John F' Schnelle, PhD

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John F. Schnelle, PhD

• Vanderbilt Center for Quality Aging
• Professor
• School of Medicine

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Point 1

• Quality can be improved with care identified in
  practice and regulatory guidelines.
• Care is labor intensive and hard to manage.

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Point 2

• Nursing Homes can or do not implement
  recommended care for three major reasons
• Staffing numbers and poor information for
  management.
• Motivation regulatory system does not reinforce
  improvement in direct care.
• Knowledge Required care is not described with
  adequate specificity to implement.

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Point 3

• There are immediate and realistic solutions if we
  think differently.
• Solutions are outlined in the last slide.

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Point 1 Quality can be improved with simple but
labor intense care

• Functional incidental training controlled
  clinical trial.
• Incontinent Nursing Home Residents (60 )
• Care every 2 hours.
• Resident offered toileting assistance (choice).
• Resident assisted with incidental exercise
  standing transfer movement.

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Outcomes

• Intervention group significantly better than
  control group.
• Urinary Incontinence
• One constipation measure
• ADL decline
• Resident family report of met needs
• Family report of positive communication with staff

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Labor costs and Management

• 21 minutes aide time per resident ever 2 hours.
• 30 minutes of supervisory time per day.
• Staffing projection- Ratio 5 residents to 1 aide.
• 90 Nursing homes are staffed below this level.
• Staffing ratios are only part of the problem.
• Schnelle et al. Journal of American Geriatric
  Society.2002.

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Management

• Homes staffed at high levels (5-1 ratio) did
  better but still did not implement consistent
  care in some areas.
• Schnelle et al. Health Services Research.2004.

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Barriers to Management

• Inaccurate information about care.
• Unrealistic expectations given resources.
• No objective method to target care given
  suboptimal staffing.

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Regulatory Issues

• Nursing homes highly sensitive to regulatory
  feedback.
• Regulatory feedback does not reinforce
  improvement.

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External regulation works bestif
provider/regulator consensus

• Definition of Quality Measures
• Methods of measurement.
• Rules to link measures to deficiency statements.

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Current regulatory system meets none of these
criteria

• Unrealistic expectations about how many
  recommended care processes can be measured.
• Poor definition of measures and methods of
  measurement
• (e.g.) observe quality of assistance at meal
  times.
• Confusing rules linking measures to deficiency
  statements.

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Failure to provide realistic survey task and
standardized protocols

• Survey culture that depends on expert judgment.
• Inconsistency
• Confused providers who do not know how to improve
  care.

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Solutions for improving quality

• More active bedside research as opposed to
  statistical manipulation of secondary data.
• Labor costs and management
• Outcomes (Quality of Life and Clinical)

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Staffing and Management IssuesBest practice
demonstration site

• Develop consensus about important care.
• Implement care and document labor costs and
  outcomes.
• Improve efficiency (alternative staffing models,
  alternative environments).
• Match staffing levels to care expectations.

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Regulatory System

• Develop and test standardized investigation
  protocols based on existing survey guidelines.
• Determine resources to implement protocols.
• Focus on realistic set of quality measures.
• Make procedures known to Nursing Home Staff and
  obtain consensus.