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The focus of this chapter is the clinical care of nursing home residents. Some of the basic demographic and economic aspects of nursing home care are discussed in Chapters 2 and 15. Ethical issues relevant to nursing home care and palliative care are discussed in Chapters 17 and 18, respectively. Many older people who would have otherwise been in nursing homes are now residing in assisted living facilities or in their own homes. Management of older people with multiple medical problems and geriatric conditions in this setting is challenging. Chapter 15 and the Suggested Readings at the end of this chapter provide more information on this level of care.
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The poor quality of care provided in many nursing homes has been recognized for decades (Institute of Medicine, 2000). 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. More recently, the Centers for Medicare and Medicaid Services (CMS) has instituted several changes that are designed to improve the quality of nursing home care. These include the Nursing Home Compare website (http://www.medicare.gov/nhcompare/home.asp), which shows consumers (and nursing homes) how individual homes perform on surveys and specific quality indicators; the new federal survey process employing the Quality Indicator Survey (QIS; http://www.cms.gov); the Five-Star rating system (http://www.Medicare.gov); and the new requirement in the Patient Protection and Affordable Care Act that all nursing homes must have a Quality Assurance and Performance Improvement (QAPI) program. Because older people who are typically in nursing homes suffer from multiple underlying diseases, good medical care is especially important. Despite the logistical, economic, and attitudinal barriers that can foster inadequate medical care in the nursing home, many straightforward principles and strategies can improve the quality of medical care for nursing home residents. Fundamental to achieving these improvements is a clear perspective on the goals of nursing home care, which differ in many respects from the goals of medical care in other settings and patient populations.
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The modern nursing home serves multiple roles. Table 16–1 lists the key goals of nursing home care. While the prevention, identification, and treatment of chronic, subacute, and acute medical conditions are important, most of these goals focus on the functional independence, autonomy, quality of life, comfort, and dignity of the residents. Physicians and other clinicians who care for nursing home residents must consider these goals while the more traditional goals of medical care are being addressed.
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