Year: 2008
Type: article
Abstract: To the Editor: With support from the Commonwealth Fund, the Rhode Island Department of Health is exploring ways in which the existing regulatory framework might be used to facilitate resident-centered nursing home care. The Individualized Care Pilot sought to clarify where existing regulations support resident-centered care (RCC) practices, investigate instances in which providers perceive regulatory barriers to offering such care, and orient the current regulatory process to emphasize the provision of RCC. The pilot ran from November 2007 to April 2008, with key foci of resident-directed choice, staff-resident relationships, and personalized living environments. A first step in shaping the pilot was to assess administrators' perceptions of whether the nursing home regulatory process inhibits RCC. Even though current regulations (defined for 2 decades by the Nursing Home Reform Act, commonly referred to as OBRA '87) are ostensibly resident centered, some stakeholders have criticized their prescriptive nature as impeding innovative and flexible resident care.1 To learn more about these perceptions, surveys were sent to all (94) nursing home administrators in Rhode Island in May and June 2007; anonymous responses were received from 49 (52%). The regulatory process was found to be one of several important barriers to providing RCC but not the primary impediment. Almost half of respondents indicated that the regulatory process had prevented RCC from being achieved at their facility at some point, and a similar proportion pointed to occasions when their facility had hesitated to accommodate resident preferences for fear of negative repercussions from the state service agency (SSA), yet only a few facilities reported having a deficiency upon inspection during the previous 3 years for a practice aimed at making care more resident focused. Similarly, nearly 30% indicated that the regulatory process was not a barrier to RCC, and another 30% characterized it as only a minor barrier. Several respondents expressed frustration with the overall burden of regulations, stating that required documentation and related activities take resources away from resident care. The importance of these concerns is recognized, but this study focused primarily on whether particular components of the regulatory process impeded the provision of RCC. In detailing specific practices that the regulatory process had hampered, administrators focused prominently on issues concerning food, noting that regulations prevented offering flexible meal times and varied dining options. In cases such as these, it is useful to examine existing statute for potential misperceptions. Several administrators indicated that one impediment to offering flexible meal times is the requirement of no more than 14 hours between meals, yet the Centers for Medicare and Medicaid Services previously clarified these guidelines to respond to such concerns, noting that facilities must offer meal or snack options within specified time intervals but that residents may exercise their right to establish alternate schedules.2 One also might ask whether regulation is being used effectively to promote RCC. Although it is far from clear whether the current regulatory process performs optimally,3,4 regulation can be a powerful tool for change. Traditionally, nursing home regulators have concentrated on identifying and punishing noncompliance with standards of care. Along these lines, regulators might enforce existing quality-of-life and residents'-rights standards more strongly, because nearly 90% of respondents felt that surveyors gave relative priority to quality-of-care standards. Administrators also expressed a strong desire for positive direction from the regulatory process. The Rhode Island SSA was generally characterized as collaborative and trustworthy, but providers still felt the agency could be more supportive of RCC by emphasizing education and dissemination of best practices, lessening its punitive focus, and offering positive feedback. The desire for positive feedback raises possible tensions between SSAs' roles as regulator and consultant.5 In navigating this issue, Rhode Island engaged the state's Quality Improvement Organization, an entity well positioned to provide direct assistance to facilities. Beyond regulation, facility administrators noted several other barriers to achieving RCC. Nearly 60% of administrators mentioned money, reimbursement, or resources in open-ended responses. Although it is unclear whether providing RCC is more expensive than traditional types of care, providers are particularly attuned to staffing, noting that it is difficult to provide RCC in the context of high staff turnover. Importantly, the implementation of RCC models has the potential to improve staff satisfaction and reduce turnover.6 Achieving resident-centered nursing home care is a shared goal of regulators, providers, and consumers; it is also an ideal supported by the regulatory framework defined by OBRA '87 more than 20 years ago. Ultimately, effecting these broader changes in nursing home care requires a paradigm shift in expectations of such care. Regulation has an important part to play in this process, in pushing for necessary change and in allowing this desired transformation to occur. The authors are grateful for generous support from the Commonwealth Fund and for overall guidance from Mary Jane Koren. We are also indebted to Marie Stoeckel and her staff at the Rhode Island Department of Health for assistance with the project and to Laurie Coots at Harvard Medical School for excellent research assistance. The views presented here are those of the authors and should not be attributed to the Rhode Island Department of Health or The Commonwealth Fund, its directors, officers, or staff. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: David Stevenson: concept, study design, collecting data, conducting analyses, interpreting data, and preparation of letter. David Gifford: concept, study design, reviewing analyses, and preparation of letter. Sponsor's Role: Review of survey instrument and review of manuscript.
Authors: David G. Stevenson, David R. Gifford
Institutions: Harvard University, Rhode Island Department of Health
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,760
OpenAlex ID: W1536682272