Patterns of change in functional status in extended care

Most investigators and policymakers assume that the functional abilities of long-term care patients are stable over time. If short-run fluctuations in functional ability occur, then reimbursement and quality control systems based on case mix will have to account for whatever changes can be reasonably expected. However, the probability that the functional status of an extended-care patient will decline, improve, remain constant, or fluctuate over the short run is unknown. Analysis of 191 Veterans Administration extended-care patients over 12 weeks reveals that patient functional status is unstable in some wards and that patients in wards providing a higher level of care are more likely to be unstable and to be discharged in an improved condition. These findings suggest that nursing homes operating under case-mix reimbursement systems will find skilled patients to be more attractive than other nursing home patients. Variability in dependency is related to patient turnover. Turnover rates can be used to adjust patient assessments for expected variability in dependency. Adjusted dependency scores should be used in long-term care reimbursement systems for planning quarterly staffing requirements and for quality control systems based on patient outcomes.