- Email: [email protected]
Should Reimbursement Rates be Increased for Feeding Assistance in Nursing Homes?
EDITORIALS
Should Reimbursement Rates Be Increased for Feeding Assistance In Nursing Homes? The purpose of the study in this issue by Dr. Mitchell and colleagues was to evaluate the nursing home staff and medical costs of providing nutritional care to long term residents with feeding tubes versus a comparable group who required handfeeding.1 This study provides interesting and important cost data, which are limited in the research literature, for two groups of nursing home residents at risk for poor nutritional status. The authors suggest that there may be a financial incentive for feeding tube placement because of lower staff care costs (ie, less staff time) and higher reimbursement rates (ie, Medicaid) for residents who have a feeding tube compared with the staff costs and reimbursement rates for residents who require hand-feeding. It is distressing to believe, however, that finances significantly influence the medical decision to insert a feeding tube into individual nursing home residents. Feeding tube placement is an invasive and costly medical procedure, as evidenced by the Medicare-associated costs reported in this study incurred by the tube-fed group as a result of a myriad of needed medical services (initial surgery and more frequent physician, emergency room, and hospital visits). In addition, a recent study showed that family members of nursing home residents, who often serve as the proxy for treatment preferences, prefer feeding assistance, food quality improvements, and the provision of food and fluid items between meals as the three primary nutritional interventions of choice. This same study showed that most family members would not want a feeding tube placed, even if all other nutrition interventions failed.2 Other studies have shown few health benefits to feeding tube placement and a number of risks.3 Finally, a separate study showed that feeding tube placement among residents with advanced dementia in Kansas nursing homes, which do have an increased reimbursement rate for residents with feeding tubes, was significantly influenced by nonclinical factors that did not include Medicaid payment status.4 One important limitation of this study is the reliance on nursing home staff self-report, which is likely to be biased or
University of California, Los Angeles, School of Medicine, Department of Geriatrics, Borun Center for Gerontological Research, Los Angeles, and The Los Angeles Jewish Home for the Aging, Reseda, California.
Copyright ©2003 American Medical Directors Association DOI: 10.1097/01.JAM.0000043424.41989.D2 52 Simmons
erroneous, for time estimates of feeding tube and feeding assistance care. Nursing home staff self-reported in this study that they spent an average of 20 minutes per resident, per meal providing feeding assistance. These data are consistent with data reported in other studies that are based on nursing home staff self-report estimates.5 In contrast, multiple observational studies have shown that physically dependent residents receive less than 20 minutes of assistance.6 –9 Furthermore, 20 minutes of assistance or less is likely to reflect inadequate feeding assistance care based on the results of other studies, which have shown that eating dependent persons require an average of 25 to 60 minutes of feeding assistance for each mealtime period.9,10 Direct observations of feeding assistance care in this study may have revealed that: many of the residents did not, in fact, receive 20 minutes of staff assistance at all; the amount of assistance varied between meals such that a resident received 20 minutes of assistance at breakfast but only 10 minutes of assistance at lunch, for example; or, the quality of the assistance was questionable (eg, physical feeding was provided without any verbal prompting or social interaction between the resident and the staff member). Even though the residents in this study were severely cognitively impaired and completely physically dependent, staff should still talk to the resident during the hand-feeding process (eg, “Good morning. My name is Sandra and I will be helping you with your breakfast today.” “I am going to give you a bite of soup next, okay?”).8,9,11 Most US nursing homes do not have enough staff (ie, nurse aides) to provide adequate amounts of feeding assistance to all residents in need of such assistance.7,9,12 Thus, the cost of feeding assistance care delivery determined in this study likely reflects an underestimate of the staff time required for optimal feeding assistance care. In addition, most residents should, at a minimum, be offered fluids between meals to ensure adequate hydration, which requires additional staff time.13 Therefore, the findings suggest that an increase in the reimbursement rate is warranted for residents who require feeding assistance. The reimbursement increase could be used to offset the cost of hiring additional nurse aides (increase the number of staff) to provide adequate feeding assistance during meals and to encourage hydration between meals. The results of this study even suggest the interesting possibility that the JAMDA – January/February 2003
increase in staff costs could be offset by a reduction in medical costs often associated with feeding tube placement. Sandra F. Simmons, Ph.D. REFERENCES 1. Mitchell SK, Buchanan, JL, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: A cost comparison, J Am Med Dir Assoc 2003;4:27–33. 2. Simmons SF, Lam H, Rao G, Schnelle, JF. Family members’ preferences for improving nursing home residents’ oral food and fluid intake. J Am Geriatr Soc 2003;51:1– 6. 3. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999;282:1365–1370. 4. Gessert CE, Mosier MC, Brown EF, Frey B. Tube feeding in nursing home residents with severe and irreversible cognitive impairment. J Am Geriatr Soc 2000;48:1593–1600. 5. Backstrom A, Norberg A, Norberg B. Feeding difficulties in long-stay patients at nursing homes. Caregiver turnover and caregivers’ assessments of duration and difficulty of assisted feeding and amount of food received by the patient. Int J Nurs Stud 1987;24:69 –76. 6. Amella EJ. Factors influencing the proportion of food consumed by nursing home residents with dementia. Advancing Geriatrics Nursing Practice. Mezey M, Fulmer T, Series Editors. J Am Geriatr Soc 1999;47:879–885.
EDITORIALS
7. Schnelle JF, Cretin S, Saliba D, Simmons SF. Minimum nurse aide staffing required to implement best practice care in nursing homes. Chapter in report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Health Care Financing Administration. Summer 2000, Volume 2, Chapter 14. 8. Simmons SF, Babinou S, Garcia E, Schnelle JF. Quality assessment in nursing homes by systematic direct observations: Feeding assistance. J Gerontol A: Biol Sci Med Sci 2002;57:M665–M671. 9. Simmons SF, Osterweil D, Schnelle JF. Improving food intake in nursing home residents with feeding assistance: A staffing analysis. J Gerontol A Biol Sci Med Sci 2001;56A:M790-M794. 10. Hu TW, Huang LF, Cartwright WS. Evaluation of the costs of caring for the senile demented elderly: A pilot study. Gerontologist 1986;26:158 – 163. 11. Reuben D. Quality indicators for malnutrition in vulnerable communitydwelling and hospitalized elders. Assessing the Care of Vulnerable Elders (ACOVE) project (June 1999). RAND Corporation, 1700 Main Street, PO Box 2138, Santa Monica, CA 90407–2138 (monograph). 12. Kayser-Jones J, Schell E. The effect of staffing on the quality of care at mealtime. Nurs Outlook 1997;45:64 –72. 13. Simmons SF, Alessi C, Schnelle JF. An intervention to increase fluid intake in nursing home residents: Prompting and preference compliance. J Am Geriatr Soc 2001;49:926 –933.
Simmons 53
Should Reimbursement Rates Be Increased for Feeding Assistance In Nursing Homes? The purpose of the study in this issue by Dr. Mitchell and colleagues was to evaluate the nursing home staff and medical costs of providing nutritional care to long term residents with feeding tubes versus a comparable group who required handfeeding.1 This study provides interesting and important cost data, which are limited in the research literature, for two groups of nursing home residents at risk for poor nutritional status. The authors suggest that there may be a financial incentive for feeding tube placement because of lower staff care costs (ie, less staff time) and higher reimbursement rates (ie, Medicaid) for residents who have a feeding tube compared with the staff costs and reimbursement rates for residents who require hand-feeding. It is distressing to believe, however, that finances significantly influence the medical decision to insert a feeding tube into individual nursing home residents. Feeding tube placement is an invasive and costly medical procedure, as evidenced by the Medicare-associated costs reported in this study incurred by the tube-fed group as a result of a myriad of needed medical services (initial surgery and more frequent physician, emergency room, and hospital visits). In addition, a recent study showed that family members of nursing home residents, who often serve as the proxy for treatment preferences, prefer feeding assistance, food quality improvements, and the provision of food and fluid items between meals as the three primary nutritional interventions of choice. This same study showed that most family members would not want a feeding tube placed, even if all other nutrition interventions failed.2 Other studies have shown few health benefits to feeding tube placement and a number of risks.3 Finally, a separate study showed that feeding tube placement among residents with advanced dementia in Kansas nursing homes, which do have an increased reimbursement rate for residents with feeding tubes, was significantly influenced by nonclinical factors that did not include Medicaid payment status.4 One important limitation of this study is the reliance on nursing home staff self-report, which is likely to be biased or
University of California, Los Angeles, School of Medicine, Department of Geriatrics, Borun Center for Gerontological Research, Los Angeles, and The Los Angeles Jewish Home for the Aging, Reseda, California.
Copyright ©2003 American Medical Directors Association DOI: 10.1097/01.JAM.0000043424.41989.D2 52 Simmons
erroneous, for time estimates of feeding tube and feeding assistance care. Nursing home staff self-reported in this study that they spent an average of 20 minutes per resident, per meal providing feeding assistance. These data are consistent with data reported in other studies that are based on nursing home staff self-report estimates.5 In contrast, multiple observational studies have shown that physically dependent residents receive less than 20 minutes of assistance.6 –9 Furthermore, 20 minutes of assistance or less is likely to reflect inadequate feeding assistance care based on the results of other studies, which have shown that eating dependent persons require an average of 25 to 60 minutes of feeding assistance for each mealtime period.9,10 Direct observations of feeding assistance care in this study may have revealed that: many of the residents did not, in fact, receive 20 minutes of staff assistance at all; the amount of assistance varied between meals such that a resident received 20 minutes of assistance at breakfast but only 10 minutes of assistance at lunch, for example; or, the quality of the assistance was questionable (eg, physical feeding was provided without any verbal prompting or social interaction between the resident and the staff member). Even though the residents in this study were severely cognitively impaired and completely physically dependent, staff should still talk to the resident during the hand-feeding process (eg, “Good morning. My name is Sandra and I will be helping you with your breakfast today.” “I am going to give you a bite of soup next, okay?”).8,9,11 Most US nursing homes do not have enough staff (ie, nurse aides) to provide adequate amounts of feeding assistance to all residents in need of such assistance.7,9,12 Thus, the cost of feeding assistance care delivery determined in this study likely reflects an underestimate of the staff time required for optimal feeding assistance care. In addition, most residents should, at a minimum, be offered fluids between meals to ensure adequate hydration, which requires additional staff time.13 Therefore, the findings suggest that an increase in the reimbursement rate is warranted for residents who require feeding assistance. The reimbursement increase could be used to offset the cost of hiring additional nurse aides (increase the number of staff) to provide adequate feeding assistance during meals and to encourage hydration between meals. The results of this study even suggest the interesting possibility that the JAMDA – January/February 2003
increase in staff costs could be offset by a reduction in medical costs often associated with feeding tube placement. Sandra F. Simmons, Ph.D. REFERENCES 1. Mitchell SK, Buchanan, JL, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: A cost comparison, J Am Med Dir Assoc 2003;4:27–33. 2. Simmons SF, Lam H, Rao G, Schnelle, JF. Family members’ preferences for improving nursing home residents’ oral food and fluid intake. J Am Geriatr Soc 2003;51:1– 6. 3. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999;282:1365–1370. 4. Gessert CE, Mosier MC, Brown EF, Frey B. Tube feeding in nursing home residents with severe and irreversible cognitive impairment. J Am Geriatr Soc 2000;48:1593–1600. 5. Backstrom A, Norberg A, Norberg B. Feeding difficulties in long-stay patients at nursing homes. Caregiver turnover and caregivers’ assessments of duration and difficulty of assisted feeding and amount of food received by the patient. Int J Nurs Stud 1987;24:69 –76. 6. Amella EJ. Factors influencing the proportion of food consumed by nursing home residents with dementia. Advancing Geriatrics Nursing Practice. Mezey M, Fulmer T, Series Editors. J Am Geriatr Soc 1999;47:879–885.
EDITORIALS
7. Schnelle JF, Cretin S, Saliba D, Simmons SF. Minimum nurse aide staffing required to implement best practice care in nursing homes. Chapter in report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Health Care Financing Administration. Summer 2000, Volume 2, Chapter 14. 8. Simmons SF, Babinou S, Garcia E, Schnelle JF. Quality assessment in nursing homes by systematic direct observations: Feeding assistance. J Gerontol A: Biol Sci Med Sci 2002;57:M665–M671. 9. Simmons SF, Osterweil D, Schnelle JF. Improving food intake in nursing home residents with feeding assistance: A staffing analysis. J Gerontol A Biol Sci Med Sci 2001;56A:M790-M794. 10. Hu TW, Huang LF, Cartwright WS. Evaluation of the costs of caring for the senile demented elderly: A pilot study. Gerontologist 1986;26:158 – 163. 11. Reuben D. Quality indicators for malnutrition in vulnerable communitydwelling and hospitalized elders. Assessing the Care of Vulnerable Elders (ACOVE) project (June 1999). RAND Corporation, 1700 Main Street, PO Box 2138, Santa Monica, CA 90407–2138 (monograph). 12. Kayser-Jones J, Schell E. The effect of staffing on the quality of care at mealtime. Nurs Outlook 1997;45:64 –72. 13. Simmons SF, Alessi C, Schnelle JF. An intervention to increase fluid intake in nursing home residents: Prompting and preference compliance. J Am Geriatr Soc 2001;49:926 –933.
Simmons 53