Module1 Nursing Homes The Basics

Nursing Homes: The Basics
Sarah Greene Burger, RN-C, MPH, FAAN

Ethel Mitty, EdD, RN
Mathy Mezey, EdD, RN, FAAN
Hartford Institute for Geriatric Nursing,
New York University College of Nursing
Module 1 of Nursing Homes as Clinical Placement Sites for Nursing Students Series
Acknowledgments
This is a joint project of
With support from
Grant to the
University of Minnesota Sc
hool of Nursing
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
This project is endorsed by:
Project Steering Committee

View List of Members
About Module 1- Nursing Homes: The Basics
Objectives/Purpose:  Evaluate attributes of nursing homes that can affect the

educational experience of students
At the end of this module  Compare and contrast quality of care in nursing homes
you will be able to: using objective criteria
 Explain how nursing homes are regulated and

reimbursed
 Evaluate the potential for a nursing home to serve as a

clinical training site for nursing students
Nursing Home Characteristics and Services
1.7 Million
Most Nursing Medicare
Homes (67%) and/or
are for-profit Medicaid
16,000+ certified beds
Nursing
Homes
1.5 million+
people (6%+ Average
of people >65 Nursing
years old) are Home Size:
in Nursing 104 beds
Homes
Resident Characteristics
Most residents are white Age range: 75-84: 30%,

(86%), female (62%), >85 y/o: 45%,
married (17%) and live alone <65 y/o: 12%
Assistance Incontinent of
needed with 3-4 bladder or
ADLs: 95% bowel: 50%
Dementia of Depressed (at

some kind: 65% least one clinical
symptom): 20%
Physical restraint use: Receiving psychotropic

6% (some NHs: 0%) medication: 63%
46% of residents are admitted from

acute care
Resident Length of Stay
50%+ 50% + Short-Term (typically Medicare

covered)
2.5 years 14-32 days Long-Term (typically Medicaid
(mean) (mean) covered)
Hospitalization of Residents
 Between 25%-50% of
residents are hospitalized
during any one year
 Some residents can be
hospitalized as many as 4
times in one year (e.g.
with diagnosis of COPD,
CHF)
Reasons for Hospitalization
Reasons for hospitalization

include:
 Physician practice pattern

and hospital vacancy rate
 Resident’s Medicare
eligibility
 Nursing Home resources
(staffing; IV administration;
diagnostic services)
 Family pressure
Special Care Units (SCU)
3000 Nursing Homes (19+%) have designated a

Special Care Unit (SCU)
Dementia SCUs are the most common type (22%) (Originally for residents
with mild/moderate stage dementia)
Sub-acute Care Units provide short-term intensive rehab and continuous

medical monitoring
Types of Sub-acute Care Units include ventilator dependent, traumatic
brain injury, oncology, pressure ulcer care, AIDS, skilled rehab,
palliative care and hospice units
Nursing Home Regulations: The Nursing Home
Reform Act 1987 (NHRA [OBRA’87]) (PL 100-203)
Most federal regulation of Nursing Homes stems from The Nursing

Home Reform Act 1987. Components of the Act include the
following:
 Nursing homes are certified as a Medicare and/or Medicaid skilled
nursing facility by the federal government (Centers for Medicare and
Medicaid [CMS]).
 “Conditions of Participation”: Spells out the mandates that a nursing
home is obliged to meet in order to remain Medicare/Medicaid certified
and eligible for reimbursement
 Specifies that people living in a nursing home are “residents” – not
patients.
 Requires that every facility is “to care for its residents in such a manner
and in such an environment as will promote maintenance or
enhancement of quality of life of each resident” and to “provide services
and activities to attain or maintain, for each resident, the highest,
practicable physical, mental and psychological well-being.”
Staffing in Medicare and Medicaid Skilled
Nursing Homes
 On-site supervision 24/7 by a licensed nurse (RN, LPN); an RN

must be on duty 8 hrs/day, 7 days/wk.
-Nursing: 66%+ of Nursing Home staff (RN, LPN, Certified
Nurse Assistant or CNA) See Module 2: An Overview of Nursing homes
Generally
 Full-time licensed administrator
 Therapeutic staff: social worker, activities therapist, nutritionist,
and rehab therapy staff (full or part time required)
 Medical director (at least 20% time)
 Physician for every resident
CMS Mandated Services and Committees in
Medicare and Medicaid Skilled Nursing Homes
Podiatric,ophthalmology and dental services

Rehabilitation services (PT, OT, ST) intensity
can vary)
Pharmacy, clinical lab, radiology
End of Life (EOL) Care
Psychiatry consultation
Resident and Family Council (to express
concerns & interests, and receive information and

updates).
Committees: Pharmacy & Therapeutics
(P&T), Infection Control, Quality Assurance,

Safety (Risk Management), Utilization Review
CMS Mandate for Interdisciplinary Team in
Medicare and Medicaid NHs
Physicians are the legal head of the team and

the team includes nursing, social worker,
activities therapist, nutritionist, rehabilitation,
and others (e.g. psych) on ad hoc basis
CNAs can (and should) be a member of the

interdisciplinary team
Resident, family, health proxy/surrogate, if

resident wishes, are also part of the team
Oversight and Monitoring of Nursing Homes
The following are used in monitoring Nursing Homes:
 State Departments of Health: Conducts surveys on

behalf of CMS
 CMS 5-Star Quality Rating System
 Long Term Care Ombudsman: State office
(federally funded) investigates and resolve
complaints regarding resident rights, quality of care
(in most but not all nursing homes).
 Joint Commission: optional except for Nursing
Homes seeking managed care contracts or that
are hospital-based
State Departments of Health Surveys on
Behalf of CMS
Surveys assess 17 different Survey assessment of individual

Categories, including: residents includes:
 Resident rights  Use of physical restraints

 Admission and discharge rights  Psychotropic medication
 Resident behavior and facility  Staff training & supervision
practices  Staffing
 Quality of life  Care planning
 Resident assessment  Specific outcomes of care and
 Quality of care others…
 Nursing services
 Dietary services
 Infection control
CMS 5 Star Quality Rating System
The CMS 5 Star Quality Rating System is a nationally recognized

standard against which to assess nursing homes.
Star rating reflects a Nursing Home’s quality status for the past
12-15 month period.
Higher star ratings reflect better quality:

 5 Stars: top 10% of nursing homes within the state
 2, 3, 4 Stars: middle 70% of nursing homes within the state
 1 Star: bottom 20% of nursing homes within the state
Sample Nursing Home Rating
View the Nursing Home Compare web site
CMS 5 Star Quality Rating System: 3 Domains
(Performance Measures)
There are 3 performance measures of the CMS 5

Star Quality Rating System:
 Staffing (Nursing) Domain

 Quality Measures Domain
 Health Inspection Domain
Staffing (Nursing) Domain of CMS 5 Star Quality
Rating System
 Nurse staffing includes RNs, LPNs, and

Certified Nursing Assistants (CNAs)
 Nurse staffing typically reported as hours
per resident day (HPRD). HPRD computed
The Staffing (Nursing) Domain,
for RNs only and for total nursing staffing. *
consists of the following  Relationship of staffing to quality. CMS
characteristics: studies show a clear association between
nursing staffing and quality of care
outcomes
 Staff-to-resident ratios indicate when NH
residents are at high risk for quality
problems (CMS data).
*
Nurse staffing data provided by Nursing Homes is available in the annual federal On-line Survey,
Certification and Reporting system.
Quality Domain of the CMS 5 Star Quality Rating
System
 Assessment of Quality based on data in

the Minimum Data Set
The Quality Domain,  Quality Measures (QMs) are issued by
the NHQI Quality Initiative*
consists of the following
 All QMs are validated, reliable and
characteristics: endorsed by the quality measure rating
agency: National Quality Forum
Quality Measures (QMs) are believed to be within the NHs ability to

influence and control
Seven Long-stay QMs: The percent of residents (1) whose need for
ADL assistance increased; (2) whose in-room mobility decreased; (3)
are “high-risk” and have pressure ulcers; (4) have an indwelling urinary
catheter; (5) are physically restrained; (6) have a UTI; (7) have
moderate to severe pain.
Four Short-stay QMs: The percent of residents with (1) pressure
ulcers; (2) delirium; (3) moderate to severe pain.
For comparison of quality measures across homes go to www.medicare.gov/NHCompare
Health Inspection Domain of the CMS 5 Star
Quality Rating System
The Health Inspection Domain carries the strongest weight.

It uses annual health survey and complaint data and also
indicates the relative performance of a nursing home within
the state.
Resident Assessment:
The Minimum Data Set (MDS)
 The Minimum Data Set (MDS) is:

 a functional assessment instrument; required
by NHRA [OBRA ’87]
 provided by the interdisciplinary team members
according to their specialty.
 the basis for interdisciplinary assessment, care
planning, reimbursement, and quality
monitoring.
Click here for more information about MDS

NH Costs and Reimbursement
 The mean national cost for a nursing home stay is $

62,000+/year. A two-bed shared room is $169/day
 62%+ of residents are dually Medicare and Medicaid
eligible.
 Medicare is primary payer for residents in a Nursing Home
for post-hospital skilled nursing and/or rehab (100 days
maximum).
 Medicaid is primary payer for residents in a Nursing Home
for an entire year (or longer).
 Other residents are “private pay,” i.e. they pay for Nursing
Home care “out of pocket.”
Resource Utilization Groups III (RUGs)
 Resource Utilization Groups III (RUGs) is a method of assigning

payment for care in NHs (achieving a similar aim as DRGs in
hospitals)
 It is a case-mixed reimbursement system in which ADL data is

essential. It also reflects the amount of resources (human and other)
needed to provide care
Click here for more information about RUGs

Recap: Key Points about
Nursing Homes: The Basics
 Knowing the characteristics of

residents in nursing homes is
helpful in creating strong clinical
We present the following assignments for students
key points to consider:
 Objective criteria exist for
comparing and contrasting
quality of care in nursing homes
 Understanding regulation and

reimbursement in nursing homes
can help students meet learning
objectives related to the health
care system
Please Proceed to the following modules of the Series
Nursing Homes as Clinical Placement Sites
for Nursing Students
Overview of the Project
Module 1: An overview of nursing homes generally
Module 2: An overview of nursing in nursing homes
Module 3: Content on resident directed care and culture change
Module 4: Selecting and

structuring clinical placements in nursing homes
Module 5: A case study to help faculty introduce resident directed care a

nd culture change
Module 6: Strategies to help nursing homes position themselves as clini

cal placement

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Nursing Homes: The Basics

Sarah Greene Burger, RN-C, MPH, FAAN

This is a joint project of

With support from

Project Steering Committee

Objectives/Purpose:  Evaluate attributes of nursing homes that can affect the

 Explain how nursing homes are regulated and

 Evaluate the potential for a nursing home to serve as a

Most residents are white Age range: 75-84: 30%,

Dementia of Depressed (at

Physical restraint use: Receiving psychotropic

46% of residents are admitted from

50%+ 50% + Short-Term (typically Medicare

Reasons for hospitalization

 Physician practice pattern

3000 Nursing Homes (19+%) have designated a

Sub-acute Care Units provide short-term intensive rehab and continuous

Most federal regulation of Nursing Homes stems from The Nursing

 On-site supervision 24/7 by a licensed nurse (RN, LPN); an RN

Podiatric,ophthalmology and dental services

concerns & interests, and receive information and

(P&T), Infection Control, Quality Assurance,

Physicians are the legal head of the team and

CNAs can (and should) be a member of the

Resident, family, health proxy/surrogate, if

The following are used in monitoring Nursing Homes:

 State Departments of Health: Conducts surveys on

Surveys assess 17 different Survey assessment of individual

 Resident rights  Use of physical restraints

The CMS 5 Star Quality Rating System is a nationally recognized

Higher star ratings reflect better quality:

View the Nursing Home Compare web site

There are 3 performance measures of the CMS 5

 Staffing (Nursing) Domain

 Nurse staffing includes RNs, LPNs, and

 Assessment of Quality based on data in

Quality Measures (QMs) are believed to be within the NHs ability to

For comparison of quality measures across homes go to www.medicare.gov/NHCompare

The Health Inspection Domain carries the strongest weight.

 The Minimum Data Set (MDS) is:

Click here for more information about MDS

 The mean national cost for a nursing home stay is $

 Resource Utilization Groups III (RUGs) is a method of assigning

 It is a case-mixed reimbursement system in which ADL data is

Click here for more information about RUGs

 Knowing the characteristics of

 Understanding regulation and

Overview of the Project

Module 1: An overview of nursing homes generally

Module 2: An overview of nursing in nursing homes

Module 3: Content on resident directed care and culture change

Module 4: Selecting and

Module 5: A case study to help faculty introduce resident directed care a

Module 6: Strategies to help nursing homes position themselves as clini

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