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Correspondence: Address correspondence to Jill Quadagno, Pepper Institute on Aging and Public Policy, Florida State University, Tallahassee, FL 32306. E-mail: jquadagno{at}coss.fsu.edu
Nursing home residents, mostly frail and near the end of their lives, are housed in a health care sector whose condition has been deemed in crisis by both the popular media and the federal government (Health Care Financing Administration [HCFA], 2000a, 2000b). Although the percentage of aged Americans residing in nursing homes has declined slightly in recent years, rapid aging of the population and especially the growth of the population 85 years and older, means that demand for nursing home care will likely increase in the future.
On March 20–21, 2002, a conference entitled "Challenges in Nursing Home Care" was held at Florida State University and sponsored by a National Institute on Aging conference grant (U13 AG20154) and a grant from the Robert Wood Johnson Foundation. The articles presented addressed central concerns facing families, care providers, and policymakers about nursing home care including cost containment, the quality of care, access to care, consumer preferences and decision making, liability and workplace issues. They help provide answers to questions such as how nursing home care can best be financed and delivered, how it should be organized, how to measure quality of care, and how to provide optimal levels of care within the constraints of limited resources. In addition, these state-of-the-science articles begin the process of setting a research agenda for investigators in this central gerontological issue. This volume presents a series of articles meant to recommend a research-oriented agenda for the nursing home section of the long-term care institution in the United States. An earlier Institute of Medicine volume emphasizes issues of quality of long-term care and presents recommendations for its improvement (Wunderlich & Kohler, 2001).
In the past decades, several important changes in the long-term care system in the United States have had both direct and indirect consequences for the quality of nursing home care. Changing demographics, including increased longevity among the older population, combined with the increased incidence of women in the labor market and smaller families means that there are fewer potential informal caregivers. Changing expectations about later life care and continuing preferences for remaining at home have given rise to competing settings to nursing home care. Retirement communities, assisted living facilities, continuing care retirement communities, and home health care agencies now provide care that used to be delivered through informal care at home or formal care in nursing homes. Frequently the option of last resort, although still a necessary one, the nursing home operates in an evolving social, political, and economic climate, and under changing visions of how long-term care should be delivered and financed.
In the past decade, there has been a decline in the proportion of people aged 65 years and older who reside in nursing homes. This transformation appears to be largely due to changes in the financial incentives associated with reimbursement systems for alternative types of long-term care as well as a decline in disability in the aging population. Nursing home growth was rapid in the early 1990s, as skilled nursing facilities were created to match changes in Medicare reimbursement patterns. For much the same reason, there was a spurt of growth in home health care agencies as alternatives to nursing home care. Subsequent reforms to Medicare reimbursement patterns, including the 1997 Balanced Budget Act, had implications for the nursing home industry. Some individuals lost home health agency support resulting in nursing home admission. At the same time, Medicare reimbursement to nursing homes declined sharply. Increasingly, Medicaid has become the primary payor of nursing home care. States, which bear the primary burden of Medicaid financing, have been attempting to contain the costs of Medicaid, partly by tightening controls on reimbursement rates for nursing home residents. This has put financial pressure on nursing home operators and led to charges of "patient dumping" and the withdrawal or withholding of services to Medicaid-eligible patients.
Recent changes in terms of size, profit and/or nonprofit status, and the integration of nursing homes with allied settings (e.g., hospitals) contribute to differential access among subsets of the aged population (i.e., rural or urban residents, racially and ethnically diverse populations) to appropriate long-term and nursing home care. Among other organizational factors, staffing has become a critical issue in policy–oriented and applied research. Nursing home staff primarily includes registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing aides or assistants (CNAs; HCFA, 2000a). Most of the direct resident care is provided by nursing aides, who spend about 1.99 hr per day in patient care compared with 1.25 hr for RNs and LPNs combined (HCFA, 2000b). Overall, nursing aides provide about 60% of total nursing hours to residents (HCFA, 2000b). Compared to other service industries, nursing homes have higher employee turnover rates for all staff members with nursing aides demonstrating the highest rates of turnover. In a nationally representative sample of nursing homes, over 93% of nursing aide positions turned over in 1997 (Agency for Heath Care Administration [AHCA], 1999).
The problems of nursing aide turnover and retention create dilemmas at both the national and state levels. Even if training programs produce adequate numbers of certified nursing aides, a labor shortage remains because of aides leaving the field (Florida Department of Elder Affairs [FDEA], 2000). High turnover rates have multiple causes: (a) low unemployment and increased opportunities in the service sector, (b) low wages and benefits combined with high job demands and a lack of resources, (c) lack of respect and rewards, and (d) unappealing work environments (FDEA, 2000; Florida Policy Exchange Center on Aging [FPECA], 1999). Additionally, increasing resident acuity levels demand higher staffing levels and more intensive medical treatment, while stagnant or decreased reimbursement levels leave many nursing homes lacking the necessary funds (Close, Estes, Linkins, & Binney, 1994). Thus, a major challenge at both the national and state levels concerns the effective recruitment, training, and retention of certified nursing aides. High staff turnover in nursing homes clearly has important consequences for the care of residents.
The central challenge nursing homes face is their capacity to deliver quality care to residents. Already in frail health, residents of nursing homes are likely to experience rapid decline in their health status if they are subject to inappropriate or inadequate personal treatment and medical care. Questions remain about whether inappropriate or inadequate treatment is due to understaffing or poor staff training. Further, there is still much that is unknown about what types of treatment are appropriate and/or effective for this vulnerable population. Efforts in recent years have focused on developing measurable quality standards for nursing home care. Such standards serve the dual purpose of certifying the quality of care for regulatory purposes and as a basis for consumer decision making about entering, or placing a frail dependent, in a nursing home.
Progress in medical technology has made it possible to prolong life significantly, raising questions about the lengthening of the dying process and the preservation of human dignity (Emanuel & Emanuel, 1998). In a comprehensive study of the state of end-of-life care in America, the Institute of Medicine concluded that serious deficiencies exist in clinical practice, in professional training, and in the ensuing attitudes and assumptions of professional caregivers. Existing health care financing and methods of health care delivery often diminish access to quality end-of-life care (Field & Cassel, 1997). In some states, as many as one third of nursing home residents die in any given year (Matesa, 2000), prompting the need for improving the quality of end-of-life care in these facilities. Scientists are now studying such topics as how to improve palliative care training, the role of regional ethics committees regarding end-of-life decision making, the development of quality-of-care indicators, the effect of reimbursement systems on end-of-life care for people in nursing homes, and the role of the hospice movement in nursing home care (Bain, 2000; Buckwalter, 2002). This includes understanding, which varies state by state, and other factors affecting end-of-life care in nursing homes.
The State of Florida, with its high proportion of aged citizens, is often viewed as a "natural laboratory" for the investigation of trends in aging populations. Recently the state threatened to close over 432 nursing home beds for failure to meet quality standards. The insurance industry has increased the costs of providing liability insurance coverage to Florida nursing homes, and some insurers have withdrawn completely, claiming that high monetary damage awards in negligence cases undermine the insurability of the nursing home sector. Over 40% of all nursing home beds in Florida are currently operated by corporate nursing home chains that have filed for bankruptcy. These issues are not unique to Florida, but mirror larger nationwide trends. One response advocated by the Florida nursing home industry is tort reform and insurance regulation as it applies to the nursing home industry.
The objective of this collection of articles resulting from the Florida State University conference on "Challenges in Nursing Home Care" is to provide the basis of a research agenda on this segment of the long-term care industry. Concurrent changes are occurring in the population of seniors: (a) growth in numbers and proportion in the population, (b) declines in disability, (c) the financing of extended care, (d) the intimate link found uniquely in long-term care settings between place of residence and personal care, (e) the variety and multiple locations of services provided, and (f) the personnel problems associated with nursing homes. These problems, elaborated in the articles contained in this volume, suggest the urgent need for focused research addressing solutions for America's aging population.
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1 Pepper Institute on Aging and Public Policy, Florida State University, Tallahassee.
2 Behavioral and Social Research Program, National Institute on Aging/National Institutes of Health, Bethesda, MD.
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