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NURSING-HOME CARE..........Updated July 2018 Suzanne M. Gillespie, MD, RD, CMD, AGSF; Timothy J. Holahan, DO, CMD

KEY POINTS

  • Nursing-home regulations, originally driven by the Omnibus Budget Reconciliation Act of 1987, require a periodic comprehensive assessment of all nursing-home residents, set minimum staffing requirements, and foster residents’ rights by limiting the use of restraints and psychoactive medications.

  • The care of nursing-home residents has become more complex over the past several years, commensurate with an increasing level of medical acuity in an environment constrained by limited resources.

  • Dementia is the most common condition in the nursing home.

Nursing homes have evolved dramatically over the past several years, responding to a variety of government and market-driven forces. Highly regulated institutions for people who often have severe physical and mental disabilities, nursing homes, more than ever, present the clinician with a set of unique and complex care issues, many of which are best understood in the context of population needs, government policy, and reimbursement and staffing patterns.

THE NURSING-HOME POPULATION

Currently, more than 1.4 million Americans reside in certified nursing facilities. Relatively speaking, this is a small portion of Americans who are >65 years old (2.6%); 15% of nursing-home residents are <65 years old, and <1% are ≤30 years old. The typical nursing-home resident is a non-Hispanic, white, unmarried (usually widowed) woman >85 years old with limited social supports. Most people admitted to nursing homes are older adults.

In the last 20 years, the proportion of the nursing-home population that is <65 years old has increased (8%­–15%), as has the population of residents >85 years old (38%–­43%). The numbers of Hispanic, Asian, and black Americans living in nursing homes have also increased. Although some of this increase is explained by increasing numbers of these populations in American demographics, the rate of increase of minority populations in nursing homes has exceeded changing population demographics, suggesting that nursing-home use is increasing by these populations. It has been speculated that disparities in access to community-based long-term care services may mediate this differential use, but more study is needed. Some cultural groups, particularly Hispanic and Asian Americans may be reluctant to consider nursing-home placement because of concerns about the lack of staff on all shifts who speak the same language, as well as the perception that the nursing home will not be able to serve familiar foods or follow other cultural traditions. As their older parent-caregivers are lost, older adults with intellectual and/or developmental disabilities constitute another unique population that is requiring nursing-home level care in higher numbers. These individuals often require specialized care that many nursing homes may have difficulty providing.

Functional disability is prevalent in nursing-home residents. A quarter of long-stay nursing-home residents require supervision or hands-on assistance in 5 ADLs (ie, eating, dressing, bathing, transferring, and toileting). Cumulative disability is high, with almost 90% of nursing-home residents requiring assistance in ≥3 ADLs. Many residents require assistance with eating (59%), more than a third require a mechanically altered diet consistency (32.5%), and 5% receive tube feedings. Difficulty with bladder or bowel control, or both, is reported in >60% of long-stay nursing-home residents, and 34% are described as always incontinent. Hearing and visual impairments are also common, with each affecting approximately one-third of nursing-home residents. Not surprisingly, most residents have communication problems, with frequent difficulty both in being understood and in understanding others. In 2000, <18% of nursing-home residents ambulated independently; the number of nursing-home residents able to independently ambulate has diminished steadily since that time. Currently, few residents (8.8%) walk without assistance or supervision, and most (65.8%) can be described as “chairfast,” reflecting reliance on a chair for mobility and an inability to take steps without extensive or constant weight-bearing support.

Today’s nursing-home population is sicker than that of the past. Over two-thirds of long-stay residents in skilled-nursing facilities have multiple medical conditions. More than 1 in 20 nursing-home residents have pressure injuries, and more than three-quarters of residents require special skin care to maintain skin integrity. Nearly 40% of older adults in the nursing home are diagnosed with heart failure or ischemic heart disease. Diabetes and stroke are reported in 22% and 26% of new nursing-home admissions, respectively. COPD, hypertension, arthritis, and hip fractures are also prevalent health conditions among nursing-home residents. Special treatments are often required; in 2015, more than 20% of residents received injections, 15% received respiratory therapies (respirators/ventilators, oxygen, inhalation therapy, and other treatments), and almost 5% received tube feedings.

Dementia is the most commonly condition in nursing homes, being formally diagnosed in 46% of residents. The prevalence of cognitive impairment is reflected in the fact that about 80% of nursing-home residents are felt by nursing home staff to be impaired in their ability to make daily decisions, and two-thirds have orientation difficulties or memory problems, or both. Comorbid physical and mental diagnoses in this population are common; approximately 30% of nursing-home residents have psychological diagnoses with depression diagnosed in 20%–25%. More than 60% of residents are treated with psychoactive medications. Additionally, behavioral issues, such as verbal and social inappropriateness, wandering, and resistance to care, are seen in one-third of nursing-home residents.

NURSING-HOME AVAILABILITY

According to CMS data, there are currently 15,640 certified nursing homes in the United States with 1.65 million beds and 2.4 million discharges (ie, to home, hospital, or secondary to death). Of these facilities, 68.4% are proprietary (ie, for profit), with voluntary nonprofit (23.8%) and government nursing homes (7.1%) accounting for the remainder. Nursing-home care is provided to eligible veterans in 132 Veterans Affairs Community Living Centers. The U.S. Department of Veterans Affairs also recognizes 161 State Veterans Homes, which are owned, operated, and funded by all 50 states and Puerto Rico to provide long-term care services to veterans. In some states, nonveteran spouses and parents may also be eligible for care in a State Veterans Home. Nationally, nursing homes operate an average of 109 beds, but facility size varies greatly by state. Most commonly, nursing facilities have between 100–199 beds (44.1%), with a minority having >200 beds. Associations between facility size and quality of care have been explored and suggest that smaller facilities may provide higher quality of care on average than larger facilities. Evidence also suggests that nursing homes with larger populations of residents whose stay is funded by Medicaid have lower quality as defined by the federal government. A similar relationship is suggested for proprietary status. While these relationships are complex, the association is likely mediated in large part by staffing levels. A little more than half of all nursing homes are part of a chain, and about 5% are hospital-based. Nursing homes vary with respect to what ancillary services are available. Many facilities offer on-site mobile radiography services and infusion service.

Most admissions to nursing facilities come from acute hospitals, followed by private residences and other nursing homes. Not surprisingly, assisted-living facilities are becoming a greater source of older adults admitted to nursing facilities of total admissions. Assisted-living facilities do not operate under the oversight of a single national regulatory or licensure agency. In general, assisted-living facilities have greater heterogeneity than nursing homes in services offered and are most commonly paid for with out-of-pocket funds. Assisted-living facilities accommodate a population of older adults that significantly overlaps that found in nursing homes, particularly regarding their underlying physical and psychological deficits. Although the social model of care still predominates in most assisted-living facilities, rising medical acuity and resident complexity is demanding more substantive physician involvement. Several models of physician practice in assisted-living facilities exist; however, there is a paucity of research demonstrating the superiority of one model over another. Greater on-site care, scheduled team rounds, and possibly a defined medical director role for the assisted-living facility will be seen with increasing frequency in the future.

Risk of nursing-home admission is high with 1 of every 3 adults >65 years old requiring a nursing-home admission in their lifetime. The risk of nursing-home admission rises steeply with age. While 2.4% of those 75–84 years old reside in nursing homes, this figure approaches 10% for those ≥85 years old. Barring breakthroughs in the treatment of dementia, the number of people ≥65 years old using nursing homes could significantly increase by the year 2030. Interestingly, the occupancy rates in nursing homes nationally have declined over the past several years and now stand at 82%. This decline has generally been attributed to the availability of other community-based long-term care options, such as assisted living, but there are likely other causal social and financial variables that have yet to be identified.

Postacute care is increasingly being offered in nursing-home settings, a response to the higher-care needs of older adults in conjunction with shorter hospital stays and the presence of a Medicare payment stream. Although the types of postacute services and programs vary significantly from one locale to another (eg, dialysis, orthopedic, ventilator, postoperative, rehabilitative, wound care), they remain distinct from the standard nursing-home services by integrating the features of acute medical, long-term care nursing, and rehabilitative settings. The challenge in postacute care is that of accommodating patients with varying degrees of disease severity, functional dependence, and comorbidities. Some limited studies suggest that, for selected patient populations, postacute care in the nursing home has outcomes equal to or better than those of postacute care in acute hospitals. Definitions as to what constitutes postacute care, however, vary widely, as do regulatory standards, which make comparison studies difficult.

The average length of stay for Medicare beneficiaries in a nursing facility is 26.8 days. On any given day, residents with a length of stay of <3 months comprise about 20% of the total nursing-home population. Conversely, long-stay residents, whose length of stay is ≥90 days after admission, account for 80% of the nursing-home population. Among all nursing-home residents, about 25% have a length of stay >3 years. This diversity in nursing-home stays is reflected in a mean length of stay for those admitted to a nursing home of 835 days, with a median length of stay of only 463 days. Historically, increases in the number of residents with shorter lengths of stay coincided with increased Medicare funding of postacute care in nursing homes.

This continuum spanning subacute and long-term care in nursing homes contributes to the development of 2 populations of residents. Many short-stay residents are admitted for rehabilitation, targeting restoration of the functional ability and endurance that will allow them to return to community-based living settings. Others enter nursing homes for end of life or hospice type care. A recent study revealed that approximately one-third of Medicare beneficiaries have at least 4 transitions of care in the last 6 months of life, with the skilled-nursing facility as a common site of care. As a result, many have speculated that improving palliative care in nursing homes may help reduce the number of care transitions at the end of life.

In contrast, many of those who ultimately become long-stay residents present to nursing homes for ongoing supportive care of progressive, chronic illnesses. Interestingly, improvement in function among long-stay nursing-home residents is quite common, further reflecting the heterogeneity of the nursing-home population. The role of the nursing home in the continuum of health care is expected to become more important as health care systems adapt to the need to provide high-quality, accountable care to the expanding population of older adults and disabled adults.

FINANCING

Across all payers, nursing-home expenditures total more than $140 billion dollars. In 2012, the national median daily rate for a private room in a nursing home was $267, or $97,455 annually. Public health programs primarily finance this cost; Medicaid and Medicare account for 62% and 14% of nursing-home care payments, respectively. With the high annual costs, those paying for nursing-home care out-of-pocket often deplete their personal funds and turn to public funding. Although purchase of long-term care insurance has been increasing, these policies generally pay for only a small fraction of nursing-home care. Medicare funding for nursing-home costs is available for certain limited conditions for beneficiaries who require skilled-nursing or rehabilitation services. In general, to be covered, beneficiaries must receive services from a Medicare-certified skilled-nursing home after a qualifying hospital stay. A qualifying hospital stay is a hospital stay of at least 3 days before entering a nursing home. Some groups have argued for elimination of this requirement for a 3-day qualifying hospital stay on the basis that it limits accessibility to appropriate levels of care for patients, increases cost, and unnecessarily exposes patients to hazards of hospitalization. To that end, some accountable care organizations and some private insurance companies have begun to waive the 3-day qualifying stay requirement for admission.

Medicare covers only those skilled-nursing facility services rendered to help a beneficiary recover from an acute illness or injury. Medicare pays for skilled care in full for the first 20 days in a skilled-nursing facility. For days 21–100, a co-payment from the resident is required for skilled-nursing facility services; beyond 100 days, Medicare does not cover skilled-nursing facility care.

As part of the Balanced Budget Act of 1997, Medicare payments to nursing homes are based on an individual’s functional needs and potential for rehabilitation. This prospective payment system, also called PPS, requires careful documentation of functional gains, particularly by rehabilitation therapists. Although the PPS has not conclusively limited access to skilled-nursing care for Medicare beneficiaries, it has forced nursing homes to be more diligent with regard to their admission policies. Not unexpectedly, physical, occupational, and speech therapies are commonly prescribed in the nursing home; according to one study, half of all patients admitted to nursing homes receive at least 90 minutes daily of these rehabilitation services. The PPS requires nursing-home staff to carefully document gains in function to ensure reimbursement. A recent legal decision (Jimmo v. Sebelius, 2013) clarifies that the skilled services may include those interventions to prevent or slow further deterioration.

Supplemental increases in reimbursement are made to offset costs of caring for those with HIV/AIDS. Despite the high cost of nursing-home care, resources remain constrained. In general, psychiatric conditions are undervalued with respect to reimbursement in long-term care. Residents with active psychiatric illness often require increased care and staff time, but mechanisms do not exist for increased reimbursement for those efforts. Shortages of psychiatric specialists trained in nursing-home care, combined with relatively low reimbursement rates for care in nursing homes, add to the challenge of providing optimal mental health care in this setting. Many are exploring telemedicine as one potential means to increase access to urgent and consultative medical care in the nursing home.

STAFFING PATTERNS

Resident care and evaluation in the nursing home largely depend on nurses and nursing assistants. Nursing facilities are required to provide nurse staffing sufficient to provide the care outlined in its care plans. According to federal guidelines, every nursing home must have the following on staff: a licensed nurse who acts as charge nurse on each shift; a registered nurse who is on duty at least 8 consecutive hours, 7 days a week; and a registered nurse who is designated as the director of nursing. Studies have confirmed the correlation between the provision of quality care to total nursing hours and the ratio of professional nurses (ie, registered nurses) to nonprofessional nursing staff. For many years, experts, including the Institute of Medicine, have advocated for increasing nurse staffing levels to enhance the quality of nursing-home care, spurring Congress to debate the merits of mandatory minimal staffing ratios. Although recommendations for minimal and optimal staffing at nursing facilities have been made by CMS based on links to quality of care, current federal regulations do not mandate specific nurse-to-resident staffing ratios. The total direct care staffing averages 4.05 hours per resident day (HPRD), or roughly 243 minutes per resident per day, but varies significantly both within and between states. Nursing assistants contribute most direct staff time, at 2.43 HPRD. Licensed nurses and registered nurses contribute 0.81 and 0.80 HPRD, respectively. Physical and occupational therapy staff HPRD have increased to 0.190 and 0.159, respectively, commensurate with increasing medical acuity and a rise in the proportion of skilled-nursing facility days. However, HPRD has remained flat for licensed nurses and nursing assistants providing direct care. It has been estimated that 9 of 10 nursing homes are inadequately staffed, and nearly $8 billion dollars would be needed to bring staffing to adequate levels.

Recruiting and retaining staff, particularly nursing assistants who constitute the bulk of the nursing-home workforce, also continues to be difficult. Yearly turnover rates of approximately 50% for direct care staff of nursing facilities, including 50% of nurse assistants and registered nurses and 35% of licensed practical nurses, have been reported. Stability of staff has been associated with better quality of care. Turnover rates have been associated with increased rates of hospitalization for nursing-home residents and have been linked to the organizational culture within the nursing facility.

Staffing issues are also pertinent to the medical providers who practice in nursing homes. Many physicians avoid nursing-home practice because of perceptions of excessive regulations, paperwork, limited reimbursement, and aversion to the long-term care environment. Recent data is consistent with only a minority of physicians ever billing in nursing homes (9.8%) and a small but increasing number of physicians who dedicate the majority of their practice to nursing-home medicine (n=2,225). In this vein and taking a lead from the recent hospitalist practice movement in acute care hospitals, formal creation of postacute and long-term care specialists (or “SNFists”) has been proposed, a concept that has been put into practice in the Netherlands. Closed-staff models are thought to deliver a higher intensity and quality of care in part because of the integration of the physician into the nursing-home facility culture, which ultimately improves interdisciplinary communication and treatment. Emerging evidence suggests that quality of clinical outcomes and hospitalization rates for nursing-home residents may be lower in facilities that employ a limited number of committed physicians (SOE=B). In one study, physicians who spent >85% of their total practice time in nursing homes had a 50% lower rate of potentially preventable hospitalizations than those physicians devoting ≤5% of their practice to nursing-home care. In another study, the quality of prescribing in the nursing home was positively correlated with enhanced nurse-physician communication and with regular interprofessional team discussions. Historically, a paucity of credible role models for physicians in training also contributed to a lack of interest and involvement in long-term care issues. However, use of the nursing home as an academic training site can offer important exposure to this practice opportunity and professional role models and may help to stimulate interest among trainees.

FACTORS ASSOCIATED WITH PLACEMENT

Although there is a significant chance of being admitted to a nursing home with increasing age, other factors, such as low income, poor family supports (especially lack of spouse and children), and low social activity have been associated with institutionalization (SOE=B). Cognitive and functional impairments have also predicted nursing-home placement. Interestingly, for patients with dementia, education and caregiver support have been shown to delay the need for nursing-home placement for up to 1 year (SOE=B). The range of long-term care services that are now available (ie, skilled nursing, home care, assisted living) further increases the complexity of placement decisions. The use of formal (ie, paid-for) community services does not necessarily reduce the likelihood of nursing-home placement for patients with severe disabilities.

THE INTERFACE OF ACUTE CARE AND THE NURSING HOME

Approximately 1 in 5 Medicare beneficiaries are discharged from hospitals to a skilled-nursing facility. Conversely, nursing-home residents frequently use emergency department and acute hospital care. Nursing-home residents account for >2.2 million emergency department visits annually in the United States, or 1.6 emergency department visits for every nursing-home resident. The Office of the Inspector General reported that in 2011, one-quarter of Medicare nursing-home residents experienced hospitalizations at a cost to Medicare of $14.3 billion. Although most nursing-home residents who were hospitalized were hospitalized once (63.8%), many experienced multiple transfers with 20% having two transfers, 7% three transfers, and 5% four or more transfers. Hospital admissions from nursing homes cost a third more than the average Medicare hospital admission. The most frequent causes of hospital admission by nursing-home residents include septicemia, pneumonia, and congestive heart failure.

Unfortunately, suboptimal information transfer often complicates transitions between acute- and long-term care settings. Illegible or nonexistent transfer summaries; omission of prescribed medications; and the lack of documentation of advance directives, psychosocial information, and behavioral issues are but a few of the information gaps commonly reported. Risk of hospital readmission from the nursing facility is likely influenced by a variety of nursing-home structural characteristics and processes. For example, geographic location, larger bed size, free-standing facilities (as opposed to hospital-based), a higher percentage of Medicaid patients, and for-profit status have all been associated with higher readmission rates. Higher nurse staffing ratios are associated with lower readmission rates.

Five conditions account for most (78%) of these rehospitalizations: congestive heart failure, respiratory infection, urinary tract infection, sepsis, and electrolyte imbalances. Polypharmacy and a lack of thorough medication reconciliation have also been found to contribute to higher readmission rates, especially days 1–7 after discharge from an acute-care setting. Reduction of hospital readmission from skilled-nursing facilities is the focus of recently enacted value-based purchasing program for skilled-nursing facilities.

Better understanding of contributing factors and best practices to target reduction in the high rates of hospital admission and readmission by nursing-home residents is needed. Several recent quality initiatives have focused on early identification of change in condition in the nursing home, as well as improved transition of care processes to and from the nursing home. Interventions to Reduce Acute Care Transfers (INTERACT) is a quality improvement program that seeks to improve the identification, evaluation, and management of acute change of conditions in nursing-home residents. Through a focus on advance care planning, structured communication between nurses and physicians, and the use of care pathways, acute hospital admissions have been reduced up to 17% in some facilities. However, a recent randomized study of 85 nursing homes did not demonstrate an impact of INTERACT on hospitalization or emergency department visit rates.

About 50% of the community-dwelling adults discharged from the hospital to a postacute stay in a skilled-nursing facility are subsequently discharged home. Attention is also being paid to preventing hospital readmission after discharge from the skilled-nursing facility to the community.

REGULATIONS

In 1983, a published Institute of Medicine report documented significant deficiencies in the care of nursing-home residents and influenced the passage of the Omnibus Budget Reconciliation Act (OBRA) in 1987. OBRA set new, higher standards for quality of care provided in nursing facilities certified for reimbursement under Medicare and Medicaid (which includes most skilled-nursing facilities) by CMS. CMS pays Medicare claims and interprets legislation into written regulations for skilled-nursing facilities. CMS interprets federal statutes and also writes regulations for Medicaid that are administered by each state’s Medicaid program. Federal regulations, including those pertaining to long-term care, are compiled in the Code of Federal Regulations. Each federal regulation is given a tag number, often called “F-tags.” To qualify for federal reimbursement under Medicare and Medicaid, facilities must comply with these CMS regulations. In October 2016, CMS updated the rules of participation for nursing homes that are reimbursed by Medicare and Medicaid. This new “final rule” expanded measures with the goal of improving the overall care and safety for residents living in nursing homes.

In the years since OBRA was instituted, nursing-home regulations have targeted many residents’ rights issues, including setting limits on restraint use and regulating use of psychoactive medications. These regulations have had notable impact on quality of care including significant decreases in the use of restraints in nursing homes, increases in registered nurse staffing, and the establishment of training requirements for certified nursing assistants.

OBRA also mandates comprehensive periodic assessments of all nursing-home residents. This is accomplished by the Minimum Data Set (MDS), which surveys a host of clinical issues thought to directly relate to the quality of resident care and thus considered pertinent to effective care planning. A resident’s medical regimen must be consistent with the assessment compiled in the MDS. CMS also uses the MDS for individual facilities to compile nursing-facility quality measures data, which are reported publicly on the CMS website and used for payment (www.medicare.gov/NHcompare/Home.asp). Measures include outcomes data such as prevalence of pain, pressure injury, weight loss, and depression, as well as rates of vaccination, restraint use, and urinary tract infection. Although publication of these measures is intended to offer a way to compare facilities, it has been criticized for lack of standardization of data to account for the substantial variability in disability and medical acuity between different facilities. For quality measures of nursing homes that are publicly reported by CMS, see Table 1 and Table 2. The MDS was updated to version 3.0 by CMS in 2010 and resulted in changes in the publicly reported quality measures. Included in the measures of nursing-home quality publicly reported by CMS is the 5-star quality rating for nursing homes. This rating was developed to help consumers, families, and caregivers make comparisons about nursing homes and areas of strength or concern. The 5-star rating is based on three sources of data: the facility’s health inspection survey results, staffing levels, and 13 MDS-based quality measures and 3 quality measures drawn from MDS- and Medicare claims-based data. Nursing-home ratings take into account a variety of measures that are thought to reflect the facility’s practice such as the percentages of residents who are prescribed antipsychotic drugs, who have indwelling catheters inserted and left in their bladder, or who experience falls with major injury. In 2016, five new quality measures were introduced into the star rating methodology, including a focus on hospital readmissions and prevention of avoidable declines in resident function.

Table 1─Quality Measures for Nursing Homes Based on the Minimum Data Set and Publicly Reported by CMS

For Long-Stay Residents
Percent assessed and given, appropriately, the seasonal influenza vaccination
Percent assessed and given, appropriately, the pneumococcal vaccination
Percent whose ability to move independently worsened
Percent whose need for help with daily activities has increased
Percent who self-report moderate to severe pain
Percent who were physically restrained
Percent who have depressive symptoms
Percent who have/had a catheter inserted and left in their bladder
Percent with a urinary tract infection
Percent who lose too much weight
Percent who experience one or more falls with major injury
Percent who received an antianxiety or hypnotic medication
Percent who received an antipsychotic medication
For Long-Stay Low-Risk Residents
Percent who lose control of their bowels or bladder
For Long-Stay High-Risk Residents
Percent who have pressure injuries
For Short-Stay Residents
Percent assessed and given, appropriately, the seasonal influenza vaccination
Percent assessed and given, appropriately, the pneumococcal vaccination
Percent who newly received an antipsychotic medication
Percent who self-report moderate to severe pain
Percent with pressure injuries that are new or worsened
Percent who improved in their ability to move around on their own
Percent who were rehospitalized after a nursing-home admission
Percent who were successfully discharged to the community
SOURCE: Adapted from Department of Health and Human Services, Medicare. Nursing Home Compare. www.medicare.gov/NHcompare/.

Table 2—Examples of New CMS Quality Measures for Skilled-Nursing Facilities
Example
Justification
Percentage of short-stay residents who were re-hospitalized after a nursing home admission
Nursing homes help residents recuperate from a hospital stay and avoid going back to the hospital. Sometimes it is necessary for a resident to return to the hospital. However, if a nursing home sends many residents back to the hospital, it may indicate that the nursing home is not properly assessing or taking care of its postacute residents.
Percentage of short-stay residents who have had an outpatient emergency department visit
Emergency departments provide necessary care for many residents of nursing homes. However, if a nursing home regularly sends many residents to the emergency room, it may indicate that the nursing home is not properly assessing or taking care of its residents to prevent development of conditions that require emergency treatment.
Percentage of short-stay residents who were successfully discharged to the community
High rates of successful discharge, or a resident remaining in the community for at least a month, indicate that the nursing home is restoring a resident’s function.

Adherence to regulations is assessed by mandatory site visit surveys. These surveys are mandated every 15 months but occur on average every 12 months. During traditional nursing-home surveys, facility procedures and records are reviewed, and quality of care and quality of life for residents are observed. The Quality Indicator Survey process (QIS) is used during regulatory survey. QIS is a computer-assisted, 2-staged long-term survey process used to systematically review nursing-home requirements and objectively investigate any triggered regulatory areas. In the QIS, a sample of residents, developed from census, admission, and MDS data, is created and used to strategically perform interviews, observations, and chart reviews that calculate indicators of quality of care and quality of life in that facility. Those areas, as well as a group of standard facility-level tasks, are then assessed in an in-depth fashion.

Failure to meet regulatory standards for care is cited in a “deficiency.” Penalties imposed for deficiencies depend on the nature and severity of the deficiency and can range from implementation of a corrective action plan to monetary fines, limits on facility admissions, or even facility closure. Each deficiency is rated according to a standard matrix of scope and severity. Severity refers to the level of harm to the resident or residents involved, from no harm or minimal potential for harm to immediate jeopardy to health or safety. Scope of a deficiency may be isolated, a pattern, or widespread in nature. Scope and severity scores follow an alphabetical pattern from least severity “A” to greatest severity “L.” Inspections can also occur at any time in between mandated surveys as a result of a complaint received by the state. In 2015, the mean number of deficiencies received by nursing homes during regulatory visits was 8.6, with 21% of facilities cited for deficiencies relating to actual harm or immediate jeopardy of residents.

OBRA mandates that each individual in a nursing facility receive and be provided the necessary care and services to achieve and maintain “the highest practicable physical, medical, and psychological well-being” that can be obtained. The facility must ensure that the resident optimally improves or deteriorates only within the limits of that resident’s right to refuse treatments and within the influence of their illnesses and normal aging. When a resident declines (or does not improve), a survey team may investigate whether the decline was avoidable. A decline may be determined unavoidable if the resident has been given a careful and thorough assessment, which directs the resident’s care plan. The interventions included in the care plan should be evaluated and revised as necessary. Documentation of a resident’s reasonable prognosis and the risks versus reasonable expected benefits of treatments has an important role in care planning in the nursing home, particularly given current regulatory and liability influences.

OBRA requires that a state agency must screen and preapprove the admission of individuals with intellectual disability or serious mental illness to a nursing facility (F285). This screening is done to ensure that the facility can provide appropriate programs and services to meet the individual’s needs. Residents readmitted to a nursing facility from a hospital, or those admitted from a hospital with an anticipated stay of <30 days who require treatment at the nursing facility for the same problem for which they were hospitalized, are exempt from screening.

Medical Director

The quality of physician practice in the nursing home is, in many ways, determined by the medical director. CMS requires that every skilled-nursing facility designate a licensed physician to serve as medical director (F501). The United States is the only country in the world that requires a nursing home medical director. The medical director has many roles (Table 3) that differ from the roles of the attending physician and include coordination of medical care that meets current standards for care in the nursing home. Integral to the medical director’s role is providing guidance in development and implementation of resident-care policies. The medical director must ensure compliance with all relevant state and federal guidelines and work with the nursing-home administrator and director of nursing to foster effective team care and continuing staff education. The medical director of a nursing home works closely with all disciplines and must be constantly aware of the unique interplay between laws, regulations, organization, and delivery of medical care. Certification for medical directors (CMD) after completion of a formal course is offered through the American Medical Directors Association. Over 3,000 physicians have the CMD designation. Presence of certified medical directors has been found to be an independent predictor of quality in U.S. nursing homes (SOE=B). In recognition of this relationship, Maryland recently became the first state to enact legislation that specifically outlines the regulatory responsibilities and educational prerequisites for its medical directors.

Table 3─Roles and Functions of the Nursing Facility Medical Director

Roles of the Medical Director
  • Physician Leadership: The medical director serves as the physician responsible for the overall care and clinical practice carried out at the facility.
  • Patient Care-Clinical Leadership: The medical director applies clinical and administrative skills to guide the facility in providing care.
  • Quality of Care: The medical director helps the facility develop and manage both quality and safety initiatives, including risk management.
  • Education, Information, and Communication: The medical director provides information that helps others (including facility staff, practitioners, and those in the community) understand and provide care.
Functions of the Medical Director
  • Administrative: The medical director participates in administrative decision making and recommends and approves relevant policies and procedures.
  • Professional Services: The medical director organizes and coordinates physician services and the services provided by other professionals as they relate to patient care.
  • Quality Assurance and Performance Improvement: The medical director participates in the process to ensure the quality of medical care and medically related care, including whether it is effective, efficient, safe, timely, patient-centered, and equitable.
  • Education: The medical director participates in developing and disseminating key information and education.
  • Employee Health: The medical director participates in the surveillance and promotion of employee health, safety, and welfare.
  • Community: The medical director helps articulate the long-term care facility’s mission to the community.
  • Rights of Individuals: The medical director participates in establishing policies and procedures for assuring that the rights of individuals (patients, staff, practitioners, and community) are respected.
  • Social, Regulatory, Political, and Economic Factors: The medical director acquires and applies knowledge of social, regulatory, political, and economic factors that relate to patient care and related services.
  • Person-Directed Care: The medical director supports and promotes person-directed care.
SOURCE: Adapted, with permission, from AMDA, The Society for Post-Acute and Long-Term Care Medicine. White Paper on the Nursing Home Medical Director: Leader and Manager (March 1, 2011). Available at http://paltc.org/amda-white-papers-and-resolution-position-statements/nursing-home-medical-director-leader-manager.

Medication Oversight

Additional regulations require medication review at regular intervals and that each resident’s medication regimen includes no unnecessary drugs. Clinical documentation must demonstrate the indication for all drugs, especially psychoactive medications. Unnecessary medications are those given without indication, at excessive dosages, for excessive duration, without adequate monitoring, or when there has been a significant adverse event. Residents without a history of antipsychotic drug use should not be treated with antipsychotic medication unless the drug is required to treat a specific diagnosed condition (eg, schizophrenia, Huntington disease, psychosis) that is documented in the medical record. For those residents receiving psychoactive medications, gradual dosage reductions and behavioral interventions are mandated unless a clinical contraindication exists and is documented in the medical record. In 2012, CMS convened The National Partnership to Improve Dementia Care in Nursing Homes. This initiative joins efforts of federal and state partners, nursing homes and other providers, advocacy groups, and caregivers to improve the quality of care for adults with dementia, including a specific target of appropriate care and use of antipsychotic medications for nursing-home patients. By the end of 2016, the Partnership had met its goal of reducing the national prevalence of antipsychotic use in long-stay nursing-home residents by 30% and set a new goal of a 15% reduction by the end of 2019 for long-stay residents in those homes with currently limited reduction rates.

A thorough evaluation of medication regimens, done monthly by a pharmacist, is also required. This monthly medication review is intended to minimize adverse events and unnecessary medication use and to ensure proper medication monitoring. A facility must ensure that the medication error rate is <5% and that no significant medication errors occur. No errors should occur that cause a resident discomfort or jeopardize his or her health and safety. Care in assisted-living facilities is not subject to the same regulations that guide care in nursing homes. For a brief summary of selected regulations influencing medical and psychiatric care in skilled-nursing facilities, see Table 4.

Table 4─ Brief Summary of Selected Medicare and Medicaid Requirements for Long-Term Care Facilities

Tag Number
Subject
Regulation
Guideline
F309
Quality of care
CFR 483.25
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. “Highest practicable” is defined as the highest level of functioning and well-being possible, limited only by the individual’s presenting functional status and potential for improvement or reduced rate of functional decline.
F319-320
Quality of care: mental and psychosocial functioning
CFR 483.25(f)
Based on the comprehensive assessment of a resident, a facility must ensure that a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem and a resident whose assessment did not display a pattern of decreased social interaction and/or withdrawn, angry, or depressive behaviors, unless that residents’ clinical condition demonstrates that such a pattern is unavoidable.
F329-331
Medications, appropriate and unnecessary
CFR 483.25(I)(1)
Residents’ medications regimens must be free of unnecessary drugs. These are defined as “those given without indication, at excessive doses, for excessive duration, without adequate monitoring, or in setting of significant adverse reaction.”
F385-386
Physician services
CFR 483.40
It is the attending physician’s responsibility to participate in the resident’s assessment and care planning, monitoring changes in the resident’s medical status and providing consultation or treatment when called by the facility. At scheduled visits, the physician must review the total plan of care; write, sign, and date a progress note; and sign and date all orders.
F501
Medical director, required duties
CFR 483.75(i)
Each facility must designate a physician to serve as medical director. The medical director is responsible for implementation of resident-care policies and the coordination of care in the facility.
SOURCE: Adapted, with permission, from the American Medical Directors Association. Synopsis of Federal Regulations in the Nursing Facility. Copyright 2010.

Quality

The 2010 Affordable Care Act included a provision that requires all nursing homes certified by CMS to establish Quality Assurance and Performance Improvement (QAPI) programs. Effective in November 2017, the addition of performance improvement to the traditional quality assurance required in nursing homes significantly expands the level and scope of facility activities not only to correct defects but also to proactively prevent problems and optimize performance throughout all levels of the organization. A number of tools are available to assist nursing homes in QAPI program planning and implementation. Recent regulatory requirements for nursing facilities have also focused on preventing abuse of older adults and promoting person-centered care, improved care planning, and infection control including antibiotic stewardship.

MEDICAL CARE

The care of nursing-home residents has become more complex over the past several years, commensurate with an increasing level of medical acuity in an environment continually constrained by lack of adequate resources. Comprehensive, ongoing assessment within an interdisciplinary framework works to restore function, when possible, and to enhance quality of life.

Clinical challenges abound in the nursing home, created, in part, by the atypical and subtle presentation of illness so characteristic of residents with profound physical and psychologic frailty. In addition, limited access to biotechnology, frequent dependence on non-physicians such as nurses and nurse assistants for resident evaluation, and the high prevalence of cognitive impairment in a setting of intense regulatory oversight all complicate the medical decision-making process. Families of nursing-home residents remain an integral part of the overall care plan and may benefit from specific educational and psychosocial supports. Ethical and legal concerns are also very common, particularly those regarding end-of-life, feeding, hydration, and resident rights issues. Finally, the heterogeneity among nursing-home residents demands an individualized, thoughtful, and reasoned approach to each individual.

Problems in nursing homes that commonly require unique diagnostic and treatment strategies include infections, falls, malnutrition, dehydration, incontinence, and behavioral disturbances. For example, determining the risks and benefits of tube feedings for frail nursing-home residents must be predicated not only on underlying illness but also on the resident’s and family’s value system, the resources available in the nursing facility, and staff acceptance of the intervention. Many of the problems commonly seen in the nursing home result when multiple comorbidities interact with a host of environmental factors, all of which may be only partially remediable. Unfortunately, expectations of family, as well as regulations, often do not account for these complexities and commonly engender “risk-averse” behavior that may be counter to autonomy and optimal quality of life.

Over the last 40 years, many have advocated for culture change in nursing-home care from institutional, provider-centered models to person-centered models that are driven by choice and self-determination of older adults and their caregivers. Transformed nursing-home culture includes resident direction of activities; a homelike atmosphere; close relationships between staff, residents, and families; empowered staff members who are trained to respond to residents’ needs; and collaborative decision making with residents and families about care. Several culture-change initiatives, including the Eden Alternative, the Wellspring Model, and the Green House Model, have been described. The Eden Alternative focuses on development of collaborative partnerships between caregivers and older adults and on development of a human habitat with continued contact with plants, animals, and children. In the Wellspring Model, learning collaborative alliances between nursing homes have been developed to share management, training, and data systems with the goal of implementing interdisciplinary best-care practices through empowerment of frontline workers. In the Green House Model, 6 to 10 older adults reside in small non-institutional homes set in residential neighborhoods. Care in these homes is provided by empowered direct-care staff who manage all care and meal preparation. Close relationships between staff and residents are developed in each of the models. Evidence to date suggests these models improve resident quality of life and employee satisfaction, while preserving or improving quality of care; however, additional research regarding the benefits and costs of culture change is needed.

THE ROLE OF THE MEDICAL DIRECTOR

Physicians have traditionally had limited involvement in nursing homes. Perceptions of excessive regulations, paperwork, and limited reimbursement are further disincentives to nursing-home practice. In reality, the medical care of nursing-home residents is challenging and fulfilling, requiring excellent clinical skills as well as sensitivity to a variety of ethical, legal, and interdisciplinary issues. Medical interventions, whether curative, preventive, or palliative, demand an individualized approach that recognizes the complex interplay among resident, family, and staff needs. Further, the evidence on which to base treatment may be nonexistent.

The comorbidity present in most nursing-home residents commonly creates the need for multiple drug therapies, with attendant risk of complications. The prevalence of nursing-home residents who were prescribed ≥9 medications was reported as a quality measure for nursing facilities for many years. With revisions to the MDS, this is no longer included in the regulated quality measures, in part reflecting that the use of multiple medications by nursing-home residents with prevalent comorbid illnesses cannot always be avoided. The most common health conditions found in the nursing home for those ≥65 years old are dementia, heart disease, hypertension, arthritis, and stroke. The approaches to these and other illnesses have evolved dramatically and complicate treatment decisions when cost-effectiveness is increasingly considered a desirable goal. Clear documentation of the rationale for a given medication or intervention is the best way to protect against potential scrutiny; frequent discussion with the facility’s consultant pharmacist is also helpful.

Physicians and other medical providers, such as advanced practice providers, play a critical role in the quality equation. Physician commitment and nursing-home practice competency and organizational structure have all been linked to care outcomes. Commitment refers to the percentage of a physician’s practice devoted to nursing-home care and the amount of time spent per each nursing-home encounter. Although fewer than 1% of attending physicians spend >90% of their time in the nursing home, evidence suggests that this “committed” cohort has significantly lower rehospitalization rates. Medical staff organization, which in part measures the extent to which the physician is integrated into the “culture” of the nursing home, has been found to be an independent predictor of MDS-derived quality markers. AMDA-The Society for Post-Acute and Long-Term Care Medicine (formerly the American Medical Directors Association) has developed an online curriculum for 26 competencies specific to medical providers practicing in the postacute and long-term care setting. These competencies have informed the development of quality measures specific to the medical practitioner and that are based on the ACOVE paradigm. Ongoing research using these new quality measures will further delineate their relationship to outcomes emblematic of high-quality care. Finally, AMDA’s recent job task analysis, a step toward eventual certification status, recognizes the link between quality care and the unique set of skills and experience necessary to fulfill the complex role of the nursing-home attending physician. For information regarding physician responsibilities, see Table 5 and the website of the American Medical Directors Association (www.paltc.org).

Table 5─Competencies for Post-Acute and Long-Term Care Medicine

Foundation (Ethics, Professionalism and Communication)
  • Addresses conflicts that may arise in the provision of clinical care by applying principles of ethical decision-making
  • Provides and supports care that is consistent with (but not based exclusively on) legal and regulatory requirements
  • Interacts with staff, patients, and families effectively by using appropriate strategies to address sensory, language, health literacy, cognitive, and other limitations
  • Demonstrates communication skills that foster positive interpersonal relationships with residents, their families and members of the interdisciplinary team (IDT)
  • Exhibits professional, respectful, and culturally sensitive behavior towards residents, their families, and members of the IDT
  • Addresses patient/resident care needs, visits, phone calls, and documentation in an appropriate and timely fashion
Medical Care Delivery Process
  • Manages the care of all post-acute patients/long-term care residents by consistently and effectively applying the medical care delivery process, including recognition, problem definition, diagnosis, goal identification, intervention, and monitoring progress
  • Develops, in collaboration with the IDT, a person-centered, evidence-based medical care plan that strives to optimize quality of life and function, within limits of an individual’s medical condition, prognosis, and wishes
  • Estimates prognosis based on a comprehensive patient/resident evaluation and available prognostic tools, and discusses the conclusions with the patient/resident, their families (when appropriate), and staff
  • Identifies circumstances when palliative and/or end-of-life care (eg, hospice) may benefit the patient/resident and family
  • Develops and oversees, in collaboration with the IDT, an effective palliative care plan for patients/residents with pain, other significant acute or chronic symptoms, or who are at the end of life
Systems
  • Provides care that uses resources prudently and minimizes unnecessary discomfort and disruption for patients/residents (eg, limited nonessential vital signs and blood sugar checks)
  • Can identify rationale for, and uses of key patient/resident databases (eg, the Minimum Data Set), in care planning, facility reimbursement, and monitoring quality
  • Guides determinations of appropriate levels of care for patients/residents, including identification of those who could benefit from a different level of care
  • Performs functions and tasks that support safe transitions of care
  • Works effectively with other members of the IDT, including the medical director, in providing care based on understanding and valuing the general roles, responsibilities, and levels of knowledge and training for those of various disciplines
  • Informs patients/residents and their families of their healthcare options and potential impact on personal finances by incorporating knowledge of payment models relevant to the post-acute and long-term care setting
Medical Knowledge
  • Identifies, evaluates, and addresses significant symptoms associated with change of condition, based on knowledge of diagnosis in individuals with multiple comorbidities and risk factors
  • Formulates a pertinent and adequate differential diagnosis for all medical signs and symptoms, recognizing atypical presentation of disease, for post-acute patients and long-term care residents
  • Identifies and develops a person-centered medical treatment plan for diseases and geriatric syndromes commonly found in post-acute patients and long-term residents
  • Identifies interventions to minimize risk factors and optimize patient/resident safety (eg, prescribes antibiotics and antipsychotics prudently, assesses the risks and benefits of initiation or continuation of physical restraints, urinary catheters, and venous access catheters)
  • Manages pain effectively and without causing undue treatment complications
  • Prescribes and adjusts medications prudently, consistent with identified indications and known risks and warnings
Personal QAPI
  • Develops a continual professional development plan focused on post-acute and long-term care medicine, using relevant opportunities from professional organizations (AMDA, AGS, AAFP, ACP, SHM, AAHPM), licensing requirements (state, national, province) and maintenance of certification programs
  • Uses data (eg, PQRS indicators, MDS data, patient satisfaction) to improve care of patients/residents
  • Strives to improve personal practice and patient/resident results by evaluating patient/resident adverse events and outcomes (eg, falls, medication errors, healthcare-acquired infections, dehydration, return to hospital)
SOURCE: Adapted, with permission, from AMDA, Competencies for Post-Acute and Long-Term Care Medicine Setting of Care: SNF/NF. Available at www.paltc.org/competencies-post-acute-and-long-term-care-medicine.

Responsibilities encompass ongoing comprehensive assessment and coordination of care to ensure resident autonomy and safety as well as optimal physical and psychosocial function. Regulations mandate that the initial comprehensive visit for the purpose of certifying that a newly admitted nursing-home resident requires a skilled level of care be done by a physician. During this visit, the physician performs a thorough assessment, develops a plan of care, and writes appropriate orders for the nursing-home resident. Nurse practitioners may perform initial history and physical examination visits for long-term care residents who do not require a skilled level of care. Regulations mandate that nursing-home residents be seen for subsequent face-to-face medical visits every 30 days for the first 90 days after admission and then at least every 60 days thereafter. For these subsequent visits, a visit by an advanced practice provider may be substituted for every other physician visit. Additional medical visits should take place if acute medical needs or changes in condition develop. Medicare allows for physician reimbursement for evaluation and management activities for both nursing-home regulatory visits and medically necessary visits to provide acute care. Availability of on-site medical providers can improve timeliness of acute medical care and decrease hospitalization rates.

Several studies have documented misdiagnoses, inappropriate interventions, and poor preventive care practices in nursing homes. The Office of Inspector General reported that 22% of Medicare beneficiaries experienced at least one harmful adverse event during a postacute nursing home stay. Over half (59%) of the adverse events were clearly or likely preventable and resulted in $2.8 billion spent on hospital readmissions for corrective treatment. The Office of Inspector General recommendations to reduce resident harm included strategies to develop more effective safety cultures, like those that have been used in hospitals.

Fortunately, many strategies to improve medical care in nursing homes are being implemented. Electronic health records (EHRs) are increasingly prominent in postacute care facilities. As of 2016, 64% of nursing facilities have implemented EHRs, and almost 20% use both an EHR and a regional health information organization. These EHRs have been used to improve transitional care communication and to reduce medication errors. Unfortunately, building reliable EHR infrastructure can be physically, culturally, and financially challenging for postacute and long-term care facilities.

Infection prevention and antibiotic stewardship is another important strategy for improving medical care in nursing facilities. Recent additions to the regulations for nursing homes require that facilities work to ensure appropriate use of antibiotics and to prevent infections in their residents with the goal of reducing antibiotic use, decreasing antibiotic resistance, and improving overall care of residents. CMS and the CDC have developed relevant tools and resources to help facilities implement antibiotic stewardship programs.

Vaccination rates for eligible chronic-care nursing-home residents vary. Nationally, current vaccination rates in nursing homes are 94% for both influenza and pneumococcal vaccines. Vaccination programs for long-term care employees are also considered a primary prevention strategy for influenza in nursing facilities. Vaccination of employees is thought to decrease the influenza incidence in residents through decreased entry of influenza virus into facilities and decreased resident-to-resident transmission through staff. Unfortunately, health care worker vaccination rates are generally suboptimal. Although brief educational programs have been associated with increased acceptance of vaccines, improved understanding of individual and operational barriers to and facilitators of optimal immunization is needed. The CDC has developed a toolkit for long-term care employers, “Increasing Influenza Vaccination among Health Care Personnel in Long-term Care Settings” (available at https://www.cdc.gov/flu/toolkit/long-term-care/). More than 600 health care organizations have moved to increase vaccination rates in health care workers by instituting policies that require health care workers to be vaccinated. Additionally, more than 20 states have influenza vaccine requirement laws for health care workers.

SPECIAL-CARE UNITS

Special-care units, although conceptually attractive, have not consistently been shown to enhance quality of care apart from the involvement of individual professionals. Some nursing facilities have formed distinct nursing-home units specifically designed and staffed for populations of residents with specific care needs or diagnoses. Examples might include dementia care, respiratory care, and dialysis care. However, specific consultation services in the nursing home may improve care practices and condition-specific resident outcomes, such as reduction of falls (SOE=A). In addition, an interactive educational program for physicians and nursing staff may improve practice, as has been demonstrated in programs to promote appropriate psychoactive drug use (SOE=B). Clinical practice guidelines for the care of nursing-home residents have been developed by AMDA-The Society for Post-Acute and Long-Term Care Medicine (www.paltc.org) and the American Geriatrics Society (www.americangeriatrics.org).

ADVANCE CARE PLANNING

Understanding each nursing-home resident’s preference for care in the context of his or her underlying value system will undoubtedly improve overall quality. This can be challenging in the nursing-home setting given that the number of nursing-home residents who do not have medical decision-making capacity has been noted to be as high as 44%. Early advance care planning may be invaluable for nursing-homes residents and those at risk of nursing-home placement. According to the CDC, 65% of nursing-home residents have at least one advance care directive on record. Living wills and do-not-resuscitate orders are the most common advance directives, in place for 18% and 56%, respectively, of all nursing-home residents. Nursing-home residents >65 years old are more likely to have advance directives than their younger counterparts. White nursing-home residents are more likely than black nursing-home residents to have a living will (20% versus 6%) and do-not-resuscitate orders (61% versus 28%). This disparity in advance directives highlights the need for long-term care research that contributes to development of culturally sensitive approaches to advance care determination in the nursing home.

Durable power of attorney for health care documentation is present for 26% of nursing-home residents at admission and for 39% after 1 year of residence. Less than 5% of nursing-home residents have “do-not-hospitalize” orders, which document that the resident is not to be hospitalized even after developing a condition that is generally treated in the hospital. Although ongoing discussion of care preferences appears to be present in the nursing home, there likely remain ongoing opportunities for improved understanding of nursing-home resident preferences for care. A recent study found almost one-third of older adults receive care in a skilled-nursing facility in the last 6 months of life under the Medicare post-hospitalization benefit, and 1 in 11 older adults will die while enrolled in the skilled-nursing facility benefit. Although use of formal hospice programs to augment end-of-life care for long-term residents in nursing homes has increased in recent years, many have called for providing additional palliative care services to care for the diverse population receiving care in nursing-home settings. When ethical dilemmas arise in nursing-home care, institutional ethics committees can provide important guidance. The multidisciplinary nature of these committees ensures a spectrum of opinion and insight critical for nursing-home residents.

RESOURCES

Harrington C, Carrillo H, Garfield R. Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2015. The Henry J. Kaiser Family Foundation [Jul 11, 2017]. Available at www.kff.org/medicaid/report/nursing-facilities-staffing-residents-and-facility-deficiencies-2009-through-2015/.

This report compiles recent data from federal reporting systems on nursing facilities to describe the characteristics of nursing facilities, their residents, facility staffing, and the deficiencies identified during recent regulatory surveys. Through examination of this data, population trends and opportunities for improvement in nursing facility care are identified.

Horney C, Capp R, Boxer R, et al. Factors associated with early readmission among patients discharged to post-acute care facilities. J Am Geriatr Soc. 2017;65(6):1199–1205.

This study examines the factors associated with patients readmitted from postacute care facilities. It focuses on the first week after nursing-home admission when hospital readmission is the likeliest to occur. The main factor associated with this was a shorter index hospitalization length of stay. This may point to a modifiable variable in early readmissions from the postacute care facility, which will likely lead to further research into hospital discharge processes in both the hospital and postacute care facility.

Katz PR, Wayne M, Evans J, et al. Examining the rationale and processes behind the development of AMDA’s competencies for post-acute and long-term care medicine. Annals of Long-Term Care: Clinical Care and Aging. 2014;22(11):36–39.

As the complexity of clinical care in nursing-home settings increases, the association between physician care and quality in skilled-nursing homes is gaining interest. This article describes AMDA – The Society for Post-Acute and Long-Term Care Medicine’s efforts to develop and define physician competencies necessary for attending physicians in nursing homes. These competencies offer objective metrics with the hope that physicians are adequately prepared to provide effective, high-quality care.

Lindquist LA, Miller RK, Saltsman WS, et al. SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients’ Healthcare from Skilled Nursing Facilities to the Community. J Gen Intern Med. 2017;32(2):199–203.

Significant attention and resources have been invested in improving transitional care from hospital to home. Many adults, however, are discharged to skilled-nursing facilities before returning home. For these patients, optimizing the transition of care from the nursing facility to the community home is equally important. In this article, a team of physicians with various backgrounds (primary care, home care, skilled-nursing facilities, geriatrics), along with human factors engineers, transitional care researchers, and three professional societies, present best practices to providing safe and high-quality transitions in care for patients moving between skilled-nursing facilities and primary care.

Unroe KT, Nazir A, Holtz LR, et al. The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care approach: preliminary data from the implementation of a Centers for Medicare and Medicaid Services nursing facility demonstration project. J Am Geriatr Soc. 2015;63(1):165–169.

This paper describes the approach of OPTIMISTIC, an innovative, CMS-sponsored clinical demonstration project designed to reduce avoidable hospitalizations from nursing homes. OPTIMISTIC uses a multifaceted approach, including implementation of an evidence-based quality improvement program with clinical support led by nurse practitioners. Chronic care management, enhanced transitional care, and systematic advanced care planning are used to improve the quality of medical care.

Zimmerman S, Bowers BJ, Cohen LW, et al. New evidence on the Green House model of nursing home care: synthesis of findings and implications for policy, practice and research. Health Serv Res. 2016;51(S1):475–496.

An important development in nursing-home care in recent decades has been the concept of “culture change.” The Green House model of nursing home care is one example of comprehensive transformation of nursing-home care. This paper describes the impact of the model, including lower hospital readmission rate, improvement in select quality measures, and reduction of Part A Medicare costs, and discusses the implications of those findings on the Green House model and other culture change and person‐centered care initiatives in the nursing home.