Clinical Outcomes of Aging in Place

Karen Dorman Marek ▼ Lori Popejoy ▼ Greg Petroski David Mehr ▼ Marilyn Rantz ▼ Wen-Chieh Lin

Editor’s Note Additional information, provided by the authors, expanding this article is on the editor’s Web site at http://nursing-research-editor.com.

Marek, K. D., Popejoy, L., Petroski, G., Mehr, D., Rantz, M., & Lin, W.-C. (2005). Clinical Outcomes of Aging in Place. Nursing Research, 54(3), 202–211.

Background: Programs such as Medicaid Home and Com- he aging of the United States’ population is causing munity-based Services (HCBS) have provided an alterna- T major changes in the healthcare system. Dramatic tive to institutionalization through community-based, long- restructuring is needed to prepare for the needs of the term care services; however, there are limited studies on growing older population. The most elderly population, the clinical outcomes of participants in these programs as those who are aged 85 and older, is expected to expand to compared to (NH) residents. more than 9 million by the year 2030 (U.S. Census Bureau, 2000). By the year 2020, 19% of adults aged 65 Objective: To compare clinical outcomes of individuals in a and older will have limitations in activities of daily living community-based, long-term care program to individuals of (ADLs) and approximately 4% will be severely disabled similar case mix in institutional-based, long-term care. (Administration on Aging, 2001). It is estimated that as Methods: A program called Aging in Place (AIP) was developed many as one half of the individuals aged more than 85 by the Sinclair School of Nursing in cooperation with the state experience some type of cognitive deficit (Evans et al., of Missouri’s HCBS program.The AIP intervention consisted of 1989). Those individuals, who are aged 85 and older, will nurse coordination of the HCBS program and Medicare home require the majority of long-term care services. New meth- health services. A total of 78 AIP participants were matched ods of delivering care are necessary and desired, especially with 78 NH residents on admission period, activities of daily liv- in the area of long-term care. In this research article, the ing (ADLs), cognitive status, and age. The Minimum Data Set clinical outcomes of individuals in the Aging in Place (AIP) (MDS) was collected on the AIP group at admission and every program will be compared to the clinical outcomes of individuals of similar case mix in institutional long-term 6 months over a 30-month period. Cognition was measured by care. the MDS Cognitive Performance Scale (CPS), ADLs by the Older adults prefer to live in their own homes for as sum of 5 MDS ADL items, depression by the MDS-Depression long as possible. Most elders prefer that they receive long- Rating Scale, and incontinence by rating on 2 MDS items term care services in their home instead of in an assisted related to urinary continence. The Cochran–Mantel–Haenszel living facility or nursing home (NH; Mattimore et al., method was used to test the association between the AIP inter- 1997). For many older adults, home-based services are a vention and clinical outcomes. viable alternative to NH placement. Even with this alter- Results: The AIP group clinical outcomes were better at a statis- native available, it is estimated that more than 15% of tically significant level (less than .05) for the following out- individuals residing in NHs are there inappropriately comes: (a) cognition at 6, 12, and 18 months (p .00); (b) depression at 6 and 12 months (p .00); (c) ADL at 6 (p .02), 12 (p .04), and 24 (p .00) months; and (d) inconti- Karen Dorman Marek, PhD, MBA, RN, FAAN, is an Associate nence at 24 (p .02) months. In all 4 outcome measures, the Professor, University of Wisconsin–Milwaukee. AIP group stabilized or improved outcome scores whereas the Lori Popejoy, APRN, BC, GCNS, is John A. Hartford Building NH group’s outcome scores deteriorated. Academic Geriatric Nursing Capacity Scholar, Research Coordi- nator, Boone Hospital Center, Columbia, MO. Discussion: Study results suggest that community-based care Greg Petroski, MS, is a Statistician, School of Medicine, Office of with nurse coordination enhances clinical outcomes of long- Medical Research; David Mehr, MD, MS, is an Associate Profes- term care participants. sor, Family and Community Medicine; Marilyn Rantz, PhD, RN, FAAN, is a Professor, Sinclair School of Nursing and Family and Key Words: home and community based services long-term Community Medicine, and Wen-Chieh Lin, PhD, is an Assistant care nursing case management Professor, Family and Community Medicine, University of Missouri–Columbia.

202 Nursing Research May/June 2005 Vol 54, No 3 Nursing Research May/June 2005 Vol 54, No 3 Clinical Outcomes of Aging in Place 203

(Spector, Reschovsky, & Cohen, 1996). Reasons for inap- In a study by Naylor et al. (1999), postacute home propriate placement include (a) public financing that healthcare was enhanced by comprehensive discharge favors NHs over alternatives, (b) state regulations that planning and follow-up visits by advanced practice nurses. reduce viable options, and (c) lack of consensus on the best A total of 363 patients were enrolled with 177 in the inter- clinical setting. vention group and 186 in the control group. Those who Recognition of the institutional bias of the Medicaid received the advanced practice nurse intervention had program prompted the creation of the Medicaid Home and fewer hospital readmissions (p .001) and fewer hospital Community–based Services (HCBS) Waiver program. This days (p .001); however, no difference was found in func- was established through the Omnibus Budget Reconcilia- tional status between the experimental and control groups. tion Act (OBRA) of 1981. The purpose of the HCBS Naylor et al. (2004) conducted a subsequent study of 239 Waiver program was to encourage states to develop alter- (treatment, n 118; control, n 121) older adults dis- native options to institutional care for those in need of charged from acute care with heart failure. The treatment long-term care services (Duckett & Guy, 2000). However, group not only had fewer hospital readmissions (p .047) there is large variation from state to state in how these pro- and lower costs (p .002) but also demonstrated short- grams are organized and implemented (LeBlanc, Tonner, & term improvement in overall quality of life at 12 weeks Harrington, 2001). Evaluation of the effectiveness of the (p .05). No significant difference was found in func- HCBS waiver programs is difficult because each state tional status between groups. However, Tinetti et al. determines its own eligibility criteria, and unlike NH care, (2002) implemented an enhanced postacute, home health- there is no standardized clinical assessment to allow clini- care intervention via a restorative care model. Participants cal outcome comparisons between community and institu- receiving care in this model scored higher than the com- tional long-term care. parison group on functional status of self-care (p . 07), The majority of studies conducted to compare community- home management (p .05), and mobility (p .02). In based long-term care with institutional care have focused addition, the treatment group had fewer visits to the emer- on comparing the cost of the two different approaches. gency department (p .001) and were more likely to Demonstration projects such as the Channeling Demon- remain in their home (p .001) than the comparison strations of the early 1980s had disappointing results group. related to cost savings. It was found that the majority of Current federal initiatives, such as the Program for All the demonstration projects were more expensive than insti- Inclusive Care for the Elderly (PACE) and Social Health tutional care (Applebaum, Harrigan, & Kemper, 1986; Maintenance Organizations, are designed to provide coor- Weissert, Cready, & Pawelak, 1988). One reason cited for dinated healthcare to individuals who are certified as NH the additional cost of the Channeling Demonstrations was eligible but are able to live safely in the community at the that individuals targeted for the programs were time of enrollment. Providers are paid at a capitated rate not at high risk for NH placement. Therefore, services based on Medicare and state Medicaid rates. Outcomes of were provided to additional low-risk people rather than to PACE programs have been positive, including good con- those who were at high risk for institutional care. In addi- sumer satisfaction, reduction in use of institutional care, tion, improvement in health outcomes was limited, usually and cost savings to public and private payers of care (Eng, benefiting only a handful of residents. Outcome measures Padulla, Eleazer, McCann, & Fox, 1997). When compared in these studies often were based on service utilization to individuals who declined PACE participation (n 305), such as the number of hospitalizations or emergency PACE participants (n 790) demonstrated a higher level department visits. There was limited evidence of higher of ADL functioning (p .10) at 24 months and self- functioning in ADLs in community participants (Hughes, reported quality of life at 6 months (p .10; Chatterji, 1985). Burstein, Kidder, & Whilte, 1998). Studies of community-based care in the postacute There have been concerns that long-term care of frail home health period, usually reimbursed by Medicare, older adults in alternative settings to NHs can leave them have demonstrated home healthcare to be clinically effica- vulnerable to poor care (General Accounting Office, cious during transition periods or short-time periods 1999). In an effort to examine the effectiveness and safety posthospitalization (Capitman, 2003). Kane et al. (2000) of assisting living care in comparison to NH care, Frytak studied the result of four different venues of posthospital Kane, Finch, Kane, and Maude-Griffin (2001) examined the care (home, home healthcare, rehabilitation, and NH) on outcome trajectories of functional status, pain and discom- the functional status of Medicare beneficiaries (n fort, and psychological well-being in a group of partici- 1,837). Individuals who received home health and reha- pants from (n 605) and NH (n 610) set- bilitation care had the highest functional status whereas tings over a 12-month period. At baseline the NH group participants who received NH care had significantly lower had a significantly higher ADL score (more impaired; p functional status at 6 weeks posthospitalization (p .05). .001), whereas there was no statistical difference in pain In another study, Hadley, Rabin, Epstein, Stein, and Rimes and discomfort or psychological well-being. No difference (2000) followed 2,127 nondisabled community-dwelling was found in the outcome trajectories of the three mea- elderly Medicare beneficiaries who were hospitalized sures suggesting that a lower level of care provided in within a 6-month period and found that post–acute care assisted living did not result in poorer outcomes of its res- improvement in functional status was 13% higher for idents. This study pointed to the need for additional stud- those who received home healthcare than for those who ies that examine differences in multiple clinical outcome did not. measures such as depression, cognition, and incontinence, 204 Clinical Outcomes of Aging in Place Nursing Research May/June 2005 Vol 54, No 3 in addition to ADL measures, in older adults who are Working with the Missouri Department of Health and receiving long-term care in both community and institu- Senior Services, the University of Missouri Sinclair School tional settings. The clinical outcome component of the of Nursing created an enhanced version of the MCO pro- evaluation of a community-based long-term care program gram called “Aging in Place.” To implement the AIP pro- called “Aging in Place” is described in the current research gram, a home care agency called Senior Care was formed. article. To provide the AIP intervention, Senior Care secured a home health license and Medicare certification and became Aging in Place Program a designated MCO provider. There were six MCO providers in the county area. The MCO case workers made The state-funded HCBS program in Missouri is called referrals to MCO providers on a rotating basis. Unlike Missouri Care Options (MCO). An individual is consid- home healthcare participants, MCO participants enrolled ered eligible for MCO if he or she (a) is “medically eligi- in the AIP program generally were in need of personal care ble” for nursing facility care, (b) reasonably could have services or medication management, whereas Medicare care needs met outside a nursing facility, and (c) is quali- home care admissions usually occurred following hospital- fied for Medicaid funding. Individuals are screened and ization or an acute health episode. In the AIP program, each assigned a level of care score by a MCO case manager participant was assigned a nurse care coordinator who who then authorizes services, otherwise known as the ser- completed a comprehensive admission assessment and cre- vice plan. Services in the MCO program include basic per- ated a care plan that coordinated both the participant’s sonal care, advanced personal care, nurse visits, home- physician, nurse, and other prescribing professional’s inter- maker care, and respite care. An MCO caseworker ventions for his or her clinical conditions and the MCO ser- authorizes a specified number of monthly units and the vices of personal care and homemaking. Participants bene- provider is reimbursed retrospectively on the authorized fited from close nursing supervision of their clinical units provided. conditions with early detection of problems and communi- Although the MCO program authorizes nurse visits, cation with other healthcare providers such as their physi- the major focus of the program is homemaking and per- cian. In addition, if at any time while in the AIP program sonal care. The MCO participants who are assessed as the participant qualified for more acute Medicare home requiring nursing care are provided a limited number of healthcare services, the nurse care coordinator could pro- nursing visits per month. However, the reimbursement for vide Medicare home health skilled nursing as well as coor- nurse visits is very low, barely covering the labor cost of a dinate other services such as physical therapy. The partici- visit, and there is no reimbursement for indirect care activ- pants benefited by keeping the same nurse and aide ities such as care coordination. With such poor reimburse- providers during their acute home care episode as they did ment there is little incentive to coordinate the care of MCO when their condition was stabilized. If the participant sta- participants. Participants receive only those services that bilized and no longer required Medicare home health ser- can be handled easily within a short visit, such as medica- vices, the nurse care coordinator remained engaged in the tion box refills. In addition, the MCO caseworkers have participant’s care. Nurse visits to the AIP participants dur- large caseloads and are required to visit the MCO partici- ing the nonacute Medicare periods of care varied from once pant only once a year. Because of this, identification of a week to once a month depending on the participant’s care health and/or service problems often is not completed in a needs. timely manner. This is problematic, especially considering the frailty of the MCO participants. Conceptual Framework To further complicate care management, if a partici- pant requires Medicare home health services, a different An adaptation of the Medical Outcomes Study framework agency or a separate department of an MCO-authorized (Kelly, Huber, Johnson, McCloskey, & Maas, 1994; Tarlov agency provides the care. Often there is little or no coordi- et al., 1989) and Donabedian’s (1980) quality assessment nation between Medicare home health and MCO service model were used to organize the evaluation. The frame- provider. This is due in part to the presence of different reg- work is categorized using three major components: struc- ulations and reimbursement methods under which each ture, process, and outcome (Figure 1). Structure compo- program functions. In Missouri, the Medicare Conditions nents such as client characteristics, payment source, and of Participation are used as the guidelines for home health living arrangements are inputs to the system. Structural licensure. The Medicare Home Health benefit is limited to components influence both process and outcome compo- specific acute conditions and does not cover the care needs nents of the framework. Process components have repre- of most chronically ill, older people. An MCO participant sented the content or configuration of care (Donabedian, who is acutely ill may receive Medicare home health ser- 1980). In this study the two types of long-term care, insti- vices, but once the participant’s condition stabilizes, tutionally based NH care and community based AIP with Medicare home health services are discontinued. MCO ser- nurse care coordination, were examined. In the original vices are under a different set of standards. The skilled ser- Donabedian framework, site of care is viewed as a struc- vices available and reimbursement for MCO services are tural variable. However, for purposes of this evaluation, site substantially less than those in the Medicare program. The of care is a component of the process of care and is incor- disconnect between these two types of home-based services porated into the process component. The final component is not conducive to providing the coordinated care needed of the framework is the outcome—the procedural end point for frail, chronically ill, older adults. or impact of the process component. Both process items Nursing Research May/June 2005 Vol 54, No 3 Clinical Outcomes of Aging in Place 205

FIGURE 1. Aging in place evaluation framework.

and structural items can influence outcomes. The outcomes ning (Morris et al., 1990). This Act required routine assess- of interest in this study are clinical health outcomes or mea- ment of all Medicare and Medicaid residents using the sures of the participant’s health status at a designated point MDS, which is a part of the resident assessment instrument in time (Marek, 1997). (RAI). The MDS data are used to develop a plan of care and also to determine payment for all Medicare NH resi- Methods dents using the resource utilization groups (RUGs; Fries & Cooney, 1985). The MDS data are used also to measure The purpose of this evaluation was to compare clinical quality of care through the identification of key quality outcomes between older adults who resided in NHs and a indicators or measures (Zimmerman et al., 1995). The group of similar older adults who received services in the MDS data are routinely collected upon admission, quar- AIP program. The clinical outcomes of interest were ADLs, terly, at times of significant change of condition, and annu- cognitive function, depression, incontinence, and pressure ally as mandated by OBRA of 1987. Reliability of the ulcers. MDS items has been tested in multiple studies (Hawes et The design of the evaluation was quasi experimental, al., 1995; Mor, 2004; Morris et al., 1990, 1997). In a using an individually matched group of NH residents for recent large field reliability trial, more than 85% of the comparison. The Missouri Minimum Data Set (MDS) data MDS elements manifested adequate interrater reliability repository provided data to assist in identifying NH resi- (κ 0.6; Mor et al., 2003). dents in mid-Missouri. A major criticism of community- The research team identified the following five clinical based, long-term care programs is that individuals at low conditions prevalent in both NH and home care: (a) cog- risk for NH placement often are enrolled. Matching the nitive decline, (b) decline in functional status, (c) depres- comparison group on key variables provided a comparison sion, (d) pressure ulcers, and (e) incontinence. The MDS group with similar risk for clinical outcome decline. Vari- has data elements related to each of these clinical condi- ables included in the matching strategy were age, AIP tions such that comparison of AIP and NH groups was enrollment date and NH admission date, ADLs, and cog- possible. The MDS has worked equally well in community nitive function. The NH admission date, ADLs, and cogni- and NH settings (Morris et al., 1997). The data elements tive function were derived from the MDS. were reviewed again to determine the appropriateness of Since MDS collection is not mandated on private pay the assessment for use in the community setting, because NH residents, only participants with Medicaid as their the assessment was initially designed for use in institution- payment source for long-term care were included in this ally based care. The 1997 RUGS III quarterly had the data evaluation. There were 93 participants enrolled in the AIP elements required to calculate the clinical outcomes of program who were Medicaid eligible also. To obtain a sim- interest. The MDS quarterly data elements were collected ilar group of NH participants, AIP participants were on admission and every 6 months on all AIP program par- matched on ADLs (within 2 points), cognitive performance ticipants who entered the program from April 1, 2000, to (within 1 point), age (within 4 years), and admission date December 31, 2002. Nursing staff were trained on the use (within 90 days) to 1,038 Medicaid NH residents using of the MDS by an advanced practice nurse with significant data from the Missouri MDS repository. A total of 78 AIP training, research, and consultation experience using the participants were matched to 78 NH residents, using this MDS. process. To measure functional status, MDS ADL items reflect- In the OBRA of 1987, Congress mandated the devel- ing the need for assistance with bed mobility, transfers, opment of the MDS for resident assessment and care plan- locomotion, eating, and toilet use were summed. Each of 206 Clinical Outcomes of Aging in Place Nursing Research May/June 2005 Vol 54, No 3 these items was scored 0 to 4 with 0 indicating indepen- Results dent functioning (no need for help or oversight) and 4 indi- The age of participants ranged from 50 to 94 years (M cating total dependence (full staff performance of the activ- 72). The AIP group was more racially diverse with 26% ity). The summated scale thus had a range of 0–20 with Black versus 4% in the NH group. Also the AIP group was larger values corresponding to greater impairment in ADL less likely to be married (Table 1). Because participants were functioning. Coefficient alpha for this 5-item scale was .90 enrolled over a 30-month period, the number of participants for both the AIP and NH groups. per time period not only is dependent on attrition, but also Cognition was measured using the MDS Cognitive is related to time of enrollment. For example, 13 AIP par- Performance Scale (CPS; Morris et al., 1994). The CPS is ticipants were enrolled in the last 17 months of the study a 7-point ordinal scale with 0 indicating intact cognitive and therefore had outcome data collected only at baseline, 6 status and 6 indicating severely impaired. The CPS scale months, and 12 months. To control for the effect of time uses five MDS cognitive items (i.e., comatose, short-term enrolled, groups were matched on quarter of enrollment, memory, ability to make decisions, making self under- therefore allowing for each group to receive a similar “dose” stood, and eating performance) within a single hierarchi- of the intervention (Figure 2). A total of 9 (12%) of the AIP cal cognitive rating scale creating seven categories of cog- participants died, 7 (9%) were admitted to NHs, 6 (8%) nitive impairment. Validity and reliability of the CPS had moved, and 3 (4%) declined to participate for the entire substantial agreement with the MMSE in the identifica- study (Figure 2). There was no statistically significant rela- tion of cognitive impairment (Hartmaier, Sloane, Guess, tionship between initial ADL score (p .95) or initial CPS & Koch, 1994; Hartmaier, Sloane, Koch, Mitchell, & score (p .42) and the point at which an individual left the Phillips, 1995). study. The MDS-based depression rating scale was used to As expected, both groups scored in the low range measure depression in the study participants. This (higher functioning) on each of the clinical outcomes mea- instrument is derived from the seven mood indicator items sured (Table 2). For example, the range of ADL scoring in the MDS. The items include (a) making use of negative was 0 to 20. The mean baseline ADL score was 1.7 (SD statements; (b) persistent anger with self and others; (c) 3.6) for the AIP group and 2.1 (SD 3.6) for the NH expressions of unrealistic fears; (d) repetitive health com- group. The AIP group had significantly better clinical out- plaints; (e) repetitive anxious complaints; (f) sad, pained comes in ADLs, cognition, depression, and incontinence in worried facial expressions; and (g) tearfulness and crying. at least one time period. Cognition was significantly better Each item was rated on a scale of 0–2 based on frequency of at 6, 12, and 18 months. Depression, however, was signif- the observed item. Construct validity and sensitivity of the icantly better only at 6 and 12 months. The ADL func- MDS depression rating scale compared favorably to the tioning was better than that in the NH group in all but the 15-item Geriatric Depression Scale (Burrows, Morris, 18-month measurement period. At baseline, the AIP group Simon, Hirdes, & Phillips, 2000). had a significantly higher incidence of incontinence; how- Incontinence was measured by two categories. An indi- ever, at the remaining time periods, the NH group had a vidual scored 0 if always continent, 1 if usually continent higher incidence of incontinence with a statistically higher (1 or fewer times a week) or occasionally incontinent incidence at 24 months. There were an insufficient number (2times a week, but not daily), and 2 if frequently (incon- of participants with pressure ulcers, so group differences tinent daily but some control present) or always inconti- nent. The incontinence items in the MDS were tested and found to accurately identify incontinent NH residents (Crooks, Schnelle, Ouslander, & McNees, 1995). Pressure TABLE 1. Demographics by Group ( N 156) ulcers were defined as a rating of Stage 1 or higher on MDS item M2a. Aging in Place Nursing Home Variable (n 78) (n 78) Analysis Outcome variables in this study were all ordinal scaled Age, years (M SD) 72.0 (10.9) 72.2 (10.6) measures; thus, rank-based nonparametric methods were Number of females (%) 55 (71) 53 (68) used. The Cochran–Mantel–Haenszel test with modified Race/ethnicity n (%) n (%) ridit scores (Stokes, Davis, & Koch, 2000) was used to Black 20 (26) 3 (4) compare groups at each follow-up point. The CMH test in combination with the rank transformation is a stratified White 57 (73) 74 (95) version of the Kruskall–Wallis test (Agresti, 1990). In the Hispanic 0 (0) 0 (0) analysis of each outcome the baseline value of that outcome Other 1 (1) 1 (1) was used as the stratifying variable. Although the NH Marital status group was constructed to be comparable to the AIP group, Married 8 (10) 16 (21) this analysis further adjusts for individual differences in ini- tial status. The point of dropout was analyzed in relation to Widowed 35 (45) 33 (42) initial ADL and cognitive status. Groups were formed on Divorced/separated 23 (29) 21 (27) the basis of the last follow-up point and the Kruskall–Wallis Never married 12 (15) 8 (10) test was used to test for differences in these groups with respect to initial ADL and CPS scores. Nursing Research May/June 2005 Vol 54, No 3 Clinical Outcomes of Aging in Place 207

FIGURE 2. Study attrition by time period. for this clinical outcome could not be analyzed. In the The difference in clinical outcomes between NH and AIP remaining four outcome measures, the AIP group stabi- participants may suggest that care outcomes are not similar lized or improved outcome scores whereas the NH group’s in both settings. Further research is needed to understand outcome scores deteriorated (Figure 3). the effect of both the type or process of care delivered and the physical environment where care is delivered. Declining ADL and cognitive functioning are two Discussion major factors related to institutionalization of older adults The results of this study are supportive of community-based (Miller & Weissert, 2000). Postponing decline in both of care for some older adults in need of long-term care ser- these areas enables the older adult to remain at a less inten- vices. The decision to move to an NH is complex and influ- sive level of care. However, compared to the study by enced by many factors (Castle, 2003; Forbes, Hoffart, & Frytak et al. (2001) in which assisted living and NH resi- Redford, 1997; Grando et al., 2002). However, little data is dents had similar outcome trajectories, the persons in the available regarding clinical outcomes if a person chooses to AIP program had more positive outcome trajectories than remain in his or her home with community-based services. did NH residents. Also, in the Frytak et al. study, the NH The majority of cost comparison studies operate from the residents were significantly more functionally impaired at assumption that care is similar in both settings (Lee, 2000). baseline. To account for the expected difference in 208 Clinical Outcomes of Aging in Place Nursing Research May/June 2005 Vol 54, No 3

Table 2. Outcome by Group by Time Period

Aging in Place Nursing Home nMSDMednMSD Med p Cognition Baseline 78 0.9 1.0 1.0 78 1.2 1.2 1.0 naa 6 months 69 0.8 1.0 0.0 73 1.4 1.4 1.0 .00 12 months 61 0.7 1.0 0.0 62 1.8 1.6 1.5 .00 18 months 38 0.6 1.0 0.0 40 1.8 1.7 1.5 .00 24 months 16 0.8 1.1 0.0 26 2.1 1.9 2.5 .38 Depression Baseline 78 0.7 1.1 0.0 78 1.1 1.9 0.0 .76b 6 months 69 0.5 0.9 0.0 73 1.4 2.0 0.0 .00 12 months 61 0.3 0.6 0.0 62 1.5 1.9 1.0 .00 18 months 38 0.5 0.9 0.0 40 1.4 2.6 0.0 .14 24 months 16 0.4 0.7 0.0 26 1.3 2.1 0.0 .39 Activities of daily living (ADLs) Baseline 78 1.7 3.6 0.0 78 2.1 3.6 1.0 nac 6 months 69 1.3 3.2 0.0 73 3.2 4.9 1.0 .02 12 months 61 1.7 3.9 0.0 62 3.5 5.3 1.0 .04 18 months 38 1.4 3.7 0.0 40 3.8 4.6 2.0 .08 24 months 16 0.8 2.2 0.0 26 3.2 5.2 1.0 .00 Incontinence Baseline 78 1.0 1.5 0.0 78 0.5 0.9 0.0 .03b 6 months 69 0.8 1.3 0.0 73 0.8 1.2 0.0 .12 12 months 61 0.8 1.4 0.0 62 0.9 1.3 0.0 .21 18 months 38 1.0 1.4 0.0 40 0.9 1.3 0.0 .28 24 months 16 0.6 1.1 0.0 26 1.1 1.4 0.0 .02

aParticipants matched on admission Cognitive Performance Scale score. bWilcoxon rank sum test. cParticipants matched on admission ADL.

functional status between the AIP group and the NH Most state Medicaid programs do not reimburse for group, groups were matched on functional and cognitive the extra care required to coordinate care. However, sev- status. eral states have initiated capitated systems for Medicaid Cognitive function and mental illness have been payment for long-term care services (Stevenson, Murtaugh, dynamically linked to decline in physical functioning Feldman, & Oberlink, 2000). The Arizona Long Term (Leveille et al., 1998). It is interesting that ADL, cognitive Care System (ALTCS) emphasizes HCBS, with incentives status, and depression improved and then declined at a to avoid institutional placement. The ALTCS has decreased slower rate in the AIP group than in the NH comparison the state Medicaid expenditures on long-term care by 16% group. One explanation could be that remaining in one’s and lowered the growth rate. Other programs such as home and maintaining independence contributes to the PACE and the Social Health Maintenance Organizations more positive outcomes. initiatives have shown limited financial savings with the Coordination between acute and long-term care sys- capitation of both Medicare and Medicaid funds. Each of tems prevents frail older adults from “falling through the these programs has an increased level of care coordination; cracks”; however, Medicaid does not usually reimburse for however, there is a lack of studies on clinical outcomes by this care. Using the same providers for postacute home site of care. healthcare and chronic illness care provides an enhanced There are several methodological issues that require level of community-based care. Similar to institutional care comment. The individual matching strategy was chosen to where nursing care is required, AIP provides nursing care ensure that participants in the two groups were compara- to facilitate communication and implementation of the ble at baseline. This previously has been shown to result in older adult’s healthcare plan. covariate balancing similar to complete randomization Nursing Research May/June 2005 Vol 54, No 3 Clinical Outcomes of Aging in Place 209

Because enrollment was over a 30-month period, the largest number of participants was available for the 6- month time period. A larger study that followed all partic- ipants for a 24-month period would provide more insight into attrition rates. The AIP program was conducted in only one agency; therefore, it cannot be generalized to all HCBS participants. However, using one agency provided control over implementation of an intervention that is organizationally based. Results from this study may pro- vide direction for future HCBS programs. The MDS data were obtained by nurses providing clinical care that may threaten internal validity. However, the MDS has been used frequently for clinical and research purposes and reli- ability equivalent to standardized clinical assessment instrument (Mor, 2004). Comparison of the AIP group to participants in the standard MCO program would be the next logical step in evaluating the effectiveness of the AIP program. This study indicates that participants of the AIP pro- gram had favorable clinical outcomes when compared to similar individuals receiving long-term care in an NH. Unique to this study was that the NH comparison group was matched to the AIP group. This minimized baseline differences in the groups, a problem identified in the majority of community-based care evaluations. Develop- ment of a standardized assessment similar to the MDS for HCBS participants is encouraged. Without such an assess- ment, quality comparison across sites is not possible. The AIP program shows promise as a viable option for frail older adults in need of long-term care. ▼

Accepted for publication January 22, 2005. This research was supported in part by a grant from the Centers for Medicaid and Medicare Services, Aging in Place: A New Model for Long Term Care, Grant 18-C-91036. The research was also sup- ported by the Robert Wood Johnson Executive Nurse Fellows Pro- gram Cohort 2000. Corresponding author: Karen Dorman Marek, PhD, MBA, RN, FAAN, University of Wisconsin–Milwaukee, PO Box 413, Milwaukee, WI 53201 (e-mail: kmarek@ uwm.edu).

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