Module 1. Nursing Homes, the Basics
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Transcript of Module 1. Nursing Homes, the Basics
Nursing Homes: The Basics
Sarah Greene Burger, RN-C, MPH, FAANEthel Mitty, EdD, RN
Mathy Mezey, EdD, RN, FAAN
Hartford Institute for Geriatric Nursing, New York University College of Nursing
Module 1 of Nursing Homes as Clinical Placement Sites for Nursing Students Series
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Acknowledgments
This is a joint project of
With support from
Grant to the University of Minnesota School of Nursing
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
This project is endorsed by:
Project Steering CommitteeView List of Members
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
About Module 1- Nursing Homes: The Basics
Evaluate attributes of nursing homes that can affect the educational experience of students
Compare and contrast quality of care in nursing homes using objective criteria
Explain how nursing homes are regulated and reimbursed
Evaluate the potential for a nursing home to serve as a clinical training site for nursing students
Objectives/Purpose:
At the end of this module you will be able to:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Nursing Home Characteristics and Services
16,000+ Nursing Homes
1.7 Million Medicare and/or Medicaid certified beds
Most Nursing Homes (67%) are for-profit
Average Nursing
Home Size: 104 beds
1.5 million+ people (6%+
of people >65 years old) are
in Nursing Homes
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Resident Characteristics
Most residents are white (86%), female (62%),
married (17%) and live alone
Assistance needed with 3-4
ADLs: 95%
Incontinent of bladder or
bowel: 50%
Age range: 75-84: 30%, >85 y/o: 45%,<65 y/o: 12%
Dementia of some kind: 65%
Depressed (at least one clinical symptom): 20%
Physical restraint use: 6% (some NHs: 0%)
Receiving psychotropic medication: 63%
46% of residents are admitted from acute care
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Resident Length of Stay
Short-Term (typically Medicarecovered)
Long-Term (typically Medicaidcovered)
50%+
2.5 years (mean)
50% +
14-32 days
(mean)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Hospitalization of Residents
Between 25%-50% of residents are hospitalized during any one year
Some residents can be hospitalized as many as 4 times in one year (e.g. with diagnosis of COPD, CHF)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Reasons for Hospitalization
Physician practice pattern and hospital vacancy rate
Resident’s Medicare eligibility
Nursing Home resources (staffing; IV administration; diagnostic services)
Family pressure
Reasons for hospitalization include:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
3000 Nursing Homes (19+%) have designated a
Special Care Unit (SCU)
Special Care Units (SCU)
Dementia SCUs are the most common type (22%) (Originally for residents with mild/moderate stage dementia)
Sub-acute Care Units provide short-term intensive rehab and continuous medical monitoring
Types of Sub-acute Care Units include ventilator dependent, traumatic brain injury, oncology, pressure ulcer care, AIDS, skilled rehab, palliative care and hospice units
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Nursing Home Regulations: The Nursing Home Reform Act 1987 (NHRA [OBRA’87]) (PL 100-203)
Most federal regulation of Nursing Homes stems from The Nursing Home Reform Act 1987. Components of the Act include the following: Nursing homes are certified as a Medicare and/or Medicaid skilled
nursing facility by the federal government (Centers for Medicare and Medicaid [CMS]).
“Conditions of Participation”: Spells out the mandates that a nursing home is obliged to meet in order to remain Medicare/Medicaid certified and eligible for reimbursement
Specifies that people living in a nursing home are “residents” – not patients.
Requires that every facility is “to care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of quality of life of each resident” and to “provide services and activities to attain or maintain, for each resident, the highest, practicable physical, mental and psychological well-being.”
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Staffing in Medicare and Medicaid Skilled Nursing Homes
On-site supervision 24/7 by a licensed nurse (RN, LPN); an RN must be on duty 8 hrs/day, 7 days/wk.
-Nursing: 66%+ of Nursing Home staff (RN, LPN, Certified Nurse Assistant or CNA) See Module 2: An Overview of Nursing homes Generally
Full-time licensed administrator Therapeutic staff: social worker, activities therapist, nutritionist,
and rehab therapy staff (full or part time required) Medical director (at least 20% time) Physician for every resident
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
CMS Mandated Services and Committees in Medicare and Medicaid Skilled Nursing Homes
Podiatric, ophthalmology and dental services Rehabilitation services (PT, OT, ST) intensity
can vary)Pharmacy, clinical lab, radiology End of Life (EOL) Care Psychiatry consultation Resident and Family Council (to express
concerns & interests, and receive information and updates).
Committees: Pharmacy & Therapeutics (P&T), Infection Control, Quality Assurance, Safety (Risk Management), Utilization Review
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
CMS Mandate for Interdisciplinary Team in Medicare and Medicaid NHs
Physicians are the legal head of the team and the team includes nursing, social worker, activities therapist, nutritionist, rehabilitation, and others (e.g. psych) on ad hoc basis
CNAs can (and should) be a member of the interdisciplinary team
Resident, family, health proxy/surrogate, if resident wishes, are also part of the team
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Oversight and Monitoring of Nursing Homes
The following are used in monitoring Nursing Homes:
State Departments of Health: Conducts surveys on behalf of CMS
CMS 5-Star Quality Rating System Long Term Care Ombudsman: State office
(federally funded) investigates and resolve complaints regarding resident rights, quality of care (in most but not all nursing homes).
Joint Commission: optional except for Nursing Homes seeking managed care contracts or that are hospital-based
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
State Departments of Health Surveys on Behalf of CMS
Surveys assess 17 different
Categories, including:
Resident rights Admission and discharge rights Resident behavior and facility
practices Quality of life Resident assessment Quality of care Nursing services Dietary services Infection control
Survey assessment of individual residents includes:
Use of physical restraints Psychotropic medication Staff training & supervision Staffing Care planning Specific outcomes of care and
others…
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
The CMS 5 Star Quality Rating System is a nationally recognized
standard against which to assess nursing homes.
Star rating reflects a Nursing Home’s quality status for the past
12-15 month period.
Higher star ratings reflect better quality: 5 Stars: top 10% of nursing homes within the state 2, 3, 4 Stars: middle 70% of nursing homes within the state 1 Star: bottom 20% of nursing homes within the state
CMS 5 Star Quality Rating System
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Sample Nursing Home Rating
View the Nursing Home Compare web site
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
There are 3 performance measures of the CMS 5
Star Quality Rating System:
Staffing (Nursing) Domain Quality Measures Domain Health Inspection Domain
CMS 5 Star Quality Rating System: 3 Domains (Performance Measures)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
*Nurse staffing data provided by Nursing Homes is available in the annual federal On-line Survey, Certification and Reporting system.
Staffing (Nursing) Domain of CMS 5 Star Quality Rating System
The Staffing (Nursing) Domain,
consists of the following
characteristics:
Nurse staffing includes RNs, LPNs, and Certified Nursing Assistants (CNAs)
Nurse staffing typically reported as hours
per resident day (HPRD). HPRD computed
for RNs only and for total nursing staffing. * Relationship of staffing to quality. CMS
studies show a clear association between
nursing staffing and quality of care
outcomes Staff-to-resident ratios indicate when NH
residents are at high risk for quality
problems (CMS data).
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Quality Domain of the CMS 5 Star Quality Rating System
Assessment of Quality based on data in the Minimum Data Set
Quality Measures (QMs) are issued by the NHQI Quality Initiative*
All QMs are validated, reliable and endorsed by the quality measure rating agency: National Quality Forum
The Quality Domain,
consists of the following
characteristics:
For comparison of quality measures across homes go to www.medicare.gov/NHCompare
Quality Measures (QMs) are believed to be within the NHs ability to influence and control
Seven Long-stay QMs: The percent of residents (1) whose need for ADL assistance increased; (2) whose in-room mobility decreased; (3) are “high-risk” and have pressure ulcers; (4) have an indwelling urinary catheter; (5) are physically restrained; (6) have a UTI; (7) have moderate to severe pain.Four Short-stay QMs: The percent of residents with (1) pressure ulcers; (2) delirium; (3) moderate to severe pain.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Health Inspection Domain of the CMS 5 Star Quality Rating System
The Health Inspection Domain carries the strongest weight.
It uses annual health survey and complaint data and also
indicates the relative performance of a nursing home within
the state.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
The Minimum Data Set (MDS) is: a functional assessment instrument; required
by NHRA [OBRA ’87] provided by the interdisciplinary team members
according to their specialty. the basis for interdisciplinary assessment, care
planning, reimbursement, and quality monitoring.
Resident Assessment: The Minimum Data Set (MDS)
Click here for more information about MDS
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
NH Costs and Reimbursement
The mean national cost for a nursing home stay is $ 62,000+/year. A two-bed shared room is $169/day
62%+ of residents are dually Medicare and Medicaid eligible.
Medicare is primary payer for residents in a Nursing Home for post-hospital skilled nursing and/or rehab (100 days maximum).
Medicaid is primary payer for residents in a Nursing Home for an entire year (or longer).
Other residents are “private pay,” i.e. they pay for Nursing Home care “out of pocket.”
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Resource Utilization Groups III (RUGs)
Resource Utilization Groups III (RUGs) is a method of assigning payment for care in NHs (achieving a similar aim as DRGs in hospitals)
It is a case-mixed reimbursement system in which ADL data is essential. It also reflects the amount of resources (human and other) needed to provide care
Click here for more information about RUGs
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Recap: Key Points about Nursing Homes: The Basics
Knowing the characteristics of residents in nursing homes is helpful in creating strong clinical assignments for students
Objective criteria exist for comparing and contrasting quality of care in nursing homes
Understanding regulation and reimbursement in nursing homes can help students meet learning objectives related to the health care system
We present the following key points to consider:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Please Proceed to the following modules of the SeriesNursing Homes as Clinical Placement Sites
for Nursing Students
Overview of the Project
Module 1: An overview of nursing homes generally
Module 2: An overview of nursing in nursing homes
Module 3: Content on resident directed care and culture change
Module 4: Selecting and structuring clinical placements in nursing homes
Module 5: A case study to help faculty introduce resident directed care and culture change
Module 6: Strategies to help nursing homes position themselves as clinical placement