As Ohio goes...? Ohio nursing homes have been subjected to close study of late. Are the findings pinpointing national trends?

Dramatic changes are occurring in the long-term care industry, if two recent studies conducted in the state of Ohio are any indication. The two studies, conducted in 1997 at the Scripps Gerontology Center at Miami University of Ohio (Oxford), revealed some rather noteworthy trends in the LTC industry in Ohio, including a marked increase in the number of people receiving home-based services and a slower but steady fall in nursing home occupancy rates.

In Ohio, as presumably in some other states, these changes are largely a result of state legislators' attempting to gain control of public spending. Medicaid expenditures on long-term care in Ohio had climbed from $651 million in 1985 to $1.8 billion in 1995. National long-term care Medicaid expenditures for roughly the same period more than tripled, from $14 billion in 1982 to $49 billion in 1995 - and rose to $58 billion in 1996.

Sharp increases of this nature challenge all states. To curtail these trends in Ohio, lawmakers took three steps:

* expanded the state's participation in the Medicaid home- and community-based care waiver program (PASSPORT) for the aged and disabled;

* implemented a nursing home pre-admission review;

* placed a Medicaid moratorium on any new construction that would increase the total number of available nursing home beds in the state.

The resulting shift toward home care is demonstrated by an increase from $5 million in PASSPORT expenditures in 1987 to $103 million in 1995 - more than a 20-fold increase. In 1995, 15,000 older Ohioans with disabilities were served by this program; that number was projected to climb to 22,000 in 1997.

Most of the PASSPORT money - approximately 70 to 75% - is spent on the wages of personal care home health aides. The next highest category is home-delivered meals (6 to 7%), followed by adult day care at approximately 3 to 4%. PASSPORT also pays for homemaking, chore services, respite programs, transportation and other services designed to help individuals remain in their homes. (In eight states, but not including Ohio, the Medicaid waiver also covers the costs of residency in an assisted living facility.)

Meanwhile, nursing home occupancy in Ohio was declining. A 91.9% occupancy rate in 1992 dropped in 1993 to 90.7%; then to 90.3% in 1994; and finally, in 1995, to 88.1% - even though the disabled older population in the state increased by 8,000 during the period studied.

The Medicare occupancy rate increased during this period: from 9.9% in 1992 to more than 16.3% in 1995. Admission and discharge trends also were analyzed in one of our studies. Nursing facility admissions in Ohio went from just under 71,000 in 1992 to 102,000 in 1995 - an increase almost entirely attributable to Medicare (approximately 30,000 admissions in 1992 and nearly 61,000 in 1995).

As one of the principal authors of these studies, I was surprised at the magnitude of the increase in those using nursing homes for short-term rehabilitative care. That the demand for subacute services increased was no surprise; due to DRGs, many individuals discharged from hospitals still have considerable disability, and often require skilled nursing. But I didn't anticipate that the increase would be so great.

The second surprise was how quickly nursing homes adapted to Medicaid spending cutbacks by increasing their Medicare admissions. Again, I was aware of this trend, but had no idea it was so robust. Two factors make Medicare funding particularly appealing to nursing homes. First, being a Federal rather than a state program, it reimburses at a higher rate (in Ohio, an average of $187 per day) than Medicaid (an average of $95 per day). Second, with the recent growth of home care and assisted living services and the accompanying loss of the nursing homes' traditional long-stay market, nursing home operators have had to compensate. They have not been slow to do so.

Accompanying these trends has been an increase in disability among nursing home residents. This has frequently been commented upon anecdotally throughout the industry; our study confirmed it. In days past it was not uncommon for non-disabled elderly people to seek residence in a nursing home merely because they lived alone, perhaps in an isolated area, and "winter was coming."

Today, because alternatives - such as home-based, assisted living and residential care services - are available and, in Ohio, because of pre-admission review, use of nursing homes in this way is not nearly so commonplace. The DRG-inspired trends only amplify these factors.

It's worth noting that a similar trend toward greater disability was seen among the individuals receiving home-based services under PASSPORT, but the 'degree of impairment for nursing home residents nevertheless remained much higher. For example, 64.5 % of all nursing home residents had four or more ADL impairments, compared with 29% of PASSPORT clients. Specifically, we saw more nursing home residents than PASSPORT clients with fairly substantial cognitive impairment and incontinence.

What do all these changes mean? It seems inevitable that in 10 years we will not recognize the long-term care industry. Nursing homes will still have a place in long-term care, but they will need to change. There is a fundamental societal judgment here - i.e., nobody wants to live in a nursing home. Policymakers are recognizing a need to provide people with a choice in care options. Once this recognition occurs, spending 95% of our public dollars on care for people in nursing homes no longer makes sense.

I believe that the nursing homes that will prosper as long-term care providers will be those providing options for home care and assisted living. Not only is this, in my opinion, the right thing to do, it is what consumers want. Nursing homes moving in this direction, though, will have to grapple with certain societal expectations having to do with the age-old debate: health and safety vs. autonomy and choice. The reason so many nursing homes have become the hospital-like institutions that they are today is that society, in the form of regulations, says health and safety are more important than autonomy and choice. Although OBRA '87 recognized that consumer autonomy was a good thing, regulators continued to emphasize health and safety above all else.

I've also noticed a fascinating paradox regarding this debate. If you ask people what is most important for their aging parent or aging spouse, they usually will say, "Of course, health and safety." But if you ask them what is important for their own lives, they almost always will say, without hesitation, "autonomy and choice."

The media contributes to the societal pressure placed on nursing homes by basically ignoring the autonomy issue and zeroing in on safety and health issues. "Mrs. Jones hurt in a nursing home fire" makes for a much catchier headline than "Mrs. Jones seeks autonomy." In short, nursing homes have to counteract these and other pressures in order to survive in the long-term care market.

Their only choice is to continue what has become a counter-trend: to opt out of traditional long-term care and become mini-hospitals for subacute care.

How long-term care will be financed and delivered as America ages remains an open and challenging question.

Robert Applebaum, PhD, is Professor and Research Fellow, Scripps Gerontology Center, Miami University, Oxford, Ohio. Co-authors of the two studies referred to in this article were Shahla Mehdizadeh, PhD, and Jane Straker, PhD.