Older Adult Client Outcome Indicator Project Report Fiscal ......Older Adult Client Outcome...

The University of Kansas School of Social Welfare

Office of Aging and Long-Term Care

Older Adult Client Outcome Indicator Project Report

Fiscal Year 2000

Roxanne Rachlin, MHSA Rosemary Chapin, Ph.D.

Melissa Cline

This research was supported in part through a contract with the

Kansas Department on Aging and Kansas Department of Social and Rehabilitation Services

Topeka, Kansas 66612

June, 2000

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Table of Contents Executive Summary ................................................................................................................ i Older Adult Outcome Indicator Project.................................................................................... 1 Indicators……………………………………………………………………………………………3 Independence Indicators................................................................................................ 6 Independence Indicators 1, 1a, 1b, and 1c: Nursing Facility Utilization Rates for People Age 65 and Over, Age 85 and Over, Age 65-74 and People Age 75-84......................................................................... 6 Independence Indicator 2: Percent of Kansans Age 65 and Over Receiving Community Based Long Term Care Services Who Would Otherwise Be at Risk of Nursing Facility Placement.............................................15 Independence Indicator 3: Discharge from Nursing Facilities to the Community for Kansans Age 65 and Over .................................................21 Independence Indicator 4: Diversion of Kansans Age 65 and Older Seeking Nursing Facility Placement....................................................................26 Regional Analysis of Integrated Indicator Data..............................................................29 Protection Indicators....................................................................................................35 Recommendations.......................................................................................................................….42 Recommendations/Implications Based on the Outcome Indicator Trends ........................42 Recommendations to Enhance Monitoring of the Indicator Data .....................................44 Recommendations on Using Outcome Indicator Data for Programming and Planning ......46 Conclusion .....................................................................................................................................46 References .....................................................................................................................................48

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The purpose of the Older Adult Client Outcome Indicators Project is to improve the overall welfare of frail elders by identifying and monitoring specific outcome criteria over time. Focus for the project is based on systems performance that will assist the older adult population in maintaining functional levels and in gaining access to services in the most appropriate living arrangements available. The project provides data on the long-term care system in Kansas that can be used by policy makers as well as state agency staff for program planning and policy development. By monitoring key outcome indicators on a yearly basis and making information on changes in these indicators available to policy makers, progress in creating an effective community based long-term care system can be charted. An important component of this project is working with agencies to develop strategies that will result in desired changes in outcomes. During Fiscal Year 2000, KU staff met with AAA executive directors and staff to discuss key indicator findings and to get detailed information on how to tailor the Outcome Indicator Report to more effectively meet their needs. This annual report summarizes the progress made regarding outcome indicator measurements associated with independence and protection. The independence indicators reflect the degree to which older Kansans live in the least restrictive environments. The protection indicators are structured to measure the incidence of abuse, neglect, and exploitation (A/N/E) of older adults receiving long term care services either in the community or in institutions. This report presents the most recent demographic trends and indicator findings at the state and county/Planning and Service Area (PSA) level.

Indicator Findings Independence Indicators 1, 1a, 1b, 1c: Nursing Facility Utilization By Age Segment The first outcome indicator is Independence Indicator 1. It reflects the nursing facility utilization rates for people age 65 and older and the subgroups of people age 85 and older, 65-74, and 75-84 years old. • Approximately 5.7% of Kansans age 65 and over resided in nursing facilities in 1998. The 1998

nursing facility utilization rates for all age subgroups declined from 1997. The largest decrease occurred in the age 85 and over subgroup.

• The majority of PSAs experienced a decrease in their nursing facility utilization rates from

1997 to 1998. • PSA 1 (Wyandotte-Leavenworth) and PSA 2 (Central Plains) had the lowest rates during both

time periods. PSAs 3 (Northwest Area), 6 (Southwest Area), 9 (Northeast Area) and 10 (South Central) Area had the highest rates for both time periods.

The following table (Table 19 in the report) displays Kansas’ nursing facility utilization rates in comparison to the most recent national nursing facility utilization rates.

Table 19. 1998 Kansas and 1996 National Nursing Facility Utilization Rates

Age Group 1998 Kansas Rates 1996 National Rates*

65-74 1.19% 1.1% 75-84 5.23% 4.2%

85 and above 22.71% 19.8% 65 and above 5.70% 4.2%

*(AARP, 1998)

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Prior to 1997, Independence Indicator 1 was calculated including both Nursing Facility and AL/RHC residents. The following combined nursing facility - assisted living/residential health care utilization rates are presented in order to analyze the longitudinal trend from 1991 through 1998 (Figure 2 in the report).

Figure 2. Combined Nursing Facility and AL/RHC Utilization Rates by Age Group, 1991 - 1998

The state, PSA and county level Independence Indicator 1 findings show that progress has been made in reducing institutionalization of older adults. Tracking nursing facility utilization rates is an important method that can be used to evaluate the impact of system changes. Trends in utilization rates over time can also identify areas where services and programs are having their intended effect and point out areas where additional efforts are needed. Independence Indicator 2: Percent of Kansans Age 65 and Over Receiving Community Based Long Term Care Services The purpose of Independence Indicator 2 is to measure the percent of Kansans age 65 and over receiving community based services that would otherwise be “at risk of nursing facility placement.” This indicator reflects only public community based long-term care services, which include programs sponsored with public money under the jurisdiction of AAAs and KDOA. Since assisted living/residential health care facilities are considered community based options, a recent decision was made to include data related to these settings under this indicator. At this time, an accurate, unduplicated number of clients between and within programs is not attainable. However, currently proxies can be used to analyze trends in community based service availability and utilization. Some of these additional sources include: 1) Individual program data (i.e. HCBS client counts); 2) CARE program/unmet need data; 3) Data from additional KU research, such as the recent study of assisted living/residential health care facilities. These sources, when analyzed together, provide a picture of the community based service delivery system.

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

1991 1992 1993 1994 1995 1996 1997 1998

Year

Per

cent

65-74

75-84

85 and Over

65 and Over

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• The number of unduplicated customers who received services through the HCBS/FE waiver

increased by 21% from FY1998 to FY 1999. • The number of customers receiving Senior Care Act (SCA) services decreased from 4,992 in

FY 1998 to 3,782 in FY 1999. Many of the customers that would have used SCA are receiving Income Eligible services. Overall, the number of SCA and IE customers combined has increased during this time.

• Approximately 1.03% of Kansans age 65 and over resided in assisted living/residential health

care facilities in 1998. This rate is very close to the 1997 rate, 1.04%. • The highest HCBS/FE utilization rates were found in PSA 5 (Southeast) and PSA 7 (East

Central) and PSA 9 (Northeast). The lowest HCBS/FE utilization rates were found in PSA 11 (Johnson County) and PSA 3 (Northwest).

The community based service data and additional sources indicate that a growing number of older adults are having their long-term care needs met in the community through in-home services as well as in assisted living/residential health care settings. It is anticipated that KDOA’s new MIS system, KAMIS, will enable the relationships between the changes in number of people served in the community and in institutional settings to be more clearly tracked. Independence Indicator 3: Discharge from Nursing Facilities to the Community for Kansans Age 65 and Over Independence Indicator 3 reflects the number of older adults who move from nursing facilities to more integrated environments in the community. It includes residents of licensed nursing facilities and residents of nursing facility beds in hospitals. • Approximately 19.55% of nursing facility residents (including nursing facility hospital

residents) returned to the community in Calendar Year 1998, decreasing slightly from 21.50% in 1997.

• Although the proportion of nursing facility residents returned to the community in 1998

decreased, the actual number of nursing facility residents returned to the community increased during this time period.

• The majority of the PSA level discharge rates decreased between 1997 and 1998.

• PSAs 5 (Southeast), 4 (Jayhawk) and 6 (Southwest) had the highest discharge rates for both time periods. PSAs 10 (South Central), 1 (Wyandotte-Leavenworth) and 2 (Central Plains) had the lowest discharge rates for both time periods.

The longitudinal discharge data show a somewhat uneven trend in the number of older adults who return to the community. Monitoring discharge rates at the state and agency/county level is important in order to ensure that clients needs are being met in the most appropriate setting and that they are given the opportunity to resume community living when possible.

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Independence Indicator 4: Diversion of Kansans Age 65 and Older Seeking Nursing Facility Placement Independence Indicator 4 is structured to measure the number and percent of people age 65 and older seeking nursing facility care who chose and received community based service as an alternative. Since the Older Adult Outcome Indicators Project is currently part of the interagency agreement between KDOA and KU, detailed diversion data (from the CARE Program) is not included as part of this report to prevent duplication for state agency staff. However, for the sake of other readers and for the purpose of analyzing the indicators in conjunction with one another, some diversion data and tables are presented below. • The diversion rate increased steadily from 15.33% in FY 1997 to 17.93% in FY 1999. • Overall, the number of initial assessments increased from FY 1997 to FY 1999, despite a

minute (.7%) decrease in FY 1998.

• The majority of PSAs experienced an increase in their diversion rates between 1998 and 1999. The largest increase (5.76%) occurred in PSA 8 (North Central). Only three PSAs, 3 (Northwest), 7 (East Central) and 9 (Northeast) experienced a decrease in their diversion rates between 1998 and 1999.

• PSA 6 (Southwest) had the highest diversion rate in FY 1999, and among the highest in

previous years. PSA 1 (Wyandotte Leavenworth) and PSA 5 (Southeast) had among the lowest diversion for the same time periods.

Regional Analysis of Integrated Inde pendence Indicator Data In the “Regional Analysis of Integrated Independence Indicator Data” of this report, the diversion data at the PSA level are presented in conjunction with the other indicator data in order to provide a comprehensive picture of long term care in Kansas. Additional sources of long-term care data are also explored. The supplemental information sources include KDHE assisted living utilization data, KDHE nursing facility occupancy data, and other program or agency reports/data as they apply to outcome indicators. This report segment presents a profile of each PSA based on these data. Protection Indicators 1, 1a and 1b: Confirmed and Substantiated A/N/E Complaints per 10,000 Long Term Care Clients Age 65 and Over Residing in the Community and in Institutional Settings The protection indicators are structured to measure the reported incidence of abuse, neglect, and exploitation (A/N/E) of older adults receiving long-term care services either in the community or in institutions. Alternative proxies for these indicators have been identified and tracked over time since an unduplicated count of elders abused and/or neglected in Kansas is not yet available. • The number of A/N/E reports involving adults age 60 and over has tripled since FY 1996. It is

important to not that confirmations have not increased at the same rate. The increase in reports is likely due to an increased awareness of a/n/e.

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• Approximately 11.58% of the age 60 and over adults involved in an A/N/E report were HCBS/FE service recipients1.

• Older adults aged 80 and older represented 45% of APS reports involving age 60 and over

potential victims. Their proportion within the age 60 and over population is much lower (around 14%), so this clearly indicates over-representation among the maltreated.

Reports involving older adults as victims of A/N/E have increased in both the community and institutional settings. The substantiation rates of community based reports and institutional confirmation rates have increased as well. These trends highlight the importance of continued monitoring of data pertaining to abuse, neglect and exploitation of older Kansans receiving long-term care services.

Recommendations In this section, implications and recommendations are offered based on the outcome indicator findings and feedback from AAA and state agency staff. Where applicable, they are discussed within the context of national literature/data. Potential implications for policy makers are also discussed. The implications and recommendations are organized under the following topics: Ø Implications based on the outcome indicator trends; Ø Recommendations to enhance monitoring of the indicator data; and Ø Recommendations on using indicator data for programming and planning. Conclusion Although institutionalization rates are still high compared to national averages, the declining institutionalization rates, the number of older adults discharging to the community from nursing facilities and number of successful nursing facility diversions indicate that Kansas has made progress in the effort to meet older adults’ long-term care needs in the most integrated setting. The national literature has also documented Kansas’ progress in its effort to balance the LTC system (Ladd and Kane, 1999). These findings are encouraging, and underscore the importance for policy makers to continue these efforts to support the preference of older adults to have their long-term care needs met in their own homes rather than in a nursing facility (AARP, 1996). Continued monitoring of the independence and protection of older adults is necessary to help inform program and policy development for older Kansans.

1 Please note that an adult between the ages of 60 and 64 can not be an HCBS/FE customer.

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Older Adult Client Outcome Indicator Project Report Project Background and Purpose Since 1993, the University of Kansas School of Social Welfare (KU) has worked jointly with the Kansas Departments of Aging (KDOA), Social and Rehabilitation Services (SRS), and Health and Environment (KDHE) to develop outcome indicators to monitor outcomes and distribution of publicly funded services to older adults in Kansas that are the mandated responsibility of the State. The indicators reflect the goals of the agencies involved as contained in their mission statements. The purpose of the Older Adult Client Outcome Indicators Project is to improve the overall welfare of frail elders by identifying and monitoring the selected outcome indicators over time. Focus for the project is based on systems performance to assist the older adult population in maintaining functional levels and in gaining access to services in the most appropriate living arrangements available. The project provides data on the long-term care system in Kansas that can be used by policy makers as well as state agency staff for program planning and policy development. By monitoring key outcome indicators on a yearly basis and making information on changes in these indicators available to policy makers, progress in creating an effective community based long-term care system can be charted. The indicators provide a means of evaluating the impact of system changes on client outcomes. It is important to continue measuring these indicators yearly in order to track progress in meeting state agency goals such as improving customer access to services and enhancing consumer autonomy. The Outcome Indicator Report is revised and updated yearly, incorporating feedback and suggestions received from state agency and Area Agency on Aging staff. A number of strategies are utilized to obtain this feedback. During the course of the year, KU staff met with KDOA and Area Agency on Aging (AAA) staff to discuss the report and receive suggestions on how to revise it to best meet their needs. In addition, KDOA staff have a “review and comment” period in which they review the final draft of the report and determine whether revisions are needed before distribution. Definition of Outcome Indicators Outcome indicators are measurement tools used to describe improvement in client situations or the curbing of deteriorating client situations. It is important not to focus solely on process or cost outcomes since these measures do not thoroughly reflect the influence of system changes from the client’s perspective. Indicators can serve as “ red flags” to draw attention to detrimental changes in desired client outcomes. However, indicators do not show why a fluctuation has taken place, only that one has occurred. It is important to investigate outcome indicator changes to discern the reasons behind them and possible implications. Monitoring of outcome indicators requires the establishment of standards, baselines, and collection of actual numbers of individual clients served. As used in this project, a standard is a numerical definition of adequacy (Lewandowski and Rapp, 1991). A baseline is a measurement that serves as a base for comparison. Baselines and standards have been established for some of the Independence Indicators. For example, in measuring the percentage of institutionalized adults age 65 and over, 7.3% was selected as a baseline since that is the proportion of people that lived in institutional settings as of December 31, 1990. Based on the projected growth of the older population in Kansas, the Long-term Care Action Committee (LTCAC) also selected 7.3% as the standard. In October 1994, the standard of 7.3% was updated to 6.8% by the LTCAC, reflecting progress in reducing older adult institutionalization. Outcome indicator data supply information that policy makers can use to evaluate strategies and costs involved in achieving goals. For example, if Kansas wishes to achieve the national average of 4.2% of

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the population age 65 and over residing in institutional facilities and sets that standard, it is possible to calculate the number of people to be served in the community and related cost implications. The indicators are measured at both the state and regional level wherever possible. Measuring indicators at the state level allows analysis of comparisons to other states, to national averages, and to Kansas itself over a time period. Monitoring indicators at the regional level (e.g. Planning and Service Area (PSA)) over time makes it possible to observe patterns between and within areas longitudinally. The current indicators focus on measuring independence and protection of older Kansans receiving publicly funded long-term care services. The current indicators address the following outcomes:

• Nursing facility utilization rates for people age 65 and over; • Community based services utilization rates; • Nursing facility discharge rates; • Diversion from nursing facility placement; and • Abuse, neglect and exploitation of older adults in community and institutional settings.

Overview of Fiscal Year 2000 Outcome Indicator Report The current Outcome Indicator Report is structured differently than previous Outcome Indicator reports. During Fiscal Year 2000, KU staff met with AAA executive directors and staff to discuss key indicator findings and to get detailed information on how to tailor the Outcome Indicator Report to more effectively meet their ne eds. The layout of this report reflects their feedback. It is designed to provide the indicator data in an accessible, “user-friendly” format. There are more indicator data tables and graphs and less narrative than previous reports. It is hoped that this format will allow the indicator data to be easily accessed for a variety of purposes identified by the AAA directors. In addition, to the change in the format and structure of the report, the timing of this report is also different than past years’ reports. In previous years, the Outcome Indicator Report was delayed by the availability of a key data source (Annual Adult Care Home Survey Data) needed to measure the indicators. Since this data is usually released sometime in late June or July, it is reasonable that the completion date of future Outcome Indicator Reports be shifted from June to October. This change would allow the report to be provided in a timely manner for use with KDOA’s internal planning needs and the legislative session. Since the Fiscal Year 1999 report was completed in August 1999, it was decided that the Fiscal Year 2000 report would serve as a “transition” into the new timing and be distributed in May, 2000. It is anticipated that the next Outcome Indicator report will be completed in October 2000 to complete the shift in the report timing. During this transition period the most recent data for all indicators are provided. However, it is important to note that not all of the indicators reflect new data due to the shorter time frame between reports in this transition year. This report is divided into the following sections: • National and Kansas demographic trends related to the independence indicators; • Independence indicator data, presented at the state and PSA/county level wherever possible; • Regional analysis of integrated indicator data, where individual independence indicator findings are

presented in conjunction with one another and other sources of long-term care data on a PSA basis. • Protection indicator data; and • Recommendations/implications based on the outcome indicator findings and feedback from state

agency and AAA staff.

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Indicators National and Kansas Demographic Trends Each year the latest national and Kansas demographic data related to the indicators are presented in the Outcome Indicator Report. This information indicates how Kansas compares nationally. The demographic trends also highlight areas of interest in planning for the future long-term care needs of older Kansans. How Older Kansans Compare Nationally The following findings show the demographic similarities and differences between older adults in Kansas and the nation. • Approximately 13.5% of Kansas’ population were age 65 or older in 1998, compared to 12.7%

nationally. It ranked 16th on this indicator in comparison with other states. (U.S. Bureau of the Census, 1999)

• Approximately 1.9% of Kansas’ population was age 85 or older in 1998, compared to 1.5%

nationally. Kansas has the seventh highest percentage of persons age 85 and over in the United States. (U.S. Bureau of the Census, 1999)

• Approximately 9.8% of Kansas seniors were below the poverty level in 1998, compared to 10.6%

nationally. (AARP, 1999) • In comparison to other states, Kansas has a very low percentage of persons age 65 and older on

Medicaid. In 1996, Kansas ranked 46th on this indicator. (Ladd, Kane and Kane 1999) • Older Kansans appear to be less disabled than older adults nationally. Ladd, Kane and Kane (1999)

ranked Kansas 34th based on the percent of its population age 65 and over that are severely disabled. • In 1990, a higher percentage of older adults live alone in Kansas than the national average (30.4%

vs. 28.2%) (AARP, 1998). • In 1996, the number of nursing facility residents per 1,000 adults age 65 and over in Kansas was

70.2 residents, while the national average was 43.7 (Graves & Bectel, 1998). Only two states had higher averages.

These figures indicate that Kansas has a higher proportion of older adults than many other states, particularly those age 85 and over. Also, fewer older adults in Kansas live below the poverty level or rely on Medicaid than in many other states. Kansas seniors also appear less disabled than seniors nationally. Finally, a greater proportion of Kansas seniors live alone in comparison to the national average. Despite these findings, the comparison data also revealed that a greater proportion of older adults in Kansas reside in nursing facilities compared to seniors nationally. In light of the projected growth rate of older adults, it is important that policy makers address these trends in order to provide comprehensive long-term care options for seniors.

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Projected Population Growth of Older Kansans The following table presents the projected growth of the 65 and over population in Kansas. It displays the yearly growth for 1995 through 2025. This growth is also represented graphically in Figure 1. As these figures show, the growth rate accelerates rapidly after 2010 as the Baby-Boom generation begins turning 65 (Hobbs & Damon, 1996).

Table 1. Population Changes for Kansans Age 65 and Older, 1995 to 2025*

Age Group

1995

2000

2005

2010

2015

2020

2025 1995 – 2025

Percent Change 65-74 183433 178608 178841 199093 248283 301530 338962 84.79% 75-84 120456 127878 131185 129979 132957 152057 193102 60.31% 85+ 47292 51685 56175 61993 65822 68087 72590 53.49%

Total 351,181 358,171 366,201 391,065 447,062 521,674 604,654 72.18% *Source: US Census Bureau Population Projections (10/96)

Figure 1.

Population Growth for Kansans Age 65 and Older, 1995 to 2025*

*Source: US Census Bureau Population Projections (10/96) The proportion of older adults relative to the overall population is also expected to increase substantially. Table 2 displays the projected increase in the proportion of Kansas seniors in comparison to the population as a whole. The state-wide population as a whole is projected to increase by approximately 21%, while the age 65 and over population is projected to increase about 73% during the same period. The Kansas population age 85 and older, those most likely to use long-term care services, is projected to grow more than 50% between 1995 and 2025 (see Table 2).

0

200000

400000

600000

800000

1995 2000 2005 2010 2015 2020 2025

Year

Proj

ecte

d Po

pula

tion

85+

75-84

65-74

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Table 2. Population (in thousands) and Percent Change for Kansans Age 65 and Older, 85 and Older and

All Ages, 1995 to 2025*

Age Group

1995

2005

2015

2025

1995 – 2025 Percent Change

65 and over 351 366 447 605 72% 85 and over 47 56 66 72.5 54%

All Ages 2565 2761 2939 3108 21% *Source: US Census Bureau Population Projections (10/96)

The demographic popula tion projections for Kansans aged 65 and older indicate the importance of monitoring long-term care service availability and utilization. Careful planning will be needed for the state to accommodate the growth of the older population in Kansas.

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Independence Indicators The independence indicators track the utilization of nursing facility services and community based care by older Kansans. They are defined as follows: • Independence Indicator 1: The percent of older adults residing in nursing facility

settings; • Independence Indicator 2: The percent of older long-term care (LTC) clients receiving

community based services who may otherwise be at risk of nursing facility placement; • Independence Indicator 3: The percent of older LTC clients returning to the

community from nursing facilities (includes nursing facilities and LTC beds in hospitals); and

• Independence Indicator 4: The percent of nursing facility applicants who select and receive community based services instead of institutional placement.

Years of measurement for indicators vary due to the availability and format of data provided by state information systems. The year of measurement is indicated on all tables and graphs. Appendix A contains a list of all the indicators and their most recent year of measurement. It should also be noted that US Census Bureau population estimates for Kansas, instead of projections, are used for indicator measurement. Independence Indicator 1, 1a, 1b and 1c: Nursing Facility Utilization by Age Segment State Level Independence Indicator 1 reflects the number of people age 65 and older residing in nursing facilities. It is referred to as the “nursing facility utilization rate.” This indicator is also analyzed by subgroups for the 85 and older, 65-74, and 75-84 age segments in Indicators 1a, 1b, and 1c (see Appendix B for Independence Indicators 1, 1a, 1b and 1c graphs and tables). These rates include nursing facility residents age 65 and older using licensed nursing facility (NF) services and long-term care clients age 65 and older using hospital based licensed nursing facility services. Data on the number of long-term care clients utilizing institutional services on December 31 of each year are collected by KDHE. Please note that prior to calendar year 1997, residents of nursing facilities and residents of assisted living/residential health care (AL/RHC) facilities were included in this indicator. It was not possible to calculate these rates separately. However, beginning with the calendar year 1997 data, it became possible to measure the utilization rates for nursing facilities separate from assisted living/residential health care facility utilization rates2. This change allowed Kansas’ institutionalization rates to be comparable to the most recent national nursing facility utilization figures (1996). Tables 3 and 4 display the most recent nursing facility utilization rates of older adults in Kansas. These data are also displayed in Chart 1. Findings from this indicator are highlighted below. • Approximately 5.7% of Kansans age 65 and over resided in nursing facilities in 1998. • The 1998 nursing facility only utilization rates for all age subgroups declined from 1997. 2 The AL/RHC utilization rates are presented under Independence Indicator 2, “the percent of older long-term care (LTC) clients receiving community based services who may otherwise be at risk of nursing facility placement.”

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• The largest decrease occurred in the age 85 and over subgroup.

Table 3. Nursing Facility Only Utilization Rates by Age Group, 1998*

Age

Group NF Clients 12/31/98

7/1/98 Age Group Population Estimate

1998 NF Utilization Rate

65-74 2,119 177,971 1.19% 75-84 6,573 125,597 5.23% 85+ 11,481 50,545 22.71%

Total, 65+ 20,173 354,113 5.70% *Source: KDHE Adult Care Home Statistics and US Census Bureau population estimates (9/99)

Table 4. 1997 and 1998 Nursing Facility Only Utilization Rates by Age Group.

Age

Group 1997 NF

Utilization Rate 1998 NF

Utilization Rate 65-74 1.35% 1.19% 75-84 5.60% 5.23% 85+ 24.08% 22.71%

Total 65+ 6.02% 5.70%

Chart 1. 1997 and 1998 Nursing Facility Utilization Rates by Age Group

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65-74 75-84 85 and over 65 and over

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Combined Nursing Facility and Assisted Living/Residential Health Care Utilization Rates As mentioned previously, prior to 1997, Independence Indicator 1 was calculated including both nursing facility and AL/RHC residents. The following combined nursing facility - assisted living/residential health care utilization rates are presented in order to analyze the longitudinal trend from 1991 through 1998. Table 5 displays the actual rates, while Figure 2 shows the overall trend. The following findings emerge from the analysis. • From 1991 through 1998 the combined nursing facility/assisted living rates have declined for

all age subgroups. • The largest decrease was experienced by the age 85 and over subgroup, it dropped 5.18%.

Table 5. Combined Nursing Facility and AL/RHC Utilization Rates by Age Group, 1991 - 1998*

Age

Group

CY1991

CY1992

CY1993

CY1994

CY1995

CY1996

CY1997

CY1998 65-74 1.55% 1.47% 1.53% 1.57% 1.53% 1.45% 1.50% 1.35% 75-84 7.35% 7.45% 6.82% 6.98% 6.70% 6.71% 6.59% 6.26% 85+ 31.96% 31.49% 30.50% 29.79% 29.6% 28.46% 28.46% 26.78% 65+ 7.36% 7.38% 7.13% 7.19% 7.10% 6.99% 7.06% 6.72%

*Source: KDHE Adult Care Home Statistics and US Census Bureau population estimates (9/99)

Figure 2. Combined Nursing Facility and AL/RHC Utilization Rates by Age Group, 1991 - 1998

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1991 1992 1993 1994 1995 1996 1997 1998

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85 and Over

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PSA/AAA Level Nursing facility utilization rates of older adults age 65 and over were calculated for 1998 on a PSA basis3. Map 1 on the next page displays the PSA level rates. These figures are also displayed in comparison to the 1997 rates in Table 6 and Chart 2 below. Findings related to the PSA level nursing facility utilization rates are bulleted below. Please note that findings at the PSA level are also presented in conjunction with other indicator data in the segment of this report entitled “Regional Analysis of Integrated Indicator Data,” beginning on page 30. • The 1998 PSA level nursing facility utilization rates ranged from 3.92% to 7.41%. • The majority of PSAs experienced a decrease in their nursing facility utilization rates from

1997 to 1998. • The metropolitan PSAs had lower than average nursing facility only utilization rates for both

years. • PSA 1 (Wyandotte-Leavenworth) and PSA 2 (Central Plains) had the lowest rates during both

time periods. • PSAs 3 (Northwest Area), 6 (Southwest Area), 9 (Northeast Area) and 10 (South Central)

Area had the highest rates for both time periods. • PSAs 1 (Wyandotte-Leavenworth) and 7 (East Central) showed the greatest decreases in their

utilization rates between 1997 and 1998.

Table 6. 1997 and 1998 PSA Level Nursing Facility Utilization Rates From Lowest to Highest

PSA 1997 PSA 1998

01 Wyandotte-Leavenworth Area 4.92% 01 Wyandotte-Leavenworth Area 3.92% 02 Central Plains Area 4.97% 02 Central Plains Area 4.32% 11 Johnson County Area 5.04% 07 East Central Area 4.82% 05 Southeast Area 5.49% 11 Johnson County Area 4.85% 07 East Central Area 5.89% 04 Jayhawk Area 5.68% 04 Jayhawk Area 6.50% 05 Southeast Area 5.90% 08 North Central/Flint Hills 6.95% 08 North Central/Flint Hills 6.45% 03 Northwest Area 6.99% 06 Southwest Area 6.70% 06 Southwe st Area 7.01% 10 South Central Area 7.39% 10 South Central Area 7.28% 09 Northeast Area 7.39% 09 Northeast Area 7.65% 03 Northwest Area 7.41% Statewide Average 6.02% Statewide Average 5.70%

3 Please note that both the 1997 and 1998 rates were calculated using population estimates. Population projections were used in previous Outcome Indicator reports.

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Chart 2. 1997 and 1998 Nursing Facility Utilization Rates, by PSA

Adjusted County Level Nursing Facility/Assisted Living/Residential Health Care Rates Nursing facility utilization rates were calculated with an adjustment for in and out migration. In-migration refers to the number of nursing facility residents in a particular county, i.e. Allen County, that are not from Allen County, while out migration refers to the number of residents from Allen county receiving nursing facility services in other counties in the state. This allows each county’s nursing facility utilization rate to more accurately reflect the number of people from that county using nursing facility services in the state of Kansas. As mentioned previously, prior to 1997, this indicator was calculated including both nursing facility and AL/RHC residents. Therefore, in order to analyze the longitudinal trend, combined nursing facility/assisted living rates, adjusted for migration, were calculated for 1997 and 19984. These rates are presented in Table 7 and Map 2. The 1998 adjusted nursing facility-AL/RHC utilization rates ranged from 0% to 11.27%. Overall trends in the adjusted utilization rates from 1994 to 1998 are bulleted below. • The majority of the county level adjusted institutionalization rates showed a decrease from

1997. These rates have consistently declined since 1994. The differences between the 1997 and 1998 rates ranged from a decrease of 7.22% to an increase of 7.81%.

• The counties with the largest decreases in their adjusted institutionalization rates between

1997 and 1998 were Chautauqua, Morton and Barber. • The greatest increases to the adjusted institutionalization rates occurred in the following

counties: Rawlins, Scott, Labette, and Thomas. 4 Please note that both the 1997 and 1998 rates were calculated using population estimates. Population projections were used in previous Outcome Indicator reports.

0.00%1.00%2.00%3.00%4.00%5.00%6.00%7.00%8.00%9.00%

1 2 3 4 5 6 7 8 9 10 11

Planning and Service Area

Per

cent 1997

1998

12

• The majority of the metropolitan counties (i.e. Wyandotte, Sedgwick, Johnson) had below average institutionalization rates in both 1997 and 19985.

• The counties with the highest 1998 adjusted institutionalization rates included Scott (11.27%),

Mitchell (10.53%), Nemaha (10.43%), Comanche (10.36%) and Stafford (10.26%). • Out migration had the greatest effect on the adjusted rates of Pawnee and Jackson counties for

1998. These counties also showed patterns of high out migration in 1996 and 1997. • In migration had the greatest effect on the adjusted rates of Kingman, Morton, Marion, and

Nemaha counties for 1998. Nemaha and Marion counties also showed relatively high in-migration for 1997 and previous years.

The state, PSA and county level Independence Indicator 1 findings show that progress has been made in reducing institutionalization of older adults. Although the institutionalization rates are generally lower in the urban areas, the rural areas have made definite progress. Tracking nursing facility utilization rates is an important method that can be used to evaluate the impact of system changes. Trends in utilization rates over time can also identify areas where services and programs are having their intended effect and point out areas where additional efforts are needed.

5 This finding may seem contrary to the conventional wisdom that the number of nursing facility beds leads to increased utilization. However, it is necessary to analyze the number of beds in relation to the older adult population of the area to get a true picture of the bed supply. KU will examine this issue more in-depth in the next Outcome Indicators Report.

13

Table 7. 1997 and 1998 Combined Nursing Facility-AL/RHC Rates, Adjusted for Migration COUNTY 1997 Rate 1998 Rate COUNTY 1997 Rate 1998 Rate Allen 7.81% 8.41% Linn 5.22% 3.63% Anderson 7.32% 7.56% Logan 5.69% 5.92% Atchison 7.63% 8.13% Lyon 8.45% 6.29% Barber 6.69% 2.52% Marion 7.20% 7.39% Barton 7.31% 6.38% Marshall 7.95% 7.46% Bourbon 7.29% 4.33% Mcpherson 10.69% 8.58% Brown 8.33% 7.65% Meade 9.48% 5.69% Butler 5.50% 4.58% Miami 6.97% 4.14% Chase 8.67% 8.05% Mitchell 9.23% 10.53% Chautauqua 7.04% 1.97% Montgomery 7.33% 7.73% Cherokee 6.10% 4.20% Morris 6.15% 7.24% Cheyenne 7.36% 8.20% Morton 11.51% 7.09% Clark 10.70% 8.99% Nemaha 9.70% 10.43% Clay 8.65% 8.63% Neosho 7.16% 6.77% Cloud 9.37% 9.98% Ness 7.74% 5.97% Coffey 8.61% 7.05% Norton 7.61% 7.77% Comanche 7.31% 10.36% Osage 6.10% 7.64% Cowley 7.64% 8.10% Osborne 7.33% 7.92% Crawford 5.72% 6.50% Ottawa 9.48% 10.04% Decatur 8.59% 8.30% Pawnee 10.28% 9.46% Dickinson 7.48% 7.31% Phillips 8.56% 9.78% Doniphan 4.98% 5.50% Pottawatomie 7.40% 6.62% Douglas 7.01% 4.94% Pratt 9.46% 7.36% Edwards 7.15% 6.59% Rawlins 0.00% 7.81% Elk 7.03% 7.85% Reno 8.06% 8.17% Ellis 8.82% 8.20% Republic 7.85% 6.77% Ellsworth 9.91% 7.99% Rice 7.08% 7.10% Finney 6.66% 4.51% Riley 7.99% 7.63% Ford 8.77% 7.85% Rooks 4.33% 6.48% Franklin 6.31% 6.20% Rush 10.62% 9.20% Geary 7.71% 4.87% Russell 5.83% 3.62% Gove 8.51% 5.47% Saline 7.28% 6.05% Graham 7.94% 9.32% Scott 6.30% 11.27% Grant 9.15% 6.49% Sedgwick 5.79% 5.11% Gray 9.74% 8.95% Seward 7.82% 6.12% Greeley 8.54% 4.81% Shawnee 7.59% 8.47% Greenwood 7.89% 9.00% Sheridan 10.28% 7.58% Hamilton 0.83% N/A6 Sherman 5.92% 6.05% Harper 7.30% 8.40% Smith 8.34% 7.63% Harvey 9.40% 7.84% Stafford 7.86% 10.26% Haskell 6.93% 2.96% Stanton 7.22% N/A Hodgeman 7.51% 4.90% Stevens 5.96% 7.65% Jackson 12.52% 9.42% Sumner 4.79% 6.80% Jefferson 5.02% 5.00% Thomas 6.32% 10.07% Jewell 5.41% 3.39% Trego 8.99% 9.20% Johnson 5.04% 4.19% Wabaunsee 5.65% 4.22% Kearny 7.39% 6.42% Wallace N/A N/A Kingman 7.24% 7.33% Washington 8.02% 8.51% Kiowa 1.66% 1.46% Wichita 7.48% 4.35% Labette 5.32% 9.17% Wilson 5.40% 6.89% Lane 6.33% 3.14% Woodson 4.20% 4.49% Leavenworth 6.80% 5.48% Wyandotte 5.62% 4.98% Lincoln 10.00% 9.77% Statewide Average 7.06% 6.72%

6 Hamilton, Stanton and Wallace county data were not available due to missing data.

14

15

Independence Indicator 2: Percent of Kansans Age 65 and Over Receiving Community Based Long-Term Care Services The purpose of Independence Indicator 2 is to measure the percent of Kansans age 65 and over receiving community based services that would otherwise be “at risk of nursing facility placement” (see Appendix D for Independence Indicator 2 graph and tables). This indicator reflects only public community based long-term care services, which include programs sponsored with public money under the jurisdiction of AAAs and KDOA. Some of these services are designed to assist with activities of daily living, while others are intended to provide attendant or limited medical assistance at the client’s residence. The indicator’s initial list has been modified to include only those services that are provided in the client’s residence and to reflect the current services offered under the HCBS/FE waiver. Since assisted living/residential health care facilities are considered community based options, a recent decision was made to include data related to these settings under this indicator. Programs included in this indicator are as follows: • Senior Care Act services, including homemaker and attendant care services;

• Income Eligible Services • Older Americans Act Title III-B In Home Services, including: • Homemaker; • Personal care; • Respite care; and • Chore services.

• Older Americans Act Title III-C-2 State General Fund Services and Home Delivered Meals Services;

• Older Americans Act Title III-D In-Home Services; • State In-Home Nutrition Services;

• HCBS/FE Waiver services: Health Care Attendant (levels one and two), Sleep Cycle Support, Wellness Monitoring, Adult Day Care, Personal Emergency Response and Respite Care.

It is anticipated that the implementation of Kansas Aging Management Information System (KAMIS) in 2000 will provide an unduplicated count of community based customers between and within programs. At this time, proxies are used to analyze trends in community based service availability and utilization. Some of these additional sources include: 1) Individual program data (i.e. HCBS client counts); 2) CARE program/unmet need data; 3) Data from additional KU research, such as the recent study of assisted living/residential health care facilities. These sources, when analyzed together, provide a picture of the community based service delivery system. Individual Community Based Service Program Data Individual program data for the HCBS/FE Waiver, Senior Care Act, Income Eligible programs and Title III-B In-Home, Title C-2, and Title D specific service data indicate that the number of older adults having their needs met in the community has increased. • The number of unduplicated customers who received services through the HCBS/FE waiver

increased from 5,622 in FY1998 to 6,822 in FY 1999 (these figures are derived from the Medicaid fiscal agent)*. This is an increase of 21%.

16

• The number of customers receiving Senior Care Act (SCA) services decreased from 4,992 in FY 1998 to 3,782 in FY 1999. Betwe en 1997 and 1998 the number of Senior Care Act customers had increased by 7.3%, from 4,651 to 4,9927. Many of the customers that would have used SCA are receiving Income Eligible services. Overall, the number of SCA and IE customers combined has increased during this time.

It is important to note that although the number of Senior Care Act customers decreased, the total units of service was relatively constant. This indicates that Senior Care Act customers in 1998 received more service units each than customers in 1997. In addition to the state level data, HCBS/FE plans of care data by PSA for Federal Fiscal Year 1998 (October 1997 through September 1998) were analyzed. These data were used to develop an “HCBS/FE utilization rate” based on the age 65 and over population of the area. They are displayed in Table 8 below. Since the HCBS/FE program serves older, low-income adults, these rates may be a reflection of the poverty level of the area. • The highest HCBS/FE utilization rates were found in PSA 5 (Southeast) and PSA 7 (East

Central) and PSA 9 (Northeast). • The lowest HCBS/FE utilization rates were found in PSA 11 (Johnson County) and PSA 3

(Northwest).

Table 8. FFY 1998 HCBS/FE Utilization Rates

PSA FFY 1998

Plans of Care Population Estimate

Rate

01 Wyandotte-Leavenworth Area 428 25,613 1.67% 02 Central Plains Area 869 65,550 1.33% 03 Northwest Area 229 20,137 1.14% 04 Jayhawk Area 455 32,603 1.40% 05 Southeast Area 1,185 31,835 3.72% 06 Southwest Area 482 30,506 1.58% 07 East Central Area 379 14,264 2.66% 08 North Central/Flint Hills 590 42,535 1.39% 09 Northeast Area 324 14,120 2.29% 10 South Central Area 694 34,202 2.03% 11 Johnson County Area 260 42,750 0.61% Statewide Average 5895 354115 1.66%

Client Assessment Referral and Evaluation (CARE) /Unmet Need Data Data collected through the Client Assessment Referral and Evaluation (CARE) Program provide information on the community based services needed across the state. Unmet community based service needs are collected through two sources. The first source is Section VI of the CARE Assessment Instrument (“Market Analysis Data”) which identifies services that are needed to keep the customer safely in his/her home. The second source is the 30 day follow-up form. The Market Analysis Data also showed a slight

7 Data provided from the Program Evaluation Supervisor at KDOA.

17

increase in the number of unmet service needs identified at the time of the CARE assessment from FY 1998 to FY 1999. The service needs that are most commonly identified as unmet are for attendant care and night support. This finding is consistent with the findings from the last few years. According to the most recent CARE data, the services most frequently “identified as being available in the AAAs are assistance with home health care, attendant care, homemaker services, and home delivered meals” (FY1999 CARE Annual Report). The report also noted, based on CARE program data, in each PSA for some customers “Adult Day Care, Night Support and Assisted Living services were unavailable or unaffordable” (FY1999 CARE Annual Report). Data from Additional KU Research Studies conducted by the KU Office of Aging and Long-Term Care on assisted living/residential health care (AL/RHC) settings have yielded a number of findings applicable to this indicator. For example, it was found that although the growth of AL/RHC settings in Kansas has been rapid, the availability of these settings in relation to the older adult population varies widely by PSA. In order to analyze the utilization of these settings by older adults, AL/RHC utilization rates were calculated at the state, PSA and county level. Assisted Living/Residential Health Care Facility Utilization Rates • Approximately 1.03% of Kansans age 65 and over resided in assisted living/residential health

care facilities in 1998. This rate is very close to the 1997 rate, 1.04%. The PSA level AL/RHC utilization rates for 1998 are displayed in comparison to the 1997 rates in Table 9 and Chart 3 below. As the table shows, PSA 1 (Wyandotte-Leavenworth) had the lowest rate during both time periods and PSA 5 (Southeast) had the highest. Additional findings related to the PSA level AL/RHC rates are bulleted below. • Most PSAs experienced an increase in their AL/RHC utilization rate between 1997 and 1998.

However, overall the rates were lower in 1998 than 1997 because of large decreases in a few PSAs.

• The largest PSA AL/RHC facility utilization rate increase occurred in PSA 9 (Northeast). The

rate increased from .65% in 1997 to 1.06% in 1998, an increase of .41%. • PSA 4 (Jayhawk) and PSA 2 (Central Plains) also experienced relatively large increases during

this time period, .33% and .32% respectively. • PSA 11, Johnson County, experienced the largest decrease, .38%. • PSA 6 (Southwest) and PSA 8 (North Central) had similar decreases during this time period,

.31% and .30% respectively.

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Table 9. 1997 and 1998 AL/RHC Utilization Rates, by PSA from Lowest to Highest

PSA 1997 PSA 1998

01 Wyandotte-Leavenworth Area 0.23% 01 Wyandotte-Leavenworth Area 0.26% 09 Northeast Area 0.65% 03 Northwest Area 0.58% 02 Central Plains Area 0.85% 06 Southwest Area 0.68% 03 Northwest Area 0.85% 11 Johnson County Area 0.76% 06 Southwest Area 0.99% 09 Northeast Area 1.06% 04 Jayhawk Area 1.10% 08 North Central/Flint Hills 1.10% 11 Johnson County Area 1.14% 02 Central Plains Area 1.17% 10 South Central Area 1.17% 10 South Central Area 1.19% 08 North Central/Flint Hills 1.40% 07 East Central Area 1.33% 07 East Central Area 1.45% 04 Jayhawk Area 1.43% 05 Southeast Area 1.48% 05 Southeast Area 1.50% Statewide Average 1.04% Statewide Average 1.03%

Chart 3.

1997 and 1998 Assisted Living/Residential Health Care Utilization Rates, by PSA

County Level Assisted Living /Residential Health Care Facility Utilization Rates Assisted living/residential health care utilization rates were also measured at the county level. These rates are displayed in Table 10 on the following page. Since many counties do not have AL/RHC facilities, their AL/RHC utilization rate is 0%. It is hoped that county in and out migration related to AL/RHC facilities can be calculated for future data. Findings related to the assisted living/residential health care utilization rates include: • The highest assisted living/residential health care utilization rates for 1998 were found in Allen

County (3.3%), Stafford County (2.71%), Seward County (2.38%) and Ellis County (2.28%).

0.00%0.20%0.40%0.60%0.80%1.00%1.20%1.40%1.60%

1 2 3 4 5 6 7 8 9 10 11


Per

cent 1997

1998

19

• Of the counties with AL/RHC facilities, the lowest rates for 1998 were found in Wyandotte County (.17%), Jefferson County (.33%), Doniphan County (.38%) and Leavenworth County (.53%).

• The largest rate increases between 1997 and 1998 occurred in Brown County (1.07%),

Marshall County (.99%) and Linn County (.91%). • The greatest decreases between 1997 and 1998 were found in Thomas County (4.13%), Pratt

County (2.23%), Riley County (2.08%) and Wilson County (1.99%). The findings from this indicator are also examined in combination with the other indicator findings in the report segment entitled, “Regional Analysis of Integrated Indicator Data.” The community based service data and additional sources indicate that a growing number of older adults are having their long-term care needs met in the community through in-home services as well as in assisted living/residential health care settings. It will be important to continue to monitor the assisted living/residential health care utilization rates to analyze the impact of these settings on the long-term care system. Finally, it is anticipated that KDOA’s new MIS system, KAMIS, will enable the relationships between the changes in number of people served in the community and in institutional settings to be more clearly tracked.

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Table 10. 1997 and 1998 AL/RHC Utilization Rates

COUNTY 1997 Rate 1998 Rate COUNTY 1997 Rate 1998 Rate Allen 3.17% 3.30% Linn ---- 0.91% Anderson 1.18% 1.55% Logan ---- ---- Atchison 0.81% 0.89% Lyon 2.98% 1.38% Barber ---- ---- Marion 0.74% 0.73% Barton 0.49% 1.03% Marshall 1.00% 2.00% Bourbon 2.62% 1.59% Mcpherson 1.09% 0.80% Brown ---- 1.07% Meade ---- ---- Butler 1.17% 1.06% Miami 1.23% 0.59% Chase ---- ---- Mitchell ---- ---- Chautauqua ---- ---- Montgomery 0.92% 1.28% Cherokee 1.57% 1.96% Morris ---- ---- Cheyenne ---- ---- Morton ---- ---- Clark ---- ---- Nemaha 1.40% 1.32% Clay 0.89% 1.17% Neosho 1.34% 2.07% Cloud 2.20% 2.04% Ness ---- ---- Coffey 1.57% 2.09% Norton ---- ---- Comanche 1.31% 1.43% Osage 1.98% 2.15% Cowley 1.03% 1.47% Osborne ---- ---- Crawford 0.92% 0.82% Ottawa 1.49% 1.75% Decatur ---- ---- Pawnee ---- 0.59% Dickinson 1.54% 1.82% Phillips 0.71% 0.66% Doniphan ---- 0.38% Pottawatomie 0.78% 0.90% Douglas 1.06% 0.79% Pratt 2.23% ---- Edwards ---- ---- Rawlins ---- ---- Elk ---- ---- Reno 2.16% 2.01% Ellis 2.54% 2.28% Republic ---- ---- Ellsworth ---- ---- Rice ---- ---- Finney 1.30% ---- Riley 3.24% 1.17% Ford 2.81% 1.61% Rooks ---- ---- Franklin 2.05% 1.18% Rush ---- ---- Geary 1.34% 0.94% Russell ---- ---- Gove ---- 0.00% Saline 1.57% 1.53% Graham 1.20% 1.19% Scott ---- ---- Grant ---- ---- Sedgwick 0.65% 1.08% Gray ---- ---- Seward 2.95% 2.38% Greeley ---- ---- Shawnee 1.23% 1.77% Greenwood 1.33% 1.39% Sheridan ---- ---- Hamilton ---- ---- Sherman ---- ---- Harper ---- ---- Smith ---- ---- Harvey 2.29% 2.20% Stafford 2.17% 2.71% Haskell ---- ---- Stanton ---- ---- Hodgeman ---- ---- Stevens ---- ---- Jackson 0.97% 1.17% Sumner 0.63% 0.68% Jefferson ---- 0.33% Thomas 5.28% 1.15% Jewell ---- ---- Trego ---- ---- Johnson 1.14% 0.76% Wabaunsee 0.34% 0.97% Kearny 2.16% 2.12% Wallace ---- ---- Kingman 1.14% 1.17% Washington ---- ---- Kiowa ---- ---- Wichita ---- ---- Labette 0.97% 1.40% Wilson 3.06% 1.07% Lane ---- ---- Woodson ---- ---- Leavenworth 0.52% 0.53% Wyandotte 0.14% 0.17% Lincoln ---- 0.73% Statewide Average 1.03% 1.04%

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Independence Indicator 3: Discharge from Nursing Facilitie s to the Community for Kansans Age 65 and Over

Independence Indicator 3 reflects the number of older adults who move from nursing facilities to more integrated environments in the community. It includes residents of licensed nursing facilities and residents of nursing facility beds in hospitals8. It is important to note that these figures do not include residents of assisted living or residential health care facilities. The Minimum Data Set (MDS) is used to provide the data needed for this indicator. For the current year of measurement, CY 1998, data were drawn from both the MDS Plus and the MDS 2.0. This was necessary since the MDS 2.0 was implemented in June of 1998. State Level Table 11 below provides a summary of the number of nursing facility residents who returned to the community from CY1993 to CY1998. These rates are also displayed graphically in Figure 3. Findings from this indicator include: • Approximately 19.55% of nursing facility residents (including nursing facility hospital

residents) re turned to the community in Calendar Year 1998, decreasing slightly from 21.50% in 1997.

• In 1998, 43.9% of nursing facility hospital residents were discharged to the community. This

rate is much lower than the rate in 1997, 85.6%. • If nursing facility hospital residents are not included, approximately the same percentage

(17.45%) of nursing facility residents discharged to the community in 1997 and 1998. • Although the proportion of nursing facility residents returned to the community in 1998

decreased, the actual number of nursing facility residents returned to the community increased during this time period.

8 The specific type of hospital beds included are those certified for Medicaid long-term care and licensed for nursing facility (NF) care. Some beds are dually licensed for nursing facility care (NF) and skilled nursing facility (SNF) care. These dually certified beds are also included in the discharge indicator. Therefore, the hospital discharge statistics capture some SNF beds. They represent about 11% of the total number of hospital based beds included in this indicator. The focus of the care provided in these beds is generally short term. Therefore, the inclusion of these SNF beds may have an impact on the hospital discharge figures.

22

Table 11.

Nursing Facility Level Residents Age 65 and Over Returned to the Community CY1993 - CY1998

Year

Total Number of Residents Returned

Total Number of Nursing Facility Residents

Percent

CY 1993 2,345 22,661 10.3%

CY 1994 3,401 24,739 13.75%

CY 1995 4,403 22,574 19.5%

CY 1996 4,962 20,842 23.81%

CY 1997 3,930 18,281 21.50%

CY 1998 4,179 21,377 19.55%

Figure 3.

Nursing Facility Residents Age 65 and Over Returned to the Community CY1993 - 1998

The change from the MDS+ to the MDS 2.0 may have had some effect on the discharge figures. According to staff from Myers and Stauffer LC, the discharge statistics generated from the MDS+ may not have eliminated short-term stay residents as effectively as the MDS 2.0. They noted that it is likely, however, that the discharge rate trend accurately reflects what is taking place. PSA Level Data were collected on the number of nursing facility residents discharged to the community on a county and PSA basis for calendar years 1997 and 1998. The county level data show a relatively wide range in discharge rates between counties. As mentioned previously, there may be some data irregularities due to the MDS database transition. Therefore, it is useful to analyze the discharge rates in terms of the PSAs.

0.00%

5.00%10.00%15.00%20.00%25.00%30.00%

1993 1994 1995 1996 1997 1998

Calendar Year

Per

cent

23

These rates are presented in Table 12, Chart 4 and Map 3. Please note that these rates include residents of licensed nursing facilities and residents of nursing facility beds in hospitals. As the table shows, generally the same PSAs had the lowest and highest rates during both time periods. • PSAs 5 (Southeast), 4 (Jayhawk) and 6 (Southwest) had the highest discharge rates for both

time periods. • PSAs 10 (South Central), 1 (Wyandotte-Leavenworth) and 2 (Central Plains) had the lowest

discharge rates for both time periods. • The majority of the PSA level discharge rates decreased between 1997 and 1998. • The largest discharge rate decrease occurred in PSA 7 (East Central).

Table 12. 1997 and 1998 Nursing Facility Level Discharge Rates, by PSA from Lowest to Highest

PSA 1997 PSA 1998

10 South Central Area 10.05% 10 South Central Area 10.09% 01 Wyandotte-Leavenworth Area 10.28% 01 Wyandotte-Leavenworth Area 10.25% 02 Central Plains Area 14.24% 02 Central Plains Area 11.89% 09 Northeast Area 19.06% 07 East Central Area 12.68% 03 Northwest Area 20.37% 03 Northwest Area 16.06% 08 North Central/Flint Hills 20.64% 08 North Central/Flint Hills 17.00% 07 East Central Area 21.23% 11 Johnson County Area 19.26% 11 Johnson County Area 24.34% 09 Northeast Area 20.47% 06 Southwest Area 27.02% 06 Southwest Area 25.78% 04 Jayhawk Area 30.72% 04 Jayhawk Area 28.99% 05 Southeast Area 38.66% 05 Southeast Area 37.47% Statewide Average 21.50% Statewide Average 19.55%

Chart 4. 1997 and 1998 Nursing Facility Level Discharge Rates, by PSA

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

1 2 3 4 5 6 7 8 9 10 11

PSA

Perc

ent

1997

1998

24

The longitudinal discharge data show a somewhat uneven trend in the number of older adults who return to the community. The higher rates in 1996 and 1997 may be attributable to the growth and availability of assisted living/residential health care settings during this time period, indicating older adults were discharging from nursing facilities to these settings. Therefore, the discharge rate dropped in 1997 and 1998 as these transitions leveled off. In addition, the growth of the HCBS/FE waiver during this time period may account for some customers who previously would have had short term nursing facility stays. The decreasing discharge rate may also be due to older adults who reside in nursing facilities being more impaired than in previous years. Therefore, the likelihood of discharging to the community is reduced. Additional data, such as an analysis of MDS data of the functional status of nursing facility residents upon admission over the last few years, are needed to validate these explanations.

25

26

Independence Indicator 4: Diversion of Kansans Age 65 and Older Seeking Nursing Facility Placement Independence Indicator 4 is structured to measure the number and percent of people age 65 and older seeking nursing facility care who chose and received community based service as an alternative (see Appendix F). Nursing facility diversion is considered from two perspectives: potential and actual diversions. Potential diversions are defined as cases in which individuals chose nursing facility services instead of other long-term care options, because community based services were unavailable or unable to meet their needs. Actual diversions “represent individuals in the community with services and those in the community setting in alternative living situations, at the time of the AAA 30-day follow up.” (The Client Assessment Referral and Evaluation (CARE) Program FY 99 Annual Report). Since the Older Adult Outcome Indicators Project is currently part of the interagency agreement between KDOA and KU, detailed diversion data (from the CARE Program) is not included as part of this report to prevent duplication for state agency staff. However, for the sake of other readers and for the purpose of analyzing the indicators in conjunction with one another, some diversion data and tables are presented below. Potential Diversions Through the AAA 30 day follow up contact, customers who have entered a nursing facility respond to the question “if additional help had been available, could you have stayed in your home?” Data are provided on the specific services that were needed and affected their decision to enter a nursing facility. As discussed previously, the two most common services needed were night support and attendant care. The Fiscal Year 1999 data indicate that there were 1,605 and 1,017 unmet needs for these services, respectively. Actual Diversions State Level Table 13 displays the diversion rates for the last three years. Findings include: • The diversion rate increased steadily from FY 1997 to FY 1999. • Overall, the number of initial assessments increased from FY 1997 to FY 1999, despite a

minute (.7%) decrease in FY 1998.

Table 13. Fiscal Year 1997 -1999 Diversion Rates

Year

30 Day Follow Ups Initial

Assessments

Diversions

Percent

FY 1997 12,064 12,107 1,850 15.33%

FY 1998 11,867 12,017 1,952 16.45%

FY 1999 12,303 12,524 2,206 17.93%

27

PSA Level The PSA level actual diversion rates for Fiscal Year 1999 are displayed on Map 4 on the following page. The following table and chart display the rates from FY 1997 through FY 1999. The following are highlights from this analysis. • PSA 6 (Southwest) had the highest diversion rate in FY 1999, and among the highest in

previous years. • PSA 1 (Wyandotte Leavenworth) and PSA 5 (Southeast) had among the lowest diversion rates

for all three time periods. • The majority of PSAs experienced an increase in their diversion rates between 1998 and 1999.

The largest increase (5.76%) occurred in PSA 8 (North Central). • Only three PSAs, 3 (Northwest), 7 (East Central) and 9 (Northeast) experienced a decrease in

their diversion rates between 1998 and 1999.

Table 14. Fiscal Year 1997 -1999 Diversion Rates, by PSA

PSA 1997 1998 1999 01 Wyandotte-Leavenworth Area 4.81% 12.34% 13.73% 02 Central Plains Area 15.54% 16.50% 17.26% 03 Northwest Area 15.92% 17.64% 14.74% 04 Jayhawk Area 12.43% 14.88% 17.86% 05 Southeast Area 13.41% 11.41% 11.89% 06 Southwest Area 15.69% 23.22% 25.66% 07 East Central Area 15.40% 13.83% 12.82% 08 North Central/Flint Hills 22.58% 15.34% 21.10% 09 Northeast Area 14.55% 22.86% 21.16% 10 South Central Area 15.17% 19.49% 20.96% 11 Johnson County Area 18.05% 16.38% 17.14% Statewide Average 15.33% 16.45% 17.93%

Chart 5.

Diversion Rate by PSA, Fiscal Year 1997 through 1999

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

1 2 3 4 5 6 7 8 9 10 11


Per

cent FY 1997

FY 1998

FY 1999

28

In the following section, the diversion data at the PSA level are presented in conjunction with the other indicator data in order to provide a comprehensive picture of long-term care in Kansas. Additional sources of long-term care data are also explored. The supplemental information sources include KDHE assisted living utilization data, KDHE nursing facility occupancy data, and other program or agency reports/data as they apply to outcome indicators. The following segment presents a profile of each PSA based on these data.

29

Regional Analysis of Integrated Indicator Data

The regional analysis presents the PSA level indicator data and additional data regarding the long-term care system of each area. The indicator and other long-term care data at the PSA level provide a “picture” of the long-term care system in each area across the state. This analysis also draws attention to the relationship between the indicators, for example how the availability of community based services may influence the institutionalization rate. The regional analysis also uncovers potential “red flags” where attention and extra efforts may be needed. KU School of Social Welfare staff met with staff at each AAA9 during FY2000 to discuss the PSA level indicator data. Feedback and insights from the field staff were used to verify the trends and to discern possible reasons behind the trend. Since AAA staff stated that the PSA level data are most useful presented in a concise, “user friendly” manner, the indicator data are presented in a table format for each area. Additional findings related to each area are also presented. Since 1998 is the most recent year available for all of the indicators, data are examined for this time period. Indicator data from 1997 are also provided to show trends. Wyandotte-Leavenworth AAA (PSA 1)

INDICATOR

1997

Rank (lowest to highest)

1998

Rank (lowest to highe st)

“NF Only” Utilization Rate 4.92% 1st 3.92% 1st AL/RHC Utilization Rate .23% 1st .26% 1st Discharge Rate 10.28% 2nd 10.25% 2nd Diversion Rate (Fiscal Years) 4.81% 1st 12.34% 2nd

Additional 1998 data regarding PSA 1:

ADDITIONAL DATA

1998


NF Occupancy Rate* 90.79% 10th AL/RHC Occupancy Rate 78.01% 10th AL/RHC Availability Rate** (beds per 1000) 3.2 1st HCBS/FE Utilization Rate***(Federal Fiscal Year) 1.67% 7th

9 At this time KU staff have not met with staff from PSA 7 (East Central). * The NF occupancy rate does not include hospital long-term care units. The source for occupancy data is the Adult Care Home Semi-Annual Survey. ** The AL/RHC availability rate measures the availability of AL/RHC settings in proportion to the older adult population of the area. The rate reflects the number of AL/RHC beds per 1000 adults age 65 and over. *** The HCBS/FE utilization rate measures the use of HCBS/FE services in proportion to the older adult population of the area. The rate reflects the percent of older adults who used HCBS/FE services in relation to the number of adults age 65 and over.

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Central Plains AAA (PSA 2)

INDICATOR

1997


1998


“NF Only” Utilization Rate 4.97% 2nd 4.32% 2nd AL/RHC Utilization Rate .85% 3rd (tied) 1.17% 7th Discharge Rate 14.24% 3rd 11.89% 3rd Diversion Rate (Fiscal Years) 15.54% 7th 16.50% 7th


ADDITIONAL DATA

1998


NF Occupancy Rate* 90.11% 9th AL/RHC Occupancy Rate 76.06% 7th AL/RHC Availability Rate** (beds per 1000) 17.3 7th HCBS/FE Utilization Rate***(Federal Fiscal Year) 1.33% 3rd

Northwest Area (PSA 3)

INDICATOR

1997


1998


“NF Only” Utilization Rate 6.99% 8th 7.41% 11th AL/RHC Utilization Rate .85% 3rd (tied) .58% 2nd Discharge Rate 20.37% 5th 16.06% 5th Diversion Rate (Fiscal Years) 15.92% 9th 17.64% 8th


ADDITIONAL DATA

1998


NF Occupancy Rate 86.08% 7th AL/RHC Occupancy Rate 72.83% 5th AL/RHC Availability Rate (beds per 1000) 9.2 2nd HCBS/FE Utilization Rate (Federal Fiscal Year) 1.14% 2nd

* The NF occupancy rate does not include hospital long-term care units. The source for occupancy data is the Adult Care Home Semi-Annual Survey. ** The AL/RHC availability rate measures the availability of AL/RHC settings in proportion to the older adult population of the area. The rate reflects the number of AL/RHC beds per 1000 adults age 65 and over. *** The HCBS/FE utilization rate measures the use of HCBS/FE services in proportion to the older adult population of the area. The rate reflects the percent of older adults who used HCBS/FE services in relation to the number of adults age 65 and over.

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Jayhawk AAA (PSA 4)

INDICATOR

1997


1998


“NF Only” Utilization Rate 6.50% 6th 5.68% 5th AL/RHC Utilization Rate 1.10% 6th 1.43% 10th Discharge Rate 30.72% 10th 28.99% 10th Diversion Rate (Fiscal Years) 12.43% 2nd 14.88% 4th


ADDITIONAL DATA

1998


NF Occupancy Rate* 84.58% 3rd AL/RHC Occupancy Rate 67.57% 3rd AL/RHC Availability Rate** (beds per 1000) 24.8 10th HCBS/FE Utilization Rate***(Federal Fiscal Year) 1.40% 5th

Southeast AAA (PSA 5)

INDICATOR

1997


1998


“NF Only” Utilization Rate 5.49% 4th 5.90% 6th AL/RHC Utilization Rate 1.48% 11th 1.50% 11th Discharge Rate 38.66% 11th 37.47% 11th Diversion Rate (Fiscal Years) 13.41% 3rd 11.41% 1st


ADDITIONAL DATA

1998


NF Occupancy Rate 85.33% 4th AL/RHC Occupancy Rate 76.97% 9th AL/RHC Availability Rate (beds per 1000) 23.2 9th HCBS/FE Utilization Rate (Federal Fiscal Year) 3.72 % 11th


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Southwest AAA (PSA 6)

INDICATOR

1997


1998


“NF Only” Utilization Rate 7.01% 9th 6.70% 8th AL/RHC Utilization Rate .99% 5th .68% 3rd Discharge Rate 27.02% 9th 25.78% 9th Diversion Rate (Fiscal Years) 15.69% 8th 23.22% 11th


ADDITIONAL DATA

1998


NF Occupancy Rate* 85.49% 5th AL/RHC Occupancy Rate 76.40% 8th AL/RHC Availability Rate** (beds per 1000) 12.6 4th HCBS/FE Utilization Rate***(Federal Fiscal Year) 1.58% 6th

East Central AAA (PSA 7)

INDICATOR

1997


1998


“NF Only” Utilization Rate 5.89% 5th 4.82% 3rd AL/RHC Utilization Rate 1.45% 10th 1.33% 9th Discharge Rate 21.23% 7th 12.68% 4th Diversion Rate (Fiscal Years) 15.40% 6th 13.83% 3rd


ADDITIONAL DATA

1998


NF Occupancy Rate 81.48% 1st AL/RHC Occupancy Rate 68.22% 4th AL/RHC Availability Rate (beds per 1000) 30.3 11th HCBS/FE Utilization Rate (Federal Fiscal Year) 2.66% 10th


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North Central/Flint Hills AAA (PSA 8)

INDICATOR

1997


1998


“NF Only” Utilization Rate 6.95% 7th 6.45% 7th AL/RHC Utilization Rate 1.40% 9th 1.10% 6th Discharge Rate 20.64% 6th 17.00% 6th Diversion Rate (Fiscal Years) 22.58% 11th 15.34% 5th


ADDITIONAL DATA

1998


NF Occupancy Rate* 84.26% 2nd AL/RHC Occupancy Rate 77.43% 6th AL/RHC Availability Rate** (beds per 1000) 16.8 6th HCBS/FE Utilization Rate***(Federal Fiscal Year) 1.39% 4th

Northeast AAA (PSA 9)

INDICATOR

1997


1998


“NF Only” Utilization Rate 7.65% 11th 7.39% 9th AL/RHC Utilization Rate .65% 2nd 1.06% 5th Discharge Rate 19.06% 4th 20.47% 8th Diversion Rate (Fiscal Years) 14.55% 4th 22.86% 10th


ADDITIONAL DATA

1998


NF Occupancy Rate 85.52% 6th AL/RHC Occupancy Rate 88.40% 11th AL/RHC Availability Rate (beds per 1000) 12.1 3rd HCBS/FE Utilization Rate (Federal Fiscal Year) 2.29% 9th


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South Central AAA (PSA 10)

INDICATOR

1997


1998


“NF Only” Utilization Rate 7.28% 10th 7.39% 10th AL/RHC Utilization Rate 1.17% 8th 1.19% 8th Discharge Rate 10.05% 1st 10.09% 1st Diversion Rate (Fiscal Years) 15.17% 5th 19.49% 9th


ADDITIONAL DATA

1998


NF Occupancy Rate* 86.97% 8th AL/RHC Occupancy Rate 51.30% 1st AL/RHC Availability Rate** (beds per 1000) 22.1 8th HCBS/FE Utilization Rate***(Federal Fiscal Year) 2.03% 8th

Johnson County AAA (PSA 11)

INDICATOR

1997


1998


“NF Only” Utilization Rate 5.04% 3rd 4.85% 4th AL/RHC Utilization Rate 1.14 % 7th .76% 4th Discharge Rate 24.34% 8th 19.26% 7th Diversion Rate (Fiscal Years) 18.05% 10th 16.38% 6th


ADDITIONAL DATA

1998


NF Occupancy Rate 91.62% 11th AL/RHC Occupancy Rate 65.39% 2nd AL/RHC Availability Rate (beds per 1000) 15.8 5th HCBS/FE Utilization Rate (Federal Fiscal Year) .61% 1st


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Protection Indicators The protection indicators are structured to measure the reported incidence of abuse, neglect, and exploitation (A/N/E) of older adults receiving long-term care services either in the community or in institutions. National Trends: Abuse, Neglect and Exploitation (A/N/E) Each year the latest A/N/E data related to the protection indicators are presented in the Outcome Indicator Report. This information highlights the national trends in A/N/E and may serve as a comparison for the Kansas data. The National Elder Abuse Incidence Study (1998) conducted by the National Center on Elder Abuse (NCEA) has provided important insight into the current state of mistreatment of older adults. The study collected data on the national incidence of domestic elder abuse and neglect of older adults age 60 and older. The National Elder Abuse Incidence Study gathered data on domestic A/N/E using a stratified sampling of counties. The data was gathered from two sources: 1)reports from the Adult Protective Services agencies; and 2) “reports from ‘sentinels’-specially trained individuals in a variety of community agencies having frequent contact with the elderly” (NCEA, 1998). It is important to note that the National Elder Abuse Incidence Study statistics represent unduplicated incidents of elder maltreatment. Findings from the NCEA are bulleted below. National Incidence of Elder Abuse • The NCEA documented a 150% increase in domestic elder abuse reports between 1986 and

1996. • Approximately 450,000 older adults, aged 60 and older, were victims of abuse and/or neglect in

domestic settings in 1996. It is estimated that 16% of these incidents were reported to Adult Protective Services agencies.

• When self-neglect is included in these figures, the estimate rises to about 550,000 and the

reporting rate rises to 21%. • According to the NCEA, 64.2% of the elder abuse reports in 1996 were substantiated. • The NCEA found the most common form of mistreatment to be neglect. Physical abuse and

financial exploitation were the second and third most common, respectively. National Victims of A/N/E • The majority of elder abuse victims were women. In 1996, 67.3% of the reports involved

female victims, while 32.4% involved male victims. • In 1996, 66.4% of domestic elder abuse victims were white, 18.7% were African American,

and 10.4% were Hispanic. Approximately 8% of adults age 65 and over were African American and 5.1% were of Hispanic origin (AARP, 1999).

• In 1996, the median age of elder abuse victims (including self-neglect) was 77.6 years.

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The national data indicate that A/N/E is still vastly underreported. The low reporting rates can most likely be attributed to the dynamics of elder abuse. The majority of perpetrators of A/N/E against older adults are family members, most often an adult child. This surrounds the abuse in a complex web of family dynamics and can leave the older adult without a trusted confidant. The signs of elder abuse are often not recognized, leading to gross under-reporting of the problem (NCEA, 1998). The national trend does show reports are increasing. The national data underscore the importance of monitoring A/N/E and its impact on older Kansans. Protection Indicator 1: Confirmed and Substantiated A/N/E Complaints per 10,000 Long-Term Care Clients Age 65 and Over Residing in the Community and in Institutional Settings Protection Indicator 1 addresses abuse/neglect/exploitation (A/N/E) in both the community and in institutions for Kansans age 65 and over receiving long-term care services. Protection Indicator 1a addresses A/N/E in the community, and Protection Indicator 1b addresses A/N/E in institutions (see Appendix G for Protection Indicators graphs and tables). Alternative proxies for these indicators have been identified and tracked over time since an unduplicated count of elders abused and/or neglected in Kansas is not yet available. Protection Indicator 1a: Confirmed Abuse/Neglect/Exploitation Complaints per 10,000 Long-Term Care Clients Age 65 and Over Residing in the Community Protection Indicator 1a addresses abuse/neglect/exploitation in the community for recipients of long-term care services (see Appendix G for tables and graphs). Since an unduplicated count of Kansans who are receiving in-home services is not yet available, this indicator cannot be measured as originally defined. However, data on the number of A/N/E reports involving older adults has been tracked and analyzed. Table 15 below displays the number of A/N/E reports involving adults age 60 and over. • The number of A/N/E reports involving adults age 60 and over has tripled since FY 1996.

Table 15. A/N/E Reports Involving Adults Age 60 and Over, FY 1996 - FY 199910

Fiscal Year A/N/E Reports Involving Adults Age 60 and Over

Percent Increase

FY 1996 840 N/A FY 1997 1270 51.19% FY 1998 2,224 75.12% FY 1999 2,512 12.95%

Source: SRS “Abuse/Neglect/Exploitation/Fiduciary Abuse” Report The rapid increase in reports may be attributed to greater public awareness of adult maltreatment and how to report suspicions. Public advertisements and trainings have raised public knowledge of the dynamics of adult abuse and encouraged neighbors, service providers, and concerned citizens to become involved and make reports. In addition, the number of mandated reporters of A/N/E was increased

10 These figures could include nursing facility residents if the occurrence involved a resident to resident or other non-staff to resident incident. Incidents that involve a staff member would be investigated by KDHE.

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through a July 1998 revision to the law. This change is likely resulting in increased reports. Finally, increased efforts have been made by SRS to work with law enforcement regarding A/N/E. The most recent A/N/E data also provide information on the number of community based service recipients, broken out by program, involved in A/N/E reports. The FY 1999 figures are displayed below and will serve as a baseline for future years. • Approximately 11.58% of the age 60 and over adults involved in an A/N/E report were

HCBS/FE service recipients11.

Table 16. A/N/E Reports Involving Adults Age 60 and Over Who are Service Recipients, FY 1999*

Service Type Service

Recipients A/N/E Reports Involving Adults Age 60 and Over

Percent

HCBS/FE 291 2512 11.58% Income Eligible 56 2512 2.23% Senior Care Act 36 2512 1.43% Older Americans Act 107 2512 4.26%

*Source: SRS “Abuse/Neglect/Exploitation/Fiduciary Abuse” Report As Table 16 shows, approximately 19.5% of the age 60 and over adults involved in an A/N/E report were recipients of publicly funded in-home services. Fiscal Year 1999 A/N/E data for all ages provides information on the relationship of the alleged perpetrator to the victim. These figures are displayed in Table 17.

Table 17. Relationship of the Alleged Perpetrator to the Victim, FY 1999*

Relationship of

Alleged Perpetrator

Number

A/N/E Reports

of All Ages

Percent

Self 1988 4877 40.76% Spouse 139 4877 2.85%

Family/Relative 801 4877 16.42% Neighbor/Friend 165 4877 3.38%

Guardian/Conservator 34 4877 0.70% Patient/Resident 10 4877 0.21%

Facility Staff 419 4877 8.59% Medicaid Provider 826 4877 16.94%

Other 859 4877 17.61% *Source: SRS “Abuse/Neglect/Exploitation/Fiduciary Abuse” Report

11 Please note that an adult between the ages of 60 and 64 can not be an HCBS/FE customer.

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As Table, 17 shows , 16.9% of all APS reports involved an alleged perpetrator paid for providing a Medicaid service. Since this data is not broken out by age groups, this figure may include customers receiving HCBS/FE or other waivered services such as HCBS/PD. The following chart shows the proportion of A/N/E reports involving age 60 and over victims broken out by age subgroups.

Chart 6. A/N/E Reports Involving Adults Age 60 and Over by Age Subgroup, FY 1999*

*Source: SRS “Abuse/Neglect/Exploitation/Fiduciary Abuse” Report This chart highlights the vulnerability of the oldest old. These figures show that older adults aged 80 and older represented 45% of APS reports involving age 60 and over potential victims. Their proportion within the age 60 and over population is much lower (around 14%), so this clearly indicates over-representation among the maltreated. Many of these cases may involve self-neglect. However, it is not possible to determine the exact figure since the FY 1999 APS data does not break out self-neglect as a separate category. When SRS investigates an incident, the agency's conclusion regarding whether abuse, neglect, exploitation or fiduciary abuse occurred is based on facts gathered during the investigation. The findings are categorized into one of three categories as follows: • Confirmed - When a social worker’s response is, "Yes, a reasonable person would conclude that

more likely than not abuse, neglect, exploitation or fiduciary abuse has occurred.

• Unconfirmed - When a Social Worker's response is " No, a reasonable person would not believe abuse, neglect, exploitation, or fiduciary abuse exists or occurred".

• Potential Risk - When a Socia l Worker's response is "A reasonable person cannot conclude that

evidence is sufficient to determine a confirmation, but the facts and circumstances would cause a

80 - 89(33%)

70 - 79 (32%)

60 - 69 (23%)

90 and Over(12%)

39

person to believe that risk of abuse, neglect, exploitation or fiduciary abuse exists". (The Kansas Economic & Employment Support Manual, 5/00)

Prior to FY 1999, the monthly A/N/E report included data on the number of A/N/E investigations involving adults age 60 and over that are confirmed, potential risks and unconfirmed. However, the FY 1999 reports only provide this information for all ages, it does not separate out the age 60 and over subgroup. The FY 1996 through 1998 data on the number of A/N/E investigations involving adults age 60 and over that are confirmed, potential risks and unconfirmed have been tracked and analyzed. These data are presented in Chart 7. • The number of A/N/E reports involving adults age 60 and over increased approximately 75%

between FY1997 and FY1998. During the same period, confirmations increased approximately 17%. The increase in reports is likely due to an increased awareness of a/n/e.

Chart 7.

A/N/E Reports, Confirmations And Potential Risks Involving Adults Age 60 And Over

A/N/E Reports Confirmed Potential Risks

FY1996

FY1997

FY1998

These data are not available broken out by age for FY 1999. The confirmation rates for Kansas can be compared to the national rates with caution. Kansas’ APS system uses a classification of “potential risk” for A/N/E. Not all states use this finding, and it is unknown what effect this has on overall substantiation rates. In FY98, the confirmation rates for cases involving adults 60 years and older were 8.64% for abuse; 20% for neglect; 10.1% for exploitation; and 0% for fiduciary abuse. These rates are considerably lower than those reported nationally in the NCEA report. The lower confirmation rates could be due to the additional “potential risk” category or to differences in definitions or procedures.

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Protection Indicator 1b: Substantiated Abuse/Neglect/Exploitation Complaints per 10,000 Long-Term Care Clients Age 65 and Over Residing in Institutional Facilities Protection Indicator 1b monitors A/N/E of older adults residing in institutions (see Appendix G for tables and graphs). KDHE staff hand counted the number of substantiated cases for indicator measurement. Current A/N/E figures from KDHE represent cases/reports and are not age specific. In addition, the A/N/E figures contain more than just staff to resident incidences of A/N/E. They also include institutional deficiencies, some resident-to-resident abuse and elopements (“neglect”). • The number of institutional A/N/E investigations has increased slightly. As with older adults residing in the community, the number of A/N/E investigations involving residents of nursing facilities have also increased over time. For FY 1999 there were 1807 institutional investigations, increasing from 1772 for FY98. This represents a slight increase in investigations, approximately 2%. The substantiation figures, derived from manual tabulation, are displayed in Table 18 and Figure 4 below. As the table and graph show, the number of substantiated A/N/E reports involving institutional investigations increased from CY1993 through CY1996, fell slightly in CY1997 and then increased in CY 1998.

Table 18.

Substantiated A/N/E Complaints Involving Institutional Residents, All Ages CY1993 - CY1998

CY1993 CY1994 CY1995 CY1996 CY1997 CY1998

Substantiations 100 199 210 241 226 244

Figure 4. Substantiated A/N/E Complaints of Involving Institutional Residents, All Ages

CY1993 - CY1998

0

50

100

150

200

250

300

CY93 CY94 CY95 C96 CY97 CY98

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As mentioned previously, there is an increased awareness of the A/N/E network in Kansas and therefore a higher rate of A/N/E reporting compared to previous years. The SRS APS data also showed a similar trend during this time period. In summary, reports involving older adults as victims of A/N/E have increased in both the community and institutional settings. The substantiation rates of community based reports and institutional confirmation rates have increased as well. These trends underscore the importance of continued monitoring of data pertaining to abuse, neglect and exploitation of older Kansans receiving long-term care services.

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Recommendations In this section, implications and recommendations are offered based on the outcome indicator findings and feedback from AAA and state agency staff. Where applicable, they are discussed within the context of national literature/data. Potential implications for policy makers are also discussed. The implications and recommendations are organized under the following topics: • Implications based on the outcome indicator trends; • Recommendations to enhance monitoring of the indicator data; and • Recommendations on using indicator data for programming and planning. Recommendations/Implications Based On The Outcome Indicator Trends Ø Nursing Facility Utilization Over time the nursing facility utilization rate of older Kansans has declined. However, older Kansans reside in nursing facilities at a higher rate than older adults nationally. Table 19 below displays Kansas’ rates and national rates. 1996 is the latest national data broken out by age groups. However, data from the 1997 National Nursing Home Survey show that the proportion of adults age 65 and over who reside in nursing facilities nationally remained around 4.3% for 1997.

Table 19. 1998 Kansas and 1996 National Nursing Facility Utilization Rates

Age Group 1998 Kansas Rates 1996 National Rates*

65-74 1.19% 1.1% 75-84 5.23% 4.2%

85 and above 22.71% 19.8% 65 and above 5.70% 4.2%

*(AARP, 2000) An AARP study found that Kansas’ rate of older adults age 65 and over who reside in nursing facilities was the 3rd highest in the nation (Graves and Bectel, 1998). This comparison indicates that further program and policy development is needed so that Kansans’ long-term care needs are met in the most integrated setting possible. A key area to examine is the supply of nursing facility beds. Kansas was found to have the highest number of beds per adults age 65 and over of any state (Graves & Bectel, 1998). Greene et al. (1993) found that the risk of NF admission is higher in areas with high bed density, even with controlling for disability levels. AAA directors also expressed possible concern regarding a possible “over supply” of nursing facility beds. However, it is important to note that the number of nursing facility beds in Kansas has been decreasing over the last number of years. Many states have utilized strategies to successfully control the number of available nursing facility beds. In 1995, 45 states regulated the growth of nursing home beds either through certificates of need, a moratorium on bed construction, or a combination of both mechanisms (Coleman, 1998). Some states, in attempts to restrict the growth of NF beds, have instituted a policy of taking beds out of circulation, called “banking” beds. It has many variations including grants for converting nursing facility units to lower levels of care. Policy makers could explore these ideas for potential use in Kansas. In addition, continued monitoring of Kansas’ nursing facility utilization rate over time and in comparison to the national rate is needed.

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Ø Assisted Living Availability for Medicaid Consumers Assisted living/residential health care settings are a growing segment of the long-term care continuum in Kansas. Approximately, 1% of Kansans age 65 and over resided in these settings in 1997 and 1998. However, the availability of assisted living is somewhat uneven across the state. In addition, the AL/RHC occupancy rates are generally lower than the occupancy rates of the nursing facilities. Many AAA executive directors expressed concern over the lack of AL/RHC availability in their area, particularly for Medicaid consumers. They felt that these settings were often not a residential option for Medicaid customers. KU recently found that approximately 15% of the AL/RHC residents in Kansas receive HCBS/FE services. In comparison, 25% of assisted living residents in Oregon relied on Medicaid. These settings are playing an important role in the community based care options for older adults relying on public funds for services. It was also noted by AAA staff that there is pressure from AL/RHC facilities for case managers to increase the number of services provided for in the plan of care of Medicaid HCBS/FE residents in order to increase the amount of money the facilities receive. The AAA staff and AL/RHC administrators have commented that the current HCBS/FE reimbursement structure is a barrier for Medicaid residents. Therefore, policy makers may want to explore strategies to increase the availability of these settings for low-income customers. In addition, the impact of these settings on the long-term care system should be analyzed for their effect on customer choice and outcomes12. Ø Urban and Rural Differences in Outcome Indicator Findings For the most part, the PSA level data did not show much difference between urban and rural areas. This indicates that factors other than rurality such as the poverty level of an area are affecting outcome indicator results. However, one notable finding is that nursing facility institutionalization rates in urban areas (PSAs 1, 2, 4 and 11) are lower than the rates in the rural areas. One possibility for this finding may be that older adults in urban areas are more likely to have informal support available in the community. A number of the AAA directors in rural areas expressed concern over the decrease of informal family support in their areas. They stated that many of the younger residents have moved out of their areas. Therefore, these areas have a greater proportion of older adults and fewer younger residents. Strategies need to be developed that address the loss of informal support of older adults in these areas and reduce unnecessary nursing facility utilization. There were some common themes identified by AAA executive directors in both urban and rural areas. For example, most of the directors attributed their positive indicator trends to an increased awareness by older adults of the services available through the aging network. The availability of provider staff was mentioned as an issue in many of the areas. They stated that during this period of low unemployment, in-home service providers are experiencing difficulty in finding workers. A few of the areas also noted that gaming establishments have reduced the available work force of people that would be likely to work for the provider agencies. This issue has serious effects on the availability and provision of services for older adults and should be addressed. Another subject discussed by the directors was an interest in sharing information related to indicator trends. They felt it would be possible to learn from the success of other areas and apply it to their own area. Areas that are economically or demographically similar could benefit from a comparison analysis. Therefore, venues for sharing successful indicator strategies and innovative ideas between AAAs should be developed. For example, some AAAs have developed detailed county “data sheets” for use with 12 KU is currently conducting a study of AL/RHC facilities and residents in the state of Kansas and issues surrounding “aging in place”.

44

County Commissions that could serve as templates for other areas to develop. The success of one region can be studied as a source of best-practice ideas and used to guide improvements in others. Ø Abuse, Neglect and Exploitation Reports Both SRS and KDHE data indicate that reports of A/N/E of older adults in the community and in institutional settings are increasing in Kansas. A recent finding that highlights the importance of monitoring A/N/E in Kansas is that even when other risk factors are controlled, elders who are victims of A/N/E (including self-neglect) are more likely to die of non-abuse related causes than are elders who are not maltreated or self-neglected. (Lachs and Pilmer, 1998 in NCEA, 1998). This finding also indicates that A/N/E investigations may result in a reduced likelihood of abuse-related deaths. Another noteworthy finding related to A/N/E is that national data show that the oldest old are at a greater risk of maltreatment (NCEA, 1998). Since Kansas has a relatively high proportion of the “oldest old,” this finding is of particular interest. In fact, the data from APS indicates that the oldest old are potential victims more often than other age groups. Further exploration into the risk factors present in this group is needed to illuminate this issue. Specific strategies can then be targeted towards recognizing and reducing A/N/E among the oldest old. Ø Future Demographic Trends As noted previously, the outcome indicator data trends show that older Kansans are having their long-term care needs met in the community at an increasing rate. Based on the demographic projections, Kansas will face a heavy demand on its long-term care system by the year (US Census Bureau Population Projections, 1996). Program and planning efforts will be needed to continue the progress Kansas has made. AAA directors identified the need for an “Aging Agenda” to address this population growth as a primary concern. For example, the same core services (e.g. night support and attendant care) are consistently identified as having the most unmet need and contributing to nursing facility placement. Specific efforts will be needed to ensure that these service gaps do not “widen” as the older adult population, particularly those 85 and over, increase. It is anticipated that the creation of a task force on long-term care services through House Bill 2780 will be one mechanism through which the older adult population growth will be addressed. Recommendations to Enhance Monitoring of the Indicator Data Ø New Standards for Outcome Indicators Monitoring of outcome indicators requires the establishment of standards, baselines, and collection of actual numbers of individual clients served. As used in this project, a standard is a numerical definition of adequacy (Lewandowski and Rapp, 1991). In 1994, the Long-Term Care Action Committee (LTCAC) recommended updated standards for Independence Indicator 1. These standards, which represent goals for reducing nursing facility utilization rates in Kansas, are outlined in Table 20 below. Since these standards include assisted living/personal care beds they are only applicable to the combined nursing facility-AL/RHC rates. Therefore, new standards for this indicator could be established that apply only to nursing facility utilization. National data could be used to revise the existing standards for the Kansas long-term care system. In addition, standards could also be set for the other outcome indicators. The new long-term care services task force being discussed could undertake the responsibility of setting new standards.

45

Table 20. Standards for Independence Indicator 1, Nursing Facility Utilization

Age Group

Standard 65-74 1.4% 75-84 6.1% 85+ 24% 65+ 6.8%

Ø A/N/E Data Enhancements Currently A/N/E data in Kansas are not broken out by age subgroups. Therefore it is not possible to track A/N/E trends among the age 65 and over population separate from the whole population. In order to effectively monitor A/N/E among older adults in Kansas, SRS and KDHE A/N/E data (such as confirmations) should be available by age subgroups. In particular, data are needed on the age 85 and older subgroup due to their increased risk of maltreatment. In addition, AAA directors stated that they would be interested in receiving A/N/E data on an area basis. Local AAAs and SRS offices could work together to identify needed information and ways to provide it. Ø Indicator Data Demographic Breakdowns The AAA executive directors identified a need for outcome indicator data broken out by various demographic variables, such as gender and ethnicity. They discussed the usefulness of being able to analyze the indicator trends separately for the various subgroups. In addition, this type of data could be focused on subgroups of interest and used with those groups. An example used by one AAA director is service utilization by veterans. It was pointed out that using the data in this way “mirrors your audience” and increases their interest. All of the directors also said that county level data would be extremely useful. Providing data at this level of measurement could be used by AAA staff for local planning and community efforts. KU is willing to work with state agency staff to explore the feasibility of presenting the outcome indicator data broken out by various demographic variables and by county. Ø Community Based Service Effectiveness Information There has been tremendous pressure on state agencies to trim their budgets and reduce spending. Agencies are faced with the task of providing services that meet the customer’s needs and are cost effective. Given the increasing scarcity of resources relative to demand, information on the effectiveness of community-based services in extending community tenure (after the CARE Assessment 30-day follow-up) is needed. This information can be used to target limited public resources13. In addition, policy makers could explore the idea of prioritizing customers based on their risk factors for nursing facility placement.

13 KU is currently working on a study that will provide data on community tenure.

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Recommendations on Using Outcome Indicator Data for Programming and Planning Ø Foster Provider Development AAA directors recommended that the outcome indicator information be used to foster development of service alternatives and encourage new providers. It was suggested that the indicator data could be used to convince providers to offer additional services or possibly serve new geographic areas. In addition, a number of the directors thought that the information regarding assisted living/residential health care settings would be particularly useful for the purpose. It was noted that the information could help increase the availability of AL/RHC for low-income older adults by encouraging conversion of nursing facility beds. Ø Demonstrate Cost Savings Another use of the indicator data identified by AAA directors is to demonstrate the potential cost savings associated with the shifting of resources from institutional to community-based care. For example, if Kansas wishes to achieve the national average of 4.2% of the population age 65 and over residing in institutional facilities and sets that standard, it is possible to calculate the number of people to be served in the community and related cost implications. This information could be used with the legislature to justify funding levels for community based service programs based on the potential cost savings they provide. In addition, AAA directors stated that the indicator data could be used at the county level to demonstrate cost savings and help procure the county match for certain publicly funded programs. Ø Disseminate Indicator Information to Key Players AAA directors discussed the importance of sharing the outcome indicator information with key players in the aging network such as county commissions and advocacy groups. For example, the indicator data can be used to document the progress the state has made to advocacy groups, local agencies, long-term care customers, service providers, and the general public. Another idea for using the indicator data is to use it to facilitate interagency meetings between KDOA, SRS and KDHE on areas of common concern, for example, abuse, neglect and exploitation. It was also recommended that KDOA and the AAAs could disseminate indicator information through web pages, publications, and other state media outlets. Ø Provide “Information at a Glance” The AAA directors cited a need for information that is easy to understand and access. In particular, data that is presented in a concise, “user friendly” manner is most useful. It can be used by AAA staff for local planning and community efforts. To this end, KU is currently developing briefing sheets for each PSA. AAA briefing sheets present data trends focused on their area and in comparison to the state as a whole. In addition to the briefing sheets this edition of the Outcome Indicator Report has been restructured to provide more detailed tables, charts, and graphs to enhance usefulness. KU will continue to collaborate with state agency staff to refine the Outcome Indicator report to meet the informational needs of state agency staff and policy makers. Conclusion

Although institutionalization rates are still high compared to national averages, the declining institutionalization rates, the number of older adults discharging to the community from nursing facilities

and number of successful nursing facility diversions indicate that Kansas has made progress in the effort to meet older adults’ long-term care needs in the most integrated setting. The national literature has also documented Kansas’ progress in its effort to balance the LTC system (Ladd and Kane, 1999). These

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findings are encouraging, and underscore the importance for policy makers to continue these efforts to support the preference of older adults to have their long-term care needs met in their own homes rather

than in a nursing facility (AARP, 1996). Continued monitoring of the independence and protection of older adults is necessary to help inform program and policy development for older Kansans.

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