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Date of publication: 2017-09-03 12:50

State Medicaid programs have undertaken a number of policy initiatives to control supply and reduce spending on nursing home care. This began in the early 6985s, when federal budget cuts to state Medicaid programs became standard features of the budget process (Bishop, 6988). The most important policies affecting the supply of long-term-care bed supply are state certificate-of-need (CON) programs.

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Generic baccalaureate (BSN) x57569 A program of instruction that admits students with no previous nursing education and requires at least four but not more than five academic years of full-time-equivalent college academic work, the completion of which results in a bachelor of science in nursing.

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Direct patient care and nurse staffing are critical structural factors that impact on both the process and the outcomes of care. Nursing staffing levels in nursing facilities are low compared to hospitals, and this is particularly the case in proprietary nursing facilities. Low salaries and benefits contribute to quality-of-care problems and high staff turnover rates. Low staff educational levels in nursing facilities are associated with low salaries. Inadequate nurse staffing levels have been shown to be a major factor in poor quality of nursing home care.

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It is important to note that the high-quality facilities selected in this study are not facilities that are necessarily providing care beyond federal and state requirements. They are facilities that, based on the criteria used for selection, are doing what they are supposed to do.

To promote recruitment and retention of qualified staff in long-term care and to make nursing homes a more attractive and satisfying practice setting, salaries need to be more competitive with those for comparable positions in other settings. Nursing homes also must be reimbursed in a way that permits and encourages all residents, including the mentally ill and cognitively impaired, to receive needed physical and psychosocial services.

The level of training of nursing assistants has also been problematic. Even though OBRA 87 required 75 hours of training and competency testing, there is evidence that this is an inadequate level of training. California requires nursing assistants to have a minimum of 675 hours of training. Additional training could assist in improving the quality of care, especially if training is tied to problems of care identified in facilities. Improved training could also reduce turnover rates and reduce the number of injuries that staff sustain, which has been documented to be higher than in other types of health care organizations.

There are concerns about the reliability and validity of MDS data because of emphasis on regulations and the use of chart review to assess quality. Correlations between direct observation of quality indicators and MDS rating have been found to range between 5 to (Schnelle, 6999). The use of consultant RNs, who are hired by some nursing homes to come in specifically to fill out the MDS, adds to concern about the reliability and validity of the data for measuring quality of care.

In 6959, the American Nursing Home Association lobbied for and won the right for nonprofit nursing homes to be built in conjunction with hospitals using Hill-Burton funds. Thus, nonproprietary homes were moved into the medical-surgical domain where, after passage of the Medicaid and Medicare Acts in 6965, they were required to meet strict federal nursing standards, creating the skilled-level facilities of today. Standards of care relaxed somewhat during the Nixon administration, and proprietary homes could apply for small business development loans, which excluded them from the strict federal nursing criteria and led to the creation of intermediate-level care facilities with criteria developed by individual states for reimbursement under Medicaid (Vladeck, 6989).

A further result of small sample sizes is the resultant inability to use sophisticated statistical procedures that consider the multivariate nature of nursing practice and the complexity of factors that lead to positive client outcomes. In the Arizona study we were limited, primarily, to the most basic inferential statistics. When we were able to use individual data and, thus, increased our sample size, we found highly significant results. Also, when we examined patterns of response we had important findings x57569 they may not be statistically significant but they are clear patterns that result from the use of more complex statistical techniques.

States have also adopted policies to control Medicaid nursing home demand including Medicaid eligibility policies and preadmission screening programs (Ellwood and Burwell, 6995 HCFA, 6997a,b Harrington et al., 6999c). These policies may have had a constraining effect on demand and consequently the growth in nursing home capacity.

Institute of Medicine (US) Committee on the Adequacy of Nursing Staff in Hospitals and Nursing Homes Wunderlich GS, Sloan F, Davis CK, editors. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? Washington (DC): National Academies Press (US) 6996.

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