Caregivers ARE Caregivers ARE Quality in Long Term Quality in Long Term

CareCare

Christine T. Kovner, R.N., Ph.D.Christine T. Kovner, R.N., Ph.D.

Division of Nursing, Steinhardt Division of Nursing, Steinhardt School of Education, NYUSchool of Education, NYU

April 30, 2003April 30, 2003

Total Nurse Staffing Hours per Resident per Day, 2001

Certified nurse aides (CNA)- 2.1 hours Licensed practical/vocational nurse

(LPN/LVN) - 0.7 hours Registered nurses (RN) – 0.7 hours Only RN hours have increased from

0.4 hours per day in 1993, while acuity has increased

Harrington from CMS OSCAR data

Reported Staff Ratios Reported Staff Ratios on each Shift – Nursing on each Shift – Nursing

Homes 2001Homes 20011 CNA to 11.8 Residents1 CNA to 11.8 Residents 1 LVN/LPN to 34 Residents1 LVN/LPN to 34 Residents1 RN to 32 Residents 1 RN to 32 Residents

Harrington from CMS OSCAR dataHarrington from CMS OSCAR data

Research Studies: Positive Research Studies: Positive Relationship Between Licensed Relationship Between Licensed

Nurses & QualityNurses & Quality Increased licensed nursing hours were Increased licensed nursing hours were

related to improved functional ability and related to improved functional ability and decreased probability of deathdecreased probability of death

Facilities with higher nurse staffing levels Facilities with higher nurse staffing levels have fewer deficiencieshave fewer deficiencies

Facilities with more RNs per LPN had fewer Facilities with more RNs per LPN had fewer assessment deficiencies assessment deficiencies

Bliesmer et al., 1998; Harrington et al., 2000; Moseley & Jones, Bliesmer et al., 1998; Harrington et al., 2000; Moseley & Jones, 20032003

Research Studies: Positive Research Studies: Positive Relationship Between Licensed Relationship Between Licensed

Nurses & QualityNurses & Quality Nursing homes meeting HHS preferred minimum Nursing homes meeting HHS preferred minimum

staffing levels had no violation that caused actual staffing levels had no violation that caused actual harm to patientsharm to patients

68% of homes that did not meet HHS standards 68% of homes that did not meet HHS standards had such violationshad such violations

Less than 2.0 hours of nurse aid care per nursing Less than 2.0 hours of nurse aid care per nursing home resident were almost 4 times more likely to home resident were almost 4 times more likely to get pressure sores than those in nursing homes get pressure sores than those in nursing homes that provided more than 2 hoursthat provided more than 2 hours

(Stark report, 2001); (DHHS Report to Congress: Appropriateness of (Stark report, 2001); (DHHS Report to Congress: Appropriateness of Minimum Nursing Staffing Ratios in Nursing Homes, 12- 1 (Spring 2000).Minimum Nursing Staffing Ratios in Nursing Homes, 12- 1 (Spring 2000).

Medication Errors in Home Medication Errors in Home Care for Patients 65 years Care for Patients 65 years

and olderand older 1.4% of patients taking medications 1.4% of patients taking medications

older adults should always avoidolder adults should always avoid

8.4% of patients taking medications 8.4% of patients taking medications rarely appropriate for older adultsrarely appropriate for older adults

Kovner, Menezes, & Feldman, 2003; MEPS data from AHRQKovner, Menezes, & Feldman, 2003; MEPS data from AHRQ

Occupational Training Occupational Training Requirements Requirements

Many believe minimum Many believe minimum training for nursing assistants training for nursing assistants should be increased:should be increased:

Nursing Assistants --75 hoursNursing Assistants --75 hours Manicurists -- 400 hoursManicurists -- 400 hours Barber -- 1500 hoursBarber -- 1500 hours

www.barbercosmo.ca.gov/www.barbercosmo.ca.gov/

Recommended Nursing Recommended Nursing Hours in NHs (direct and Hours in NHs (direct and

indirect) indirect) Registered Registered

NursesNurses69 minutes (1.15 69 minutes (1.15 hours) per day hours) per day

Licensed Licensed practical/ practical/ vocational vocational

nursesnurses

42 minutes (.70 42 minutes (.70 hours) per dayhours) per day

Nursing Nursing assistantsassistants

162 minutes (2.7 162 minutes (2.7 hours) per dayhours) per day

Total NursingTotal Nursing 273 minutes (4.55 273 minutes (4.55 hours) per dayhours) per dayHarrington, C., Kovner, C., et al. (2000). Experts recommend

minimum nurse staffing standards for nursing facilities in the U.S. The Gerontologist 40, 5-16.

Geriatric PreparationGeriatric Preparation

Less than <1% (21,500) of working Less than <1% (21,500) of working RNs are certified in geriatricsRNs are certified in geriatrics

Fewer than 0.3% (333) of the 97,362 Fewer than 0.3% (333) of the 97,362 physician residents slots are for physician residents slots are for geriatricsgeriatrics

Only 0.3% (720) of 200,000 Only 0.3% (720) of 200,000 pharmacists have geriatric certification pharmacists have geriatric certification

Kovner, C.T., Mezey, M., & Harrington, C. (2002). Kovner, C.T., Mezey, M., & Harrington, C. (2002).

References 

Anderson, R. A., Hsieh, P., Su, H. (1998). Resource allocation and resident outcomes in nursing homes: Comparisons between the best and worst. Research in Nursing and Health, 21, 297-313.  Kovner, C.T., Menezes, J. & Feldman, P. (2003). Paper in progress.  Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Berger, S., Muhler, M., Reilly, K., Burice, R., Zimmerman, D. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the U.S. The Gerontologist 40, 5-16. Kovner, C.T., Mezey, M., & Harrington, C. (2002). Who cares for older adults? Workforce implications of an aging Society. Health Affairs 21(5), 78-89. Bliesmer, M. M., Smayling, M. , Kane, R. & Shannon, I. (1998) The relationship between nursing staffing levels and nursing home outcomes. Journal of Aging and Health, 10(3), 351-371.  Harrington, C. Zimmerman, D., Karon, S. L., Robinson, J. & Beutel, P. (2000). Nursing home staffing and its relationship to deficiencies. Journal of Gerontology: Social Sciences, 55B(5), S278-S287.  Linn, M. G., L. & Linn, B. A. (1977). Patient outcomes as a measure of quality of nursing home care. American Journal of Public Health. 67(4), 337-344. Nyman, J. A. (1988). Improving the quality of nursing home outcomes: Are adequacy or incentive-oriented policies more effective? Medical Care, 26(12), 1158-1171. Kayser-Jones, Wiener, C. L. & Barbaccia, J. C. (1989). Factors contributing to the hospitalization of nursing home residents. The Gerontologist, 29, 502-510.  Spector, W. D., & Takada, H. A. (1991). Characteristics of nursing homes that affect resident outcomes. Journal of Aging and Health 3(4), 427-454.  Cherry, R. L. (1991). Agents of nursing home quality of care: Ombudsman and staff ratios revised. The Gerontologist. 31, 302-308. Kayser-Jones, J. & Schell, E. (1997). The effect of staffing on the quality of care at mealtime. Nursing Outlook, 45(2), 64-72.  Harrington, C., Carrillo, H., Thollaug, S., & Summers, P. (1999)Nursing facilties, staffing, residents, and facility deficiencies 1991-1997. (Report prepared for the Health Care Financing Administration. San Francisco: University of California.