Improving the Quality of Long-Term Care (2001) / Chapter Skim
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Introduction
Introduction
Pages 21-35
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From page 21... ...
Its recommendations provided the basis for Congress to enact a major reform of nursing home regulations embedded in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87~. The legislation was refined through subsequent enactments in 1988, 1989, and 1990.
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From page 22... ...
Over the past decade, federal Medicare policies dramatically expanded and then more recently contracted coverage for home health care. Moreover, the increased use of preadmission screening for nursing homes, the expanded role of Medicaid home and community-based waivers, the introduction of Medicare and Medicaid managed care programs, the general trend toward prospective payment and more rapid discharges from hospitals, and the emergence of various long-term care provider industries, all have altered the patterns of long-term care.
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From page 23... ...
This rapid growth in the oldest-old population (85 years and older) will have a major effect on the demand for and supply of longterm care services and the resources needed to provide these services.
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From page 24... ...
Continuing improvements in medical care that allow more children and nonelderly adults with serious congenital or chronic disorders and injuries to survive for longer periods also are likely to contribute to a growing demand for long-term care services. Such care for children requires more than a scaled-down version of care for adults; it requires provision of social support services and coordination with the educational system.
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From page 25... ...
THE IOM STUDY Committee Charge Now, more than a decade since the 1986 IOM report, it is timely to take another look at the state of quality in long-term care and to consider quality assessment and improvement strategies. In the context of evolving long-term care options and needs and persistent concerns about the quality of nursing home care, the Robert Wood Johnson Foundation requested the Institute of Medicine to undertake another examination of the quality of long-term care provided in nursing homes and other long-term care settings.
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From page 26... ...
Some of these meetings consisted of workshops that were open to the public. They provided an opportunity for the committee to expand its perspective and views by obtaining a wide range of opinions from interested and concerned groups such as health care associations and advocacy groups from skilled nursing facilities, home health agencies, and assisted living agencies on matters under consideration, especially ideas and concepts of how the presenters perceive, measure, and evaluate quality within the different long-term care settings.
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From page 27... ...
Health care includes medical, nursing, and other care provided by nurses, nursing aides, therapists, physicians, and other health workers serving people who need long-term care. Personal care services include assisting people of all ages with chronic conditions and limitations with ADLs.
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From page 28... ...
The notion of consumer-centered care is not a new one, but it has accelerated rapidly in recent years and there is now tangible evidence, at least in the acute and primary care encounters, of consumer-centered care in many facets of health care delivery and financing, medical law, and quality assessment (Laine and Davidoff, 1996~. Historically much health care, particularly institutional care, has operated in a health care environment managed by professionals whose training and medical ethics standards have traditionally emphasized expertise, responsibility, and benevolence more than patient autonomy and informed decision making (see Cassell, 1991; Gerteis et al., 1993; Goodwin, 1999~.
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From page 29... ...
consumer monitoring of the quality of care (Delong et al., 1992; Fenton et al., 1997; Scala and Mayberry, 1997~. Such models have been applicable mostly to people with physical and developmental disabilities using personal attendant services, although some approaches to consumer-directed services are beginning to emerge for the elderly population with chronic illness and functional limitations.
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From page 30... ...
They may require long-term care services for lengthy periods, but the goal often but not always achieved is eventual independence from long-term care services and integration into the community as participating members of society. Rehabilitative services aim to restore function that once existed, whereas habilitative services are aimed at initially developing a function that had not existed berg., helping children with congenital disabilities achieve more than they would without special assistancey.
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From page 31... ...
Outcomes and other indicators of the quality of care likewise would need to be extended from traditional clinical health assessment to include consumer-reported experiences of care, processes of care, satisfaction with care, as well as consumer self-report of the achievement of health outcomes and quality of life goals specified in a care plan. Finally, the collection of data to assess the quality of care would need to be accomplished by providers and consumers jointly seeking to identify processes of care and environments that achieve desired outcomes, to target areas for care improvement, and to assign responsibilities for implementing these improvements.
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From page 32... ...
Moreover, given resource constraints and the frail condition of many of those using long-term care services, especially residents in nursing homes, often it may be impractical to ask people about how they experience and value the care they receive. Inadequate staffing in terms of numbers as well as education and training, combined with high turnover rates, also tends to lead to care that is provider-centered rather than consumer-centered.
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From page 33... ...
In setting forth the basic standards for providers of care, federal and state policies provide a foundation and safeguard for the other principles enumerated here. Although consumer choice and market forces have roles to play in the evolution of more consumer-centered long-term care, neither can operate effectively without a basic regulatory framework that covers contracting, information provision, complaint handling, and similar matters.
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From page 34... ...
Although the committee recognizes their growing importance, for reasons of lack of available data as well as resource and time constraints, the committee was unable to address every possible long-term care service and setting, population group, and issue that might be considered relevant or related to its charge. For instance, a fuller consideration of the quality of long-term care for children, adolescents, and younger adults with developmental disabilities; personal attendant services for people with severe cognitive impairment, severe and persistent mental illness, AIDS, and other conditions; and some settings such as intermediate care facilities for the mentally retarded, long-term psychiatric hospitals, and others can and should be the subjects of separate studies.
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From page 35... ...
These efforts include improvements in defining and enforcing basic standards of care, maintaining an adequate and qualified work force, building organizational capacity to improve care, and finally, designing reimbursement methods that encourage both quality and efficiency in care. Although the committee has made every effort to obtain data and objective evidence based on research, some of its conclusions are necessarily derived from professional judgment based on the expertise and experience of committee members and on testimony and information provided by constituencies.
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