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


This project is endorsed by:

Project Steering CommitteeView List of Members


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:


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


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


Resident Length of Stay

Short-Term (typically Medicarecovered)

Long-Term (typically Medicaidcovered)

50%+

2.5 years (mean)

50% +

14-32 days

(mean)


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)


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:


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


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.”


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


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


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


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


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…


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


Sample Nursing Home Rating

View the Nursing Home Compare web site


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)


*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).


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.


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.


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


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.”


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


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:


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

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Module 1. Nursing Homes, the Basics

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