U of M researchers: culture change will be imperative to improve care of Alzheimer’s patients in nursing homes

Monday, April 7, 2014

University of Minnesota researchers have assessed the current state of nursing home care for individuals with Alzheimer’s disease and have identified a number of state and federal policies that currently act as barriers to improvements in patient care.

According to the authors, a culture change will be imperative to improve quality of life for Alzheimer’s patients in nursing homes while preparing for an influx of patients battling dementia as the population ages.

The research appears today in the April issue of the journal Health Affairs and was led by Joseph Gaugler, Ph.D., an associate professor and McKnight Presidential Fellow in the University of Minnesota’s School of Nursing and Center on Aging. Gaugler has studied long-term care for more than 15 years. Study coauthors are Fang Yu, Ph.D., R.N., Heather Davila and Tetyana Shippee, Ph.D., with the University of Minnesota. 

According to the authors, state and federal regulations should be updated to:

  • Result in better patient assessment. Comprehensive assessments of people with Alzheimer’s could ensure more patients avoid eligibility gaps and qualify for nursing home care subsidies. They could also identify potential problems for patients, such as fall risks or behavioral challenges.
  • Increase state Medicaid payments to nursing homes. Such funding would help eliminate funding disparities among nursing homes and offer up-front resources to those wanting to make longer-lasting improvements and potentially cost-beneficial changes in quality of care.
  • Expand pay-for-performance nursing home care models. These models would  create financial incentives – in lieu of today’s penalties – for health care improvements. 

“A culture change is needed in nursing homes to provide an appropriate quality of life to aging national and state populations,” said Joseph Gaugler, Ph.D. “To confront the coming epidemic of Alzheimer’s disease, it’s time we invest in better care outcomes. The emphasis for long-term dementia care is not on curing a disease, but on effectively managing the disease by maintaining strengths and independence as long as possible. We have to invest in care practices reflecting that.”

Alzheimer’s disease or a related dementia affect 64 percent of Medicaid recipients in nursing homes today. According to the Alzheimer’s Association, without medical breakthroughs the number of Americans with Alzheimer’s disease may triple over the next 35 years. The disease can persist for 3 to twenty years, underscoring the need for attention to long-term quality-of-life improvements and the cost reductions that can result in tandem.

Ensuring nursing home residents with dementia are engaging with their physical environment, living with the greatest amount of autonomy possible, and living in accordance with their individual care preferences, are important contributors to high-quality nursing home care. The same elements can also provide greater peace-of-mind for family members and friends.

Improving assessments
Current state assessment criteria can restrict the eligibility of individuals with dementia to needed Medicaid nursing home care. Assessments need to do a better job of factoring in behavioral problems that can result from dementia. Related falls, wandering off and similar accidents can incur high-costs in emergency room and hospital care.

Increasing state Medicaid payments to care facilities 
Changes to Medicaid reimbursement rates could help close the disparity gaps that exist among nursing home care facilities. Today, care improvements are most likely in resource-rich nursing homes not funded by Medicaid. Because Medicaid recipients are often concentrated in lower-ranked facilities with records of care deficiencies, proven funding incentives may be a viable solution. 

Funding to provide more dementia-care training for staff, an updated care environment, additional qualified staff members and other needed patient-centered-care advancements are needed.
 
Pay-for-performance
Expanding proven chronic care models – such as those seen in Minnesota – nationally is one route that could improve nursing home care. Minnesota is ranked number one for long-term care on a state scorecard compiled by AARP, The Commonwealth Fund, and the SCAN Foundation.

The Minnesota Performance-Based Incentive Payment Program (PIPP) specifically has been shown to improve patient outcomes and potentially reduce perennial costs associated with long-term care like emergency room and hospital admissions. Gaugler calls PIPP – which provides short-term grants to individual care facilities to help meet self-identified care improvement goals – a great example of a pay-for-performance model that works.

Positive impacts on behavior and depression, number of falls, use of restraints, use of anti-psychotic medication, and more are frequent PIPP results. Tying money to outcomes and performance in a chronic care model has a significant potential to improve care outcomes.

Funding for this research was provided by the National Institutes of Health grant no. 1KL2RR033182-02.