Improving the Quality of Long-Term Care (2001) / Chapter Skim
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Strengthening the Caregiving Work Force
Strengthening the Caregiving Work Force
Pages 180-219
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From page 180... ...
, and nursing assistants or aides (NAB) and home health aides represent the largest component of personnel in long-term care.
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From page 181... ...
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, particularly for the regulation of health professionals and lon~-term care administrators.
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From page 182... ...
California increased its minimum nursing home requirements for direct caregivers to 3.2 hours per resident-day (excluding administrative nurses) (California State Budget Act, 1999~.
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From page 183... ...
Some facilities report very low nurse staffing levels. Table 6.2 shows that of the total certified nursing homes, 2,701 facilities (19 percent)
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From page 184... ...
In 1990, Congress passed legislation requiring HCFA to develop a Nursing Home Casemix and Quality Demonstration program (OBRA, 1990~. This HCFA project developed a method for classifying nursing home residents into 44 different Resource Utilization Groups (RUGs)
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From page 185... ...
Prior to the implementation of the PPS, HCFA commissioned three major studies to measure staff time in nursing facilities. The purpose of these studies was to define the relationship between resident resource utilization and nursing and therapy staff time.
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From page 186... ...
Mean = 3.52 hours per resident day. N = 13,693 certified nursing facilities.
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From page 187... ...
tJ 1 en As reviewed in the 1996 Institute of Medicine report on the adequacy of nurse staffing in hospitals and nursing homes (IOM, 1996a) , a number of studies have shown a positive association between nurse staffing levels and the processes and outcomes of nursing home care (see for example
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From page 188... ...
lo: Q u) o I 2.0 1 .5 1.0 0.5 0.0 IMPROVING THE QUALITY OF LONG-TERM CARE z 1991 1992 1993 1994 1995 1996 1997 1998 v, ~ RN Hours ::3 LPN Hours Tear 0 Nursing Assistant Hours FIGURE 6.2 Average nursing hours per resident day in all certified nursing facilities: United States, 1991-1998.
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From page 189... ...
In contrast, one longitudinal study of nursing home residents in Massachusetts found that better health outcomes (e.g., survival time, functional status, incontinence, and mental status) were not related to higher RN staffing levels (Porell et al., 1998~.
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From page 190... ...
The committee supports the recommendation of the IOM Committee on the Adequacy of Nurse Staffing in hospitals and nursing homes that nursing facilities use geriatric nurse specialists and geriatric nurse practitioners in both leadership and direct care positions (IOM, 1996a)
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From page 191... ...
on the quality of nursing home care. Although it is obvious that these specialties are of critical importance, the amount and type of services delivered by such professionals have to be studied so that clear recommendations can be developed to improve quality of care.
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From page 192... ...
However current staffing levels in some facilities are not sufficient to meet the minimum needs of residents for provision of quality of care, quality of life, and rehabilitation. As shown above, research provides abundant evidence of quality-of-care problems in some nursing homes and such problems are related at least in part to inadequate staffing levels.
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From page 193... ...
The committee concludes that in view of the increased acuity of nursing home residents, federal staffing levels must be made more specific and that the minimum level of staffing has to be raised and adjusted in accord with the casemix of residents. The objective should be to bring those facilities with low staffing levels up to an acceptable level and to have all facilities adjust staffing levels appropriately to meet the needs of their residents, by taking casemix into account.
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From page 194... ...
The cost of the additional staffing can be estimated by examining the differential time between the current staffing levels and the average facility staffing level needed, multiplied by the average wages of nursing home staff. Medicaid costs estimates would depend on the minimum requirements established by HCFA and the current staffing levels that are built into state Medicaid rates.
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From page 195... ...
HCFA should consult with consumer groups and with the nursing home industry in designing staffing report forms. By comparing staffing data with resident characteristics, HCFA will be better able to monitor compliance with staffing requirements and quality standards.
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From page 196... ...
Nursing management and leadership are central to providing high quality of care in nursing facilities, especially given the complex needs of residents. At present, there are no specific federal requirements for directors of nursing in nursing homes other than that they be RNs.
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From page 197... ...
~5~. Once the nursing assistants pass the competency examination, they are considered "certified nursing assistants." The training is specified in the legislation (the training for home health aides is the same as that for nursing assistants in nursing homes)
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From page 198... ...
Increased levels of training are expected to increase the quality of care in nursing facilities. Unfortunately, research is lacking on the effect of different levels and types of training on the quality of care provided in nursing homes.
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From page 199... ...
showed that administrator's education, job tenure, and professional involvement were positive predictors of innovations in nursing homes. Medical Directors and Practitioners in Nursing Homes Medical services are relatively unavailable in day-to-day nursing home care.
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From page 200... ...
Many medical directors agree that such time is not sufficient and that more involvement by medical directors is essential (Levenson, 1993; Tangalos, 1993~. Few nursing homes have staff physicians; rather, they rely on community-based attending physicians to provide medical care to nursing home residents.
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From page 201... ...
Although the American Medical Directors Association supports the minimum visit requirements for residents to prevent resident abandonment by physicians, it argues that the appropriate number of physician visits should be based on patient acuity and medical necessity and not on arbitrary limits. The committee is concerned that HCFA rules do not adequately recognize the need for medical judgments that take into account the multiple complex medical problems that many nursing home residents have.
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From page 202... ...
More than three-quarters of the work force in residential care settings, such as board and care homes and assisted living facilities, are unlicensed personal care workers and home health aides, while RNs and LPNs constitute less than 3 percent of the positions in these settings (Feldman, 1998~. The survey of board and care facilities in ten states, described in previous chapters, found 92 percent of the licensed homes and 62 percent of unlicensed homes provided personal care, such as assistance with activities of daily living (Hawes et al., 1995a)
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From page 203... ...
Many of the professional nursing services provided in residential care facilities were arranged through home health care agencies. Since the conduct of that survey, however, licensing requirements in only 24 states and the District of Columbia allow nonnurses to administer medications all of them include in-house medication training requirements.
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From page 204... ...
The kinds of intensive time and resource-use studies described earlier for nursing homes have not been conducted in residential care settings. In part, this gap in information reflects variability of models, definitions, populations served, and state regulations.
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From page 205... ...
developed quality indicator groups to classify clients into groups with similar needs and quality challenges. Although few studies have assessed quality of care, there are many complaints about home health aides and personal care workers (Harrington and Grant, 1990; Eustis et al., 1993~.
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From page 206... ...
Under this enlarged definition, individuals could receive home health aide coverage (Bishop and Skwara, 1993; Cohen and Tumlinson, 1997~. When Congress enacted OBRA 87, it included new legislative requirements for certified home health agencies similar to those for nursing homes.
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From page 207... ...
Independent workers, usually known as personal care attendants, may also provide personal care services. The duties of home health aides and personal care attendants overlap in that both are allowed to provide direct care to clients, such as help with bathing, dressing, toileting, and eating (Harrington et al., 2000d,e)
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From page 208... ...
484.36) also specify the training of home health aides to provide personal care services.
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HOME CARE As noted in the previous sections, the home care work force includes workers in home health and home care agencies, including personal care agencies, and those workers who are independent care providers. All of the problems with the home health care work force are also seen in home care, but very few studies have examined home care personnel issues and their relationship to quality.
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From page 210... ...
In states that have licensing requirements for personal care attendants, many require attendants to be supervised by an RN who visits the client every 60 to 180 days. Beyond these requirements, most states have few specific regulations regarding personnel in home care agencies or independent providers (Harrington et al., 2000e)
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From page 211... ...
LABOR FORCE ISSUES As stated earlier in this chapter, in addition to staffing levels and staff characteristics, the education and training of staff, job satisfaction, turnover, and salaries and benefits also affect the quality of care provided. The 1996 IOM report on the adequacy of nurse staffing included a review of the literature on labor shortages and the unstable labor pool for the nursing home market and the factors contributing to these problems (IOM, 1996a)
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From page 212... ...
The vast majority of these additional jobs will be for low-paid, low-benefit, low-skill home health aides, personal care workers, and certified nursing assistants. Obviously, an economic downturn could end the current shortage, but the long-run demographic imbalance between the demand for and supply of workers can only worsen over time, making it difficult to recruit the staff needed to achieve higher staffing levels.
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From page 213... ...
Although cyclical economic conditions significantly affect the demand for unskilled workers, low wages and benefits along with difficult working conditions and heavy workloads also make recruitment difficult, even when unemployment rates are relatively high. Wages and benefits for home and home health care workers, and for those in nursing homes, are significantly lower than for those in acute care settings (Crown et al., 1995; Feldman, 1996; Leavitt, 1998~.
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From page 214... ...
The low rates built into Medicare and Medicaid reimbursement rates are particularly important because these programs are the major payers for both nursing home and home health care services. Unless wages and benefits are set at levels that allow the long-term care industry to be competitive in the labor market, the work force is structured for instability.
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From page 215... ...
Criminal Background Checks Nursing homes and home health agencies are required under Medicare and Medicaid regulations to maintain written personnel policies and procedures. Federal regulations specify that nursing home residents and home health agency clients have the right to be free from abuse and neglect and to be in a safe and secure environment (OIG, 1998~.
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From page 216... ...
At the present time, certified nursing homes and home health agencies are not required by Medicare or Medicaid to conduct a criminal record check before hiring personnel. The American Health Care Association has also recommended the development of a national abuse registry and criminal background checks for workers.
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From page 217... ...
Involvement of Informal Caregivers Client and family involvement in the provision of long-term care services, generally on an unpaid basis, is of critical importance in the provision of long-term care. As indicated earlier in this report, family members provide an estimated 80 percent of the long-term care for elderly people (Barusch, 1991)
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From page 218... ...
have suggested that liability concerns for consumers and programs can be minimized by making the consumer the employer of record, delineating the responsibilities of the program and the consumer, educating and assisting consumers in the selection and supervision of care providers, encouraging consumers to require criminal history checks for their providers, and providing workers' compensation as a part of the benefits package. CONCLUSION To succeed, efforts to improve the quality of long-term care require a work force that is sufficient in size, with the necessary skills, competence, and commitment to provide the needed health and personal care services and to manage the delivery of this care in a supportive environment.
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From page 219... ...
STRENGTHENING THE CAREGIVING WORK FORCE 219 The committee recognizes that the recommendations presented in this chapter would entail additional costs for providers of care. Substantial improvements in the long-term care work force are not possible without increased resources for providers of care.
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