasks that require higher functioning, such as bathing and dressing. Senile dementia or other organic brain disorders, conditions that in general qualify a person for nursing care, were among the medical conditions reported. In addition to the resident’s dependency level and the presence ofa medical diagnosis, the presence of senile dementia was used to assess the need for nursing care. Either of two criteria was sufficient to qualify a resident as being in need of nursing care. One criterion was a medical diagnosis plus either three or more dependencies, incontinence of the bladder or bowel, or need for help in eating. The second qualifying criterion was the presence of dementia. However, according to the regulations, dementia alone does not qualify mentally retarded patients for nursing care (18). For such dually diagnosed persons, the need for nursing care is demonstrated by only the first criterion, in which the medical diagnosis is other than dementia.
783
Table 2 Demographi
c characteristics
Discharge, admission
ofa 11residents
non-
of certifi ed nursing
Choose, needs active treatment
homes
in 1985
Stay, no need for active treatment
(N=
1 , 298,9
needs active treatment Stay,
79),
by OBRA
Stay,
-87 d ispositio
nal category
needs
mental health care
Characteristic
N’
Age Under65 65-74 75-84 85, over Gender Female Race White Location Urban
RSE
N
%
RSE
N
%
RSE
64 23 11 2
.16 .38 .60 1.33
33.2 73.3 239.5 354.4
5 11 34
.12 .08 .04
23.8 18.7 32.5
24 19 32
.13 .15
.10
51
.03
25.7
26
6.1
53
.20
530.5
76
.02
63.8
.01
10.0
87
.08
642.1
92
.01
62
.04
6.8
59
.17
479.2
68
2.5
22
.40
147.5
%
RSE2
N
%
33.9 37.3 79.9 76.1
15 16 35 34
.11 .11 .06 .07
7.3 2.7 1.3 .3
148.6
65
.03
212.0
93
140.7
N
%
RSE
26.3
10
.13
44.9
17
.10
95.2
37
.06
.12
92.8
36
63
.05
190.5
93.4
93
.02
.02
61.5
61
21
.05
24.2
Total
%
RSE
124.5
10
.06
176.9
14
.05
448.4
35
.03
.06
549.2
42
.02
74
.03
939.6
72
.01
235.0
91
.01
1,192.6
92
.01
.06
180.7
70
.03
868.8
67
.01
24
.13
56.1
22
.08
283.7
22
.04
North-
east
53.5
24
.09
North Central
83.1
37
.06
5.2
45
.23
231.3
33
.04
27.4
27
.12
92.9
36
.06
439.9
34
.03
South West
62.7 27.9
28 12
.08 .13
2.5 1.3
22 12
.40 .58
216.0 105.6
31 15
.04 .06
34.3 14.8
34 15
.10 .17
71.1 39.1
27 15
.07 .10
386.7 188.7
30 15
.03 .05
Stay
(months) < 1
9.7
4
.22
-
-
-
-
-
-
3.5 46.9
4 47
.37 .08
12.5 152.0
5 59
.08
.04
.10 .02
5
62
6 58
69.7
139.6
44.0 407.0
.20
1-30
.04
745.6
57
.02
>30
77.8
34
.08
-
249.3
36
.04
50.3
50
.07
94.7
37
.06
483.7
37
.03
1 2
In thousands Relative standard
11.5
100
error
Mental disorder. The presence or absence of mental illness or mental retardation was determined by a staff review of the resident’s medical record. One or more ofthe following conditions were taken to indicate mental illness: depressive disorder, schizophrenia or other psychosis, anxiety disorder, alcohol abuse or dependence, drug abuse or dependence, and personality or character disorders. Needforactive treatment. According to OBRA-87 regulations, determination ofthe need for active treatment must be independent of the need for nursing care. Because active treatment is defined as the level of care typically provided in an inpatient psychiatric unit, it does not include intermittent or periodic psychiatric services for nursing home
orders that normally would not warrant active treatment and therefore would not serve as barriers to continued residence in a nursing fitcility. For residents with schizophrenia,
residents
self
who
do not
require
24-hour
paranoia,
major
affective
disorder,
and other psychotic conditions, mdividualized evaluations must be conducted to determine ifthe mental illness
is of sufficient
rant
active
treatment.
severity For
to warthis
study,
the need for active treatment was indicated by the presence ofany of the mental illnesses listed above plus evidence that the resident was a danger to selfor others. For mentally retarded patients, the need for active treatment was indicated by severe impairment in the three instrumental activities of cornrnunity living (the ability to make a phone call and so forth) or danger to or others.
supervision by qualified mental health professionals. OBRA-87 specifies that the state’s authority may devise a list ofminor mental dis-
Needfor mental dents who did not ment but who had were identified as
784
August
1992
health care. Resineed active treata mental disorder needing mental
Vol. 43
No.
health care. Residents requiring mental health care were those with a diagnosis of mental illness or mental retardation who were not currently deemed dangerous to themselves or others and who had fewer than three dependencies. Additional d,escr:tors and indicators ofneed. Other factors were assessed to estimate the needs of residents in each category. They included whether the resident was receiving mental health
treatment
(at least
one
mental
health visit in the past month) and whether the resident had a disabling mood disturbance or problematic behaviors. Mood disturbance was assessed by questioning the staff respondent about whether the resident displayed depression, anxiety, or fearfulness and worry “to such degree that the resident is distressed or restricted in functioning nearly every day.”
Behaviors disruptive dency were
8
Hospital
and
generally or indicative noted. (For
considered of depenresidents on
Community
Psychiatry
Table 3 Indicators category
ofdisability
and need among
Discharge,
non-
admission
Indicator
N’
Receives mental healthcare Has three or more dependencies Needs active treatment3 Needs mental health care3 Disabling
%
RSE2
all residents
ofcertified
nursing
homes
in 1985 (N= 1 ,298,979),
Choose, needs active
Stay, no need for active
Stay,
active
mental
treatment
treatment
treatment
health
N
%
RSE
N
%
RSE
needs
N
Stay,
%
RSE
19.0
8
.16
2.3
20
.41
22.1
3
.15
10.6
11
.21
1.5
1
.61
.3
2
1.40
640.0
91
.01
93.3
93
.02
11.6
5
.20
11.5
100
-
-
100.7
100
79.9
35
.06
69.7
31
.07
-
-
by OBRA-87
needs
N
care
%
19.2
-
RSE
7 .16
226.6
-
dispositional
259.2
100
181.7
71
%
RSE
73.1
6
.08
.02
961.4
74
.01
-
123.9
10
.06
-
339.1
26
.03
560.1
43
.02
87 -
Total
depression
oranxiety4 ,
In thousands
2
Relative
standard
3.3
.33
234.5
34
70.8
.04
71
.05
.03
error
3 Except 4
29
for these mutually exclusive N=1,291,722 (7,257 missing data)
categories,
medications, the presence of these behaviors while on medications was observed.) The behaviors included screaming, disrobing or exposing oneself, being physically abusive to selfor others, stealing, getting lost or wandering into unacceptable places, and displaying an inability to avoid simple dangers.
residents
may be represented
in more
than one disability
Results Projections from the 1 985 nursing home survey data were used to estimate what proportion ofthe population of 1 ,298,979 residents of cerrifled nursing homes fell into each of the five OBRA-87 dispositional categories described in Table 1 In the category requiring immediate discharge were 227,160 residents (18 percent, RSE = .04); 1 1 ,527 patients (1 percent, RSE = .20) had stays exceeding 30 months and were in need ofactive treatment for mental illness or mental retardation but not in need of nursing care, allowing them to choose whether to remain in the nursing home; 700,380 residents (54 percent, RSE< .01) needed nursing care but not active treatment or mental health care; 100,716 residents (8 percent, RSE=.02) needed
both nursing care and active treatment, which OBRA-87 requires the flicility to provide; and 259,195 residents (20 percent, RSE=.04) required nursing care in addition to mental health care (but not active treatment) for mental illness or retardation. The projected demographic characteristics ofthe nursing home population are summarized in Table 2 by dispositional category. Overall, of residents ofpublicly funded nursing homes in 1 985, some 10 percent were below age 65; 14 percent were between the ages of 65 and 74; 35 percent were between the ages of 75 and 84; and 42 percent were over age 84. The median age was 81. Women represented 72 percent of the residents. Whites constituted 92 percent. Most residents of certified nursing homes in 1985 (67 percent) were projected to live in nursing homes in metropolitan areas. Twenty-two percent were projected to live in the Northeast, 34 percent in the North Central region, 30 percent in the South, and 1 5 percent in the West. In addition, it was estimated that 94 percent (RSE= .01) of residents of
Hospital
August
.
and Community
Psychiatry
1992
Vol. 43
No.8
or need category.
publicly funded homes were recipients of Medicare or Medicaid. Residents’ length of stay was distributed as follows: 5 percent for up to one month, 57 percent for one to 30 months, and 37 for more than 30 months. There were significant demographic differences between the residents in the five dispositional categories. They differed in age (adjusted X26155, df=12, p
