Methods for evaluating quality of care in nursing homes are under scrutiny. The 10th Federal Circuit Court of Appeals ruled in Smith vs. Heckler that the government is responsible for ensuring that a facility is actually providing good care, not merely capable of doing so. Thus, outcome measures have replaced many of the more structural aspects of quality assessment.
Through (he Health Care Financing Administration, the federal gov¬ernment requires states to maintain surveillance agencies. These agen¬cies inspect nursing homes to make sure they are complying with state regulations and adhering to specific requirements for participation in Medicare and Medicaid programs. The inspeclion report for a particu¬lar facility, including any deficiencies cited, must be provided to the nursing home’s attending physicians and may be useful to families or physicians when selecting a nursing home. However, no report can sub¬stitute for a personal visit when choosing a nursing home.
Through actual observations of care, interview of residents and staff, and review of the clinical records, surveyors attempt to assess a facil¬ity’s performance. Physical findings or events that are objective and easily measured (such as falls, contractures, use of nasogastric feeding tubes, devclopmenl of urinary tract infections or pressure sores) help indicate the quality of care, particularly nursing care. However, quality-of-life factors arc difficult to assess. If a surveyor observes that resi¬dents’ rights are being violated, examples of the violations can be sub¬mitted along with evidence of poor care. A statement of deficiencies can show that the facility has systemic problems.
In the past, nursing homes were divided conceptually into those of¬fering skilled services for “sicker” people who required more care from licensed nurses or rehabilitative services and Ihose offering custodial services (a euphemism for warehousing) for the vast majority of de¬mented, disabled nursing home residents. Today, facilities (hat receive any federal funding, whether Medicare or Medicaid, musl be able to provide all services to its residents if and when they need them (see TABI,K24—1). Nursing home operators and staff are beginning to realize that they must take a new approach to caring for demented, frail, or debilitated residents if they wish to preserve the residents’ indepen¬dence and function. Maintenance and rehabilitation must be pursued 300   Specific Approaches
with equal vigor. Practitioners can demand that their nursing home pa¬tients receive all the services necessary to attain and maintain the high¬est level of functioning, although coverage of these services by Medic¬aid varies by stale.
The level of services can also vary considerably. Some nursing homes provide IV therapies, enteral nutrition through gastrostomy or jcjunoslomy tubes, hyperalimentation, and chronic oxygen treatment or ventilator support; others do not. Some homes have a full-time activ¬ities staff; mothers, activities are minimal. Activity programs oi’high quality often include scheduled group events as well as leisure time and self-selected diversional choices for residents, especially those who are cognitively impaired or bedridden. Some homes provide personal ser¬vices such as hairdressing and makeup, which are psychologically im¬portant to some residents bul are usually paid for by residents’ personal funds (out-of-pocket expenses).
Some homes have programs for persons with special needs. For ex¬ample, a special unit for patients with dementia may provide a support¬ive physical environment where (rained staff and creative programming diminish the use of physical and pharmacologic restraints and focus on preserving the patient’s residual skills. Some facilities specialize in pro¬viding intensive rehabilitation for patients with hip fractures or head injuries. In fact, many homes segregate patients who need acute re¬habilitation and skilled services after hospitalization (usually those patients with Medicare coverage) from patients whose needs may be similar although Iheoretically of lesser intensity (usually those with Medicaid coverage). Medicaid units often have fewer staff members and may riot provide any rehabilitative services. However, a federally certified nursing home must provide care to meet a resident’s assessed needs, whether the resident’s care is covered by Medicare. Medicaid. or private payment. Some nursing homes are not federally certified and are licensed only by the stale. Unless state regulations arc comprehen¬sive and well enforced, the lack of federal certification may indicate
poor quality of care.
Social services vary as well. Usually, social workers provide mini¬mal assistance to palienls and families; however, in better facilities they help alleviate transfer trauma, identify social withdrawal and isolation, and actively assist in maintaining the residents’ psychosocial well-being. Good social workers also help ensure that families are given timely information and assistance when applying for Medicare or Med¬icaid coverage, planning appropriate discharge, or learning about other
services.
Although some slates set minimum nurse resident ratios, staffing ra¬tios vary considerably. In homes thai have only a minimal staff, the staff rarely has time to adequately care for sicker or needier patients, particularly those with dementia; such situations place unrealistic bur¬dens on the nursing staff. Social workers, nurses, and physicians, as well as patients and their families, should be aware that some residents
require more nursing care and should demand appropriate staffing levels on all shifts in all parts of the facility. If health care professionals refuse to accept substandard care for their patients, then perhaps nurs¬ing homes can shed their generally unsavory reputation.