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Incontinent elderly persons more likely to enter nursing
homes if they live in rural areas
Elderly persons who are incontinent and live in rural areas are
more likely to be institutionalized in a nursing home than their
urban or suburban counterparts, according to a study supported in
part by the Agency for Health Care Policy and Research (National
Research Service Award fellowship F32 HS00086). Once an already
disabled elder develops urinary incontinence (UI), it is often
very difficult for the family to continue to care for that person
at home. And despite the success of community-based programs to
assist older adults in coping with this problem so they can
remain in the community, such programs are unlikely to exist in
small towns and rural communities, where residents typically have
a smaller number and narrower range of community and home-based
services available to them.
On the other hand, rural regions usually have more available
nursing home beds than suburban or urban areas, explains Chuck W.
Peek, Ph.D., of the University of Florida Health Science Center.
Dr. Peek and his colleagues used data from the Longitudinal Study
on Aging (LSOA) 1984-1990 on persons 55 years of age and older
who were living in the community. They selected from the LSOA
sample persons who reported trouble with UI (9.6 percent) in 1984
and examined the impact of a variety of factors on the
probability these individuals would enter a nursing home.
The researchers found that the effect of place of residence on
the likelihood of institutionalization remained significant, even
after the effects of other factors known to influence nursing
home admission—such as health status, social support,
availability of community services, and sociodemographic
characteristics—were taken into account. Residents of rural
counties had rates of institutionalization (35.4 percent) that
were substantially higher than older adults with UI who lived in
small and medium-sized metropolitan areas (22.6 percent).
For more details, see "Predicting nursing home admissions among
incontinent older adults: A comparison of residential differences
across six years," by Raymond T. Coward, M.S.W., Ph.D., Claydell
Horne, R.N., Ph.D., and Dr. Peek, which appears in The
Gerontologist 35(6), pp. 732-743.
At least 15 percent of nursing home residents could be
placed in lower levels of care
Researchers at the Agency for Health Care Policy and Research
made three estimates of the number of nursing home residents who
could be appropriately placed in lower levels of care such as
community-based personal care homes and home care. The most
stringent estimate represents residents who could be placed in
lower levels of care without major changes in the resource
intensity in those settings. The middle and high estimates
assume that resource intensity would increase in these lower
levels of care to accommodate the greater disability of the
additional residents and that the supply of lower level
alternatives would grow to accommodate the large shift in
Based on the least stringent criteria, 70 percent of nursing home
residents would be deemed appropriate for lower levels of care.
Under these criteria, all residents except those who are
comatose, bed- or chair-fast, a danger to themselves or others,
unable to communicate or understand others, suffer from bedsores,
or have substantial rehabilitation or medical needs, would be
appropriate for lower levels of care. The estimated proportion is
reduced to 47 percent if persons with fecal incontinence are also
Using the most stringent criteria, approximately 15 percent of
nursing home residents could be treated in lower levels of care.
These criteria additionally exclude residents who need help with
activities of daily living beyond bathing and dressing, have
urinary incontinence, exhibit behavior problems such as wandering
and not avoiding dangers, or experience hallucinations or
The researchers conclude that the potential for cost savings by
transferring or diverting persons needing long-term care from
nursing homes to lower-level settings may be great but that
policies to encourage use of lower levels of care are difficult
to design. Thus, realizing this potential for cost savings will
not be easy. The study is based on analysis of data from the
Institutional Population Component of the National Medical
Expenditure Survey, a nationally representative survey of
long-term care facilities and residents in 1987, as well as a
sample of State-licensed personal care home residents.
Details are in "Appropriate placement of nursing home residents
in lower levels of care," by William D. Spector, Ph.D., James D.
Reschovsky, Ph.D., and Joel W. Cohen, Ph.D., in the March 1996
issue of The Milbank Quarterly 74, pp. 139-160.
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