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Promoting Quality Care in the Nursing Home
INTRODUCTION
As of 2000, 1.6 million elderly and disabled Americans received care in approximately 17,000 nursing homes across the United States. The Medicaid program pays for the care of about two-thirds of nursing home residents and is responsible for about half of nursing home revenues, while Medicare pays for the care of about 10% of residents, accounting for 12% of nursing home revenues.1 As the largest purchaser of nursing home services, the Centers for Medicare & Medicaid Services (CMS) has a vested interest in the quality of nursing home care. In 2001, CMS launched the Nursing Home Quality Initiative (NHQI), embracing principles of continuous quality improvement as a means of improving the quality of care provided in nursing homes.2,3 This is a laudable attempt to promote quality that branches away from the regulatory role traditionally played by CMS. The quality of care provided in nursing homes has long been an issue of public concern.
Despite previous legislative attempts at reform, such as the Nursing Home Reform Act in 1987, the concern persists. Nursing home litigation is on the rise. The average long-term care general liability and professional liability costs per annual occupied skilled nursing bed have increased from $310 in 1992 to $2290 in 2003. The average size of a claim has more than doubled from $65,000 in 1992 to just under $150,000 in 2003. Countrywide, long-term care operators now incur 15.3 claims per year for every 1000 occupied skilled nursing care beds. This rate is three times higher than the 1992 frequency rate of 4.8 claims per 1000 beds.4 Even if these trends are not an accurate reflection of current trends in the quality of care, numerous government reports from the General Accounting Office and the Institute of Medicine have highlighted the problems that exist in nursing home care.5-8
In recent years, the number of nursing home beds has not significantly increased as predicted but increasing demand is still expected. In 1990, the Senate Aging Committee predicted that 2.1 million older persons would be in nursing homes by 2005, based on the best data then available. Newly analyzed 1999 data show that this predicted level will be pushed back to 2017 if the 1999 rate continues. And, if recent rates of decline in utilization continue, the nursing home population will not reach 2.1 million until 2034.9 Since the oldest baby boomer will not turn 85 until 2030, time is available to fix the major quality issues that plague nursing home care before we experience a marked increase in the number of older adults requiring these services.
A HISTORICAL PERSPECTIVE ON QUALITY
In the U.S., nursing homes evolved during the 20th century out of the 19th century poorhouses. This meager beginning meant that public old-age homes remained institutions of last resort with no clear standards of care until the situation began to change in the 1950s with the Hill-Burton Act. This federal legislation provided subsidies to build nursing homes according to construction standards that mirrored acute care hospitals. Although safety has improved, the institutional nature of nursing homes continues to plague the industry into the 21st century.10 There were few external pressures to improve or standardize the quality of care provided in nursing homes until 1965 when Medicare and Medicaid were established. With this expansion of public financing, standards of eligibility were established. However, many homes struggled to meet these standards; to avoid exclusion from the program, a category of “substantial compliance” was established to give homes more time to comply, but many never reached full compliance and were not sanctioned in the process.10 The 1970s was a decade of growth in the nursing home industry, mostly in the for-profit sector. Scandals in the industry due to poor quality of care led to an outcry for more stringent standards of care along with the means to enforce these standards.7
More than ever, government regulation was seen as the means to achieve these goals. The Nursing Home Reform Act became part of the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87). OBRA ‘87 brought about federal regulations with minimum staffing requirements for registered nurses and licensed practical nurses, and minimum training requirements for nurse aides. The new regulations emphasized chemical and physical restraint reduction, reduction in the use of urinary catheters, and attaining and maintaining the highest possible level of physical, mental, and psychosocial well-being.11 It also brought about the availability of greater enforcement sanctions. Remedies included civil monetary penalties, a directed plan of correction, installation of temporary management, and payment denials for all new or current Medicare and Medicaid admissions. All nursing homes that receive Medicare or Medicaid funding now undergo annual unannounced surveys, during which a subset of patients and family members are interviewed, in addition to a review of their medical charts and care plans in order to confirm consistency between the resident’s record, condition, and care.
Each deficiency identified is categorized according to the extent of patient harm (severity) and the number of adversely affected residents (scope). The severity and scope of the deficiencies identified determine how the facility is penalized. The federal government now conducts validation surveys of at least 5% of the total number of facilities surveyed during each year in each state. An additional major quality initiative of OBRA ‘87 was the introduction of the Resident Assessment Instrument that must be completed on individual residents at admission, yearly and quarterly intervals, and at any substantial change in status; these assessments form the Minimum Data Set (MDS). Prior to OBRA ‘87, each nursing facility used its own assessment procedures to collect data to determine nursing care plans. The MDS has provided a national standard that is not only a tool for internal care planning, but is also used to determine levels of reimbursement for Medicare patients and individual facility performance on quality indicators. All MDS data are now transmitted electronically to state and federal regulators to a national database, On-line Survey, Certification, and Reporting (OSCAR). The effectiveness of OBRA ‘87 in improving nursing home quality has been hotly contested. Overall it seems there have been substantial improvements. The most consistent change has been decreased use of restraints.8,12
NURSING HOME QUALITY INITIATIVE
OBRA ‘87, and especially the introduction of the MDS, set the stage for the current NHQI, begun by CMS in 2001.3 Medicare and Medicaid expenditures for nursing home care totaled approximately $55 billion in 2002.13 As the largest purchaser of nursing home care, CMS has adopted a three-pronged approach to improve the quality of health care in nursing homes by: (1) delivering reliable information to beneficiaries about quality of care in individual nursing homes; (2) improving quality for nursing homes through enhanced technical assistance; and (3) maintaining quality monitoring and enforcing regulations. This approach is heavily reliant on principles of continuous quality improvement, a concept first embraced by manufacturing.
Continuous quality improvement is a philosophy and an attitude for analyzing capabilities and processes and improving them repeatedly to achieve the objective of customer satisfaction. It does not emphasize blame but, instead, promotes innovation and focuses on a team approach to improving care that incorporates workers at every level of the organization. In preparation for quality reporting to beneficiaries, CMS embarked on a process that identified quality indicators, reviewed their value, and in some cases developed new indicators.14 These quality indicators include disease-specific outcomes of care, patient and family satisfaction, functional status, utilization of health care resources, and standardization of care processes. A small number of quality indicators that could be calculated from the MDS were selected for national reporting on the CMS website Nursing Home Compare (www.medicare.gov/nhcompare) and for reporting in local newspapers. After a brief pilot project, national reporting for all facilities began in 2002.
Although the process of selecting and utilizing quality indicators has been based on the best available research and scientific process, many issues remain. These issues relate to measurement methods and tools, uses of quality data, organizational and cultural factors, information and informatics, and the impact of evaluation and research. For example, how well do quality measures identify nursing homes with better health outcomes? How should appropriate goals or benchmarks for quality improvement be established? Can a single set of outcomes measures serve well for public reporting and internal quality improvement for facilities? Does organizational structure affect quality outcomes? Do the burden of data collection and the timeliness of available quality data affect quality outcomes? Does public reporting of quality measures improve health outcomes? These are the strategic issues that would be valuable in advancing quality and outcomes research in the near future.13
The reason to provide quality data to consumers is so that market forces will drive the industry toward quality improvement and healthy competition. Unfortunately, it is questionable whether consumers truly have a choice in nursing home care. The number of nursing home beds is tightly controlled in most states in an effort to minimize Medicaid expenditures. Desirable nursing homes have long waiting lists. Most nursing home patients are admitted from hospitals. To minimize hospital length of stay, patients are strongly encouraged to take the first nursing home bed that is made available. If a patient wants a nursing home bed close to home in their county of residence, they may have little choice in the actual facility. The other new facet of the CMS approach to improve health care quality is offering technical assistance to providers of nursing home services. This assistance has been provided to facilities through CMS funding to each state’s quality improvement organization (QIO). These organizations chose clinical topics for their services, provided some assistance to all facilities, and provided more intensive training for approximately 10% of the facilities in their state.
Data on quality indicators are now being collected and will be analyzed to determine whether participation in these intensive quality improvement initiatives has produced improvements in relevant quality indicators. How effective these initial efforts prove to be will likely influence whether this type of funding continues to be made available. The QIOs work with local and national experts to collect and disseminate best-practice guidelines and develop their own methods for teaching and promoting continuous quality improvement. Even with these new resources, continuous quality improvement has not been uniformly adopted within the nursing home industry. In a study of 35 nursing homes maintained by the Department of Veterans Affairs, quality improvement (QI) implementation, described as a structured, organization-wide approach to improving underlying work processes, was measured by surveying employees.15
Quality improvement implementation was found to be greater in nursing homes with an organizational culture that emphasized innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation reported greater job satisfaction and were more likely to report adoption of specific clinical guidelines. However, there was no significant association between QI implementation and adherence to pressure ulcer guideline recommendations, as abstracted from patient records, or the rate of pressure ulcer development. It would seem that many nursing homes simply have not made a concerted effort to adopt this methodology, perhaps because they have not yet been convinced that it will serve to improve quality. This lack of adoption of quality improvement methods is probably not because of a lack of appropriate standards or assessment methods. Guidelines for prevention and management of specific medical conditions that are prevalent in nursing homes, such as pressure ulcers and urinary incontinence, are available as are a growing number of quality assessment tools.16-20 Yet, review of specific quality indicators for these problems would indicate that implementation of the guidelines and use of the quality assessment tools is low and widely variable.21
LOOMING DETERRENTS
Although many stakeholders applaud CMS’ new emphasis on quality that extends far beyond the traditional sphere of monitoring and enforcement of regulations, several factors may derail these efforts. As other care options have become available, such as assisted living and home care services, the nursing home population has become limited to the frailest and most functionally impaired older adults, a trend that serves to increase care needs. The reasons for older adults utilizing nursing services are becoming more heterogeneous.
Nursing homes provide rehabilitation services for acutely ill short-stay residents, custodial care for chronically ill long-stay residents, and palliative care for residents in the final stages of terminal illness. More than half of nursing home residents suffer from some form of dementia, and many have behaviors that make it difficult to provide safety and basic care. Providing quality care to this diverse and vulnerable group of individuals is challenging; properly assessing that quality is an even more significant challenge. Greater attention to staffing issues has been proposed as an important focus for effective quality improvement. Most of the care that residents of nursing homes receive is provided by certified nursing assistants (CNAs). These jobs are very low-paying; in North Carolina in 2000, the median hourly wage was $7.86 with an annualized wage of $16,356.22 Benefits such as health care are often lacking or are too expensive.
Literacy and English language proficiency hinder training and care provision. CNA turnover rates exceed 60% in 65% of states, exceed 80% in 37% of states, and are above 100% in 20% of states.23 Many stakeholders are advocating for improved compensation and benefits, established means of job advancement, professional organization of CNAs, and more favorable staffing ratios.22,24 Resident satisfaction with staff care has been shown to have a positive effect on other aspects of resident satisfaction, including the room, the facility as a whole, social interactions, and meals.25
Furthermore, staffing level has been found to be a strong predictor of the amount of time that patients were observed in bed, even when other important predictors were controlled.26 Staffing levels have been predictive of other quality measures that are particularly related to the care provided by nurse aides.27 Inasmuch as total quality improvement methodology overlooks chronic entrenched issues such as inadequate training of care providers, low numbers of care providers, and lack of substantial financial remuneration, it may be insufficient to bring substantial quality improvement to the nursing home industry. The financial instability of the nursing home industry looms as another issue hindering the advancement of quality health care for older adults. In September 2000, before the Senate Special Committee on Aging, Steven Pelovitz, Director of the Survey and Certification Group of CMS, reported that approximately 9% of nursing homes nationally were operating in bankruptcy.1 This was particularly scrutinized at the time because of the implementation of the Prospective System for nursing homes in 1998. On the other hand, the majority of nursing homes in the United States are proprietary (for-profit), and the debate continues to rage regarding whether this business arrangement has a significant effect on quality.
Nonproprietary homes have fewer Medicare and Medicaid residents and a greater percentage of residents who pay for services out of personal funds, thus more opportunity to raise rates and revenue as quality rises, which may account for observed differences in quality measures. However, proprietary status alone may not be the real issue but, rather, excessive profit margins. A recent study of proprietary homes found differences in the number and severity of deficiency citations among homes with the highest profit margin.28 Excessive profit margins may have a negative effect on quality of care. Rapidly increasing liability insurance rates for nursing homes is another substantial financial issue that threatens the stability of the industry. Since 1995, lawsuits against nursing homes have increased dramatically, especially in Florida, Texas, and other southern states. Prior to 1995, industry liability rates per nursing home bed were typically about 7% of the rates per hospital bed. Currently rates are as high as 100% of the hospital rates.
Several factors may have contributed to the increasing number of lawsuits and the size of the claims. For example, many states have enacted legislation to protect nursing home residents against abuse, to guarantee a minimum standard of care, and to establish residents’ bill of rights. Such standards have been viewed to increase support for plaintiff’s claims. Furthermore, law firms have begun to specialize in nursing home litigation. Many insurance companies have stopped offering nursing home liability insurance.29 The data on this subject are sparse and potentially biased according to a report by the AARP. Better data should soon be available with the publication of a report commissioned by the Department of Health and Human Services. Potential solutions that might make liability insurance more readily available include limits on residents’ right to sue, so-called tort reform, strengthening enforcement of nursing home quality standards, risk management, experience ratings (ie, rate nursing homes on the basis of risk to the insurer), alternatives to traditional insurance (eg, joint underwriting), and strengthening regulation of the insurance industry, which may be overcharging customers with inflated loss development factors and excessive trend factors.30
OTHER APPROACHES TO IMPROVED HEALTH CARE DELIVERY
At present, it seems that continuous quality improvement will be the primary means of achieving quality improvement in nursing home health care delivery. Yet, other approaches continue to be tested and promoted. For example, nursing home advocacy groups are strongly promoting the formation of family counsels within nursing facilities to advocate more effectively regarding issues of concern within the facility.31 Involvement of families and friends is a common-sense approach to promotion of quality care. Nurse practitioners are advanced practice nurses with master’s degrees and training in medical assessment and treatment, who work under the direction of a physician. Nurse practitioners represent a financially viable means for early assessment and treatment of frail, chronically ill residents before their condition deteriorates and requires hospitalization. Nurse practitioners also contribute to the training of other nursing staff and this can markedly improve the early detection and treatment of acute illness and other health problems.32
Physician involvement and communication with nursing staff have been perceived as chronically inadequate.33 Physicians are finding it increasingly difficult to follow their patients when they move to nursing homes. Most physicians restrict their involvement to one or two facilities. For most physicians, it is time-inefficient and financially burdensome to travel to numerous homes to see a handful of patients. This barrier is necessitating change in the nursing home environment. More physicians are “specializing” in nursing home care by exclusively practicing in this setting, thus establishing more effective relationships with the nursing home staff to more positively impact quality of care. Some physicians may employ nurse practitioners who manage resident care issues on a daily basis. In some instances, nurse practitioners are employed directly by nursing homes to provide day-to-day medical care services, thus providing consistent and timely attention to medical management issues. Models for nurse practitioner employment by the physician or the clinical agency are financially feasible.
The involvement of nurse practitioners, physician assistants, and specializing physicians may serve to improve the overall quality of care.34 Physicians have the opportunity to provide leadership and contribute to enhancing the care provided in nursing facilities. The position of the nursing home medical director was mandated by federal regulations in 1974 and strengthened in OBRA ‘87 as a means of improving physician participation and enhancing the quality of medical care provided in nursing homes. Medical directors are required by the Code of Federal Regulations, Title 42 483.75(i)(2), to be responsible for “the implementation of resident care policies and coordination of medical care services in the facility.” However, wide variation in medical directors’ level of involvement has been documented.35,36
There seems to be little consensus regarding the amount of time, types of involvement, and training that is necessary to fulfill the role, even among physicians who are currently serving in this capacity.37 CMS is in the process of developing more specific and stringent standards for the physician medical directors of nursing facilities to articulate effective leadership strategies. The real issue may be educating and interesting practicing physicians in the care of nursing home residents. One national sample found that only 33% of practicing physicians report any time caring for nursing home residents. Of all practitioners, family practitioners were the most likely group to have a nursing home practice, with 56% reporting some time spent in the care of nursing home residents; however, only 23% spent more than 2 hours per week caring for these residents.38 With the growing clinical and regulatory complexity of the nursing home environment, it is difficult to imagine that physicians who spent such a small percentage of their time providing nursing home care would have the knowledge and skills to do so effectively. More physicians who are willing to invest all or a significant portion of their professional practice in nursing home care are needed.
Resources are available through the American Medical Directors Association for physicians in practice to gain the necessary knowledge and skills to effectively fulfill the role of medical director (www.amda.com). A certification process is available, and the state of Maryland is now requiring certification of all medical directors, a trend that may grow. Many advocates of improved health care quality have proposed a system of accreditation similar to that used for hospitals. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) does offer accreditation to nursing homes, but few pursue this option at present since there is limited reward for doing so. Proponents of accreditation argue that it is more effective in promoting the highest standards of care in comparison to minimum standards that tend to be the focus of regulation through a survey process.
To avoid conflict of interest, some individuals have proposed separating the regulatory function from CMS to another agency because of its role as the largest payer for nursing home services. Another consideration would be to direct services and resources toward poor quality homes rather than treating all homes the same regardless of their survey results, as is the case at present.10 Continuous quality improvement may be an effective methodology for improving health care delivery of outcomes that can be easily measured, but much of the care that is provided in nursing homes is not easily measured. Recently, the identification of residential care as a separate quality domain is an attempt to recognize such issues as choice and control over daily activities, assistance with activities of daily living, the interpersonal quality of assistance, privacy, promotion of function, daily physical activity, access to assistive devices, ongoing information about health status, participation in care planning, and consistent access to the physician.39 Conceptually and pragmatically, this is a move away from the more traditional diagnosis or geriatric syndrome–centered quality domains. Still, the quality of life that is provided by a casual conversation or the tender squeeze of a hand is not easily measured.
Many residents of nursing facilities are cognitively impaired to a degree that measuring their satisfaction with the staff, the degree of autonomy that is afforded to them, and the general level of respect that they feel is extremely difficult if not impossible to determine. In an effort to improve the overall quality of life that is experienced, several methodologies have been employed. One example is the Eden Alternative™, a program that has become most well-known for the approach of making nursing facilities more homelike by introducing plants, pets, and other environmental changes that remove the institutional austerity.40 The Eden Alternative model also directly addresses ways in which direct care staff can become more engaged in the care delivery process through communication procedures and methods to enhance person-centered care. Unfortunately, there has been little traditional research into the effectiveness of these types of grassroots initiatives; however, that may be changing. For example, Wellspring Innovative Solutions, Inc., an alliance of 11 nonprofit nursing homes in Wisconsin formed in 1994, seeks to improve care principally by empowering staff.
Facilities that belong to the alliance provide their “frontline” workers—particularly certified nursing assistants—with training in nationally recognized best practices, while at the same time allowing all staff a voice in how their work should be performed Findings from a Commonwealth Fund–supported study comparing Wellspring nursing homes with other facilities in Wisconsin have clearly been encouraging: (1) rates of staff turnover declined or increased more slowly in Wellspring homes; (2) Wellspring facilities performed better on annual inspections conducted by the state department of health; (3) some evidence suggests that Wellspring staff are more vigilant in assessing problems in quality and take a more proactive approach to resident care; (4) based on observation and interviews, Wellspring residents enjoyed a better quality of life and benefited from improved interaction with the staff; (5) no additional increases in net resources were required for the model’s implementation, and (6) Wellspring facilities generally had lower costs than other nursing homes.41
The Commonwealth Fund is also supporting a research investigation of the Green House Project in Tupelo, Mississippi (www.thegreenhouseproject.com/index.html). Green House is intended to de-institutionalize long-term care by eliminating large nursing facilities and creating habilitative, social settings. Its primary purpose is to serve as a place where elders can receive assistance and support with activities of daily living and clinical care, without the assistance and care becoming the focus of their existence. More emphasis may be needed on the process of change within organizations. Innovation diffusion is the process by which change is adopted.42
In health care, change has traditionally been adopted very slowly, even when these changes have been shown to have positive effects on health outcomes. Yet, the pace and style of innovation diffusion can be influenced by attention to several dynamics, such as the relative advantage of the innovation, investment in a trial period, the extent to which potential adopters can witness the positive outcomes of other users, communication of opinion leaders, the adaptability of the innovation itself, compatibility with existing technology and systems of care, and the existence of a compatible infrastructure to support the innovation.43
Effective change requires careful planning, and ongoing support and models of this approach appear to be effective.44 In this vein, CMS has granted a special study to Quality Partners of Rhode Island to work with 21 state quality improvement organizations who will, in turn, work with five to ten nursing homes to promote culture change that will embrace innovation diffusion in the model called person-centered care. This person-centered care model encompasses transformational practices and procedures in three domains that include workplace practice, care practice, and environment. Strategic changes in these domains assist a nursing home in moving from a traditional institutionalized model to homelike model. This shift from an institutional model to a homelike model is notably attributed to the work of the Eden Alternative, the Pioneer Network, and Wellspring, as well as many other organizations whose vision and philosophy has created a firm base for culture change.
SUMMARY
Substantial improvements in the quality of care provided in nursing facilities must be achieved to meet the needs of a growing older adult population. The nursing home industry must leave its historical roots and embrace systematic changes that will promote quality. The process is likely to involve a strong emphasis on continuous quality improvement based on established quality indicators. However, many issues will not be fully addressed by this methodology. Continued development, innovation, and collaboration are necessary to fully address the issues that influence quality.
The research reported in this article was supported by the Geriatric Academic Career Award, U.S. Department of Health and Human Services.
