Evaluation of a sampling approach. Nursing home reimbursement and level of care determination.

Under existing federal regulations, it is mandated that the care of all nursing home residents be reviewed annually. A four-year demonstration project in Wisconsin tested a sampling approach to nursing home resident review. The rationale for the sampling approach is that one can more effectively identify pervasive problems with resident care by an in-depth examination of a sample of residents than by cursory assessment of all residents. If problems are identified in the sample, all residents can then be reviewed. However, reimbursement for nursing home care is also influenced by level of care and given that nursing home inspectors review the appropriateness of level of care, the issue arises as to what impact a sampling approach would have on reimbursement. This evaluation compares the changes in reimbursement owing to resident review under the sampling and federally mandated, 100% review methods. The results indicate that reviewing a sample of nursing home residents may offer similar reductions in nursing home reimbursement as a 100% resident review--but at a lower cost.