Abstract
Since the evolution of nursing homes from 19th century almshouses to more medicalized environments in the 20th century, enhancing quality of care in nursing homes has remained paramount for gerontologists. The acknowledgment of quality of care deficiencies and the need for sweeping reform culminated in the 1987 Omnibus Budget Reconciliation Act which implemented a number of regulatory constraints on the nursing home industry, but concerns about the quality of care in nursing homes and other residential settings continue to persist. Advocates, researchers, policymakers, families, and residents themselves have collaborated to develop a number of striking innovations in how residential long-term care is delivered, marketed, and even “rebalanced” toward community-based service options. However, sufficient quality of care (or, processes of care as well as outcomes that may indicate fulfillment of or gaps in care) is less than universal in nursing homes and other residential settings.
This particular issue of the Journal of Applied Gerontology describes, in compelling fashion, this ongoing quality care “chasm” in various residential settings. In the first article, Castle and colleagues surveyed more than 4,000 nurse aides in a representative sample of 767 nursing homes. Somewhat alarmingly, one in five nurse aides reported complying with hand washing regulations “all of the time” when caring for residents, and only four in 10 facilities appeared to ensure that such hand washing was performed. Castle, Handler, and Wagner (2016) identify a critical gap in quality of care in nursing homes, as it appears that the facilitation of necessary hand washing is an area ripe for future intervention development. Felix, Bradway, Ali, and Li (2016) offer an innovative article on barriers to admission for morbidly obese older adults following discharge from the hospital. More than 900 nursing directors in nursing homes in Arkansas and Pennsylvania were surveyed to ascertain predictors of admission for morbidly obese patients. Two thirds of the respondents indicated that obesity was a barrier to admission in their particular facilities; if nursing homes were staffed appropriately, obesity was perceived as less of an admission barrier. Alternatively, concerns about unavailable bariatric equipment were positively associated with perceived barriers to admission. Given the trends of increasing obesity across the life span in the United States, determining how nursing homes can not only successfully admit residents but also provide appropriate care for these individuals is likely to increase; again, Felix and colleagues reveal an area of clinical concern that is ripe for intervention and service innovation.
Bowblis and colleagues focus specifically on post-acute care residents in for-profit and not-for-profit skilled nursing facilities and propose a conceptual model suggesting that there is a greater reimbursement incentive among for-profit skilled nursing facilities to prolong length of stay among post-acute residents. Following adjustment of case mix and similar resident selection factors, there was no statistical difference in length of stay between for-profit and not-for-profit post-acute care providers, although there were considerable differences in non-adjusted comparisons. Vincent Mor and others have argued that there are currently “two tiers” of nursing homes that appear to contribute to disparities, with those residing in not-for-profit facilities (among other factors) potentially having access to better quality of care (see Grabowski, Elliot, Leitzell, Cohen, & Zimmerman, 2014; Mor, Zinn, Angelelli, Teno, & Miller, 2004). Bowblis, Horowitz, and Brunt (2016) provide an important piece of evidence to either contribute to or challenge the notion of two tiers of nursing home quality. Mortenson and Bishop (2016) further identify a key gap in nursing home practice: specifically, admission and discharge criteria from specialized dementia care units (DCUs). Utilizing a random sample of DCUs, Mortenson and Bishop found that although there were common admission (e.g., exhibition of cognitive and behavioral issues) and discharge criteria (e.g., ability to management in a non-specialized long-term care environment), overall discharge from DCUs appears to occur without standardized or evidence-based criteria in place.
The final two articles in this issue examine innovations that could possibly enhance quality of care in nursing homes or other environments. Coordination of care, and specifically integration of acute and long-term care services, is seen as a particular gap in nursing homes (Gaugler, 2015); the use of electronic health records may help to address such challenges. Davis, Zakoscielna, and Jacobs (2016) utilize data from 2,300 residential facilities that participated in the 2010 National Survey of Residential Care Facilities. Overall use of electronic information systems was greatest among not-for-profit settings; in contrast, for-profit residential settings were least likely to adopt electronic information systems. The findings provide a useful complement to Bowblis et al. (2016), and again raise the concerns of the two-tiered structure of nursing home quality of care. The final article in this issue is an intriguing analysis of a museum object-handling intervention that included 30 to 40 min facilitator-led sessions where participants could handle and discuss museum objects (Thomson & Chatterjee, 2016). The pre-/post-test single group evaluation was conducted with 40 participants living in various settings and found that long-term care residents indicated statistically significant increases in positive affect and wellness. Smaller scale studies have emerged suggesting the therapeutic benefits of museum and other arts-oriented therapies for older adults in community and residential settings (Cowl & Gaugler, 2014), and Thomson and Chatterjee further demonstrate the potential of such a program for nursing home residents.
When we think of “applied” gerontology, we often envision research that demonstrates immediate efficacy/effectiveness. However, just as important in the life cycle of translational and implementation research is the identification of clinical or practice gaps most worthy of improvement. The articles in this issue of the Journal of Applied Gerontology do so wonderfully. Although great strides have been made in advancing long-term care, gaps ranging from sanitary health care practices to electronic information system utilization remain challenges to quality of care in nursing homes. That such gaps occur in the shadow of disparities lend the articles in this issue of the Journal of Applied Gerontology that much more urgency.