Improving the Quality of Long-Term Care (2001) / Chapter Skim
Currently Skimming:
State of Quality of Long-Term Care
State of Quality of Long-Term Care
Pages 73-109
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 73... ...
The committee's task was made difficult by the unevenness of available empirical evidence. Although information to judge quality of care in nursing homes is extensive and systematic, for most other settings it is nonexistent or very limited, and lacks uniformity.
|
From page 74... ...
Since the mid-1960s, quality assessment has been measured in terms of three concepts: structures of care, processes of care, and outcomes of care (Donabedian, 1966~. Over the years, nursing home quality has been measured by structural variables such as level, mix, and education and training of staff; and characteristics of the facilities in relation to characteristics of the residents such as demographics, payer mix, and casemix.
|
From page 75... ...
Application of the concept of consumer-oriented longterm care requires that the quality of long-term care be judged not only in terms of the structure, processes, and outcomes of clinical care, but also in terms of access to care, the nonmedical personal assistance services that are an important part of long-term care, and the long-term care user's quality of life. Because perspectives can differ among recipients of longterm care services and between care recipients and care providers, one of the challenges is establishing priorities reflecting different perspectives.
|
From page 76... ...
3. For nursing homes and residential care settings including assisted living, 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.
|
From page 77... ...
Pain, pressure sores, malnutrition, and urinary incontinence have all been shown to be serious problems in recent studies of nursing home residents (GAO, 1998a; Mortimore et al., 1998~. The committee recognizes that change in eliminating or reducing persistent and serious problems is a long process requiring diligent monitoring and enforced adherence to standards.
|
From page 78... ...
found that serious and potentially lifethreatening quality-of-care problems in the categories of neglect, abuse, malnutrition, and pressure sores occurred in approximately 30 percent of California nursing homes over a two-year period. This study found that another 33 percent of facilities had poor care that caused less serious harm, and 35 percent had more than minimal deficiencies.
|
From page 79... ...
This includes use of physical and chemical restraints, pressure sores, malnutrition, continence care, pain, and aspects of care related to quality of life. Physical and Chemical Restraints The greatest improvement in nursing home care is in the substantial reductions in use of physical restraints since the reforms in the Omnibus Budget Reconciliation Act of 1987 (hereafter OBRA 87~.
|
From page 80... ...
reported a 36 percent decrease in antipsychotic drug use in a sample of Maryland nursing homes between fuly and December 1990, when OBRA 87 regulations were being implemented. A longitudinal study of Tennessee Medicaid recipients in nursing homes showed a 26.7 percent decrease in antipsychotic drug use following implementation of OBRA 87 (Shorr et al., 1994~.
|
From page 81... ...
Data generally indicate, however, that pressure sores are a continuing problem in nursing facilities. They were reported for 7.1 percent of all nursing home residents in 1998, which was about the same as in 1991 (Harrington et al., 2000b)
|
From page 82... ...
(See Chapter 6 for further discussion of this subject.) Continence Care Incontinence is a common problem for nursing home residents and requires that they receive assistance in toileting and care to prevent accidents.
|
From page 83... ...
Pain Management Despite widespread agreement that much pain can be ameliorated by appropriate use of medications, undiagnosed and untreated pain has been a widespread problem in many health care settings (AHCPR, 1994; IOM, 1997~. Prevalence of chronic pain is estimated in 45 to 80 percent of nursing home residents (Ferrell, 1995; IOM, 1997~.
|
From page 84... ...
Hospitalization As Johnson and Kramer (1998) point out, nosocomial infections, pressure ulcers, and deterioration of functional abilities because of bed rest are common iatrogenic complications of hospitalization of nursing home residents.
|
From page 85... ...
One approach to measuring quality of life for nursing home residents, called real experiences and assessment of life (REAL) , was developed by researchers at Vital Research in California and tested in facilities under the auspices of a small business grant from the National Institutes of Health (Vital Research, 2000~.
|
From page 86... ...
The work with these three directinterview tools, as well as work with the REAL mentioned above, gives encouragement to the idea that data can be gathered by direct report from many nursing home residents with dementia. Finally, the apparent affect rating scale (Lawson et al., 1996, 1999)
|
From page 87... ...
for example, found that it was difficult for nursing home residents to exercise desired choices or for nursing assistants to enhance residents' choices. Poor quality of life in many nursing facilities continues to be a concern.
|
From page 88... ...
One well-known innovative experiment, called the Eden Alternative, has brought plants, birds, and a variety of animals, and visits by children into nursing homes. This approach also moved towards empowering staff and developing caregiving teams that would make nursing homes more amenable to individualized care (Thomas, 1994~.
|
From page 89... ...
More than 50 waivers of regulations were required in one model to implement its demonstration unit (Wolfe, 1999~. These approaches are intuitively very appealing and appear to avoid some of the quality-of-life problems common in traditional nursing homes.
|
From page 90... ...
In summary, there is sufficient cause for concern about poor quality of care in a number of nursing homes in the United States. Although care has improved in many facilities since OBRA 87 and there are some interesting models evolving to improve the physical environment, the configuration of staff, and the overall quality of life of residents that should be evaluated, the attention of policy makers must continue to be focused on those facilities that provide inadequate quality of care.
|
From page 91... ...
Given the variations within and across states, comparisons among even similarly labeled facilities can be difficult. Moreover, assessments of the quality of residential care can be further complicated by the inclusion of measures of the physical environment, the ability of residents to remain in place following declines in functional status, and the delivery of services by facility staff versus external agency staff.
|
From page 92... ...
Assisted Living Facilities Assisted living has become a popular subset of residential care facilities. They have been marketed as an option that could combine a capacity for high-quality individual service with physical environments that promote consumer choice, autonomy, dignity, privacy, and continuity with preferred lifestyles.
|
From page 93... ...
Assisted living facilities on a multilevel campus with nursing homes and other programs (45 percent) were more likely to express a willingness to retain residents with greater health care needs and to offer more nursing care; however, they did not report having a more demanding casemix than freestanding programs.
|
From page 94... ...
. Controlling for casemix, a cross-sectional study found more socialization and satisfaction among foster home clients than nursing home residents (Kane et al., 1991a)
|
From page 95... ...
Community-based living and smaller facility size have been associated with benefits such as increased community integration, adaptive behavior, choice making, mobility, family satisfaction, improved health, and decreased challenging behavior (Rotegard et al., 1983; Wilson et al., 1991; Heller et al., 1995; Conroy, 1996; Tossebro, 1996; Stancliffe, 1997; Stancliffe and Abery, 1997; Heller et al., 1998~. Even for older persons with developmental disabilities, evidence indicates a positive long-term adjustment following movement from nursing homes to community-based settings (Heller, 1985; Heller et al., 1995, 1998~.
|
From page 96... ...
In any case, it raises the issue of the need for research on quality of care and particularly outcomes of care. Home Health Care Data on the quality of home health care are much less voluminous and systematic than those available for nursing homes.
|
From page 97... ...
In the process of developing OASIS, a prospective study was conducted to assess the care provided for new patients by 44 Medicare-certified agencies in 27 states with approximately 2,600 patients, particularly related to six activities of daily living. The study compared rates of stabilization and improvements in functional status for two groups those admitted for home health care from the hospital and those admitted from the community.
|
From page 98... ...
Subsequent analyses stemming from this study concluded that at six weeks, six months and one year post-hospital discharge, patients who received home health care experienced significantly higher functional improvement than patients discharged to other post-acute care modalities (rehabilitation facilities, skilled nursing facilities or home without home health care)
|
From page 99... ...
When agencies' status as feefor-service versus prospective payment providers was considered, the study found no significant difference in the existence of confirmed quality problems with a potential to adversely affect patients (Phillips et al., 1994~. Although the study agencies contained a mix of ownership status and geographic representation, the researchers cautioned that as volunteers for a national demonstration, the agencies might not be representative of the home health industry as a whole.
|
From page 100... ...
Satisfaction is also high among general users of adult day care (Weissert et al., 1990~. The extent to which the availability of HCBS actually accounts for keeping people out of nursing homes has been hotly debated and is the subject of decades worth of research (Applebaum et al., 1986; Kane and
|
From page 101... ...
terms home care a failure because its users enter nursing homes at the same rate as the control groups. This also presupposes that the worth of home care is to be measured by its substitution for some other form of care (e.g., nursing home care or hospital care)
|
From page 102... ...
Wage, benefit, and working condition studies may be needed to assist states in establishing market-based rates for home care providers. Perhaps special federal financial support could be designed to assist state Medicaid programs in increasing their state reimbursement rates for HCBS providers.
|
From page 103... ...
The committee believes that HCFA and state governments should work with providers and consumers to undertake research towards developing an appropriate array of community-based long-term care services to meet the needs of consumers and assess the quality of the service and outcomes. At the same time, access to and choice of appropriate services can be argued to be essential to quality of care and quality of life for individuals with disabilities.
|
From page 104... ...
Nursing staff providing home care also have less supervision than hospital staff, and again agencies or programs may lack personnel equipped to supervise home and community care for children. Parents also report that equipment suppliers provide too little information regarding the use of their devices in the home, making it difficult for families to determine when the machine is malfunctioning or what to do about it.
|
From page 105... ...
Other problems facing families caring for children at home include increased risk of depression and financial hardship (Quint et al., 1990; Thyen et al., 1999~. These shortcomings in home care services, especially for children, point to several likely opportunities to improve the quality of this care.
|
From page 106... ...
Most consumer-directed services and their evaluation have focused on personal care services. For example, a 1993 poll of 800 Medicaid beneficiaries who hired independent providers, rather than using agency providers, reported higher levels of satisfaction with care, provider stability, and quality of life (Harris and Associates, 1993~.
|
From page 107... ...
Although these consumer-directed options are relatively untested, preliminary evidence suggests their viability for people with disability receiving personal care services. Long-term care service users may be more satisfied with consumer-directed services and may benefit from other aspects of the arrangement, but from a quality perspective, there is little evidence-based research for concluding that consumer-directed services result in better quality of care.
|
From page 108... ...
Moreover data and research are very scant for residential care and home care compared to information for nursing homes. Much of the long-term care literature other than nursing homes has focused more on adequacy of access and consumer satisfaction than on quality of care.
|
From page 109... ...
Evidence regarding the quality of home health care is more limited than that for nursing home care, but also points to a mixed experience. Moreover, most of the research in this area measures satisfaction and unmet need, and not quality of care.
|
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.