The power of relationship for high quality long term care

the power of relationship for high quality long term care

Despite this, studies of nursing home residents reveal a generally high level of satisfaction, Relationships, activities, comfort, functioning, and dignity are important to both groups, but the Assessing The Quality Of Long-Term Care For The Elderly The perceived impotence of LTC has undermined its political power. Although care aides are a major resource for residents living in nursing homes and provide basic .. The power of relationship for high-quality long-term care. quality of care and reducing costs of care that affect the lives of the long-term care Long-term care facilities endure problems due to the high rate turnover ( Kutney- relationships between employee turnover intention of CNAs in the long -term care .. Although older adults can lose their exchange power as they age.

Critics of existing federal and state regulation argue that the current regulatory system has numerous deficiencies. First, they argue the nursing facility regulations are not evidence-based and do not measure what is important.

Despite OBRA 87, federal and state regulations still emphasize inputs, manuals, paperwork, and structural capacity rather than resident outcomes. Second, regulators are alleged to be inconsistent in their application of the rules, resulting in a systematic variation across states in the strictness of enforcement.

For example, inthe average facility in the United States had 5. On its face, it is difficult to believe that quality of care actually varies that much across states. Third, opponents of stricter regulation also argue that detailed rules stifle innovation, with few incentives for doing more than the minimum.

In this view, too many providers concentrate their energies on meeting the minimum requirements instead of excellence. The dilemma is how to give good quality facilities more flexibility, while still requiring substandard facilities to meet detailed standards. The risk is that providers might use less prescriptive standards to provide inadequate care.

the power of relationship for high quality long term care

Moreover, they contend that the unrelentingly negative view of nursing homes in the media has made it extremely difficult to recruit and retain high-quality staff. Fifth, many proposals for improving the regulatory system require substantially more financial resources for gathering information and for surveying facilities and enforcing sanctions. Lack of funding for nursing facility quality assurance at both the federal and state levels has been a chronic problem, with federal appropriations essentially level funded for many years.

Finally, whereas regulatory sanctions are meant to punish the owners or administrators of poor-quality nursing facilities, it is hard to separate the residents from the nursing homes.

It also requires relocation of residents, which is both hard to achieve because of relatively high nursing home occupancy rates and its disruption to residents' lives and social relations. Improving Information Systems for Quality Monitoring Valid, reliable, and timely data about nursing facility residents and the care they receive are fundamental to all strategies for monitoring and improving quality of care.

It is essential both to outside regulators and to individual providers. Key data about all nursing home residents are collected as part of the federal-mandated minimum data set MDS. Originally designed for needs assessment and care planning, the MDS periodically collects information on resident functional and medical status. Sincenursing homes have been required to collect MDS data for every resident upon admission, when there are major changes in health status, and at least annually.

the power of relationship for high quality long term care

CMS uses these quality indicators as part of the survey and certification process both to help measure quality and to identify specific residents who may be receiving poor-quality care. At least three concerns have been voiced about the use of MDS data for quality assurance purposes. First, the data may not be accurate, especially now that it is being used for regulatory purposes, as well as care planning. A key issue is that facility staff fills out the MDS. If CMS uses this data to punish the facility, staff have incentives to alter reporting to avoid these negative sanctions.

However, a recent CMS-funded study found good levels of reliability in MDS-derived quality indicators, at least among the study facilities Morris et al. Second, quality indicators face difficult statistical issues. Some of the more serious quality indicators, such as decubutis ulcers, do not involve very many residents, even in poor facilities.

Given the relatively small number of residents in nursing homes the average facility only has about 90 residentsrandom variation in the prevalence of decubitis ulcers may be substantial. In addition, case-mix adjustment may be crucial to properly identifying poor performers, but these adjustments are quite complicated to perform, requiring Bayesian multilevel hierarchical modeling Angellilli, Failure to risk-adjust the measures would punish facilities that admit more severely disabled and medically complex residents.

Third, although, in theory, poor performance on the quality indicators is supposed to trigger additional investigation to establish whether poor-quality care is actually provided, advocates, researchers, and regulators may be inclined to take them, in and of themselves, as evidence of poor-quality care. For example, CMS is starting a five-state pilot project to make 11 quality indicators widely available to consumers with the explicit assumption that they measure quality of care U.

Department of Health and Human Services, This may or may not be the case. However, a recent CMS-sponsored study found a substantial number of quality indicators to have a high degree of validity and a significant number of additional ones to have a good level of validity Morris et al. As mentioned previously, though, merely the absence of negative outcomes still may not identify a facility in which we would want to live our lives.

Strengthening the Caregiving Workforce Nursing home care is a service that is provided by people, not machines. Three approaches have been proposed to improve nursing home care by strengthening the caregiving workforce.

The first strategy is to increase the amount of personnel in nursing homes by mandating higher minimum staffing ratios. The second approach is to increase the required minimum training of people who work in nursing homes, especially certified nurse assistants.

Staffing Ratios Federal standards for staffing in nursing homes do not specify particular quantities of staff. Although OBRA 87 requires that nursing facilities have licensed nurses on duty 24 hours a day, an RN on duty at least 8 hours a day 7 days a week, and an RN Director of Nursing, these requirements are not adjusted for facility size or case-mix.

The number of personnel per resident varies widely across facilities. For example, inthe median facility provided 3.

the power of relationship for high quality long term care

A number of studies have found a positive association between nurse staffing levels especially for registered nursesand the processes and outcomes of care Institute of Medicine, For example, Harrington and colleagues c showed that higher nurse staffing hours were associated with fewer nursing home deficiencies.

Many reports of poor-quality care e.

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Many clinicians, researchers, and consumer advocates consider the federal nursing home staffing standards to be too vague and have called for higher, more specific standards.

The nursing home industry and many government officials oppose the imposition of higher and more specific staffing requirements for several reasons.

First, they argue that how staff are organized, supervised, and motivated is at least as important as the number of workers. Second, a major difficulty in setting standards is that there is little empirical, quantitative research on what the minimal staffing level should be. Up until the recent CMS study, all of the proposed standards rely solely on expert opinion and fail to adjust for case-mix, which is the primary determinant of staffing needs. Third, depending on the minimum staffing level established, additional costs could be significant.

In part because of the costs involved, the Bush Administration does not plan on proposing minimum staffing levels for nursing homes. Staff Training One possible reason for poor quality in nursing homes is that staff is not adequately trained.

Especially with the increased acuity of nursing home residents and the greater complexity of care needed today, one strategy to improve quality of care is to significantly increase training requirements for all types of nursing home staff.

Certified nurse assistants make up the largest proportion of caregiving personnel in nursing homes and provide most of the direct care, but they receive little formal training. OBRA 87 requires nursing assistants to receive a minimum of 75 hours of entry-level training, to participate in 12 hours of inservice training per year, and to pass a competency examination within 4 months of employment.

Some states, such as California, require longer periods of training Harrington, Kovner, Mezey, et al. As minimal as the training requirements are, they exceed what most other low-skill, low-paid jobs require, and may deter some people from working in the industry. On the other hand, the minimal training also means that there is no career ladder for certified nurse assistants.

There are three major issues involving staff training requirements. First, although there is a logic to formal minimum training requirements, there is no research on what those levels should be and what the impact of increased training has on quality of care. Second, training is not free. The facility, the worker, or some third party must pay for it. Third, higher training requirements may exacerbate the staffing shortage by making it more difficult to work in nursing home settings. Difficulty in recruiting aides is likely to worsen over time as the number of people needing long-term care increases more quickly than the working age population.

Nursing home workers, especially nurse assistants, receive low wages and generally lack fringe benefits. Higher real wages and benefits for nursing assistants should help draw more marginal workers into the labor force. Moreover, increases in the relative compensation for nursing home staff could help reallocate available low-wage workers to the long-term care sector.

Obviously, providing higher wages and benefits could also provide a better life for workers. Raising wages faces three difficulties, although they are not technically insurmountable. They are more a problem of political will. First, although it is always difficult to increase government spending, the recent recession, federal and state tax cuts, and the aftermath of the terrorist attacks of September 11th make it especially difficult now.

Many states are considering reimbursement cuts rather than increases Johnson, Second, making sure that reimbursement increases result in wage and benefit increases is not always easy to verify, although increased regulatory oversight could solve this problem.

Third, no empirical research confirms that increased wages and benefits result in improved recruitment and retention or have an impact on quality of care.

the power of relationship for high quality long term care

Thus, although there is a strong logic in favor of increased wages, policy makers do not have confidence that the impact of higher wages will be worth the cost. Voluntary and External Providing Consumers With More Information One popular strategy for improving the quality of care is to provide consumers and their families with more information about quality of care in individual nursing homes, which they can use to help choose facilities.

The premise is that, armed with information about quality of care, consumers will choose high-quality facilities and avoid poor facilities. Thus, market competition will force improvements in quality of care.

The relatively nontechnical nature of much of nursing home care means that consumers should be able to make choices based on quality Bishop, The assumption is also that merely making the information available to providers will motivate action on their part. Operating sincethis Web site provides information about individual nursing homes in a searchable database, including information on general characteristics of the facility e.

It is a very popular source of information about nursing homes, receiving aboutvisits a month U. Although there is widespread support for providing more information to consumers, there are a number of concerns about this approach. First, to date, there is no research on the impact of providing information about individual facilities on consumer choice of facilities or on quality of care.

Many nursing home placements are made on an urgent basis, and consumers may not have the time or ability to thoroughly research a variety of nursing homes.

Searches are typically made in small geographic areas, limiting the number of possible choices. In addition, although nursing facility occupancy rates have fallen, they are still relatively high, limiting consumer choice, at least for those who cannot wait for a placement. Moreover, it is not clear that consumers are able to interpret the information provided, especially because an overall rating as in Consumer Reports is not provided on the federal Web site and is rarely provided on state Web sites.

Second, the information on nursing homes inevitably draws on existing regulatory data about facilities or residents, the potential problems of which already have been discussed.

This data may also be incomplete or out-of-date. Implementing person-directed care in culture change, therefore, requires recognizing and addressing these adaptive challenges as well as technical challenges. When we either ignore adaptive challenges or confuse adaptive challenges for technical challenges, we risk that a specific practice change i.

the power of relationship for high quality long term care

Rather, an adaptive leadership framework suggests that developing organizational capacity for culture change requires recognizing adaptive challenges and fostering adaptive leadership behaviors to address these adaptive challenges. Fundamentally, culture change requires the transformation of an organization to develop new, normative values and behaviors congruent with person-directed care. Generating new rules and procedures alone will not result in new caregiver values and principles.

For example, implementing person-directed care requires that direct caregivers and residents know one another. A common approach to meet this requirement is to have staff permanently assigned to a set of residents. Enacting a new policy of permanent assignments is an example of viewing the need for caregivers and residents to know one another as a technical challenge and using administrative leadership alone to address this challenge. However, viewed as an adaptive challenge, we can see that for caregivers and residents to know one another is a challenge with no currently known, readily applied solution.

Adaptive work is required of caregivers and residents to generate new ideas of how they will develop connections and strategies for learning about one another and sustaining positive relationships. Managers may need to talk with caregivers and residents and gain new insights into what kinds of interventions will nurture relationships.

Perhaps permanent assignments will be one component of the solution, but perhaps not. Everyone will be asked to reframe how they may have thought about the caregiving relationship in the nursing home and develop new attitudes and beliefs. By acknowledging the adaptive challenges for caregivers and residents to know one another, we expand the opportunities to problem-solve, increase the probability of achieving our aim, and enrich our understanding of the leadership required to successfully implement culture change.

The purpose of this study is to describe key adaptive challenges and leadership behaviors to implement culture change for person-directed care. Therefore, we asked the following two research questions: Methods The overall study design is a qualitative, observational study of nursing home staff perceptions of the implementation of culture change in each of three nursing homes.

A qualitative methodological approach was selected due to the descriptive, hypothesis-generating nature of the research questions. Approval for the study was obtained from the two Institutional Review Boards affiliated with the researchers.

These focus groups were supplemented with two additional focus groups of key stakeholders, including medical care providers, and nursing home administrators. The participant sampling frame included all licensed and unlicensed nursing staff, medical care providers, and nursing home administrators in each of three nursing homes within a mile radius of the university.

We first identified a convenience sample of nursing homes with which we have had research, practice, or educational collaborations within a 1-hr drive 50 miles of our affiliated institutions. From this set of nursing homes, we purposively selected homes for diversity in ownership and payment mix see Table 1based on previously cited findings of resources and regulations as key barriers to culture change; this ensured variability in each of these barriers.

We did not sample nursing homes based on the degree of implementation of culture change; however, the nursing home administrators of all three homes described their organizations as actively engaged in culture change activities.