Federal Regulations Led To Better Elder Care, Lower Hospitalization Rate

August 04, 1997

PROVIDENCE, R.I.--A new study indicates that Congressionally mandated regulation of the nursing home industry, designed to improve assessment of patient health, led to a 28-percent reduction in the rate of hospitalization among the frailest nursing home residents, with no increase in death rate.

"This is a case of industry regulation that did some good," said Vincent Mor, one of the leaders of the federally funded study. Mor directs the Center for Gerontology and Health Care Research at Brown University. "The quality of care for old sick folks living in nursing homes seems to have improved, and money was saved because hospitalizations were reduced."

The study suggests that hospitalizing frail, elderly nursing home residents is not always best. "Not going to the hospital didn't deny nursing home residents care," Mor said. "In fact, care improved, because the nursing home staff had a better idea of what was wrong with the residents."

The study, which appears in the current issue of the Journal of the American Geriatrics Society, examines the rates of hospitalization over a six-month period among nursing home residents in 1990 and in 1993, after the federally mandated Resident Assessment Instrument (RAI) was implemented. The RAI is a focused form of patient documentation designed to improve monitoring and care-planning.

A research team analyzed 1990 data from a sample of 2,118 nursing home residents in 268 facilities in 10 states and 1993 data from 2,078 occupants in 254 of the same sites.

The hospitalization rate for a six-month period dropped 28 percent in 1993 compared to 1990. The biggest reductions in hospital use occurred among nursing home residents whose cognitive abilities remained fairly stable. Finally, the likelihood of hospitalization fell more rapidly from 1990 to 1993 among those who eventually died than among survivors.

The results suggest that the RAI made it possible to target better hospital use, reducing admissions among those with the least likelihood of benefiting from them, including the severely impaired, terminally ill and those who may not have needed to be admitted.

Mor thinks managed-care companies will take note of the findings. "If you run a managed-care firm and some of your subscribers go to nursing homes, you will want them in facilities that can make proper decisions about hospitalizations, because the right decisions will save you money without compromising the quality of care."

In the study, researchers found that hospitalizations were less prevalent even after adjusting for a 60-percent increase in do-not-resuscitate orders that occurred after the federal Patient Self-Determination Act (PSDA) took effect, about the same time as the RAI. The PSDA requires health care facilities to tell patients of their right to have an advanced directive, or living will and led to an explosion of do-not-resuscitate orders, influencing hospitalizations. However, researchers found that the hospital use rate still dropped from 20.1 percent to 13.5 percent among the most sickly nursing home residents, independent of the effect of the increased number of do-not-resuscitate orders.

The study is one of a series of articles in the current issue of the Journal of the American Geriatrics Society on the impact of the RAI. Co-authors of the article are Orna Intrator, The Hebrew University of Jerusalem; Brant E. Fries, University of Michigan; Charles Phillips, Meyer Research; Joan Teno, M.D., George Washington Medical Center; Jeffrey Hiris, Brown University; Catherine Hawes, Research Triangle Institute; and John Morris, Hebrew Rehabilitation Center for the Aged.

Brown University

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