UCSF

1
UCSF Advocating in Gerontological Nursing
Everyones Responsibility Charlene Harrington,
Ph.D., R.N., FAAN Professor of Nursing and
Sociology
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Poor Quality of Care for Older People

• Hospitals
• Nursing Homes
• Residential Care
• Home Care

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Poor Quality of Care in Hospitals

• Unnecessary Deaths
• Medication errors
• Decubitus ulcers
• Untreated Pain
• Reduced physical functioning
• Falls

• Urinary/kidney infections
• Wound infections
• Pneumonia
• Pulmonary compromise
• Failure to rescue
• Post surgery complications

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Higher RN Staffing Improved Hospital Outcomes

• Aiken, Clarke, Cheung, Sloane, Silber, 2003. JAMA
• McGillis, Doran, Baker et al., 2003 Med Care
• Aiken, Clarke, Sloane, et al. 2002, JAMA
• Aiken, Clarke, Sloane, 2002, Nurs Outlook
• Kovner, Jones, Zhan, et al., 2002. Health Serv
  Research
• Kovner Gergan, 1998 Image

• Seago, Williamson Atwood, 2006 J. Nursing Admin
• Needleman, Buerhaus, Stewart et al. 2006, Health
  Affairs
• Rothberg, Abraham, Lindenauer, Rose, 2005 Med
  Care
• McGillis, Doran, Pink 2004. J. Nurs Adm

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Lower RN Staffing Poor Hospital Outcomes

• Deaths
• Medication errors
• Decubitus ulcers
• Pain Control
• Physical functioning
• Falls
• Urinary/kidney infections

• Wound infections
• Pneumonia
• Pulmonary compromise
• Failure to rescue
• Post surgery complications

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Higher RN Staffing Outcomes

• Reduced staff burnout
• Reduced staff turnover
• Increased staff satisfaction
• Aiken, Clarke Sloane 2002 Nurs Outlook

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A Business Case for Hospital Nurse Staffing

• Raising the proportion of RN hours without
  increasing total hours is associated with a net
  reduction in costs
• Increasing nursing hours reduces hospital days,
  adverse outcomes death, but increases costs
  by1.5
• Depends on the value assigned to avoid death and
  complications
• Needleman, Buerhaus, Stewart et al Health
  Affairs. 2006 25 (1)204-11.

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Improving Hospital Outcomes

• Increase licensed staffing levels minimum
  staffing standards (e.g. California 15 ratio for
  med-surg and 12 for ICU)
• Increase the proportion of RNs
• Increase the education levels bachelors degree
• Increase the gerontological training of nursing
  staff (e.g NICHE program)
• Increase use of gerontological CNSs NPs

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Poor Nursing Home Quality US Senate Committee
on Aging, Hearings 1974
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Harrington et al. 2004 OSCAR Data
OSCAR, 2002
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Harrington et al. 2005 OSCAR Data
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Poor Quality and Weak Nursing Home Enforcement
Continues

• US Senate Committees, 1998-2003
• Institute of Medicine, 1996, 2001, 2003
• Health Care Financing Admin., 1998
• US General Accounting Office, 1997 1998 1999a,b
  2000 2002 a,b 2003
• US Office of the Inspector General, 1999, 2003

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California Nursing Home Study 2001

• Study of 34 nursing homes and 887 residents
• Sample included nursing homes in
• top 10 (4.1 hrpd) on staffing
• top bottom 25 on staffing clinical
  indicators
• Seven Standard Protocols/measured for 3 days
  observations, assessments, chart reviews,
  interviews

Schnelle et al, HSR, 2004
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Poor Care in Most CA Homes

• Weight loss problems
• Only 4 to 7 minutes of assistance
• Verbal interactions only 28of time
• False charting on food intake
• Incontinence only toileted 1.8 times in 12 hrs
• Residents turned every 5-6 hours
• Bedfast left in bed most of the day (gt22 hrs)
• Walking assistance only 1 time a day
• Untreated pain most of the time
• Untreated depression

Schnelle et al., Health Serv Res, 2004
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Causes of Poor Nursing Home Care

• Weak regulatory oversight enforcement
• Inadequate nurse staffing levels
• Inadequate education training
• Low government reimbursement and prospective
  payment systems Inadequate public information
  about quality

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Strengthen the Oversight Enforcement System
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NURSING HOME REFORM ACT -- OBRA 1987

• Quality of Life Residents Rights
• Quality of Care
• Comprehensive Resident Assessment
• Improved Survey Process
• Tough Enforcement With Monetary Sanctions

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Few US Nursing Homes Are Sanctioned, 1999

• 16,000 facilities surveyed
• 31 facilities caused harm or jeopardy
• 4 deficiencies received civil money penalties
• 2 facilities denied new admissions
• 15 temporary managers appointed
• 0.002 (42) had state revocations
• 0.002 (46) decertifications/ (39)
  recertifications

Harrington, Mullan, Carrillo. 2004.
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State Rank on 5 Enforcement Measures, 1999
Harrington, Mullan, and Carrillo. 2004.
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Harrington et al. 2004 OSCAR Data
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State Survey Agency Problems

• Continued predictability of surveys
• Inadequate complaint investigation
• No toll-free complaint hotlines in 15 states
• Poor state investigation/documentation
• Inexperienced state surveyors
• Federal oversight of states is inadequate
• Inadequate funds for oversight
• Lack of monitoring of facility reporting

GAO, 2003 Walshe Harrington, 2002
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Regulation Recommendations

• Enforce existing federal and state regulations,
  especially staffing standards
• Ensure adequate regulatory funding
• Collect current fines and increase penalties for
  inadequate care

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Improve Nurse Staffing Levels
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NURSING HOME RESEARCH STUDIES POSITIVE
RELATIONSHIP BETWEEN NURSES QUALITY - IOM 2001
and 2003

• Kayser-Jones 1997
• Bliesmer, Smayling et al, 1998
• Kayser-Jones, 1999
• Harrington et al 1999
• Harrington et al 2001
• Carter Porell, 2003
• Weech-Maldonado, Meret-Hanke, Neff, 2004
• Zhang Grabowski, 2004
• Carter Porell, 2005
• Horn, et al, 2005
• Dorr, Horn Smout 2005

• Linn et al. 1977
• Fottler et al. 1981
• Nyman l988
• Kayser-Jones l989
• Monroe l990
• Gustafson et al 1990
• Spector/Takada 1991
• Cherry 1999
• Braun 1991
• Johnson-Pawlson 1993
• Cohen/Spector 1994

Includes RNs, LVNs, and Nursing Assistants
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MORE NURSES (Especially RNs) IN NURSING HOMES

• Improve functional ability
• Improve nutritional status
• Improve quality of life
• Reduce pressure ulcers
• Reduce mortality
• Reduce hospitalizations
• Reduce UTIs and catheterizations
• Reduce restraint use
• Reduce weight loss
• Reduce behavioral problems
• Reduce deficiencies

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Nursing Home Cost Studies

• 30-40 minutes of RNs per resident day reduces
  resident costs by 3,191per resident year
• Increasing RNs can result in cost savings
• Dorr, Horn Smout, JAGS, 2005
• Also Weech-Maldonaldo, Shea Mor, 2006
• NPs/PAs in NHs decrease hospitalizations and may
  save money
• Intrator, Zinn, Mor, JAGS, 2004

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Harrington, et al 2005 OSCAR
3.6 hrpd 25 drop in RN hours
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Average US Staffing Ratios 2003

• NA -- 1 to 10 residents
• LVN 1 to 34 residents
• RN 1 to 40 residents

Harrington et al 2003. OSCAR data
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97 higher
126 higher
Harringon OMeara, 2005
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42 higher
45 higher
Harrington and OMeara, 2005
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CMS Staffing Study, 2001

• Dr. Schnelles Simulation Model
• 2.8 to 3.2 NA hprd is a conservative minimum
  level just to carry out 5 basic care activities
  (1 to 7-8 residents in day/evening, 1 to 12
  night)
• 2.8 for low, 3.0 average, 3.2 high casemix

CMS 2001. Appropriateness of Minimum Nurse
Staffing Ratios in Nursing Homes. Final Report.
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CMS 2001 STAFFING STUDYLower Staffing Resulted
In

• Short Stay Residents
• Congestive heart failure
• Electrolyte imbalance
• Respiratory infection
• Urinary tract infections
• Sepsis

• Long Stay Residents
• Less functional improvement
• Pressure sores
• Weight Loss

CMS 2001. Appropriateness of Minimum Nurse
Staffing Ratios in Nursing Homes. Final Report.
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CMS 2001 STAFFING STUDY

• Staffing levels below
• 2.8 NA hprd (18 ratio)
• 1.3 licensed hprd (118 ratio) including .75 RN
  hprd
• 4.1 hprd total
• have substantial probably of jeopardizing the
  health and safety of residents shows a
  threshold

CMS 2001. Appropriateness of Minimum Nurse
Staffing Ratios in Nursing Homes. Final Report.
Excludes the Director of Nursing
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Quality Measures from the Minimum Data Set
Resident Assessment

• Medicare Resource Utilization Groups (RUGs)
  payment system
• Quality measures (QMs) quarterly reports to
  facilities to improve care
• QMs reports sent to state surveyors
• Public information - www.Medicare.gov/NursingHome
  Compare

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Current CMS NH Quality Measures Long Stay
Residents

• Bedfast or in Chair most of time
• Loss of Physical Functioning
• Ability to Move got worse
• Depression
• Pain

• Pressure Ulcers high and low risk
• Incontinence low risk
• Catheter
• UTI
• Physical Restraints
• Weight Loss

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Problems

• Many nurses not trained to do resident
  assessments
• Many nurses dont use assessments for care
  planning
• Data accuracy problems are serious
• Data are not audited
• Facilities inflate payment measures
• Facilities underreport quality indicators
• Risk adjustment is difficult

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California Nursing Home Study

• Studied Quality Indicators
• Nurse Staffing
• Weight Loss
• Restraints
• Bedfast
• Pain
• Pressure Ulcers
• Incontinence
• Depression
• Physical activities

• Staffing is the best quality indicator on 13 of
  16 process measures of care
• Staffing is a better predictor of processes of
  care

Schnelle et al, HSR, 2004
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CA Nurse Staffing Study, 2001

• Facilities with 4.1 hprd had better nursing care
  processes
• Feeding assistance
• Helping residents out of bed
• Incontinence care
• Confirmed that there is a staffing threshold (4.1
  hprd) before differences in care processes can be
  identified

Schnelle et al, 2004. Health Services Research
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CMS Staffing Cost Estimates in 2001

• Costs to increase staffing to 4.1 hprd
• 7.6 billion to increase staffing
• (7 of total expenditures)

CMS 2001 Appropriateness of Nursing Staffing
Report
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State Legislative Actions

• 14 States increased nurse staffing
• California --3.2 hprd direct care - 1999
• Delaware 3.3 hprd direct care - 2002
• D.C. 3.5 direct care -2005
• Florida -- 3.6 total hprd (total care) - 2001
• State staffing levels are well below the 4.1 hprd
  that are needed -- they need to be increased

Harrington 2001 DHHS, ASPE 2003
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Nursing Home Nurse Turnover Rates in 2003

• High turnover rates
• RN Turnover Rates 50
• NA Turnover Rates -- 71
• Turnover ranges from 4 to 300 in CA
• Causes poor continuity of care quality
• High staffing reduces worker injury rates

AHCA, 2003
Trinkoff, Johantgen Muntaner, AJPH, 2005
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Nurse Home Staffing and Turnover

• Predictors of Low Staffing
• Low wages for NAs
• High turnover
• Predictors of Low Turnover
• High staffing
• High Turnover
• Related to low staffing, low quality,
  for-profit, large facilities

Harrington and Swan, 2003.
Castle Engber, 2006
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Increase Wages Benefits

• NA average wages -- 8.57/hr in 2000 - need to
  increase 17-22 (1.45-1.89/hr)
• RN wages need increase by 5-7
• LVNs wages need 3.3 to 4.5 increase

CMS 2001 Appropriateness of Nurse Staffing
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Inadequate Nursing Assistant Training Requirements

• 75 hours for nursing assistants
• 350 hours Manicurists
• 1500 hours Hair stylists
• Need to increase staff training requirements

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Positive Education (RN) Effects

• Monroe 1990
• Spector and Takada, 1991
• Braun, 1991
• Cohen and Spector 1996
• Bleismer et al., 1998
• Harrington et al., 2000
• Carter and Porell, 2003

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Need to Regulate Staffing

• Staffing is dramatically below the levels needed
  to protect health and safety
• RN staffing levels are declining
• Nursing homes are attempting to make money by
  lowering staffing levels
• Conclude that minimum nursing home staffing
  levels must be regulated
• Federal and state standards should specify 4.1
  hprd as a minimum and be adjusted for resident
  casemix
• Encourage use of CNSs and NPs

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Reform Government Reimbursement Policies
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1997 -Medicare Prospective Payment System for SNFs

• Established a prospective payment system
• Pays higher rates based on casemix/acuity need
  for nursing and therapy services - Resource
  Utilization Groups (RUGs)
• Encourages facilities to inflate the care needs
  of residents and is administratively complex --
  44 groups
• Dropped rates - 305 to 240 per day for
  freestanding facilities in 2000

GAO, 2002
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BBA 1997 -Medicare PPS Resulted in Poor Staffing

• CMS removed requirements to show expenditures for
  nursing and therapy services to receive payments
• Resulted in a decrease in nurse staffing ratios
  and an increase in deficiencies Konetzka,
  Norton, Kilpatrick. HSR. 2004
• Facilities allowed to make profits by cutting
  staffing
• Adverse outcomes have increased (UTIs pressure
  ulcers Konetzka, et al Med Care 2006

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Medicaid Nursing Home Reimbursement Rates

• Most states use prospective payment systems (PPS)
  (payment set in advance)
• Incentive for facilities to cut costs
• Facilities cut costs of staffing and
  wages/benefits
• Facilities admit the least costly residents
  unless a state uses case mix reimbursement
• Most states Medicaid rates are too low

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Raise Medicaid Rates to Increase Staffing
Quality

• Medicaid reimbursement rate increases
• improve quality as measured by an increase in
  the use of RN staff
• reduce deficiencies in the tightest regional
  markets (Grabowski, 2001)
• A 10 increase in rates reduces pressure sores
  (Grabowski, 2004)
• Higher reimbursement rates are related to higher
  staffing (Harrington and Swan, 2003)

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Cost Center Controls

• Government should set up cost centers
• Direct care, Indirect care, capital,
  administrative costs
• Funds should not be diverted from one cost center
  to another
• Profits should be limited
• Limits on staffing levels should be removed
• More financial audits and accountability is
  needed

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Use Public Information to Improve Care
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CONSUMER INFORMATION STRATEGY

• Assist in selection decisions
• Use for monitoring quality
• Embarrass facilities so they improve their
  quality
• Encourage payers/ purchasers to select on the
  basis of quality

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Medicare

• www.Medicare.gov/NHCompare/home.asp

Established in 1999 by HCFA/CMS
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Medicare Nursing Home Compare

• Lacks guides or ratings of facilities
• Limited staffing data no rating or risk
  adjustment
• No state deficiency/complaint data
• Includes misleading quality measures, e.g. pain
  and depression
• Lacks financial and ownership data

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CALIFORNIA HEALTHCARE FOUNDATION www.calnhs.org D
eveloped by UCSF, UCLA, UWisc, RAND
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Summary Page
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Staffing and Turnover
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Consumer Information Recommendations

• Expand and improve federal website information
• Invest public funds into websites for state and
  advocacy groups
• Educate the public to use website quality
  information

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Residential Care/ Assisted Living

• Residential care/AL beds have doubled in past 12
  years
• Few nursing staff to provide care and few RNs
• Few standards for staff, training, and quality
• No data reporting
• Services are expensive
• Residents who spend down resources are required
  to move
• Medicare and Medicaid generally do not pay for
  residential care

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Residential Care/ Assisted Living

• Expand the number of RNs and professionals in
  RC/AL
• Establish minimum standards for staff, training,
  and quality including
• minimum RN oversight
• basic training for unlicensed personnel
• comprehensive assessments
• Require data reporting
• Improve monitoring and oversight
• Develop public reporting
• Ensure adequate primary care for residents

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Pressures to Provide HCBS

• Poor quality of nursing home care and increasing
  costs
• Consumer demand for alternatives to nursing homes
  especially by the disabled community
• Consumer demand for consumer directed care and
  independent providers
• Olmstead Supreme Court decision giving
  individuals pay by government the right to live
  at home and the community if they are able and
  choose to do so.

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Medicaid HCBS Expenditures by Program, 1999-2002
25.3bn
22.5bn
19.6bn
17.4 bn
Kitchener et al, 2005
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Home and Community Based Services Quality Problems

• Prospective payment increased hospitalization
  rates
• Anderson, Clarke, Helms Foreman, J. Nurs
  Scholarship 2005
• Unstable workforce with low pay/benefits high
  turnover
• Shortages of workers and difficulty recruiting
• Lack of professional oversight
• Problems with
• timeliness and dependability
• quality of care
• negative attitudes
• lack of consumer directed care
• theft
• abuse

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HCBS Challenges

• Expand access to HCBS services and eliminate
  unmet need
• Ensure adequate numbers of providers and home and
  personal care workers
• Improve standards and the quality of care for LTC
• Improve oversight of unlicensed personnel
• Provide consumer information about access to
  services and quality
• Keep costs at a reasonable level

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Educational Challenges

• Nursing schools should require an undergraduate
  course in gerontology
• including geriatric assessment and supervision
  of unlicensed personnel
• Certification programs in gerontology are needed
  for current nurses
• Board examinations should require gerontology
  competency
• Nursing schools should establish graduate
  programs in gerontology for clinical nurse
  specialists and nurse practitioners
• Nursing schools should establish doctoral
  programs in gerontology and health policy

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LESSONS LEARNED

• Policy changes to improve quality take a long
  time
• Policy changes require extensive research
• Gerontological education is needed to improve
  quality
• Gerontological nursing needs to advocate for
  change in care delivery, policies, education, and
  research

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