Understanding Frailty in Senior Housing Using Medicare Claims Data

In a discussion addressing gaps in care at the 2023 NIC Spring Conference, Dr. Bruce Leff, Director of The Center for Transformative Geriatric Research and Professor of Medicine at Johns Hopkins University, addressed the importance of understanding the functional status of residents.  

“Functional status is the biggest empty spot in most of the data discussions we have – and functional status predicts everything.”  – Dr. Bruce Leff 

Leff also emphasized the importance of being able to accurately describe the resident populations that live within a senior housing community when working with payors or having policy discussions with Centers for Medicare and Medicaid Services (CMS). Unfortunately, as he highlights, getting to this data is no easy feat.  

Assessing Resident Health Status

Nursing care communities collect a standard set of data on every resident, known as the Minimum Data Set (MDS). The MDS is a standardized assessment tool that measures the health status of every resident, and this assessment occurs on a regular, recurring basis. Unlike nursing care communities, however, there is no standard set of care metrics that are consistently collected on residents entering senior housing communities.  

It is with these thoughts in mind that NIC engaged NORC at the University of Chicago to collaborate on further research into the topic of frailty across senior housing and care settings. With the aim of giving more insight into the issue, the research study looks to improve care for older adults across the care continuum as well as drive new investment into the senior housing and care sectors.  

Understanding Frailty

Frailty is a state of age-related decline and vulnerability characterized by decreased physiological reserves and vulnerability typically seen with advanced age. Frailty is a key determinant of health status and outcomes of health care interventions in older adults. Falls, impairment, disability, hospitalization, and mortality are all associated with frailty.  

On average, frailty impacts one in six community-dwelling older adults, but the prevalence differs by setting and by population characteristics. There is current consensus, however, that frailty is potentially reversible with appropriate interventions including physical activity, nutrition, and cognitive training in older adults. As such, monitoring frailty indicators in senior housing settings is recommended to identify residents who could benefit from disability prevention programs.  

Measuring Frailty

Despite frailty being of such high importance, it has not been readily measured using Medicare data until recently. Over the last several years, there has been increasing effort to measure frailty using U.S. Medicare data.  

One such effort is Harvard University’s Claims-Based Frailty Index (CFI). The CFI measures frailty from administrative claims data over a twelve-month period using CPT, ICD, and HCPCS diagnoses codes. Unique weights attached to each diagnoses code are used to create a CFI score for each individual.  

The CFI goes beyond simply identifying a Medicare beneficiary as frail or not. In these indices, frailty is stratified by risk – non-frail, pre-frail, mildly frail, moderately frail, and severely frail. These frailty stratifications can be used to broadly anticipate changes in hospitalization rates and healthcare spending. 

The methodology employed for the NIC-sponsored NORC research study is done by linking Medicare administrative and claims data with the NIC MAP Vision property database, which includes over 14,000 senior housing and care properties. This methodology, along with the Claims-Based Frailty Index, enables NORC to gain insight into the prevalence of various conditions – heart disease, pulmonary disease, mental health, diabetes, chronic kidney disease, and dementia, for example – by property type as well as identify useful patterns leading to move-in at a senior housing and care community. Findings will also provide insight into the proportion of risk-stratified frailty within each care segment. 

Using Frailty Measures in Senior Housing

For senior housing and care operators and investors, the benefits that come with an improved understanding of frailty and its impacts on the senior population are extremely important. Operators and investors alike would be able to know which market areas had the highest prevalence of frail seniors, which would be pivotal when looking at opportunities for new communities.  

Taken even further, frailty measures could be used to identify inflection points in health and functional status that result in moves to senior housing. Across a given market area, these inflection points could characterize near-term demand for senior housing and care communities. The ability to predict move-in to senior housing and care based on Medicare claims data could be immensely valuable. 

Because of how impactful these predictions could be for the senior housing and care industry, there is mounting interest in the study findings.  

The research study will aim to answer the following questions: 

• What are common medical events and diagnoses that may precede a move to senior housing? 
• How does the relative gradual decline compare to certain precipitating events? 
• What do frailty levels look like within each care segment (IL, AL, MC, NC, and CCRC)? 

The frailty study being conducted by NORC at the University of Chicago is currently underway. Study deliverables are slated to be released in September 2023 and will be addressed at the inaugural NIC Data & Analytics Conference, being held September 27-28, 2023, in Minneapolis, MN.