Determinants of hospital-to-nursing home placement delays: a pilot study

Estimates of hospital-to-nursing home placement delays have always been varied, and given Medicare's new Prospective Payment System (PPS) based on diagnosis-related groups (DRGs), they are likely to have changed again. Theory and previous research suggest that four patient characteristics are the main causes of delays: Medicaid as the patient's nursing home payer source; need for heavy care due to major physical or mental problems; admission to the hospital from a nursing home; and lack of social support. A pilot study of all 1,016 elderly awaiting nursing home placement in two admission cohorts (pre- and post-PPS) from the three largest hospitals in the county surrounding Charlotte, North Carolina--where nursing home beds are in short supply--indicates that other factors are more important. While most placements were delayed, delays were short. Multiple regression results show that Medicaid patients' delays were only about a day longer than those of private-pay patients. Of the many heavy-care conditions studied, only three were associated with delay. Patients without social support and patients admitted from a nursing home, discharged to a hospital-affiliated facility, or placed after PPS had shorter delays. Long delays were found among patients who had applied for Medicaid coverage but had not yet been certified as financially eligible. Nonwhites and males were also delayed. These findings, if replicated in other areas with perceived nursing home bed shortages, appear to have important implications not only for the usefulness of nursing home case-mix reimbursement and subacute levels of nursing home care, but for nursing home bed-need estimates, too, as well as for Medicaid eligibility determination practices and civil rights law enforcement.