Question

Question One |

What unique factors in assisted living create difficulty in defining quality of care and safety?

Question Two | 3-4 Paragraphs Each

Outline and explain the main points in the Eden Alternative, Green House and Pioneer Network models.

Answer 1

Question 1)

Quality of care in long-term care “is a complex concept confounded by regulations [and] debates about what should be measured to assess quality” (IOM, 1996b, p. 129). Defining quality in long-term care has been a difficult process; it is defined both as an input measure and as an outcome. Since the mid-1960s, quality assessment has been measured in terms of three concepts: structures of care, processes of care, and outcomes of care (Donabedian, 1966). Over the years, nursing home quality has been measured by structural variables such as level, mix, and education and training of staff; and characteristics of the facilities in relation to characteristics of the residents such as demographics, payer mix, and casemix. Process measures assess the services actually provided to the residents. Deficiencies in processes of care can be described as overuse of care, underuse of care, or poor technical performance (see, for example, IOM, 1990; Chassin and Galvin, 1998). Other process problems in long-term care have been characterized as neglect (e.g., inattention to weight loss) or even abuse (e.g., physical assault).

Outcomes of care include changes in health status and conditions attributable to the care provided or not provided. Unlike acute care, for which successful outcomes often mean restoring patients to their level of functioning before the onset of illness, successful outcomes in long-term care are likely to be based on criteria such as maximizing quality of life and physical function in the presence of permanent, and sometimes worsening, impairment. The occurrence of specific problems, such as pressure sores or inappropriate weight loss, is generally viewed as evidence of poor quality of care. Because care processes and structural factors are the means through which desired outcomes are achieved, they are key components in defining quality. In principle, health and quality-of-life outcomes are the end results of the structures and processes of care. Outcomes of interest might include overall health status, the presence or absence of specific conditions (e.g., pressure sores), social and psychological well-being, and satisfaction with care. However, using outcomes to assess quality of care is often difficult because of conceptual and practical (e.g., cost) considerations in collecting information on health status and quality of life. As a result, measures of structure and process (e.g., staffing levels or rates of sedative use) are frequently used as proxies for outcome measures of quality of care in various long-term settings. Opinions in the literature and in testimony given to the committee, and even among the committee, vary widely about the empirical evidence linking specific structural features or processes of care to the outcomes in question. At the same time, adequate availability of structural measures, such as staffing and facility characteristics, is essential to the provision of consumer-oriented long-term care.

In evaluating the quality of long-term care, multiple perspectives have to be considered. Application of the concept of consumer-oriented long-term care requires that the quality of long-term care be judged not only in terms of the structure, processes, and outcomes of clinical care, but also in terms of access to care, the nonmedical personal assistance services that are an important part of long-term care, and the long-term care user's quality of life. Because perspectives can differ among recipients of long-term care services and between care recipients and care providers, one of the challenges is establishing priorities reflecting different perspectives.

Standards for evaluating whether the quality of long-term care is good or bad, improving or deteriorating, are shaped by several considerations including views of the nature and scope of long-term care, the operational definitions of quality, and the ways quality-of-care data and research findings are interpreted. Different observers such as physicians, nurses, consumers, family members, and society also will have different perspectives. Different circumstances will require assessing the views of these and other participants. Long-term care can encompass a broad range of services affecting many aspects of daily life. It is easy to see how observers might differ in their views on the nature and scope of the field and therefore the basis on which the quality of long-term care should be judged. The following are three aspects of long-term care that are relevant to the assessment of its quality:

1.

Long-term care is both a health and a social program. Although many long-term care programs are currently identified and judged primarily as either social models or medical models (R.A. Kane, 1999), users' needs do not divide so readily. Some aspects of long-term care are based on services that require knowledge of health conditions and their treatment. Other aspects are aimed at services to help people with functional limitations live in ways that maximize their capability and productivity. Long-term care funding comes partly from health programs, but also from social service and income support programs. For the health services components of long-term care, judgments about quality of care emphasize medical and technical aspects of care. For other aspects of long-term care, judgments about quality of care reflect the opinions and satisfaction of consumers (or their surrogate agents).

2.

The potential and actual role of consumers is an essential element in long-term care. As indicated in Chapter 1, long-term care, and therefore the basis for evaluating the quality of such care, is being redefined (at least in some care settings) by the growing recognition of the role of consumers and their involvement in choosing and directing many features of their care and in assessing the adequacy of care.

3.

For nursing homes and residential care settings including assisted living, the physical environment of the facility can contribute to the physical safety and functional mobility of residents and, more broadly, to their quality of life. Privacy is an aspect of the physical environment and is intimately tied to the consumer-centered principles the committee endorses.

CURRENT STATE OF QUALITY OF CARE

No single or simple formula is available to guide those attempting to evaluate the quality of long-term care. Evaluators must determine how to interpret a variety of data on health outcomes and provider performance, on many different aspects of care for many individual consumers, and on many providers over a period of time.

Regulatory quality standards often focus on deficiencies in care, defined by the presence or absence of specified problems. When such standards are applied, the quality of care is considered lower if problems are found than if they are not found. At the present time, most measurable standards of quality do not recognize excellence in care with criteria based on positive outcomes, such as maximizing physical functioning or, in the psychological sphere, going beyond minimizing depression and anxiety to maximizing well-being. The following sections examine the state of quality of care in each of the specific long-term care settings addressed in this report.

Nursing Homes

The committee reviewed a large volume of research and investigative reports to examine the quality of nursing home care. In addition, two sources of data are available on nursing home care: (1) the On-Line Survey and Certification Assessment Reporting (OSCAR) System from the federal survey and certification system permits the analysis of longitudinal patterns of deficiencies identified in nursing home inspections; and (2) studies using resident-level data from the Minimum Data Set (MDS), which permits tracing quality indicators in nursing homes. (These information systems are discussed in Chapter 4.) Other research studies provide information on the state of quality, as do recent studies by the General Accounting Office (GAO). Some information also can be inferred from testimony presented to the committee.

Evidence indicates that the quality of nursing home care in general has improved over the past decade, even though nursing homes are serving a more seriously ill population (Hawes, 1996; Johnson and Kramer, 1998). For example, many facilities have successfully reduced the inappropriate use of physical and chemical restraints. The focus of increased regulatory scrutiny on these two areas of care was a major contributing factor in reductions in both of these. Despite these improvements, serious quality-of-care problems persist in some nursing homes. Pain, pressure sores, malnutrition, and urinary incontinence have all been shown to be serious problems in recent studies of nursing home residents (GAO, 1998a; Mortimore et al., 1998). The committee recognizes that change in eliminating or reducing persistent and serious problems is a long process requiring diligent monitoring and enforced adherence to standards. In a paper prepared for the committee, Johnson and Kramer (1998) 1 noted that continuing problems include physical pain and insufficient attention to rehabilitation and restorative nursing. GAO (1999b) and the Office of the Inspector General of the Department of Health and Human Services (OIG, 1999c) reported that national data from the OSCAR system between July 1995 and October 1998 provide evidence of increasing problems with some aspects of care, including lack of supervision to prevent accidents, improper care for pressure sores, and inadequate assistance with activities of daily living.

Data based on state certification surveys of facilities indicate that problems occur in many nursing homes and that they are persistent in a smaller subset of facilities (GAO, 1999b). About one-quarter of nursing homes had deficiencies 2 in the highest-severity categories. Figure 3.1 shows the ten most frequent deficiencies for poor quality of care cited in the United States. In 1998, the most frequent deficiency was poor food sanitation (23.7 percent of the 15,401 facilities surveyed) (Harrington et al., 2000b). Failure to remove accident hazards was cited in 18 percent of facilities, poor general quality of care was cited in 17.2 percent, and failure to prevent or properly treat pressure sores was cited in 17.1 percent. Poor care planning, improper resident assessment, failure to prevent accidents, poor housekeeping, failure to protect the dignity of residents, and improper use of physical restraints were also problems in a significant proportion of homes.The 10 principles of the Eden Alternative ®:

The three plagues of loneliness, helplessness, and boredom account for the bulk of suffering among our Elders.

An Elder-centered community commits to creating a Human Habitat where life revolves around close and continuing contact with people of all ages and abilities, as well as plants and animals. It is these relationships that provide the young and old alike with a pathway to a life worth living.

Loving companionship is the antidote to loneliness. Elders deserve easy access to human and animal companionship.

An Elder-centered community creates the opportunity to give and receive care. This is the antidote to helplessness.

An Elder-centered community imbues daily life with variety and spontaneity by creating an environment in which unexpected and unpredictable interactions and happenings can take place. This is the antidote to boredom.

Meaningless activity corrodes the human spirit. The opportunity to do activities we find meaningful is essential to human health.

Medical treatment should be the servant of genuine human caring, never its master.

An elder-centered community honors its Elders by de-emphasizing top-down bureaucratic authority, seeking instead to place the maximum possible decision-making authority into the hands of the Elders or of those closest to them.

Creating an Elder-centered community is a never-ending process. Human growth must never be separated from human life.

Wise leadership is essential for any struggle against the three plagues.

The Eden Alternative ® Domains Of Well-Being

The Eden Alternative ® aims to revolutionize the experience of home by bringing well-being to life.

“Well-being is a much larger idea than either quality of life or customer satisfaction. It is based on a holistic understanding of human needs and capacities. Well-being is elusive, highly subjective, and the most valuable of all human possessions.” – Dr. William Thomas, What Are Old People For?

The Domains of Well-Being are:

Identity: Being well-known, having personhood and individuality; wholeness; having a story.

Growth: Development, enrichment, expanding, self-actualization.

Autonomy: Choice and self-determination; freedom from the arbitrary exercise of authority.

Security: Freedom from fear, anxiety, and doubt; feeling safe; having privacy, dignity, and respect.

Connectedness: Belonging; feeling engaged and involved; having close, meaningful relationships.

Meaning: Purpose; activity that speaks to one’s personal values; rituals, recognition, and self-esteem.

Joy: Happiness, enjoyment, pleasure, contentment.

Person Directed Care

We stress that the Elders do not live in the staff’s workplace but rather the staff work in the Elders’ homes. The Eden Alternative ® focuses on moving away from the institutional hierarchical (medical) model of care into a constructive culture of “home” where Elders direct their own lives.

Question 2)

Eden Alternative

The Eden Alternative philosophy is focused on the care of the human spirit as well as the care of the human body. For too long the nursing home has focused on proper care of the body instead of the human being.

Another hallmark of the philosophy is that staff is consistently assigned to the same Elders. In that way the elder is well known, and they are able to forge close relationships with staff and don’t have to teach them each time how to provide their care.

Care becomes consistent, which is especially important with people living with dementia. In the Eden Alternative ® we focus on the importance of relationships and know that they grow in the moments when staff are with the Elders completing their tasks.

The philosophy also discourages medical treatment that does not benefit the elder. The use of physical restraints and chemical restraints, for example, is in direct opposition to person directed care. No one wishes to be tied up or sedated. Basically, both of these interventions are used in the “institution” to control the “behaviours” of people living with dementia so that it is more acceptable.

We have learned that these responses are the expression of an unmet need and that we need to identify and meet the need rather than mask the expression of it. To restrain someone must be a last resort and should only happen when the unmet need cannot be met and there is a risk for injury.

Restraining someone is the opposite of person directed care. Sherbrooke has zero physical restraints and the fourth lowest rate of chemical restraint use of the 29 homes in the Saskatoon Health Region. In addition, we have 90 specialized spots for people with dementia. Almost without exception the people who come to these neighbourhoods are on chemical restraints which we in turn reduce and hopefully discontinue.

Green house model

Objective

To describe the Green House (GH) model of nursing home (NH) care, and examine how GH homes vary from the model, one another, and their founding (or legacy) NH.

Data Sources/Study Setting

Data include primary quantitative and qualitative data and secondary quantitative data, derived from 12 GH/legacy NH organizations February 2012—September 2014.

Study Design

This mixed methods, cross‐sectional study used structured interviews to obtain information about presence of, and variation in, GH‐relevant structures and processes of care. Qualitative questions explored reasons for variation in model implementation.

Data Collection/Extraction Methods

Interview data were analyzed using related‐sample tests, and qualitative data were iteratively analyzed using a directed content approach.

Principal Findings

GH homes showed substantial variation in practices to support resident choice and decision making; neither GH nor legacy homes provided complete choice, and all GH homes excluded residents from some key decisions. GH homes were most consistent with the model and one another in elements to create a real home, such as private rooms and baths and open kitchens, and in staff‐related elements, such as self‐managed work teams and consistent, universal workers.

Pioneer network model

The Pioneer Network is a national grass roots network of individuals in the field of aging, working for deep systemic change through both evolutionary and revolutionary means, using Pioneer values and principles as the foundations for change. Pioneers are individuals who work in residential long-term care settings and community based settings, in government, research, advocacy and education whose goal is to seed and cultivate a new culture of aging. In-depth change in systems requires transformation of individual and societal attitudes toward aging and elders, transformation of elders' attitudes toward themselves and their aging, changes in the attitudes and behavior of caregivers toward those for whom they care and changes in governmental policy and regulation. Pioneers refer to this work as culture change.

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