Challenges in Nursing Home Care: A Research Agenda

Nursing home residents, mostly frail and near the end of their lives, are housed in a health care sector whose condition has been deemed in crisis by both the popular media and the federal government (Health Care Financing Administration [HCFA], 2000a, 2000b). Although the percentage of aged Americans residing in nursing homes has declined slightly in recent years, rapid aging of the population and especially the growth of the population 85 years and older, means that demand for nursing home care will likely increase in the future. On March 20–21, 2002, a conference entitled ‘‘Challenges in Nursing Home Care’’ was held at Florida State University and sponsored by a National Institute on Aging conference grant (U13 AG20154) and a grant from the Robert Wood Johnson Foundation. The articles presented addressed central concerns facing families, care providers, and policymakers about nursing home care including cost containment, the quality of care, access to care, consumer preferences and decision making, liability and workplace issues. They help provide answers to questions such as how nursing home care can best be financed and delivered, how it should be organized, how to measure quality of care, and how to provide optimal levels of care within the constraints of limited resources. In addition, these state-of-thescience articles begin the process of setting a research agenda for investigators in this central gerontological issue. This volume presents a series of articles meant to recommend a research-oriented agenda for the nursing home section of the long-term care institution in the United States. An earlier Institute of Medicine volume emphasizes issues of quality of long-term care and presents recommendations for its improvement (Wunderlich & Kohler, 2001). In the past decades, several important changes in the long-term care system in the United States have had both direct and indirect consequences for the quality of nursing home care. Changing demographics, including increased longevity among the older population, combined with the increased incidence of women in the labor market and smaller families means that there are fewer potential informal caregivers. Changing expectations about later life care and continuing preferences for remaining at home have given rise to competing settings to nursing home care. Retirement communities, assisted living facilities, continuing care retirement communities, and home health care agencies now provide care that used to be delivered through informal care at home or formal care in nursing homes. Frequently the option of last resort, although still a necessary one, the nursing home operates in an evolving social, political, and economic climate, and under changing visions of how long-term care should be delivered and financed. In the past decade, there has been a decline in the proportion of people aged 65 years and older who reside in nursing homes. This transformation appears to be largely due to changes in the financial incentives associated with reimbursement systems for alternative types of long-term care as well as a decline in disability in the aging population. Nursing home growth was rapid in the early 1990s, as skilled nursing facilities were created to match changes in Medicare reimbursement patterns. For much the same reason, there was a spurt of growth in home health care agencies as alternatives to nursing home care. Subsequent reforms to Medicare reimbursement patterns, including the 1997 Balanced Budget Act, had implications for the nursing home industry. Some individuals lost home health agency support resulting in nursing home admission. At the same time, Medicare reimbursement to nursing homes declined sharply. Increasingly, Medicaid has become the primary payor of nursing home care. States, which bear the primary burden of Medicaid financing, have been attempting to contain the costs of Medicaid, partly by tightening controls on reimbursement rates for nursing home residents. Disclaimer: The opinions published herein are not necessarily those of the National Institutes of Health. These articles are not intended as a statement of Federal guidelines of policy. Address correspondence to Jill Quadagno, Pepper Institute on Aging and Public Policy, Florida State University, Tallahassee, FL 32306. E-mail: jquadagno@coss.fsu.edu Pepper Institute on Aging and Public Policy, Florida State University, Tallahassee. Behavioral and Social Research Program, National Institute on Aging/National Institutes of Health, Bethesda, MD.