How many long-stay nursing home residents experience conditions indicating potential problems with the quality of their care?

In 2005, 2 percent to 48 percent of long-stay nursing home residents in the United States experienced at least one of 12 specific problems or conditions that might indicate gaps in the quality of nursing care.

Why is this important?

Nursing homes cared for about 1.4 million individuals in 2004, at a cost of $115 billion (AHCA 2005; Smith et al. 2006). The federal–state Medicaid program paid for 44 percent of long-term nursing home care for low-income individuals (elderly and nonelderly).

The quality of nursing home care has long been a matter of concern, substantiated by a 1986 Institute of Medicine (IOM 1986) report that exposed significant quality problems, leading to increased federal and state regulatory oversight. In a 2001 report, the IOM found that nursing home quality had generally improved, yet many deficiencies persisted (IOM 2001).

The proportion of nursing homes cited for serious quality deficiencies by state inspectors declined from 29 percent during 1999–2000 to 15 percent during 2003–2005. However, the Government Accountability Office found that state inspections are often inconsistent and fail to catch many serious deficiencies (GAO 2005).

Nursing homes that care for Medicare or Medicaid beneficiaries must periodically assess their residents' health status. Some conditions or problems identified on resident assessments may indicate quality problems in nursing home care. These quality indicators are being publicly reported by the federal government (CMS 2006).

Findings

During the fourth quarter of 2005, up to one-half of long-stay residents in Medicare- and Medicaid-certified nursing homes experienced at least one of 12 specific problems or conditions that might indicate deficiencies in nursing home care. (Some residents might have experienced more than one of these problems.) In some cases, however, these conditions might be unavoidable even with good care (CMS 2006).

• One of two low-risk residents (those without severe dementia or mobility limitations) often lost control of their bowels or bladder in the past 14 days, and one of 16 residents had a catheter inserted and left in their bladder, which can lead to complications. These patients might need treatment for medical or physical problems or help getting to the bathroom.
• One of six residents experienced an increase in their need for help with basic activities of daily living (feeding oneself, changing positions in bed, moving from one chair to another, and going to the bathroom alone) compared with the last time they were checked, which might indicate a need for treatment, therapy, or medication adjustment to help regain functional abilities.
• One of seven residents experienced an increase in depression or anxiety in the past 30 days, which might indicate a need for treatment or social support.
• One of eight high-risk residents (those in a coma or with malnutrition or limited mobility) and one of 50 low-risk residents had a pressure sore in the past seven days. Pressure sores are often preventable with good nursing care (some of these sores might have been in the healing stages).
• Almost one of eight residents was less able to move about their room since the last time they were evaluated, and one of 25 residents spent most of their time in bed or a chair in the past seven days. These residents might need encouragement and help to stay active or participate in social activities.
• One of 11 residents had a urinary tract infection in the past 30 days, indicating a need for improved hygiene and medical treatment to prevent infections and keep them from spreading to the bladder and kidneys.
• One of 12 residents lost too much weight (more than 5 percent of body weight in the past 30 days or 10 percent in the past six months), which might indicate inadequate nutrition or medical care.
• One of 14 residents was physically restrained daily in the past seven days, which can lead to adverse effects. Under federal law, restraints may only be used when medically necessary. Research and experience suggest that it is feasible to greatly reduce or eliminate the use of restraints.
• One of 16 residents suffered moderate pain daily or severe pain in the past seven days, which might indicate inadequate pain management. However, some residents may refuse pain medication or choose to take less medication than prescribed.

Implications

A lack of information on what is clinically appropriate or achievable makes it difficult to interpret the degree to which these problems were avoidable. Nevertheless, the public reporting of these indicators serves as a useful starting point for focusing attention on quality among consumers, policymakers, and nursing home administrators (Mor 2005). Additional quality measures are needed to assess processes of care for medical and geriatric conditions affecting nursing home residents (Saliba et al. 2004a, 2004b).

Improvement Ideas and Resources

Nursing homes that emphasize the importance of staff, communication, teamwork, and standards of care tend to have higher quality of care and to initiate and sustain quality improvements (Scott-Cawiezell et al. 2005a; 2005b).

Collaborative projects involving multiple nursing homes have reported improvements in pain assessment and pressure sore prevention practices and decreases in resident pain and pressure sores through the use of interventions such as training staff, promoting quality improvement methods, and collecting and sharing performance data (Abel et al. 2005; Baier et al. 2003; 2004; Horn 2006).

The Institute of Medicine (2001, 2004) recommended that the federal government establish minimum staffing levels to promote improved quality in nursing homes.

• Quality tends to be better among long-stay nursing home residents when there is one nursing assistant for every 8.5 residents (2.8 hours per resident-day) and one licensed nurse for every 18 residents (1.3 hours per resident-day), including one registered nurse for every 32 residents (0.75 hours per resident-day) (Abt Associates 2001). Other research has reported similar findings (Horn et al. 2005; Schnelle et al. 2004b).
• A 2001 analysis estimated that achieving these staffing levels nationwide would require substantial staffing increases in many facilities, resulting in an overall 8 percent increase in nursing home spending (Feuerberg 2001).
• A more recent analysis found that increasing registered nurse (RN) staffing so as to provide 30 to 40 minutes of RN time per resident per day would be cost-saving from a societal perspective by reducing adverse events such as pressure sores, urinary tract infections, and hospitalizations (Dorr et al. 2005).

Measure:

These quality indicators were endorsed for public reporting by the National Quality Forum (NQF 2004). Rates represent simple (nonweighted) averages of state rates, which are averages of rates reported by Medicare- and Medicaid-certified nursing homes in each state. The denominator for each facility rate includes residents with a valid assessment who meet inclusion criteria for each indicator (e.g., a prior assessment for indicators that make a time comparison). The numerator is the subset of the denominator population who experienced a given condition or problem as defined above. Rates are generally risk-adjusted by excluding residents who are not at-risk for the condition (e.g., patients in a coma are not considered at-risk for a decrease in activities of daily living). In addition, resident-level risk-adjustment is applied to certain indicators (CMS 2006). For more information, see the National Nursing Home Quality Measures User's Manual.

Limitations:

Federally sponsored research found that these measures are generally valid and reliable (Norris et al. 2003). Other studies have confirmed the validity of some measures while casting doubt on the validity of others (Bates-Jensen et al. 2005; Cadogan et al. 2004; Schnelle et al. 2003; Schnelle et al. 2004; Simmons et al. 2003; Simmons et al. 2004). For example, higher rates on the pain and depression indicators might reflect better assessment or detection of symptoms rather than worse management or treatment.

Source:

Rates were compiled by the Centers for Medicare and Medicaid Services (CMS 2006) based on data reported by nursing homes using the Minimum Data Set, which contains regularly updated information on health, physical functioning, mental status, and general well-being for every resident in a Medicare- or Medicaid-certified nursing home.

References:

* Indicates source of data used in the chart(s).Abel, R. L., K. Warren, G. Bean et al. 2005. Quality Improvement in Nursing Homes in Texas: Results from a Pressure Ulcer Prevention Project. Journal of the American Medical Directors Association 6 (3): 181–8.

Abt Associates. 2001. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. Cambridge, Mass.: Abt Associates for the Centers for Medicare and Medicaid Services.

AHCA (American Health Care Association). 2005. The State Long-Term Health Care Sector 2004: Characteristics, Utilization, and Government Funding. Washington, D.C.: American Health Care Association.

Baier, R. R., D. R. Gifford, C. H. Lyder et al. 2003. Quality Improvement for Pressure Ulcer Care in the Nursing Home Setting: The Northeast Pressure Ulcer Project. Journal of the American Medical Directors Association 4 (6): 291–301.

Baier, R. R., D. R. Gifford, G. Patry et al. 2004. Ameliorating Pain in Nursing Homes: A Collaborative Quality-Improvement Project. Journal of the American Geriatrics Society 52 (12): 1988–95.

Bates-Jensen, B. M., S. F. Simmons, J. F. Schnelle et al. 2005. Evaluating the Accuracy of Minimum Data Set Bed-Mobility Ratings Against Independent Performance Assessments: Systematic Error and Directions for Improvement. Gerontologist 45 (6): 731–8.

Cadogan, M. P., J. F. Schnelle, N. Yamamoto-Mitani et al. 2004. A Minimum Data Set Prevalence of Pain Quality Indicator: Is It Accurate and Does It Reflect Differences in Care Processes? The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 59 (3): 281–5.

* CMS (Centers for Medicare and Medicaid Services). 2006. Nursing Home Compare. Washington, D.C.: U.S. Department of Health and Human Services.

Dorr, D. A., S. D. Horn, and R. J. Smout. 2005. Cost Analysis of Nursing Home Registered Nurse Staffing Times. Journal of the American Geriatrics Society 53 (5): 840–5.

Feuerberg, M. 2001. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Overview of the Phase II Report: Background, Study Approach, Findings, and Conclusion. Baltimore, Md.: Centers for Medicare and Medicaid Services.

GAO (Government Accountability Office). 2005. Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety. GAO-06-117. Washington, D.C.: Government Accountability Office.

Horn, S. 2006. Partnerships for Quality: Preventing Pressure Ulcers in Long-Term Care. Translating Research into Practice and Policy Conference, July 10–12, Washington, D.C.: Agency for Healthcare Research and Quality.

Horn, S. D., P. Buerhaus, N. Bergstrom et al. 2005. RN Staffing Time and Outcomes of Long-Stay Nursing Home Residents. The American journal of Nursing 105 (11): 58–70.

IOM (Institute of Medicine). 1986. Improving the Quality of Care in Nursing Homes. Washington, D.C.: National Academy Press.

IOM (Institute of Medicine). 2001. Improving the Quality of Long-Term Care. Washington, D.C.: National Academy Press.

IOM (Institute of Medicine). 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, D.C.: National Academy Press.

Mor, V. 2005. Improving the Quality of Long-Term Care with Better Information. Milbank Quarterly 83 (3): 333–64.

Norris, J. M., T. Moore, R. Jones et al. 2003. Validation of Long-Term and Post-Acute Care Quality Indicators: Final Report. CMS Contract No. 500-95-0062. Cambridge, Mass.: Abt Associates for the Centers for Medicare and Medicaid Services.

NQF (National Quality Forum). 2004. National Voluntary Consensus Standards for Nursing Home Care. Washington, D.C.: National Quality Forum.

Saliba, D., D. Solomon, L. Rubenstein et al. 2004a. Feasibility of Quality Indicators for the Management of Geriatric Syndromes in Nursing Home Residents. Journal of the American Medical Directors Association 5 (5): 310–9.

Saliba, D., D. Solomon, L. Rubenstein et al. 2004b. Quality Indicators for the Management of Medical Conditions in Nursing Home Residents. Journal of the American Medical Directors Association 5 (5): 297–309.

Schnelle, J. F., B. M. Bates-Jensen, L. Levy-Storms et al. 2004. The Minimum Data Set Prevalence of Restraint Quality Indicator: Does It Reflect Differences in Care? Gerontologist 44 (2): 245–55.

Schnelle, J. F., M. P. Cadogan, J. Yoshii et al. 2003. The Minimum Data Set Urinary Incontinence Quality Indicators: Do They Reflect Differences in Care Processes Related to Incontinence? Medical Care 41 (8): 909–22.

Schnelle, J. F., S. F. Simmons, C. Harrington et al. 2004b. Relationship of Nursing Home Staffing to Quality of Care. Health Services Research 39 (2): 225–50.

Scott-Cawiezell, J., K. Jones, L. Moore et al. 2005a. Nursing Home Culture: A Critical Component in Sustained Improvement. Journal of Nursing Care Quality 20 (4): 341–8.

Scott-Cawiezell, J., D. S. Main, C. P. Vojir et al. 2005b. Linking Nursing Home Working Conditions to Organizational Performance. Health Care Management Review 30 (4): 372–80.

Simmons, S. F., M. P. Cadogan, G. R. Cabrera et al. 2004. The Minimum Data Set Depression Quality Indicator: Does It Reflect Differences in Care Processes? Gerontologist 44 (4): 554–64.

Simmons, S. F., E. T. Garcia, M. P. Cadogan et al. 2003. The Minimum Data Set Weight-Loss Quality Indicator: Does It Reflect Differences in Care Processes Related to Weight Loss? Journal of the American Geriatrics Society 51 (10): 1410–8.

Smith, C., C. Cowan, S. Heffler et al. 2006. National Health Spending in 2004: Recent Slowdown Led by Prescription Drug Spending. Health Affairs (Millwood) 25 (1): 186–96.