Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? by Committee on the Adequacy of Nurse Staffing in Hospitals & Nursing Homes

Author:Committee on the Adequacy of Nurse Staffing in Hospitals & Nursing Homes
Language: eng
Format: epub
Tags: Health and Medicine: Medical Training and Workforce
Publisher: NATIONAL ACADEMY PRESS
Published: 1996-02-22T00:00:00+00:00

General Issues in Health Care Delivery

Information derived from site visits documented several broad issues: increasing patient acuity-of-care needs; an aging population; the movement from inpatient to outpatient delivery of care; and cost containment approaches to the delivery of care, which ranged from managed care to low Medicaid reimbursement rates to the "restructuring" being undertaken in many hospitals.

Both acute care and long-term-care settings reported increased acuity levels and the need for higher intensities of services in the past few years. This change in the needs of the patient populations was attributed to several factors, including the aging of the U.S. population. For acute care settings, a primary reason cited in the facilities visited was the change in lengths of stay and the incentives to delay admissions. A significant change in the kinds of illness presented has also altered hospital acuity levels. In some regions, many cases of AIDS and drug-resistant tuberculosis and an increase in the numbers of trauma patients have compounded the general increases in acuity levels.

Similar issues—changes in the kinds of residents, their acuity of illness, and age and comorbidities—were also described in nursing facilities. The staff at some facilities pointed out, first, that many or most of their residents have been in the facility for a while and are "aging in place," and, second, that they are getting more short-term rehabilitative patients discharged from the hospital and more patients classified as "subacute." This means that nursing homes are now receiving people with such care needs as in-house kidney dialysis, tracheotomy care, and intravenous pain management; 10 or 15 years ago, these patients would have remained in an acute care setting.

Alternative models for delivering long-term care, such as increased placement of the elderly in community-based care settings, are extensively used in some areas. This also increases the acuity level in nursing homes because the existence of alternate forms of long-term-care services essentially results in the selection of relatively healthier persons for placement elsewhere. Consequently, higher concentrations of severely ill or debilitated individuals can be found in nursing facilities.

In some urban areas, the age groups served appear to be expanding. Urban facilities are providing chronic, but intense, care to younger populations, in part because of AIDS and violent trauma. Another specific reason for the increased acuity is the closing of mental hospitals. Whatever the various causes, however, the concentration of high-acuity residents—those who need extensive help with eating and elimination and are less mobile; those who have greater psycho-behavioral problems; and those with intravenous pumps, oxygen concentrators, and other such devices—is straining the staff and, at times, the physical plant of nursing facilities.

Managed care and other cost containment efforts are also greatly affecting the environment in which health care is delivered. Hospitals are currently feeling the immediate effects of these pressures, but managed care for Medicaid patients is starting to affect nursing home residents. Committee members heard some concern that managed care for Medicaid patients may mean, for long-term care, more focus on cost, a lower priority for quality, and, therefore, the possibility of further reductions in staffing levels.

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