Quality of Long-Term Care

Concerns about the quality of nursing home care and ineffective government regulation of facilities dates back to at least 1970. (Medicare and Medicaid were enacted in 1965 and soon after, there was an expansion of nursing homes and increasing concerns about quality.) A 1987 law known as the Omnibus Budget Reconciliation Act (OBRA 1987) raised quality-of-care standards for nursing homes participating in Medicare and Medicaid and strengthened federal and state oversight. Following the law's implementation, several studies found evidence of improvements in nursing home care, including a decline in the use of physical and chemical restraints, reduced prevalence of dehydration and pressure ulcers, and less frequent use of catheters. Pressure ulcers are a standard measure of nursing home quality, simply because avoiding these skin wounds requires coordinated care efforts to turn and take care of bedridden residents.

Despite these improvements, studies indicate that many nursing homes continue to provide inadequate care. The U.S. General Accounting Office (GAO) in 1999 found that one-fourth of nursing facilities have serious deficiencies that have caused actual harm to residents or placed their health and safety at risk (see Scalon 2001). According to the Institute of Medicine, many of these homes have had repeated serious deficiencies, and even when problems have been identified, state and federal enforcement policies are often effective in ensuring that they are corrected and remain corrected.

There is a growing awareness among nursing-home administrators, state and federal regulators, consumer advocates, and others that staff shortages and insufficient staff training are part of the problem. High turnover in nursing-home staff (currently at 40 to 75 percent nationally, and as high as 500 percent in certain facilities) makes it difficult to recruit and retain a high quality workforce. Staff turnover among certified nursing assistants (CNAs), who are at the front lines of nursing-home care, is particularly detrimental to overall quality of care. Instability in the CNA workforce means that residents are constantly receiving care from new people who often lack experience and a knowledge of individual residents. In such an environment, continuity of care is compromised. In addition, the cost of training new staff drains resources from resident care.

Improvements in the basic elements of nursing-home care, such as fire safety, inappropriate use of physical or chemical restraints, and a lack of available social programs, have been recorded. Nursing-home quality now needs to broaden its focus to address both issues of quality of care and quality of life. The emphasis on health and safety, which has been dominant in the U.S. regulatory system, needs to be expanded to emphasize the critical aspects of life, such as choice and control of the services received, if nursing homes are to be quality settings.