What makes better care?

by Jill Aitoro

Largely because of federal law, nursing homes are often highly regulated and tend to be somewhat similar. State law regulates assisted-living settings, resulting in more variation. "There’s no reason to assume that one type of facility is inherently worse than another," says Sheryl Zimmerman, associate professor of social work. Rather, she and Philip Sloane, professor of family medicine, intend to identify what characteristics have a positive effect on residents. "We are not comparing one to another but looking at how facility characteristics influence outcomes," Zimmerman says.

Zimmerman and Sloane, codirectors of the Program on Aging, Disablement, and Long-Term Care at the Cecil G. Sheps Center for Health Services Research, are conducting more than 10 interrelated studies on the quality of care provided to the elderly. The largest project involves nurses, graduate students, and research assistants going out across four states to 250 facilities and collecting data through direct observation, interviews, and telephone follow-up. Another study involves videotaping activities at 15 facilities. The locations range from small, personal-care homes with as few as four residents to large facilities with hundreds of beds. By studying 3,000 individuals over two years in a wide range of facility types, they can determine the relationship between facility characteristics and such outcomes as injuries, infections, mortality, and other quality-of-life issues.

Already Sloane and Zimmerman have found that, whether in nursing homes or assisted-living settings, residents with Alzheimer’s disease appear to have similar risks of death and of developing new or worsening medical conditions. That shows that residents are not increasing their chances of death or illness by choosing less-medicalized settings, Zimmerman says.

Sloane and Zimmerman are also attempting to quantify some of the more difficult concepts by going beyond what is written in a resident’s chart. Does she look sad or happy? Was it good that he stumbled because he had been provided with some freedom or bad because the safety measures were inadequate? For several of the studies, the researchers have refined existing measures that evaluate mood by categorizing facial expressions. "Ideally, we will be able to say ‘this woman, who can no longer speak, appears to be happy and is doing well,’" Zimmerman says, "Whereas this one, in another facility, appears unhappy and to be doing poorly." They can then evaluate how the facility is run to determine why that might be.

"We are developing structured ways of seeing, then training people to do that efficiently," Sloane says. When one of Sloane’s students returned from a visit to a facility, he had a hard time putting into words what made that facility a good one. "I tried to get at what it was that he saw," Sloane says. "Was there a lot of touching going on? What were people’s facial expressions? Were people milling around interacting or were they by themselves?"

nother issue is that the number of workers in the field does not nearly meet the demand. Not enough people on the job means more staff injuries—often from trying to lift residents. Sloane says that one-third of nursing home patients with Alzheimer’s disease act out physically—hit, bite, scratch, kick, spit—during bathing or dressing. "And the pay that care workers receive is no better than flipping burgers at McDonald’s," Zimmerman says. Much of the care depends on the frontline worker, so one goal is to figure out how to improve the performance of nursing assistants by increasing skills and providing better professional support. Having a clinical psychologist or nurse specialist work directly with nursing assistants resulted in a 50 percent decrease in violence against staff, Sloane says.

Sloane and Zimmerman hope their findings will help inform administrators what they should be doing and what they are doing well. "We are trying to identify what is important in quality of care; we’re not in a position to change the way the system is financed or run," Sloane says.

But with Zimmerman as a member and Sloane on the support staff of North Carolina’s Long-Term Care Task Force, they may be in a position to influence those capable of enacting change. The task force recently issued 47 recommendations to the N.C. legislature, focusing on access and financing, the quality of care, the structure of the facility, and the adequacy of the workforce. Their intention is to help older people and their families obtain appropriate, high-quality, cost-efficient care in the least restrictive setting.

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