Understanding and improving psychosocial services in long-term care.

In this issue of the Health Care Financing Review, we present research that speaks to the importance of psychosocial care and its relationship to the overall well-being and quality of life for people receiving long-term care (LTC) services in nursing homes and community-based settings. The articles address numerous psychosocial processes of care and outcomes within the LTC service spectrum. This overview discusses the rationale for examining psychosocial services in the context of quality of life in LTC; summarizes the focus of the articles in this issue; and highlights current CMS initiatives relevant to psychosocial needs in LTC including national data sources that measure psychosocial services and outcomes of care and can be used to develop programs to improve care and outcomes.

Introduction

The LTC system serves people with diverse needs, including those with recent impairment in activities of daily living after an acute event or surgery; those with LTC disabilities or advanced chronic conditions including dementia; and people who are approaching the end of life. The needs of these individuals extend beyond assistance with function and medical care, and as a society we have come to recognize the importance of quality of life regardless of one's limitations. While quality of life in LTC is variably defined, it can be understood to include emotional health, social function, and self-worth, in addition to physical health and function (Sloane et al., 2005). These domains fit within the purview of psychosocial assessment, care planning, and care. More specifically, psychosocial services are those that enhance mental, social, and emotional well-being to promote quality of life. In this context, psychosocial providers address psychological, social and environmental stressors that negatively affect quality of life outcomes.

Not only must LTC address psychosocial needs, but outcome data must indicate whether this care results in improved quality of life. Given our historic focus on medical indicators of quality care (e.g., bed sores) and easily observable processes of care (e.g., restraint use), a significant gap exists in our knowledge regarding the provision of psychosocial care and quality of life. That is, psychosocial indicators, such as promoting patient dignity or assessing and providing services to maintain social engagement or lessen symptoms of depression, have been deemed less important and are generally more complex and time-consuming to measure and target for quality improvement. However, LTC providers and administrators, payers, regulators, and policymakers stand to benefit from research findings that inform psychosocial care and outcomes, especially given the rapid growth and associated costs in this health care sector.

CMS is committed to improving the quality of care in LTC. Consistent with the culture change transformation being promoted in these settings, CMS' vision for LTC is person-centered, meaning that it is individualized and responsive to an individual's choice. An example of this vision is CMS' revision to the federally mandated Minimum Data Set (MDS) 2.0 of the nursing home Resident Assessment Instrument, which is scheduled for implementation as MDS 3.0 in fall 2009. The MDS contains standardized items that measure comprehensive physical and psychosocial functioning for all residents in Medicare and/or Medicaid-certified long-term care facilities (Centers for Medicare & Medicaid Services, 2008a). One advance in MDS 3.0 gives nursing home residents a voice in reporting on their status rather than having staff do so, which has the potential to improve resident care and outcomes.

The person-centered approach to LTC is also reflected in CMS' Home and Community Based Services (HCBS) Waiver, Real Choice Systems Change Grant, and Money Follows the Person Grant programs. The HCBS waiver programs, administered by States, facilitate the delivery of LTC services in community settings as an alternative to nursing home care (Centers for Medicare & Medicaid Services, 2008b). The Real Choice Systems Change Grants and Money Follows the Person Demonstration Grants under the New Freedom Initiative both provide funding to assist States in implementing changes to their LTC support systems to better serve frail elderly and individuals with disabilities in their setting of choice (Centers for Medicare & Medicaid Services, 2008c).

Content of Issue

In 2001, the Institute of Medicine issued a report of findings reflecting that nursing home residents had experienced limited gains in quality of life following the nursing home reform enacted by the Omnibus Budget Reconciliation Act of 1987; it also indicated that the evidence regarding home based care is sparse and tends to measure satisfaction and unmet need, as opposed to quality of care. This issue of the Health Care Financing Review provides a glimpse of how LTC research is making progress to promote better psychosocial care, and also conveys systemic and programmatic challenges to evaluating psychosocial care in different types of LTC settings.

The four articles in this issue contain findings on psychosocial outcomes of care in various LTC settings from the perspectives of consumers, family members, and social service providers. The volume is organized conceptually into three sections: (1) quality of care in traditional nursing homes, (2) quality of care in a newer model of nursing home, and (3) community based services outcomes. In addition, data highlights from the Medicare Current Beneficiary Survey (MCBS) are presented on psychosocial data captured by the facility-based component of the survey.

In a study on psychosocial care quality in certified nursing homes, Zang, Gammonly, Paek, and Frahm analyzed Online Survey Certification and Reporting (OSCAR) data for Medicare and Medicaid certified facilities to explore the association between the stringency of State requirements compared to Federal minimum regulations for qualified social services staffing and six psychosocial service related deficiency measures. Numerous nursing home demographic characteristics (e.g., ownership, payer status, Medicaid concentration) extracted from the national Area Resource File (ARF) were also evaluated to measure their relationships with psychosocial care quality. Bonifas analyzed a different aspect of nursing home quality, using OSCAR data to evaluate how the work environment in skilled nursing facilities in Washington State related to social service providers' ability to deliver effective care as measured by resident outcomes. Together, these articles suggest that nursing home demographic and caseload characteristics are good predictors of psychosocial care quality and warrant further research, because they may indicate disparities in care and areas in which more attention is needed.

Culture change in LTC represents an organizational-based approach that has taken root over the past several years to transform nursing homes from medicallyoriented facilities to more resident-centered, home-like environments (Ragsdale and McDougal, 2008). As one evaluation component of a larger longitudinal study of a small-house nursing home model implemented in 2003 in Mississippi, Lum, Kane, Cutler, and Yu present findings on the Green House nursing home program related to family members' satisfaction and burden. As this model of LTC is relatively new, their study speaks to alternate models of LTC that address psychosocial wellbeing and quality of life. In comparison to the traditional nursing home model, findings are that families prefer the small house nursing home model, are engaged, and do not experience increased burden. One area identified as needing improvement was social activities, including religious observances.

In the final article, Glass et al. evaluate a State waiver program that provides home based and community based personal care services in Virginia. They conducted a representative statewide consumer survey to collect data on caregiver performance and consumer satisfaction, as well as quality of life outcome data. The study found that consumers generally are satisfied with care received. More importantly, the services provided enable consumers to better deal with health problems and enjoy an improved quality of life. Further, the evaluation model they developed could potentially be tailored for use by other States' community based LTC programs.

The MCBS Highlight presented in this issue is one example of CMS data that may be used to study quality of care in LTC settings. Other publicly-available data that include rich psychosocial information are three federally mandated LTC data sources; these include (1) home health patient outcome measures captured by the Outcome & Assessment Information Set, (2) OSCAR, and (3) MDS databases. In addition, Medicare claims data are available for skilled nursing facilities, home health, and hospice settings. These databases include service and/or outcome information relevant to psychosocial care and quality of life. Outside of CMS, the Centers for Disease Control and Prevention also collect LTC data through the National Nursing Home Survey. Through the collection of new primary data and the use of these and other existing databases to understand psychosocial care and outcomes, the future is being directed toward improved quality of life in LTC.