Areas for Improving Care in Nursing Homes

All clinical settings have areas where care could be improved. Some of these areas may be obvious, whereas others may be less recognized or remain unaddressed for a variety of reasons. In long-term care (LTC), because patients have complex clinical pictures and more taxing care requirements, there are some care issues that have remained overlooked or unaddressed, particularly as LTC facilities continue to struggle with limited administrative and staffing resources. In this American Association for Long Term Care Nursing (AALTCN) Spotlight issue, we include several articles that outline key areas for care improvement in nursing homes.

In our first AALTCN article, “Using Xylitol Products and MI Paste to Reduce Oral Biofilm in Long-Term Care Residents”, the author examines the challenge of addressing poor oral care among nursing home residents. As she notes, oral care, for many reasons, is often inadequate. Residents may refuse to have their teeth brushed, nursing home staff may not have the resources to devote to oral care, and/or a resident’s more immediate and pressing care needs may take precedence. However, neglecting oral care can have significant consequences, from exacerbating existing medical conditions such as diabetes to increasing susceptibility to life-threatening respiratory infections. To minimize the challenges of providing oral care, the author conducted a small study at a nursing home to see if providing xylitol-based chewing gum and mints in combination with a mineral paste could reduce oral biofilm levels in the six study participants, similar to what had been reported in the literature for children. At the end of the 3-month study, oral biofilm levels were significantly reduced in the residents. In addition, one resident who had become isolated due to his oral malodor experienced such improvement that he was able to engage in social activities again. As the author notes, this is an area for further research and may be a good opportunity for initiating a quality improvement project.

In our second AALTCN article, “Managing Chronic Pain in Older Adults”, the author reviews how pain can be better managed in LTC facilities. As the author notes, chronic pain is prevalent in this setting. Reports indicate that anywhere between 45% and 80% of nursing home residents experience chronic pain, with many experiencing it on a daily basis. Again, there are a variety of reasons for underrecognition of pain, including a high prevalence of cognitive impairment among nursing home residents as well as staffing challenges at LTC facilities. Yet uncontrolled pain or suboptimal pain management can have profound consequences, significantly decreasing residents’ quality of life, worsening existing medical conditions, and increasing the risk of complications such as falls. The author advocates that healthcare providers start with nonpharmacological management strategies and use the World Health Organization’s stepladder approach to pain management when medication is indicated, taking into consideration the precautions outlined in the American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Following the article is a useful tip sheet that outlines how healthcare providers can properly assess patients with chronic pain so that an appropriate plan of care can be developed. 

This issue also includes a Medicare Update, “Looking Ahead to Issues Affecting Geriatric Care in 2014”, which outlines how geriatric healthcare professionals will be expected to provide care in 2014. The article explores three key categories in which there will be changes: insurance expansion, reimbursement, and care delivery. I encourage you to read the article so that you can be better prepared for the changes ahead.

As this year concludes, the staff of Annals of Long-Term Care: Clinical Care and Aging^® would like to wish you a wonderful holiday season and a healthy and happy New Year! We thank you for your readership and contributions to the journal and look forward to continuing to serve you.

Thank you for reading!