Medicaid Census Research Articles

Electronic Health Record Implementation Enhances Financial Performance in High Medicaid Nursing Homes.

The nursing home (NH) industry operates within a two-tiered system, wherein high Medicaid NHs which disproportionately serve marginalized populations, exhibit poorer quality of care and financial performance. Utilizing the resource-based view of the firm, this study aimed to investigate the association between electronic health record (EHR) implementation and financial performance in high Medicaid NHs. A positive correlation could allow high Medicaid NHs to leverage technology to enhance efficiency and financial health, thereby establishing a business case for EHR investments. Data from 2017 to 2018 were sourced from mail surveys sent to the Director of Nursing in high Medicaid NHs (defined as having 85% or more Medicaid census, excluding facilities with over 10% private pay or 8% Medicare), and secondary sources like LTCFocus.org and Centers for Medicare & Medicaid Services cost reports. From the initial sample of 1,050 NHs, a 37% response rate was achieved (391 surveys). Propensity score inverse probability weighting was used to account for potential non-response bias. The independent variable, EHR Implementation Score (EIS), was calculated as the sum of scores across five EHR functionalities-administrative, documentation, order entry, results viewing, and clinical tools-and reflected the extent of electronic implementation. The dependent variable, total margin, represented NH financial performance. A multivariable linear regression model was used, adjusting for organizational and market-level control variables that may independently affect NH financial performance. Approximately 76% of high Medicaid NHs had implemented EHR either fully or partially (n = 391). The multivariable regression model revealed that a one-unit increase in EIS was associated with a 0.12% increase in the total margin (p = 0.05, CI: -0.00-0.25). The findings highlight a potential business case -long-term financial returns for the initial investments required for EHR implementation. Nonetheless, policy interventions including subsidies may still be necessary to stimulate EHR implementation, particularly in high Medicaid NHs.

TRENDS IN COMMUNITY-BASED CARE STAFFING LEVELS IN OREGON: DIFFERENCES BY FACILITY CHARACTERISTICS

Abstract The COVID-19 pandemic re-centered the workforce crisis across long-term care settings in the U.S. Variation in regulatory requirements, industry practices, staff training, and lack of longitudinal data introduces complexity in understanding workforce trends specific to assisted living and residential care (AL/RC). Pooling five waves of the Oregon Community-Based Care study, we examine trends in AL/RC care staff levels and associations with facility characteristics: license type, Medicaid census, profit status, and rurality. From 2017-2022, 548 unique facilities participated in the study, 55% contributing to four to five waves. The estimated average care staff-to-resident ratio was 0.79 (median= 0.67), increasing between 2017 (0.74) and 2022 (0.87). The average staffing level (care hours per resident per day; hours:minutes) was 3:28 (median= 2:58). We estimated ordinary least squares regression models with robust standard errors, controlling for facility-level characteristics and year. On average, staffing levels were higher by 1:38 in memory care (MC) and 0:42 in nonprofit settings. Compared to non-Medicaid settings, overall staffing levels were about 1:00-1:30 lower in mixed-payer settings, and 2:00 higher in settings providing specialty care (e.g., behavioral health, bariatric) at increased Medicaid reimbursement rates. Licensed nursing staff levels were slightly higher in MC, nonprofit, and special contract Medicaid settings. Certified nursing/medication aide levels were 0:30 higher in nonprofit settings. There were no differences in caregiver levels by profit status or rurality, though mixed-payer setting levels were lower by 0:32-0:44. Reduced occupancy during the pandemic resulted in higher staffing levels, though findings suggest continued disparities in staff mix by facility characteristics.

Inpatient Rehabilitation Facility Ownership Type Yields Mixed Performances on Quality Measures

ObjectiveTo evaluate the effects of inpatient rehabilitation facility (IRF) ownership type on IRF-Quality Reporting Program (IRF-QRP) measures. DesignCross-sectional, observational design. SettingWe used 2 Centers for Medicare and Medicare publicly-available, facility-level data sources: (1) IRF compare files and (2) IRF rate setting files – final rule. Data from 2021 were included. ParticipantsThe study sample included 1092 IRFs (N=1092). InterventionsNot applicable. Main Outcome MeasuresWe estimated the effects of IRF ownership type, defined as for-profit and nonprofit, on 15 IRF-QRP measures using general linear models. Models were adjusted for the following facility-level characteristics: (1) Centers for Medicare and Medicaid census divisions; (2) number of discharges; (3) teaching status; (4) freestanding vs hospital unit; and (5) estimated average weight per discharge. ResultsOwnership type was significantly associated with 9 out of the fifteen IRF-QRP measures. Nonprofit IRFs performed better with having lower readmissions rates within stay and 30-day post discharge. For-profit IRFs performed better for all the functional measures and with higher rates of returning to home and the community. Lastly, for-profit IRFs spent more per Medicare beneficiary. ConclusionsIdeally, IRF performance would not vary based on ownership type. However, we found that ownership type is associated with IRF-QRP performance scores. We suggest that future studies investigate how ownership type affects patient-level outcomes and the longitudinal effect of ownership type on IRF-QRP measures.

Facility characteristics and costs associated with meeting proposed minimum staffing levels in skilled nursing facilities.

Federal minimum nurse staffing levels for skilled nursing facilities (SNFs) were proposed in 2019 U.S. Congressional bills. We estimated costs and personnel needed to meet the proposed staffing levels, and examined characteristics of SNFs not meeting these thresholds. This was a cross-sectional analysis of 2019Q4 payroll data, the Hospital Wage Index, and other administrative data for 14,964 Medicare and Medicaid-certified SNFs. We examined characteristics of SNFs not meeting proposed minimum thresholds: 4.1 total nursing hours per resident day (HPRD); 0.75 registered nurse (RN) HPRD; 0.54 licensed practical nurse (LPN) HPRD; and 2.81 certified nursing assistant (CNA) HPRD. For SNFs falling below the thresholds, we calculated the additional HPRD needed, along with the associated full-time equivalent (FTE) personnel and salary costs. In 2019, 25.0% of SNFs met the minimum 4.1 total nursing HPRD, while 31.0%, 84.5%, and 10.7% met the RN, LPN, and CNA thresholds, respectively. Only 5.0% met all four categories. In adjusted analyses, factors most strongly associated with SNFs not meeting the proposed minimums were: higher Medicaid census, larger bed size, for-profit ownership, higher county SNF competition; and, for RNs specifically, higher community poverty and lower Medicare census. Rural SNFs were less likely to meet all categories and this was explained primarily by county SNF competition. We estimate that achieving the proposed federal minimums across SNFs nationwide would require an estimated additional 35,804 RN, 3509 LPN, and 116,929 CNA FTEs at $7.25 billion annually in salary costs based on current wage rates and prepandemic resident census levels. Achieving proposed minimum nurse staffing levels in SNFs will require substantial financial investment in the workforce and targeted support of low-resource facilities. Extensive recruitment and retention efforts are needed to overcome supply constraints, particularly in the aftermath of the COVID-19 pandemic.

COVID-19 Death in High-Medicaid Nursing Homes: The Role of Employment Empowerment

This study examines the association between COVID-19 death and employee empowerment in under-resourced nursing homes (70% or higher Medicaid census). Employee empowerment captures elements of participative decision making, autonomy, responsibility, open communication, decentralization, and decision-making flexibility within an organization. Survey data from 391 Directors of Nursing (response rate of 37%) from 2017-2018, were merged with secondary data from CMS Nursing Home COVID-19 Public File, LTCFocus, Area Health Resource File, and Nursing Home Compare. A Poisson regression was used to examine reported COVID-19 death and employee empowerment. The independent variable employee empowerment was the mean score of summated Likert scale questions. Control variables included organizational (size, location, ownership, chain affiliation, quality, payer mix, acuity, occupancy, and race/ethnicity, staffing mix), and county factors (Medicare Advantage penetration, per capita income, poverty, unemployment, education, 65+ population, and competition). Employee empowerment was associated with a lower number of COVID-19 cases (p < 0.05). Rural, not-for-profit, and payer-mix were also significantly associated with a lower number of COVID-19 deaths. Employee empowerment captures the decentralization of authority and an employee’s ability to make decisions without approval. In light of this crisis, empowerment may have helped under-resourced nursing homes be more agile and faster in their response. High-Medicaid nursing homes may need to consider different decision-making practices when faced with a crisis, such as, COVID-19.

Mapping and Identifying Community Risk Factors for COVID‐19 Nursing Home Deaths

Research ObjectiveAlthough emerging research has identified facility‐level or community‐level risk factors for nursing home COVID‐19 infection cases, little research has been conducted to understand the risk factors for nursing home COVID‐19 death rates. This study has two aims: 1) identify geographic clusters with high nursing home COVID‐19 death rates; 2) understand facility‐level and community‐level risk factors for facilities residing within the hot spots versus those not in the hot spots.Study DesignThis is a cross‐sectional research design. We utilized nursing home COVID data from Centers for Medicare & Medicaid Services (as of November 13th, 2020) linked with Brown University's LTCfocus data and Nursing Home Compare, along with zip code‐level data from American Community Survey. Geospatial hot spot analysis (Getis‐Ord Gi*) was applied to identify statistically significant hot spots of COVID‐19 death rates in nursing homes. We compared facility‐level and community‐level factors associated with COVID death rates by performing multivariate regressions stratified by whether the nursing home was located in the hot spot area identified.Population StudiedThe sample included 15,341 nursing homes.Principal Findings322 zip code areas were identified as having a significantly high level of nursing home COVID death rates at the 95% confidence level. We found statistically significant clustering of COVID‐19 death rates in nursing homes in Northeastern United States (New Jersey, Massachusetts, Connecticut, and New York), South Carolina, Georgia, Florida, Kentucky, and parts of Texas, Mississippi and Louisiana. The hot spot areas tend to be communities with lower household income, higher household sizes, and higher unemployed rates. Regression results indicated common facility‐level risk factors as low total nursing staffing levels, high proportion of Medicaid residents, and low deficiency/quality ratings. Significant zip code‐level factors included household income, average household size, unemployed rate, and proportion of Hispanic residents. However, among nursing homes residing in hot spot zip code areas, total nursing staffing levels (β = −0.04, p < 0.001) and proportion of Medicaid residents (β = 0.03, p < 0.001) had greater effects on death rates.ConclusionsNursing homes located in communities of lower social‐economic status were hit the hardest in terms of having high death rates. Among nursing homes located in hot spot communities, nurse staffing and facility resources (i.e. proportion of Medicaid) play more critical roles in preventing further damage to residents.Implications for Policy or PracticePolicymakers should target resources to nursing homes in the hot spot areas identified, particularly nursing homes with low staffing and high Medicaid census in those areas.

Nursing Home Staffing Levels Did Not Change Significantly During COVID-19.

Prior research and the popular press have anecdotally reported inadequate nursing home staffing levels during the COVID-19 pandemic. Maintaining adequate staffing levels is critical to ensuring high-quality nursing home care and an effective response to the pandemic. We therefore sought to examine nursing home staffing levels during the first nine months of 2020 (compared with the same period in 2019), using auditable daily payroll-based staffing data from the Centers for Medicare and Medicaid Services. We found that the total number of hours of direct care nursing declined in nursing homes during the COVID-19 pandemic, as did the average nursing home census. When we accounted for changes in census, the number of nurse staff hours per resident day remained steady or, if anything, increased slightly during the pandemic. The observed increases in staff hours per resident day were small but concentrated in nursing homes operating in counties with high COVID-19 prevalence, in nursing homes with low Medicaid census (which typically have more financial resources), and in not-for-profit nursing homes (which typically invest more in staffing). These findings raise concerns that although the number of staff hours in nursing homes did not decline, the perception of shortages has been driven by increased stresses and demands on staff time due to the pandemic, which are harder to quantify.

The Impact of Leadership Styles on Quality and Financial Performance in High Medicaid Nursing Homes

This study examines the association between leadership styles on resident quality and financial performance in under resourced nursing homes (70% or higher Medicaid census). The Bonoma/Slevin leadership model was used to classify managers into four categories, autocrat, consultative autocrat, consensus manager, and shareholder manager. Survey data from 391 nursing home directors (response rate of 37%) from 2017- 2018, were merged with secondary data from LTCFocus, Area Health Resource File, Medicare Cost Reports, and Nursing Home Compare. Two models were ran to examine the effect of leadership styles on the dependent variable(s) nursing home STAR data (quality) and operating margin (financial performance). The independent variables were composite scores for leadership styles, with autocrat as the reference group. Control variables included organizational (ownership, chain affiliation, size, occupancy, payer mix, staffing, and race/ethnicity), and county factors (Medicare Advantage penetration, per capita income, poverty, education, unemployment, and competition). Multivariate regression was used to model the relationship between leadership styles and nursing home quality and financial performance. The consultative autocrat was associated with lower quality (p < 0.05), while the consensus manager was associated with lower profit margin (p < 0.05), as compared to autocratic leadership. The consultative autocrat, who solicits information from the staff yet still makes all significant decisions, is associated in lower quality; however, a consensus manager, who delegates their authority to the group, is associated with lower financial performance. Under-resourced nursing homes who face dual pressures need to recognize trade-offs of different decision making styles for quality and financial performance.

Is It What You Have or What You Do With It? Staffing, Human Resource Management, and Knowledge Management Practices

Research in the nursing home industry shows more robust knowledge management activities are associated with the adoption of patient-centered, culture change initiatives among high Medicaid nursing homes. These findings are notable because they highlight the important role that knowledge management activities may play for improving quality of care in under-resourced nursing homes. They also raise important questions about the conditions that may support or hinder the use of these activities. Using survey responses from 393 nursing home administrators, we empirically examined whether two components of human resources – staffing levels and HRM practices – are associated with the level of knowledge management activities in high Medicaid census nursing homes. More robust HRM practices were associated with greater levels of knowledge management activities, as well as three separate domains of knowledge management (acquisition, dissemination, and responsiveness). Staffing levels, in contrast, were not significantly associated with the level of knowledge management activities.

The Relationship of Nursing Home Medicaid Census to Nurses’ Assessments of Care Quality and Work Environment

Medicaid is the largest payer of nursing home (NH) care in the U.S., yet there are long-standing concerns that Medicaid payments are insufficient to cover actual costs of care and contribute to poor care quality. Prior work has shown that low Medicaid reimbursement rates impair administrators’ abilities to employ sufficient nursing staff, but it is unclear how Medicaid funding may contribute to administrators’ abilities to ensure that other elements of safe nursing work environments are in place. In this study, we examined the relationship of nursing home (NH) Medicaid census to nurse ratings of care quality and work environment.

THE IMPACT OF CULTURE CHANGE ON FINANCIAL PERFORMANCE OF HIGH MEDICAID NURSING HOMES

This study examines the association between culture change artifacts and financial performance among under-resourced nursing homes (70% or higher Medicaid census). Culture change represents a transformational process to become person-centered, through staff and resident empowerment. Cultural artifacts represent the physical evidences that culture change is occurring. In this study, we focus on the workplace (nurse staffing consistent assignments) and leadership (residents engagement) artifacts to assess the relationship between culture change practices and performance. Survey data came from 387 nursing home directors from 2016- 2018, merged with secondary data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. The dependent variable consisted of the total profit margin (%), while the independent variables comprised composite scores for leadership (0-25) and workplace artifacts (0-15). Control variables included organizational-level (ownership, chain affiliation, size, occupancy rate, and Medicare and Medicaid payer mix), and county-level factors (Medicare Advantage penetration, per capita income, educational level, unemployment rate, poverty level and competition). Multivariate regression was used to model the relationship between cultural change artifacts and financial performance. Workplace artifacts in nursing homes were found to be associated with significantly higher profit margin (β = 0.30, p < 0.05), while leadership artifacts were not. Culture change practices aimed at improving nursing staff consistent assignments are associated with better financial performance. Given increasing nursing home market competition and declining resources for high Medicaid nursing homes, facilities with a greater emphasis on workplace culture may be able to perform better financially among these under-resourced facilities.

ORGANIZATIONAL AND COMMUNITY FACTORS ASSOCIATED WITH NURSING HOME ORGANIZATIONAL CULTURE

This study examines how organizational and community factors are associated with organizational culture among high Medicaid nursing homes (70% or higher Medicaid census). According to the Competing Values, Framework, there are four types of organizational culture: clan culture (friendly working environment); adhocracy culture (dynamic/creative working environment); market culture (results-based organization); and hierarchy culture (formalized/structured work environment). Survey data from 324 nursing home administrators (30% response rate) from 2017- 2018 were merged with secondary data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. The dependent variable consisted of organizational culture type. The independent variables comprised organizational factors (facility has nurse practitioner/physician assistant (NP/PA), RN/LPN/CNA hours per resident day, RN skill mix, ownership, chain affiliation, size, occupancy rate, and Medicare and Medicaid payer mix) and community factors (Medicare Advantage penetration, per capita income, educational level, unemployment rate, poverty level and competition). Multinomial regression results showed that, compared to facilities with hierarchical cultures, those with a market culture have greater odds of having an NP/PA and higher RN skill mix and LPN intensity, but lower odds for RN intensity, Medicaid payer mix, occupancy rate, and Black residents. Also compared to facilities with hierarchical cultures, those with a clan culture have lower odds for having an NP/PA, beds and occupancy rate, but higher odds of being located in communities with lower unemployment and higher Medicare managed care. In conclusion, different organizational cultures are associated with different staffing patterns, as well as organizational and community factors.

THE RELATIONSHIP BETWEEN ORGANIZATIONAL CULTURE AND FINANCIAL PERFORMANCE AMONG HIGH-MEDICAID NURSING HOMES

This study examines the relationship between organizational culture and financial performance of high Medicaid census (70% or higher) nursing homes (NHs). Based on the Competing Values Framework, there are four types of organizational culture: clan culture (friendly working environment); adhocracy culture (dynamic/creative working environment); market culture (results-based organization); and hierarchy culture (formalized/structured work environment). This study used facility survey data from approximately 324 nursing home administrators (30% response rate) from 2017- 2018, merged with secondary data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. The dependent variable consisted of the operating margin, while the independent variable comprised type of organizational culture. Control variables were organizational (ownership, chain affiliation, size, occupancy rate, and payer mix), and county-level factors (Medicare Advantage penetration, income, education, unemployment rate, poverty, and competition). Multivariable regression was used to model the relationship between organizational culture type and financial performance. Regression results show that compared to a market culture, a hierarchy culture was associated with an 11.8 % lower operating margin, a clan culture with a 10.6% lower operating margin, and a non-dominant culture with 11.4% lower operating margin. Organizational culture is associated with financial performance among high Medicaid facilities, with market cultures outperforming other organizational cultures. Given increasing competition in the nursing home market and declining resources for high Medicaid nursing homes, facilities with a more external orientation and focus on results may be able to perform better financially. Future research should examine the effect of organizational culture on quality of care.

KNOWLEDGE MANAGEMENT AND THE ADOPTION OF CULTURE CHANGE INITIATIVES BY HIGH-MEDICAID-CENSUS NURSING HOMES

Culture change represents an organizational transformational process to become person-centered, through staff and resident empowerment. Culture change initiatives have been associated with fewer health-related deficiency citations and better psychosocial outcomes. Knowledge management, defined as the process of creating or locating knowledge, and managing the dissemination of knowledge within and between organizations, has been shown to be associated with the adoption of innovations such as culture change initiatives. This study examines the relationship between knowledge management activities of high Medicaid census (70% or higher) nursing homes (NHs) and the adoption of culture change initiatives. This study used facility survey data from approximately 324 nursing home administrators (30% response rate) from 2017- 2018, merged with data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. Binary logistic regression models revealed that the probability of adopting a culture change initiative was 0.12 higher for facilities reporting a one-unit higher level of knowledge management activities. Additional interaction analysis revealed that knowledge management activities were associated with a greater likelihood of adopting a culture change initiative for NHs where the director had been in his/her position fewer years. Similarly, higher levels of overall knowledge management activities were significantly associated with greater adoption of culture change initiatives at intermediate levels of nurse retention. Results suggest that knowledge management activities may help high Medicaid NHs acquire and mobilize informational resources in ways that can support the adoption of patient-centered initiatives. These activities may be particularly effective in nursing homes with leadership and nursing staff instability.

Correlates of Administrator Tenure in US Residential Care Communities

ObjectiveTo determine community- and individual-level correlates of administrator tenure in US residential care communities (RCCs). DesignSecondary data analysis of the 2010 National Survey of Residential Care Facilities designed by the National Center for Health Statistics. Analysis was conducted using Tobit regression. Setting and participantsA nationally representative sample of RCCs in the United States (n = 2302). MeasuresThe outcome measure for this study is RCC administrator tenure. Residential care community characteristics include chain ownership, size, occupancy rate, profit status, years of operation, if the building was purposely constructed as an RCC, Medicaid census, presence of a dementia care unit, and whether administrative staff provided care. Administrator characteristics included age, gender, race/ethnicity, and level of education. ResultsOver a quarter of administrators in this sample remained employed with the same RCC for 10 or more years (28%). Chain membership, community size, and presence of a dementia care unit are associated with shorter administrator tenure (P < .001). Communities with greater than 80% occupancy, administrator's age 40+, and Hispanic race/ethnicity were associated with longer administrator tenure (P < .001). Conclusions/ImplicationsVarious community and administrator characteristics are associated with shorter or longer tenure within the same community. More setting-specific research is needed to identify how RCC administrators influence care quality and what different lengths of tenure indicate in the context of RCC operations.

High Medicaid Nursing Homes: Organizational and Market Factors Associated With Financial Performance.

High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower quality and poorer financial performance. However, there is significant variation in performance among high Medicaid nursing homes. The purpose of this study is to examine the organizational and market factors that may be associated with better financial performance among high Medicaid nursing homes. Data sources included Long-Term Care Focus (LTCFocus), Centers for Medicare and Medicaid Services’ (CMS) Medicare Cost Reports, CMS Nursing Home Compare, and the Area Health Resource File (AHRF) for 2009-2015. There were approximately 1108 facilities with high Medicaid per year. The dependent variables are nursing homes operating and total margin. The independent variables included size, chain affiliation, occupancy rate, percent Medicare, market competition, and county socioeconomic status. Control variables included staffing variables, resident quality, for-profit status, acuity index, percent minorities in the facility, percent Medicaid residents, metropolitan area, and Medicare Advantage penetration. Data were analyzed using generalized estimating equations with state and year fixed effects. Results suggest that organizational and market slack resources are associated with performance differentials among high Medicaid nursing homes. Higher financial performing facilities are characterized as having nurse practitioners/physician assistants, more beds, higher occupancy rate, higher Medicare and Medicaid census, and being for-profit and located in less competitive markets. Higher levels of Registered Nurse (RN) skill mix result in lower financial performance in high Medicaid nursing homes. Policy and managerial implications of the study are discussed.

EHR IMPLEMENTATION AMONG NURSING HOMES: IS IT ASSOCIATED WITH BETTER FINANCIAL PERFORMANCE?

While electronic health records (EHR) implementation has the potential to improve quality and financial performance, the rate of EHR adoption is relatively low in nursing homes. This study explores whether EHR implementation is associated with better financial performance, among resource-constrained nursing homes (85% or higher Medicaid census). Survey data on EHR implementation among a national sample of 242 high-Medicaid nursing homes in 2017 was merged with secondary data (LTCFocus, Area Resource File, and Medicare Cost Reports). The dependent variable consisted of the total profit margin (net income/revenues). The independent variable consisted of five categories of EHR functionalities (administrative functions, documentation, order entry, results viewing, and clinical tools) derived from 23 items. Control variables consisted of organizational and market factors. Data were analyzed using multivariable regression with state fixed effects. Results shows a positive relationship between the scope of EHR implementation and total margin (β=3.92, p<0.05). However, only the documentation (β=0.35, p<0.05) and order entry (β=1.26, p<0.05) functionalities were found to have a positive association with financial performance. Documentation provides resident information, such as demographics, problem list, and medication administration and treatment records. Order entry provides resident information on medication orders and other medical orders. These EHR functionalities may be particularly important for coordination of care and in reducing duplication. High Medicaid nursing homes face unique resource challenges, which may affect the degree of EHR implementation. However, despite the initial costs of EHR implementation, it has the potential to reduce costs and ultimately improve financial performance among these resource-constrained nursing homes.

Interaction effect of Medicaid census and nursing home characteristics on quality of psychosocial care for residents

Numerous studies have identified disparities in nursing home quality of care. Although previous studies have found the overlap among Medicaid census, nursing home characteristics, and negative quality of care outcomes, few studies have examined how the psychosocial well-being of nursing home residents is associated with Medicaid census and other nursing home characteristics. The purpose of this study was to elucidate the intertwined relationships between Medicaid census and other important nursing home factors and its impact on psychosocial care for residents. This study examined the interactive effects of (1) nursing home ownership status and Medicaid census, (2) staffing level and Medicaid census, and (3) resident ethnic mix and Medicaid census on psychosocial well-being outcomes. The sample, derived from a combined data set of New York State nursing homes' Online Survey Certification and Reporting System and Minimum Data Set, included 565 nursing homes in rural and urban areas of the state. Medicaid census had no main effect on psychosocial well-being outcomes of nursing home care but had a significant interactive effect with other nursing home characteristics. High Medicaid census was associated with lower level of psychosocial symptom detection in nonprofit nursing homes and nursing homes with a higher proportion of ethnic minority residents. Nursing staff training on better psychosocial well-being care, in particular, better psychosocial assessment, is important. To obtain the training resources, nursing homes with high Medicaid census can collaborate with other nursing homes or social service agencies. Considering that nursing homes with a high proportion of ethnic minority residents have lower level of detection rate for psychosocial well-being issues, culturally competent care should be a component of quality improvement plans.

Provision of Mental Health Services in U.S. Nursing Homes, 1995–2004

Provision of Mental Health Services in U.S. Nursing Homes, 1995–2004

Nursing home performance in resident care in the United States: is it only a matter of for-profit versus not-for-profit?

Poorer resident care in US for-profit relative to not-for-profit nursing homes is usually blamed on the profit motive. But US nursing home performance may relate to Medicaid public financing in a manner qualifying the relationship between ownership and quality. We investigated effects of Medicaid resident census, Medicaid payment, and occupancy on performance. Resource dependence theory implies these predictors may affect discretion in resources invested in resident care across for-profit and not-for-profit facilities. Models on physical restraint use and registered nurse (RN) staffing were studied using generalized estimating equations with panel data derived from certification inspections of nursing homes. Restraint use increased and RN staffing levels decreased among for-profit and not-for-profit facilities when the Medicaid census increased and Medicaid payment decreased. Interaction effects supported a theory that performance relates to available discretion in resource allocation. Effects of occupancy appear contingent on the dependence on Medicaid. Poorer performance among US for-profit nursing homes may relate to for-profit homes having lower occupancy, higher Medicaid census, and operating in US states with lower Medicaid payments compared to not-for-profit homes. Understanding the complexity of factors affecting resources expended on resident care may further our understanding of the production of quality in nursing homes, whether in the US or elsewhere.