Improving the Quality of Care in Nursing Homes (1986) / Chapter Skim
Currently Skimming:
1. Introduction and Summary
1. Introduction and Summary
Pages 1-44
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 1... ...
In May 1982, the Health Care Financing Administration (HCFA) announced a proposal to change some of the regulations governing the process of certifying the eligibility of nursing homes to receive payment under the Medicare and Medicaid programs.
|
From page 2... ...
policies and regulations governing the certification of nursing homes so as to make those policies and regulations as appropriate and effective as possible." THE PUBLIC POLICY CONTEXT OF THE STUDY There is broad consensus that government regulation of nursing homes, as it now functions, is not satisfactory because it allows too many marginal or substandard nursing homes to continue in operation. The implicit goal of the regulatory system is to ensure that any person requiring nursing home care be able to enter any certified nursing home and receive appropriate care, be treated with courtesy, and enjoy continued civil and legal rights.
|
From page 3... ...
In the past 15 years many studies of nursing home care have identified both grossly inadequate care and abuse of residents.2~23 Most of the studies revealing substantial evidence of appallingly bad care in most parts of the country have dealt with conditions during the 1970s. However, testimony in public meetings conducted by the committee in September 1984, news reports published during the past 2 years, recent state studies of nursing homes, and committee-conducted case studies of selected state programs have established that the problems identified earlier continue to exist in some facilities: neglect and abuse leading to premature death, permanent injury, increased disability, and unnecessary fear and suffering on the part of residents.
|
From page 4... ...
Thus, physicians, as well as nurses, have substantial responsibility for quality of care in nursing homes. These observations do not mean that the picture of American nursing homes is entirely gloomy or that the regulatory efforts of the past decade have been entirely unsuccessful.
|
From page 5... ...
Most people enter nursing homes as private-pay residents and soon "spend down" their income and assets until they become eligible for Medicaid. With few exceptions, community-based or home-based long-term care services -- that might keep some people who require long-term care from entering nursing homes -- are not eligible for Medicaid or other sources of public support.
|
From page 6... ...
Although regulation alone is not sufficient to achieve high-quality care, easing or relaxing regulation is inappropriate under current circumstances. The federal regulations now governing the certification of nursing homes under the Medicare and Medicaid programs have been in place, essentially unchanged, since the mid-1970s.
|
From page 7... ...
The nursing home industry itself has grown in managerial capability and professionalism. These developments make it possible now to redesign the regulatory system so that it will be much more likely to assure that all nursing homes provide care of acceptable quality.
|
From page 8... ...
Although more of these types of long-term care arrangements are being developed, they still represent collectively only a small fraction of the total person-days of care provided by nursing homes.3t In 1985, in most communities in this country, long-term care services for the physically frail and mentally impaired elderly are available only through informal support provided by family or friends or in nursing homes. Nursing homes must provide care to a very heterogeneous resident population.
|
From page 9... ...
These pressures are certain to increase.32 There were about 15,000 nursing homes in operation in the United States in 1985, with a total of about 1.5 million beds, that are certified to receive patients/ residents under the Medicare and/or Medicaid programs.33 About 1,000 nursing homes and perhaps 6,000-7,000 "board and care" homes (sometimes referred to as "domiciliary care" facilities) without nursing services are licensed by the states but are not certified to accept Medicare or Medicaid payments.34 There are two types of nursing homes recognized in federal regulations: Skilled Nursing Facilities (SNFs)
|
From page 10... ...
A recent report projected the population aged 75 and over in the year 2000 to be 17.3 million, a 46 percent increase over the 1985 population of that age group. For people 85 years of age or older, one in five of whom is currently in a nursing home, the numbers are projected to increase from 2.85 million in 1985 to 5.1 million in 2000, an 80 percent increase.37 In 1984, over $30 billion was spent on nursing home care.38 According to Department of Labor estimates, "nursing and personal employed over 1 million people in 1982.~9 Quality of Care and Quality of Life care" facilities Providing consistently high quality care in nursing homes to a varied group of frail, very old residents, many of whom have mental impairments as well as physical disabilities, requires that the functional, medical, social, and psychological needs of residents be individually determined and met by careful assessment and care planning -- steps that require professional skill and judgment.
|
From page 11... ...
This is difficult when most rooms are semiprivate -- as is the case in most nursing homes. Making one's room as home-like as possible is important to many residents, but fire safety codes may limit the use of personal furniture or other belongings.
|
From page 12... ...
to control and account for the large public expenditures-mainly Medicaid -- used to pay for nursing home care. Regulation for quality assurance in nursing homes involves three main components, all of which are more or less embodied in both federal and state regulations and are, to some extent, intertwined with one another.
|
From page 13... ...
The history of nursing home regulation is relatively brief. Until the passage of the Medicare and Medicaid legislation in 1965, the regulation of nursing homes was entirely a state responsibility.
|
From page 14... ...
The 1967 amendments to the Medicaid legislation authorized two categories of Medicaid nursing homes: SNFs and ICFs. Development of certification regulations for both categories proved to be very controversial.
|
From page 15... ...
combined the SNF and ICE regulations into a single set applicable to all nursing homes; 2. consolidated all resident care planning requirements into a single condition of participation requiring a resident care management system that called for interdisciplinary teams to assess residents and plan their care; and 3.
|
From page 16... ...
The federal district court found that (1) serious deficiencies exist in some nursing homes, which it labeled "orphanages for the aged," (2)
|
From page 17... ...
Half of the industry revenues, paying for part or all of the care of about two-thirds of the nursing home residents, comes from state Medicaid programs.43 In most states Medicaid reimbursement rates are lower than the rates charged by the same nursing homes to private pay residents.3t And because most states also have restricted the expansion of nursing home beds, the demand for beds exceeds the supply in all but a very few states. This supplier's market is advantageous to nursing home management because it allows nursing homes to be selective in their admissions and still keep their beds full.
|
From page 18... ...
Timely access to necessary data and other information is the life blood of effective regulation and of sound public policy development. But despite the importance of both federal and state government regulation in the nursing home industry, and the large proportion of public funds that flow into the nursing homes, there is a striking paucity of detailed information available about almost every aspect of nursing home operations.
|
From page 19... ...
Consumers, the Community, and Nursing Home Management and Sta If Three other sets of factors affect quality of care and quality of life in nursing homes: (1) consumer involvement and consumer advocacy, (2)
|
From page 20... ...
Positive motivation and attitudes on the part of the owners and managers of nursing homes, and well-trained, well-supervised, and properly motivated staff are essential for high-quality care. Although pressures by regulators and consumers can have important positive effects on staff and management attitudes and behavior, they are not sufficient to produce the motivation and attitudes that will attract the kinds and quality of personnel needed to provide high quality of care and quality of life to nursing home residents.
|
From page 21... ...
A stronger federal role is essential. Regulation of nursing homes both by state and federal governments is necessary to assure safety and acceptable quality of care for nursing home residents because of the vulnerability of the residents and the lack of institutional choices available to them.
|
From page 22... ...
payment policies or beet supply. It is especially important to reorient and strengthen nursing homes to reduce or eliminate the many remediable weaknesses in the process of monitoring nursing home performance, and to strengthen compliance (enforcement)
|
From page 23... ...
Since this is an issue of major importance, the HCFA should continue to support research and demonstration projects on the effects of Medicaid reimbursement policy on quality of care and quality of life in nursing homes. In this connection, one of the major recommendations discussed in Chapter 3 -- resident assessment -- will make it feasible to arrive at objective methods of assessing quality of care that will be important for such studies.
|
From page 24... ...
To reorient the regulatory system from its current "structural" and "facility-centered" orientation to a "resident-centered" and "outcome-oriented" approach will require development and introduction of a standard resident assessment data system that has multiple uses both for nursing home management and for government regulatory agencies. This concept is discussed in Chapters 2, 3, and 7.
|
From page 25... ...
A single set of conditions of participation and standards should be used to certify all nursing homes. The current SNF conditions and stand ard s, with the mod if ications and ad d itions recommended below, should become the bases for new certifying criteria.
|
From page 26... ...
Recommendation 3-3: The existing SNF conditions and standards should be rewritten in accordance with the above principles and made applicable to all nursing homes.
|
From page 27... ...
5. There is a need to reorient the approach to regulation of nursing homes to make it more resident-centered and outcome-oriented.
|
From page 28... ...
b. Each resident has the right to know the name, address, and phone number of the state survey office, state or local nursing home ombudsman office, and state or local legal service office.
|
From page 29... ...
7. Seven of the current conditions of participation-governing body and management, utilization review, transfer agreement, disaster preparedness, medical direction, laboratory and radiological services, and medical records -- should be consolidated into one new condition to be called "administration." New standards should be added on nurse's aide training, access, Medicaid discrimination, notification, and consumer participation.
|
From page 30... ...
The standard should require that all nurse's aides complete a preservice state-approved training program in a state-accredited institution such as a community college. Recommendation 3-7C: A new standard should be written under the administration condition that prohibits facilities that have signed a Medicaid Provider Agreement f rom having d ifferent stand ard s of ad mission, bans fer, discharge, and service for individuals on the basis of sources of payment.
|
From page 31... ...
Two new elements should be added to the governing body and management standard as follows: a. Certified nursing homes should be required to permit access to the homes by an ombudsman (whether volunteer or paidJ who has been certified by the state.
|
From page 32... ...
However, the HCFA should establish a minimum level of effort for social services in exempted facilities -- for example, one day of consultation per week. Monitoring Nursing Home Performance The following recommendations are made to strengthen the process of determining the extent to which nursing homes are complying with the conditions of participation: 1.
|
From page 33... ...
The extended survey would be used if the standard survey findings indicated that there were -- or might be -- evidence of inadequacies in the quality of care being provided to some or all of the residents. Good nursing homes would normally experience only the standard survey.
|
From page 34... ...
Recon~n~endation 4-6: Facilities that perform poorly on key indicators of quality of resident care or life should be subjected to a full or partial extended survey, depending on the range of problem areas discovered. The purpose of the extended survey is to determine the extent to which the facility is responsible for the poor outcomes due to noncompliance with the federal cond itions and standards.
|
From page 35... ...
· At the close of the survey, the following notice should be posted in a location accessible to residents and visitors: The (state survey agency) completed its regular certification survey of {facility name)
|
From page 36... ...
· The results of research and evaluation studies should be analyzed and disseminated by the HCFA. Recommendation 4-15: Title XIX of the Social Security Act should be amendect to authorize 100 percent federal funding of costs of the nursing home survey and certification activities of the states.
|
From page 37... ...
Recommendation 4-19: The HCFA should increase its capabilities to oversee state survey and certification of nursing homes and to enforce federal requirements on states as well as facilities by · adding enough additional federal surveyors to each regional office to ensure that the random sample of nursing hones surveyed each year in each state is large enough to allow reasonable inferences about the adequacy of the state's survey anc/t certification activities;
|
From page 38... ...
But ind ivid ual resid ent reviews should be required for a sample of residents (private-pay as well as Meclicaid) rather than for all relic/tents (although individual states may elect to continue 100 percent reviews)
|
From page 39... ...
Revisions should includ e · specifying that survey agency personnel not be used as consultants to providers with compliance problems; · specifying how to evaluate plans of correction and what constitutes an acceptable plan of correction; · specifying the circumstances under which onsite followup visits may be waived; · s peel f ying circumstances und er which f ormal enforcement action should be initiated, and how actions should be taken; anc/t ~ requiring that states have formal enforcement procedures and mechanisms.
|
From page 40... ...
Recommendation 5-5: The HCFA should strengthen state en forcement ca pabilities by ~ requiring states to commit adequate resources to enforcement activities, including legal and other enforcement-related staff; ~ requiring survey anc/t certification survey agency staffs to incIncle enforcement-related specialists, such as lawyers, auditors, and investigators, to work as part of special survey teams for problem situations and to help support enforcement decision-n~aking; · including more training in investigatory techniques, witness preparation, and the legal syster'' in the basic surveyor training course; and ~ providing federal training support for state survey agency and welfare agency attorneys in nursing home enforcement matters.
|
From page 41... ...
Recommendation 6-2: The Older Americans Act should be amended to: · establish the ombudsman program under a se parate title in the Act; · increase funds for state programs by authorizing federal-state matching formula grants for state ombudsman programs. The formula should provide each state with a minimum annual budget in the range of $100,000 fl985 clollarsJ plus an additional amount based on the number of elderly residents in the state.
|
From page 42... ...
Recommendation 6-4: The HCFA shouic! require state long-term-care regulatory agencies to develop written agreements with state ombudsman programs covering information-sharing, training, and case referral.
|
From page 43... ...
The federal government should undertake a systematic study of these interrelated issues to facilitate development of appropriate policies in these areas. If the committee's major recommendations are carried out there may be some effect on the number of currently certified nursing homes that will continue to participate in the Medicaid program.
|
From page 44... ...
Or, if it does occur to a significant extent, whether states will respond by easing their restrictions on expansion of bed supply only for certified homes, or by making licensure contingent on participation in the Medicaid program. Sta f f ing o f Nursing Homes Based on the availability of systematic resident assessment data, two kinds of staffing studies should be undertaken: (1)
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.