In the United States, introduction of the Nursing Home Reform Act of 1987 established standards of care for ensuring the physical, mental, and social well-being of nursing home residents. More than two decades later, however, little improvement in the quality of nursing home care has been documented. This slim volume, targeted primarily at practitioners, students, and policy makers, seeks to provide a comprehensive analysis of the issues surrounding the quality of U.S. nursing home care, with the goal of providing evidence-based approaches to improve the quality of that care.
Wan and colleagues open with a brief synopsis of the U.S. system of nursing home care – namely Medicare, Medicaid, and the survey and certification process – and associated costs. Although the synopsis is a useful introduction for readers less familiar with the U.S. system, some discussion of the key particulars of the Nursing Home Reform Act would have provided additional context. Building on this introduction, chapter 1 offers a general overview of the issues surrounding nursing-home quality of care. Definitions are highlighted, as are the key resources used to examine care quality (i.e., Minimum Data Set, and the Online Survey Certification and Reporting system), and the disparities that exist across ethnic groups and rural/urban location.
The chapter introduces a deficiency-based approach to assessing care quality, an approach on which most of the book is predicated. A deficiency is defined as a facility’s failure to satisfy one or more federal or state requirements for care (p. 7). Although this approach is common to much of the U.S. research on care quality, some researchers have argued that it represents a somewhat narrow approach that foregrounds physical health and safety (e.g., continence, infection control, nutritional status, pressure ulcers, psychotropic drug use, and physical restraint use) and the presence of negative, as opposed to positive, outcomes while minimizing attention to resident quality of life (Kane, Reference Donabedian2001). Indeed, little reference is made by Wan and colleagues to residents’ quality of life in this or subsequent chapters. Although some researchers might consider increased attention to quality of life almost trivial, given the urgency of ongoing care quality issues (Kane, Reference Donabedian2001), a worthwhile addition to this chapter would have been broader discussion of the place that quality of life holds in determining care quality, and the conceptual linkages between the two.
If the causal factors influencing nursing home care are not identified, strategies to effectively improve care quality cannot be readily developed. Subsequently, chapter 2 examines, in depth, the measurement of quality of care. The authors review the benefits and limitations of two key data sources: the Minimum Data Set (MDS), which provides in-depth resident data (e.g., clinical, functional, behavioural, and social attributes), and the Online Survey, Certification and Reporting system (OSCAR), a comprehensive repository of both facility data (e.g., bed size, staffing, services offered, and resident case mix) and aggregate resident data which also serves as the principal source of deficiency citations. Importantly, the authors call attention to the necessity of using multi-level modeling to analyse such data, a technique which remains relatively uncommon despite the hierarchical structure of nursing homes (i.e., residents “nested” within facilities). The most noteworthy contribution of this chapter is the authors’ expansion of Donabedian’s (Reference Dodson and Zincavage1988) structure-process-outcome model as a framework for understanding how nursing homes function to deliver quality care. A particular strength of the framework is its inclusion of macro-level contextual factors (i.e., social, legal, and political) and the acknowledgement of the (oft-overlooked) external environment’s influence on health care institutions and providers.
Chapter 3 focuses on factors contributing to the variability of quality of care, such as staff size and mix, nursing home size (i.e., number of beds), and geographical location. There is, however, no discussion of the role that ethnic/racial background, cultural differences, and language barriers may play, a noteworthy oversight given that care/nursing aide positions are disproportionately filled by racial minorities and immigrants (Dodson & Zincavage, Reference Castle and Engberg2007). The relationship between staffing and care quality is expanded upon in chapter 6, wherein the authors discuss state and federal regulations regarding staffing levels as well as recent recommendations and research regarding staffing thresholds. Researchers are increasingly recognizing, however, that care quality depends not only on how much care is provided, but also on the coordination and consistency of care, as well as care practices (Castle & Engberg, 2008). Regrettably, there is little critical discussion concerning these, or other, important staffing issues (e.g., remuneration, training, staffing models, and leadership). Given their targeted audience, the authors subsequently miss a prime opportunity to foster broader policy debate regarding nursing home staffing.
Several examples of the authors’ own research are featured; the authors’ work on deficiency citations for pressure ulcers (chapter 4) nicely illustrates the potential of adopting a multidisciplinary approach (clinical, organizational, management, and market strategies) for dealing with persistent deficiencies. Similarly, the authors’ use of longitudinal data and latent growth curve modeling provides insight into the effects of contextual, organizational, and process factors on the overall quality improvement of resident outcomes (chapter 5). Although the findings from both studies are likely to be of interest to practitioners and policy makers, the highly detailed descriptions of the statistical techniques may prove challenging to such an audience, ultimately serving to confuse rather than enlighten.
A particular strength of this book is the manner in which each chapter builds upon the previous one, proceeding from a general overview and discussion of key issues pertaining to care quality to specific in-depth analyses of its determinants. The exception to this, however, is the book’s final chapter in which the authors present their solution for improving care quality – the use of health informatics (i.e., telemedicine and e-health). The reader is several pages into the chapter before the rationale for such a proposition – offering staff ready access to health information necessary for directing care plans and care delivery – becomes apparent. While access to such information may indeed enhance resident care and outcomes, the authors’ proposed solution rests on the assumption that poor care quality is the result of limited staff knowledge, the evidence for which receives little, if any, attention in the preceding chapters. Such a solution again overlooks the complexity of staffing issues; for example, providing ready access to how best to treat pressure ulcers is of little use if front-line staff members do not have sufficient time to turn and reposition bed-bound residents. Focusing on staff access to health information also unwittingly serves to retain an emphasis on micro-level (i.e., individual) solutions, rather than on more macro-level, systemic solutions (e.g., funding, reimbursement).
The brevity of this volume makes for an easy read, although this comes at some cost to its comprehensiveness. More in-depth critical discussion in several of the chapters would have been a welcome addition, as would a little tighter editing. Several of the concluding comments (at both chapter and book levels) refer to material not actually presented, or to a sequencing of chapters that is incorrect. Nevertheless, this book offers practitioners, policy makers, and students a useful introduction to the issues surrounding the provision of quality nursing home care in the United States. Although perhaps best suited to a U.S. audience, there are insights in the book to be gleaned for Canadian and international readers.
