The COVID-19 pandemic exacerbated long-standing challenges in US nursing homes around staffing conditions, with nearly one in five nursing homes reporting severe staffing shortages during the early months of the pandemic in 2020. However, less is known about how nursing home staffing has evolved since the early part of the pandemic. This study used Payroll-Based Journal daily staffing data from the second quarter of 2018 through the fourth quarter of 2024 and other administrative data to examine trends in nursing home staffing levels and turnover before, during, and after the COVID-19 pandemic. Since the start of the pandemic, staffing hours per resident day decreased for all nurse types, especially in nursing homes associated with private equity funds or real estate investment trusts, during the late pandemic and postpandemic periods. Staff turnover decreased slightly during the pandemic and postpandemic periods for all nurse types. Policy makers should consider additional measures to ensure appropriate nursing home staffing levels going forward.

Importance:Skilled nursing facilities (SNFs) are the primary provider of institutional postacute care. Following the COVID-19 pandemic, there have been reports of SNFs reducing their capacity, affecting access to care and disrupting hospital discharges, yet little empirical evidence exists. Objective:To describe changes in SNF capacity after 2020 and assess whether changes were associated with staffing shortages and hospital discharge outcomes. Design, Setting, and Participants:In this cross-sectional study, data from the 2018-2024 Centers for Medicare & Medicaid Services Payroll-Based Journal on patient censuses in US skilled nursing facilities were assessed. Descriptive analyses characterized trends in SNF capacity from 2018 to 2024. Main Outcomes and Measures:Main outcomes were SNF licensed bed count and estimated operating capacity. Secondary outcomes included SNF staffing shortages, mean hospital length of stay, percentage of hospital admissions lasting 28 days or more, and the median distance traveled to admitting SNFs. County-level regression analyses examined the association between changes in SNF capacity and the frequency of SNF staffing shortages. Hospital-level regressions examined the association between changes in nearby SNF capacity and discharge outcomes. Results:Among US skilled nursing facilities, the number of licensed SNF beds declined by 2.5% between 2019 and 2024, while operating capacity declined by 5.0% over the same time period. There was substantial geographic variation-1 in 4 counties experienced operating capacity declines of 15.1% or more, with the largest declines being more common among rural counties. SNF capacity declines were larger in counties with more frequent reports of SNF staffing shortages-a 1-percentage point decline in county SNF capacity was associated with a 0.20-percentage point (95% CI, 0.11-0.29) increase in the frequency of reported shortages. Additionally, hospitals that experienced larger declines in nearby SNF capacity experienced greater increases in mean length of stay, percentage of stays lasting 28 or more days, and median distance traveled to admitting SNFs. Conclusions and Relevance:Results of this study suggest that SNF operating capacity declined following the pandemic and these declines were larger than the observed declines in licensed SNF bed counts, potentially because of staffing shortages. Greater loss of SNF capacity was associated with longer hospital stays and increased travel distances to SNFs, suggesting that declines in operating capacity may be impairing access to care.

Importance:Nursing home residents with dementia are often unnecessarily hospitalized at the end of life. Institutional Special Needs Plans (I-SNPs) are a type of Medicare Advantage plan for long-term nursing home residents that use advanced practice clinicians to manage care. Studies have demonstrated the effectiveness of the original and largest I-SNP operated by UnitedHealthcare (UHC), but there has been minimal evaluation of non-UHC I-SNPs, which have driven recent growth, nor specific focus on end-of-life outcomes. Objective:To examine the association of I-SNP enrollment with end-of-life outcomes for nursing home residents with dementia, separately for UHC and non-UHC I-SNPs. Design, Setting, and Participants:This retrospective cohort study used 2010 to 2022 Medicare data on 1.4 million long-stay nursing home residents with dementia who died between 2013 and 2022. Facility-level and patient-level selection bias were addressed with cross-temporal propensity score matching and difference-in-differences models. Both the direct effects of I-SNP enrollment, as well as the indirect (ie, spillover) effects on nonenrollees residing in nursing homes offering I-SNPs were assessed. Variation in these relationships by I-SNP maturity was also examined. Data were analyzed from November 2024 to April 2026. Exposure:Four I-SNP exposure categories: UHC I-SNP enrollment and spillover; non-UHC I-SNP enrollment and spillover. Main Outcomes and Measures:Hospitalization and hospice use in the last month of life. Results:The study cohort included 1 415 265 long-stay nursing home residents with dementia who died between 2013 and 2022. The unadjusted hospitalization rate in the last 30 days of life was 27.7%. UHC I-SNP enrollment was associated with a 9.0-percentage point (pp) reduction in hospitalization (95% CI, -10.3 pp to -7.7 pp) while non-UHC I-SNP enrollment was associated with a 5.9-pp reduction (95% CI, -8.4 pp to -3.5 pp). The spillover effect on nonenrollees in nursing homes offering a UHC I-SNP was a 1.7-pp (95% CI, -2.4 pp to -1.1 pp) decline in hospitalizations; the spillover effect in non-UHC nursing homes was not statistically significant. Similar trends appeared with hospitalization in the last 3 days of life, intensive care unit admission, and mechanical ventilation, but there was no association with hospice use. The reduction in hospitalizations increased in the 3 years after nursing home I-SNP adoption, then plateaued. Conclusions and Relevance:In this retrospective cohort study, I-SNP enrollment was associated with significantly fewer hospitalizations for nursing home residents with dementia at the end of life, with effect sizes larger for UHC vs non-UHC I-SNPs. Plan maturity and volume are likely important factors impacting success.

The U.S. nursing home industry faces severe labor shortages that have worsened following the Covid-19 pandemic. Because nursing homes are highly reliant on immigrant labor, a frequently proposed policy lever to address shortages is to increase national immigration flows. Although debates over immigration remain contentious, existing evidence using geographic-level data indicates that greater immigration increases the supply of nurses and nurse aides with some improvements in nursing home quality. This paper extends earlier work using nursing home- and patient-level data and shift-share analyses to assess the impact of increased immigration on nursing home staffing and care quality. Additionally, we explore heterogeneity in observed treatment effects and potential mechanisms through which changes in patient outcomes occur. In our preferred specifications, we show that increased immigration significantly raises the direct care staffing ratios of nursing homes, with effects concentrated among full-time workers. We then show that this has a robust and very positive effect on a variety of patient outcomes. Effects were strongest from increases in Hispanic immigrants. We find suggestive evidence that immigrants increase both the supply and quality of the nursing home workforce, supporting the critical role that immigration may play in addressing long-standing staffing and quality issues in this industry.

BACKGROUND:Hospice services are growing among Medicare beneficiaries, yet concerns remain about the hospice quality for residents in assisted living (AL) communities. Little is known about how AL characteristics and state regulations are associated with hospice care in these settings. OBJECTIVES:To examine (1) whether AL user-generated google maps ratings (AL google maps ratings) and (2) state-level regulations on AL staffing are associated with hospice ratings: METHODS: We conducted a cross-sectional analysis of 15,947 AL communities. We included data on AL-specific direct care worker (DCW) state staffing and staff training regulations. Logistic regression models were used to assess associations, adjusting for AL, hospice, and market-level characteristics. RESULTS:A one-star increase in an AL google maps rating was associated with 6% higher odds of being served by hospices with higher HIS scores (OR = 1.06, p = 0.032), but not with CAHPS scores. AL communities in states with higher regulatory specificity for DCW staffing had higher odds of being served by hospices with higher CAHPS (OR = 1.46, p < 0.001) and HIS scores (OR = 1.35, p < 0.001). ALs in states mandating more than 21 h of DCW training, AL communities were more likely to be served by hospices with higher CAHPS scores (OR = 1.33, p < 0.001). CONCLUSION:Higher AL google maps ratings were associated with higher hospice HIS performance. DCW staffing regulations were associated with both CAHPS and HIS, and DCW training regulations were associated with CAHPS only. These findings underscore the role of organizational quality and state regulatory policies in guiding end-of-life care in AL communities.

BACKGROUND:Medical directors are thought to be key determinants of nursing home quality, yet their role is highly variable and evidence of their effects on patient outcomes is limited. This paper examines the relationship between hiring a medical director with a Certified Medical Director (CMD) certification and facility-level quality measures. METHODS:We linked a national roster of physicians who completed CMD certification to facility-level quality data from LTCFocus (2011-2021) and CMS Nursing Home Provider Information files. Using a stacked difference-in-differences event study design, we compared changes in quality outcomes before and after CMD hire with matched facilities that never hired a CMD. Matching was based on state, profit status, and baseline 5-star rating. Outcomes included 30-day rehospitalizations for new admissions, total hospitalizations per 1000 resident-days, pressure ulcers, functional decline, restraint use, and successful community discharge. Models adjusted for staffing levels, resident case-mix, and facility and year fixed effects. RESULTS:The analytic sample included 495 facilities that hired a CMD and 11,823 matched comparators that did not. In the 4 years following a CMD hire, facilities experienced a reduction in 30-day rehospitalization rates of 0.78 percentage points annually (95% CI: -1.26, -0.30) compared to those without a CMD, representing a 4.6% relative decline. Evidence of declines in total hospitalizations was also found: 2 years after CMD hire, facilities experienced -0.081 fewer hospitalizations per 100 resident years (95% CI: -0.161, -0.001) compared to control facilities, a 2.7% relative reduction. No differences in the other quality outcomes were found. CONCLUSION:Hiring a CMD was associated with meaningful reductions in hospitalizations, suggesting that the medical director position is an important determinant of care quality and that individual physicians may vary in their effectiveness in this role. Findings support policy efforts to strengthen medical director engagement and accountability in nursing homes.

Throughout the COVID-19 pandemic, the Centers for Medicare and Medicaid Services and state health agencies implemented numerous regulations for nursing homes addressing infection control and data reporting. This study explores interviews (n = 156) with administrators of 40 nursing homes across the U.S. between July 2020 and December 2021 to better understand their experiences with governmental agencies amid shifting regulatory standards, frequent inspections, and possible enforcement actions. Administrators highlighted confusion due to the evolving and sometimes conflicting guidance between state and federal agencies, although some states offered valuable COVID-19-specific assistance. They also described challenges in understanding and implementing new, frequently changing requirements, resulting in potential inspection deficiencies. Although enforcement actions, including financial penalties, are intended to deter noncompliance, administrators expressed concerns about added resource strain. Recommendations included increasing collaboration and data collection between regulatory agencies; reducing administrative burden during outbreaks and incorporating feedback from centers during regulatory changes; and increasing reimbursement to support compliance. Continued changes to oversight, including increased penalization and risk-based survey prioritization, should be evaluated to determine differential impacts on nursing home operations and resident care.

The Patient Driven Payment Model (PDPM), a major reform in the way Medicare reimburses for skilled nursing facility (SNF) care, went into effect in October 2019, prioritizing intensity of nursing care provided over volume of therapy. The purpose of this study was to understand how the PDPM shaped SNF admissions and care delivery, using SNF administrator perspectives. Findings from this qualitative thematic analysis suggest that the PDPM created incentives for SNFs to prioritize more clinically complex patients over patients requiring less complex rehabilitation, improved care coordination between hospitals and SNFs, as well as within the SNF interdisciplinary care team, and emphasized the patient documentation review required for reimbursement. Findings suggest that these changes contributed to SNF care teams better understanding patients' care needs. When considering how best to balance efficiency and quality in patient care delivery, it is important to understand the nuanced changes the PDPM has on SNF operations.

Introduction:Medicare beneficiaries face significant health risks and care disruptions during public health emergencies, but little is known about how care patterns evolved throughout the COVID-19 pandemic or differed between traditional Medicare (TM) and Medicare Advantage (MA). Methods:Using Medicare claims data for over 20 million hospital discharges during 2018-2022, we examined trends in hospital length of stay, discharge disposition, and mortality among beneficiaries with 5 major comorbidities (dementia, diabetes, congestive heart failure, hip fracture, and stroke), stratified by COVID status and payer type. Results:We found that COVID patients initially experienced substantially longer hospital stays (8.3 vs 4.6 days) and higher 30-day mortality (34% vs 5%) compared to patients without COVID. MA beneficiaries showed consistently higher home health utilization but similar mortality patterns to TM enrollees. By mid-2022, most outcome differences had converged between COVID and non-COVID patients, suggesting health system adaptation to the pandemic. Conclusion:Our findings highlight how the pandemic was associated with shifts toward home-based post-acute care, emphasizing the need for policies supporting home-based care infrastructure and flexible care delivery models that could help health systems better adapt during future public health emergencies.

BACKGROUND:Hospice services are widely used by assisted living residents at the end of life, yet concerns exist about the adequacy and quality of hospice care in this setting. PARTICIPANTS AND SETTING:This cohort study analyzed Medicare claims data from 51,303 assisted living residents who received hospice care and died in 2018-2019. Data were linked to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey to evaluate perceived hospice quality. METHODS:The primary exposure was the number of hospice staff visits in the last 3 days of life, categorized as clinical (physicians, nurses) or nonclinical (social workers, hospice aides, chaplains, bereavement counselors). The primary outcome was hospice quality ratings from the CAHPS Hospice Survey. Multivariable regression models were used to examine associations between hospice staff visits and quality ratings, adjusting for resident and hospice characteristics. RESULTS:Among 51,303 assisted living residents, the average CAHPS rating was 80.83. Increased hospice clinical staff visits were associated with improvements in emotional support (0.04-point increase per visit, p < 0.001), family rating of hospice (0.03-point increase, p < 0.001), willingness to recommend (0.03-point increase, p < 0.001), and feeling respected (0.02-point increase, p < 0.001). Increased nonclinical staff visits had stronger associations, including a 0.14-point increase in emotional support (p = 0.01), a 0.28-point increase in willingness to recommend (p < 0.001), and a 0.18-point increase in average scores (p = 0.01). CONCLUSIONS:Higher frequency of hospice staff visits was associated with better perceived hospice quality. Policies supporting greater hospice staff engagement, including nonclinical staff, may enhance end-of-life care experiences for assisted living residents.

The COVID-19 pandemic exacerbated staffing shortages in U.S. nursing homes. Staff who are immigrants may have stronger tendencies to remain in their jobs than U.S.-born staff, but evidence is lacking. In this study, we predicted the share of immigrant staff and used a difference-in-differences regression to investigate whether nursing homes with a higher vs. lower proportion of immigrant certified nursing assistants (CNAs) experienced lesser declines in staff hours per resident day (HPRD) during the pandemic. We found that facilities with a larger-than-median predicted share of immigrant staff exhibited a relatively smaller decrease in CNA HPRD by 0.03 HPRD, equivalent to a 1.4% difference of the sample mean. We further found that CNA turnover rates during the pandemic were lower in facilities with relatively higher shares of immigrant staff. Our findings suggest that nursing homes with more immigrant staff may be more resilient in meeting staffing needs during crises.

OBJECTIVES:To examine (1) whether hospice staff visits are associated with end-of-life (EOL) transitions, place of death (POD), and live discharges among assisted living (AL) residents, and (2) whether state AL regulations on staffing and medication administration influence these outcomes. We hypothesized that more frequent staff visits and specific regulatory provisions would be associated with improved EOL outcomes. DESIGN:Retrospective cohort study using Medicare claims data from 2018-2019. Sensitivity analyses used logistic regression models to assess robustness. SETTING AND PARTICIPANTS:National, population-based study of Medicare decedents residing in licensed AL communities across the United States. The main analytic sample included 42,466 AL residents who received hospice and died during enrollment. A separate sample of 61,851 was used to assess live discharges. Participants were identified by linking 9-digit ZIP codes of 10,452 licensed ALs to Medicare enrollment files. Individuals younger than 55 years, not enrolled in hospice, or enrolled in Medicare Advantage were excluded. METHODS:Key exposures included the frequency of hospice staff visits (clinical vs nonclinical) and the presence of state AL regulations related to staffing and medication delegation. Outcomes included EOL transitions within the last 7 days of life, POD in AL vs other settings, and live discharges from hospice. RESULTS:More frequent clinical staff visits were associated with lower rates of EOL transitions [-12 percentage points (pp)], reduced live discharges (-4 pp), and increased likelihood of dying in place (+4 pp; all P < .001). Nonclinical visits showed modest but consistent associations with improved outcomes. State regulations requiring on-site staffing and permitting medication delegation were associated with fewer transitions and higher rates of in-place death. CONCLUSIONS AND IMPLICATIONS:Hospice staffing intensity, especially clinical visits, appears to be associated with EOL outcomes for AL residents. AL state regulations are also associated with hospice quality. These findings underscore the role of both organizational practices and regulatory policy in shaping hospice experiences in AL settings.

Importance Skilled nursing facilities (SNFs) experienced high mortality during the COVID-19 pandemic, leading them to adopt preventive measures to counteract viral spread. A critical appraisal of these measures is essential to support SNFs in managing future infectious disease outbreaks. Objective To perform a scoping review of data and evidence on the use and effectiveness of preventive measures implemented from 2020 to 2024 to prevent COVID-19 infection in SNFs in the US. Evidence Review Two analyses were performed. First, an analysis of the federal COVID-19 SNF Database was conducted to describe time trends in COVID-19 incidence, deaths, testing, vaccination, and treatment among SNF residents and staff, as well as shortages in staff and personal protective equipment (PPE). Then, a comprehensive literature search was conducted from May 2023 to April 2024 to identify high-quality evidence on the use and effectiveness of modifiable preventive measures used among SNF residents. Both nonpharmacologic (facility characteristics, PPE, cohorting, and isolation, visitation, staffing, testing) and pharmacologic (vaccination, treatment) measures were reviewed. Findings Nationwide data indicated early shortages of PPE, infrequent testing, and persistent staff shortages in SNFs. Other nonpharmacologic measures, such as visitor restrictions or ventilation modifications, were widely adopted but there were no available national data to quantify their effectiveness. These nonpharmacologic measures lacked high-quality studies to verify effectiveness. In contrast, the effectiveness of vaccination and antiviral treatment was shown in multiple studies. Evidence also showed associations between COVID-19 outcomes in residents and crowding, staff size, hours per residents and networks, and surveillance testing of residents and staff. Despite high initial uptake, up-to-date vaccination status was suboptimal in residents and staff from 2022 to 2024. Only a minority of infected residents received antiviral treatment. Conclusions and Relevance This scoping review found that although many preventive measures were implemented in SNFs in the US throughout the COVID-19 pandemic, few were based on clear evidence of their effectiveness. Pharmacologic measures, such as vaccination and antiviral treatment, had more robust evidence supporting their efficacy than nonpharmacologic interventions. Using the scarce resources and staff of SNFs on measures of questionable effectiveness could distract from known effective ones such as vaccination and antiviral treatment. When possible, implementation efforts should be commensurate with the demonstrated effectiveness of available preventive measures.

Background Medicare Advantage (MA) plans now cover 54% of all Medicare beneficiaries. However, MA is understudied in the nursing home population. We analyzed MA enrollment trends and resident and facility characteristics from 2010 through 2023.Methods We calculated the point prevalence of MA enrollment for long-stay nursing home residents, short-stay residents, and all other Medicare beneficiaries from 2010 to 2023, and compared variation in MA growth at the state level between long-stay residents and the general Medicare population. We analyzed how the composition of Traditional Medicare- and MA-enrolled long-stay residents changed over time, changes in special needs plan (SNP) enrollment, and nursing home quality for MA enrollees. We also tracked monthly MA enrollment rates among nursing home residents before and after they became long-stay.Results MA enrollment among long-stay residents increased from 12.9% in 2010 to 36.5% in 2023, a 183% increase, outpacing the growth rate among the overall Medicare population. There was substantial geographic variation in MA growth between long-stay residents and others across states. Enrollment in Institutional SNPs grew substantially, accounting for about 35% of MA enrollment among long-stay residents. Dual-Eligible SNP enrollment also accounted for a substantial proportion among MA long-stay residents, ranging between 12% and 20% across years. Long-stay residents covered by Traditional Medicare and MA showed comparable clinical characteristics and had similar shares residing in high-quality nursing homes. Disenrollment from MA sharply increased as beneficiaries entered nursing homes for long-term care.Conclusions The substantial growth in MA enrollment among long-stay nursing home residents, coupled with the notable geographic variation and disenrollment, underscores the importance of recognizing that not all beneficiary groups experience MA in the same way. Targeted monitoring is needed to ensure that MA plans adequately address the care needs of this high-risk population.

Importance:The Patient Driven Payment Model (PDPM), implemented in October 2019, fundamentally changed how Medicare reimburses skilled nursing facilities (SNFs) for postacute care, shifting from therapy volume-based payment to reimbursement based on patient clinical and functional characteristics. Understanding the relationship of the PDPM to SNF coding practices, Medicare expenditures, and clinical outcomes is essential for evaluating its policy and clinical implications. Objective:To evaluate changes in SNF diagnostic coding intensity, Medicare expenditures, and patient outcomes before and after PDPM implementation. Design, Setting, and Participants:This retrospective cohort study used regression discontinuity analysis of traditional Medicare beneficiaries aged 65 and older who were admitted to SNFs for postacute care after hospitalization between January 2018 and February 2020. All analysis was completed between August 2024 and April 2025. Exposures:PDPM implementation on October 1, 2019. Main Outcomes and Measures:Primary outcomes included SNF relative coding intensity measured as the difference between SNF and hospital Elixhauser Comorbidity index scores, 30-day rehospitalization, 30-day mortality, SNF episode expenditures, SNF length of stay, and mean daily therapy minutes. Results:The study included 2 065 809 Medicare beneficiaries (mean [SD] age, 81.2 [8.6] years; 61% female individuals; 8.8% Black, 1.3% Hispanic, and 86.8% White). PDPM implementation was associated with a significant increase in SNF relative coding intensity (0.54 points; 95% CI, 0.40-0.68; P < .001) and a $665 increase (95% CI, $437-$892; P < .001) in SNF episode expenditures. No significant changes were observed in 30-day rehospitalization or mortality rates. Increases in spending were concentrated among beneficiaries with higher clinical complexity and in for-profit SNFs. Conclusions and Relevance:This study found that PDPM implementation was associated with increased coding intensity and Medicare expenditures in SNFs, without changes in patient mortality and readmissions. These findings suggest that SNFs responded to PDPM incentives through changes in coding practices, underscoring the importance of continued monitoring to ensure that the financial incentives of PDPM promote support accurate coding, equitable reimbursement, and high-quality care.

Importance:Hospitals have reported growing difficulty in discharging patients in a timely manner, often citing bottlenecks in postacute care. Medicare Advantage plans, now the dominant form of Medicare coverage, may contribute to these delays due to administrative and network constraints, yet national evidence is lacking. Objective:To quantify changes in hospital length of stay for Medicare Advantage vs traditional Medicare beneficiaries. Design, Setting, and Participants:This retrospective cohort study used Medicare claims from 2017 through the third quarter of 2023. The sample included short-stay inpatient admissions to US acute care and critical access hospitals. Adjusted analyses were conducted on a 20% random sample, with subgroup analyses of patients discharged to skilled nursing facilities. Data were analyzed from June 2024 to June 2025. Exposure:Medicare coverage type at the time of hospital admission. Main Outcomes and Measures:Primary outcomes included length of stay (in days) and indicators for extended stays (≥7, ≥14, ≥21, and ≥28 days). Difference-in-differences regression models estimated changes in length of stay for Medicare Advantage relative to traditional Medicare, adjusting for patient demographics and hospital fixed effects. Results:The sample included 89.3 million hospital admissions. Over the study period, the mean (SD) length of stay for Medicare Advantage admissions increased from 6.0 (5.7) to 7.1 (7.6) days compared with an increase from 5.8 (SD) to 6.3 (SD) days for traditional Medicare. By the end of the study period, Medicare Advantage admissions were 1.2 percentage points (95% CI, 1.0-1.3) more likely than traditional Medicare admissions to last 14 or more days, a 19.5% increase relative to the sample mean at baseline. Relative increases were larger for stays of 21 or more days (1.2 percentage points; 95% CI, 1.0-1.3; a relative increase of 25.1%) and 28 or more days (0.28, 95% CI, 0.23-0.33; a relative increase of 31.9%). Among patients discharged to skilled nursing facilities, the adjusted probability of Medicare Advantage admissions lasting 14 or more days increased by 3.1 percentage points (95% CI, 2.6-3.6) relative to traditional Medicare, a 28.1% increase relative to the baseline sample mean. In 2022 alone, prolonged stays among Medicare Advantage patients accounted for an estimated 1.8 million additional hospital bed-days, equivalent to 288 000 additional admissions with average length of stay. Conclusions and Relevance:This cohort study found that from 2017 to 2023, Medicare Advantage beneficiaries experienced disproportionately greater increases in hospital length of stay than traditional Medicare beneficiaries, especially among those discharged to skilled nursing facilities. These trends may reflect insurance-related discharge barriers that contributed to millions of additional hospital bed-days. As Medicare Advantage enrollment continues to grow, addressing barriers to discharge may be critical for improving hospital throughput and patient outcomes.

BackgroundHome time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed nurse staffing.MethodsMedicare beneficiaries who entered AL communities in 2018 were identified, and their home time in the year following admission was measured. Home time was calculated as the percentage of time spent at home per day being alive. Resident characteristics and state regulations in DCW staffing, DCW training, and licensed staffing were measured. We used a multivariate linear regression model with AL-level fixed effects to estimate the relationship between person-level characteristics and home time. Linear regression models adjusting for resident characteristics were used to estimate the association between state regulations and residents' home time.ResultsThe study sample included 59,831 new Medicare beneficiary residents in 12,143 ALs. In the year following AL admission, residents spent 94% (standard deviation = 14.6) of their time at home. Several resident characteristics were associated with lower home time: Medicare-Medicaid dual eligibility, having more chronic conditions, and specific chronic conditions, for example, dementia. In states with greater regulatory specificity for DCW training and staffing, and lower specificity for licensed staffing, residents had longer adjusted home time.Conclusion/ImplicationsHome time varied substantially among AL residents depending on resident characteristics and state-level regulatory specificity. AL residents eligible for Medicare and Medicaid had substantially shorter home time than the Medicare-only residents, largely due to longer time spent in nursing homes. State AL regulatory specificity for DCWs and licensed staff also impacted AL residents' home time. These findings may guide AL operators and state legislators in efforts to improve this important quality of life metric.

ObjectivesAssess prevalence of serious mental illness (SMI) alone, and co-occurring with Alzheimer disease and related dementias (ADRD), among Medicare beneficiaries in assisted living (AL). Examine the association between permanent nursing home (NH) placement and SMI, among residents with and without ADRD.Design2018-2019 retrospective cohort of Medicare beneficiaries in AL. Residents were followed for up to 2 years to track their NH placement. We used data from the Medicare Enrollment Database, the Medicare Beneficiary Summary File, Minimum Data Set, and a national directory of state-licensed AL communities. AL residents were identified using a validated, previously reported 9-digit zip code methodology.Setting and ParticipantsA cross-sectional study sample included 289,350 Medicare beneficiaries in 17,265 AL communities across 50 states and in the District of Columbia.MethodsThe outcome was permanent NH placement: a continuous stay for more than 90 days. Key independent variable was presence of SMI—schizophrenia, bipolar disorder, and major depression. Other covariates included sociodemographic factors and presence of other chronic conditions, including ADRD. A linear probability model with robust SEs, and AL-level random effects, was used to test the association between SMI diagnoses, ADRD, and their interactions on NH placement.ResultsMore than half (55.65%) of AL residents had a diagnosis of SMI, among them 93.2% had major depression, 28.5% schizophrenia, and 22.2% bipolar disorder. Individuals with schizophrenia and bipolar disorder had a significantly lower probability of NH placement, a 32% and a 15% decrease relative to the cohort mean, respectively. Placement risk was significantly greater for residents with ADRD compared to those without, increasing for those who also had schizophrenia or bipolar disorder, 12.9% and 1.5% relative to the sample mean, respectively.Conclusion and ImplicationsPresence of schizophrenia and bipolar disorder, in conjunction with ADRD, significantly increases the risk of long-term NH placement, suggesting that ALs may not be well prepared to care for these residents.

BackgroundAssisted living (AL) community caregivers are known to report lower quality of hospice care. However, little is known about hospice providers serving AL residents and factors that may contribute to, and explain, differences in quality. We examined the association between hospice providers' AL patient-day volume and their quality ratings based on Hospice Item Set (HIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Surveys.MethodsThis cross-sectional study employed information from the Medicare Compare website and Medicare claims data. Medicare-eligible AL residents were identified using previously validated methods and merged with hospice claims. Linear probability models adjusting for county fixed effects were used to examine the association between hospice provider AL volume, measured as the share of annual hospice patient days from AL residents, and quality measures obtained from HIS and CAHPS. Models controlled for hospice providers' profit status and daily patient census.ResultsHigher AL-volume hospice providers were 7 percentage points more likely to have caregivers reporting lower median scores on domains of pain assessment, dyspnea treatment, and emotional support. Their caregivers also reported lower scores in team communications and training family to provide care. Higher AL-volume hospice providers also were 5 percentage points less likely to get higher aggregated scores from all CAHPS domains and 7 percentage points less likely to have higher HIS composite scores.ConclusionsHospice providers serving higher volumes of AL patient days had lower quality scores. In order to identify targeted opportunities for quality improvement, research is needed to understand why lower quality providers are concentrated in the AL market.