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*Last Updated January 1, 2000*
BACKGROUND
Quality of care in long-term care
facilities has been a topic of national concern during the last
three decades. Through the 1960's and 1970's, complex regulatory
standards were developed in response to perceived quality problems.
At the same time, skepticism regarding the usefulness and application
of those standards was prevalent. Studies by the Health Care Financing
Administration (HCFA) and several states during the 1970's suggested
that compliance with existing regulations varied widely. During
the 1980's there was increasing consensus by individuals and organizations
concerned with nursing home care that regulations placed undue emphasis
on structure and process rather than the resulting outcomes. In
response to public and professional concern, Congress directed HCFA
to study how to improve nursing home regulation. HCFA contracted
with the Institute of Medicine (IoM), which established a committee
on nursing home regulation.
After a lengthy process of information
gathering and analysis, the Committee based its report (Institute
of Medicine, 1986) "Improving the Quality of Care in Nursing
Homes" on both objective information and a consensus of professional
opinion. Congress acted quickly on that report and mandated many
of the IoM recommendations as part of the 1987 Omnibus Budget Reconciliation
Act (OBRA). The law set new requirements for resident assessment,
residents' rights, nurses aide training, monitoring of psychotropic
medications, medical direction, and the level of staffing by professional
nurses. Translating those requirements into regulation and creating
the format, as in the case of the Minimum Data Set for resident
assessment, has been a lengthy process. Nevertheless, many aspects
of the 1987 OBRA have been or are being implemented.
POSITIONS
1. The 1987 OBRA regulations are
based on principles that should improve quality of care in long-term
care facilities. However, some of these principles have been the
subject of limited study. Data collection and analysis will be essential
to identifying problems in applying these regulations. Based on
the results of such analysis, the regulations and instruments should
be modified as necessary to achieve the desired results of this
legislation, i.e., improvement in the quality of care in nursing
homes.
Rationale: The IoM report serves
as an excellent starting point upon which regulations can be based.
However, the authors of that report admit that there was not always
sufficient information on which to base recommendations and that
they
often had to rely on professional
opinions. Based on the IoM report, OBRA 87 regulations require that
residents of nursing facilities be assessed in 18 functional areas.
The Minimum Data Set (MDS) was developed under federal contract
as a recommended format for that assessment. Functional difficulties
identified on the MDS can be evaluated by using the Resident Assessment
Protocols (RAP), which were developed for that purpose. Because
the IoM recommendations were sometimes based on a limited number
of studies, it would seem essential that information from the MDS,
RAPs, etc., be collected and analyzed in an effort to learn more
about the problems being addressed and the limitations of the instruments
and evaluations. A standard approach to assessment of residents
provides an opportunity to: 1) better define the scope of problems,
2) identify useful interventions and, 3) identify portions of the
assessment that have no substantial effect on resident well-being.
2. State regulators should base their
policies and procedures on the federal requirements and avoid duplication.
Rationale: Over the last several
decades, poorly coordinated federal and state requirements have
placed a substantial burden on long-term care providers. When the
burden is great, providers are pressured into "paper compliance"
at the expense of patient care. A single set of regulations uniformly
applied to all institutions, nursing facilities, and residences
holds the greatest promise for improving the quality of care. State
regulators should focus their efforts on understanding the federal
procedures and assisting long-term care providers in meeting those
standards. When possible, states should use elements of the Minimum
Data Set to serve state-specific purposes such as reimbursement.
3. The new regulations promise to
raise the standard of care provided in long-term care facilities
by identifying and addressing resident problems and improving the
expertise of staff providing care. Payors must assume the greater
costs created by the implementation of these changes.
Rationale: More involvement of physicians,
more professional nurse coverage, and better training of aides will
increase costs in long-term care facilities. Screening, identifying
and treating disorders of communication, speech, hearing, vision,
physical function, and continence, and implementing restraint-free
environments, will sometimes be more costly as these problems are
prevalent among residents of long-term care facilities. All payors
for long-term care services must be aware of the financial implications
and be willing to assume greater costs, if the new regulations are
to have their intended positive effect.
4. Ultimately, the basis of nursing
facility regulation should be quality outcome measures. The present
regulations are useful only if they assist facilities in procedures
that improve outcomes.
Rationale: Current regulation is
based on identifying and assessing common problems seen in long-term
care patients. Emphasis is also placed on adequate staff training
and availability to assess and intervene in those problem areas.
If these interventions are effective, outcomes should improve. Therefore,
the ultimate test of effectiveness should be tied to quality outcome
measures. Mechanisms are available to estimate the expected course
of care in nursing facilities. Comparison of observed to expected
outcomes, given the case mix in a given facility, would be the best
estimate of the quality of the care provided.
Developed by the Public Policy Committee
and approved July 1985 by the Board of Directors. Revised May 1991.
Reviewed April 1993. The American Geriatrics Society, The
Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY
10118, 212-308-1414, Fax: 212-832-8646, info.amger@americangeriatrics.org.
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