Improving the Quality of Long-Term Care (2001) / Chapter Skim
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Executive Summary
Executive Summary
Pages 1-20
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Their needs range from minimal personal assistance with basic activities of everyday life to virtually total care. Those needs are met in a variety of care settings such as nursing homes, residential care facilities, or people's homes.
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Although long-term care creates the image of an elderly person in a nursing home, it is not limited to the needs of older persons or to care provided in nursing homes. Needs can occur at any age.
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Long-term care is no longer synonymous with nursing home care. The use of alternative non-institutional settings for long-term care has increased to include home health care, personal care, residential care, care management, and other services.
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In responding to its charge, the committee decided to devote most of its attention to older adults, both because they are the major users of longterm care, with prospects for further growth in their numbers, and because the long-term care literature and policy agendas focus primarily on aged adults and adults with disabilities. The committee also examined nursing homes in more depth than other service settings, because of the longstanding problems of quality of care in these settings, and because of the paucity of literature on the quality of care in other settings.
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Third, for nursing homes and residential care facilities, the physical environment of the facility can contribute to the physical safety and functional mobility of residents and, more broadly, to their quality of life. Privacy is an important aspect of the physical environment, and is intimately tied to the consumer-centered principles that the committee endorses.
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From page 6... ...
As a result of OBRA 87 and in response to market competition, the quality of life and the physical environment in nursing homes have improved somewhat, but concerns remain. Outside of nursing homes, little is known about the quality of care or outcomes of services provided by medically oriented home health agencies, and even less about the quality of social service oriented homeand community-based services.
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the On-line Survey Certification and Reporting (OSCAR) System for nursing homes and home health care is a computerized national database for long-term care facilities used for maintaining and retrieving survey and certification data for providers that are approved to participate in the Medicare or Medicaid programs.
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Other types of long-term care settings, such as assisted living facilities and non-Medicare-certified home health care providers, have introduced various consumer-based information systems that include data on the individual recipients of care. Because a variety of residential care facilities offer room, board, and supervision to frail individuals without certification by the Medicaid or Medicare programs, several states have developed assessment systems for use in such residential care environments, based on the RAI and MDS for nursing homes.
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Federal and state governments share regulatory responsibilities for long-term care. Overall, the federal government has a dominant presence in nursing home and home health regulation through certification for Medicare and Medicaid participation.
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Some of the suggested changes include targeting chronically poor performing providers, paying more attention to chain facilities, focusing on resident problems, improving sampling techniques and sample sizes, reducing the predictability of the surveys, strengthening consistency of survey determinations, improving complaint investigations, and certifying the accuracy of nursing home data. Residential care programs such as board and care homes have been around for a long time.
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Federal standards have been set for some personnel in nursing homes and home health agencies, but not for personnel providing care in other types of long-term care settings. Some states also have their own requirements for personnel in the facilities and programs that they regulate, particularly regarding health professionals and long-term care administrators, but these requirements vary widely across states.
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Moreover, nurse staffing levels alone are a necessary, but not a sufficient, condition for positively affecting care in nursing homes. Many factors influence the quality of care provided by staff to consumers of tin this report "staffing levels" includes numbers of staff, ratios of staff to residents, and the mix of different types of staff in nursing homes and residential care facilities.
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Considering the growing emphasis on the provision of care at home or in alternative residential care settings rather than in nursing homes, total employment in nursing facilities is projected to grow less quickly, but still substantially. Many of these new jobs will be in what today are relatively lowpaid, low-benefit positions.
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The committee examined the organizational capacity of providers to manage information and personnel, the technology and resources needed to translate knowledge into improved long-term care, and the management needed for meeting policy makers' demands for accountability. Although the committee focused mostly on nursing homes, many issues are applicable, directly or with some adaptation, to providers in other long-term settings and home health care.
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From page 15... ...
Clearly, research is needed to test the feasibility and cost effectiveness of implementing clinical practice guidelines and proven care interventions in long-term care settings. Most nursing homes, even highly motivated ones, may lack the technical expertise and resources including but not limited to staffing levels necessary to translate OBRA 87 regulations, practice guidelines, and quality improvement systems into practice.
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For Medicaid home and community-based waiver services, states have always had complete freedom in determining reimbursement levels. Second, the Act also dramatically altered Medicare reimbursement methods for nursing homes and home health care agencies and combined these changes with large budget savings.
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This analysis found a small but positive relationship between Medicaid reimbursement and nurse staffing levels (except for nurse assistants) and reported fewer certification deficiencies in facilities with higher staffing levels.
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