“The real cause of problems is solutions.” — Eric Sevareid, American Journalist Nursing home reform seems to be a perpetual endeavor. Over the years, I have written about the many diverse initiatives to try to improve — if not “fix” — the nation’s nursing homes. On the 25th anniversary of the Omnibus Budget and Reconciliation Act of 1987, I asked, “Twenty-five years after OBRA ’87, are things substantially better than they were 25 years ago? Why are there continuing concerns about long-term care? Is more reform still warranted, or are we just talking about fine tuning an already greatly improved service?” (Caring for the Ages 2012;13[9]:10). The latest initiative to reform nursing homes is the National Academies of Sciences, Engineering, and Medicine (NASEM) report, The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff (National Academies Press, 2022). This 577-page tome follows the previous reports from 1986 and 2000 from the Institute of Medicine (a branch of NASEM). It recites the five-decade history of nursing home reform efforts, followed by discussions of quality measurement and quality improvement, care delivery, workforce, the nursing home environment and resident safety, payment and financing, oversight and regulation, and health information technology. It concludes with a series of recommendations. The NASEM report recognizes the dual role of nursing homes to provide health care and to serve as a residence. It also recognizes that nursing home residents have a higher acuity level and comorbidity burden and need more sophisticated and complex care, but “staffing requirements and regulations have not kept pace.” Throughout, the NASEM report seems to imply that, despite some improvement, there is an urgent need for “immediate action to initiate fundamental change.” It also claims that “despite significant measures to improve the quality of care in nursing homes in ... OBRA 87, too few nursing home residents today receive high-quality care” and that “too many nursing home workers, surveyors, and others do not receive adequate and appropriate support to fulfill their critical responsibilities.” The NASEM report tends to emphasize the conventional narrative about nursing homes, wherein negative outcomes are widely presumed to be due to indifferent owners and inadequate staffing. Alternative explanations are not considered, even though the care of older individuals with complex problems is challenging and inconsistent across all settings, not just nursing homes. After reading the entire NASEM report, I wondered why so much still seems to be amiss and apparently needs even more urgent reform and oversight despite expending an enormous amount of time, effort, and money over many decades. Why do we still need urgent, fundamental change? I argue that much of the answer lies in the failures of the reform and the reformers themselves. The call continues to be for increasingly elaborate versions of the things that have already been proven to be inadequate, which prevents us from focusing on simple practices that are shown to work. I will give several examples. My first example is how the report addresses the long-standing challenge of reducing rehospitalization. It calls for more research and cites examples of related initiatives such as INTERACT (Interventions to Reduce Acute Care Transfers) and projects such as those from the Missouri Quality Initiative (MOQI), New York–Reducing Avoidable Hospitalizations (NY-RAH), and Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC). However, although the INTERACT tool can serve as a guide for staff in reporting a resident’s symptoms, it is unclear just how much of a difference it ultimately makes (JAMA Intern Med 2017;177:1257–1264). As with other issues, rehospitalization can be addressed by following the care delivery process, including consistently correct cause identification, clarification of patient goals and wishes, and optimal management of symptoms, conditions, and risk factors. We do not need special tools or projects or initiatives for every situation or issue. For another example, the NASEM report’s discussion of advance care planning, Physicians Orders for Life-Sustaining Treatment (POLST), and life-sustaining treatment decision-making is nothing new. Advance care planning and end-of-life decision-making involve medical, functional, and psychosocial considerations and require a coordinated approach. These essential elements have not changed in decades, and they should already be built into everyday practice and individualized as needed (J Am Med Dir Assoc 2000;1:77–85). Another example of introducing too much complexity is the NASEM report’s heavy emphasis on health information technology and adapting computer-based records. In some ways, electronic medical records can be beneficial, but they require costly investments and extensive technical support and oversight. Furthermore, data entry is just the beginning. Knowing how to find, interpret, and use the information in a computerized or a paper-based record is a huge challenge, which the NASEM report barely acknowledges. More data sets are not the answer. Many nursing homes are already drowning in data and don’t know how to use it correctly. What was originally called the Minimum Data Set (MDS) has now expanded to become a Monstrous Data Set, with a 1,300-plus-page manual and more items added continually over the years. Completing the MDS automatically triggers Care Area Assessments that allegedly support care plans. Thus, the MDS can best be viewed as a topic-oriented data set that must then be extensively analyzed, sorted, and combined with other sources of information, including details of all symptoms and findings. In practice, there is often only a semblance of effective information management and interpretation, and there are too many protocols and guidelines. Inadequate attention is paid to the common thought processes underlying all of them, such as knowing whether we have enough information to draw conclusions (see chapter 4 in the MDS 3.0 Resident Assessment Instrument Manual, Centers for Medicare & Medicaid Services [CMS], 2013). Additional progress is unlikely to occur until there has been a widespread commitment to vastly improving clinical reasoning and problem solving. Additionally, we need to consolidate multiple tasks by doing smarter case reviews (J Am Med Dir Assoc 2021;22:2212–2215). Additionally, the NASEM report doesn’t cover the relatively simple and inexpensive use of the internet to search for vital information and improve care. Knowing how to do word searches on the internet is am underused tool (Provider 2020;47[6], https://bit.ly/447e9kn). We do not need to wait for expensive health information technology systems to be able to do that. The NASEM report has identified that many of the original OBRA ’87 nursing home regulations have not been fully enforced. What I wrote in 2012 again holds true:•“Some of the recommendations incorporated into the law and regulations have been less successful.” However, the NASEM report focuses on inadequate enforcement more than on these shortcomings.•“While the surveyor guidance has been improved and standardized, its actual interpretation and application to determine compliance remains inconsistent.” This situation persists despite the 800-plus pages of the State Operations Manual, over 200 pages of Critical Element Pathways, many other survey and certification memos, and a massive surveyor training program. The scope and detail of the case examples in the surveyor guidance are both limited and hard to generalize.•“While the regulatory capacity of states has been strengthened, federal oversight of state survey performance is often anything but logical, rational, or consistent.” The NASEM report’s analysis of improving survey performance seems to focus on statistical performance measurement; it barely assesses how well the surveyors understand and apply the guidance to specific situations. “For example, there are still widespread differences in applying one of the central themes of the OBRA ’87 regulations and guidance: related to medically unavoidable outcomes.” The NASEM report finds that more oversight, sanctions, and penalties are warranted, despite also acknowledging the shortcomings of decades of attempted oversight. In addition, simple explanatory documentation by facilities and medical practitioners is often inadequate to permit reasonable compliance determination. This reflects the continuing challenges of citing and receiving deficiencies without understanding the basis for fixing the underlying causes. According to the NASEM report, “the nursing home sector has suffered for many decades from both underinvestment in ensuring the quality of care and a lack of accountability for how resources are allocated.” It claims that “quality measurement and improvement efforts have largely ignored the voice of residents and their chosen families.” The NASEM report’s discussions about quality care in relation to person-centered care appear to focus principally on a psychosocial definition of “person-centered care” that emphasizes freedom, self-fulfillment, and choice. It says little about basic competent and organized clinical performance as a vital foundation for person-centered care. The NASEM report also claims that more “high-quality research is needed to advance the quality of care in nursing homes,” and that the current “lack of evidence presents challenges to determining the best approaches to improving quality of care in several areas.” However, a massive amount of relevant research does indeed exist. The bulk of the problem lies in interpreting and individualizing these research findings to specific situations (J Am Med Dir Assoc 2010;11:84–91). A prominent quality issue is the enormous impact of medication on outcomes. As noted in the CMS State Operations Manual surveyor guidance on unnecessary medications, “Medication management is based in the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring, and revising interventions, as warranted as well as documenting medication management steps” (p. 567). A good care process leads to judicious decisions about medications that maximize person-centered care and minimize resident harm. An inadequate care process leads to problematic decisions that result in avoidable adverse drug events. I have previously addressed the essential strategies to stem this perennial problem (Caring 2020;21[5]:18). The NASEM report lacks viable, specific strategies in this regard. The NASEM report emphasizes quality measurement as a principal tool in quality improvement (QI), which has been a common theme in QI for decades; the report proposes adding more measures. However, the NASEM report largely overlooks real-life implementation issues in the socially complex and politically challenging nursing home environment (see Medical Direction in Long-Term Care: A Guidebook for the Future, Carolina Academic Press, 1993; Medical Direction in the Nursing Home, North Ridge Press, 1991). In other words, effective management principles — not more research and data — are the principal route to improvement. NASEM brought together academics, researchers, consumers, and a few others to produce this report. The resulting report mostly rehashes conventional narratives and promotes doing more of the same familiar approaches with a few new twists. It may offer some new thoughts about areas such as financing, but it largely ignores the key question: Why are we still needing urgent reform after decades of enormous and costly efforts? Its general answer is that we should do more elaborate versions of the things that have already proven to be inadequate. As with all large and small QI efforts that turn out to be only partially successful, we must take a fresh look at the way in which we have analyzed and addressed these issues and their causes (J Am Med Dir Assoc 2010;11:161–170). Otherwise, we will be talking about “urgent reform” needs for many more decades — with the same limited success. Dr. Levenson has spent 42 years working as a PALTC physician and medical director in Maryland. He has helped lead the drive for improved medical direction and nursing home care nationwide as author of major references in the field. The author’s views do not represent those of the Society or any other entity.
Search from 250 M+ research papersSearch from 250 M+ research papers
Apr 1, 2024
Lauren R. Pollack + 11
Open Access