6
Staffing and Quality of Care in Nursing Homes

Nursing homes are an important component of the health care industry that is becoming increasingly complex. As discussed in Chapter 3, the nursing home market is being stressed by an increasing demand for services combined with a constrained growth rate.

The previous chapter explores the relationship of staffing patterns of nursing personnel to quality of patient care in hospitals and examines the structural variables of staffing and their relationship to processes and outcomes of care. This chapter examines the interrelationship of quality of care and staffing in nursing homes. The chapter begins with a discussion of the measurement of quality of care in nursing homes, followed by an overview of the status of quality and the legislative and regulatory efforts to improve quality. The chapter next discusses whether these efforts have achieved their objectives, namely, improvement of the quality of care. It then examines staffing levels and skills as they exist today and their linkages to quality of care. Finally, it examines the determinants of staffing, by taking into consideration the roles of third-party payment and regulation.

To gain insights on these issues, the committee examined the statutory requirements, available empirical evidence, and information gathered during site visits and public testimony. It also reviewed extensive research literature on the relationship between staffing patterns and quality of care. The committee deliberated long and hard on the issues before reaching the conclusions and recommendations put forth in this chapter.



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--> 6 Staffing and Quality of Care in Nursing Homes Nursing homes are an important component of the health care industry that is becoming increasingly complex. As discussed in Chapter 3, the nursing home market is being stressed by an increasing demand for services combined with a constrained growth rate. The previous chapter explores the relationship of staffing patterns of nursing personnel to quality of patient care in hospitals and examines the structural variables of staffing and their relationship to processes and outcomes of care. This chapter examines the interrelationship of quality of care and staffing in nursing homes. The chapter begins with a discussion of the measurement of quality of care in nursing homes, followed by an overview of the status of quality and the legislative and regulatory efforts to improve quality. The chapter next discusses whether these efforts have achieved their objectives, namely, improvement of the quality of care. It then examines staffing levels and skills as they exist today and their linkages to quality of care. Finally, it examines the determinants of staffing, by taking into consideration the roles of third-party payment and regulation. To gain insights on these issues, the committee examined the statutory requirements, available empirical evidence, and information gathered during site visits and public testimony. It also reviewed extensive research literature on the relationship between staffing patterns and quality of care. The committee deliberated long and hard on the issues before reaching the conclusions and recommendations put forth in this chapter.

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--> Measurement Of Quality Quality of care in nursing homes is a complex concept, confounded by regulations, debates about what should be measured to assess quality, case-mix, facility characteristics, and methods of measurement (Mezey, 1989; Mezey and Lynaugh, 1989). ''Quality of nursing home care has proven to be one of the most politically volatile—yet societally critical—issues confronting the American public. The issue strikes at the core of individual concern about possible functional impairment and potential loss of impairment and potential loss of independence [, c]omplicated by the likelihood of personal impoverishment …" (Wilging, 1992b, p. 13). In short, it is the focus of providers, consumers, regulators, and public policymakers. Defining quality in nursing facilities has been a difficult process. Quality of care in nursing homes has been defined both as an input measure and as an outcome (Kruzich et al., 1992). The Institute of Medicine (IOM) definition is cited in Chapter 5. As elaborated there, quality can be approached in terms of three concepts: structure, process, and outcome. Table 6.1 presents an illustrative list of the measures of quality of care in nursing homes. These include human, organizational, and material resources. Elements of Quality of Care Traditionally, nursing home quality has been measured by structural variables. Important among these are (1) inputs, such as the level and mix of staffing; (2) characteristics of facilities, such as ownership, size, accreditation, and teaching status; and (3) characteristics of the facility's residents, such as demographics and payer mix. Staffing is a structural measure that affects the processes and outcomes of care in nursing facilities, but it is considered in part to be determined by facility ownership and payment sources. Case-mix relates to quality in that demands on staff (both numbers and quality) are highly related to the needs of patients. Studies indicate that a low percentage of private-pay patients in a facility is a negative indicator of quality of care (using deficiencies as indicators). It is argued that because private-pay residents pay a higher per diem rate than do Medicaid residents, nursing homes generally compete for private-pay residents on aspects of structure and process associated with quality. This competition may be desirable because it also creates an incentive to provide quality care even in a bed-shortage environment. (Nyman, 1988b; Spector and Takada, 1991). Although structural measures assess the availability of resources as a necessary precondition for their use, process measures examine actual services or activities provided to or on behalf of residents. In the context of nursing homes, the process of care focuses on providing special care and treatment to prevent problems with outcomes such as cognition, hearing and vision, physical functioning, continence, psychosocial functioning, mood and behavior, nutritional and

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--> TABLE 6.1 Illustrative Measures of Quality of Care in Nursing Homes Structural Measures • Staffing levels (nurses, PTs, OTs, etc.) • Governance • Staffing mix • Age/condition of plant, equipment (include mobility development) • Staff turnover • Payer mix (percent mix, etc.) • Wages/benefits • Case mix • Management/leadership structure • Accreditation • Facility: size, location, ownership • Teaching status • Availability of private rooms   • Volunteers   Process-of-Care Measures • Assists with ADL/IADL (includes bathing, skin care) • Delivery of "hotel" services (sanitation) • Injury (staff and patient) • Assessment (includes care planning), frequency and completeness • Infection control (includes residents and staff) • Abuse prevention • Resident services: special care to prevent problems • Quality assurance (RA and MDS) • Overuse of restraints • Access and use of medical care • Use of urinary catheters • Resident rights • Bladder training   Outcome Measures • Mortality • Weight loss • Hospitalization • Infectious disease • Facility-acquired pressure sores, skin breakdown • Patient satisfaction • Functional status change • Family satisfaction • Pain control • Thefts/abuse • Depression • Staff injuries/illness • Injuries • Staff satisfaction • Urinary incontinence   NOTE: ADL = activities of daily living; IADL = instrumental activities of daily living; OT = occupational therapist; PT = physical therapist, RA = resident assessment; MDS = Minimum Data Set.

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--> dental care, skin condition, and medications (Morris et al., 1990). Because many persons tend to stay in nursing facilities for considerable lengths of time, often for months or years, process measures tend to assume greater importance than they do in hospitals, where the average length of stay is 7 days (Kane, 1988; Kane and Kane, 1988). A number of studies of nursing home quality have examined process measures (Zimmer, 1983, 1989; Zimmer et al., 1986). Some of these measures describe how personal services to residents are provided. These measures include help with activities of daily living (ADL) and provision of special services. At the same time, in high-quality institutions, staff avoid overuse of psychotropic medications (chemical restraints) and physical restraints. Critical to provision of high-quality care is a patient-specific care plan. Finally, residents have basic rights that society accords to other individuals. Thus, these rights also constitute elements of quality captured by the process measures. The outcomes of nursing home care include changes in health status and conditions attributable to the care provided or not provided. Outcomes of long-term care are "most fairly expressed in terms of the relationship between expected and actual outcomes." For some nursing home residents, realistic expectations for the outcomes of care may be maintained levels of health or slower-than-expected rates of decline, rather than improved health (R.L. Kane, 1995, p. 1379). The currently used measures of outcome include global measures such as mortality rates and rehospitalization rates (Lewis et al., 1985; GAO, 1988a,b; Spector and Takada, 1991); summary measures of functional status; and specific indicators such as incidence of facility-acquired pressure sores and urinary incontinence (Nyman, 1989b). Satisfaction of both residents and their families are also quality indicators because nursing home care and professional performance encompass more than the provision of technical services (Hay, 1977). Ultimately, determining the expected and actual outcomes of care for nursing home residents will require sophisticated and increased attention to assessment of individuals' initial health status, quality of life, sociodemographic characteristics, and the nature of treatment provided (e.g., palliative or curative), with the goal of determining the outcomes attributable to treatment after controlling for other variables (R.L. Kane, 1995). Patient Characteristics Nursing home residents and the primary missions of nursing homes vary, as well as the way in which variations affect how specific quality-of-care measures should be interpreted. At the risk of oversimplification, there are three types of residents: (1) those who use the facilities for recovery and rehabilitation following an acute hospital stay; (2) the terminally ill; and (3) persons with multiple chronic conditions and cognitive and functional impairments who are expected to stay in nursing facilities for the rest of their lives. The second and third types of

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--> patients have been predominant in past years. In the last decade or so, the number of residents in the first category has grown appreciably (Spence and Weiner, 1990). Patient mix affects staffing and the levels and mix of services provided, but also how various quality-of-care indicators should be interpreted. For example, a resident undergoing rehabilitation should maintain or experience improvements in functional status as the stay progresses. By contrast, for the terminally ill, decline in functional status is to be expected; control of pain and other dimensions of quality of life are paramount. Because indicators have different meanings depending on the resident's circumstances, quality-of-care indicators must be applied and interpreted with due regard for those meanings. Status Of Quality Of Care In Nursing Facilities Although in many facilities good care has been provided, even in the face of considerable financial constraints, the quality of care in some nursing facilities has long been a matter of great concern to consumers, health care professionals, and policymakers (NCCNHR, 1983). The IOM Committee on Nursing Home Regulation (IOM, 1986b) reported widespread quality-of-care problems in nursing homes. These findings were confirmed by the U.S. Senate (1986) and the General Accounting Office (GAO, 1987). Using studies from the 1970s and early 1980s, testimony in public meetings conducted by the committee, news reports, state studies of nursing homes, and committee-conducted case studies of state programs, the earlier IOM committee concluded that "problems identified earlier continue to exist in some facilities: neglect and abuse leading to premature death, permanent injury, increased disability, and unnecessary fear and suffering on the part of residents" (IOM, 1986b, p. 3). Although that IOM report noted some indication that these "disturbing practices now occur less frequently" (p. 3), the study also expressed concern about the poor quality of life in many nursing homes. It singled out problems of residents being treated with disrespect and of frequently being denied any choices of food, roommates, the time they rise and go to sleep, their activities, the clothes they wear, and when and where they may visit with family and friends. The committee stated flatly that the quality of medical and nursing care in nursing homes ''left much to be desired" (p. 3). Other studies, many published around the time of the IOM (1986b), U.S. Senate (1986), and GAO (1987) reports, have specifically examined quality of care in nursing homes. A number of clinical practices have been associated with poor patient outcomes.1 For example, urethral catheterization may place residents at greater risk for urinary infection and hospitalization or other complications such as bladder and renal stones, abscesses, and renal failure (Ouslander et 1   These are clinical problems that are not necessarily unique to nursing home settings.

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--> al., 1982; Ouslander and Kane, 1984; Ribeiro and Smith, 1985). Similarly, tube feedings also increase the risk of complications including lung infection, respiration, misplacement of the tube, and pain (Libow and Starer, 1989). Several studies of nursing facilities have shown the prevalence of a range of negative (or poor) patient outcomes such as urinary incontinence, falls, weight loss, infectious disease (Libow and Starer, 1989). Other poor patient outcomes identified include preventable declines in physical functioning (Linn et al., 1977); mortality and hospital readmissions during the first year of nursing home placement/residency (Lewis et al., 1985; GAO, 1988a,b; Spector and Takada, 1991); behavioral/emotional problems, cognitive problems, psychotropic drugs reactions, and decubitus ulcers (Zinn et al., 1993a,b). Legislative and Regulatory Efforts to Improve Quality To participate in the Medicare or Medicaid programs, long-term care facilities are required to meet federal certification requirements established by the Health Care Financing Administration (HCFA) (42 CFR Part 843) under the Social Security Act. Long-term care facilities include skilled nursing facilities (SNF) certified for Medicare, nursing facilities (NF) certified for Medicaid, and dual-certified facilities for both programs. State survey agencies are authorized to determine whether SNFs and NFs meet the federal requirements. Surveyors conduct on-site inspections to observe care, review records, and determine compliance. These surveys are used as the basis for entering into, denying, or terminating a provider agreement with the facility. In the early 1980s, the federal government proposed deregulation of the nursing home industry. At the same time, Congress was concerned about quality-of-care problems in nursing facilities because of reports and complaints by consumer groups. Problems with the regulatory process had been identified in an evaluation of state survey processes (Zimmerman et al., 1985). Because of the growing concern about nursing home quality, Congress requested a study by the IOM to examine the regulation of nursing facilities. The IOM Committee on Nursing Home Regulation documented quality-of-care problems and recommended revision and strengthening of the federal/state regulatory process (IOM, 1986b). Its recommendations, as well as the active efforts of many consumer advocacy and professional organizations, led Congress to enact a major reform of nursing home regulation in 1987 included in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87). This legislation was refined through subsequent related legislative enactments in 1988, 1989, and 1990. OBRA 87 OBRA 87 has been characterized as a "watershed"; it provided a definition of quality in long-term care that focused measurement of quality on resident

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--> outcomes and resident rights, and it recognized that without appropriate attitude and motivation, quality of care cannot be provided (Wilging, 1992a, p. 22). OBRA 87 specified that a nursing facility "must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care …" (sec. 1919(b)(2)). This legislation was a "landmark" statute in at least three respects. First, for the first time, nursing homes receiving federal funds were required to ensure a high quality of life in addition to providing a high quality of care. Second, the requirement that well-being be maximized implied that improvements in health and functional status be achieved, when possible, thereby shifting the focus from provision of custodial to provision of rehabilitative care. To achieve the objective of the highest level of well-being, nursing homes were required to develop individual care plans and a resident assessment process. Under the provisions of OBRA 87 and federal guidelines, nursing homes participating in Medicare and Medicaid programs must use the resident assessment instrument (RAI) to assess residents on admission, annually thereafter, and on any significant change in the resident's status. The RAI consists of the minimum data set (MDS) for resident care assessment and care screening (which is described more fully below) and resident assessment protocols (RAP). The purpose of these assessments is to identify a resident's strengths, preferences, and needs in key areas of functioning and to guide the development of the resident's care plan (Phillips et al., 1994). Third, OBRA 87 recognized that implementation of its provisions would require additional resources and training. Therefore, it encouraged state Medicaid programs to adjust their rates to reflect the new OBRA standards. This is arguably the first time that Congress explicitly recognized that high-quality care and quality assurance efforts come at a price. HCFA Regulations HCFA issued the enabling regulations in October 1990. These regulations mandated a number of changes. First, the regulations eliminated the hierarchy of conditions, standards, and elements that had been in prior regulations to that point. Second, the 1990 regulations mandated comprehensive assessments of all nursing home residents, using the MDS forms (Morris et al., 1990). Nursing facilities are required to complete the MDS forms for each resident within 14 days of admission, when there are major changes in health status, and at least annually. Facilities also are required to use the assessment in the care planning process. The federal survey procedures (conducted by state agencies) check the accuracy and appropriateness of the assessment and care planning process for a sample of residents. Third, more specific requirements for nursing, medical, and psychosocial

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--> services were designed to attain and maintain the highest practicable mental and physical functional status (Zimmerman, 1990). These requirements were specified in the new regulations, and a detailed set of HCFA interpretive guidelines was developed for use by state surveyors in 1990. The state surveys were redesigned to be more outcomes oriented than had previously been the case. Such outcome measures include residents' behavior, their functional and mental status, and certain physical conditions (such as incontinence, immobility, and decubitus ulcers). For example, the regulations established criteria for and prohibited the use of physical restraints and antipsychotic drugs without a specific indication of need, and they require periodic review and dose reduction unless clinically contraindicated. In addition, regulations detailing and protecting residents' rights were added. Nursing Home Resident Assessment Tools An important recent advance stemming from OBRA 87 was the development of the Nursing Home Resident Assessment System by Hawes, Phillips, and their colleagues. This system designed the nursing home minimum data set mentioned above for resident assessment and developed detailed protocols for resident assessment of specific problem areas to guide the care planning process (Morris et al., 1990). The purpose is to assess the functional, cognitive, and affective levels of residents. The MDS items were field-tested in 1990; the final version included 15 domains: cognitive patterns, communication/hearing patterns, vision patterns, physical functioning and structural problems, continence, psychosocial well-being, mood and behavior patterns, activity pursuit patterns, disease diagnoses, health conditions, oral/nutritional status, oral/dental status, skin condition, medication use, and special treatments and procedures (Morris et al., 1990). Now under development are quality indicators (QI), which use the MDS as a part of the National Nursing Home Case-Mix and Quality Demonstration (NHCMQ) study funded by HCFA. Among them are QIs for accidents, behavioral/emotional problems, cognitive problems, incontinence, psychotropic drugs, decubitus ulcers, physical restraints, weight problems, and infections. The QIs for individual residents and for facilities are compared to national norms, by taking into account predisposing factors and case-mix factors related to each QI. QIs that may indicate poor quality of care are identified and given to state surveyors to examine in the certification survey process (Zimmerman et al., 1995). Using QI data, state surveyors are expected to determine whether or not the identified QIs are the result of or are related to poor care processes. HCFA has proposed issuing regulations to require all nursing facilities to store and transmit RAI information electronically. Although, as of late 1995, the final rule had not been published, most providers are proceeding on their own. Nearly 62 percent of nursing facilities have begun computerizing resident assess-

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--> ments (AHCA, 1995). When fully computerized, QIs may be a valuable tool for monitoring the quality of nursing home care. Certainly, the QIs will augment the current nursing home survey process. Survey and Certification In November 1994, HCFA (1994a) released its final regulations for the survey, certification and enforcement of SNFs and NFs (42 CFR Parts 401–498). The provisions shaped the process of surveying and certifying facilities and specified procedures for enforcement. HCFA is also undertaking efforts to train state surveyors in using the new survey, certification, and enforcement procedures. Several alternative remedies may be imposed on facilities that do not comply with federal requirements, instead of or in addition to termination. These include civil money penalties of up to $10,000, denial of payment for new admissions, state monitoring, temporary management, immediate termination, and other approaches. The extent and type of enforcement actions depend on the scope of problems (whether deficiencies are isolated, constitute a pattern, or are widespread) and the severity of violations (whether there is harm or jeopardy to residents). Has Quality Of Care Improved Since Obra 87? The committee sought to determine whether quality of care in nursing homes is improving as a result of these increased efforts by the federal government to regulate quality. Consumer groups, staff, and providers report some improvements in nursing home care (Cotton, 1993; Fagin et al., 1995; 1995 IOM public hearings). A number of facilities have successfully focused on reducing the inappropriate use of physical and chemical restraints, and some report that the focus of the federal survey on resident problems represents a substantial improvement in the survey process. Between 1989 and 1993 the percentage of residents who were restrained dropped from 40 percent to 19 percent. Despite this progress, wide variations among states indicate that further progress is possible (AHCA, 1995). Deficiencies issued to facilities have declined since OBRA 87 was implemented. The average number of deficiencies declined from 8.8 per facility in 1991 to 7.9 in 1993 (Harrington et al., 1995). Survey data also show that the percentage of facilities without any deficiencies has increased slightly to 11.4 percent in 1993. Nevertheless, a recent analysis of the On-Line Survey and Certification Reporting System (OSCAR) data for 1993 also showed that despite some improvements in quality, state surveyors continue to find deficiencies of varying kinds and seriousness (see Table 6.2). Data compiled on all nursing facilities in the United States surveyed in 1993 were examined. With respect to the process of

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--> TABLE 6.2 Deficiencies in Certified Nursing Facilities from the Federal On-Line Survey Certification and Reporting System, United States, 1993 Types of Deficiencies Percent of Facilities with Deficiency Process Deficiencies Unsanitary food (The facility must prepare and serve food under sanitary conditions) 30 Inadequate care plan (The facility must develop a comprehensive care plan for each resident) 25 Inadequate sanitary environment (The facility must provide housekeeping/maintenance services for a sanitary environment) 20 Hazards in the environment (The facility must ensure that the resident environment remains free of accident hazards) 20 Improper restraints (Residents have the right to be free of physical restraints used for discipline or facility convenience) 18 No comprehensive assessment (The facility must make a comprehensive assessment of resident needs) 16 Inadequate infection control (The facility must investigate, control, and prevent infections) 15 Inadequate activities (The facility must provide an ongoing program of activities to meet resident needs) 12 No 24-hour nursing (The facility must provide sufficient numbers of personnel on a 24-hour basis) 5 No RN on duty 7 days a week (The facility must have an RN on duty 8 hours a day for 7 days a week) 5 Outcome Deficiencies Failure to maintain dignity (The facility must promote care for residents that maintains dignity and respect) 19

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--> Types of Deficiencies Percent of Facilities with Deficiency Inadequate treatment of incontinence (Incontinent residents must receive appropriate treatment) 12 Failure to prevent pressure sores (The facility must ensure that residents without pressure sores do not develop them) 9 Inadequate treatment of pressure sores (The facility must provide necessary treatment of residents with pressure sores) 9 Poor nutrition (The facility must ensure that residents maintain acceptable levels of nutritional status) 9 Abuse of residents (Residents have the right to be free of verbal, mental, and other abuse) 2   SOURCE: Harrington et al., 1995. care, nursing facilities were given deficiencies for a range of problems. Frequently cited problems include inadequate care plans, unsanitary and hazardous environments, and unsanitary food (this category is a "catch all" and includes minor problems such as crumbs left under the toaster and dumpster left uncovered to more serious problems such as unclean kitchen, inappropriate food and dishwasher temperatures, and other sanitation issues that could lead to foodborne disease transmission). In the area of outcomes, failure to maintain dignity and respect toward residents was a significant problem. Restraints have been severely criticized because their use may cause decreased muscle tone and increased likelihood of falls, incontinence, pressure ulcers, depression, confusion, and mental deterioration (Evans and Strumpf, 1989; Libow and Starer, 1989; Burton et al., 1992; Phillips et al., 1993). Although much progress has been made in reducing the use of restraints, Graber and Sloane (1995) found that a number of facilities fail to recognize and promote the independence of residents. They found that despite the implementation of OBRA 87 regulations, nearly one-third of North Carolina nursing home residents remained physically restrained. The characteristics associated with restraint use and with restraint violations can be used to identify facilities most likely to benefit from

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--> nursing facilities and the complexity of care needed today, some argue that additional training tied to the clinical problems identified in nursing facilities is desirable. The committee heard testimony from certified nurse assistants working in nursing homes about the need for more clinical training and experience as part of their program leading to certification, as well as for the development of career ladders for NAs. There is also a management issue of provision of continuing on-the-job training and one-on-one guidance. Unfortunately, research is lacking on the effect of nurse assistant staffing and training on quality of care in nursing homes. As stated above, in public testimony and on site visits, however, the committee heard support for this relationship. RECOMMENDATION 6-3: The committee recommends that the training for nurse assistants in nursing homes be structured and enriched by including training of the following types: appropriate clinical care of the aged and disabled; occupational health and safety measures; culturally sensitive care; and appropriate management of conflict. RECOMMENDATION 6-4: The committee recommends that research efforts on staffing levels and skill mix specifically address the relationship of licensed practical nurses and nurse assistants to quality of care. Management and Leadership The changing focus of services and the increasingly complex nature of the care provided in nursing facilities place new demands for skills, judgment, supervision, and management of nursing services. Concern has been expressed by a number of nursing leaders about the training and educational preparation of RNs working in nursing facilities and especially of the directors of nursing (DON). Ballard (1995) indicates that the role of the DON or a nurse administrator ideally involves knowledge of nursing, management, organization theory, finance, marketing and planning, personnel administration, supervision, and government regulations. Most DONs in nursing facilities are not academically prepared for their positions (Bahr, 1991), having little or no specific education about the aging process, gerontological nursing principles, or managerial skills. In contrast to hospitals, where DONs only rarely have less than a bachelor's degree and often have graduate education, those in nursing homes are often graduates of associate degree and diploma programs in which leadership and management are not part of the basic preparation, and they rarely have advanced clinical training in gerontology. Again, this comparison is at the national aggregate level. Wide rural–urban variations can be found in the educational levels of RNs in managerial positions in hospitals. Turnover among DONs in nursing facilities is high, amounting to more than

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--> 36 percent annually (AHCA, 1995), their salaries are low in comparison to hospitals, and they have limited opportunities for advancement. None of these factors is conducive to strong leadership. However, in view of the number of employees, budgets, and complexity of the care in nursing facilities today, strong leadership from the DON is a prerequisite for provision of high-quality, cost-effective care. Therefore: RECOMMENDATION 6-5: The committee recommends that, in view of the increasing case-mix acuity of residents and the consequent complexity of the care provided, nursing facilities place greater weight on educational preparation in the employment of new directors of nursing. In this regard, the committee is of the opinion that a bachelor's degree in nursing with special training in management and gerontology should be the preferred credential. In particular DONs need training in the management and administration of nursing facilities. The committee also urges that such facilities ensure a commitment to continuing education. Job Satisfaction, Turnover, and Compensation The committee can find no direct evidence of a relationship between job satisfaction and quality of care, although a relationship is widely perceived to exist (Bond and Bond, 1987). Staff Turnover Nursing homes with higher NA-to-bed ratios and those that include nursing assistants as part of the care team, value their opinions, and acknowledge their important role in provision of quality care have lower turnover rates (Reagan, 1986; Wagnild and Manning, 1986; Willcocks et al., 1987; Wagnild, 1988; Birkenstock, 1991; Robertson et al., 1994; Mor, 1995). As discussed earlier in this chapter, information gathered from site visits, testimony, and small group meetings with DONs and others suggests that some facilities have reduced turnover by providing free on-site child care, health insurance, and other benefits. High RN and LPN turnover is associated with lower quality of care (Erickson, 1987; Wright, 1988; Munroe, 1990; Spector and Takada, 1991). More specifically, high turnover compromises the continuity of care and supervision of staff. Job turnover is also costly in terms of hiring, training, and facility productivity losses, but most important, high turnover rates adversely affect residents who do not cope well with frequent changes in staff (McDonald, 1994). Excessive turnover of these personnel, heavy use of part-time staff, and the use of floating or agency staff also compromise the quality of care (Erickson, 1987). Permanent assignment of staff to residents results in more quality outcomes

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--> TABLE 6.5 Average Turnover Rates in Nursing Facilities by Staff Category, United States, 1990–1994 Type of Staff July 1990 July 1991 January 1993 January 1994 Administrator 28.5 26.4 21.4 27.2 RN 43.5 51.6 45.3 56.3 LPN a a 44.8 52.5 NA 85.1 94.3 80.1 100.4 a Before 1993, data for LPN and RN positions were collected as a combined category. SOURCE: AHCA, 1994b, 1995. for residents and greater satisfaction and feelings of accountability for employees (Patchner and Patchner, 1993). Evaluation of a primary care model of delivery of nursing aide care (e.g., permanent aide assignment, a team approach, and enhanced communication) in nursing homes demonstrated increased quality-of-care indicators such as improved behavior, affect, and social activities among residents (Teresi et al., 1993). National data on turnover indicate very high rates for all types of nursing personnel in nursing homes, especially nurse assistants (see Table 6.5). Moreover, staff turnover rates appear to have increased in recent years. Compensation High rates of turnover in nursing homes are attributable to several causes. The low rate of compensation, compared to hospitals, has been a factor. In 1992, RNs' annual earnings in nursing homes were 14–17 percent below those in hospitals (Moses, 1994). On the one hand, RNs in nursing homes have, on the average, less educational preparation than those in hospitals. On the other hand, RNs in nursing facilities are much more likely to be employed in administrative positions than are those in hospitals (24 versus 3 percent in 1992) (Moses, 1994). Wages of nursing assistants are generally near the minimum wage and are comparable to levels offered by fast food chains and retail establishments. As with RNs, nursing assistants are paid appreciably less in nursing homes than in hospitals (Gold, 1995) (see Table 6.6), and they lag behind NAs in home health care agencies as well (Hospital and Healthcare Compensation Service, 1994). Many nursing facilities do not provide their employees with health benefits. Recently, AHCA (1994a) estimated that if mandatory national health insurance were adopted by Congress, nursing facility costs passed on to Medicaid would increase by $1 billion, and similar costs to Medicare would increase by $100

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--> TABLE 6.6 Nursing Facility Hourly Wages by Staff Category, United States, 1990–1993   Year Type of Staff 1990 1991 1992 1993 Administrator $18.55 $19.43 $20.74 $21.58 DON 15.66 16.75 18.36 19.30 RN 12.81 13.76 14.75 15.49 LPN 9.74 10.31 10.96 11.51 NA 5.19 5.48 5.81 6.06 NOTE: DON = director of nursing; RN = registered nurse; LPN = licensed practical nurse; NA = nurse assistant. SOURCE: AHCA, 1994b, 1995. million. The 1994 average health insurance costs for nursing facilites were estimated to be 4 to 6 percent of the payroll. If all employees were provided health benefits, the health insurance costs would increase to almost 8 percent of the payroll (AHCA, 1994a). Under a number of assumptions about the behavior of nursing facilities, higher levels of RN compensations result in reduced nursing home demand for RNs. Using data from 14,000 nursing facilities in 1987, Zinn (1993b) found that nursing facilities adjust staffing and care practices to local market conditions, as would be expected. In areas where RN wages were higher, nursing facilities employed more nonprofessional nursing staff. Thus, after controlling for resident characteristics, nursing facilities have economic incentives to hire fewer RNs in areas with high RN wages. Clearly, the combination of low average wages and benefits contributes to high turnover and poor quality of care. During its site visits and in public testimony the committee heard many comments about the low level of wages and fringe benefits in nursing facilities, with the result that recruiting and retaining nurses are major problems for nursing homes. The committee is sympathetic to the need for increased compensation as a means of improving care. To achieve parity with other providers such as hospitals would increase the cost of care especially to Medicare and Medicaid. Higher compensation can possibly reduce the demand for RNs in nursing homes. It depends, however, on state Medicaid reimbursement methods and the internal resource allocation priorities that are established by nursing homes themselves. These quality and cost trade-offs must be considered in addressing this major problem in nursing homes.

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--> Ownership The relationship of facility ownership to staffing, quality, and costs has been the subject of numerous studies and controversy. One of the key issues debated is whether the proprietary nature of the nursing home industry affects quality. A review of the research on ownership and quality shows a mixed picture in terms of the relationship (Koetting, 1980; Greene and Monahan, 1981; O'Brien et al., 1983; Hawes and Phillips, 1986; Nyman et al., 1990; Davis, 1991). Some researchers have found no relationship between ownership and quality (Cohen and Dubay, 1990); others have found nonprofit nursing facilities to be associated with higher quality of care. Davis (1991) in her review of the literature on ownership and quality concluded that the findings were mixed. A recent study of nursing facilities using the 1987 MMACS data from 449 free-standing nursing facilities in Pennsylvania found that nonprofit nursing facilities provided significantly higher quality of care to Medicaid beneficiaries and to self-pay residents than for-profit facilities when case-mix is controlled for (Aaronson et al., 1994). The authors found that nonprofit facilities had higher staffing levels and fewer adverse outcomes from pressure sores, controlling for case-mix, but no difference in restraint use. Johnson and colleagues (Part II of this report) also explored the relationship of ownership and quality by categorizing facilities into high- and low-quality facilities using OSCAR data and examining the characteristics of each set of facilities. They found that for-profit facilities that are not chain owned fell into the high-quality category at as high a rate as nonprofit facilities, while having substantially fewer staff and the highest proportion of Medicaid covered residents. Chain-owned for-profit facilities fell into the poor-quality category at a higher rate than expected. They suggest that this could be because chain-owned facilities do not have a direct accountability or because the management structure of some chain-owned facilities does not provide effective oversight of quality of care. Another interesting finding of their analysis is that rural facilities are more than twice as likely to be in the high-quality category. The authors suggest that a rural facility may be more community sensitive than a facility in urban areas. The community sensitivity may be due to staff knowing the residents they care for and being concerned about the reputation of the facility. Effects Of Reimbursement And Other Factors On Nursing Staff Reimbursement and Staffing Method and Level of Reimbursement As discussed in Chapter 3, nursing homes derive most of their revenue from

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--> charges to private-pay patients and from Medicaid. Conceptually, both the level and the method of Medicaid reimbursement are determinants of nurse staffing levels. Traditionally, Medicaid is paid on a retrospective cost basis. Under this form of reimbursement, payment is made on the basis of costs incurred. This approach has been rapidly supplanted by other methods in which some or all of the rate is set prospectively (Swan et al., 1993a,b). Prospective-class (flat-rate) methods set prospective rates for groups of nursing homes within a state. Prospective facility-specific methods set rates by facility, generally using cost reports from earlier periods. Some states set rates prospectively but allow for retroactive adjustments (Swan et al., 1993a,b). There is limited empirical evidence on the effect of level and method of Medicaid reimbursement on nurse staffing in nursing homes. Cohen and Spector (in press), using data from the 1987 National Medical Expenditure Survey, found that states with higher Medicaid reimbursement had more LPNs per 100 residents, adjusting for case-mix. However, a statistically significant effect was not obtained for RN staffing. They further found that Medicaid cost-based reimbursement led to substitution of RNs for LPNs. Presumably because payment is lower and there is excess demand for care on the part of Medicaid eligibles, facilities with high proportions of residents on Medicaid tend to have a lower quality of care as measured by process indicators (Nyman, 1985, 1989b; Gertler, 1989). Elderly persons who are potentially eligible for Medicaid have experienced access barriers to nursing home care in areas where a high proportion of potential nursing home residents are private (Ettner, 1993). One suggestion has been to tie the Medicaid reimbursement rate to the proportion of private patients in the home (Nyman, 1989b). Case-Mix Reimbursement Case-mix reimbursement attempts to tie payment to a facility's case-mix severity. Case-mix reimbursement systems were developed for Medicaid as a means of making closer linkages among resident needs, payments, and costs and as a way of removing access barriers for heavy-care Medicaid patients (Schlenker et al., 1985; Schlenker, 1991a,b). As noted above, 19 states were using case-mix systems in 1993 (Swan et al., 1994). The most commonly used case-mix measure has been functional status (using activities of daily living), although other disability scales have been used (Weissert and Musliner, 1992a,b). As mentioned earlier, one of the best known approaches has been the RUGS methodology developed by Fries and Cooney (1985), which has been updated into RUGS II and RUGS III versions (Fries et al., 1994). Resident characteristics are typically examined for the amount of personnel resources needed to provide care to residents, which can be determined in different ways such as staff time and cost studies (Weissert et al., 1983; Fries and Cooney, 1985; Arling et al., 1987; Fries et al., 1989, 1994). Once costs are determined, they are tied to resident character-

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--> istics (Weissert and Musliner, 1992a,b). As Fries and colleagues (1994) point out, the development of classification systems and resource use groups is primarily a technical process, but the development and assignment of reimbursement categories is primarily a political process. Several studies have been conducted of case-mix (Weissert et al., 1983; Cameron, 1985; Fries and Cooney, 1985; Arling et al., 1987, 1989; Schneider et al., 1988; Fries et al., 1994). Weissert and Musliner (1992a,b) have summarized the results of the many studies of case-mix reimbursement. These studies reported that most states that have used case-mix reimbursement have improved access for some heavy-care residents (Ohio, Illinois, Maryland, and New York). On the other hand, there continued to be problems with access in some case-mix reimbursement states such as West Virginia (Holahan, 1984; Butler and Schlenker, 1988; Weissert and Musliner, 1992a,b). Access problems under case-mix, such as lengthy waiting lists for admissions, have occurred especially in areas where there is a low supply of beds (Nyman, 1988b), where there are Medicaid processing delays (Weissert and Cready, 1988), and where reimbursement rates are low. Access problems occurred for those with low-care needs and where community-based alternatives were not necessarily available (Butler and Schlenker, 1988; Feder and Scanlon, 1989). Critical to the success of case-mix reimbursement is the adequacy of the case-mix measures themselves. The committee construes analysis of the underlying technical issues to be beyond the scope of its charge. (There is an extensive literature on this subject. See, for example, Fries and Cooney, 1985; Hu et al., 1986; Rohrer et al., 1989; Fries et al., 1994.) However, although attempting to base payment on severity is meritorious in principle, there may be problems in implementation. Classification errors may actually discourage delivery of quality therapeutic care, for example, if the system does not adequately account for comorbidities such as behavioral problems stemming from mental illness (Rohrer et al., 1989). Case-mix reimbursement generally has not led to increases in nursing staff-to-resident ratios. In Maryland, there was no evidence that extra nursing home payments were used to add more staff (Feder and Scanlon, 1989). New York also did not increase staff even though resident case-mix increased (Butler and Schlenker, 1988). Although West Virginia had some evidence of poor quality (e.g., increased catheterization), nursing resources did increase in 1979–1981 (Holahan and Cohen, 1987; Weissert and Musliner, 1992a,b). In the San Diego experiment, where facilities were given financial incentives to take more heavy-care residents, there was no evidence that extra payments were spent on extra care (Meiners et al., 1985). Of the six state systems reviewed by Weissert and Musliner (1992a,b), only Illinois was rated as having improved quality (Holahan, 1984; Butler and Schlenker, 1988). HCFA is undertaking a demonstration project to introduce Medicaid case-mix reimbursement in four states in 1994–1995. As Weissert and Musliner

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--> (1992a) have noted, it is not clear whether substantial new advances will be made in designing improved case-mix reimbursement systems in the demonstration project. An evaluation has been planned that will examine the outcomes of the demonstration on access, quality, and costs. Incentives to Enhance Quality of Care A conceptually attractive alternative to basing payment on inputs is to reward nursing homes based on aggregate outcomes achieved (Willemain, 1980; Kane et al., 1983). There have been several experiments with outcomes-based incentives. A social experiment was conducted in San Diego to test the effectiveness of monetary incentives in improving the health of nursing home residents and reducing Medicaid expenditures. With data from the San Diego project, Norton (1992) used the Markov model to represent the resulting health changes of nursing home residents. He found that offering incentives for improved outcomes had beneficial effects on both the quality and the cost of nursing home care. Furthermore, nursing homes admitted more persons with severe disabilities. The savings came not from more efficient use of nursing homes, but rather from savings from earlier hospital transfers. The experience in other locations has been mixed, however. Although the Illinois quality incentive program appears to have succeeded in increasing the quality of care, the validity of the outcome measures was not established (Geron, 1991). Connecticut's system was discontinued because the program's goals were not reached (Geron, 1991). Maryland's system of paying facilities to turn and position patients to prevent decubitus ulcers and to pay for improvement in ADLs for 2 months has been rated as effective (Weissert and Musliner, 1992a,b). Michigan's effort has not been evaluated (Lewin/ICF, 1991). The committee finds the concept of reimbursing for improved outcomes intriguing, but recognizes that the implementation issues require further analysis. Also, using outcomes-based incentives may have some practical limits. In such cases, consideration should be given to linking reimbursement to process measures known to be associated with high quality of care. RECOMMENDATION 6-6: The committee recommends that the Secretary of Health and Human Services fund additional research and demonstration projects on the use of financial and other incentives to improve quality of care and outcomes in nursing homes. Residents, Families, Volunteers, And Ombudsmen The role of residents, family members, and other persons external to the nursing home has received limited attention in the context of discussions of quality of care in nursing homes. Family members and others have at least three

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--> potential roles: as care givers and as advocates for patients, and as payers. The nursing home industry has become one of the most regulated in the country, not only because of the importance of government funding but also because patients lack power in relationship to nursing homes. They generally lack the ability to leave or to change the facility when they are dissatisfied. Often they are deficient in their ability to communicate their opinions and feelings. To avoid additional regulation, greater reliance needs to be placed on other agents to act in residents' interests. In particular, the committee notes that information gathered from site visits and testimony supports the use of volunteers in nursing facilities. Volunteers are used by nursing facilities to various degrees and in various roles. Representatives of the two "model" nursing facilities testified to the committee about their successful implementation of innovative approaches to the delivery of care. One received a great deal of help from volunteers, while the other received some, but not a notably large amount of, help. Although volunteers can clearly add to the quality of life for residents, both of these witnesses emphasized the role of the nursing staff in achieving the great improvements in residents' well-being following implementation of the new models. Benefits to residents include improved linkages to the community, multigenerational interactions, human contact, avoidance of isolation, and special errands and services, such as letter writing and craft activities. The committee endorses these practices and urges nursing facilities to develop and strengthen volunteer programs. The committee found very little research on the role of families in nursing home care. Bowers (1988) proposed a collaborative approach to care that would encourage families to become more involved in technical aspects of care while facilitating staff's emotional involvement with residents. Kayser-Jones (1990) examined the use of nasogastric (NG) feeding tubes in nursing homes. Two themes of interest emerged from family interviews: (1) there was little or no communication among health care providers, patients, and their families regarding the use of NG tubes; and (2) some families perceived that the tubes were used for the convenience of the staff who did not want to take the time, or did not have the patience, to feed residents (Kayser-Jones, 1990). In a study to evaluate the effects of a special care unit (SCU) for Alzheimer's residents, Maas and colleagues (1991) found that family members were dissatisfied with their lack of involvement in the care of their relatives, with the activities provided for the residents, and with the amount of resources devoted to the provision of care. Maas and colleagues (1994) are currently testing the effects on family and staff satisfaction and stress, as well as on resident outcomes, of an intervention designed to create a family–staff partnership for the care of institutionalized persons with Alzheimer's disease. Staff and family members need to have the knowledge and skills that best prepare them to understand and recognize quality resident outcomes, to be better able to establish cooperative relationships, and to

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--> share decisions so that the optimal resources of both staff and families are used to achieve quality outcomes. Ombudsman programs and other forms of community presence may improve nursing home quality of care. Long-term care ombudsmen ''advocate to protect the health, safety, welfare, and rights of the institutionalized elderly," and a recent IOM study has come out strongly in favor of this program (IOM, 1995, p. 1). The IOM report is an in-depth examination of the strengths and weaknesses of the ombudsman program; it specifically addresses the extent of compliance with the program's federal mandates; the availability of, unmet need for, and effectiveness of the ombudsman program; the adequacy of resources available to operate the program; and the need for and feasibility of providing ombudsman services to older individuals who are not residing in long-term care facilities. Cherry (1991) compared the effects of community presence programs on the quality of nursing care with a random sample of 134 Medicare-or Medicaid-certified long-term care facilities in Missouri. The presence of an ombudsman program was found to be one of the more important factor associated with quality for intermediate-care facilities and also was significantly associated with quality for skilled nursing homes where there was ample staffing of RNs. Conclusion Ideally, the committee would have found some major source of inefficiency that, when remedied, would release substantial revenues that could be used to enhance the ability of nursing homes to improve staffing. Such staffing increases would then lead to improved quality of care, as the empirical studies have demonstrated can be accomplished. An alternative approach would be to convert "excessive" nursing home profits and overhead to patient care. No rigorous study of profitability in nursing homes, or for that matter in hospitals or managed care systems, has been conducted, but the committee found a widespread perception of an imbalance of compensation between care givers, on the one hand, and executive officers and owners, on the other. Committee members are sympathetic with the notion that such an imbalance exists, but even if such resources were reallocated to patient care, the committee is not certain that this would provide the "magic bullet" for appreciably increasing the number and quality of staff capacity. Any discussion of staffing needs to take into account the financing of staffing needs. To the extent that additional funds from an outside source are necessary, it becomes a question of from where they will come. A major barrier to increased staffing in nursing facilities concerns the fiscal limits of governmental support. Since government pays for nearly 63 percent of current nursing home expenditures (Levit et al., 1994), Congress has been reluctant to increase staffing requirements to needed levels, even though some members of Congress have been sympathetic to the need for increased staffing. The small staffing increases

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--> under OBRA 87 required substantial new resources. These staffing increases were apparently based on the amount legislators and industry leaders considered to be politically and fiscally feasible, because most of the costs for increased staffing would be reflected in increases in federal and state Medicaid budgets. Since OBRA 87 was passed, federal legislation has been considered by selected congressional representatives for increased staffing beyond the OBRA requirements, but such legislation has not had the political support to proceed. States have the authority to increase their Medicaid payment rates as a means of increasing staffing standards, but the pressures on some states with rapidly growing Medicaid budgets make it unlikely that they will initiate increases in nursing home staffing requirements. The research reviewed has shown that low-quality facilities have a higher proportion of Medicaid residents, and Medicaid rates are usually lower than private-pay rates. Policymakers are faced with difficult choices involving trade-offs between quality and costs. Since the population of this country is aging and the oldest-old age group is increasing, and there is no cure in sight for chronic diseases such as Alzheimer's, the demand for nursing home care will not abate, even with the growth of alternative long-term care facilities. Funding mechanisms will have to be explored to ensure adequate staffing to care for residents with multiple chronic conditions and with special care or subacute care needs. It is clear that substantial improvements in the quality of nursing home care are not possible without the allocation of increased financial resources for additional and appropriately qualified staffing.