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Research Findings #6: Special Care Units in Nursing Homes - Selected Characteristics, 1996

Jeffrey A. Rhoades, PhD

Introduction

Nursing homes in the United States are devoting more resources to the treatment needs of special populations, primarily through the formation of special care units. Several trends have contributed to the creation of these units. The size of the nursing home population has increased 1 to 2 percent annually from 1987 to 1996, and today's nursing home population is more functionally and cognitively disabled and requires more skilled and/or specialized care than ever before (Spillman, Krauss, and Altman, 1997). Shorter lengths of stay in hospitals also have resulted in a greater need for skilled and rehabilitative care following hospitalization. Home health care has partially addressed this need, but there continues to be a subset of individuals who need sophisticated, labor-intensive, 24-hour skilled supervision. In addition, increasing public awareness of Alzheimer's disease and related dementias has created interest in programs that provide services tailored to the needs of people with these conditions.

This report is based on the 1996 Medical Expenditure Panel Survey (MEPS) Nursing Home Component (NHC), conducted by the Agency for Health Care Research and Qualtiy (AHRQ). It provides estimates of the number and distribution of nursing homes by type of facility, type of ownership and chain affiliation, certification status, facility size, and geographic distribution. The nursing home characteristics presented in this report are derived from information provided by facility administrators and designated staff in sampled nursing homes.

The 1996 MEPS NHC is a national, yearlong panel survey of nursing homes and their residents. MEPS is the third in a series of AHRQ-sponsored surveys to collect information on the health care use and spending of the American public. The first survey was the 1977 National Medical Care Expenditure Survey (NMCES), and the second was the 1987 National Medical Expenditure Survey (NMES). NMES was the first national expenditure survey to contain an institutional component designed explicitly to collect detailed medical expenditure information on people in long-term care facilities (Potter, 1998).

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Defining Special Care Units

Special care programs span a continuum, from individualized treatment of people with special needs through formal programs where specialized providers care for people with special needs. These programs may also set aside specific portions of a nursing facility for people with special needs or form distinct units specifically designated and staffed for people with specific needs. For example, the range of possibilities with regard to the treatment of Alzheimer's disease and related dementias is explored in the survey results reported in Leon, Chang-Kuo, and Alvarez (forthcoming). In this Research Findings, "special care" refers to units established for any special population, not just units designated for Alzheimer's disease and related dementias.

The MEPS NHC gathered data on "formal" special care units as part of an effort to delineate the structure of the nursing facility and any larger facility of which it might be a part. Specifically, the survey interviewer asked:

"We're interested in learning about any special care units within [the nursing home]—units with a specified number of beds identified and dedicated for residents with specific needs or diagnoses. Does [the nursing home] have any special care units, such as those listed on this card?"

The respondent was then shown a card listing the following types of special care units and asked which type(s) of units the facility contained:

  • Alzheimer's and related dementias.
  • AIDS/HIV.
  • Dialysis.
  • Children with disabilities.
  • Brain injury (traumatic or acquired).
  • Hospice.
  • Huntington's disease.
  • Rehabilitation.
  • Ventilator/pulmonary.
  • Some other kind of unit.

If "some other kind of unit" was chosen, the respondent was asked for specifics, and the responses were coded into existing or new categories. Respondents also were asked for the number of beds in each type of unit they identified. Because there appears to be no clear and generally accepted distinction in the nursing home industry between rehabilitation and subacute care units, facilities that reported "some other kind of unit" as "subacute" had their units grouped in the rehabilitation category. If a facility reported more than one unit in a category, the beds in these units were summed and the facility was counted as having only one unit in that category.

A subsequent question asked, "Does [the special care unit] have direct patient care staff dedicated to it?" In 96 percent of the cases, the response was "yes" (data not shown). This information provides further support for the perspective that the special care treatment analyzed here is furnished in formal distinct units.

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Findings

As shown in Table 1, 19.2 percent of all nursing facilities had at least one distinct special care unit. These special care units contained 120,440 beds, or 6.9 percent of all nursing home beds.

Hospital-based nursing homes were less likely than other facility types to have special care units (8.0 percent versus 20.4 percent of nursing homes with only nursing beds and 22.9 percent of nursing homes with independent living and/or personal care beds).

Almost two-thirds (65.9 percent) of nursing homes operate for profit, and nearly 20 percent (19.1 percent) of those facilities contain special care units. Among for-profit facilities, special care units were more likely to be found in nursing homes that were part of a group or chain (22.0 percent) than in independent facilities (12.8 percent). Indeed, almost half (48.1 percent) of all beds in special care units were found in for-profit facilities that were part of a group or chain (derived from Table 1). There also was a clear correlation between the number of nursing beds in the facility and the probability that it contained a special care unit. The percentage of nursing homes with a special care unit increased from 4.2 percent of facilities with fewer than 75 beds to 46.7 percent of facilities with 200 or more beds.

Table 2 provides greater detail on the types of special care units. By far the largest category of special care units was for Alzheimer's disease and related dementias; these units constituted two-thirds (65.7 percent) of all special care units found in our sample (data derived from Table 2). More than a tenth (12.6 percent) of nursing homes—or 2,130 homes—had an Alzheimer's unit, with the number of beds in these units totaling 73,400. In addition, 4.9 percent of nursing homes had a distinct rehabilitation and/or subacute care unit, for a total of 28,500 beds. Finally, almost 800 facilities had some other kind of special care unit or units; there were 18,500 beds in these units. Types of units included in this "other" grouping were ventilator/pulmonary, hospice, AIDS/HIV, and brain injury (traumatic or acquired) units. Each of these types was present in less than 1.5 percent of the sample, which precludes separate reliable estimation of these categories.

Nursing Homes With Special Care Units

Table 3 presents characteristics of facilities with special care units, and with Alzheimer's units specifically, compared to nursing homes without any special care units. Only 4.7 percent of nursing homes with special care units and 5.1 percent of nursing homes with Alzheimer's units were hospital based, compared with 13.0 percent of facilities without any type of special care unit.

There was little difference in the distribution of for-profit/nonprofit ownership among nursing homes without any special care units, facilities with special care units, and those with Alzheimer's units. However, among for-profit facilities, there were differences between nursing homes that were part of a group or chain and those that were independent. Only 13.8 percent of nursing homes with special care units and 14.5 percent of those with Alzheimer's units were independent for-profit homes, whereas 22.4 percent of facilities without special care units were independent and for profit.

Nursing homes with any type of special care unit, as well as those with Alzheimer's units specifically, were more likely to be certified by both Medicare and Medicaid (84.7 percent and 80.0 percent, respectively) than facilities without any special care unit (70.4 percent). Further, over half (53.5 percent) of nursing homes with special care units had 125 or more total nursing beds, whereas only 18.1 percent of homes without any special care units fell into this size range.

Alzheimer's Units

Because Alzheimer's units accounted for two-thirds (65.7 percent) of all special care units, we can present greater detail on the characteristics of such units. In 1996, the average Alzheimer's unit had been in existence for a little more than 6 years (data not shown). According to Figure 1, 55.6 percent of the units had been in operation for 5 years or less. Less than a tenth (9.7 percent) of the units had been operating for 11 years or more.

The average Alzheimer's unit contained 34 beds (data not shown). Figure 2 shows that 46.7 percent of the units had 26-60 beds. Less than a tenth (8.9 percent) of the units had more than 60.

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Figures

1. Number of years in operation
2. Number of beds

Figure 1: Number of years in operation

Figure 2: Number of beds

 

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Tables

1. Characteristics of nursing homes with special care units and  number of beds
in special care units
2. Types of special care units in nursing homes and number of beds in each type
3. Characteristics of nursing homes with special care units, without special care 
units, and with Alzheimer's units

 

Table 1: Characteristics of nursing homes with special care units and number of beds in special care units

 

Table 2: Types of special care units in nursing homes and number of beds in each type

 

Table 3: Characteristics of nursing homes with special care units, without special care units and with Alzheimer's units.

Table 3: Characteristics of nursing homes with special care units, without special care units and with Alzheimer's units, continued.

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References

Agency for Health Care Policy and Research. Round 1, facility-level public use file codebook. In: Medical Expenditure Panel Survey (MEPS) NHC-001: Round 1 Sampled Facility and Person Characteristics, March 1997 [CD-ROM]. Rockville (MD), 1997. AHRQ Pub. No. 97-DP21.

Bethel J, Broene P, Sommers JP. Sample design of the 1996 Medical Expenditure Panel Survey Nursing Home Component. Rockville (MD): Agency for Health Care Policy and Research; 1998. MEPS Methodology Report No. 4. AHRQ Pub. No. 98-0042.

Leon JL, Chang-Kuo C, Alvarez RJ. Trends in special care: changes in SCU from 1991 to 1995. Journal of Mental Health and Aging (forthcoming).

Potter, DEB. Design and methods of the 1996 Medical Expenditure Panel Survey Nursing Home Component. Rockville (MD): Agency for Health Care Policy and Research; 1998. MEPS Methodology Report No. 3. AHRQ Pub. No. 98-0041.

Shah BV, Barnwell BG, Bieler GS. SUDAAN user's manual: software for the statistical analysis of correlated data. Research Triangle Park (NC): Research Triangle Institute; 1995.

Spillman B, Krauss N, Altman B. A comparison of nursing home resident characteristics: 1987 to 1996. Presented at the annual meeting of the Gerontological Society of America; 1997. Cincinnati (OH).

U.S. Bureau of the Census. Statistical abstract of the United States: 1996 (116th edition). Washington; 1996.

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Appendix

Data Sources and Methods of Estimation    Reliability and Standard Error Estimates
Facility Eligibility   Standard Error Tables
Definitions of Variables    

 

Data Sources and Methods of Estimation

The data in this report were obtained from a nationally representative sample of nursing homes from the Nursing Home Component (NHC) of the 1996 Medical Expenditure Panel Survey (MEPS). The sampling frame was derived from the updated 1991 National Health Provider Inventory. The NHC was primarily designed to provide unbiased national and regional estimates for the population in nursing homes, as well as estimates of these facilities and a range of their characteristics.

The sample was selected using a two-stage stratified probability design, with facility selection in the first stage. The second stage of selection consisted of a sample of residents as of January 1, 1996, and a rolling sample of persons admitted during the year (Bethel, Broene, and Sommers, 1998). Of the 1,123 eligible nursing homes sampled in the NHC, 85 percent responded. Estimates in this report are based on these 952 eligible responding facilities. To bring the sample size in line with the original design of approximately 800 facilities by the end of Round 3, the facility sample was subsampled at the end of Round 1. A total of 127 facilities were randomly deselected.

The MEPS NHC data analyzed here were collected in person during the first of three rounds of data collection. A computer-assisted personal interview (CAPI) system was used for data collection. The Round 1 interview took place during the period March-June 1996. The entire three-round data collection effort took place over a 1 1/2 year period, with the reference period being January 1, 1996, to December 31, 1996 (Potter, 1998).

The facility questionnaire was designed to elicit information on the complex structure of institutions that provide residential care or treatment. Some nursing homes or units exist within larger establishments. In such cases, the entity that appeared on the sampling frame might be the larger facility, the nursing home or unit within the larger facility, or only one of several nursing units within the larger facility. Therefore, the NHC's Round 1 facility questionnaire was designed to identify the larger facility, each eligible nursing home or unit within the larger establishment, and other nonhospital residential parts. Because of this, the point of reference for a specific question may be the sampled nursing home or unit (hereafter referred to as "nursing home"), a larger facility, another nonhospital residential part of a larger facility, one or several nursing homes within a larger facility, or a smaller subunit of the eligible nursing home (Agency for Health Care Policy and Research, 1997).

Data on the sampled nursing homes were obtained using a facility questionnaire administered through CAPI to facility administrators or designated staff. Estimates provided are preliminary and are subject to revision as more information from other parts of the NHC becomes available.

Data in data files released to the public have, in some instances, been masked to preserve the confidentiality of responding nursing homes. As a result, estimates made using the public use version of the data may differ slightly from the estimates presented in this report.

Facility Eligibility

Only nursing homes were eligible for inclusion in the MEPS NHC. To be included as a nursing home, a facility must have at least three beds and meet one of the following criteria:

  • It must have a facility or distinct portion of a facility certified as a Medicare skilled nursing facility (SNF).
  • It must have a facility or distinct portion of a facility certified as a Medicaid nursing facility (NF).
  • It must have a facility or distinct portion of a facility that is licensed as a nursing home by the State health department or by some other State or Federal agency and that provides onsite supervision by a registered nurse or licensed practical nurse 24 hours a day, 7 days a week (Bethel, Broene, and Sommers, 1998).

By this definition, all SNF- or NF-certified units of licensed hospitals are eligible for the sample, as are all Department of Veterans Affairs (VA) long-term care nursing units. In such cases, and in the case of retirement communities with nursing facilities, only the long-term care nursing units(s) of the facility were eligible for inclusion in the sample. If a facility also contained a long-term care unit that provided assistance only with activities of daily living (e.g., a personal care unit) or provided nursing care at a level below that required to be classified as a nursing facility, that unit was excluded from the sample (Potter, 1998).

Definitions of Variables

Facility Type

This variable, constructed from data from the facility questionnaire, defines the facility's organizational structure as one of three types:

  • Hospital-based nursing home. This indicates that the sampled nursing home was part of a hospital or was a hospital-based Medicare SNF.
  • Nursing home with independent living or personal care unit. This category includes continuing care retirement communities (CCRCs) and retirement centers that have independent living and/or personal care units, as well as nursing homes that contain personal care units. Non-hospital-based nursing homes with a separate unit in which personal care assistance is provided also are included.
  • Nursing home with only nursing home beds. This category includes a small number of nursing homes (less than 1 percent) with an intermediate care unit for the mentally retarded (ICF-MR).

The order of priority for coding facility type followed the sequence listed above.

Ownership

Respondents reported the ownership type that best described their facility (or larger part of the facility, in situations where the sampled nursing home was part of a larger facility), as follows:

  • For profit (i.e., individual, partnership, or corporation).
  • Private nonprofit (e.g., religious group, nonprofit corporation).One of four types of public ownership—city/county government, State government, VA, or other Federal agency.

Respondents also reported whether their facility was part of a chain or group of nursing facilities operating under common management.

Facility Certification StatusRespondents were asked whether any unit in their facility or part of the larger facility (in cases where the sampled nursing home was reported to be part of a larger facility) was certified by Medicare as an SNF and/or Medicaid as an NF. For the purpose of this report,facilities were assigned to mutually exclusive categories based on their responses.

Facility SizeThe size of the sampled nursing home was determined by the number of nursing beds regularly maintained for residents. Beds contained within the sampled nursing home but not licensed for nursing care were excluded; 65 of the 952 nursing homes reported having such unlicensed beds. There were 28,000 unlicensed beds in addition to the 1,756,800 total weighted beds in the sample. These unlicensed beds represented less than 2 percent of the beds in the sampled nursing homes. If the sampled nursing home was part of a larger facility, only the licensed nursing home beds were included.

 

Census Region

Sampled nursing homes or units were classified in one of four regions—Northeast, Midwest, South, and West—based on their

geographic location according to the MEPS NHC sampling frame. These regions are defined by the U.S. Bureau of the Census.

Facility LocationA metropolitan statistical area (MSA) is defined as including (1) at least one city with 50,000 or more inhabitants or (2) a Census Bureau-defined urbanized area of at least 50,000 inhabitants and a total metropolitan population of at least 100,000 (75,000 in New England) (U.S.Bureau of the Census, 1996).

MSA data were missing for 14 facilities; an MSA/non-MSA determination was made after a review of the county's population density according to the 1990 census.

 

Reliability and Standard Error Estimates

Since the statistics presented in this report are based on a sample, they may differ somewhat from the figures that would have been obtained if a complete census had been taken. This potential difference between sample results and a complete count is the sampling error of the estimate.

The chance that an estimate from the sample would differ from the value for a complete census by less than one standard error is about 68 out of 100. The chance that the difference between the sample estimate and a complete census would be less than twice the standard error is about 95 out of 100.

Tests of statistical significance were used to determine whether differences between estimates exist at specified levels of confidence or whether they simply occurred by chance. Differences were tested using Z-scores having asymptotic normal properties, based on the rounded figures at the 0.05 level of significance.

Estimates for sample sizes of less than 50 do not meet standards of reliability or precision and are not reported. In addition, estimates with a relative standard error greater than 30 percent are marked with an asterisk. Such estimates cannot be assumed to be reliable.

Rounding

Estimates of percentages presented in the tables have been rounded to the nearest 0.1 percent. The rounded estimates, including those underlying the standard errors, will not always add to 100 percent or the full total. To avoid conveying a false sense of precision, estimates of the number of nursing homes and/or units have been rounded to the nearest ten, and estimates of the number of beds have been rounded to the nearest hundred.

Standard Errors

The standard errors in this report are based on estimates of standard errors derived using the Taylor series linearization method to account for the complex survey design. The standard error estimates were computed using SUDAAN (Shah, Barnwell, and Bieler, 1995). The direct estimates of the standard errors for the estimates in Tables 1-3 in the text are provided in Tables A-C, respectively; the standard errors for Figures 1 and 2 are provided in Tables D and E, respectively.

For example, the estimate of 120,440 beds in special care units (Table 1) has an estimated standard error of 8,340 beds (Table A). The estimate that 65.4 percent of facilities with special care units operate for profit (Table 3) has an estimated standard error of 3.2 percent (Table C).

Table A: Standard errors for Table 1.

Table B: Standard errors for Table 2.

Table C: Standard errors for Table 3.

Table D: Standard errors for Figure 1.

Table E: Standard errors for Figure 2.

 

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Suggested Citation: Research Findings #6: Special Care Units in Nursing Homes - Selected Characteristics, 1996. January 1999. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/data_files/publications/rf6/rf6.shtml