Skip Navigation U.S. Department of Health and Human Services
Agency for Healthcare Research Quality
Archive print banner
2003 National Healthcare Quality Report

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Chapter 3. Effectiveness (Continued)

Nursing Home and Home Health Care


Background and Impact
How the NHQR Measures Nursing Home and Home Health Quality of Care
How the Nation Is Doing
What We Don't Know
What Can Be Done
List of Measures

Key Findings:

  • The measures used in this report reveal variation across both States and measures, thereby highlighting the opportunity to improve quality of nursing home and home health care.
  • Progress has been made in reducing use of physical restraints in nursing homes. Nationally, fewer than 10% of chronic care nursing home residents are in physical restraints, although this ranged from 2.7% to 22.4 % among States.
  • Although not all patients can be expected to improve, 57% of home health patients who needed assistance with bathing improved.
  • Although not all patients can be expected to improve, 35% of home health patients who needed assistance with managing oral medications improved.

Background and Impact

Nursing home and home health services are an important component of the U.S. health care system, accounting for at least $132 billioni or 9% of national health expenditures in 2001.1 According to the latest available national data, there were 1.6 million current nursing home residents and 2.5 million discharges from nursing homes during 1999, and approximately 1.4 million patients were served by home health agencies in 2000.2,3 Nearly all (98%) of the Nation's 18,000 nursing homes and 90% of home health agencies are certified by either the Medicare or Medicaid programs.

Nursing home and home health are part of the spectrum of services addressing a person's needs for long-term care, post-acute care, and rehabilitative, chronic, and palliative care. Care in this spectrum consists of a broad range of health and social services delivered in a variety of settings (institutions, outpatient and community settings, and the home) by many different providers. This section of the report focuses on the quality of services provided by a subset of all these providers—nursing homes, the major institutional provider of long-term care services, and home health agencies— because national data are currently available on these providers. Table 1 illustrates the different types of patient needs and the types of providers offering care for these needs. These categories are not mutually exclusive, since people often have multiple needs (e.g., a frail elder with several chronic conditions recently discharged from the hospital), and providers may serve many types of patients (e.g., nursing homes providing care, long-stay residents with dementia or physical disabilities, and short-stay residents who have post-acute care needs, such as hip fractures, or who are terminally ill).

Table 1. Spectrum of patient needs and providers

Distinctions Post-acute health care Long-term care Palliative care Chronic health care
Types of needs People who need treatment after or instead of hospitalization for an acute illness, injury, or exacerbation of a disease process People who need assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) People who need care for minimizing effects of terminal illnesses, including supportive care services providing physical, psychosocial, and spiritual care for themselves and their families People who need on-going management or treatment of a health condition, such as diabetes, arthritis, hypertension, or heart disease
Types of providers Skilled nursing facilities (SNF)ii

Home health agencies

Specialty hospitals-rehabilitation and long-term care hospitals

Outpatient/independent therapy services

Informal care (family and friends)
Nursing facilities (NF)ii

Community based residential care (assisted living facilities, life care communities, board and care, adult foster care)

Home health agencies

Home and community- based service provider (e.g., adult day care, In-home, personal care, homemaker service agencies)

Consumer-directed care

Informal care (family and friends)
Hospice care agencies

Home health agencies

Nursing homes

Informal care (family and friends)
Outpatient and physician offices

Home health agencies

Nursing homes

Informal care (family and friends)

Note: Measures examined in this report appear in bold and italics.

Source: Adapted from Scanlon, Understanding Post-Acute, Chronic, and Long-term Care.4

Services within this spectrum often are not disease- or condition-specific; rather, they focus on ADL and IADL needs, minimizing the effects of disability, maintaining function, and slowing deterioration. At the palliative care end of the spectrum, there is hospice care for terminally ill people and their families.5

Quality of care in nursing homes has been an ongoing concern for years.6,7 This concern was addressed in the Omnibus Budget Reconciliation Act of 1987 (OBRA-87, or Public Law 100-203), which established goals for quality care and patient quality of life in nursing homes. OBRA-87 also mandated monitoring of the quality of home health care.

i This amount does not include expenditures for hospital-based nursing homes or home health agencies.
ii Skilled nursing facility and nursing facility are terms used by Medicare and Medicaid. In this report, the term "nursing home" is used for both.

Return to Contents

How the NHQR Measures Nursing Home and Home Health Quality of Care

Nursing Home Care

OBRA-87 and subsequent Federal regulations added new requirements for quality of care, resident assessment, and care planning and provided a range of new enforcement remedies.8 The regulations required that all Medicaid and Medicare certified nursing homes use a standardized comprehensive functional assessment tool to assess all residents and assist in developing individualized care plans. The Minimum Data Set (MDS) is used as the core functional assessment instrument of the Resident Assessment Instrument (RAI) and covers a number of domains, including ADLs, continence, cognitive patterns and delirium symptoms, mood and behavior patterns, skin condition, nutritional status and weight loss, disease and health conditions (including pain), and special treatments and procedures.iii Since OBRA-87 was enacted, the following improvements have been reported:

  • Improved processes of nursing home care, such as increased comprehensiveness of care plans and decreased use of restraints.8
  • Improved outcomes of selected health conditions (dehydration, malnutrition, pressure sores).9
  • Slowed deterioration in seven of nine outcomes of nursing home residents.10
  • Declines in the rates of antipsychotic drug use.11

Using measures derived from MDS data for 2002, this report presents information on quality by facility performance for both long- and short-stay residents.iv

The development of these measures and their selection are described elsewhere.12,13 All of these nursing home measures are used by CMS for their Nursing Home Quality Initiative, for which national public reporting started in November 2002.

More detail on all these measures, including risk adjustment, is available in the Measure Specifications Appendix.

Home Health Care

OBRA-87 also affected home health services by mandating that Medicare monitor the quality of home health care and services with a "standardized reproducible assessment instrument...the extent to which the quality and scope of items and services furnished by the agency attained and maintained the highest practicable functional capacity of each individual as reflected in such individual's plan of care...and clinical records..."14 Starting in 1999, uniform assessment data are collected for all adult, nonmaternity Medicaid and Medicare patients in home health agencies, using the Outcome and Assessment Information Set. The OASIS data do not constitute a comprehensive assessment, but agencies are required to integrate the OASIS items into their own assessment instruments. Agencies are required to submit their OASIS data for only a subset of their patients (Medicare and Medicaid patients receiving skilled services). The data are then sent to CMS, and a variety of outcome reports are derived for quality assurance and improvement.

The Home Health Outcome-Based Quality Improvement (OBQI) System is a voluntary framework for quality improvement based on OASIS data.15,16 This OBQI system includes a total of 41 outcome measures.

Quality of care in the area of home health is summarized by performance in 12 of these outcome measures in the following categories:

  • Meeting the patient's basic daily needs (four measures).
  • Improvement in getting around (four measures).
  • Improvement in physical health (two measures) and mental health status (one measure).
  • Percentage of patients admitted to acute-care hospitals (one measure).

These quality measures are based on OASIS assessment data from January 1, 2002 to December 31, 2002 for approximately 7,000 home health agencies (HHAs), predominantly for Medicare patients (about 92%). Most of these home health measures are also being used by CMS for the Home Health Quality Initiative. The AHRQ Technical Expert Panel on Home Health Quality Measures provided input for both the CMS public reporting initiative and this report. The TEP noted that some measures were better than others for national, as compared with agency-level, reporting and also better for different audiences, e.g., consumers versus policymakers.17

More detail on all of these measures, including risk adjustment, is available in the Measure Specifications Appendix.

iii Refer to the Measure Specifications Appendix and for more information on the MDS.
iv This report uses the CMS definition of chronic care and post-acute care. Chronic care refers to patients who typically enter a nursing facility because they are no longer able to care for themselves at home. These patients (or residents) tend to remain in the nursing facility from several months to several years. The chronic quality measures (QMs) are calculated on any residents with a full or quarterly MDS in the target quarter. Post-acute care refers to patients who are admitted to a facility and stay less than 30 days. These admissions typically follow an acute-care hospitalization and involve high-intensity rehabilitation or clinically complex care. The post-acute QMs, are calculated on any patients with a 14-day MDS assessment (required under the Prospective Payment System [PPS]) in the last 6 months. Refer to the CMS Web site for exact specification:

Return to Contents

How the Nation Is Doing v

Assessing how the Nation is doing requires a comparison of State rates with national averages, since there are no data or only limited trend data on the home health and nursing home measures included in this report. Some measures show a large variation in State performance on both nursing home and home health quality. This variation highlights the opportunities for improvement in both nursing home and home health quality of care.

Providing Quality Services to Chronic Care Nursing Home Residentsvi


OBRA-87 states that, "residents have the right to be free from any physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms."18 Restraints should be imposed only to ensure the physical safety of the resident or that of other residents and only on the written order of a physician, "with a time limit and circumstances of use noted." CMS encourages gradual restraint reduction because of the many negative outcomes associated with restraint use.

The baseline data in this report indicate a national average (see the Measure Specifications Appendix for calculation) of less than 10% of residents in physical restraints, ranging from 2.7% to 22.4 % among the States. Twenty-eight States had significantly fewer residents in restraints than the national average and 12 States had significantly more residents in restraints (go to Figure 15A).

State survey data over a number of years indicate that use of restraints has declined dramatically, from 44% in 1989 to 21% in 1992, and approximately 13% in 2002.19 These data also show that the percentage of nursing facilities that are restraint-free has risen from 1% to 11% during this time.


Although untreated pain reduces quality of life, it is a common problem in nursing homes.20 Pain control is important for both chronic and post-acute care patients. Pain is often unrecognized, especially for the most cognitively impaired residents.21

Nationally, almost 11% (range of 7% to 29.3%) of long-stay residents experiencing pain are reported by staff to have moderate or excruciating pain during a 7-day period. Seventeen States report greater percentages of residents in pain than the national average (see Figure 15C). This measure is very limited as a quality measure because it only counts the percentage of residents with pain symptoms; it does not directly measure the facility efforts to control or reduce the pain.

Activities of Daily Living

The functional capacity to perform ADLs declines naturally with many disease states, but it is not an inevitable consequence. There are intervention programs nursing homes can provide to residents to minimize the rate of decline in ability.22,23,24,25 This particular measure focuses on four ADLs (bed mobility, transfers, toilet use, and eating), termed "late-loss", because these are generally the last four ADL functions to be lost.vii Nationally, 15.4% (range of 10.4% to 24.5%) of long-stay patients experience a loss in ability to perform at least one of four late-loss ADLs. Although there is no clinical benchmark rate, there may be opportunities for preventing decline in late-loss ADLs. Fifteen States are doing better at preventing this decline than the national average, and 11 States are doing worse.

Pressure Sores

Prevention and treatment of pressure sores in nursing homes is a quality of care dimension subject to Federal regulations. Pressure ulcers are defined as any lesion caused by unrelieved pressure resulting in damage to the underlying tissue. Lesions are classified according to stage of tissue damage, with Stage 1 being the least serious and Stage 4 being the most serious. Pressure sores are associated with considerable morbidity and a fourfold risk of death among the geriatric population.26

The incidence of pressure sores may be minimized but not totally eliminated with proper prevention practices,27 and there may be opportunities to improve the treatment of pressure sores.28,29

The national prevalence rate for pressure sores (Stages 1 to 4) for long-stay residents is 8.5%.viii This rate ranges in States from about 5% to 12%. Fifteen States have higher prevalence rates for pressure sores, and 21 States have lower rates than the national average. The State rate for pressure sores is unlikely to be zero since not all facilities can achieve zero pressure sore rates given the fact that some pressure sores cannot be prevented among high-risk residents.

Providing Quality Care to Post-Acute Care (Short-Stay) Nursing Home Residents


It is estimated that nationally one-fourth of all short-stay nursing home residents reported daily pain. There is considerable variation among the States, ranging from 15% to 48%. Thirteen States have a lower occurrence of daily pain in residents than the national average, and 17 States have a higher occurrence (go to Figure 15B).

A larger percentage of short-stay patients report pain compared with long-stay residents. Part of this difference may be attributed to the types of diagnoses and procedures among the post-acute care patients (e.g., more pain as a result of surgery or post-fall trauma). It is also more difficult to detect pain in long-stay patients with dementia.21

Walking Maintenance or Improvement

This measure demonstrates achievement of a rehabilitative goal for many short-stay patients. Walking plays a vital role in performing daily activities, and it is important in maintaining and preventing functional decline. Often, post-acute care patients are temporarily or permanently impaired as a result of surgical procedures or other injuries. The national rate is 30% of patients with improved walking within 2 weeks, with some variation among States (range of 21.7% to 38.7%). Ten States have better walking rates than the national average, and 13 States have worse walking rates. With a 30% average, it is possible that the time frame for measurement (between day 5 and day 14 of a PPS assessment) may be too short to capture maximum improvement in walking for many short-stay residents. Also, an interactive effect could exist with pain whereby if pain is resolved or reduced in the patient, walking improvement might be more likely to occur. Early mobilization and adequate pain control are deemed to be goals for many hip fracture patients to improve their ability to walk.30


Delirium is an acute state of confusion, with changes in awareness, attention, cognition, and perception, which often fluctuate over the course of a day. Delirium represents a sudden and significant decline in previous level of functioning. Not all cases are preventable. Delirium is a complex condition and is considered an acute medical emergency, for which the underlying cause needs to be promptly treated. However, because of its broad range of signs and symptoms, delirium is often misdiagnosed as a psychosis, depression, or dementia. If left misdiagnosed or untreated, delirium can significantly increase the need for nursing care, decrease ability to function, delay rehabilitation, and increase length of stay.

The national prevalence rate for residents with delirium symptoms is less than 4%, ranging from 1.6% to 7.1%. There is no clinical benchmark rate for delirium.

Providing Quality Care to Home Health Patientsix

There are national data for the selected OASIS measures for 2 years (2001 and 2002). However, since the differences are small (1% or less) between the 2 years, this report provides the national rates for 2002 and rates for each State to illustrate variation in performance. In the home health areas measured by OASIS data, there are no established target clinical benchmarks although each agency can view their rates as baselines for continuous quality improvement.

Meeting Basic Daily Needsx

Bathing is an important ADL to maintain independence in the community. Almost 57% of all episodesxi that can achieve improvementxii achieved improvement in this ADL. State rates ranged from 51% to 65%, with 25 States below the national average (go to Figure 15D).

Management of oral medications is another area where there are opportunities for improvement. The national average was 35%, with States ranging from 25% to 43%. Thirty States were below the national average (go to Figure 15E).

Upper body dressing is an area where 61% of episodes showed improvement, and there was less variation in rates among the States (range of 56% to 65.8%).

Because not every patient can be expected to improve, the measure set includes a stabilization measure to indicate the percentage of patients that stayed the same or did not decline. Almost 91% of episodes did achieve stabilizationxiii in bathing, with States ranging from 88.5% to 96%.

Getting Around

This category contains four distinct measures for describing how well a home health patient can get around his or her home. Nationally, one-third of episodes showed improvement in walking or moving around. Fourteen States did significantly better than the national average, while 22 States did significantly worse. Three of the measures—"improving in getting to and from the toilet without help," "improving in getting in and out of bed without help," and " having less pain when moving around"—had national average rates between 50% and 60%. However, the measure for "pain when moving around" had more variation among the States, with 31 States achieving less than the national average.

Physical Health

About half of the episodes experienced a decrease in shortness of breath (53%) and urinary incontinence (47%). Eighteen and 22 States showed less improvement than the national average for shortness of breath and urinary incontinence, respectively.

Mental Health Status

About 40% of episodes experienced improvement in patients being confused less often. The rates of improvement in States ranged from 30% to 48%, with 23 States showing less improvement than the national average.

Acute Care Hospitalization

Overall, 28% of all home health episodes had an admission to an acute care hospital. State rates range between 21.5% and 35.3%, with 21 States having worse rates (i.e., higher) than the national average (see Figure 15F). Some of these hospitalizations may represent good quality home health care, i.e., serious health problems are recognized by the home health agencies, and the patient is appropriately hospitalized. Also, this measure, as defined in OASIS, may also include some scheduled admissions, such as for elective surgery or chemotherapy, or it may include hospitalizations that may not be avoidable due to patient frailty.

v Adjusting for known contributing factors, such as gender, age, and insurance status (multivariate analysis) would allow for more detailed exploration of the data, but this generally was not feasible for this report. Any adjustments that were done are noted in the detailed tables. The data presented in this report do not imply causation.
vi Nursing home data are from MDS, downloaded from the CMS Nursing Home Compare Web site, November 2002,
vii This general pattern of ADL loss has been studied by Cohen-Mansfield, et al. Temporal order, 974-8, and Katz, et al. Studies of illness, 914-9.
viii Although patients with pressure sores at nursing home admission are excluded, their subsequent MDS reassessments are included in the numerator if the sore has not healed.
ix Home health data are from the Center for Health Services and Policy Research, University of Colorado, from OASIS data,
x Across these measures, different scales are used. For example, management of oral medications is measured on a three-point scale, while bathing has six levels. This may be one reason for the big difference in improvement rates between bathing (57%) and oral medications (35%).
xi Episode is defined as the period of start of care to home health agency discharge or transfer to inpatient facility.
xii A person is not included if he or she is at the highest level and cannot improve any more. Refer to the Measure Specifications Appendix.
xiii A person is excluded from stabilization measures if he or she is at the lowest level and cannot decline any more. See the Measure Specifications Appendix.

Return to Contents

What We Don't Know

National data are available on certain key aspects of nursing home care because uniform data collection has been mandated in Medicare and Medicaid certified facilities since 1990. More recently, the government has required home health care reporting using uniform OASIS data for most adult patients. Thus, certain key outcomes can be tracked in home health as well. However, these areas, such as those reported in this section, are only a portion of the spectrum of care required by the frail elderly and other people who need long-term, post-acute, and palliative care services. Improvements can be made in our national tracking in this area. For example, the home health data used in this report largely represent the Medicare and Medicaid populations receiving skilled home health care (92%); so it is unknown how representative these data may be for quality of care for other home health patient populations.

National quality measurement of long-term care and home health care poses special challenges. There are other age groups besides the elderly who use home health and nursing home services. Although both the MDS and OASIS data are collected for these age groups, the quality measures are not disaggregated by age because, on average, groups other than the elderly constitute only a small proportion of nursing home residents and home health patients. Although the numbers for these measures may be too small to be reported separately, it is not known if quality outcomes may vary by age groups. In addition to distinct age groups, other groupings exist for which data are not always available or analyzed (e.g., short- and long-term home health patients, reason for entering care, diseased condition trajectory). Finally, clinically achievable benchmarks have not been identified for some of the measures in this section (e.g., late-loss ADL decline, delirium, and walking improvement).

A number of MDS and OASIS data limitations exist.31,32 The nursing home and home health measures are based on patient assessment data reported by the nursing facilities and agency providers. It is, therefore, possible that facility or agency reports may not always accurately reflect the real prevalence of a condition. For example, it is likely that pain in nursing homes is underestimated because MDS data are completed by staff and pain may be unrecognized.20 The MDS data only identify residents with pain or suspected to have pain; they do not identify efforts in controlling the pain. Patients may also differ in their acceptance of pain medication for personal or cultural reasons. Finally, staff in some nursing homes may do a better job of checking for pain than in others; lower rates may be misleading. Lower rates may also be misleading for pressure sores. For example, facilities that closely monitor for skin changes or those who serve a more disabled population may actually have higher rates than facilities that do not closely monitor. In addition, determination of Stage 1 pressure sores is known to be the least reliable of all stage determinations.

Post-acute care measures entail issues unique to their population. The post-acute measures only include residents accessing their Medicare Part A benefit; those enrolled in Medicare HMO coverage are not included. For some nursing homes with large or active post-acute care units, this population can constitute a majority of their admissions. Small sample sizes are an issue for post-acute measures, i.e., they exclude facilities with less than 20 patients over a 6-month period; thus, there is no information on nursing homes with small numbers of residents. This minimum denominator size results in about 40% to 45% of facilities being excluded. The short timeframe for the post-acute care measure that calculates change between the 5th and 14th day may make the rates seem lower than expected. Furthermore, in terms of data limitations, many post-acute care residents are excluded because they are discharged before getting a second assessment.

Some controversy exists as to whether the nursing home measures have been sufficiently validated to be considered as a more global measure of quality care, rather than as indicators of potential quality problems.33 In addition, there is some concern about the appropriateness of the risk adjustment methodology used.34 HHS is continuing to work on refining measures and considering alternative risk adjustment methods. In the home health area, there is variation among outcome measures in how well risk adjustment works using current methods, i.e., some measures are better risk adjusted than others.xiv

The selected nursing home and home health measures do not represent all possible key domains,35 such as satisfaction with care or quality of life. For these two domains, no national data yet exist. Some States, however, have begun collecting resident and family satisfaction data.19 Staffing levels in nursing homes and the overall shortage of nurse aides are important issues;36 however, there is not sufficient evidence on thresholds to make a link with quality. HHS is currently reevaluating its approach to assessment and data collection in post-acute and long-term care. In particular, developments in electronic records will enhance data collection in these settings. CMS also has a program for the refinement and evolution of OASIS and OBQI. This program involves monitoring issues and conducting ongoing applied research for improving OASIS, outcome reporting, outcome measures, risk adjustment, and OBQI applications.

xiv Go to Saughnessy, et al. OASIS, for a summary of the risk-adjustment methodology, including a discussion of ongoing research to improve risk adjustment.

Return to Contents

What Can Be Done

A number of strategies may be considered for improving quality of long-term care.37 Some of the most common strategies include:

  • Providing consumers with more information.
  • Developing and implementing practice guidelines.
  • Developing and improving approaches to quality.
  • Improving information systems.

In November 2001, HHS announced the Quality Initiative, a commitment to ensure quality health care for all Americans through accountability and public disclosure. The initiative, led by CMS, has two components: 1) to empower consumers with quality of care information to make more informed decisions about their health care, and 2) to stimulate and support providers and clinicians to improve the quality of health care.

The Quality Initiative was launched nationally in the fall of 2002 for nursing homes. As part of the information component, CMS's Nursing Home Comparexv began reporting quality measures on all certified nursing homes in November 2002. In May 2003, Home Health Compare began reporting measures for certified home health agencies in eight States and started national reporting in the fall of 2003. These measures are also intended to motivate nursing home facilities and home health agencies to improve care.

For the second component of the Quality Initiative, CMS has contracted with two Quality Improvement Organizations— one for nursing homes and one for home health care—to lead and support other QIOs in every State in implementing quality improvement objectives for the specific CMS quality measures. For nursing home care, the QIOs are working with a volunteer group of 15% of nursing homes nationally to help them implement a system of quality improvement within their organization for three to five of the quality measures. For this subset, QIOs are bringing nursing home teams together for training sessions in quality improvement and for sharing best practices, as well as working with nursing homes between training sessions to provide technical assistance to nursing home teams. QIOs are also working closely with other State organizations to conduct State and regional educational sessions and provide educational materials to help improve quality of care for each of the measures. Home health care is a new setting for QIO activities, and QIOs are working with Medicare certified agencies to teach them how to implement and manage continuous quality improvement systems by using the Outcome-Based Quality Improvement system. QIOs will work with the agencies on an ongoing basis to assist them in interpreting quality data, selecting the most appropriate areas for improvement, developing plans to improve care and monitoring, and evaluating patient outcomes over time. As a resource to providers and QIOs, the Medicare Quality Improvement Clearinghouse at, and another site, www.obqi.orgExit Disclaimer, have links to a number of guidelines, educational tools, interventions, and other resources that have been developed for many key areas in nursing home and home health care.

In the area of home health, two OBQI demonstration projects in 28 States found that the OBQI process had an impact on patient outcomes as measured by OASIS. The relative rate of decline in hospitalization was 22%, and the rates of improvement for other targeted home health outcome measures averaged between 5% and 7% per year.38

Implementation of guidelines and practice protocols can improve quality in nursing homes,39,40 but there are some barriers to sustained and widespread use of the guidelines and protocols. These protocols may not always be feasible with current nursing home staffing numbers, staff educational levels, and turnover.41,42

The researchers recommended that staffing needs be estimated for implementing guidelines to do realistic quality change planning.

For nursing home and home health care, the strategy of improving information systems for quality monitoring has been combined with the regulatory oversight process. For several years, the MDS data have been used by State survey agencies to identify potential problems as part of their onsite nursing home evaluations, which occur at least once during a 15month period or as a result of a complaint being investigated. The evaluations ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. As of May 1, 2003, State survey agencies began using data generated by OASIS to help identify areas of focus or the types of patients to include in the sample selection in their home health evaluations. These evaluations generally are conducted at least once every 36 months.

There are some studies and evaluations underway on how to change the culture and working conditions in the nursing home and home care settingsxvi and some studies on small scale initiatives have been completed.43 The expectation is that these work and culture changes will result in improved quality of care for patients.44

xv Nursing Home Compare at provides information about every Medicare-certified nursing home in the country.
xvi AHRQ grant HS11962-01, "Working Conditions and Adverse Events in Home Health Care," AHRQ grant HS11523-01, "Patient Safety in Home Care," and AHRQ grant HS12028-01, "Nursing Home Working Conditions and Quality of Care.

Return to Contents

List of Measures

Nursing Home and Home Health Care

Measure Title National/Statexvii
Nursing facility care:
Chronic care: % of residents with pain Table 1.87
Chronic care: Late-loss ADL worsening Table 1.88
Chronic care: Infections prevalence Table 1.89a (UTI, some states)
Table 1.89b (all infections, more states)
Chronic care: Stage 1-4 pressure ulcer prevalence Table 1.90a
Table 1.90b (sheet=w/risk adj)
Chronic care: Restraint use prevalence Table 1.91
Post-acute care: Failure to improve/manage delirium symptoms Table 1.92a
Table 1.92b (sheet=w/risk adj)
Post-acute care: % of residents with pain Table 1.93
Post-acute care: Improvement in walking Table 1.94
Home health care:
Meeting the patient's basic daily needs
Outcome: improvement in upper body dressing Table 1.95
Outcome: improvement in management of oral medications Table 1.96
Outcome: improvement in bathing Table 1.97
Outcome: stabilization in bathing Table 1.98
Improvement in getting around
Outcome: improvement in transferring Table 1.99
Outcome: improvement in ambulation/locomotion  
Outcome: improvement in toileting  
Outcome: improvement in pain interfering with activity Table 1.102

Note: Go to Tables Appendix for tables listed above.

xvii National and State rates are contained in same table.

Return to Contents


1 Centers for Medicare & Medicaid Services. National health accounts: definitions, sources, and methods used in the NHE 2001.

2 Jones A. The National Nursing Home Survey: 1999 summary. Vital Health Stat 13 2002(152): 1-116. Available at: Accessed July 15, 2010.

3 National Center for Health Statistics. National Home and Hospice Care Survey. Hyattsville, MD; 2002.

4 Scanlon W. Understanding Post-Acute, Chronic, and Long-term Care, presentation at National Health Policy Forum Fundamentals Briefing: General Accounting Office; 2003 Jan 24.

5 Gabrel CS. An overview of nursing home facilities: data from the 1997 National Nursing Home Survey. Adv Data 2000 Mar;311:1-12. Available at: Accessed July 15, 2010.

6 Institute of Medicine. Improving the quality of care in nursing homes. Washington, D.C.: National Academies Press; 1986.

7 General Accounting Office. Nursing home quality: prevalence of serious problems, while declining, reinforces importance of enhanced oversight. Report to Congressional Requestors.; 2003 Jul. GAO Publication No. 03-561.

8 Hawes C, Mor V, Phillips CD, et al. The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality. J Am Geriatr Soc 1997;45(8):977-85.

9 Fries BE, Hawes C, Morris JN, et al. Effect of the National Resident Assessment Instrument on selected health conditions and problems. J Am Geriatr Soc 1997;45(8):994-1001.

10 Phillips CD, Morris JN, Hawes C, et al. Association of the Resident Assessment Instrument (RAI) with changes in function, cognition, and psychosocial status. J Am Geriatr Soc 1997;45(8):986-93.

11 Garrard J, Chen V, Dowd B. The impact of the 1987 federal regulations on the use of psychotropic drugs in Minnesota nursing homes. Am J Public Health 1995;85(6):771-6.

12 Morris J, Moore T, Jones R, et al. Validation of long-term care and post-acute care quality indicators. Final report. 2003 Jun 10. CMS Contract No. 500-95-0062/T.O. #4.

13 Centers for Medicare & Medicaid Services. Nursing home quality initiative: quality measure criteria and selection. 2002 Aug 9.

14 Omnibus Budget Reconciliation Act of 1987, §1891(c)(2)(C). Available at: Accessed January 16, 2004.

15 Centers for Medicare & Medicaid Services. Outcome-based quality improvement implementation manual. 2002 Sep.

16 Shaughnessy PW, Crisler KS, Hittle DF, et al. OASIS and outcome-based quality improvement in home health care; 2002.

17 Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. Technical expert panel meeting on home health measures. 2002 Oct 21-22. Rockville, MD. Available at: Accessed January 16, 2004.

18 Omnibus Budget Reconciliation Act of 1987, §1819(c)(1)(A)(ii). Available at: Accessed January 16, 2004.

19 Castle NG. Nursing homes with persistent deficiency citations for physical restraint use. Med Care 2002;40(10):868-78.

20 Teno JM, Weitzen S, Wetle T, et al. Persistent pain in nursing home residents. JAMA 2001;285(16):2081.

21 Fries BE, Simon SE, Morris JN, et al. Pain in U.S. nursing homes: validating a pain scale for the minimum data set. Gerontologist 2001;41(2):173-9.

22 Schnelle JF, Alessi CA, Simmons SF, et al. Translating clinical research into practice: a randomized controlled trial of exercise and incontinence care with nursing home residents. J Am Geriatr Soc 2002;50(9):1476-83.

23 Morris JN, Fiatarone M, Kiely DK, et al. Nursing rehabilitation and exercise strategies in the nursing home. J Gerontol A Biol Sci Med Sci 1999;54(10):M494-500.

24 Cohen-Mansfield J, Werner P, Reisberg B. Temporal order of cognitive and functional loss in a nursing home population. J Am Geriatr Soc 1995;43(9):974-8.

25 Katz S, Ford AB, Moskowitz RW, et al. Studies of illness in the aged. the index of Adl: a standardized Measure of biological and psychosocial function. JAMA 1963;185:914-9.

26 Ratliff CR, Rodeheaver GT. Pressure ulcer assessment and management. Lippincotts Prim Care Pract 1999;3(2):242-58.

27 Bergstrom N, Allman R, Carlson C, et al. Pressure ulcers in adults: prediction and prevention. Clinical practice guideline number 3. Rockville, MD: Agency for Health Care Policy and Research; 1992. AHCPR Publication No. 92-0047. Available at: Accessed July 15, 2010.

28 Bergstrom N, Bennett M, Carlson C. Treatment of pressure ulcers. Clinical guideline number 15. 1994 Dec. AHCPR Publication No. 95-0652. Available at: Accessed November 28, 2003.

29 Saliba D, Rubenstein LV, Simon B, et al. Adherence to pressure ulcer prevention guidelines: implications for nursing home quality. J Am Geriatr Soc 2003;51(1):56-62.

30 Morrison RS, Magaziner J, McLaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain 2003;103(3):303-11.

31 National information infrastructure: a key strategy for improving quality in long term care: U.S. Department of Health and Human Services; 2003 May. Contract No. 282-98-0006.

32 Fortinsky RH, Garcia RI, Joseph Sheehan T, et al. Measuring disability in Medicare home care patients: application of Rasch modeling to the outcome and assessment information set. Med Care 2003;41(5):601-15.

33 Manard B. Nursing home indicators: their uses and limitations. Washington, D.C.: AARP Public Policy Institute; 2002 Dec. Publication No. 2002-16. Available at: Disclaimer Accessed November 28, 2003.

34 Shaughnessy PW, Hittle DF. Overview of risk adjustment and outcome measures for home health agency OBQI reports: highlights of current approaches and outline of planned enhancements. 2002 Sep.

35 Fortinsky RH. Data, information, and quality indicators for home health care. Paper prepared for the National Policy Meeting on Home Health Care Quality, sponsored by the Center for Home Care Policy and Research, Visiting Nurse Service of New York. 2003 Jun 30-Jul 1.

36 Centers for Medicare & Medicaid Services. Appropriateness of minimum staffing ratios in nursing homes. Report to Congress. Baltimore, MD; 2002.

37 Wiener JM. An assessment of strategies for improving quality of care in nursing homes. Gerontologist 2003;43 Spec No 2:19-27.

38 Shaughnessy PW, Hittle DF, Crisler KS, et al. Improving patient outcomes of home health care: findings from two demonstration trials of outcome-based quality improvement. J Am Geriatr Soc 2002;50(8):1354-64.

39 Institute of Medicine. Improving the quality of long term care. Washington, D.C.: National Academies Press; 2001. Available at: Exit DisclaimerAccessed on November 26, 2003.

40 Schnelle JF, Kapur K, Alessi C, et al. Does an exercise and incontinence intervention save healthcare costs in a nursing home population? J Am Geriatr Soc 2003;51(2):161-8.

41 Schnelle JF, Ouslander JG, Cruise PA. Policy without technology: a barrier to improving nursing home care. Gerontologist 1997;37(4):527-32.

42 Schnelle JF, Cruise PA, Rahman A, et al. Developing rehabilitative behavioral interventions for long-term care: technology transfer, acceptance, and maintenance issues. J Am Geriatr Soc 1998;46(6):771-7.

43 Reinhard S, Stone R. Promoting quality in nursing homes: the Wellspring model. New York: The Commonwealth Fund; 2001 Sep.

44 Eaton SC. Beyond "unloving care": linking human resource management and patient care quality in nursing homes. International Journal of Human Resource Management. 2000;11(3):591-616.

Proceed to Next Chapter
Return to Contents


The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care