Medicaid-Financed Institutional Services: Characteristics of Nursing Home and ICF/IID Residents and Their Patterns of Care. C. Associations Between Lengths of Stay in Intermediate Care Facilities for People with Intellectual Disabilities and State Policy-Related Variables

08/01/2013

To understand how policy may be related to ICF/IID use, we assessed the associations between the length of enrollees' ICF/IID stays and policy-related measures. Although these associations may be informative to policymakers seeking to improve ICF/IID services and LTSS more generally for the ID/DD population, it is not possible to determine causal relationships from the data presented here.

In general, we found little relationship between the percentage of ICF/IID stays lasting less than three months and state policy variables such as the percentage of Medicaid LTC expenditures allocated to HCBS or the percentage of Medicaid LTC recipients using HCBS (Figures III.2-5), regardless of whether outlier states were included in the analysis. Similarly, there was no obvious association between the prevalence of very short ICF/IID stays and several structural variables, including the percentage of ICFs/IID with more than 15 beds in 2007 (Figure III.6) or the change in the number of ICFs/IID with more than 15 beds from 2006 to 2007 (not shown). However, there was a negative relationship between the percentage of ICF/IID stays that were very short and the percentage change from 2006 to 2007 in the number of ICFs/IID in a state, with a 10 percentage point decrease in the number of ICFs/IID in a state corresponding to a 5.2 percentage point increase in the percentage of stays that lasted less than three months (Figure III.7).31

  FIGURE III.2. The Relationship Between the Percentage of Medicaid LTC Expenditures Allocated to HCBS and the Length of ICF/IID Spells  
FIGURE III.2, Scatter graph: Shows the points representing the states in the sample. Since the relationship portrayed was not statistically significant, a regression line is not plotted. The diagram show the relationship between the percentage of Medicaid LTC expenditures allocated to HCBS and the length of ICF/IID spells. Most of the data points are concentrated between 22% and 46% of Medicaid LTC expenditures allocated to HCBS, and 0% and 26% of ICF/IID spells lasting less than 3 months.
SOURCE: MAX, 2006-2007.
NOTES: The relationship between the two variables was not statistically significant.

  FIGURE III.3. The Relationship Between the Percentage of Medicaid LTC Users' Total Medicaid Expenditures Accounted for by HCBS Users and the Length of ICF/IID Spells  
FIGURE III.3, Scatter graph: Shows the points representing the states in the sample. Since the relationship portrayed was not statistically significant, a regression line is not plotted. The diagram show the relationship between the percentage of Medicaid LTC users total expenditures allocated to HCBS and the length of ICF/IID spells. Most of the data points are concentrated between 32% and 70% of total Medicaid LTC expenditures allocated to HCBS, and 0% and 32% of ICF/IID spells lasting less than 3 months.
SOURCE: MAX, 2006-2007.
NOTES: The relationship between the two variables was not statistically significant.

  FIGURE III.4. The Relationship Between the Percentage of Medicaid LTC Recipients Using HCBS and the Length of ICF/IID Spells  
FIGURE III.4, Scatter graph: Shows the points representing the states in the sample. Since the relationship portrayed was not statistically significant, a regression line is not plotted. The diagram show the relationship between the percentage of Medicaid LTC users receiving HCBS and the length of ICF/IID spells. Most of the data points are concentrated between 36% and 80% of Medicaid LTC users receiving HCBS, and 0% and 30% of ICF/IID spells lasting less than 3 months.
SOURCE: MAX, 2006-2007.
NOTES: The relationship between the two variables was not statistically significant.

  FIGURE III.5. The Relationship Between the Percentage of Potential Medicaid LTC Recipients Using HCBS and the Length of ICF/IID Spells  
FIGURE III.5, Scatter graph: Shows the points representing the states in the sample. Since the relationship portrayed was not statistically significant, a regression line is not plotted. The diagram show the relationship between the percentage of potential Medicaid LTC users receiving HCBS and the length of ICF/IID spells. Most of the data points are concentrated between 5% and 26% of potential Medicaid LTC users receiving HCBS, and 0% and 30% of ICF/IID spells lasting less than 3 months.
SOURCE: MAX, 2006-2007.
NOTES: The relationship between the two variables was not statistically significant.

  FIGURE III.6. The Relationship Between the Percentage of ICFs/IID with More Than 15 Beds in 2007 and the Length of ICF/IID Spells  
FIGURE III.6, Scatter graph: Shows the points representing the states in the sample. Since the relationship portrayed was not statistically significant, a regression line is not plotted. The diagram show the relationship between the percent of ICFs/IID with more than 15 beds and the length of ICF/IID spells. Six states have all of their beds in large ICFs/IID with 0% and 20% of ICF/IID spells lasting less than 3 months.
SOURCE: MAX, 2006-2007.
NOTES: The relationship between the two variables was not statistically significant.

  FIGURE III.7. The Relationship Between the Percentage Change in the Number of ICFs/IID Between 2006 and 2007 and the Length of ICF/IID Spells  
FIGURE III.7, Scatter graph: Shows the relationship between the percent change in the number of ICFs/IID between 2006 and 2007 and the length of ICF/IID spells expressed as a regression of the percentage of all first ICF/IID spells lasting less than 3 months as a linear function of the percent change in the number of ICFs/IID between 2006 and 2007. At the left end of the regression line, approximately 29% of nursing home stays lasted less than 3 months corresponding with a 30% decrease in the number of ICFs/IID between 2006 and 2007. The line declines in slope, ending at 0% of nursing home stays lasting less than 3 months corresponding with 26% increase in the number of ICFs/IID between 2006 and 2007. Most of the states reported no change in the number of ICFs/IID.
SOURCE: MAX, 2006-2007; Lakin et al. (2008); Prouty et al. (2007).

Because only a portion of elderly and people with disabilities who require LTC are part of the ID/DD population, we also examined the percentage of Medicaid LTC expenditures for enrollees with ID/DD only that were allocated to HCBS and continued to find no meaningful association with length-of-stay.

Assessing the relationship between policy-related variables and other lengths of stay (for example, the percentage of stays lasting more than one year)32 yielded similar results. Given the small population of ICF/IID users, most of whom are young or middle-aged adults who live in these facilities for very long periods of time,33 these results are not entirely surprising. To the extent that policy affects how individuals with an ICF/IID level of need receive their care, it is likely through the diversion of would-be residents to community-based services or smaller group homes.

D. Summary of ICF/IID Findings

Enrollees residing in ICFs/IID were generally younger adults who remained in residence for a year or longer. Among those who had shorter stays, it is likely that some of these resulted from either: (1) residents being transitioned to the community upon the closure of their facility; or (2) individuals entering the Medicaid system in certain states who are initially placed in state institutions (or other settings that receive people entering the residential service system) on a short-term basis while waiting for a placement in a more appropriate care setting to be arranged. The vast majority (89 percent) qualified for Medicaid even before they were admitted to the ICF/IID and those who qualified in advance generally retained the same MAS upon admission. This is not surprising since their disabilities are generally lifelong and often limit their ability to earn income.

More than 40 percent of enrollees living in ICFs/IID used HCBS before their ICF/IID stay, suggesting (as with nursing homes) that it is not uncommon for an individual to use both communityand institutional services rather than solely ICF/IID services. Although few enrollees had both ICF/IID and nursing home stays during the study period, most of those individuals moved from nursing homes to ICF/IIDs, rather than the other way around; these enrollees might have used nursing homes prior to their ICF/IID admission either for post-acute care or while waiting for an ICF/IID bed to become available.

There was little meaningful relationship between lengths of ICF/IID spells and state policy variables, although the percentage of stays lasting three months or less was lower in states that closed facilities during the study period.

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