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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
Support for this project was provided by the Robert Wood Johnson Foundation, the Archstone Fund, Irvine Health Foundation, Department of Veterans Affairs, and Health Care Financing Administration. The views presented in this report are those of the Institute of Medicine Committee on Improving Quality in Long-Term Care and are not necessarily those of the funding agencies.
Library of Congress Cataloging-in-Publication Data
Institute of Medicine (U.S.). Committee on Improving Quality in Long-Term Care, Improving the quality of long-term care / Gooloo S. Wunderlich and Peter Kohler, editors ; Committee on Improving Quality in Long-Term Care, Division of Health Care Services, Institute of Medicine.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-309-06498-8
1. Long-term care facilites—Quality control. 2. Long-term care of the sick—Quality control. 3. Quality assurance. 4. Nursing homes—Quality control. I. Wunderlich, Gooloo S. II. Kohler, Peter O., 1938-III. Title
[DNLM: 1. Long-Term Care—United States. 2. Outcome and Process Assessment (Health Care)—United States. 3. Quality Assurance, Health Care—United States. W 84.7 I587 20001]
RA997 .I57 2001
362.1′6′0685—dc21
00-067864
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The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
THE NATIONAL ACADEMIES
National Academy of Sciences
National Academy of Engineering
Institute of Medicine
National Research Council
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.
COMMITTEE ON IMPROVING QUALITY IN LONG-TERM CARE
PETER O. KOHLER (Chair), President,
Oregon Health Sciences University
RICHARD DELLA PENNA, Regional Elder Care Coordinator,
Southern California Permanente Group, Kaiser Permanente
PENNY HOLLANDER FELDMAN, Director,
Center for Home Care Policy and Research,
Vice President,
Research and Evaluation, Visiting Nurse Service of New York
JANET GEORGE, Former Vice President,
Quality Improvement, Manor Care, Inc., Gaithersburg, Maryland
CHARLENE A. HARRINGTON,
Department of Social and Behavior Sciences, University of California
ROSALIE A. KANE, Director,
National LTC Resource Center, University of Minnesota
VINCE MOR, Director,
Center for Gerontology and Health Care Research, Brown University
VIVIAN OMAGBEMI, Program Manager,
Health and Human Services, Aging and Disability Services, Montgomery County, Maryland
JAMES PERRIN, Associate Professor of Pediatrics, Harvard Medical School, Director,
Division of General Pediatrics, and
Director,
MGH Center for Child and Adolescent Health Policy, Massachusetts General Hospital for Children, Boston
LAURIE E. POWERS, Associate Professor and
Co-Director of the Center on Self-Determination, Oregon Health Sciences University
ELLEN REAP, Vice President,
Senior Living Services, Adventist Health Care, Rockville, Maryland
JOHN F. SCHNELLE,
UCLA/Jewish Home Borun Center, Sepulvada VA Hospital, Reseda, California
PAUL M. SCHYVE, Senior Vice President,
Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Illinois
ERIC TANGALOS, Professor of Medicine and Chair,
Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota
ARTHUR Y. WEBB, President and CEO,
Village Care of New York/Village Center for Care, Inc.
JOSHUA M. WIENER, Principle Research Associate,
The Urban Institute, Washington, D.C.
KEREN BROWN WILSON, Former President and CEO,
Assisted Living Concepts, Inc., Portland, Oregon
BOARD ON HEALTH CARE SERVICES INSTITUTE OF MEDICINE
DON E. DETMER (Chair),
Professor of Medical Education in Health Evaluation Sciences, University of Virginia
BARBARA J. McNEIL (Vice Chair), Ridley Watts Professor,
Department of Health Care Policy, Harvard Medical School
LINDA AIKEN,
The Claire Mo Fagin Leadership Professor of Nursing and
Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research,
University of Pennsylvania
STUART H. ALTMAN, Sol C. Chaikin Professor of National Health Policy,
The Florence Heller Graduate School for Social Policy, Brandeis University
HARRIS BERMAN, Chairman and Chief Executive Officer,
Tufts Health Plan, Waltham, Massachusetts
BRIAN BILES, Chair and Professor,
Department of Health Services Management and Policy, The George Washington University, Washington, D.C.
CHRISTINE CASSEL, Chairman,
Henry L. Schwarz Department of Geriatrics and Adult Development, Mount Sinai Medical Center, New York City
PAUL D. CLAYTON, Medical Informaticist,
Intermountain Health Care, Salt Lake City, Utah
PAUL F. GRINER, Vice President and Director,
Center for the Assessment and Management of Change in Academic Medicine, Association of American Medical Colleges, Washington, D.C.
RUBY P. HEARN, Senior Vice President,
Robert Wood Johnson Foundation, Princeton, New Jersey
PETER BARTON HUTT, Partner,
Covington and Burling, Washington, D.C.
ROBERT L. JOHNSON, Professor of Pediatrics and Clinical Psychiatry and Director of Adolescent and Young Adult Medicine,
University of Medicine and Dentistry of New Jersey, New Jersey Medical School
JACQUELINE KOSECOFF, President and Co-Chief Executive Officer,
Protocare, Santa Monica, California
SHEILA T. LEATHERMAN, Founder,
The Center for Health Care Policy and Evaluation and
Executive Vice President,
United Health Group, Minneapolis, Minnesota
UWE E. REINHARDT, James Madison Professor of Political Economy and Professor of Economics and Public Affairs,
Princeton University
SHOSHANNA SOFAER, Robert P. Luciano Professor of Health Care Policy,
School of Public Affairs, Baruch College
GAIL L. WARDEN, President and Chief Executive Officer,
Henry Ford Health System, Detroit, Michigan
JANET M. CORRIGAN, Director,
Board on Health Care Services, IOM
Acknowledgments
The Institute of Medicine (IOM) Committee on Improving Quality in Long-Term Care acknowledges with appreciation the many persons and organizations, not all of whom can be individually listed, who contributed to the success of the study.
The primary support for this study was provided by the Robert Wood Johnson Foundation. Generous support was also provided by the Archstone Foundation, Irvine Health Foundation, Department of Veterans Affairs, and Health Care Financing Administration.
Many individuals shared unselfishly with the committee the results of their work and background information from their organizations. The committee appreciates the organizations and individuals that presented testimony at a public hearing. These individuals are listed in Appendix A.
During the course of the study the committee held meetings at which experts made thoughtful presentations on various aspects of the committee 's mandate. The presenters are listed in Appendix A; their contribution of time and knowledge is appreciated.
We are grateful to the authors of the commissioned papers prepared for the study. Their names and the subjects of their papers are listed in Chapter 1. The papers were used by staff and committee to guide them in drafting the report.
A number of people within IOM provided support and assistance to the study committee. The committee acknowledges with gratitude their contributions. Marilyn Field served as study director until May 1999. Many other staff assisted her and the committee at various times and in
various capacities. Kay Harris and later Jennifer Cangco (since March 2000) helped keep our budget in order. Claudia Carl managed the logistics of the report review process, and Mike Edington shepherded the report through the editing and production process. Sally Stanfield at the National Academy Press was supportive as always.
We also acknowledge Janet Corrigan, Director, Division of Health Care Services, for her support in a difficult time by providing staff from her division to complete the study. We are grateful to Nicole Amado and Kathleen Nolan for their enormous efforts in staffing the study through its completion. They cheerfully labored over 30 pages of references correcting them and making the citations and references consistent and the text accurate, developing the charts and tables in the report, and reviewing and editing the report drafts for accuracy and style under very tight deadlines. We appreciate Nicole's meticulous work formatting the manuscript for prepublication release.
Finally we would like to thank Gooloo Wunderlich for the enormous contribution she made to this study. Gooloo's professionalism, knowledge, and extraordinary commitment were critical to resolving many policy and technical issues and completing the study.
Reviewers
The report was reviewed by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their participation in the report review process:
Floyd Bloom, Chairman, Department of Neuropharmacology, The Scripps Research Institute, La Jolla, California
Robert Butler, President and Chief Executive Officer, International Longevity Center-USA, Ltd., New York City
Karen Davis, President, The Commonwealth Fund, New York City
Toby Edelman, Attorney, National Senior Citizens Law Center, Washington, D.C.
Catherine Hawes, Senior Research Scientist, Myers Research Institute, Menorah Park Center for the Aging, Beachwood, Ohio
Susan Hughes, Professor, Health Research and Policy Centers, University of Illinois at Chicago
Mathey Mezey, Director, The John A. Hartford Foundation Institute for the Advancement of Geriatric Nursing Practice, New York University
Robert J. Newcomer, Professor and Chair, Department of Social and Behavioral Sciences, University of California at San Francisco
Joe Ouslander, Co-Director, The Southeast Center for Excellence in Geriatric Medicine, Emory Clinic at Wesley Woods, Atlanta, Georgia
David R. Zimmerman, Director, Center for Health Systems Research and Analysis, University of Wisconsin
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Frank Sloan, Professor, Duke University, appointed by the Institute of Medicine, and Mary Jane Osborn, Professor and Head, Department of Microbiology, University of Connecticut Health Center, appointed by the NRC's Report Review committee, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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, |
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2.2 |
Number of Long-Term Care Facilities and Beds: United States, 1992 and 1998, |
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2.3 |
Number and Percent Distribution of Nursing Homes, Beds, and Residents, by Facility Characteristics: United States, 1997, |
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2.4 |
Number and Percent Distribution of Certified Home Health Agencies and People Served, by Agency Characteristics: United States, 1996, |
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2.5 |
Total Medicaid Personal Care Services and 1915(c) Home and Community-Based Services Waivers: United States, 1997–1998, |
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2.6 |
Number and Percent of Selected Categories of Occupations Employed in Selected Long-Term Care Settings and in Hospitals: United States, 1998, |
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2.7 |
Expenditures and Source of Funds for Nursing Home and Home Health Care: United States, 1997, |
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2.8 |
Medicaid Payments, by Type of Service and Category of Beneficiary: United States, 1997, |
5.1 |
Average Number of Deficiencies per Certified Facility and Percent of Facilities with No Deficiencies, by State: United States, 1992 –1998, |
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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, |
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6.1 |
Nursing Staff Levels per Resident Day, by Facility Type and Region for Nursing Homes: United States, 1998, |
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6.2 |
Distribution of Combined Nursing Hours per Resident Day in All Certified Nursing Facilities: United States, 1998, |
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6.3 |
Comparison of Average Nursing Hours per Resident Day for OSCAR Data, HCFA Time Studies, and Time Proposed by Experts, |
FIGURES
2.1 |
Distribution of assisted living facilities by bed size: United States, 1998, |
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2.2 |
Percent distribution of ownership of home health and hospice agencies: United States, 1996, |
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2.3 |
Percent of patients receiving home health care services by type of service: United States, 1996, |
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2.4 |
Percent of patients receiving home health care services by service provider: United States, 1996, |
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3.1 |
Top 10 deficiencies of nursing facilities and percent of facilities with the deficiency cited: United States, 1998, |
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4.1 |
Proposed classification scheme for measuring a person's perspective about his/her quality of medical care, |
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5.1 |
Average number of deficiencies and percent of facilities without deficiencies: United States, 1991–1998, |
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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, |
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6.1 |
Mean staffing hours per resident day for nursing facilities in the United States surveyed in calendar year 1998, |
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6.2 |
Average nursing hours per resident day in all certified nursing facilities: United States, 1991–1998, |