Going the Extra Mile? How Provider Network Design Increases Consumer Travel Distance, Particularly for Rural Consumers.

CONTEXT: The practical accessibility to medical care facilitated by health insurance plans depends not just on the number of providers within their networks but also on distances consumers must travel to reach the providers. Long travel distances inconvenience almost all consumers and may substantially reduce choice and access to providers for some. METHODS: The authors assess mean and median travel distances to cardiac surgeons and pediatricians for participants in (1) plans offered through Covered California, (2) comparable commercial plans, and (3) unrestricted open-network plans. The authors repeat the analysis for higher-quality providers. FINDINGS: The authors find that in all areas, but especially in rural areas, Covered California plan subscribers must travel longer than subscribers in the comparable commercial plan; subscribers to either plan must travel substantially longer than consumers in open networks. Analysis of access to higher-quality providers show somewhat larger travel distances. Differences between ACA and commercial plans are generally substantively small. CONCLUSIONS: While network design adds travel distance for all consumers, this may be particularly challenging for transportation-disadvantaged populations. As distance is relevant to both health outcomes and the cost of obtaining care, this analysis provides the basis for more appropriate measures of network adequacy than those currently in use.

Net Benefits of Recovery High Schools: Higher Cost but Increased Sobriety and Educational Attainment.

BACKGROUND: Recovery high schools (RHS) provide a supportive educational and therapeutic environment for students subsequent to treatment for substance use disorders (SUDs). Most students served by RHSs have concurrent mental health disorders and are at risk for school failure or dropout and substance use relapse. AIMS OF THE STUDY: The central question addressed is whether RHSs are economically efficient alternatives to other high school settings for students in recovery. The aim is to estimate the incremental cost-benefit of RHSs. METHODS: A quasi-experimental non-equivalent pretest-posttest comparison group design was used. We compared substance use and educational outcomes for adolescents who had received specialty SUD treatment; 143 who enrolled in an RHS were compared to 117 who enrolled in a non-RHS school. Groups were balanced by use of a propensity score to drop students who were not similar to those in the other group. The propensity score was also used as a covariate in multiple regression to estimate cost and outcome parameters and standard errors. To take account of uncertainties in impacts and shadow prices, we used Monte Carlo simulations to estimate the distribution of incremental benefits of RHS relative to non-RHS schooling. RESULTS: Two beneficial impacts of statistical and substantive importance were identified: increased probability of high school graduation and increased sobriety. RHS students had significantly (p<.05) less substance use during the study period -- at 12-month follow-up, 55% of RHS and 26% of comparison students reported 3 month abstinence from alcohol and drugs. Urinalysis confirmed abstinence from THC (cannabis) for 68% of RHS versus 37% of comparison students. RHS students' high school graduation rates were 21 to 25 percentage points higher than comparison students. Adopting a societal perspective, incremental benefits of RHSs were estimated by monetizing the increased probability of high school graduation and comparing it to incremental costs. Mean net benefits ranged from USD16.1 thousand to USD51.9 thousand per participant; benefit-to-cost ratios ranged from 3.0 to 7.2. DISCUSSION: Monetizing the benefits and the incremental costs of RHS relative to conventional schooling show substantial positive net benefits from RHS participation. Two factors lend credibility to the results. First, the RHS improvement in substance use indicates a mechanism through which the increased probability of high school graduation can plausibly occur. Second, the estimated increases in the probability of high school graduation were large and statistically significant. As the productivity gains from high school graduation are also large, the dominant benefit category is very plausible. Limitations include the non-randomized design; selection bias into the study conditions not fully controlled by the propensity scores; generalizability only to young people with treated behavioral health disorders; lack of estimates for direct monetization of reduced substance use among adolescents; possible attenuation of the value of education among individuals with behavioral health issues; and uncertainty in calculation of school costs. IMPLICATIONS FOR BEHAVIORAL HEALTH POLICIES: This research provides evidence that the recovery high school model provides cost beneficial support for high school students after primary SUD treatment. The students who enroll in RHSs typically have co-occurring mental health and substance use disorders, adding complexity to their continuing care. Funding policies recognizing the multiple systems of care (behavioral health, education, child and family services, juvenile justice) responsible for these young people are called for.

A Knotty Problem: Consumer Access and the Regulation of Provider Networks.

In order to increase access to medical services, expanding coverage has long been the preferred solution of policy makers and advocates alike. The calculus appeared straightforward: provide individuals with insurance, and they will be able to see a provider when needed. However, this line of thinking overlooks a crucial intermediary step: provider networks. As provider networks offered by health insurers link available medical services to insurance coverage, their breadth mediates access to health care. Yet the regulation of provider networks is technically, logistically, and normatively complex. What does network regulation currently look like and what should it look like in the future? We take inventory of the ways private and public entities regulate provider networks. Variation across insurance programs and products is truly remarkable, not grounded in empirical justification, and at times inherently absurd. We argue that regulators should be pragmatic and focus on plausible policy levers. These include assuring network accuracy, transparency for consumers, and consumer protections from grievous inadequacies. Ultimately, government regulation provides an important foundation for ensuring minimum levels of access and providing consumers with meaningful information. Yet, information is only truly empowering if consumers can exercise at least some choice in balancing costs, access, and quality.

Examination of the New Short-Stay Nursing Home Quality Measures: Rehospitalizations, Emergency Department Visits, and Successful Returns to the Community.

In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced 3 new quality measures (QMs) to its report card, Nursing Home Compare (NHC). These measures-rehospitalizations, emergency department visits, and successful discharges to the community-focus on short-stay residents. We offer a first analysis of nursing homes' performance in terms of these new measures. We examined their properties and distribution across nursing homes using descriptive statistics and regression models. We found that, similar to other QMs, performance varies across the country, and that there is very minimal correlation between these 3 new QMs as well as between these QMs and other NHC QMs. Regression models reveal that better performance on these QMs tends to be associated with fewer deficiencies, higher staffing and more skilled staffing, nonprofit ownership, and lower proportion of Medicaid residents. Other characteristics are associated with better performance for some but not all 3 QMs. We also found improvement in all 3 QMs in the second year of publication. This study contributes to the validity of these measures by demonstrating their relationship to these structural QMs. It also suggests that these QMs are important by demonstrating their large variation across the country, suggesting substantial room for improvement, and finding that nursing homes are already responding to the incentives created by publication of these QMs.

The Thin Reed: Accommodating Weak Evidence for Critical Parameters in Cost-Benefit Analysis.

Policy analysis often demands quantitative prediction-especially cost-benefit analysis, which requires the comprehensive quantification and monetization of all valued impacts. Using parameter estimates and their precisions, analysts can apply Monte Carlo simulation to create distributions of net benefits that convey the levels of certainty about the fundamental question of interest: Will net benefits be positive if the policy is adopted? An inappropriate focus on hypothesis testing of parameters rather than prediction sometimes leads analysts to treat statistically insignificant coefficients as if they, and their standard errors, are zero. One alternative method is to use all estimates and their standard errors whether or not the estimates are statistically significant. Another alternative is to use all estimates but to shrink them toward zero and adjust their standard errors in an effort to guard against regression to the mean. Comparing the three methods (only use statistically significant estimates and their standard errors, use all estimates and their standard errors, use shrunk estimates and adjusted standard errors) in Monte Carlo simulation suggests that treating statistically insignificant coefficients as zero rarely minimizes the mean squared error of prediction. Using shrunk estimates appears to provide a more robust minimization of the mean squared error of prediction. The simulations presented here suggest that routinely shrinking estimates is a robust approach if one believes that there is a substantial probability that the true value of the parameter is near zero.

You Can't Make Me Do It, but I Could Be Persuaded: A Federalism Perspective on the Affordable Care Act.

The Affordable Care Act (ACA) seeks to change fundamentally the US health care system. The responses of states have been diverse and changing. What explains these diverse and dynamic responses? We examine the decision making of states concerning the creation of Pre-existing Condition Insurance Plan programs and insurance marketplaces and the expansion of Medicaid in historical context. This frames our analysis and its implications for future health reform in broader perspective by identifying a number of characteristics of state-federal grants programs: (1) slow and uneven implementation; (2) wide variation across states; (3) accommodation by the federal government; (4) ideological conflict; (5) state response to incentives; (6) incomplete take-up rates of eligible individuals; and (7) programs as stepping-stones and wedges. Assessing the implementation of the three main components of the ACA, we find that partisanship exerts significant influence, yet less so in the case of Medicaid expansion. Moreover, factors specific to the insurance market also play an important role. Finally, we conclude by applying the themes to the ACA and offer an outlook for its continuing implementation. Specifically, we expect a gradual move toward universal state participation in the ACA, especially with respect to Medicaid expansion.

Top-down and bottom-up approaches to health care quality: the impacts of regulation and report cards.

The high cost of the US health care system does not buy uniformly high quality of care. Concern about low quality has prompted two major types of public policy responses: regulation, a top-down approach, and report cards, a bottom-up approach. Each can result in either functional provider responses, which increase quality, or dysfunctional responses, which may lower quality. What do we know about the impacts of these two policy approaches to quality? To answer this question, we review the extant literature on regulation and report cards. We find evidence of both functional and dysfunctional effects. In addition, we identify the areas in which additional research would most likely be valuable.

Who Visits Relatives in Nursing Homes? Predictors of at Least Weekly Visiting.

OBJECTIVES: Within the context of a single study, assess the relative importance of the 6 factors identified in a 2019 systematic review as associated with the likelihood that family members will visit nursing home residents. DESIGN: Retrospective statistical analysis of an existing survey data set. SETTINGS AND PARTICIPANTS: A national survey conducted with 4350 relatives of long-term nursing home residents. METHODS: Probit models of the probability of visiting a family member at least once weekly, stratified by age of the visitor, were estimated. To account for possible endogeneity of respondent involvement in the choice of nursing home and visit rate, visit rates were estimated using 2-stage residual inclusion in which the first stage explained involvement in nursing home choice. RESULTS: Involvement in nursing home choice has a substantively and statistically significant positive effect on visit probability for all age groups of respondents. Travel time has a substantively and statistically significant negative association on visit probability for all age groups. Younger women are more likely to visit than younger men. For all but the oldest respondents, higher income and full-time employment contribute to involvement in nursing home choice as does being Black or Hispanic. CONCLUSIONS AND IMPLICATIONS: As in previous research, travel time is an important determinant of visit rates. The strong association of involvement in nursing home choice with visit probability suggests a strong psychological motivation for visiting. To improve visiting, future research should focus on better understanding of the psychological factors that are associated with it and rely on better data and improved statistical methods. Our findings also suggest that nursing home administrators should consider adopting initiatives to facilitate and empower family members' involvement in nursing home choice, which in turn may lead to increased visitations.

Does state regulation of quality impose costs on nursing homes?

BACKGROUND: Government regulation is intended to enhance quality, safety, fairness, or competition in the regulated industry. Such regulation entails both direct and indirect costs. OBJECTIVES: To estimate the costs associated with the regulation of quality of the nursing home industry. SAMPLE: This study includes 11,168 free-standing nursing homes nationally, between 2004 and 2006. RESEARCH DESIGN: Data included information from the Medicare cost reports, Minimum Data Set, Medicare Denominator file, OSCAR, and a survey of States' Certification and Licensing Offices conducted by the authors. These data were used to create variables measuring nursing homes costs, outputs, wages, competition, adjusted deficiency citations, ownership, state-fixed effects, and an index of each state's regulatory stringency. We estimated hybrid cost functions which included the regulatory stringency index. RESULTS: The estimated cost functions demonstrated the typical behavior expected of nursing home cost functions. The stringency index was positively and significantly associated with costs, indicating that nursing homes located in states with more stringent regulatory requirements face higher costs, ceteris paribus. The average incremental costs of a 1 standard deviation increase in the stringency index resulted in a 1.1% increase in costs. CONCLUSIONS: This study for the first time places a price tag on the regulation of quality in nursing homes. It offers an order of magnitude on the costs to the industry of complying with the current set of standards and given the current level of enforcement. Complementary studies of the benefits that these regulations entail are needed to gain a comprehensive assessment of the effect of the regulation.

Addressing the shortage of kidneys for transplantation: purchase and allocation through chain auctions.

Transplantation is generally the treatment of choice for those suffering from kidney failure. Not only does transplantation offer improved quality of life and increased longevity relative to dialysis, it also reduces end-stage renal disease program expenditures, providing savings to Medicare. Unfortunately, the waiting list for kidney transplants is long, growing, and unlikely to be substantially reduced by increases in the recovery of cadaveric kidneys. Another approach is to obtain more kidneys through payment to living "donors," or vendors. Such direct commodification, in which a price is placed on kidneys, has generally been opposed by medical ethicists. Much of the ethical debate, however, has been in terms of commodification through market exchange. Recognizing that there are different ethical concerns associated with the purchase of kidneys and their allocation, it is possible to design a variety of institutional arrangements for the commodification of kidneys that pose different sets of ethical concerns. We specify three such alternatives in detail sufficient to allow an assessment of their likely consequences and we compare these alternatives to current policy in terms of the desirable goals of promoting human dignity, equity, efficiency, and fiscal advantage. This policy analysis leads us to recommend that kidneys be purchased at administered prices by a nonprofit organization and allocated to the transplant centers that can organize the longest chains of transplants involving willing-but-incompatible donor-patient dyads.

Families' and Residents' Perspectives of the Quality of Nursing Home Care: Implications for Composite Quality Measures.

OBJECTIVES: To assess (1) the relationship of consumers' assessment of overall nursing home quality to their assessment of specific dimensions of quality; and (2) the implications of this relationship for composite quality measures in Nursing Home Compare. DESIGN: A survey conducted in 2017 elicited respondents' assessments of the quality of overall care and 13 specific dimensions of care. SETTINGS AND PARTICIPANTS: The sample consisted of 4449 respondents who either resided in a nursing home or had a family member who resided in a nursing home during the 6 months before the survey. METHODS: We estimated regression models to infer the relationship between consumers' assessments of overall quality and 13 specific dimensions of quality. The regression coefficients, indicating the implicit importance/weight assigned by respondents to each dimension as a component of the consumers' assessment of overall quality, were used to create a prototype composite quality measure. RESULTS: For long-stay residents, 8 of the 13 quality dimensions were significantly associated with their overall ratings of quality. Five dimensions achieved significance for short-stay residents. The magnitude of importance weights varied substantially across dimensions of care. CONCLUSIONS AND IMPLICATIONS: Our findings suggest that Nursing Home Compare could be improved by augmenting the technical information in the 5-Star composite measure with consumers' assessments of the additional, nontechnical dimensions of quality.

Changes in clinical and hotel expenditures following publication of the nursing home compare report card.

BACKGROUND: Nursing Home Compare first published clinical quality measures at the end of 2002. It is a quality report card that for the first time offers consumers easily accessible information about the clinical quality of nursing homes. It led to changes in consumers' demand, increasing the relative importance of clinical versus hotel aspects of quality in their search and choice of a nursing home. OBJECTIVES: To examine the hypothesis that nursing homes responding to these changes in demand shifted the balance of resources from hotel to clinical activities. SUBJECTS: The study included 10,022 free-standing nursing homes nationwide during 2001 to 2006. RESEARCH DESIGN AND DATA: A retrospective multivariate statistical analysis of trends in the ratio of clinical to hotel expenditures, using Medicare cost reports, Minimum Data Set and Online Survey, Certification and Reporting data, controlling for changes in residents' acuity and facility fixed effects. Inference is based on robust standard errors. RESULTS: The ratio of clinical to hotel expenditures averaged 1.78. It increased significantly (P < 0.001) by 5% following the publication of the report card. The increase was larger and more significant among nursing homes with worse reported quality, lower occupancy, those located in more competitive markets, for-profit ownership and owned by a chain. CONCLUSIONS: The increase in the ratio of clinical to hotel expenditures following publication of the report card suggests that nursing homes responded as expected to the changes in the elasticity of demand with respect to clinical quality brought about by the public reporting of clinical quality measures. The response was stronger among nursing homes facing stronger incentives.

Factors influencing nursing home response to quality measure publication: A resource dependence perspective.

BACKGROUND: The Centers for Medicare and Medicaid Services provides a report card on nursing homes at a Web site called Nursing Home Compare (NHC) that includes information on 19 clinical quality measures (QMs). The information is intended to inform consumer choice, to provide a focus for state regulatory initiatives, and to promote nursing home quality improvement efforts. PURPOSE: This study aimed to determine what factors were associated with nursing homes' investment in quality after publication of the NHC report card. METHODOLOGY: A 2007 survey sent to nursing home administrators nationally inquired about their response to publication of QMs on NHC. Survey data were merged with data on QMs and organizational characteristics from NHC. The dependent variables represent actions requiring a significant investment of resources in staffing and/or equipment. Independent variables tested hypotheses regarding the influence of constituent groups, competition, and managed care participation on investment. We estimated logistic regression models adjusting for clustering within states. FINDINGS: The degree to which nursing homes perceive that the report card influences key constituencies (professional referral sources, consumers, and state surveyors) is associated with the odds of committing substantial resources to improve report card performance. Facilities with lower reported QM scores were three times more likely to make certain investments than high-quality facilities in competitive markets. Perceived QM validity and close monitoring of scores also motivates investment. PRACTICE IMPLICATIONS: A substantial proportion of nursing homes now perceive that the report card influences professional referrals, consumer choice, and state survey investigatory process. This suggests that QM publication may indeed have a competitive impact as it concerns these constituencies, thus increasing the stakes in improving the scores and making substantial investments much more likely.

Comparison of Consumer Rankings With Centers for Medicare & Medicaid Services Five-Star Rankings of Nursing Homes.

Importance: The Centers for Medicare & Medicaid Services (CMS) Five-Star measure for nursing homes is designed with input from expert panels about the importance of multiple quality indicators. Consumers may assign different values to these indicators, creating different 5-star ratings. Objective: To compare nursing homes' rankings based on the CMS Five-Star measure with rankings based on consumers' judgment about the importance of the same quality indicators. Design, Setting, and Participants: In this quality improvement study, CMS Five-Star data were linked with a measure calculated from CMS quality indicators and consumer values obtained from a national survey. Data covered the last quarter of 2016 and the first three quarters of 2017. The study included 10 676 nursing homes, comprising 69.8% of those with reported Five-Star measures. The national survey included adults, either nursing home residents or their family members who reported being familiar with the quality of care their relative received. Data analysis was performed from January 2019 to February 2020. Main Outcomes and Measures: The contingent valuation method was administered via the survey to obtain consumers' relative values of the quality indicators, and statistical analyses were used to create the contingent valuation measure. Agreement in nursing home rankings was assessed using the Five-Star measure, which is based on weights developed by expert panels, compared with rankings based on the contingent valuation measure. Results: Among 10 676 study nursing homes with a mean (SD) of 119.4 (59.4) beds, 7845 (73.5%) were for profit, 6424 (61.8%) were part of a chain, and 8009 (75.0%) were urban. The 4310 survey respondents (mean [SD] age, 39.9 [15.6] years; 1143 [26.5%] men; 3448 [80%] white) included mostly family members (3879 participants [90.0%]). The Pearson correlation coefficient (0.65) and weighted κ statistics (0.48) indicated only moderate agreement between ranking of nursing homes' performance by the 2 measures and disagreement on ranking for approximately one-half of the nursing homes. Conclusions and Relevance: Current nursing home report cards might not reflect consumers' values and the relative importance consumers place on each of the quality indicators that compose the overall Five-Star measure. Quality report cards might be more relevant to consumers by augmenting the Five-Star measure with a measure reflecting consumers' preferences. It is unknown whether these conclusions are generalizable to other report cards, such as Hospital and Home Health Compare, without conducting similar studies for these report cards.

Early identification and treatment of Alzheimer's disease: social and fiscal outcomes.

BACKGROUND: Alzheimer's disease (AD) is a progressive neurodegenerative disease that places substantial burdens on those who provide support for family members with declining cognitive and functional abilities. Many AD patients eventually require formal long-term care services because of the absence, exhaustion, or inability of family members to provide care. The costs of long-term care, and especially nursing home care, often deplete private financial resources, placing a substantial burden on state Medicaid programs. Current evidence suggests that pharmacological treatments and caregiver interventions can delay entry into nursing homes and potentially reduce Medicaid costs. However, these cost savings are not being realized because many patients with AD are either not diagnosed or diagnosed at late stages of the disease, and have no access to Medicare-funded caregiver support programs. METHODS AND RESULTS: A Monte Carlo cost-benefit analysis, based on estimates of parameters available in the medical literature, suggests that the early identification and treatment of AD have the potential to result in large, positive net social benefits as well as positive net savings for states and the federal government. CONCLUSIONS: These findings indicate that the early diagnosis and treatment of AD are not only socially desirable in terms of increasing economic efficiency, but also fiscally attractive from both state and federal perspectives. These findings also suggest that failure to fund effective caregiver interventions may be fiscally unsound.

Using contingent valuation to develop consumer-based weights for health quality report cards.

OBJECTIVE: The current 5-Star composite measure for nursing homes uses expert-driven weights to combine elements of quality into a single score. We assessed the feasibility of using the contingent valuation method (CVM) to derive consumers' preference-based weights for the Nursing Home Compare report card as a potential alternative approach. DATA SOURCES: Survey of 4310 adults with nursing home experience (residents or family members of a resident) administered between September 25 and October 9, 2017. STUDY DESIGN: Contingent valuation method based on respondents' answers to questions about willingness-to-trade (WTT) visit travel time for better quality in seven quantitative indices included in Nursing Home Compare. We calculated WTT amounts per standard deviation change in quantitative indices to derive weights. DATA COLLECTION METHODS: Web-based survey. PRINCIPAL FINDINGS: Contingent valuation method results are consistent with respondents making economically rational trade-offs between quality and travel time. Estimates of mean WTT vary across quantitative quality indices. They also vary in terms of respondent status and behavioral factors. Weights based on mean WTT per standard deviation vary substantially across indices, with the largest weights for inspections and staffing. CONCLUSIONS: Contingent valuation method has promise as a method for deriving weights for use in summary measures that incorporate consumer preferences.

Strategic orientation and nursing home response to public reporting of quality measures: an application of the miles and snow typology.

OBJECTIVE: To assess whether differences in strategic orientation of nursing homes as identified by the Miles and Snow typology are associated with differences in their response to the publication of quality measures on the Nursing Home Compare website. DATA SOURCES: Administrator survey of a national 10 percent random sample (1,502 nursing homes) of all facilities included in the first publication of the Nursing Home Compare report conducted in May-June 2004; 724 responded, yielding a response rate of 48.2 percent. STUDY DESIGN: The dependent variables are dichotomous, indicating whether or not action was taken and the type of action taken. Four indicator variables were created for each of the four strategic types: Defender, Analyzer, Prospector, and Reactor. Other variables were included in the seven logistic regression models to control for factors other than strategic type that could influence nursing home response to public disclosure of their quality of care. DATA COLLECTION/EXTRACTION METHODS: Survey data were merged with data on quality measures and organizational characteristics from the first report (November 2002). PRINCIPAL FINDINGS: About 43 percent of surveyed administrators self-typed as Defenders, followed by Analyzers (33 percent), and Prospectors (19 percent). The least self-selected strategic type was the Reactor (6.6 percent). In general, results of the regression models indicate differences in response to quality measure publication by strategic type, with Prospectors and Analyzers more likely, and Reactors less likely, to respond than Defenders. CONCLUSIONS: While almost a third of administrators took no action at all, our results indicate that whether, when, and how nursing homes reacted to publication of federally reported quality measures is associated with strategic orientation.

Hospital Discharge and Selecting a Skilled Nursing Facility: A Comparison of Experiences and Perspectives of Patients and Their Families.

PURPOSE OF STUDY: A currently proposed rule by the Centers for Medicare & Medicaid Services would require providers to devote more resources to discharge planning from hospitals to ensure the prioritization of patient preferences and goals in the discharge planning process. Annually, more than 3 million persons enter a nursing home in the United States, with the vast majority of patients coming directly from hospitals. Although early evidence suggests more family involvement than patient involvement in the discharge process, most of this work has relied on retrospective reports of the decision-making process postplacement. This article seeks to examine and compare the experiences and perspectives of patients and others involved in the selection of the nursing home (predominately adult children and spouses). PRIMARY PRACTICE SETTING: Large academic medical hospital with patients being discharged to a skilled nursing facility. METHODOLOGY AND SAMPLE: A total of 225 patients or their family members and involved others who completed an exit survey assessing their experiences and perspectives in selecting a skilled nursing home and in experiencing the discharge process more generally. RESULTS: Patients were the primary decision makers about 23% of the time but were often involved in the decision even when family members/involved others were primarily making decisions in the discharge process. Although patients were involved in the selection of the nursing home to a lesser degree than involved others, their level of satisfaction with the decision to be discharged to a skilled nursing home and their level of satisfaction with their personal level of involvement with the selection of the specific nursing home did not differ from the satisfaction ratings of the involved others. Furthermore, their confidence in the decision and their satisfaction with the decision did not differ from ratings provided by family members/involved others. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Recommendations for case management practice include (1) encouraging patients and their families to take an active role in the discharge process; (2) incorporating technology into the discharge process that promotes this active level of engagement; and (3) facilitating access to data to promote discharge to the highest quality nursing homes available.