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The focus of this chapter is the clinical care of nursing home (NH) residents. “Nursing home” refers to facilities that are also often called “skilled nursing facilities”, “nursing facilities”, and “long-term care facilities”. Many older people who would have otherwise been in NHs are now residing in assisted living facilities or in their own homes. Issues discussed in this chapter may also apply to these other settings of care, but the role of the physician and the availability of trained health professionals vary between these setting. Most NHs have two distinct populations. One is there for postacute care (PAC) after a hospitalization. The focus of care for these “patients” is rehabilitation and management of unstable medical conditions, generally with the goal of achieving a higher level of function and discharge back to the community, if feasible. The average length of stay for PAC patients is close to 25 days, but changes in reimbursement are driving even shorter lengths of stay. The second population are long-stayers, who have a stay over 100 days, with an average duration of between 1 and 2 years. The focus of care for these “residents” is managing chronic medical and neuropsychiatric conditions, and maintaining function and a good quality of life.
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Management of older people with multiple medical problems and geriatric conditions in the NH setting is challenging for a number of reasons. Although many NHs provide excellent care, the poor quality of care provided in many other NHs has been recognized for decades. Since the Institute of Medicine issued its critical report in 1986 (Institute of Medicine, 1986), and the mandating of the Resident Assessment Instrument in 1987, the overall quality of care has improved. The Centers for Medicare & Medicaid Services (CMS) has instituted several strategies that are designed to improve the quality of NH care. These include the NH Compare website (www.medicare.gov/nhcompare/home.asp), which shows consumers (and NHs) how individual homes perform on surveys and specific quality indicators; the new federal survey process employing the Quality Indicator Survey (QIS; www.cms.gov); the Five-Star Quality Rating System (www.Medicare.gov); and the new requirement in the Affordable Care Act that all NHs must have a Quality Assurance and Performance Improvement (QAPI) program. All of these strategies have limitations, but they are intended to make improvements in care quality. Despite all of these efforts, the U.S. Office of Inspector General issued a report documenting the high frequency of adverse events among NH residents during the first 1 to 2 months of admission. The report documented that about one in three residents suffer an adverse event (including medication-related side effects; adverse events related to the quality of care such as falls, electrolyte disturbances; and infections). Thus, much remains to be done to improve NH care in the United States.
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Because typical older NH residents suffer from multiple underlying diseases, good medical care is especially important. Despite the logistical ...