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State Long-term Care Programs: Balancing Cost, Quality, and Access

Quality of Nursing Home Care


Catherine Hawes, Ph.D., Professor, Department of Health Policy and Management, School of Rural Public Health, Texas A&M University, College Station, TX.

Charles D. Phillips, Ph.D., M.P.H., Professor, Department of Health Policy and Management, School of Rural Public Health, Texas A&M University System Health Science Center, College Station, TX.

Achieving high quality care in nursing homes has challenged policymakers and providers. The Omnibus Budget and Reconciliation Act (OBRA) of 1987 addressed three primary elements for reforming Government's approach to nursing home quality:

  • Setting standards.
  • Survey and monitoring to determine compliance with the standards.
  • Enforcement actions when facilities do not meet the standards.

Catherine Hawes, Texas A&M School of Rural Public Health, credits OBRA 1987 with reducing the use of restraints, improving resident outcomes, and cutting hospital admissions during the early to mid-1990s. However, a series of studies by the General Accounting Office and hearings by the U.S. Senate Special Committee on Aging brought attention to the continuing quality problems in nursing home care.

Based on a study funded by the Retirement Research Foundation, Dr. Hawes described indicators of effective regulatory systems:

  • They make use of ombudsman reports and complaints to identify and pursue problems.
  • They use qualified surveyors and employ specialized survey teams to address specific problem areas, such as including dietitians on survey visits when food service may be poor or unintended weight loss is present.
  • They enforce quality standards and require availability and use of a range of remedies and guidelines for selecting them.
  • They sanction facilities when deficiencies are found rather than when facilities have failed to correct past deficiencies.

Other attributes of effective oversight include good communication with providers and the ombudsman program through regular meetings, use of a toll free hotline to receive complaints, and disseminating useful information to the public.

Some might attribute high quality with high spending. Research by Charles Phillips, Texas A&M School of Rural Public Health, found that high quality can be achieved even when costs are lower. Studies of facilities in Cleveland and New York City identified "high quality" based on ombudsman reports and information from the Minimum Data Set (MDS).

Dr. Phillips found that nutritional status increased and costs declined when a nutritionist prepared entrees that included vegetables rather than offering individual servings of vegetables that residents did not eat. Some facilities offered a higher rate for workers on evening and night or weekend shifts when facilities are sometimes short-staffed and unable to offer as much care.

Dr. Phillips contends that adopting a specific strategy for cost control of quality improvement is less important than having some strategy to which the facility is committed. For example, there was little difference in quality whether a facility designated one person to make all decisions related to cost control or assigned responsibility to specific departments. Dr. Phillips also discussed findings of studies of two new models for achieving quality in nursing homes, the Eden Alternative and Wellspring.

Reports of improvement using the Eden Alternative have not been replicated in facilities that have attempted them and two studies found the model had no effect on outcomes. An evaluation by Dr. Phillips, et. al. of Wellspring found little difference in outcomes but did find lower staff turnover and fewer survey deficiencies.

From his studies, Dr. Phillips concluded there is no single formula for achieving quality and the process of change within facilities is often poorly understood.

Additional Resource

Phillips CD, Rose M. Expense control strategies in nursing homes. Cleveland (OH): Myers Research Institute, Menorah Park Center for Senior Living; 2000.

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