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Long-Term Care - Ensuring Quality Of Long-term Care

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Monitoring quality of long-term care services has been a long-standing challenge, especially in nursing homes. The Nursing Home Reform Act of 1987 set new standards for care and established rights of nursing home residents, in response to numerous reports of neglect and abuse in nursing homes. A notable impact of the act is a substantial reduction in the unnecessary use of physical restraints and chemical restraints (drugs) in nursing homes.

The Nursing Home Reform Act has been difficult to enforce, however, and has often failed to protect nursing home residents from poor care and unsafe conditions. Federal and state inspections showed that more than one in four nursing homes nationwide had deficiencies that caused harm to residents or placed them at risk of death or serious injury each year from 1995 to 1998 (GAO, Nursing Homes, 1999).

Because the picture is often bleak in nursing homes, home and community-based services may offer better quality of life. These services allow individuals to receive care in a home or community setting rather than in an institution. In 1987 federal law mandated new quality standards for home health care agencies that are reimbursed by Medicare and Medicaid. States also have their own licensing laws for home health services covered by state-funded programs. Within the same state, several government agencies may be involved in regulating or contracting for home care services. In addition, there are hundreds of unlicensed agencies, such as agencies that provide temporary home care workers for private-paying consumers, operating in every state. Many researchers are skeptical that the fragmented regulatory system can effectively enforce quality home care (Coleman).

Quality of home care has been difficult to assess. Studies have found that clients reported high levels of satisfaction and at the same time reported serious deficiencies in worker performance. These inconsistencies suggest that clients may overstate their levels of satisfaction (Coleman).

A new movement called consumer-directed care presents an opportunity to empower individuals to manage their own home care. Many publicly funded programs now give beneficiaries the option to choose their own care providers and to manage their own plans of care, much as privately paying individuals do. Consumer-directed care is advocated primarily by younger adults with disabilities, who want to live in the least restrictive environment possible and to direct their own care. While some advocates contend that providing consumers with autonomy and control will improve care quality, others are concerned about potential health and safety risks. Experts have noted that long-term care often involves a trade-off between maximizing consumer choice and ensuring safety (Coleman).

Assisted living facilities often emphasize a philosophy of facilitating residents' privacy, autonomy, independence, and dignity, and promoting care in a homelike environment (Lewin-VHI). They are licensed and regulated by the states rather than the federal government, and standards and oversight approaches vary across the states. In a 1999 study of assisted living in four states, the General Accounting Office found that more than a quarter of facilities were cited by state oversight agencies for having five or more quality-of-care or consumer protection deficiencies or violations during 1996 and 1997. Frequently identified serious problems providing insufficient care to residents; having insufficient, unqualified, and/or untrained staff; not providing residents the appropriate medications or storing medications improperly; and violating state admission and discharge regulations (GAO, Assisted Living, 1999). Nonetheless, older persons and their families frequently choose assisted living for persons who do not need the more intense services of nursing homes, because the quality of life in assisted living is typically preferred over that in nursing homes.



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