Omnibus Budget Reconciliation Act Research Articles

Characteristics of a Hospital Based Adult Transitional Care Unit and It's Impact on Nutrition Services

LEARNING OUTCOME: To provide data on a new Adult Transitional Care Unit that receives its population from an attached, affiliated tertiary/quartenary care facility, and to evaluate it's impact on nutrition services. A growing number of Acute Transitional Care Units (ATCU) have been established throughout the country in both hospital and long term care settings. For the hospital based ATCU's, these units often present a challenge for the nutrition services department primarily due to new rules and regulations enforced by the Omnibus Budget Reconciliation Act (OBRA), increased patient turnover, new documentation requirements, and aggressive rehabilitation goals. Our objective was to review data on the newly established 20 bed ATCU in our tertiary/quartenary care facility, and evaluate it's impact on nutrition services, including the functions of the Registered Dietitian (RD) and the Food Service Department (FSD). Data from the past 5 months was reviewed using the Monthly Census Statistical Review Report, and the Monthly Productivity Report with the goal to evaluate the daily average census, percent occupancy rate, length of stay, referrals, and diet orders. In light of the data obtained, the role of the RD would be required to 1) provide timely assessments, and frequent follow-up documentation 2) establish a broad knowledge of various disease states with emphasis on the geriatric population 3) consult with acute care RD's regarding previously established goals and treatment plans to provide a continuum of care 4) become proficient in nutrition support to deal with complex medical/surgical patients, and 5) become efficient in completing interdisciplinary care plans. The changes for the FSD would include 1) preparation of more specialized foods to cater to the special needs of the ATCU patient 2) development of a 3-week cycle menu to meet OBRA guidelines to ensure variety on the standard hospital menus 3) initiation of a snack program to provide patients with a choice of a substantial evening snack and 4) development of a texturized meal program to improve on presentation, taste, and quality of meals.

The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality.

To characterize changes in key aspects of process quality received by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms. A quasi-experimental study using a complex, multistage probability-based sample design, with data collected before (1990) and after (1993) implementation of the RAI and other OBRA provisions. Two independent cohorts (n > 2000) of residents in a random sample of 254 nursing facilities located in metropolitan statistical areas in 10 states. OBRA-87 enhanced the regulation of nursing homes and included new requirements on quality of care, resident assessment, care planning, and the use of neuroleptic drugs and physical restraints. One of the key provisions, used to help implement the OBRA requirements in daily nursing home practice, was the mandatory use of a standardized, comprehensive system, known as the RAI, to assist in assessment and care planning. OBRA provisions went into effect in federal law on October 1, 1990, although delays issuing the regulations led to actual implementation of the RAI during the Spring of 1991. MEASUREMENTS AND ANALYSES: Research nurses spent an average of 4 days per facility in each data collection round, assessing a sample of residents, collecting data through interviews with and observations of residents, interviews with multiple shifts of direct staff caregivers for the sampled residents, and review of medical records, including physician's orders, treatment and care plans, nursing progress notes, and medication records. The RNs collected data on the characteristics of the sampled residents, on the care they received, and on facility practices. The effect of being a member of the 1990 pre-OBRA or the 1993 post-OBRA cohort was assessed on the accuracy of information in the residents' medical records, the comprehensiveness of care plans, and on other key aspects of process quality while controlling for any changes in resident case-mix. The data were analyzed using contingency tables and logistic regression and a special statistical software (SUDAAN) to assure proper variance estimation. Overall, the process of care in nursing homes improved in several important areas. The accuracy of information in residents' medical records increased substantially, as did the comprehensiveness of care plans. In addition, several problematic care practices declined during this period, including use of physical restraints (37.4 to 28.1% (P < .001)) and indwelling urinary catheters (9.8 to 7% (P < .001)). There were also increases in good care practices, such as the presence of advanced directives, participation in activities, and use of toileting programs for residents with bowel incontinence. These results were sustained after controlling for differences in the resident characteristics between 1990 and 1993. Other practices, such as use of antipsychotic drugs, behavior management programs, preventive skin care, and provision of therapies were unaffected, or the differences were not statistically significant, after adjusting for changes in resident case-mix. The OBRA reforms and introduction of the RAI constituted an unprecedented implementation of comprehensive geriatric assessment in Medicare- and Medicaid-certified nursing homes. The evaluation of the effects of these interventions demonstrates significant improvements in the quality of care provided to residents. At the same time, these findings suggest that more needs to be done to improve process quality. The results suggest the RAI is one tool that facility staff, therapists, pharmacy consultants, and physicians can use to support their continuing efforts to provide high quality of care and life to the nation's 1.7 million nursing home residents.

Stark II and Its Effect on Orthopaedic Practice

The Omnibus Budget Reconciliation Act (OBRA) of 1989, "Stark I," and OBRA 1993, "Stark II," contain provisions introduced by Rep. Fortney "Pete" Stark of California that limit certain referral and compensation arrangements for physicians. Since some of these restrictions affect the practice of orthopaedic surgeons and the nurses employed in these practice settings, this article provides general information related to the Stark self-referral legislation.

Occupational Therapy Intervention for Residents in a Skilled Nursing Facility: A Focus on Atypical Patients

The 1990 implementation of the Omnibus Budget Reconciliation Act (OBRA) has expanded opportunities for occupational therapists to treat individuals with non-traditional illnesses. Therapists working in skilled nursing and long term care can benefit from gaining an understanding of the OBRA guidelines and patient's rights, especially regarding restraint reduction. Occupational therapists possess the necessary skills to assess and treat these individuals to help maximize their functioning as well as improve their quality of life (Moon-Sperling & Pinson, 1991). The premise of this article is to inform therapists about various types of ethical and legal intervention with atypical patients in skilled nursing facilities and to introduce therapists to the laws supporting provision of these services. [Article copies available for a fee from The Haworth Document Delivery Service: 1–800–342–9678. E-mail address: getinfo@haworth.com]

Occupational Therapy Intervention for Residents in a Skilled Nursing Facility: A Focus on Atypical Patients

The 1990 implementation of the Omnibus Budget Reconciliation Act (OBRA) has expanded opportunities for occupational therapists to treat individuals with non-traditional illnesses. Therapists working in skilled nursing and long term care can benefit from gaining an understanding of the OBRA guidelines and patient's rights, especially regarding restraint reduction. Occupational therapists possess the necessary skills to assess and treat these individuals to help maximize their functioning as well as improve their quality of life (Moon-Sperling & Pinson, 1991). The premise of this article is to inform therapists about various types of ethical and legal intervention with atypical patients in skilled nursing facilities and to introduce therapists to the laws supporting provision of these services. [Article copies available for a fee from The Haworth Document Delivery Service: 1–800–342–9678. E-mail address: getinfo@haworth.com]

Recent Antipsychotic Regulations in Long-term Care

The excellent article by Cox Hayley et al 1 in the February 12, 1996, issue of theARCHIVESoffers practical insight into the management of ethical and legal issues faced by the practitioner caring for nursing home residents. However, there is one point that requires further clarification. Provisions for the proper use of neuroleptics are incorporated in the Interpretative Guidelines for 'Unnecessary Drugs'. The Unnecessary Drug regulations, which are part of OBRA (Omnibus Budget Reconciliation Act) 1987, assure nursing home residents that they have a right to be free from the use of unnecessary drugs, which are defined as medications used in excessive doses (including duplicative therapies), for an excessive duration, without adequate monitoring, in the presence of adverse consequences that indicate the dose should be reduced or discontinued, or a combination of any of the above. 2 Cox Hayley and colleagues state that neuroleptic use on an as-needed basis

Protecting Confused Patients from Falls

ails are well known to compromise patient outcomes, resulting in loss of independence and confidence as well as susceptibility to future falls. While the majority of falls don't result in serious physical injury, they can influence morbidity and mortality. A general hesitancy among hospital staff to file incident reports makes it difficult to obtain actual fall statistics, but falls are estimated to account for nearly 90% of all reported hospital incidents. It's also well documented that falls increase hospital costs and length of stay. Depending on cognitive impairment, muscle weakness, and balance and visual impairment, a patient with a hip fracture requires a sevento 10-day stay in the acute care setting. National expenses for fall-related fractures are calculated at $10 billion annually. The confused patient, who's at risk for falls, presents a particular nursing challenge. You're often called upon to intervene before the cause of the patient's confusion is even identified. And though immediate action is necessary, you must comply with the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Omnibus Budget Reconciliation Act (OBRA) in using any physical or chemical restraints. That's why, in 1992, as part of a quality improvement project, nurses at Lutheran Medical Center in Wheat Ridge, Colorado, implemented a fall-prevention program with special emphasis on the confused patient. We developed an algorithm for assessing confused patients and intervening appropriately. Here we'll present our algorithm and describe how it works.

OBRA regulations and the use of psychotropic drugs in long-term care facilities: Impact and implications for geropsychiatric care

This article reviews governmental guidelines regulating the use of psychotropic drugs in long-term care facilities as established by the Omnibus Budget Reconciliation Act (OBRA) of 1987 and their impact on the use of psychotropic agents in these settings. A major component of these guidelines is to regulate the clinical indications for psychoactive drugs (neuroleptics, benzodiazepines, and sedative hypnotics) in residents of long-term care facilities. Responsibilities of the prescribing physician, facility medical director, and consulting pharmacist—as well as quality assurance procedures—in complying with OBRA regulations are examined. Evidence that OBRA regulations have reduced the use of psychotropic drugs and physical restraints in long-term nursing facilities is reviewed. Implications of the OBRA regulations for the training and clinical practice of psychiatrists and primary care clinicians are discussed as well as recommendations for increasing the availability of mental health services for this patient population via multidisciplinary geropsychiatric consultation-liaison teams.

Welfare Versus Workfare: Policy Implications∗

The Omnibus Budget Reconciliation Act (OBRA) of 1981 and the 1988 Family Support Act (FSA) have made workfare programs an integral part of the American welfare system. The OBRA and FSA required states to mandate participation in a Community Work Experience Program (CWEP) for recipients of Aid to Families with Dependent Children (AFDC). This paper reviews the experience with workfare programs in the past 25 years. The paper summarizes their results, including positive and negative aspects of the programs, and identifies some key issues and unanswered questions from this experience. The authors conclude with suggestions toward a more viable direction of welfare reform. ∗The authors presented a version of this paper to the Fourth Annual Conference of Global Awareness Society International on May 19, 1995, in Shanghai, China.

Predictors of Nursing Home Residents' Participation in Activity Programs

Nursing homes are mandated by the Omnibus Budget Reconciliation Act (OBRA) to provide activity programs (U.S. Congress, 1987). Little information exists, however, as to residents' participation in activity programs. Using data from a Health Care Financing Administration project, the present study examines the relationship between resident characteristics and time participating in activities. Among 2,672 nursing home residents we found measures of resource use, cognitive abilities, depression, sense of initiative/involvement, activity repertoire, location preferences, and gender all to be significant in explaining the amount of activity time.

Medication use and the elderly: current status and opportunities.

The crucial role played by medication use in the elderly is common knowledge in the worlds of health services research, clinical epidemiology, and geriatrics. It is now widely known that although persons over age sixty-five represent only about 13 percent of the population, they consume nearly one-third of all medications in the United States; that medications probably are the single most important health care technology in preventing illness, disability, and death in the geriatric population; that drugs represent one of the largest and fastest-rising out-of-pocket health care expenditures for the elderly; and that the old, because of their high drug usage rate, greater frequency of coexisting illnesses, and diminished physiological reserves, are at greater risk of experiencing adverse drug effects. Yet despite this knowledge, the use of drugs by the elderly and their clinical outcomes have not been prominent research or programmatic priorities for federal government, philanthropic, or corporate grantmakers. Beginning in the mid-1980s, The John A. Hartford Foundation began a grant-making program in the area of medication use and aging, out of an interest in enhancing the therapeutic effect of drugs used by this age group and in reducing the frequency and consequences of adverse drug events. After a number of years of active support in this area, the foundation convened its Expert Panel on Medications and Aging. This panel brought together authorities in the disciplines of geriatrics, gerontology, epidemiology, health services research, public policy, and pharmacology. Its mandate was to provide a consensus report that would critically define the further work needed to make the use of medications by the elderly more effective. This essay represents a synthesis of the work of that panel. The positions and opinions expressed below are extracted from transcripts of the expert panel’s deliberations, a structured survey administered to panel members,

Reducing restraints. Impact on staff attitudes.

1. Changing the practice of using physical restraints must include nursing staff members as one of the main targets for change. 2. Following education and the implementation of a restraint-reduction program, 58% of the nursing staff participants found restraint use to be less important in caring for the elderly. Changes were more significant, however, immediately after the mandatory inservice program. 3. Nursing staff members whose perceptions changed tended to be registered nurses or licensed practical nurses who had more years of experience and more seniority at work. 4. The provision of ongoing education to nursing staff members is a necessary step to decrease feelings of frustration and stress and to assist the staff in being aware of alternatives to restraints.

OBRA Regulations for Nursing Homes—Enhancing Paperwork or Patient Care?

Letters1 November 1994OBRA Regulations for Nursing Homes—Enhancing Paperwork or Patient Care?Valery A. Portnoi, MDValery A. Portnoi, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-121-9-199411010-00024 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:In their commendable review [1], Ouslander and Osterweil describe extensive physician responsibilities but confess that the cost-effectiveness and efficiency of these practices for preventing morbidity and death in nursing homes have never been tested. Instead, the authors rely on guidelines of federal rules for nursing homes, particularly the Omnibus Budget Reconciliation Act (OBRA) of 1987 [2]. The authors do acknowledge that OBRA regulations will be difficult to implement in light of the negative “nature of the nursing home environment” and inadequate Medicare reimbursement for physician care.Medical practice cannot be neatly regulated by government, nor will extensive ...

The relationship of antipsychotic drug use, behavior, and diagnoses among nursing home residents.

Nursing homes have been criticized for frequent use and possible misuse of psychoactive agents. These issues are of clinical concern and policy relevance, especially since the passage of the Omnibus Budget Reconciliation Act (OBRA) of 1987. Using a sample of 419 residents, the authors examined the relationships among antipsychotic drug (AP) use, behavior, and mental health diagnoses. Only 23.2% of the residents were administered APs on a routine and/or "as-needed" basis. Based on the Multidimensional Observation Scale for Elderly Subjects (MOSES) ratings, AP users were more irritable, disoriented, and withdrawn than were nonusers. Also, AP users demonstrated agitated behaviors more frequently. Notably, AP users and nonusers differed significantly in terms of documented mental health diagnoses. Among AP users, 70.1% had documented dementia, 8.3% were psychotic or had other psychiatric disorders, and 21.6% had no mental health diagnoses. In contrast, the majority of nonusers had no mental health disorders. Logistic regression revealed that diagnostic factors, frequency of agitation, level of withdrawal, and marital status were significant predictors of AP use.

MASLOW HIERARCHY OF NEEDS AND OBRA 1987: TOWARD NEED SATISFACTION BY NURSING HOME RESIDENTS

Human beings have needs that they strive to fulfill regardless of their psy‐chophysical limitations. Need satisfaction by the elderly is examined along Maslow's hierarchy of needs and the requirements of the Omnibus Budget Reconciliation Act (OBRA) of 1987. Maslow (1954) theorized that need satisfaction is hierarchical, progressing from satisfying the lower level of physiological needs to those of safety, belong‐ingness, esteem, and self‐actualization. Despite the principle of relative potency of needs and the elderly's apparent lack of adjustment capabilities toward ungratified needs, OBRA implies an appropriate need mix to enable the elderly to survive adequately. Functional departments within nursing homes should therefore strive to develop effective programs aimed at improving each resident's quality of life. There are some misgivings, however, concerning how many of the higher needs are met by the residents. Need satisfaction by the elderly cannot be limited to meeting lower‐level needs for food and ...

Emergency care guidelines

Examination and treatment for emergency medical conditions and women in labor. Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 USC 1395 dd) as amended by the Omnibus Budget Reconciliation Acts (OBRA) of 1987, 1989 and 1990.

Expanding Medicaid to Cover Uninsured Americans

Prologue: In recent years, those in Congress who seek to increase health care coverage, particularly for poor women and children, have relied on mandates to expand Medicaid. The latest iteration of such action is the 1990 Omnibus Budget Reconciliation Act (OBRA), which mandates that states phase in Medicaid coverage by 2002 for children age eighteen and under in families earning up to 100 percent of the federal poverty level Such expansion will greatly affect states' budgets, perhaps by as much as $17 billion over the next five years. At a National Governors' Association meeting in February 1991, governors called on Congress to delay implementation of the Medicaid mandates in OBRA 1990 by two years. Deeply concerned about the budgetary effects, the governors seek the delay “to assess the depth of the recession and the opportunity to develop long-term solutions for the restructuring of the Medicaid program,” according to the resolution. In this article, John Holahan and Sheila Zedlewski simulate the effects of the OBRA 1990 Medicaid expansion, as well as alternative expansion strategies. They discover that while Medicaid expansions can greatly reduce the number of uninsured Americans, they would also have a large impact on state and federal budgets. The authors examine the implications of combining employer mandates with Medicaid expansion and discuss the impact of Medicaid buy-in approaches. Holahan directs the Health Policy Center of The Urban Institute in Washington, D.C. He earned his doctorate in economics from Georgetown University. Zedlewski is a senior research associate in the Income and Benefits Policy Center at Urban, and also program director, Aging and Retirement Studies. She received a masters degree in public administration from The American University. The authors currently are studying who bears the cost of health care in the United States and how costs would shift under various reforms.

Multiple Questions Require Multiple Designs

In 1981 major changes were made to the Aid to Families with Dependent Children (AFDC) program by the Omnibus Budget Reconciliation Act (OBRA). These changes redirected program resources to those welfare recipients with the least financial resources and thus affected the eligibility and benefit levels of many working welfare recipients. Numerous questions were raised about the effects of the changes—questions concerning the reasonableness of projected program savings, welfare recipients' work effort, and changes in the quality of life for families losing AFDC. This article describes an evaluation study, composed of multiple quasi-experimental research designs, that sought to address these questions. It emphasizes the kinds of issues faced by evaluators when designing research on complex and sensitive topics.

The Effect of the 1981 Omnibus Budget Reconciliation Act on Welfare Recipients and Work Incentives

The 1981 Omnibus Budget Reconciliation Act (OBRA) altered the Aid to Families with Dependent Children (AFDC) program in important ways, especially regarding the work incentives in the benefit formula. We use a set of data on AFDC recipients active just prior to OBRA to determine how recipients were affected by the legislation. We find that working recipients were very hard hit and that the "tax rate" implicit in the program rose to 78 percent. The introduction of a gross income screen contributed the most to eliminating workers from the rolls, while the elimination of the "30-and-one-third" deduction was most important in raising the tax rate.

A Quasi-Experimental Assessment of the National Impact of the 1981 Omnibus Budget Reconciliation Act (Obra) On the Aid To Families With Dependent Children (Afdc) Program

The 1981 Omnibus Budget Reconciliation Act (OBRA) called for important changes in the Aid to Families with Dependent Children (AFDC) program. This article reports the findings of a study that tracked two nationally representative samples of AFDC cases to learn about caseload dynamics prior to and following OBRA's implementation. Simple comparisons and the use of life-table techniques revealed that amendments to the AFDC program had a significant impact on program participation and costs that was not offset by any change in work behavior. Various features of the evaluation design and their relationship to the study objectives are described.