Overview and Introduction:
The number of individuals 65 years and older that reside in nursing homes has increased from 505,000 in 1963, to 1.6 million as of 2004. There are over 16,400 nursing homes in the USA as of 2004 (Action Plan for Nursing Home Quality, Contemporary Report, p. 2). More than 3 million older adults access nursing home services at some point during each year (Nursing Home Quality Initiative Overview, p. 1)
A major catalyst impacting current regulation and the focus on quality is the shift from acute care to chronic, in tandem with the "graying" of America. The prior acute care model emphasized research, funding and physician management of acute conditions, while individuals with chronic care conditions were medicated for pain and encouraged to minimize physical activity. The acute medical model minimized the role of rehabilitation in long-term care. The shift towards chronic care management was a direct response to the increased number of older adults with chronic care conditions, which accounted for more than 50% of all national healthcare expenditures in 1984 and set the stage for Omnibus Budget Reconciliation Act (Stefanakos, K., 2001).
The "graying" of America, with increased expenditures on chronic care, became the focus of regulatory reform in 1987 when the Omnibus Budget Reconciliation Act (OBRA) was enacted, revising skilled nursing and intermediate care facility requirements. The intent of ORBA '87 was reflected in the slogan, "If you don't use it, you lose it." This was evident in the federal regulatory focus of maintaining the resident's highest level of function, thereby, promoting the greatest quality of life. OBRA prompted national attention on quality of life and moved it into the survey process, which has only continued to gain momentum.
Focus on quality of life and quality of care requires a working definition of quality, indicators or monitors of quality and a systematic way to measure it in nursing homes across the United States. To address these requirements, the Resident Assessment Instrument (RAI) was implemented in 1990, for all long-term facilities participating in Medicare and Medicaid. The RAI consists of the Minimum Data Set (MDS), the primary screening and assessment tool, and the Resident Assessment Protocols (RAPs), which specify triggers that identify potential problems and provide guidelines for the development of care plans. The MDS Version 2.0 has 190 screening/assessment items and 23 coding categories.
The Centers for Medicare and Medicaid Services (CMS) has built specific intervals for assessment and mandated processes to ensure uniformity and accuracy:
- All nursing home residents are to be comprehensively evaluated upon admission to a facility for the purpose of determining their level of functioning, needs and patterns of activity.
- A care plan is created for every resident based on a comprehensive assessment and is designed to ensure the ability of the resident to attain/maintain his or her highest level of function and quality of life.
- Beyond the initial comprehensive assessment, the long-term care facility must review and re-assess each resident by administering the MDS no less than every three months.
- A comprehensive assessment (RAI) must be done after a significant change in the resident's mental and/or physical health status and no less than every 12 months.
- It is a facility's obligation to see that a resident's abilities in activities of daily living do not diminish unless the individual's clinical condition indicates that the loss of function was unavoidable.
The passage of OBRA and the uniform assessment and measurement of all residents has not achieved the desired level of quality outcomes as assessed by CMS. As the largest purchaser of long-term care services, exceeding $64 billion per year, CMS has, and continues to exert significant leverage to improve the quality of care for services provided in nursing homes so the intent of OBRA can be realized for every resident. These steps by CMS to improve quality of care are detailed in the "Nursing Home Quality Initiative and the Action Plan (For Further Improvement of) Nursing Home Quality" released in December 2004 www.cms.hhs.gov/quality/nhqi/NHActionPlan.pdf The single espoused CMS intent is a call for healthcare stakeholders, including consumers and their families, providers, professionals, professional organizations, etc., to embrace quality and "do it." There is no single approach or manner that can fully ensure quality; it takes a full coordination and mobilization of everyone involved in the resident's care.
It is the intent of this paper to identify the current and proposed regulatory reforms for quality of care and quality of life by CMS, to summarize a resident-centered quality driven process and partnership with the nursing home, and to specify outcomes regarding speech-language pathology.
