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6 An Overview of the Collaborative Studies of Long-Term Care Sheryl Zimmerman, Ph.D., Philip D. Sloane, M.D., M.P.H., J. Kevin Eckert, Ph.D., Verita Custis Buie, M.S., Joan F. Walsh, Ph.D., Gary Grove Koch, Ph.D., and J. Richard Hebel, Ph.D. Despite the prevalence and diversity of residential care/assisted living (RC/AL) (see part 1), there are virtually no comparative outcome data in this area, and even less is known regarding the relationship of the structure and process of care to resident quality of life. To begin to address these issues, two grants were funded in 1996 by the National Institute on Aging: “Medical and Functional Outcomes of Residential Care” (Sheryl Zimmerman, principal investigator; J. Kevin Eckert, co–principal investigator ), and “Alternatives to Nursing Home Care for Alzheimer’s Disease ” (Philip D. Sloane, principal investigator). In consideration of their similar goals and design, the efforts of these two grants were integrated and conducted cooperatively under the title “The Collaborative Studies of Long-Term Care” (CS-LTC). The CS-LTC is the largest, most comprehensive study of RC/AL ever undertaken, and it is the first to examine and compare the relationship of the structure and process of care with outcomes for this population . The primary aim is to determine adverse medical outcomes, change in functional status, and health service utilization over one year and to discover how they relate to resident-level characteristics and the quality (structure and process) of care in RC/AL and nursing homes, for persons residing in RC/AL and similar persons residing in nursing homes. Between October 1997 and November 1998, CS-LTC study staff enrolled 2,839 residents and collected data on-site from 233 facilities; outcome data were collected through November 1999. A wealth of descriptive data were collected during subject enrollment and constitute the basis of part 2 of this book. These data address resident characteristics, the physical environment and process of care, aging in place, care for persons with dementia , economics and financing, and interpersonal connectedness. This chapter presents an overview of the methods of the CS-LTC, to allow the subsequent findings to be put into context. Sampling Design State Selection and Regional Determination As explained in chapter 1, no national standards exist for RC/AL; state regulations differ, and RC/AL exhibits great interstate and intrastate variability . Therefore, as the CS-LTC was designed, the inclusion of multiple states was a paramount consideration. It was also necessary that they be in proximity to each other, to enable on-site data collection. After consultation with national experts, including Robert Mollica, Rosalie Kane, Catherine Hawes, and Keren Brown-Wilson; a review of state regulations ; consideration of other research currently being conducted; and evaluation of logistical considerations, four states were identified that re- flect the variation of this field: Florida, Maryland, New Jersey, and North Carolina. In the eastern United States, New Jersey has progressed the furthest in defining new-model RC/AL, including a provision for Medicaid funding. It is among the states with the broadest parameters for admission and retention and allows extensive services, thus enabling aging in place. Nationally, Florida contains almost 10 percent of all licensed RC/AL beds, and North Carolina has almost one-half of all RC/AL Medicaid beneficiaries. Maryland is notable in comparison because its regulations were only beginning to be developed at the inception of the CS-LTC; also, it is less penetrated by new-model RC/AL (discussed below). To increase efficiency in data collection, a purposive sample of counties (i.e., a sampling region) was selected within each state. Data on county characteristics were obtained from the 1994 Area Resource File, the 1996 U.S. Census Website, the 1995 physician listings, and the 1996 hospital listings, as well as from lists of licensed homes in each county, to help assure the selection of a representative sampling region. The following criteria were used to select the region: (1) the number and proportion of facilities : each region must contain at least 15 percent of the state’s RC/AL facilities of each type; (2) rural/urban diversity: each region must include both urban and suburban areas (defined as being in or outside of a Standard Metropolitan Statistical Area); and (3) state representativeness: when compared with the entire state, a proposed sampling region must fall within 30 percent of the state mean on each of eight measures listed in table...

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