The Centers for Medicare and Medicaid Services' Nursing Home Case-Mix and Quality Demonstration

Abstract

This paper presents the first comprehensive account of a major national demonstration designed to integrate skilled nursing facilities (SNF) prospective case-mix payment and quality of care. It describes the Centers for Medicare and Medicaid Services' Nursing Home Case-Mix and Quality (NHCMQ) Demonstration—the template for Medicare's SNF Prospective Payment System (PPS) implemented July 1998. The NHCMQ Demonstration provided the basis for one of the most significant changes in SNF reimbursement and quality monitoring policies to date. Prospective reimbursement policies created positive incentive for providers to admit Medicare residents under more equitable payment rates. However, controversy regarding unanticipated perverse provider incentives remains. The quality management system designed under the NHCMQ Demonstration is currently used in over 17,000 nursing homes. Furthermore, under the NHCMQ Demonstration, one standardized assessment tool—the MDS—was used to assess a resident's clinical condition, to monitor quality, and to calculate provider reimbursement. Experiences from the NHCMQ Demonstration and continued evaluation of the current national PPS, along with state systems, provide a rich information source regarding prospective, case-mix reimbursement, and provider incentives.     

Being a man in long term care

PurposeMen tend to represent a distinct minority in long term care (LTC) facilities. Here we explore men's seldom examined experience in LTC.Design and methodsAs part of a major study of Bereavement in Long Term Care, we focus on 21 men who live in five LTC facilities (assisted living facilities and nursing homes). Transcribed qualitative, in-person interviews are examined using standard qualitative analytic methods.ResultsThrough multiple rounds of coding three inter-related themes emerged as salient. (1) Men's work experience as central to their sense of identity. (2) The presence of a wife often is associated with men's sense of couplehood and of feeling protective. (3) Men often regulate their relationships with other LTC residents.ImplicationsDiscussion examines how these three themes are related to men's maintenance of a masculine role in LTC.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Bringing Assisted Living Services into Congregate Housing

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents—the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.     

The Role of the Academic Nurse and Physician in the Criminal Prosecution of Nursing Home Mistreatment

Academic health care professionals have worked with the Commonwealth of Pennsylvania Attorney General's office in a number of capacities to examine the quality of care in several Philadelphia area nursing homes. These tasks include: evaluating the quality of care; helping the prosecution understand the complexities of the cases; and testifying in court, in particular, educating the court about aging, disease, nursing homes, and the appropriate care of infirm elderly. This paper discusses the responsibilities of physician and nurse expert witnesses, using the cases of Ms. E and Ms. W as examples. It also describes some of the tensions that arise when educators work with prosecutors.     

Factors That Explain Marital Happiness When a Spouse Lives in a Nursing Home: Married but Living Apart

ABSTRACT

Little attention has been given to factors that affect the marital happiness of well spouses when their partners reside in nursing homes. Using two established scales, a telephone survey of 60 community dwelling individuals whose spouses were being cared for in nursing homes across Ohio was conducted. Multiple regression analysis indicated factors that contributed to the degree of happiness in the marital relationship were the amount of time married and coping techniques associated with mobilizing resources, social support, and spiritual support. These variables accounted for 35% of the variance in participants' stated degree of happiness with their marital relationship.     

Culture Change in Skilled Nursing: An Exploratory Comparison of a Traditional Home to a New Model

Abstract

The culture change movement has pushed for reform for more than two decades to align policy, the long-term care industry, and resident preferences with regard to care. Evidence from research indicates that culture change has the potential to improve quality in nursing homes. There is no one-size-fits-all way to implement culture change; however, there are key elements and associated concepts and models. A common thread is that they run counter to the medical model, typically found in nursing homes, where care is provided in a hospital-like setting according to the schedules and routines of physicians and staff with little resident input. This qualitative study looks for evidence of culture change in a traditional model of care compared to a newer culture change model, by describing the differences in practices associated with the medical model, person-centered care, and person-directed care between the two settings. Our results indicate that there is evidence of person-directed care in one model of culture change—the Green House home—but not in the traditional nursing home. Future studies should examine other culture change models to compare the differences in the utilization of person-directed care. This information will help to clarify the definitions and concepts of culture change, along with developing best practices for future culture change models.     

Commentary: The Physician's Role in Nursing Home Quality of Care: Focus on Restraints

The physician can play an important role in managing high-risk nursing home residents without restraints and working with interdisciplinary care teams in comprehensive fall evaluations. A reduction or elimination of physical restraints can be measured for a facility over time, and it represents a relevant quality indicator of physician and facility interactions during the process of care. We discuss how the physician's role fits into this quality of care equation for nursing homes and its implications for new clinical, research, and policy directions for long-term care.     

The “Our Homes,Not Nursing Homes” Project

ABSTRACT

The voices of non-elderly adults with disabilities who currently-or used to-reside in nursing homes are rarely heard. A grassroots disability advocacy organization conducts participatory action research in the form of a writing workshop in collaboration with a local community-college. Participants with disabilities describe their lives and their experiences in nursing homes with the help of volunteer scribes. The information provided in their accounts will help strengthen community-organizing efforts of the disability advocacy organization. And participants have been empowered by the realization that their life stories are helping others to leave nursing homes and join community settings.     

The experience of quality of life among older people

Although quality of life has been in the focus of attention for over a decade there are few studies available investigating, how the old and the oldest old experience their quality of life or what quality of life actually means for them? To illuminate this, eleven in-depth interviews were conducted with six women and five men (80+) living in their home. An interpretative hermeneutic phenomenological analysis revealed that quality of life in old age meant a preserved self and meaning in existence. Maintained self-image meant that the older people experienced a coherent life with an intact meaning. How quality of life was valued depended on the meaning the old people attached to the areas of importance as well as how they were evaluated. Additionally, areas not generally included when measuring quality of life became discernible. The meaning of home, how life was viewed, thoughts about death and dying, and telling ones story proved to be areas of importance for their perception of quality of life. Thus, indicating that older people's view of quality of life is more complex than some of today's most commonly used quality of life instruments capture and that quality of life assessment tools needs to measure beyond pure health indices. For nursing care the use of life review in everyday care, and an open way towards existential topics as well as a family oriented care along with preventive work helping people to remain in their own homes may enhance their experience of quality of life.     

Shaping social situations: A hidden aspect of care work in nursing homes

A significant aspect of care work in nursing homes involves dealing with emotional responses such as anxiety, fear, pain, depression and anger on the part of residents and their families. Previous care and nursing research on this topic centers around dyadic relationships and does not provide useful conceptualizations of how care workers actively deal with the social situations they encounter as part of their work. Drawing on ethnographic field work and interviews conducted in two Norwegian nursing homes, this article aims to describe and conceptualize a previously neglected aspect of good care work: the active shaping of social situations in order to lessen uneasy feelings of residents and their families. Three episodes of good work are described to illustrate how social situations can be shaped. Strategies include such actions as timing events, regulating one's presence, and composing social groups. The concluding section discusses some implications for nursing home management.     

Contact with Outdoor Greenery Can Support Competence Among People with Dementia

SUMMARY

Dementia disorders are increasing among populations all over the world due to growing life expectancy. Since dementia widely affects cognition, especially short-term memory and orientation, people with dementia are more dependent on provisions from their environment to act successfully than those without dementia. Green environments have been associated with reduced autonomic arousal leading to stress recovery and improved affective state. In this paper we introduce theories and empirical studies about healing and green environment, and present our findings on the impact of plants, and of seeing and being outdoors on the well-being of people with dementia in day care and in residential care. The first study is based on a survey of 65 nursing staff from ten residential care homes. The second study involved 123 people with dementia from two day care units and six residential care units.     

Impact of Regulation and Financing on Small Board-and-Care Homes in Maryland

ABSTRACT

States use forms of regulation in small board-and-care homes to control quality; however, quality varies in spite of these efforts. This study of 94 small facilities compared quality of care measures in homes regulated by a state-administered program with those in nonregulated homes. It also compared homes on those variables using average payment for services as the independent variable. Results indicate that higher payments for services had a greater impact on quality than did participation in a regulatory program. Adequate funding may be key to maintaining reasonable quality in these homes.     

The Impact of the Social Environment on Nursing Home Residents

ABSTRACT

This study contrasted the experienced quality of life of residents living on one of two nursing home units: a unit for those considered socially intact and a unit combining residents who had moderately impaired cognition or physical function with those requiring skilled nursing or therapy. Qualitative interviews were held with residents of both units. The findings indicate that the social environment of each of the units played a fundamental role in the residents' quality of life. The social environment affected the residents' conceptions of self, their interactions with other residents and their interactions with the nursing staff. The article suggests the processes behind the social environment of each floor that may have resulted in different perceptions of the quality of life.     

The Role of the American Nurses' Association in Maintaining Professional Accountability

Abstract

A professional association has been defined as a group of practitioners who organize to perform functions they cannot perform as separate individuals and to judge one another as professionally competent. History reveals that when a profession becomes clearly defined, the responsible practitioners form an association in order to establish standards of practice and enforce rules of conduct.

As the professional association for nurses, the American Nurses' Association is inextricably involved in the development of mechanisms that guarantee professional accountability. A standing priority of the association is to improve the quality of care provided to the public by such means as 1) setting a timetable for establishing qualifications for entry into nursing practice; 2) evolving a coherent credentialing system; 3) establishing systems to assure the profession's accountability for practice and for the delivery of services; and 4) providing for expansion, accessibility, and improvements in continuing education in nursing.

If nurses are to assume greater responsibility, the profession must be in a position to assure the public of quality nursing care. Since the public holds the profession (as a whole) accountable for the competence of its practitioners, the professional association has a responsibility to establish mechanisms by which to judge the competence of its practitioners and to evaluate the quality of care.     

“It’s a Dignity Thing”: Nursing Home Care Workers’ Use of Emotions1

This article examines how nursing home care workers use emotions to construct dignity at work. Previous scholarship has shown how the financial and organizational characteristics of nursing homes shape and constrain emotion work among staff. Using evidence gathered during 18 months of participant observation in two nursing homes and 65 interviews with staff, this article analyzes how, despite obstacles, nursing home care workers generated authentic emotional attachments to residents. Surprisingly, some staff members said they particularly appreciated working with residents difficult to control. They felt accomplished when such residents successfully transitioned from life at home to life in institutional care. Emotions created dignity for staff and induced compliance among residents. Emotions are not only generated by organizations and imposed on workers; staff themselves produced emotions—sometimes in ways consistent with organizational demands, and sometimes not—and they consistently found in their emotions a resource to manage the strains of their work lives.     

Detouring Nursing Home Entrants

Under the Omnibus Budget Reconciliation Bill of 1981, states can apply for waivers to underwrite nonmedical home care services for Medicaid clients who would otherwise enter nursing homes. Ideally, subsidized home services should improve the quality of life for older people, relieve the demand on nursing homes, and reduce overall Medicaid expenditures; yet in Rhode Island the program has served few people. This discussion proposes reasons for the minor impact of "waiver channeling."     

Australian Approaches to Resident Classification and Quality Assurance in Residential Care

Summary

This paper begins with an account of the structure of Australia's residential long-term care program, which was divided into two distinct levels of hostel and nursing home care until 1997. In response to changed policy objectives, a number of measures were then taken to create an integrated residential care system. The main measures were the development of a single scale for classification of resident care need and associated funding to replace two previous separate scales, and the implementation of a new quality assurance system, which included new standards for buildings as well as revised standards for care. I give accounts of these measures and the extent to which they have achieved their intended outcomes before proposing some further developments that could see closer links among pre-admission assessment, resident classification, and quality assurance.     

Elder Abuse in Nursing Homes: The Theft of Patients' Possessions

ABSTRACT

Although there has been an increasing concern about physical and psychological abuse in nursing homes, one aspect of elder abuse that has been relatively overlooked and understudied is theft of nursing home patients' property. This paper discusses the nature of this type of abuse and explores some theoretical explanations for it. In addition, some theft-reducing techniques ranging from simple target hardening to formal and informal surveillance are suggested.