Nursing Homes and Quality of Care: concepts and Measures

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(1)NURSING HOMES AND QUALITY OF CARE:-· CONCEPTS AND MEASURES - The Example of U. s•. (~t6*.l± • • KiIU*1f). •••. -. " ••. ... *1I;gAACJ.Ltf§lJd:i~.ACJ({(JllS,;gA • • • • 1!L• • Jnmit:bllff~. •• •• •• •• •••. .1I~;gA • • • • *~.@.~m.n ~-*~.,.~@.~~X~.~_. ~. *3t=lE~·iMazffi!i • • • • ~.~.3~:n~ A:ttiMatjt-arf1~. 0. ~~~. ~~. ~~~#,@. ~. o. , Mm-f~Ug~1t~.~azffi!i .:fimmazffi!i• • • • • ~}jUtt.~.lJi 0. Introduction. I. The cost of health care has continued to rise over recent. decades. Health care spending tripled between 1971 and 1981,. substantially outpacing the growth of the national economy. The. structures of health organization have also changed during this. period with more cOllpetition , more regulation , and new technolo gies. Among these, the most significant factor influencing health care is demand for organizational cost-containment, cost-benefit and accountability (Levey a Loomba,1984). Nursin9 home expenditures have also been a target of cost. containment because of their growing share of overall health. expenditures. Of the total national personal health care expen. ditures spent in 1982, nursing home care accounted for 27 billion. dollars or 9!~1 of the GNP (Gibson,Valdo, a Levitt, 1983). It. increased at a rate of 17.41 between 1980 and 1981, and 12.91. between 1981 and 1982 (Swan a Harrington, 1985). Because of. increasing costs in nursing homes, they are also subjected to close scrutiny of their performance. This paper will include several parts. First, I will introduce. the growing needs of nursing homes. Then, I will compare the. differences between nursing homes and general hospitals to see how. these differences influence the way of evaluating the quality of care in nursing homes. Second,I will focus on the concept of quality of care from a general hospital's context. In fact, many concepts and measures are similar and originated from measuring. - 45. :. I. !. I I. I. I:: \. '. I. 1. j. ,. ).

(2) the quality of care in-hospitals. Last, I will try to apply approaches which were developed to evaluate the quality of care i hospitals to nursing homes and see what factors influence quality of. nursing home care.. II. The growth of nursing home industry: The increase of the expenditures in nursing homes was caused by two principally interrelated trends: the growth of elderly population and the growth need of nursing homes. The population in the United States aged 65 and over-has been increasing steadily during the 20th century both in absolute numbers and as a percentage of the total '.population. In 1900, about 41 of the population was aged 65 and over. By 1980, this proportion had increased to 111. During this same period the percentage of people aged 85 and over had risen from 0.21 to 1.lS. (Boling et al., 1983) The growth rate in the very oldest categries increased faster than that of the younger bracket of the elder population. This rapid change in the size of the older elderly population has significant meaning because as of 1960, 101 of the popualtion eighty-five and over was residing in nursing homes-- a rate of use nearly four times that of the younger bracket of the elderly population (Dunlop, 1979). With the anticipated surge in the number of elderly people, the demand for nursing home care is increasing now. Nursing homes have experienced significant growth since the Second World War. Huch of this growth was during the 1960s when long term· care facilities increased by 1401, beds by 2321, residents by 2101, employees by 4051, and expenditures for care by 4651. Furthermore , if we measured the growth from the 1960s to mid 1970s, the number is even greater, e.g. expenditures during that period increased almost 1,4001 (Boling, et al., 1983). If conservative population projec tions based on the recent age and sex distribution rates of- nursing home residents are used, in 2050, there will be 5,403,000 who are .. 65 and over living in nursing homes. Among these are 1.5 million males and 3.8 million females. In the same year, there will be projected 3.6 million elderly people who are 85 and over living in nusing homes (Brody, Foley, 1985). The development of nursing homes can be explained partly by the growth of the elderly popualtion and partly by the changing needs. -46 . long long the term Fami of form qual cont popu. III. in nurs nurs in We 1. soc' (Shl timl mea lop liv yea in nur and res.

(3) F. care. as caused F el derly. 'has been absolute In 1900, 180, this !riod the to loU. :ategries :he elder , elderly S of the omes-- a t of the. ple, the lies have Much of ~i lities nployees , if we is even almost projec nursing who are million wi 11 be ving in. , by the Ig needs. the public for this type of organization. Care of the elderly in nursing homes has cOile to replace a substantial portion of care that was delivered formerly in mental 'hospitals. Pollack had estimated that the diversion to nursing ho.es of elderly persons who formerly would have gone into mental' hospitals could account fo~ up to-32S of the growth in nursing home ,utilization between 1960 and 1970 {Pollak, 1976).The'specialization ~ of hospitals for acute care is another force. Hospitals were no longer the place to care for the impaired and indige~t elderly on a long-term basis. This created increasing pressure to provide for the chronically ill or functionlly impaired in specialized long term care settings, principally nursing homes (Dunlop, 1979). F8Blily structure and functions were changed also. Some proportion of nursing home growth reflects substitution for informal care formerly rendered in the home. Therefore, calls for evaluating the quality of- care in nursing homes are based on the need both to contain costs and to provide humanitarian care for this elderly population.. \ii! !. ". III. Characteristics of nursing homeA. Differences compared to general hospitals: Before applying the framework developed to measure differences in general hospitals to the evaluation of quality of care in nursing homes, some differences need to be identified. Care in nursing homes (also known as institutionalized long-term care) is in many ways different from care provided by general hospitals. We review the most significant ones below. First, the main purpose of nursing homes is maintenance and social support while hospitals are primarily treatment oriented (Shortell and Kaluzny, 1983). Therefore, patients spend a longer time in nursing homes than in general hospitals. For example, the .ean length of stay in general hospitals is 7.8 days in 1974 (Dun lop, 1979). In contrast, about 1/3 of residents in nursing homes live for 1 to 3 years and another 1/3 have been there for 3 years or more (Brody, 1985). Owing to the different functions in the organizations, the concept of • homes· is important- in nursing homes. The medical oriented atmosphere is less appropriate and the fundamental concern should be the quality of life and restorati on of functi on. Qua 1i 't-y of care in nursi ng homes shou 1d - 47. J"~. ,. J :J. :'f. 1 ,~. .1 !. ,l i. 'j. ..!j.

(4) ·easure the social climate and be long-term outcome oriented. Second, ownership of nursing homes is largely for profit. 1974, 83.5~ of nursing homes in Alabama were proprietary, 79.61 in Florida, 70.31 in Hississippi, and 541 in New York (Dunlop,1979).In 1981, among 7,972 skilled nursing homes, 5,401(67.71) were for profit. Among 11,242 intermediate care facilities, 8,079(71.91) wer.e for profit organizations (Shortell & Kaluzny, 1983 ). An e.phasison efficiency, especially on cost-saving practices, would be especially true for proprietary nursin9 homes (Kosberg & Tobin, 1972). Third, the source of payment is different. 571 of nursing homes costs are paid by public funds. The remaining )31 is paid almost entirely by direct personal out-of-pocket payments by the residents and their families. Hospitals have about the same proportion of costs paid by public and private expenditures as do nursing homes. However, private insurance plans covered about 751 of the private expenditures on hospital costs, but less than 21 of the private expenditures on nursing home costs ( Brody & Foley, 1985). The distribution of the residents having different sources of payment is very skewed. Thus access to_ nursing homes is an important problem especially for the middle class or poor. Host nursing homes in suburban areas served primarily white, private-pay, self referred residents ( Gottesman, 1974). These nursing homes have better performance than those which received a high proportion of public-pay residents. For example, Gottesman(lg74) in his nursing ho.e study found that high public-pay proprietary facilities had a high proportion of socially marginal resident~ with fewer financial resources. Fourth, nursing homes are less technologically sophisticated due to maintenance and social support function (Shortel and Kaluzny , 1983). To measure quality of care in nursing homes, therefore, we need to focus on social function and atmosphere which provide quality of ~ife for residents rather than measure only the com plicated technology provided. Fifth, many patients in nursing homes have some degree of mental health problems, for example, progressive senile deterior ation and severe depression. Nursing home staffs must learn how to. ( gener nke'mJ. on t~ for the Nurses. .t. nursin~. i.port.: ThE care ! next ! hospita qual it; applici. explor~. B. On. ho.es : who ar, do.ina Un.arr (Dunlo patien urinar forget hear in isolat i.pove SymptCl diffi (.

(5) ·91) • An Duld oi n,. [)mes nost !nts 'l of nes. ,ate ,ate The ~ent. :ant tmes. !If-. lave I of. in9 d a. ial ted zny we ide [)m. of. )r. with these behavioral problems (Kramer and Kramer"1976). Also ,because of these special symptoms, sometimes it is not appropriate to measure the positive health as an outcome only. What procedures (of processes) have been done are more important here. Sixth, physicians are relatively absent from the nursin9 home. Access to physicians in nursin9 homes can be a problem. Only 171 of physicians who would normally be expected to serve the elderly (general practitioners, family physicians, internists) actually lake nursing home visits. Furthurmore,primary care phys~cians spend , on the average, less than one and half hours per month caring for their patients in nursing homes (Hezey, Lynaugh & Aiken ,1985). Nurses take the major responsibilities of carin9 residents in the nursing home. Therefore, nursing staffs' qualifications are important. These differences make the application of evaluating quality of care somewhat different from those in the general hospital. In the next section, I will explicate the concept of quality of care in hospitals which has occupied the most attention when evaluating the quality of care in health care organizations. Then, in the applicatfon, section, some adaptations for nursing homes will be explored. 8. Characteristics of nursing home patients: Only 51 of persons aged sixty-five or older live in nursing homes at any given time , but the percent increases to 20 of those who are over eighty-five years old (Kane and Kane, 1982). Women. dominate the nursing home population at all levels of ages. Unmarried elderly .\ke up 891 of the nursing home population (Dunlop, 1979). Besides the demographic characteristices, elderly patients in nursing homes have problems in common like immobility, urinary or fecal incontinence, intellectual impairment (from mild forgetfulness to complete disorientation), deficit in vision and bearing, infections, side-effects or interaction-effects of drugs, isolation/depression because of losses of social roles, and impoverishment (Kane and Kane, 1982). Owing to these special symptoms or problems encountered in nursing home patients, it is difficult (sometimes impossible) to do certain kinds of evaluation. to. - 49. i i ;. :"I~. ~.. II: 'I~~, l~r. ' ,. " " ,Jp. •.

(6) of quality of care in nursing.homes such as those which dem•• information from the patient. This will be explored more in a section.. IY. Quality' of care A. Defintion of quality of care: Understanding the meaning of quality of care can help conceptualize and to measure the quality of care in hospital. nursing homes. Donabedian(1980) defines quality of care fro. different senses. By the absolutist definition, he means that health professional should define health status} what their i vention can contribute to health and how that contribution is measured. It focuses on the nature of the health problem that i be managed. By an individualized definition of quality, he that we should take tnto account the patient's wishes, tions, valuations, and means. By a social definition of quality· means we should consider the welfare of a certain population or value for the entire society. However, when he develops the conceptual framework . structure-process-outcome, he only chooses the perspective fro. absolutist definition and measured the physician's nAl·~ftP.llftN principally. We will discuss.more about his conceptual later in this section. The other definition accepted by many people is the defini from the Institute of "edicine: The primary goal---~should ba make-health care. more effective in bettering the health status satisfaction of a population, within the resources which Rftr, . . and individuals have chosen to spend for that care (Greene, Basically, this latter definition also focuses on the change health status produced by professionals and the satisfaction of a population. It is similar to Donabedi absolutist d,finition and social definition of quality of care..

(7) ta he. the. of he. ce. rt. )n. ;0. Id. Y. f'. t. B. Dimensions of quality of care in health organizations: There are five major aspects of quality in health care which the definitions of quality:. (a)efficiency. (b)effectiveness, (c)accessibility~ (d)accepta .ility, and (e)provider competence (Greene,1g76). (a)Efficiency: Efficiency refers to the ratio of inputs to outputs and the number of products and/or services provided by ~inimized resources. (Scott I Shortell, 1983; Flood' Scott, 1987) The differences between effectiveness and efficiency lie in that , ~he first is goal-oriented, and the second cost-oriented (Levey, 100mba , 1984). Applying the concept of efficiency to the hospital sector 'requires one to focus on the organizational resources under the control of the hospital. But, when one focuses on this, some limitations must be recognized. For example, one limitation is that a.hospital has multiple outputs. It is not a 'place-which produces a standardized product or service. Hospitals provide a wide range of services such as dietary services and laboratory tests. Host of these services support the clinical services. Another is that hospitals do not control proscriptive medical service. The control over which and how many services and when to deliver them lies in the hand of physicians. This mean that physicians control the usage of resources allocation (Johnson, 1981). Wyszewianski and his colleagues (1982) note that efficiency in , producing care in a hospital is determined by clinical efficiency and production efficiency. Clinical efficiency requires the pro vider to select services in a manner that produces the greatest increment in health status for a 9iven amount of resources. Produc tion efficiency refers to how the services that make up any given clinical strategy are produced. Simply speaking,clinical efficiency requires using a certain amount of resources to achieve the maximum objectives and is thus related to effectiveness. Production efficiency, on the other side, tries to lower costs. (b)Effectiveness: Effectiveness means the degree to which goals are met. It always includes goals or objectives of a progra. or a practice. Levels of goals need to be identified first before. - 51.

(8) evaluating the effectiveness of perfor.ance, where levels are on i ••ediate goals, inter.ediate goals and ulti.ate goals. exa.ple, recruiting a coordinator for the hospital's quality ance program is an i ••ediate goal; i.proving the practice pat is an inter.ediate goal, and reduction of .ortality for a rA,~al'_ disease is the ulti.ate goal (Scott and Shortell,1983). (c) Accessibility as a di.ension of quality of care depends on the fact that ease of access is closely related to receiving .axi.u. possible benefit fro. health intervention. Organizationall, caused delays in receiving care or the provider's failure to persist with appropriate followups can produce poor health outco.es. Therefore, accessibility to good .edieal care is regard.d as an .ssontial ingredient of ·good· quality of care. (d) Acceptability is the sa.e as patient satisfaction or a.enities of care (Donabedian,1980). (e) Provider co.petence is used to describe the assess.ent of the professional activities of an individual provider. To provide good care or better quality of care, the provider needs to have .nough skills and knowledg•• The skills have two compon.nts: one is technical skill; the other is interpersonal skill (Greene, 1976; Wyszewianski and Donabedian, 1982). T.chnical skill refers to -the application of the sci.nce and technology of ••dicin., and of the . other health scienc.s, to the .anagell.nt of a personal h.alth probl ••• • (Donabedian, 1980) 8arro further states that technical skill includes psycho.otor skill ( perforlling exallinations, procedures. and operations) and cognitive skills (data-gathering, date interpretation, and decision-.aking). Interpersonal skills are those the provider e.ploys in verbal and non-verbal communication with his patients ( Donabedian, 1980). in other words, it is the .anner that a provider delivers the service. As Barro points out, .ost studies of physician p.rfor.ance focus on technical perfor .ance and, within t.chnical perfor.ance, on cognitive skills (1975). C. Approaches to evaluate quality of care in hospitals: Three types of indicators are taken here following Donabedian (1980) and Flood and Scott (1987). The 1I0del was proposed by Donabedian but D33,U'-. ui1IniZI. cA. . .. tndicate . qualifi4. be att (Starfi pSychol outCO.4 -ad.in' eff.ct patien person Wh separl kinds. v. ] v;. nursi frequ varia plan1 in 1 educ~. , 191. tota. - 52.

(9) • receivi zationally failure to 'or health. action or. Ine, 1976: s to 'the nd of the' III health technical Inations, ltherin9, :ills are nication t is the nts out, perfor skills. :: Three 180) and ian but. been modified and adaptedby almost every other writer in this .ld. uses structure, process, and outcome measures to quality • Structure indicators refer to the· relatively e characteristics of the providers of care, of the tools and they have at their disposal and the physical and zagional setting in which they work· (Donabedian,1980).These indicators may include: descriptions of facilities and equipment, qualification and experience of' personnel ,staffing patterns. Process indicators refer to the set of activities that go on between the providers and patients,· including the management of both ~e technical and the interpersonal processes involved. Examples are procedures made and diagnosis work-up etc (Donabedian, 1980). Outcomes are the changes in a patient's health status that can attributed to the intervention of health care providers (Starfield, 1973; Shapiro, 1967). They are changes of physiological, psychological and social functions. Bonner fUrther classified outcomes of patients care as ·patient outcomes', ·process outcomes', 'administrative outcomes·, and 'ec'onomic outcomes· ( i.e. cost effectiveness data) (Greene,1976). This classification implied that patient' outcomes are not contributed by physicians only. Other personnel also contribute to care. When measuring the quality of care, we can use different methods · separately. We can also build causal relationships among these three kinds of indicators and have a relatively holistic framework. i. I. Imp1ications for nursing home qua1ity of care: Variables in each approach: When monitoring the quality of · nursing home care, structural and process criteria are_most. frequently used (Kane a Kane, 1982). Structural criteria concern. variables like the condition and safety features of the physical. · plant, the record-keeping system, and qualification of the personnel·. in the nursing home (Kane a Kane,1982), licensin9 of the" homes,. educational and training programs of the nursing home personnel (Lee. , 1984), and community involvement (Barney ,1974 ). Nursing hours,. total staff to patient ratio, and the professionalstaff to patient. - 53. :1d. i. :1. i'. j. ,.J.

(10) ratio are other important structural variables exhibiting. quality of nursing home care (Linn, Gurel, and Linn, 1977).. and Honahan (1981) use direct patient care resources. quality of nursin9 home care. Specifically, they use nursing. nursing expenditures, patient dietary expenditures etc. as .1~llaUII·". of the quality of structure.. When we use the term, nursing homes, we connote that provide a home-like atmosphere for those patients who need 1 term care. Hoos developed an instrument that measures the climate of the residential environments for olde~ persons (Eustis and Patten, 1984). He used the psychosocial meaning setting as measures ofquality. Process measurement in nursing homes is particularly important and usually done because of their use in regulatory enforcement (Lee, 1984). In particular, in order to stay in the nursing home industry, nursing homes must be licensed by the state health department. If they expect to receive federal fund through Hedicare and Hedicaid, federal certification is also required (Dunlop,1979). Host licensing processes focus on structural and procedural inspection in order to see whether the nursing homes meet the minimum standards. (Lee, 1984). The process meansures usually test the orthodoxy of care such as the frequency of physician visits and the adequacy of nursing procedures, care plans and discbarge plans. Sometimes, they borrow the process criteria from the hospital sector using the experts' judgments as a standard in order to compare the procedures done by the personnel. Outcome measures are frequently used as an approach to assessing quality too. Patients' outcomes in nursing homes are multidimensional and differ from those measured for patients in the hospital sector to some extent. ~ane and ~ane (1982) argue that nursing home patients need long-term care because of functional inpairment. Heasuring the outcome would center on the functional status of~patients. Physical functioning 1s typically measured through the patient's ability to perform basic self-care activities of daily living (ADL) such as bathing, feeding, toileting and dressing. The mental. can. '" bolle. argl. tnt4. aSS4. VI.. qua sue of. -n. ou1. Vh;. be1 to af". re~. be. - 54.

(11) Dcial. 1977. f. the'. ~tant. !ment 'sing !alth care, 79) •. ural the test and. Ins.. Ital to. :ing are the hat nal rial ~ 's. tL). ;al. '. in includes cognitive functioning and affective functioning. former is usually measured through the variables that assess ent's orientation for time, place, persons; recent and remote and judgment and reasoning ability. The latter includes iables which determine the extent of anxiety and depression, etc. al functioning measures patients' relations to other~ and social sfaction. However, Linn et al (1977) argue that measuring the ~~'ft~+ional status alone may be misleading. 'They explain that one of ,the primary functi ons of nursi n9 homes is to provi de humane care for 41i ng or severely ill pati ents. They used three types of outcomes "refl ecti ng pati ents' hea 1th status: (a) mortality: li vi ng or dead; ~b) changes in functional status: improved, the same, deteriorated and (c) location: discharged, still in nursing home, to the hospital or dead. The occurrence of decubitus lcers and bedsores are good indicators of poor quality of nursing eire of-patients with.chronic diseases (Thomsons, 1977). These also can be used as outcome measures of nursing home care since nursing boles patients are chronically ill and functionally impaired. In addition to these outcome measures, Kane and Kane (1982) also Irgue that since institutional long-term care is an intrusive ;tntervention for patients, the outcome should be measured by assessing satisfaction of the patients.. ~. VI. Conceptual issues and methodological issues: A. Conceptual issues: A conceptual framework to measure the quality of care i~,nursing homes must be able to address questions 'such as: What variables should be included in measuring the quality Should outcome be measured by the -health model- or the -illness model- 1 Should we focus on short-term outcome or long term outcome 1 Should we include social factors in processing the care 1 What are the appropri ate procedures 1 What quanti ty of care provi des better care? Is more always better?What are the standards of process to which we can compar.e 1 How does the individual levels of measures ,'Iffect the organizational level of measures 1 (Flood & Scott, 1987). The answers to these questions- are still not clear or easily nursing home care. We enumerate some of the problems. - 55.

(12) (a) Structurual variables and process variables sometimes be distinguished from each other very well. For example, nurse hours can be treated as structural measures because they an indicator of staffing patterns. They also can be t"'AtI.i'A.!I'~ process measures because RN hours dictate the nursing procedures sOlre extent. (b) Process variables are often used as a tool for regul systems to safeguard against the risk to health and against the r of litigation. However, such a regulating system permitting patients to- engage in those risk-laden associated with patient autonomy, for example, b~thing independently tor leaving the facility unsupervised (Kane & Kane, 1982). Therefor. when measuring quality by procedures used only, we may encourage i good- process on the one hand and poor quality of life on the other. (c) Outcome variables are important especially for long-tert care. They should include positive health and mental health too. However, these dimensions are intercorrelated with each other, for example, when a patient is severely depressed, then he is likely to experience poor health due to poor eating and sleeping ( Hangen,. • COl. t. 1984) •. B. Methodological issues: Several problems are shared by all approaches when measuring the quality of care. These problems are inadequate data quality, incomplete information, difficulties in generalization of the findings, problems in the comparability of the units of measurement, difficulties in setting standards for comparison, reactivity to the evaluation process and difficulty in creating indices of performance (Flood & Scott, 1987). Specific examples in nursing home quality of care are: (a) Process criteria tend to focus on auditing the medical record. Yet, one of the characteristics of low technology industry is inadequate record keeping. Basing an evaluation of the quality of the care on inadequate infor~ation may lead to e~roneous results. (b) Assessjng the satisfaction of patients is an important' outcome measure. However, many patients in nursing homes have problems of disorientation and thus information on self-report from such patients has low validity. An alternative is to evaluate. - 56. -- sl. -data or dtfferen' -- i. -- s . several to colle. -- s. related. --. ~. --. ~. structu' measure.

(13) sfaction through asking family members. However, taking care patients is a burden for many families and they may be prone to satisfaction with the care because nursing home at least ease them from some problems. Therefore, using indirect data·from lies on satisfaction also has problems.. • Conclusion:. 'age .. Ither.. 1gen, all. ,lellS s in the for , in Ific. cal try ity ts.. Int·. lve. Evaluating the care of nursing homes -- should use longitudinal research whicn is based on the of health status of residents, comparing their condition and after the admission of nursing home. -- should use physician expectation or prognosis as an indicator inst which to compare the outcome (Kane, 1982; Linn, Gurel & Linn 1974). -- should use on-site observation rather than use self-report or medical record only in order to. triangulate or validify fferent sources of data. -- in using the self report method for data collection, we ld take the respondent's ability to respond and ease in .ft.wa~ing into account. -- should be based on a reliable scale, summing responses from , ~aua~~l related items (kane, 1982). That would decrease time needed collect data. the -- should consider the causal relationships among fferent tYRes of quality measures, for example, how the process lated to any change in the outcome. -- should include social climate measures and also measure the lity of life of the residents. -- should consider the residents' value priorities in terms of , process and outcome. In other words, we should develop about individualistic meaning of quality of care. -- should be very careful in making generalizations. ~. '011 ~te. - 57.

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