Facilities Special Care Units Residents

 Research

Nursing Home Trends,1987 and 1996

o. 3
Suggested citation:

Rhoades JA, Krauss NA. Nursing home trends, 1987 and 1996. Rockville (MD): Agency for Health CarePolicy and Research; 1999. MEPS Chartbook No. 3.AHCPR Pub. No. 99-0032.
i

There were 14,050 nursing homes witha total of 1.48 million beds in 1987,compared to 16,840 nursing homes and1.76 million beds in 1996. The numberof nursing homes and the number ofnursing home beds both increasedalmost 20% from 1987 to 1996.

Facilities

The proportion of nursing homescertified by both Medicare and Medicaid(dually certified) rose from 28% in 1987to 73% in 1996. Meanwhile, theproportion certified by Medicaid onlyfell from 50% in 1987 to only 17% in1996. Passage of the Omnibus BudgetReconciliation Act of 1987 reduced theincentive to remain certified by Medicaidonly.

Growth in the elderly population hasoutpaced growth in the supply ofnursing home beds. The supply ofnursing home beds for people 75 yearsand over dropped 8% from 1987 to1996—from 127 to 117 beds per 1,000people this age.

Special Care Units

In 1996 the most common type ofspecial care unit was for treatment ofAlzheimer’s and related dementias.Most Alzheimer’s units are relativelynew; only 10% have been operating formore than 10 years.

Residents

Nursing homes are caring for an olderpopulation now. From 1987 to 1996,the proportion of nursing homeresidents who were 85 and over rosefrom 49% to 56% for women and from29% to 33% for men.

Functional disability has increased.Almost 72% of 1987 nursing homeresidents–but 83% of residents in1996—needed help with three or moreactivities of daily living, a 15% increase.

Male residents were more likely to bemarried when entering a nursing homein 1996 than in 1987. In 1987, 24.8%of males were married at the time of theinterview, while 29.6% had never beenmarried. In 1996, 34.3% of males weremarried (an increase of 38.3%), while21.5% had never been married (a 27.4%decline from 1987). There was verylittle change in the patterns of maritalstatus for female residents over the sameperiod.

Medical Expenditure Panel Survey

Agency for Health Care Policy and Research

How have the nursing home market and characteristics of the nursing home population changed from 1987 to 1996?

Throughout this report, a nursing home is defined as having atleast three beds and being either certified by Medicare orMedicaid or licensed by a government agency as a nursinghome and providing 24-hour skilled nursing care.

iii

1 Introduction

Nursing Home Policy

3 Sources of Data for This Report

5 Section 1

Facilities

13 Section 2

Special Care Units

17 Section 3

Residents

24 Conclusions25 References26 Technical Notes

Medical Expenditure Panel Survey

Agency for Health Care Policy and Research

Nursing

Home Policy

Nursing homes serve only a

minority of the functionallyimpaired elderly, but nursing homecare dominates long-term carefinancing. State and Federalspending for nursing homesamounted to $80 billion in 1995(Burner and Waldo, 1995).

With increasing life expectancy

and a growing population withfunctional impairments, meetinglong-term care needs will continueto be a challenge. Demand fornursing home care could require600,000 new beds by 2010 (Porterand Witek, 1991). The magnitudeof expenditures and potential forgrowth in demand have drawn theattention of policymakers andresearchers.

This report presents the latest

available information concerning

three key elements related tonursing home care. The first sectionof the report presents data on thenursing home market from 1987 to1996. The second section addressesspecial care units within nursinghomes, such as designated units forAlzheimer’s disease. Only 1996 dataon special care units are shownbecause there are no 1987 data.Finally, the third section of thereport turns its focus to thecharacteristics of nursing homeresidents in 1987 and 1996.

For this report, a nursing home

is defined as having at least threebeds and being either certified byMedicare or Medicaid or licensed bya government agency as a nursinghome and providing 24-hour skillednursing care. Some other surveys,including the National NursingHome Survey conducted by theNational Center for HealthStatistics, use a broader definition ofnursing home that does not requirethe facility to provide round-theclock nursing care (Strahan, 1987and 1997).

Medical Expenditure Panel Survey

Agency for Health Care Policy and Research

1

Sources of

Data for This

Report

The estimates presented in this

report are drawn from the 1996Medical Expenditure Panel Survey(MEPS) Nursing HomeComponent (NHC) and the 1987National Medical ExpenditureSurvey (NMES) InstitutionalPopulation Component (IPC).Both surveys are designed toprovide extensive data on the typesof health care services Americansuse, how frequently they use them,how much is paid for the services,and who pays for them. The NHCand IPC are nationallyrepresentative surveys, sponsored bythe Agency for Health Care Policyand Research (AHCPR) to collectdetailed information specifically onnursing homes and nursing home

residents with regard to facility andresident characteristics, and use ofand expenses for nursing home andhealth care services.

The estimates presented here

are nationally representative ofnursing homes and their residents.Estimates for residents are based ona sample of current residents.Current residents are sampledpersons living in a nursing home atthe beginning of the data collectionreference period, January 1 of 1987or 1996. Unless otherwise noted,only differences that are statisticallysignificant at the 0.05 level arediscussed in the text. In some cases,the totals on tables or figures maynot add precisely to 100% as aconsequence of rounding.

MEPS data are released to the

public in a number of formats,including public use data files andthe printed MEPS Research Findingsand MEPS Highlights series. Thenumbers shown in this chartbookare drawn from a variety of theResearch Findings reports, as well asadditional analyses conducted by theMEPS staff. The sources ofinformation are listed in thereferences at the end of this report.

Medical Expenditure Panel Survey

Agency for Health Care Policy and Research

3

Facilities Data on the nursing home market are critically important because of the

dramatic growth in the number ofAmericans age 75 and over and thedesire to minimize the length ofexpensive inpatient hospital stays. Whilethe trend in long-term care is towardexpansion of community-based care forpersons with functional limitations,some people need 24-hour skillednursing care. The need for differenttypes and levels of long-term care hasresulted in an increasing number ofoptions for obtaining care. Given thesechanges in the long-term care market, itbecomes increasingly important to makeclear and consistent distinctions amongthe different kinds of facilities that liealong the continuum of care. A betterunderstanding of the current nursinghome market, as defined in this report,and the changes from 1987 to 1996 cancontribute to informed decisions aboutthe provision of long-term care.

Medical Expenditure Panel Survey

Agency for Health Care Policy and Research

5
Medical Expenditure Panel Survey

How has the size of the nursing homemarket changed from 1987 to 1996?

16,840

1996

The number of nursing homes

increased by 19.9% and the numberof nursing home beds by 18.9% from1987 to 1996.

• In 1987 there were 14,050

nursing homes in the UnitedStates, for a total of 1.48 millionbeds.

• In 1996 there were 16,840

nursing homes, for a total of1.76 million beds.

• The average size of a nursing

home did not changesignificantly from 1987 (105.3beds) to 1996 (104.5 beds).

See Technical Note 1.

0

500,000

1,000,0001,500,0002,000,000

1,760,000

1,480,000

1987 1996

Nursing home beds
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7

Medical Expenditure Panel Survey

Agency for Health Care Policy and Research 

iod from 1987 to 

way from 

homes (nursing 

ursing home 

oward nursing

d assisted or

beds in addition

eds.

• In 1987 fully 87.4% of nursing

homes had only nursing homebeds. This proportion decreasedto 77.3% in 1996.

• Conversely, the proportion of

nursing homes that were hospitalbased or had affiliated nonnursing beds (e.g., assisted or independent living beds) increased. The proportion of hospital-based nursing homes rose from 5.7% in 1987 to 11.4% in 1996. The proportion with affiliated non-nursing beds rose from 6.9% to 11.3% in the same

time period.

e structure of the nursing home

d?

Hospital-based

Affiliated non-nursing beds

Nursing home beds only

6.9%

5.7%

87.4%

11.4%

11.3%

77.3%

1987 1996

Nursing home structure
Medical Expenditure Panel Survey

Have there been changes in ownershiptype?

Nursing home ownership

remained relatively stable from 1987to 1996; there were no statisticallysignificant differences between thetwo years.

• The nursing home market

remained largely proprietary.

• The proportion of for-profit

homes was 70.1% in 1987 and65.9% in 1996. The proportionof nonprofit homes was 21.9% in1987 and 26.2% in 1996. Thesedifferences were not statisticallysignificant.

• The remaining 8% of homes in

both years were owned byFederal, State, or localgovernments.

Nonprofit

Government

For-profit

70.1%

7.9%

65.9%

26.2%

987 1996

ownership
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Agency for Health Care Policy and Research

9

Medical Expenditure Panel Survey

Budget

of 1987 reduced

facility to remain

only. How has the

of nursing homes

nactment?

n of nursing

different types of

ed dramatically

6.

• In 1996 fully 73.2% of all

nursing homes were certified byboth Medicaid and Medicare(dually certified). In 1987 only27.8% were dually certified.

• Conversely, in 1996 just 17.0% of

all nursing homes were certifiedby Medicaid only, compared tofully 49.5% in 1987. Medicareonly certified nursing homes made up 5.0% of the market in 1996, down from 19.5% in 1987. • In both years, a very small percentage, less than 5%, of all nursing homes were certified neither by Medicare nor Medicaid.

as the certification status of nursing

changed?

Medicare onlyNoncertifiedDually certifiedMedicaid only

1987 1996

3.2%

49.5%

27.8%

19.5%

5.0%

73.2%

4.8%

17.0%

Nursing home certification status
In both 1987 and 1996, the for-profit

segment of the nursing home market wasnearly entirely represented by nursing homeswith only nursing home beds, as opposed toother more organizationally complex nursinghome types (nursing homes with affiliatednon-nursing beds and hospital-based nursinghomes). Nonprofit and government facilitieswere more likely than for-profit facilities to

have affiliated non-nursing beds, such asassisted or independent living beds.

• In 1996, 90.9% of for-profit nursing

homes contained only nursing home bedsas compared to 96.9% in 1987.

Medical Expenditure Panel Survey

-profit nursing homes differ structurally

onprofit and government facilities?

Hospital-based

Affiliated non-nursing beds

Nursing home beds only

2.7% 0.4%

96.9%

1.9%

90.9%

7.2%

1987 1996

For-profit
1996, 20.8% of nonprofit

rsing homes had affiliated nonrsing beds (e.g., assisted or

ependent living beds), 2

rcentage points less (but not

nificantly less) than in 1987.

• 7.2% of for-profit nursing homes

had affiliated non-nursing beds in1996, representing an increase of4.5 percentage points over 1987.

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Agency for Health Care Policy and Research

11

Medical Expenditure Panel Survey

profit nursing homes differ structurally

onprofit and government facilities?

d)

1987 1996

2.6%

8.9% 11.5%

65.9% 83.6% 20.8%

26.1%

53.1%

Nonprofit

1987 1996

0.1%

64.1%

35.8% 41.8%

14.3%

43.9%

Government
While the number of elderly has increased,

the supply of nursing home beds per 1,000people 75 and over has declined. At the sametime, the overall occupancy rate declined from92.3% in 1987 to 88.8% in 1996.

• In 1987 there were 127 nursing home beds

per 1,000 people 75 years and over.

• In 1996 there were 117 nursing home beds

for the same population, representing a 

7.9% decrease in the supply of nursing homebeds over the 9-year period.

• Statistically significant declines in occupancy

rates occurred in each region of the UnitedStates.

Medical Expenditure Panel Survey

What trends can be seen in nursinghome supply and occupancy?

0

20406080

100120140160180

Total Northeast Midwest South West

127

117

128

112

149

142

111113

119

98

19871996

Nursing home beds per 1,000 population75 and over

0

20406080

100

Total Northeast Midwest South West

92.3%

88.8%

95.5%93.3% 90.8%

87.5%

92.2%

87.9% 90.8%87.0%

1987

1996

Nursing home occupancy rate
Special Care

Units

Nursing homes are increasing

the level of resources devoted toformal and distinct care units for thespecialized treatment needs ofspecial populations. Several trendshave contributed to the creation ofsuch units:

• Today’s nursing home

population is more frail andneeds more skilled and/orspecialized care than was thecase in 1987.

• Shorter lengths of stay in

hospitals have resulted in agreater need for skilled andrehabilitative care followinghospitalization.

• Increasing public awareness of

Alzheimer’s disease and relateddementias has increased interestin programs that provideservices tailored to the needs ofpersons with such conditions.

Medical Expenditure Panel Survey

Agency for Health Care Policy and Research

13
Medical Expenditure Panel Survey

Which nursing homes have specialcare units?

Almost one-fifth of all nursing homes in

1996 had at least one distinct special care unit.These special care units contained 120,400beds, or 6.8% of all nursing home beds.

• Among for-profit facilities, special care units

were more common in nursing homes thatwere part of a chain than in independentfacilities (22.0% versus 12.8%).

• The larger the nursing home, the more

likely it was to have a special care unit. Theproportion of homes with a special care unitrose from only 4.2% for facilities with lessthan 75 beds to 46.7% for facilities with 200or more beds.

12.8%

05

10152025

Non- Government

profit

chain

Nonprofit

independent

Forprofit

chain

Forprofit

independent

22.0%

17.1%

22.9% 22.2%

Percent of nursing homes with special care units, 1996

4.2%

0

1020304050

Less than 75 75-124 125-199 200 or more

18.9%

39.0%

46.7%

Ownership Bed size
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Agency for Health Care Policy and Research

15

Medical Expenditure Panel Survey

est category of special care units are

ease and related dementias, which

alf of all special care units found in the

% of nursing homes had an Alzheimer’s

ts accounted for 73,400 beds.

ursing homes had a distinct

nd/or subacute special care unit.

ounted for 28,500 nursing home

• Just under 5% of nursing homes had either a

ventilator unit or some other type of special care unit(including hospice, AIDS/HIV, and brain injury).These units accounted for the remaining 18,500special care unit beds.

Alzheimer'sRehabilitation or subacuteVentilator or otherNo special care unit

77.8%

g homes, 1996

re the most common types of special

it?

0

20406080

Rehabilitation Ventilator Other

or subacute

Alzheimer's

73,400

28,500

4,600

13,900

13.3

Type of unit

Nursing home beds in special care units,1996
Medical Expenditure Panel Survey

Alzheimer’s units are usually a

relatively new phenomenon.

• In 1996, over half of Alzheimer’s

units had been in operation for 5years or less. Only about 10% hadbeen operating for 11 years ormore.

• Over half of Alzheimer’s units had

16-40 beds, and three-quarters fellin the range of 16-60 beds. Onlyabout 9% had more than 60 beds.

See Technical Note 2.

ow long have Alzheimer’s units been in

istence? How many beds do they have?

s

15.5%

29.0%

22.6%

8.9%

24.1%

Alzheimer’s units, 1996

6-1011 or more5 or less

55.6% 34.7%

9.7%

Size Years in operation
Residents Despite the increasing availability of long-term care

alternatives, such as communitybased care and personal carefacilities, nursing homes continue tobe an important part of the longterm health care system. Thenursing home population representsa small proportion of both theelderly population and the generalpopulation of people withdisabilities. Nursing homes primarilyserve members of these populationswho have severe medical anddisability problems that requirenursing home care. A lack offinancial resources or familycaregivers also contributes to theneed for these institutions(Congressional Budget Office,1991).

Medical Expenditure Panel Survey

Agency for Health Care Policy and Research

17
Are nursing homes still serving the

ame age groups?

Medical Expenditure Panel Survey

Nursing homes in 1996 served an older

pulation than they served in 1987.

The mean age for elderly residents (those65 and over) increased from 83.5 years in1987 to 84.6 years in 1996.

• Over the 9-year period there was a

statistically significant rise in theproportion of women residents who were85 and over.

• In both years, about one-half of women,

but only one-third of men, were 85 andover.

0

20406080

100

65 and over

Years 49.3 50.8

83.5 84.6

Under 65

19871996

Mean age of residents
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19

Medical Expenditure Panel Survey

rsing homes still serving the

ge groups? (continued)

Agency for Health Care Policy and Research

Males 1987 Males 1996

Females 1987 Females 1996

85 and over75-8465-74Under 65

29.0%

16.5%

18.3%

36.3% 32.6%

16.0%

18.1%

33.4%

32.8%

11.1%

7.4%

48.7%

28.9%

9.4%

6.3%

55.6%

of nursing home residents
Has the gender or racial composition of

nursing homes changed?

Medical Expenditure Panel Survey

he gender and racial composition of

ursing home population remained

nged from 1987 to 1996. The

ty of nursing home residents were

n and the nursing home population

ned almost entirely white.

omen made up more than two-thirds

the nursing home population in both

87 (73.4%) and 1996 (71.6%).

 both years, approximately 90% of

rsing home residents were white. Female

26.6% 28.4%

73.4% 71.6%

Male

19871996

0

1020304050607080

0

20406080

100

Black

90.7% 88.7%

7.7% 8.9%

White Other

1.6% 2.4%

19871996

Nursing home residents
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though there was little significant

 in marital status from 1987 to

men and women present very

nt patterns.

both years, almost three-fourths of

men but only one-third of men

re widowed at the time of the

vey. 

e proportion of male residents who

re married at the time of the survey

e from 24.8% in 1987 to 34.3% in

96 (an increase of 38.3%). The

oportion of male residents who had

ver married fell from 29.6% in 1987

21.5% in 1996 (a decline of 27.4%).

ry little change occurred in the

terns of marital status for female

dents over the 9-year period.

Agency for Health Care Policy and Research

21

Medical Expenditure Panel Survey

e the patterns of marital status for

nursing home residents changed?

Males 1987 Males 1996

Females 1987 Females 1996

Never marriedDivorced or separatedWidowedMarried

29.6%

24.8%

11.3% 34.3%

31.0%

13.3%

34.3%

21.5%

71.3%

6.1%

13.4% 9.1%

71.1%

7.6%

11.7% 9.7%

Marital status of nursing home residents
Measured by whether or not

they received assistance with activitiesof daily living (ADLs)—bathing,dressing, transferring, feeding, andtoileting—nursing home residentswere more functionally disabled in1996 than in 1987.

• In 1987, 71.8 percent of nursing

home residents receivedassistance with three or moreADLs. By 1996 this proportionhad risen to 82.9 percent—a15.5% increase. 

See Technical Notes 2 and 3.

Medical Expenditure Panel Survey

nursing home residents more likely to be

ctionally disabled today than in the past?

6.4% 2.7%

21.8%

14.3%

None

19871996

0

20406080

100

3 or more

71.8%

82.9%

1-2

Number of activities of daily living in which assistance received

Nursing home residents
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ses in the age and

y of nursing home

ortion of nursing

o exhibited

dangerous

from 1987 to

ors include being

wandering, and

 (e.g., disruptive

ate sexual

ng in public,

ng food, or

n of nursing home

were physically

ed from 11.5% in

n 1996.

n with disruptive

om 19.7% to

same time

• The proportion with wandering

behavior declined from 11.4% to9.3%

See Technical Notes 2, 3, and 4.

Agency for Health Care Policy and Research

23

Medical Expenditure Panel Survey

e inappropriate and dangerous behaviors

creased among nursing home residents?

11.5%

9.1%

19.7%

14.4%

Physically abusive

19871996

Wanders

11.4%

9.3%

Disruptive

Type of behavior

05

101520

Nursing home residents
Medical Expenditure Panel Survey

The data presented in this report suggest that:

From 1987 to 1996 the need todeliver skilled nursing care hasincreased. Nursing home residentsare older and have a greater degreeof dependence in 1996 than in 1987.There is a growing interest inproviding more specialized nursinghome care. Most Alzheimer’s unitsare relatively new, with over halfbeing in operation less than 6 years.Special care units are an importantpart of nursing home care. Units forAlzheimer’s and related dementiasare the most common type of specialcare unit, with those forrehabilitation and subacute carebeing the next most common.

Despite an increase from 1987 to1996 in the number of nursinghomes and nursing home beds, thesupply of beds for the population 75and over has declined. Nonetheless,nursing home occupancy rates havefallen. This suggests that theelderly’s long-term care needs areincreasingly being met outside ofnursing homes.

A large shift in the certificationstatus of nursing homes—fromcertification by Medicaid only todual certification by Medicare andMedicaid— corresponded with theimplementation of revisedcertification requirements mandatedby the Omnibus BudgetReconciliation Act of 1987.
Medical Expenditure Panel Survey

Agency for Health Care Policy and Research

25

Burner S, Waldo D. National health

expenditure projections, 1994-2005.Health Care Financing Review 1995;16(1):221-242

Congressional Budget Office (US). Policy

choices for long-term care. Washington:Congressional Budget Office; 1991.

Freiman M, Brown E. Special care units in

nursing homes–selected characteristics,1996. Rockville (MD): Agency for HealthCare Policy and Research; 1999. MEPSResearch Findings No. 6. AHCPR Pub.No. 99-0017. (Chartbook pages 14-16)

Porter M, Witek J. The nursing home

industry: past, present, and future. Topicsin Health Care Finance 1991; 17(4):42-48.

Rhoades J. Nursing homes–structure and

selected characteristics, 1987 and 1996.Statistical Bulletin 1998; 79(2):2-9.(Chartbook pages 6, 9, and 12)

Rhoades J, Potter DEB, Krauss N.

Characteristics of nursing homes in 1987and 1996. Paper presented at theNovember 1997 Annual Meetings of theGerontological Society of America,Cincinnati, Ohio. (Chartbook pages 7, 8,10, and 11)

Spillman B, Krauss N, Altman B. A

comparison of nursing home residentcharacteristics: 1987 to 1996. Paperpresented at the November 1997 AnnualMeetings of the Gerontological Society ofAmerica, Cincinnati, Ohio. (Chartbookpages 18-23)

Strahan, B. Nursing home characteristics:

preliminary data from the 1985 NationalNursing Home Survey. Hyattsville (MD):National Center for Health Statistics,1987. Advance Data From Vital andHealth Statistics, No. 131. DHHS Pub.No. (PHS) 87-1250.

Strahan, B. An overview of nursing homes

and their current residents: data from the1995 National Nursing Home Survey.Hyattsville (MD): National Center forHealth Statistics, 1997. Advance DataFrom Vital and Health Statistics, No. 280.DHHS Pub. No. (PHS) 97-1250.

Please consult the MEPS Web site at

http://www.meps.ahcpr.gov/

for an updated publications list or additional

copies of this publication. Contact the MEPS

information coordinator at AHCPR

(301-594-3075) for additional information.
Medical Expenditure Panel Survey

Note 1: A nursing home is defined as having at least three beds and being

either certified by Medicare or Medicaid or licensed by agovernment agency as a nursing home and providing 24-hourskilled nursing care.

Note 2: Estimates for years of operation for Alzheimer’s units, activities of

daily living, and behavioral characteristics have been adjusted for asmall amount of item nonresponse.

Note 3: When it was reported that an activity of daily living did not occur

(e.g., the resident was unable to perform the activity of daily livingor was comatose), residents were classified as receiving assistancewith the activity. In order to be classified as independent intoileting, residents who used wheelchairs had to be able to transferindependently and those who did not use wheelchairs had to beindependently mobile.

Note 4: In 1996 disruptive behavior was measured using a single question

that included the definition from the Minimum Data Set (MDS),which is a uniform series of questions assessing the nursing homeresident’s physical and mental health. The MDS describesdisruptive behavior as follows: “made disturbing sounds, noisy,screams, self-abusive acts, sexual behavior or disrobing in public,smeared/threw food/feces, hoarding, rummaged through others’belongings.” In 1987 information on disruptive behaviors waselicited in a series of separate questions. Persons were identified asexhibiting disruptive behavior if there was a positive response toany of the following single items: hoarding, stealing, injuring self,dressing inappropriately, or exposing self. In 1996 wanderingbehavior was measured using the following MDS definition:“moved with no rational purpose, seemingly oblivious to needs ofsafety.” For 1987, wandering behavior was measured as “gettinglost or wandering.”