title: Community-based care and risk of nursing home placement.
abstract: OBJECTIVE
  To test the substitution hypothesis, that community-based care reduces the probability of institutional placement for at-risk elderly.
  
  
  METHODS
  The closure of the Social Health Maintenance Organization (Social HMO) at HealthPartners (HP) in Minnesota in 1994 and the continuation of the Social HMO at Kaiser Permanente Northwest (KPNW) in Oregon/Washington comprised a "natural experiment." Using multinomial logistic regression analyses, we followed cohorts of Social HMO enrollees for up to 5 years, 1995 to 1999. To adjust for site effects and secular trends, we also followed age- and gender-matched Medicare-Tax Equity and Fiscal Responsibility Act (TEFRA) cohorts, enrolled in the same HMOs but not in the Social HMOs.
  
  
  METHODS
  All enrollees in the Social HMO for at least 4 months in 1993 and an age-gender matched sample of Medicare-TEFRA enrollees. To be included, individuals had to be alive and have a period out of an institution after January 1, 1995 (total n = 18,143).
  
  
  METHODS
  The primary data sources were the electronic databases at HP and KPNW. The main outcomes were long-term nursing home placement (90+ days) or mortality. Covariates were age, gender, a comorbidity index, and geographic site effect.
  
  
  RESULTS
  Adjusting for variations in the 2 sites, we found no difference in probability of mortality between the 2 cohorts, but approximately a 40% increase in long-term institutional placement associated with the termination of the Social HMO at HealthPartners (odds ratio, 1.43; 95% confidence interval, 1.15-1.79).
  
  
  CONCLUSIONS
  The Social HMO appears to help at-risk elderly postpone long-term nursing home placement.
authors.affiliation: HealthPartners Research Foundation, Minneapolis, Minnesota, USA. lfischer2@mn.rr.com
authors.forename: Lucy Rose
authors.initials: LR
authors.lastname: Fischer
authors.forename: Carla A
authors.initials: CA
authors.lastname: Green
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Goodman
authors.forename: Kathleen K
authors.initials: KK
authors.lastname: Brody
authors.forename: Mikel
authors.initials: M
authors.lastname: Aickin
authors.forename: Feifei
authors.initials: F
authors.lastname: Wei
authors.forename: Linda W
authors.initials: LW
authors.lastname: Phelps
authors.forename: Walter
authors.initials: W
authors.lastname: Leutz
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003153:Community Health Services / Q000458:organization & administration*; D005260:Female; D006271:Health Facility Closure; D006279:Health Maintenance Organizations / Q000458:organization & administration*; D006302:Health Services Research; D006299:Health Services for the Aged / Q000458:organization & administration*; D006801:Humans; D007326:Institutionalization / Q000706:statistics & numerical data*; D016015:Logistic Models; D008134:Long-Term Care / Q000458:organization & administration*; D008297:Male; D006278:Medicare; D008910:Minnesota / Q000453:epidemiology; D009026:Mortality; D009735:Nursing Homes / Q000706:statistics & numerical data*; D009922:Oregon / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D015397:Program Evaluation; D018570:Risk Assessment; D012307:Risk Factors; D014861:Washington / Q000453:epidemiology