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1st
appeared 18 June 1999
Advocating Humane Treatment in Nursing Homes
Despite a plethora of research citing widespread
nursing home abuse and neglect and national legislation designed to improve and monitor
quality, many residents still live in deplorable and even dangerous conditions, a UCSF
researcher says.
 Much needs to done to protect the roughly 1.6 million elderly and
disabled folks in 16,800 nursing homes across America, reports Charlene Harrington, UCSF
professor of sociology and nursing in the department of social and behavioral sciences in
the School of Nursing.
Delivering the 19th annual Helen Nahm Research Lecture in a full auditorium on June 4,
Harrington painted a dreary picture of the nation's nursing homes based on her extensive
research and that of her colleagues.
"When confronted with the reality of chronic illness and disability, we would like to
believe that our institutions provide humane treatment for the ill and dying," she
says. "Although that is true for some fortunate individuals who live in high-quality
nursing homes, many residents are living in deplorable conditions where they experience
painful and unnecessary death."
Examining federal data for all US nursing homes, Harrington found that half of all nursing
home residents were incontinent and almost half were placed on psychotropic drugs -- which
"often serve as chemical restraints to keep residents quiet." Most residents
were unable to bathe, dress and feed themselves. Many residents had contractures or
immobile joints from lack of movement and pressure sores from unrelieved pressure on the
skin. Others lacked proper nutrition and suffered from dehydration.
"Good nursing care can prevent and/or reduce most of these widespread problems in
nursing homes," Harrington says. "Unfortunately, most of these serious problems
have either remained the same or worse yet, increased over the past seven years."
Of 185 separate items federal standards used to measure the quality of nursing homes,
Harrington says, "tragically most nursing homes don't meet these minimum standards
according to the findings by state surveyors."
The Politics of Reform
Giving historical perspective to the issue, Harrington says reform efforts began in 1984
when President Reagan's attempt to deregulate nursing homes prompted the Congress to ask
the Institute of Medicine (IOM) to study nursing home regulation. Harrington served on the
IOM committee which drafted a report advocating for the passage of the Nursing Home Reform
Act as part of the Omnibus Budget Reconciliation Act (OBRA) of 1987.
The act placed unprecedented emphasis on the quality of life and quality of care of
nursing homes, launched a comprehensive resident assessment program, improved the survey
process focusing on outcomes of care and toughened enforcement with monetary sanctions for
substandard care.
But, Harrington says, implementation of the act was problematic from the beginning. The
Health Care Financing Administration (HCFA), a federal agency which administers Medicare
and Medicaid and regulates survey and certification and quality of care improvement, did
not issue the final enforcement regulations until seven years after the act was passed.
"The failure of the OBRA 1987 can best be explained by politics, which interfered
with regulatory reform under both the Bush and Clinton administrations," she says.
"The extensive lobbying effort mounted by the nursing home industry and almost $1
million in annual campaign contributions appears to be directly related to the series of
federal policy actions that weakened the entire enforcement program."
Harrington first learned about the problems in nursing home care in 1975 when the
California Little Hoover Commission, which studies governmental problems, asked her to
review and critique the state health programs.
"We found that the California Licensing and Certification program, responsible for
regulating nursing homes, was completely ineffective. About one-third of the facilities in
California were considered to be operating below the minimum acceptable federal
standards."
Little was done to remove the substandard nursing homes from the Medicare and Medicaid
financing program, "even when life-threatening situations existed and deaths
occurred," Harrington says.
"After I was appointed the director of the California Licensing and Certification
program, I soon learned how difficult it is to change a non-responsive bureaucracy heavily
influenced by the nursing home industry to one that would take swift and effective actions
against poor performing facilities," Harrington says. "More importantly, I
learned that enforcement actions incurred the wrath of the nursing home industry and this
quickly translated into angry responses from legislators, representing their wealthy and
powerful industry campaign contributors.
"As regulation proved to be unpopular, Governor Jerry Brown's staff removed me from
my appointed position and since then I have worked with consumer groups to advocate for
nursing home reform."
The political tide may now be changing, she notes. The US Senate Subcommittee on Aging,
chaired by Senator Chuck Grassley (R-Iowa), began a series of hearings last year to urge
HCFA to improve its nursing home enforcement process. Harrington testified before that
committee.
"Immediately prior to the July 1998 hearings, President Clinton announced a major new
initiative to toughen the enforcement system. We can only hope this effort will actually
make a difference and at least remove the substandard facilities from the Medicare and
Medicaid programs."
And State Assembly Majority Leader Kevin Shelley (D-San Francisco/San Mateo) has
introduced a bill to reform nursing home care. Winning support from both Republicans and
Democrats, the bill, AB 1160, increases staffing ratios, reimbursements and enforcement of
the more than 1,400 nursing homes statewide. The bill easily cleared the Assembly with a
53-to-15 vote on June 3 and was read for the first time on the Senate floor on June 7.
Enforcement Problems
"After the 1987 Nursing Home Reform Act passed, it was assumed that enforcement would
improve," Harrington says. "Rather than taking more actions against poor
performing facilities, we found that the state surveyors have been giving fewer
deficiencies. Over the last seven years, the average number of deficiencies declined by 44
percent, while facilities with no deficiencies increased by 100 percent."
At the same time, she says, HCFA changed the way deficiencies were classified so that
fewer deficiencies were classified in the most severe category. Harrington also found wide
variations in state agency enforcement practices, where some state agencies only rarely
gave deficiencies.
The government pays 61 percent of the nursing home bill in the US or $87.5 billion per
year. Of that amount, she says, only 36 percent is actually spent on care while
administrative costs absorb 27 percent of the budget.
Indeed, one of the major problems facing nursing homes is inadequate federal standards for
nursing services. The federal government only calls for one registered nurse for eight
hours per day seven days a week and one licensed vocational nurse on duty 24 hours per
day, regardless of the size of the facility, she notes.
Predictors for low staffing levels are -- not surprisingly -- more typical in a for-profit
nursing home, which seeks to maximize profits for the company's stockholders. Large
facilities, chains and those with higher numbers of Medi-Cal patients also are likely to
operate with fewer staff.
She and other experts recommend higher staff ratios that vary depending on the time of
day, doubling training requirements and increasing wages and benefits in an attempt to
improve high staff turnover rates. On average nursing home nurses earn 15 percent less
than their counterparts working in an acute care hospital and half do not receive any
health care benefits, according to Harrington.
Some 66 percent of the nation's nursing homes are for-profit businesses, publicly traded
to investors looking for short-term gains. "The volatility of the stock market
threatens the quality of nursing homes," she says. Harrington and other nursing home
advocates also call for full public disclosure of financial information of nursing homes
and information on quality.
President Clinton agreed to put federal nursing home survey results and violation records
on the Internet to increase accountability and make information more accessible. For the
first time ever, consumers now can compare nursing homes online, Harrington says. The
information on the new website Nursing Home Compare (www.medicare.gov/nursing/home.asp)
contains the most recent information from state inspections of every Medicare- and
Medicaid-certified nursing home. The data is based on information from HCFA's Online
Survey, Certification, and Reporting database, which provides survey results provided and
updated by states.
"Real reform must be in the political arena," says Harrington, who adds that 21
states, including California are considering nurse-staffing legislation this year.
"The vision for the future is actually quite simple, even straightforward,"
Harrington says. "It is to provide quality of care and quality of life for those
living in nursing homes. These are values that our country purportedly holds dear for its
citizens when they are unable to care for themselves. The problem is to generate awareness
and outrage among our good citizens and politicians to underwrite costs of decent
long-term care."
Links:
UCSF School of Nursing
Medicare's Nursing Home Compare
Editorial
by Jeanie Kayser-Jones on nursing homes published in Geriatric Nursing (Scroll 2/3rd
down page to access editorial)
School Honors Advocate of
Nursing Home Quality Care (1997 Nahm Lecture)
Source: Lisa Cisneros, Newsbreak
editor |
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