Do Services and Staffing in Residential Care Facilities Vary With Residential Needs?. 4. Methods

07/22/2013

We conducted descriptive and multivariate analyses for this study. For the descriptive analysis, frequencies for categorical variables and means for continuous variables were calculated and tested for statistical differences using chi-square tests for categorical variables and t-tests for continuous variables.

For this study, we constructed several variables:

  1. Residents were categorized as having cognitive impairment if they had a diagnosis of Alzheimer's disease or dementia, exhibited any related behavioral symptoms,1 or had short or long-term memory impairments.

  2. Functional limitations were measured by an ADL scale (0-5) and by individual ADL variables: receiving assistance with bathing, dressing, eating, transferring, and toileting. ADLs were measured by receipt of human assistance.

  3. Functional limitations were also measured by an instrumental ADL (IADL) scale (0-5) and by individual IADL variables: limitations in taking medications, managing money, shopping, housekeeping, and using a telephone.

  4. Direct care staffing was measured by the ratio of RN, LPN/licensed vocational nurse (LVN), personal care aide, and direct care administrator hours per resident day (HPRD).

  5. Nursing care staffing was measured by the ratio of RN/LPN/LVN HPRD.

This study presents descriptive analysis at the resident and facility levels as well as regression modeling at the facility level. Much of the descriptive analysis is done at the resident level. However, facility-level descriptive analysis is done for the independent variables included in the regression model.

For the multivariate analysis, we estimated an ordinary least squares (OLS) regression model. For the OLS regression model, we use total direct care staffing per person per day as the dependent variable and present the beta coefficients of the predictor variables along with their corresponding t-test p-values.

We follow National Center for Health Statistics conventions by presenting only those estimates that are statistically reliable and have the appropriate sample size. All analyses were conducted in SUDAAN® software for statistical analysis of correlated data (Research Triangle Institute, 2008). The stratification variables of number of beds and census region, in addition to the final sample weights for the facilities and residents and the sampling design method, were incorporated into the SUDAAN procedures to account for the complex sampling design. Only weighted results are presented.

RCFs are characterized by a large number of small facilities (4-10 beds) that serve a relatively small proportion of residents. More specifically, 50 percent of RCFs are small, but they serve only 10 percent of residents (Park-Lee et al., 2011). Therefore, most RCF residents live in larger facilities even though small facilities account for half of facilities. To obtain a full understanding of RCFs and their residents, data are presented from several perspectives with different units of analysis. We show facility characteristics with the facility as the unit of analysis; then, to present a perspective that more closely aligns with the number of persons served and to represent the perspective of people living in RCFs, we present data on the characteristics of facilities in which people live with the resident as the unit of analysis. All charts and Table 1, Table 2 and Table 3 include data where the resident is the unit of analysis. Table 4 shows facility characteristics both ways: first as a proportion of facilities with this characteristic, and then as a proportion of residents who live in facilities with the same characteristic. Table 5 and Table 6 present data with only the facility as the unit of analysis.

TABLE 1. Percentage of Residents Who Live in Residential Care Facilities That Offer Specific Services, by Functional Limitations and Cognitive Impairment

Services Offered by RCFs Where Residents Live Total RCF Population
  (n=8,094)  
No Need for
ADL Assistance
  (n=1,934)  
Need for Assistance
with 1-2 ADLs
  (n=2,944)  
Need for Assistance
with 3+ ADLs
  (n=3,216)  
  Stat.  
Sign.
No Cognitive
Impairment
  (n=2,391)  
Cognitive
Impairment
  (n=5,702)  
  Stat.  
Sign.
Special diets 89.3 85.2 88.8 92.6 *** 86.4 90.7 ***
Skilled nursing 39.8 39.4 37.9 41.9 * 38.4 40.5 ns
Basic health monitoring 96.5 94.3 97.3 97.3 ** 94.9 97.3 **
Assistance with ADLs 99.7 99.0 99.8 100.0 ** 99.6 99.7 ns
Incontinence care 94.2 89.4 93.2 98.5 *** 91.7 95.5 ***
Transportation to medical appointments 84.4 89.3 84.0 81.5 *** 86.6 83.3 **
Transportation to stores or elsewhere 85.9 92.2 86.4 80.9 *** 90.0 83.9 ***
Transportation to educational programs 33.6 40.2 33.3 29.4 *** 38.4 31.3 ***
Transportation to a sheltered workshop, work training program, or supported employment 19.1 21.3 18.7 18.1 ns 20.3 18.6 ns
Social services counseling 44.1 45.4 47.9 39.4 *** 46.4 43.0 *
Case management services 64.2 65.3 65.3 62.3 ns 65.5 63.5 ns
Occupational therapy 52.9 53.2 51.4 54.1 ns 54.1 52.3 ns
Physical therapy 55.9 55.9 54.8 57.0 ns 57.1 55.4 ns
Personal laundry services 99.3 98.6 99.4 99.8 ** 99.0 99.5 ns
Social or recreational activities in the facility 99.7 99.5 99.9 99.6 * 99.7 99.7 ns
Social or recreational activities outside the facility 89.9 92.4 91.5 86.6 *** 92.5 88.6 ***
SOURCE: RTI analysis of the NSRCF.
NOTES: Stat. Sign.: statistical significance. "Cognitive impairment" signifies residents with any indication of cognitive impairment, including Alzheimer's disease or other dementia diagnosis, behavioral symptoms, or memory problems.
*p<0.1, **p<0.05, ***p<0.0001, ns: not statistically significant (p>0.1).

TABLE 2. Percentage of Residents With Functional Limitations and Cognitive Impairment Who Use Specific Services

Services Used by Residents1 Total RCF Population
  (n=8,094)  
No Need for
ADL Assistance
  (n=1,934)  
Need for Assistance
with 1-2 ADLs
  (n=2,944)  
Need for Assistance
with 3+ ADLs
  (n=3,216)  
  Stat.  
Sign.
No Cognitive
Impairment
  (n=2,391)  
Cognitive
Impairment
  (n=5,702)  
  Stat.  
Sign.
Special diets 30.7 21.1 26.9 41.0 *** 24.4 33.8 ***
Skilled nursing 12.5 5.7 10.1 19.6 *** 7.4 15.1 ***
Basic health monitoring 75.1 60.8 77.7 82.3 *** 67.4 78.9 ***
Assistance with ADLs 69.2 22.6 73.9 96.5 *** 49.3 79.0 ***
Incontinence care 37.6 4.5 19.5 78.3 *** 14.7 48.9 ***
Transportation to medical appointments 58.9 59.3 60.6 56.9 ns 58.8 58.9 ns
Transportation to stores or elsewhere 39.3 53.2 42.5 26.6 *** 47.3 35.4 ***
Social service counseling 15.8 15.9 17.2 14.5 ns 13.8 16.8 **
Personal laundry services 86.6 69.6 89.9 95.0 *** 78.5 90.6 ***
Social or recreational activities in the facility 80.3 71.4 81.4 85.4 *** 75.4 82.7 ***
Social or recreational activities outside the facility 44.7 54.9 46.6 35.8 *** 50.0 42.1 ***
SOURCE: RTI analysis of the NSRCF.
NOTES: Stat. Sign.: statistical significance. "Cognitive impairment" signifies residents with any indication of cognitive impairment, including Alzheimer's disease or other dementia diagnosis, behavioral symptoms, or memory problems.
  1. The list of services used by residents in Table 6 is derived from the resident-level NSRCF file. This list of services is slightly different from the list of services offered by facilities in Table 5, which is derived from the facility-level NSRCF file.

**p<0.05, ***p<0.0001, ns: not statistically significant (p>0.1).

TABLE 3. Facility Staffing Ratio, by Staff Type

Types of Staff   Mean Staff HPRD  
Facility Level
Mean Staff HPRD:
  Facilities Where Residents Live  
All direct care staff 4.15 2.32
RN care 0.13 0.08
LPN or LVN 0.12 0.16
All nursing care1 0.26 0.24
Personal care aide direct care 2.96 1.81
Administrator/assistant administrator direct care   0.93 0.27
SOURCE: RTI International analysis of the NSRCF.
NOTE:
  1. Nursing care staffing was measured by the ratio of RN/LPN/LVN hours per resident day.

TABLE 4. Total Facility Direct Care Staffing Ratio, by Facility Characteristics

Facility Characteristics Mean HPRD:
  Facility Level  
Mean HPRD in
  Facilities Where Residents Live  
Overall 4.15 2.32
Facility size *** ***
   Small (4-10 beds) 5.81 5.17
   Medium (11-25 beds) 3.43 3.16
   Large (26-100 beds) 2.20 2.01
   Extra-large (over 100 beds) 1.65 1.59
Facility is owned by a chain, group, or multifacility system 3.30*** 2.13***
Non-chain facility 4.67 2.57
Serving Medicaid residents 4.18 2.30
Not serving Medicaid residents 4.11 2.35
Facilities with more than 50% of residents needing help with either bathing, eating, or transferring 5.17*** 3.09***
Facilities with less than 50% of residents needing help with bathing, eating, or transferring 3.07 1.90
Private, for-profit ownership 4.39*** 2.48***
Private non-profit or state, county, or local government 3.04 1.85
Facility has a distinct unit, wing, or floor designated as a dementia or Alzheimer's special care unit or serve only adults with dementia or Alzheimer's disease 2.40*** 2.09***
Facility without a special dementia unit 4.37 2.42
Metropolitan Statistical Area (MSA) location 4.52** 2.69**
Non-MSA location 3.54 2.36
SOURCE: RTI International analysis of the NSRCF.
NOTES: Metropolitan statistical area (urban setting); Stat. Sign.: statistical significance. Direct care hours include nursing, personal care aide, and direct administrator hours per patient per day.
**p<0.05, ***p<0.0001.

TABLE 5. Facility Staffing Levels for the Facilities in Which Residents Live, by Residents' Need for Assistance With Activities of Daily Living and by Cognitive Impairment Status: Hours per Resident per Day

  All Residents
  (n=8,094)  
No Need for
ADL Assistance
  (n=1,934)  
Need for Assistance
with 1-2 ADLs
  (n=2,944)  
Need for Assistance
with 3+ ADLs
  (n=3,216)  
  Stat.  
Sign.
No Cognitive
Impairment
  (n=2,391)  
Cognitive
Impairment
  (n=5,702)  
  Stat.  
Sign.
Staff Type HPRD HPRD HPRD HPRD HPRD HPRD HPRD HPRD
All direct care staff1 2.32 1.79 2.11 2.90 *** 1.87 2.54 ***
RN care 0.08 0.06 0.08 0.09 *** 0.07 0.09 **
LPN/LVN care 0.16 0.13 0.17 0.18 *** 0.15 0.17 **
All nursing care2 0.24 0.19 0.25 0.27 *** 0.22 0.25 ***
Personal care aide direct care 1.81 1.38 1.64 2.28 *** 1.45 1.90 ***
Administrator/assistant administrator direct care 0.27 0.21 0.22 0.35 *** 0.20 0.30 ***
Facilities without nursing staff % % % % --- % % ---
No RNs on staff 45.8 43.1 45.6 47.9 ns 45.1 46.2 ns
No LPNs or LVNs on staff 38.7 39.5 36.6 40.3 * 36.8 39.7 *
No nurses of any type on staff 19.5 19.2 16.9 22.2 *** 17.4 20.5 **
SOURCE: RTI analysis of the NSRCF.
NOTES: Stat. Sign.: statistical significance. "Cognitive impairment" signifies residents with any indication of cognitive impairment, including Alzheimer's disease or other dementia diagnosis, behavioral symptoms, or memory problems.
  1. Direct care staffing was measured by the ratio of combined RN, LPN, LVN; personal care aide; and direct care administrator HPRD.
  2. Nursing care staffing was measured by the ratio of RN, LPN, and LVN HPRD.

*p<0.1, **p<0.05, ***p<0.0001, ns: not statistically significant (p>0.1).

TABLE 6. Facility Characteristics: Sample Description for Multivariate Analysis

Facility Characteristics   Unweighted  
N
  Weighted  
N
  Weighted  
%
All facilities 2,302 31,134 100
Facility size --- --- ---
Small (4-10 beds) 626 15,439 49.6
Medium (11-25 beds) 654 4,947 15.9
Large (26-100 beds) 803 8,656 27.8
Extra-large (over 100 beds) 219 2,092 6.7
Facility is owned by a chain, group, or multifacility system 974 11,724 37.7
Non-chain facility 1,328 19,410 62.3
Serving Medicaid residents 1,292 17,609 43.1
Not serving Medicaid residents 998 13,358 56.9
Facilities with more than 50% of residents needing help with either bathing, eating, or transferring 976 16,058 51.7
Facilities with less than 50% of residents needing help with bathing, eating, and transferring 1,320 14,994 48.3
Percentage of residents with short-term memory problems 2,288 30,973 43.9
Private, for-profit ownership 1,776 25,648 82.4
Private non-profit or state, county, or local government 526 5,486 17.6
Facility has a distinct unit, wing, or floor designated as a dementia or Alzheimer's special care unit or serves only adults with dementia or Alzheimer's disease   329 3,430 17.0
Facility without a special dementia unit 1,972 27,669 83.0
MSA location 1,525 23,382 80.5
Non-MSA location 558 5,660 19.5
SOURCE: RTI International analysis of the NSRCF.
NOTES: Numbers may not add to 100% due to rounding.

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