Changes in the Quality of Nursing Home Care in the U.S.: A Review and Data Update
This report summarizes the literature and presents syntheses of data from over the last half decade on changes in nursing home quality as measured by staffing, process and outcome quality, as well as the results of regulators' inspections. Since these changes in quality occurred within the context of substantial changes in the role of U.S. nursing homes, changes that resulted in large increases in the acuity and complexity of those being served, we also summarize changes in case-mix acuity and in the "segmentation" of the nursing home market as facilities increasingly specialized in caring for different groups of residents.
This report focused on the manner in which policies ranging from state Medicaid reimbursement to federal public reporting efforts have influenced nursing home quality since provider efforts to improve quality have not occurred in a vacuum. The report closes with recommendations made in the light of the changing role and composition of U.S. nursing homes and the need for measures of quality that more precisely reflect the different reasons people use nursing homes and in light of impending policy changes.
Improvements in process and outcome quality were observed in spite of substantial evidence of increasing case-mix acuity and specialization amongst U.S. nursing homes. The clinical complexity and functional impairment of both admitted and long stay residents has increased virtually across the board, and since 2002, there was almost a doubling of the proportion of free-standing facilities serving more than 20 percent of Medicare patients on any given day, a phenomenon that more than offset losses in the number of hospital-based facilities. Other more challenging forms of segmentation are also underway, with some facilities increasingly "specializing" in psychiatric patients and the concentration of Medicaid patients in selected facilities.
"The acuity of the nursing home resident population has increased dramatically and the length of stay of most residents is now less than 90 days."
Nursing home policies that affect quality have achieved their intended effect, although not as completely as many would desire. Public reporting of nursing homes' quality performance has clearly stimulated many providers to institute quality improvement efforts which appear to have resulted in greater improvements in both measured and some unmeasured quality scores, but there is also evidence suggesting that public reporting has begun to "steer" those seeking nursing home care to better performing facilities, at least in the post-acute care arena.
The report finds that we need better measures if we are to understand how we are making improvements and where there are gaps to fill. If we are to respond to the growing specialization of nursing home care in the United States, we must develop measures that are appropriate to the different populations of people using nursing homes for different purposes.
"It is clear that nursing home quality is multi-dimensional; what is also clear is that it is no more appropriate to compare all nursing homes with one another than it would be to compare an obstetrics hospital with an oncology hospital."
This report underscores the heterogeneity of U.S. nursing homes and the need to explicitly take the heterogeneity into account in describing their performance and staffing, in comparing the manner in which they serve their distinct populations and in comparing outcomes evidenced by their residents.
