Abstract
Objectives:
Older adults’ prior health status can influence their recovery after a major illness. We investigated the association between older adults’ independence in self-care tasks prior to a skilled nursing facility (SNF) stay and their self-care function at SNF admission, discharge, and the change self-care function during a SNF stay.
Design:
Retrospective study of 100% national CMS data files from October 1, 2018, to December 31, 2019.
Settings and Participants:
The sample included 616,073 Medicare fee-for-service beneficiaries who were discharged from a SNF between 10/01/2018 and 12/31/2019.
Methods:
The admission Minimum Data Set (MDS) was used to determine residents’ prior ability (independent, some help, dependent) to complete self-care tasks before the current illness, exacerbation, or injury. Seven self-care tasks from MDS Section GG were used to calculate total scores (range 7–42 points) for self-care at admission, discharge, and the change in self-care between admission and discharge.
Results:
Most residents (62.0%) were independent, 35.3% needed some help, and 2.64% were dependent in self-care prior to SNF admission. Nearly 25% of residents with urinary incontinence, 28.8% with bowel incontinence, and 31.7% with moderate-severe cognitive impairment were independent in self-care prior to SNF admission compared to approximately 70% of residents without these conditions. Compared to residents who were dependent in self-care prior to SNF admission, those who were independent or needed some help had significantly higher self-care total scores at admission (5.67 points; 4.21 points, respectively) and discharge (6.44 points; 3.82 points, respectively) and exhibited greater improvement in self-care (3.48 points; 1.62 points, respectively).
Conclusions and Implications:
Our findings are evidence that the new MDS item for a resident’s independence in self-care tasks before SNF admission is a valid measure of their prior self-care function. This is clinically useful information and should be considered when developing rehabilitation goals.
Keywords: Post-acute care, Health services, Activities of daily living
Brief summary:
Older adults’ who were independent or needed some help in self-care before a skilled nursing facility stay exhibited greater improvement in self-care during a skilled nursing facility stay than older adults who were dependent.
INTRODUCTION
Skilled nursing facilities (SNF) provide short-term nursing care and rehabilitation services to patients who have been discharged from the hospital. Approximately twenty percent of Medicare fee-for-service beneficiaries are discharged to a SNF after a hospital stay.1 In 2019, Medicare spent a total of $27.8 billion on SNF care and the median payment per SNF stay was nearly $19 thousand.1
Up to 40% of older adults have limitations in one or more activities of daily living (ADL) when admitted to a SNF and many are highly dependent in ADLs.2–4 Functional limitations are often a consequence of the medical condition that led to the hospitalization5 and the long periods of inactivity during a hospital stay.6 SNF residents with a greater number of ADL limitations are at an increased risk for poor outcomes such as rehospitalization,7 transition to long-term care,8 and mortality.9
Most older adults lead functionally independent lives before experiencing a major illness or hospitalization, but due to age-related conditions, some will experience a prolonged decline in function.10 Evidence from the Precipitating Events Project indicates that disability and functional decline prior to a SNF stay are associated with lower likelihood for functional recovery.11, 12 The generalizability of these findings may be limited as they are based on a relatively small cohort of older adults living in the Northeast United States. Additionally, an analysis of 4,769 patient stays from 38 inpatient rehabilitation facilities indicated that the risk-adjusted self-care score at discharge for residents who were previously dependent or needed some help in self-care was 1.89 and 0.67 points lower, respectively than those who were independent.13
On October 1st, 2018, items for prior level of functioning in self-care, indoor mobility, ability to walk up and down stairs, and ability to plan regular tasks before the current illness, exacerbation, or injury were added to the resident assessment instrument (Minimum Data Set [MDS]) that is used to evaluate the health and function of nursing home residents. Prior functioning in self-care is included in the risk adjustment of two facility-level quality measures in the SNF Quality Reporting Program. These quality measures are self-care function at SNF discharge and the change in self-care functioning during a SNF stay.14 The public reporting of these quality measures began on October 28, 2018. Residents who are dependent or need some help in self-care prior to SNF admission have lower adjusted self-care functional scores at SNF discharge and have significantly less improvement in self-care during a SNF stay.15
Our primary objective was to leverage this newly added information for prior functioning and investigate if residents’ level of independence in self-care before being admitted to a SNF is associated with their self-care function at SNF admission, discharge, and the change in self-care during a SNF stay. We hypothesize that residents who are independent in self-care before being admitted to a SNF will have higher self-care function at admission and discharge and will exhibit greater improvement in self-care than residents who need some help or are dependent.
METHODS
Data Sources and Cohort Selection
We analyzed Medicare files from October 1, 2018, to December 31, 2019: (1) Master Beneficiary Summary File; (2) Medicare Provider Analysis and Review (MedPAR) file; and (3) Version 3.0 of the MDS. The Master Beneficiary Summary File was used to determine Medicare Part A coverage, original reason for Medicare eligibility, dual enrollment in Medicare and Medicaid, age, and sex. The MedPAR file was used to determine the total number of comorbidities diagnosed in the previous year. The MDS was used for residents’ race and ethnicity, prior level of function, and their functional and health characteristics during the SNF stay. We accessed these files after review from our institutional review board (IRB # 13-0549) and approval of a data use agreement by the Centers for Medicare and Medicare Services.
Figure 1 shows the exclusion criteria used to select the final sample. We first identified Medicare beneficiaries who were discharged from a SNF between October 1, 2018, and December 31, 2019. We then excluded beneficiaries who were not admitted to a SNF within 3-days of hospital discharge, were younger than 66 at time of SNF discharge, did not have continuous fee-for service coverage or were enrolled in Medicare advantage in the year before SNF discharge, died during the SNF stay, and did not have information for prior functioning in self-care. We also excluded residents who did not have complete information for self-care at admission or discharge. Finally, we excluded residents who were missing information for selected characteristics in the MDS. The final sample included 616,073 residents.
Figure 1:
Selection of the final analytic sample.
Resident Characteristics
Prior Level of Function in Self-Care
The admission MDS assessment includes items to indicate a resident’s prior level of independence when completing everyday activities before the current illness, exacerbation, or injury. The MDS describes self-care as a resident’s need for assistance with bathing, dressing, toileting, or eating. Nursing home staff determine a resident’s prior need for assistance by talking with the resident and their family and reviewing their medical record. This information is used to categorize the resident as independent (no assistance from another person), needed some help (partial assistance from another person), and dependent (other person completed the activities).
Self-care during the SNF stay
We used 7 self-care activities from Section GG of the admission and discharge MDS assessments to calculate total scores for self-care: eating, toilet hygiene, oral hygiene, showering / bathing, upper body dressing, lower body dressing, and putting on / taking off shoes. Nursing home staff evaluate a resident’s level of independence in completing these tasks and if the resident needs assistance from a facility employee. Each item is rated on a scale from 1 (dependent; helper does all the effort) to 6 (independent; no assistance from a helper). Residents who do not attempt an activity can be coded as having refused, not applicable because the resident did not do the activity prior to current illness, exacerbation, or injury, and not attempted because of safety or health concerns. We recoded residents who did not attempt an item to 1 (dependent).14 The total score ranges from 7 points (dependent on all items) to 42 points (independent on all items). These seven self-care items have been shown to have strong psychometric properties with good reliability and internal validity (Cronbach’s alpha 0.95).16
Our outcomes are the total scores for self-care function at the admission MDS assessment, discharge MDS assessment, and the difference in self-care function between admission and discharge. A change score of greater than zero indicates functional improvement.
Other characteristics
We selected resident characteristics that have been associated with self-care function during a SNF stay.17–19 Demographic characteristics included age, sex, race / ethnicity, original reason for Medicare entitlement, and dual enrollment in Medicare and Medicare. SNF length of stay was categorized as less than 14 days, 14–20 days, 21–31 days, and more than 31 days. We used the admission MDS assessment to determine hearing and vision impairments (none, minimal, moderate/high), urinary and bowel incontinence (none, occasionally, frequently, always, not rated), primary condition that led to the SNF admission, and cognitive status. The primary condition was categorized as: stroke and neurological conditions, trauma, amputation, orthopedic conditions, debility and cardiorespiratory conditions, medically complex conditions, and other. Cognitive status was categorized as none, mild, and moderate / severe impairment according to the Cognitive Function Scale.20 We used the list of health conditions from the Hierarchical Conditions Categories (HCC) codes to identify the total number of health conditions diagnosed in the past year. The HCC codes are included in a risk adjustment model that is used by CMS to adjust capitated payments for Medicare Advantage beneficiaries.21
Statistical Analysis
Resident characteristics across different prior levels of self-care function were assessed using chi-square tests for categorical variables and analysis of variance for continuous variables. Linear regression was used to examine the association between level of prior function and self-care total scores at admission, discharge, and change in self-care total score. All models controlled for residents’ demographics, health characteristics, and a facility random effect to account for residents being nested within facilities. The model for the change in self-care function also adjusted for the self-care total score at admission. We centered this variable by subtracting the sample mean for the self-care total score at admission from all observed values. This allows for a more meaningful interpretation of the model intercept as it represents the mean change in the self-care total score when the self-care total score at admission equals the sample mean.
RESULTS
Table 1 presents the observed characteristics of the 616,073 residents included in the final sample. The final sample was predominately female (64.1%) and White (86.0%). Approximately 33% of residents were aged 86 and older. Nearly 25% of residents had a SNF stay that was longer than 31 days.
Table 1.
Self-care, demographic, and health characteristics of Medicare fee for service beneficiaries admitted to a skilled nursing facility (SNF) within three days of hospital discharge according to level of functioning in self-care tasks prior to SNF admission.
| Characteristic, n (%) | Prior Function | ||||
|---|---|---|---|---|---|
| Total | Independent | Some help | Dependent | p-value | |
| Total | 616,073 (100) | 382,077 (62.0) | 217,735 (35.3) | 16,261 (2.64) | |
| Admission self-care score, mean (SD) | 23.6 (6) | 25.0 (6) | 21.7 (6) | 14.9 (6) | <0.0001 |
| Discharge self-care score, mean (SD) | 33.5 (8) | 35.7 (7) | 30.4 (8) | 23.1 (10) | <0.0001 |
| Change in self-care score, mean (SD) | 9.9 (7) | 10.7 (6) | 8.7 (6) | 8.1 (8) | <0.0001 |
| Age category | <0.0001 | ||||
| 66–70 | 73,721 (12.0) | 50,700 (68.8) | 21,360 (29.0) | 1,661 (2.3) | |
| 71–75 | 99,050 (16.1) | 67,222 (67.9) | 29,514 (29.8) | 2,314 (2.3) | |
| 76–80 | 116,526 (18.9) | 76,629 (65.8) | 37,051 (31.8) | 2,846 (2.4) | |
| 81–85 | 124,364 (20.2) | 77,424 (62.3) | 43,776 (35.2) | 3,164 (2.5) | |
| 86+ | 202,412 (32.9) | 110,102 (54.4) | 86,034 (42.5) | 6,276 (3.1) | |
| Sex | 0.70 | ||||
| Male | 221,444 (35.9) | 137,388 (62.0) | 78,168 (35.3) | 5,888 (2.7) | |
| Female | 394,629 (64.1) | 244,689 (62.0) | 139,567 (35.4) | 10,373 (2.6) | |
| Race/ethnicity | <0.0001 | ||||
| Other | 20,178 (3.3) | 11,973 (59.3) | 7,548 (37.4) | 657 (3.3) | |
| White | 530,074 (86.0) | 334,075 (63.0) | 183,187 (34.6) | 12,812 (2.4) | |
| Black | 43,821 (7.1) | 23,916 (54.6) | 17,996 (41.1) | 1,909 (4.4) | |
| Hispanic | 22,000 (3.6) | 12,113 (55.1) | 9,004 (40.9) | 883 (4.0) | |
| Length of stay | <0.0001 | ||||
| < 14 days | 145,550 (23.6) | 102,133 (70.2) | 40,861 (28.1) | 2,556 (1.8) | |
| 14 – 20 days | 131,975 (21.4) | 84,992 (64.4) | 44,293 (33.6) | 2,690 (2.0) | |
| 21 – 31 days | 189,414 (30.7) | 111,896 (59.1) | 72,343 (38.2) | 5,175 (2.7) | |
| > 31 days | 149,134 (24.2) | 83,056 (55.7) | 60,238 (40.4) | 5,840 (3.9) | |
| Original entitlement | <0.0001 | ||||
| Age | 532,940 (86.5) | 332,641 (62.4) | 186,688 (35.0) | 13,611 (2.6) | |
| Disability/ESRD | 83,133 (13.5) | 49,436 (59.5) | 31,047 (37.3) | 2,650 (3.2) | |
| Dual enrollment | <0.0001 | ||||
| No | 515,681 (83.7) | 327,947 (63.6) | 175,057 (33.9) | 12,677 (2.5) | |
| Yes | 100,392 (16.3) | 54,130 (53.9) | 42,678 (42.5) | 3,584 (3.6) | |
| Hearing impairment | <0.0001 | ||||
| None | 505,210 (82.0) | 320,699 (63.5) | 171,746 (34.0) | 12,765 (2.5) | |
| Minimal | 76,355 (12.4) | 43,563 (57.1) | 30,606 (40.1) | 2,186 (2.9) | |
| Moderate/High | 34,508 (5.6) | 17,815 (51.6) | 15,383 (44.6) | 1,310 (3.8) | |
| Vision impairment | <0.0001 | ||||
| None | 537,177 (87.2) | 341,326 (63.5) | 182,986 (34.1) | 12,865 (2.4) | |
| Minimal | 57,289 (9.3) | 31,311 (54.7) | 23,997 (41.9) | 1,981 (3.5) | |
| Moderate/High | 21,607 (3.5) | 9,440 (43.7) | 10,752 (49.8) | 1,415 (6.5) | |
| Urinary incontinence | <0.0001 | ||||
| None | 232,515 (37.7) | 175,322 (75.4) | 55,658 (23.9) | 1,535 (0.7) | |
| Occasionally | 186,950 (30.3) | 120,754 (64.6) | 63,487 (34.0) | 2,709 (1.4) | |
| Frequently | 126,932 (20.6) | 57,124 (45.0) | 63,922 (50.4) | 5,886 (4.6) | |
| Always | 31,458 (5.1) | 8,821 (28.0) | 18,655 (59.3) | 3,982 (12.7) | |
| Not rated | 38,218 (6.2) | 20,056 (52.5) | 16,013 (41.9) | 2,149 (5.6) | |
| Bowel incontinence | <0.0001 | ||||
| None | 355,201 (57.7) | 252,910 (71.2) | 98,940 (27.9) | 3,351 (0.9) | |
| Occasionally | 82,516 (13.4) | 49,142 (59.6) | 31,694 (38.4) | 1,680 (2.0) | |
| Frequently | 123,074 (20.0) | 58,724 (47.7) | 58,839 (47.8) | 5,511 (4.5) | |
| Always | 41,530 (6.7) | 12,747 (30.7) | 23,513 (56.6) | 5,270 (12.7) | |
| Not rated | 13,752 (2.2) | 8,554 (62.2) | 4,749 (34.5) | 449 (3.3) | |
| Primary condition | <0.0001 | ||||
| Stroke/ Neurological conditions | 36,756 (6.0) | 20,991 (57.1) | 14,384 (39.1) | 1,381 (3.8) | |
| Trauma | 116,755 (19.0) | 75,868 (65.0) | 37,587 (32.2) | 3,300 (2.8) | |
| Amputation | 3,317 (0.5) | 2,108 (63.6) | 1,113 (33.6) | 96 (2.9) | |
| Orthopedic | 81,042 (13.2) | 61,353 (75.7) | 18,654 (23.0) | 1,035 (1.3) | |
| Debility, Cardiorespiratory Conditions | 72,702 (11.8) | 43,699 (60.1) | 27,570 (37.9) | 1,433 (2.0) | |
| Medically Complex Conditions | 187,381 (30.4) | 107,872 (57.6) | 73,857 (39.4) | 5,652 (3.0) | |
| Other | 118,120 (19.2) | 70,186 (59.4) | 44,570 (37.7) | 3,364 (2.8) | |
| Cognitive impairment | <0.0001 | ||||
| None | 421,060 (68.3) | 293,612 (69.7) | 121,060 (28.8) | 6,388 (1.5) | |
| Mild | 120,830 (19.6) | 64,935 (53.7) | 52,301 (43.3) | 3,594 (3.0) | |
| Moderate/severe | 74,183 (12.0) | 23,530 (31.7) | 44,374 (59.8) | 6,279 (8.5) | |
| HCC score, mean (SD) | 4.2 (3) | 3.9 (3) | 4.5 (3) | 4.9(3) | <0.0001 |
Note: SD (standard deviation), end-stage renal disease (ESRD), hierarchical conditions categories (HCC). Dual enrollment indicates if the resident was enrolled in Medicare and Medicaid. Urinary continence is not rated if the resident had a catheter, urinary ostomy, or no urine output for the past 7-days. Bowel continence is not rated if the resident had an ostomy or did not have a bowel movement for the past 7-days.
Sixty-two percent of residents were independent in self-care prior to SNF admission, 35.3% required some help, and 2.64% were totally dependent (Table 1). The average self-care total score at admission (discharge) was 25.0 points (35.7 points), 21.7 points (30.4 points), and 14.9 points (23.1 points) for residents who were independent, needed some help, and dependent in self-care prior to SNF admission, respectively. Residents who were independent also exhibited greater improvement (10.7 points) than residents who needed some help (8.7 points) or were dependent (8.1 points). Residents who were independent in self-care prior to SNF admission were younger, more likely to be White, to be eligible for Medicare because of age, to not be dually enrolled in Medicaid, and were in generally better health than residents who were dependent prior to SNF admission. Most residents with no cognitive impairment were independent in self-care prior to SNF admission (69.7%) whereas 31.7% of residents with moderate-severe cognitive impairment were independent. Approximately 70% of residents who had no urinal or bowel incontinence were independent in self-care prior to SNF admission compared to 25% to 30% of residents who were always incontinent.
Figure 2 shows the distributions of the self-care total scores at admission and discharge according to prior level of self-care function. Approximately 30% of residents who were independent and 11% of residents who needed some help prior to SNF admission were independent in all self-care tasks at discharge. As shown in Figure 3, nearly 10% of residents who were dependent prior to SNF admission had no change in self-care between admission and discharge, compared to approximately 4% of residents who needed some help or were independent prior to SNF discharge.
Figure 2:
Distribution of self-care total scores at admission (blue) and discharge (red) according to level of self-care function prior to skilled nursing facility (SNF) admission for 100,248 Medicare fee-for-service beneficiaries admitted to a SNF within three days of hospital discharge.
Figure 3:
Distribution of the change in self-care total score between admission and discharge according to prior level of self-care function before skilled nursing facility admission
The average adjusted self-care total score at admission was 5.67 points higher for residents who were independent and 4.21 points higher for residents who needed some help compared to residents who were dependent prior to SNF admissions (Table 2). The difference in average adjusted self-care total scores at discharge between the three groups were similar to the self-care total scores at admission. The change in self-care function was 3.48 and 1.62 points higher for residents who were independent and needed some help, respectively as compared to residents who were dependent prior to SNF admission.
Table 2.
Adjusted associations between resident characteristics and self-care total scores at skilled nursing facility (SNF) admission, discharge, and change in self-care for 100,248 Medicare fee-for-service beneficiaries admitted to a SNF within three days of hospital discharge.
| Self-Care Score | |||
|---|---|---|---|
| Characteristic | Admission | Discharge | Difference |
| Model intercept | 23.33 ** | 33.40 ** | 9.95 ** |
| Prior function (vs dependent) | |||
| Some help | 4.21 ** | 3.82 ** | 1.62 ** |
| Independent | 5.67 ** | 6.44 ** | 3.48 ** |
| Self-care score on admission (centered) | - | - | −0.48 ** |
| Age category (vs 66–70) | |||
| 71–75 | −0.26 ** | −0.31 ** | −0.18 ** |
| 76–80 | −0.48 ** | −0.71 ** | −0.46 ** |
| 81–85 | −0.61 ** | −1.04 ** | −0.72 ** |
| 86+ | −0.83 ** | −1.78 ** | −1.35 ** |
| Sex (female vs male) | −0.05 ** | 0.17 ** | 0.20 ** |
| Race/ethnicity (vs white) | |||
| Other | −0.47 ** | −0.57 ** | −0.32 ** |
| Black | 0.18 ** | −0.32 ** | −0.41 ** |
| Hispanic | −0.68 ** | −0.82 ** | −0.46 ** |
| Length of stay (vs < 14 days) | |||
| 14 – 20 days | −1.28 ** | 0.55 ** | 1.22 ** |
| 21 – 31 days | −2.24 ** | 0.43 ** | 1.60 ** |
| > 31 days | −3.50 ** | 0.77 ** | 2.59 ** |
| Original entitlement (vs age) | |||
| Disability/ESRD | −0.27 ** | −0.32 ** | −0.18 ** |
| Dual enrollment (yes vs no) | −0.10 ** | −0.13 ** | −0.07 * |
| Hearing impairment (vs none) | |||
| Minimal | −0.10 ** | −0.12 ** | −0.07 * |
| Moderate/High | −0.11 ** | −0.40 ** | −0.34 ** |
| Vision impairment (vs none) | |||
| Minimal | −0.41 ** | −0.55 ** | −0.34 ** |
| Moderate/High | −1.15 ** | −1.76 ** | −1.15 ** |
| Urinary incontinence (vs none) | |||
| Occasionally | −0.85 ** | −0.89 ** | −0.45 ** |
| Frequently | −2.94 ** | −3.59 ** | −2.06 ** |
| Always | −4.26 ** | −5.50 ** | −3.27 ** |
| Not rated | −3.01 ** | −3.77 ** | −2.20 ** |
| Bowel incontinence (vs none) | |||
| Occasionally | −0.65 ** | −0.81 ** | −0.47 ** |
| Frequently | −1.56 ** | −2.13 ** | −1.32 ** |
| Always | −3.43 ** | −5.10 ** | −3.31 ** |
| Not rated | −0.79 ** | −1.01 ** | −0.60 ** |
| Primary condition (vs Orthopedic) | |||
| Stroke - Neurological Conditions | 0.13 ** | −1.14 ** | −1.20 ** |
| Trauma | −0.84 ** | −0.97 ** | −0.53 ** |
| Amputation | 1.04 ** | −1.01 ** | −1.55 ** |
| Debility, Cardiorespiratory Conditions | 1.43 ** | 0.21 ** | −0.54 ** |
| Medically Complex Conditions | 1.25 ** | −0.09 * | −0.74 ** |
| Other | 1.20 ** | −0.05 | −0.68 ** |
| Cognitive impairment (vs None) | |||
| Mild | −0.71 ** | −1.88 ** | −1.51 ** |
| Moderate/severe | −2.31 ** | −4.98 ** | −3.78 ** |
| HCC score | −0.12 ** | −0.21 ** | −0.14 ** |
Note. End-stage renal disease (ESRD), hierarchical conditions category (HCC). Adjusted differences in self-care at admission, discharge, and change in self-care were estimated using multivariable linear regression models. All models controlled for the resident characteristics in Table 1 and a random effect for facility.
p<0.01;
p-value < 0.0001.
Several other resident characteristics were significantly associated with self-care total scores at SNF admission and discharge (Table 2). The greatest differences were for urinary or bowel incontinence of any frequency (i.e., occasional, frequent, always) and mild or moderate-severe cognitive impairment. These characteristics were also associated with significantly less improvement in self-care function between SNF admission and discharge.
DISCUSSION
Our objective was to investigate differences in SNF residents’ self-care function during a SNF stay according to their prior level of self-care function. We detected large differences in self-care at admission, discharge, and change in self-care according to residents’ prior level of function. The average adjusted self-care scores at admission and discharge for residents who were independent or needed some help prior to SNF admission were 3 to 5 points higher than residents who were dependent. The improvement in self-care function for residents who were independent or needed some help prior to SNF admission were 1.6 and 3.5 points higher than residents who were dependent. This evidence indicates that it is important to consider a resident’s prior level of function when evaluating functional recovery during a SNF stay.
Our results for the differences in adjusted self-care scores at discharge and the change in self-care according to prior level of functioning are larger than the estimates from the CMS risk-adjustment model for the discharge self-care score and change in self-care quality measures.15 This may be due to the more extensive risk-adjustment in the CMS models. Residents who needed some help and were dependent had discharge scores that were 1.36 and 2.35 points lower than residents who were independent. Similarly, the change in self-care scores for residents who needed some help was 1.36 points lower than residents who were independent, and 2.37 points lower for residents who were dependent in self-care prior to SNF admission.
Sixty-two percent of residents were recorded as independent in self-care prior to SNF admission and 35% needed some help. These percentages are consistent with prospective studies of community-dwelling older adults that assessed self-reported limitations in basic daily activities prior to a nursing home admission.22–24 We observed that residents with chronic medical conditions were less likely to be independent in self-care prior to SNF admission than residents who did not have chronic conditions. The largest differences were for cognitive status and incontinence. A large majority of caregivers report having to assist a person with cognitive impairment or dementia complete self-care and other daily tasks.25 Incontinence has been associated with increased dependency in other self-care tasks.26, 27 These findings along with the large differences in self-care function during a SNF stay according to residents’ prior level of function is evidence that the new MDS self-care item is a valid measure of a resident’s prior self-care function.
The item for prior functioning in self-care is an important addition to the MDS. A resident’s self-care function at SNF discharge can be compared to their level of independence prior to being admitted to the SNF. This may be useful in determining if a resident has shown a meaningful improvement in function during the SNF stay. While it may not always be realistic for a resident to return to their prior level of function,23 our findings indicate that most residents had at least some improvement in self-care during a SNF stay and the amount of improvement was proportional to their prior level of functioning. It is also important that the resident and their family are meant to be the major sources of information for determining a resident’s prior level of functioning. This builds on the changes made to the MDS in which resident interviews for assessing cognitive function, depressive symptoms, pain, and importance of certain daily activities were added in 2010.28
The new prior functioning items may also be useful in informing a resident’s treatment and rehabilitation goals at the start of care.29 As part of the SNF Quality Reporting Program, SNFs are now required to document on the admission MDS assessment a functional goal at discharge for at least one self-care or mobility item.15 Several factors can inform a clinician’s determination of a resident’s discharge goals, such as medical history, the resident’s functional abilities on admission, expected treatments and rehabilitation needs, and conversations with the resident and their family.29 It is also important to consider if the resident and SNF staff believe that the resident can improve in function when determining discharge goals.30
A limitation of our analysis is that we excluded residents who died during the SNF stay or did not have complete information for the seven self-care tasks at SNF admission and discharge. Self-care function is documented on the discharge MDS for residents who had a planned discharge, stayed in the SNF for more than 2 days, and were not discharged to an acute hospital.29 Thus, our sample only includes residents with a complete SNF stay. Residents who become deceased or have an unplanned discharged are likely more dependent in self-care prior to SNF admission and to have poorer self-care function during a SNF stay than residents in the final sample. Second, the MDS does not specify a time-period (e.g., days, weeks, months) when assessing a resident’s prior level of functioning. The number of functional limitations increases in the months leading up to a SNF admission.11 Without a specific timeframe, a resident’s interpretation of their prior functional level might vary, which could introduce unnecessary errors in the information. Third, nursing home staff may have to resolve conflicting information from the resident and family about the resident’s level of prior function. Information may also not be accurate if a resident has dementia or severe cognitive impairment. In such instances it will be important for staff to use a resident’s medical history to resolve conflicting information or concerns about the reliability of the reported information. Future studies should assess if the documenting of residents’ prior level of functioning changes as nursing staff become more experienced in collecting this information.
CONCLUSIONS AND IMPLICATIONS
Most SNF residents were independent in self-care before the illness, exacerbation, or injury that led to their SNF stay, and over one-third of residents needed some help in self-care. These residents were more independent in self-care at SNF admission, discharge, and showed greater improvement in self-care than residents who were dependent prior to SNF admission. Residents with chronic conditions or cognitive impairment were less likely to be independent in self-care than residents who did not have these conditions. These findings give evidence that the item for prior functioning in self-care is a valid measure of a resident’s ability to complete self-care tasks that are important to living in a community setting.
Acknowledgments:
We thank Mr. Allen Haas, MS of the University of Texas Medical Branch Office of Biostatistics for creating the analytical file for this analysis. The funding sponsors had no role in the design, methods, data acquisition, analysis, or preparation of this paper.
Funding sources:
This work was supported by the National Institute on Aging (K01AG058789 to BD, P30AG024832); National Center for Advancing Translational Sciences (KL2TR001441 to RD); and National Institute of Child Health and Human Development (K01HD101589 to CL, K12HD055929 to MJL).
Footnotes
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Conflicts of interest. No authors have any conflicts of interest to report.
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