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Long-term Care

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Nursing home staffing and quality improved after passage of the Nursing Home Reform Act

Any nursing home that admits Medicare and Medicaid residents must be certified yearly by means of a Centers for Medicare & Medicaid Services (CMS) survey. The CMS imposes penalties, including fines, on homes with a high number of deficiencies. Despite this government involvement, nursing home quality has been considered substandard over the past three decades. The good news is that the quality of nursing home care improved following passage of the 1987 Nursing Home Reform Act (NHRA), according to a study by University of Alabama researchers, Xinzhi Zhang, M.D., Ph.D., and David C. Grabowski, Ph.D.

The NHRA mandated a reduction in the use of unnecessary drugs, unnecessary physical restraints, any significant medication errors, pressure ulcers, and incontinence. It also required that certified nursing homes have licensed practical nurses (LPNs) on duty 24 hours a day; a registered nurse (RN) on duty at least 8 hours a day, 7 days a week; and an RN director of nursing in place, as well as 75 hours of training for nurses aides (NAs) and "sufficient" staff and services.

Nursing home staffing levels jumped substantially following passage of the NHRA. Per resident day, RN hours increased 18 percent from 0.26 in 1987 to 0.30 in 1993, LPN hours rose 30 percent from 0.46 to 0.60, and NA hours increased 24 percent from 1.61 to 1.99. Also, the proportion of residents with urinary catheters decreased from 10 percent to 8 percent, and the proportion of those with physical restraints declined from 39 percent to 23 percent. However, the proportion of nursing home residents with pressure ulcers increased 8 percent, perhaps due to a more chronically ill nursing home population in 1993 relative to 1987. The researchers, who were supported by the Agency for Healthcare Research and Quality (HS13503), based their findings on analysis of data files before and after implementation of the NHRA for nursing homes from 22 States.

See "Nursing home staffing and quality under the Nursing Home Reform Act," by Drs. Zhang and Grabowski, in the Gerontologist 44(1), pp. 13-23, 2004.

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