Susan C. Reinhard

Unintended Consequences Of Steps To Cut Readmissions And Reform Payment May Threaten Care Of Vulnerable Older Adults

The US health care system is characterized by fragmentation and misaligned incentives, which creates challenges for both providers and recipients. These challenges are magnified for older adults who receive long-term services and supports. The Affordable Care Act attempts to address some of these challenges. We analyzed three provisions of the act: the Hospital Readmissions Reduction Program; the National Pilot Program on Payment Bundling; and the Community-Based Care Transitions Program. These three provisions were designed to enhance care transitions for the broader population of adults coping with chronic illness. We found that these provisions inadequately address the unique needs of vulnerable subgroup members who require long-term services and supports and, in some instances, could produce unintended consequences that would contribute to avoidable poor outcomes. We recommend that policy makers anticipate such unintended consequences and advance payment policies that integrate care. They should also prepare the delivery system to keep up with new requirements under the Affordable Care Act, by supporting providers in implementing evidence-based transitional care practices, recrafting strategic and operational plans, developing educational and other resources for frail older adults and their family caregivers, and integrating measurement and reporting requirements into performance systems.

Nursing delegation and medication administration in assisted living.

Assisted living (AL) residences are residential long-term care settings that provide housing, 24-hour oversight, personal care services, health-related services, or a combination of these on an as-needed basis. Most residents require some assistance with activities of daily living and instrumental activities of daily living, such as medication management. A resident plan of care (ie, service agreement) is developed to address the health and psychosocial needs of the resident. The amount and type of care provided, and the individual who provides that care, vary on the basis of state regulations and what services are provided within the facility. Some states require that an RN hold a leadership position to oversee medication management and other aspects of care within the facility. A licensed practical nurse/licensed vocational nurse can supervise the day-to-day direct care within the facility. The majority of direct care in AL settings is provided by direct care workers (DCWs), including certified nursing assistants or unlicensed providers. The scope of practice of a DCW varies by state and the legal structure within that state. In some states, the DCW is exempt from the nurse practice act, and in some states, the DCW may practice within a specific scope such as being a medication aide. In most states, however, the DCW scope of practice is conscribed, in part, by the delegation of responsibilities (such as medication administration) by a supervising RN. The issue of RN delegation has become the subject of ongoing discussion for AL residents, facilities, and regulators and for the nursing profession. The purpose of this article is to review delegation in AL and to provide recommendations for future practice and research in this area.

Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: expert panel recommendations.

In 2003, a panel of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care convened to examine and make recommendations about care quality and safety issues related to advanced practice nurses (APNs) in nursing home practice. This article reports on the panel recommendation that addressed expanding the evidence base of resident and facility outcomes of APN nursing home practice. A review of the small but important body of research related to nursing home APN practice suggests a positive impact on resident care and facility outcomes. Recommendations are made for critically needed research in four key areas: (a) APN nursing home practice, (b) relative value unit coding, (c) outcomes related to geropsychiatric and mental health nursing services, and (d) outcomes related to geriatric specialization. The APN role could be significantly enhanced and executed if its specific contribution to resident and facility outcomes was more clearly delineated through the recommended rigorous research.

EXECUTIVE SUMMARY: PROFESSIONAL PARTNERS SUPPORTING FAMILY CAREGIVERS

TODAY, MORE THAN three-quarters of adults who live in the community and need long-term care depend on family and friends as their only source of assistance with activities of daily living (such as bathing, dressing, and eating) or instrumental activities of daily living (such as transportation and managing finances) (Thompson, 2004). Research suggests that the more than 33 million caregivers who provide help to someone age 50 or older (National Alliance for Caregiving & AARP, 2004) often assume these responsibilities for a relative, partner, or friend with little preparation for the role and little ongoing support. The results frequently are poor physical and mental health for the caregiver and preventable institutionalization for her or his loved one. A 2008 Institute of Medicine report, Retooling for an Aging America: Building the Health Care Workforce, emphasizes the need to prepare professionals, paraprofessionals, and informal family caregivers for an older U.S. population (Committee on the Future Health Care Workforce for Older Americans, 2008).

The Importance and Challenge of Paying for Quality Nursing Care

Historically, the economic value that nursing brings to the patient care process has not been recognized or quantified. Improving the quality of nursing care through work environment changes or increases in staffing is viewed by many as an added cost, but the benefits in terms of money saved through improved nursing satisfaction and patient outcomes are not considered. This article introduces nine articles that were originally presented at the Economics of Nursing Invitational Conference: Paying for Quality Nursing Care held at the Robert Wood Johnson Foundation in Princeton, New Jersey, June 13 and 14, 2007. Recommendations are to conduct research on the impact of policy and payment changes on the nursing workforce and quality of care and to correct the misalignment of socioeconomic and business case incentives for quality by payment systems and other changes.

Strategies to promote safe medication administration in assisted living settings

Assisted living (AL) provides lower cost, less institutional environments than skilled nursing facilities, yet less professional oversight, despite the high prevalence of chronic conditions among residents. Unlicensed staff administer large quantities of medications daily, and medication management is one of the three top quality issues in AL, with error rates ranging from 10% to 40%. This qualitative study described AL provider views on medication safety and strategies used to promote safety in medication administration. The sample included 96 participants representing all parties involved in medication administration (i.e., medication aides, administrators, RNs, consulting pharmacists, primary care providers) in 12 AL settings in three states. Core themes were the importance of medication safety, unique contextual factors in AL, and strategies used to promote medication safety. This study has implications for research on interventions to improve medication safety at the individual, facility, and policy levels.

A bold new vision for America's health care system : The Future of Nursing report becomes a catalyst for change.

Risa Lavizzo-Mourey, president and chief executive officer of the Robert Wood Johnson Foundation (RWJF), center, and Susan B. Hassmiller, director of the Future of Nursing: Campaign for Action and senior adviser for nursing at the (RWJF), center right, meet with members of the District of Columbia and New Jersey action coalitions during the Campaign for Action’s Summit 2013: Transforming Health Care Through Nursing, in Washington, DC. Photo by Greg Gibson from Greg Gibson Photography, on behalf of AARP. The 2010 Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health (IOM, 2011), offers a bold vision for a new kind of health care system in America. The report redefines the field of nursing and asserts that nurses should be full partners in reforming health care. It recognizes the invaluable contributions nurses make as both acute care and primary care providers and envisions pivotal roles for nurses in public health, education, research, business, governance, and public policy. The report challenges the nation’s 3 million nurses, the largest segment of the professional health care workforce, to learn more and lead moredand it urges decision makers to create circumstances that will help nurses to succeed in all of these roles. Issued at a time when the United States was reinventing its health care system through unprecedented national reform, the IOM report generated both broad and deep interest. It quickly became the primary reason people visited the IOM website, and it has been the IOM’s most-read report. Since its release, it has generated conversation among a wide array of stakeholders, including policymakers, and has set in motion not just incremental changes but significant momentum toward a new U.S. health care delivery systemdone that offers the promise of improving access and quality while lowering costs. Less than two months after the report’s release in early October 2010, the Robert Wood Johnson Foundation (RWJF) and AARP teamed up to launch the farreaching, multifaceted Future of Nursing: Campaign for Action to implement the IOM’s recommendations. Risa Lavizzo-Mourey, MD, the president and chief executive officer of the RWJF, noted the importance of the campaign, which was announced during the National Summit on Advancing Health Through Nursing in

The Escalating Complexity of Family Caregiving: Meeting the Challenge

The escalating complexity of family caregiving today is all too familiar to American families struggling to provide care for an aging relative or friend. This chapter describes the increasing complexity of family care from the perspective of two emerging trends: (i) family caregivers are now providing medical/nursing tasks at home that were once provided only in hospitals and nursing homes, and by healthcare professionals, and (ii) more family caregivers are in the labor force, juggling demands to balance work, caregiving, and other family responsibilities. Public policies and practices can help to address these challenges if we begin now to lay the foundation for a better system of family support in the future.

A Bold New Vision for America's Health Care System

The Future of Nursing report becomes a catalyst for change.

Uniting States, sharing strategies: the technical assistance program of the CCNA.

How a national organization is helping to expand nursing education capacity state by state.