Medicaid in Residential Care. Admission and Discharge Policies

09/01/2013

Facility admission and discharge policies largely determine who lives in these settings. These policies are determined by a combination of facility preferences, state regulations, and for RCFs serving Medicaid residents, Medicaid regulations and contract requirements. Although states give facilities some flexibility over admissions and discharges, RCFs may have little or no discretion on certain policies. For example, if state regulations prohibit RCFs from serving individuals who need skilled nursing care or who cannot self-evacuate the facility in an emergency, then RCFs will not be able to admit or retain these individuals. On the other hand, many states allow RCFs to determine whether they can safely and adequately serve--and continue to serve--residents with high levels of need. In addition, facilities may decide to waive certain general policies for particular individuals.

Table 2a presents data on admission policies for all RCFs and for RCFs by Medicaid status at the facility level. Table 2b presents similar data but at the resident level (i.e., facilities in which the residents live). A high percentage of RCFs admit individuals who are regularly incontinent of urine (81.6 percent) and who need daily health monitoring (81.3 percent). A smaller but still large percentage admit individuals who are regularly incontinent of feces (68.9 percent), require end-of-life care (61.5 percent), are unable to leave the facility in an emergency without help (56.3 percent), and have moderate to severe cognitive impairment (55.3 percent). A smaller percentage of facilities admit individuals with behavior problems (40.0 percent), need a two-person assist to get in and out of bed (32.7 percent), or require skilled nursing care (20.4 percent).

TABLE 2a. Facility Admission Policies, by Medicaid Status: Facility Level
Residential Care Facilities Total RCF FacilitiesN=2,302 (%) Non-Medicaid FacilitiesN=1.292 (%) Facilities Serving Any Residents on MedicaidN=998 (%) Significance Test p-value

SOURCE: RTI analysis of the 2010 NSRCF.

*p<0.1, **p<0.05, ***p<0.001, ns: not significant, p>0.1.

Facility Admission Policies
Facilities will admit residents who:
   Are unable to leave the facility in an emergency without help   56.3 59.4 52.2 **
   Have moderate to severe cognitive impairment 55.3 56.3 54.1 ns
   Need skilled nursing care on a regular basis 20.4 17.5 24.2 ***
   Need daily monitoring for a health condition 81.3 78.1 85.7 ***
   Are regularly incontinent of urine 81.6 83.9 78.5 **
   Are regularly incontinent of feces 68.9 72.4 64.2 ***
   Need two people/Hoyer lift to help them get in and out of bed 32.7 32.7 32.6 ns
   Exhibit problem behavior 40.0 36.0 35.9 ns
   Have history of drug or alcohol abuse 45.5 43.8 47.8 **
   Require end-of-life care 61.5 63.4 58.7 *

The admissions policies of Medicaid and non-Medicaid facilities show a similar pattern as for RCFs overall. However, there are statistically significant differences between Medicaid and non-Medicaid facilities on several admission policies. A higher proportion of Medicaid facilities admit individuals who need skilled nursing on a regular basis or daily monitoring for a health condition, or who have a history of alcohol or drug abuse. On the other hand, a higher proportion of non-Medicaid facilities report admitting residents who are unable to leave the facility in an emergency without help and who are regularly incontinent of urine or feces. There are no statistically significant differences between Medicaid and non-Medicaid facilities on the remaining admission policies.

TABLE 2b. Facility Admission Policies, by Medicaid Status: Resident Level
Residential Care Facilities Where Residents Live All ResidentsN=8,094 (%) Non-Medicaid ResidentsN=6,122 (%) Medicaid ResidentsN=1,904 (%) Significance Test p-value

SOURCE: RTI analysis of the 2010 NSRCF.

*p<0.1, **p<0.05, ***p<0.001, ns: not significant, p>0.1.

Residents Living in Facilities with the Following Admission Policies
Facilities will admit residents who:
   Are unable to leave the facility in an emergency without help   53.2 54.8 45.9 **
   Have moderate to severe cognitive impairment 49.6 50.8 44.4 *
   Need skilled nursing care on a regular basis 11.6 10.6 15.9 **
   Need daily monitoring for a health condition 85.0 83.8 90.5 ***
   Are regularly incontinent of urine 78.6 79.1 76.8 ns
   Are regularly incontinent of feces 62.5 63.7 58.1 **
   Need two people/Hoyer lift to help them get in and out of bed 26.0 26.3 28.4 ns
   Exhibit problem behavior 32.8 33.2 31.1 ns
   Have history of drug or alcohol abuse 50.1 49.4 54.1 ns
   Require end-of-life care 59.4 60.9 53.5 **

The patterns of admission policies of the facilities where Medicaid and non-Medicaid residents live are similar to those at the facility level. However, the differences regarding policies on admitting residents who are regularly incontinent (urine) and those with substance abuse problems are not statistically significant.

Discharge policies are important because they determine whether residents whose needs change over time can age in place. Some discharge criteria mirror admission criteria. If regulations do not allow RCFs to serve individuals with certain conditions, this prohibition applies to both admissions and retentions. As with admission policies, beyond regulatory constraints, facilities have substantial discretion about whether to retain residents who develop specific impairments or become more severely impaired.

Table 3a and Table 3b present data on discharge policies for all RCFs and RCFs by Medicaid status. Table 3a shows the data at the facility level and Table 3b presents the same data for facilities in which the residents live (the resident level). More than half (56.5 percent) of all RCFs discharge residents who need skilled nursing care on a regular basis. A somewhat smaller percentage discharge individuals who need a two-person assist to get in and out of bed (43.7 percent), those with behavior problems (42.9 percent), and those who have a history of drug or alcohol abuse (33.9 percent). Fewer facilities discharge individuals who have moderate to severe cognitive impairment (18.3 percent), are unable to leave the facility in an emergency without help (14.7 percent), and those who are regularly incontinent of feces (12.5 percent). A small percentage of RCFs discharge residents who require end-of-life care (8.8 percent), those who need daily health monitoring (8.0 percent), and those who are regularly incontinent of urine (5.3 percent).

TABLE 3a. Facility Discharge Policies, by Medicaid Status: Facility Level
Residential Care Facilities Total RCF FacilitiesN=2,302 (%)   Non-Medicaid FacilitiesN=1.292 (%) Facilities Serving Any Residents on MedicaidN=998 (%) Significance Test p-value

SOURCE: RTI analysis of the 2010 NSRCF.

NOTES: † Estimate cannot be assumed to be reliable. Sample size is between 30 and 59, and/or the sample size is greater than 59 but has a relative standard error of 30% or more.

**p<0.05, ***p<0.001, ns: not significant, p>0.1.

Facility Discharge Policies
Facilities will discharge residents who:
   Are unable to leave the facility in an emergency without help 14.7 14.1 15.4 ns
   Have moderate to severe cognitive impairment 18.3 18.1 18.5 ns
   Need skilled nursing care on a regular basis 56.5 60.3 51.5 **
   Need daily monitoring for a health condition 8.0 10.1 5.4† ***
   Are regularly incontinent of urine 5.3 4.3 6.6 ***
   Are regularly incontinent of feces 12.5 10.6 15.0 ***
   Need two people/Hoyer lift to help them get in and out of bed 43.7 42.9 44.7 ns
   Exhibit problem behavior 42.9 42.4 43.6 ns
   Have history of drug or alcohol abuse 33.9 33.7 34.2 ns
   Require end-of-life care 8.8 8.0 9.9 **

Medicaid and non-Medicaid facilities have similar discharge policies but there are statistically significant differences on several policies. A smaller proportion of Medicaid RCFs discharge residents who need skilled nursing care (51.5 percent compared to 60.3 percent of non-Medicaid facilities) and daily monitoring for health conditions (5.4 percent compared to 10.1 percent of non-Medicaid facilities), but a larger proportion of Medicaid RCFs discharge residents who become regularly incontinent of urine (4.3 percent compared to 6.6 percent of non-Medicaid facilities), incontinent of feces (10.6 percent compared to 15.0 percent) or who need end-of-life care (8.8 percent compared to 9.9 percent of non-Medicaid facilities). Although statistically significant, the absolute percentage differences are not large, except for policies regarding discharge of residents who need skilled care.

TABLE 3b. Facility Discharge Policies, by Medicaid Status: Resident Level
Residential Care Facilities Where Residents Live All ResidentsN=8,094 (%) Non-Medicaid ResidentsN=6,122 (%) Medicaid ResidentsN=1,904 (%) Significance Test p-value

SOURCE: RTI analysis of the 2010 NSRCF.

**p<0.05, ***p<0.001, ns: not significant, p>0.1.

Residents Living in Facilities with the Following Discharge Policies
Facilities will discharge residents who:
   Are unable to leave the facility in an emergency without help   16.7 16.3 18.2 ns
   Have moderate to severe cognitive impairment 23.5 23.5 23.8 ns
   Need skilled nursing care on a regular basis 66.4 67.3 62.4 ns
   Need daily monitoring for a health condition 5.5 6.2 2.5 ***
   Are regularly incontinent of urine 6.2 6.1 7.0 ns
   Are regularly incontinent of feces 16.4 15.8 18.8 ns
   Need two people/Hoyer lift to help them get in and out of bed 52.2 51.4 55.7 ns
   Exhibit problem behavior 46.3 45.5 49.8 ns
   Have history of drug or alcohol abuse 27.9 27.2 31.1 **
   Require end-of-life care 6.7 5.8 10.8 ***

Discharge policies are largely the same for the facilities where Medicaid and non-Medicaid residents live; however, there are a few differences, all of which are statistically significant. Fewer facilities serving Medicaid residents report that they will discharge residents who need daily monitoring for a health condition (2.5 percent of facilities in which Medicaid residents live compared to 6.2 percent of RCFs serving non-Medicaid residents). Almost a third (31.1 percent) of Medicaid residents live in facilities that will discharge residents who have substance abuse problems compared to just over a quarter of the facilities in which non-Medicaid residents live (27.2 percent). The proportion of Medicaid residents who live in facilities that will discharge residents who require end-of-life care (10.8 percent) is twice that of non-Medicaid residents (5.8 percent).

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