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Panel Analyzes Current State of Nursing Home Care

By Emily P. Walker, CQ Staff

December 7, 2007 -- Patients' rights have improved drastically in the two decades after Reagan-era legislation overhauled a shoddy nursing home system, but staffing shortages, lags in technology, and a lack of transparency are preventing further progress, panelists concluded Friday at a briefing sponsored by the Alliance for Health Reform.

The briefing commemorated the 20-year anniversary of the Omnibus Budget Reconciliation Act (OBRA) of 1987, which included the first major revision of federal nursing home standards since the creation of Medicare and Medicaid in 1967.

Prior to OBRA, some nursing homes were so bad they resembled a turn-of-the-century asylum rather than a long term care facility, according to a Kaiser Family Foundation video shown at the briefing,

"There was widespread neglect, which often turned into abuse, and then death," said Elma Holder, founder of the National Citizen's Coalition for Nursing Home Reform (NCCNHR).

OBRA created "rigorous standards that were more focused on resident rights," including banning the use of physical restraints in most situations, requiring centers to patient care plans and requiring that nurses aids have at least 75 hours of training, according to Joshua Wiener, program director for Aging, Disability and Long Term Care at RTI International.

The law also linked Centers for Medicare and Medicaid Service (CMS) payments to quality care benchmarks, and defined sanctions for facilities that did not comply with the new, tougher, standards.

Despite OBRA acting as "a map to a new way of thinking about nursing home care that we hadn't even imagined," regulation of the law hasn't exactly lived up to the law itself, according to Mary Jane Koren, assistant vice president of The Commonwealth Fund.

According to Janet Wells, director of public policy for NCCNHR, states and licensing boards are often poor enforcers of nursing home standards like care quality and staff-to-patient ratios.

But perhaps the biggest major barrier to further improving nursing home care is the nationwide nursing shortage, said Jack MacDonald, senior vice president for Golden Horizons, which operates more than 80 nursing homes nationwide. In addition, nursing homes often have a difficult time attracting nurse's aides because the pay is generally a few dollars short of what hospitals pay, MacDonald said.

Aside from addressing staffing issues, nursing home care lags behind improvements seen in other medical industries because of the absence of telemedicine in the nursing home setting, panelists said.

"In this age of the internet, computers, data access, why is it that we cannot introduce that concept into a nursing home," MacDonald said. "And especially to a rural nursing home where they have the problem of gaining access to certain specialties."

Other panelists suggested making data—such as staff-to-patient ratios, staff turnover, and care quality metrics&#8212available to consumers and the government.
"I applaud Medicare for releasing the list of the 75 worst performing nursing homes," said John Rother, director of policy and strategy for AARP.

As in 1987, it may be up to Congress to make further changes, according to Wells, who said it's time to look at a new overhaul law to augment OBRA.

Meanwhile, a coalition-based two-year campaign called "Advancing Excellence in America's Nursing Homes" that asks nursing home to select and set goals for three out of eight quality care indicators may help establish better baseline standards for nursing homes to follow. Wells said 40 percent of all nursing homes are a part of the voluntary initiative, which began in 2006.

Susan Weiss, senior vice president for Advocacy at the American Association of Homes and Services for the Aging said negative public perceptions of nursing homes and the intense focus on measuring care quality have shrouded what should be the entire mission of nursing homes.

"The standard of nursing homes is quality of life. And another word for that is joy," Weiss said. "How we manage people clinically and compassionately as they get to the end of life, that is something we haven't really talked about."

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