This dissertation research examines Residential Care Facilities for the Elderly (RCFEs), often referred to as Assisted Living (AL), by considering policy and regulation, state licensing and monitoring systems and concerns regarding quality of care.

The first study examines the intended and unintended consequences of federal and state policy and regulation affecting the Residential Care/Assisted Living industry. An economic framework forms the basis for the examination of two broad effects of policy: the availability of assisted living facilities, and residents' ability to afford those services. The conceptual framework is described and progresses through a description of illustrative policy domains and intended and unintended consequences are discussed.

The second study proposes an adaptation of the Donabedian structure-process-outcome theory as a framework for designing and more effectively using the administrative data collected in the licensing and regulation of Residential Care/Assisted Living facilities. Structural components are represented by facility, staff and resident characteristics. Process components include the types of services available and safety and injury prevention. Possible outcome measures include deficiencies and complaints, changes of resident health status and quality indicators, and discharge and medical event data. Emphasis is on measures available in administrative records.

The last study was designed to evaluate the applicability of adapting the State of California administrative data regarding Residential Care Facilities for the Elderly (RCFEs) into a statewide system to monitor the quality of care provided. A randomly selected sample of 340 facilities was identified from the 3349 facilities licensed in Northern and Central California. Stratification of the sample was by facility capacity and State district office. Data collection consisted of a five-year retrospective review of the public files maintained across offices. A conceptual framework was developed to identify components thought to be indicative of quality of care. Such information was abstracted from the public files for data analyses. Collected data were analyzed using various descriptive statistics. Findings suggest that substantial limitations in current State data sources exist, as do concerns regarding quality of care. Suggestions are made to inform future researchers to further evaluate and improve the current monitoring system and develop a comprehensive, accessible information system.

Purpose: This study describes hospital revenue for direct participation in the safety net--treating the poor--from 2006 through 2008 and associations with environmental and organizational factors of theoretical interest.

Background and Significance: During the past 40 years U.S. hospital care has decentralized and grown increasingly competitive. Vague or overly detailed hospital regulations provide no specific goals regarding care for the poor. Studies have documented concentration of hospital safety net care, and a need for new outcome measures. This study uses hospital safety net revenue to measure theoretically responsive behavior by hospitals to serve poor populations.

Design and Analysis: This research includes secondary analysis of hospital safety net revenues from OSHPD's Hospital Annual Financial Report Data, 2004 through 2005, and 2006 through 2008. Safety net revenues were compared as organizational and market shares. Hospital isomorphism toward low shares prompted the use of logistic regression to test the effect of factors on the odds of participation above an equal distribution.

Key Findings: The 70 hospitals with high safety-net revenue as both organizational and market shares accounted for $7.7 billion of $11.5 billion in total safety net revenue. These hospitals were positively associated with concentrated markets, clinical teaching, larger size, less medically complex patients, and city/county or nonprofit ownership.

Hospitals with high safety net revenue as market share only earned $1.1 billion of total safety net revenue. These facilities were positively associated with location in a concentrated market, increased size, nonprofit ownership, and system affiliation.

Hospitals with high safety net revenue as organizational share only earned $1 billion of total safety-net revenue. This group was more likely than the others to be located in a more competitive county, independently operated by investors or a public district, smaller and treating less medically complicated patients.

Implications: Regulators should work to encourage hospital safety net participation and better distribute the burden of low margin hospital care. Additional research is needed on hospital ownership, access, and quality, especially regarding patient acuity.

Background: Through years of observational research it has become accepted that the influenza (flu) vaccination reduces mortality in an older population. However, despite 50 years of targeted administration, the national statistics for influenza-related mortality among the elderly are unchanged.

Objectives: We attempt to distinguish vaccine effective from selection bias using data from a California Veterans Medical Centers (n=38,736) age 65 and older.

Methods: Two methods were used to differentiate effect from bias. The first method was the development of a 24 month mortality prediction logistic model. The second method was stratification by risk of death into deciles from low risk (0.03) to high risk (0.59) and evaluating the vaccine's effect on mortality within each decile.

Results: There was very little change in model concordance between the model with influenza vaccine (77.8%) as a variable and the model without influenza vaccine (77.7%). For the division by risk deciles, we had precision to the third decimal point and could not detect a vaccine effect.

Discussion: We evaluated all-cause mortality across 7 years, starting in October of 2002 and ending September 2009, in an elderly California Veteran population. During this time there were 7,944 deaths. Vaccine coverage averaged 42%. We could detect no overt effect of the current vaccine dose given to veterans.

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