Study Finds ‘Oldest Old’ Are Shifting From NHs

Abstract

Nursing home use by the “oldest old”—or those aged 85 and older—has declined sharply since 1984, according to the Lewin Group. The health care and human services consulting firm cites less disability, new alternatives to nursing homes, and changes in the pattern of nursing home care. But an Urban Institute expert says a change in definitions may also be a factor. In a study released in November, the Lewin Group found that if all older adults (ages 65 and older) had continued to use nursing homes as they did in 1985, 1.95 million older adults would reside in nursing homes today. Instead, just 1.32 million residents ages 65 and older lived in nursing homes in 2004. At the same time, “the total number of people age 85 and older nearly doubled over the period,” but the number of individuals age 85 and over in nursing homes “remained about the same,” wrote Lisa Alecxih, vice president of the Lewin Group and author of the report, “Nursing Home Use by ‘Oldest Old’ Sharply Declines.” Consequently, the use rate among the oldest old fell from 21.1% in 1985 to 13.9% in 2004, and is likely to drop further, the study found. The finding reflects a desire of many older adults to continue to live in the community, and also suggests continued change as the Baby Boom generation begins to need long-term care, Ms. Alecxih concluded in her report. Several factors likely contributed to the decline in use rate, she said. First, age-adjusted disability rates among the elderly declined from 1984 to 1999, although the decline was somewhat less among the oldest old. And, the poverty rate for individuals 85 and older dropped 28%, from 18.7% in 1985 to 13.4% in 2005. The poverty rate for all seniors also fell about 20%. Changes in Medicare reimbursement have led to more of a focus on post-acute stays and shorter custodial stays, resulting in a decline of average length of stay from 2.9 years in 1985 to 2.4 years in 2004, and in median length of stay from 1.7 years to about 1.3 years. At the same time, alternatives to traditional nursing homes, such as assisted living facilities, continued to develop. They now house approximately 1 million residents with an average age over 80, said Ms. Alecxih, who leads the group's Center for Long-Term Care. Separately, approximately 10% of all adults 65 and older now own a long-term care insurance policy, which provides a small group of policyholders with the resources to choose where they want to receive care. Many states have tried to reduce the number of Medicaid recipients in nursing homes by providing more home and community-based services, while implementing pre-admission screening or single entry point systems in order to divert people away from nursing homes, the report said. With the aging of the Baby Boom generation, the United States will see twice as many older adults in 2030 as there were in 2006. But if the demand for nursing homes continues to decline at just half the national average over the past 20 years, the use rate among adults age 65 and older would drop from a projected 3.2% to 2.5% in 2030, Ms. Alecxih said. That would mean an increase of just 320,000 older adults by 2030, Ms. Alecxih wrote in the report. The decline may be more related to how states define and regulate nursing homes, according to Brenda Spillman, Ph.D., a senior research associate with the Urban Institute's Health Policy Center. “States have begun licensing other types of long-term care settings and other supportive residential care settings, and some of the more marginal places changed licensure,” she said. That could mean some institutions now are classified as assisted-living facilities rather than as nursing homes, even though the care provided in them has not changed, Dr. Spillman explained. “They may not be nursing homes any longer, but Mrs. Jones may be sitting in the same bed in the same room. And, there may be less quality oversight,” said Dr. Spillman, who co-authored in January 2006 the Urban Institute study “Size and Characteristics of the Residential Care Population: Evidence from Three National Surveys.” Still, measuring and improving quality of care at all residential facilities—not just nursing homes—is becoming a bigger is-sue for regulators, Dr. Spillman said. And even though those 85 or older increasingly are choosing alternatives to nursing homes, she said, that doesn't mean they won't enter one eventually. “In assisted living settings, it is very likely you will reach a point where they won't keep you any more. I wonder if they aren't becoming a step between home and a nursing home.