The association of individual and facility characteristics with psychiatric hospitalization among nursing home residents

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2009; 24: 261–268.

Published online 26 August 2008 in Wiley InterScience

(www.interscience.wiley.com) DOI: 10.1002/gps.2099

The association of individual and facility characteristicswith psychiatric hospitalization among nursing homeresidents

Marion Becker1*, Ross Andel1, Timothy Boaz1 and Timothy Howell2

1University of South Florida, Tampa, FL, USA2University of Wisconsin-Madison, Madison, WI, USA

SUMMARY

Objective To examine resident and facility characteristics associated with psychiatric hospitalizations (PH) for Medicaidenrolled nursing home (NH) residents.Methods Participants were all Medicaid enrolled NH residents (n¼ 32,604) from all Medicaid certified nursing homes inFlorida (n¼ 584) with complete data. We used individual demographic and diagnostic characteristics, as well as facilitycharacteristics, to explore risk of psychiatric hospitalization in this dataset.Results Using generalized estimating equations, we found that younger age, male gender, poor physical health, seriousmental illness, dementia, and drug use disorder were associated with risk of psychiatric hospitalization. Most notably,residents under 65 were more than three times more likely to undergo psychiatric hospitalization and dementia wasassociated with a three-fold increase in the risk of psychiatric hospitalization. Predictors of PH differed somewhat foryounger and older residents. Among facility characteristics, greater facility size, low proportion of those paying viaMedicareand high proportion of residents with serious mental illness were associated with increased risk of psychiatric hospitalization,whereas, low proportion of residents paying via Medicaid, high proportion of residents paying via Medicare, and lowproportion of resident with serious mental illness were associated with reduced risk.Conclusions Both resident and facility characteristics impact risk for psychiatric hospitalization. Attention to identifiedpredictors may reduce risk and improve outcomes for nursing home residents. Copyright # 2008 John Wiley & Sons, Ltd.

key words—Medicaid; nursing home residents; psychiatric hospitalisation

INTRODUCTION

Over the past two decades issues regarding nursinghome (NH) residents with mental health problemshave received increased attention (Tariot et al., 1993;Bartels et al., 2003; Nursing Home Reform, 2007).Estimates suggest about 80% of NH residents have adiagnosable psychiatric disorder (Kim and Rovner,1996; Strahan, 1997). Over half of NH residents arediagnosed with dementia, 40% suffer from depression,and up to 20% from anxiety disorders (Magaziner

*Correspondence to: DrM. A. Becker, Department of Mental HealthLaw and Policy – MHC 2735, Louis de la Parte Florida MentalHealth Institute, University of South Florida, 13301 Bruce B.Downs, Tampa, FL 33612, USA. E-mail: [email protected]

Copyright # 2008 John Wiley & Sons, Ltd.

et al., 2000; Jones et al., 2003). Despite an obviousneed, few residents receive appropriate mental healthtreatment, with less than 20% seen by a mental healthprofessional (Shea et al., 2000; Bartels et al., 2002).Psychiatric problems that could be addressed oravoided with timely access to proper clinical servicesall too often worsen until hospitalization is required(Carter, 2003), making relocation to a hospital forpsychiatric evaluation and treatment more common inthis population.In any 6-month period as many as 25% of NH

residents are hospitalized for mental and/or physicalhealth disorders (Castle and Mor, 1996; Intrator et al.,1999). Although those hospitalizations may havebeneficial effects, they also expose NH residents tomultiple health risks including iatrogenic illness,

Received 6 February 2008Accepted 3 July 2008

262 m. becker ET AL.

delirium, increased mortality and relocation stresssyndrome (Mallick and Whipple, 2000; Ouslanderet al., 2000; McKinney and Melby, 2002), and mayincrease the risk of suicide (Karvonen et al., 2008).Such hospitalizations are also associated withincreased subsequent health service utilization andpost-discharge costs (Swan et al., 2001). While theeffects of relocation on NH residents have beenstudied since the 1960s (Aldrich and Mendkoff, 1963;Coffman, 1981; Mirotznik and Lombardi, 1995), fewstudies have specifically focused on psychiatrichospitalization (PH).In light of the cost and disruption associated with

PH of vulnerable NH residents, it is important toidentify risk factors for these events, particularly giventhat hospitalizations may sometimes be preventable(Mor et al., 1997; Saliba et al., 2000; Intrator et al.,2007). The objective of this study was to examineresident and facility characteristics that predictpsychiatric hospitalization among Medicaid-enrollednursing home residents.

METHODS

Participants

We used 2.5 years (31 December 2002, through30 June 2005) of FloridaMedicaid enrollment and fee-for-service claims data. The Online Survey Certifica-tion and Reporting (OSCAR) database was used toidentify specific NH characteristics. OSCAR data arecollected annually through surveys of all certifiednursing facilities in the United States. These dataprovide information on facility structure (e.g. size,staffing ratio), organization (e.g. chain membership,

Table 1. Diagnostic definitions for mental illness

Diagnosis

Disorders making up definition of Serious Mental Illness or SMIMajor Psychotic Disorder Anyone with

(schizophreni298.8 (brief p

Bipolar Disorder Anyone withobeginning wit

Major Affective Disorder Anyone withodiagnosis cod

Other diagnosesAlcohol Use Disorder Anyone withDrug Use Disorder Anyone with

305.2 to 305.Alzheimer’s Disease Anyone withOther Dementia Anyone with

290.0-290.9


for- vs not-for-profit status), citations for deficienciesin quality of care, and other characteristics. TheOSCAR database is frequently used for nursinghome research because it is the most comprehensivesource of facility information (Lapane and Hughes,2004; Gruneir et al., 2007).

We were able to gather valid OSCAR and Medicaiddata for 83% of the 704 Medicaid-certified nursinghomes in Florida (n¼ 584). Reasons for the inabilityto match data for the remaining 120 nursing homesinclude missing and duplicate Medicaid IDs and/orincomplete data in the OSCAR files. We followed all32,604 Medicaid eligible residents who were enrolledin one of the 584 Florida nursing homes on 31December 2002, for a maximum of 2.5 years. We usedadditional data collected prior to 31 December 2002 toobserve the use of services within six months prior topsychiatric hospitalization.

Measures

Occurrence of a psychiatric hospitalization for nursinghome residents was determined by Medicaid inpatientclaims from a psychiatric or general hospital in whichthe primary admitting diagnosis was a mental healthdisorder as defined by the ICD-9 codes found inTable 1. Psychiatric hospitalization was measured asno (0) vs yes (1). For participants that had a PH,Medicaid claims for the 6 months prior to thathospitalization were assessed to determine if theresident received psychotropic medication or beha-vioral health services.

Facility characteristics were extracted from theOSCAR data and included for- vs not-for-profit status,

Description

an ICD-9 diagnosis code beginning with 295a), 297.1 (delusional disorder), 297.3 (shared psychotic disorder),sychotic disorder), or 298.9 (psychotic disorder NOS)ut a major psychotic disorder and with an ICD-9 diagnosis codeh 296.0, 206.1, 296.4, 296.5, 296.6, 296.7, or 296.80 or 296.89ut a major psychotic disorder, bipolar disorder and with an ICD-9e beginning with 296.2, 296.3, 296.90 and 311

an ICD-9 diagnosis codes 291, 303.0, 303.3, 303.9 and 305.0an ICD-9 diagnosis code beginning with 292.0-292.9 304.0- 304.99an ICD-9 diagnosis code of 331.0an ICD-9 diagnosis code beginning with 331.1-331.9 294.1and


DOI: 10.1002/gps

psychiatric hospitalizations among nursing home residents 263

membership in a chain, facility size (fewer than120 beds vs 120 or more), the proportion of residentspaying via Medicaid or Medicare, the number and typeof quality-of-care citations, and the ratio of the full-timelicensed practical nurses and registered nurses perresident. In addition, we determined the proportion ofparticipants with serious mental illness (SMI) in eachfacility, including major psychotic disorder, bipolardisorder or major affective disorder (see Table 1).

Demographic characteristics, age (younger than65 years vs 65þ) gender, and race (White vs non-White) were extracted from the Medicaid enrollmentdata. Mental disorder was determined by documen-tation in the Medicaid outpatient and inpatient claimsfiles of one of the ICD-9-CM codes listed in Table 1.The Charlson Index (Charlson et al., 1987) was used tomeasure physical health status. The index is aprospective method for classifying physical healthconditions demonstrated to alter the risk of morbidityand mortality. The index uses ICD-9-CM physicalhealth codes to classify 19 major physical illnessesinto a single weighted severity score. Extensivelyresearched, this instrument reliably measures physicalhealth status in longitudinal studies using adminis-trative data (e.g. Bravo et al., 2002; Quan et al., 2002).

Analysis

We analyzed individual and facility factors separatelyand within one fully adjusted model. We usedgeneralized estimating equations (GEE) in SAS(version 9) procedure GENMOD to estimate the riskof psychiatric hospitalization. This procedure yieldsrelatively conservative estimates by using empirical

Table 2. Resident characteristics by event status

Resident characteristics All residents

Total n¼ 32604

n % n

Age, 65 years and older 28,692 88.0 16Gender, female 23,602 72.4 15Race, White 23,415 71.8 18

Diagnostic informationAD or other dementia 12,751 39.1 20Any serious mental illness 6,318 19.4 23Major Psychotic disorder 3,036 9.3 18Bipolar Disorder 300 0.9 1Major Affective 2,982 9.1 4

Alcohol use disorder 429 1.3 2Drug use disorder 162 0.5 2

Charlson Index, 1 or more 19,347 59.3 26


(robust) standard errors. Specifically, the procedureadjusts for correlations across error terms forobservations obtained from the same facility, whichartificially reduce standard error of measurement(Tabachnik and Fidell, 2006). In addition, theprocedure can adjust for proportionality of the riskacross participants with unequal time in the study. Thelevel of significance was set at two-tailed 0.05. Theprocedure can provide Risk Ratios (RR). Risk ratioslower than 1.00 indicate reduced risk whereas RRabove 1.00 indicate increased risk. The result issignificant when the lower and upper limits of the 95%Confidence Interval (CI) do not span across 1.00.We stratified four facility variables—proportion of

residents paying via Medicaid or Medicare, thenumber of quality-of-care citations, and the proportionof residents with serious mental illness—into threelevels such that the middle level (which served as thereference group) comprised approximately the middle50% of the facilities. We also calculated a test of alinear trend for these variables. Specific types ofquality-of-care citations or types of SMI diagnoseswere not included as separate variables in the mainanalyses due to a possible multicolinearity bias.Rather, we created composite measures for thesevariables. Finally, because only 3% of the facilitiesmet CMS registered nurse staffing standards, weinstead did a median split on the obtained nursing staffratios.

RESULTS

The characteristics of the 32,604 participants arepresented in Table 2. Most participants were 65 years

Psychiatric hospitalisations Hospitalizationrate (per 1000)

Yes; n¼ 306 No; n¼ 32,298

% n %

5 53.9 28,527 88.3 5.84 50.3 23,448 72.6 6.55 60.5 23,230 71.9 7.9

6 67.3 12,545 38.8 16.28 77.8 6,080 18.8 37.77 61.1 2,849 8.8 61.61 3.6 289 0.9 36.70 13.1 2,942 9.1 13.49 9.5 400 1.2 67.64 7.8 138 0.4 148.13 85.9 19,084 59.1 13.6


DOI: 10.1002/gps

Table 3. Association between resident characteristics and psychiatric hospitalization

All Age< 65 Age� 65

RR 95% CI RR 95% CI RR 95% CI

Age, ref.¼ 65 years or older 3.41 2.61 4.45 — — — — — —sex, ref.¼ female 0.54 0.42 0.70 0.55 0.38 0.81 0.53 0.38 0.74White, ref.¼ non-White 0.96 0.74 1.23 1.34 0.92 1.94 0.69 0.50 0.95Dementia, ref.¼ no 3.04 2.34 3.96 2.34 1.60 3.43 4.02 2.70 5.99Serious mental illness, ref.¼ no 8.34 6.30 11.04 18.78 9.59 36.76 6.07 4.35 8.47Alcohol use disorder, ref.¼ no 1.58 0.96 2.59 1.77 1.02 3.05 1.47 0.51 4.23Drug use disorder, ref.¼ no 4.77 2.62 8.69 2.68 1.40 5.15 26.47 9.92 70.63Charlson index score, ref.¼ 0 1.94 1.38 2.74 1.63 1.02 2.61 2.24 1.36 3.71

There were 3,910 participants younger than 65 years and 28,686 were 65 years of age or older.CI¼ 95% confidence interval; ref.¼ reference group; RR¼Risk Ratio 95%.

Table 4. Facility characteristics by event status

Facility characteristic AllfacilitiesTotal

n¼ 584

Psychiatrichospitalization

Yes;n¼ 184

No;n¼ 400

n % n % n %

Ownership Type, for-profit 452 77.4 138 75.0 314 78.5Member of a chain 373 63.9 117 63.6 256 64.0Facility size, 120 beds or more 404 69.2 140 76.1 264 66.0

Proportion of Medicaid beneficiaries<50% 136 23.3 16 8.7 120 30.050–74% 284 48.6 93 50.5 191 47.875% or more 164 28.1 75 40.8 89 22.3

Proportion of Medicare beneficiaries<8% 129 22.1 65 35.3 64 16.08–19% 298 51.0 96 52.2 202 50.520% or more 157 26.9 23 12.5 134 33.5

Citations by type, at least one citationHad a Quality of Life Citation 317 54.3 100 54.3 217 54.3Had a Quality of Care citation 391 67.0 130 70.7 261 65.3Had a citation for Abuse/Neglect 101 17.3 30 16.3 71 17.8

Total citations<3 128 21.9 35 19.0 93 23.34–8 295 50.5 95 51.6 200 50.09 or more 161 27.6 54 29.3 107 26.8

Proportion of persons with serious mental illness<11% 165 28.3 24 13.0 141 35.311–22% 271 46.4 85 46.2 186 46.523% or more 148 25.3 75 40.8 73 18.3

Nursing staff ratio, % above median 292 50.0 89 48.4 203 50.8

CMS¼Center for Medicare and Medicaid Studies; RN¼ registerednurse.


of age or older, female, and White. Almost 40% haddementia, 19% had a SMI, and 59% had at least oneserious physical health condition. Length of stay in thenursing home averaged 460 days (SD¼ 334). A littlemore than a third (36%) of residents (n¼ 11,811)experienced one or more hospitalizations for anyreason for a total of 14,984 hospitalizations. Theoverall rate of PHs was 0.9% or 9 per 1,000 residents(see Table 2 for rates by group).The results of a multivariate GEE model with

individual-level factors are shown in Table 3. Beingyounger than 65 years and male was associated withincreased risk of PH. Having dementia was associatedwith about three times greater risk of PH, and having aSMI increased the risk of PH more than eight times.Drug abuse disorder and having at least one seriousphysical health condition were associated with greaterrisk of PH.Since younger age was associated with increased

risk of PH, we stratified the data at age 65 to explorewhether the same effects would be observed (seeTable 3). These analyses confirmed that the associ-ations were similar for the two cohorts except foralcohol use disorder, which was only associated withincreased risk of PH in the younger cohort, and beingwhite, which was associated with 40% lower risk ofPH in the older cohort. In addition, the magnitude ofassociations varied on several variables. Specifically,serious mental illness was substantially more import-ant for risk of PH in the younger cohort, whereasdementia, drug use disorder, and co-morbidity (asmeasured by the Charlson Index) was more importantin the older cohort.The characteristics of the 584 participating facilities

are presented in Table 4. About three-fourths of thefacilities were for-profit, almost two-thirds weremembers of a chain, and the majority (69%) had at


least 120 beds. The majority of residents were coveredby Medicaid (median¼ 64%) and only a smallproportion used Medicare as the source of paymentfor their NH care (median¼ 19%). Almost all


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Table 5. Association between facility characteristics and psychia-tric hospitalization

RR 95% CI

For-profit status, ref.¼ no 0.82 0.51 1.32Member of a chain, ref.¼ no 1.11 0.73 1.67Facility size, ref.¼<120 beds 1.90 1.21 2.99

Proportion of Medicaid to other beneficiaries<50% 0.38 0.20 0.7150–74%, ref. 1.00 — —75% or more 1.22 0.78 1.91

Proportion of Medicare to other beneficiaries<8% 2.02 1.26 3.248–19%, ref. 1.00 — —20% or more 0.52 0.29 0.90

Total citations<4% 0.66 0.39 1.094–8%, ref. 1.00 — —9% or more 0.80 0.51 1.26

Proportion of persons with SMI — — —<11% 0.45 0.27 0.7711–22%, ref. 1.00 — —23% or more 1.99 1.27 3.12

Nursing staff ratio, ref.¼ below median 1.44 0.96 2.15

95% CI¼ the lower and upper limit of the 95% Confidence Interval;ref.¼ reference group; RR¼Risk Ratio; SMI¼ serious mental lillness.


facilities were cited for quality-of-care deficiencies(only 14 were not).

There were 184 NHs with at least one PH occurringduring the course of the study. Of these, 114 facilitiesregistered one, 35 registered two, 19 registered three,and the remaining 16 facilities registered more thanthree PHs. Results for the association between facilitycharacteristics and the odds of PH are shown inTable 5. As might be expected, greater facility sizewas associated with higher odds of PH. Having lessthan 50% of the residents paying via Medicaidreduced the odds of PH by 62% when compared tohaving 50–74% of residents on Medicaid. Conversely,the odds of PH almost doubled for facilities withthe smallest proportion of residents paying viaMedicare and were reduced by 48% in facilities withthe highest proportion of residents with Medicare asthe payer. Facilities with lower proportion ofparticipants with SMI had reduced odds of PH.Finally, we found a significant linear trend for three ofthe four three-level variables included in the model,proportion ofMedicaid paying residents, proportion ofMedicare paying residents, and proportion of residentswith SMI (p< 0.01 for the three results). The numberof quality-of-care deficiencies did not yield astatistically significant linear trend (p¼ 0.56).


We also estimated risk of PH for all studyparticipants in a model that included both individual-and facility-level factors. The associations betweenindividual-level variables and risk of PH wereessentially unchanged. Among the facility-levelvariables, high proportion of residents paying viaMedicare (RR¼ 0.62, 95% CI 0.40–0.96) and lownumber of quality of care citations (RR¼ 0.66, 95%CI 0.47–0.93) were associated with reduced risk of PHamong residents.To better understand our findings, we reviewed

service claims data for outpatient behavioral healthservices (e.g. psychotherapy, family counseling, andcase management) and psychotropic medication forthe participants who had a PH. Only 48% of theseresidents received outpatient behavioral health ser-vices (other than medication) in the 6 monthspreceding their hospitalization. In contrast, 89% ofthem received psychotropic medication precedingtheir hospitalization.

DISCUSSION

We explored associations of resident and facilityvariables with PH among Medicaid enrolled NHresidents. A few studies have investigated the effect offacility and organizational characteristics on risk ofhospitalization among NH residents and none hasfocused on psychiatric hospitalization. This isnoteworthy as relocation to a hospital setting mightbe particularly stressful for residents who are having amental health crisis serious enough to warranthospitalization. In fully adjusted, multilevel models,resident characteristics including younger age, malegender, poor physical health, serious mental illness,dementia, and previous drug use were associated withgreater risk of PH. Facilities with either a high or lowproportion of residents reimbursed by Medicare hadreduced risk of PH.Several results stand out. The fact that NH residents

under 65 years of age were more likely to undergopsychiatric hospitalization even after results wereadjusted for factors such as serious mental illness andcomorbidity may indicate that the care provided in thenursing home setting is not consistent with thecomplex needs of younger residents with behavioralhealth problems. The finding that dementia tripled therisk of PH is of concern because hospitalization maynot be the optimal way of handling a mental healthcrisis in a resident with dementia. Ideally hospital-ization of dementia patients should be minimizedunless geropsychiatric expertise is needed but notaccessible in the NH, or the patient’s behavior


DOI: 10.1002/gps


presents a more severe danger to self or others thanthe NH can manage. Still, it is unlikely that all or mostof the psychiatric hospitalizations of residents withdementia would be attributable to unpreventableproblems.Residents with mental illness and/or dementia tend

to have communication and behavioral problems thatincrease the complexity of their care and can maskinteracting physical and mental health conditions.Mental health problems can generate physical healthproblems (e.g. weight loss or bed sores withdepression) and vice versa (e.g. urinary tractinfection in patients with dementia causing agita-tion). These problems increase the need for skilledNH staff trained at dealing with dementia-specificissues to help avoid unnecessary psychiatric hospi-talization. Given the increased risk of adverse healthevents associated with hospitalization (Cunninghamand Archibald, 2006), this finding deserves furtherattention from researchers, practitioners, and NHadministrators.The finding that NHs with a higher proportion of

residents using Medicare as their source of paymentwas associated with a lower likelihood of PHoccurring at those facilities deserves additionalattention. Facilities with a higher proportion ofMedicare reimbursements may be likely to havehigher revenues which can enable them to hire morenursing staff and/or provide a higher quality of care.Lower nurse staffing ratios and Medicaid reimburse-ments have been associated with hospitalizations ofNH residents in general (Carter, 2003; Intrator andMor, 2004), although this association only approachedsignificance in our study (p¼ 0.08).Whether these observations apply equally to

hospitalizations occurring for acute mental versusphysical health conditions remains to be determined.More generous per diem reimbursement rates havebeen associated with higher staffing and the use ofnurse practitioners/physician assistants, which mayaffect the ability to provide early intervention andprevent resident hospitalization (Grabowski et al.,2004; Intrator et al., 2004). Specifically, a $10 increasein per diem reimbursement has been found to beassociated with a 5–9% reduction in risk ofhospitalization (Intrator and Mor, 2004; Intratoret al., 2007).The finding that most facilities failed to meet the

RN staffing levels of CMS is worrisome, particularlyin light of empirical evidence documenting thepositive impact of higher RN staffing levels on qualityof care (Bliesmer et al., 1998; Harrington et al., 2000)and likelihood of lawsuits (Johnson et al., 2004).


Although the optimal level and mix of nursing homestaffing for quality care remains uncertain, the benefitof relatively high RN staffing levels has consistentlybeen associated with better service delivery (Davis,1991; Steffen and Nystrom, 1997).

Although the results regarding quality-of-carecitations were not statistically significant, the RRfor a high number of citations was lower than 1.00,suggesting reduced risk compared to the medium level(see Table 5). It is possible that facilities with a highnumber of quality-of-care citations were somewhatless likely to hospitalize residents for psychiatric careeven when such hospitalization may have beenappropriate.

We also found that a relatively high proportion ofthe residents who subsequently underwent PHreceived psychotropic medication prior to theirhospitalization. However, less than half received otheroutpatient behavioral health services. While thereason for underutilization of behavioral healthservices for any one individual is unknown, thegeneral finding of underutilization of behavioralhealth services in nursing home settings has beenwell documented (Reichman et al., 1998; Callegariet al., 2006). Reported reasons for this include lack ofaccess, inadequate resources, inadequate reimburse-ment rates, or staff attitudes toward NH residents withmental health disorders (Reichman et al., 1998; Hsuet al., 2004; Callegari et al., 2006). It is possible thattimely provision of behavioral health services withinthe nursing home setting might well reduce thefrequency of resident relocation for PH.

This study has some limitations. We relied onadministrative data from one state only. Adminis-trative data also tend to suffer from imperfect recordkeeping, coding errors within the data, and incompletedata. However, these data also have advantages such asdetailed information on participants and facilities thatis not otherwise available, low attrition due to lostcontact, and low cost. Finally, longitudinal studydesign would be useful in examining change overtime.

In conclusion, this study highlights the influenceof resident and facility characteristics on risk ofpsychiatric hospitalizations. While PHs may bebeneficial in general, resident relocation to a hospitalinvolves a health risk and therefore deserves furtherattention (Castle and Mor, 1996; Kunik et al., 1996).Findings suggest that behavioral health serviceswithin the nursing home setting are likely under-utilized. More attention should be directed to over-coming barriers to behavioral health services fornursing home residents, determining effectiveness of


DOI: 10.1002/gps


these services, and examining the impact of reimbur-sement rates on levels of care.

CONFLICT OF INTEREST

None known.

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The association of individual and facility characteristics with psychiatric hospitalization among nursing home residents