News Release

Nationwide improvement in nursing home care not likely, despite some changes

Experts review the challenges of nursing home care in the United States

Peer-Reviewed Publication

The Gerontological Society of America

Nursing home care in America is in crisis and the prospects of nationwide improvement are not high. However, increasing staffing and raising wages of nursing home workers appear to be necessary preconditions to improving quality of care and should receive high priority, according to Joshua Wiener of the Urban Institute.

Despite substantial regulatory oversight, noted Dr. Wiener, "quality of care in nursing homes remains problematic." He added: "Quality of care in nursing facilities remains a major problem for which there are no simple solutions."

Dr. Wiener made this assessment of care in nursing homes in the April 2003 special issue of The Gerontologist that highlights the challenges in nursing home care.

The articles in this special issue address central concerns in nursing home care and help provide answers to questions such as how nursing home care can best be financed and delivered. The guest editors for this special issue are two preeminent scholars in the field aging: Jill Quadagno of Florida State University and Sidney M. Stahl of the National Institute on Aging. The articles in this issue are a result of a conference held at Florida State University and sponsored in part by the National Institute on Aging.

Dr. Quadagno and Dr. Stahl believe that a major challenge at both the national and state levels concerns the effective recruitment, training, and retention of certified nursing aides. Nursing aides, they pointed out, provide about 60 percent of total nursing hours to residents.

The State of Florida, with its high proportion of aged citizens, is often viewed as a natural laboratory for the investigation of trends in aging population. A look at the nursing home problem in Florida might mirror the nursing homes problems in other parts of the country.

According to a group of researchers led by Larry Polivka of the University of South Florida, "The nursing home problem in Florida was characterized as a debate over quality of care and the rapid increase of lawsuits against nursing homes that led to a decline in the availability of affordable liability insurance." In 2001 the Florida legislature addressed the question by providing significant tort protection (caps on punitive damages, a negligence standard, and removal of automatic attorneys' fees) for nursing homes and assisted living facilities. "Whether or not these initiatives will be sufficient to mitigate litigation and make liability insurance available on an affordable basis is an empirical question we will not be able to answer for at least another year or two," noted Dr. Polivka and colleagues.

Dr. Polivka argues that the tort protection is only the first phase of long-term care reform in Florida. "Phase II will require a sustained multiyear effort to increase the availability of home- and community-based services and a create a far more balanced long-term care system than currently exists."

How do you define and measure the quality of life of nursing home residents? Rosalie A. Kane of the University of Minnesota noted, "Measuring quality of life is a relatively low priority in nursing homes because of focus on markers of poor quality of care." This is because, she added, those who believe that nursing home quality of life (QOL) ranges from bad to unspeakably abysmal rarely focus on improving it. According to Dr. Kane QOL "needs to be approached in the spirit of humility, with recognition of individual differences. Easy measures that bring false reassurance need to be avoided. The subject of QOL must be elevated, not trivialized."

Writing on "The Quality of Quality Measurement in U.S. Nursing Homes," Vincent Mor of Brown University and others noted that "a variety of new statistical models that address some of the worst technical problems (in quality measurement) are now under development and may be more generally available for application to performance benchmarking efforts."

Charlene Harrington of the University of California at San Francisco and her colleagues presented why and how to create a report card for nursing facilities much like report cards for hospitals and health plans. Older consumers could use such report cards to make informed decisions about long-term care.

Dana B. Mukamel of the University Rochester and William D. Spector of the Agency for Healthcare Research and Quality argued that quality report cards should be viewed as one of several options to ensure higher quality nursing home care.

Many experts contend that the overall quality of nursing home care in America remains poor. There are serious, ongoing nursing home quality problems. What can be done about it? Joseph Angelelli of Brown University and his colleagues in their study found that nursing homes that receive a high number of deficiencies tend to exit the Medicare/Medicaid market. They argued that public reporting may indeed promote overall quality in some facilities, but it also hastens the demise of the most "at-risk" facilities. And the demise of these facilities creates a void with no clear plan as to what will take their place.

The study by Jeanie Kayser-Jones of the University of California at San Francisco and her colleagues investigated the physical environment and organization factors that influenced the process of providing care to terminally ill home residents. They found that the nursing home environment in two facilities studied were inappropriate for end-of-life care. Among other problems, the rooms were crowded, there was little privacy, and the facilities were noisy.

David R. Mehr of the University of Missouri at Columbia, and his colleagues compared treatment and mortality in U.S. and Dutch nursing home residents with lower respiratory infection (LRI). They "found striking differences in management among residents with dementia who had LRI." Hospitalization and antibiotics were very common in the United States, rare in the Netherlands. In other words severe illness is associated with antibiotic treatment in the U.S. and with palliative treatment without antibiotics in the Netherlands.

Partners in Caregiving (PIC) is a program designed to increase cooperation and effective communication between family members and nursing home staff. In a study of the program Karl Pillemer of Cornell University and his colleagues found positive outcomes for both the family and staff in the treatment group. Both showed improved attitudes toward each other, and families of residents with dementia reported less conflict with staff.

University of North Carolina researcher Sheryl Zimmerman and her colleagues studied the current state of residential care/assisted living care and residents and how it compares with nursing home care and residents. They found that nursing homes have significantly more health services and more lenient admission policies than residential care/assisted living facilities.

The study by Debra Street of Florida State University and her colleagues investigated how changes in Medicare and Medicaid policies have affected skilled nursing facility (SNF) revenue and residents characteristics in Florida during the 1990s. They found that pro-profit SNFs maximized their revenues by admitting fewer Medicaid paying residents, whereas nonprofit facilities increased their percentage of Medicaid admissions.

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The Gerontologist is a refereed publication of The Gerontological Society of America, the national organization of professionals in the field of aging.

The special issue's table of contents and article abstracts are available online at http://gerontologist.gerontologyjournals.org/content/vol43/suppl_2/index.shtml


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