title: Level of Need, Divertibility, and Outcomes of Newly Admitted Nursing Home Residents.
abstract: OBJECTIVE
  To describe the level of need and divertibility of newly admitted nursing home residents, describe the factors that drive need, and describe the outcomes of residents across different levels of need.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  A total of 640 publicly funded nursing homes (also known as long-term care facilities) in Ontario, Canada.
  
  
  METHODS
  All newly admitted residents between January 1, 2010 and March 1, 2012.
  
  
  METHODS
  We categorized residents into 36 groups based on different levels of (1) cognitive impairment, (2) difficulty in activities of daily living (ADL), (3) difficulty in instrumental ADLs, and (4) whether or not they had a caregiver at home. Residents were then categorized as having low, intermediate, or high needs; applying results from previous "Balance of Care" studies, we also captured the proportion who could have been cost-effectively diverted into the community. We then contrasted the characteristics of residents across the needs and divertible groupings, and compared 4 outcomes among these groups: hospital admissions, emergency department visits, mortality, and return to home.
  
  
  RESULTS
  A population-level cohort of 64,105 incident admissions was captured. About two-thirds had great difficulty performing ADLs (65%) and had mild to severe cognitive impairment (66%); over 90% had great difficulty with instrumental ADLs. Just less than 50% of the new admissions were considered to be residents with high care needs (cognitively impaired with great ADL difficulty), while only 4.5% (2880 residents) had low care needs (cognition and ADL intact). Those with dementia (71.0%) and previous stroke (21.5%) were over-represented in the high needs group. Those that cannot be divertible to anywhere else but an institution with 24 hour nursing care comprised 41.3% (n = 26,502) of residents. Only 5.4% (n = 3483), based on community resources available, could potentially be cost-effectively diverted to the community. Those at higher needs experienced higher rates of mortality, higher total cost across all health sectors, and lower rates of return to home.
  
  
  CONCLUSIONS
  The majority of those admitted into nursing homes have high levels of need (driven largely by dementia and stroke) and could not have their needs met cost-effectively elsewhere, suggesting that the system is at capacity. Caring for the long-term care needs of the aging population should consider the balance of investments in institution and community settings.
authors.affiliation: Bruyère Research Institute, Bruyère Center of Learning, Research and Innovation in Long-Term Care, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Population Health and Primary Care, Ottawa, Ontario, Canada. Electronic address: peter.tanuseputro@mail.utoronto.ca.
authors.forename: Peter
authors.initials: P
authors.lastname: Tanuseputro
authors.affiliation: Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada.
authors.forename: Amy
authors.initials: A
authors.lastname: Hsu
authors.affiliation: Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Kerry
authors.initials: K
authors.lastname: Kuluski
authors.affiliation: Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Population Health and Primary Care, Ottawa, Ontario, Canada.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Chalifoux
authors.affiliation: Bruyère Research Institute, Bruyère Center of Learning, Research and Innovation in Long-Term Care, Ottawa, Ontario, Canada.
authors.forename: Melissa
authors.initials: M
authors.lastname: Donskov
authors.affiliation: Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada.
authors.forename: Sarah
authors.initials: S
authors.lastname: Beach
authors.affiliation: Bruyère Research Institute, Bruyère Center of Learning, Research and Innovation in Long-Term Care, Ottawa, Ontario, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Walker
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D060825:Cognitive Dysfunction / Q000175:diagnosis* / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D015577:Geriatric Assessment / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D009735:Nursing Homes; D009864:Ontario; D010343:Patient Admission / Q000706:statistics & numerical data*; D012189:Retrospective Studies
keywords: Nursing homes; activities of daily living; cognitive function; hospitalization; institutionalization; long-term care; mortality