Quality of mental health care for nursing home residents: A literature review

Medical Care Research and Review

Volumn 67, Issue 6, 2010, Pages 627-656

  Grabowski, David C ^a   Aschbrenner, Kelly A ^b   Rome, Vincent F ^a   Bartels, Stephen J ^b  

^a HARVARD MEDICAL SCHOOL   (United States)

^b DARTMOUTH MEDICAL SCHOOL   (United States)

Author keywords

mental health; nursing homes; quality

Indexed keywords

BENZODIAZEPINE; HYPNOTIC SEDATIVE AGENT; NEUROLEPTIC AGENT;

CLINICAL ASSESSMENT; CONCEPTUAL FRAMEWORK; FINANCIAL MANAGEMENT; HEALTH CARE QUALITY; HEALTH SURVEY; HOSPITALIZATION; HUMAN; MEDICAL LITERATURE; MENTAL DISEASE; MENTAL HEALTH CARE; MENTAL HEALTH CARE PERSONNEL; MENTAL HEALTH SERVICE; NURSING HOME; NURSING HOME PATIENT; NURSING STAFF; PREVALENCE; PSYCHOTHERAPY; REVIEW; SCREENING TEST; WELFARE;

HUMANS; MENTAL HEALTH SERVICES; NURSING HOMES; QUALITY OF HEALTH CARE; UNITED STATES;

EID: 78650195840     PISSN: 10775587     EISSN: 15526801     Source Type: Journal    
DOI: 10.1177/1077558710362538     Document Type: Review

References (113)

1. Accordino, M.P., Porter, D.F., & Morse, T. (2001). Deinstitutionalization of persons with severe mental illness: Context and consequences. Journal of Rehabilitation, 67 (2). 16-21.
2. Administration on Aging. (2001). Older adults and mental health: Issues and opportunities. Rockville, MD: Department of Health and Human Services.
3. American Geriatrics Society & American Association for Geriatric Psychiatry. (2003 a). The American Geriatrics Society and American Association for Geriatric Psychiatry recommendations for policies in support of quality mental health care in U.S. nursing homes. Journal of the American Geriatrics Society, 51, 1299-1304.
4. American Geriatrics Society & American Association for Geriatric Psychiatry. (2003 b). Consensus statement on improving the quality of mental health care in U.S. nursing homes: Management of depression and behavioral symptoms associated with dementia. Journal of the American Geriatrics Society, 51, 1287-1298.
5. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4 th ed.). Washington, DC: Author.
6. Ames, D. (1990). Depression among elderly residents of local-authority residential homes: Its nature and the efficacy of intervention. British Journal of Psychiatry, 156, 667-675.
7. Andrews, A.O., Bartels, S.J., Xie, H., & Peacock, W.J. (2009). Increased risk of nursing home admission among middle aged and older adults with schizophrenia. American Journal of Geriatric Psychiatry, 17, 697-705.
8. Arling, G., & Williams, A.R. (2003). Cognitive impairment and resource use of nursing home residents: A structural equation model. Medical Care, 41, 802-812.
9. Bagchi, A.D., Verdier, J.M., & Simon, S. E. (2009). How many nursing home residents live with a mental illness ? Psychiatric Services, 60, 958-964.
10. Bartels, S.J., Brewer, G., Mays, W., & Rawlings, B. (2005). Community integration for older adults with mental illnesses: Overcoming barriers and seizing opportunities. Rockville, MD: U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Mental Health Services.
11. Bartels, S.J., & Colenda, C.C. (1998). Mental health services for Alzheimer's disease. Current trends in reimbursement and public policy, and the future under managed care. American Journal of Geriatric Psychiatry, 6, 85-100.
12. Bartels, S.J., & Drake, R.E. (2005). Evidence-based geriatric psychiatry: An overview. Psychiatric Clinics of North America, 28, 763-784.
13. Bartels, S.J., Horn, S.D., Smout, R.J., Dums, A.R., Flaherty, E., Jones, J.K., et al. (2003). Agitation and depression in frail nursing home elderly patients with dementia: Treatment characteristics and service use. American Journal of Geriatric Psychiatry, 11, 231-238.
14. Bartels, S.J., Miles, K.M., Dums, A.R., & Levine, K.J. (2003). Are nursing homes appropriate for older adults with severe mental illness? Conflicting consumer and clinician views and implications for the Olmstead decision. Journal of the American Geriatrics Society, 51, 1571-1579.
15. Bartels, S.J., Moak, G.S., & Dums, A.R. (2002). Models of mental health services in nursing homes: A review of the literature. Psychiatric Services, 53, 1390-1396.
16. Bartels, S.J., Mueser, K.T., & Miles, K.M. (1997). A comparative study of elderly patients with schizophrenia and bipolar disorder in nursing homes and the community. Schizophrenia Research, 27, 181-190.
17. Bartels, S.J., & Van Citters, A.D. (2005). Community-based alternatives for older adults with serious mental illness: The Olmstead decision and deinstitutionalization of nursing homes. Ethics, Law, and Aging Review, 11, 3-22.
18. Beck, C., Doan, R., & Cody, M. (2002). Nursing assistants as providers of mental health care in nursing homes. Generations, 26 (1). 66-71.
19. Beck, C., Frank, L., Chumbler, N.R., O'Sullivan, P., Vogelpohl, T.S., Rasin, J., et al. (1998). Correlates of disruptive behavior in severely cognitively impaired nursing home residents. The Gerontologist, 38, 189-198.
20. Becker, M., Andel, R., Boaz, T., & Howell, T. (2009). The association of individual and facility characteristics with psychiatric hospitalization among nursing home residents. International Journal of Geriatric Psychiatry, 24, 261-268.
21. Bellows, N.M., & Halpin, H.A. (2008). Impact of Medicaid reimbursement on mental health quality indicators. Health Services Research, 43, 582-597.
22. Bharucha, A.J., Dew, M.A., Miller, M.D., Borson, S., & Reynolds, C., III. (2006). Psychotherapy in long-term care: A review. Journal of the American Medical Directors Association, 7, 568-580.
23. Black, B.S., Rabins, P.V., German, P., McGuire, M., & Roca, R. (1997). Need and unmet need for mental health care among elderly public housing residents. The Gerontologist, 37, 717-728.
24. Blazer, D.G. (2003). Depression in late life: Review and commentary. Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 58, 249-265.
25. Bowie, C.R., Fallon, C., & Harvey, P.D. (2006). Convergence of clinical staff ratings and research ratings to assess patients with schizophrenia in nursing homes. Psychiatric Services, 57, 838-843.
26. Brannon, D., Smyer, M.A., & Cohn, M.D. (1992). Strategies for improving nursing home care: A research roundtable. Journal of Long Term Care Administration, 20 (4). 18-20.
27. Briesacher, B.A., Limcangco, M.R., Simoni-Wastila, L., Doshi, J.A., Levens, S.R., Shea, D.G., et al. (2005). The quality of antipsychotic drug prescribing in nursing homes. Archives of Internal Medicine, 165, 1280-1285.
28. Brown, J.F. (2005). Psychiatric emergency services: A review of the literature and a proposed research agenda. Psychiatric Quarterly, 76, 139-165.
29. Brown, M.N., Lapane, K.L., & Luisi, A.F. (2002). The management of depression in older nursing home residents. Journal of the American Geriatrics Society, 50, 69-76.
30. Burns, B.J., Scott, J.E., Burke, J.D., Jr., & Kessler, L.G. (1983). Mental health training of primary care residents: A review of recent literature (1974-1981). General Hospital Psychiatry, 5, 157-169.
31. Burns, B.J., Taube, C.A., Fogel, B.S., Furino, A., & Gottlieb, G.L. (1990). Mental health services in general medical care and in nursing homes. In B. S. Fogel, A. Furino, & G. L. Gottlieb (Eds.), Mental health policy for older Americans: Protecting minds at risk (pp. 63-84). Washington, DC: American Psychiatric Association.
32. Burns, W.J. (1998). Psychologists as mental health administrators. Ann Arbor, MI: ProQuest.
33. Carling, P.J. (1981). Nursing homes and chronic mental patients: a second opinion. Schizophrenia Bulletin, 7, 574-579.
34. Castle, N.G. (2001). Deficiency citations for mental health care in nursing homes. Administration and Policy in Mental Health, 29, 157-171.
35. Castle, N.G., & Mor, V. (1996). Hospitalization of nursing home residents: A review of the literature, 1980-1995. Medical Care Research and Review, 53, 123-148.
36. Castle, N.G., & Myers, S. (2006). Mental health care deficiency citations in nursing homes and caregiver staffing. Administration and Policy in Mental Health, 33, 215-225.
37. Castle, N.G., & Shea, D.G. (1998). The effects of for-profit and not-for-profit facility status on the quality of care for nursing home residents with mental illnesses. Research on Aging, 20, 246-263.
38. Colenda, C.C., Streim, J., Greene, J.A., Meyers, N., Beckwith, E., & Rabins, P. (1999). The impact of OBRA '87 on psychiatric services in nursing homes. American Journal of Geriatric Psychiatry, 7, 12-16.
39. Cook, E.A. (1991). The effects of reminiscence on psychological measures of ego integrity in elderly nursing home residents. Archives of Psychiatric Nursing, 5, 292-298.
40. Davis, M.A. (1991). On nursing home quality: A review and analysis. Medical Care Review, 48, 129-166.
41. Dobalian, A., Tsao, J.C., & Radcliff, T.A. (2003). Diagnosed mental and physical health conditions in the United States nursing home population: Differences between urban and rural facilities. Journal of Rural Health, 19, 477-483.
42. Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 44, 166-206.
43. Fenton, J., Raskin, A., Gruber-Baldini, A.L., Menon, A.S., Zimmerman, S., Kaup, B., et al. (2004). Some predictors of psychiatric consultation in nursing home residents. American Journal of Geriatric Psychiatry, 12, 297-304.
44. Frey, D.E., Kelbley, T.J., Durham, L., & James, J.S. (1992). Enhancing the self-esteem of selected male nursing home residents. The Gerontologist, 32, 552-557.
45. Fullerton, C.A., McGuire, T.G., Feng, Z., Mor, V., & Grabowski, D.C. (2009). Trends in mental health admissions to nursing homes, 1999-2005. Psychiatric Services, 60, 965-971.
46. Glaister, J.A., & Blair, C. (2008). Improved education and training for nursing assistants: Keys to promoting the mental health of nursing home residents. Issues in Mental Health Nursing, 29, 863-872.
47. Goldman, H.H., Feder, J., & Scanlon, W. (1986). Chronic mental patients in nursing homes: Reexamining data from the National Nursing Home Survey. Hospital & Community Psychiatry, 37, 269-272.
48. Goldwasser, A.N., Auerbach, S.M., & Harkins, S.W. (1987). Cognitive, affective, and behavioral effects of reminiscence group therapy on demented elderly. International Journal of Aging and Human Development, 25, 209-222.
49. Grabowski, D.C. (2001). Medicaid reimbursement and the quality of nursing home care. Journal of Health Economics, 20, 549-569.
50. Grabowski, D.C., Aschbrenner, K.A., Feng, Z., & Mor, V. (2009). Mental illness in nursing homes: Variations across States. Health Affairs (Millwood). 28, 689-700.
51. Grabowski, D.C., Stewart, K.A., Broderick, S.M., & Coots, L.A. (2008). Predictors of nursing home hospitalization: A review of the literature. Medical Care Research and Review, 65, 3-39.
52. Gruneir, A., Lapane, K.L., Miller, S.C., & Mor, V. (2008). Does the presence of a dementia special care unit improve nursing home quality ? Journal of Aging and Health, 20, 837-854.
53. Gupta, S., & Goldstein, M.Z. (1999). Practical geriatrics: Psychiatric consultation to nursing homes. Psychiatric Services, 50, 1547-1550.
54. Haight, B.K., Michel, Y., & Hendrix, S. (1998). Life review: Preventing despair in newly relocated nursing home residents short- and long-term effects. International Journal of Aging and Human Development, 47, 119-142.
55. Health Care Financing Administration. (1991). Medicare and Medicaid: Requirements for long-term care facilities, final regulations. Federal Register, 56, 48865-48921.
56. Health Care Financing Administration. (1992). Medicare and Medicaid Programs: Preadmission screening and annual resident review. Final Rule with Comment. Federal Register, 56, 48865-48921.
57. Health Care Financing Administration. (1995). State operations manual: Provider certification. Washington, DC: Department of Health and Human Services.
58. Heston, L.L., Garrard, J., Makris, L., Kane, R.L., Cooper, S., Dunham, T., et al. (1992). Inadequate treatment of depressed nursing home elderly. Journal of the American Geriatrics Society, 40, 1117-1122.
59. Hillmer, M.P., Wodchis, W.P., Gill, S.S., Anderson, G.M., & Rochon, P.A. (2005). Nursing home profit status and quality of care: Is there any evidence of an association ? Medical Care Research and Review, 62, 139-166.
60. Holmes, D., Teresi, J., & Kong, J. (2000). Service inputs and costs of care related to outcomes among cognitively impaired nursing home residents. Journal of Mental Health Policy and Economics, 3, 121-127.
61. Hughes, C.M., & Lapane, K.L. (2005). Administrative initiatives for reducing inappropriate prescribing of psychotropic drugs in nursing homes: How successful have they been ? Drugs & Aging, 22, 339-351.
62. Hughes, C.M., Lapane, K.L., & Mor, V. (2000). Influence of facility characteristics on use of antipsychotic medications in nursing homes. Medical Care, 38, 1164-1173.
63. Jencks, S.F., Goldman, H.H., & McGuire, T.G. (1985). Challenges in bringing exempt psychiatric services under a prospective payment system. Hospital and Community Psychiatry, 36, 764-769.
64. Institute of Medicine. (1986). Improving the quality of care in nursing homes. Washington, DC: National Academies Press.
65. Jones, E.D. (2003). Reminiscence therapy for older women with depression. Effects of nursing intervention classification in assisted-living long-term care. Journal of Gerontological Nursing, 29, 26-33.
66. Jones, R.N., Marcantonio, E.R., & Rabinowitz, T. (2003). Prevalence and correlates of recognized depression in U.S. nursing homes. Journal of the American Geriatrics Society, 51, 1404-1409.
67. Jongenelis, K., Pot, A.M., Eisses, A.M., Beekman, A.T., Kluiter, H., van Tilburg, W., et al. (2003). Depression among older nursing home patients. A review. Tijdschrift voor gerontologie en geriatrie, 34(2), 52-59.
68. Kamble, P., Chen, H., Sherer, J., & Aparasu, R.R. (2008). Antipsychotic drug use among elderly nursing home residents in the United States. American Journal of Geriatric Pharmacotherapy, 6, 187-197.
69. Karlawish, J. (2006). Alzheimer's disease-Clinical trials and the logic of clinical purpose. New England Journal of Medicine, 355, 1604-1606.
70. Krauss, N.A., & Altman, B.M. (1998). Characteristics of nursing home residents-1996. Rockville, MD: Agency for Health Care Policy and Research.
71. Kruzich, J.M. (1986). The chronically mentally ill in nursing homes: Issues in policy and practice. Health & Social Work, 11 (1). 5-14.
72. Kunik, M.E., Ponce, H., Molinari, V., Orengo, C., Emenaha, I., & Workman, R. (1996). The benefits of psychiatric hospitalization for older nursing home residents. Journal of the American Geriatrics Society, 44, 1062-1065.
73. Lantz, M.S., Giambanco, V., & Buchalter, E.N. (1996). A ten-year review of the effect of OBRA-87 on psychotropic prescribing practices in an academic nursing home. Psychiatric Services, 47, 951-955.
74. Lapane, K.L., & Hughes, C.M. (2004). Which organizational characteristics are associated with increased management of depression using antidepressants in US nursing homes ? Medical Care, 42, 992-1000.
75. Lawton, M.P., Casten, R., Parmelee, P.A., Van Haitsma, K., Corn, J., & Kleban, M.H. (1998). Psychometric characteristics of the minimum data set II: Validity. Journal of the American Geriatrics Society, 46, 736-744.
76. Levin, C.A., Wei, W., Akincigil, A., Lucas, J.A., Bilder, S., & Crystal, S. (2007). Prevalence and treatment of diagnosed depression among elderly nursing home residents in Ohio. Journal of the American Medical Directors Association, 8, 585-594.
77. Lieff, S.J., & Silver, I.L. (2001). Planning mental health educational programs for long-term care. In D. C. Conn, N. Herrmann, A. Kaye, D. Rewilak, & B. Schogt (Eds.), Practical psychiatry in the long term care facility: A handbook for staff (2 nd ed., pp. 239-248). Kirkland. WA: Hogrefe & Huber.
78. Linkins, K.W., Lucca, A.M., Housman, M., & Smith, S.A. (2006). Use of PASRR programs to assess serious mental illness and service access in nursing homes. Psychiatric Services, 57, 325-332.
79. Llorente, M.D., Olsen, E.J., Leyva, O., Silverman, M.A., Lewis, J.E., & Rivero, J. (1998). Use of antipsychotic drugs in nursing homes: current compliance with OBRA regulations. Journal of the American Geriatrics Society, 46, 198-201.
80. Magaziner, J., German, P., Zimmerman, S.I., Hebel, J.R., Burton, L., Gruber-Baldini, A.L., et al. (2000). The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: Diagnosis by expert panel. Epidemiology of dementia in Nursing Homes Research Group. The Gerontologist, 40, 663-672.
81. Magaziner, J., Zimmerman, S.I., Fox, K.M., & Burns, B.J. (1998). Dementia in United States nursing homes: Descriptive epidemiology and implications for long-term residential care. Aging & Mental Health, 2, 28-35.
82. Mallick, M.J., & Whipple, T.W. (2000). Validity of the nursing diagnosis of relocation stress syndrome. Nursing Research, 49 (2). 97-100.
83. Mechanic, D., & McAlpine, D.D. (2000). Use of nursing homes in the care of persons with severe mental illness: 1985 to 1995. Psychiatric Services, 51, 354-358.
84. Mercer, S.O., Heacock, P., & Beck, C. (1993). Nurse's aides in nursing homes: Perceptions of training, work loads, racism, and abuse issues. Journal of Gerontological Social Work, 21, 95-112.
85. Moak, G.S., Borson, S., & Jackson, J. (2000, June). The AAGP long term care survey. Paper presented at the Long-Term Care Consensus Conference of the American Association for Geriatric Psychiatry, Washington, DC.
86. Mor, V., Zinn, J., Angelelli, J., Teno, J.M., & Miller, S.C. (2004). Driven to tiers: Socioeconomic and racial disparities in the quality of nursing home care. Milbank Quarterly, 82, 227-256.
87. Nishtala, P.S., McLachlan, A.J., Bell, J.S., & Chen, T.F. (2009). Determinants of antidepressant medication prescribing in elderly residents of aged care homes in Australia: A retrospective study. American Journal of Geriatric Pharmacotherapy, 7, 210-219.
88. Office of Inspector General. (2001). Medicare payments for psychiatric services in nursing homes: A follow-up. Washington, DC: U.S. Department of Health and Human Services.
89. Ouslander, J.G., Weinberg, A.D., & Phillips, V. (2000). Inappropriate hospitalization of nursing facility residents: A symptom of a sick system of care for frail older people. Journal of the American Geriatrics Society, 48, 230-231.
90. Ravelli, D.P., Buwalda, V.J., Slooff, C.J., Schrijvers, A.J., & van Engeland, H. (2003). Do integrated mental healthcare organisations facilitate process quality in the treatment of people with schizophrenia and related psychoses? International Journal of Integrated Care, 3, e 17.
91. Reichman, W.E., Coyne, A.C., Borson, S., Negron, A.E., Rovner, B.W., Pelchat, R.J., et al. (1998). Psychiatric consultation in the nursing home: A survey of six states. American Journal of Geriatric Psychiatry, 6, 320-327.
92. Rigler, S.K., Perera, S., Redford, L., Studenski, S., Brown, E.F., Wallace, D., et al. (2003). Urban-rural patterns of increasing antidepressant use among nursing facility residents. Journal of the American Medical Directors Association, 4, 67-73.
93. Sakauye, K.M., & Camp, C.J. (1992). Introducing psychiatric care into nursing homes. The Gerontologist, 32, 849-852.
94. Schmidt, L.J., Reinhardt, A.M., Kane, R.L., & Olsen, D.M. (1977). The mentally ill in nursing homes. New back wards in the community. Archives of General Psychiatry, 34, 687-691.
95. Schneider, L.S., Dagerman, K.S., & Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. Journal of the American Medical Association, 294, 1934-1943.
96. Shadish, W.R., Jr., & Bootzin, R.R. (1984). Nursing homes: The new total institution in mental-health policy. International Journal of Partial Hospitalization, 2, 251-262.
97. Shea, D.G., Russo, P.A., & Smyer, M.A. (2000). Use of mental health services by persons with a mental illness in nursing facilities: Initial impacts of OBRA87. Journal of Aging and Health, 12, 560-578.
98. Shea, D.G., Streit, A., & Smyer, M.A. (1994). Determinants of the use of specialist mental health services by nursing home residents. Health Services Research, 29, 169-185.
99. Sherwood, S., & Mor, V. (1980). Mental Health Institutions and the Elderly. In J. E. Birren & R. B. Sloane (Eds.), Handbook of mental health and aging (2 nd ed., pp. 400-428). Englewood Cliffs, NJ: Prentice Hall.
100. Sirey, J.A., Bruce, M.L., Carpenter, M., Booker, D., Reid, M.C., Newell, K.A., et al. (2008). Depressive symptoms and suicidal ideation among older adults receiving home delivered meals. International Journal of Geriatric Psychiatry, 23, 1306-1311.
101. Smith, M., Mitchell, S., Buckwalter, K.C., & Garand, L. (1994). Geropsychiatric nursing consultation: A valuable resource in rural long-term care. Archives of Psychiatric Nursing, 8, 272-279.
102. Smyer, M.A. (1989). Nursing homes as a setting for psychological practice. American Psychologist, 44, 1307-1314.
103. Smyer, M.A., Shea, D.G., & Streit, A. (1994). The provision and use of mental health services in nursing homes: Results from the National Medical Expenditure Survey. American Journal of Public Health, 84, 284-287.
104. Snowden, M., & Roy-Byrne, P. (1998). Mental illness and nursing home reform: OBRA-87 ten years later. Psychiatric Services, 49, 229-233.
105. Stevenson, D.G., Decker, S.L., Dwyer, L.L., Huskamp, H.A., Grabowski, D.C., Metzger, E.D., et al. (In press). Antipsychotic and benzodiazepine use among nursing home residents: Findings from the 2004 National Nursing Home Survey. American Journal of Geriatric Psychiatry.
106. Streim, J.E., Beckwith, E.W., Arapakos, D., Banta, P., Dunn, R., & Hoyer, T. (2002). Mental health services in nursing homes: Regulatory oversight, payment policy, and quality improvement in mental health care in nursing homes. Psychiatric Services, 53, 1414-1418.
107. Svarstad, B.L., Mount, J.K., & Bigelow, W. (2001). Variations in the treatment culture of nursing homes and responses to regulations to reduce drug use. Psychiatric Services, 52, 666-672.
108. Tariot, P.N., Podgorski, C.A., Blazin, L., & Leibovici, A. (1993). Mental disorders in the nursing home: Another perspective. American Journal of Psychiatry, 150, 1063-1069.
109. Wagenaar, D., Colenda, C.C., Kreft, M., Sawade, J., Gardiner, J., & Poverejan, E. (2003). Treating depression in nursing homes: Practice guidelines in the real world. Journal of the American Osteopathic Association, 103, 465-469.
110. Williams, L. (2000). Long-term care after Olmstead v. L.C.: Will the potential of the ADA's integration mandate be achieved ? Journal of Contemporary Health Law & Policy, 17, 205-239.
111. Yakimo, R., Kurlowicz, L.H., & Murray, R.B. (2004). Evaluation of outcomes in Psychiatric Consultation-Liaison Nursing practice. Archives of Psychiatric Nursing, 18, 215-227.
112. Zerhusen, J.D., Boyle, K., & Wilson, W. (1991). Out of the darkness: Group cognitive therapy for depressed elderly. Journal of Psychosocial Nursing & Mental Health Services, 29, 16-21.
113. Zimmerman, D.R., Karon, S.L., Arling, G., Clark, B.R., Collins, T., Ross, R., et al. (1995). Development and testing of nursing home quality indicators. Health Care Financing Review, 16, 107-127.