Quality care is often considered from a medical perspective, with the focus on providing the best possible medical services. This is, of course, an essential element of the services provided in long-term care.
But at a time when there’s a greater push for community care over nursing and rehabilitation centers, it’s worth rethinking what quality means to the residents themselves. After 20-plus years of talking to them, some general themes are clear.
Which features are most important to a particular resident depends to a significant degree on which of the four categories they fall into: short-term rehab (STR), long-term care (LTC), end of life (EOL), or relatively young with concurrent substance abuse and/or mental health problems (SAMI). While the categories aren’t mutually exclusive, I find them a helpful framework in considering resident needs.
Moreover, while most nursing homes have residents from each category, some facilities have a larger proportion of one population over another. For example, tallying data from LTCFocus.org shows that in 2019 the average U.S. facility had almost 12% of its population with a diagnosis of schizophrenia or bipolar disorder, but some facilities had none and some had over 95% of their residents with these diagnoses.
Facilities should therefore consider their population makeup to better address their particular mix of residents.
All residents in each category require their basic needs met. As we learned in grade school, this means food, clothing and shelter. In a nursing home setting, we can include assistance with activities of daily living (ADLs).
Facilities consistently provide food and shelter, but if residents don’t have clothing, they wear hand-me-downs or medical gowns. This is a frequent source of distress for residents, who find it humiliating and depersonalizing.
Meager personal needs allowances (PNA) without inflation adjustments cannot cover clothing costs. In New York State, for instance, the PNA has been $50 per month since 1980. An inflation-adjusted amount would be a more reasonable $159.60 per month, which would allow for a haircut (not a covered necessity!), cell phone service and a new shirt.
Quality care would offer residents a better means to access their funds so that they’re not dependent on family or staff, especially since an increasing number of residents have no community contacts. I like the idea of a debit card linked to their facility accounts so that they can order items online, thereby increasing their independence and reducing demands on staff.
We also fall short on providing an adequate level of assistance with ADLs. The single most distressing aspect of care for virtually all residents is not being toileted in a timely fashion. If we addressed this, the perception of quality care would increase dramatically and we’d prevent a host of additional and costly problems such as falls and skin breakdown, as I outlined in If toileting were a billable service….
Residents who are admitted for short-term rehab following brief illnesses, knee replacement surgeries, etc. require the usual focus on their physical health, including medical care and rehabilitation.
Other primary concerns for these residents include pain management, adjusting to physical impairment and practical issues such as paying bills so that they have a home upon discharge.
Quality care would suggest swift access to pain management specialists and universal referral for psychological evaluations (rather than on a case-by-case basis), as well as a better means to assist people with managing problems at home.
STR residents frequently require medical follow-up from outside professionals, necessitating coordination between providers. If the field had “transition specialists,” to track and meet resident needs from hospital to clinic to nursing facility to home, this would vastly improve care. Transition specialists could also take on tasks such as picking up mail and clothing to ease the foreseeable difficulties of STR residents.
LTC residents tend to be more stable medically and to have completed the process of impoverishment (a very troubling issue for them) so that they’re no longer worried about bills and finances. Their focus is generally on remaining connected to family members, engaging in absorbing recreational pursuits and maintaining their physical abilities.
Facilitation of family communication, connection with other residents in meaningful activities and ongoing exercise by dedicated staff leads to quality care to this group.
End of life care
For a variety of reasons, very ill residents frequently receive medical interventions that are painful, stressful, expensive and unlikely to improve their conditions. Hospice and palliative care are often initiated too late for residents to gain the most benefit.
Quality care for these residents would involve deeper conversations about end of life wishes for residents and their family members, a greater team emphasis on providing a “good” death based on their wishes and earlier involvement of the hospice and/or palliative care team.
Younger, mentally ill and substance-abusing residents
It’s a societal failure that relatively young individuals with mental illness, many of whom have lacked adequate social supports and have attempted to self-medicate with drugs and alcohol, would find themselves living in a nursing home following a physical health crisis.
It would be more fitting for the country to develop care homes where people with concurrent physical and mental health problems can be treated for both, in an environment with more independence and suitable activities and peers.
Nevertheless, our facilities are increasingly filled with such residents, who have almost doubled in number since 2000. Providers looking for suggestions on how to manage this population will find ideas in my 2019 column, Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave.
As the provision of eldercare is reexamined in the aftermath of the pandemic, we have the opportunity to rework old assumptions and procedures. The framework outlined above is one way to consider the needs of a diverse population and to create long-term care that provides higher quality care for all residents.
Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her at EleanorFeldmanBarbera.com.