Research Findings #4: Nursing Homes - Structure and Selected Characteristics, 1996

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Jeffrey Rhoades, Ph.D., D.E.B. Potter, M.S., and Nancy Krauss, M.S., Agency for Health Care Policy and Research

On this page: Introduction - Findings - Tables - References - Appendix

Introduction

Because of the dramatic growth in the number of Americans over age 75 and the desire to minimize the duration of expensive inpatient hospital care, data pertaining to the nursing home industry are of critical importance. The trend in long-term care is toward expansion of community-based care for persons with functional limitations. However, there continues to be a subset of individuals who need sophisticated 24-hour skilled supervision. A better understanding of the current nursing home market can contribute to informed decisions about the provision of long-term care.

This report is based on the 1996 Nursing Home Component (NHC) of the Medical Expenditure Panel Survey (MEPS). It provides estimates of the number and distribution of nursing homes by nursing home type, ownership and chain affiliation, certification status, size, and geographic distribution. The estimates of 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 survey of nursing homes and their residents. MEPS is the third in a series of surveys sponsored by the Agency for Health Care Research and Quality (AHRQ) to collect information on the health care use and expenditures 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).

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Findings

In 1996 there were 16,840 nursing homes with three beds or more, for a total of 1,756,800 beds (Table 1). The average size of a nursing home was just over 104 beds. Three-quarters (75.1 percent) of nursing homes had fewer than 125 beds. Nursing homes with 125 beds or more represented only a quarter (24.9 percent) of all nursing homes but almost half (45.5 percent) of all nursing beds.

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Ownership

Approximately 92 percent of nursing homes were privately owned. Of all nursing homes, 65.9 percent were for-profit and 26.2 percent were nonprofit. The remaining 7.9 percent were owned by Federal, State, or local governments. For-profit nursing homes were much more likely than nonprofit nursing homes to be part of a group or chain. Nearly 70 percent of for-profit nursing homes were affiliated with a group or chain, while less than 30 percent of nonprofit nursing homes had such an affiliation (derived using data from Table 1).

Analysis of nursing home type by ownership reveals another unmistakable pattern (Table 2). The for-profit segment of the nursing home market was nearly entirely represented (90.9 percent) by nursing homes with only nursing home beds, as opposed to other, more complex nursing home types (defined in detail in the technical appendix). Nonprofit facilities were more evenly distributed among the three different types of nursing homes, as follows:

* Nursing homes with only nursing home beds (53.1 percent).

* Nursing homes with independent living or personal care units (20.8 percent).

* Hospital-based nursing homes (26.1 percent).

Reflecting this distribution by type of facility, nonprofit facilities were more likely than for-profit facilities to have affiliated non-nursing beds (derived using data from Table 3). Non-nursing beds included personal care and independent living beds.

In each region of the United States, approximately three-quarters of facilities were nursing homes with only nursing home beds. In three of the four regions, the remaining quarter of the facilities were fairly evenly split between nursing homes with independent living or personal care units and hospital-based nursing homes. Only the West failed to follow this pattern. The West had roughly double the proportion of hospital-based facilities found in the Northeast and South Regions of the United States. Hospital-based nursing homes were twice as prevalent in areas that were not metropolitan statistical areas (MSAs) as compared to MSAs.

Facility Certification Status

An important characteristic of nursing homes is certification status. A nursing home can receive certification from both the Medicare and Medicaid programs or from either one separately. In addition, a nursing home may not meet certification criteria or may choose not to participate in the programs. In these cases, the nursing home would be classified as not federally certified. Nearly all nursing homes had some form of certification in 1996. Close to three-quarters (73.2 percent) of all nursing homes, representing four-fifths (80.5 percent) of all nursing beds, were certified by both Medicare and Medicaid (Table 1). However, while 96.3 percent of the beds in these dually certified facilities were certified for Medicaid, only 47.9 percent of the beds were certified by Medicare (Table 3).

A very small percentage of all nursing homes were certified neither by Medicare nor Medicaid (Table 1). If a nursing home was neither Medicare nor Medicaid certified, it was included in the sample if it met both of the following criteria:

* It was licensed by the State health department or some other State or Federal agency.

* It provided 24-hour, 7-day, onsite supervision by a registered nurse or licensed practical nurse.

Nursing Bed Characteristics

The distribution of Medicare skilled nursing facility (SNF) beds was quite similar for three regions of the United States (Table 3). In the Midwest, South, and West Regions, approximately 30 to 45 percent of all beds were Medicare certified. In contrast, nearly two-thirds (64.3 percent) of the beds in the Northeast were SNF beds. About 90 percent of nursing beds in all four regions were certified by Medicaid as nursing facility beds.

Facility Size

The overall average size for nursing homes was 104 beds. The size distribution of nursing homes was similar for nursing homes with only nursing home beds and nursing homes with independent living or personal care units (Table 4). Approximately 35 to 45 percent of both types of facilities had 75-124 beds. However, for hospital-based nursing homes the picture was quite different. Less than 25 percent of hospital-based nursing homes had 75-124 beds, and nearly 70 percent had fewer than 75 beds.

Size also varies by ownership and chain affiliation. As facility size increases, the proportion of nursing homes that report independent ownership decreases. However, nursing homes reporting chain affiliation were clustered within a narrow size range--almost half (49.0 percent, based on calculations using data from (Table 4) had 75-124 beds.

The size distribution of nursing homes also differed by region. For the Midwest and West, the most numerous facilities were those with fewer than 75 beds (46.0 and 43.6 percent, respectively). In contrast, the Northeast and South had larger facilities on average; most common were facilities with 75-124 beds (38.8 and 48.2 percent, respectively). The average size of nursing homes by region ranged from a low of 86.2 beds in the West to a high of 129.3 beds in the Northeast (data not shown). Nearly half (46.7 percent) of nursing homes not located in MSAs had fewer than 75 beds, while less than a third (29.1 percent) of nursing homes in MSAs had fewer than 75 beds. Over two-thirds (69.0 percent) of nursing beds were located in MSAs. Nursing homes located outside MSAs were twice as likely to be hospital based.

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Use

Measures of nursing home care use are presented in Table 5. The total nursing home population was approximately 1.56 million. The occupancy rate is a measure of the percent capacity at which a nursing home is operating. The ratio of residents to beds produced an overall occupancy rate of 88.8 percent. Generally, there was little variation in occupancy rates by facility characteristics. There was slight variation among regions, however, ranging from 93.3 percent in the Northeast to 87.0 percent in the West.

There were 1.96 million admissions in 1995. This represents a rate of 111.8 admissions per 100 beds, or a turnover rate of approximately one admission per bed per year.

The admissions rate was greatest for hospital-based nursing homes (306 admissions per 100 beds), while the admissions rate for nursing homes with only nursing home beds and nursing homes with independent living or personal care units combined was approximately 97 admissions per 100 beds (Table 5) . The higher admissions rate for hospital-based nursing homes was due in part to the fact that such nursing homes had a greater proportion of Medicare SNF beds (Table 3). Length of stay would be constrained by Medicare reimbursement policy, leading to a greater admissions rate than in the other two types of nursing homes. Admissions rates were also highest in facilities with fewer than 75 beds (181 admissions per 100 beds) and facilities located in the West (198 admissions per 100 beds), as shown in Table 5. This is probably at least partially accounted for by the greater proportion of hospital-based nursing homes in the West and in facilities with fewer than 75 beds.

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Tables:

1. Number of nursing homes and beds by selected characteristics: United States, 1996

2. Percent distribution of nursing homes by type of facility and selected characteristics: United States, 1996

3. Selected characteristics of nursing home beds and affiliated non-nursing beds: United States, 1996

4. Percent distribution of nursing homes by facility size and selected characteristics: United States, 1996 Facility size

5. Selected use data for nursing homes by selected characteristics: United States, 1995 and 1996

Table 1. Number of nursing homes and beds by selected characteristics: United States, 1996

	Nursing homes		Nursing home beds
Facility characteristic	Number	Percent distribution	Number^a	Percent distribution
Total	16,840	100.0	1,756,800	100.0
Type of nursing home
Nursing home with only nursing home beds^b	13,020	77.3	1,425,100	81.1
Nursing home with independent living
or personal care unit^c	1,910	11.3	208,200	11.9
Hospital-based nursing home	^d1,910	^d11.4	^d123,500	^d7.0
Ownership
For profit	11,090	65.9	1,171,800	66.7
Independent	3,490	20.8	348,200	19.8
Part of group or chain	7,600	45.1	823,600	46.9
Nonprofit	4,420	26.2	423,400	24.1
Independent	3,170	18.8	295,700	16.8
Part of group or chain	^d1,250	^d7.4	^d127,700	^d7.3
Government	1,330	7.9	161,600	9.2
Facility certification status
Medicare and Medicaid certified	12,320	73.2	1,414,200	80.5
Medicare certified only
Medicaid certified only	2,870	17.0	227,700	13.0
Not federally certified
Facility size
Fewer than 75 beds	6,010	35.7	282,400	16.1
75-124 beds	6,630	39.4	674,700	38.4
125-199 beds	2,880	17.1	448,300	25.5
200 or more beds	1,320	7.8	351,400	20.0
Census region
Northeast	2,910	17.3	375,900	21.4
Midwest	5,680	33.8	544,300	31.0
South	5,080	30.2	561,900	32.0
West	3,170	18.8	274,700	15.6
Metropolitan statistical area (MSA)
MSA	10,490	62.3	1,212,000	69.0
Not MSA	6,350	37.7	544,800	31.0
^aExcludes unlicensed nursing home beds.
^bIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^cIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
^dBecause this statistic is based on a sample of less than 75, statistical tests that assume a normal distribution may not be appropriate, especially in applications with proportions.
^eSample size less than 50.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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Table 2. Percent distribution of nursing homes by type of facility and selected characteristics: United States, 1996

		Type of facility
		Nursing homes with only nursing home beds^a	Nursing homes with independent living or personal care unit^b	Hospital-based nursing home
Facility characteristic	Total nursing homes	Percent distribution
Total	16,840	77.3	11.3	11.4
Ownership
For profit	11,090	90.9	7.2	*1.9
Independent	3,490	91.0	6.7	*2.2
Part of group or chain	7,600	90.9	7.4	*1.7
Nonprofit	4,420	53.1	20.8	26.1
Independent	3,170	51.6	18.3	30.1
Part of group or chain	^c1,250	^c56.8	^c27.4	*^c15.8
Government	1,330	43.9	*14.3	41.8
Facility certification status
Medicare and Medicaid certified	12,320	80.2	10.4	9.4
Medicare certified only	(^d)
Medicaid certified only	2,870	79.4	13.4	*7.1
Not federally certified		(^d)
Facility size
Fewer than 75 beds	6,010	66.4	11.5	22.1
75-124 beds	6,630	83.2	10.0	6.8
125-199 beds	2,880	85.6	12.6	*1.8
200 or more beds	1,320	79.6	14.2	6.2
Census region
Northeast	2,910	81.2	10.2	8.6
Midwest	5,680	75.7	13.0	11.3
South	5,080	78.4	13.5	8.1
West	3,170	74.9	*5.7	19.3
Metropolitan statistical area (MSA)
MSA	10,490	80.2	11.5	8.3
Not MSA	6,350	72.5	11.1	16.4
^aIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^bIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
^cBecause this statistic is based on a sample of less than 75, statistical tests that assume a normal distribution may not be appropriate, especially in applications with proportions.
^dSample size less than 50.
*Relative standard error greater than 0.3.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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Table 3. Selected characteristics of nursing home beds and affiliated non-nursing beds: United States, 1996

	Nursing home beds					Non-nursing beds affiliated with nursing home--ratio to 100 nursing home beds
Facility characteristic	Total		Percent certified as skilled nursing facility^a	Percent certified as nursing facility^b	Percent in special care units^c	Personal care beds	Independent living beds
Total	1,756,800		40.3	90.0	6.9	5.1	6.5
Type of nursing facility
Nursing home with only
nursing home beds^d	1,425,100		38.5	92.9	6.8	--	--
Nursing home with independent
living or personal care unit^e	208,200		39.4	81.9	7.9	41.5	54.6
Hospital-based nursing home	^f123,500		^f62.8	^f69.9	*^f5.7	*^f2.7	*^f0.4
Ownership
For profit	1,171,800		34.5	91.8	6.3	2.4	*2.3
Independent	348,200		38.7	88.4	4.7	*3.4	*2.5
Part of group or chain	823,600		32.7	93.1	7.0	2.0	*2.3
Nonprofit	423,400		55.3	87.7	7.4	13.1	20.1
Independent	295,700		54.7	85.8	6.6	9.8	12.4
Part of group or chain	^f127,700		^f56.6	^f92.2	^f9.1	*^f20.6	*^f37.9
Government	161,600		43.2	83.2	9.2	3.6	*1.3
Facility certification status
Medicare and Medicaid certified		1,414,200	47.9	96.3	7.1	4.5	4.5
Medicare certified only	(g)		(^g)	(^g)	(^g)	(^g)	(^g)
Medicaid certified only	227,700		--	96.4	3.0	*4.4	*9.4
Not federally certified	(g)		(^g)	(^g)	(^g)	(^g)	(^g)
Facility size
Fewer than 75 beds	282,400		38.9	83.4	*2.0	7.7	* 9.9
75-124 beds	674,700		40.6	90.8	5.1	6.3	* 7.0
125-199 beds	448,300		39.7	94.5	10.3	3.5	* 6.6
200 or more beds	351,400		41.7	87.9	9.7	2.7	* 2.7
Census region
Northeast	375,900		64.3	91.5	8.0	4.0	*3.7
Midwest	544,300		31.2	90.8	6.6	*7.0	6.6
South	561,900		31.7	88.6	5.9	4.8	*9.6
West	274,700		42.9	89.1	7.6	*3.5	*3.7
Metropolitan statistical area (MSA)
MSA	1,212,000		42.8	87.4	7.9	6.1	7.0
Not MSA	544,800		34.8	95.7	4.5	2.8	* 5.3
^aFederally certified as Medicare only or dually certified by both Medicare and Medicaid.
^bFederally certified as Medicaid only or dually certified by both Medicare and Medicaid.
^cNursing home units designated for specific nursing home populations, e.g., Alzheimer's and subacute care.
^dIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^eIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
^fBecause this statistic is based on a sample of less than 75, statistical tests that assume a normal distribution may not be appropriate, especially in applications with proportions.
^gSample size less than 50.
*Relative standard error greater than 0.3.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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Table 4. Percent distribution of nursing homes by facility size and selected characteristics: United States, 1996

		Facility size
Facility characteristic	Total nursing homes	Fewer than 75 beds	75-124 beds	125-199 beds	200 or more beds
		Percent distribution
Total	16,840	35.7	39.4	17.1	7.8
Type of nursing facility
Nursing home with only
nursing home beds^a	13,020	30.7	42.4	18.9	8.0
Nursing home with independent
living or personal care unit^b	1,910	36.3	35.0	19.0	9.8
Hospital-based nursing home	^c1,910	^c69.5	^c23.5	*^c2.7	*^c4.2
Ownership
For profit	11,090	30.6	45.1	17.5	6.7
Independent	3,490	41.6	36.3	13.6	8.5
Part of group or chain	7,600	25.5	49.2	19.3	5.9
Nonprofit	4,420	42.7	31.8	17.6	8.0
Independent	3,170	48.3	25.6	16.7	9.4
Part of group or chain	^c1,250	^c28.6	^c47.4	^c19.7	*^c4.4
Government	1,330	55.2	16.8	11.9	16.1
Facility certification status
Medicare and Medicaid certified	12,320	25.7	44.5	20.7	9.0
Medicare certified only	(^d)	(^d)	(^d)	(^d)	(^d)
Medicaid certified only	2,870	60.9	26.8	9.5	*2.9
Not federally certified	(^d)	(^d)	(^d)	(^d)	(^d)
Census region
Northeast	2,910	24.7	38.8	23.5	13.0
Midwest	5,680	46.0	31.9	13.2	8.8
South	5,080	25.5	48.2	20.0	6.4
West	3,170	43.6	39.3	13.5	3.6
Metropolitan statistical area (MSA)
MSA	10,490	29.1	39.4	20.7	10.9
Not MSA	6,350	46.7	39.5	11.2	2.7
^aIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^bIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
^cBecause this statistic is based on a sample of less than 75, statistical tests that assume a normal distribution may not be appropriate, especially in applications with proportions.
^dSample size less than 50.
*Relative standard error greater than 0.3.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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Table 5. Selected use data for nursing homes by selected characteristics: United States, 1995 and 1996

Facility characteristic	Mean occupancy rate for nursing beds, 1996	Admissions, 1995^a	Residents, 1996	Admissions per 100 nursing beds, 1995^a
Total	88.8	1,963,200	1,559,700	111.8
Type of nursing facility
Nursing home with only
nursing home beds^b	88.7	1,374,900	1,263,500	96.5
Nursing home with independent living
or personal care unit^c	91.3	211,100	190,000	101.4
Hospital-based nursing home	^d86.0	^d377,200	^d106,200	^d305.6
Ownership
For profit	87.5	1,281,600	1,025,400	109.4
Independent	88.0	314,200	306,300	90.2
Part of group or chain	87.3	967,400	719,200	117.5
Nonprofit	91.5	567,800	387,400	134.1
Independent	92.1	447,700	272,400	151.4
Part of group or chain	^d90.0	^d120,100	^d114,900	^d94.1
Government	90.9	113,800	146,900	70.4
Facility certification status
Medicare and Medicaid certified	89.3	1,495,600	1,263,500	105.8
Medicare certified only	(^e)	(^e)	(^e)	(^e)
Medicaid certified only	89.9	111,400	204,700	48.9
Not federally certified	(^e)	(^e)	(^e)	(^e)
Facility size
Fewer than 75 beds	88.1	509,800	248,800	180.5
75-124 beds	88.2	723,800	595,300	107.3
125-199 beds	89.8	441,200	402,700	98.4
200 or more beds	89.1	288,400	312,900	82.1
Census region
Northeast	93.3	336,600	350,600	89.5
Midwest	87.5	567,900	476,100	104.3
South	87.9	515,100	493,900	91.7
West	87.0	543,600	239,100	197.9
Metropolitan statistical area (MSA)
MSA	89.2	1,501,300	1,081,200	123.9
Not MSA	87.8	461,900	478,500	84.8
^a1996 figures will be available with the full-year data release in fall 1998.
^bIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^cIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
^dBecause this statistic is based on a sample of less than 75, statistical tests that assume a normal distribution may not be appropriate, especially in applications with proportions.
^eSample size less than 50.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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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.

American Hospital Association: American Hospital Association guide to the health care field, 1996-97 edition. Chicago; 1996.

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 (forthcoming). MEPS Methodology Report No. 4.

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 (forthcoming). MEPS Methodology Report No. 3.

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.

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

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Technical 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, forthcoming). 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 sub sampled 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, forthcoming).

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.

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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, forthcoming).

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 unit(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, forthcoming).

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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. Eleven facilities initially classified as "other nursing home type" were recoded to the latter two categories on further review.

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. Three facilities whose ownership type originally was reported as "other specify" were recoded based on the 1996 American Hospital Association Guide to Hospitals (American Hospital Association, 1996).

Facility Certification Status

Respondents 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 Size

The 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 Location

A 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.

Special Care Beds

Respondents were asked about any special care units within the licensed part of the sampled nursing home--that is, units with a specified number of beds identified and dedicated for residents with specific needs or diagnoses. If the nursing home had a special care unit, respondents were asked to select the type of special care unit(s) from a list provided and to supply the number of beds in each identified unit. The types of special care units identified were Alzheimer's and related dementias, AIDS/HIV, dialysis, children with disabilities, brain injury (traumatic or acquired), hospice, Huntington's disease, rehabilitation, ventilator/ pulmonary, subacute, and "some other kind of unit." Beds from all identified special care units within the sampled facility were added to obtain total special care beds.

Non-Nursing Beds

Respondents were asked whether the sampled nursing home was part of a larger facility or campus, or if the sampled nursing home had any beds not licensed or certified as nursing home beds. If so, all the parts or units of the larger facility or campus were enumerated and/or the number of unlicensed beds was obtained. The numbers of personal care beds, independent living beds, and hospital beds also were obtained.

Personal care beds. The total number of personal care beds was derived by adding the number of beds from all identified parts or units of the sampled nursing home or larger facility that the respondent reported to be "assisted living," "board and care," "domiciliary care," "rest home unit," or "personal care."

Independent living beds. The total number of independent living beds was derived by adding the number of beds from all parts or units of the larger facility or campus or unlicensed units identified as "independent living units."

Hospital beds. The total number of hospital beds was derived by adding the number of beds from all parts or units of the larger facility or campus or unlicensed units identified as "hospital."

1995 Admissions

The number of admissions the sampled nursing home/unit(s) had in 1995-- that is, from January 1, 1995, through December 31, 1995--for the certified or licensed nursing beds in the sampled facility/unit(s) was obtained from the Self-Administered Questionnaire (SAQ). During the interview, the SAQ was left with the facility administrator or designated staff for completion. Approximately 12.5 percent of the sample had missing responses, which were imputed.

1996 Residents

Respondents were asked how many residents were in the sampled facility/unit(s) at midnight on the date of interview. Residents in unlicensed parts of the sampled nursing home were excluded.

Occupancy Rate

The occupancy rate was calculated as the number of residents divided by the total number of nursing home beds within the sampled nursing home, excluding unlicensed beds.

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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 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.

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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 1-5 in the text are provided in Tables A-E, respectively.[Table A][Table B][Table C] [Table D][Table E] For example, the estimate of 77.3 percent for nursing homes with only nursing home beds (Table 1) has an estimated standard error of 1.6percentage points (Table A). The estimate of 1,263,500 residents for nursing homes with only nursing home beds as of January 1, 1996 (Table 5) has an estimated standard error of 20,557 residents (Table E).

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Table A. Standard errors for number of nursing homes and beds by selected characteristics: United States, 1996 Corresponds to Table 1

	Nursing homes		Nursing home beds
Facility characteristic	Number	Percent distribution	Number^a	Percent distribution
	Standard error
Total	368	0.0	11,241	0.0
Type of nursing facility
Nursing home with only nursing home beds^b	335	1.6	22,196	1.2
Nursing home with independent living
or personal care unit^c	185	1.1	18,396	1.1
Hospital-based nursing home	254	1.4	10,657	0.6
Ownership
For profit	342	1.8	26,781	1.4
Independent	283	1.6	23,638	1.3
Part of group or chain	312	1.9	28,579	1.6
Nonprofit	342	1.8	23,863	1.4
Independent	319	1.7	20,900	1.2
Part of group or chain	163	1.0	14,781	0.8
Government	171	1.0	15,226	0.9
Facility certification status
Medicare and Medicaid certified	336	2.0	24,316	1.3
Medicare certified only
Medicaid certified only	275	1.6	19,290	1.1
Not federally certified
Facility size
Fewer than 75 beds	469	2.1	20,222	1.2
75-124 beds	227	1.8	27,777	1.6
125-199 beds	164	1.1	25,363	1.4
200 or more beds	96	0.7	24,110	1.3
Census region
Northeast	214	1.3	23,112	1.3
Midwest	343	1.7	22,602	1.3
South	279	1.7	26,856	1.5
West	274	1.5	18,706	1.1
Metropolitan statistical area (MSA)
MSA	362	2.0	28,217	1.5
Not MSA	383	2.0	26,722	1.5
^aExcludes unlicensed nursing home beds.
^bIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^cIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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Table B. Standard errors of selected characteristics of nursing homes by type of facility: United States, 1996 Corresponds to Table 2

		Type of facility
Facility characteristic	Total nursing homes	Nursing homes with only nursing home beds^a	Nursing homes with independent living or personal care unit^b	Hospital-based nursing home
	Standard error
Total	368	1.6	1.1	1.4
Ownership
For profit	342	1.5	1.1	1.0
Independent	283	2.4	2.0	1.5
Part of group or chain	312	1.8	1.4	1.3
Nonprofit	342	4.2	2.9	4.3
Independent	319	5.4	3.1	5.7
Part of group or chain	163	6.7	6.0	5.4
Government	171	6.6	4.5	7.1
Facility certification status
Medicare and Medicaid certified	336	1.8	1.2	1.6
Medicare certified only	--	--	--	--
Medicaid certified only	275	4.1	3.2	3.0
Not federally certified	--	--	--	--
Facility size
Fewer than 75 beds	469	4.0	2.2	3.8
75-124 beds	277	2.0	1.6	1.3
125-199 beds	164	2.3	2.2	0.8
200 or more beds	96	3.1	2.8	1.6
Census region
Northeast	214	3.2	2.4	2.4
Midwest	343	3.3	2.0	3.1
South	279	2.9	2.3	2.3
West	274	4.5	1.8	4.3
Metropolitan statistical area (MSA)
MSA	362	1.9	1.4	1.5
Not MSA	383	3.3	1.8	3.2
^aIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^bIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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Table C. Standard errors of selected characteristics of nursing home beds and affiliated non-nursing beds: United States, 1996
Corresponds to Table 3

	Nursing home beds				Non-nursing beds affiliated with nursing home--ratio to 100 nursing beds
Facility characteristic	Totat	Percent certified as skilled nursing facility^a	Percent certified as nursing facility^b	Percent in special care units^c	Personal care beds	Independent living beds
	Standard error
Total	11,241	1.3	0.9	0.5	0.8	1.3
Type of nursing facility
Nursing home with only
nursing home beds^d	22,196	1.4	0.8	0.5	--	--
Nursing home with independent
living or personal care unit^e	18,396	3.8	3.3	1.4	6.0	9.7
Hospital-based nursing home	10,657	5.5	5.7	1.9	1.3	0.2
Ownership
For profit	26,781	1.4	1.0	0.6	0.6	1.1
Independent	23,638	3.1	2.4	1.0	1.5	1.9
Part of group or chain	28,579	1.5	0.9	0.7	0.5	1.4
Nonprofit	23,863	2.9	2.1	1.0	3.0	4.2
Independent	20,900	3.5	2.6	1.1	2.0	3.1
Part of group or chain	14,781	5.2	3.2	2.1	8.6	11.6
Government	15,226	4.8	3.8	1.7	1.0	1.3
Facility certification status
Medicare and Medicaid certified	24,316	1.4	0.4	0.5	0.9	1.1
Medicare certified only	--	--	--	--	--	--
Medicaid certified only	19,290	--	1.1	0.7	1.7	3.3
Not federally certified	--	--	--	--	--	--
Facility size
Fewer than 75 beds	20,222	3.4	2.8	0.8	1.9	4.3
75-124 beds	27,777	2.0	1.4	0.7	1.9	2.3
125-199 beds	25,363	2.4	1.1	1.1	0.8	2.2
200 or more beds	24,110	3.1	2.3	1.1	0.7	1.1
Census region
Northeast	23,112	2.7	1.8	1.0	1.1	1.6
Midwest	22,602	2.1	1.5	0.8	2.3	1.9
South	26,856	2.1	1.7	0.8	1.0	3.3
West	18,706	3.2	2.2	1.1	1.3	1.6
Metropolitan statistical area (MSA)
MSA	28,217	1.5	1.2	0.6	1.2	1.5
Not MSA	26,722	2.3	0.9	0.6	0.6	2.4
^aFederally certified as Medicare only or dually certified by both Medicare and Medicaid.
^bFederally certified as Medicaid only or dually certified by both Medicare and Medicaid.
^cNursing home units designated for specific nursing home populations, e.g., Alzheimer's and subacute care.
^dIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^eIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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Table D. Standard errors of percent distribution of nursing homes by facility size and selected characteristics: United States, 1996
Corresponds to Table 4

		Facility size
Facility characteristic	Total nursing homes	Fewer than 75 beds	75-124 beds	125-199 beds	200 or more beds
	Standard error
Total	368	2.1	1.8	1.1	0.7
Type of nursing facility
Nursing home with only
nursing home beds^a	335	2.3	2.0	1.3	0.8
Nursing home with independent living
or personal care unit^b	185	5.3	4.8	3.4	2.1
Hospital-based nursing home	254	6.1	5.4	1.3	1.4
Ownership
For profit	342	2.5	2.2	1.4	0.8
Independent	283	4.7	4.0	2.2	1.5
Part of group or chain	312	2.8	2.6	1.7	0.9
Nonprofit	342	4.6	3.5	2.3	1.3
Independent	319	5.5	3.8	2.7	1.7
Part of group or chain	163	7.3	6.7	4.3	1.7
Government	171	6.6	4.5	3.2	3.2
Facility certification status
Medicare and Medicaid certified	336	2.3	2.1	1.4	0.8
Medicare certified only	--	--	--	--	--
Medicaid certified only	275	4.5	4.0	2.1	0.9
Not federally certified	--	--	--	--	--
Census region
Northeast	214	4.4	4.0	3.0	1.9
Midwest	343	3.7	3.0	1.7	1.2
South	279	3.4	3.3	2.2	1.1
West	274	5.2	4.5	2.4	1.0
Metropolitan statistical area (MSA)
MSA	362	2.7	2.2	1.5	1.0
Not MSA	383	3.5	3.1	1.5	0.7
^aIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^bIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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Table E. Standard errors of selected use data for nursing homes by selected characteristics: United States, 1995 and 1996
Corresponds to Table 5

Facility characteristic	Standard error
	Mean occupancy rate for nursing beds, 1996		Admissions, 1995^a	Residents, 1996		Admissions per 100 nursing beds, 1995^a
Total	0.4		105,143	11,416		5.9
Type of nursing facility
Nursing home with only nursing home beds^b	0.4		59,753	20,557		3.8
Nursing home with independent living
or personal care unit^c	0.9		25,873	16,888		8.5
Hospital-based nursing home	1.9		89,835	9,085		70.0
Ownership
For profit	0.5	79,437		24,056		6.2
Independent	1.0	32,787		20,798		7.3
Part of group or chain	0.6	77,468		25,464		8.2
Nonprofit	0.7	83,168		22,051		18.4
Independent	0.8	82,808		19,428		26.1
Part of group or chain	1.4	17,492		13,410		8.4
Government	1.1	15,674		13,968		8.1
Facility certification status
Medicare and Medicaid certified	0.4	55,152		22,239		3.4
Medicare certified only	--	--		--		--
Medicaid certified only	1.0	11,362		17,533		2.8
Not federally certified	--	--		--		--
Facility size
Fewer than 75 beds	1.0		101,216		17,962	33.3
75-124 beds	0.7		44,060		24,765	4.8
125-199 beds	0.7		34,101		23,003	5.2
200 or more beds	0.9		26,274		21,546	4.7
Census region
Northeast	0.6		37,524		21,777	8.5
Midwest	0.7		69,208		19,981	11.9
South	0.7		35,164		24,047	4.3
West	0.9		78,049		16,353	25.3
Metropolitan statistical area (MSA)
MSA	0.4		107,186		25,565	8.3
Not MSA	0.7		39,677		23,722	6.0
^a1996 figures will be available with the full-year data release in fall 1998.
^bIncludes a small number of nursing homes (less than 1 percent of this category) with an intermediate care unit for the mentally retarded.
^cIncludes continuing care retirement communities and retirement centers that include independent living and/or personal care units, as well as nursing homes that contain or are affiliated with independent living or personal care units.
Source: Center for Financing, Access, and Cost Trends, Agency for Health Care Policy and Research: Medical Expenditure Panel Survey Nursing Home Component, 1996 (Round 1).

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Suggested Citation: Research Findings #4: Nursing Homes - Structure and Selected Characteristics, 1996. January 1998. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/data_files/publications/rf4/rf4.shtml