It Is Not Your Parents' Long-Term Services System: Nursing Homes in a Changing World.

The long-term services system has changed substantially since the mid-1970s, when the landmark book Last Home for the Aged argued that the move to the nursing home was the last move an older person would make until death. Using detailed nursing home utilization data from the Minimum Data Set, this study tracks three cohorts of first-time nursing home admissions in Ohio from 1994 through 2014. Each cohort was followed for a 3-year period. Study results report dramatic reductions in nursing home length of stay between the 1994 and 2011 cohorts. Reduction in length of stay has important implications for nursing home practice and quality monitoring. The article argues that administrative and regulatory practices have not kept pace with the dramatic changes in how nursing homes are now being used in the long-term services system.

Is There a Woodwork Effect? Addressing a 200-Year Debate on the Impacts of Expanding Community-Based Services.

In U.S. social welfare history, many have suggested that if benefits were too attractive, consumers would come out of the woodwork to take advantage of the opportunity. Clinical trials have provided evidence of the woodwork effect's existence, suggesting caution when expanding home- and community-based services (HCBS). However, it is unclear whether these studies are best suited to assess whether a system-level effect occurs. Using state and federal data tracking Ohio's long-term services and support (LTSS) system from 1995 to 2015, this paper examines changes in the utilization rates and expenditures of Medicaid LTSS to explore whether a woodwork effect occurred as Ohio moved to improve its LTSS system balance (80% Nursing Home [NH], 20% HCBS) to (49% Nursing Home [NH], 51% HCBS). After accounting for population growth of individuals older than 60 and those with two or more impairments in activities of daily living, there was no change in utilization rates of older people with severe disability (1995: 491 per 1000 population, 2015: 495 per 1000 population) or overall LTSS expenditures (1997: $2.7 million [in 2013 dollars], 2013: $2.9 million). Our results suggest that states can make significant strides in HCBS expansion without increasing the overall long-term services utilization rate.

Functional Status and Adaptation: Measuring Activities of Daily Living and Device Use in the National Health and Aging Trends Study.

OBJECTIVE: The objective of this study is to evaluate the functional status and adaptation of older Americans and discover the factors that contribute to device use. METHOD: Using the community participants' portion of the first round of National Health and Aging Trends Study (NHATS), we demonstrate the prevalence of device use and reduction in activities, creating a multilevel measure of activities of daily living (ADL) functionality as compared with Katz's dichotomous measure. In determining whether adaptation is universal irrespective of age, sex, race, living arrangement, and income, or dependent on these variables, we create a measure of device use, performing a path analysis of the device use measure and sociodemographic variables, with disability score as an intervening measure. RESULTS: ADL functionality becomes more nuanced between the Katz-ADL and NHATS-ADL. Age, sex, and living arrangement were predictors of device use; income was indirectly, whereas race was not. DISCUSSION: When assessors design service plans, consideration should be given to older adults' ability, capacity, and resources to adapt.

Worker injuries and safety equipment in Ohio nursing homes.

A survey of Ohio nursing homes was conducted in 2007 to examine whether injury rates were related to facility characteristics and availability of safety equipment. The median rate of injury in the 898 facilities was 5.7 injuries per 100 workers per year. Although 95% of the facilities had written resident lift-ing policies, only 22% of these were zero-lift policies. Gait transfer belts(99%) and portable total-lift hoists(96%) were common, whereas ceiling-mounted total-lift hoists were rarely reported (7%). In a multivariable analysis, injury rate ratios increased with the proportion of residents using wheel-chairs and were lower in smaller facilities. Facilities without a lifting policy had a higher estimated injury rate than facilities without such a policy; however, none of the safety equipment was associated with significant changes in injury rates. More information, such as frequency of use and access to ver-sus availability of equipment, may be needed to better understand the im-pact of safety equipment on nursing home worker injury rates.

Fall risk factors in community-dwelling elderly who receive Medicaid-supported home- and community-based care services.

OBJECTIVE: This study identifies fall risk factors in an understudied population of older people who receive community-based care services. METHOD: Data were collected from enrollees of Ohio's Medicaid home- and community-based waiver program (preadmission screening system providing options and resources today [PASSPORT]). A total of 23,182 participants receiving PASSPORT services in 2005/2006 was classified as fallers and nonfallers, and a variety of risk factors for falling was analyzed using logistic regressions. RESULTS: The following factors were identified as risk factors for falling: previous fall history, older age, White race, incontinence, higher number of medications, fewer numbers of activity of daily living limitations, unsteady gait, tremor, grasping strength, and absence of supervision. DISCUSSION: Identifying risk factors for the participants of a Medicaid home- and community-based waiver program are useful for a fall risk assessment, but it would be most helpful if the community-based care service programs incorporate measurements of known fall risk factors into their regular data collection, if not already included.

The changing world of long-term care: a state perspective.

Based on data from an eight year longitudinal study of Ohio's long-term care use patterns, this paper describes the changes now being experienced by this industry. Although Ohio has been a state with a heavy reliance on institutional services, the data suggest a change in how long-term care is provided in the state. Over the past eight years, despite an increasing disabled older population, nursing home occupancy rates have fallen from 92.5% to 83.5%. At the same time, in-home service and assisted living use has increased. The paper concludes by describing how such changes are likely to impact the system of the future.

Health and long-term care use trajectories of older disabled women.

PURPOSE: I examined health and long-term care use trajectories of a sample of chronically disabled older women eligible for both Medicare and Medicaid by exploring their use data in order to understand and anticipate the increasing demand on the health and long-term care delivery systems as aging female baby boomers reach age 65 and older. DESIGN AND METHODS: A sample of older disabled women in Ohio who completed preadmission review was divided into three groups on the basis of the setting in which they received their initial long-term care services. RESULTS: I was able to establish a long-term care career for the sample members beginning with receiving long-term care in the community, followed by a transition stage in which care was received in the community and in a nursing home, and finally by a stage at which they entered and remained in a nursing home. As the sample members proceeded along their long-term care career and their health and disability status worsened, I found a clear shift in the kind of care needed from hospital and home care to nursing home care. There was also a shift in the major payer, from Medicare to Medicaid. IMPLICATIONS: As the baby boomers age, a much larger number of women will be disabled and need health and long-term care services. For a considerable number of these women, Medicaid gradually becomes the major payer for care, an issue that needs close observation.

Using high-intensity care management to integrate acute and long-term care services: substitute for large scale system reform?

This study evaluates a demonstration that used high intensity care management to improve integration between the acute and long-term care service systems. The demonstration intervention included the use of clinical nurse care manager, supervised by a geriatrician, to supplement an existing in-home care management system. Chronically disabled home care clients age 60 and over were randomly assigned (N = 308) to receive enhanced clinical services plus traditional care management, or to the control group, to receive the normal care management services provided. Treatment group members were expected to experience lower use of hospitals and nursing homes and lower overall health and long-term care costs. Research subjects were followed for up to 18 months using Medicare records and mortality data. A subsample (N = 150) also received in-person interviews to cover a range of health and social outcomes anticipated as a result of the intervention. Although there was some variation in health use and cost across treatment and control groups over the 18 month time period, the overall conclusion is that there were no differences between groups on any of the outcome variables examined. Efforts to integrate the acute and long-term care systems have proven to be difficult. This intervention, which attempted to create integration through high intensity care managers, but without financial or regulatory incentives, was simply unable to create enough change in the care system to produce significant change for the clients served.