Nursing Home Initiative - quality assessment efforts of the Health Care Financing Administration - Statistical Data Included

Health Care Financing Review, Fall, 2000 by Jan Shankroff, Patricia Miller, Marvin Feuerberg, Edward Mortimore

INTRODUCTION

HCFA is responsible for the survey and certification program, which ensures that institutions providing health care services to Medicare and Medicaid beneficiaries meet Federal health, safety, and quality standards. HCFA contracts with survey agencies in each State to perform initial inspections of providers who request participation in the Medicare program, annual recertification inspections of nursing homes, and periodic recertification inspections of other health care providers.

One of the major focuses of the survey and certification program is the quality of care provided to nursing home residents. Currently 1.6 million elderly and disabled people receive care in about 17,000 nursing homes across the United States.

ADDRESSING NURSING HOME QUALITY

In response to concerns about the quality of care provided by nursing homes, Congress passed major nursing home reforms in the Omnibus Budget Reconciliation Act (OBRA) of 1987. OBRA 1987 defined the role of the State survey and certification process in determining the compliance of nursing homes with Federal standards. This act also adopted new enforcement procedures, including intermediate remedies, sanctions, and decertification procedures for facilities failing to meet Federal standards.

The 1996 Appropriations Act required HCFA to study and report to Congress on the effectiveness of the current system of survey and certification in nursing homes nationally. HCFA's report was released in July 1998 and concluded that, while some improvement in resident outcomes had been shown, such as in restraint reduction, we needed to do more to improve resident care. On July 21, 1998, the President announced new steps to increase Federal oversight of nursing homes' performance, including enhanced monitoring of poorly performing homes, collection of new fines from non-compliant ones, and an increased focus on special care areas such as nutrition, pressure sores, and abuse.

HCFA responded to the President's announcement with the NHI, which was intended to improve the quality of care nursing home residents receive through new and enhanced Federal and State monitoring activities, as well as imposition of swift and certain sanctions when inadequate care is identified. Some of these new activities include:

* Focusing on preventing bedsores, mainutrition, and resident abuse through increasing the survey sample size of residents, ensuring that facilities have an abuse prevention system, placing a repository of best practice guidelines for at-risk residents on HCFA's website, and launching related educational campaigns.

* Staggering or otherwise varying the scheduling of surveys to reduce the predictability of surveyor visits and requiring that at least 10 percent of surveys be conducted on weekends, in early morning, and in the evening, when quality, safety, and staffing problems often occur.

* Taking faster action to sanction a facility when it has serious non-compliance problems, when it has a history of termination from our programs, or any other time when HCFA or the State believes immediate action is warranted without giving the facility an opportunity to correct its problems before imposing sanctions.

* Inspecting problem facilities twice as often so that persistent problems can be addressed quickly with no decrease in inspections of other facilities.

* Collecting fines of up to 810,000 from facilities when single deficient practices have been found or deficient events have occurred.

* Requiring that complaints alleging harm to residents be investigated within 10 days.

* Posting survey results on the Internet. Many of these new activities have already begun, but it will take more time to have all of them fully implemented.

LOOKING AHEAD

During summer 2000, HCFA released two Reports to Congress that provided additional information related to the NHI. The first Report, entitled "Appropriateness of Minimum Staffing Ratios in Nursing Homes," provides findings on the first phase of a study examining nurse and certified nurse assistant staffing. The preliminary findings are that there may be a minimum ratio of nurse or certified nurse assistant hours per resident below which nursing home residents are at risk for quality of care problems. The preliminary minimum ratio for certified nurse assistants is approximately 2.0 hours per day per resident. For total licensed staff, licensed practical nurses and registered nurses combined, the ratio is 1.0 hour per resident per day. In addition, this report discusses a time-motion study approach to set the nurse staffing level. This approach measures the amount of time it takes to perform certain patient care tasks, such as feeding assistance, repositioning, and toileting. This approach determined that the minimal nurse aide time required to provide optimal daily care services to residents is 2.9 hours per resident per day. Phase 2 of this study, which began summer 2000, will refine the estimates developed in Phase 1 and will also determine the financial implications of establishing minimum nurse staffing levels.