Nursing Facility Quality, Staffing, and Economic Issues

Charlene A. Harrington, Ph.D.

Nursing facilities are an important component of a health industry that is increasingly complex. This paper examines the interrelationships of quality, staffing, costs, and ownership. The paper is divided into two sections. First, quality of care in nursing facilities (or nursing homes) is discussed including a review of how to measure quality. The quality of care continues to vary widely with some facilities known to provide exceptional care. On the other hand, two decades of studies have identified poor quality of care provided by some nursing facilities. Federal and state regulatory efforts have been initiated to improve quality but quality continues to be problematic.

Quality problems are closely associated with historic low registered nurse (RN) staffing levels in nursing facilities. Research on the relationship between staffing levels and quality is reviewed. A discussion of data on current staffing levels and appropriate staffing levels is presented along with discussion of current regulatory efforts to ensure adequate staffing.

Quality of care and staffing are intricately related to nursing home economics, discussed in Part II of this paper. The growing demand for nursing home care and the constrained supply of services form the context for examining these issues. Public reimbursement policies and industry resource allocation decisions have direct effects on both staffing levels and quality of care. Political and

Dr. Harrington is chair of the Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco.



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--> Nursing Facility Quality, Staffing, and Economic Issues Charlene A. Harrington, Ph.D. Nursing facilities are an important component of a health industry that is increasingly complex. This paper examines the interrelationships of quality, staffing, costs, and ownership. The paper is divided into two sections. First, quality of care in nursing facilities (or nursing homes) is discussed including a review of how to measure quality. The quality of care continues to vary widely with some facilities known to provide exceptional care. On the other hand, two decades of studies have identified poor quality of care provided by some nursing facilities. Federal and state regulatory efforts have been initiated to improve quality but quality continues to be problematic. Quality problems are closely associated with historic low registered nurse (RN) staffing levels in nursing facilities. Research on the relationship between staffing levels and quality is reviewed. A discussion of data on current staffing levels and appropriate staffing levels is presented along with discussion of current regulatory efforts to ensure adequate staffing. Quality of care and staffing are intricately related to nursing home economics, discussed in Part II of this paper. The growing demand for nursing home care and the constrained supply of services form the context for examining these issues. Public reimbursement policies and industry resource allocation decisions have direct effects on both staffing levels and quality of care. Political and Dr. Harrington is chair of the Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco.

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--> economic factors influence the feasibility of new policies to improve the care for nursing home residents. Part I: Quality Of Nursing Home Care Quality of care is the basic product of nursing facility care and the focus of providers, consumers, regulators, and public policymakers. Defining quality has been a difficult process. Traditionally, three types of indicators have been classified by Donabedian (1980) to define and measure the quality of care: structure, process, and outcomes. Structural measures include human, organizational, and material resources (e.g., size, ownership). Because such structural measures are the most objective, reliable, easily measured, and readily available, structural measures have historically formed the basis for quality indicators. Staffing is a structural measure that affects the processes and outcomes of care, but is considered in part to be determined by facility ownership and payment sources. Studies of nursing facilities generally consider the special characteristics of nursing home residents (physical, mental, and social) that could increase the difficulty of providing high quality of care. Although structural measures assess the availability of resources as a necessary precondition for their use, process measures examine actual services or activities provided to residents. The process of care focuses on providing special care and treatments to prevent problems with outcomes such as cognition, communication and hearing, vision, physical functioning, continence, psychosocial functioning, mood and behavior, oral, nutritional, and dental care, skin condition, and medications (Morris et al., 1990). A number of studies of nursing home quality have examined process measures with nursing home quality (Zimmer, 1983, 1989; Zimmer et al., 1986). The most important approach to quality focuses on individual or group outcomes, but structure and process information are also needed (Kane, 1988; Kane and Kane, 1988). Measuring Quality of Care Over the past two decades, many efforts have been undertaken to refine the measures of nursing home quality. Simple unidimensional quantitative measures of quality have frequently been used in research, such as staff hours per patient day (Fottler et al., 1981; Greene and Monahan, 1981; Elwell, 1984), changes in physical functioning (Linn et al., 1977), mortality rates or hospital readmission rates (Lewis et al., 1985; GAO, 1988a,b; Spector and Takada, 1991), the number of deficiencies (Nyman, 1989b), and subjective measures (Hay, 1977). Moos and Lemke (1984a,b) developed one of the early methods for conducting assessments of residential facilities on multidimensions: the Multiphasic Environmental Assessment Procedure (MEAP). The MEAP measures resources in terms of four conceptual domains: resident and staff characteristics, physical

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--> features, policies and services, and the social climate (Moos and Lemke, 1984a,b). The MEAP instruments are expensive to administer and are more appropriate for residential living arrangements than for skilled nursing facilities. Shaughnessy and his colleagues developed measures of nursing home processes of care. Using expert panels, 27 patient problems were categorized into 4 groups: nursing, medical, communicative, and psychosocial problems. Processes were measured through a comparison of the frequency and the provider type for each service rendered with preset standards for such services for each patient problem (Shaughnessy and Kramer, 1989; Shaughnessy et al., 1990). Kane and colleagues (1983a,b) developed a multidimensional approach to measuring quality of care utilizing data from chart reviews, observations, and interviewer ratings. This approach was utilized in a longitudinal study of nursing home residents (Kane et al., 1983a,b). Gustafson and colleagues (1980, 1990) also constructed an instrument for measuring nursing home quality entitled the Quality Assessment Index (QAI). The QAI is a multidimensional instrument that used expert panels of judges to develop components of quality each with three to seven subcomponents. This instrument was used to measure quality in a 2-day nursing home visit. Zimmerman and colleagues (1985) used the QAI instrument to evaluate the state survey processes in three states for the Health Care Financing Administration (HCFA). The QAI also requires primary data collection that is costly to collect. All of these instruments use primary data collection from individual residents. They are primarily designed to identify problems with quality for individuals and not to measure facility quality (except for the QAI instrument). Instruments for measuring quality that require primary data collection efforts on residents are costly to administer and impractical for use as a national approach to measuring quality (Harrington, 1990a). In spite of these many efforts, quality measures continue to be difficult to define and measure, especially for individuals with deteriorating conditions such as many of the residents of nursing facilities. Extensive research efforts continue to be needed in order to develop better process and outcome measures. Variations in Quality of Care A number of nursing facilities have been noted for providing high quality of care. The National Institute on Aging and the Robert Wood Johnson (RWJ) Foundation both initiated teaching nursing home programs to improve quality of care during the 1980s. The RWJ project was a 5-year program that ended in 1987 in 12 nursing facilities. These programs added geriatric and geropsychiatric nurse practitioners and clinicians to nursing facilities in collaboration with schools of nursing. The findings from the studies of these programs were that these nursing personnel were able to reduce hospitalization rates, bowel and urinary incontinence, and restraint use and to improve care (Mezey and Lynaugh, 1989,

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--> 1991). These programs were found to be successful and documented in a series of articles and books (Mezey et al., 1989; Shaughnessy and Kramer, 1989). Poor Quality of Care The quality of care provided in nursing facilities has long been a matter of great concern to consumers, health care professionals, and policymakers (NCCNHR, 1983). The Institute of Medicine (IOM) Committee on Nursing Home Regulation reported widespread quality-of-care problems (IOM, 1986). The problems were confirmed by the General Accounting Office (GAO, 1987) and the U.S. Senate (1986), which found that many of the nation's nursing facilities were operating at a substandard level by failing to meet minimum nursing home requirements considered to affect residents' health and safety. A number of clinical practices have been associated with poor patient outcomes. Urethral catheterization may place residents at greater risk for urinary infection and hospitalization or other complications such as bladder and renal stones, abscesses, and renal failure (Ouslander et al., 1982; Ouslander and Kane, 1984; Ribeiro and Smith, 1985). Restraints have been under criticism because their use may cause decreased muscle tone, and increase the likelihood of falls, incontinence, pressure ulcers, depression, confusion, and mental deterioration (Evans and Strumpf, 1989; Libow and Starer, 1989; Burton et al., 1992; Phillips et al., 1993). A recent study by Phillips and colleagues (1993) suggests that the use of physical restraints continues to be a problem and the use of such restraints should require more nursing care and more nursing assistant time. They concluded that residents free of restraints are less costly to provide care to and that this could improve the quality of care and quality of life. Tube feedings also increase the risk of complications including lung infections, aspiration, misplacement of the tube, and pain (Libow and Starer, 1989). The improper use of psychotrophic drugs has been identified as a common problem in nursing facilities in numerous studies (Harrington et al., 1992b). Recent Senate hearings focused on the problems associated with the misuse and inappropriate use of chemical restraints, which the regulations of the 1990 Omnibus Budget Reconciliation Act were designed to reduce (U.S. Senate, 1991). There are many negative outcomes in nursing facilities that have been identified in numerous studies (Zinn et al., 1993a,b). These include urinary incontinence, falls, weight loss, and infectious disease (Libow and Starer, 1989). Declines in physical functioning that could have been prevented are also important negative outcomes (Linn et al., 1977). Mortality rates or hospital readmission rates are simple outcome measures that are commonly used (Lewis et al., 1985; GAO, 1988a,b; Spector and Takada, 1991). Other common negative outcomes include accidents, behavioral and emotional problems, cognitive problems, psychotropic drugs reactions, and decubitus ulcers (Zinn et al., 1993a,b). A recent analysis of the On-Line Survey Certification and Reporting (OS-

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--> CAR) data showed that state surveyors continue to find problems with nursing home care. Data on all nursing facilities in the United States surveyed in 1993 found that 30 percent were given deficiencies for unsanitary food, 25 percent for inadequate care planning, 20 percent for inadequate sanitary environment, 20 percent for hazards in the environment, 19 percent for failure to maintain personal dignity, 18 percent for improper restraints, 16 percent for having no comprehensive assessment, 15 percent for inadequate infection control, 12 percent for inadequate treatment of incontinence, 12 percent for inadequate activities for residents, and other facilities received deficiencies for other problems (Harrington et al., 1995). (See Table 1.) The frequency of these deficiencies show that quality problems continue to exist in many nursing facilities. In summary, probably no other type of health care organization has been demonstrated to have as many quality-of-care problems as nursing facilities. These problems have demonstrated the need for continued research and the development of public policies that could improve both the process and outcomes of care. Regulatory Efforts In order to participate in the Medicare or Medicaid programs, long-term-care facilities are required to meet federal certification requirements established by HCFA (42 CFR Part 843) under the Social Security Act. Long-term-care facilities include skilled nursing facilities (SNF) for Medicare (Title 18), nursing facilities (NF) for Medicaid (Title 19), and dually-certified facilities (for both Title 18 and 19). State survey agencies are authorized to determine whether SNFs and NFs meet the federal requirements. Surveyors conduct on-site inspections to observe care, review records, and determine compliance. These surveys are used as the basis for entering into, denying, or terminating a provider agreement with the facility. In the early 1980s, the Reagan administration proposed deregulation of the nursing home industry. At the same time, Congress was concerned about quality-of-care problems in nursing facilities because of reports and complaints by consumer groups. Problems with the regulatory process had been identified in an evaluation of the state survey processes (Zimmerman et al., 1985). Because of the growing concern about nursing home quality, Congress requested a study by the IOM to examine the regulation of nursing facilities. The IOM Committee on Nursing Home Regulation documented quality-of-care problems and recommended revision and strengthening of the federal and state regulatory processes (IOM, 1986). Their recommendations, as well as the active efforts of many consumer advocacy and professional organizations, resulted in Congress passing the Omnibus Budget Reconciliation Act of 1987 (OBRA 87), a major reform of nursing home regulation (OBRA 87, 1987). This legislation was refined under subsequent legislation in 1988, 1989, and 1990.

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--> TABLE 1 Deficiencies in Certified Nursing Facilities from the Federal On-Line Survey Certification and Reporting System, United States, 1993 Types of Deficiencies Percent of Facilities with Deficiency Process Deficiencies Unsanitary food (The facility must prepare and serve food under sanitary conditions; F377) 30 Inadequate care plan (The facility must develop a comprehensive care plan for each resident; F295) 25 Inadequate sanitary environment (The facility must provide housekeeping/maintenance services for a sanitary environment; F261) 20 Hazards in the environment (The facility must ensure that the resident environment remains free of accident hazards; F329) 20 Improper restraints (Residents have the right to be free of physical restraints used for discipline or facility convenience; F221) 18 No comprehensive assessment (The facility must make a comprehensive assessment of resident needs; F271) 16 Inadequate infection control (The facility must investigate, control, and prevent infections; F441) 15 Inadequate activities (The facility must provide an ongoing program of activities to meet resident needs; F255) 12 No 24-hour nursing (The facility must provide sufficient numbers of personnel on a 24-hour basis; F354) 5 No RN on duty 7 days a week (The facility must have an RN on duty 8 hours a day for 7 days a week; F356) 5 Outcome deficiencies Failure to maintain dignity (The facility must promote care for residents that maintains dignity and respect; F241) 19 Inadequate treatment of incontinence (Incontinent residents must receive appropriate treatment; F322) 12 Failure to prevent pressure sores (The facility must ensure that residents without pressure sores do not develop them; F319) 9

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--> Types of Deficiencies Percent of Facilities with Deficiency Inadequate treatment of pressure sores (The facility must provide necessary treatment to residents with pressure sores; F320) 9 Poor nutrition (The facility must ensure that residents maintain acceptable levels of nutritional status; F331) 9 Abuse of residents (Residents have the right to be free of verbal, mental, and other abuse; F233) 2 NOTE: The relevant deficiency code follows the description of what the facility is obliged to provide. SOURCE: Harrington et al., 1995. The nursing home reform legislation in OBRA 87, which was implemented by HCFA regulations in October 1990, mandated a number of changes. First, the regulations eliminated the priority hierarchy of conditions, standards, and elements that were in the prior regulations. Second, the new 1990 regulations mandated comprehensive assessments of all nursing home residents using the new minimum data set (MDS) forms (Morris et al., 1990). Nursing facilities must complete the MDS forms for each resident within 14 days of admission and at least annually in order to assess the functional, cognitive, and affective levels of residents and must use the assessment in the care planning process. The federal survey procedures (conducted by state agencies) check the accuracy and appropriateness of the assessment and care planning process for a sample of residents. Third, more specific requirements for nursing, medical, and psychosocial services were designed to attain and maintain the highest practicable mental and physical functional status (Zimmerman, 1990). These requirements were specified in new regulations and a detailed set of HCFA interpretive guidelines were developed for use by state surveyors in 1990. The state surveys were redesigned to be more outcome oriented than previously. Such outcome measures include residents' behavior, their functional and mental status, and conditions (e.g., incontinence, immobility, and decubitus ulcers). For example, the regulations established criteria for the use of antipsychotic drugs, prohibited their use without a specific indication of need, and required periodic review and dose reduction unless clinically contraindicated (Zimmerman, 1990). In addition, regulations detailing and protecting residents' rights were added. One important recent advance was the development of the Nursing Home

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--> Resident Assessment System. This system used the nursing home MDS for resident assessment and developed detailed protocols for resident assessment of specific problem areas to guide the care planning process (Morris et al., 1990). The MDS items were field-tested in 1990 and finalized with 15 domains: cognitive patterns, communication and hearing patterns, vision patterns, physical functioning and structural problems, continence, psychosocial well-being, mood and behavior patterns, activity pursuit patterns, disease diagnoses, health conditions, oral and nutritional status, oral and dental status, skin condition, medication use, and special treatments and procedures (Morris et al., 1990). Since October 1990, nursing facilities are required by HCFA to collect MDS data for every resident upon admission, when there are major changes in health status, and at least annually. Zimmerman is currently developing Quality Indicators (QI) using the Minimum Data Set as a part of the National Nursing Home Case-Mix and Quality Demonstration study funded by HCFA. This effort builds upon his earlier work with the QAI to develop new QIs. Using MDS data on individual nursing home residents, a number of QIs have been developed: accidents, behavioral and emotional problems, cognitive problems, incontinence, psychotropic drugs, decubitus ulcers, physical restraints, weight problems, infections, and others. The QIs for individual residents and for facilities are compared to national norms, taking into account predisposing factors and case-mix factors related to each QI. Quality indicators that may indicate poor quality of care are identified and given to state surveyors to examine in the certification survey process. Using QI data, state surveyors are expected to determine whether or not the identified QIs are the result of, or are related to, poor care processes. HCFA regulations are being proposed to require nursing facilities to computerize the MDS data, and then the QIs may be a valuable tool for monitoring the quality of nursing home care. The QIs will augment the nursing home survey process that collects and monitors quality of care for facilities for federal Medicare and Medicaid certification. In November 1994, HCFA (1994a) released its final regulations for the survey, certification, and enforcement of skilled nursing facilities and nursing facilities (42 CFR Parts 401–498). The regulations made changes in the process of surveying and certifying facilities and developed procedures for enforcement. A number of alternative remedies instead of or in addition to termination may be imposed on facilities that do not comply with federal requirements. These include civil money penalties of up to $10,000, denial of payment for new admissions, state monitoring, temporary management, and other approaches. The extent and type of enforcement actions depend upon the scope (whether deficiencies are isolated, constitute a pattern, or are widespread) and severity of violations (whether there is harm or jeopardy to residents). The Health Care Financing Administration is also undertaking new efforts to train state surveyors in using the new survey, certification, and enforcement procedures.

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--> Is Quality Improving? One question is whether quality of care is improving as a result of increased efforts by the federal government to regulate quality. Consumer groups and anecdotal evidence from providers suggest there are improvements in nursing home care (Cotton, 1993). There are reports that a number of facilities have focused on reducing the inappropriate use of physical and chemical restraints and that the federal survey focus on resident problems represent substantial improvements in the survey process. The U.S. Office of the Inspector General (1993) concluded that positive improvements are being made in the regulatory process. State budgets for regulation increased and state survey agencies were using the new resident outcome approach. Complaints about nursing facilities, however, were increasing on average by 74 percent, and state facilities expressed concern about their ability to respond to complaints quickly and effectively. The report concluded that work to improve the current survey process continues to be needed (U.S. Office of the Inspector General, 1993). A national evaluation of the survey process also identified a number of areas where improvement is needed in the survey process (Abt Associates and the Center for Health Policy Research, 1993). The recent release of the final federal enforcement regulations for skilled nursing facilities and nursing facilities should also improve the regulatory process (HCFA, 1994a). It remains to be seen whether these extensive new regulatory efforts can make a substantial impact on improving the quality of care in nursing facilities. Deficiencies issued to facilities have actually declined since OBRA was implemented. The average deficiencies declined from 8.8 per facility in 1991 to 7.9 in 1993 (Harrington et al., 1995). Survey data also show that the percent of facilities without any deficiencies has increased slightly to 11.4 percent in 1993. Although the nursing facilities argue that this is an indication of improvements in quality of care, such declines could indicate problems with the enforcement process. In summary, in spite of the recent possible improvements in nursing home quality and regulations, the quality of care provided by some nursing facilities is still problematic. The number and type of deficiencies and complaints reported by the state licensing agencies, consumer advocacy groups, families, and residents show poor quality in some facilities. Nursing Home Staffing Pre-OBRA Staffing Levels Staffing is a critical structural factor that affects the processes and outcomes of nursing home care. Staffing levels in nursing facilities have been traditionally

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--> low and these are considered to affect quality of care directly. Of the 1.2 million full-time-equivalent (FTE) nursing home employees providing direct or indirect care, the National Nursing Home Survey indicates that about 7 percent were RNs in 1985 (Strahan, 1987). The ratios of nurses to residents has traditionally been substantially below the nurse-to-patient ratios in hospitals. In 1985, the national average was 1 RN per 49 patients in nursing facilities in contrast to a ratio of 1 RN for every 8 patients in hospitals (Jones et al., 1987; Strahan, 1987; Kanda and Mezey, 1991). Another analysis of the National Nursing Home survey data reported an overall average of 6.3 RNs per 100 beds in 1985 (or 0.063 FTEs per bed). (FTEs can be converted to hours per resident day by multiplying by 35 hours per week for each nurse and dividing by 7 for each resident day.) Converting FTEs to resident hours showed that the average RN hours per resident day was 0.3 hours (19 minutes) in 1985 (Strahan, 1988). Of the total nursing staff in nursing facilities in 1985, 12 percent were RNs, 17 percent were licensed vocational nurses (LVN), and 71 percent were nurses assistants (NA). The total direct care staff was 0.43 FTEs per resident day, or 2.15 hours per resident day (Strahan, 1987). Similar staffing ratios were identified in a study of 14,000 nursing facilities in 1987 using federal Medicare and Medicaid Automated Certification Survey (MMACS) data (now referred to as OSCAR data). Zinn (1993b) found that the average number of RNs per resident over 24 hours was 0.04 FTEs, licensed practical nurses (LPN) per resident was 0.09 FTEs, and aides per resident was 0.32 FTEs. The total direct care staffing per resident was an average of 0.45 FTEs per day. Zinn (1993a) found wide variations in nursing home staffing patterns in 10 standard metropolitan statistical areas, even after controlling for case-mix differences in residents using 1987 MMACS survey data. The number of RNs per resident over 24 hours varied from 0.01 FTEs in Oklahoma to 0.08 FTEs in Boston. OBRA 87 Nurse Staffing Minimum Standards The IOM Committee on Nursing Home Regulation recommended that nurse staffing standards be increased to improve the overall quality of nursing care (IOM, 1986). Following this recommendation, Congress increased the minimum standards for nursing home staffing in OBRA 87. This legislation was implemented in the 1990 Medicare and Medicaid regulations for SNFs and NFs, requiring a RN director of nursing, an RN on duty for 8 hours a day, 7 days a week, and a licensed nurse (either an RN, a licensed practical/vocational nurse, or both) on duty around the clock for nursing facilities (HCFA, 1991). OBRA 87 also required that nursing assistants must receive minimum training (75 hours) and be tested for competency. In addition, sufficient nursing staff were required to provide nursing and related services to attain or maintain the highest practicable

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--> level of physical, mental, and psychosocial well-being of each resident (HCFA, 1991). Staffing regulations for Medicare skilled nursing facilities are the same as for Medicaid, where both are required to meet the actual care needs of clients. Because Medicare skilled nursing residents have higher care needs than Medicaid residents, Medicare has traditionally had higher staffing levels. Many Medicare certified beds are in acute care facilities where staffing levels have been higher than in freestanding facilities. Medicare payment rates are substantially higher than Medicaid rates to take these higher resident care and resource needs into account (Dor, 1989). The OBRA 87 legislation allowed for waivers to the minimal nursing facility staffing requirements in areas where it may be difficult to hire RNs. Staffing waivers for Medicaid-only certified facilities (Title 19) can be granted by states, whereas staffing waivers for facilities with both Medicare and Medicaid certification (Title 18 and 19 facilities) or Medicare-only certified facilities (Title 18 only) must be granted by HCFA. The law allows the 24-hour licensed nursing coverage requirements and the 8 hours of RN coverage for 7 days a week to both be waived by states, but Medicare facilities are only allowed to have waivers for the 8 hours of RN coverage for 2 out of 7 days a week. Recent data from HCFA (1994b) reported that 518 facilities in 13 states had been granted waivers for Medicaid-only facilities by states through 1994. These included 66 waivers for the 24-hour licensed nursing coverage and 490 waivers for the 8 hours of RN coverage. As of March 1994, only 16 waivers had been given to Medicare skilled nursing facilities (Title 18 and 19 or Title 18 only) for the 8 hours of RN coverage by HCFA. At this point, HCFA has not released guidelines to the states for issuing waivers. Perhaps the number of waivers will decline as the availability of RNs improves with recent layoffs of hospital nurses. Mohler surveyed states regarding their staffing requirements for nursing facilities. She found that the majority of states had specific minimum staffing standards in addition to the federal standards for nursing facilities. These standards varied across states with some states specifying standards for RNs, others for nursing assistants, and still other states having standards for both (Mohler, 1993). Minnesota required a minimum of 2 hours of nursing care per resident day for all licensed nursing facilities but these were not required to be distributed evenly across the evening or night shifts (Chapin and Silloway, 1992). States are allowed to impose state penalties for facilities who have substandard staffing according to state regulations. Thus, the data demonstrate that minimum staffing standards for nursing facilities are considered necessary by most states, as well as by the federal government. Staffing Levels After OBRA 87 Data from the 1991 National Health Provider Inventory identified 15,511

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--> 1989; Weissert and Musliner, 1992b). Thus, some public officials are unwilling to support additional profit making. Current Medicaid and Medicare reimbursement allocations could be used to redistribute existing payments toward resident care. Another problem is the historic opposition of the nursing home industry to regulation, which represents a major political obstacle to regulatory reform. Although the nursing home industry supports financial incentives for higher quality, their opposition to further regulation may stifle reform efforts. In the current economic and political environment, consumer and professional organizational pressures for reform may not have the political power to counter the opposition of the nursing home industry to new regulation. Summary Findings And Discussion The nursing home market is being strained by a growing demand for services. The greater acuity of illness and disability of individuals needing long-term care is placing new demands on providers of care. The supply of nursing facility beds has not kept pace with the growth in the oldest old population. This has resulted in nursing facilities being able to be somewhat selective in their admission practices and has limited the access to care of some individuals who may have the greatest need for services. The limited supply in some areas also appears to have a negative impact on the quality of nursing home care delivered in those areas. There are a number of high quality nursing home facilities in the United States. These facilities have demonstrated that they can provide high quality of care even under the current economic constraints. On the other hand, the quality provided by nursing facilities is variable. In spite of increased regulatory efforts resulting from the implementation of the Nursing Home Reform Act in OBRA 87, there are still many problems with quality identified by state surveyors, residents and family members, ombudsmen, advocates, and researchers. Process measures for nursing home quality have been well developed and are used as a part of the nursing home survey process. Quality outcomes measures continue to be difficult to define and measure, especially for individuals with deteriorating conditions. Nevertheless, new data systems and outcomes measures have been developed and advances are being made in outcome measurement and monitoring. Direct patient care and nurse staffing are critical structural factors that impact on both the process and the outcomes of care. Nursing staffing levels in nursing facilities are low compared to hospitals, and this is particularly the case in proprietary nursing facilities. Low salaries and benefits contribute to quality-of-care problems and high staff turnover rates. Low staff educational levels in nursing facilities are associated with low salaries. Inadequate nurse staffing levels have been shown to be a major factor in poor quality of nursing home care.

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--> Economic factors are major forces shaping nursing home quality and staffing. The primary source of all nursing home revenues is Medicaid, so state Medicaid reimbursement policies have a major impact on the nursing home industry. As most states have adopted Medicaid prospective payment systems and strict methods for controlling costs, major problems with access and quality have developed. Moreover, many state methods specifically limit spending for direct resident care, which can have a negative impact on quality. Case-mix reimbursement systems that link payment to resident characteristics are being widely adopted by Medicaid programs and are under consideration by Medicare. Goals of these systems are to encourage facilities to improve access for heavy care residents and to design a more rational approach to payment. Evaluations of case-mix systems suggest that this approach will not improve quality and may not improve either access or cost controls. In fact, depending upon the design, such systems may encourage poorer quality of care and put unnecessary limits on staffing expenditures. Case-mix systems require careful monitoring to ensure that staffing levels and quality are maintained. New and improved reimbursement approaches that provide incentives to improve quality and staffing levels are needed. Nursing home facilities are primarily private, profit-making organizations that are increasingly part of multiorganizational systems and investor-owned corporations. Consequently, nursing facilities are oriented toward increasing profits. Profit margins for the industry are generally good and historically have been increased by government policies that have paid for a return on equity. New policies have eliminated such payments for Medicare and some states are attempting to eliminate reimbursement, limit profit margins, or do both. Reimbursement policies that allow facilities to make profits by lowering staffing levels and quality of care are problematic. The regulation of nursing facility quality may have improved since the implementation of OBRA 87. Nevertheless, regulatory efforts to assure quality need to be improved. One approach is to establish stricter minimum staffing standards and to develop guidelines for determining staffing levels that both facilities and regulators monitoring facility staffing can use. Another approach is to regulate how facilities allocate reimbursement resources to ensure that sufficient resources are directed to resident care and to limit excess profit taking and administrative costs. Another approach is to remove reimbursement limitations on nurse staffing expenditures, while controlling reimbursement for other cost areas such as profits, administration, and capital. Finally, reimbursement incentive systems are another way to encourage higher staffing levels and higher quality of care. One problem with increasing staffing requirements is that the increased costs would fall primarily on the Medicaid and Medicare programs. Government officials have been reluctant to adopt new policies that will increase federal and state costs. In the current climate of federal deficits and stalled economic growth, such new policies would be feasible only if strict cost controls were placed on

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