Relating personnel costs in special care units and in traditional care units to resident characteristics.

BACKGROUND: There are over 16 000 nursing homes in the United States (US), among which approximately 70% of residents are cognitively impaired. Reflecting this, approximately 20% of US nursing homes maintain Special Dementia Care Units (SCUs). SCUs supposedly provide more staff time and more specialized staff assignments to residents than do traditional care units. AIMS OF THE STUDY: This paper addresses the issues of staff time and assignment: do the costs of personal care inputs differ according to whether they are provided by SCUs or in traditional care settings? Related to this, are differences associated with the different settings, or are they accounted for by resident characteristics within the settings? METHODS: Given the bias generally associated with collection of staff time data, the author developed (supported by the Health Care Financing Administration and the National Institute on Aging) and used in this study a barcode-based system ('InfoAide'). Using InfoAide, each provider automatically recorded task- and resident-specific time expenditure data which were subsequently monetized, using prevailing local wage rates. Individual resident personal characteristics and status data were provided by another simultaneous study of SCU impacts among the same residents. Regression analysis (MANCOVA for significantly correlated dependent variables) was used to examine the relationships between cost and SCU/traditional status, and individual resident characteristics, separately for each category of provider. RESULTS: Controlling for resident characteristics, the cost of aide care is significantly (positively) related (p <=0.01) to SCU status. Cognitive impairment, ADL impairment and being restrained are also related to higher aide care cost (p <=0.05, p <=0.01, and p <=0.05, respectively). The same is generally true of Speech Therapy, Social Service and care by licensed practical nurses, although the differences between SCU and traditional care units are essentially trivial - and there are no SCU/traditional care differences for registered nurses. DISCUSSION: SCU/traditional unit status, even when combined with the central resident covariates, explains very little variance in service costs, other than among nursing aides; in separate MR analyses in which monetized service time was the dependent variable, the cumulative adjusted R2 among aides was 0.37; for each of the other categories of service provider, the adjusted R2 was less than 0.10. There were differences (particularly in cognitive and ADL impairment) between SCU and non-SCU residents; these differences were related to differences in basic services which were, in turn, provided primarily by aides. The increased level of care provided in SCUs is attributable primarily to nursing aides. However, there is relatively little (albeit statistically significant) variation in more 'elective'services according to individual characteristics or to SCU versus traditional unit placement. This discussion is limited by the absence of analyses of possible interactions among variables, and by the cross-sectional nature of the data presented here. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This absence of a substantial relationship between SCU/traditional status suggests that dichotomization between SCU and traditional care is misplaced, and that more attention should perhaps be given to the targeting and tailoring of services related to individual gradations of impairment and need. IMPLICATIONS FOR HEALTH POLICY FORMULATIONS: A very considerable literature has developed recently pertaining to Special versus Traditional care for persons with dementing illness. These data suggest that this is not a fruitful distinction, and that more effort should be devoted to defining and quantifying the elements and quality of care provided to nursing home residents. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed into the components of optimal quality care for demented nursing home residents, and into the interaction among these components as they relate to resident outcomes.