Feature Stories

Incontinent elderly persons more likely to enter nursing homes if they live in rural areas

Elderly persons who are incontinent and live in rural areas are more likely to be institutionalized in a nursing home than their urban or suburban counterparts, according to a study supported in part by the Agency for Health Care Policy and Research (National Research Service Award fellowship F32 HS00086). Once an already disabled elder develops urinary incontinence (UI), it is often very difficult for the family to continue to care for that person at home. And despite the success of community-based programs to assist older adults in coping with this problem so they can remain in the community, such programs are unlikely to exist in small towns and rural communities, where residents typically have a smaller number and narrower range of community and home-based services available to them.

On the other hand, rural regions usually have more available nursing home beds than suburban or urban areas, explains Chuck W. Peek, Ph.D., of the University of Florida Health Science Center. Dr. Peek and his colleagues used data from the Longitudinal Study on Aging (LSOA) 1984-1990 on persons 55 years of age and older who were living in the community. They selected from the LSOA sample persons who reported trouble with UI (9.6 percent) in 1984 and examined the impact of a variety of factors on the probability these individuals would enter a nursing home.

The researchers found that the effect of place of residence on the likelihood of institutionalization remained significant, even after the effects of other factors known to influence nursing home admission—such as health status, social support, availability of community services, and sociodemographic characteristics—were taken into account. Residents of rural counties had rates of institutionalization (35.4 percent) that were substantially higher than older adults with UI who lived in small and medium-sized metropolitan areas (22.6 percent).

For more details, see "Predicting nursing home admissions among incontinent older adults: A comparison of residential differences across six years," by Raymond T. Coward, M.S.W., Ph.D., Claydell Horne, R.N., Ph.D., and Dr. Peek, which appears in The Gerontologist 35(6), pp. 732-743.

At least 15 percent of nursing home residents could be placed in lower levels of care

Researchers at the Agency for Health Care Policy and Research made three estimates of the number of nursing home residents who could be appropriately placed in lower levels of care such as community-based personal care homes and home care. The most stringent estimate represents residents who could be placed in lower levels of care without major changes in the resource intensity in those settings. The middle and high estimates assume that resource intensity would increase in these lower levels of care to accommodate the greater disability of the additional residents and that the supply of lower level alternatives would grow to accommodate the large shift in demand.

Based on the least stringent criteria, 70 percent of nursing home residents would be deemed appropriate for lower levels of care. Under these criteria, all residents except those who are comatose, bed- or chair-fast, a danger to themselves or others, unable to communicate or understand others, suffer from bedsores, or have substantial rehabilitation or medical needs, would be appropriate for lower levels of care. The estimated proportion is reduced to 47 percent if persons with fecal incontinence are also excluded.

Using the most stringent criteria, approximately 15 percent of nursing home residents could be treated in lower levels of care. These criteria additionally exclude residents who need help with activities of daily living beyond bathing and dressing, have urinary incontinence, exhibit behavior problems such as wandering and not avoiding dangers, or experience hallucinations or delusions.

The researchers conclude that the potential for cost savings by transferring or diverting persons needing long-term care from nursing homes to lower-level settings may be great but that policies to encourage use of lower levels of care are difficult to design. Thus, realizing this potential for cost savings will not be easy. The study is based on analysis of data from the Institutional Population Component of the National Medical Expenditure Survey, a nationally representative survey of long-term care facilities and residents in 1987, as well as a sample of State-licensed personal care home residents.

Details are in "Appropriate placement of nursing home residents in lower levels of care," by William D. Spector, Ph.D., James D. Reschovsky, Ph.D., and Joel W. Cohen, Ph.D., in the March 1996 issue of The Milbank Quarterly 74, pp. 139-160.

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