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Improving the Quality of Long-Term Care
nursing home Resident Assessment Instrument was introduced early in 1990 and has become the basis for various payment and quality monitoring initiatives. The perceived policy “success” of the nursing home system prompted the Health Care Financing Administration (HCFA) to mandate the introduction of a measurement system for Medicare in order to reimburse for home health care. A number of states have had long-standing patient assessment systems of their own for users of assisted living facilities, senior centers, and non-Medicare home care providers. Numerous states are now struggling with the adoption of common, clinically relevant data elements pertinent to all long-term care clients that are applicable across all provider settings in order to facilitate and track Medicaid-managed care reforms tentatively being applied to the long-term care population.
The notion that information about care recipients and care providers, all linked into a single database, can be used to monitor and improve care is consistent with the extensive literature emanating from the continuous quality improvement field. The same data that make it possible for providers to identify current care practices that contribute to undesirable patient outcomes, can also be used by regulators to identify providers that may manifest care practices associated with problematic outcomes. Presumably these data could be used also to classify providers as “poor performers,” which information then could be made available to the public.
This chapter discusses the current state of the major information systems in long-term care, their implementation status, their reliability and validity, and their application for clinical assessment, quality monitoring, and reimbursement. The discussion primarily focuses on the federal systems that provide basic information on monitoring compliance with regulations and on the quality of long-term care offered by nursing homes and home health agencies. These are the On-line Survey and Certification Assessment Reporting (OSCAR) System for nursing homes and home health, the minimum data set (MDS) for the Resident Assessment Instrument (RAI) for nursing homes used in developing quality indicators, and the Outcome and Assessment Information Set (OASIS) for home health care. The chapter then briefly describes the need to improve these existing information systems in light of their extensive use for policy and quality monitoring; state assessment systems for home and community-based service; and the measurement and implementation issues involved in efforts to extend their use to other long-term care settings and to include consumer perspectives in assessments of the quality of life and satisfaction with care. Because most existing data systems in long-term care have been developed primarily for adults, and the elderly in particular, some of the special challenges in assessing children's care also are discussed.