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Teaching nursing home program: A lesson in quality
Teaching Nursing Home Program:
A Lesson in Quality Ni
investment in nursing care in nursing homes pays off,not only . better patient outcomes but in actual dollars saved. We may have suspected or known that intuitively. At last, however, the analysis of the data from the Robert Wood J ohnson Teaching Nursing Home (TNH) Program is available,withthe statisticsto prove it. For example, hospitalization of residents dropped seven percent in nursing homes affiliated with baccalaureate nursing schools and rose five percent in homes not linked to schools. Imagine the Medicare savings that could accrue if more expert nurses and faculty were paid to assume responsibility for clinical care in more nursing homes. The formal collaboration between academia and service to improve clinical care, educate students, and foster research is a recent development for nursing homes and nursing schools. But it is a familiar model in teaching hospitals affiliated with medical schools. In fact, the medical school-medical center partnerships have been subsidized with federal funds for years. The TNH Program, a five-year project that ended in 1987, funded between 1.5 and 2.0 full-time equivalent new positions in 12 nursing homes, filled primarily by faculty/clinicians from 11 university schools of nursing.
The authors were codirectors of the Robert Wood Johnson Teaching Nursing Home Program. MATHY MEZEY, RN, EdD, FAAN, is now Independence Foundation professor of Nursing Education, New York University, New York City. JOAN LYNAUGH, RN, PhD, FAAN, is associateprofessor,University of PennsylvaniaSchoolofNursing,Philadelphia,PA.
76 Geriatric Nursing March/April1991
Most commonly the new positions were held by geriatric and geropsychiatric nurse practitioners and clinicians. Many had joint faculty and facility appointments; all spent the greatest portion of their time in the homes providing direct care. The academic affiliations made the homes clinical sites for large numbers of students. The practitioners/clinicians cared for residents, provided staff inservice education, precepted students, and participated in quality assurance and infection control. In some homes, geriatric nurse practitioners (GNPs) also were responsible for employee health. The GNPs reported to the director of nursing, the medical director, or both. Some sawall residents, others saw only the residents of selected physicians. Key Questions Answered
The TNH Program sought to discover whether the collaboration between nursing schools and nursing homes would improve care in a costeffective manner. The University of Colorado Center for Health Services Research analyzed and compared longitudinal and cross-sectional data on more than 5,000 residents in six of the TNHs versus six comparison nursing homesfl ). The program evaluators looked at the overall cost and cost-perday, as well as resident outcome eliteria, such as the rates of hospitalization, of discharge to independent living, and of improvements in clinical indicators and functional abilities, as well as the capacity of participating nursing homes to accept sicker patients.
Hospitalization of residents within the first three months' stay in the TNHs fell from 19 to 12 percent, while they rose from 13 to 18 percent in the matched comparison nursing homes(I). Declines in hospitalizations also were evident for long-stay residents in the TNH, but the drop was not as pronounced. Quality of care rose and morbidity fell with the assessment, planning, and collaboration between universityfaculty and facilitystaff. Avoiding hospitalization meant that the TNHs were keeping their sick residents rather than transferring them to acute care centers. Yet, the qualityof care for residents did not decline and, in fact, even improved in the TNHs. More residents had bowel continence,fewer had urinary catheters and incontinence,and more were stabilized in dressingand moving about (1). The TNHs were also more effective than the comparison homes in lowering the use of physical restraints and in managing wandering and aggressive behavior in brain-failed patients. (See "Outcomes ata Glance," at right.) Staff turnover decreased in the TNHs. In contrast to the typicalnursing home, the THN Program relied heavily on the nurseclinicians to retain staff.The decrease wasattributable,in part, to decentralization of the nursing practice. With a nurse specialistreadily available to verify observations by the nursing staff,clinical decisionswere handled on the unit.Staffreceived prompt feedback and did not refer problems to the director of nursing, all of which improved staff morale. At the conclusion of the program, the participating homes were sufficiently satisfied to retain 15positions for nurse clinicians(2).
Giving nursing schools clinical responsibility in nursing homes is one way of ensuring sicker residents receive the more complex care they need.
Moreover, the program was cost neutral. The added costs of placing nurse clinicians in the nursing homes were offset by reducing the use of expensive hospital services(l).
Where to Go from Here The program clearly shows the benefits to patients and staff when academic nursingdepartments join with nursing homes, and it establishes the value of geriatric and geropsychiatric nurse cliniciansin improvingcare to residents.
Decreasing hospital use by nursing home residents has significant implications for Medicare. Medicare pays virtually the full cost of visits to physicians' offices and emergency rooms and for hospital care. A conservative estimate of these coststo Medicare for all nursing home residents, in 1986 dollars, is at least $1.5 billion for physician care and $3 billion for hospital care(3). Considerable cost savings could accrue if nursinghomes provided some of this care. The TNH showed that you can reduce hospital use with-
Outcomes at a Glance Nursing Homes
Teaching
I
I
19% 12%
13%0 18%0
55% 54%
33%b 47%C
36% 41%
25%C 32%d
44%
31%e
I
PATIENT STATUS Bowel continence improved Dressing/transfer stabilized Episodes of incontinence ovoided withtimed voidings No restraints used on confused residents Restraints on confused residents checked every 30 minutes
I
Comparison
HOSPITALIZATION RATE WITHIN 3 MONTHS OF ADMISSION Before Atter
I
V5.
I
WHO PARTICIPATED IN PLANNING CARE Nurse clinician Nurses' aide Physical therapist Resident
1%0 29%0 68%C 17%f
28% 55% 61% 12%
Difference significant at a level of a <0.001
b 0.004
c 0.01
d 0.005
e 0.007
f 0.02
out jeopardizing and, in fact, while improving the quality of care. Findings from the TNH and other demonstration projects were influential in achieving passage of legislation to reimburse NPs under Medicare Part B for services in nursing homes(4). The TNH results also suggest that reimbursing geropsychiatric nurse clinicians, whose services are not currently covered, could lead to even more benefits. The 1NH Program results also suggest that we need to reform the current structure of nursing homes, which discourages employment of nurse clinicians. New funding options must expand the use of the nurse specialists in nursing homes, thus permitting a better level of care for sicker patients currently being admitted into nursing homes. We hope that Medicare will choose to establish higher levels of reimbursement for "sub-acute" nursing home residents who require the care of a nurse clinician. Such a move would further encourage hospitals to discharge to a nursing home those patients who require special monitoring and management and allow nursing homes to maintain patients there during an acute illness. REFERENCES l. Shaughnessey P., and others. The Teaching Nursing Home Experiment: lis Effects and Implications. (Study Paper 6) Denver: Center for Health Services Research, University of Colorado, March, 1990. 2. Mezey, M., and Lynaugh, J. The leaching nursing home program: Outcomes of care. Nul'S. Clin. North Am. 24:769-780. Sept. 1990. 3. Walsh, M., and Small, N., eds. Teaching Nursing Homes: The Nursing Perspective. OWingsMill, MD: National Health Publishing, 1988, pp. 83-104. 4. Omnibus Reconciliation Act, Washington, DC. U.S. Government Printing Office, 1989.
Geriatric Nursing Mllrch/Aprill991 77
A Lesson in Quality Ni
investment in nursing care in nursing homes pays off,not only . better patient outcomes but in actual dollars saved. We may have suspected or known that intuitively. At last, however, the analysis of the data from the Robert Wood J ohnson Teaching Nursing Home (TNH) Program is available,withthe statisticsto prove it. For example, hospitalization of residents dropped seven percent in nursing homes affiliated with baccalaureate nursing schools and rose five percent in homes not linked to schools. Imagine the Medicare savings that could accrue if more expert nurses and faculty were paid to assume responsibility for clinical care in more nursing homes. The formal collaboration between academia and service to improve clinical care, educate students, and foster research is a recent development for nursing homes and nursing schools. But it is a familiar model in teaching hospitals affiliated with medical schools. In fact, the medical school-medical center partnerships have been subsidized with federal funds for years. The TNH Program, a five-year project that ended in 1987, funded between 1.5 and 2.0 full-time equivalent new positions in 12 nursing homes, filled primarily by faculty/clinicians from 11 university schools of nursing.
The authors were codirectors of the Robert Wood Johnson Teaching Nursing Home Program. MATHY MEZEY, RN, EdD, FAAN, is now Independence Foundation professor of Nursing Education, New York University, New York City. JOAN LYNAUGH, RN, PhD, FAAN, is associateprofessor,University of PennsylvaniaSchoolofNursing,Philadelphia,PA.
76 Geriatric Nursing March/April1991
Most commonly the new positions were held by geriatric and geropsychiatric nurse practitioners and clinicians. Many had joint faculty and facility appointments; all spent the greatest portion of their time in the homes providing direct care. The academic affiliations made the homes clinical sites for large numbers of students. The practitioners/clinicians cared for residents, provided staff inservice education, precepted students, and participated in quality assurance and infection control. In some homes, geriatric nurse practitioners (GNPs) also were responsible for employee health. The GNPs reported to the director of nursing, the medical director, or both. Some sawall residents, others saw only the residents of selected physicians. Key Questions Answered
The TNH Program sought to discover whether the collaboration between nursing schools and nursing homes would improve care in a costeffective manner. The University of Colorado Center for Health Services Research analyzed and compared longitudinal and cross-sectional data on more than 5,000 residents in six of the TNHs versus six comparison nursing homesfl ). The program evaluators looked at the overall cost and cost-perday, as well as resident outcome eliteria, such as the rates of hospitalization, of discharge to independent living, and of improvements in clinical indicators and functional abilities, as well as the capacity of participating nursing homes to accept sicker patients.
Hospitalization of residents within the first three months' stay in the TNHs fell from 19 to 12 percent, while they rose from 13 to 18 percent in the matched comparison nursing homes(I). Declines in hospitalizations also were evident for long-stay residents in the TNH, but the drop was not as pronounced. Quality of care rose and morbidity fell with the assessment, planning, and collaboration between universityfaculty and facilitystaff. Avoiding hospitalization meant that the TNHs were keeping their sick residents rather than transferring them to acute care centers. Yet, the qualityof care for residents did not decline and, in fact, even improved in the TNHs. More residents had bowel continence,fewer had urinary catheters and incontinence,and more were stabilized in dressingand moving about (1). The TNHs were also more effective than the comparison homes in lowering the use of physical restraints and in managing wandering and aggressive behavior in brain-failed patients. (See "Outcomes ata Glance," at right.) Staff turnover decreased in the TNHs. In contrast to the typicalnursing home, the THN Program relied heavily on the nurseclinicians to retain staff.The decrease wasattributable,in part, to decentralization of the nursing practice. With a nurse specialistreadily available to verify observations by the nursing staff,clinical decisionswere handled on the unit.Staffreceived prompt feedback and did not refer problems to the director of nursing, all of which improved staff morale. At the conclusion of the program, the participating homes were sufficiently satisfied to retain 15positions for nurse clinicians(2).
Giving nursing schools clinical responsibility in nursing homes is one way of ensuring sicker residents receive the more complex care they need.
Moreover, the program was cost neutral. The added costs of placing nurse clinicians in the nursing homes were offset by reducing the use of expensive hospital services(l).
Where to Go from Here The program clearly shows the benefits to patients and staff when academic nursingdepartments join with nursing homes, and it establishes the value of geriatric and geropsychiatric nurse cliniciansin improvingcare to residents.
Decreasing hospital use by nursing home residents has significant implications for Medicare. Medicare pays virtually the full cost of visits to physicians' offices and emergency rooms and for hospital care. A conservative estimate of these coststo Medicare for all nursing home residents, in 1986 dollars, is at least $1.5 billion for physician care and $3 billion for hospital care(3). Considerable cost savings could accrue if nursinghomes provided some of this care. The TNH showed that you can reduce hospital use with-
Outcomes at a Glance Nursing Homes
Teaching
I
I
19% 12%
13%0 18%0
55% 54%
33%b 47%C
36% 41%
25%C 32%d
44%
31%e
I
PATIENT STATUS Bowel continence improved Dressing/transfer stabilized Episodes of incontinence ovoided withtimed voidings No restraints used on confused residents Restraints on confused residents checked every 30 minutes
I
Comparison
HOSPITALIZATION RATE WITHIN 3 MONTHS OF ADMISSION Before Atter
I
V5.
I
WHO PARTICIPATED IN PLANNING CARE Nurse clinician Nurses' aide Physical therapist Resident
1%0 29%0 68%C 17%f
28% 55% 61% 12%
Difference significant at a level of a <0.001
b 0.004
c 0.01
d 0.005
e 0.007
f 0.02
out jeopardizing and, in fact, while improving the quality of care. Findings from the TNH and other demonstration projects were influential in achieving passage of legislation to reimburse NPs under Medicare Part B for services in nursing homes(4). The TNH results also suggest that reimbursing geropsychiatric nurse clinicians, whose services are not currently covered, could lead to even more benefits. The 1NH Program results also suggest that we need to reform the current structure of nursing homes, which discourages employment of nurse clinicians. New funding options must expand the use of the nurse specialists in nursing homes, thus permitting a better level of care for sicker patients currently being admitted into nursing homes. We hope that Medicare will choose to establish higher levels of reimbursement for "sub-acute" nursing home residents who require the care of a nurse clinician. Such a move would further encourage hospitals to discharge to a nursing home those patients who require special monitoring and management and allow nursing homes to maintain patients there during an acute illness. REFERENCES l. Shaughnessey P., and others. The Teaching Nursing Home Experiment: lis Effects and Implications. (Study Paper 6) Denver: Center for Health Services Research, University of Colorado, March, 1990. 2. Mezey, M., and Lynaugh, J. The leaching nursing home program: Outcomes of care. Nul'S. Clin. North Am. 24:769-780. Sept. 1990. 3. Walsh, M., and Small, N., eds. Teaching Nursing Homes: The Nursing Perspective. OWingsMill, MD: National Health Publishing, 1988, pp. 83-104. 4. Omnibus Reconciliation Act, Washington, DC. U.S. Government Printing Office, 1989.
Geriatric Nursing Mllrch/Aprill991 77