Contents

Title Page and Notice		i
National Academies Statement		iv
Committee		v
Acknowledgments		ix
Reviewers		xi
EXECUTIVE SUMMARY		1
1	INTRODUCTION	21
	Long-Term Care Needs	22
	The IOM Study	25
	Basic Concepts and Definitions	27
	Scope and Limitations	34
2	PROFILE OF LONG-TERM CARE	36
	Characteristics of Long-Term Care Users	38
	Providers of Long-Term Care	41
	Financing Long-Term Care	62
	Coordination of Long-Term Care Services	69
	Conclusion	72
3	STATE OF QUALITY OF LONG-TERM CARE	73
	Measurement of Quality of Care	74
	Current State of Quality of Care	76
	Conclusion	108
4	INFORMATION SYSTEMS FOR MONITORING QUALITY	110
	On-Line Survey and Certification Assessment Reporting System	112
	The Resident Assessment Instrument and the Minimum Data Set for Nursing Homes	115
	Outcome and Assessment Information Set for Home Health Care	120
	Challenges in Using Assessment Data	122
	Assessment and Quality Monitoring Instruments for Other Settings	124
	Incorporating Consumer Perspectives in Measurement of Quality	127
	Measurement Considerations for Children and Young Adults	132
	Conclusion	134
5	IMPROVING QUALITY THROUGH EXTERNAL OVERSIGHT	135
	Central Role of Government	136
	Basic Standards of Quality	140
	Residential Care Facilities	163
	Home Health Agencies	169
	Home Care and Related Services	173
	The Role of Advocacy	174
	Accreditation	178
	Conclusion	179
6	STRENGTHENING THE CAREGIVING WORK FORCE	180
	Nursing Homes	182
	Education and Training of Staff in Nursing Homes	196
	Residential Care Settings	202
	Home Health Agency Staff	205
	Home Care	209
	Education and Training Recommendations	210
	Labor Force Issues	211
	Conclusion	218
7	BUILDING ORGANIZATIONAL CAPACITY	220
	Recent Initiatives to Improve Caregiving Capacity in Long-Term Care	220
	From Rules, Data, and Guidelines to Effective Practice	221
	Quality Management Systems	222
	Organizational Capacity to Translate Knowledge into Practice	223
	Identifying Effective Interventions	227
	Care Process Implementation and Improvement	228
	Measurement Issues	231
	Improving Organizational Capacity	233
	Conclusion	234
8	REIMBURSING TO IMPROVE QUALITY OF CARE	235
	Reimbursement and Quality	236
	Limited Nursing Home Bed Supply and Quality of Care	244
	Conclusion	246
9	CLOSING REMARKS	248
REFERENCES		253
APPENDIXES
A	Committee Meetings and Presenters of Testimony	283
B	Separate Dissenting Opinions	287
ACRONYMS		295
BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS		299
INDEX		307

Tables and Figures

TABLES

2.1	Demographic Characteristics of Long-Term Care Users Aged 18–64 and Aged 65 and Older Living in the Community and in Nursing Homes: United States, 1994 and 1996	39
2.2	Number of Long-Term Care Facilities and Beds: United States, 1992 and 1998	43
2.3	Number and Percent Distribution of Nursing Homes, Beds, and Residents, by Facility Characteristics: United States, 1997	44
2.4	Number and Percent Distribution of Certified Home Health Agencies and People Served, by Agency Characteristics: United States, 1996	52
2.5	Total Medicaid Personal Care Services and 1915(c) Home and Community-Based Services Waivers: United States, 1997–1998	56
2.6	Number and Percent of Selected Categories of Occupations Employed in Selected Long-Term Care Settings and in Hospitals: United States, 1998	61
2.7	Expenditures and Source of Funds for Nursing Home and Home Health Care: United States, 1997	64
2.8	Medicaid Payments, by Type of Service and Category of Beneficiary: United States, 1997	66
5.1	Average Number of Deficiencies per Certified Facility and Percent of Facilities with No Deficiencies, by State: United States, 1992–1998	146
5.2	Level of Deficiencies, Based on Scope and Severity of Substandard Care, and the Remedy Categories Available to States for Each Level of Deficiency	155
6.1	Nursing Staff Levels per Resident Day, by Facility Type and Region for Nursing Homes: United States, 1998	185
6.2	Distribution of Combined Nursing Hours per Resident Day in All Certified Nursing Facilities: United States, 1998	186
6.3	Comparison of Average Nursing Hours per Resident Day for OSCAR Data, HCFA Time Studies, and Time Proposed by Experts	187

FIGURES

2.1	Distribution of assisted living facilities by bed size: United States, 1998	48
2.2	Percent distribution of ownership of home health and hospice agencies: United States, 1996	53
2.3	Percent of patients receiving home health care services by type of service: United States, 1996	53
2.4	Percent of patients receiving home health care services by service provider: United States, 1996	54
3.1	Top 10 deficiencies of nursing facilities and percent of facilities with the deficiency cited: United States, 1998	78
4.1	Proposed classification scheme for measuring a person's perspective about his/her quality of medical care	129
5.1	Average number of deficiencies and percent of facilities without deficiencies: United States, 1991–1998	145
5.2	Surveyor evaluations of the scope and severity of deficiencies, as a percentage of total deficiencies, cited in all nursing facilities: United States, 1996, 1997, and 1998	157
6.1	Mean staffing hours per resident day for nursing facilities in the United States surveyed in calendar year 1998	184
6.2	Average nursing hours per resident day in all certified nursing facilities: United States, 1991–1998	188