Cost Effective Quality Nursing Home Care
For thirty years since the start of the Medicare and Medicaid regulatory systems in nursing homes, quality care and cost reimbursement solutions are continually debated. The debate has been complicated by the changes in nursing homes from more custodial to more hospital like and how assistant living facilities emerged to complete the shifting demographics of sicker patients in nursing homes. Sadly, however, these changes did little to improve cost-effective quality in nursing homes. In fact during these changes, nursing homes have become less efficient in the way staff is hired, organized, structured and scheduled to care for patients. The result is “more money and people are being used to provide less care.” Part of this inefficiency is due to the unnecessary and complicated patient acuity measures related to quality care and cost reimbursement. Another part is due to the inability of both providers and government regulators to realize that the current system of caring for patients requires major changes beyond more staffing. Also, the current solutions promoting even more regulation and more money will not create more cost-effective quality and will further exacerbate nursing home problems.
Every year regulations and reimbursement increases, but nursing homes are continually struggling to provide quality care and even going bankrupt trying to do so. While the nursing homes focus on increasing reimbursement limits and the government regulators focus on creating better quality care measures, the basic problems do not get resolved. For example, every year there are solutions to increase the minimum staffing ratios for nurses and assistants along with the corresponding reimbursement rates. These solutions have not resolved the problems, and it has prevented nursing homes from focusing on the important issue of cost-effective quality. The solution that “more means more” is not the answer. Perhaps stepping out of the box and analyzing the possibilities that “more could mean less” is a good first step in finding a better solution. Also, is it possible that a “less could mean more” solution exists?
Before examining this possibility, it is important to address some historical facts. Every year nursing homes try to increase their reimbursement formulas by claiming that they have to take care of sicker patients that require more nursing staff. On the surface it appears to be a simple approach, but the facts are that nursing homes have traditionally lost money on the nursing care portion of their reimbursement costs. Nursing homes only make a profit on other cost centers and various reimbursement formulas related to real estate and other capital investments. When nursing homes increase the level of services for sicker patients, they increase their regulatory obligations and their legal and financial risk of providing less quality of care. Regardless of the risk, nursing homes will not profit from nursing care unless they stop relying on the “more means more” solution and effectively change the current system of nurse staffing. Nursing home providers may offset their losses by reducing other non-nursing costs or by selling ancillary products, but it does not resolve basic issue of how to deliver cost-effective quality nursing care.
The current nurse staffing system as it exists today is based on professional nurse supervisors spending most of their time doing required paperwork while nursing assistants are pooled together and assigned various structured duties all of which are designed to meet daily government regulations. The paperwork and duties are spread out over three daily shifts and allocated by specific numbers of staff required by specific numbers of patients. The quality care and reimbursement regulations force providers to get high numbers of nursing staff hours as cheaply as possible, but the high numbers result in the “more means less” problem in delivering quality care. In addition, the numbers are adjusted upwards or downwards according to patient acuity levels. More professional staff time is needed to analyze the adjustments that result in chaotic methods of dealing with fluctuating numbers of nursing assistants required for this nurse staffing system. Unfortunately, the staffing system is driven more by poorly designed regulatory requirements than by a well organized structure created by staff and management as to what will yield the most cost-effective quality.
There are two major problems to finding a better cost-effective quality staffing structure. One is the unwillingness of government regulators to encourage innovation. The other is the fear of providers to change and innovate without the government regulators telling them to do so. Therefore it will not be easy to implement solutions considering these two major problems. New solutions will have to be introduced very carefully. One way of doing this is for nursing homes to implement small-scale research projects designed to find a better staffing system that will result in cost-effective quality care.
One such research project is being sponsored by the QE Foundation to introduce the QE Staffing and Scheduling Methods. The methods are designed to improve the quality and efficiency (cost effectiveness) of nursing homes by creating a better way for nurses and assistants to be hired, trained, organized into high performance teams and scheduled to care for patients. Utilizing these methods will not violate government regulations, but they will demonstrate there is a better way to improve cost-effective quality care without depending on existing regulations. For more information about these small-scale trial research projects in nursing homes, please contact the QE Foundation.