Few would argue that most frail older adults and people with disabilities would prefer to be cared for in their own homes. Yet with so few community resources available to enable them to do so, many have little recourse but to turn to institutional care.
Indications are that things may be changing, however. Last July, Department of Health and Human Services (DHHS) secretary Mike Leavitt announced that $1.75 billion in competitive grants will go to states over five years to encourage them to move Medicaid-eligible residents from long-term care facilities back into the community. It's part of an initiative by the Centers for Medicare and Medicaid Services (CMS) to "rebalance" long-term care and "[offer] individuals a reasonable array of balanced options, particularly adequate choices of community and institutional options." Funds will support a range of services, such as home care, home modification (including furniture and equipment), respite for family caregivers, transportation to community services, and training and compensation for caregivers.
And on December 21, 2006, President Bush signed into law the Lifespan Respite Care Act, which will give states $289 million over five years to provide relief for family caregivers.
But who will these caregivers be? A report released in 2003 by the DHHS's National Family Caregiver Support Program noted that 86% of states already described a need for additional caregiver support. Studies by the United Hospital Fund, the National Alliance for Caregiving, and others note that more than one-fifth of American households are involved in caregiving and nearly 60% of caregivers received little or no training (see "Family Caregivers," August 2006).
"Nurses can be a big part of this movement toward home-based care," says Susan Reinhard, codirector of the Center for State Health Policy at Rutgers University, New Brunswick, New Jersey. Nurses have ample experience in helping people "manage chronic conditions outside of institutions by identifying their strengths and building their practical skills and confidence," she says. And according to Charlene Harrington, University of California, San Francisco, professor of nursing and expert on gerontologic nursing care, "Some states, such as Oregon and Washington, are making excellent progress in shifting to home- and community-based services and expanding personal care services to individuals at home." But in other states, she warns, limits in Medicaid funding result in "long waiting lists" for those wanting noninstitutional care.
Those who cannot remain at home, for lack of funding or caregivers, will find themselves in facilities where care is costly and leaves much to be desired, according to several reports. A December 2005 Government Accountability Office (GAO) report stated that nursing home inspectors often fail to report serious deficiencies that jeopardize residents. An analysis reported in January 2006 by the New York State Office of the Attorney General concluded that 98% of that state's 600 nursing homes were staffed at levels below those recommended in a federal study. And in May 2006 the DHHS Office of Inspector General revealed that nursing homes with violations are not always penalized by the CMS. Although CMS data indicate that nursing home quality has improved significantly, the GAO found in a review of five states that state inspectors missed serious deficiencies in 8% to 33% of cases, discrepancies it attributed to state surveyors conducting inspections inconsistently and understating the occurrence of serious deficiencies.
Nursing homes undergo state inspection every nine to 15 months and are funded by the CMS if they comply with the standards of care set out by the Nursing Home Reform Act of 1987. If a noncompliant facility takes longer than three months to correct deficiencies, payments for new admissions must be withheld. But of 706 incidents that merited denial of payment in 2002, funds were still released 28% of the time, according to the report from the Office of Inspector General.
In addition to highlighting inadequate staffing, the New York State report also found that among for-profit facilities, those with a majority of residents covered by Medicaid provided fewer hours of daily nursing care than did those with a majority of residents who were not covered by Medicaid.
Nursing assistants provide up to 90% of nursing home care; in 19 states in 2002, the turnover rate for that position exceeded 80%. "Turnover is ghastly, so how can you achieve quality?" asks Joan Saunders, founder and past executive director of the 6,200-member National Association Directors of Nursing Administration/Long Term Care (http://www.nadona.org).
The shortage of personnel to provide nursing care also extends to nursing home inspectors, many of whom are nurses. Hospitals and clinics lure away nurses with higher salaries, or after a few years they "become high-paid consultants to nursing homes with problems," says Saunders. She suggests making inspectors federal employees who receive standardized training and competitive salaries. In addition, the CMS should collaborate with hands-on professionals to establish quality criteria. "We're dealing with the lives of frail people who deserve dignity," says Saunders, "whether they're truck drivers or bank presidents."
Carol Potera
Maureen Shawn Kennedy, MA, RN
news director
World Health Roundup
Iraq's nurses, an endangered species. A news report from the United Nations Office for the Coordination of Humanitarian Affairs released by http://IRINnews.org quotes an official at the Iraqi ministry of health as saying that more than 160 of the country's nurses have been murdered and more than 400 wounded since the March 2003 invasion by U.S.-led forces. Yehia al-Mawin, the ministry official, says thousands of other nurses have fled the country or quit working after being threatened by insurgents or militia members. The country's medical facilities, which in some areas receive dozens of new casualties daily, are in dire need of nurses. One nurse, Nissrin Muhammad, says she works 13-hour days, six days a week at a public hospital in Baghdad for a monthly salary of approximately $150. Conditions at the hospital, according to the report, are "dangerous and deteriorating."
The polio epidemic that began in India has spread, according to the Global Polio Eradication Initiative November 28 report. The number of cases in India reported as of December 13, 2006, is 10 times greater than in 2005 (583 versus 56), according to World Health Organization statistics. Nigeria, the leader among polio-endemic countries, accounts for more than half of all cases globally. To prevent a polio outbreak during this year's Muslim pilgrimage to Mecca and Medina, Saudi Arabia has instituted new immunization requirements for travelers from polio-infected countries. Updated polio statistics are posted weekly and situation reports are posted monthly at http://www.polioeradication.org.
Misoprostol cut the rate of acute severe postpartum hemorrhage by 80% among low-risk women delivering at home or in village health "subcenters" in rural India, according to a study published in the October 7 issue of the Lancet. Globally, approximately 150,000 women die from postpartum hemorrhage each year. Oxytocin, the most commonly used agent in controlling postpartum hemorrhage, cannot be used in settings lacking refrigeration or high-level professional monitoring. Misoprostol, a much more inexpensive and stable uterotonic, was administered by auxiliary nurse midwives as an alternative to oxytocin. It had minimal maternal and no neonatal adverse effects, and India's health ministry has approved its use in rural settings.