NURSING-HOME AVAILABILITY AND FINANCING
FACTORS ASSOCIATED WITH NURSING-HOME PLACEMENT
THE INTERFACE OF ACUTE AND LONG-TERM CARE
PHYSICIAN PRACTICE IN THE NURSING HOME
THE ROLE OF THE MEDICAL DIRECTOR
Nursing homes have evolved dramatically over the past several years, responding to a variety of government and market-driven forces. The almshouse, common at the turn of the century, has been transformed into a highly regulated institution for persons with severe physical and mental disabilities. Nursing homes, more than ever, present the clinician with a set of unique and complex care issues, many of which are best understood in the context of population needs, government policy, and reimbursement and staffing patterns.
The average nursing-home resident is characterized by significant impairments in physical and instrumental activities of daily living (ADLs). Overall, the level of disability in the nursing home has increased over the past decade and exceeds that found in persons receiving home care. Among nursing-home residents, 22.3% require assistance with one or two ADLs, and 74.9% require assistance with three or more. In addition to impairments of ADLs, 81% of nursing-home residents are impaired in their ability to make daily decisions; two thirds have orientation difficulties or memory problems, or both, and over half (54%) have either bowel or bladder incontinence. Hearing and visual impairments are found in 36% and 39% of residents, respectively. Dementia remains the most commonly occurring condition in the nursing home, with estimates ranging from 50% to 70%. Behavioral problems, understandably, are also common, occurring in at least one third of nursing-home residents. Such behaviors include verbal and physical abuse, social inappropriateness, resistance to care, and wandering. Communication problems are noted in 60% of residents; 44% have difficulty with both being understood and understanding others. Depression is diagnosed in 20% of nursing-home residents.
Almost half of all nursing-home residents are aged 85 years or over, with fewer than 9% under the age of 65. The majority are women (72%), white (89%), and unmarried (60% widowed) with limited social supports. The percentage of black residents in U.S. nursing homes has increased in recent years (9%), approaching national population norms. In fact, black Americans 65 to 74 years of age are more likely than white Americans to be admitted to a nursing home. Nonetheless, other nonwhite populations, such as Hispanic Americans, Asian Americans, and Native Americans, are underrepresented in nursing homes despite even higher disability rates in these groups. Older adults with developmental disabilities constitute another unique population that is requiring increasing nursing-home care as their elderly parents die. These persons often require specialized care that many nursing homes have difficulty providing (see Mental Retardation).
Currently there are 17,000 U.S. nursing homes with 1.8 million beds, 1.6 million residents, and 2.4 million discharges (ie, to home, hospital, or secondary to death). Of these facilities, 65% are proprietary (for-profit), with voluntary nonprofit (25%) and government nursing homes (10%) accounting for the remainder. The average nursing home operates 107 beds, and a minority (8%) have more than 200 beds. A little more than half of all nursing homes (56%) are part of a chain.
By age 65 a person’s risk of nursing-home admission before death is estimated at 46%; one third have lifetime risk of nursing-home stays of 90 days or less. The risk of nursing-home admission rises steeply with age; approximately 20% of persons aged 85 years and over reside in nursing homes versus 1.4% of those aged 65 to 74 years. Barring breakthroughs in the treatment of dementia, the number of persons 65 years and older using nursing homes will double by the year 2020. Interestingly, the occupancy rates in nursing homes nationally have declined over the past several years and now stand at 88%. This decline has generally been attributed to the availability of other long-term-care options, such as assisted living, but there are likely other causal social and financial variables that have yet to be articulated. The availability and use of home-care services for Medicare-eligible patients have not been found to consistently reduce nursing-home admissions.
Postacute care is increasingly being offered in nursing-home settings, a response to the higher care needs of older persons occurring in conjunction with declining lengths of hospital stays. Though the types of postacute services and programs vary significantly from one locale to another (ie, dialysis, orthopedic, ventilator, postoperative, rehabilitative, or wound care), they remain distinct from the standard nursing-home services by integrating the features of acute medical, long-term-care nursing, and rehabilitative settings. The challenge in postacute care is that of accommodating to patients with varying degrees of disease severity, functional dependence, and comorbidities. Some limited studies suggest that, for selected patient populations, postacute care in the nursing home achieves outcomes equal to or better than postacute care in acute hospitals. Definitions as to what constitutes postacute care, however, vary widely, as do regulatory standards, thus making comparison studies difficult.
Despite the significant disability associated with most nursing-home residents, the population remains quite heterogeneous. Short stayers (3 months or less) currently account for 25% of all nursing-home admissions, 50% will spend at least 1 year in the nursing home, and 21% will reside in the nursing home almost 5 years. Many short-stay residents are admitted for rehabilitation, and some enter nursing homes for terminal care. Interestingly, improvement in function for the longer-stay nursing-home residents is quite common, which reflects the heterogeneity of this population. The number of nursing-home admissions has risen since 1994, reflecting the dynamic nature of this sector of the long-term-care continuum.
Nursing-home expenditures currently total $90 billion and are projected to increase to $150 billion by 2007. Public expenditures constitute 62% of all nursing-home spending (Medicaid 48%, Medicare 12%, other 2%), with private spending constituting 38% of the total (31% out of pocket, 5% health insurance, 2% other private funds). On admission to a nursing home, almost one third of residents are eligible for Medicaid, and another third eventually qualify as financial resources are depleted. Under the new prospective payment system enacted as part of the Balanced Budget Act of 1997, Medicare payments to skilled nursing facilities are no longer cost-based, but are predicated on the person’s functional needs and rehabilitative potential. Although the prospective payment system has not conclusively limited access to skilled nursing care for Medicare beneficiaries, it has definitely forced nursing homes to be more diligent with regard to their admission policies. Not unexpectedly, physical, occupational, and speech therapies are commonly prescribed in the nursing home, with half of all nursing-home admissions receiving at least 90 minutes of these rehabilitation services, according to one study. The prospective payment system requires nursing-home staff to carefully document gains in function to ensure reimbursement. Interestingly, declines in Medicare spending on home-health care since enactment of prospective payment may eventually force some individuals into nursing homes for lack of affordable home-care options. (See Financing, Coverage, and Costs of Health Care.)
It is generally conceded that the current nursing-home population is “sicker” and more disabled than nursing-home residents were in the past. Studies have confirmed the correlation between the provision of quality care to total nursing hours and the ratio of professional nurses (ie, registered nurses) to nonprofessional nursing staff. An Institute of Medicine report in 2001 recommended increasing nurse staffing levels to enhance the quality of nursing-home care and has spurred Congress to debate the merits of mandatory minimum staffing ratios. The Centers for Medicare and Medicaid Services (CMS) has refused to institute regulatory changes that would be based on current evidence but has rather called for additional research in this area. Even if significantly higher staffing ratios eventually are mandated, the financial resources to achieve them remain elusive. Recruiting and retaining staff, particularly nursing assistants who constitute the bulk of the nursing-home workforce, also continues to be difficult. Turnover rates for registered nurses and licensed practical nurses also are very high, at more than 50% per year. Turnover rates have been associated with increased rates of hospitalization for nursing-home residents and have been linked to the organizational culture within the nursing facility.
Staffing issues are also pertinent to physicians practicing in nursing homes. The typical nursing-home physician is a primary care internist or family physician who devotes 2 hours or less per week to nursing-home care. Many physicians avoid nursing-home practice because of perceptions of excessive regulations, paperwork, limited reimbursement, and aversion to the long-term-care environment. A paucity of credible role models for physicians in training has greatly contributed to this lack of interest and involvement in long-term-care issues. Closed staff models are thought to deliver a higher intensity and quality of care in part because of the integration of the physician into the nursing facility culture, which ultimately facilitates interdisciplinary communication and treatment. Limited evidence suggests that hospitalization rates for nursing-home residents may be lower in facilities that employ a limited number of committed physicians. One study has demonstrated that the quality of drug use in the nursing home is positively correlated with enhanced nurse-physician communication and with regular multidisciplinary team discussions.
Although there is a significant chance of being admitted to a nursing home with increasing age, other factors, such as low income, poor family supports (especially lack of spouse and children), and low social activity have been associated with institutionalization. Cognitive and functional impairments have also predicted nursing-home placement, often permanently. Interestingly, for patients with dementia, education and caregiver support have been shown to delay the need for nursing-home placement for up to 1 year. Not surprisingly, older adults with more positive attitudes toward nursing homes are more likely to use skilled nursing facilities than are adults with less favorable dispositions. The range of long-term-care services that are now available (ie, skilled nursing, home care, assisted living) further increases the complexity of placement decisions, as the relative value and merits of available options have not been empirically tested. The use of formal (ie, paid-for) community services does not necessarily reduce the likelihood of nursing-home placement for patients with severe disabilities.
The majority of nursing-home admissions derive from acute-care hospitals. Conversely, nursing-home residents have high rates of hospitalization, ranging upward of 549 admissions per 1000 nursing-home beds per year. A 2001 survey by the Centers for Disease Control and Prevention noted that nursing-home residents constitute 2% to 3% of all emergency department visits. Infection is the most common reason for transfer of nursing-home residents to short-stay hospitals, accounting for one quarter of all such admissions. Studies to date suggest that nurse practitioners and physician assistants, who act in concert with the primary care physician, provide more intensive care in the nursing home, enhance satisfaction with care, and often decrease hospitalization rates while maintaining cost neutrality. Unfortunately, the transition from acute to long-term care is often complicated by suboptimal information transfer. Illegible or nonexistent transfer summaries, omission of prescribed medications, and the lack of documentation of advanced directives, psychosocial information, and behavioral issues are but a few of the information gaps commonly reported. (See also the section on transitions from hospital care in Hospital Care, and Perioperative Care.)
Extensive nursing-home reforms enacted in 1987 (in the Omnibus Budget Reconciliation Act of 1987) significantly changed the landscape of long-term care. In addition to setting training guidelines and minimum staffing requirements and bolstering residents’ rights, including limiting the use of restraints and psychoactive medications, the law required a periodic comprehensive assessment of all nursing-home residents. This assessment, known as the Minimum Data Set (MDS), focuses specifically on clinical issues with relevance to quality care. If any real or potential problems are identified with any of these issues, the health care team must review accompanying resident assessment protocols that outline standard diagnostic and therapeutic approaches to the specific problems in question. The protocols are, in essence, practice guidelines that the team, including the primary care physician, is encouraged to use. In addition to comprehensive assessments, the physician must also clearly document the need for all medications, particularly psychoactive agents. Unnecessary drugs are defined as those that are given in excessive doses, for excessive periods of time, without adequate monitoring, without adequate indications for use, or in the presence of adverse consequences that indicate the need for dose reduction or discontinuation. In addition to these generic instructions, specific types of drugs have been banned (ie, usage will warrant a citation from the state survey inspection team unless a clear rationale is documented in the chart) from use in the nursing home on the basis of criteria developed by a group of experts. Although some evidence exists to suggest that the 1987 act and subsequent mandates have resulted in a decreased prevalence of pressure ulcers and reduced use of restraints, their impact on the quality of care overall has been difficult to quantify. Interestingly, recent surveys indicate that only a minority of physicians ever review the MDS or related care plans. A new set of quality indicators based on MDS items has been instituted nationally in an effort to hasten efforts to improve quality. With this system, nursing facilities are able to compare their individual performance with regional and national norms to help guide their efforts to improve the quality of care (see http://www.cms.hhs.gov). Future versions of the MDS will likely include additional quality-of-life measures relating to personal preferences and activities.
A host of variables interact in nursing homes to determine the level of quality achieved. These include staffing levels, reimbursement rates, and processes of care extant in the nursing home. Although surveys of nursing facilities are mandated every 15 months, there is much debate as to whether the survey process can adequately identify quality practices and engender lasting improvements when deficiencies in care are found. The survey process, based on a deterrent regulatory paradigm, has been criticized for its inconsistencies, disassociation between outcome and process, surveyor subjectivity, and a failure to discriminate between trivial and important quality issues. The percentage of nursing-home residents receiving inadequate care or experiencing physical harm has declined to 20%, according to a recent General Accounting Office report. This figure, however, remains unacceptably high.
The care of nursing-home residents has become more complex over the past several years, commensurate with an increasing level of medical acuity in an environment continually constrained by lack of adequate resources. Comprehensive, ongoing assessment within an interdisciplinary framework provides the practitioner the opportunity to restore function, whenever possible, and almost always to enhance quality of life.
Clinical challenges abound in the nursing home, created, in part, by the atypical and subtle presentation of illness so characteristic of patients with profound physical and psychologic frailty. In addition, limited access to biotechnology, frequent dependence on nonphysicians such as nurses and nurse assistants for patient evaluation, and the high prevalence of cognitive impairment in a setting of intense regulatory oversight all complicate the medical decision-making process. Families of nursing-home residents often remain an integral part of the overall care plan and may require specific educational and psychosocial supports. Ethical and legal concerns are also very common, particularly those regarding end-of-life, feeding, hydration, and resident rights issues. (See Legal and Ethical Issues.) Finally, the heterogeneity among nursing-home residents precludes a uniform care plan, but rather demands an individualized, thoughtful, and reasoned approach to each person in the nursing-home setting.
Problems in nursing homes that commonly require unique diagnostic and treatment strategies include infections, falls, malnutrition, dehydration, incontinence, behavioral disturbances, the use of multiple medications, and prevention and screening. (See Infectious Diseases; Falls; Malnutrition; Urinary Incontinence; Behavioral Problems in Dementia; Pharmacotherapy; and Prevention.) For example, determining the risks and benefits of tube feedings for frail nursing-home patients must be predicated not only on underlying illness but also on the resident’s and the family’s value system, the resources available in the nursing facility, and staff acceptance of the intervention. Given that the evidence for and against enteral feeding in nursing-home patients is controversial (ie, benefits are not well established, with up to one fourth of residents with chewing and swallowing problems able to have their feeding tubes removed), the practitioner must continue to individualize therapy. (See Eating and Feeding Problems.) Many of the problems commonly encountered in the nursing home result when multiple comorbidities interact with a host of environmental factors, all of which may only be partially remediable. Unfortunately, expectations of family, as well as state regulators, often do not account for these complexities and commonly engender “risk-averse” behavior that is counter to autonomy and optimum quality of life.
Physicians have traditionally had limited involvement in nursing homes. Perceptions of excessive regulations, paperwork, and limited reimbursement raise further disincentives to nursing-home practice. In reality, the medical care of nursing-home residents is both challenging and fulfilling, requiring excellent clinical skills as well as sensitivity to a variety of ethical, legal, and interdisciplinary issues. Medical interventions, whether they be curative, preventive, or palliative, demand an individualized approach that recognizes the complex interplay among resident, family, and staff needs. Further, the evidence upon which to base treatment may be nonexistent.
The comorbidity present in most nursing-home residents commonly creates the need for multiple drug therapies, with attendant complications. Even though residents receiving more than nine medications (one third of all nursing-home residents) are flagged by state survey teams as reflecting potential quality concerns, the use of multiple medications cannot always be avoided. The most common health conditions found in the nursing home for persons aged 65 years and older, following dementia, are heart disease, hypertension, arthritis, and stroke. The approaches to these and other illnesses have evolved dramatically in recent years and complicate treatment decisions where cost-effectiveness is increasingly looked upon as a desirable goal. Clear documentation of the rationale for a given medication or intervention is the best way to protect against potential scrutiny; frequent discussion with the facility’s consultant pharmacist is also helpful. (See Pharmacotherapy.)
Physicians who schedule and structure their visits to the nursing home will benefit from the resultant efficiencies and secondarily will be more fully integrated into the health care team. Nurse practitioners and physician assistants have become increasingly involved in the primary care of nursing-home residents. Studies suggest that nurse practitioners and physician assistants who act in concert with the primary care physician as a coordinated team provide more intensive care to the nursing-home resident and may decrease hospitalization rates while maintaining cost neutrality. Information regarding physician responsibilities and Omnibus Budget Reconciliation Act mandates can be found at the Web site of the American Medical Directors Association (http://www.amda.com). Such responsibilities encompass ongoing comprehensive assessment and coordination of care in order to assure patient autonomy and safety as well as optimization of physical and psychosocial function. (See Table 15.1.)
Several studies have documented misdiagnoses, inappropriate interventions, and poor preventive care practices in nursing homes. In an often-cited study of Maryland nursing homes, for example, only 11% of patients with four common types of infection were found to have received even a minimal evaluation (eg, failure to obtain a urine sample when treated for a urinary tract infection). In a study of nursing-home patients with nonmalignant pain, 25% were found to be receiving no analgesics. Intensive research is currently being directed to understand the processes necessary to integrate validated care guidelines into nursing homes in an effort to improve quality of care.
Certain care strategies that have been developed may enhance care quality. The commonly employed special care units, though conceptually attractive, have not consistently been shown to enhance quality of care apart from the involvement of individual professionals. Specific consultation services in the nursing home, however, may improve care practices and patient outcomes, as shown by a randomized controlled trial of an effort to reduce falls in a group of Tennessee nursing-home residents. In addition, interactive educational programs for physicians and nursing staff may improve practice, as has been demonstrated in programs to promote appropriate psychoactive drug use.
Understanding each nursing-home resident’s preference for care in the context of his or her underlying value system will undoubtedly improve overall quality. Interestingly, fewer than one in eight nursing-home residents have discussed preferences with their health care providers. In addition, there is often a lack of follow-up of do-not-resuscitate discussions in the hospital when the patient is subsequently admitted to the nursing home. Sixty percent of nursing-home residents have orders for cardiopulmonary resuscitation, and almost 90% desire hospitalization for acute illness. When ethical dilemmas do present themselves, the availability of institutional ethics committees can provide important guidance. The multidisciplinary nature of these committees ensures a spectrum of opinion and insight critical for nursing-home residents, and they are particularly relevant to end-of-life issues. (See also Legal and Ethical Issues.)
The quality of physician practice in the nursing home is, in many ways, determined by the medical director. The medical director, in concert with the medical staff, sets quality standards for the nursing home and operationalizes these through specific policies and procedures. The medical director must ensure compliance with all relevant state and federal guidelines and work with the nursing-home administrator and director of nursing to foster effective team care and continuing staff education. The medical director of a nursing home works closely with all disciplines and must be constantly aware of the unique interplay between laws, regulations, organization, and delivery of medical care. Certification for medical directors following completion of a formal course is now offered through the American Medical Directors Association.
■ Dimant J. Roles and responsibilities of attending physicians in skilled nursing facilities. J Am Med Dir Assoc. 2003;4(4):231–243.
■ Dimant J. The role of the consultant in long-term care facilities. J Am Med Dir Assoc. 2003;4(5):274–280.
The author describes the roles and responsibilities of both nursing-home attending physicians and consultants in great detail. Although these seem daunting and subject to countless rules and regulations, it is important for the physician not to lose sight of the primary goal in the nursing home—that of promoting the quality of care for each resident. An accompanying editorial (Katz PR. A silver lining. J Am Med Dir Assoc. 2003;4[4]:222) attempts to place the physician’s role in realistic perspective.
■ Kane RA. Definition, measurement, and correlates of quality of life in nursing homes: toward a reasonable practice, research, and policy agenda. Gerontologist. 2003;43(Spec No. 2):28–36.
This seminal review challenges our current constructs of quality of life for nursing-home residents. Barriers to defining and measuring quality of life are clearly articulated; the centrality of the nursing-home residents’ voice is emphasized. Several methodologic challenges in measuring quality of life are described, and potential solutions are offered.
■ Katz PR, Mezey M, Kapp M, eds. Physician practice in long-term care: workforce shortages and implications for the future. In: Advances in Long-Term Care. Vol. 5. New York: Springer Publishing Co.; 2003.
Continued concerns about the quality of care delivered in nursing homes have increased focus on staffing levels and competency. Although studies have generally affirmed the correlation between nurse staffing levels and quality, little if any research has systematically described the relationship between physician staffing patterns and relevant outcomes. This chapter summarizes the extant literature on physician practice patterns in the nursing home and offers a research agenda for the future.
■ Saliba D, Kington R, Buchanan J, et al. Appropriateness of the decision to transfer nursing facility residents to the hospital. J Am Geriatr Soc. 2000;48(2):154–163.
The transfer of older patients between acute and long-term-care facilities is common, expensive, and fraught with potential morbidity. The dynamics underlying these transfers are complex, particularly those involving acutely ill nursing-home residents in need of acute care. The authors of this article make use of peer reviews of medical records in order to document the reasons underlying inappropriate transfers. This study, and the accompanying editorial, set the stage for future research in this arena.
■ Wunderlich GS, Kohler PO, eds. Strengthening the caregiving work force. In: Improving Quality in Long-Term Care. Washington, DC: National Academy Press; 2001.
This Institute of Medicine report profiles long-term care, both users and providers, with a primary focus on quality of care. Issues related to the measurement and monitoring of quality of care are clearly articulated. Approaches to strengthening the caregiving workforce are presented, as well as the means to improve care through the building of organizational capacity. Although quality of care has improved somewhat, this report highlights the many obstacles yet to be overcome.
Paul R. Katz, MD
Jurgis Karuza, PhD