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.

With age, many functions that affect driving ability may deteriorate, including muscle strength, reaction time, mobility, vision, and cognition (see TABLE 112-1).

Muscle Strength and Reaction Time
Decreased muscle strength, particularly decreased grip strength, can pose a problem. Dynamometric values of < 35 lb in the dominant hand should raise concern.
An increased reaction time also is a concern. Reaction time, which increases with the difficulty or number of choices, should be evaluated clinically. No established test exists.
Mobility
Formal evaluation of range of motion by an occupational or physical therapist using a goniometer is usually not required except in unusual circumstances. The neck is often a concern in patients with debilitating rheumatologic conditions because limited mobility may restrict the field of view, especially in critical traffic situations. Restricted mobility of the shoulder, wrist, or elbow can affect the ability to steer, though
power steering and adaptive devices often can compensate adequately. In many metropolitan areas, body shops can equip vehicles with these devices, but they may be expensive.
Although proprioception is important, measurement is often crude. It should be assessed clinically, particularly in patients with subacute combined degeneration caused by vitamin B12 deficiency. Patients with obvious deficits may warrant road testing or other focused evaluations.
Vision    /
Several age-related changes in vision can affect driving. Central visual acuity frequently declines because of physiologic or anatomic changes, such as increasing opacification of the lens, or medical conditions, such as diabetic retinopathy. Peripheral vision also declines with age, mostly through the same mechanisms that affect central vision.

The total horizontal peripheral visual field typically declines from 170° in a young adult to 140° by age 50. Because the peripheral retina is less sensitive to low levels of light, twilight can be the most difficult time for driving. Drivers with peripheral vision deficits have twice as many collisions as those with normal vision. Other age-related functional deficits include poor visual adaptation to light changes, increased sensitivity to glare, declining visual accommodation (ie, presbyopia), and diminishing depth perception.
In most states, central visual acuity and peripheral vision are routinely evaluated at the department of motor vehicles. The frequency of evaluations and the minimum acceptable, corrected, central visual acuity depend on state regulations. The most common requirements are visual acuity of 20/40 in the better eye and horizontal peripheral vision of 120°. Medical or surgical therapy, such as cataract surgery, may be helpful.
Cognition
About 3% of community-dwelling elders between ages 65 and 74, 14% between 75 and 84, and > 20% over 85 have moderate degrees of cognitive impairment. Those with such impairment may not fully recognize their limitations, and elderly drivers with mild to moderate dementia have a fivefold greater risk of collisions. To evaluate cognitive impairment, the physician can use the Mini-Mental State Examination. Persons who score less than 23 should probably stop driving pending further investigation (see Ch. 89). About 5% to 10% of demented outpatients have reversible components to their dementia.
Although patients with severe dementia should not drive, most older drivers with illness-related dementia do not have severe cognitive impairment. In these patients, attention deficits may play a role in motor vehicle collisions. The three major types of attention are selective, divided, and sustained. Selective attention, the ability to shift focus between competing stimuli, is evaluated using several neuropsychologic tests, such as the dichqtic listening test and the Stroop test. Selective attention is important in driving, where stimuli, such as a radio or a cellular phone, interfere with driving tasks. Divided attention, the ability to process two or more stimuli at once and make an appropriate response, is important when approaching intersections or merging onto freeways. Finally, sustained attention, an endurance in alertness, may be relevant to a driver with a chronic medical condition