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Nursing Facilities American Geriatrics Society (AGS) REGULATION OF NURSING FACILITIES POSITION STATEMENT *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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