Recently, there has been increasing attention focused on the performance and quality of nursing home care, most recently because of the rise in the number of ownership transactions, as well as the tendency for transactions which involve a transfer of ownership from a public entity to entities commonly referred to as private and/or private equity companies.

At the heart of this debate and scrutiny is a corollary issue that should, in fact, be the centre of our attention, and that is being lost in the scuffles over private equity ownership. That issue is transparency.

Below are suggested solutions to improve nursing home quality of care.   

Solution 1: There should be complete transparency on full ownership of every nursing home

It should be undeniable that the purchaser and recipient of nursing home care have the right to know who is providing that care. When that purchaser is the federal government, which spends billions of dollars on nursing home care every year, the case for complete transparency is compelling. Simply put, the federal government should have the right to know, with complete transparency, the complete ownership structure of every nursing home participating in residential aged care, as well as the provision of aged care packages. This should be true no matter which or what type of entity owns them. There are several corollary principles that follow from the right to ownership transparency:

1. The complete ownership structure of all entities involved in the provision and administration of resident care should be fully reported to the Department of Health and Ageing.
2. The ownership reporting requirement should be the responsibility of the provider organisation. The provider organisation should set forth, in understandable detail, the complete ownership of all parties involved in the provision and administration of resident care.
3. The principle of transparency should apply no matter what level of complexity in the labyrinth of organisational structures exists. In fact, the more complex the web, the greater the need for more detailed transparency. And, the greater the complexity, the more reasonable it is that the originator of that complexity ought to have the responsibility for explaining it to the purchaser of care.

Solution 2: Staffing information for every nursing home should be reported in a standardised format

In addition to ownership transparency, there should be transparency on the staffing in nursing homes. In the world of health systems, we often describe the nature of the work along two dimensions: “tech”(nology) and “touch.” In an industry as “high-touch” as nursing home care, it is reasonable for the purchaser of care to know the labor resources that are being devoted to that task. Nursing homes should report the staff resources, on a resident-time basis, that are devoted to resident care. This information should be based on payroll data, which exist in accessible form for virtually every nursing home in the country. The technological means exist to submit and receive staffing data, in a standardised format, for the entire nursing home industry. Reasonable people representing all stakeholders can make sound decisions about how to structure the definitions into a common taxonomy. Acuity-based staffing in this industry is far more crowed about than practiced, but these adjustments can be taken into account if necessary.

Solution 3: There needs to be greater ability to expand the scope of observation and analysis from individual facilities to nursing home corporations and networks

Currently, virtually all regulatory activity is focused on the individual nursing home. To a large extent this is because of the concept that the “approved provider” is the operator of record and accountability. Yet in many nursing home inspections or reviews, it is the corporate entity that will be integrally involved in the process from the provider side. Related and equally important, it is often the corporation’s policies and procedures that govern the system of care in the facility. In some cases these corporate policies and procedures are inadequate to provide proper governance to the delivery of care. Yet in many other cases, the problem at the facility and resident levels is that reasonable policies and procedures are not being executed consistently across facilities in the network. A stronger focus on this level of management would be a much more efficient way to improve care systematically across an organisation, as opposed to one facility at a time. Mmuch more could be done to utilise a range of available information in an aggregated fashion to focus on regional and even national nursing home networks.

The government should have the authority to take corrective action with respect to corporate entities if there are problems at individual facilities. More often than not, the problems found at a network’s facilities display a common set of patterns and issues; it is much more efficient to deal with these issues and corrective responses on a broader basis than just individual facility actions.

Solution 4: There should be more use of intermediate corrective measures

There have long been calls for broader and more innovative ways to incentivise, exhort, and pressure providers into taking better and more systematic corrective actions to improve care and sustain that higher care level. These appeals have continued unabated, and have actually become more urgent in recent years, because of the confluence of three very troubling trends:

1. the demographic graying of Australia,
2. the increasing complexity of the nursing home population as it accepts more post-acute patients, and
3. the stagnant or decreasing skill sets of provider staff.

Care problems need to be identified earlier and addressed—in meaningful ways—more promptly and with more ingenuity and commitment. The current arsenal of intermediate sanction weapons—including no funding for new residents only, and the appointment of nursing home advisors —have been used to varying degree and imposed inconsistently. There needs to be more stable use of these vehicles for correction and improvement. But there also needs to be increased scrutiny on providers—at both the facility and network levels—who have not demonstrated the ability to adequately self-identify a problem and fix it; and then keep it fixed.  The current regime of accreditation from a consumer perspective, is also seen as an "industry friendly initiative".

One measure that has demonstrated success in both process and outcomes is the use of monitors to provide additional scrutiny on the care provided in problematic facilities, as well as the systems put in place to correct identified problems and sustain the fix.  

In particular, the focus of attention on the corporate district level—the level of the corporation just above the individual facility level—has proven extremely valuable, improving the consistency of the quality assurance protocols and activities as they are rolled out from this level to facilities. Similarly, focus on the systems of care delivery and quality assurance has shown both model practices and complete breakdowns in how care is provided, and how quality improvement efforts have been effective or not. Providers sometimes focus inordinate attention on finding "managers," then expecting them to work miracles without giving them the support they need to be successful, and then holding them solely responsible if this impossible task is not accomplished.  Monitoring can correctly place the focus on the systems of care that need to be implemented consistently across every facility, every shift, and at every bedside.

The monitoring process can promote and expand the concept of transparency described earlier. Facilities and organisations that have demonstrated problems in providing and assuring quality care will be the focus of additional attention and scrutiny, with the transparency that monitors can provide to determine the capability of the provider to improve their systems and oversight. 

Solution 5: Increase the focus on the landlord as well as the approved provider

Currently, the entity owning the actual physical asset of the nursing home (the "bricks and mortar" as it is called) has virtually no responsibility or accountability for the adequacy of the care provided at the facility. Yet we have seen cases in which the actions (or inactions) of the landlord have had deleterious, and sometimes direct, effects on the quality of care in the facility. For example, there are sometimes restrictive clauses in the lease agreements that effectively prohibit the approved provider from making needed upgrades or renovations consistent with evidence-based care practices. Other restrictive lease practices might make the implementation of physical or structural changes so onerous financially that it becomes prohibitive for the approved provider to even consider such changes. It is certainly conceivable that an approved provider might find itself in the "Catch 22" situation of being in violation of federal certification or state licensure regulations that cannot be fixed without taking steps that are legally or financially prohibitive in the lease it has with a landlord.  The worse case scenario would be to lose a quality provider over renewing leasing arrangements, leaving the residents with the terrifying prospect of facing eviction.

We realise that this problem, in particular, might be very difficult to solve. Holding the landlord to the same certification and licensing requirements of the operator may not be feasible. But consideration should be given to:

1. making sure that the lease provisions are transparent, along with other aspects of ownership, and
2. finding a way to ensure that if lease agreements stand in the way of corrective actions necessary to bring about compliance with conditions of participation, there is a way to deal with these situations.

Conclusion:

All the solutions we propose above have to do, in some way, with increasing the transparency of information about who provides care, and who owns whatever entity or entities responsible for the decisions pertaining to that care. Transparency is essential to the continued delivery of nursing home care through existing private and public markets. There is an elegant simplicity to transparency solutions. With full transparency of ownership, so we know who is and should be accountable, and transparency on staffing so we know who is providing care, we can examine the outcomes as they are produced through the survey process and examination of resident-level outcomes.

Facilities and organisations demonstrating their ability to deliver adequate (and hopefully excellent) care can continue on with this critical task, and with our appreciation. Facilities and organisations that have demonstrated an inability to deliver adequate care can expect to see additional scrutiny and even greater transparency requirements, including outside monitors to assure that they can earn our trust to provide care and protect the health and safety of our most vulnerable population.

This was inspired and adapted from an excerpt from a testimony of David R. Zimmerman, Ph.D for the United States Senate Select Committee on Aging
- Nursing Home Transparency and Improvement (November 2007)