- Email: [email protected]
Economic Aspects of Dementia Special Care Units in Veterans Affairs Nursing Homes
SPECIAL ARTICLE
Economic Aspects of Dementia Special Care Units in Veterans Affairs Nursing Homes Elizabeth Bass, PhD, Karen Putney, RN, MSN, and Myrna Alvear, RN, MS Given the intermittent use of special care units (SCUs), we consider economic aspects associated with dementia SCUs by reviewing the literature and surveying 2 nursing homes in the VA healthcare network. In addition to reporting the features in different types of facilities in the Veterans Affairs (VA), we present an economic characterization useful for hospital and nursing home administrators whose decision-making processes incorporate
clinical, management, and financial factors. We conclude that, theoretically, benefits likely outweigh the costs of instituting dementia SCUs in VA nursing homes with a large number of cognitively impaired residents. (J Am Med Dir Assoc 2005; 6: 276–280)
Dementia special care units (SCUs) are among the newer options nursing home administrators have in meeting longterm care needs for persons with cognitive impairment. Alzheimer’s disease and related dementias are among the top primary diagnoses in nursing homes managed by the Department of Veterans Affairs (VA) through the Veterans Health Administration (VHA). The VA projects that by 2012, patients aged 65 and older will account for more than 50% of its healthcare expenditures.1 As the veteran patient population ages, more facilities will be expected to provide quality care to veterans with dementias associated with aging. The Veterans
Millennium Health Care and Benefits Act of 1999 may place additional pressure on nursing home demand by increasing the number of veterans eligible for long-term care services, mandating the VA either provide or pay for veterans who meet the new criteria.2* In the past decade, the private sector has seen a rapid increase in SCUs for dementia where cognitively impaired residents have designated staff and programs for their specific needs.3 There is, however, no clear evidence that dementia SCUs are the most effective way to care for dementia patients. Since VA resource allocation is highly localized, dementia SCUs are used intermittently throughout the VA system, there being no consensus on the optimal way to care for the cognitively impaired. We take up the debate surrounding dementia SCUs from an economic standpoint. Economics is the study of how resources are produced, allocated, and consumed in the face of scarcity. Hospital administrators who are confronted with restricted budgets and competing clinical demands may find an economic conceptualization of SCUs useful. In the first part of this article, we summarize the economic studies on SCUs. Next, after providing a brief background of VA longterm care facilities, we examine 2 nursing homes in the VA healthcare network. One facility is a traditional, hospitalbased program where persons with dementia are integrated throughout all 3 units; the other facility has a dementia SCU. Last, we characterize the major economic considerations pertinent to SCUs.
VISN 8 Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL (E.B.); Orlando Nursing Home Care Unit, Orlando VA Healthcare Center, Orlando, FL (K.P.); Tampa Nursing Home Care Unit, James A. Haley VAMC, Tampa, FL (M.A.). This research was supported by the Department of Veterans Affairs, Veterans Health Administration, Patient Safety Center of Inquiry at the James A. Haley VAMC in Tampa, FL. The views expressed are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. We acknowledge the valuable suggestions of Audrey Nelson, Director of the Tampa VA Patient Safety Center of Inquiry, in preparing this work. *The new eligibility conditions include all VHA enrollees who require nursing home care for a service-connected condition, those who have a service-connected disability rating of 70% or more, those with at least a 60% serviceconnected condition and 100% unemployment disability, or nonservice-connected disabled veterans who require nursing home care and meet the lowincome and assets criteria. Address correspondence to Elizabeth Bass, PhD, VISN 8 Patient Safety Center of Inquiry, 11605 N. Nebraska Avenue, Tampa, FL 33612. E-mail: [email protected]
Copyright ©2005 American Medical Directors Association DOI: 10.1016/j.jamda.2005.05.002 276 Bass et al.
Keywords: Dementia; special care units; Veterans Administration
ECONOMIC LITERATURE SCUs are used in the treatment of various conditions and have diverse forms. The kind of dementia SCU considered JAMDA – July/August 2005
here is a physically separate ward. Creating a dementia SCU entails an allocation of resources organized primarily to serve cognitively impaired patients. Cost-effectiveness and costbenefit analysis, both well-established economic methods used to evaluate cost and outcomes of healthcare interventions,4 can be used to assess SCUs. Theoretically, if the benefits to having a ward solely for demented residents are greater than the costs incurred, then establishing separate wards is prudent. Practically, measuring costs and benefits in healthcare settings is problematic, particularly in the case of dementia. This ambiguity means the decision-making process for administrators can be difficult. Considerable research has been done on particular aspects of dementia SCUs, though a definitive cost-effectiveness or cost-benefit analysis is lacking. The bulk of the literature focuses on costs generated by hours of care or resource use by patients with Alzheimer’s disease, common suffers of dementia. The increased resource use, primarily nursing staff time, required to care for patients with dementia is well documented.5– 8 This suggests higher costs per patient on SCUs if these units establish programs or services that do not exist on traditional long-term care wards. On the other hand, by concentrating care of demented patients, gains from specialization may result in lower costs for SCUs. Empirical evidence has been vague. Some studies found higher personnel costs in SCUs than on traditional care units.9,10 Conversely, one study calculated a lower average cost for a VA dementia SCU compared to a traditional long-term care setting.11 Another study reported that in facilities with SCUs, nursing resource use was the same among all residents.12 Higher costs appeared only when comparing resource use in nursing homes with Alzheimer’s SCUs to nursing homes without SCUs. Other studies have tried to assess the effectiveness of SCUs using health or functional outcomes,13,14 although the appropriateness of these measures is uncertain given the progressive nature of dementia. SURVEY OF VA FACILITIES The VA operates 137 nursing homes throughout the country. VA nursing homes coordinate and deliver interdisciplinary care such as skilled nursing, rehabilitation, dementia care, respite, and hospice. In 2004, approximately 113,000 VA patients were suspected of having Alzheimer’s or other dementias.15 In addition to being more medically and financially needy than the general population,16 –21 VA patients oftentimes have accompanying service-connected disabilities. Many of these veterans will enter nursing homes. At the current time, roughly one third of the VA nursing home patient population is treated in VA facilities,2 with the remaining patients served in community or state nursing homes reimbursed under local VA contracts. The age and organization of VA nursing homes vary widely, even within local healthcare networks. The administration of the VA’s programs for dementia is decentralized, but any designated dementia SCU must have a written philosophy of care statement and a patient population that has been diagnosed with Alzheimer’s dementia at a rate of at least 50%.22 The VA reports some facilities have developed exemplary Alzheimer’s SPECIAL ARTICLE
programs,22 but these successes have not initiated any systemwide policies that apply to the accommodation of dementia patients. We describe 2 VA nursing homes in Florida. Facility X is hospital-based and Facility Y has a dementia SCU. The patient populations are similar: predominantly male and ranging in age from 60 to 98 years. Most residents have multiple medical problems dominated by dementia and compounded by inadequate socioeconomic means, limited psychosocial support systems, and a lack of healthcare support in the home. All VA nursing homes are restraint-free. Staff in both facilities undergoes specialized training and continuing education for treating dementia patients. Facility X is a multistory structure attached to a large VA hospital by an underground tunnel. The nursing home has 3 units with 60 beds each. Cognitively impaired patients are not segregated, in keeping with most hospital-based nursing homes.3 Floor D houses most of the demented residents. The elevator doors open directly onto the wards, so none of the floors are locked or otherwise secured. Patients on Floor D with dementia wear adult transmitters, or wander monitors, on the ankle. The batteries cost $100, last for 2 years, and are tested weekly. The bands are checked daily. The accompanying sensor beeps when a patient enters its range near the elevator or stairs and cannot distinguish genuine attempted exits. The constant beeping adds to the loud environment and blends in with other noisy machines. In addition to wander monitors, the nursing home staff conducts patient accountability rounds every 2 hours, 24 hours a day. But the combination of an out-of-date monitoring system and the lack of a locked unit mean the nursing home is not secure. This skews admissions of demented persons either to those with mild dementia or severe dementia who have physical impairments limiting mobility. An interdisciplinary team of nurses, physicians, social workers, creative arts therapists, and other professionals provide medical care and therapeutic and recreational activities, and the families are actively involved in the veterans’ treatment plans. Activities of daily living are supervised by nursing staff, one licensed member per 15 residents. Nursing staff administers medication and intravenous therapy, transports residents to appointments, meets with family, feeds patients, and assists with laundering of residents’ clothing, among other activities. The combination of demented and cognitively intact residents is a challenge for the nurses, licensed practical nurses, and nursing assistants. Stress and frustration are common. To offset staff burnout, the nurse manager and nursing staff have instituted diverse activities and planned leave, which contribute to a stable workforce and has resulted in less turnover on Floor D compared to other units. In accordance with a restraint-free environment, dementia residents are free to ambulate throughout the unit. Interactions with non-demented patients, however, can result in conflict. Dementia patients may wander into rooms of other patients and upset treatment by manipulating intravenous drip bags, tube feedings, and meal trays. Their removal of signage, pictures, and personal belongings also Bass et al. 277
angers the non-demented patients. Adverse events with severe outcomes are infrequent. In the past 2 years, one demented patient had a hip fracture in Facility X. Five patients have eloped since 1999 but were all returned within 24 hours without injury. Facility Y is one of the VA’s newer nursing homes and sits on the same grounds as a large outpatient clinic. A hallway connects the two. The nursing home is a singlestory building with 120 beds divided between 2 wards, Unit A and Unit B. Unit B is a 40-bed SCU for dementia patients. With the exception of a 900 square-foot fenced-in porch and additional yard space, there are few structural differences between the wards. Although the SCU is locked, all residents wear wander monitors on their wrists. These guards cost $90 per band and are effective for 1 year. In addition, bed and wheelchair alarms are bolted onto the equipment. Hip protectors are worn by the majority of residents. Environmental features include extra lighting, soft colors, and limits on stimuli. The dementia unit is activity-based, encompassing a wide range of recreational interventions and trained professionals. The staff strongly believes that this type of program reduces wandering and behavior disorders, a claim substantiated by some research23,24 but not undisputed.25 Facility Y employs 3 recreational therapists, one who works full-time in the dementia unit. Other professional staff, such as nurses, social workers, dietitians, speech pathologists, and a physician, provides services to all nursing home residents. Residents in Unit B with supplementary medical equipment, like an intravenous drip, are rare. Nurses do dispense medications. Research suggests patients with Alzheimer’s disease have more comorbidities,26,27 but there is no indication from the staff that dementia residents receive higher quantities or more costly medications than other patients. The nursing staff finds the SCU environment supportive and prefers that the cognitively impaired are segregated. Since Facility Y opened in 1999, 2 patients on Unit B sustained hip fractures. There was one elopement when workmen accidentally left the doors on Unit B open but the resident was quickly found unharmed. DISCUSSION Using economic theory, evidence from the literature and observations from the 2 VA nursing homes, we present a theoretical framework useful for evaluating dementia SCUs from an economic standpoint. The general components of an SCU can be classified as capital, environmental features, resource use, and patient safety. Ideally, emotional costs should also be considered. The anxiety experienced by both staff and family members when a dementia patient is injured or elopes is significant, despite the difficulty in quantifying this psychic cost. To assess effectiveness, the likely financial outlays for each component are weighed against the potential benefits a dementia SCU provides. We discuss each category in sequence. Capital modifications for a separate dementia SCU are easiest when building plans are formulated. In Facility Y, the design of the nursing home into 2 wings did not 278 Bass et al.
constitute any exceptional adjustments and no post-construction alterations were made to accommodate an SCU. In the case of Facility X, doors could be added in the ward entranceway just outside the elevators. While locked doors are not a substitute for wander monitors and other environmental safeguards, they do reduce sensor noise, which has been shown to irritate dementia patients.28,29 A locked ward, however, may not be feasible for smaller, older VA nursing homes that also provide post-acute care for adjoining hospitals. Along with capital, the design and implementation of environmental features for SCUs can generate significant start-up costs. Specialized flooring, lighting, and exit controls are identified by the Joint Commission on Accreditation of Healthcare Organizations as important characteristics for a dementia SCU.30 Several studies have found a strong correlation between environmental features and resident behavior with researchers positing that a specialized environment contributes positively to resident behavior,28 –33 although this assertion has been contradicted.34 Specific equipment safeguards, increasingly in the form of technological devices, can enable residents while minimizing adverse events35 and appear cost-effective. Wander monitors allow dementia patients freedom of movement and privacy while warning staff of attempted exits. Hip protectors and bed or chair alarms as well as wheelchairs, signage, and grab bars are also used for injury prevention and monitoring. Since staff time accounts for the bulk of resource use, evaluating productivity and work satisfaction among the staff is important. Nurses tend to specialize, so when they self-select into a dementia ward, this indicates they are probably more efficient care providers. Studies show a separate dementia ward also provides a supportive environment for treating these patients, resulting in less stress while on duty and lower turnover.36,37 The amount of skilled nursing care given to dementia patients is reportedly higher than for cognitively intact patients, though this is not the case in Facility Y, which has the same nurse-topatient ratio on both units. It may be that at different stages of disease progression some basic care, like feeding, could be supplied by nursing assistants rather than registered nurses. The patient safety implications of mixed wards are grave. Patients with bedside equipment risk having a demented patient disrupt their treatment. Patients without dementia may become annoyed by and even assault other residents who wander into their rooms.38 An administrator in Facility X reported that mildly demented patients are wellintegrated with the rest of the nursing home community. But as dementia progresses, housing severely demented patients with other non-demented residents can be risky. One study found cognitively intact patients may be more satisfied with their living situation when cognitively impaired patients are housed separately.39 A second study from Sweden found nurses view commingling as a problem for both cognitively intact and demented patients.40 In addition to keeping non-demented patients safe, residents on dementia SCUs may also have a lower risk of injury and JAMDA – July/August 2005
elopement. Cognitively impaired patients are more likely to fall from wandering, agitation, and medication.41 The lighting, color, and specialized staff training on a dementia SCU may reduce this risk.29 Equipment safeguards were addressed previously. In addition to the aforementioned costs, VA nursing homes are constrained further by the institutional environment. Healthcare provided by the VA is an entitlement for eligible veterans. Unlike private nursing homes, VA facilities may not refuse patients, at least not without providing substitute care. When a resident’s condition deteriorates such that he no longer benefits from the activity-based program at Facility Y, the resident may remain on the dementia unit if the family insists he not be moved, a provision added to the Veterans Millennium Health Care and Benefits Act. While most healthcare administrators are subjected to financial stressors, VA nursing homes may also experience political pressures unique to that environment. CONCLUSIONS When deliberating the merits of dementia SCUs, the VA must consider the well-being of all patients and staff as well as associated costs. For administrators, who must justify their allocation decisions, the fiscal outlays associated with SCUs seem significant. These certain costs are compared to potential savings through higher staff productivity and reduced adverse events, benefits not easy to quantify. Available evidence suggests that benefits likely outweigh the costs of instituting separate dementia SCUs in VA nursing homes with a large number of cognitively impaired residents. Smaller facilities could cluster demented patients. We described the costs and benefits of dementia SCUs without measuring them, and more empirical work is needed to confirm or disprove the theoretical results. The number of elderly veterans requiring nursing home care for dementia will only increase. By concentrating the care of these patients, the VA can benefit from more efficient resource allocation, fewer adverse events and improved welfare for patients and staff. REFERENCES 1. US Department of Veterans Affairs. FY04 VA Enrollee Health Care Projection Model. Available at: http://vaww.va.gov/vhaopp/enroll02/ enrlfy04/volumeI_04.pdf. Accessed July 2004. 2. US Department of Veterans Affairs. VA long-term care. VA Fact Sheet. Available at: http://vaww1.va.gov/OPA/fact/ltcare.html. Accessed January 2005. 3. Freiman M, Brown E Jr. Research findings no.6: special care units in nursing homes—selected characteristics, 1996. Rockville, MD: Agency for Healthcare Research and Quality. Available at: http://www.meps. ahcpr.gov/papers/rf6_99-0017/rf6.htm. Accessed July 2004. 4. Russell LB, Siegel JE, Daniels N, et al. Cost-effectiveness analysis as a guide to resource allocation in health: Roles and limitations. In: Gold MR, Siegel JE, Russell LB, Weinstein MC, editors. Cost-effectiveness in health and medicine. New York: Oxford University Press, 1996:3–24. 5. O’Brien JA, Caro JJ. Alzheimer’s disease and other dementia in nursing homes: Levels of management and cost. Int Psychogeriatr 2001;13:347– 358. 6. Small GW, McDonnell DD, Brooks RL, et al. The impact of symptom severity on the cost of Alzheimer’s disease. J Am Geriatr Soc 2002;50: 321–327. SPECIAL ARTICLE
7. Svensson M, Edebalk PG, Persson U. Group living for elderly patients with dementia: A cost analysis. Health Policy 1996;38:83–100. 8. Arling G, Williams AR. Cognitive impairment and resource use of nursing home residents: A structural equation model. Med Care 2003; 41:802– 812. 9. Holmes D, Teresi JA. Relating personnel costs in special care units and in traditional care units to resident characteristics. J Ment Health Policy Econ 1998;1:31– 40. 10. Grant LA, Potthoff SJ, Ryden M, et al. Staff ratios, training and assignment in Alzheimer’s special care units. J Gerontol Nurs 1998;24:9 –16. 11. Volicer L, Collard A, Hurley A, et al. Impact of special care units for patients with advanced Alzheimer’s disease on patients’ discomfort and costs. J Am Geriatr Soc 1994;42:686 – 687. 12. Mehr DR, Fries BE. Resource use on Alzheimer’s SCUs. Gerontologist 1995;35:179 –184. 13. Phillips CD, Sloane PD, Hawes C, et al. Effects of residence in Alzheimer’s disease SCUs on functional outcomes. JAMA 1997;278:1340 – 1345. 14. McCann JJ, Beineias JL, Evans DA. Change in performance tests of activities of daily living among residents of dementia special care and traditional nursing homes. In: Holmes D, Teresi JA, Orey M, editors. Research and practice in Alzheimer’s disease: Special care units. Vol. 4. New York: Springer, 2000:141–150. 15. Office of the Assistant Deputy Under Secretary for Health. Projections of the prevalence and incidence of dementias including Alzheimer’s Disease for the total, enrolled and patient veteran population age 65 or older. Available at: http://vaww.va.gov/vhaopp/enroll01/ dementia/Dem022004.pdf. Accessed July 2004. 16. Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM. Are patients at the Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use. Arch Intern Med 2000;160:3252–3257. 17. VA Information Resource Center. Research findings from the VA Medicare Date Merge Initiative: Veterans’ enrollment, access and use of Medicare and VA health services. Hines, IL: Edward J. Hines VA Hospital, 2003. 18. Yu W, Ravelo A, Wagner TH, et al. Prevalence and costs of chronic conditions in the VA health care system. Med Care Res Rev 2003;60S: 146S–167S. 19. Kazis LE, Miller DR, Clark J, et al. Health-related quality of life in patients served by the Department of Veteran Affairs: Results from the Veterans Health Study. Arch Intern Med 1998;158:626 – 632. 20. Wilson NJ, Kizer KW. The VA health care system: An unrecognized national safety net. Health Aff 1997;16:200 –204. 21. Selim AJ, Berlowitz DR, Fincke G, et al. The health status of elderly veteran enrollees in the Veterans Health Administration. J Am Geriatr Soc 2004;52:1271–1276. 22. US Department of Veterans Affairs. Alzheimer’s/Dementia Program. Available at: http://vaww1.va.gov/GeriatricsSHG/page.cfm?pg⫽21. Accessed August 2001. 23. Holmes D, Teresi J, Kong J. Service inputs and costs of care related to outcomes among cognitively impaired nursing home residents. J Ment Policy Econ 2000;3:121–127. 24. Aronstein Z, Olsen R, Schulman E. The nursing assistants’ use of recreational interventions for behavioral management of residents with Alzheimer’s disease. Am J Alzheimers Dis Other Demen 1996;11:26 –31. 25. Wagner AW, Teri L, Orr-Rainey N. Behavior problems among dementia residents in special care units: Changes over time. J Am Geriatr Soc 1995;43:784 –787. 26. Menzin J, Lang K, Friedman M, et al. The economic cost of Alzheimer’s disease and related dementias to the California Medicaid Program in 1995. Am J Geriatr Psychiatry 1999;7:300 –308. 27. Gutterman EM, Markowitz JS, Lewis B, et al. Cost of Alzheimer’s disease and related dementia in managed care. J Am Geriatr Soc 1999;47:1065– 1071. 28. Monney P, Nicell PL. The importance of exterior environment for Alzheimer residents: Effective care and risk management. Healthc Manage Forum 1992;5:23–29. Bass et al. 279
29. Ragneskog H, Gerdner LA, Josefsson K, Kihlgren M. Probable reasons for expressed agitation in persons with dementia. Clin Nurs Res 1998;7: 189 –206. 30. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Standards and survey protocol for dementia special care units. Oakbrook Terrace, IL: JCAHO; 1994. 31. Zeisel J, Silverstein NM, Hyde J, et al. Environmental correlates to behavior health outcomes in Alzheimer’s special care units. Gerontologist 2003;43:697–711. 32. Sloane PD, Mitchell CM, Preisser JS, et al. Environmental correlates of resident agitation in Alzheimer’s disease special care units. J Am Geriatr Soc 1998;46:862– 869. 33. Swanson EA, Maas ML, Buckwalter KC. Catastrophic reactions and other behaviors of Alzheimer’s residents: Special unit compared with traditional units. Arch Psychiatr Nurs 1993;7:292–299. 34. Chappell NL, Reid RC. Dimensions of care for dementia sufferers in long-term care institutions: Are they related to outcomes? J Gerontol B Psychol Sci Soc Sci 2000;55:S234 –S244.
280 Bass et al.
35. Nelson AL, Powell-Cope G, Gavin-Dreschnack D, et al. Technology to promote safe mobility in the elderly. Nurs Clin North Am 2004;39:649–671. 36. Philips VL, Potter SJ, Simon S. Special care units for Alzheimer’s patients: Their role in the nursing market. J Health Hum Serv Adm 1998;20:300 –310. 37. Maas ML, Specht JP, Weiler K, et al. Special care units for people with Alzheimer’s disease. Only for the privileged few? J Gerontol Nurs 1998; 24:28 –37. 38. Shinoda-Tagawa T, Leonard R, Pontikas J, et al. Resident-to-resident violent incidents in nursing homes. JAMA 2004;291:591–598. 39. Teresi JA, Holmes D, Monaco C. An evaluation of the effects of commingling cognitively and noncognitively impaired individuals in long-term care facilities. Gerontologist 1993;33:350 –358. 40. Ragneskog H, Gerdner LA, Hellstrom L. Integration of lucid individuals and agitated individuals with dementia in different care units. J Clin Nurs 2001;10:730 –736. 41. Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: A prospective study. J Gerontol 1991;46:M164 –M170.
JAMDA – July/August 2005
Economic Aspects of Dementia Special Care Units in Veterans Affairs Nursing Homes Elizabeth Bass, PhD, Karen Putney, RN, MSN, and Myrna Alvear, RN, MS Given the intermittent use of special care units (SCUs), we consider economic aspects associated with dementia SCUs by reviewing the literature and surveying 2 nursing homes in the VA healthcare network. In addition to reporting the features in different types of facilities in the Veterans Affairs (VA), we present an economic characterization useful for hospital and nursing home administrators whose decision-making processes incorporate
clinical, management, and financial factors. We conclude that, theoretically, benefits likely outweigh the costs of instituting dementia SCUs in VA nursing homes with a large number of cognitively impaired residents. (J Am Med Dir Assoc 2005; 6: 276–280)
Dementia special care units (SCUs) are among the newer options nursing home administrators have in meeting longterm care needs for persons with cognitive impairment. Alzheimer’s disease and related dementias are among the top primary diagnoses in nursing homes managed by the Department of Veterans Affairs (VA) through the Veterans Health Administration (VHA). The VA projects that by 2012, patients aged 65 and older will account for more than 50% of its healthcare expenditures.1 As the veteran patient population ages, more facilities will be expected to provide quality care to veterans with dementias associated with aging. The Veterans
Millennium Health Care and Benefits Act of 1999 may place additional pressure on nursing home demand by increasing the number of veterans eligible for long-term care services, mandating the VA either provide or pay for veterans who meet the new criteria.2* In the past decade, the private sector has seen a rapid increase in SCUs for dementia where cognitively impaired residents have designated staff and programs for their specific needs.3 There is, however, no clear evidence that dementia SCUs are the most effective way to care for dementia patients. Since VA resource allocation is highly localized, dementia SCUs are used intermittently throughout the VA system, there being no consensus on the optimal way to care for the cognitively impaired. We take up the debate surrounding dementia SCUs from an economic standpoint. Economics is the study of how resources are produced, allocated, and consumed in the face of scarcity. Hospital administrators who are confronted with restricted budgets and competing clinical demands may find an economic conceptualization of SCUs useful. In the first part of this article, we summarize the economic studies on SCUs. Next, after providing a brief background of VA longterm care facilities, we examine 2 nursing homes in the VA healthcare network. One facility is a traditional, hospitalbased program where persons with dementia are integrated throughout all 3 units; the other facility has a dementia SCU. Last, we characterize the major economic considerations pertinent to SCUs.
VISN 8 Patient Safety Center of Inquiry, James A. Haley VAMC, Tampa, FL (E.B.); Orlando Nursing Home Care Unit, Orlando VA Healthcare Center, Orlando, FL (K.P.); Tampa Nursing Home Care Unit, James A. Haley VAMC, Tampa, FL (M.A.). This research was supported by the Department of Veterans Affairs, Veterans Health Administration, Patient Safety Center of Inquiry at the James A. Haley VAMC in Tampa, FL. The views expressed are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. We acknowledge the valuable suggestions of Audrey Nelson, Director of the Tampa VA Patient Safety Center of Inquiry, in preparing this work. *The new eligibility conditions include all VHA enrollees who require nursing home care for a service-connected condition, those who have a service-connected disability rating of 70% or more, those with at least a 60% serviceconnected condition and 100% unemployment disability, or nonservice-connected disabled veterans who require nursing home care and meet the lowincome and assets criteria. Address correspondence to Elizabeth Bass, PhD, VISN 8 Patient Safety Center of Inquiry, 11605 N. Nebraska Avenue, Tampa, FL 33612. E-mail: [email protected]
Copyright ©2005 American Medical Directors Association DOI: 10.1016/j.jamda.2005.05.002 276 Bass et al.
Keywords: Dementia; special care units; Veterans Administration
ECONOMIC LITERATURE SCUs are used in the treatment of various conditions and have diverse forms. The kind of dementia SCU considered JAMDA – July/August 2005
here is a physically separate ward. Creating a dementia SCU entails an allocation of resources organized primarily to serve cognitively impaired patients. Cost-effectiveness and costbenefit analysis, both well-established economic methods used to evaluate cost and outcomes of healthcare interventions,4 can be used to assess SCUs. Theoretically, if the benefits to having a ward solely for demented residents are greater than the costs incurred, then establishing separate wards is prudent. Practically, measuring costs and benefits in healthcare settings is problematic, particularly in the case of dementia. This ambiguity means the decision-making process for administrators can be difficult. Considerable research has been done on particular aspects of dementia SCUs, though a definitive cost-effectiveness or cost-benefit analysis is lacking. The bulk of the literature focuses on costs generated by hours of care or resource use by patients with Alzheimer’s disease, common suffers of dementia. The increased resource use, primarily nursing staff time, required to care for patients with dementia is well documented.5– 8 This suggests higher costs per patient on SCUs if these units establish programs or services that do not exist on traditional long-term care wards. On the other hand, by concentrating care of demented patients, gains from specialization may result in lower costs for SCUs. Empirical evidence has been vague. Some studies found higher personnel costs in SCUs than on traditional care units.9,10 Conversely, one study calculated a lower average cost for a VA dementia SCU compared to a traditional long-term care setting.11 Another study reported that in facilities with SCUs, nursing resource use was the same among all residents.12 Higher costs appeared only when comparing resource use in nursing homes with Alzheimer’s SCUs to nursing homes without SCUs. Other studies have tried to assess the effectiveness of SCUs using health or functional outcomes,13,14 although the appropriateness of these measures is uncertain given the progressive nature of dementia. SURVEY OF VA FACILITIES The VA operates 137 nursing homes throughout the country. VA nursing homes coordinate and deliver interdisciplinary care such as skilled nursing, rehabilitation, dementia care, respite, and hospice. In 2004, approximately 113,000 VA patients were suspected of having Alzheimer’s or other dementias.15 In addition to being more medically and financially needy than the general population,16 –21 VA patients oftentimes have accompanying service-connected disabilities. Many of these veterans will enter nursing homes. At the current time, roughly one third of the VA nursing home patient population is treated in VA facilities,2 with the remaining patients served in community or state nursing homes reimbursed under local VA contracts. The age and organization of VA nursing homes vary widely, even within local healthcare networks. The administration of the VA’s programs for dementia is decentralized, but any designated dementia SCU must have a written philosophy of care statement and a patient population that has been diagnosed with Alzheimer’s dementia at a rate of at least 50%.22 The VA reports some facilities have developed exemplary Alzheimer’s SPECIAL ARTICLE
programs,22 but these successes have not initiated any systemwide policies that apply to the accommodation of dementia patients. We describe 2 VA nursing homes in Florida. Facility X is hospital-based and Facility Y has a dementia SCU. The patient populations are similar: predominantly male and ranging in age from 60 to 98 years. Most residents have multiple medical problems dominated by dementia and compounded by inadequate socioeconomic means, limited psychosocial support systems, and a lack of healthcare support in the home. All VA nursing homes are restraint-free. Staff in both facilities undergoes specialized training and continuing education for treating dementia patients. Facility X is a multistory structure attached to a large VA hospital by an underground tunnel. The nursing home has 3 units with 60 beds each. Cognitively impaired patients are not segregated, in keeping with most hospital-based nursing homes.3 Floor D houses most of the demented residents. The elevator doors open directly onto the wards, so none of the floors are locked or otherwise secured. Patients on Floor D with dementia wear adult transmitters, or wander monitors, on the ankle. The batteries cost $100, last for 2 years, and are tested weekly. The bands are checked daily. The accompanying sensor beeps when a patient enters its range near the elevator or stairs and cannot distinguish genuine attempted exits. The constant beeping adds to the loud environment and blends in with other noisy machines. In addition to wander monitors, the nursing home staff conducts patient accountability rounds every 2 hours, 24 hours a day. But the combination of an out-of-date monitoring system and the lack of a locked unit mean the nursing home is not secure. This skews admissions of demented persons either to those with mild dementia or severe dementia who have physical impairments limiting mobility. An interdisciplinary team of nurses, physicians, social workers, creative arts therapists, and other professionals provide medical care and therapeutic and recreational activities, and the families are actively involved in the veterans’ treatment plans. Activities of daily living are supervised by nursing staff, one licensed member per 15 residents. Nursing staff administers medication and intravenous therapy, transports residents to appointments, meets with family, feeds patients, and assists with laundering of residents’ clothing, among other activities. The combination of demented and cognitively intact residents is a challenge for the nurses, licensed practical nurses, and nursing assistants. Stress and frustration are common. To offset staff burnout, the nurse manager and nursing staff have instituted diverse activities and planned leave, which contribute to a stable workforce and has resulted in less turnover on Floor D compared to other units. In accordance with a restraint-free environment, dementia residents are free to ambulate throughout the unit. Interactions with non-demented patients, however, can result in conflict. Dementia patients may wander into rooms of other patients and upset treatment by manipulating intravenous drip bags, tube feedings, and meal trays. Their removal of signage, pictures, and personal belongings also Bass et al. 277
angers the non-demented patients. Adverse events with severe outcomes are infrequent. In the past 2 years, one demented patient had a hip fracture in Facility X. Five patients have eloped since 1999 but were all returned within 24 hours without injury. Facility Y is one of the VA’s newer nursing homes and sits on the same grounds as a large outpatient clinic. A hallway connects the two. The nursing home is a singlestory building with 120 beds divided between 2 wards, Unit A and Unit B. Unit B is a 40-bed SCU for dementia patients. With the exception of a 900 square-foot fenced-in porch and additional yard space, there are few structural differences between the wards. Although the SCU is locked, all residents wear wander monitors on their wrists. These guards cost $90 per band and are effective for 1 year. In addition, bed and wheelchair alarms are bolted onto the equipment. Hip protectors are worn by the majority of residents. Environmental features include extra lighting, soft colors, and limits on stimuli. The dementia unit is activity-based, encompassing a wide range of recreational interventions and trained professionals. The staff strongly believes that this type of program reduces wandering and behavior disorders, a claim substantiated by some research23,24 but not undisputed.25 Facility Y employs 3 recreational therapists, one who works full-time in the dementia unit. Other professional staff, such as nurses, social workers, dietitians, speech pathologists, and a physician, provides services to all nursing home residents. Residents in Unit B with supplementary medical equipment, like an intravenous drip, are rare. Nurses do dispense medications. Research suggests patients with Alzheimer’s disease have more comorbidities,26,27 but there is no indication from the staff that dementia residents receive higher quantities or more costly medications than other patients. The nursing staff finds the SCU environment supportive and prefers that the cognitively impaired are segregated. Since Facility Y opened in 1999, 2 patients on Unit B sustained hip fractures. There was one elopement when workmen accidentally left the doors on Unit B open but the resident was quickly found unharmed. DISCUSSION Using economic theory, evidence from the literature and observations from the 2 VA nursing homes, we present a theoretical framework useful for evaluating dementia SCUs from an economic standpoint. The general components of an SCU can be classified as capital, environmental features, resource use, and patient safety. Ideally, emotional costs should also be considered. The anxiety experienced by both staff and family members when a dementia patient is injured or elopes is significant, despite the difficulty in quantifying this psychic cost. To assess effectiveness, the likely financial outlays for each component are weighed against the potential benefits a dementia SCU provides. We discuss each category in sequence. Capital modifications for a separate dementia SCU are easiest when building plans are formulated. In Facility Y, the design of the nursing home into 2 wings did not 278 Bass et al.
constitute any exceptional adjustments and no post-construction alterations were made to accommodate an SCU. In the case of Facility X, doors could be added in the ward entranceway just outside the elevators. While locked doors are not a substitute for wander monitors and other environmental safeguards, they do reduce sensor noise, which has been shown to irritate dementia patients.28,29 A locked ward, however, may not be feasible for smaller, older VA nursing homes that also provide post-acute care for adjoining hospitals. Along with capital, the design and implementation of environmental features for SCUs can generate significant start-up costs. Specialized flooring, lighting, and exit controls are identified by the Joint Commission on Accreditation of Healthcare Organizations as important characteristics for a dementia SCU.30 Several studies have found a strong correlation between environmental features and resident behavior with researchers positing that a specialized environment contributes positively to resident behavior,28 –33 although this assertion has been contradicted.34 Specific equipment safeguards, increasingly in the form of technological devices, can enable residents while minimizing adverse events35 and appear cost-effective. Wander monitors allow dementia patients freedom of movement and privacy while warning staff of attempted exits. Hip protectors and bed or chair alarms as well as wheelchairs, signage, and grab bars are also used for injury prevention and monitoring. Since staff time accounts for the bulk of resource use, evaluating productivity and work satisfaction among the staff is important. Nurses tend to specialize, so when they self-select into a dementia ward, this indicates they are probably more efficient care providers. Studies show a separate dementia ward also provides a supportive environment for treating these patients, resulting in less stress while on duty and lower turnover.36,37 The amount of skilled nursing care given to dementia patients is reportedly higher than for cognitively intact patients, though this is not the case in Facility Y, which has the same nurse-topatient ratio on both units. It may be that at different stages of disease progression some basic care, like feeding, could be supplied by nursing assistants rather than registered nurses. The patient safety implications of mixed wards are grave. Patients with bedside equipment risk having a demented patient disrupt their treatment. Patients without dementia may become annoyed by and even assault other residents who wander into their rooms.38 An administrator in Facility X reported that mildly demented patients are wellintegrated with the rest of the nursing home community. But as dementia progresses, housing severely demented patients with other non-demented residents can be risky. One study found cognitively intact patients may be more satisfied with their living situation when cognitively impaired patients are housed separately.39 A second study from Sweden found nurses view commingling as a problem for both cognitively intact and demented patients.40 In addition to keeping non-demented patients safe, residents on dementia SCUs may also have a lower risk of injury and JAMDA – July/August 2005
elopement. Cognitively impaired patients are more likely to fall from wandering, agitation, and medication.41 The lighting, color, and specialized staff training on a dementia SCU may reduce this risk.29 Equipment safeguards were addressed previously. In addition to the aforementioned costs, VA nursing homes are constrained further by the institutional environment. Healthcare provided by the VA is an entitlement for eligible veterans. Unlike private nursing homes, VA facilities may not refuse patients, at least not without providing substitute care. When a resident’s condition deteriorates such that he no longer benefits from the activity-based program at Facility Y, the resident may remain on the dementia unit if the family insists he not be moved, a provision added to the Veterans Millennium Health Care and Benefits Act. While most healthcare administrators are subjected to financial stressors, VA nursing homes may also experience political pressures unique to that environment. CONCLUSIONS When deliberating the merits of dementia SCUs, the VA must consider the well-being of all patients and staff as well as associated costs. For administrators, who must justify their allocation decisions, the fiscal outlays associated with SCUs seem significant. These certain costs are compared to potential savings through higher staff productivity and reduced adverse events, benefits not easy to quantify. Available evidence suggests that benefits likely outweigh the costs of instituting separate dementia SCUs in VA nursing homes with a large number of cognitively impaired residents. Smaller facilities could cluster demented patients. We described the costs and benefits of dementia SCUs without measuring them, and more empirical work is needed to confirm or disprove the theoretical results. The number of elderly veterans requiring nursing home care for dementia will only increase. By concentrating the care of these patients, the VA can benefit from more efficient resource allocation, fewer adverse events and improved welfare for patients and staff. REFERENCES 1. US Department of Veterans Affairs. FY04 VA Enrollee Health Care Projection Model. Available at: http://vaww.va.gov/vhaopp/enroll02/ enrlfy04/volumeI_04.pdf. Accessed July 2004. 2. US Department of Veterans Affairs. VA long-term care. VA Fact Sheet. Available at: http://vaww1.va.gov/OPA/fact/ltcare.html. Accessed January 2005. 3. Freiman M, Brown E Jr. Research findings no.6: special care units in nursing homes—selected characteristics, 1996. Rockville, MD: Agency for Healthcare Research and Quality. Available at: http://www.meps. ahcpr.gov/papers/rf6_99-0017/rf6.htm. Accessed July 2004. 4. Russell LB, Siegel JE, Daniels N, et al. Cost-effectiveness analysis as a guide to resource allocation in health: Roles and limitations. In: Gold MR, Siegel JE, Russell LB, Weinstein MC, editors. Cost-effectiveness in health and medicine. New York: Oxford University Press, 1996:3–24. 5. O’Brien JA, Caro JJ. Alzheimer’s disease and other dementia in nursing homes: Levels of management and cost. Int Psychogeriatr 2001;13:347– 358. 6. Small GW, McDonnell DD, Brooks RL, et al. The impact of symptom severity on the cost of Alzheimer’s disease. J Am Geriatr Soc 2002;50: 321–327. SPECIAL ARTICLE
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