Arling G, Zimmerman D, Updike L
Center for Health Systems Research and Analysis, University of Wisconsin, Madison 53706.
Med Care. 1989 Feb;27(2):164-81. doi: 10.1097/00005650-198902000-00007.
Along with many other states, Wisconsin is considering a case mix approach to Medicaid nursing home reimbursement. To support this effort, a nursing home case mix model was developed from a representative sample of 410 Medicaid nursing home residents from 56 facilities in Wisconsin. The model classified residents into mutually exclusive groups that were homogeneous in their use of direct care resources, i.e., minutes of direct care time (weighted for nurse skill level) over a 7-day period. Groups were defined initially by intense, Special, or Routine nursing requirements. Within these nursing requirement categories, subgroups were formed by the presence/absence of behavioral problems and dependency in activities of daily living (ADL). Wisconsin's current Skilled/Intermediate Care (SNF/ICF) classification system was analyzed in light of the case mix model and found to be less effective in distinguishing residents by resource use. The case mix model accounted for 48% of the variance in resource use, whereas the SNF/ICF classification system explained 22%. Comparisons were drawn with nursing home case mix models in New York State (RUG-II) and Minnesota. Despite progress in the study of nursing home case mix and its application to reimbursement reform, methodologic and policy issues remain. These include the differing operational definitions for nursing requirements and ADL dependency, the inconsistency in findings concerning psychobehavioral problems, and the problem of promoting positive health and functional outcomes based on models that may be insensitive to change in resident conditions over time.
与许多其他州一样，威斯康星州正在考虑采用病例组合方法来进行医疗补助养老院报销。为支持这一工作，从威斯康星州56家机构的410名医疗补助养老院居民的代表性样本中开发了一种养老院病例组合模型。该模型将居民分为相互排斥的组，这些组在直接护理资源的使用上是同质的，即7天内的直接护理时间（根据护士技能水平加权）。组最初由高强度、特殊或常规护理需求定义。在这些护理需求类别中，亚组由行为问题的存在/不存在以及日常生活活动（ADL）中的依赖性形成。根据病例组合模型对威斯康星州目前的熟练/中级护理（SNF/ICF）分类系统进行了分析，发现该系统在按资源使用区分居民方面效果较差。病例组合模型解释了资源使用差异的48%，而SNF/ICF分类系统解释了22%。与纽约州（RUG-II）和明尼苏达州的养老院病例组合模型进行了比较。尽管在养老院病例组合研究及其在报销改革中的应用方面取得了进展，但方法学和政策问题仍然存在。这些问题包括护理需求和ADL依赖性的不同操作定义、关于心理行为问题的研究结果不一致，以及基于可能对居民状况随时间变化不敏感的模型促进积极健康和功能结果的问题。
