LTC Regulations: Devil in the Details

Part One of a Series on the Survey Process

by Steven Levenson, MD, CMD

At a recent Nursing Home Stakeholders' Group Meeting in Baltimore, the research group under contract to the Centers for Medicare and Medicaid Services (CMS; formerly HCFA) made it clear that all quality indicators are being reconsidered, many of the current ones have been found to be of questionable value, and it appears that none of the current quality indicators can stand by themselves without some sort of risk or population adjustment. At the same time, additional quality indicators are being developed and will be recommended as replacements.

What to make of these modifications? How will they help improve care in nursing homes? There are some important reasons to challenge the conventional wisdom that outcome indicators are the key to improving health care quality. Although such indicators undoubtedly play a role, they may do little by themselves to identify the root causes of problematic outcomes or to direct either surveyors or providers to find and correct those root causes. Without root-cause analysis and correction, these outcome indicators may remain little more than statistical and academic curiosities. So, perhaps we are trying to make all of this much more complicated than it needs to be. Perhaps, once again, we need to think hard about this and many other "truisms" that pervade the field of long-term care.

Long-Term Care a Long-Term Concern

Many of the risks and problems of frail elderly individuals in today's nursing homes--delirium, dementia, depression, osteoporosis, fluid and electrolyte imbalance, and so on--are not new, but most likely have existed for centuries. However, only since the 1950s have enough individuals lived long enough to bring these problems to the fore.

By the 1970s, nursing homes had become the focus of considerable public and political attention. The growing long-term care population, and the cumulative impact of scandals and deadly infectious outbreaks from the 1950s through the 1970s, led to growing public pressure for reform. The states--not the federal government--were responsible for regulating nursing homes, including establishing requirements for care. Yet, although there were structural requirements (e.g., specific personnel), there were few substantive state requirements for such care (e.g., formal assessment or problem management).

Geriatric and gerontologic principles had been identified for at least several decades prior to the 1970s. Therefore, after the 1965 passage of Medicare and Medicaid funding, the federal government became much more involved, trying to ensure that individuals in facilities receiving Medicare and Medicaid funds received appropriate care. The findings of the 1986 Institute of Medicine (IOM) report, Improving Quality of Care in Nursing Homes, led to the changes that were incorporated into the Omnibus Budget Reconciliation Act of 1987 (OBRA '87).

Thus, the struggle to scrutinize and improve nursing home care has actually been going on for decades. Some aspects of care have improved. Since 1987, the federal government has spent millions of dollars to establish and implement a complex nationwide survey and certification process. But the public perception of nursing homes remains broadly negative. There is no shortage of negative press coverage and continuing criticism in Congress and many state legislatures.

Something is very wrong with this picture. After so many decades of regulations, sanctions, political pressures, and reform efforts, the "powers that be" continue to believe that if a proposed solution to a problem is not succeeding, then more of that "solution" surely will work.

Either the care in nursing homes is really much better than it seems, or some of the expectations are not realistic, or the expectations are reasonable but the means of achieving them are flawed, or the ways in which we have gone about trying to fix the problems are simply not working, or some combination of all of the above. In this series, we will attempt to show that all of the above are true, to some extent.

Are Expectations of Nursing Homes Reasonable?

Expectations of nursing homes as identified under the OBRA regulations fall into two categories: personal and technical. Personal expectations relate to the treatment of nursing home residents as persons with certain rights and needs. Technical expectations concern the identification and management of certain situations, conditions, risks, problems, and deficits according to identifiable principles and practices.

After initial definitions, the OBRA regulations begin with a discussion of resident rights. Section 483.10 states that "the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident." Examples of rights guaranteed under state and federal law include: the right of each individual to be informed about his or her rights and responsibilities, the right to privacy and confidentiality, and the right to participate in decisions and care planning.

The OBRA regulations also have a lengthy section on technical issues related to care quality, starting with Section 483.20 Resident Assessment. Many of these technical requirements derive from the IOM report, which was based on advice from those familiar with basic geriatrics principles and practices.

The link between the personal and technical expectations of the OBRA regulations can be summarized as follows. Nursing facility residents are a diverse population, including many frail elderly and seriously impaired younger individuals. They have certain rights, including the right to a reasonable quality of life, within the limits imposed by their underlying impairments. Achieving those rights requires some individualized approaches. Each person has an underlying psychosocial and physical foundation.

The psychosocial foundation includes, among other factors, one's background, values, interests, and strengths. The physical foundation includes, among others, medical conditions, risk factors, and current treatments. Quality of life depends on biological as well as psychosocial components—for example, the effects of "normal" aging, cognitive impairments, acute illnesses, chronic conditions, and iatrogenic illness (such as medication complications). Thus, physical and medical factors should be managed in the context of their impact on an individual's function and quality of life.

Well-established principles underlying the technical aspects of the OBRA regulations may actually be found in many medical and geriatrics references. They have not changed materially for several decades, and include the following:

Diverse Population: The long-term care population is diverse. Nursing facilities care for long-term care residents and short-term patients. Many of these individuals have chronic medical and psychiatric conditions and functional impairments. Many arrive after a recent major acute illness, while others have major acute illnesses or complications after admission.

Common Problems & Symptoms: Long-term care residents and patients typically have significantly impaired function, and they often also have impaired cognition. A few common problems and conditions occur repeatedly. The residents and patients often have nonspecific symptoms such as confusion, lethargy, altered mental status, anorexia, dizziness and falling. An individual's symptoms often reflect a mix of acute illnesses, unstable chronic conditions, and side effects or complications from medications and other treatments.

Causes & Consequences: Historically, some segments of the health care system (for example, the hospital) have focused on the causes of illness and injury. Other segments (for example, nursing homes, assisted living) have focused on the consequences. But the proper management of those with chronic illness and disability requires attention to both.

Good geriatric, nursing, and medical practices are based on understanding the link between causes and consequences, to decide intelligently when to treat one or the other, both, or neither. Sometimes, only symptomatic treatment is feasible. Often, however, cause-specific treatment is both feasible and desirable. Frequently, symptomatic treatment makes problems worse by failing to identify and address underlying causes, whereas both symptomatic and cause-specific treatment can actually produce additional symptoms and complications.

Preventive Efforts: Secondary and tertiary prevention (preventing complications or worsening of existing complications) are the hallmarks of geriatric care. They are often feasible even when primary prevention (preventing the onset of illness) is not. It may be possible to improve an individual's level of functioning even when underlying causes cannot be resolved. For instance, there are ways to reduce pain and discomfort, enhance autonomy, reduce morbidity, prevent the spread of communicable illness, and minimize the subsequent need for more costly and prolonged medical care.

Rationale for Interventions: Explanations for treatment choices and other interventions would be unnecessary if the management of individuals with chronic illness and disability were routinely beneficial and of relatively low risk. However, because treatment is often risky, many interventions are of unproven benefit, and many symptoms and abnormalities do not respond readily to interventions, many treatment choices require some substantiation.

The presence of a diagnosis does not necessarily warrant a treatment. Whether treatment is appropriate or not depends on each patient's prognosis, goals, and the individual's overall body function, not just the effects of the treatment on a specific abnormality or organ system.

Treatment Risks: Every medication carries a risk of an adverse drug reaction (ADR). Multiple medications with similar side effects (anticholinergic properties, hypotensive effects, sedation, volume depletion) often cause problems even when the individual medications may not. Certain medications are frequently associated with a risk of ADRs or with the chance of a serious ADR. The symptoms related to ADRs are often identical to those related to medical illnesses. ADRs must be distinguished from illnesses because the correct intervention for ADRs (stop or change a medication) may be markedly different from the management of a presumed medical illness (perform more tests, increase or add medications).

Domino Effect: Condition changes and impaired or declining function in someone with chronic illness and disability--especially the frail elderly--often occur in a cascade (the "domino" effect). When this happens, we must try to identify and manage the root cause(s), not just treat the eventual symptoms. For example, a medication or an acute infection may lead to lethargy and decreased appetite, which leads to volume depletion, which leads to delirium, which can accelerate decline and agitated behavior. Treating the resulting agitation with more psychoactive medications often worsens the situation and leads to further decline because it does not correct underlying causes such as the fluid and electrolyte imbalance.

Risks of Hospitalization: Hospitalization is a known risk to the frail elderly and others with chronic illness and disability. It is associated with functional decline and a high incidence of delirium, impaired nutrition, skin breakdown, and ADRs. Many of the acute illnesses and problems that arise in long-term care residents and patients can be managed effectively and safely without hospitalization.

Values & Rights: By federal and state law, everyone has the right to know about realistic treatment options and to accept or refuse any treatment, including lifesustaining technologies. Treatments may be medically ineffective (that is, unlikely to have a significant positive physiological impact) or potentially medically effective but ethically inadvisable (not consistent with the patient's values and wishes or unlikely to achieve the patient's goals).

Expectations for a Care Process

Another essential expectation underlying the OBRA regulations is that each facility will follow a systematic care process. The reason lies both in the complexity of these patients and in basic gerontologic, medical, and nursing care principles. For instance, since symptoms such as altered mental status and falling have various causes, there must be a care process that identifies individuals with a significant acute change in mental status or at risk of falling, seeks causes of the problems or risks, and defines appropriate interventions either to prevent problems or identify when they occur in order to mitigate possible consequences.

The elements of the care process are depicted in the box below. These can be summarized as follows: Proper care of human beings requires following universally acknowledged methods to identify and address complex issues. It starts with collecting enough of the right information about them to be able to draw certain conclusions.

Correct interpretation means that the information is used to properly define an individual's characteristics, strengths, deficits, risks, and problems; to distinguish real problems from mere abnormalities; and to identify situations requiring some additional analysis and intervention. Then it is necessary to try to distinguish and relate causes and consequences, as the foundation for proper interventions. Additionally, an individual's values, goals, wishes, and prognosis must be identified in order to properly assess the relevance of current and proposed interventions.

Next, appropriate interventions must be determined. This may mean continuing, modifying, or replacing current or recent approaches. Additionally, preventive measures must be instituted, where feasible, for identified risks. Then, a period of monitoring is needed to review the individual's progress toward defined goals and to adjust interventions accordingly.

Summary

The OBRA regulations are based upon some enduring principles that reflect (1) people's basic rights; (2) the realities of being frail, chronically ill, or severely impaired functionally and cognitively; and (3) basic care processes that are widely and commonly recognized and should be familiar to nurses, physicians, and other health care practitioners. There is little arguable about these generalities.

But then, the devil is in the details. Do the regulations properly identify and promote the necessary processes, and does the survey process adequately identify the proper or improper performance of such processes?

Not surprisingly, the answer is mixed. Our next column will discuss this in detail, and consider the positive and negative effects on the improvement of long-term care.

Steven Levenson, MD, CMD, is a Multi-Facility Medical Director in Baltimore, MD, and Chair of Caring's Editorial Board. He is author of numerous books and journal articles that address quality of care, care processes, nursing home policies and procedures, and regulatory oversight of long-term care facilities. For more information, see www.ltcinfo.net.

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