Waiting times for nursing-home placement: the impact of ... - NCBI

Waiting times for nursing-home placement: the impact of patients' choices Evelyn Shapiro, MA; Robert B. Tate, MSc; Ellen Tabisz, MSW Objective: To identify patient characteristics and characteristics of long-term care facilities that significantly affect the waiting time for transfer from hospital to nursing home. Design: Cohort study. Participants: All patients designated to be transferred from four Winnipeg hospitals between June 1, 1988, and May 31, 1989. The patients were followed up until placement, death or May 31, 1990. Main outcome measure: Length of time waiting for nursing-home placement and relative rates of placement. Results: The variable found to shorten the waiting time the most was the patient's choice of a for-profit or nonprofit secular facility; other sinificant variables were male sex, age of 75 to 84 years and occupancy of an acute care bed during the wait. Conclusion: The province has three policy options: it can increase the proportion of secular nursing-home beds when new facilities are built; it can require that hospital patients accept an interim nursing-home placement pending transfer to the nursing home of their choice; or it can tie the sponsorship of new facilities to a formula based on the ethnoreligious distribution of the population currently aged 55 to 64 years.

Objectif: Identifier les caracteristiques des patients et des etablissements de soins prolonges qui ont un effet significatif sur la periode d'attente pour un transfert de l'h6pital a un foyer pour personnes agees. Conception: Etude de cohortes. Participants: Tous les patients designes pour un transfert a partir de quatre hopitaux de Winnipeg entre le ler juin 1988 et le 31 mai 1989. Les patients ont ete suivis jusqu'a leur placement, leur deces ou jusqu'au 31 mai 1990. Principale mesure des resultats: Duree d'attente pour le placement dans un foyer pour personnes agees et taux relatifs de placement. Resultats: On a constate que la variable qui reduit davantage la periode d'attente etait le choix par le patient d'un etablissement laique a but lucratif ou non lucratif; parmi les autres variables significatives, on a note le sexe masculin, l'age de 75 a 84 ans et l'occupation d'un lit pour soins aigus pendant l'attente. Conclusion: La province doit choisir entre trois politiques: elle peut augmenter la proportion de lits dans les centres laiques lorsqu'on construira de nouveaux etablissements; elle peut exiger que les patients hospitalises acceptent d'etre places provisoirement dans un centre d'accueil en attendant d'etre transferes dans le centre de leur choix; ou elle peut faire dependre le parrainage de nouveaux etablissements d'une formule fondee sur la distribution ethnoreligieuse de la population actuellement agee de 55 a 64 ans.

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overnments and the media receive frequent transferred to a long-term care facility. Canadian, complaints from hospitals that too many British and US studies have reported that hospital acute care beds are being occupied by peo- patients with the most serious problems leaving

ple who are no longer acutely ill but are waiting to be

hospital are women, people aged 75 or more, those

Ms. Shapiro is professor and Mr. Tate is a statistician with the Biostatistical Consulting Unit, Department of Community Health Sciences, University ofManitoba, Winnipeg, Man. Ms. Tabisz is coordinator, Department ofSocial Work, St. Boniface General Hospital, Winnipeg, Man.

Reprint requests to: Ms. Evelyn Shapiro, Rm. S113, Department of Community Health Sciences, Faculty ofMedicine, University of Manitoba, 750 Bannatyne Ave., Winnipeg, MB R3E 0W3 APRIL 15, 1992

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who have cognitive impairment and those who require a high level of care.' -4 Studies have also shown that physicians and hospital staff do not find working with these patients rewarding, because the hospital system is designed to cure rather than provide care and to arrange for as quick a discharge as possible.5'6 Finally, long stays in hospital have been found to place elderly people at risk of iatrogenic illnesses and other adverse consequences.7'8 Little is known about the effect of patients' characteristics on waiting times for transfer when structural or systems factors are taken into account. For example, Markson, Steel and Kane2 found that the biggest problem faced by US patients awaiting transfer from 49 hospitals was their indigence (i.e., they were Medicaid patients with inadequate financial resources or insurance). We therefore designed this study to identify the factors that significantly affect waiting times for transfer from hospitals to nursing homes.

or safety or without costs higher than those associated with the same level of facility care. In order to ensure that institutional placement is a "last resort," the program has panels, each comprising a physician, two senior staff members and the regional continuing care coordinator or designate. The panel makes the final decision on admission, the level of care required and the urgency with which the placement is required. The Continuing Care Program is then responsible for effecting the placement. However, policy dictates that patients have the right to be placed in a nursing home of their choice and that each nursing home has the right to refuse admission even if a person requires the type of care it delivers. If patients choose a facility that has a long waiting list they can remain at home or in hospital until they are admitted. Once their placement has been approved by the panel patients awaiting transfer must pay the per-diem rate that would be required if they were in a long-term care

facility.

Background information Manitoba In July 1973 the Manitoba government added all levels of care in long-term care facilities to its universal insurance coverage of medical and hospital services but required that residents pay a per-diem room-and-board fee. This fee was designed to leave elderly residents receiving minimum pensions (i.e., recipients of Old Age Security and Guaranteed Income Supplement payments) about $90 per month for personal expenditures. Since 1973 the per-diem charges have increased regularly in line with pension increases. Manitoba has proprietary and nonproprietary nursing homes. The private, for-profit homes are owned by a variety of small and large companies. The nonprofit homes, managed by boards of directors, fall into two categories: ethnoreligious homes, run by cultural and religious organizations, and secular homes, usually run by service organizations. The province pays the nonprofit nursing homes according to the level of care required by their residents and gives the proprietary homes the median per-diem rate of the nonprofit sector. Manitoba was the first province to treat nursinghome beds as a scarce resource. Although the residents who were in the facilities as of July 1973 were automatically insured all new residents were admitted contingent to assessed need. The Continuing Care Program, which assesses the need for home care, is also responsible for placing people in homes. One objective of the program is to limit access to facility care exclusively to people who can no longer be cared for at home without danger to their health 1344


People aged 75 years or more constitute 80% of all people admitted to nursing homes. From 1974 to 1981 the number of nursing-home beds was maintained at about 166 per 1000 people aged 75 or more; more beds were built as this segment of the population increased. Since 1981, however, the province has reduced this rate to about 140 per 1000. The community care program and informal caregivers are therefore expected to provide care at home to more people who might otherwise require care in an institution. The staff of the Continuing Care Program are aware that some facilities have a longer waiting list than others because they are chosen by more people awaiting placement and that facilities vary in the rate at which they have vacancies. In addition, anecdotal evidence from Manitoba and elsewhere supports research findings that other factors, such as the need for a high level of care and cognitive impairment, especially in people perceived to have behavioural problems as well, also affect waiting time.

Winnipeg Of the 4556 nursing-home beds in Winnipeg 2029 (44.5%) are in ethnoreligious facilities, 1890 (41.5%) are in for-profit homes, and 637 (14.0%) are in nonprofit secular facilities. Some of the ethnoreligious nursing homes were built before nursing-home services were insured; others were built by the government after 1973 and placed under the sponsorship and administration of an ethnoreligious organization. These facilities are distinguished not only by their religious affiliation and culture but also by the language most often LE 1 5 AVRIL 1992

spoken by many of the residents (e.g., German, Yiddish, Ukrainian or French). In recognition of the demand on urban acute care beds and of the inevitability that some in-hospital patients cannot subsequently be discharged except to a nursing home, each acute care hospital in Winnipeg is assigned a maximum number of beds that can be occupied by people awaiting transfer to a nursing home. If a hospital reaches this "trigger" number the Continuing Care Program gives priority to placements from that hospital until the number awaiting transfer falls below the limit. However, giving a hospital priority does not mean that patients who have been waiting the longest or for whom the move would be most beneficial are the first to be transferred. Those who are transferred under these conditions are people for whom the Continuing Care Program can most quickly arrange a placement. In any event, such problems occur only sporadically and are usually confined to one or two hospitals. The maximum proportion of beds assigned to people awaiting transfer in all Winnipeg hospitals is 8.6%, but the last day census in March 1989 revealed that only 6.8% of the beds were so occupied.9

Methods

level of care needed, the nursing home chosen, the location (acute care ward or geriatric unit) of the patient before placement and the discharge date. Panel assessment dates and designated levels of care were checked against the forms completed by the panel. The independent variables assessed for their impact on the length of time in hospital from panel assessment to discharge were age (less than 65 years, 65 to 74, 75 to 84 or 85 or more), sex, level of care needed (low, medium or high), cognitive impairment (not impaired, somewhat impaired or impaired), location while awaiting placement (acute care ward or geriatric unit), presence or absence of behavioural problem and type of nursing home (for-profit, nonprofit secular or nonprofit ethnoreligious). The hospital records did not specify how the extent of cognitive impairment was determined. However, the interviewer of all the patients (or the family if cognitive impairment was present) found that she could successfully interview only one patient listed in the hospital records as having such impairment and only one-quarter of those noted as having some degree of impairment; this suggested reasonable reliability. Although 275 of the 366 patients were admitted to acute care beds and 91 to geriatric unit beds 24 people were transferred from an acute care ward to a geriatric unit during their hospital stay. Thus, 251 patients were awaiting transfer from an acute care bed and 115 from a geriatric unit bed. The cumulative probability of placement after panel assessment was calculated over time with the Kaplan-Meier estimation procedure. The log-rank test was used to examine differences in probability for categories of each independent variable. This statistical procedure takes account of follow-up times that varied because of different panel assessment dates and censored data (i.e., patients who died before placement or were not yet placed at the end of follow-up). We can thus estimate and test for differences between the cumulative probability of placement over the first 120 days and over the whole study period for people who differed from each other on the basis of categories of independent variables. Variables identified as being related to rate of placement at this stage were then jointly examined with the use of the Cox regression model to identify the variables still associated with an increased rate of early transfer when all the variables are taken into account. The magnitude of the effect on the placement rate with corresponding 95% confidence intervals for the significant variables was estimated.

From June 1, 1988, to May 31, 1989, data were gathered from hospital records for all 366 patients who were found by the Continuing Care Program panel to require placement in a nursing home. Four Winnipeg hospitals (two teaching and two community hospitals) were included in the study. The patients were followed up until placement, death or May 31, 1990. Sixty-eight patients died before placement within the year after assessment by the panel; these patients were included in the analysis. The four hospitals have 2089 acute care beds (over 75% of all such beds in Winnipeg) and on the basis of 1988-89 statistics obtained from each of these hospitals admit just over 72 000 people annually. The study hospitals also have an additional 387 beds in special geriatric rehabilitation units that are for patients admitted directly from the community or the hospital. The geriatric rehabilitation beds comprise 87.4% of the geriatric beds in acute care hospitals and 60.7% of all such beds in Winnipeg. The geriatric units were not assigned a "trigger" number, since patients' stays are expected to be longer than those in acute care beds and because these units are better staffed than acute care wards to care for in-transit, mostly elderly patients. The information collected from the hospital records included basic psychosocial data, date of admission, admission location (acute care medical, Results surgical or psychiatric ward or geriatric unit), the panel assessment date, the panel's decision on the Table 1 shows the levels of care designated for APRIL 15, 1992


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the 366 hospital patients assessed between June 1, 1988, and May 31, 1989, and compares them with the levels designated for all people in hospital or in the community in Winnipeg awaiting placement during roughly the same period (Lynn Fineman, director, Continuing Care Program: personal communication, 1990). Almost half of the hospital patients required a high level of care, as compared with just over one-third of patients waiting in the community. Table 2 shows the age and sex distribution for the 366 patients; 77% were aged 75 years or more. The mean age was 80.3 years, which was less than the mean age of 85 years for all people awaiting placement (only the mean age of people who had undergone panel assessment was available from the Continuing Care Program). Men were younger than women on average and constituted about two-fifths of the 366 patients. Cognitive impairment was evident in 40% of the patients; an additional 37% had some lesser degree of impairment (Table 3). Almost one-third were perceived by the hospitals as having a behavioural problem. Table 4 shows the median waiting time for placement (i.e., the time at which 50% of the patients were estimated to have been placed) for those classified within categories of variables possibly related to a shorter wait. The significance levels of the difference in waiting time between the shortterm period (i.e., the first 120 days) and the whole study period are given. In the short term, significantly shorter waiting times were associated with (in descending order of significance) the choice of a for-profit or nonprofit secular facility, the need for a high level of care, the occupancy of an acute care bed during the wait, the absence of cognitive impairment and the presence of a behavioural problem. For the entire study period two additional variables were found to shorten the wait significantly: male sex and age of 75 to 84 years (p < 0.05); the presence of a behavioural problem no longer affected the placement rate significantly.

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To emphasize the impact of a patient's choice of nursing home on transfer time half of the patients who chose a for-profit secular home were transferred within 115 days, and half of those who chose a nonprofit secular home were transferred within 195 days. On the other hand, it was almost a year before half of those who selected a nonprofit ethnoreligious home were out of hospital. The results of the Cox regression analysis are summarized in Table 5. Of the total x2 value (78.5) the type of nursing home chosen accounted for 58.6. When all the factors were taken into account patients who selected a for-profit secular home had a rate of placement 3.22 times higher and those who selected a nonprofit secular home a rate 2.16 times higher than the rate among patients who chose a nonprofit ethnoreligious nurs-

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ing home. The rate of placement was higher Discussion among the men than among the women. Patients Our findings show that studies, impressions and aged 75 to 84 years and those waiting in an acute care bed were likely to wait significantly anecdotal observations of the effect of any one factor less time than the other patients. No other vari- on nursing-home placement are not always correct when other factors are taken into account. Patients ables contributed independently to this model.

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requiring a high level of care were not likely to wait significantly longer for transfer than those requiring a lower level of care. Neither cognitive impairment nor the presence of behavioural problems significantly affected the waiting time. Furthermore, people aged 75 to 84 years tended to leave the hospital sooner than those who were older or younger. Ethnoreligious nursing homes afford both language and cultural continuity to their residents. In addition, they offer residents the opportunity to renew relationships with former friends and neighbours. The Continuing Care Program recognizes the importance of the cultural and spiritual contributions these facilities make to their residents. Yet, of the factors that affected waiting time in hospital, the choice of nursing home was by far the one with the greatest impact and, unlike age, sex and level of care, is one factor that policy can address. Two recommendations to address this issue have been made to the province by the recently government appointed Task Force on Extended Treatment Bed Review. In its draft report, which was circulated to all health care organizations, the task force recommended that all future long-term care facilities in Winnipeg be secular. However, a well-organized, negative response from the boards of ethnoreligious nursing homes resulted in a decision by the task force to change its recommendation in favour of retaining the current secular and nonsecular proportions, even though nursing homes are accommodating increasing numbers of acculturated children or grandchildren of first-generation and second-generation immigrants. In addition, the strong objection by the ethnoreligious communities to the draft report has made politicians wary of increasing the proportion of secular facilities. The second recommendation by the task force was for the government to change the policy of the Continuing Care Program regarding the placement of in-hospital patients in a nursing home. The new policy would continue to honour the patient's choice of facility but would require that people accept an interim placement in another facility until space becomes available in the nursing home of their choice. The advantage of such a policy would be the ability to transfer patients who have been in hospital a very long time before those who are assessed by the panel later. This recommendation has thus far not been adopted. The Continuing Care Program staff have for some time approached patients and their families on an informal basis to suggest an interim placement with an assurance of eventual transfer to their chosen facility. However, this process is time consuming, and the results of such negotiations are mixed, primarily because patients and their families are reluctant to agree to two transfers, especially if 1348


the patient is very old or debilitated. Nevertheless, moving twice may be the "lesser evil," because studies have shown that the attitudes of medical and hospital staff toward long-stay patients are less than desirable6 and that elderly hospital patients are at considerable risk of nosocomial infection.8 If the proportion of ethnoreligious beds is maintained over the next 20 years, a third option is to tie the decision about the sponsorship of new facilities to a formula based on the ethnoreligious distribution of the Winnipeg population currently aged 55 to 64 years. Rather than having especially long waiting lists for specific ethnoreligious nursing homes, as is now the case, appropriate planning could establish whether this problem is temporary or long term and determine which ethnoreligious organizations will manage these new beds. Winnipeg has one of the lowest numbers of long-term care beds per 1000 people aged 75 years or more in urban Canada and one of the lowest proportions of acute care beds occupied by people awaiting transfer. Unless Manitoba adopts policies to address these issues the system will eventually come under extreme pressure. The burden of inaction will then be borne by hospitals, the community care program and patients requiring institutional placement. This study was funded by grant 6607-1471-55 from the Research Programs Directorate, Department of National Health and Welfare.

References 1. Fisher RH, Zorzitto ML: Placement problem: Diagnosis, disease or term of denigration? Can Med Assoc J 1983; 129: 331-334 2. Markson EW, Steel K, Kane E: Administratively necessary days: more than an administrative problem. Gerontologist 1983; 23: 486-492 3. Rubin SG, Davies GH: Bed-blocking by elderly patients in general hospital wards. Age Ageing 1975; 4: 142-147 4. Robertson D: Long Term Care Patients in Acute Care Beds: Implications for Action. Report to the Capital Regional Hospital District Hospital and Health Planning Commission, Victoria, 1985 5. Rosenthal CJ, Marshall VW, Macpherson AS et al: Nurses, Patients and Families: Care and Control in the Hospital, Springer, New York, 1980 6. Marshall V: Physician characteristics and relationships with older patients. In Haug M (ed): Elderly Patients and Their

Doctors, Springer, New York, 1981: 94-118 7. Steel K, Gertman PM, Crescenzi C et al: latrogenic illness on a general medical service at a university hospital. N Engl J Med

1981; 304: 638-642 8. Gillick MR, Serell NA, Gillick LS: Adverse consequences of hospitalization in the elderly. Soc Sci Med 1982; 16: 1033-

1038 9. Report of the Task Force on Extended Treatment Bed Review, Manitoba Department of Health, Winnipeg, 1990

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