- Genevieve Strahan, National Center for Health Statistics
- Esther Hing, National Center for Health Statistics
- Edward S. Sekscenski, National Center for Health Statistics
Facilities participating in the 1985 NNHS were selected from a universe of over 20,000 nursing and related-care homes. Of the 1,220 facilities selected, six were identified as having been included in the pretest phase of the survey. It was decided by NCHS not to recontact these same facilities but instead to transcribe data from the pretest instruments to the national survey instruments. During the fielding effort of the remaining 1,214 facilities, 56 were identified as out-of-scope. Of the remaining in-scope facilities 1,079 participated in the survey for a response rate of 93 percent.
First contact to the facility was made in May 1985 prior to the beginning of the survey. A telephone prescreening procedure was performed to verify contact information for facilities selected in the sample. This prescreening was designed to update facility data concerning facility name, address, telephone number, and the administrator's name.
The next contact made to the sample facility was in the form of an introductory information packet to the administrator. The packet contained a letter from the Director of NCHS explaining the importance of the survey and informing the administrator that an interviewer would be calling for an appointment. The packet also included letters of endorsement from professional health organizations. About a week after the packet should have been received, the interviewer contacted the administrator to set up the appointment to conduct the survey. Depending on the size of the facility, one interviewer or a team of two or three interviewers visited the facility.
A part of the facility visit included the administration of three questionnaires: (1) Facility Questionnaire, (2) Expense Questionnaire, and (3) Nursing Staff Questionnaire.
II. FACILITY FILE
The Facility Questionnaire (FQ), printed in canary yellow, was completed by the interviewer in a face-to-face interview with the administrator or his/her designee. Collected on the FQ was basic information about the facility: ownership, certification status, bed size, number of admissions and inpatient days of care, services provided to residents and nonresidents, and number of nonresidents served. Staffing in several occupational categories was collected for full-time and part-time employees. Full-time equivalent employees for each category were tabulated utilizing the number of hours worked which was collected for all part-time employees. Thirty-five hours of part-time work are taken to equal that of one full-time employee. The survey collected for the first time in 1985, per diem rates for routine care set by nursing homes. These rates were collected separately for Medicare, Medicaid, and private pay patients. Per diem rates will be one of the key units of analysis from the facility file. By matching the unique facility ID number from all documents completed in a sample home, information about residents collected in two other components of the survey can be described by characteristics of the facility. For example, estimates of current residents can be tabulated by ownership of the facility.
The administrator did not always have all the data required for the FQ at hand and needed to consult records or staff in other offices. Questions that required specific numerical data were printed on a separate sheet, referred to as the FQ work sheet. The interviewer gave this work sheet to the administrator at the end of the interview to be completed later. The interviewer picked up the work sheet at the end of the day or at a later date.
In 1985, the typical nursing home was independently and privately owned. It had about 85 beds -- most of which had some form of certification. This typical home had 71 employees per 100 beds. The estimated 19,100 nursing homes set average rates of $61 for skilled private pay daily care and $62 for Medicare skilled care.
These data and more are included in Advance Data report, Number 131, "Nursing Home Characteristics -- Preliminary Data from the 1985 National Nursing Home Survey." Data from the facility file along with data from four other components of the NNHS will be included in a special report to be published by the end of this year.
III. EXPENSE DATA FILE
Upon completion of the FQ, the Expense Questionnaire (EQ), and its accompanying Definition Booklet, printed in green, were presented to the administrator for completion. In many facilities, the administrator completed the EQ; in others, he referred the interviewer to an accountant, a bookkeeper, or a central office. This instrument was completed by a respondent at his or her convenience. A postage-paid return envelope was provided for the return of the EQ. The EQ collected data on two major topics: expenses and revenues. Expense data included payroll, health care services, insurance, taxes, food, utilities, maintenance, and drug expenses. Revenue data included sources of income from patient and nonpatient sources such as contributions. In lieu of a completed EQ, each facility was offered the option of providing the interviewer with a recent financial statement.
IV. NURSING STAFF FILE
After obtaining the financial statement or the name and address of the anticipated respondent for any necessary follow-up, the interviewer introduced the nursing staff component of the NNHS. These two documents (the Nursing Staff Sampling List and the Nursing Staff Questionnaire) were used to collect data on RNs working in nursing homes.
The Nursing Staff Sampling List, printed in blue, was completed by the interviewer in collaboration with a staff member designated to help. For the preparation of this list, it was necessary to divide employment status of all facility RNs into one of three categories: (1) those who are employed on the staff of the facility, (2) those scheduled to work who were retained through a special contractual relationship, and (3) those scheduled to work who were retained through a temporary service. Three columns were provided in which to list separately persons in each category. The sampling list provided the universe of RNs separated into the three groupings. With the introduction of the Nursing Staff Sampling List came the first need to use sampling tables. Each interviewer received a pack of sampling tables. The pack consisted of ten independent sets of three different kinds of tables, which were numbered and color-coded according to the component to which they applied. Table 1 was blue and was used to select the nursing staff sample.
In order to ensure random in-facility samples, Table 1 had ten versions, numbered 0 to 9. The fourth digit of a facility ID number determined which version of Table 1 was to be used to select the RN sample at that facility. For example, if the facility ID number were 1234-00-7, the interviewer would consult version 4 or Tables 1-4. This method of assignment assured a fairly even distribution of facilities among all the versions of the sampling tables.
After finding the total number of RNs recorded on the Nursing Staff Sampling List, the interviewer referred to the version of Table 1 mandated by the fourth digit of the facility ID number. After locating the correct total in the "Total # Listed" column, the interviewer read across to find out which sample line numbers on the sampling list determined the individuals chosen for questionnaire completion. The selection of up to four RNs from each sampled nursing home yielded a sample of 3,349 nurses.
The Nursing Staff Questionnaire (NSQ) also printed in blue, was, when at all possible, personally distributed by the interviewer to those RNs selected on the sampling list. The NSQ was self-administered. When personal delivery was not possible, the questionnaire was either mailed to a home address or left at the facility. A postage-paid business reply envelope was provided for return of the completed questionnaire. If a questionnaire was not received within 28 days of the facility visit, a reminder letter and duplicate instrument were sent.
The NSQ gathered information on the work experience, hours, activities, education, training, salary, and opinions about recruitment and retention issues of RNs working in nursing homes. Basic demographics about each RN were also collected.
Data were collected from 2,763 of the sampled RNs for a 80 percent response rate.
The typical RN working in a nursing home was prepared to work as an RN in a diploma program and has been employed as an RN for more than ten years. She (98 percent are female) worked full-time on a nonrotating day shift. She is white, married with either no children living at home, or the children are of school age (6 to 18). She is scheduled to work an average of 32.5 hours per week and earns about $334 per week.
An Advance Data report should be released this year, reporting characteristics of RNs in nursing homes. Future reports will provide detailed information about RNs working in nursing homes and will be published in both Series 13 and Series 14 reports. Data on RNs will also appear in the special report that combines data from several other components.
Now Esther Hing will talk about the current resident component of the 1985 National Nursing Home Survey.
V. DESCRIPTION OF CURRENT RESIDENT QUESTIONNAIRE
Data from the Current Resident Component of the NNHS are cross sectional and are representative of nursing home residents in the United States as of the night before the survey. To draw the sample of residents, lists of residents in the facility were constructed at the time of the survey. In nearly half of the sample homes, the nursing home provided photocopied or computer generated lists of current residents. In the remaining homes, the lists had to be constructed by copying the names of residents from ledgers, or other lists of patients. A sample of five or fewer residents were selected per sample home resulting in an overall sample of 5,395 current residents.
The Current Resident Questionnaire (CRQ) was used to collect data on the sample of residents. This questionnaire was administered by personal interview with a knowledgeable staff member who referred to the residents' medical record when necessary. The most frequent respondent to the CRQ was a nurse (55 percent), followed by the administrator or owner of the nursing home (17 percent). In about 3 percent of the cases, no staff was available and the interviewer abstracted the data from the medical records. Participation for this questionnaire was very high, the response rate was 97 percent. Item response rate in this questionnaire were also high. This result is by design, since items with low response rates in our pretest of the NNHS were not included on the final questionnaire. Item response rates from the national study were similar to those found in the pretest.
Follow-up information on the sample of current residents was also obtained in a telephone interview with the residents' next-of-kin. The residents' next-of-kin, friends or guardian may have been contacted. Only sample residents with no next-of-kin or other known contacts were ineligible to have this telephone follow-up. The instrument used to collect the follow-up data was called the Next-of-Kin Questionnaire.
The CRQ collects information about the demographic, medical and other utilization characteristics of the nursing home population. These items are summarized in Table 1. Demographic variables include age, sex, race, hispanic origin, and martial status. Medical data include the diagnoses at admission and currently. Up to eight diagnoses were listed for each time period. The data were coded according to the Clinical Modification of the Ninth Revision of the International Classification of Diseases. Other medical data collected include vision and hearing status and prevalence of mental disorders. Utilization data collected include the length of stay since admission and the total monthly charge last month.
Table 1 shows items collected for the first time in the NNHS. These items have asterisks to the left. These items include marital status at admission, presence of living children, diagnoses-related group data for hospital transfers, hospital stays while a resident, history of other nursing home stays, instrumental activities of daily living (this involves the need for help in such activities as caring for personal possessions, handling money, securing personal items and using the telephone), disorientation or memory impairment and sources of payment at admission.
|TABLE 1. Summary of Current Resident Data Items|
|* Marital status at admission|
|Current marital status|
|* Presence of living children|
|Length of stay since admission|
|Residence before admission|
|* Diagnoses-Related Group (DRG) for persons admitted from a short-stay hospital|
|* Hospital stays while a resident|
|* History of nursing home stays at sample facility and other nursing homes|
|Diagnoses at admission and currently|
|Therapy received last month|
|Vision and hearing status|
|Activities of daily living characteristics|
|* Instrumental activities of daily living (IADL)|
|* Disorientation or memory impairment|
|Disturbance of mood|
|* Sources of payment at admission|
|Sources of payment last month|
|Total monthly charge for care|
|* = Collected for first time in the NNHS.|
This table also shows that the tape for the CRQ will include the facility number and the resident weight. The facility number uniquely identifies each facility in the survey. By matching the facility number on the CRQ with the facility number on the FQ, information from the FQ such as bed size or ownership type can be moved to the CRQ for further analysis. The resident weight is used to inflate the sample data to national estimates. The weights associated with each file and how they were computed are discussed below.
One of the principal strengths of the current resident data is that it provides national estimates of the population in nursing homes. This is useful to health planners and policy makers who need descriptive data on the utilization of nursing homes.
In particular, several of the new items collected in the CRQ were added to shed light on long-term care policy issues. The items on sources of payment at admission and last month, for example, provides estimates of nursing home residents who had to "spend-down" before becoming eligible for medical assistance from Medicaid. A question was also added to the CRQ on the diagnoses-related group code for all persons transferred to the nursing home from short-stay hospitals. This data, along with other variables from the survey, may be used to assess the impact of the Medicare prospective payment system (PPS) on nursing home care since its implementation in 1983.
Data from the CRQ, however, have certain limitations. Because of the resident sample is selected from patients currently residing in the facility, the length of stay for respondents is incomplete and underestimates the true length of stay that would be achieved at some point in the future. Residents with long length of stay, however, are over-represented in the current resident sample because of the short-time frame -- overnight -- of the sample. As a result, a person admitted to the nursing home for a short stay, for example, one day, has fewer chances of being included in the sample than a person with a stay of one year. Because of these limitations, the current resident data is inappropriate for examining the flow of patients in and out of nursing homes. The best data for investigating this issue would be a longitudinal study of a cohort of persons admitted to nursing homes. Longitudinal surveys, however, are expensive to conduct.
To date one report on the use of nursing homes by the elderly has been published using the current resident data. This report discussed the utilization rate or number of residents per 1,000 population, 65 years and over by age, sex, and race. Selected health and socioeconomic characteristics were also examined. The report found that about 5 percent of the elderly resided in nursing homes on any given day during the survey period of the 1985 NNHS. Use of nursing homes increased with age for both sexes but was greater for females than males. Use of nursing homes was lower for elderly persons who were black or of other races than for white persons. For the most part, these trends have not changed since 1973-74, when the first NNHS was conducted; however, there were some exceptions. There was an increase in the use of nursing homes by elderly black persons and a decrease in use by those 85 years and over. If any one is interested in receiving a copy of this report, they can write to us.
As Genevieve has mentioned, the next NNHS report to be published will be a summary report presenting data from most components of the 1985 NNHS. This report will include current resident tabulations covering all topics covered on the questionnaire. This report will probably be released at the end of the year.
After the summary report, the next scheduled report using current resident data will be a study of the impact of the Medicare PPS on nursing home care.
And now Ted will discuss the data on discharged residents.
VI. DATA PROCESSING
Once data were collected, a series of checks were performed to assure that all responses were accurate, consistent, logical and complete. Manual edits were performed to check the completeness, format and consistency of the data. For example, sampling lists for current residents were checked to determine that the sample was correctly selected. Following the manual edit, diagnostic data were coded according to the Clinical Modification of the Ninth Revision of the International Classification of Diseases. Range checks and checks of identifiers were also performed at the time of keying. At all steps of data preparation and data entry, quality control procedures were taken to minimize processing errors. Once the data were entered, separate files for each questionnaire were created, and extensive computer edits were performed. Computer edits performed were basically of two types: (1) data cleaning based on consistency tests and (2) data flagging for imputation. Data flagged as "missing" during the editing process were then replaced with "good data" from a randomly picked similar responding case. Once the data base was edited and missing data imputed, weights were assigned, and constructed variables such as, length of stay and age of resident were computed. At this point, national estimates may be produced from the data tapes.
Data processing of the next-of-kin file followed a different track, since the data were basically keyed during the telephone interview. Data cleaning of the next-of-kin file was not as extensive as data obtained from the nursing home, because the computer assisted telephone interview automatically followed correct skip patterns. Quality control procedures for the next-of-kin interviews included silent monitoring of calls, review of complete and incomplete cases, and nonresponse conversion efforts. At the conclusion of interviewing for the next-of-kin, the relationship of the respondent to sampled current or discharged resident was coded. Then weights were assigned and constructed variables or recodes were computed.
And now I will talk about how data from the NNHS are weighted to produce national estimates.
The design of the 1985 NNHS is a complex multistage probability sample survey. For the sample data to reflect national estimates, the data needs to be inflated by a weighting factor. The weights for the 1985 NNHS estimators include three basic components:
- Inflation by the reciprocal of the probability of selection,
- Adjustment for nonresponse, and
- A first-stage ratio adjustment to total beds in the sampling frame.
For facility level estimates such as the number of nursing homes, number of beds, or total cost of providing care, the probability of selection is the product of the facilities' probability of being included in the sampling frame times the probability of its being selected from the frame. Only homes from the Complement Survey had a probability of being included in the sampling frame of less than 1. For second-stage estimates of current and discharged residents, and RNs, the probability of selection is the product of the probability of facility selection times the secondstage probability of selection for these sampling units.
The nonresponse adjustment factor brings estimates based on the responding cases up to the level that would have been achieved if all eligible cases had responded. The effect of the first-stage bed ratio adjustment is to bring the sample in closer agreement with the known universe of beds.
All three components were used to estimate facility characteristics correlated with bed size, and estimates of current residents, discharged residents, and RNs. The first-stage bed size ratio adjustment, however, was not included in estimates of nursing homes and facility characteristics uncorrelated with bed size.
Weighting factors used to estimate the number of residents and discharges with next-of-kin are similar to the weights for current and discharged residents with the exception of an additional nonresponse adjustment factor for nonresponse to the question requesting the names of next-of-kin and an adjustment factor for the existence of next-of-kin or other contacts for sample residents and discharges.
As a result, estimates of residents and discharges from the next-of-kin file will be less than the overall estimates of residents and discharges.
It should be noted that caution should be used when producing estimates by metropolitan status since the sample was not specifically designed to produce detailed estimates by this characteristic.
VIII. DISCHARGE RESIDENTS
My presentation deals exclusively with the discharged resident component of the 1985 NNHS. Comparisons made with other data files, including previous NNHS, are illustrative and not exhaustive; continuities do exist with many of the data items in the 1973-74 and 1977 discharged resident segments of the NNHS although some items have not been repeated and a number of new items have been added to the 1985 NNHS. This section will outline some but not all of the similarities and differences between the 1973-74, 1977 and 1985 surveys, and hope to cover all items on the 1985 survey. It is also possible to cross a number of the data items available from other components of the 1985 NNHS to yield further information on the discharged population.
Data in the discharged resident file of the 1985 NNHS were obtained from personal interviews conducted in the sample nursing homes with employees deemed most knowledgeable of the discharge residents' health status and conditions during their stay at the sample home. In most cases the interviewee was either a nurse or medical records person who consulted with the available medical records of the discharged resident during the course of the interview. As was true in both previous NNHSs and in the current resident segment of the 1985 survey, no residents were consulted personally in the discharge component of the 1985 survey.
Unlike the 1973-74 and 1977 surveys, the 12-month reference period from which the discharged resident's sample was drawn for the 1985 survey, ended on the date immediately preceding the survey date. Previous survey reference periods for discharges were the calendar year 1972 and 1976. The survey's reference period was changed for the 1985 survey in an attempt to obtain both more current and readily available data and to provide for information on the utilization of nursing homes by both residents and discharges over a more closely related period of time. However, data from the 1985 NNHS for the discharged resident population and current resident population continue to differ in several major areas.
Briefly, while the discharged resident estimates represent all discharges over a 12-month period, the current resident population is estimated for a single night, that immediately prior to the survey date. The discharge sample, therefore, may underestimate those nursing home residents who tend to stay for very lengthy durations, while the current resident population may underestimate those persons with very short durations of stay. While the current resident file provides for what may be considered a "snapshot" of nursing home residents on any given day, the discharged resident file provides for some indication of the over-the-year changes in the nursing home population at least, this is, in terms of whom is being discharged from the nation's approximately 20,000 nursing and related-care homes.
A sample of six or fewer discharged residents were selected per sample home resulting in an overall sample of 6,023 discharged residents. The Discharged Resident Questionnaire (DRQ) collected data on the discharged residents' demographic characteristics (including age, sex, race, Hispanic origin, and marital status), their discharge diagnoses, and the discharge destinations of live discharges, whether or not the resident had difficulty in controlling his/her bowel and whether he/she was bedfast or chairfast during the seven days prior to being discharged from the nursing home. Also obtained was information on the primary sources of payment for the month of discharge (although unlike in the CRQ, no charge data were obtained on the discharged residents). All of these above data items provide continuity with similar data obtained in the 1977 NNHS.
New to the 1985 discharged resident component of the NNHS are data items on the primary diagnoses of discharged residents at admission, categorical information on prior living arrangements immediately preceding admission, and primary source of payment data for the month of admission. Also new were questions on the discharged resident's history of other stays in the sample and other nursing homes, including dates of admission and discharge, and the total number of homes in which the discharged resident had been a resident patient. These questions' data will begin to provide some evidence of patterns of nursing home utilization over a lengthier period of time than a single stay in a single nursing home.
I have a limited number of copies of the 1985 Discharge Resident Questionnaires available for anyone who would like to peruse them after the session today. I will be open for other questions on the DRQ of the 1985 NNHS also at that time.
Publications from the discharged resident component of the 1985 NNHS will include an Advancedata report, scheduled to be released later this summer, and a Series 13 report to be released in 1988.