Journal of Applied Gerontology

Previous efforts to evaluate nursing home quality have been hampered by the lack of a conceptual model that specifies the major components and specifically associates measurable indicators with quality. An extensive literature review reveals many fragmented pieces of information, but no framework in which to fit the pieces together. The model presented here identifies four major dimensions of nursing home quality: (a) staff intervention, (b) physical environment, (c) nutrition/food service, and (d) community relations. These dimensions go beyond traditional "quality of care" by including quality-of-life considerations as well. The dimensions are each further divided into two subdimensions. I propose that measurable indicators for each of these eight subdimensions can be combined to make an effective and comprehensive quality measure.

This article clarifies concepts and theories used in quality assurance and their applications and offers a time-ordered conceptual framework for quality assurance standards and indicators, emphasizing the necessity for balance among them. Processes of monitoring and feedback are discussed as major components of quality assurance systems. This time-ordered, systems approach to quality assurance was applied to home care services in Ohio. This theoretical perspective is related to current public policy aimed at nursing home reform.

This article presents a framework for evaluating long-term care policies and programs to determine how well community-based programs benefit the older adult population. Equity, accessibility, quality, and efficiency are identified as core criteria for implementing and evaluating long-term care policy. Special problems with conducting process and/or outcome evaluation of community-based programs are noted, and findings of evaluation research on community-based health care programs are reviewed. Most previous research indicates that community-based health programs for older adults are not a substitute for institutional care and do not reduce either informal caregiving or ambulatory medical services. The article concludes with policy implications.

This descriptive study examined state regulatory activities for home health agencies in California and Missouri. In California, the state survey agency was increasingly unable to meet its annual survey requirements. Missouri's survey agency was able to remain current with its survey activities. Neither state used enforcement actions to any great extent for those facilities with problems to any great during the 1983 to 1988 period. Regulatory activities for home health agencies were not given a high priority in either state, and many barriers to the effective regulation of agencies were identified. This study suggests that additional research should be directed toward the study of state regulation and its relationship to quality of home health care.

This article examines the social impact of Medicaid policy on the elderly in long-term care and identifies a previously unrecognized problem produced by Medicaid in New York State. Recent fieldwork in proprietary nursing homes in New York City shows that this state's Medicaid system results in a selection hierarchy on admissions and within nursing homes not only in terms of sponsor of payment but also in value, based on residents' functional level. Specifically, New York State Medicaid's Resource Utilization Groups (RUGs II) system is responsible for a new and startling phenomenon in long-term health care of the elderly: the creation of "minihospitals" in lieu of traditional skilled nursing facilities. This problem indicates the complex ways in which reimbursement policy drives priorities in nursing homes and creates unintended negative outcomes. In light of this consideration, various policy alternatives to Medicaid that would improve the plight of the elderly in long-term care are suggested and evaluated.

The quality of long-term home health services is particularly difficult to study because of (a) the multidimensionality and chronicity of patients' needs, (b) the complexity of and the number of social and health-related services provided, (c) the isolation of care in individual homes, and (d) the lack of norms and standards on which to base judgments. A study was undertaken of the quality of care received by two client groups receiving home- and community-based services, in which some of these difficulties were addressed An expert committee of home health practitioners wrote criteria for process and outcomes of care based on local norms of practice. Applying these criteria to the care received by the study groups, the committee found a high degree of quality of care. Specific problems identified m the care were a lack of appropriate case management and poor chart documentation. In most cases, if good care was received, the client experienced good outcomes.

Increasing concern over the quality of care in nursing homes has prompted the National Institute of Medicine to recommend that residents have regular input into nursing home administration, primarily through the development of resident councils. Yet little is known of the effectiveness of resident councils. The literature is divided in its assessment of the potential of the institution alized to represent themselves. Rather than suggesting either that resident councils are impotent or that they are a cure-all, these data, which examine the activities and effectiveness of existing resident councils, suggest that resident councils are successful in accomplishing some but not all of their objectives, that their success is maximized when professional organizers are available to help residents overcome the many barriers they face, and that there are many institutional factors that resident councils are seldom in any position to control.

This survey of grantmakers and experts in the field of aging gives a picture of where grantmakers say their funds will be targeted in the first half of the 1990s and where experts believe these funds should go. A review of the similarities between grantmakers and experts indicates that community-based support services geared toward traditional populations are a priority among both groups. The most dramatic difference is in how best to package these services. We discuss implications of the findings.